CHAPTER 53 - AIRWAY MANAGEMENT

Question 1

CHAPTER 53

Answer 1

Airway Management

Question 2

Managing airway compromise

Answer 2

includes respiratory assessment and measuring vital signs, including oxygen saturation via pulse oximetry and administration of oxygen.

Question 3

Oxygen helps maintain adequate

Answer 3

cellular oxygenation for clients who have many acute and chronic respiratory problems (bronchitis, cystic fibrosis, asthma) or are at risk for developing hypoxia (respiratory illness, circulatory impairment).

Question 4

Maintaining a patent airway is a nursing priority. It involves

Answer 4

mobilizing secretions, suctioning the airway, and managing artificial airways (endotracheal tubes, tracheostomy tubes) to promote adequate gas exchange and lung expansion.

Question 5

● A pulse oximeter is a device

Answer 5

with a sensor probe that attaches securely to the fingertip, toe, bridge of nose, earlobe, or forehead with a clip or band.

Question 6

● A pulse oximeter measures pulse saturation (SpO2) via a wave of

Answer 6

infrared light that measures light absorption by oxygenated and deoxygenated hemoglobin in arterial blood. SpO2 reliably reflects the percent of saturation of hemoglobin (SaO2) when the SaO2 is greater than 70%.

Question 7

● Oxygen is a tasteless and colorless gas that accounts fo

Answer 7

r 21% of atmospheric air.

Question 8

● Oxygen flow rates vary to maintain an SpO2 of

Answer 8

95% to 100% using the lowest amount of oxygen to achieve the goal without risking complications.

Question 9

● The fraction of inspired oxygen (FiO2) i

Answer 9

s the percentage of oxygen the client receives.

Question 10

Noninvasive measurement of the oxygen saturation of the blood for monitoring respiratory status when assessment findings include any of the following.

Answer 10

● Increased work of breathing
● Wheezing
● Coughing
● Cyanosis
● Changes in respiratory rate or rhythm
● Adventitious breath sounds
● Restlessness, irritability, confusion
● Dyspnea
● Orthopnea

Question 11

● The expected reference range is 95% to 100%. Acceptable levels range from

Answer 11

91% to 100%. Some illness states can allow for 85% to 89%.

Question 12

Readings less than 90% reflect

Answer 12

hypoxemia.

Question 13

● Values can be slightly lower for

Answer 13

older adult clients and clients who have dark skin.

Question 14

● Additional reasons for low readings include

Answer 14

hypothermia, poor peripheral blood flow, too much light (sun, infrared lamps), low hemoglobin levels, jaundice, movement, edema, metal studs in nails, and nail polish.

Question 15

Oxygen is a therapeutic gas that

Answer 15

treats hypoxemia (low levels of arterial oxygen).

Question 16

Administering and adjusting it requires

Answer 16

a prescription.

Question 17

MANIFESTATIONS OF HYPOXIA - early on

Answer 17

EARLY
● Tachypnea
● Tachycardia
● Restlessness, anxiety, confusion
● Pale skin, mucous membranes
● Elevated blood pressure
● Use of accessory muscles, nasal flaring, adventitious lung sounds

Question 18

MANIFESTATIONS OF HYPOXIA - later on

Answer 18

LATE
● Stupor
● Cyanotic skin, mucous membranes
● Bradypnea
● Bradycardia
● Hypotension
● Cardiac dysrhythmias

Question 19

NURSING ACTIONS for hypoxia

Answer 19

● Monitor respiratory rate and pattern, level of consciousness, SpO2, and arterial blood gases (ABGs).
● Provide oxygen therapy at the lowest liter flow that will correct hypoxia.
● Make sure the mask creates a secure seal over the nose and mouth.
● Assess/monitor hypoxia and hypercarbia (elevated levels of CO2): restlessness, hypertension, and headache.
● Auscultate the lungs for breath sounds and adventitious sounds (crackles and wheezes).
● Assess/monitor oxygenation status with pulse oximetry and ABGs.
● Promote oral hygiene.
● Encourage turning, coughing, deep breathing, and the use of incentive spirometry and suctioning.
● Promote rest and decrease environmental stimuli.
● Provide emotional support.
● Assess nutritional status. Provide supplements.
● Assess skin integrity. Provide moisture and pressure‑relief devices.
● Assess and document the response to oxygen therapy.
● Titrate oxygen to maintain the recommended oxygen saturation.
● Discontinue supplemental oxygen gradually.
● Monitor for respiratory depression (decreased respiratory rate and level of consciousness).
● Low‑flow oxygen delivery systems deliver varying amounts of oxygen based on the delivery method and the client’s breathing pattern.

