Respiratory Mix Flashcards
The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings?
Select all that apply.
- Excessive bubbling in the water seal chamber
- Vigorous bubbling in the suction control chamber
- Drainage system maintained below the client’s chest
- 50 mL of drainage in the drainage collection chamber
- Occlusive dressing in place over the chest tube insertion site
- Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation
The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires notification of the health care provider. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client’s chest allows gravity to drain the pleural space.
The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action?
1.
Stay very still.
2.
Exhale very quickly.
3.
Inhale and exhale quickly.
4.
Perform the Valsalva maneuver.
When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.
The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the water seal chamber. What action is most appropriate?
1.
Do nothing, because this is an expected finding.
2.
Check for an air leak, because the bubbling should be intermittent.
- Increase the suction pressure so that the bubbling becomes vigorous.
- Clamp the chest tube and notify the health care provider immediately.
Fluctuation with inspiration and expiration, not continuous bubbling, should be noted in the water seal chamber. Intermittent bubbling may be noted if the client has a known pneumothorax, but this should decrease as time goes on and as the pneumothorax begins to resolve. Therefore, the nurse should check for an air leak. If a wet chest drainage system is used, bubbling would be continuous in the suction control chamber and not intermittent. In a dry system, there is no bubbling. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so if using a wet system. Dry systems will allow for only a certain amount of suction to be applied; an orange bellow will appear in the suction window, indicating that the proper amount of suction has been applied. Chest tubes should be clamped only with a health care provider’s prescription.
Normal Carbon monoxide levels are between
1-10%
Mild carbon monoxide poisoning is between __________% and results in
11-20%; Flushing, headache, decreased visual activity, decreased cerebral functioning, slight breathlessness
Moderate carbon monoxide poisoning occurs between __________% and manifestations include
levels of 21% to 40% result in nausea, vomiting, dizziness, tinnitus, vertigo, confusion, drowsiness, pale to reddish-purple skin, and tachycardia
Severe carbon monoxide poisoning levels occur between………..
manifestations include
41-60%
coma, seizures,cardiopulmonary instability
fatal carbon monoxide poisoning levels
61-80%
in a respiratory injury____________respirations will occur
increased
A _____________sound at the site of injury would be noted with an open chest injury.
sucking
Clinical manifestations of chronic obstructive pulmonary disease
hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced
Pulmonary function tests will demonstrate decreased vital capacity.
What is vital capacity ?
the maximum amount of air a person can expel from the lungs after a maximum inhalation
patients with COPD will have decreased vital capacity
What is the purpose of pursed lip breathing ?
To promote CO2 elimination
Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation
For tuberculosis patients, after___________- weeks of medication therapy, it is unlikely that the client will infect anyone.
2-3
For tuberculosis patients, a sputum culture is needed every______________ weeks once medication therapy is initiated. When the results of _________sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.
2-4; 3
The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider?
1.
Dry cough
2.
Hematuria
3.
Bronchospasm
4.
Blood-streaked sputum
If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias
What can be caused by proloned suctioning?
Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
Suctioning a client should be limited to ________seconds
10
The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
During suctioning, the nurse should monitor the client closely for adverse effects, including _______________________. If adverse effects develop, especially cardiac irregularities, the procedure is ______________________
hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing
stopped and the client is reoxygenated.
Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include
pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site.
most distinctive sign of flail chest
paradoxical chest movement
What is flail chest?
Flail chest results from multiple rib fractures. This results in a “floating” section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.
paradoxical chest movement - remembering that a flail chest has broken rib segments that move independently of the rest of the rib cage.
What is the earliest sign of acute respiratory distress syndrome?
Increased respiratory rate
can begin from 1 to 96 hours 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.
The tuberculosis client is continued on medication therapy for up to _____months, depending on the situation. The client generally is considered noncontagious after _________weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of _________sputum cultures are negative.
12; 2 to 3; 3
Typical signs of pulmonary embolism
The most common initial symptom in pulmonary embolism 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 pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.
The client with HIV infection is considered to have positive results on tuberculin skin testing with an area of induration larger than ___________mm
5
The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor
What do you know about histoplasmosis ?
Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the client’s lymph nodes, liver, and spleen may occur as well.
