F2 Test 3

What structure is not located within the mediastinum A.Heart B. Bronchus C.Larynx D. Trachea

C. Larnyx

Air entering the pleural space when an opening at the outer chest wall is known as? A. Closed pneumothorax B.Tamponade C. Open pneumothorax D. Pneumothorax

C. Open pneumothorax

You are unable to place a peripheral intravenous line on a newly admitted obese patient. The physician comes to the hospital and places a central venous line. A portable chest x-ray is taken. Over the next two hours your patient complains of shortness of breath and oxygen saturation is 90% on room air. You contact the physician with your findings and suspect A. Hemothorax B. Tension pneumothorax C. Pneumothorax D. Intravenous infiltration

C. Pneumothorax

The nurse is caring for a patient who had a cuffed tracheostomy tube inserted 2 days ago. The practitioner has ordered the cuff inflated at all times. When the nurse enters the room the patient clearly speaks of having pain at the insertion site. What action should the nurse take first?

Check the pressure in the tracheostomy cuff Rationale: The inflated cuff of the tracheostomy tube prevents normal airflow over and vibration of the vocal cords, thus preventing the patient from speaking. The presence of speech implies that the airway is unprotected. This is not considered an expected or normal finding. The patient's ability to speak in this situation is not normal and needs to be addressed immediately. The nurse's first action should be to check the pressure in the patient's tracheostomy cuff to ensure that it is properly inflated. The patient's pain should be addressed as soon as possible, but cuff pressure must be maintained to prevent aspiration and ensure adequate ventilation.

Which action should the nurse include when providing tracheostomy care?

Clean the inner cannula with saline solution Rationale: Saline solution loosens secretions from the inner cannula and should be used to clean the inner cannula. The nurse should clean the area around the stoma starting at the stoma and working outward in order to pull contaminant to the periphery. New ties need to be applied before removing the old ties to prevent dislodgment. Suctioning after the procedure may cause the patient to cough secretions into the tube; tubes are usually suctioned before the procedure. There is no outer cannula to clean, only an inner cannula.

The nurse suctions the tracheostomy tube of a patient who received a tracheostomy the night before. When suctioning, the nurse notices a moderate amount of bloody secretions. The patient notices the blood and appears to be disturbed by it. What should the nurse do next?

Comfort the patient and explain that blood in the sputum is normal after tracheostomy tube insertion Rationale: For patients with a new tracheostomy, the nurse should explain that bloody secretions may occur after initial placement of the tracheostomy tube and after each tracheostomy tube change. Turning the lights down so that the patient has difficulty seeing the secretions may only increase the patient's anxiety and stress. Because this is an expected finding, there is no need to notify the practitioner. More vigorous suctioning may lead to more bleeding.

While injecting air into the cuff, the nurse notes that there is no audible leak on inhalation during ventilation with the MRB, and the patient is unable to speak. Which intervention is the most appropriate?

Connect the patient to the ventilator to implement mechanical ventilation because cuff inflation is appropriate. Rationale:The nurse should connect the patient to the ventilator to implement mechanical ventilation, because cuff inflation is appropriate. The cuff is inflated when an audible leak is not heard and vocalization is not possible. Injection of additional air would lead to increased pressure and might increase the risk of mucosal damage. Leaving a syringe on the inflation valve may cause it to become stuck in the open position, allowing air to escape. The cuff is working properly and does not need to be replaced.

While assessing a patient who is receiving mechanical ventilation through an ET tube, the nurse notes an increase in peak airway pressure and thick beige secretions. What is the most appropriate nursing action?

Consider hyperoxygenating the patient and then suction secretions from the patient's airway using the closed-system technique. Rationale:An increase in peak airway pressure in a patient receiving mechanical ventilation is an indication of accumulated airway secretions that require suctioning. Hyperoxygenation with 100% oxygen may be used to prevent a decrease in oxygen saturation during the suctioning procedure. Sedation would not decrease airway pressure. Increasing tidal volumes may increase peak pressure. Increased peak pressure alone is not an indicator for immediately obtaining a chest radiograph.

A nurse is teaching a new graduate nurse about tracheostomy tubes. Which statement by the new graduate nurse indicates understanding of the capabilities of a fenestrated tracheostomy tube?

"A fenestrated tube allows the patient to speak." Rationale: A fenestrated tracheostomy tube allows speech when a fenestrated inner cannula is in place and the cuff has been deflated. Many patients with tracheostomy tubes of any sort have the ability to protect their airway enough to eat and drink normally. A fenestrated tracheostomy tube does not affect the production of mucus in the airway and thus does not change the necessary suctioning frequency for a patient.

The nurse is teaching the patient about self-suctioning a tracheostomy. The patient asks if normal saline should be instilled into the tracheostomy as advised by a family member, who is a retired nurse. Which response is appropriate?

"Instilling normal saline solution is no longer recommended." Rationale: Instilling normal saline solution before suctioning, once a common practice, is no longer recommended. Instilling saline may cause decreased oxygen saturation, dislodgment of bacterial biofilm that colonizes the tracheostomy tube, and tachycardia.

A student nurse asks why chlorhexidine gluconate was ordered twice daily for a patient with an ET tube. Which response should the nurse preceptor provide?

