Unit 1: Iggy 10th Ed Practice Questions Flashcards
25-1. Which statements about oxygen and oxygen therapy are true? SATA
A. An oxygen concentrator reduces the amount of carbon dioxide in atmospheric air.
B. Clients must provide informed consent to receive oxygen therapy.
C. Excessive oxygen use is a contributing cause of chronic obstructive pulmonary disease.
D. In non-emergency situations, a health care provider’s prescription is needed for oxygen therapy.
E. Oxygen can explode when handled improperly.
F. Oxygen is a beneficial element but can harm lung tissue.
G. The liquid form of oxygen is a drug to manage hypoxia, whereas the gaseous form is only an atmospheric element.
H. Unless humidity is added, therapy with oxygen dries the upper and lower mucous membranes.
C. Excessive oxygen use is a contributing cause of chronic obstructive pulmonary disease.
D. In non-emergency situations, a health care provider’s prescription is needed for oxygen therapy.
F. Oxygen is a beneficial element but can harm lung tissue.
H. Unless humidity is added, therapy with oxygen dries the upper and lower mucous membranes.
An oxygen concentrator reduces the amount of nitrogen in atmospheric air, which has the highest concentration of all gases in the atmosphere.
Oxygen is a drug that requires a prescription but not informed consent.
Excessive oxygen can form reactive oxygen species that injures lung tissue but does not cause COPD.
Oxygen is a gas that promotes combustion but does not explode.
Only oxygen gas is directly inhaled to improve gas exchange. Liquid oxygen must first be converted to a gas before it can be used.
When oxygen is delivered without humidification, especially at higher flow rates, respiratory mucous membranes can become dry and irritated.
25-2. The SpO2 of a client receiving oxygen therapy by nasal cannula at 6L/minute has dropped from 94% an hour ago to 90%. Which action does the nurse perform first to promote gas exchange before reporting the change to the primary health care provider?
A. Tighten the straps on the nasal cannula
B. Increase the oxygen flow rate to 8L/minute
C. Check the tubing for kinks, leaks, or obstructions
D. Check to determine whether the oxygen delivery system is adequately humidified
C. Check the tubing for kinks, leaks, or obstructions
Oxygen tubing is flexible and has a narrow lumen. Tubing that is kinked or obstructed or has a leak can interfere with oxygen delivery to the client and result in desaturation. The maximum flow rate is 6 L/minute for a nasal cannula and increasing the rate above this value does not result in an increase in oxygen delivery to the client. Tightening the straps on the nasal cannula can make the client uncomfortable and does not increase oxygenation. Humidifying the oxygen prevents drying of mucous membranes but does not increase the actual amount of oxygen delivered.
25-3. Which action does the nurse use to prevent harm by loss of tracheal tissue integrity in a client with a tracheostomy?
A. Providing meticulous oral care every 8 hours
B. Deflating the cuff for 15 minutes every 2 hours
C. Feeding the client liquids rather than solid foods
D. Maintaining cuff inflation pressure less than 25 cm H2O
D. Maintaining cuff inflation pressure less than 25 cm H2O
An overinflated cuff can cause tissue injury and necrosis of the tracheal tissue. Although cuff pressure must be adequate to prevent leaks, it is critical to keep the pressure lower than 25 cm H2O. Meticulous oral care can help maintain tissue integrity of oral muscous membranes but does not help tracheal tissue integrity. Neither liquids nor solid foods should enter the trachea. Deflating the cuff reduces the effectiveness of the tracheostomy for adequate ventilation.
25-4. Which conditions or changes indicate to the nurse that a client with a tracheostomy requires suctioning? Select all that apply.
A. The client has a fever.
B. Crackles and wheezes are heard on auscultation.
C. The client requests that suctioning be performed.
D. Suctioning was last performed more than 3 hours ago.
E. The tracheostomy dressing has a moderate amount of serosanguious drainage.
F. The skin around the tracheostomy is puffy and makes a crunching sound when touched.
B. Crackles and wheezes are heard on auscultation.
C. The client requests that suctioning be performed.
To avoid tissue injury, tracheostomy suctioning is performed only when indication are present that it is needed. Such indications include when crackles and/or wheezes are heard on auscultation, secretions in the airways that the client cannot clear are audible, restlessness is increased along with elevations of heart rate or respiratory rate, the client requests to be suctioned, and when the ventilator peak airway pressure is increased. Suctioning is not performed on a scheduled basis. Subcutaneous emphysema and drainage on the dressing are not indications of suctioning need. In addition, suctioning is not an appropriate response to the presence of a fever.
25-1. Which assessment finding for a client receiving oxygen therapy with a nonrebreather mask requires the nurse to intervene immediately?