Dyspnea is an expected finding
what do you know about sarcoidosis ?
this is a pulmonary disorder. there is a presence of epitheloid cell tubercles in the lung
assessment includes night sweats, cough, dyspnea, fever, weight loss, skin nodules, polyarthritis
Kveim test: Sarcoid node antigen is injected intradermally and causes a local nodular lesion in about 1 month
What do you know about silocosis ?
Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust.
The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure.
The _____________-mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation such as chronic obstructive pulmonary disease, because it delivers a precise oxygen concentration.
Venturi
Positions that will assist the client with emphysema with breathing include
sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.
Symptoms of Tuberculosis
Fatigue, Lethargy, Anorexia, Weight Loss, Low grade fever, chills, night sweats, persistent cough and the production of mucoid and mucopurulent sputum, which is occasionally streaked with blood
chest tightness and a dull, aching chest pain may accompany the cough
Tuberculosis is definitively diagnosed through
culture and isolation of Mycobacterium tuberculosis.
A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.
The nurse is assisting to defibrillate a client in ventricular fibrillation. After placing the pad on the client’s chest and before discharge, which intervention is a priority?
1.
Ensure that the client has been intubated.
2.
Set the defibrillator to the “synchronize” mode.
3.
Administer an amiodarone bolus intravenously.
4.
Confirm that the rhythm is actually ventricular fibrillation.
Once the defibrillator has been attached, the electrocardiogram is checked to verify that the rhythm is ventricular fibrillation or pulseless ventricular tachycardia. Leads also are checked for any loose connections.
Note the strategic word, priority. Focus on the subject, ventricular fibrillation. Note that the correct option directly addresses this subject and also addresses assessment of the client.
The energy level used for all defibrillation attempts with a monophasic defibrillator is _______-joules.
360
The jaw thrust without the head tilt maneuver is used when …………
head or neck trauma is suspected.
This maneuver opens the airway while maintaining proper head and neck alignment, reducing the risk of further damage to the neck
A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect?
1.
Serous
2.
Bloody
3.
Serosanguineous
4.
Bloody, with frequent small clots
In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing
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?
Deflate the cuff on the tube
Plugging a tracheostomy tube is usually done by inserting the tracheostomy plug (decannulation stopper) into the opening of the outer cannula. This closes off the tracheostomy, and airflow and respiration occur normally through the nose and mouth. When plugging a cuffed tracheostomy tube, the cuff must be deflated. If it remains inflated, ventilation cannot occur, and respiratory arrest could result. A tracheostomy plug could not be placed in a tracheostomy if an inner cannula was in place.
Clients at greatest risk for deep vein thrombosis and pulmonary emboli are ___________-clients
immobilized
Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting.
A pillow under the knees may cause venous stasis. Heat should not be applied without a health care provider’s prescription.
The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action?
Document the findings
Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected.
The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes constant bubbling in the water seal chamber. Which is the most appropriate initial nursing action?
Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. A focused respiratory assessment should be done immediately, specifically checking for respiratory difficulty and subcutaneous emphysema.
The nurse is caring for a client who is mechanically ventilated and is monitoring for complications of mechanical ventilation. Which assessment finding, if noted by the nurse, indicates the need for follow-up?
1.
Muscle weakness in the arms and legs
2.
A temperature of 98.6°F (37°C), decreased from 99.0°F (37.2°C)
3.
A blood pressure of 90/60 mm Hg, decreased from 112/78 mm Hg
4.
A heart rate of 80 beats/minute, decreased from 85 beats/minute
Complications of mechanical ventilation include the following: hypotension caused by application of positive pressure, which increases intrathoracic pressure and inhibits blood return to the heart; pneumothorax or subcutaneous emphysema as a result of positive pressure; gastrointestinal alterations such as stress ulcers; malnutrition if nutrition is not maintained; infections; muscular deconditioning; and ventilator dependence or inability to wean.
Regarding chest tubes
Does the presence of fluctuation of the fluid level in the water seal chamber indicate a patent drainage system?
YES !
With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, a dependent loop exists, the suction is not working properly, or the lung has re-expanded.
Regarding chest tubes
What would cause fluctuations within the water seal chamber to stop ?
Fluctuation stops if the tube is obstructed, a dependent loop exists, the suction is not working properly, or the lung has re-expanded
How does the nurse immediately verify the placement of an ET tube ?
by ventilating the client using an Ambu bag and by auscultating for breath sounds bilaterally, which ensures ventilation of both lungs. After this initial assessment, placement is checked radiographically.
