prepU respiratory

A client in the ICU has had an endotracheal tube in place for 3 weeks. The health care provider has ordered that a tracheostomy tube be placed. The client's family wants to know why the endotracheal tube cannot be left in place. What would be the nurse's best response? "Long-term use of an endotracheal tube diminishes the normal breathing reflex." "The physician may feel that mechanical ventilation will have to be used long-term." "It is much harder to breathe through an endotracheal tube than a tracheostomy." "When an endotracheal tube is left in too long it can damage the lining of the windpipe."

"When an endotracheal tube is left in too long it can damage the lining of the windpipe." Explanation: Endotracheal intubation may be used for no longer than 2 to 3 weeks, by which time a tracheostomy must be considered to decrease irritation of and, trauma to, the tracheal lining, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing. The need for long-term ventilation would not be the primary rationale for this change in treatment. Endotracheal tubes do not diminish the breathing reflex.

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 is explosive. Oxygen is combustible. Oxygen prevents the dispersion of smoke particles. Oxygen supports combustion.

Oxygen supports combustion. Explanation: Because oxygen supports combustion, there is always a danger of fire when it is used. It is important to post "No Smoking" signs when oxygen is in use, particularly in facilities that are not smoke free.

A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should: raise the arm on the side of the client's body on which the physician will perform the thoracentesis. assist the client to a sitting position on the edge of the bed, leaning over the bedside table. place the client supine in the bed, which is flat. raise the head of the bed to a high Fowler's position.

assist the client to a sitting position on the edge of the bed, leaning over the bedside table. Explanation: A physician usually performs a thoracentesis when the client is sitting in a chair or on the edge of the bed, with the legs supported and the arms folded and resting on a pillow or on the bedside table. Raising an arm, lying supine, or raising the head of the bed won't allow the physician to easily access the thoracic cavity.

A nurse is developing the plan of care for a client who has just received a tracheostomy. The nurse would include interventions to prevent which early postoperative complication? Select all that apply. air embolism pneumothorax tracheoesophageal fistula innominate artery rupture bleeding

bleeding pneumothorax air embolism Explanation: Postoperative complications may occur early or late in the course of tracheostomy tube management. Early complications include bleeding, pneumothorax, air embolism, aspiration, subcutaneous or mediastinal emphysema, recurrent laryngeal nerve damage, and posterior tracheal wall penetration. Long-term complications include airway obstruction from accumulation of secretions or protrusion of the cuff over the opening of the tube; infection; rupture of the innominate artery; dysphagia; tracheoesophageal fistula, tracheal dilation; and tracheal ischemia and necrosis. Tracheal stenosis may develop after the tube is removed.

A nurse is examining a client's chest. During the exam, the nurse palpates what feels like bubbles under the client's chest muscles. Which term would the nurse use when documenting this finding? wheeze crepitus crackles rhonchi

crepitus Explanation: Crepitus or subcutaneous emphysema is indicated by the presence of air bubbles in the subcutaneous tissues or underlying muscle; upon palpation, the sensation of bubbles under the fingers can be felt and, occasionally, crackling can be heard. Crackles, rhonchi, and wheezes are adventitious breath sounds heard on auscultation.

During assessment of the respiratory system, the nurse inspects and palpates the trachea in order to assess: color of the mucous membranes. deviation from the midline. evidence of exudate. evidence of muscle weakness.

deviation from the midline. Explanation: During a physical examination, the nurse must inspect and gently palpate the trachea to assess for placement and deviation from the midline. The nurse examines the posterior pharynx and tonsils with a tongue blade and light and notes any evidence of swelling, inflammation, or exudate; or changes in color of the mucous membranes. The nurse also examines the anterior, posterior, and lateral chest walls for any evidence of muscle weakness.

A client has been newly diagnosed with emphysema. The nurse should explain to the client that by definition, ventilation: provides a blood supply to the lungs. is breathing air in and out of the lungs. helps people who cannot breathe on their own. is when the body changes oxygen into CO2.

is breathing air in and out of the lungs. Explanation: Ventilation is the actual movement of air in and out of the respiratory tract. Diffusion is the exchange of oxygen and CO2 through the alveolar-capillary membrane. Pulmonary perfusion refers to the provision of blood supply to the lungs. A mechanical ventilator assists patients who are unable to breathe on their own.

Arterial blood gas analysis would reveal which value related to acute respiratory failure? PaCO2 32 mm Hg PaO2 80 mm Hg pH 7.35 pH 7.28

pH 7.28 Explanation: Acute respiratory failure is defined as a decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH less than 7.35.

A 64-year-old patient and his wife have presented to their primary care provider. The patient's wife has prompted her husband to seek care because she is worried about his apneic episodes and loud snoring. The husband had earlier undergone a diagnostic workup for obstructive sleep apnea (OSA) and been diagnosed with the disease but is not motivated to treat his health problem. How can the nurse at the clinic best characterize the risks of OSA? "People with sleep apnea are much more susceptible to infections in their sinuses and throat." "Sleep apnea has actually been identified as a risk factor for throat cancer." "Without treatment, your sleep apnea could progress to chronic obstructive lung disease." "Sleep apnea actually increases your risk of having a stroke or heart attack."