A. The oxygen flow rate is set at 12 L/minute.
B. The exhalation ports are open during exhalation.
C. The exhalation ports are closed during inhalation.
D. The reservoir bag is not inflated during inhalation.
D. The reservoir bag is not inflated during inhalation.
The nonrebreather mask has a one-way valve between the mask and the reservoir and has two flaps over the exhalation ports. The flaps should be closed during inhalation to prevent room air from entering and diluting the oxygen concentration. During exhalation, air leaves through these exhalation ports. The client can only draw needed air with oxygen from the reservoir bag, which must be inflated during inhalation. The flow rate of 12 L/min is sufficient to keep the bag inflated during inhalation.
25-2. Which statement made by a client prescribed oxygen therapy at home indicates to the nurse that more instruction is needed?
A. “When I want to smoke, I will use the liquid oxygen reservoir instead of the compressed oxygen tank.”
B. “Using oxygen should help me have more breath and stamina when I eat, bathe, and take care of myself.”
C. “Even though they contain alcohol, I can still drink a glass of wine or can of beer while using oxygen.”
D. “If my shortness of breath becomes worse or if I have chest pain, I will contact my primary health care provider immediately.”
A. “When I want to smoke, I will use the liquid oxygen reservoir instead of the compressed oxygen tank.”
Oxygen, whether from a liquid reservoir or compressed oxygen tank, enhances combustion and is not to be used around open flames. Thus, the statement that switching to a liquid oxygen reservoir is safer to use while smoking rather than a oxygen from a compressed tank is completely erroneous and dangerous. Clients should contact their health care providers if breathing becomes more difficult or if chest pain occurs. Neither wine nor beer contain enough alcohol to be combustible in the presence of oxygen. Oxygen therapy can improve a client’s activity tolerance and stamina.
25-3. Which action does the nurse take care to avoid while suctioning a client’s tracheostomy tube?
A. Twirling the catheter while applying suction
B. Applying suction only when withdrawing the catheter
C. Performing oral suctioning before suctioning the artificial airway
D. Lubricating the suction catheter with sterile saline before insertion
C. Performing oral suctioning before suctioning the artificial airway
Infection is possible during tracheal suctioning because each catheter pass introduces bacteria into the trachea. Sterile technique is used for suctioning and the mouth or nose is suctioned only after suctioning the artificial airway. Tissue injury is prevented by lubricating the catheter with sterile water or saline before insertion, applying continuous suction only during catheter withdrawal, and using a twirling motion during withdrawal to prevent grabbing of the mucosa.
The client, who is 24 hours postoperative after a right lower lobectomy for stage II lung cancer and has two chest tubes in place, reports intense burning pain in his lower chest. On assessment, the nurse notes there is no bubbling on exhalation in the water seal chamber. What action will the nurse perform first?
A. Immediately notify either the Rapid Response Team or the thoracic surgical resident.
B. Assist the client to a side-lying position and re-assess the water seal chamber for bubbling.
C. Administer the prescribed opioid analgesic immediately, and then assess the chest tube system.
D. No action is needed because these responses are normal for the first post-op day after lobectomy.
B. Assist the client to a side-lying position and re-assess the water seal chamber for bubbling.
The tip of the chest tube could be lying against tissue, becoming occluded and causing the burning pain. Repositioning the client can change the position of the chest tube tip, relieving the pain and allowing drainage to continue.
A is incorrect because although no bubbling means no drainage and could lead to a tension pneumothorax, troubleshoot quickly before call the rapid response team. If repositioning does not solve the problem, then call the rapid response team.
A client who is 3 days postoperative from extensive abdominal surgery for cancer reports having difficulty “catching her breath” and having a reddish-purple, non-itchy rash on her chest. After assessing the client, what is the nurse’s best action or response to prevent harm?
A. Ask the client about possible drug allergies
B. Apply oxygen and call the rapid response team
C. Determine when she last received an opioid dose
D. Check the oxygen saturation and encourage her to cough
B. Apply oxygen and call the rapid response team
This client is at high risk for developing a pulmonary embolism from a venous thromboembolism (has cancer and recently underwent extensive abdominal surgery). She has two major symptoms of PE, sudden onset shortness of breath and petechiae on her chest. These are significant enough to call the rapid response team because and without assessing oxygen saturation or most recent opioid dose (she has no symptoms of respiratory depression) because time is of the essence in starting appropriate therapy to prevent permanent lung damage or death. Applying oxygen can help improve her gas exchange and should be done immediately. Rash caused by a drug allergy are usually red, raised, itchy, and do not look like petechiae.
Which condition, sign, or symptom does the nurse consider most relevant in assessing a client suspected to have ARDS? Select all that apply.
