NCLEX 6 RESPIRATORY MODALITIES

The nurse is preparing to perform nasotracheal suctioning on a client. The nurse places the client's bed in which position to effectively perform this procedure? Refer to figure. 1. 1 2. 2 3. 3 4. 4

1. 1

The nurse is planning to suction a client through a tracheostomy tube. Which is the amount of time for application of suction during withdrawal of the catheter? 1. 10 seconds 2. 25 seconds 3. 30 seconds 4. 35 seconds

1. 10 seconds Rationale: During suctioning, the nurse should apply suction during the withdrawal of the catheter for a period of 5 to 10 seconds. Suction applied longer than this can cause hypoxia in the client.

The nurse is caring for a client at home who has had a tracheostomy tube for several months. The nurse monitors the client for complications associated with the long-term tracheostomy and suspects tracheoesophageal fistula if which observation is noted for the client? 1. Abdominal distention 2. Purulent drainage around the tracheotomy site 3. Excessive secretions from the tracheotomy site 4. Inability to pass a suction catheter through the tracheotomy

1. Abdominal distention Rationale: Necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and the esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distention. It also can cause aspiration of gastric contents. Option 2 may indicate an infection. Option 3 may indicate the need for more frequent suctioning. Option 4 may indicate an obstruction of some sort or the presence of bronchoconstriction.

The nurse is performing tracheal suctioning on an assigned client. The nurse uses which parameter as the accurate indicator of the effectiveness of suctioning? 1. Breath sounds are now clear. 2. Suctioning is required only once a shift. 3. Oxygen saturation has increased two points. 4. Respiratory rate has gone down by four breaths per minute.

1. Breath sounds are now clear. Rationale: Clear breath sounds are the most accurate indicator of the effectiveness of a suctioning procedure. Options 3 and 4 are incorrect because they are less precise. Option 2 is incorrect because the need for suctioning may be influenced by factors other than the effectiveness of previous suctioning. These other factors could include improvement of underlying respiratory condition, fluid status, and effectiveness of cough.

The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client? 1. Lateral position 2. Low-Fowler's position 3. Semi-Fowler's position 4. Head of the bed elevation at 40 degrees

1. Lateral position Rationale: Complete lateral positioning is contraindicated for a client following pneumonectomy. Because the mediastinum is no longer held in place on both sides by lung tissue, lateral positioning may cause mediastinal shift and compression of the remaining lung. The head of the bed should be elevated.

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse should provide the client with which information about this type of tube? 1. Enables the client to speak 2. Prevents the client from speaking 3. Is necessary for mechanical ventilation 4. Prevents air from being inhaled through the tracheostomy opening

1. Enables the client to speak Rationale: A fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx; this type of tube enables the client to speak. Options 2, 3, and 4 are incorrect with regard to this type of tube.

The nurse is assisting in caring for a postoperative client who had a pneumonectomy. The nurse monitors the client for which adverse signs and symptoms indicating acute pulmonary edema? 1. Frothy sputum 2. Pain with deep breathing 3. Increased chest tube drainage 4. Respiratory rate of 20 breaths per minute

1. Frothy sputum Rationale: The client developing pulmonary edema after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. A respiratory rate of 20 breaths per minute is within normal limits. Pain with deep breathing is expected and managed with analgesics. The client with pneumonectomy usually does not have a chest tube.

A client with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. The nurse asks the health care provider whether this process should be delayed temporarily, based on administration of which medication to the client in the last hour? 1. Lorazepam (Ativan) 2. Furosemide (Lasix) 3. Digoxin (Lanoxin) 4. Metoclopramide (Reglan)

1. Lorazepam (Ativan) Rationale: Antianxiety medications (such as lorazepam) and opioid analgesics are used cautiously or withheld whenever possible in the client being weaned from a mechanical ventilator. These medications may interfere with the weaning process by suppressing the respiratory drive. The other medications do not interfere with the respiratory drive and will not affect the weaning process.

A client begins to drain small amounts of red blood from a tracheostomy tube 36 hours after a supraglottic laryngectomy. The licensed practical nurse should perform which action? 1. Notify the registered nurse. 2. Increase the frequency of suctioning. 3. Add moisture to the oxygen delivery system. 4. Document the character and amount of drainage.