"Sleep apnea actually increases your risk of having a stroke or heart attack." Explanation: OSA is associated with myocardial infarction and stroke, but it is not known to contribute to chronic obstructive lung disease, infections, or cancer.

Which hollow tube transports air from the laryngeal pharynx to the bronchi? bronchioles pharynx larynx trachea

trachea Explanation: The trachea is a hollow tube composed of smooth muscle and supported by C-shaped cartilage. The trachea transports air from the laryngeal pharynx to the bronchi and lungs. This is a cartilaginous framework between the pharynx and trachea that produces sound. The bronchioles are smaller subdivisions of bronchi within the lungs. The pharynx, or throat, carries air from the nose to the larynx and food from the mouth to the esophagus.

A client is scheduled for endotracheal intubation prior to surgery. What can the nurse tell this client about an endotracheal tube? "The ET tube will maintain your airway while you're under anesthesia." "The ET tube will be inserted through an opening in your trachea." "The ET tube will be connected to a negative-pressure ventilator." "The ET tube will remain in place for at least a day postsurgery."

"The ET tube will maintain your airway while you're under anesthesia." Explanation: An endotracheal tube provides a patent airway for clients who cannot maintain an adequate airway on their own. Tracheostomy tubes are inserted into a surgical opening in the trachea, called a tracheotomy. Clients receiving endotracheal intubation for the purpose of general anesthesia should not require long-term placement of the ET tube. Positive-pressure ventilators require intubation and are used for clients who are under general anesthesia. They are also used for clients with acute respiratory failure, primary lung disease, or who are comatose.

What would the critical care nurse recognize as a condition that may indicate a client's need to have a tracheostomy? A client exhibits symptoms of dyspnea. A client has a respiratory rate of 10 breaths per minute. A client requires permanent ventilation. A client has respiratory acidosis.

A client requires permanent ventilation. Explanation: A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed client. Indications for a tracheostomy do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory acidosis.

A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4" (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate? The ET tube must be pulled back. A disease process is present. The ET tube must be advanced. The X-ray is inconclusive.

A disease process is present. Explanation: This X-ray suggests tuberculosis. An ET tube that's 3/4" above the carina is at an adequate level in the trachea. There's no need to advance it or pull it back.

The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from? A catheter in the arm vein The pleural surfaces The trachea and bronchi A puncture at the radial artery

A puncture at the radial artery Explanation: ABGs determine the blood's pH, oxygen-carrying capacity, levels of oxygen, CO2, and bicarbonate ion. Blood gas samples are obtained through an arterial puncture at the radial, brachial, or femoral artery. A client also may have an indwelling arterial catheter from which arterial samples are obtained. Blood gas samples are not obtained from the pleural surfaces or trachea and bronchi.

A patient with chest trauma is admitted to the ICU. The nurse notes the patient's chest and neck are swollen and there is a crackling sensation when palpated. The nurse knows the patient has subcutaneous emphysema. If this condition becomes severe, what treatment is most likely indicated? A feeding tube A chest tube A tracheostomy An endotracheal tube

A tracheostomy Explanation: In severe cases in which there is widespread subcutaneous emphysema, a tracheostomy is indicated if airway patency is threatened by pressure of the trapped air on the trachea.

The nurse is mentoring a new graduate nurse and the two are caring for a client with a new tracheostomy. The new graduate nurse asks what the complications of tracheostomy are. Which complication(s) would the nurse identify for the new nurse? Select all that apply. Infection Absence of secretions Tracheal stenosis Injury to the laryngeal nerve Aspiration

Aspiration Infection Injury to the laryngeal nerve The long-term and short-term complications of tracheostomy include infection, bleeding, airway obstruction resulting from hardened secretions, aspiration, injury to the laryngeal nerve, erosion of the trachea, fistula formation between the esophagus and trachea, and penetration of the posterior tracheal wall. Tracheal stenosis may develop after the tube is removed.

A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? Auscultate breath sounds bilaterally every 4 hours. Encourage the client to deep-breathe and cough every 2 hours. Instruct the client to breathe into a paper bag. Administer oxygen by nasal cannula as ordered.

Administer oxygen by nasal cannula as ordered. Explanation: When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client re-inhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation.

A nonverbal client has just finished undergoing a bronchoscopy procedure and writes that he want to eat lunch now. Which intervention is necessary for the nurse to complete at this time? Assess for bowel sounds. Call dietary services to send the client's tray now. Perform mouth care. Assess for a cough reflex.

Assess for a cough reflex. Explanation: Before a bronchoscopy procedure, the nurse will administer preoperative medications, usually atropine and a sedative. These are prescribed to inhibit vagal stimulation, suppress the cough reflex, sedate the client, and relieve anxiety. After the procedure, it is important that the client take nothing by moth until the cough reflex returns. This is because the preoperative medication impairs the protective laryngeal reflex and swallowing for several hours. Once the client demonstrates a cough reflex or the nurse positively assesses one, then the nurse may offer ice chips and fluids.