A. Dyspnea
B. Electrocardiograph shows ST elevation
C. Intercostal retractions
D. PaO2 84% on oxygen at 6 L/minute
E. Substernal pain or rubbing
F. Wheezing on exhalation
A. Dyspnea
C. Intercostal retractions
D. PaO2 84% on oxygen at 6 L/minute
The defining feature of ARDS is continued hypoxemia despite vigorous oxygen therapy. The hypoxia and hypoxemia triggers dyspnea and an increased breathing effort seen as intercostal retractions. Substernal pain or rubbing are not associated with ARDS. The pathophysiological problems of ARDS are in the lung tissue and not in the airways. Thus, wheezing is not a manifestation of the disorder. Although the hypoxia stimulates a variety of dysrhythmias, there are no specific ECG changes. ST elevation is associated with an evolving myocardial infarction.
The client is a 5 foot 11 inches tall, 176 lb (80 kg) woman who has been mechanically ventilated at a tidal volume of 400 mL and a respiratory rate of 12 breaths per minute for the past 24 hours. The most recent arterial blood gas (ABG) results for this client are:
pH= 7.32;
PaO2 = 84 mm Hg;
PaCO2 = 56 mm Hg.
What is the nurse’s interpretation of these results?
A. Ventilation adequate to maintain oxygenation.
B. Ventilation excessive; respiratory alkalosis present.
C. Ventilation inadequate; respiratory acidosis present.
D. Ventilation status cannot be determined from information presented.
C. Ventilation inadequate; respiratory acidosis present.
The average-size adult female has a normal tidal volume of 400-500 mL. However this client is larger than average and would have a greater tidal volume. Usually the tidal volume is set at 6 to 8 mL/kg of body weight, which would range between 480mL to 640 mL. At the current tidal volume setting this woman is being underventilated with inadequate gas exchange. Not enough oxygen is available and not enough carbon dioxide is being lost leading to respiratory acidosis.
Which symptom or change in assessment of a client with 4 broken ribs on the right side indicates to the nurse the possibility of a tension pneumothorax?
A. Distended neck veins
B. Mediastinal shift toward the left side
C. Right-sided pain on deep inhalation
D. Right side of the chest more prominent than the left
A. Distended neck veins
Any type of pneumothorax can shift the mediastinum to the unaffected side and cause the affected side to be more prominent. Pain on deep inhalation is related to the broken ribs and not a pneumothorax. The distended neck veins are a strong indicator of the life-threatening tension pneumothorax and immediate action is needed.
29-1 An attempt by a primary health care provider to intubate a client for mechanical ventilation is unsuccessful after 45 seconds. What is the nurse’s priority action?
A. Placing a nasotracheal tube
B. Assessing for bilateral breath sounds
C. Assessing oxygen saturation by pulse oximetry
D. Applying oxygen with a bag-valve-mask device
D. Applying oxygen with a bag-valve-mask device
During the intubation procedure the client is not breathing. The intubation attempt should last not longer than 15 to 30 seconds. After 45 seconds the client is very hypoxic and assessing oxygen saturation is not necessary. The client needs oxygen as quickly as possible. Assessment for bilateral breath sounds is performed after intubation to determine ensure that the tube is not in one bronchus. Placing a naso-tracheal tube is not a bedside nursing function.
29-2. Which actions does the nurse ensure are performed for a client being mechanically ventilated to prevent ventilator-associated pneumonia (VAP)? Select all that apply.
A. Assessing temperature every 4 hours
B. Checking ventilator settings every 4 hours
C. Getting the patient out of bed as soon as prescribed
D. Keeping the head of the bed elevated to 30 degrees or above
E. Maintaining the client in the prone position
F. Providing adequate humidification
G. Providing meticulous mouth care every 12 hours
H. Suggesting that the pneumonia vaccine be prescribed
C. Getting the patient out of bed as soon as prescribed
D. Keeping the head of the bed elevated to 30 degrees or above
G. Providing meticulous mouth care every 12 hours
Getting the client out of bed as quickly as possible helps prevent VAP by reducing the risk of fluid stasis in the lungs and aspiration, a common cause of VAP. Keeping the head of the bed elevated when the client is in bed also reduces the risk for aspiration. Meticulous oral care prevents colonization of bacteria that can move into the respiratory tract. Assessing temperature can help identify VAP early but does not prevent its occurrence. Checking the ventilator settings is crucial to ensure adequate gas exchange and prevent injury but does not prevent pneumonia. The prone position during mechanical ventilation is recommended only for clients with ARDS and does not prevent VAP. Humidifying the oxygen and air received by the client helps prevent drying of the respiratory tract but not VAP. VAP is not caused by the same organisms that cause infectious pneumonia and vaccination against these organisms does not prevent VAP.
29-3 A client being mechanically ventilated has all of the following changes. Which changes are most relevant in helping the nurse determine whether suctioning is needed at this time? Select all that apply.