1. Notify the registered nurse. Rationale: Immediately following laryngectomy, there is a small amount of bleeding from the tracheostomy, which resolves within the first few hours. Bleeding 24 hours after the surgery may be a sign of impending rupture of a vessel. The bleeding in this instance represents a potentially life-threatening situation, and the registered nurse needs to be notified, who will then contact the health care provider. Although the other options may be appropriate, they do not address the urgency of the problem. Failure to notify the health care provider in a timely fashion places the client at risk.

The nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. Which equipment should the nurse plan to have at the bedside when the client returns from surgery? 1. Obturator 2. Oral airway 3. Epinephrine 4. Tracheostomy tube with the next larger size

1. Obturator Rationale: A replacement tracheostomy tube of the same size and an obturator is kept at the bedside at all times, in case the tracheostomy tube is dislodged. In addition, a curved hemostat that could be used to hold the trachea open, if dislodgment occurs, should also be kept at the bedside. An oral airway and epinephrine would not be needed.

The nurse is assisting in caring for the client immediately after removal of the endotracheal tube following radical neck dissection. The nurse interprets that which sign experienced by the client should be reported immediately to the registered nurse (RN)? 1. Stridor 2. Lung congestion 3. Occasional pink-tinged sputum 4. Respiratory rate of 26 breaths per minute

1. Stridor Rationale: The nurse reports the presence of stridor to the RN immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. It indicates airway edema and places the client at risk for airway obstruction. A respiratory rate of 26 breaths per minute and congestion are abnormal, but additional data are needed to determine if these pose a serious problem at this time. Occasional pink-tinged sputum may be expected at this time.

The nurse is caring for a client with an endotracheal tube attached to a ventilator. The high-pressure alarm sounds on the ventilator. The nurse prepares to perform which priority nursing intervention? 1. Suction the client. 2. Check for a disconnection. 3. Notify the respiratory therapist. 4. Evaluate the tube cuff for a leak.

1. Suction the client. Rationale: When the high-pressure alarm sounds on a ventilator, it is most likely caused by an obstruction. The obstruction can be caused by the client biting on the tube, kinking of the tubing, or mucous plugging requiring suctioning. It is also important to check the tubing for the presence of any water and determine whether the client is out of rhythm with breathing with the ventilator. A disconnection or a cuff leak can result in the sounding of the low-pressure alarm. The respiratory therapist should be notified if the nurse could not determine the cause of the alarm.

The nurse has finished suctioning a client. The nurse should use which parameters to best determine the effectiveness of suctioning? 1. Client skin color (pink) 2. Breath sounds are clear 3. Client statement of comfort 4. Sao2 is 98% by pulse oximetry

2. Breath sounds are clear Rationale: The nurse evaluates the effectiveness of the suctioning procedure by auscultating breath sounds. This helps determine if the respiratory tract is clear of secretions. In addition, breath sounds must be auscultated before every suctioning procedure. Options 1, 3, and 4 do not determine the effectiveness of suctioning.

The nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. Which action should the nurse implement? 1. Continue suctioning to remove the blood. 2. Check the amount of suction pressure being applied. 3. Encourage the client to cough out the bloody secretions. 4. Remove the suction catheter from the nose and begin vigorous suctioning through the mouth.

2. Check the amount of suction pressure being applied. Rationale: The return of bloody secretions is an unexpected outcome related to suctioning. If this occurs, the nurse should first assess the client and then determine the amount of suction pressure being applied. The amount of suction pressure may need to be decreased. The nurse also needs to be sure that intermittent suction and catheter rotation are being done during suctioning. Continuing with the suctioning or vigorous suctioning through the mouth will cause increased trauma and thus increased bleeding. Suctioning is normally performed on clients who are unable to expectorate secretions. Therefore, it is unlikely that the client will be able to cough out the bloody secretions.

A client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. The nurse determines that which method for communication may be the easiest for the client? 1. Use a pad and paper. 2. Use a picture or word board. 3. Have the family interpret needs. 4. Devise a system of hand signals.

2. Use a picture or word board. Rationale: The client with a tracheostomy in place cannot speak. The nurse devises an alternative communication system with the client. Use of a picture or word board is the simplest method of communication because it requires only pointing at the word or object. A pad and pencil is an acceptable alternative but requires more client effort and more time. The use of hand signals may not be a reliable method because it may not meet all needs and is subject to misinterpretation. The family does not need to bear the burden of communicating the client's needs, and they may not understand them either.