A client who is intubated for mechanical ventilation has met the criteria for weaning. Which additional assessment findings indicate to the nurse that the client is eligible for a T-piece? Select all that apply. Breathing without difficulty Awake and alert Cough reflex intact Suctioned every 2 hours Gag reflex intact

Awake and alert Gag reflex intact Cough reflex intact Breathing without difficulty Respiratory weaning, the process of withdrawing the client from dependence on the ventilator, occurs in stages. Weaning from mechanical ventilation is performed at the earliest possible time according to client safety. Weaning is started when the client is physiologically and hemodynamically stable, demonstrates spontaneous breathing capability, is recovering from the acute stage of medical and surgical problems, and when the cause of respiratory failure is sufficiently reversed. Weaning through the use of a T-piece is conducted by disconnecting the client from the ventilator so that the client performs all the work of breathing. This method of weaning is used when the client is awake and alert, has intact gag and cough reflexes, and is breathing without difficulty. The frequency of suctioning is not among the criteria used to determine if a client is eligible for weaning with a T-piece.

If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment? Left lower lobe Posterior bronchioles Anterior bronchioles Bilateral lower lobes

Bilateral lower lobes Explanation: Crackles are secondary to fluid in the alveoli and create a soft, discontinuous popping sound. Because fluid creates these adventitious sounds, the principle of gravity will remind the nurse to focus the assessment on the lower portion of the thorax or the lower lobes of the lungs.

Which is a deformity of the chest that occurs as a result of overinflation of the lungs? Funnel chest Kyphoscoliosis Barrel chest Pigeon chest

Barrel chest Explanation: A barrel chest occurs as a result of overinflation of the lungs. The anteroposterior diameter of the thorax increases. Funnel chest occurs when a depression occurs in the lower portion of the sternum, which may result in murmurs. Pigeon chest occurs as a result of displacement of the sternum, resulting in an increase in the anteroposterior diameter. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax.

The nurse is caring for a client with an endotracheal tube who is on a ventilator. When assessing the client, the nurse knows to maintain what cuff pressure to maintain appropriate pressure on the tracheal wall? Between 20 and 25 mm Hg Between 15 and 20 mm Hg Between 25 and 30 mm Hg Between 10 and 15 mm Hg

Between 20 and 25 mm Hg Explanation: Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 20 and 25 mm Hg.

A client presents to the emergency department with fluid overload. The nurse is concerned about fluid accumulation in the lungs. On which of the following areas would the nurse focus the lung assessment? Bilateral lower lobes Posterior bronchioles Right lower lobe Anterior bronchial tree

Bilateral lower lobes Explanation: Assessment of the anterior and posterior lungs is part of the nurse's routine evaluation. Fluid overload should be monitored for accumulation in the lungs. Dependent areas must be assessed for breath sounds. The bases of the lungs are considered dependent areas. Fluid in the lungs will usually produce the adventitious sounds of crackles, most frequently auscultated in the bilateral bases of the lungs.

A patient has been brought to the emergency department (ED) by the paramedics. The patient is suspected of having acute respiratory distress syndrome (ARDS). What action should the nurse anticipate? Setting up oxygen at 3 LPM by nasal prongs Consulting physiotherapy Preparing to assist with intubating the patient Setting up a nebulizer

Correct response: Preparing to assist with intubating the patient Explanation: A patient who has ARDS usually requires mechanical ventilation with a higher than normal airway pressure. While oxygen, nebulizer, and physiotherapy will be used at various stages of the treatment of ARDS, the priority is to secure the airway.

What client would be most in need of an endotracheal tube? Comatose clients Ambulatory clients Older adult clients A client status post tonsillectomy

Comatose clients Explanation: Examples include those with respiratory difficulty, comatose clients, those undergoing general anesthesia, and clients with extensive edema of upper airway passages.

Which term refers to lung tissue that has become more solid in nature as a result of a collapse of alveoli or an infectious process? Consolidation Atelectasis Bronchiectasis Empyema

Consolidation Explanation: Consolidation occurs during an infectious process such as pneumonia. Atelectasis refers to the collapse or airless condition of the alveoli caused by hypoventilation, obstruction to the airways, or compression. Bronchiectasis refers to the chronic dilation of a bronchi or bronchi in which the dilated airway becomes saccular and a medium for chronic infection. Empyema refers to accumulation of purulent material in the pleural space.

The nurse is completing a client's health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases? "Have you ever lived in an area that has high levels of air pollution?" "Does anyone in your family have any form of lung disease?" "Do you currently smoke, or have you ever smoked?" "Have you ever been employed in a factory, smelter, or mill?"

Correct response: "Do you currently smoke, or have you ever smoked?" Explanation: Smoking is the single most important contributor to lung disease, exceeds the significance of environmental, occupational, and genetic factors.

A client appears to be breathing faster than during the last assessment. Which of the following actions should the nurse perform? Assess the radial pulse. Count the rate of respirations. Inquire if there have been any stressful visitors. Assist the client to lie down.