"Oral decontamination reduces pathogenic bacterial colonization in the oral cavity, which may cause VAP if contaminated secretions are aspirated." Rationale: Oral decontamination with chlorhexidine gluconate, as part of an evidence-based bundle of interventions, has been shown to reduce rates of VAP in mechanically ventilated patients. Studies have not shown that chlorhexidine gluconate decreases mortality from VAP or that it shortens the duration of mechanical ventilation. Frequent use of chlorhexidine may cause mucosal irritation and tooth staining in some patients.

While instructing a family member how to suction a child, the nurse correctly teaches that to prevent hypoxemia, each suction pass should last no longer than which time frame?

5 seconds Rationale: To prevent hypoxemia in a child, suctioning should not last more than 5 seconds per pass. In addition, the child should be allowed to rest between suctioning passes and suctioned only three times per suctioning occurrence. Suctioning for a longer time allows excessive depletion of oxygen from the lungs, resulting in hypoxemia.

The nurse is caring for a neonate who is intubated with a size 4.0 Fr ET tube. The nurse's assessment reveals increasing respiratory distress and coarse rhonchi during auscultation. What size suction catheter should the nurse use to suction the neonate?

8 Fr Rationale: One method to determine the most appropriate catheter size is to double the size of the ET tube and to select the suction catheter size closest to the resulting number. The entire internal diameter of the ET tube should not be occluded with the suction catheter. The suction catheter should not exceed half the internal diameter of the ET tube, and the 8 Fr catheter meets that requirement for a 4.0 Fr ET tube. The 12 Fr catheter would be too large. The largest appropriate catheter size is recommended to facilitate maximum secretion removal; thus, the 5 Fr and 6 Fr catheters would be too small.

The nurse should teach suctioning using aseptic technique to which patient?

A 47-year-old patient with AIDS Rationale: The immunocompromised patient with AIDS is at risk for severe infections and needs to continue to be suctioned using aseptic technique. Patients who are infected (not colonized) should be suctioned with sterile technique until the infection is resolved. As long as the 32-year-old patient who had a stroke or the 60-year-old patient who has undergone cardiac catheterization does not show signs of being infected, being immunocompromised, or living in an unhygienic environment, aseptic technique is not required.

You as the nurse know that chest tube placement is a sterile procedure. You inadvertently break the sterile field holding the patient's arm. You need to A. Alert the physician B. Do nothing and continue to assist C. Medicate the patient so it does not happen again D. Tell your co-workers so they can assist with the procedure

A. Alert the physician

You are caring for a confused patient in the intensive care unit. His oxygen is out of place and he hands you his chest tube. You notice that the air holes of the chest tube are exposed and sucking wound is visible. What is the most appropriate nursing action? A. Place an occlusive dressing B. Obtain a new chest tube and drainage unit C. Place X4 dressing D. Medicate for anxiety as ordered

A. Place an occlusive dressing

Intrapleural pressure is A. Usually below atmospheric pressure B. Above atmospheric pressure C. Equal to atmospheric pressure D. None of the above

A. Usually below atmospheric pressure

The nurse has just suctioned the patient's oropharynx. Which finding should the nurse expect as an outcome of this action?

Absence of gurgling in the oropharyngeal area Rationale: With oropharyngeal suctioning, expectations are that the oropharynx is cleared of secretions, which is evidenced by the absence of gurgling in the oropharyngeal area. Wheezes changing to crackles may indicate a worsening of the patient's respiratory status. Bloody secretions at any time after suctioning are indicative of tissue trauma requiring further investigation. Oropharyngeal suctioning has no impact on wheezes heard on expiration because these are the result of airway issues below the level of the oropharynx.

A nurse is performing tracheal suctioning. Which action is essential to prevent hypoxemia during suctioning?

Administer 100% oxygen before suctioning. Rationale: The nurse should preoxygenate the patient by delivering 100% oxygen in preparation of suctioning the patient for 30 to 60 seconds. Removal of secretions will be done with suctioning, so it is not necessary. Auscultating the chest is done before suctioning but does not prevent hypoxemia. Routine instillation of normal saline solution before ET suctioning is not recommended, even though it may be considered "routine practice" in many facilities. Evidence shows an association between instillation of normal saline and VAP and hemodynamic changes.

A nurse is caring for a patient with a mediastinal chest tube. One hour after walking the patient around the unit, the nurse notices an increase in the amount of drainage from the patient's chest tube. Which statement is true regarding this finding?

An increase in drainage after ambulation is normal but should be monitored closely. Rationale: An increase, not a decrease, in the amount of drainage from a chest tube is common after ambulation. If the patient had tamponade, the nurse would observe other signs, such as diaphoresis, hypotension, muffled heart sounds, and perhaps tachypnea. If the drainage had become sanguineous and were at least three times the actual output, a ruptured suture line would be a concern.

An infant requires oxygen therapy at 28% FIO2. What are the most appropriate setup and flow rate for the infant?

An oxygen hood at 5 L/min Rationale: An oxygen hood at 5 L/min delivers 28% FIO2 to an infant. Simple face masks are not appropriate for infants because they cannot be used for lower concentrations of inspired oxygen. A nasal cannula may be used for an infant; however, the flow rate of 5 L/min provides nearly 40% FIO2, which is too high for the desired oxygen concentration of 28% FIO2. An oxygen tent used at 10 to 15 L/min delivers an FIO2 of up to 50%, which would be too broad to achieve a level of 28% FIO2.

The nurse should expect a premedication order to relieve discomfort during chest tube removal. Which of the following is the most appropriate premedication choice?

