Nur1130-test2-ch21-wrong
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 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." "I just changed into my running suit; we can do my CPT now." "I received my pain medication 10 minutes ago, let's do my CPT now." "I have been coughing all morning and am barely bringing anything u
"I just finished eating my lunch, I'm ready for my CPT now."
The sigh mechanism of a ventilator may be adjusted to deliver at least 1 to 3 sighs per hour at ________ times the tidal volume if the patient is receiving assist-control ventilation.
1.5
PaO2 baseline
60 to 95 mm Hg.
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? 45 mm Hg 58 mm Hg 84 mm Hg 120 mm Hg
84 mm Hg clients with respiratory conditions are given oxygen therapy only to increase the arterial oxygen pressure (PaO2) back to the client's normal baseline, which may vary from 60 to 95 mm Hg.
ranges of water pressure identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration?
> 20 & < 25 OR 20-25
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
Which of the following is a potential complication of a low pressure in the ET cuff? Tracheal bleeding Aspiration pneumonia Tracheal ischemia Pressure necrosis
Aspiration pneumonia Explanation: Low pressure in the cuff can increase the risk for aspiration pneumonia.
Which of the following ventilator modes provides full ventilatory support by delivering a present tidal volume and respiratory rate? IMV SIMV Assist control Pressure support
Assist control Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. 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.
For a client with an endotracheal (ET) tube, which nursing action is the most important? Auscultating the lungs for bilateral breath sounds Turning the client from side to side every 2 hours Monitoring serial blood gas values every 4 hours Providing frequent oral hygiene
Auscultating the lungs for bilateral breath sounds Explanation: This ensures proper tube placement and effective oxygen delivery. Other choices are secondary to ensuring adequate oxygenation.
Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? Fluid intake for the past 24 hours Baseline arterial blood gas (ABG) levels Prior outcomes of weaning Electrocardiogram (ECG) results
Baseline arterial blood gas (ABG) levels Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical.
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
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? Anemic hypoxia Circulatory hypoxia Histotoxic hypoxia Hypoxic hypoxia
Circulatory hypoxia Given this patient's vital signs, he appears to be in shock. Circulatory hypoxia is hypoxia resulting from inadequate capillary circulation. It may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause.
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 s patient's vital signs, he appears to be in shock.
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 Consults with the physician about removing the client from the ventilator Changes the setting on the ventilator to increase breaths to 14 per minute Continues assessing the client's respiratory status frequently Contacts the respiratory therapy department to report the ventilator is malfunctioning
Continues assessing the client's respiratory status frequently Explanation: The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client. There are not sufficient data to suggest the client could be removed from the ventilator. There is no reason to increase the ventilator's setting to 14 breaths per minute or to contact respiratory therapy to report the machine is not working properly.
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 tube removal Deflating the cuff routinely Checking the cuff pressure every 6 to 8 hours Ensuring that humidified oxygen is always introduced through the tube
Deflating the cuff routinely
A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education? Have the patient lie in a supine position during the use of the spirometer. Encourage the patient to try to stop coughing during and after using the spirometer. Inform the patient that using the spirometer is not necessary if the patient is experiencing pain. Encourage the patient to take approximately 10 breaths per hour, while awake.
Encourage the patient to take approximately 10 breaths per hour, while awake.
Which type of oxygen therapy includes the administration of oxygen at pressure greater than 1 atmosphere? Low-flow systems Hyperbaric High-flow systems Transtracheal
Hyperbaric
Which type of oxygen therapy includes the administration of oxygen at pressure greater than 1 atmosphere? Low-flow systems Hyperbaric High-flow systems Transtracheal
Hyperbaric oxygen therapy is the administration of oxygen at pressures greater than 1 atmosphere. As a result, the amount of oxygen dissolved in plasma is increased, which increases oxygen levels in the tissues.
pursed-lip breathing purpose
Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing
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? Promote a more efficient and controlled ventilation and to decrease the work of breathing Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing Promote the strengthening of the patient's diaphragm Promote the patient's ability to intake oxygen
Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing..helps prevent airway collapse secondary to loss of lung elasticity in emphysema.
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. Use aerosol sprays to deodorize the client's environment after postural drainage. Perform this measure with the client once a day. Administer bronchodilators and mucolytic agents following the sequence.