Count the rate of respirations. Explanation: Observing the rate and depth of respiration is an important aspect of a nursing assessment. The normal adult resting respiratory rate is 12 to 18 breaths per minute. Tachypnea is rapid breathing with a rate greater than 24 breaths per minute. An increase in the rate of respirations needs further investigation and must be reported.

The nurse is aware that the clinical manifestations of atelectasis are correlated to the severity of the affected collapse. Which of the following indications are consistent with a smaller, affected area? Select all that apply. Egophony Trachea deviation toward the ateliotic area Decreased tactile fremitus Decreased breath sounds Crackles Asymmetry of the chest

Crackles Decreased breath sounds Decreased tactile fremitus For a small atelectatic area, findings include crackles, decreased breath sounds, and decreased tactile fremitus over the affected lung area(s). For a large atelectatic area, findings include trachea deviation toward the atelectatic area, decreased fremitus, bronchial breath sounds, egophony (secondary to lobar or lung collapse), and asymmetry of the chest.

The nurse working on a gerontology unit admits a 77-year-old with recent shortness of breath. The nurse knows that the amount of respiratory dead space increases with age. What do these changes result in? Decreased diffusion capacity for oxygen Decreased shunting of blood Increased diffusion of gases Increased ventilation

Decreased diffusion capacity for oxygen Explanation: The amount of respiratory dead space increases with age. These changes result in a decreased diffusion capacity for oxygen with increasing age, producing lower oxygen levels in the arterial circulation. Shunting does not typically decrease and ventilation does not increase.

The nurse is receiving shift report about a patient who has a tracheostomy. The nurse learns that the patient was suctioned seven times during the past shift and has questioned the necessity of such frequent suctioning. Why is it important not to perform unnecessary tracheal suctioning? Frequent suctioning is a risk factor for respiratory alkalosis. Frequent suctioning inhibits the patient's existing cough reflex. Excessive suctioning produces "rebound" production of secretions. Excessive suctioning can result in bronchospasm.

Excessive suctioning can result in bronchospasm. Explanation: Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa. It does not inhibit the cough reflex, produce rebound secretions, or contribute to acid-base imbalances.

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? Promote the client's ability to take in oxygen Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Promote the strengthening of the client's diaphragm Promote more efficient and controlled ventilation and to decrease the work of breathing

Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Explanation: Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? Increase oxygen administration Schedule the client for pulmonary surgery Intubate the client and control breathing with mechanical ventilation Administer a large dose of furosemide (Lasix) IVP stat

Intubate the client and control breathing with mechanical ventilation Explanation: A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.

A critical care nurse is caring for a patient with an endotracheal tube who is on a ventilator. The nurse knows that meticulous management of this patient's needs is necessary. What is the rationale for this? Increasing the patient's lung compliance Preventing the need for suctioning Maintaining a patent airway Decreasing the patient's time on the ventilator

Maintaining a patent airway Explanation: Maintaining a patent (open) airway is achieved through meticulous airway management, whether in an emergency situation, such as airway obstruction, or in long-term management, as in caring for a patient with an endotracheal or a tracheostomy tube.

Which term is used to describe the inability to breathe easily except in an upright position? Hypoxemia Dyspnea Orthopnea Hemoptysis

Orthopnea Explanation: Clients with orthopnea are placed in a high Fowler's position to facilitate breathing. Dyspnea refers to labored breathing or shortness of breath. Hemoptysis refers to expectoration of blood from the respiratory tract. Hypoxemia refers to low oxygen levels in the blood.

A patient describes his chest pain as knife-like on inspiration. Which of the following is the most likely diagnosis? Pleurisy A lung infection Bacterial pneumonia Bronchogenic carcinoma

Pleurisy Explanation: Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration. Some patients describe the pain as being "stabbed by a knife." Chest pain associated with the other conditions may be dull, aching, and persistent.

A client suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. Which intervention may improve oxygenation and provide comfort for the client? Position the client in the prone position Force fluids for the next 24 hours Assist the client into a chair Administer small doses of pancuronium

Position the client in the prone position Explanation: The patient is extremely anxious and agitated because of the increasing hypoxemia and dyspnea. It is important to reduce the patient's anxiety because anxiety increases oxygen expenditure. Oxygenation in patients with ARDS is sometimes improved in the prone position. Rest is essential to limit oxygen consumption and reduce oxygen needs.

The nurse is caring for a client who is intubated for mechanical ventilation. Which intervention(s) will the nurse implement to reduce the client's risk of injury? Select all that apply. Provide oral hygiene. Assess for a cuff leak. Reduce pulling on ventilator tubing. Position with head above the stomach level. Monitor cuff pressure every 8 hours.

Provide oral hygiene. Assess for a cuff leak. Reduce pulling on ventilator tubing. Monitor cuff pressure every 8 hours. Position with head above the stomach level. Maintaining the endotracheal or tracheostomy tube is an essential part of airway management. Oral hygiene is provided frequently because the oral cavity is a primary source of lung contamination in the client who is intubated. Assessing for a leak from the cuff of the endotracheal tube needs to be done at the same time as providing other respiratory care. Ventilator tubing should be positioned so that there is minimal pulling or distortion of the tube in the trachea which reduces the risk of trauma to the trachea. Cuff pressure is monitored every 8 hours to maintain the pressure at 20 to 25 mm Hg. The head of the bed should be higher than the stomach to reduce the risk of aspiration.

