Respiratory (PrepU Ch17+19, Saunders, uWorld)

The client with a lower respiratory airway infection is presenting with the following symptoms: fever, chills, dry hacking cough, and wheezing. Which nursing diagnosis best supports the assessment by the nurse? a) Ineffective airway clearance b) Impaired gas exchange c) Ineffective breathing pattern d) Infection risk

a) Ineffective airway clearance The symptom of wheezing indicates a narrowing or partial obstruction of the airway from inflammation or secretions. Infection Risk is a potential issue because the client is already exhibiting symptoms of infection (fever with chills). Impaired Gas Exchange may occur, but no symptom listed supports poor exchange of gases. No documentation of respiratory rate or abnormalities is listed to justify this nursing diagnosis.

While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? a) The system has an air leak. b) The system is functioning normally. c) The patient has a pneumothorax. d) The chest tube is obstructed.

a) The system has an air leak. Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The patient with a pneumothorax will have intermittent bubbling in the water-seal chamber. Patients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber. Add a Note

(uWorld) A self-employed auto mechanic is diagnosed with carbon monoxide poisoning. Admission vital signs are blood pressure 90/42 mm Hg, pulse 84/min, respirations 24/min, and oxygen saturation 94% on room air. What is the nurse's priority action? a) Administer 5mg inhaled albuterol nebulizer treatment to decrease inflammatory bronchoconstriction b) Administer 100% oxygen using a nonrebreather mask with flow rate of 15L/min c) Administer methylprednisolone to decrease lung inflammation from toxic inhalant d) Titrate oxygen to maintain pulse oximeter saturation of >95%

b) Administer 100% oxygen using a nonrebreather mask with flow rate of 15L/min The purpose of hemoglobin (Hgb) is to pick up oxygen in the lungs and deliver it to the tissues. It must be able to pick up oxygen and release it in the right places. Carbon monoxide (CO) has a much stronger bond to Hgb than oxygen does. Consequently, CO displaces oxygen from Hgb, causing hypoxia that is not reflected by a pulse oximeter reading. The nurse's primary action is to administer highly concentrated (100%) oxygen using a nonrebreather mask at 15 L/min in order to reverse this displacement of oxygen. (Option 1) Albuterol is not a priority action as bronchoconstriction is not a consequence of CO poisoning. (Option 3) Administration of corticosteroids is not a priority/primary action as direct inflammation of the lungs is not an underlying cause for hypoxemia and hypoxia associated with CO poisoning. (Option 4) When all available Hgb binding sites are occupied (oxyhemoglobin or carboxyhemoglobin), saturation (SaO2) is 100%. The conventional pulse oximeter cannot differentiate carboxyhemoglobin from oxyhemoglobin as both absorb the oximeter's red and infrared light wavelengths. Consequently, the pulse oximeter reading may be adequate (>90%), but severe hypoxemia and hypoxia may be present. Alternate methods of CO saturation measurement (eg, multiple wavelength CO pulse oximeter, spectrographic blood gas analysis) are recommended. Educational objective: The conventional pulse oximeter is not effective in identifying hypoxia in CO poisoning; diagnosis requires co-oximetry of a blood gas sample. The priority action is to administer 100% oxygen using a nonrebreather mask to treat hypoxia and help eliminate CO.

The nurse is caring for a client in the ICU who required emergent endotracheal (ET) intubation with mechanical ventilation. The nurse receives an order to obtain arterial blood gases (ABGs) after the procedure. The nurse recognizes that ABGs should be obtained how long after mechanical ventilation is initiated? a) 10 minutes b) 15 minutes c) 20 minutes d) 25 minutes

c) 20 minutes The nurse records minute volume and obtains ABGs to measure carbon dioxide partial pressure (PaCO2), pH, and PaO2 after 20 minutes of continuous mechanical ventilation.

​​​​​​​(uWorld) The nurse receives an obese client in the postanesthesia care unit who underwent a procedure under general anesthesia. The nurse notes an oxygen saturation of 88%. Which is the most appropriate initial intervention? a) assess pupillary response b) auscultate lung sounds c) inform anesthesia professional d) perform head tilt and chin lift

d) perform head tilt and chin lift Head tilt and chin lift is a maneuver used to open the airway. The tongue may fall back and occlude the airway due to muscular flaccidity after general anesthesia. Manifestations associated with airway obstruction include snoring, use of accessory muscles, decreased oxygen saturations, and cyanosis. (Option 1) Constricted pupils can help identify opioid overdose. However, this should not be assessed before opening the airway. (Option 2) Auscultation of lung sounds should be done for every client as part of the postoperative assessment. However, the initial goal is to return the oxygen saturation level to normal (95%-100%). Hypoxia in an obese postoperative client who received general anesthesia is most likely due to airway obstruction. (Option 3) The anesthesia professional may need to be informed, but methods to restore the oxygen saturation level should be tried first. The anesthesia professional may then want to assess the sedation level of the client and prescribe a reversal agent. Educational objective: Postoperative client care after general anesthesia requires careful monitoring for hypoxia. One of the first nursing interventions is the head tilt and chin lift to open an occluded airway.

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

c) Unresponsive arterial hypoxemia. 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 mechanically ventilated client is receiving a combination of atracurium and the opioid analgesic morphine. The nurse monitors the client for which potential complication? a) Venous thromboemboli b) Pneumothorax c) Pulmonary hypertension d) Cor pulmonale

a) Venous thromboemboli Neuromuscular blockers predispose the client to venous thromboemboli (VTE), muscle atrophy, foot drop, peptic ulcer disease, and skin breakdown. Nursing assessment is essential to minimize the complications related to neuromuscular blockade. The client may have discomfort or pain but be unable to communicate these sensations.

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? a) The patient is in a hypermetabolic state. b) The patient is having a stress reaction. c) The patient is having a myocardial infarction. d) The patient is hypoxic from suctioning.

d) The patient is hypoxic from suctioning. Apply suction while withdrawing and gently rotating the catheter 360 degrees (no longer than 10-15 seconds). Prolonged suctioning may result in hypoxia and dysrhythmias, leading to cardiac arrest.

(uWorld) The client has a chest tube for a pneumothorax. While repositioning the client for an x-ray, the technician steps on the tubing and accidently pulls the chest tube out. The client's oxygen saturation drops and the pulse is 132/min; the nurse hears air leaking from the insertion site. What is the nurse's immediate action? a) Apply an occlusive sterile dressing secured on 3 sides b) Apply an occlusive sterile dressing secured on 4 sides c) Assess lung sounds d) Notify the HCP

a) Apply an occlusive sterile dressing secured on 3 sides If the chest tube is dislodged from the client and the nurse hears air leaking from the site, the nurse's immediate action should be to apply a sterile occlusive dressing (eg, petroleum jelly dressing) taped on 3 sides. This action permits air to escape on exhalation and inhibits air intake on inspiration. The nurse would then notify the HCP and arrange for the reinsertion of another chest tube (Option 1). (Option 2) A tension pneumothorax develops when air enters the pleural space but cannot escape. Increased intrapleural pressure and excessive accumulation of air can apply pressure to the heart and great vessels and drastically decrease cardiac output. An occlusive dressing taped on 4 sides would prevent the air in the pleural space from escaping on exhalation and would increase the risk for a tension pneumothorax. (Option 3) The nurse would stay with the client, assess lung sounds, and monitor vital signs frequently; however, this is not the immediate action. (Option 4) The nurse would notify the HCP and prepare for reinsertion of a chest tube, but it is not the immediate action. Educational objective: If a chest tube is dislodged from the client and the nurse hears air leaking from the site, the immediate action should be to apply an occlusive sterile dressing taped on 3 sides. This action decreases the risk for a tension pneumothorax by inhibiting air intake on inspiration and allowing air to escape on expiration.

A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse a) Assesses the client's tracheostomy and lung sounds every 15 minutes b) Sets a schedule to suction the tracheostomy every hour c) Decreases the amount of humidity set to flow through the tracheostomy tube d) Encourages the client to cough every 30 minutes and prn

a) Assesses the client's tracheostomy and lung sounds every 15 minutes Tracheal suctioning is performed when secretions are obvious or adventitious breath sounds are heard. The client is producing thick yellow mucus frequently, so the nurse needs to make frequent assessments about the need for suctioning. Suctioning every hour could be too frequent or not frequent enough. It also does not address the client's needs. The client needs high humidity to liquify the mucus, which is described as thick. The client has a decreased effectiveness of coughing with a tracheostomy tube. Again, this is not a viable option.

(uWorld) The nurse is caring for a client with a chest tube to evacuate a hemopneumothorax after a motor vehicle accident. The drainage has been consistently 25-50 mL/hr for the majority of the shift. However, over the past 2 hours there has been no drainage. Which actions should the nurse take? Select all that apply. a) Auscultate breath sounds b) Increase amount of suction c) Instruct client to cough and deep breathe d) Milk the chest tube e) Reposition the client

a) Auscultate breath sounds c) Instruct client to cough and deep breathe e) Reposition the client When chest drainage stops abruptly, the nurse must perform assessments and interventions to ascertain if this is an expected finding. Auscultating breath sounds (Option 1) helps the nurse detect whether breath sounds are audible in all lung fields, potentially indicating that the lung has re-expanded and there is no more drainage. Other interventions to facilitate drainage include having the client cough and deep breathe (Option 3) and repositioning the client (Option 5). If a client has been in one position for a prolonged period, drainage may accumulate and a position change may facilitate improved drainage. (Option 2) A change in suction level should be performed only after obtaining a health care provider (HCP) prescription. The nurse should perform the assessment of breath sounds, coughing and deep breathing, and client repositioning before notifying the HCP about a change in suction level. In general, suction above 20 cm H2O is not indicated. (Option 4) Milking chest tubes to maintain patency is performed only if prescribed. It is generally contraindicated due to potential tissue damage from highly increased pressure changes in the pleural space. Educational objective: The nurse should assess breath sounds, encourage coughing and deep breathing, and reposition the client who has a decrease in chest tube drainage.

