Respiratory failure

Question 1

The nurse is planning care with a client who 2 days earlier had a total laryngectomy with creation of a new tracheostomy. Which is a priority goal for the client?

a. Learn to care for the tracheostomy.
b, Maintain a patent airway.
c, Decrease secretions.
d. Relieve anxiety related to the tracheostomy.

Answer 1

b. maintain a patent airway.

The main goal for a client with a new tracheostomy is to maintain a patent airway. A fresh tracheostomy frequently causes bleeding and excess secretions, and clients may require frequent suctioning to maintain patency. Decreasing secretions may be a component of a client’s care after laryngectomy and tracheostomy, and relieving anxiety is always an important goal; however, the primary goal is to maintain a patent airway. Instruction on how to care for a tracheostomy is a priority later in the client’s recovery.

Question 2

The nurse is planning care for a client with acute respiratory distress syndrome (ARDS). Which action will be most helpful to promote effective airway clearance?
a. Administer oxygen every 2 hours.
b, Turn the client every 4 hours.
c. Administer sedatives to promote rest.
d. Suction if cough is ineffective.

Answer 2

d. suction if cough is ineffective.

The nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned every 2 hours to help move secretions; every 4 hours is not often enough. Administering sedatives to promote rest is contraindicated in ARDS because sedatives can depress respirations.

Question 3

Immediately following an automobile accident, a 21-year-old client has severe pain in the right chest from hitting the steering wheel, a compound fracture of the right tibia and fibula, and multiple lacerations and contusions. What is the priority nursing goal for this client?
a. Reduce the client’s anxiety.
b. Maintain adequate oxygenation.
c. Decrease chest pain.
d, Maintain adequate circulating volume.

Answer 3

b. maintain adequate oxygenation.

Blunt chest trauma can lead to respiratory failure. Maintenance of adequate oxygenation is the priority for the client. Decreasing the client’s anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation, as is maintaining adequate circulatory volume.

Question 4

After suctioning a client’s tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent which outcome?
a. stimulating the client’s cough reflex
b. depriving the client of sufficient oxygen supply
c. dislodging the tracheostomy tube
d. obstructing the suctioning catheter with secretions

Answer 4

b. depriving the client of sufficient oxygen supply.

After suctioning, the client should rest for at least 3 minutes or until respirations return to normal before suctioning is repeated, unless secretions interfere with breathing. Intermittent suctioning prevents oxygen deprivation. Hypoxia can lead to cardiac arrhythmias and cardiac arrest. The client should receive 100% oxygen between suctionings.

The nurse should not prevent stimulating the cough reflex as it helps mobilize secretions.

Intermittent suction does not prevent dislodgment of the tracheostomy tube.

Intermittent suction does not keep the suction catheter from becoming obstructed; clearing the catheter with normal saline will keep the catheter clear.

Question 5

Which complication is associated with mechanical ventilation?
a. gastrointestinal hemorrhage
b, immunosuppression
c. increased cardiac output
d. pulmonary emboli

Answer 5

a. gastrointestinal hemorrhage

Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged mechanical ventilation because of the development of stress ulcers. Clients who are receiving steroid therapy and those with a previous history of ulcers are most likely to be at risk. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis.

Question 6

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?
a. “Clean the tracheostomy tube with alcohol and water.”
b, “Family members should continue to talk to the client.”
c. “Oral intake of fluids should be limited for 1 week only.”
d. “Limit the amount of protein in the diet.”

Answer 6

b. “Family members should continue to talk to the client.”

Commonly, family members are reluctant to talk to the client who has had a total laryngectomy and can no longer speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing.

Question 7

The nurse is caring for a client who has experienced severe multiple trauma. The client’s arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. This finding is an indicator of the development of which of the following conditions?
a. Hospital-acquired pneumonia.
b. Hypovolemic shock.
c, Acute respiratory distress syndrome (ARDS).
d. Asthma.

Answer 7

c. Acute respiratory distress syndrome (ARDS)

ARDS frequently develops after a major insult to the body. The major diagnostic indicator is low arterial oxygen levels that are not responsive to the administration of high concentrations of oxygen. Early recognition of ARDS is important to increase the client’s chances of recovery. The oxygen levels of clients with hospital-acquired pneumonia, hypovolemic shock, or asthma would be expected to improve with oxygen administration.