The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should the nurse perform first? Pulse oximetry Pulmonary function test Chest x-ray Arterial blood gases

Pulse oximetry Explanation: Pulse oximetry is a noninvasive method to determine arterial oxygen saturation. Normal values are 95% and above. Using this diagnostic test first provides rapid information of the client's respiratory system. All other options vary in amount of time and patient participation in determining further information regarding the respiratory system.

The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client? Watery sputum Masses in pleural space Respiratory distress Loss of consciousness

Respiratory distress Explanation: After invasive procedures, the nurse must carefully check for signs of respiratory distress and blood-streaked sputum. Masses in the pleural space are a condition that affects fremitus. General examination of overall health and condition includes assessing the consciousness of a client.

A client being mechanically ventilated through an endotracheal tube for 14 days has a percutaneous tracheostomy inserted at the bedside. Which interventions will the nurse anticipate will be included in the client's plan of care? Select all that apply. Check cuff pressure every 8 hours Monitor oxygen saturation Use clean technique for tracheostomy care Suction as necessary Change tape and dressing as needed

Suction as necessary Monitor oxygen saturation Check cuff pressure every 8 hours Change tape and dressing as needed Endotracheal intubation may be used for no longer than 14 to 21 days, by which time a tracheostomy must be considered to decrease irritation of and trauma to the tracheal lining, and to reduce the incidence of vocal cord paralysis. For a client who is intubated and mechanically ventilated, a newer surgical technique referred to as a percutaneous tracheostomy can be performed at the bedside with the use of local anesthesia and sedation and analgesia. Once the tracheostomy is placed, nursing care includes suctioning as necessary, monitoring oxygen saturation, checking cuff pressure every 8 hours, and changing the tape and dressing as needed. Care of the tracheostomy is completed using sterile and not clean technique.

The nurse caring for a client with an endotracheal tube recognizes several disadvantages of an endotracheal tube. What would the nurse recognize as a disadvantage of endotracheal tubes? Daily arterial blood gases (ABGs) are necessary. Cognition is decreased. Slight tracheal bleeding is anticipated. The cough reflex is depressed.

The cough reflex is depressed. Explanation: There are several disadvantages of an endotracheal tube. Disadvantages include suppression of the client's cough reflex, thickening of secretions, and depressed swallowing reflexes. Ulceration and stricture of the larynx or trachea may develop, but bleeding is not an expected finding. The tube should not influence cognition and daily ABGs are not always required.

Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? Tidal volume Functional residual capacity Vital capacity Maximal voluntary ventilation

Tidal volume Explanation: Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.

The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS? Increased PaO2 Unresponsive arterial hypoxemia Tachypnea Diminished alveolar dilation

Unresponsive arterial hypoxemia Explanation: Acute respiratory distress syndrome (ARDS) can be thought of as a spectrum of disease, from its milder form (acute lung injury) to its most severe form of fulminate, life-threatening ARDS. This clinical syndrome is characterized by a severe inflammatory process causing diffuse alveolar damage that results in sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP, and the absence of an elevated left atrial pressure.

The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as sibilant wheezes. crackles. pleural friction rub. sonorous wheezes.

pleural friction rub. Explanation: A pleural friction rub is heard secondary to inflammation and loss of lubricating pleural fluid. Crackles are soft, high-pitched, discontinuous popping sounds that occur during inspiration. Sonorous wheezes are deep, low-pitched rumbling sounds heard primarily during expiration. Sibilant wheezes are continuous, musical, high-pitched, whistle-like sounds heard during inspiration and expiration.

The nurse is caring for a client who has just had a tracheostomy. What should the nurse monitor frequently? Pain level Psychological status Airway patency Level of consciousness

Airway patency Explanation: The nurse monitors for potential complications and checks airway patency frequently. Secretions can rapidly clog the inner lumen of the tracheostomy tube, resulting in severe respiratory difficulty or death by asphyxiation. The priorities are always airway, breathing, and then circulation.

The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply. Nasal flaring with abdominal retractions A decreased respiratory rate Increased respiratory effort Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 Administration of a corticosteroid inhaler for quick relief Lung sounds of wheezing

Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 Nasal flaring with abdominal retractions Lung sounds of wheezing Increased respiratory effort The nurse would be calling to report signs of respiratory distress. This includes nasal flaring with abdominal retractions, stridor and an increased respiratory effort. Also arterial blood gases with an elevated CO2 and lower oxygen level indicates respiratory compromise. An increased respiratory rate occurs in respiratory compromise. Administration of a corticosteroid decreases inflammation over a period of time.

Which of the following is a potential complication of a low pressure in the endotracheal cuff? Tracheal ischemia Pressure necrosis Aspiration pneumonia Tracheal bleeding

Aspiration pneumonia Explanation: Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.