(uWorld) A hospitalized client with a history of obstructive sleep apnea sleeps while wearing a full-face mask with continuous positive airway pressure. Oxygen saturation drops to 85% during the night. What is the nurse's first action? a) Check the tightness of the straps and mask b) Notify the HCP immediately c) Remove the mask and administer supplemental oxygen d) Replace the old pulse oximeter probe with a new probe

a) Check the tightness of the straps and mask Obstructive sleep apnea (OSA) is a chronic condition characterized by repeated episodes of partial (ie, hypopnea) or complete (ie, apnea) airway obstruction during sleep, which are related to the relaxation of pharyngeal muscles. Clinical manifestations include frequent periods of sleep disturbance, loud snoring, morning headaches, daytime sleepiness, and difficulty concentrating. Continuous positive airway pressure (CPAP) uses a nasal or full-face mask to deliver positive pressure to the upper airway to prevent the structures of the pharynx and tongue from collapsing backward and obstructing the airway. An incorrectly fitted CPAP mask is a common cause of a sudden decrease in oxygen saturation while sleeping. The full-face mask must fit snugly over the client's nose and mouth without air leakage to maintain positive airway pressure. The nurse should first check the tightness of the straps and mask (Option 1). (Options 2, 3, and 4) The nurse should first assess the client's mask, then check the monitoring equipment. The pulse oximeter may need to be replaced if it is not adhered correctly. If the mask is fitting appropriately and the monitoring equipment is functioning yet oxygen saturation is dropping, the nurse should remove the mask, initiate supplemental oxygen, and notify the health care provider immediately. Educational objective: Continuous positive airway pressure is prescribed for clients with obstructive sleep apnea to prevent the structures of the pharynx and tongue from collapsing backward and obstructing the airway. If the client experiences a sudden decrease in oxygen saturation, the nurse should first check the tightness of the straps and mask.

(uWorld) The charge nurse of the emergency department (ED) is mentoring a new registered nurse (RN). They are caring for a client who has a chest tube connected to wall suction for a pneumothorax. The client is being transferred from the ED to the telemetry unit. Which action by the new RN would cause the charge nurse to intervene? a) Clamping the chest tube at the insertion site during transfer b) Disconnecting the suction tubing from the wall suction unit c) Hanging the chest tube collection unit to the underside of the stretcher d) Taping connections between the chest tube and suction tubing

a) Clamping the chest tube at the insertion site during transfer Clamping the chest tube during transport is contraindicated. Doing so can cause air to accumulate in the pleural cavity as it has no means of escape. This can lead to the development of a tension pneumothorax, a potentially life-threatening condition. A tension pneumothorax results in compression of the unaffected lung and pressure on the heart and great vessels. As the pressure increases, venous return is decreased and cardiac output falls. (Option 2) The wall suction needs to be temporarily disconnected during transport. It should be reconnected promptly at the destination. (Option 3) The chest tube collection unit should be hung below the level of the chest to promote drainage and keep fluids from re-entering the chest cavity. (Option 4) All connections should be secured with tape to prevent accidental disconnection or air to enter the system. Educational objective: Chest tubes should not be clamped during transport of a client. A clamped chest tube may cause a tension pneumothorax, a potentially life-threatening event.

(uWorld) The emergency nurse admits a semiconscious client with periorbital bruising and severe tongue edema after a laceration sustained in an unwitnessed tonic-clonic seizure. The health care provider prescribes a nasopharyngeal airway to maintain airway patency. Which initial action by the nurse is appropriate? a) Contact the HCP and clarify the prescription b) Ensure correct placement after insertion by auscultating the lungs c) Select an appropriate size by measuring from nose tip to earlobe d) Verify that the client has no history of bleeding disorders or aspirin use

a) Contact the HCP and clarify the prescription A nasopharyngeal airway (NPA) is a tube-like device used to maintain upper airway patency. NPAs are frequently used in alert or semiconscious clients, as they are less likely to cause gagging, and in clients with oral trauma or maxillofacial surgery. NPAs should never be inserted in clients who may have head trauma (eg, facial or basilar skull fractures), such as might occur during an unwitnessed seizure. NPAs inserted in clients with skull fractures may be malpositioned into underlying tissues/structures (eg, brain). Therefore, the nurse should immediately clarify prescriptions for NPAs in clients with head trauma (Option 1). An NPA may be inserted after imaging (eg, CT scan) rules out fracture. (Option 2) Once skull fracture is ruled out and an NPA is inserted, the nurse verifies appropriate airway placement by auscultating the lungs. (Option 3) Inappropriate NPA size increases the risk for airway obstruction, sinus blockage, and infection. To select an appropriate size, the nurse measures from the tip of the client's nose to the earlobe and selects a diameter smaller than the naris. (Option 4) Bleeding disorders and use of anticoagulant or antiplatelet medication (eg, aspirin) are relative contraindications to NPA insertion, as these increase the risk of bleeding. However, skull fracture must be excluded prior to placement. Educational objective: A nasopharyngeal airway (NPA) is a tube-like device used to maintain upper airway patency. NPAs should not be inserted in clients with suspected head trauma until skull fracture can be excluded as there is a risk for unintentional malpositioning into underlying tissue/structures (eg, brain).

(uWorld) A client had a thoracotomy 2 days ago to remove a lung mass and has a right chest tube attached to negative suction. Immediately after turning the client to the left side to assess the lungs, the nurse observes a rush of approximately 125 mL of dark bloody drainage into the drainage tubing and collection chamber. What is the appropriate nursing action? Click on the exhibit button for additional information. a) Document and continue to monitor chest drainage b) Immediately clamp the chest tube c) Notify the HCP d) Request repeat hematocrit and hemoglobin levels

a) Document and continue to monitor chest drainage Immediately following a thoracotomy, chest tube drainage (50-500 mL for the first 24 hours) is expected to be sanguineous (bright red) for several hours and then change to serosanguineous (pink) followed by serous (yellow) over a period of a few days. A rush of dark bloody drainage from the chest tube when the client was turned following a period of minimal drainage is most likely related to retained blood due to a partial blockage in the tube. Bright red drainage indicates active bleeding and would be of immediate concern. (Option 2) The chest tube should not be clamped because it is placed to drain the fluid leaking after surgery. (Option 3) The nurse would notify the health care provider immediately of bright red drainage or continued increased drainage (>100 mL/hr) and of changes in the client's vital signs and cardiovascular status that could indicate bleeding (eg, hypotension, tachycardia, tachypnea, decreased capillary refill, cool and pale skin). This is not the appropriate action. (Option 4) It would be appropriate to request repeat serum hematocrit and hemoglobin levels if active bleeding is suspected, but the postoperative levels are stable at this time. This is not the appropriate action. Educational objective: A client will usually have a chest tube in place for several days following a thoracotomy to drain blood from the pleural space. A rush of dark bloody drainage from the tube when the client coughs, turns, or is repositioned following a period of minimal drainage is most likely related to retained blood due to a partial blockage in the tube. Bright red chest drainage indicates active bleeding and would be of immediate concern.

(uWorld) A client was medicated with intravenous morphine 2 mg 2 hours ago to relieve moderate abdominal pain after appendectomy. The client becomes lethargic but arouses easily to verbal and tactile stimuli, and is oriented to time, place, and person. The pulse oximeter reading has dropped from 99% to 89% on room air. Which oxygen delivery device is the most appropriate for the nurse to apply? a) Nasal cannula b) Non-rebreather mask c) Simple face mask d) Venturi mask

a) Nasal cannula The nasal cannula is the most appropriate oxygen delivery device to apply at this time because it is comfortable, used for the short term, inexpensive, and permits the client to eat and drink fluids. It can supply adequate oxygen concentrations of up to 44%. This client is most likely hypoventilating as a result of the opioid medication. The client is alert and oriented and able to follow directions. Because pain relief is effective according to the pain scale, the client should be able to breathe deeply through the nose, and the hypoxemia should reverse rapidly. (Option 2) The non-rebreather mask is used in emergencies, delivers high concentrations of oxygen (up to 90%-95%), requires a tight face seal, and is restrictive and uncomfortable. (Option 3) The simple face mask delivers a higher concentration of oxygen (40%-60%), is more uncomfortable and restrictive, must be removed to eat or drink, and is not appropriate at this time. It can be used if hypoxemia does not resolve. (Option 4) The Venturi mask is a more expensive device used to deliver a guaranteed oxygen concentration to clients with unstable chronic obstructive pulmonary disease. These clients cannot tolerate changes in oxygen concentration. Educational objective: The nasal cannula is an inexpensive, comfortable, low-flow oxygen delivery device capable of delivering oxygen concentrations of up to 44%. It can be used in the short term in responsive postoperative clients to treat hypoventilation and reverse hypoxemia effectively.

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? a) Notify the physician. b) Milk the chest tube. c) Place the head of the patient's bed flat. d) Disconnect the system and get another.

a) 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 leaks.

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? a) Place the end of the chest tube in a container of sterile saline. b) Apply an occlusive dressing and notify the physician. c) Clamp the chest tube immediately. d) Secure the chest tube with tape.

a) Place the end of the chest tube in a container of sterile saline. 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 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? a) Position the client in the prone position b) Assist the client into a chair c) Force fluids for the next 24 hours d) Administer small doses of pancuronium

a) Position the client in the prone position 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.

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. a) Tracheal ischemia b) Tracheal bleeding c) Tracheal aspiration d) Pressure necrosis e) Hypoxia

a) Tracheal ischemia b) Tracheal bleeding d) Pressure necrosis Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 20 and 25 mm Hg. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can increase the risk of aspiration pneumonia. Routine deflation of the cuff is not recommended because of the increased risk of aspiration and hypoxia.

A client is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action first? a) Troubleshoot to identify the malfunction. b) Reposition the endotracheal tube. c) Notify the respiratory therapist. d) Manually ventilate the client.

a) Troubleshoot to identify the malfunction. The nurse should first immediately attempt to identify and correct the problem; if the problem cannot be identified and/or corrected, the client must be manually ventilated with an Ambu bag. The respiratory therapist may be notified, but this is not the first action by the nurse. The nurse should not reposition the endotracheal tube as a first response to an alarm.

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? a) Unresponsive arterial hypoxemia b) Increased PaO2 c) Diminished alveolar dilation d) Tachypnea

a) Unresponsive arterial hypoxemia 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 caring for a 2-year-old near-drowning victim monitors for what possible complication? a) Respiratory acidosis b) Acute respiratory distress syndrome c) Metabolic alkalosis d) Atelectasis

b) Acute respiratory distress syndrome Factors associated with the development of acute respiratory distress syndrome include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. The nurse would not monitor for atelectasis, metabolic alkalosis, or respiratory acidosis in this scenario.