Question 8

For a client with an endotracheal (ET) tube, which nursing action is the most important?
a. auscultating the lungs for bilateral breath sounds
b. turning the client from side to side every 2 hours
c. monitoring serial blood gas values every 4 hours
d. providing frequent oral hygiene

Answer 8

a. auscultating the lungs for bilateral breath sounds.

For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they’re secondary to ensuring adequate oxygenation.

Question 9

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. Hyperoxemia, hypocapnia, and hyperventilation
d. Hypercapnia, hypoventilation, and hypoxemia

Answer 9

d. 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.

Question 10

The nurse is conducting a focused assessment of a client at risk for acute respiratory distress syndrome (ARDS). Which finding indicates the client is becoming hypoxemic?
a. elevated carbon dioxide level
b. hypoxia not responsive to oxygen therapy
c. metabolic acidosis
d. severe, unexplained electrolyte imbalance

Answer 10

b. hypoxia not responsive to oxygen therapy.

A hallmark of early ARDS is refractory hypoxemia. The client’s partial pressure of arterial oxygen (PaO2) level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS.

Question 11

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client’s bedside?
a. tracheostomy cleaning kit
b. water-seal chest drainage set-up
c. manual resuscitation bag
d. oxygen analyzer

Answer 11

c. manual resuscitation bag

The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn’t have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn’t necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.

Question 12

A client with a nasotracheal tube needs to be suctioned. What is the length of time the nurse should apply the suction for each pass of the catheter?

a. 1 to 5 seconds
b. 20 to 25 seconds
c. 10 to 15 seconds
d. 40 to 45 seconds

Answer 12

c. 10-15 seconds

Suction should be applied for 10 to 15 seconds for each pass of the catheter. Suctioning for longer than 15 seconds removes oxygen from the respiratory tract and cause hypoxemia. Suctioning less than 10 seconds would not be adequate to remove the secretions.

Question 13

A client has a tracheostomy. Which nursing action would prevent complications of suctioning?
a. Suction for at least 15 seconds.
b. Keep a replacement cuff at the bedside.
c. Maintain sterility of the suction catheter.
d. Record time, amount, character of secretions.

Answer 13

c. maintain sterility of the suction catheter.

Trach suction should be limited to 10 seconds. Although a replacement cuff must be at the bedside and it is important to record secretions, these will not prevent complications. Trach suctioning is a sterile procedure and rinsing the catheter will be the priority to prevent infections.

Question 14

A client who is intubated on mechanical ventilation develops subcutaneous emphysema. Which ventilator setting should the nurse anticipate being adjusted for this client?

a. ventilator rate
b. oxygen concentration
c. number of assisted breaths
d. positive end-expiratory pressure (PEEP)

Answer 14

d. positive end-expiratory pressure (PEEP)

For a client being mechanically ventilated, subcutaneous emphysema occurs because the alveoli are overdistended and rupture, permitting air to escape into the surrounding tissues. PEEP keeps the alveoli open between breaths. Because subcutaneous emphysema has developed, the PEEP setting should be adjusted. The development of subcutaneous emphysema did not occur because of the ventilator rate, oxygen concentration, or number of assisted breaths set on the ventilator.

Question 15

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. They’re placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than
a. 0.21.
b. 0.35.
c. 0.5.
d. 0.7.

Answer 15

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. The ideal oxygen source is room air FIO2 0.18 to 0.21.

Question 16

While changing the tapes on a tracheostomy tube, the client coughs and the tube is dislodged. which is the initial nursing action?
a. call the health care provider to reinsert the tube.
b. grasp the retention sutures to spread the opening.
c. call the respiratory therapy department to reinsert the tracheostomy.
d. cover the tracheostomy site with sterile dressing to prevent infection.

Answer 16

c.

Question 17

the nurse is caring for a client immediately after removal of the endotracheal tube. the nurse should report which sign immediately if experienced by the client?
a. stridor
b. occasional pink-tinged sputum
c. respiratory rate of 24 breaths/minute
d. a few basilar lung crackles on the right

Answer 17

a. stridor

Question 18

the nurse is suctioning a client via an endotracheal tube. during the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. which nursing intervention is most appropriate?
a. continue to suction.
b. notify the health care provider immediately.
c. stop the procedure and reoxygenate the client.
d. ensure that the suction is limited to 15 sections.

Answer 18

c.