Analgesic 30 minutes before the procedure Rationale: An appropriate analgesic should be administered 30 minutes before tube removal to relieve discomfort. Antianxiety medication and anticholinergic medication do not relieve the pain or discomfort of chest drain removal.

The nurse is providing tracheostomy care for a comatose patient. What action should the nurse take if there is no assistant available to help?

Apply the new tie before removing the old tie Rationale: If working without an assistant, the nurse should not cut the old ties until the new ties are securely in place. Removing the old tie first may lead to dislodgment. Postponement may not be an option, and the procedure does allow for single-person manipulation. The nurse should not remove gloves because this exposes the nurse to possible contamination.

A patient is ready to be discharged home and requires home oxygen therapy. Which situation should the nurse ensure before the patient goes home?

Appropriate referrals are in place so that the patient's therapy is not interrupted. Rationale: Interruption in oxygen therapy should be avoided; therefore, the nurse should ensure that a referral for home oxygen is in place so that the patient has continuity of care and a decreased risk of hypoxia. Patients may be discharged with oxygen delivery systems other than nasal cannulas. Expecting oxygen saturations of 99% with home oxygen therapy may not be realistic, especially in certain patients, such as those with type II respiratory distress. The nurse ensures a referral for home oxygen is in place but may not know the patient's insurance coverage.

While assessing a patient with a tracheostomy tube, the nurse notes audible air through the patient's nose and observes that the pilot balloon is deflated. What should the nurse do?

Assess the patency of the cuff and notify the practitioner, because these are indications that cuff integrity may have been lost. Rationale: Audible air passing through the mouth and nose; inability to maintain cuff inflation; low-pressure, low-volume alarms; and pilot balloon deflation are all indications of cuff leak or rupture. The integrity and pressure of the cuff must be assessed and corrected as needed. Audible air through the nostrils and a deflated pilot balloon are indications that the cuff is already deflated. Cuff pressure that is too low increases the risk of tube dislodgment and aspiration. Suctioning secretions from the patient to prevent pulmonary aspiration is not an appropriate intervention in this situation.

Your shift has just begun. As you assess your patient you observe vigorous bubbling in the air leak chamber of the drainage unit. Further assessment reveals subcutaneous crepitus palpable on the left upper chest and the patient is complaining of pain. Breath sounds are also absent in the left upper chest. You know that this is A. Normal for this patient B. A pneumothorax C. Cardiac tamponade D. A tension pneumothorax

B. A pneumothorax

Which of the following is not a benefit of autotransfusion A. Compatible with the patient B. Difficult to collect C. Performed by a nurse D. Oxygen carrying capacity better than banked blood.

B. Difficult to collect

When a chest tube clamp is placed between the air leak and the water seal chamber, the bubbling has ceased. This means that the leak is A. Absent B. Isolated C. Present at the drainage unit D. Within the patient, and you need more suction

B. Isolated

Clamping chest tube when moving the patient is A. Always done B. Never done C.Sometimes done D. Widely accepted in nursing practice.

B. Never done

Breathing is regulated centrally by chemoreceptors located in the A. Diaphragm B. Pons and medulla C. Lungs D. Cerebrum

B. Pons and medulla

Your patient is returned to bed with your assistance. The chest drainage unit is knocked over. You as the nurse know A.It is not a problem, forget it happened B. Return the unit to the upright position, mark the drainage, and continue to monitor C. Change the drainage unit D. Notify the physician there is a problem

B. Return the unit to the upright position, mark the drainage, and continue to monitor

A multiple trauma patient has been admitted to the intensive care to you. As the nurse, you were told that there was a chest tube placed due to left hemothorax that was confirmed by chest X-ray. He is intubated and being Ambu-bagged with great difficulty. Pending lab values. His blood pressure on admit was 70/40. He is tachycardic at 140 BPM and fluids are infusing. His trachea is not midline and you are having difficulty ventilating the patient. You assess that there are no breath sounds on the right side of the chest. You suspect A. Cardiac tamponade B. Tension pneumothorax C. Poor endotracheal tube placement D.Hemothorax

B. Tension pneumothorax

An increase of chest tube drain from a patient who is postoperative chest surgery of over 100cc in an hour is an increased amount and a physician must be notified. You know that A. This may go away in a few minutes B.Not too important as the patient was vigorously coughing C. Continued increases at this rate could return the patient to surgery for further intervention D. None of the above

C. Continued increases at this rate could return the patient to surgery for further intervention

Which statement regarding endotracheal tube and tracheostomy tube cuffs is accurate?

Cuff pressure should be maintained between 27 and 41 cm H2O to decrease the risk of mucosal damage and establish an effective seal. Rationale: Cuff pressures should be maintained between 20 and 30 mm Hg (27 and 41 cm H2O) to decrease the risk of mucosal damage. A high-volume, low-pressure cuff provides maximum airway seal with minimal tracheal wall pressure by distributing the pressure over a much greater area, thus decreasing the risk of tracheal tissue damage. While a larger tube may facilitate better oxygenation and ventilation, a high pressure cuff increases the risk of tracheal trauma as the cuff requires high pressure to obtain an effective seal.

Which factor should the nurse consider when developing a plan of care for a patient with an endotracheal tube in place?