The health care provider has prescribed continuous positive airway pressure (CPAP) with the delivery of a client's high-flow oxygen therapy. The client asks the nurse what the benefit of CPAP is. What would be the nurse's best response? CPAP allows for the elimination of bacterial growth in oxygen delivery systems. CPAP allows a lower percentage of oxygen to be used with a similar effect. CPAP allows a higher percentage of oxygen to be safely used. CPAP allows for greater humidification of the oxygen that is given.

CPAP allows a lower percentage of oxygen to be used with a similar effect. Explanation: Prevention of oxygen toxicity is achieved by using oxygen only as prescribed. Often, positive end-expiratory pressure (PEEP) or CPAP is used with oxygen therapy to reverse or prevent microatelectasis, thus allowing a lower percentage of oxygen to be used. Oxygen is moistened by passing through a humidification system. Changing the tubing on the oxygen therapy equipment is the best technique for controlling bacterial growth.

The instructor of the pre-nursing physiology class is explaining respiration to the class. What does the instructor explain is the main function of respiration? To exchange atmospheric air between the blood and the cells To move CO2 out of the atmospheric air and into the expired air To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells To move O2 out of the atmospheric air and into the retained air

Correct response: To exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells Explanation: The main function of the respiratory system is to exchange oxygen and CO2 between the atmospheric air and the blood and between the blood and the cells. This process is called respiration. The purpose of respiration is not to move any gas into the expired air; retained air is simply a distractor for this question; and atmospheric air is not exchanged between the blood and the cells.

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? Absent breath sounds Egophony Bronchial breath sounds Crackles at lung bases

Crackles at lung bases Explanation: A patient with pulmonary edema would be expected to have crackles in the lung bases, and possible wheezes. Egophony may occur in patients diagnosed with pleural effusion. Absent breath sounds occurs in pneumothorax. Bronchial breath sounds occur in consolidation, such as pneumonia.

Which is a late sign of hypoxia? Somnolence Cyanosis Restlessness Hypotension

Cyanosis Explanation: Cyanosis is a late sign of hypoxia. Hypoxia may cause restlessness and an initial rise in blood pressure that is followed by hypotension and somnolence.

A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour? Cyanosis Crackles Respiratory rate Son's statement

Cyanosis Explanation: The client's appearance may give clues to respiratory status. Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence of cyanosis is from decreased unoxygenated hemoglobin. In the presence of a pulmonary condition, cyanosis is assessed by observing the color of the tongue and lips.

The nurse is assisting with the removal of an oral endotracheal tube. Place in order the actions the nurse will take to provide care to the client. Use all options.

Explain the procedure. Place a self-inflating bag and mask at the bedside. Suction the tracheobronchial tree and oropharynx. Remove tape. Deflate the cuff. Provide a few breaths of 100% oxygen. Insert a new sterile suction catheter inside the tube. Instruct the client to inhale. Remove the tube while suctioning the airway as it is removed When removing the endotracheal tube, the procedure is first explained to the client. A self-inflating bag and mask is to be at the bedside in case the client needs ventilatory assistance after the tube is removed. The tracheobronchial tree and oropharynx are then suctioned before removing the tape. The cuff is then deflated on the tube and the client is provided with a few breaths of 100% oxygen. Next a new sterile suction catheter is inserted inside of the tube. The client is then instructed to inhale a deep breath, and at the peak of the inspiration, the tube is removed while suctioning the airway through the tube as it is pulled out.

A sputum study has been ordered for a client who has developed coarse chest crackles and a fever. At what time would it be best for the nurse to collect the sample? At bedtime Immediately after a meal After a period of exercise First thing in the morning

First thing in the morning Explanation: Sputum samples ideally are obtained early in the morning before the client has had anything to eat or drink.

During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events? Systemic hypotension Hypercapnia Pulmonary hypotension Increased smooth muscle contractility

Hypercapnia Explanation: Repetitive apneic events result in hypoxia and hypercapnia, which triggers a sympathetic response (increased heart rate and decreased tone and contractility of smooth muscle).

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? Hyperventilation, hypertension, and hypocapnia Hypotension, hyperoxemia, and hypercapnia Hyperoxemia, hypocapnia, and hyperventilation Hypercapnia, hypoventilation, and hypoxemia

Hypercapnia, hypoventilation, and hypoxemia Explanation: The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.

The nurse is caring for a patient at risk for atelectasis and chooses to implement a first-line measure to prevent atelectasis development in the patient. What is an example of a first-line measure to minimize atelectasis? Incentive spirometry Intermittent positive pressure-breathing (IPPB) Bronchoscopy Positive end-expiratory pressure (PEEP)

Incentive spirometry Explanation: Strategies to prevent atelectasis, which include frequent turning, early ambulation, lung volume expansion maneuvers (deep breathing exercises, incentive spirometry), and coughing serve as the first-line measures to minimize or treat atelectasis by improving ventilation. In patients who do not respond to first-line measures or who cannot perform deep-breathing exercises, other treatments such as PEEP, continuous or intermittent positive pressure-breathing (IPPB), or bronchoscopy may be used.