Question 20

LOW‑FLOW OXYGEN DELIVERY SYSTEMS

Answer 20

Nasal cannula / simple face mask / Partial rebreather mask / Non-rebreather mask

Question 21

Nasal cannula

Answer 21

Tubing with two small prongs for insertion into the nares

Question 22

FRACTION OF INSPIRED OXYGEN

Answer 22

FRACTION OF INSPIRED OXYGEN: Delivers an FiO2 of 24% to 44% at a flow rate of 1 to 6 L/min.

Question 23

ADVANTAGES nasal canula

Answer 23

● A cannula is a safe, simple, and easy‑to‑apply method.
● A cannula is comfortable and well‑tolerated.
● The client is able to eat, talk, and ambulate.

Question 24

DISADVANTAGES nasal canula

Answer 24

● The FiO2 varies with the flow rate, and the rate and depth of the client’s breathing.
● Extended use can lead to skin breakdown and dry mucous membranes.
● Tubing is easily dislodged.

Question 25

NURSING ACTIONS - nasal canula

Answer 25

● Assess the patency of the nares.
● Ensure that the prongs fit in the nares properly.
● Use water‑soluble gel to prevent dry nares.
● Provide humidification for flow rates of 4 L/min and greater.

Question 26

Simple face mask

Answer 26

Covers the client’s nose and mouth

Question 27

FRACTION OF INSPIRED OXYGEN

Answer 27

● It delivers an FiO2 of 35% to 50% at flow rates of 6 to 12 L/min.
● The minimum flow rate is 6 L/min to ensure flushing of CO2 from the mask.

Question 28

ADVANTAGES - simple face mask

Answer 28

● A face mask is easy to apply and can be more comfortable than a nasal cannula.
● It is a simple delivery method.
● It is more comfortable than a nasal cannula.
● It provides humidified oxygen.

Question 29

DISADVANTAGES - simple face mask

Answer 29

● Flow rates less than 6 L/min can result in rebreathing of CO2.
● Clients who have anxiety or claustrophobia do not tolerate it well.
● Eating, drinking, and talking are impaired.
● Moisture and pressure can collect under the mask and cause skin breakdown.
● Face masks pose a greater risk of aspiration.

Question 30

NURSING ACTIONS simple face mask

Answer 30

● Assess proper fit to ensure a secure seal over the nose and mouth.
● Make sure the client wears a nasal cannula during meals.
● Use with caution for clients who have a high risk of aspiration or airway obstruction.
● Monitor for skin breakdown.

Question 31

Partial rebreather mask

Answer 31

Covers the client’s nose and mouth

Question 32

FRACTION OF INSPIRED OXYGEN:

Answer 32

FRACTION OF INSPIRED OXYGEN:
Delivers an FiO2 of 60% to 75% at flow rates of 6 to 11 L/min.

Question 33

ADVANTAGES: Partial rebreather mask

Answer 33

The mask has a reservoir bag attached with no valve, which allows the client to rebreathe up to ⅓ of exhaled air together with room air. It also allows easier humidification of oxygen.

Question 34

DISADVANTAGES - Partial rebreather mask

Answer 34

● Complete deflation of the reservoir bag during inspiration causes CO2 buildup.
● The FiO2 varies with the client’s breathing pattern.
● Clients who have anxiety or claustrophobia do not tolerate it well.
● Eating, drinking, and talking are impaired.
● The bag can twist or kink easily.

Question 35

NURSING ACTIONS - Partial rebreather mask

Answer 35

● Keep the reservoir bag from deflating by adjusting the oxygen flow rate to keep the reservoir bag ⅓ to ½ full on inspiration.
● Assess proper fit to ensure a secure seal over nose and mouth. Assess for skin breakdown beneath the edges of the mask and bridge of the nose.
● Make sure the client uses a nasal cannula during meals.
● Use with caution for clients who have a high risk of aspiration or airway obstruction.

Question 36

Non-rebreather mask

Answer 36

Covers the client’s nose and mouth

Question 37

FRACTION OF INSPIRED OXYGEN:

Answer 37

FRACTION OF INSPIRED OXYGEN:
Delivers an FiO2 of 80% to 95% at flow rates of 10 to 15 L/min to keep the reservoir bag ⅔ full during inspiration and expiration.

Question 38

ADVANTAGES - Non-rebreather mask

Answer 38

It delivers the highest O2 concentration possible (except for intubation).
● A one‑way valve situated between the mask and reservoir allows the client to inhale maximum O2 from the reservoir bag. The two exhalation ports have flaps covering them that prevent room air from entering the mask.

Question 39

DISADVANTAGES - Non-rebreather mask

Answer 39

The valve and flap on the mask must be intact and functional during each breath.
● It is poorly tolerated by clients who have anxiety or claustrophobia.
● Eating, drinking, and talking are impaired.
● Use with caution for clients who have a high risk of aspiration or airway obstruction.