Cuff pressure should be measured every shift and maintained between 20 and 30 mm Hg to decrease the risk of tracheal injury and pulmonary aspiration. Rationale: Cuff pressure should be measured at least once per shift and maintained between 20 and 30 mm Hg (27 and 41 cm H2O) to decrease the risk of tracheal injury and establish an effective seal to prevent pulmonary aspiration. Cuff pressure below 20 mm Hg (27 cm H2O) increases the risk of a cuff leak and pulmonary aspiration. The head of the bed should be elevated greater than 30 degrees (unless contraindicated), but a cuff should be deflated only when problems arise. Air leaking around the cuff indicates that the seal is not tight, creating an increased risk for tube dislodgment and aspiration.

A disposable drainage unit uses the same principles as the bottle system A. The first chamber is the collection chamber B. The second chamber is the water seal chamber C. The third chamber is the suction source D. All of the above

D. All of the above

A new chest tube was placed by a physician at the bedside and connected to a drainage unit with suction. Your nursing documentation should include A. The amount of the drainage collected upon insertion B. Presence or absence of an air leak C. Tidaling D. All of the above

D. All of the above

A patient with a chest tube must be taught to A. Never kink or pull on the tubing B. Continue to cough and deep breath C. Notify the nurse of discomforts D. All of the above

D. All of the above

Signs and symptoms of a tamponade may include A. Neck vein distension B. Tachycardia C.Decreased blood pressure D. All of the above

D. All of the above

Which of the following is not an iatrogenic cause of a pneumothorax A. Swan-Ganz catheter placement B. Bronchoscopy C. Mechanical ventilation D.Gunshot wound

D. Gunshot wound

A physician, to alleviate a pneumothorax, placed a small bore catheter. A one way valve was applied to the end of the catheter tubing. This one way valve is known as a _______valve. A. ________ valve B. Re-expansion C.Decompression D. Heimlich

D. Heimlich

When negative pressure is lost within the pleural space the result is A. Arrest B. Respiratory failure C. Bleeding D. Lung collapse

D. Lung Collapse

The responsibility of the nurse caring for a patient with a chest tube is to A.Maintain an intact and patent pleural drainage system B.Discontinue to system C.Acknowledge the suction amount D.Tell the patient that everything is as it should be

D. Maintain an intact and patent pleural drainage system

Fluid that causes compression of the lung tissue and now occupies space previously filled by the expanded lung is known as a A. Pneumothorax B. Hemothorax C. Chylothorax D. Pleural effusion

D. Pleural effusion

Collection of free air or gas within the tissue under the skin is known as A. Purulent B. Serous C. Oxygen D. Subcutaneous emphysema

D. Subcutaneous emphysema

Movement back and forth within the air leak chamber during inhalation and exhalation is known as A. Pneumothorax B. Air leak C. Loss of suction source D. Tidaling

D. Tidaling

During suctioning of secretions from a patient who is intubated, the patient develops cardiac arrhythmias, with an acute drop in oxygen saturation. What is the priority in this situation?

Discontinue suction and hyperoxygenate the patient using ventilator-supplied 100% oxygen. Rationale:The suction process should be terminated immediately if the patient develops cardiac arrhythmias or decreases in oxygen saturation. The underlying problem needs immediate intervention. Lidocaine may decrease the risk for bronchospasm, but immediate termination of the suction process is indicated in this clinical scenario. Inline suction may prevent further desaturation episodes but does not improve the patient's current status. Continued suctioning should not be performed, because it is evident the patient is not tolerating suctioning.

On entering a patient's room, the nurse determines that the patient's tracheostomy tube needs to be suctioned because of the patient's audible, forceful, productive coughing. To prevent splash contact with pulmonary secretions, the nurse should take which action?

Don gloves, gown, mask, and eye protection or face shield Rationale: Patients with excessive secretions or forceful, productive coughs place the nurse at risk for splash contact with pulmonary secretions. Gloves, gown, mask, and eye protection or face shield are necessary to protect the nurse during suctioning. Standing to the side does not decrease the risk of splash contact. Humidification increases secretions, allowing the patient to mobilize and expectorate the secretions. This patient is unable to cough up the mucus plug or secretions easily, as noted by the forceful coughing, so his or her tracheostomy tube needs to be suctioned to clear the airway.

A patient is being discharged home on oxygen. Which teaching point should be included in the patient education plan regarding oxygen safety?

Electrical equipment must be properly grounded. Rationale: Electrical equipment must be properly grounded to prevent electrical sparks, which can lead to a serious fire. To prevent leakage of oxygen gas, oxygen tanks should be securely stored upright, either with chains or in an appropriate holder. Smoking should not be permitted on the premises. Oxygen is humidified for patient comfort, but this is not a safety consideration.

When preparing to provide oral care and reposition a patient's ET tube, the nurse notes that the patient is uncooperative and restless. Which intervention is the most appropriate for managing the situation?

Enlist assistance when retaping or repositioning the tube of a patient who is anxious or uncooperative and thoroughly explain the procedure to the patient. Rationale: Having assistance when caring for a patient who is anxious or uncooperative helps prevent accidental tube dislodgment during retaping and repositioning. Repositioning the tube may cause some anxiety for the patient; therefore, the nurse should thoroughly explain the procedure first. Chlorhexidine gluconate oral rinse should be used immediately after intubation and every 12 hours thereafter, rather than each time oral care is performed. Oral care should be provided routinely every 2 to 4 hours or more often if needed, rather than on an as-needed basis only. Using mouthwash routinely as a cleansing agent is not recommended.