A. Decreased SpO2
B. Elevated temperature
C. Crackles auscultated over the trachea
D. Crackles auscultated in the lung periphery
E. High-pressure ventilator alarm sounds
F. Presence of fluid within the endotracheal tube
G. Presence of fluid within the ventilator tubing
A. Decreased SpO2
C. Crackles auscultated over the trachea
E. High-pressure ventilator alarm sounds
F. Presence of fluid within the ET tube
Decreased SpO2 is often caused by excessive airway secretions and is a major indicator of the nees for suctioning. Crackles over the trachea are caused by fluid in the trachea and suctioning is needed to remove this fluid. Pressure is increased when resistance is present in the airway such as that caused by secretions. Fluid in the endotracheal tube indicates a need for immediate suctioning regardless of how recently it was last performed. Elevated temperature is not related to the need for suction. Crackles in the lung periphery would not be reduced by endotracheal suctioning. Fluid in the ventilator tubing is caused by condensation, not increased secretions in the airway.
With which client will the nurse take immediate actions to reduce the risk for developing a pulmonary embolism (PE)?
A 50 year old with type 2 diabetes mellitus and cellulitis of the leg
A 36 year old who had open reduction and internal fixation of the tibia
A 25 year old receiving IV antibiotics through a peripheral line
A 72 year old with dehydration and hypokalemia taking oral potassium supplements
A 36 year old who had open reduction and internal fixation of the tibia
To reduce the risk for developing PE, the nurse provides immediate interventions for the client who had an open reduction and internal fixation of the tibia. Lower limb surgery and perioperative immobility are high risks for deep vein thrombosis (DVT) formation and PE. Peripheral infusion of antibiotics in a younger client is not a significant risk for PE. Although dehydration is a mild risk for thrombosis, this is not as common as thromboembolic complications after orthopedic surgery.
What is the basis for the decreased oxygen saturation the nurse assesses in a client with a pulmonary embolism (PE)?
Partial bronchial airway obstruction
Thickened alveolar membranes and poor gas exchange
Increased oxygen need resulting from a septic clot PE
Shunting of deoxygenated blood to the left side of the heart
Shunting of deoxygenated blood to the left side of the heart
A PE lodges in the blood vessels decreasing perfusion to a lung area, which wastes ventilation. When this blood that has not been oxygenated is returned to the left side of the heart, it dilutes the oxygen concentration of the arterial blood entering systemic circulation.
PE does not block bronchial airways or thicken alveolar membranes. A septic clot is not the same as general sepsis, which when widespread, does increase tissue metabolism and the need for more oxygen.
Drugs from which class will the nurse prepare to administer as first-line therapy for a client just diagnosed with pulmonary embolism (PE)?
Anticoagulants
Antihypertensives
Antidysrhythmics
Antibiotics
Anticoagulants
A PE is collection of particulate matter (solids, liquids, or air) that enters venous circulation and lodges in the pulmonary vessels. Anticoagulants are the first-line therapy drugs for this problem, even if the actual particulate matter is not a clot. Anything lodged in the blood vessels will cause clot formation around it. Anticoagulants help prevent new clots from forming in the area and extension of existing clots.
Depending on other problems cause by a PE, antibiotics, or antidysrhythmics may also be used but not always. Clients with PE are hypotensive, not hypertensive.
Which new assessment finding in a client being managed for a pulmonary embolism (PE) indicates to the nurse that the client’s condition is worsening?
Increasing temperature
Abdominal cramping
Hand tremors
Distended neck veins in the high-Fowler position
Distended neck veins in the high-Fowler position
Distension of neck veins in the upright (high-Fowler) position occurs with right-sided heart failure, which is a complication of PE. None of the other changes in assessment findings are directly associated with worsening PE.
Which assessment findings in a postoperative client suggest to the nurse the possibility of a pulmonary embolism (PE) and pulmonary infarction?
Hemoptysis and shortness of breath
Fever and tracheal deviation
Audible wheezing on inhalation and exhalation
Paradoxical chest movements
Hemoptysis and shortness of breath
Symptoms of a PE with infarction include profound shortness of breath and bloody sputum (hemoptysis) from poor gas exchange and hypoxic damage to lung tissues. Paradoxical chest movements are associated with a flail chest, not PE. Tracheal deviation is associated with a pneumothorax. Audible wheezing on inhalation and exhalation is a partial obstruction of the tracheobronchial tree.
In addition to notifying the pulmonary health care provider, what is the most important action for the nurse to take first for a client with a pulmonary embolism (PE) whose arterial blood gas (ABG) values are pH 7.28, PaCO2 50 mm Hg, PaO2 62 mm Hg, and HCO3− 24 mEq/L (24 mmol/L)?
Administering sodium bicarbonate
Having the client breathe rapidly and deeply into a paper bag
Assessing for the presence of adventitious lung sounds
Increasing the oxygen flow rate
Increasing the oxygen flow rate
These ABG values indicate respiratory acidosis (low pH and high PaCO2) and severe hypoxemia (low PaO2) from greatly reduced gas exchange.