Question 40

NURSING ACTIONS - Non-rebreather mask

Answer 40

Perform an hourly assessment of the valve and flap.
● Assess proper fit to ensure a secure seal over the nose and mouth. Assess for skin breakdown beneath the edges of the mask and bridge of nose.
● Make sure the client uses a nasal cannula during meals.

Question 41

HIGH‑FLOW OXYGEN DELIVERY SYSTEMS

Answer 41

Venturi mask / Aerosol mask

Question 42

Venturi mask

Answer 42

Covers the client’s nose and mouth

Question 43

FRACTION OF INSPIRED OXYGEN:

Answer 43

Delivers an FiO2 of 24% to 50% at flow rates of 4 to 12 L/min via different size adapters, which allows specific amounts of air to mix with oxygen.

Question 44

ADVANTAGES Venturi mask

Answer 44

It delivers the most precise oxygen concentration w/ humidity added.
● Best for clients who have chronic lung disease.

Question 45

DISADVANTAGES Venturi mask

Answer 45

Use is expensive.
● Eating, drinking, and talking are impaired.
● The mask and added humidity can lead to skin breakdown.

Question 46

NURSING ACTIONS Venturi mask

Answer 46

Assess frequently to ensure an accurate flow rate.
● Assess proper fit to ensure a secure seal over the nose and mouth. Assess for skin breakdown beneath the edges of the mask, particularly on the nares.
● Make sure the tubing is free of kinks.
● Ensure that the client wears a nasal cannula during meals.

Question 47

Aerosol mask

Answer 47

Face tent: fits loosely around the face and neck
Tracheostomy collar: a small mask that covers the surgically created opening of the trachea

Question 48

FRACTION OF INSPIRED OXYGEN

Answer 48

● Delivers an FiO2 of 24% to 100% at flow rates of at least 10 L/min.
● Provides high humidification with oxygen delivery.

Question 49

ADVANTAGES Aerosol mask

Answer 49

● Use with clients who do not tolerate masks well.
● Useful for clients who have facial trauma, burns, and thick secretions.

Question 50

DISADVANTAGES: Aerosol mask

Answer 50

High humidification requires frequent monitoring.

Question 51

NURSING ACTIONS Aerosol mask

Answer 51

● Empty condensation from the tubing often.
● Ensure adequate water in the humidification canister.
● Ensure that the aerosol mist leaves from the vents during inspiration and expiration
● Make sure the tubing does not pull on the tracheostomy.

Question 52

Oxygen toxicity (complication)

Answer 52

Oxygen toxicity can result from high concentrations of oxygen (typically greater than 50%), long durations of oxygen therapy (typically more than 24 to 48 hr), and the severity of lung disease.

Question 53

Oxygen toxicity (complication)MANIFESTATIONS

Answer 53

: Nonproductive cough, substernal pain, nausea, vomiting, fatigue, dyspnea, restlessness, paresthesias

Question 54

NURSING ACTIONS Aerosol mask / Oxygen toxicity (complication)

Answer 54

● Use the lowest level of oxygen necessary to maintain an adequate SpO2.
● Monitor ABGs and notify the provider if SpO2 levels are outside the expected reference range.
● Decrease the FiO2 as the client’s SpO2 improves.

Question 55

Oxygen‑induced hypoventilation

Answer 55

Clients who have conditions that cause alveolar hypoventilation can be sensitive to the administration of oxygen.

Question 56

NURSING ACTIONS Oxygen‑induced hypoventilation

Answer 56

● Monitor respiratory rate and pattern, level of consciousness, behavior, and SpO2.
● Provide oxygen therapy at the lowest liter flow rate that manages hypoxemia.
● If the client tolerates it, use a Venturi mask to deliver precise oxygen levels.
● Notify the provider of impending respiratory depression (a decreased respiratory rate and a decreased level of consciousness).

Question 57

Combustion

Answer 57

Oxygen is combustible.

Question 58

NURSING ACTIONS - oxygen is combustible

Answer 58

● Post “No Smoking” or “Oxygen in Use” signs to alert others of the fire hazard.
● Know where to find the closest fire extinguisher.
● Educate about the fire hazard of smoking w/ oxygen use.
● Have clients wear a cotton gown because synthetic or wool fabrics can generate static electricity.
● Ensure that all electric devices (razors, hearing aids, radios) are working well.
● Make sure all electric machinery (monitors, suction machines) is grounded.
● Do not use volatile, flammable materials (alcohol, acetone) near clients receiving oxygen.

