Nursing Care: Advanced Airways and Mechanical Ventilation
The nurse is assessing the client in respiratory distress. For each clinical finding, click to specify if the finding is consistent with chronic obstructive pulmonary disease (COPD), pneumonia, and/or tension pneumothorax. Note: Each finding may support more than one disease process. Each column will have at least one response option selected.
Chronic Obstructive Pulmonary Disease: Diminished breath sounds in lower lobes Use of accessory muscles of respiration Pulse oximetry reading of 84% Pneumonia: Use of accessory muscles of respiration Temperature 101.5 °F (38.6 °C) Pulse oximetry reading of 84% Tension Pneumothorax: Deviation of the trachea Pulse oximetry reading of 84% Use of accessory muscles of respiration
Click on the words or phrases within the nurse's note that indicate the client's respiratory status has changed. Select all that apply.
HR 136 RR 34 skin is cool to touch face, chest, and arms client moaning and unresponsive to questions
Specify if the client's most recent arterial blood gas results indicate their condition has improved, declined, or is unchanged. Select one option for each finding.
Improved: pH PCO2 PO2 O2 saturation Unchanged HCO3‾ Declined:
The nurse is caring for a client with an endotracheal tube (ETT) connected to mechanical ventilation. The client was calm and appeared to be sleeping without a cough 30 minutes ago. Now the client is restless and coughing frequently. Which nursing actions are indicated or contraindicated regarding this client's situation? Select one option for each action item.
Indicated: Increase intravenous (IV) sedation medication. Assess the need for suctioning. Check endotracheal tube (ETT) placement markings. Assess oxygen saturation. Contraindicated: Insert an oropharyngeal airway. Extubate the client.
For each healthcare provider order listed, specify if it is indicated or contraindicated. Select one option for each order.
Indicated: Arterial blood gas Propofol intravenous infusion Ventilator-associated pneumonia protocol Chest x-ray Contraindicated: Full liquid diet
84-year-old with history of chronic obstructive pulmonary disease; admitted with community-acquired pneumonia 55-year-old with obstructive sleep apnea (OSA) and morbid obesity
Indication for Use: Retention of carbon dioxide Type of Airway: Indication for Use: Increased airway pressure Type of Airway: CPAP
Based on the client's current status, which actions should the nurse take to meet the needs of this client and which actions can be delegated or delayed?
Meets the Client's Needs: Gather equipment for intubation Initiate rapid response team (RRT) Stay with the client Clear the room of obstacles Prepare to hyperoxygenate with a bag-valve-mask device Can be Delegated or Delayed: Obtain informed consent Cancel dietary order for dinner
The nurse is preparing a client in respiratory distress to be intubated by colleagues on the rapid response team (RRT). Which actions should be taken by the nurse? Select all that apply.
Obtain informed consent if time permits and the client is alert or family is present. Prepare rapid-sequence induction (RSI) medications for administration. Obtain a bag-valve-mask (BVM) device. Bring intubation equipment to the bedside. Verify patency of venous access device (VAD). Initiate continuous cardiac monitoring.
The nurse is caring for a client intubated and on mechanical ventilation. Which three nursing actions reduce the client's risk for ventilator-associated pneumonia (VAP)?
Providing continuous aspiration of subglottal secretions Providing oral care every 2-4 hours Placing the client in an upright or semi-upright position
Select one answer from each drop-down list.
The nurse identifies that the client is at risk for respiratory arrest due to recent extubation and history of chronic obstructive pulmonary disease (COPD)
Select one answer from each drop-down list.
The trachea bifurcates into the right and left mainstem bronchi at a point called the carina The carina is located at the angle of Louis, which is at the level of the 4th and 5th thoracic vertebrae. The carina is highly sensitive Stimulation of this area during suctioning causes vigorous coughing
42-year-old; 8 hours after heart surgery; intubated; keeps chewing on the endotracheal tube (ETT) 39-year-old; head trauma; unresponsive with spontaneous breathing; unable to clear respiratory secretions; frequent nasotracheal suctioning
Type of Airway: oropharyngeal airway Indication for Airway: protects endotracheal tube (ETT) Type of Airway: nasopharyngeal airway Indication for Airway: protects nasal mucosa from trauma during suctioning
Indicate the parts of the airway by dragging the anatomical terms to their proper location on the image.
1. Trachea 2. Bronchi 3. Bronchioles 4. Alveoli 5. Carina
After an endotracheal tube has been placed for mechanical ventilation, which assessment of tube placement should be done first?
end tidal carbon dioxide (CO2) monitoring
The nurse is discussing bilevel positive airway pressure (BiPAP) therapy with a client and their partner. Which contraindications to BiPAP should the nurse recognize in the partner's statement? Click to specify the words or phrases that should concern the nurse regarding the use of BiPAP therapy.
panics anytime his mouth or nose is covered amyotrophic lateral sclerosis (ALS)
The nurse is caring for a client being assessed for extubation. Review the electronic health record (EHR) and then answer the question.
worsened PaO2 respiratory rate labored breathing