This client needs more oxygen now.
by a low partial pressure of arterial carbon dioxide (PaCO2 of 30 mm Hg) and a high pH (7.46). Breathing more rapidly and deeply into a paper bag would decrease oxygen levels and increase CO2 further, making hypoxemia and acidosis worse. The bicarbonate level is normal and requires no intervention. Adventitious sounds are expected and identifying them is not the first priority.
Which action is a priority for the nurse to prevent harm for a client with a pulmonary embolism who is receiving a continuous heparin infusion?
Assessing gums daily for indications of bleeding
Monitoring the platelet count daily
Assessing breath sounds
Comparing pedal pulses bilaterally
Monitoring the platelet count daily
Daily platelet counts are a safety priority in assessing for heparin-induced thrombocytopenia (HIT), a potential side effect of heparin.
Assessing breath sounds each shift is an important action, as is examining for indications of bleeding. However, identifying HIT early is a greater priority so that appropriate interventions can be initiated. Assessing bilateral pedal pulses is important if the source of the embolism is a venous thromboembolism (VTE) in the legs; however, this is not an important general action for a client with PE.
Which client will the nurse consider to be at the greatest risk for developing acute respiratory distress syndrome (ARDS)?
A 22 year old with a fractured clavicle
A 39 year old with uncontrolled diabetes
A 56 year old with chronic kidney disease
A 74 year old who aspirates a tube feeding
A 74 year old who aspirates a tube feeding
ARDS is a type of acute respiratory failure with hypoxemia that persists even when 100% oxygen is given, decreased pulmonary compliance, dyspnea, bilateral pulmonary edema, and dense pulmonary infiltrates on x-ray (ground-glass appearance). It often occurs after an acute lung injury such as could result from aspiration of acidic gastric contents. Clients who are receiving tube feedings are at particular risk for lung damage by aspiration.
Fractured clavicle, diabetes, and chronic kidney disease is associated with an increased risk for lung injury or ARDS.
What is the primary emphasis for the nurse who is providing care to a client with acute respiratory distress syndrome (ARDS) currently in the exudative management stage of the disorder?
Assessing the client at least hourly for tachypnea and dyspnea
Performing meticulous mouth during mechanical ventilation
Assessing for abnormal lung sounds
Monitoring urine output to identify multiple organ dysfunction syndrome early
Assessing the client at least hourly for tachypnea and dyspnea
The exudative phase includes early changes of dyspnea and tachypnea resulting from the alveoli becoming fluid filled and from pulmonary shunting and atelectasis. Early interventions focus on frequent assessment of respiratory status, supporting the client, and providing oxygen.
Abnormal lung sounds are not present at this stage because the edema is present in the interstitial tissues and not in the airways. At this stage, clients are neither intubated nor being mechanically ventilated. Multiple organ dysfunction syndrome is not a feature of this stage.
What is the best first action when the nurse assesses that the respirations of a sedated client with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures but the ventilator tubing is clear?
Suctioning the tracheostomy tube
Remove the inner cannula of the tracheostomy
Humidifying the oxygen source
Increasing the percentage of oxygen
Suctioning the tracheostomy tube
The best first action by the nurse is to suction the tracheostomy tube. This will likely result in clear lung sounds and lower peak pressure.
Humidifying the oxygen source may help mobilize secretions but is not an immediate helpful action. Increasing oxygenation does nothing to clear the airway of whatever is making it noisy and is elevating peak pressures. Removing the inner cannula of a ventilated client is contraindicated.
Which action will the nurse take first for a client being mechanically ventilated who begins to pick at the bedcovers?
Administering the prescribed sedating drug
Explaining to the client that the tube helps with breathing
Requesting that the family leave to decrease the client’s agitation
Assessing for adequate oxygenation
Assessing for adequate oxygenation
The best first action by the nurse would be to assess for adequate oxygenation. Restlessness, agitation, anxiety, and tachycardia are early symptoms of hypoxemia.
Increasing sedation is not indicated for this client and may mask symptoms such as hypoxemia or worsening respiratory failure. Although the nurse may explain to the client that he or she is intubated, it does not take priority over assessing for hypoxemia. The presence of family members may decrease, not increase, the client’s anxiety.
Which action has the highest priority for the nurse to take to prevent harm for a client being mechanically ventilated with 100% oxygen for the past 24 hours who now has new-onset crackles, decreased breath sounds, and a PaO2 level of 95 mm Hg?
Collaborating with the pulmonary health care provider to lower the FiO2 level
Assessing cognition
Placing the client in the prone position
Preparing to suction the client
Collaborating with the pulmonary health care provider to lower the FiO2 level
Prompt identification and correction of the underlying disease process and potential oxygen toxicity may require delivery of a lower FiO2. The pulmonary health care provider needs to be notified when PaO2 levels are greater than 90 mm Hg. Preventing harm from oxygen toxicity and absorptive atelectasis (new onset of crackles and decreased breath sounds) are essential. Oxygen toxicity is related to the concentration of oxygen delivered, duration of oxygen therapy, and degree of lung tissue present. The need for 100% oxygen delivery indicates that the client continues to require intubation and mechanical ventilation.