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 disconnected ventilator tube An ET cuff leak A change in the oxygen concentration without resetting the oxygen level alarm
Kinking of the ventilator tubing
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Tracheostomy cleaning kit Water-seal chest drainage set-up Manual resuscitation bag Oxygen analyzer
Manual resuscitation bag The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions.
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? Measuring and documenting the drainage in the collection chamber Maintaining continuous bubbling in the water-seal chamber Keeping the collection chamber at chest level Stripping the chest tube every hour
Measuring and documenting the drainage in the collection chamber
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. Place the head of the patient's bed flat. Milk the chest tube. Disconnect the system and get another.
Notify the physician. Observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. In addition, assess the chest tube system for correctable external leaks. Notify the primary provider immediately of excessive bubbling in the water seal chamber not due to external leak
Laboratory Values-Indications for Mechanical Ventilation
PaO2 <55 mm Hg PaCO2>50 mm Hg and pH <7.32 Vital capacity <10 mL/kg Negative inspiratory force <25 cm H2O FEV1 <10 mL/kg
A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do?
Place the end of the chest tube in a container of sterile saline. Explanation: If a chest drainage system is disconnected, the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. The nurse should apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected. The nurse shouldn't clamp the chest tube because clamping increases the risk of tension pneumothorax. The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected.
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? Check for an apical pulse. Suction the client's artificial airway. Increase the oxygen percentage. Ventilate the client with a handheld mechanical ventilator.
Suction the client's artificial airway. alarm = obstruction O2 from the machine to pt
The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for: Symmetry of the client's chest expansion Tracheal cuff pressure set at 30 mm Hg Cool air humidified through the tube A scheduled time for deflation of the tracheal cuff
Symmetry of the client's chest expansion Immediately after intubation, the nurse should check for symmetry of chest expansion. This is one finding that indicates successful endotracheal placement. The tracheal cuff pressure is set between 15 and 20 mm Hg. Routine deflation of the tracheal cuff is not recommended, because the client could then aspirate secretions during the period of deflation. Warm, high, humidified air is administered through the endotracheal tube
A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to: Lay in bed with the head on a pillow. Take prescribed albuterol (Ventolin) before performing postural drainage. Perform drainage 1 hour after meals. Hold each position for 5 minutes.
Take prescribed albuterol (Ventolin) before performing postural drainage.
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.
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.) Tracheal aspiration Hypoxia Tracheal ischemia Tracheal bleeding Pressure necrosis
Tracheal ischemia Tracheal bleeding Pressure necrosis Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 15 and 20 mm Hg
Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration? Negative pressure Volume cycled Time cycled Pressure cycled
Volume cycled
Which type of ventilator has a present volume of air to be delivered with each inspiration? Negative-pressure Volume-controlled Time-cycled Pressure-cycled
Volume-controlled
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
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 Air-leak chamber Collection chamber Suction control chamber
Water-seal chamber Explanation: Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations.
After PaO2 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? a) Collection chamber b) Water-seal chamber c) Air-leak chamber d) Suction control chamber
Water-seal chamber Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest. (less)
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." Explanation: When assisting in the chest tube's removal, instruct the patient to perform a gentle Valsalva maneuver or to breathe quietly. The chest tube is then clamped and quickly removed. Simultaneously, a small bandage is applied and made airtight with petrolatum gauze covered by a 4 × 4-inch gauze pad and thoroughly covered and sealed with nonporous tape.
Hyperbaric oxygen therapy
admin of oxygen at pressures greater than 1 atmosphere. As a result, the amount of oxygen dissolved in plasma is increased, which increases oxygen levels in the tissues.
Hyperbaric oxygen therapy
administration of oxygen at pressures greater than 1 atmosphere. As a result, the amount of oxygen dissolved in plasma is increased, which increases oxygen levels in the tissues.
What detects air leaking frompleural space in drainage system.
air-leak meter
A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?
ascultation
potential complication of a low pressure in the ET cuff?
aspiration pneumonia
An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure?
bedtime -reduce secretions in client's lungs during night.
Percussion and vibration, components of chest physiotherapy, may worsen
bronchospasms;
Low-flow oxygen systems
contribute partially to inspired gas pt breathes, which means that the patient breathes some room air along with the oxygen.
client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:
cough as the cuff is being deflated. Explanation: The nurse should instruct the client to cough during cuff deflation. If the client can't cough, the nurse should perform suctioning to prevent aspiration of secretions. Because the cuff should be deflated during expiration, the client shouldn't take a deep breath as the nurse deflates the cuff. Likewise, because the cuff is reinflated during inspiration, the client shouldn't hold the breath or exhale deeply during reinflation.