Question 59

Specimen collection and airway clearance

Answer 59

Mucosal secretion buildup or aspiration of emesis can obstruct a client’s airway.
Mucosal secretion buildup or aspiration of emesis can obstruct a client’s airway.
● Adequate hydration and coughing help the client maintain airway patency.
● Nursing interventions that mobilize secretions and maintain airway patency include assistance w/ coughing, hydration, positioning, humidification, nebulizer therapy, chest physiotherapy, and suctioning.
● These interventions promote adequate gas exchange and lung expansion.

Question 60

Mucosal secretion buildup or aspiration of emesis can

Answer 60

obstruct a client’s airway.

Question 61

CLIENTS AT RISK FOR DEVELOPING AIRWAY

Answer 61

COMPROMISE: infants, clients who have neuromuscular disorders, clients who are quadriplegic, clients who have cystic fibrosis

Question 62

INDICATIONS THAT CLIENTS NEED HELP MAINTAINING AIRWAY CLEARANCE:

Answer 62

hypoxia (restlessness, irritability, tachypnea, tachycardia, cyanosis, decreased level of consciousness, decreased SpO2 levels), adventitious breath sounds, visible secretions, absence of spontaneous cough

Question 63

CONSIDERATIONS Specimen collection and airway clearance

Answer 63

● Humidification of oxygen moistens the airways, which loosens and mobilizes pulmonary secretions.
● Nebulization breaks up medications (bronchodilators, mucolytic agents) into minute particles that disperse throughout the respiratory tract and improves clearance of pulmonary secretions.
● Chest physiotherapy involves the use of chest percussion, vibration, and postural drainage to help mobilize secretions. Chest percussion and vibration facilitate movement of secretions into the central airways. For postural drainage, one or more positions allow gravity to assist with the removal of secretions from specific areas of the lung.
● Early‑morning postural drainage mobilizes secretions that have accumulated through the night.

Question 64

NURSING ACTIONS pecimen collection and airway clearance

Answer 64

Collect sputum specimens by suctioning during coughing.
● Whenever possible, encourage coughing. Coughing is more effective than artificial suctioning at moving secretions into the upper trachea and laryngopharynx.
● Suction orally, nasally, or endotracheally, not routinely but only when clients need it.
● Maintain surgical asepsis when performing any form of tracheal s

Question 65

Collection of sputum for analysis Sputum specimen collection

Answer 65

● For cytology to identify aberrant cells or cancer
● For culture and sensitivity to grow and identify micro‑organisms and the antibiotics effective against them
● To identify acid‑fast bacilli (AFB) to diagnose tuberculosis (requires three consecutive morning samples)

Question 66

INDICATIONS Sputum specimen collection
Collection of sputum for analysis

Answer 66

● For cytology to identify aberrant cells or cancer
● For culture and sensitivity to grow and identify micro‑organisms and the antibiotics effective against them
● To identify acid‑fast bacilli (AFB) to diagnose tuberculosis (requires three consecutive morning samples)

Question 67

CONSIDERATIONS / NURSING ACTIONS Sputum specimen collection
Collection of sputum for analysis

Answer 67

● Obtain specimens early in the morning.
● Wait 1 to 2 hr after the client eats to obtain a specimen to decrease the likelihood of emesis or aspiration.
● Perform chest physiotherapy to help mobilize secretions.
● Use a sterile specimen container, a label, a laboratory requisition slip, a biohazard bag for delivery of the specimen to the laboratory, clean gloves, and a mask and goggles if necessary.
● Use a container with a preservative to obtain a specimen for cytology.
● Use a sterile container for routine cultures and AFB testing.
● If a client cannot cough effectively and expectorate sputum into the container, collect the specimen by endotracheal suctioning.
● Old

Question 68

INTERPRETATION OF FINDINGS Sputum specimen collection
Collection of sputum for analysis

Answer 68

● Presence of micro‑organisms indicating infection
● Presence of cancer cells

Question 69

Chest physiotherapy

Answer 69

ntracranial pressure; have had recent abdominal surgery; have a pulmonary embolism; or have bleeding disorders or osteoporosis

Question 70

Percussion:

Answer 70

the use of cupped hands to clap rhythmically on the chest to break up secretions

Question 71

Vibration:

Answer 71

the use of a shaking movement during exhalation to help remove secretions

Question 72

Postural drainage:

Answer 72

the use of various positions to allow secretions to drain by gravity

Question 73

CONSIDERATIONS / NURSING ACTIONS Chest physiotherapy

Answer 73

● Schedule treatments 1 hr before or 2 hr after meals, and at bedtime to decrease the likelihood of vomiting or aspirating.
● Administer a bronchodilator medication or nebulizer treatment 30 min to 1 hr prior to postural drainage.
● Offer the client an emesis basin and facial tissues.
● Apply manual percussion to the chest wall using cupped hands or a specific device.
● Place hands on the affected area, tense hand and arm muscles, and move the heel of the hands to create vibrations as the client exhales. Have the client cough after each set of vibrations.
● Have the client remain in each position for 10 to 15 min to allow time for percussion, vibration, and postural drainage.
● Discontinue the procedure if the client reports faintness or dizziness.
● Note that older adult clients have decreased respiratory muscle strength and chest wall compliance, which puts them at risk for aspiration. They require more frequent position changes and other interventions to promote mobility of secretions.