Suction is performed when rhonchi or noisy breath sounds on the anterior chest below the sternal notch (upper airway) are present. Crackles and diminished breath sounds reflect fluid or poor exchange in the lower airway, not the need for suctioning. Although prone-positioning has been used for clients with acute respiratory distress syndrome (ARDS), is not the priority action and this client has not been diagnosed with ARDS.
Which action will the nurse take first while caring for a client being mechanically ventilated when the high-pressure alarm sounds?
Comparing the ventilator settings with the prescribed settings
Turning off the alarm then assess the need for suctioning
Notifying the respiratory therapist
Auscultating the client’s breath sounds
Auscultating the client’s breath sounds
The nurse will first listen to the client’s breath sounds. Assessment always begins with the client. A typical reason for the high-pressure alarm to sound is obstruction of airflow through the ventilator circuit, usually indicating the need for suctioning. Other reasons for the high-pressure alarm to be triggered included biting the endotracheal tube or tension pneumothorax.
The nurse is concerned with the assessment of the client first, not with the ventilator or ventilator settings and does not turn off the alarms before assessing the client. Although an excessively high tidal volume could contribute to the high-pressure alarm sounding, this is not the nurse’s first concern. The professional nurse possesses the skill to assess ventilator alarms; waiting for the respiratory therapist delays intervention.
Which ventilator mode does the nurse expect will be set for a client with a tracheostomy who is beginning to take spontaneous breaths at his own rate and tidal volume between set ventilator breaths?
Assist-control (AC) ventilation
Continuous positive airway pressure (CPAP)
Synchronized intermittent ventilation (SIMV)
Bi-level positive airway pressure (BiPAP)
Synchronized intermittent ventilation (SIMV)
Synchronized intermittent mandatory ventilation (SIMV) is a ventilation mode in which volume and ventilatory rate are preset. It allows spontaneous breathing at the patient’s own rate and tidal volume between the ventilator breaths to coordinate breathing between the ventilator and the client.
BiPAP and CPAP are not used for clients who have an endotracheal tube. With assist-control ventilation, the preset tidal volume continues even when the client’s own respiratory rate increases, which could lead to over-ventilation.
What is the nurse’s best first action when assessing a client who was intubated a few minutes ago and finds the end-tidal carbon dioxide level is 0 and the SpO2 is 38%?
Documenting the finding in the electronic health record as the only action
Initiating the Rapid Response Team
Removing the endotracheal tube and ventilating the client with a bag-valve-mask
Obtaining a different monitor and rechecking the end-tidal carbon dioxide level
Removing the endotracheal tube and ventilating the client with a bag-valve-mask
A reading of 0 for the end-tidal carbon dioxide and the very low SpO2 level indicate that the endotracheal tube is not in the airway. Immediate action is needed. While it is present in the client’s throat, its presence is preventing air from reaching the airways. Removing the tube and ventilating the client with a bag-valve-mask device is critical to saving the client’s life. The nurse will perform these actions while having another health care worker call the Rapid Response Team.
If the client’s SpO2 was in the normal range, obtaining a different monitor and rechecking end-tidal carbon dioxide level would be a good action. However, the low oxygen saturation level indicates there is no time for rechecking the carbon dioxide level.
What type of acid–base problem will the nurse expect in a client who is being insufficiently mechanically ventilated for the past 4 hours and whose most recent arterial blood gas results include a pH of 7.29?
Respiratory acidosis with an acid excess
Metabolic acidosis with an acid excess
Respiratory acidosis with a base deficit
Metabolic acidosis with a base deficit
Respiratory acidosis with an acid excess
When a person being mechanically ventilated is insufficiently ventilated respiratory acidosis occurs with retention of carbon dioxide. The retained carbon dioxide is converted to hydrogen ions resulting in an acid excess. Bases have neither been lost nor retained in an acute respiratory acidosis. Insufficient ventilation does not cause any form of metabolic acidosis.
Which action will the nurse instruct a client with an endotracheal tube to perform when the tube is being removed?
Hold his or her breath
Inhale
Cough
Exhale
Exhale
The nurse instructs the client to inhale deeply right before extubation while the nurse deflates the tube cuff. The tube is removed while the client exhales. The nurse instructs the client to cough immediately after extubation.
What type of percussion note or sound will the nurse expect on the affected chest side of a client who has a hemothorax?
Dull
Hyperresonant
Crackling
Hypertympanic
Dull
With a hemothorax, percussion on the involved side produces a dull sound because the blood in the lung area prevents air from filling the area. Lung crackling sounds cannot be percussed, although skin crackling with subcutaneous emphysema can. Tympanic sounds on percussion are associated with abdominal assessment, not pulmonary. Any degree of resonance is associated with air-filled lung areas, not blood-filled areas.