The nurse is suctioning an adult client through a tracheostomy tube. During the procedure, the nurse notes that the client's oxygen saturation by pulse oximetry is 89%. Which action should the nurse implement? 1. Continue suctioning. 2. Call respiratory therapy. 3. Stop the suctioning procedure. 4. Obtain a smaller suction catheter.

3. Stop the suctioning procedure. Rationale: The nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. Oxygen desaturation below 90% indicates hypoxia. If hypoxia occurs during suctioning, the nurse stops the suctioning procedure. Using the 100% oxygen delivery system, the client is reoxygenated until baseline parameters are achieved. The size of the catheter should not exceed half of the size of the tracheal lumen. In adults, the standard catheter size is 12 to 14 French. Adequate catheter size facilitates efficient removal of secretions without causing hypoxemia.

The nurse is assisting a health care provider with the insertion of an endotracheal tube (ETT). The nurse should plan to ensure that which is done as a final measure to determine correct tube placement? 1. Hyperoxygenate the client. 2. Tape the tube securely in place. 3. Listen for bilateral breath sounds. 4. Verify placement by a chest x-ray.

4. Verify placement by a chest x-ray. Rationale: The final measure to determine ETT placement is to verify it by a chest x-ray. The chest x-ray shows the exact placement of the tube in the trachea, which should be above the bifurcation of the right and left mainstream bronchi. The other options are incorrect because they are completed initially after tube placement.

A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention? 1. Prepare for reintubation. 2. Call the health care provider. 3. Call the rapid response team. 4. Check the client for spontaneous breathing.

4. Check the client for spontaneous breathing. Rationale: If unexpected intubation occurs, the nurse would first check the client for airway patency, spontaneous breathing, and vital signs. The nurse would remain with the client, call for assistance from the registered nurse, and prepare for reintubation. There are no data in the question to indicate that a code needs to be called.

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs? 1. Suctioning is required frequently. 2. Aspiration of gastric contents occurs when suctioning. 3. The client's skin and mucous membranes are light pink. 4. Excessive secretions are suctioned from a tracheostomy.

2. Aspiration of gastric contents occurs when suctioning. Rationale: Necrosis of the tracheal wall in a client with a tracheostomy can lead to an artificial opening between the posterior trachea and esophagus. This problem is called tracheoesophageal fistula. The fistula allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 3, and 4 are not signs of this complication.

The nurse is monitoring the respiratory status of a client following insertion of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problem? 1. Fever 2. Epilepsy 3. Hypotension 4. Respiratory failure

3. Hypotension Rationale: Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings from impaired peripheral perfusion. Fever and epilepsy would not affect the accuracy of measurement. Respiratory failure also would not affect the accuracy of measurement, although the readings may be abnormally low.

The nurse is preparing to suction an adult client through the client's tracheostomy tube. Which interventions should the nurse perform for this procedure? Select all that apply. 1. Apply suction for up to 10 to 15 seconds. 2. Hyperoxygenate the client before suctioning. 3. Set the wall suction unit pressure at 160 mm Hg. 4. Apply suction while gently inserting the catheter. 5. Apply intermittent suction while rotating and withdrawing the catheter. 6. Advance the catheter until resistance is met and then pull the catheter back 1 cm.

2. Hyperoxygenate the client before suctioning. 5. Apply intermittent suction while rotating and withdrawing the catheter. 6. Advance the catheter until resistance is met and then pull the catheter back 1 cm. Rationale: The nurse should hyperoxygenate the client with a resuscitator bag/Ambu-bag connected to an oxygen source before suctioning because suction depletes the client's oxygen supply (option 2). Apply intermittent suction while rotating and withdrawing the catheter NOT while inserting (option 5). The catheter should be inserted gently until resistance is met or the client coughs, then pulled back 1 cm or ½ inch. Intermittent suction is applied while rotating and withdrawing the catheter (option 6). Option 1 is incorrect because Intermittent suction is applied while rotating the catheter for NO MORE 10 seconds. Option 3 is incorrect because wall suction should be set to 80 to 120 mm Hg. Pressure set at a higher level can cause trauma to respiratory tract tissues. Strict asepsis needs to be maintained, and the nurse would wear sterile gloves to perform this procedure. Option 4 Suction is never applied when inserting the catheter because it will deplete oxygen and can traumatize tissues.