Endotracheal tube placement
The nurse marks the ET tube at the point where it enters the _______________for ongoing monitoring of correct placement
nose or mouth
.What should the nurse do initiatially before suctioning a client with a tracheostomy tube?
The nurse should hyperoxygenate the client both before and after suctioning. This would be the initial nursing action. The safe suction range for an adult client is 80 to 120 mm Hg. When the nurse advances the catheter into the tracheostomy tube, suction is not applied because applying suction at that time will cause mucosal trauma and aspiration of the client’s oxygen
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?
1.
Suctioning the client every hour
2.
Applying suction only during withdrawal of the catheter
3.
Hyperventilating the client with 100% oxygen before suctioning
4.
Applying suction intermittently during withdrawal of the catheter
The client should be suctioned as needed. Unnecessary suctioning should be avoided because it can increase secretions and cause mechanical trauma to the tissues. The client should be hyperoxygenated with 100% oxygen before suctioning. Suction is not applied during insertion of the catheter; intermittent suction and a twirling motion of the catheter are used during withdrawal
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?
The nurse should assess the tracheostomy ties to ensure that they are not too tight. The nurse ensures that there is room for 1 finger loosely or 2 fingers snugly to slide comfortably under the ties.
The nurse is preparing for removal of an endotracheal (ET) tube from a client. In assisting the health care provider with this procedure, which is the initial nursing action?
Once the client has been weaned successfullyand has achieved an acceptable level of consciousness to sustain spontaneous respiration, an ET tube may be removed. The ET tube is suctioned first, and then the cuff is deflated and the tube is removed.
Causes of high-pressure ventilator alarms include
water or a kink in the tubing, biting on the endotracheal tube, increased secretions in the airway, wheezing or bronchospasm, displacement of the endotracheal tube, or the client fighting the ventilator
causes of low pressure ventilator alarms
A disconnection or leak in the system and the client ceasing to spontaneously breathe are causes of a low-pressure ventilator alarm.
adverse effects of suctioning include
cyanosis, excessively rapid or slow heart rate, and sudden development of bloody secretions.
If any of these signs is observed, the nurse immediately stops suctioning and reports the adverse effect to the health care provider.
Coughing is a normal response to suctioning for the client with an intact cough reflex and does not indicate that he or she cannot tolerate the procedure.
TRUE OR FALSE
secretions may be blood tinged for a few days after tracheostomy insertion
TRUE
Impaired gas exchange could occur after tracheostomy because of
excessive secretions, bleeding into the trachea, restricted lung expansion because of immobility, or concurrent respiratory conditions.
______________measures oxygen saturation in blood flowing through the blood vessels in the periphery of the body and that inaccurate measurement may result from any factor that impairs _______________-
Pulse oximetry; blood flow through the periphery such as hypotension
When the chest tube is patent, the fluid in the water seal chamber rises with inspiration and falls with expiration. This is referred to as _____________
tidaling
____________–of the ribs has a constricting effect on the ribs and on deep breathing and can actually increase the risk of atelectasis and pneumonia.
Strapping
The nurse reads that a client’s tuberculin skin test is positive and notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse should base the response on which interpretation?
A client who tests positive on a tuberculin skin test either has been exposed to tuberculosis (TB) or has inactive (dormant) TB. The client must then undergo chest radiography and sputum culture to confirm the diagnosis.
The client with TB has significant fatigue and loss of physical stamina. This can be very frightening for the client. The nurse teaches the client that this symptom will _______________________-
resolve as the therapy progresses and that the client should gradually increase activity as energy levels permit
The client with TB may report signs and symptoms that have been present for
weeks or even months. These may include fatigue, lethargy, chest pain, anorexia and weight loss, night sweats, low-grade fever, and cough with mucoid or blood-streaked sputum. It may be the production of blood-tinged sputum that finally forces some clients to seek care.
The nurse is preparing for suctioning an unconscious client who has a tracheostomy. The nurse should perform which actions for this procedure? Select all that apply.
1.
Keeping a supply of suction catheters at the bedside
2.
Auscultating breath sounds to determine the need for suctioning
3.
Hyperoxygenating the client before, during, and after suctioning
4.
Intermittently suctioning during insertion of the suction catheter
5.
Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed
Suction equipment should be kept at the bedside of an unconscious client, regardless of whether an artificial airway is used. The nurse auscultates breath sounds every 2 to 4 hours, or more frequently, to determine if suctioning is needed. The client should be hyperoxygenated before, during, and after suctioning to minimize cerebral hypoxia. Intermittent suction should be applied while the catheter is being withdrawn, not while it is being inserted. Suctioning should not be performed for longer than 10 seconds at one time to prevent cerebral hypoxia and a rise in intracranial pressure.
he tuberculin skin test is an accurate and reliable test that will provide information to the health care provider about the client’s possible exposure status to tuberculosis. Interpretation of the skin test result should be done ____________-hours after the injection.
48-72
The clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse provides which instruction to the client?
1.
Drink hot tea throughout the day.
2.
Drink hot cocoa instead of coffee.
3.
Restrict fluid intake to 1000 mL daily.
4.
Eat foods that are highly seasoned in moderation.
Foods that are highly seasoned are irritating to the throat and should be completely avoided. The client with pharyngitis should be instructed to consume cool clear fluids, ice chips, or ice pops to soothe the painful throat.
Citrus products should be avoided because they irritate the throat. Milk and milk products are avoided because they tend to increase mucus production.
The client should be instructed to eat bland foods and drink 2000 to 3000 mL of fluid daily unless contraindicated.
A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action?
Assist the client to a sitting position with the head tilted forward.
The initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. The client should be assisted to a sitting position with the head tilted slightly forward, and pressure should be applied to the nares by pinching the nose toward the septum for 10 minutes.
Ice packs can be applied to the nose and forehead. If these actions are not successful in controlling the bleeding, an ice collar may be applied, along with a topical vasoconstrictive medication.
The health care provider also may prescribe packing of the nostrils. The client should be provided with an emesis basin and should be instructed not to swallow blood so as to reduce the risk of nausea and vomiting.
The nurse provides instructions to a client after a total laryngectomy. Which statement by the client indicates a need for further instruction?
1.
“I need to protect the stoma from water.”
2.
“Soaps should be avoided near the stoma.”
3.
“I should use diluted alcohol on the stoma to clean it.”
4.
“I should apply a non–oil-based ointment to the skin surrounding the stoma.”
The client with a stoma should be instructed to wash the stoma daily with a washcloth. The client should be instructed to avoid applying diluted alcohol to a stoma because it is both drying and irritating. The client is instructed to protect the stoma from water. Soaps, cotton swabs, and tissues should be avoided because their particles may enter and obstruct the airway. A non–oil-based ointment applied to the skin around the stoma helps to prevent cracking.
A ___________–is an abnormal opening,
fistula
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?
1.
Suctioning is required frequently.
2.
The client’s skin and mucous membranes are light pink.
3.
Aspiration of gastric contents occurs during suctioning.
4.
Excessive secretions are suctioned from the tube and stoma.
Necrosis of the tracheal wall can lead to formation of an abnormal opening between the posterior trachea and the esophagus. The opening, called a tracheoesophageal fistula, allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents.
The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm sounds. The nurse assesses 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?
Manually ventilate the client
Disconnect the client from the ventilator and manually ventilate the client with a resuscitation device.
If the nurse is unable to troubleshoot an alarm or suspects equipment failure in a mechanical ventilator, the nurse should
manually ventilate the client with a resuscitation device. The nurse should never shut off the alarm.
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?
1.
Excessive secretions
2.
Kinks in the ventilator tubing
3.
The presence of a mucous plug
4.
Displacement of the endotracheal tube
The low-exhaled volume alarm (low pressure alarm) will sound if the client does not receive the preset tidal volume. Possible causes of inadequate tidal volume include disconnection of the ventilator tubing from the artificial airway, a leak in the endotracheal or tracheostomy cuff, displacement of the endotracheal tube or tracheostomy tube, and disconnection at any location of the ventilator parts.
A high-pressure alarm occurs if the amount of pressure needed for ventilating a client ___________–the preset amount
exceeds
SIMV is one of the methods used for weaning. With this method, the ____________is gradually decreased until the client assumes all of the work of breathing on his or her own.
respiratory rate
This method works exceptionally well in the weaning of clients from short-term mechanical ventilation, such as that used in clients who have undergone surgery. The respiratory rate frequently is decreased in increments on an hourly basis until the client is weaned and is ready for extubation
This device requires that the client be removed from the mechanical ventilation for short periods of time, usually beginning with a 5-minute period. The ventilator is disconnected, and the __________is connected to the client’s artificial airway. Supplemental oxygen is provided through the device, often at a FiO2 that is 10% higher than the ventilator setting.