A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:
cough as the cuff is being deflated. if the client can't cough, the nurse should perform suctioning to prevent aspiration of secretions. - client shouldn't take deep breath when nurse deflates the cuff. -client shouldn't hold the breath or exhale deeply during reinflation.
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.
pressure-cycled ventilator
delivers a flow of air (inspiration) until it reaches a present pressure, and then cycles off, and expiration occurs passively.
SIMV synchronized intermittent mandatory ventilation
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.
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 to prevent pneumonia
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. - prevent pneumonia. Fluctuations in the water-seal chamber are normal.
Cuff pressures should be checked
every 6 to 8 hours
Negative pressure ventilators
exert a negative pressure on the external chest.
Secretions that have mobilized (especially when suction equipment isn't available) are a contraindication
for postural drainage, part of chest physiotherapy.
A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?
hypoxia
Positive-pressure ventilators
inflate the lungs by exerting positive pressure on the airway, pushing air in, similar to a bellows mechanism, and forcing the alveoli to expand during inspiration. Expiration occurs passively. Endotracheal intubation or tracheostomy is usually necessary. These ventilators are widely used in the hospital setting and are increasingly used in the home for patients with primary lung disease.
Low-flow systems contribute partially to t
inspired gas the patient breathes, which means that the patient breathes some room air with oxygen.
Chest tube milking
is controversial and should be done only to remove blood clots that obstruct the flow of drainage.
Circulatory hypoxia
is hypoxia resulting from inadequate capillary circulation. It may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause.
Conditions that trigger the mechanical ventilator high-pressure alarm include
kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube coughing biting on the ET tube breathing is out of rhythm with the ventilator.
oral endotracheal tube Cuff pressures should be
maintained between 15 and 20 mm Hg
Measuring fluid volume intake and output is always important when a client is being
mechanically ventilated.
transtracheal oxygenation
minimal oxygenation at lower rates, making this method less expensive and more efficient.
suction control chamber provides the suction, which can be controlled to provide
negative pressure to the chest.
Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration? Nonrebreather mask Venturi mask Catheter Face tent
nonrebreather mask provides high oxygen concentration, but it is usually poorly fitting. However, if the nonrebreathing mask fits the patient snugly and both side exhalation ports have one-way valves, it is possible for the patient to receive 100% oxygen, making the nonrebreathing mask a high-flow oxygen system.
A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are
normal findings.
patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration?
partial rebreathing mask
During transtracheal oxygenation
patients achieve adequate oxygenation at lower rates, -less expensive and more efficient.
High-flow oxygen systems
patients who need constant /precise amount of O2
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
provide adequate transport of oxygen in the blood To decrease the work of breathing To reduce stress on the myocardium
IMV =intermittent mandatory ventilation
provides a combination of mechanically assisted breaths and spontaneous breaths.
Assist-control ventilation
provides full ventilator support by delivering a preset tidal volume and respiratory rate.
High-flow systems are indicated for patients
require a constant and precise amount of oxygen.
A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped? Respiratory rate of 16 breaths/minute Oxygen saturation of 93% Runs of ventricular tachycardia B/P increase from 120/74 mm Hg to 134/80 mm Hg
runs of ventricular tachycardia Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. B/P hasn't increased more than 20% over baseline
thoracotomy
surgical incision into the chest wall.
Clamping the chest tube could cause a
tension pneumothorax.
Time-cycled ventilators
terminate or control inspiration after a preset time.
collection chamber connects
the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber.
Fluctuations in the water-seal compartment are called_______ and indicate normal function of the system as ________
tidal movements / pressure in tubing changes with the client's respiration
High cuff pressure potential complication
tracheal bleeding, ischemia, and pressure necrosis.
potential complication of High cuff pressure
tracheal bleeding, ischemia, and pressure necrosis.
disconnected ventilator tube or an ET cuff leak would
trigger the low-pressure alarm.
Changing the oxygen concentration without resetting the oxygen level alarm would
trigger the oxygen alarm, not the high-pressure alarm.
Based on the PaO2 value, the nurse may adjust the
type of O2 delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, oxygen %
volume-controlled ventilation
volume of air to be delivered with each inspiration is present.
volume-cycled ventilation
volume of air to be delivered with each inspiration is present.
Negative pressure ventilators e
xert a negative pressure on the external chest.