The nurse is assisting in caring for a client with a newly inserted tracheostomy. The nurse notes documentation of an airway problem because of thick respiratory secretions. The nurse should monitor for which item as the best indicator of an adequate respiratory status? 1. Oxygen saturation of 89% 2. Respiratory rate of 18 breaths per minute 3. Moderate amounts of tracheobronchial secretions 4. Small to moderate amounts of frank blood suctioned from the tube

2. Respiratory rate of 18 breaths per minute Rationale: An airway problem could occur following tracheostomy from excessive secretions, bleeding into the trachea, restricted lung expansion caused by immobility, or concurrent respiratory conditions. The respiratory rate of 18 breaths per minute is well within the normal range of 14 to 20 breaths per minute. An oxygen saturation of 89% is less than optimal.

The nurse is suctioning a client through a tracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action? 1. Notify the registered nurse immediately. 2. Stop the procedure and oxygenate the client. 3. Continue to suction the client at a quicker pace. 4. Ensure that the suction is limited to 15 seconds.

2. Stop the procedure and oxygenate the client. Rationale: During suctioning the nurse should monitor the client closely for complications including hypoxemia, drop in heart rate due to vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If complications develop, especially cardiac irregularities, the nurse should stop the procedure and oxygenate the client.

The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. Which initial action should the nurse take? 1. Administer oxygen. 2. Ventilate the client manually. 3. Check the client's vital signs. 4. Start cardiopulmonary resuscitation (CPR).

2. Ventilate the client manually. Rationale: If an alarm is sounding at any time and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and a manual resuscitation device is used to support respirations until the problem can be corrected. Although oxygen is helpful, it will not provide ventilation to the client. Checking vital signs is not the initial action. There is no reason to begin CPR.

The low-exhaled volume (low-pressure) alarm sounds on a ventilator. The nurse rushes to the client's room and checks the client to determine the cause of the alarm but is unable to do so. Which would be the next immediate nursing action? 1. Call the rapid response team overhead. 2. Ventilate the client with a resuscitation bag. 3. Call the respiratory therapist to the bedside. 4. Call the client's health care provider to the bedside.

2. Ventilate the client with a resuscitation bag. Rationale: Mechanical ventilators have alarm systems that warn the nurse of a problem with either the client or the ventilator. Alarm systems must be activated and functional at all times. The nurse must recognize an emergency and intervene promptly so that complications are prevented. If the cause of an alarm cannot be determined, the nurse ventilates the client manually with a resuscitation bag until the problem is corrected by a second nurse, the respiratory therapist, or health care provider. The nurse also notifies the registered nurse (RN) of the occurrence and obtains assistance from the RN.

The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made? 1. Skin color becomes cyanotic. 2. Secretions are becoming bloody. 3. Coughing occurs with suctioning. 4. Heart rate decreases from 78 to 54 beats/minute.

3. Coughing occurs with suctioning. Rationale: Coughing is a normal response to suctioning for the client with an intact cough reflex, and it is not an indication that the client is not tolerating the procedure. The client should be encouraged to cough to help with removal of secretions from the lungs. The nurse should monitor for the adverse effects of suctioning, which include cyanosis (pulse oximetry falls below 90% or 5% from baseline), excessively rapid or slow heart rate (a 20 beat/minute change), or the sudden development of bloody secretions. If they occur, the nurse stops suctioning, administers oxygen as appropriate, and reports these signs to the health care provider immediately.

The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made? 1. Skin color becomes cyanotic. 2. Secretions are becoming bloody. 3. Coughing occurs with suctioning. 4. Heart rate decreases from 78 to 54 beats per minute.

3. Coughing occurs with suctioning. Rationale: The nurse monitors for adverse effects of suctioning, which include cyanosis, excessively rapid or slow heart rate, or the sudden development of bloody secretions. If they occur, the nurse stops suctioning and reports these signs to the health care provider immediately. Coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that the client cannot tolerate the procedure.

A client with no history of respiratory disease is admitted to the hospital with respiratory failure. The nurse reviews the arterial blood gas reports for which results that are consistent with this disorder? 1. Pao2 58 mm Hg, Paco2 32 mm Hg 2. Pao2 60 mm Hg, Paco2 45 mm Hg 3. Pao2 49 mm Hg, Paco2 52 mm Hg 4. Pao2 73 mm Hg, Paco2 62 mm Hg

3. Pao2 49 mm Hg, Paco2 52 mm Hg Rationale: Respiratory failure is described as a Pao2 of 50 mm Hg or less, and a Paco2 of 50 mm Hg or greater in a client with no history of respiratory disease. In a client with a history of respiratory disorder with hypercapnia, Paco2 elevations of 5 mm Hg or more from the client's baseline is considered diagnostic.