When performing oral care for a patient with an ET tube, the nurse notes redness at the corner of the mouth. Which intervention is the most appropriate?

Ensure that the ET tube is connected to the ventilator using a swivel adapter and reposition the tube to the other side of the mouth. Rationale: A swivel adapter decreases pressure on the ventilator tubing, and moving the tube to the opposite side of the mouth decreases the risk of pressure injury. Decreasing the cuff pressure may increase the risk of dislodgment and aspiration, and securing the tube without a bite block will allow pressure to the area to continue. Although documenting and monitoring are important, the nurse must intervene to prevent further breakdown. Changing the method of securing the tube will not necessarily relieve the pressure, and mouthwash has not been shown to decrease the risk of bacterial infection.

When managing a chest tube drainage system, which action should the nurse take?

Ensure that the chest tube is not stripped Rationale: Stripping pleural chest tubes is not recommended because it may cause large fluctuations in intrathoracic pressure. An air leak may indicate that the lung is not properly healing or that the system is not airtight and should be reported. When a patient is in the prone position, the tubing should be placed along the patient's side, parallel to the insertion site and extended off the foot of the bed to prevent kinking. Petroleum gauze, not dry gauze, should be used to prevent air from entering the pleural cavity and should be placed over the chest immediately if the chest tube is inadvertently dislodged. Looping the tubing off the side of the bed may cause an obstruction from a clot forming in the dependent loop and increased pressure in the lung. Tubing should be placed along the patient's side parallel to the insertion site.

When transporting a patient with a mediastinal tube, which action is the most appropriate?

Ensuring that the chest-drainage system is below the thoracic level Rationale: When transporting a patient, the nurse should keep the chest tube drainage system below the thoracic level because the pressure in the thoracic cavity must be greater than that in the drainage unit. The tubing should always be left open and never clamped. Occluding the tubing may cause an increase in intrathoracic pressure because air is unable to exit the system. Portable suction is not needed during transport; the suction source may be removed as long as the system stays below the insertion site. In general, tidaling does not occur with a mediastinal chest tube because the tube is not in the lung cavity.

While receiving tracheostomy care, the patient's oxygen saturation drops to 87%. What action should be the nurse's next intervention?

Hyperoxygenate the patient Rationale: When the patient's oxygen saturation level drops during tracheostomy care, the nurse should hyperoxygenate the patient to increase the oxygen saturation level. The provider does not need to be called as the first action, but may need to be notified if the saturation does not improve. High negative pressure may increase tracheal mucosal damage and should not be used. The tracheostomy tube may eventually need to be replaced, but this is not the first action.

While assessing a ventilated neonate, the nurse notes 100% oxygen saturation and an arterial partial pressure of oxygen of 308 mm Hg. The nurse knows to monitor and adjust the amount of oxygen administered to avoid hyperoxemia. Why is avoiding hyperoxemia important?

Hyperoxemia can lead to retinopathy of prematurity, periventricular leukomalacia, and chronic lung disease. Rationale: Hyperoxemia has been associated with the presence of free radicals that may lead to long-term morbidities (e.g., retinopathy of prematurity, periventricular leukomalacia, chronic lung disease). Hyperoxemia is not associated with sickle cell anemia, pulmonary hemorrhage, or an increase in secretions.

A patient with a tracheostomy tube is receiving mechanical ventilation. The nurse notes a decrease in the patient's oxygen saturation, an increase in peak airway pressure, and frequent coughing episodes. What is the most appropriate nursing action?

Hyperoxygenate the patient for 30 to 60 seconds by increasing the FIO2 on the ventilator to 100% and provide closed-system suctioning until the tube is clear (but less than 15 seconds). Rationale: A patient who experiences desaturation should be suctioned using the closed-system technique, with suction passes lasting less than 15 seconds. Hyperoxygenation with a manual resuscitation bag is not recommended. Instilling normal saline solution may cause a decrease in oxygen saturation. A sterile catheter should be used to prevent airway contamination. Using a coudé catheter is not indicated for this patient.

The nurse is performing an assessment of a patient with a T tube and notices that the patient has copious secretions. The patient becomes extremely anxious and starts using his accessory muscles to breathe. Which action is the most appropriate nursing intervention?

Immediately suction the secretions from the tracheostomy tube Rational: The patient's tracheostomy tube has become occluded with secretions, and the patient is becoming hypoxemic; therefore, the secretions in the patient's tracheostomy tube need to be immediately suctioned. Elevating the head of the bed and assessing the connection of the T tube to the tracheostomy are both important interventions; however, the issue is hypoxemia, which was caused by occlusion of the tracheostomy with secretions, and the secretions must be suctioned immediately. A respiratory therapist may be called, but the nurse needs to suction the secretions from the patient's tracheostomy tube immediately to prevent continuous deterioration from hypoxemia.

A neonate born at 25 weeks' gestation maintained on a high-frequency oscillator has a decreasing chest wiggle and increasing oxygen requirement. What should the nurse do about this situation?