Which assessment finding on a client who is being mechanically ventilated with positive end-expiratory pressure indicates to the nurse a possible left-sided tension pneumothorax?
Left chest caves in on inspiration and “puffs out” on expiration.
The left lung field is dull to percussion and crackles are present on auscultation.
The client has bloody sputum and wheezes.
Chest is asymmetrical and trachea deviates toward the right side.
Chest is asymmetrical and trachea deviates toward the right side.
Symptoms of tension pneumothorax include chest asymmetry, tracheal deviation toward the unaffected side, dyspnea, absent breath sounds, jugular venous distention, cyanosis, and hyperresonance to percussion over the affected area. If not promptly detected and treated, tension pneumothorax is quickly fatal.
Flail chest has paradoxical chest movement with a “sucking inward” of the loose chest area during inspiration and “puffing out” of the same area during expiration. Open pneumothorax presents with decreased breath sounds, hyperresonance, and poor respiratory excursion on the affected side. Pulmonary contusion presents with hemoptysis, dullness to percussion, and crackles or wheezes.
The nurse has just received report on a group of clients. Which client is the nurse’s first priority?
A 60 year old who was recently extubated and reports a sore throat.
A 50 year old being mechanically ventilated who has tracheal deviation.
A 30 year old receiving continuous positive airway pressure (CPAP) and has intermittent wheezing.
A 40 year old receiving oxygen facemask and whose respiratory rate is 24 breaths/min.
A 50 year old being mechanically ventilated who has tracheal deviation.
The nurse needs to immediately attend to the mechanically ventilated client with a tracheal deviation. This client is showing signs of a tension pneumothorax that could lead to hypoxemia, decreased cardiac output, and shock.
The client receiving CPAP has intermittent wheezing, but is not in immediate danger or distress. The client recently extubated has sore throat which is anticipated after intubation. There is no indication this client is in need of immediate intervention. The client wearing oxygen has mild tachypnea, but is not in immediate distress or danger.
When caring for a group of clients at risk for or diagnosed with pulmonary embolism, the nurse calls the Rapid Response Team (RRT) for intervention for which client?
Client with a right pneumothorax who is being treated with a chest tube and has a pulse oximetry reading of 94%.
Client who was extubated 3 days ago and has decreased breath sounds at the posterior bases of both lungs.
Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia.
Client with deep vein thrombosis who is receiving low-molecular-weight heparin and has ongoing calf pain.
Client treated for pulmonary embolism with IV heparin who has hemoptysis and tachycardia.
The RRT needs to quickly assess the client with a diagnosed pulmonary embolism who is showing signs of possible pulmonary infarction or bleeding abnormality secondary to heparin. Tachycardia, along with bloody sputum (hemoptysis), may be a symptom of hypoxemia or hemorrhagic shock, which requires immediate intervention.
The client with deep vein thrombosis requires ongoing monitoring and is receiving appropriate treatment. Calf pain is expected in this situation. The client with a right pneumothorax requires ongoing monitoring but demonstrates adequate pulse oximetry of 94%. The client who was extubated 3 days ago requires ongoing nursing assessment, but does not have evidence of acute deterioration or severe complications.
Which assessment findings in a client at high risk for pulmonary embolism (PE) indicates to the nurse the probable presence of a PE?
Select all that apply.
Inspiratory chest pain
Dizziness and syncope
Pink, frothy sputum
Worsening dyspnea for 3 days
Tachycardia
Productive cough
Inspiratory chest pain
Dizziness and syncope
Tachycardia
Symptoms consistent with PE include: dizziness, syncope, hypotension, and fainting. Sharp, pleuritic, inspiratory chest pain, hemoptysis, and tachycardia are also characteristic of PE.
Typically SOB and dyspnea associated with PE develops abruptly rather than gradually over 2 weeks. Productive cough is associated with infection. PE typically causes a dry cough. Pink, frothy sputum is characteristic of pulmonary edema.
Which clients will the nurse monitor most closely for respiratory failure?
Select all that apply.
A 30 year old with a C-5 spinal cord injury
A 55 year old with a brainstem tumor
A 50 year old experiencing cocaine intoxication
A 65 year old with COVID-19 pneumonia
A 35 year old using client-controlled analgesia
A 40 year old with acute pancreatitis
A 30 year old with a C-5 spinal cord injury
A 55 year old with a brainstem tumor
A 65 year old with COVID-19 pneumonia
A 40 year old with acute pancreatitis
Pressure on the brainstem may depress respiratory function. Acute pancreatitis is a risk factor for acute respiratory distress syndrome; abdominal distention also ensues, which can limit respiratory excursion. Clients with cervical and high thoracic spinal cord injuries are at high risk for respiratory failure because spinal nerves that affect the diaphragm and inter-costal muscles are affected. Opioids used in client-controlled analgesia are respiratory depressants and can depress the breathing center in the brainstem causing respiratory failure. Pneumonia, whether bacterial or viral, can result in oxygenation respiratory failure, especially in an older client who often has respiratory muscle weakness.