(uWorld) The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's priority when caring for a client with a new tracheostomy? a) Changing the inner cannula within the first 8 hours to help prevent mucus plugs b) Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these ties c) Deflating and re-inflating the cuff q4hrs to prevent mucosal damage d) Performing frequent mouth care every 2hrs to help prevent infection

b) Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these ties The immediate postoperative priority goal for a client with a new tracheostomy is to prevent accidental dislodgement of the tube and loss of the airway. If dislodgement occurs during the first postoperative week, reinsertion of the tube is difficult as it takes the tract about 1 week to heal. For this reason, dislodgement is a medical emergency. The priority nursing action is to ensure the tube is placed securely by checking the tightness of ties and allowing for 1 finger to fit under these ties. (Option 1) Changing of the inner cannula and tracheostomy ties is not usually performed until 24 hours after insertion; this is due to the risk of dislodgement with an immature tract. However, the dressing can be changed if it becomes wet or soiled. Suctioning can be performed to remove mucus and maintain the airway. (Option 3) The cuff is kept inflated to prevent aspiration from secretions and postoperative bleeding. Cuffs are not regularly deflated and re-inflated. The respiratory therapist should monitor the amount of air in the cuff several times a day to prevent excessive pressure and mucosal tissue damage. (Option 4) Frequent mouth care to help prevent stomal and pulmonary infection is important in a client with an artificial airway, but it is not the priority action immediately following tracheostomy. Educational objective: The immediate postoperative priority goal for a client with a newly placed tracheostomy is to prevent accidental dislodgement of the tube and loss of the airway.

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? a) Hypoxemic hypoxia b) Circulatory hypoxia c) Anemic hypoxia d) Histotoxic hypoxia

b) Circulatory hypoxia Given the vital signs, this client appears to be in shock. Circulatory hypoxia results from inadequate capillary circulation and 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 low blood pressure is consistent with circulatory hypoxia but not consistent with the other options. Anemic hypoxia is a result of decreased effective hemoglobin concentration. Histotoxic hypoxia occurs when a toxic substance interferes with the ability of tissues to use available oxygen. Hypoxemic hypoxia results from a low level of oxygen in the blood.

The nurse is caring for a client in the ICU who is receiving mechanical ventilation. Which nursing measure is implemented in an effort to reduce the client's risk of developing ventilator-associated pneumonia (VAP)? a) Ensuring that the client remains sedated while intubated b) Cleaning the client's mouth with chlorhexidine daily c) Maintaining the client in a high Fowler's position d) Turning and repositioning the client every 4 hours

b) Cleaning the client's mouth with chlorhexidine daily The five key elements of the VAP bundle include elevation of the head of the bed (30 to 45 degrees [semi-Fowler's position)], daily "sedation vacations," and assessment of readiness to extubate; peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists); deep venous thrombosis prophylaxis; and daily oral care with chlorhexidine (0.12% oral rinses). The client should be turned and repositioned every 2 hours to prevent complications of immobility and atelectasis and to optimize lung expansion.

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.) a) Increases oxygen consumption b) Decreases hypoxemia c) Decreases patient anxiety d) Sustains positive end expiratory pressure (PEEP) e) Prevents aspiration

b) Decreases hypoxemia c) Decreases patient anxiety d) Sustains positive end expiratory pressure (PEEP) An in-line suction device allows the patient to be suctioned without being disconnected from the ventilator circuit. In-line suctioning (also called closed suctioning) decreases hypoxemia, sustains PEEP, and can decrease patient anxiety associated with suctioning (Sole et al., 2013).

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? a) Use of a cooling blanket b) Endotracheal suctioning c) Encouragement of coughing d) Incentive spirometry

b) Endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

(uWorld) The nurse develops a care plan for a critically ill client with acute respiratory distress syndrome (ARDS) who is on a mechanical ventilator. What is the priority nursing diagnosis (ND)? a) Imbalanced nutrition b) Impaired gas exchange c) Impaired tissue integrity d) Risk for infection

b) Impaired gas exchange ARDS involves damage to the alveolar-capillary membrane, the blood-gas barrier across which oxygen diffuses into the alveoli. When the membrane is damaged, the alveoli collapse and fluid leaks into the alveolar space and impairs gas exchange. Impaired gas exchange related to alveolar-capillary changes and ventilation-perfusion imbalance is the priority ND for a client with ARDS. (Option 1) Imbalanced nutrition (less than body requirements) related to increased metabolic needs and inability to ingest foods due to endotracheal intubation, is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. (Option 3) Impaired tissue (integumentary) related to altered circulation, immobility, and nutritional deficits is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. (Option 4) Risk for infection related to the presence of an endotracheal tube, frequent suctioning, intravenous devices, and indwelling catheters is an appropriate ND for the client with ARDS. However, it does not pose the greatest threat to survival and is not the priority ND. Educational objective: ARDS involves damage to the alveolar-capillary membrane, resulting in fluid leakage into the alveolar space. Impaired gas exchange related to alveolar-capillary changes and ventilation-perfusion imbalance is an appropriate ND for a client with ARDS.

(uWorld) A student nurse initiates oxygen with a nonrebreather mask for a client with acute respiratory distress. While reassessing the client, the RN notices the reservoir bag is fully deflating on inspiration. What immediate action does the RN take to correct the problem? a) Elevates the head of the bead b) Increases the oxygen flow c) Opens both flutter valves (ports) on the mask d) Tightens the face mask straps

b) Increases the oxygen flow A nonrebreather mask is an oxygen delivery device used in a medical emergency. It consists of a face mask with an attached reservoir bag and a one-way valve between the bag and mask that prevents exhaled air from entering the bag and diluting the oxygen concentration. The liter flow must be high enough (up to 15 L/min) to keep the reservoir bag at least 2/3 inflated during inhalation and to prevent the buildup of carbon dioxide in the bag. (Option 1) Elevating the head of the bed allows for maximum chest expansion and promotes oxygenation. It does not inflate the reservoir bag on inhalation or affect the proper operation of the rebreather mask. (Option 3) Ports (exhalation valves) are located on each side of the mask and are covered with rubber discs that act as flutter valves. The valves close on inhalation to prevent entry of room air and open on exhalation to prevent reinhalation of exhaled air. The ports should be occluded when initiating the device to fill the reservoir with oxygen. (Option 4) The nonrebreather mask can deliver high concentrations of oxygen if the mask is secured tightly to the face with the head strap to minimize leaks. Tightness of the mask does not affect the filling or deflating of the reservoir bag. Educational objective: A nonrebreather mask is an oxygen delivery device used in a medical emergency. It can deliver up to 95%-100% oxygen concentration if properly maintained during use. Proper care of the device includes monitoring the reservoir bag to assure continual inflation during inhalation; monitoring the 2 exhalation (flutter) valves that cover the ports on each side of the mask; and keeping the mask secured to the face by adjusting the tightness of the head strap to minimize leaks.

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? a) Schedule the client for pulmonary surgery b) Intubate the client and control breathing with mechanical ventilation c) Increase oxygen administration d) Administer a large dose of furosemide (Lasix) IVP stat

b) Intubate the client and control breathing with mechanical ventilation 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 young male client has muscular dystrophy. His PaO2 is 42 mm Hg with a FiO2 of 80%. Which of the following treatments would be least invasive and most appropriate for this client? a) Positive-pressure ventilator b) Negative-pressure ventilator c) Bilevel positive airway pressure (Bi-PAP) d) Continuous positive airway pressure (CPAP)

b) Negative-pressure ventilator This client needs ventilatory support. His PaO2 is low despite receiving a high dose of oxygen. The iron lung or drinker respiratory tank is an example of a negative-pressure ventilator. This type of ventilator is used mainly with chronic respiratory failure associated with neurological disorders, such as muscular dystrophy. It does not require intubation of the client. The most common ventilator is the positive-pressure ventilator, but this involves intubation with an endotracheal tube or tracheostomy. CPAP is used for obstructive sleep apnea. Bi-PAP is used for those with severe COPD or sleep apnea who require ventilatory assistance at night.

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? a) Oxygen-induced atelectasis b) Oxygen toxicity c) Oxygen-induced hypoventilation d) Hypoxia

b) Oxygen toxicity Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours) (Urden, Stacy, & Lough, 2014). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.

(uWorld) A client with a severe asthma exacerbation following influenza infection is transferred to the intensive care unit due to rapidly deteriorating respiratory status. Which clinical manifestations support the nurse's assessment of impending respiratory failure? Select all that apply. a) arterial pH 7.50 b) PaCO2 55mmHg (7.3kPa) c) PaO2 58mmHg (7.7kPa) d) Paradoxical breathing e) Restlessness and drowsiness

b) PaCO2 55mmHg (7.3kPa) c) PaO2 58mmHg (7.7kPa) d) Paradoxical breathing e) Restlessness and drowsiness Acute severe asthma exacerbations (status asthmaticus) occur when severe airway obstruction and lung hyperinflation (air trapping) persist despite aggressive treatment with bronchodilators and corticosteroid therapy. Clinical manifestations indicating impending respiratory failure include: PaCO2 ≥45 mm Hg (6.0 kPa): Indicates hypercapnia and hypoventilation resulting from fatigue and labored breathing. As initial tachypnea subsides and respiratory rate returns to normal, PaCO2 rises and respiratory acidosis develops (Option 2). PaO2 ≤60 mm Hg (8.0 kPa): Indicates hypoxemia resulting from increased work of breathing, decreased gas exchange (hyperinflation and air trapping), and inability of the lungs to meet the body's oxygen demand (Option 3) Paradoxical breathing (ie, abnormal inward movement of the chest on inspiration and outward movement on expiration): Indicates diaphragm muscle fatigue and use of respiratory accessory muscles (Option 4) Mental status changes (eg, restlessness, confusion, lethargy, drowsiness): Sensitive indicators of hypoxemia and hypoxia (Option 5) Absence of wheezing and silent chest (ie, no sound of air movement on auscultation): Ominous signs indicating severe hyperinflation and air trapping in the lungs Single-word dyspnea: Inability to speak >1 word before pausing to breathe due to shortness of breath (Option 1) Normal arterial pH is 7.35-7.45. A pH of 7.50 indicates alkalosis, which could be respiratory or metabolic. Clients with respiratory failure have respiratory acidosis (low pH and elevated pCO2). Educational objective: Clinical manifestations indicating impending respiratory failure in clients with asthma include hypercapnia, hypoxemia, paradoxical breathing, and mental status changes.