Increase the FIO2 by no more than 10% and suction the ET tube while monitoring the oxygen saturation and heart rate. Rationale: ncreasing the FIO2 by no more than 10% and suctioning the ET tube while monitoring the oxygen saturation and heart rate is the correct nursing response. One of the parameters to assess whether or not to suction a neonate on the high-frequency ventilator is the chest wiggle factor. In this neonate, the decreasing wiggle and the increasing oxygen requirement indicate the need to suction. Increasing the FIO2 to 100% without suctioning does not help because the air is not passing freely through the ET tube. Continuing to monitor the neonate is not appropriate in the presence of clear signs that indicate the need to suction him or her. Notifying the practitioner only wastes time when there are clear indications to suction and no indication that reintubation is needed.

A patient with a tracheostomy tube is in respiratory distress and is placed on oxygen via a T-tube connector with an FIO2 of 40%. Which finding indicates an improvement in the patient's respiratory status?

Increased alertness with the respiratory rate decreasing from 36 to 24 breaths per minute and an O2 saturation of 94%

A patient who just had a chest tube removed for a resolved pneumothorax requires a focused respiratory assessment if he or she has which of the following?

Increased work of breathing, diminished breath sounds on the affected side, and decreased oxygen saturation levels. Rationale: Increased work of breathing, diminished breath sounds on the affected side, and decreased oxygen saturation levels indicate the need for a respiratory assessment. Pulsus paradoxus and decreased blood pressure are related to cardiac tamponade.

A nurse notices that the chest tube drainage looks milky. The practitioner requests a sample of the fluid be sent to the laboratory. What should the nurse do?

Insert a 20-G needle into the dependent loop after it is cleaned. Rationale:To collect a sample of chest tube drainage, the nurse should use a 20-G or smaller needle and insert it directly into the resealable connecting tubing after proper cleaning. If output is minimal, a small portion of the tubing may be placed into a dependent loop just until enough fluid is collected for a sample. Larger (lower-gauge) needles may damage the self-sealing capability of the tubing. The grommet port on the system is for removing excess water or saline in the water seal chamber, not for obtaining a sample of chest tube drainage. Although a sample of fluid may be collected upon insertion of the chest tube, it is not common to see chylous drainage immediately.

How can the nurse prevent trauma to the neonate's airway when performing ET suctioning?

Measure the desired depth of insertion for the suction catheter before the procedure. Rationale:The recommended method is to measure the length of the ET tube and adapter and to insert the catheter no more than 1 cm (0.4 in) past that measurement. Routine instillation of sterile normal saline solution is not recommended because it is not effective in making secretions easier to remove and may introduce bacteria into the lower respiratory tract. Rotating the catheter while withdrawing it from the ET tube is not an effective practice. Recommended practice for suctioning requires that the nurse control the depth of insertion and never insert the catheter until resistance is met.

A patient with a tracheostomy tube is admitted with hypoxemia. After suctioning, the patient is placed on a tracheostomy collar with humidified oxygen per the practitioner's order. To assess the patient's oxygenation status, the nurse should initiate which intervention?

Monitor the patient with pulse oximetry Rationale: Monitoring with pulse oximetry provides noninvasive, cost-effective trending of the patient's arterial oxygen saturation. ABG values are optimum for determining a patient's oxygenation, but they are invasive and expensive and require a practitioner's order. A respiratory monitor provides only information regarding the frequency and depth of the patient's respirations, not the patient's oxygenation status. Randomly adjusting the FIO2 is not the appropriate method of oxygenating a patient. All adjustments in the patient's oxygen require a practitioner's order.

The patient requires approximately 30% FIO2. Which device is the most appropriate low-concentration delivery device that is least restrictive for the patient?

Nasal cannula Rationale: A nasal cannula delivers lower concentrations of oxygen (approximately 24% to 44% FIO2) efficiently and comfortably. A simple face mask delivers 35% to 60% FIO2, which is more than this patient requires. A partial nonrebreathing mask and a nonrebreathing mask deliver higher concentrations of oxygen than this patient requires. The partial nonrebreathing mask, nonrebreathing mask, and simple face mask are all more restrictive than the nasal cannula.

While assessing a patient with a chest tube for a pneumothorax, the nurse notes fluctuation in the water level when suction is temporarily discontinued. Also, no bubbling occurs in the water-seal chamber. Drainage has been less than 5 ml over the previous three shifts. Which of the following is the most appropriate action?

Notify the practitioner to determine if the suction should be discontinued in preparation for chest tube removal. Rationale: When the air leak has resolved and drainage from the chest is minimal, the chest tube may not be needed. In most cases, the suction on the chest drainage system is discontinued up to 24 hours before chest tube removal. Converting the drainage system to a water seal for 6 to 24 hours and then obtaining a chest x-ray can provide confirmation that the pneumothorax has resolved. Fluctuation in the chamber is normal with respiration and does not indicate a system leak. The lack of bubbling in the drainage system indicates that the pneumothorax may be resolved and would be best assessed by using the water seal for 6 to 24 hours rather than continuing the suction.

Which of the following is the correct way to check for tidaling in a patient with a right pleural chest tube?

Observe the water-seal chamber for fluctuation with inhalation and exhalation. Rationale:The water-seal chamber fluid column should rise with inhalation and fall with exhalation when no air leak is present. Air bubbles appear in the water-seal chamber if an air leak is present, indicating a pneumothorax or a leak in the chest drainage system.

When securing the tracheostomy ties, the nurse should tie the ends in a double square knot, allowing for which outcome?