Question 74

Positioning:● Both lobes in general:

Answer 74

high Fowler’s

Question 75

Positioning:● Apical segments of both lobes:

Answer 75

sitting on the side of the bed

Question 76

Positioning:● Right upper lobe, anterior segment:

Answer 76

supine w/ head elevation

Question 77

Positioning:● Right upper lobe, posterior segment:

Answer 77

on the left side with a pillow under the right side of the chest

Question 78

Positioning:● Right middle lobe, anterior segment: t

Answer 78

hree‑quarters supine with dependent lung in Trendelenburg

Question 79

Positioning:● Right middle lobe, posterior segment:

Answer 79

prone with thorax and abdomen elevation

Question 80

Positioning:● Right lower lobe, lateral segment:

Answer 80

on the left side in Trendelenburg

Question 81

Positioning:● Left upper lobe, anterior segment:

Answer 81

supine w/ head elevation

Question 82

Positioning:● Left upper lobe, posterior segment:

Answer 82

on the right side w/ a pillow under the left side of the chest

Question 83

Positioning:● Left lower lobe, lateral segment:

Answer 83

on the right side in Trendelenburg

Question 84

Positioning:● Both lower lobes, anterior segments:

Answer 84

supine in Trendelenburg

Question 85

Positioning:● Both lower lobes, posterior segments:

Answer 85

prone in Trendelenburg

Question 86

Suction orally, nasally, or endotracheally whenaneous cough).

Answer 86

clients have early signs of hypoxemia (restlessness, confusion, tachypnea, tachycardia, decreased SpO2 levels, adventitious breath sounds, audible or visible secretions, cyanosis, and absence of spont

Question 87

CONSIDERATIONS / NURSING ACTIONS

Answer 87

● Don the required personal protective equipment.
● Assist the client to high‑Fowler’s or Fowler’s position for suctioning if possible.
● Encourage the client to breathe deeply and cough in an attempt to clear the secretions without artificial suction.
● Obtain baseline breath sounds and vital signs, including SaO2 by pulse oximeter. Can monitor SaO2 continually during the procedure.
● For oropharyngeal suctioning, use a Yankauer or tonsil‑tipped rigid suction catheter and move the catheter around the mouth, gum line, and pharynx.
● For nasopharyngeal and nasotracheal suctioning, use a flexible catheter and lubricate the distal 6 to 8 cm (2 to 3 in) with water‑soluble lubricant.
● For endotracheal suctioning, use a suction catheter. The catheter should not exceed one half of the internal diameter of the endotracheal tube to prevent hypoxia. The nurse should use no larger than a 16 French suction catheter when suctioning an 8 mm endotracheal tube or tracheostomy tube. Hyperoxygenate the client using a bag‑valve‑mask (BVM) or specialized ventilator function with an FiO2 of 100%.
● Use medical asepsis for suctioning the mouth.
● Use surgical asepsis for all other types of suctioning.
● Use suction pressure no higher than 120 to 150 mm Hg.
● Limit each suction attempt to no longer than 10 to 15 seconds to avoid hypoxemia and the vagal response. Repeat suctioning if needed. Limit total suctioning time to 5 min.

Question 88

Additional guidelines for nasopharyngeal and nasotracheal suctioning

Answer 88

● Insert the catheter into the naris during inhalation.
● Do not apply suction while inserting the catheter.
● Follow the natural course of the naris and slightly slant the catheter downward while advancing it.
● Advance the catheter 15 to 20 cm (6 to 8 in).
● Apply suction intermittently by covering and releasing the suction port with the thumb for 10 to 15 seconds.
● Apply suction only while withdrawing the catheter and rotating it with the thumb and forefinger.
● Do not perform more than two passes with the catheter. Allow at least 1 min between passes for ventilation and oxygenation.

