MedSurg Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated.
"I just finished eating my lunch, I'm ready for my CPT now."
The nurse is preparing to assist the health care provider with the removal of a patient's chest tube. Which of the following instructions will the nurse correctly give the patient?
"When the tube is being removed, take a deep breath, exhale, and bear down."
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?
10 to 15 seconds
Which of the following ranges of water pressure identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration?
15-20
Which of the following is a correct endotracheal tube cuff pressure?
17mmhg
The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse will notify the primary provider if drainage is _____ or greater.
50 mL/hr
The nurse is caring for a patient following a wedge resection. While the nurse is assessing the patient's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which of the following problems?
Air leak
A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for?
Anemic hypoxia Anemic hypoxia is a result of decreased effective hemoglobin concentration, which causes a decrease in the oxygen-carrying capacity of the blood. It is rarely accompanied by hypoxemia. Carbon monoxide poisoning, because it reduces the oxygen-carrying capacity of hemoglobin, produces similar effects but is not strictly anemic hypoxia, because hemoglobin levels may be normal.
A client has a sucking stab wound to the chest. Which action should the nurse take first?
Apply a dressing over the wound and tape it on three sides.
Which of the following is a potential complication of a low pressure in the ET cuff?
Aspiration pneumonia
Which of the following is a potential complication of a low pressure in the endotracheal tube (ET) cuff?
Aspiration pneumonia
A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?
Assessing the client's respiratory status, orientation, and skin color
Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate?
Assist-control Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. Intermittent mandatory ventilation (IMV) provides a combination of mechanically assisted breaths and spontaneous breaths. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths.
A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?
Auscultate the lung for adventitious sounds.
For a client with an endotracheal (ET) tube, which nursing action is the most important?
Auscultating the lungs for bilateral breath sounds
Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?
Baseline arterial blood gas (ABG) levels
A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?
By supplying a magic slate or similar device
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse
Continues assessing the client's respiratory status frequently
The nurse is transporting a patient with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse?
Cut the contaminated tip of the tube and insert a sterile connector and reattach.
The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated?
Deflating the cuff routinely
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?
Endotracheal suctioning
A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to:
Expect coughing when using the spirometer properly.
The nurse should monitor a client receiving mechanical ventilation for which of the following complications?
Gastrointestinal hemorrhage
The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply.)
Hold the breath at the end of inspiration for a few seconds. Cough frequently. Frequently evaluate progress.
The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated.
I just finished eating my lunch, I'm ready for my CPT now."
A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority?
Impaired gas exchange
The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?
Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.
A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?
Kinking of the ventilator tubing
A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply
Monitor pulmonary status as directed and needed. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises.
A young male client has muscular dystrophy. His PaO2 is 42 mm Hg with a FiO2 of 80%. Which of the following treatments would be least invasive and most appropriate for this client?
Negative-pressure ventilator
Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration?
Nonrebreather mask
The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?
PaO2
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?
Partial pressure of arterial oxygen (PaO2)
The nurse is preparing to perform tracheostomy care on a patient with a newly inserted tracheostomy tube. Which of the following actions, if preformed by the nurse, indicates the need for further review of the procedure?
Places clean tracheostomy ties, and removes soiled ties after the new ties are in place
Which of the following statements would not be considered an appropriate intervention for a patient with an ET tube?
Routine cuff deflation is recommended Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the endotracheal tube is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.
A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?
Runs of ventricular tachycardia
The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:
Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.
A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply.
Substernal pain Dyspnea Fatigue
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?
Suction the client's artificial airway.
A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to:
Take prescribed albuterol (Ventolin) before performing postural drainage.
A client with end-stage chronic obstructive pulmonary disease (COPD) requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is associated with restraint use in the client who requires BiPAP?
The client will maintain adequate oxygenation.
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?
The patient is hypoxic from suctioning.
The nurse is caring for a patient who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on which of the following?
The patient will return to the nursing unit with two chest tubes
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
The system has an air leak.
A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply.
To provide adequate transport of oxygen in the blood To decrease the work of breathing To reduce stress on the myocardium
Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means
Venturi mask
Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?
Venturi mask
Which of the following are indicators that a client is ready to be weaned from a ventilator? Select all that apply.
Vital capacity of 13 mL/kg Tidal volume of 8.5 mL/kg PaO2 of 64 mm Hg
Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration?
Volume cycled
Which type of ventilator has a present volume of air to be delivered with each inspiration?
Volume-controlled
Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:
a compromised skin graft
Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:
a compromised skin graft.
Which of the following ventilator modes provides full ventilatory support by delivering a present tidal volume and respiratory rate?
assist control
For a client with an endotracheal (ET) tube, which nursing action is the most important?
auscultate lungs for bilateral breath sounds
The nurse is caring for a patient in the ICU who is receiving mechanical ventilation. Which of the following nursing measures are implemented in an effort to reduce the patient's risk of developing ventilator-associated pneumonia (VAP)?
cleaning the pts mouth with chlorhexidine daily
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse
continues assessing the pt respiratory status frequently
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:
encourage coughing and deep breathing
A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to:
expect coughing when using the IS properly
A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client?
impaired gas exchange related to ventilator settings adjusted
Which of the following would indicate a decrease in pressure with mechanical ventilation?
increase in compliance
The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?
instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes
Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths?
intermittent mandatory ventilation
Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration?
non re breather mask
In general, chest drainage tubes are not used for the patient undergoing
pneumonectomy
The nurse is caring for a patient who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on which of the following?
pt will return with 2 chest tubes
A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as:
synchronized intermittent mandatory ventilation (SIMV)
A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by:
using the minimal-leak technique with cuff pressure less than 25 cm H2O.