One loose or two snug finger widths of slack Rationale: The nurse ties the ends securely in a double square knot, allowing space for only one loose or two snug finger widths in the tie. One finger width of slack prevents ties from being too tight when the tracheostomy dressing is in place and also prevents movement of the tracheostomy tube into the lower airway. Two loose or three snug finger widths is too loose and can lead to dislodgment of the tube. Securing the ties too tightly can cause excessive pressure on the tissue and cause skin breakdown along with interrupting blood flow because it can place pressure on vessels in the neck. No slack in the ties can lead to tissue compression and breakdown in the trachea or other internal structures and to areas of irritation around the insertion site.

After suctioning the oropharyngeal airway with a rigid suction device, which action should the nurse perform?

Place the device in a container that is not airtight. Rationale: The rigid suction device should be kept in a container that is not airtight to ensure that it remains clean between suctioning. It is not necessary to discard the suction device between uses. Closure in an airtight container promotes bacteria growth. Placing the suction device on the patient's bedding exposes it to excretions, contaminants, and promotes bacteria growth.

The nurse has just completed a single suction pass for a patient with an artificial airway. What is the next priority?

Reassess the patient to determine the effectiveness of the intervention. Rationale: After suctioning is complete, the nurse should first assess the effectiveness of the intervention. The patient may require a second pass of the suction catheter if secretions remain in the airway. Documenting the procedure in the patient's record is necessary but is not the immediate priority postprocedure. Hand hygiene must be performed, but only after the procedure is determined to have been effective and is complete. Nasal and oropharyngeal suctioning should be performed only after the need for an additional suctioning pass is ruled out.

Which action should the nurse take before performing oropharyngeal suctioning?

Remove an oxygen mask and keep it near the patient's face. Rationale:When suctioning the oropharyngeal airway, the nurse should first remove the patient's oxygen mask to expose the mouth but keep it near the patient's face in case it is needed to prevent hypoxia. Rigid devices are used only for the oral cavity, so lubrication is not needed. Setting the vacuum regulator to the highest setting may create hypoxic states and cause tissue trauma. Because a nasal cannula does not impede the nurse from oral suctioning, it should remain in place during oropharyngeal suctioning.

Which method is the appropriate way to provide oral care to an intubated patient with a bite block?

Remove the old bite block, proceed with oral care, and insert a new bite block. Rationale: Although removing the old bite block is the appropriate first step, oral care is provided before a new bite block is inserted; the bite block may obstruct access to the oral cavity. Removing the old bite block before oral care allows the greatest access to the oral cavity, and reinserting a new bite block maintains the patency of the ET tube. Suctioning, if necessary, is always completed before removing the bite block and proceeding with oral care.

While suctioning the ET tube, the nurse notices thick, copious green secretions for the first time since assuming the neonate's care. What should the nurse do?

Report the finding to the practitioner because a change in the quantity and quality of secretions may indicate a pathologic change. Rationale: A change in the quality of the secretions may indicate the development of an infection or another pathologic change, which the practitioner needs to investigate. Normal secretions are not thick, copious, or green. Suctioning with routine frequency, such as hourly, is never indicated. Hourly suctioning may be needed but should be based on ongoing assessment. Increasing the amount of negative pressure to full is never indicated and may be damaging.

A patient has been admitted with pneumonia and is experiencing hypoxemia. Which sign or symptom would the patient most likely experience?

Restlessness Rationale: Mental status changes are often the first signs of respiratory problems and may include restlessness and anxiety. Heart rate and blood pressure are elevated during the early stages of hypoxia; eventually, they decline as the condition worsens. Skin changes include pallor, cyanosis, and cool and clammy skin.

The nurse is caring for a patient who is comatose, is not intubated, and requires frequent oral suctioning. After suctioning, in which position should the patient be placed?

Sims position Rationale: The Sims position encourages drainage and should be used after suctioning if the patient has a decreased level of consciousness. The prone position places pressure on the patient's thorax, thereby restricting his or her ability to breathe effectively. The semi-Fowler and Fowler positions both place the patient at risk for aspiration.

Which toothbrush should be used to brush the teeth of a patient who is intubated?

Soft adult toothbrush and oral cleansing solution or toothpaste Rationale: A soft adult toothbrush is needed to prevent tissue injury, and an oral cleansing solution or toothpaste is appropriate for brushing the teeth to remove debris. Mouthwash and firm toothbrushes are inappropriate for patients who are intubated.

The nurse is caring for a patient receiving mechanical ventilation. During open suctioning, the nurse notes a decrease in oxygen saturation from 95% to 85%. Before further suctioning attempts, what is the first action to take?

Stop suctioning and hyperoxygenate the patient for 30 to 60 seconds. Rationale: The best and first nursing action should be to stop suctioning and hyperoxygenate the patient. Then the nurse may consider using the closed-suction technique (or inline suctioning) because the patient developed cardiopulmonary instability when the open-suction technique was used. A PEEP valve would decrease the risk of desaturation but may not provide adequate oxygenation for patients with high levels of PEEP and FIO2. Instilling normal saline solution has the potential to compromise saturations and increases the risk of contamination.

While performing the initial assessment, the nurse notes gurgling coming from the patient's throat. The nurse examines the patient's oral cavity and sees copious amounts of saliva. Which action is the most appropriate?

Suction the patient's mouth using a rigid suction device. Rationale: A rigid suction device is used to perform oropharyngeal suctioning and remove pharyngeal secretions via the mouth. Placing the patient in the Trendelenburg position and turning him or her to the side uses gravity to help clear the airway but is not as efficient as active suctioning. Postural drainage may help loosen respiratory secretions but is not as efficient as active suctioning for oral secretions. Suctioning the nasopharynx will not remove secretions effectively from the oropharynx.