A client had a tracheostomy two hours ago. The nurse assesses the client and finds the client's breathing is shallow, with a respiratory rate of 30. The nurse notes increased mucus production around the tracheostomy and on the dressing. What are the priority nursing concern(s)? Select all that apply. Altered body image perception Infection risk Ineffective airway clearance Knowledge deficiency Impaired gas exchange

Ineffective airway clearance Impaired gas exchange The client with a new tracheostomy tube has increased secretions, which may become dried and occlude or plug the airway, requiring frequent suctioning. Impaired gas exchange and airway clearance are priority nursing concerns. Infection, knowledge deficit, and altered body image are concerns, but not priorities.

A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is Acute pain related to upper airway irritation Deficient fluid volume related to increased fluid needs Ineffective airway clearance related to excess mucus production Deficient knowledge related to prevention of upper respiratory infections

Ineffective airway clearance related to excess mucus production Explanation: All the listed nursing diagnoses are appropriate for this client. Following Maslow's hierarchy of needs, physiological needs are addressed first and, within physiological needs, airway, breathing, and circulation are the most immediate. Thus, ineffective airway clearance is the priority nursing diagnosis.

Select the nursing diagnosis that would warrant immediate health care provider notification. Deficient fluid volume related to decreased fluid intake and increased fluid loss secondary to diaphoresis associated with a fever Deficient knowledge regarding prevention of upper airway infections, treatment regimens, the surgical procedure, or postoperative care Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation Acute pain related to upper airway irritation secondary to an infection

Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation Explanation: Ineffective airway clearance can lead to respiratory depression, which necessitates immediate intervention.

What would the instructor tell the students purulent fluid indicates? Heart failure Infection Cancer Inflammation

Infection Explanation: A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician aspirates it from the pleural space by inserting a needle into the chest wall. This procedure, called thoracentesis, is performed with local anesthesia. Thoracentesis also may be used to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes such as a culture, sensitivity, or microscopic examination. Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.

When assessing a client, which adaptation indicates the presence of respiratory distress? Sore throat Orthopnea Productive cough Respiratory rate of 14 breaths per minute

Orthopnea Explanation: Orthopnea is the inability to breathe easily except when upright. This positioning can mean while in bed and propped with a pillow or sitting in a chair. If a client cannot breathe easily while lying down, there is an element of respiratory distress.

The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply. Oxygen saturation of 76% Nuchal rigidity A decreased respiratory rate Increased respiratory effort Lung sounds of wheezing Nasal flaring with abdominal retractions

Oxygen saturation of 76% Nasal flaring with abdominal retractions Lung sounds of wheezing Increased respiratory effort The nurse would be calling to report signs of respiratory distress. This includes nasal flaring with abdominal retractions, wheezing, stridor and an increased respiratory effort. The lower oxygen saturation level indicates respiratory compromise. An increased respiratory rate occurs in respiratory compromise. Nuchal rigidity is neck stiffness assocaited with meningitis and is unrelated to an airway obstruction.

Which of the following is a noninvasive method of continuously monitoring the oxygen saturation of hemoglobin (SaO2)? Arterial blood gas analysis Pulse oximetry Pulmonary function testing Sputum studies

Pulse oximetry Explanation: Pulse oximetry is a noninvasive method of continuously monitoring SaO2. Measurements of blood pH of arterial oxygen and carbon dioxide tensions are obtained when managing patients with respiratory problems and adjusting oxygen therapy as needed. This is an invasive procedure. Pulmonary function testing assesses respiratory function and determines the extent of dysfunction. Sputum studies are done to identify if any pathogenic organisms or malignant cells are in the sputum.

The nurse is preparing to perform the care of a patient's tracheostomy tube. Which of the following actions should the nurse perform during this procedure? Perform deep suctioning before and after the trach care. Wash the inner cannula with soap and warm tap water if it is not disposable. Clean the stoma and the skin surrounding the stoma with chlorhexidine. Remove the soiled twill tape after new tape has been put in place.

Remove the soiled twill tape after new tape has been put in place. Explanation: Soiled twill tape should be removed after the new tape is in place, to reduce the risk of accidental dislodgment. Chlorhexidine is not used in tracheostomy care, and a nondisposable inner cannula is cleaned with hydrogen peroxide or sterile normal saline. It is not necessary to perform suctioning before and after care.

A client has a nursing diagnosis of ineffective airway clearance related to excessive mucus production. The best short-term goal is for the client to Increase fluid intake. Use a room vaporizer to loosen secretions. Assume an upright position to facilitate drainage. Report decreased congestion.

Report decreased congestion. Explanation: A report from the client of decreased congestion indicates improvement of the problem. The other options are actually interventions or actions that the client can undertake to achieve a long-term goal of a patent airway.