Question 19

the low-pressure alarm sounds on a ventilator. the nurse assess the client and then attempts to determine the cause of the alarm. if unsuccessful in determining the cause of the alarm, the nurse should take what initial action?
a. administer oxygen.
b. check the client’s vital signs
c. ventilate the client manually
d. start cardiopulmonary resuscitation

Answer 19

c. ventilate the client manually

Question 20

the nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. the nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. which nursing action is required before plugging the tube?
a. deflate the cuff on the tube.
b. place the inner cannula into the tube.
c. ensure that the client is able to speak
d. ensure that the client is able to swallow.

Answer 20

a. deflate the cuff on the tube.

Question 21

the nurse caring for a client who is mechanically ventilated is monitoring for complications of mechanical ventilation. which assessment finding, if noted by the nurse, indicates the need for follow-up?
a. muscle weakness in the arms and legs
b. a temperature of 98.6ºF decreased from 99.0F
c. a blood pressure of 90/60 mmHg decreased from 112/78 mmHg
d. a heart rate of 80 beats per minute decreased from 85 beats per minute

Answer 21

c.

Question 22

the nurse has assisted the health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. what is the initial nursing action to evaluate proper ET tube placement?
a. tape the ET tube in place, and note the centimeter marking at the lip line.
b. ask the radiology department to obtain a stat portable radiograph at the client’s bedside.
c. use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds.
d. attach the ET tube to the ventilator and determine whether the client is able to tolerate the tidal volume prescribed.

Answer 22

c.

Question 23

the nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. what is the initial nursing action?
a. hyperoxygenate the client
b. set the suction pressure range at 150 mmHg
c. place the catheter into the tracheostomy tube.
d. apply suction on the catheter, and insert it into the tracheostomy tube.

Answer 23

a.

Question 24

the nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. which observation by the nursing instructor indicates an action by the student requiring the need for further instruction?
a. suctioning the client every hour.
b. applying suction only during withdrawal of the catheter.
c. hyperventilating the client with 100% oxygen before suctioning
d. applying suction intermittently during withdrawal of the catheter.

Answer 24

a. suctioning the client every hour.

Question 25

the nurse is changing the tracheostomy ties on a client with a tracheostomy and is assessing the security of the ties. which method is used to ensure that the ties are not too tightly placed?
a. the ties leave no mark on the neck.
b. the nurse places two fingers between the tie and the neck.
c. the tracheostomy can be pulled slightly away from the neck.
d. the nurse uses a 12-inch tie that is tightly affixed with hook-and-loop closures.

Answer 25

b.

Question 26

the nurse is preparing for removal of an endotracheal (ET) tube from a client. in assisting the health care provider in this procedure, which is the initial nursing action?
a. deflate the cuff.
b. suction the ET tube.
c. turn off the ventilator.
d. obtain a code cart, and place it at the bedside.

Answer 26

d. obtain a code cart, and place it at the bedside.

Question 27

the nurse is caring for a client who is mechanically ventilated, and the high-pressure ventilator alarm is sounding. the nurse understands that which complications may cause this alarm? select all that apply.
a. water or a kink in the tubing
b. biting on the endotracheal tube
c. increased secretions in the airway
d. disconnection or leak in the system
e. the client stops spontaneous breathing

Answer 27

a, b, c

Question 28

a client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. the nurse should assess for which finding as the best indicator of adequate ongoing respiratory status?
a. oxygen saturation of 89%
b. respiratory rate of 16 breaths per minute
c. moderate amounts of tracheobronchial secretions
d. small to moderate amounts of frank blood suctioned from the tube.

Answer 28

b.

Question 29

the nurse is monitoring the respiratory status of a client after creation of a tracheostomy. the nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problem?
a. fever
b. epilepsy
c. hypotension
d. respiratory failure

Answer 29

c.

Question 30

the nurse is suctioning an unconscious client who has a tracheostomy. the nurse should perform which actions when performing this procedure? select all that apply.
a. keeping a supply of suction catheters at the bedside.
b. auscultating breath sounds to determine the need for suctioning
c. hyperoxygenating the client before, during, and after suctioning.
d. intermittently suctioning during insertion of the suction catheter.
e. placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed.

Answer 30

a, b, c

Question 31

the nurse is preparing to assist a client with cuffed tracheostomy tube to eat. what intervention is the priority before the client is permitted to drink or eat?
a. inflate the cuff on the tracheostomy tube.
b. deflate the cuff on the tracheostomy tube.
c. maintain the head of the bed in low Fowler’s position.
d. place the tray in a comfortable position in front of the client.

Answer 31

a.