Question 89

Additional guidelines for endotracheal suctioning

Answer 89

● Remove the bag or ventilator from the tracheostomy or endotracheal tube and insert the catheter into the lumen of the airway. Advance the catheter until resistance is met. The catheter should reach the level of the carina (location of bifurcation into the mainstem bronchi).
● Pull the catheter back 1 cm (0.4 in) prior to applying suction to prevent mucosal damage.
● Apply suction intermittently by covering and releasing the suction port with the thumb for 10 to 15 seconds.
● Apply suction only while withdrawing the catheter and rotating it with the thumb and forefinger.
● Reattach the BVM or ventilator and administer 100% oxygen.
● Rinse catheter and suction tubing with sterile saline until clear.
● Do not reuse the suction catheter for subsequent suctioning sessions.

Question 90

A tracheotomy

Answer 90

sterile surgical incision into the trachea through the skin and muscles for the purpose of establishing an airway.

Question 91

● A tracheotomy can be an emergency or a

Answer 91

scheduled surgical procedure; it can be temporary or permanent.

Question 92

● A tracheostomy is the

Answer 92

stoma/opening that results from a tracheotomy to provide and secure a patent airway.

Question 93

● Artificial airways can be placed

Answer 93

orotracheally, nasotracheally, or through a tracheostomy to assist with respiration.

Question 94

● Tracheostomy tubes vary in their composition

Answer 94

(plastic, steel, silicone), number of parts, size (long vs. short), and shape (50° to 90° angles).

Question 95

● There is no standard tracheostomy sizing system. However, the diameter of the tracheostomy tube must be

Answer 95

smaller than the trachea.

Question 96

● The outside cannula has a flange or neck plate that

Answer 96

sits against the skin of the neck and has holes on each side for attaching ties around the neck to stabilize the tracheostomy tube.

Question 97

● Airflow in and out of a tracheostomy without air leakage

Answer 97

(a cuffed tracheostomy tube) bypasses the vocal cords, resulting in an inability to produce sound or speech.

Question 98

● Uncuffed tubes and fenestrated tubes, in place or capped, allow

Answer 98

speech.

Question 99

Clients who have a cuffed tube can be

Answer 99

off mechanical ventilation, can breathe around the tube, and can use a specific valve to allow for speech. The cuff is deflated and the valve occludes the opening.

Question 100

● Indications for a tracheostomy include

Answer 100

acute or chronic upper airway obstruction, edema, anaphylaxis, burns, trauma, head/neck surgery, copious secretions, obstructive sleep apnea refractory to conventional therapy, and the need for long‑term mechanical ventilation or reconstruction after laryngeal trauma or laryngeal cancer surgery.

Question 101

ARTIFICIAL AIRWAY TUBE TYPES

Answer 101

Single‑lumen (cannula) / Double‑lumen (cannula) / Cuffed tube / Fenestrated tube with a cuff / Fenestrated tube without a cuff

Question 102

Single‑lumen (cannula)

Answer 102

● Long, single‑cannula tube

Question 103

NURSING ACTIONS: Single‑lumen (cannula) do not use when

Answer 103

Do not use with clients who have excessive secretions.

Question 104

Double‑lumen (cannula)

Answer 104

● An outer cannula fits into the stoma and keeps the airway open.
● An inner cannula fits snugly into the outer cannula and locks into place.
● An obturator is a thin, solid tube the provider places inside the tracheostomy and uses as a guide for inserting the outer cannula, and removes immediately after outer cannula insertion.
● This device allows removing, cleaning, reusing, discarding, and replacing the inner cannula with a disposable inner cannula.
● It is useful for clients who have excessive secretions.

Question 105

Cuffed tube

Answer 105

It has a balloon that inflates around the outside of the distal s

Question 106

NURSING ACTIONS - CUFFED TUBE

Answer 106

● A cuffed tube permits mechanical ventilation.
● A cuffed tube prevents aspiration of oropharyngeal secretions.
● Cuffs do not hold the tube in place.
● Cuff pressures must be monitored to prevent tracheal tissue necrosis.
● The client is unable to speak.
● Children do not require a cuffed tube.

Question 107

Cuffless tube

Answer 107

It has no balloon and is for clients who have long‑term airway‑management needs.

Question 108

NURSING ACTIONS Cuffless tube

Answer 108

● The client must be at low risk for aspiration.
● Cuffless tubes are not for clients receiving mechanical ventilation.
● This device allows the client to speak.

Question 109

Fenestrated tube with a cuff

Answer 109

● It has one large or multiple openings (fenestrations) in the posterior wall of the outer cannula with a balloon around the outside of the distal segment of the tube.
● It also has an inner cannula.

Question 110

NURSING ACTIONS Fenestrated tube with a cuff

Answer 110

● This device allows for mechanical ventilation.
● Removing the inner cannula allows the fenestrations to permit air to flow through the openings.
● This device allows the client to speak.