(uWorld) The nurse caring for a client with left lobar pneumonia responds to an alarm from the continuous pulse oximeter. The client is short of breath with an oxygen saturation of 78%. After applying oxygen, the nurse should place the client in which position to improve oxygenation? a) left lateral b) right lateral c) supine d) trendelenburg

b) right lateral Pneumonia is a lung infection resulting in decreased gas exchange in the affected lung lobes. The alveoli in the affected lobes become blocked with purulent fluid, which impairs ventilation. However, these alveoli continue to receive perfusion from the pulmonary artery, resulting in poorly oxygenated or deoxygenated blood. This ventilation-to-perfusion (V/Q) mismatch, or pulmonary shunt, may result in hypoxia and respiratory distress. Blood flow in the lungs is partially influenced by gravity, meaning that blood flows in higher volumes to dependent parts of the lung. Therefore, a client with left lobar pneumonia should be positioned in right lateral position with the unaffected (good) lung down (eg, right lung) to increase blood flow to the lung most capable of oxygenating blood (Option 2). (Option 1) Left lateral positioning will worsen hypoxia by decreasing blood flow to the unaffected (ie, right) lung. (Options 3 and 4) Positioning in supine or Trendelenburg position does not promote increased perfusion to the unaffected lung, which is needed to improve hypoxia. Educational objective:Pneumonia (ie, infection of the lungs) causes decreased gas exchange in the affected lung lobes, which can lead to hypoxia and respiratory distress. Clients with unilateral pneumonia should be positioned with the unaffected (ie, good) lung down to improve perfusion and oxygenation.

(uWorld) The nurse is caring for a client receiving mechanical ventilation via tracheostomy 2 weeks following a tracheotomy. The nurse enters the client's room to address a ventilator alarm and notes the tracheostomy tube dislodged and lying on the client's chest. Which action by the nurse is appropriate? Click on the exhibit button for additional information. a) Apply a nonrebreather face mask with 100% oxygen b) Apply dry, sterile gauze over the stoma and secure with tape c) Insert a new tracheostomy tube using the bedside obturator d) Insert a sterile catheter into the stoma and suction the airway

c) Insert a new tracheostomy tube using the bedside obturator A tracheostomy tube, an artificial airway inserted into the trachea through the neck, may be secured with sutures or tracheostomy ties. Accidental dislodgment of a tracheostomy tube is a medical emergency often resulting in respiratory distress from closure of the stoma and airway loss. If accidental dislodgment of mature tracheostomies (ie, >7 days after insertion) occurs where the tract is well formed, the nurse should attempt to open the airway by inserting a curved hemostat to maintain stoma patency and insert a new tracheostomy tube with an obturator (Option 3). (Option 1) Application of supplemental oxygen via nonrebreather face mask may not resolve respiratory distress because air can escape from the stoma. (Option 2) Covering the stoma with a sterile, occlusive dressing (eg, petroleum gauze, foam tape) and ventilating the lungs with a bag-valve mask over the nose/mouth may be necessary if the tube cannot be reinserted or the stoma is immature. Dry gauze is porous and does not adequately seal the stoma for ventilation. (Option 4) Tracheal suctioning may be necessary once the airway is resecured. However, suctioning prior to establishing an airway does not improve ventilation and may further reduce the oxygen supply. Educational objective: Accidental dislodgment of a tracheostomy tube is a medical emergency. With a mature tracheostomy, an attempt to insert a new tracheostomy tube with the bedside obturator is indicated. If a tube cannot be reinserted, the stoma is covered with a sterile, occlusive dressing. Ventilation is provided with a bag-valve mask over the nose/mouth.

(uWorld) When an unlicensed assistive personnel (UAP) assists a client with a chest tube back to bed from the bedside commode, the plastic chest drainage unit accidently falls over and cracks. The UAP immediately reports this incident to the nurse. What is the nurse's immediate action? a) Clamp the tube close to the client's chest until a new chest drainage is set up b) Notify the HCP c) Place the distal end of the chest tube into a bottle of sterile saline d) Position the client on the left side

c) Place the distal end of the chest tube into a bottle of sterile saline If the chest tube disconnects from the drainage tubing without contamination, wipe the end of the chest tube with an antiseptic and immediately reconnect it. To prevent accidental disconnection of the chest tube from the tubing, secure all connections with tape or bands, according to hospital policy and procedure. If the chest tube is disconnected with contamination and cannot be immediately reattached, or if the chest drainage unit breaks, cracks, or malfunctions, submerge the distal end of the chest tube 1-2 in (2-4 cm) below the surface of a 250 mL bottle of sterile water or saline. This creates an immediate water seal and prevents air from entering into the pleural space as the new chest drainage system is established (Option 3). To be prepared for this contingency, emergency equipment should be kept at the bedside, which includes 2 chest tube clamps, a 250 mL bottle of sterile water or saline solution, and antiseptic wipes. (Option 1) Unless prescribed by the HCP, chest tube clamping time should not exceed 1 minute as it raises intrapleural pressure and can lead to a tension pneumothorax. Clamping briefly is acceptable when checking for an air leak in the system or when changing the disposable collection unit. (Option 2) It is not necessary to notify the HCP when replacing a chest drainage system unless the client develops respiratory distress. (Option 4) Positioning the client on the left side is appropriate if a central line is inadvertently pulled out so that any air that may have been sucked in will rise to the right atrium. It is not an appropriate intervention for a chest tube disconnection or crack or malfunction in a chest drainage unit. Educational objective: If a chest tube disconnects from the chest drainage system and cannot be reattached quickly, or if a chest drainage unit cracks or malfunctions, submerge the distal end of the chest tube 1-2 in (2-4 cm) below the surface of a 250 mL bottle of sterile water or saline solution.

The nurse is caring for a client who has been receiving mechanical ventilation for 4 days. During multidisciplinary morning rounds, the health care provider questions the development of a ventilator-associated pneumonia (VAP). Which of the following manifestations does the nurse assess as the best indicator of VAP? a) Blood-tinged sputum b) Positive blood cultures c) Positive, purulent sputum culture d) Rhonchi and crackles

c) Positive, purulent sputum culture Ventilator-associated pneumonia (VAP) is the second most common health care-associated (ie, nosocomial) infection in the United States and is associated with increased mortality, hospital cost, and length of stay. Because it is a nosocomial infection, signs and symptoms associated with VAP present ≥48 hours after initiation of mechanical ventilation. Characteristic clinical manifestations of VAP include purulent sputum, positive sputum culture, leukocytosis (WBC >10,000 mm3), elevated temperature (>100.4 F [38 C]), and new or progressive pulmonary infiltrates suggestive of pneumonia on chest x-ray. (Option 1) Blood-tinged sputum may occur but is not the best indicator of VAP. (Option 2) Positive blood cultures may identify the microorganism causing the infection but are not the best indicator of VAP. Positive blood cultures could be from another source of infection. (Option 4) Rhonchi and crackles are adventitious lung sounds associated with pneumonia but can be present in pulmonary edema or just from increased mucous secretions. They are not the best indicator of VAP. Educational objective: Ventilator-associated pneumonia (VAP) is a health care-associated infection that occurs ≥48 hours after the initiation of mechanical ventilation. Characteristic manifestations of VAP include purulent secretions, positive sputum culture, leukocytosis, elevated temperature, and new or progressive pulmonary infiltrates on chest x-ray.

(uWorld) A client is brought to the emergency department due to loss of consciousness after binge drinking at a college party and then taking alprazolam. Pulse oximetry shows 87% on room air. Which findings would the nurse expect to assess on an arterial blood gas? a) Metabolic acidosis and hyperventilation b) Metabolic alkalosis and hypoventilation c) Respiratory acidosis and hypoventilation d) Respiratory alkalosis and hyperventilation

c) Respiratory acidosis and hypoventilation The combination of excessive alcohol ingestion and the benzodiazepine alprazolam (Xanax) causes respiratory depression, which leads to alveolar hypoventilation secondary to carbon dioxide retention, and respiratory acidosis. Therefore, clients should be advised not to take multiple substances that increase the risk of respiratory depression (eg, opioids, benzodiazepines, alcohol, sedating antihistamines). (Option 1) Diarrhea, ketoacidosis, lactic acidosis, and renal failure can cause metabolic acidosis due to loss of bicarbonate or retention of acids; the lungs would compensate by hyperventilating. (Option 2) Vomiting, gastrointestinal suction, and administration of alkali (ie, sodium bicarbonate) are common causes of metabolic alkalosis; the lungs would compensate by hypoventilating. (Option 4) Hypoxia, anxiety, and pain are common causes of respiratory alkalosis, which is due to alveolar hyperventilation (rapid breathing). Educational objective: Over-sedation, sleep apnea, anesthesia, drug overdose, progressive neuromuscular disease, and chronic obstructive pulmonary disease depress the respiratory center; this leads to alveolar hypoventilation, secondary to carbon dioxide retention, and respiratory acidosis.

A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped? a) Respiratory rate of 16 breaths/minute b) Blood pressure remains stable c) Runs of ventricular tachycardia d) Oxygen saturation of 93%

c) 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. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. The client's blood pressure remains stable, so the weaning can continue.