Question 32

a nurse is caring for a client with a tracheostomy tube attached to a ventilator. the high-pressure alarm sounds on the ventilator. the nurse should plan to perform which action?
a. suction the client
b. evaluate the cuff for a leak
c. assess for a disconnection
d. notify the respiratory therapist

Answer 32

a.

Question 32

A nurse is planning care for a client who is scheduled fro a tracheostomy procedure. what equipment should the nurse plan to have at the bedside when the client returns from surgery?
a. obturator
b. oral airway
c. epinephrine
d. tracheostomy set with the next larger size.

Answer 32

d

Question 33

the nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. the nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs?
a. suctioning is required frequently.
b. the client’s skin and mucous membranes are light pink.
c. aspiration of gastric contents occurs during suctioning
d. excessive secretions are suctioned from the tube and stoma

Answer 33

c.
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Question 34

the nurse is caring for a client on a mechanical ventilator. the high-pressure alarm sounds. the nurse assess the client and attempts to determine the cause of the alarm. which initial nursing action would be appropriate if the nurse is unable to determine the cause of ventilator alarm?
a. shut the alarm off and call for help.
b. call the respiratory therapy department to fix the problem.
c. call the health care provider (HCP) for further instructions.
d. disconnect the client from the ventilator and manually ventilate the client with a resuscitation device.

Answer 34

d.
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Question 35

the low-exhaled volume alarm sounds on a mechanical ventilator of a client with an endotracheal tube. the nurse determines that the cause for alarm activation may be which complication?
a. excessive secretions
b. kinks in the ventilator tubing
c. the presence of mucous plug
d. displacement of the endotracheal tube.

Answer 35

d.

Question 36

the nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. the high-pressure alarm sounds, and the nurse assess the client. the nurse determines that the cause of the alarm is most likely to be due to which complication?
a. a kink in the ventilator circuit
b. a leak in the endotracheal tube cuff
c. displacement of the endotracheal tube
d. a disconnection of the ventilator tubing

Answer 36

a

Question 37

a health care provider writes a prescription to begin to wean the client from the mechanical ventilator by use of intermittent mandatory ventilation/synchronized intermittent mandatory ventilation (IMV/SMV). the nurse determines that the process of weaning will occur by which mechanism?
a. gradually decreasing the respiratory rate until the client can assume the work of breathing without ventilatory assistance.
b. attaching a T-piece to the ventilator and providing supplemental oxygen at a concentration that is 10% higher than the ventilator setting.
c. providing pressure support to decreased the workload of breathing and increase the client’s ability to initiate spontaneous breathing efforts.
d. removing the ventilator from the client and closely monitoring the client’s ability to breathe spontaneously for a predetermined amount of time.

Answer 37

a

Question 38

the nurse is preparing to wean a client from a ventilator by the use of a T-piece. which would be a component of the plan of care with this type of weaning process? select all that apply.
a. pressure support is added to the oxygen system.
b. the T-piece is connected to the client’s artificial airway.
c. the client is removed from the mechanical ventilator for a short period of time.
d. the respiratory rate on the ventilator is gradually decreased until the client can do all of the work of breathing on his or her own.
e. supplemental oxygen is provided through the T-piece at a fraction of inspired oxygen that is 10% higher than a ventilator setting.

Answer 38

b, c,

Question 39

the nurse is reviewing the ventilator settings on a client with an endotracheal tube attached to mechanical ventilation. the nurse notes that the tidal volume is set at 700 mL and determines that the tidal volume indicates which factor?
a. the amount of air delivered with each set breath
b. a breath that has a greater volume than the preset tidal volume.
c. the number of breaths that the client will receive per minute by the ventilator.
d. the fraction of inspired oxygen (FiO2) that is delivered to the client through the ventilator.

Answer 39

a.

Question 40

a client who is intubated and receiving mechanical ventilation has a problem of risk for infection. the nurse should include which measures in the care of this client? select all that apply.
a. monitor the client’s temperature.
b. use sterile technique when suctioning
c. use the closed-system method of suctioning
d. monitoring sputum characteristics and amounts.
e. drain water from the ventilator tubing into the humidifier bottle

Answer 40

a, b, c, d

Question 41

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. Maintaining the client in a high Fowler’s position
b. Turning and repositioning the client every 4 hours
c. Ensuring that the client remains sedated while intubated
d. Cleaning the client’s mouth with chlorhexidine daily

Answer 41

d. 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.