Question 111

Fenestrated tube without a cuff

Answer 111

● It has one larger or multiple openings (fenestrations) in the posterior wall of the outer cannula with no balloon.
● It also has an inner cannula.

Question 112

NURSING ACTIONS Fenestrated tube without a cuff

Answer 112

● The holes in the tube help wean the client from the tracheostomy.
● Removing the inner cannula allows the fenestrations to permit air to flow through the openings.
● This device allows the client to speak.

Question 113

CONSIDERATIONS / NURSING ACTIONS Fenestrated tube without a cuff

Answer 113

● Keep the following at the bedside: two extra tracheostomy tubes (one the client’s size and one size smaller, in case of accidental decannulation), the obturator for the existing tube, an oxygen source, suction catheters and a suction source, and a BVM.
● Provide methods to communicate with staff (paper and pen, dry‑erase board).
● Provide an emergency call system and a call light.
● Provide adequate humidification and hydration to thin secretions and reduce the risk of mucous plugs.
● Give oral care every 2 hr.
● Provide tracheostomy care every 8 hr to reduce the risk of infection and skin breakdown.

Question 114

● Provide tracheostomy care every 8 hr to reduce the risk of infection and skin breakdown.

Answer 114

◯ Suction the tracheostomy tube, if necessary, using sterile suctioning supplies.
◯ Apply the oxygen source loosely if the client’s SpO2 decreases during the procedure.
◯ Use surgical asepsis to remove and clean the inner cannula (with the facility‑approved solution). Use a new inner cannula if it is disposable.
◯ Remove soiled dressings and excess secretions.
◯ Clean the stoma site and then the tracheostomy plate.
◯ Place a fresh split‑gauze tracheostomy dressing of nonraveling material under and around the tracheostomy holder and plate.
◯ Replace tracheostomy ties if they are wet or soiled. Secure the new ties before removing the soiled ones
to prevent accidental decannulation.
◯ If a knot is needed, tie a square knot that is visible on the side of the neck. Check that one or two fingers fit between the tie and the neck.

Question 115

COMPLICATIONS
Fenestrated tube without a cuff

Answer 115

Accidental decannulation

Question 116

Accidental decannulation

Answer 116

Accidental decannulation within the first 72 hr after surgery is an emergency because the tracheostomy tract has not matured, and replacement can be difficult.

Question 117

! V entilate the client with a BVM . Call for assistance.

Answer 117

bag valve mask ventilation

Question 118

NURSING ACTIONS Fenestrated tube without a cuff

Answer 118

● Always keep the tracheostomy obturator and two spare tracheostomy tubes at the bedside.
● If unable to replace the tracheostomy tube, administer oxygen through the stoma. If unable to administer oxygen through the stoma, occlude the stoma and administer oxygen through the nose and mouth, except for clients who have had a laryngectomy.

Question 119

If accidental decannulation occurs after the first 72 hr

Answer 119

● Immediately hyperextend the neck and with the obturator inserted into the tracheostomy tube, quickly and gently replace the tube, and remove the obturator.
● Secure the tube.
● Assess tube placement by auscultating for bilateral breath sounds.

Question 120

Damage to the trachea Tracheal stenosis:

Answer 120

Narrowing of the tracheal lumen due to scar formation resulting from irritation of the tracheal mucosa from the tracheal tube cuff.

Question 121

NURSING ACTIONS Damage to the trachea Tracheal stenosis:

Answer 121

● Keep the cuff pressure between 14 and 20 mm Hg.
● Check the cuff pressure at least once every 8 hr.
● Keep the tube in the midline position and prevent pulling or traction on the tracheostomy tube.

Question 122

Tracheal wall necrosis:

Answer 122

Tissue damage that results when the pressure of the inflated cuff impairs blood flow to the tracheal wall.

Question 123

List the specific positions that facilitate secretion drainage from at least eight specific lung areas.

Answer 123

● Both lobes in general: high‑Fowler’s
● Apical segments of both lobes: sitting on the side of the bed
● Right upper lobe, anterior segment: supine with head elevation
● Right upper lobe, posterior segment: on the left side with a pillow under the right side of the chest
● Right middle lobe, anterior segment: three‑quarters supine with dependent lung in Trendelenburg
● Right middle lobe, posterior segment: prone with thorax and abdomen elevation
● Right lower lobe, lateral segment: on the left side in Trendelenburg
● Left upper lobe, anterior segment: supine with head elevation
● Left upper lobe, posterior segment: on the right side with a pillow under the left side of the chest
● Left lower lobe, lateral segment: on the right side in Trendelenburg
● Both lower lobes, anterior segments: supine in Trendelenburg
● Both lower lobes, posterior segments: prone in Trendelenburg

Question 124

Application Exercises
1. A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.)
A. Restlessness
B. Tachypnea
C. Bradycardia
D. Confusion
E. Hypertension

Answer 124

1
A. CORRECT: Monitor for restlessness, which is an early manifestation of hypoxia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds.
B. CORRECT: Monitor for tachypnea, which is an early manifestation of hypoxia.
C. Bradycardia is a late manifestation of hypoxia, along with stupor, cyanotic skin and mucous membranes, bradypnea, hypotension, and cardiac dysrhythmias.
D. CORRECT: Monitor for confusion, which is an early manifestation of hypoxia.
E. CORRECT: Monitor for hypertension, which is an early manifestation of hypoxia.