The T-piece (or Briggs device)
_______________is the amount of air delivered with each set breath on the mechanical ventilator. A __________-is a breath that has a greater volume than the preset tidal volume.
Tidal Volume; sigh
Histoplasmosis is caused by the inhalation of spores from bat or bird droppings. This disease cannot be transmitted from one person to another. TRUE OR FALSE
TRUE
A client who is intubated and receiving mechanical ventilation is at risk for infection. The nurse should include which measures in the care of this client? Select all that apply.
1.
Monitor the client’s temperature.
2.
Use sterile technique when suctioning.
3.
Use the closed-system method of suctioning.
4.
Monitor sputum characteristics and amounts.
Monitoring temperature and sputum production is indicated in the care of the client. A closed-system method of suctioning and sterile technique decrease the risk of infection associated with suctioning.
Water in the ventilator tubing should be emptied, not drained back into the humidifier bottle. This puts the client at risk of acquiring infection, especially Pseudomonas.
On removal of the chest tube, ________________is placed at the insertion site. The entire dressing is securely taped to make sure it is occlusive.
sterile petrolatum gauze and sterile 4 × 4 gauze
In most cases of ARDS, ___________ and __________ are the first clinical manifestations
tachypnea and dyspnea
. Blood-tinged frothy sputum would be a later sign, after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear
Fluid in the water seal chamber should rise with inspiration and fall with expiration (tidaling).
When tidaling occurs, the drainage tubes are patent and the apparatus is functioning properly. Tidaling stops when……………
the lung has reexpanded or if the chest drainage tubes are kinked or obstructed.
Postoperative teaching following chest tube removal
When a chest tube is removed, an occlusive dressing, usually consisting of petrolatum gauze covered by a dry sterile dressing, usually is placed over the chest tube site. This dressing is maintained in place until the health care provider says it may be removed. The client should avoid heavy lifting for 4 to 6 weeks after discharge to facilitate continued wound healing. The client is taught to monitor and report any signs of respiratory difficulty or any signs of infection or increased temperature.
A nursing student is developing a plan of care for a client with a chest tube that is attached to a chest drainage system. Which intervention in the care plan indicates the need for further teaching for the student?
1.
Position the client in semi Fowler’s position.
2.
Add water to the suction chamber as it evaporates.
3.
Instruct the client to avoid coughing and deep breathing.
4.
Tape the connection sites between the chest tube and the drainage system.
It is important to encourage the client to cough and deep breathe when a chest tube drainage system is in place. This will assist in facilitating appropriate lung reexpansion. The client is positioned in semi Fowler’s position to facilitate ease in breathing. Water is added to the suction chamber as it evaporates to maintain the full suction level prescribed. Connections between the chest tube and the drainage system are taped to prevent accidental disconnection.
TRUE OR FALSE. The client with a chest tube should not deep breathe or cough.
FALSE
It is important to encourage the client to cough and deep breathe when a chest tube drainage system is in place. This will assist in facilitating appropriate lung reexpansion. The client is positioned in semi Fowler’s position to facilitate ease in breathing.
The nurse is preparing to assist a client with a cuffed tracheostomy tube to eat. What intervention is the priority before the client is permitted to drink or eat?
1.
Inflate the cuff on the tracheostomy tube.
2.
Deflate the cuff on the tracheostomy tube.
3.
Maintain the head of the bed in low Fowler’s position.
4.
Place the tray in a comfortable position in front of the client.
Tracheostomy tubes are available in many sizes and are made of plastic or metal. The tubes may be reusable; however, most tubes are disposable. A tracheostomy tube may or may not have a cuff. It also may have an inner cannula. For clients receiving mechanical ventilation, a cuffed tube is used. A noncuffed tube may be used when mechanical ventilation is not required. If a client with a tracheostomy is allowed to eat and the tracheostomy has a cuff, the nurse should inflate the cuff to prevent aspiration of food or fluids. The cuff would not be deflated because of the risk of aspiration. Although the nurse would ensure that the meal tray is in a comfortable position for the client, this would not be the priority intervention. The head of the bed should always be elevated; low Fowler’s position could lead to aspiration.
NCLEX TEST STRATEGY
Note that the correct option and option 2 describe opposite actions; this indicates that one of these choices may be correct.