(uWorld) The nurse is caring for a client with a chest tube that was placed 2 hours ago for a pneumothorax. Where would the nurse expect gentle, continuous bubbling? a) Air leak monitor b) Collection chamber c) Suction control chamber d) Water seal chamber

c) Suction control chamber The suction control chamber (Section A) maintains and controls suction to the chest drainage system; continuous, gentle bubbling indicates that the suction level is appropriate. The amount of suction is controlled by the amount of water in the chamber and not by wall suction. Increasing the amount of wall suction would cause vigorous bubbling but does not increase suction to the client as excess suction is drawn out through the vent of the suction control chamber. Vigorous bubbling would increase water evaporation and therefore decrease the negative pressure applied to the system. The nurse should check the water level and add sterile water, if necessary, to maintain the prescribed level. (Option 1) The air leak monitor (Section C) is part of the water seal chamber. Continuous or intermittent bubbling seen here indicates the presence of an air leak. (Option 2) The collection chamber (Section D) is where drainage from the client will accumulate. The nurse will assess amount and color of the fluid and record as output. (Option 4) The water seal chamber contains water, which prevents air from flowing into the client. Up and down movement of fluid (tidaling) in Section B would be seen with inspiration and expiration and indicates normal functioning of the system. This will gradually reduce in intensity as the lung reexpands. Educational objective: The nurse should observe gentle, continuous bubbling in the suction control chamber. This indicates patency and the appropriate level of suction being applied to the drainage system.

A nurse observes a new environmental services employee enter the room of a client with severe acute respiratory syndrome. Which action by the employee requires immediate intervention by the nurse? a) The employee wears a gown, gloves, N95 respirator, and eye protection when entering the room. b) The employee removes all personal protective equipment and washes his hands before leaving the client's room. c) The employee enters the room wearing a gown, gloves, and a mask. d) The employee doesn't remove the stethoscope, blood pressure cuff, and thermometer that are kept in the room.

c) The employee enters the room wearing a gown, gloves, and a mask. The nurse should tell the employee to wear the proper personal protective equipment, including a gown, gloves, N95 respirator, and eye protection, when entering the client's room. To prevent the spread of infection, a stethoscope, blood pressure cuff, and thermometer for single client use should be kept in the room of a client who requires isolation. Removing all personal protective equipment and washing hands before leaving the client's room are correct procedures.

A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time? a) The patient will be extubated and a nasotracheal tube will be inserted. b) The patient will begin the weaning process. c) The patient will have an insertion of a tracheostomy tube. d) The patient will be extubated and another endotracheal tube will be inserted.

c) The patient will have an insertion of a tracheostomy tube. 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, to reduce the incidence of vocal cord paralysis (secondary to laryngeal nerve damage), and to decrease the work of breathing (Wiegand, 2011).

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 that apply. a) To provide visual feedback to encourage the client to inhale slowly and deeply b) To clear respiratory secretions c) To reduce stress on the myocardium d) To decrease the work of breathing e) To provide adequate transport of oxygen in the blood

c) To reduce stress on the myocardium d) To decrease the work of breathing e) To provide adequate transport of oxygen in the blood Oxygen therapy is designed to provide adequate transport of oxygen in the blood while decreasing the work of breathing and reducing stress on the myocardium. Incentive spirometry is a respiratory modality that provides visual feedback to encourage the client to inhale slowly and deeply to maximize lung inflation and prevent or reduce atelectasis. A mini-nebulizer is used to help clear secretions.

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? a) Auscultate breath sounds bilaterally every 4 hours. b) Instruct the client to breathe into a paper bag. c) Encourage the client to deep-breathe and cough every 2 hours. d) Administer oxygen by nasal cannula as ordered.

d) Administer oxygen by nasal cannula as ordered. 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.

The nurse is caring for a client being weaned from a mechanical ventilator. Which findings would require the weaning process to be terminated? a) PaO2 greater than 60 mm Hg with an FiO2 less than 40% b) Heart rate less than100 bpm c) Vital capacity of 12 mL/kg d) Blood pressure increase of 20 mm Hg from baseline

d) Blood pressure increase of 20 mm Hg from baseline In collaboration with the primary provider, the nurse would terminate the weaning process if adverse reactions occur, including a heart rate increase of 20 beats/min, systolic blood pressure increase of 20 mm Hg, a decrease in oxygen saturation to less than 90%, respiratory rate less than 8 or greater than 20 breaths/min, ventricular dysrhythmias, fatigue, panic, cyanosis, erratic or labored breathing, and paradoxical chest movement. A vital capacity of 10 to 15 mL/kg, maximum inspiratory pressure (MIP) at least -20 cm H2O, tidal volume of 7 to -9 mL/kg, minute ventilation of 6 L/min, and a rapid/shallow breathing index below 100 breaths/min/L; PaO2 greater than 60 mm Hg with FiO2 less than 40% are criteria that indicate a client is ready to be weaned from the ventilator. A normal vital capacity is 10 to 15 mL/kg.

A nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients? a) Passive range of motion exercises for the upper and lower extremities b) Incentive spirometry and deep breathing and coughing exercises c) Maintenance of SpO2 levels ≥90% using supplementary oxygen d) Early ambulation and the use of compression stockings

d) Early ambulation and the use of compression stockings For patients at risk for PE, the most effective approach for prevention is to prevent deep venous thrombosis (DVT). Active leg exercises to avoid venous stasis, early ambulation, and use of elastic compression or intermittent pneumatic compression stockings are general preventive measures. Range of motion exercises, supplementary oxygen, incentive spirometry, and deep breathing exercises are not measures that directly reduce a patient's risk of DVT and consequent PE.

(uWorld) A client is admitted with a pulmonary embolus. The nurse assesses restlessness, one-word dyspnea and shortness of breath with activity, tachycardia, pleuritic chest pain, and severe anxiety. Arterial blood gases indicate respiratory alkalosis and hypoxemia. When initiating the care plan, the nurse should choose which nursing diagnosis as the highest priority? a) Activity intolerance r/t imbalance between oxygen supply and demand b) Acute pain r/t inspiration and inflammation of pleura c) Anxiety r/t fear of the unknown, chest pain, and dyspnea d) Impaired gas exchange r/t ventilation-perfusion imbalance

d) Impaired gas exchange r/t ventilation-perfusion imbalance Pulmonary embolism (PE) is usually caused by a dislodged thrombus that travels through the pulmonary circulation, becomes lodged in a pulmonary vessel, and causes an obstruction to blood flow in the lung. The nursing diagnosis of impaired gas exchange involves an alteration in the normal exchange of oxygen and carbon dioxide at the alveolar-capillary membrane, resulting in inadequate oxygenation and hypoxemia (respiratory alkalosis, pO2 <80 mm Hg, restlessness, dyspnea, and tachycardia). Impaired gas exchange related to a ventilation-perfusion (V/Q) imbalance is the highest priority nursing diagnosis. It addresses the most basic physiologic need—oxygen. Clients will not survive without adequate oxygenation. (Options 1, 2, and 3) Activity intolerance, acute pain, and anxiety elicit autonomic responses (exertional discomfort, dyspnea, tachycardia) and are all appropriate nursing diagnoses. However, none are the highest priority or pose the greatest threat to survival. Educational objective: Activity intolerance, anxiety, acute pain, and impaired gas exchange are all appropriate nursing diagnoses to include in the plan of care for a client with PE. The highest priority nursing diagnosis is the one that poses the greatest threat to the client's survival.

(uWorld) A client's arterial blood gases (ABGs) are shown in the exhibit. The nurse would expect which finding to demonstrate that the client is compensating for the ABGs? Click on the exhibit button for additional information. PH 7.25 PO2 79 mm Hg (10.5 kPa) PaCO235 mm Hg (4.66 kPa) HCO3-12 mEq/L (12 mmol/L) a) Decrease in bicarbonate reabsorption b) Decrease in respiratory rate c) Increase in bicarbonate reabsorption d) Increase in respiratory rate

d) Increase in respiratory rate The client's ABGs have low pH consistent with acidosis. If it is a primary respiratory acidosis, pCO2 would be higher. If it is metabolic acidosis, bicarbonate would be lower. Because this client has low pH coupled with low bicarbonate, the most likely diagnosis is primary metabolic acidosis. Respiratory alkalosis is the body's natural compensation for metabolic acidosis. Respiratory alkalosis is achieved by blowing more CO2 off from the system through rapid breathing. (Option 1) Decreased bicarbonate reabsorption would produce metabolic acidosis; this would occur as a compensation for primary respiratory alkalosis (decreased pCO2 and high pH). (Option 2) When the respiratory rate is decreased, pCO2 would increase, creating a respiratory acidosis; this would occur in response to a primary metabolic alkalosis. (Option 3) Increased bicarbonate reabsorption would produce metabolic alkalosis; this would occur as a compensation for primary respiratory acidosis (increased pCO2 and low pH). Educational objective: Respiratory alkalosis is the body's natural compensation for metabolic acidosis. It is achieved by blowing more CO2 off from the system through rapid breathing.

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? a) Administer a heparin bolus and begin an infusion at 500 units/hour. b) Administer analgesics as ordered. c) Perform nasopharyngeal suctioning. d) Initiate oxygen therapy.

d) Initiate oxygen therapy. The client's signs and symptoms suggest pulmonary embolism. Therefore, maintaining respiratory function takes priority. The nurse should first initiate oxygen therapy and then notify the physician immediately. The physician will most likely order an anticoagulant such as heparin or an antithrombolytic to dissolve the thrombus. Analgesics can be administered to decrease pain and anxiety but administering oxygen takes priority. Suctioning typically isn't necessary with pulmonary embolism.

The nurse identifies which finding to be most consistent prior to the onset of acute respiratory failure? a) Loss of lung function b) Chronic lung disease c) Slow onset of symptoms d) Normal lung function

d) Normal lung function Acute respiratory failure occurs suddenly in clients who previously had normal lung function.

(uWorld) The nurse is assessing a client an hour after a left lung lobectomy. The client is awake, alert, and oriented, and reports pain of 6 on a 0-10 scale. Pulse oximetry is 92% on 4 L oxygen via nasal cannula. The chest tube is set to continuous water seal suction at -20 cm H2O. The collection chamber has accumulated 320 mL of frank red drainage in the last hour. What is the priority nursing action? a) Clamp the chest tube immediately b) Increase oxygen to 6L via nasal cannula c) Medicate client for pain and document the findings d) Notify the HCP immediately

d) Notify the HCP immediately Following lung surgery, a chest tube is inserted into the pleural space to create a negative vacuum to re-inflate the lung and prevent air from re-entering the space. A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. The collection chamber should be inspected every hour for the first 8 hours following surgery, then every 8 hours until it is removed. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately. The priority action is to contact the health care provider for further management. (Option 1) Clamping the chest tube prevents air or fluid from leaving the pleural space, which may cause a reciprocal tension pneumothorax. The chest tube is clamped only a few hours prior to removal, momentarily to check for an air leak, or if the drainage apparatus needs to be changed. (Option 2) Although a pulse oximetry of 92% is low, this is an expected finding following lung surgery. (Option 3) Pain following surgery is a concern and the client will require medication; however, hemorrhage is the priority. Educational objective: A client with a chest tube should be assessed for signs of air/fluid in the chest (eg, diminished breath sounds), excessive drainage (>100 mL/hr), pain, and infection at the drainage site. Excess drainage of frank red blood is indicative of hemorrhage and must be managed immediately.