Question 125

2. A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.)
   A. Apply petroleum jelly around and inside the nares.
   B. Remove the nasal cannula during mealtimes.
   C. Check the position of the cannula frequently.
   D. Report any nausea or difficulty breathing.
   E. Post “No Smoking” signs in prominent locations.

Answer 125

2
A. Teach the client to apply a water‑based lubricant to protect the nares from drying during oxygen therapy.
B. Teach the client to leave the nasal cannula on while eating, because it does not interfere with eating.
C. CORRECT: Teach the client that a disadvantage of the nasal cannula is that it dislodges easily. The client should form the habit of checking its position periodically and readjusting it as necessary.
D. CORRECT: Teach the client about oxygen toxicity, which is a complication of oxygen therapy, usually from high concentrations or long durations. Manifestations include a nonproductive cough, substernal pain, nausea, and vomiting. The client should report any of these promptly.
E. CORRECT: Teach the client that oxygen is combustible and thus increases the risk of fire injuries. No one in the house should smoke or use any device that might generate sparks in the area where the oxygen is in use.

Question 126

3. A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse’s priority?
   A. Increase the oxygen flow.
   B. Assist the client to Fowler’s position.
   C. Promote removal of pulmonary secretions.
   D. Obtain a specimen for arterial blood gases.

Answer 126

3
A. There might be a need to increase the client’s oxygen flow, as hypoxia can be the cause of a client’s difficulty breathing. However, another action is the priority.
B. CORRECT: The priority action to be taken when using the airway, breathing, circulation (ABC) approach to care delivery is to relieve dyspnea (difficulty breathing). Fowler’s position facilitates maximal lung expansion and thus optimizes breathing. With the client in this position, the cause of the client’s dyspnea can better assessed and determined.
C. There might be a need to suction the client’s airway or encourage expectoration of pulmonary secretions. However, another action is the priority,
D. Check the client’s oxygenation status. However, another action is the priority.

Question 127

4. A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (Select all that apply.)
   A. Apply suction while withdrawing the catheter.
   B. Perform suctioning on a routine basis every 2 to 3 hr.
   C. Maintain medical asepsis during suctioning.
   D. Use a new catheter for each suctioning attempt.
   E. Apply suction for 10 to 15 seconds.

Answer 127

4
A. CORRECT: Apply suction pressure only while withdrawing the catheter to prevent damaging the tracheal tissue.
B. Suction the client’s airway only as needed, because suctioning is not without risk. It can cause mucosal damage, bleeding, and bronchospasm.
C. Use surgical asepsis when performing endotracheal suctioning to prevent contamination with microorganisms that can cause an infection.
D. CORRECT: Use a new suction catheter, unless an in‑line suctioning system is in place, to prevent contamination with micro-organisms that can cause an infection.
E. CORRECT: To prevent hypoxemia, apply suction for only 10 to 15 seconds and allow 2 to 3 min between passes for ventilation and oxygenation.

Question 128

5. A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing
   tracheostomy care? (Select all that apply.)
   A. Apply the oxygen source loosely if the SpO2 decreases during the procedure.
   B. Use surgical asepsis to remove and clean the inner cannula.
   C. Clean the outer cannula surfaces in a circular motion from the stoma site outward.
   D. Replace the tracheostomy ties with new ties.
   E. Cut a slit in gauze squares to place beneath the tube holder.

Answer 128

5
A. CORRECT: Provide supplemental oxygen in response to any decline in oxygen saturation while performing tracheostomy care.
B. CORRECT: Use a sterile disposable tracheostomy cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure.
C. CORRECT: Cleanse the exposed surfaces of the outer cannula and the area around and under the faceplate in a circular motion from the stoma site outward. Cleansing in this manner helps move mucus and contaminated material away from the stoma for easy removal.
D. Replace the tracheostomy ties if they are wet or soiled. There is a risk of tube dislodgement w/ replacing the ties, do not replace them routinely.
E. Use a commercially-prepared tracheostomy dressing with a slit in it. Cutting gauze squares can loosen lint or gauze fibers the client could aspirate.