Which devices supply humidified gas to an artificial airway?

T-tube connector and tracheostomy collar Rationale:The T-tube connector and tracheostomy collar are both devices that fit an artificial airway, providing oxygen and humidification to the patient. A nasal cannula provides a patient with oxygen through the nose; however, an artificial airway bypasses the nose and mouth, and therefore, the nasal cannula is unable to provide the patient with the required oxygen and humidification. The Venturi mask provides both oxygen and humidification to patients who are breathing through their nose or mouth; thus, it is not an oxygen device used in patients with artificial airways.

Which statement regarding tracheostomy care and suctioning in the home is correct?

The patient and family should use clean technique. Rationale: In the home setting, the majority of patients and family members should use clean technique. Health care facilities use aseptic technique because there may be more virulent or pathogenic microorganisms present than in the home setting. The patient or family should not wait for a nurse to make a home visit before performing tracheostomy care and suctioning. The patient and family should have been taught the skills and demonstrated competent skill performance before the patient left the health care setting.

A patient who has been involved in a motor vehicle crash has a pleural chest tube. The water seal chamber is bubbling from right to left. What does this finding indicate?

The patient may have a pneumothorax. Rationale: The water seal acts as a one-way valve. Bubbles moving from right to left in the water seal chamber indicate an air leak in the system; therefore, the patient should be assessed for a pneumothorax. An air leak is expected when the chest tube is initially placed and the pneumothorax is evacuated, but it should not persist afterward. If an external air leak is suspected, the nurse should clamp the chest tube briefly. Bubbles still seen within the water seal chamber indicate an external air leak, and the system may need to be replaced. The water in the suction control chamber is used to create negative pressure within the pleural space. Decreasing the amount of water, and therefore the amount of suction, would not affect the bubbling within the water seal chamber.

Through teaching and return demonstration, the nurse is preparing a patient to go home with a tracheostomy. The nurse should continually develop, implement, and evaluate the teaching plan based on which element?

The patient's performance Rationale: The nurse continually develops, implements, and evaluates the teaching plan based on the patient's and family's performance. Some patients and their families learn quickly, while others need further education. Therefore, teaching should begin as soon as possible. Patients and families must have the opportunity to perform hands-on suctioning many times before discharge to develop confidence with skill performance; otherwise, arrangements to provide in-home skilled nursing should be made before discharge. Basing the patient's teaching plan on the practitioner's expectations, the nursing care plan, or the nurse's expectations is inappropriate.

An older man who has been intubated for 3 weeks has experienced numerous episodes of hypotension. Current ventilator settings are fraction of inspired oxygen, 50%; positive end-expiratory pressure (PEEP), +15 cm H2O; tidal volume, 500 ml; and a set respiratory rate of 16 breaths/min. When planning this patient's care, what is the most important factor for the nurse to consider?

This patient has an increased risk of tracheal stenosis and necrosis, which are more likely to occur because of a history of hypotension and prolonged time of intubation. Rationale: The potential complications of cuff inflation include tracheal stenosis, necrosis, tracheoesophageal fistulas, and tracheomalacia; these complications are more likely to occur in conditions that adversely affect tissue response to mucosal injury, such as hypotension. Age is not a factor in increased risk of unintentional extubation. Deflating the cuff every 4 hours is not an appropriate nursing intervention for this patient. The settings described are considered high-support ventilator settings, and they indicate that the patient is probably not ready to be weaned from mechanical ventilation.

A nurse has just removed a mediastinal chest tube from a patient. Which of the following would be the nurse's next action?

Tie the closing suture with a square knot and cover the insertion site with a dry sterile gauze dressing. Rationale:A square knot, rather than a slip knot, should be used when the closing suture is tied, and a sterile gauze dressing should be placed over the insertion site to prevent the influx of air. A petroleum gauze dressing should not be used because it can increase the risk of suture failure.

The nurse instructs the patient and family to report aspiration of food or liquid during suctioning of a tracheostomy tube to the practitioner because it may be an indication of which complication?

Tracheoesophageal fistula Rationale: Aspiration of food or liquid during tracheostomy tube suctioning may be an indication of a tracheoesophageal fistula. The nurse should instruct the patient and family regarding all signs and symptoms of a tracheoesophageal fistula, including aspiration of food or liquid during suctioning, excessive belching, and coughing when swallowing. Suctioning food and oral liquids from a tracheostomy tube is never normal and should be reported to the practitioner. The aspiration of food or liquid is not an indication of a stomal infection or a respiratory tract infection.

When suctioning a tracheostomy tube, the nurse should include which action?

Use the dominant hand to maneuver the sterile suction catheter Rationale: When suctioning a tracheostomy, the nurse's dominant hand remains sterile and maneuvers the suction catheter. The unsterile nondominant hand is used to connect the suction catheter to the connecting tubing. Suction should be applied while withdrawing the catheter and never during insertion. The suction catheter must remain sterile, so the function of the suction equipment is tested using sterile solution. The entire suction pass should not last longer than 10 to 15 seconds in order to prevent a decrease in oxygen saturation.

Which information should the nurse teach the patient about the care of tracheostomy supplies at home?

per the manufacturer's instruction