A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing between acute respiratory distress syndrome and acute respiratory failure? a) Bicarbonate (HCO3-) b) Partial pressure of arterial carbon dioxide (PaCO2) c) pH d) Partial pressure of arterial oxygen (PaO2)

d) Partial pressure of arterial oxygen (PaO2) In acute respiratory failure, administering supplemental oxygen elevates the PaO2. In acute respiratory distress syndrome, elevation of the PaO2 requires positive end-expiratory pressure. In both situations, the PaCO2 is elevated and the pH and HCO3- are depressed.

(uWorld) A 64-year-old hospitalized client with chronic obstructive pulmonary disease exacerbation has increased lethargy and confusion. The client's pulse oximetry is 88% on 2 liters of oxygen. Arterial blood gas analysis shows a pH of 7.25, PO2 of 60 mm Hg (8.0 kPa), and PCO2 of 80 mm Hg (10.6 kPa). Which of the following should the nurse implement first? a) Administer PRN nebulizer treatment b) Administer scheduled doses of methylprednisolone IV c) Increase client's oxygen to 4L d) Place client on the BiPAP machine

d) Place client on the BiPAP machine An elevated carbon dioxide (CO2) level (normal: 35-45 mm Hg [4.7-6.0 kPa]) is usually an indicator of hypercapneic respiratory failure. The bilevel positive airway pressure (BIPAP) machine will provide positive pressure oxygen and expel CO2 from the lungs. This client is already showing signs of lethargy and confusion, which is usually a late indicator of respiratory decline. Therefore, the nurse's priority should be to get the client on the BIPAP machine as soon as possible. (Option 1) Nebulizer treatments are commonly part of the treatment plan for a client with chronic obstructive pulmonary disease (COPD). However, these do not take priority when the client has CO2 retention and is deteriorating. If mental status worsens further (due to continued CO2 retention), the client will need intubation. Many BIPAP machines are able to deliver nebulizer treatment while providing positive pressurized oxygen. (Option 2) Steroid therapy is a common pharmaceutical intervention for COPD exacerbation, but it does not take priority over BIPAP in this deteriorating client. In addition, steroids take hours to days to have an effect. (Option 3) In a client with an elevated CO2 level and a history of COPD, the nurse should not increase the oxygen level as this could cause an increase in CO2 retention, resulting in further respiratory failure. Educational objective: BIPAP therapy is an effective treatment to decrease CO2 levels in clients with hypercapnic respiratory failure.

A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? a) Pulmonary embolism b) Heart failure c) Myocardial infarction (MI) d) Pneumothorax

d) Pneumothorax Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive? a) See if a kink has developed in the tubing. b) See if the wall suction unit has malfunctioned. c) See if the chest tube is clogged. d) See if there are leaks in the system.

d) See if there are leaks in the system. Bubbling in the water-seal chamber occurs in the early postoperative period. If bubbling is excessive, the nurse checks the system for any kind of leaks. Fluctuation of the fluid in the water-seal chamber is initially present with each respiration. Fluctuations cease if the chest tube is clogged or a kink develops in the tubing. If the suction unit malfunctions, the suction control chamber, not the water-seal chamber, will be affected.

(uWorld) A client has chronic obstructive pulmonary disease (COPD) exacerbation. The pulse oximeter shows a saturation of 86% on room air. The nurse assesses diminished lung sounds and low-pitched wheezing posteriorly, shallow respirations, respiratory rate of 32/min, and use of accessory muscles. What is the most appropriate oxygen delivery device for this client? a) Nasal cannula b) Non-rebreathing mask c) Oxymizer d) Venturi mask

d) Venturi mask The Venturi mask is a high-flow device that delivers a guaranteed oxygen concentration regardless of the client's respiratory rate, depth, or tidal volume (TV). The adaptor or barrel can be set to deliver 24%-50% (varies with manufacturer) oxygen concentration. In the presence of tachypnea, shallow breathing with decreased TV, hypercarbia, and hypoxemia, it is the most appropriate oxygen delivery device for this client as rapid changes in inspired oxygen concentration can blunt the hypoxemic drive to breathe in clients with COPD. (Option 1) The nasal cannula can deliver adequate oxygen concentrations and is best for clients with adequate TV and normal vital signs. It is not the best choice in an unstable COPD client with varying TVs because the inspired oxygen concentration is not guaranteed. (Option 2) The non-rebreathing reservoir mask can deliver 60%-95% oxygen concentrations and is usually used short term. It is often used for clients with low saturations resulting from asthma, pneumonia, trauma, and severe sepsis; it is not the most appropriate device for a COPD client in this situation. (Option 3) An oxymizer is a nasal reservoir cannula-type device that conserves on oxygen use. Clients can be sustained on a prescribed oxygen level using much less oxygen (eg, 3 L/min nasal cannula is equivalent to 1 L/min oxymizer device) to reach the same saturation. It is not the best choice in an unstable COPD client with varying TVs as the inspired oxygen concentration is not guaranteed. Educational objective: Low-flow oxygen delivery devices (eg, nasal cannula, simple face mask) deliver oxygen concentrations that vary with breathing patterns. They are appropriate for clients who can tolerate varying concentrations (eg, stable COPD, type I respiratory failure [hypoxemic]). High-flow oxygen delivery devices (eg, Venturi mask, mechanical ventilator) deliver oxygen concentrations that do not vary with breathing patterns. They are appropriate for clients who cannot tolerate varying concentrations (eg, exacerbation COPD, type II respiratory failure [hypercarbic]).

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: a) report fluctuations in the water-seal chamber. b) milk the chest tube every 2 hours. c) clamp the chest tube once every shift. d) encourage coughing and deep breathing.

d) encourage coughing and deep breathing. When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? a) pH 7.36, PaCO2 32 mm Hg b) pH 7.35, PaCO2 48 mm Hg c) pH 7.46, PaO2 80 mm Hg d) pH 7.28, PaO2 50 mm Hg

d) pH 7.28, PaO2 50 mm Hg ARF 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 >50 mm Hg (hypercapnia), with an arterial pH less than 7.35.

Which is a correct endotracheal tube cuff pressure? a) 22 mm Hg b) 13 mm Hg c) 16 mm Hg d) 19 mm Hg

a) 22 mm Hg Cuff pressures should be checked with a calibrated aneroid manometer device every 6 to 8 hours to maintain cuff pressures between 20 and 25 mm Hg. The other values are not within the normal range for adequate cuff pressure.

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. a) Breathing without difficulty b) Suctioned every 2 hours c) Cough reflex intact d) Gag reflex intact e) Awake and alert

a) Breathing without difficulty c) Cough reflex intact d) Gag reflex intact e) Awake and alert 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.

(uWorld) A nurse is caring for an elderly client who had a colectomy for removal of cancer 2 days ago. The client is becoming increasingly restless. He has been given intravenous morphine every 2 hours for severe pain. Respirations are 28/min and shallow. Which arterial blood gas (ABG) results best indicate that the client is in acute respiratory failure (ARF) and needs immediate intervention? a) PaO2 49mmHg (6.5kPa), PaCO2 60mmHg (8.0kPa) b) PaO2 64mmHg (8.5kPa), PaCO2 45mmHg (6.0kPa) c) PaO2 70mmHg (9.3kPa), PaCO2 30mmHg (4.0kPa) d) PaO2 86mmHg (11.5kPa), PaCO2 25mmHg (3.33kPa)

a) PaO2 49mmHg (6.5kPa), PaCO2 60mmHg (8.0kPa) Normal adult ABG values at sea level are as follows: pH7.35-7.45PaO280-100 mm Hg (10.7-13.3 kPa)PaCO235-45 mm Hg (4.66-5.98)Bicarbonate (HCO3-)22-26 mEq/L (22-26 mmol/L)O2 Saturation (SaO2)95%-99% ARF is defined as inadequate gas exchange that is intrapulmonary (pneumonia, pulmonary embolism) or extrapulmonary (head injury, opioid overdose) in origin. Respiratory failure associated with an alteration in O2 transfer or absorption is type I hypoxemic failure (eg, acute respiratory distress syndrome, pulmonary edema, shock). Respiratory failure associated with carbon dioxide (CO2) retention is type II hypercapnic, or ventilatory failure (eg, chronic obstructive pulmonary disease, myasthenia gravis, flail chest). ARF is a potential complication of major surgical procedures, especially those involving the thorax and abdomen, as in this client. ABG values that indicate the presence of ARF are PaO2 ≤60 mm Hg (8.0 kPa) or PaCO2 ≥50 mm Hg (6.67 kPa). ARF occurs quickly over time (minutes to hours), and so there is no physiologic compensation and pH is ≤7.30. Immediate intervention with high O2 concentrations is indicated, and noninvasive or invasive, positive-pressure mechanical ventilation may be necessary. (Option 2) PaO2 64 mm Hg (8.5 kPa) indicates hypoxemia, and PaCO2 45 mm Hg (6.0 kPa) is within the normal range, but results do not meet the criteria for ARF. (Option 3) PaO2 70 mm Hg (9.3 kPa) indicates hypoxemia, and PaCO2 30 mm Hg (4.0 kPa) indicates increased ventilation and an alkalotic state, but results do not meet the criteria for ARF. (Option 4) PaO2 86 mm Hg (11.5 kPa) is within normal range, and PaCO2 25 mm Hg (3.33 kPa) indicates increased ventilation and an alkalotic state, but results do not meet the criteria for ARF. Educational objective: Type I hypoxemic failure is associated with an alteration in O2 transfer (eg, acute respiratory distress syndrome, pulmonary edema, shock). Type II hypercapnic, or ventilatory, failure is associated with CO2 retention (eg, chronic obstructive pulmonary disease, myasthenia gravis, flail chest). ABG values that indicate the presence of ARF are PaO2 ≤60 mm Hg (8.0 kPa), PaCO2 ≥50 mm Hg (6.67 kPa), and pH ≤7.30.

