PrepU 21: Respiratory Care Modalities
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 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 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 caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?
Routinely deflating the cuff
A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client.
(1) "Inhale through your nose." (2) "Slowly count to 3." (3) "Exhale slowly through pursed lips." (4) "Slowly count to 7."
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
What assessment method would the nurse use to determine the areas of the lungs that need draining?
Auscultation
The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result?
Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing
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?
Manual resuscitation bag
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.
The nurse is preparing to assist the health care provider to remove a client's chest tube. Which instruction will the nurse correctly give to the client?
"When the tube is being removed, take a deep breath"
Which is a potential complication of a low pressure in the endotracheal tube cuff?
Aspiration pneumonia
Which ventilator mode 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?
Auscultating the lungs for bilateral breath sounds
A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which oxygen delivery method would give the greatest level of inspired oxygen?
Nonrebreather mask
A client is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 28 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 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.
- Regularly assess the client's vital signs every 2 to 4 hours. - Monitor pulmonary status as directed and needed. - Encourage deep breathing exercises.
A client with emphysema informs the nurse, "The surgeon will be removing about 30% of my lung so that I will not be so short of breath and will have an improved quality of life." What surgery does the nurse understand the surgeon will perform?
A lung volume reduction
The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to:
Assess pulse and blood pressure.
The nurse is caring for a client being weaned from a mechanical ventilator. Which findings would require the weaning process to be terminated?
Blood pressure increase of 20 mm Hg from baseline
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 client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?
Oxygen toxicity
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)
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 young man incurred a spontaneous pneumothorax. The physician has just inserted a chest tube and has prescribed suction set at 20 cm of water. The nurse instills the fluid to this level in the appropriate chamber. Mark the level of fluid on the appropriate chamber of the closed drainage system.
X next to the 20 on the top left hand side
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
Which oxygen administration device has the advantage of providing a high oxygen concentration?
Nonrebreathing mask
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 being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action first?
Troubleshoot to identify the malfunction.
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
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 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?
Encourage the patient to take approximately 10 breaths per hour, while awake.
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 is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique?
It prolongs exhalation.
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
Which type of ventilator has a preset volume of air to be delivered with each inspiration?
Volume cycled