Fluctuations in the ______ are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respiration
water-seal compartment
The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.)
• Decreases hypoxemia • Decreases patient anxiety • Sustains positive end expiratory pressure (PEEP)
A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mm Hg. The nurse is aware of what complications that can be caused by this pressure? (Select all that apply.)
• Pressure necrosis • Tracheal bleeding • Tracheal ischemia
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?
"Before you do the exercise, I'll give you pain medication if you need it."
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?
"Before you do the exercise, I'll give you pain medication if you need it." The nurse should assess the client's pain level before the client does incentive spirometry exercises and administer pain medication as needed. Doing so helps the client take deeper breaths and help prevents atelectasis. The client should breathe in slowly and steadily, and hold his breath for 3 seconds after inhalation. The client should start doing incentive spirometry immediately after surgery and aim to do 10 incentive spirometry breaths every hour.
Arterial blood gases should be obtained at which timeframe following the initiation of continuous mechanical ventilation?
20 min
A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?
84 mm Hg
A patient with COPD requires oxygen administration. What method of delivery does the nurse know would be best for this patient?
A Venturi mask
The nurse is assigned the care of a patient with a chest tube. The nurse should ensure that which of the following items is kept at the patient's bedside?
A bottle of sterile water
A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse
Assesses the client's tracheostomy and lung sounds every 15 minutes
A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?
Auscultation
Which of the following is an adverse reaction that would require termination of the weaning process from the ventilator?
Blood pressure increase of 20 mm Hg
The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?
Circulatory hypoxia
A patient is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this patient?
Continuous positive airway pressure
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?
ET suctioning
After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?
Effective breathing at a rate of 16 breaths/minute through the established airway
A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan?
Encourage the client's communication attempts by allowing him time to select or write words
A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client?
Impaired gas exchange related to ventilator setting adjustments
The nurse has instructed a patient on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which of the following?
Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing
Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths?
Intermittent mandatory ventilation (IMV)
Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration?
Non-rebreather mask
A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to reverse these manifestations?
Nonrebreather mask
The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?
Notify the physician.
A patient with emphysema is placed on continuous oxygen at 2 L/min at home. Why is it important for the nurse to educate the patient and family that they must have No Smoking signs placed on the doors?
Oxygen supports combustion
A patient with emphysema is placed on continuous oxygen at 2 L/min at home. Why is it important for the nurse to educate the patient and family that they must have No Smoking signs placed on the doors?
Oxygen supports combustion.
n general, chest drainage tubes are not indicated for a patient undergoing which of the following procedures?
Pneumonectomy
The client is postoperative for a total laryngectomy and has recovered from anesthesia. The client's respirations are 32 breaths/minute, blood pressure is 102/58, and pulse rate is 104 beats/minute. Pulse oximetry is 90%. The client is receiving humidified oxygen. To aid in the client's respiratory status, the nurse places the client in
Semi-Fowlers
The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:
Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.
A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?
Suction the client, withdraw residual air from the cuff, and reinflate it.
A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time?
The patient will have an insertion of a tracheostomy tube.
A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?
They help prevent cardiac arrhythmias.
Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration?
Volume cycled With volume-cycled ventilation, the volume of air to be delivered with each inspiration is present. Negative pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a present pressure, and then cycles off, and expiration occurs passively.
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?
Water-seal chamber
client has a sucking stab wound to the chest. Which action should the nurse take first?
apply a dressing and tape down 3 sides
Which of the following is a potential complication of a low pressure in the endotracheal tube (ET) cuff?
aspiration pneumonia
The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated?
deflating the cuff prior to removal
A young male client has muscular dystrophy. His PaO2 is 42 mm Hg with a FiO2 of 80%. Which of the following treatments would be least invasive and most appropriate for this client?
neg pressure ventilator This client needs ventilatory support. His PaO2 is low despite receiving a high dose of oxygen. The iron lung or drinker respiratory tank is an example of a negative-pressure ventilator. This type of ventilator is used mainly with chronic respiratory failure associated with neurological disorders, such as muscular dystrophy. It does not require intubation of the client. The most common ventilator is the positive-pressure ventilator, but this involves intubation with an endotracheal tube or tracheostomy. CPAP is used for obstructive sleep apnea. Bi-PAP is used for those with severe COPD or sleep apnea who require ventilatory assistance at night.
A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by:
using the minimal-leak technique with cuff pressure less than 25 cm H2O. To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.
The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply.)
• Hold the breath at the end of inspiration for a few seconds. • Cough frequently. • Frequently evaluate progress.
A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply.
• To reduce stress on the myocardium • To provide adequate transport of oxygen in the blood • To decrease the work of breathing
A client has been placed on a ventilator, and the spouse is visiting for the first time. The spouse begins to cry. The best statement by the nurse is
"Tell me what you are feeling."
The nurse is caring for a patient in the ICU who required emergent endotracheal (ET) intubation with mechanical ventilation. The nurse receives an order to obtain arterial blood gases (ABGs) following the procedure. The nurse recognizes that ABGs should be obtained at which timeframe following the initiation of mechanical ventilation?
20 minutes
A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply.
• Substernal pain • Dyspnea • Fatigue