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS? a) Rapid onset of severe dyspnea b) Inspiratory crackles c) Cyanosis d) Bilateral wheezing

a) Rapid onset of severe dyspnea The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.

A 22-year-old male patient developed a pulmonary embolism (PE) several days ago and has undergone a course of treatment in the hospital. Discharge has been delayed indefinitely, however, because the patient has developed pleurisy as a complication of his PE. When planning this patient's care, what outcome should the nurse prioritize? a) The patient will experience acceptable control of his pain. b) The patient will successfully demonstrate breathing retraining. c) The patient will demonstrate appropriate use of metered-dose inhalers (MDIs) with a spacer. d) The patient will adhere to his prescribed treatment regimen.

a) The patient will experience acceptable control of his pain. When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is severe, sharp, knife-like pain. Consequently, pain control is paramount during the treatment of pleurisy. Breathing retraining and MDIs are not normally necessary and would be superseded by the importance of pain control. Treatment takes place in a hospital setting, so adherence is a lower priority.

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

a) pH 7.28 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.

The nurse is assigned to care for a client with a chest tube. The nurse should ensure that which item is kept at the client's bedside? a) A set of hemostats b) A bottle of sterile water c) An incentive spirometer d) An Ambu bag

b) A bottle of sterile water It is essential that the nurse ensure that a bottle of sterile water is readily available at the client's bedside. If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent the development of a pneumothorax, a temporary water seal can be established by immersing the open end of the chest tube in a bottle of sterile water. There is no need to have an Ambu bag, incentive spirometer, or a set of hemostats at the bedside.

(uWorld) The charge nurse evaluates the care provided by a new registered nurse (RN) for a client receiving mechanical ventilation (MV). Which action by the new RN indicates the need for further education? a) Administers morphine to relieve anxiety and restlessness b) Applies suction when inserting the catheter in to the airway c) Increase the oxygen concentration on the MV before suctioning d) Suctions when MV high-pressure alarm continues to sound and rhonchi are present

b) Applies suction when inserting the catheter in to the airway Risks associated with suctioning include hypoxemia, microatelectasis, and cardiac dysrhythmias. Suctioning removes secretions and oxygen. To minimize both the amount of oxygen removed and mucosal trauma, suction is applied when removing, not inserting, the catheter into the artificial airway. If secretions are thick and difficult to remove, increasing hydration, not suctioning time, is indicated. Aerosols of sterile normal saline or mucolytics such as acetylcysteine (Mucomyst) administered by nebulizer can also be used to thin the thick secretions, but water should not be used. Aerosol therapy may induce bronchospasm in certain individuals and can be relieved by use of a bronchodilator (albuterol). (Option 1) Morphine is administered to promote breathing synchrony with the mechanical ventilator, reduce anxiety, and promote comfort in clients receiving MV. (Option 3) Preoxygenation with 100% oxygen for 30 seconds before suctioning, unless otherwise specified, is the recommended practice to reduce suctioning-associated risks for hypoxemia, microatelectasis, and cardiac dysrhythmias. (Option 4) It is appropriate to suction the client when the high-pressure alarm on the MV sounds, saturations drop, rhonchi are auscultated, and secretions are audible or visible. These manifestations can indicate excessive secretions impairing airway patency. Educational objective: To minimize removal of oxygen and mucosal trauma, suction should be applied only when removing the catheter, not when inserting it. Other interventions to reduce the risks associated with suctioning (eg, hypoxemia, microatelectasis, cardiac dysrhythmias) include assessment for the need to suction, preoxygenating with 100% oxygen, and limiting suction time to 10-15 seconds.

Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths? a) Synchronized intermittent mandatory ventilation (SIMV) b) Intermittent mandatory ventilation (IMV) c) Pressure support d) Assist control

b) Intermittent mandatory ventilation (IMV) IMV 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. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the client can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing.

A nurse is transporting a client with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse? a) Immediately reconnect the chest tube to the drainage apparatus. b) Place the chest tube in sterile water. c) Notify the health care provider. d) Clamp the chest tube close to the connection site.

b) Place the chest tube in sterile water. If the client is lying on a stretcher and must be transported to another area, place the drainage system below the chest level. If the tubing disconnects, place the end of the chest tube in sterile water. Reattaching the chest tube to the drainage system is a source for infection. Do not clamp the chest tube during transport. Notifying the health care provider will not help the client in the situation.

A client is being discharged following pelvic surgery. What would be included in the patient care instructions to prevent the development of a pulmonary embolus? a) Consume the majority of daily fluid intake prior to bed. b) Tense and relax muscles in the lower extremities. c) Wear tight-fitting clothing. d) Begin estrogen replacement.

b) Tense and relax muscles in the lower extremities. Clients are encouraged to perform passive or active exercises, as tolerated, to prevent a thrombus from forming. Constrictive, tight-fitting clothing is a risk factor for the development of a pulmonary embolism in postoperative clients. Clients at risk for a DVT or a pulmonary embolism are encouraged to drink throughout the day to avoid dehydration. Estrogen replacement is a risk factor for the development of a pulmonary embolism.

Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? a) T-piece b) Venturi mask c) Partial-rebreathing mask d) Nasal cannula

b) Venturi mask The Venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. Nasal cannula, T-piece, and partial-rebreathing masks are not the most reliable and accurate methods of oxygen administration.

A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for: a) 30 to 40 minutes. b) 15 to 60 seconds. c) 5 to 20 minutes. d) 45 to 60 minutes.

c) 5 to 20 minutes. Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, then gradually lengthen this interval according to the client's respiratory status. A client who doesn't require continuous mechanical ventilation already is breathing without assistance, at least for short periods; therefore, plugging the opening of the tube for only 15 to 60 seconds wouldn't be long enough to reveal the client's true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally.

A client is receiving mechanical ventilation. How frequently should the nurse auscultate the client's lungs to check for secretions? a) Every 30 to 60 minutes b) Every 1 to 2 hours c) Every 2 to 4 hours d) Every 4 to 6 hours

c) Every 2 to 4 hours Continuous positive-pressure ventilation increases the production of secretions regardless of the patient's underlying condition. The nurse assesses for the presence of secretions by lung auscultation at least every 2 to 4 hours.

Which type of oxygen therapy includes the administration of oxygen at pressure greater than atmospheric pressure? a) Transtracheal b) High-flow systems c) Hyperbaric d) Low-flow systems

c) Hyperbaric Hyperbaric oxygen therapy is the administration of oxygen at pressures greater than atmospheric pressure. As a result, the amount of oxygen dissolved in plasma is increased, which increases oxygen levels in the tissues. Low-flow systems contribute partially to the inspired gas the client breathes, which means that the client breathes some room air along with the oxygen. High-flow systems are indicated for clients who require a constant and precise amount of oxygen. During transtracheal oxygenation, clients achieve adequate oxygenation at lower rates, making this method less expensive and more efficient.

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

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

A nurse who works in a critical care setting is caring for an adult female patient who was diagnosed with acute respiratory distress syndrome (ARDS) and promptly placed on positive-end expiratory pressure (PEEP). When planning this patient's care, what nursing diagnosis should be prioritized? a) Risk for aspiration b) Acute pain c) Impaired gas exchange d) Anxiety

c) Impaired gas exchange Anxiety and pain are both possible during treatment for ARDS. However, maintenance of the patient's airway with the goal of facilitating gas exchange is an absolute priority. The patient's risk of aspiration is low due to NPO status and the presence of inline suctioning.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? a) Increase the oxygen percentage. b) Check for an apical pulse. c) Suction the client's artificial airway. d) Ventilate the client with a handheld mechanical ventilator.

c) Suction the client's artificial airway. A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of gas from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.

A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for? a) Stagnant hypoxia b) Hypoxic hypoxia c) Histotoxic hypoxia d) Anemic hypoxia

d) Anemic hypoxia Anemic hypoxia is a result of decreased effective hemoglobin concentration, which causes a decrease in the oxygen-carrying capacity of the blood. It is rarely accompanied by hypoxemia. Carbon monoxide poisoning, because it reduces the oxygen-carrying capacity of hemoglobin, produces similar effects but is not strictly anemic hypoxia, because hemoglobin levels may be normal.

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? a) Bloody drainage is observed in the collection chamber. b) Skin around tube is pink. c) Absence of bloody drainage in the anterior/upper tube d) The tissues give a crackling sensation when palpated.

d) The tissues give a crackling sensation when palpated. Subcutaneous emphysema is the result of air leaking between the subcutaneous layers. It is not a serious complication but is notable and reportable. Pink skin and blood in the collection chamber are normal findings. When two tubes are inserted, the posterior or lower tube drains fluid, whereas the anterior or upper tube is for air removal.

(Saunders) The nurse is assessing a client with multiple trauma who is at risk for developing ARDS. The nurse should assess for which EARLIEST sign of ARDS? a) bilateral wheezing b) inspiratory crackles c) intercostal retractions d) increased respiratory rate

d) increased respiratory rate The earliest detectable sign of ARDS is an increased respiratory rate, which can begin from 1 to 96hrs after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles

A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration? a) A partial rebreathing mask b) An oropharyngeal catheter c) A Venturi mask d) A nasal cannula

a) A partial rebreathing mask Partial rebreathing masks have a reservoir bag that must remain inflated during both inspiration and expiration. The nurse adjusts the oxygen flow to ensure that the bag does not collapse during inhalation. A high concentration of oxygen (50% to 75%) can be delivered because both the mask and the bag serve as reservoirs for oxygen. The other devices listed cannot deliver oxygen at such a high concentration.

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: a) Assess pulse and blood pressure. b) Administer prescribed pain medication. c) Notify the physician. d) Lay the client's head to a flat position.

a) Assess pulse and blood pressure. The client has bled 120 mL of bloody drainage in the chest drainage system within 15 minutes. It is most important for the nurse to assess for signs and symptoms of hemorrhage, which may be indicated by a rapid pulse and decreasing blood pressure. The nurse may then lay the client in a flat position and notify the physician.