A nurse is caring for a client after a lung biopsy. Which assessment finding requires immediate intervention? Client stating pain level of 7 out of 10 that decreases with pain medication Client dozing when left alone but awakening easily Respiratory rate of 44 breaths/minute Oxygen saturation level of 96% on 3 L of oxygen

Respiratory rate of 44 breaths/minute Explanation: A respiratory rate of 44 breaths/minute is significant and requires immediate intervention. The client may be experiencing postoperative complications, such as pneumothorax or bleeding. An oxygen saturation level of 96% on 3 L of oxygen, a pain level of 7 out of 10 that decreases with pain medication, and dozing when left alone are normal and don't require further intervention.

A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure? Sudden onset of lung impairment in a client who had normal lung function Insidious onset of lung impairment in a client who had compromised lung function Sudden onset of lung impairment in a client who had compromised lung function Insidious onset of lung impairment in a client who had normal lung function

Sudden onset of lung impairment in a client who had normal lung function Explanation: In acute respiratory failure, the ventilation or perfusion mechanisms in the lung are impaired. Acute respiratory failure occurs suddenly in a client who previously had normal lung function.

The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation? Bilateral breath sounds present Sudden restlessness Copious mucous secretions Harsh cough

Sudden restlessness Explanation: Sudden restlessness is indicative of respiratory distress, which may occur from the obstruction of the endotracheal tube. Blockage of the tube is life threatening. Copious mucous secretions are common from irritation of the endotracheal tube. Bilateral breath sounds are an expected finding; the absence of bilateral breath sounds should be reported to the provider immediately.

Which statements would be considered appropriate interventions for a client with an endotracheal tube? Select all that apply. Humidified oxygen should always be introduced through the tube. Suctioning the oropharynx prn is not recommended. Cuff pressures should be checked every 6 to 8 hours. Routine cuff deflation is recommended. The cuff is deflated before the tube is removed.

The cuff is deflated before the tube is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube. Explanation: The cuff is deflated before the endotracheal tube is removed. Cuff pressures should be checked every 6 to 8 hours. And must be maintained at 15- 2 mm Hg to prevent excess pressure , High cuff pressure leads to tracheal bleeding and other complications. Humidified oxygen should always be introduced through the tube. Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. It is recommended to provide oral hygiene and suction the oropharynx whenever necessary, the cough , glottic, pharyngeal ,and laryngeal reflexes are suppressed and the nurse needs to keep all airways clear for the client.

A female patient with obstructive sleep apnea (OSA) has been recommended a continuous positive airway pressure (CPAP) machine for the treatment of her health problem. The nurse's priority for patient education should be: The importance of complying with CPAP despite the inconvenience associated with its use The need to have continuous pulse oximetry in place while the CPAP machine is in use The importance of participating in daily physical exercise when using CPAP on a regular basis The need to use inhaled corticosteroids and bronchodilators each night prior to applying CPAP

The importance of complying with CPAP despite the inconvenience associated with its use Explanation: Although CPAP is effective in management of OSA, patient compliance with the treatment continues to be a major concern. Nursing interventions aimed at increasing compliance are consequently a priority. Steroids, bronchodilators, and pulse oximetry are not normally necessary. Daily exercise is beneficial but the promotion of compliance is a priority for patients using CPAP.

A nurse is aware that the diagnostic feature of ARDS is sudden: Unresponsive arterial hypoxemia. Diminished alveolar dilation. Increased PaO2 Tachypnea

Unresponsive arterial hypoxemia. Explanation: Clinically, the acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs 12 to 48 hours after the initiating event. A characteristic feature is arterial hypoxemia that does not respond to supplemental oxygen.

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing? Use of accessory muscles Pursed-lip breathing Diaphragmatic breathing Controlled breathing

Use of accessory muscles Explanation: The use of accessory muscles for respiration indicates the client is having difficulty breathing. Diaphragmatic and pursed-lip breathing are two controlled breathing techniques that help the client conserve energy.

Which type of ventilator has a preset volume of air to be delivered with each inspiration? Volume cycled Negative pressure Pressure cycled Time cycled

Volume cycled Explanation: With volume-cycled ventilation, the volume of air to be delivered with each inspiration is preset. 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 preset pressure, and then cycles off, and expiration occurs passively.

While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following? Crackles Wheezes Pleural friction rub Rhonchi

Wheezes Explanation: Wheezes, usually heard on expiration, are continuous, musical, high pitched, and whistle-like sounds caused by air passing through narrowed airways. Often, wheezes are associated with asthma.

While caring for a patient with an endotracheal tube the nurse recognizes that suctioning is required: When adventitious breath sounds are auscultated To stimulate the cough reflex Every 2 hours To prevent the patient from coughing

When adventitious breath sounds are auscultated Explanation: It is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa.

The nurse answers a client's call light. The client reports an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from the nose. rectum. stomach. lungs.

lungs. Explanation: Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bubbling sensation in the chest, and perhaps chest pain, in which case the client tends to splint the bleeding side. This blood has an alkaline pH (>7.0). Blood from the stomach is vomited rather than expectorated, may be mixed with food, and is usually much darker; it is often referred to as "coffee ground emesis." This blood has an acidic pH (<<7.0). Bloody sputum from the nose or the nasopharynx is usually preceded by considerable sniffing, with blood possibly appearing in the nose.