The nurse is assisting in caring for a client with a tracheal tube attached to a ventilator when the high-pressure alarm sounds. The nurse checks the client and system for which most likely cause? 1. Tracheal tube cuff leak 2. Loose connection in the system 3. Disconnection from the ventilator 4. Accumulation of secretions in the client's lungs

4. Accumulation of secretions in the client's lungs Rationale: When the high-pressure alarm sounds on a ventilator, it is most likely due to an obstruction. The obstruction can be caused by the client bending the tube, kinking of the tubing, or mucus in the lungs that requires suctioning. It is also important to assess the tubing for the presence of any water and determine if the client is out of rhythm with breathing with the ventilator. The incorrect options list items that may be responsible for a low-pressure alarm on the ventilator.

The nurse is suctioning a client through a tracheostomy tube. During the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. The nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. What is the nurse's priority response? 1. Call a code. 2. Administer a bronchodilator. 3. Contact the health care provider. 4. Disconnect the suction source from the catheter.

4. Disconnect the suction source from the catheter. Rationale: The inability to remove a suction catheter is a critical situation. This finding, along with the client's symptoms presented in the question, indicates the presence of bronchospasm and bronchoconstriction. The nurse would immediately disconnect the suction source from the catheter but leave the catheter in the trachea. The nurse would then connect the oxygen source to the catheter. The nurse also notifies the registered nurse, who then notifies the health care provider. The health care provider will most likely prescribe an inhaled bronchodilator. The nurse also prepares for emergency resuscitation if this situation occurs during suctioning.

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which action should the nurse take? 1. Notify the Rapid Response Team. 2. Finish the suctioning as quickly as possible. 3. Contact the respiratory department to suction the client. 4. Discontinue suctioning until the client is stabilized and monitor vital signs.

4. Discontinue suctioning until the client is stabilized and monitor vital signs. Rationale: If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. The nurse would also notify the registered nurse. It is also important to monitor the vital signs and the pulse oximetry. If the client's condition continues to deteriorate, then the respiratory department and health care provider may need to be notified. There is no data in the question that indicates that the rapid response team needs to be notified.

The nurse is determining the need for suctioning in a client with an endotracheal tube (ETT) attached to a mechanical ventilator. Which observation by the nurse is inconsistent with the need for suctioning? 1. Restlessness 2. Gurgling sounds with respiration 3. Presence of congestion in the lungs 4. Low peak inspiratory pressure on the ventilator

4. Low peak inspiratory pressure on the ventilator Rationale: Indications for suctioning include moist, wet respirations; restlessness; congestion on auscultation of the lungs; visible mucus bubbling in the ETT; increased pulse and respiratory rates; and increased peak inspiratory pressures on the ventilator. A low peak inspiratory pressure would indicate a leak in the mechanical ventilation system.

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated, when the client becomes restless and tachycardic. Which action should the nurse take? 1. Notify the health care provider as soon as possible. 2. Contact the respiratory department to suction the client. 3. Hyperoxygenate and hyperventilate the client with an Ambu bag and resuction. 4. Monitor vital signs and discontinue attempts at suctioning until the client is stabilized.

4. Monitor vital signs and discontinue attempts at suctioning until the client is stabilized. Rationale: If a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm while suctioning, the nurse must discontinue suctioning attempts until the client is stabilized. It is also important to monitor vital signs and pulse oximetry and preoxygenate the client for any repeated suctioning attempts. If the client's condition continues to deteriorate, then the respiratory department and health care provider may need to be notified.

The nurse is reviewing the arterial blood gas results of an assigned client. Which arterial blood gases indicate metabolic alkalosis? 1. pH of 7.35, Pco2 of 50 mm Hg, HCO3- of 32 mEq/L 2. pH of 7.45, Pco2 of 35 mm Hg, HCO3- of 22 mEq/L 3. pH of 7.38, Pco2 of 45 mm Hg, HCO3- of 32 mEq/L 4. pH of 7.48, Pco2 of 40 mm Hg, HCO3- of 36 mEq/L

4. pH of 7.48, Pco2 of 40 mm Hg, HCO3- of 36 mEq/L Rationale: In metabolic alkalosis, the pH is elevated along with the bicarbonate level. Option 4 is the only option that reflects these values.