The nurse has provided discharge instructions to the client who has had a pneumonectomy. Which statement, if made by the client, indicates an understanding of appropriate home care measures?
1.
“I should restrict my fluid intake for 2 weeks.”
2.
“I should perform arm exercises 2 or 3 times a day.”
3.
“If I experience any soreness in my chest or shoulder, I should notify the health care provider.”
4.
“If I experience any numbness or altered sensation around the incision, I should contact the health care provider.”
The client should be instructed to perform arm and shoulder exercises 2 or 3 times a day to prevent frozen shoulder. The client is encouraged to drink liquids to liquefy secretions, making them easier to expectorate. The client is told to expect soreness in the chest and shoulder and an altered feeling of sensation around the incision site for several weeks. It is not necessary to contact the health care provider if these symptoms occur.
Pain of pleuropulmonary (respiratory) origin usually worsens on ____________.
inspiration
A client with a fat embolus is experiencing respiratory distress. The nurse plans to assist with which therapies?
1.
Administration of plasma expanders, low-flow oxygen, and suctioning
2.
Administration of bronchodilators, intubation, and mechanical ventilation
3.
Administration of oxygen, intubation, and mechanical ventilation with positive end-expiratory pressure
4.
Administration of antihypertensives, high-flow oxygen, and continuous positive airway pressure mask
Respiratory failure is the most common cause of death after fat embolus. The client may be intubated and mechanically ventilated with positive end-expiratory pressure to treat the significant hypoxemia and pulmonary edema. The use of corticosteroids is controversial. When given, these agents are used to treat inflammatory lung reactions and control cerebral edema.
The high-pressure ventilator alarm sounds when the preset peak inspiratory pressure limit is reached by the ventilator before it has delivered a set ______________-.
tidal volume
The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which finding?
1.
A disconnection of the ventilator tubing
2.
An exaggerated client inspiratory effort
3.
Accumulation of respiratory secretions
4.
Generation of extreme negative pressure by the client
The high-pressure alarm sounds when the preset peak inspiratory pressure limit is reached by the ventilator before it has delivered a set tidal volume. Causes include tubing obstruction or kinks, breathing “out of phase” or “bucking the ventilator,” accumulation of secretions, condensation of water in the ventilator tubing, coughing or Valsalva maneuvers, increased airway resistance, bronchospasms, decreased pulmonary compliance, and pneumothorax.
The low-pressure ventilator alarm sounds when little or no __________ is generated during the delivery of the machine breaths.
pressure
Alarm triggers include disconnection of the ventilator tubing at any point in the circuit, a cuff leak, and exaggerated client respiratory effort generating extreme negative pressure.
The nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding?
1.
A tubing obstruction or kink
2.
The accumulation of secretions
3.
Disconnection of the ventilator tubing
4.
Condensation of water in the ventilator tubing
The low-pressure alarm sounds when little or no pressure is generated during the delivery of the machine breaths. Alarm triggers include disconnection of the ventilator tubing at any point in the circuit, a cuff leak, and exaggerated client respiratory effort generating extreme negative pressure. The remaining options identify causes for triggering the high-pressure alarm.
When nasal passages become blocked as a result of a URI, the client has an impaired sense of taste and smell. This occurs because one of the normal functions of the nose is to stimulate _____________ through the sense of smell.
appetite
A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the health care provider (HCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation?
1.
“It will enter the left main bronchus if inserted too far.”
2.
“It will enter the right main bronchus if inserted too far.”
3.
“It may enter the left main bronchus if not inserted far enough.”
4.
“It may enter the right main bronchus if not inserted far enough.”
If the endotracheal tube is inserted too far into the client’s trachea, the tube will enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at all will occur.
A client who is mouth breathing is receiving oxygen by face mask. The unlicensed assistive personnel (UAP) asks the registered nurse (RN) why a water bottle is attached to the oxygen tubing near the wall oxygen outlet. The RN responds that this feature facilitates which purpose?
Humidifies the oxygen that is bypassing the client’s nose
The purpose of the water bottle is to humidify the oxygen that is bypassing the nose during mouth breathing
The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit?
1.
Dilate the major bronchi.
2.
Increase surfactant production.
3.
Maintain inflation of the alveoli.
4.
Enhance ciliary action in the tracheobronchial tree.
Sustained inhalation when using an incentive spirometer helps maintain inflation of the terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk.
