Upper Respiratory Quiz
B Suction the tracheostomy using sterile technique *Complex sterile procedures are within the education and scope of practice of the experienced LPN/LVN. Completion of client referral forms, client and family teaching, and consulting with the health care provider are all actions that must be performed by an RN.
An older adult client is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN? A Complete the referral form for a home health agency. B Suction the tracheostomy using sterile technique. C Teach the client and spouse about tracheostomy care. D Consult with the health care provider about using a fenestrated tube.
1 Be certain to maintain Body Substance or Standard Precautions 3 Instruct the client not to blow the nose for 24 hours after bleeding ceases 5 Keep the client calm to reduce anxiety and elevated blood pressure *Body Substance Precautions should always be used with potential exposure to any body fluid, including the client with an anterior nosebleed. Spontaneously blowing the nose within 24 hours after a bleed can restart the bleed-always instruct the client to avoid this for at least 24 hours. Increased anxiety and elevated blood pressure can serve to increase the bleeding and/or interfere with stopping the bleeding. Pressure on the bridge of the nose may actually be placed above the site of the bleed. An anterior bleed should not cause a change in oxygenation unless there are other sources of airway obstruction or a significant rapid blood loss.
A client has an anterior nosebleed. What nursing actions would be important interventions for safe and quality care? Select all that apply. 1 Be certain to maintain Body Substance or Standard Precautions. 2 Apply pressure to the bridge of the nose to decrease bleeding. 3 Instruct the client not to blow the nose for 24 hours after bleeding ceases. 4 Watch the client closely for indications of change in oxygenation. 5 Keep the client calm to reduce anxiety and elevated blood pressure.
B Decreasing respiratory rate *Respiratory rate and depth should be monitored closely while the client receives oxygen, because hypoventilation is seen during the first 30 minutes of oxygen therapy in clients with hypoxic drive for respiration. The client's color will improve (from ashen or gray to pink) because of an increase in PaO2 level before apnea or respiratory arrest occurs from loss of the hypoxic drive. The COPD client is not sensitive to PaCO2; oxygen administration can cause high PaO2 levels. Monitoring for adventitious breath sounds is important, but these would not be a result of the oxygen that the client is receiving. The ability to cough and breathe deeply is a positive sign.
A client is admitted to the hospital for chronic obstructive pulmonary disease (COPD), and the health care provider requests oxygen via nasal cannula at 2 L/min. Within 30 minutes, the client's color improves. What does the nurse continue to monitor that may require immediate attention? A Increasing carbon dioxide levels B Decreasing respiratory rate C Increasing adventitious breath sounds D Increased coughing
A "I can only take baths, but no showers." *The client does not understand that he or she can shower with the use of a shower shield over the tracheostomy tube to prevent water from entering the airway. Additional teaching is necessary. Normal saline should be instilled into the artificial airway 10 to 15 times a day, as prescribed. The stoma should be covered with cotton or foam to protect it during the day; this filters the air entering the stoma, keeps humidity in the airway, and enhances appearance. Clients with tracheostomies should be taught clean suction technique.
A client is being discharged home with a tracheostomy. Which statement by the client indicates the need for further teaching about correct tracheostomy care? A "I can only take baths, but no showers." B "I can put normal saline in my tracheostomy to keep the secretions from getting thick." C "I should put cotton or foam over the tracheostomy hole." D "I will have to learn to suction myself."
D The client is receiving oxygen at 4 L/min *A simple facemask must receive oxygen at a rate of at least 5 L/min to prevent inhalation of exhaled breath, which has low levels of oxygen and can eventually suffocate the client. The client had a panic attack, not an asthma attack. A panic attack is not a definitive diagnostic indicator of a mental disorder. A small dose of Valium does not place a client at increased risk for respiratory distress; a large dose is required to place a client at high risk.
A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose of oral diazepam (Valium) 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress? A The client is not being treated for asthma. B The client has a mental disorder. C The client received a dose of Valium. D The client is receiving oxygen at 4 L/min.
A Hyperoxygenate before and after suctioning *The client should be preoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client should be hyperoxygenated for 1 to 5 minutes, or until the client's baseline heart rate and oxygen saturation are within normal limits. Repeat suctioning as needed for up to three total suction passes; additional suctioning will cause or worsen hypoxemia. Applying suction during insertion is inappropriate because suction makes advancement of the suction tube difficult/traumatic. Suction is applied only when the suction tube is removed. Suctioning for 30 seconds is too long and can cause or worsen hypoxemia; never suction longer than 10 to 15 seconds.
For client safety and quality care, which technique is best for the nurse to use when suctioning the client with a tracheostomy tube? A Hyperoxygenate before and after suctioning. B Repeat suctioning until the tube is clear. C Apply suction during insertion of the tube. D Suction for 30 seconds.
D Suctioning the client *Suctioning the client will likely result in clear lung sounds and lower peak pressure, and the appearance of the sputum will indicate whether bleeding is a concern. Humidifying the oxygen source will help mobilize secretions, but an active cough response is also required to clear the airway; a sedated client has a weak cough. Increasing oxygenation does nothing to clear the airway of whatever is making it noisy and is elevating peak pressures. Removing the inner cannula of a ventilated client is contraindicated.
Respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse? A Humidifying the oxygen source B Increasing oxygenation C Removing the inner cannula of the tracheostomy D Suctioning the client
2 Extend the client's head and neck *Clients who are unconscious often have airway obstruction caused by the tongue falling back or by excessive secretions. The initial step is to extend the head and neck. Inserting an oral or nasal airway device and suctioning may be done next. Once the airway is established, oxygen may be necessary.
The nurse assesses that an unconscious client is struggling to breathe. What is the nurse's first action? 1 Administer oxygen by nasal cannula. 2 Extend the client's head and neck. 3 Insert an oral airway device. 4 Suction the oropharynx.
C PaO2 of 65 mmHg *A PaO2 of 65 mm Hg indicates low levels of oxygen in the arterial blood; this is considered hypoxemia. Hemoglobin measures oxygen-carrying capacity. PaCO2 of 30 mm Hg indicates low carbon dioxide levels in the blood. Oxygen saturation measures tissue perfusion.
Which value indicates clinical hypoxemia and the need to increase oxygen delivery? A Hemoglobin of 22 g/dL B PaCO2 of 30 mm Hg C PaO2 of 65 mm Hg D Oxygen saturation of 88%