A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? a) Continuous positive airway pressure (CPAP) b) Surgery to remove the tonsils and adenoids c) Medications to assist the patient with sleep at night d) Bi-level positive airway pressure (BiPAP)

a) Continuous positive airway pressure (CPAP) CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea.

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? a) Impaired gas exchange related to ventilator setting adjustments b) Risk for infection related to endotracheal intubation and suctioning c) Risk for trauma related to endotracheal intubation and cuff pressure d) Impaired physical mobility related to being on a ventilator

a) Impaired gas exchange related to ventilator setting adjustments All the nursing diagnoses are appropriate for this client. Per Maslow's hierarchy of needs, airway, breathing, and circulation are the highest priorities within physiological needs. The client has an oxygen saturation of 91%, which is below normal. This places impaired gas exchange as the highest prioritized nursing diagnosis.

A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply. a) Substernal pain b) Dyspnea c) Fatigue d) Bradycardia e) Mood swings

a) Substernal pain b) Dyspnea c) Fatigue Oxygen toxicity can occur when clients receive too high a concentration of oxygen for an extended period. Symptoms include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia and mood swings are not symptoms of oxygen toxicity.

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

a) The cuff is deflated before the tube is removed. b) Cuff pressures should be checked every 6 to 8 hours. c) Humidified oxygen should always be introduced through the tube. 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 client who underwent thoracic surgery to remove a lung tumor had a chest tube placed anteriorly. The surgical team places this catheter to: a) remove air from the pleural space. b) ventilate the client. c) administer IV medication. d) remove fluid from the lungs.

a) remove air from the pleural space. After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand. A catheter placed in the pleural space provides a drainage route through a closed or underwater-seal drainage system to remove air. Sometimes two chest catheters are placed following thoracic surgery: one anteriorly and one posteriorly. The anterior catheter removes air; the posterior catheter removes fluid.

A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by: a) using the minimal-leak technique with cuff pressure less than 25 cm H2O. b) suctioning the tracheostomy tube frequently. c) keeping the tracheostomy tube plugged. d) using a cuffed tracheostomy tube.

a) using the minimal-leak technique with cuff pressure less than 25 cm H2O. To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned? a) Assess the CO2 level to determine if the patient requires suctioning. b) Auscultate the lung for adventitious sounds. c) Have the patient inform the nurse of the need to be suctioned. d) Have the patient cough.

b) Auscultate the lung for adventitious sounds. When a tracheostomy or endotracheal tube is in place, 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 obviously present. Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa.

Which finding would indicate a decrease in pressure with mechanical ventilation? a) Decrease in lung compliance b) Increase in compliance c) Plugged airway tube d) Kinked tubing

b) Increase in compliance A decrease in pressure in the mechanical ventilator may be caused by an increase in compliance. Kinked tubing, decreased lung compliance, and a plugged airway tube cause an increase in peak airway pressure.

In general, chest drainage tubes are not used for a patient undergoing a) segmentectomy. b) pneumonectomy. c) lobectomy. d) wedge resection.

b) pneumonectomy. Usually no drains are used for a client undergoing pneumonectomy because the accumulation of fluid in the empty hemothorax prevents mediastinal shift. With lobectomy, two chest tubes are usually inserted for drainage, the upper tube for air and the lower tube for fluid. With wedge resection, the pleural cavity usually is drained because of the possibility of an air or blood leak. With segmentectomy, drains are usually used because of the possibility of an air or blood leak.

(uWorld) The nurse cares for a client with a pulmonary embolism. Which of the following clinical manifestations would the nurse anticipate? Select all that apply. a) bradycardia b) chest pain c) dyspnea d) hypoxemia e) tachypnea f) tracheal deviation

b) chest pain c) dyspnea d) hypoxemia e) tachypnea Pulmonary embolism (PE) is a potentially life-threatening medical emergency occurring when a blood clot, fat or air embolus, or tissue (eg, tumor) travels via the venous system into the pulmonary circulation and obstructs blood flow into the lung. This prevents deoxygenated blood from reaching the alveoli, which leads to hypoxemia due to impaired gas exchange and cardiac strain due to congested blood flow in the pulmonary arteries. Clinical manifestations of PE range from mild (eg, anxiety, cough) to severe (eg, heart failure, sudden death). However, many clients initially have mild, nonspecific symptoms that are often misdiagnosed and inadequately managed, greatly increasing the likelihood of progression to shock and/or cardiac arrest. Clinical manifestations of PE include: Pleuritic chest pain (ie, sharp lung pain while inhaling) (Option 2) Dyspnea and hypoxemia (Options 3 and 4) Tachypnea and cough (eg, dry or productive cough with bloody sputum) (Option 5) Tachycardia Unilateral leg swelling, erythema, or tenderness related to deep vein thrombosis (Option 1) Tachycardia, rather than bradycardia, is expected with PE because the heart attempts to compensate for hypoxemia, right ventricular overfilling, and decreased left ventricular cardiac output. (Option 6) Tracheal deviation is a sign of tension pneumothorax (not PE), which occurs when pressure on the side of the collapsed lung pushes organs toward the unaffected lung. Educational objective: Pulmonary embolism is a potentially life-threatening medical emergency occurring when a pulmonary artery is obstructed. Common clinical manifestations include pleuritic chest pain, dyspnea, hypoxemia, tachypnea, cough, tachycardia, and unilateral leg swelling.

(uWorld) The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted to evacuate a pneumothorax caused by fractured ribs. Where would the nurse observe an air leak? a) A b) B c) C d) D

c) The presence of an air leak is indicated by continuous bubbling of fluid at the base of the water seal chamber. If the client has a known pneumothorax, intermittent bubbling would be expected. Once the lung has re-expanded and the air leak is sealed, the bubbling will cease. The nurse is expected to assess for the presence or absence of an air leak and to determine whether it originates from the client or the chest tube system. (Option 1) Section A is the suction control chamber. Gentle, continuous bubbling indicates that suction is present. (Option 2) Section B is part of the water seal chamber, but an air leak will not be evident in this upper portion. Tidaling of fluid is expected in this portion of the chamber and indicates patency of the tube. (Option 4) Section D is the collection chamber, where drainage from the client will accumulate. The nurse will assess amount and color of the fluid and record these as output. Educational objective: An air leak is indicated by bubbling of fluid in the base of the water seal chamber of a chest tube drainage unit. The client with a known pneumothorax is expected to have an intermittent air leak, with bubbling in the water seal chamber. Continuous bubbling indicates an air leak somewhere in the chest tube system.

(uWorld) The nurse is assisting the health care provider (HCP) with a client's chest tube removal. Just as the HCP prepares to pull the chest tube, what instructions should the nurse give the client? a) "Breathe as you normally would" b) "Inhale and exhale slowly" c) "Take a breath in, hold it, and bear down" d) "Take rapid shallow breaths, similar to panting"

c) "Take a breath in, hold it, and bear down" Chest tubes are indicated to drain air or fluid from the pleural space and reestablish negative pressure, which allows for proper lung expansion. When the lung has reexpanded or fluid drainage is no longer needed, the chest tube can be discontinued. The client should be given an analgesic 30-60 minutes prior to the procedure. A suture removal kit, petroleum gauze, and occlusive dressing supplies will be needed. The client should be instructed to take a deep breath, hold it, and bear down (Valsalva maneuver) while the tube is being removed. This will prevent air from being pulled back into the pleural space and possibly causing a pneumothorax. A post-procedure chest x-ray must be performed to ensure there is no reaccumulation of air or fluid in the pleural space. (Options 1 and 2) Breathing slowly or normally during the procedure may cause the client to inhale during the removal, pulling air back into the pleural space. (Option 4) Rapid shallow breaths increase the chance of inhaling during removal and pulling air into the pleural space, causing recollapse of the lung. Educational objective: During chest tube removal, the client should be instructed to take a deep breath, hold it, and bear down (Valsalva maneuver) to prevent air from reentering the pleural space and possibly causing a pneumothorax. The site is covered with a sterile airtight petroleum jelly gauze dressing. A post-procedure chest x-ray is needed.

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. The client is placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. What setting would be the best maximum FIO2 setting? a) 0.35 b) 0.7 c) 0.5 d) 0.21

c) 0.5 An FIO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. Clients with respiratory disorders are given oxygen therapy only to increase the partial pressure of oxygen (PaO2) back to the patient's normal baseline, which may vary from 60 to 95 mm Hg. In terms of the oxyhemoglobin dissociation curve, arterial hemoglobin at these levels is 80% to 98% saturated with oxygen; higher FiO2 flow values add no further significant amounts of oxygen to the red blood cells or plasma. Instead of helping, increased amounts of oxygen may produce toxic effects on the lungs and central nervous system or may depress ventilation. The ideal oxygen source is room air FIO2 0.21.

(Saunders) A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is MOST commonly reported? a) hot, flushed feeling b) sudden chills and fever c) chest pain that occurs suddenly d) dyspnea when deep breaths are taken

c) chest pain that occurs suddenly The most common initial symptom in PE is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of PE include apprehension and restlessness, tachycardia, cough, and cyanosis

What range of pressure within the endotracheal tube cuff does the nurse maintain to prevent both injury and aspiration? a) 10 to 15 mm Hg b) 25 to 30 mm Hg c) 15 to 20 mm Hg d) 20 to 25 mm Hg

d) 20 to 25 mm Hg Usually the pressure is maintained at <25 mm HG (30 cm H2O) water pressure to prevent injury and at >20 mm HG (24 cm H2O) water pressure to prevent aspiration. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can increase the risk of aspiration pneumonia. A water pressure of 10-15 or 15-20 mm Hg would indicate that the cuff is underinflated. A water pressure of 25-30 mm Hg would indicate that the cuff is overinflated.

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? a) The ET tube must be pulled back. b) The X-ray is inconclusive. c) The ET tube must be advanced. d) A disease process is present.

d) A disease process is present. 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.

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

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

The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined? a) Call respiratory therapy and wait until they arrive to determine what is happening. b) Suction the patient since the patient may be obstructed by secretions. c) Stop the ventilator by pressing the off button, wait 15 seconds, and then turn it on again to see if the alarm stops. d) Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.

d) Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. If the cause of an alarm cannot be determined, the nurse should disconnect the patient from the ventilator and manually ventilate the patient, because leaving the patient on the mechanical ventilator may be dangerous.