Cocaine is a stimulant, which would not cause respiratory failure unless a stroke ensued.
For which problems will the nurse specifically assess when the low-pressure alarm of a client’s mechanical ventilator sounds?
Select all that apply.
Mucous plugs are in the endotracheal tube.
Leak in the ventilator tubing circuit.
Client is not breathing.
Cuff leak in the endotracheal or tracheostomy tube.
Ventilator tubing is under the client.
Client is attempting to breathe against the ventilator.
Leak in the ventilator tubing circuit.
Client is not breathing.
Cuff leak in the endotracheal or tracheostomy tube.
Common causes of alarms indicating low-pressure include: cuff leaks in the endotracheal or tracheostomy tube, client stops breathing when a ventilator is in the “support” mode, and when a leak is present in the ventilator tubing circuit.
Presence of increased airway secretions or mucous plugs, client coughing or gaging, client fighting or “bucking” the ventilators, anything that decreases airway size (i.e., bronchospasms), presence of a pneumothorax, displacement of the endotracheal tube further into the tracheal bronchial tree, and external obstruction of the tubing result in high-pressure, not low-pressure.
Which blood gas value indicates to the nurse that a client is experiencing hypercarbia?
Bicarbonate = 20 mEq/L
pH = 7.33
PaO2 = 80 mm Hg
PaCO2 = 60 mm Hg
PaCO2 = 60 mm Hg
The low pH, the elevated carbon dioxide level, and the low oxygen concentration all indicate that the client is experiencing poor gas exchange and has acidosis. The low pH and the low oxygen concentration could occur without hypercarbia. Only the elevated carbon dioxide concentration confirms hypercarbia.
Which nursing action will the nurse take to prevent harm from disruption of oxygen therapy for the client receiving low-flow oxygen by simple facemask?
Keeping a small cylinder of oxygen at client’s bedside stand for emergency use in case the central oxygen delivery system fails
Changing to a nasal cannula during meals
Sealing the edges of the mask to the client’s skin with a water-soluble lubricant.
Ensuring that the flaps are closed over the exhalation ports
Changing to a nasal cannula during meals
The facemask covers the client’s mouth and must be removed during meals. Use of the nasal cannula when the client eats prevents hypoventilation or hypoxemia from the facemask being of during mealtimes.
Sealing the mask does not ensure disruption of oxygen therapy. A simple facemask does not have flaps over the exhalation ports. Central oxygen delivery system failure is a unit or facility problem that could happen anywhere; however, tank oxygen is not kept at clients’ bedsides for this potential emergency.
What is the nurse’s best first action when a client receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused?
Increasing the oxygen flow rate
Documenting the observation as the only action
Notifying the primary health care provider immediately
Repositioning the client from a high-Fowler to a low-Fowler position
Increasing the oxygen flow rate
Cerebral hypoxia is a cause of confusion and a sensitive indicator that the client needs more oxygen and action is needed. Untreated or inadequately treated hypoxemia is life threatening. Although you would want to notify the health care provider of the change in the client’s condition, the best action is to first increase the oxygen flow rate and then notify the physician.
Changing the client’s position to less upright, would not improve gas exchange.
Which changes in a client receiving oxygen therapy at 60% for more than 24 hours alert the nurse to the possibility of oxygen toxicity?
Decreased PaCO2
Client report of increased dyspnea
Production of thick, white, frothy sputum
Client demand to remove the mask
Client report of increased dyspnea
Oxygen toxicity damages the alveolar membrane, stimulating the formation of a hyaline membrane, and impairing gas exchange. Clients become increasingly more dyspneic and hypoxic.
The PaCO2 would increase, not decrease. The production of thick, frothy, white sputum is unrelated to oxygen toxicity. The client’s demand to remove the mask is not specific to oxygen toxicity.
The nurse has just received report on a group of clients. Which client is the nurse’s first priority?
A 50 year old who is 1 day postoperative from abdominal surgery and is receiving 2 L oxygen by nasal cannula.
A 55 year old was admitted yesterday with pneumonia and is receiving antibiotics and oxygen through a nasal cannula.
A 45 year old who is being discharged with a new prescription for home oxygen therapy by nasal cannula.
A 60 year old admitted 2 hours ago who has a 90–pack-year smoking history and is receiving 50% oxygen by Venturi mask.
A 60 year old admitted 2 hours ago who has a 90–pack-year smoking history and is receiving 50% oxygen by Venturi mask.
There is insufficient data to determine if this client is stable. The client is at risk for oxygen toxicity and must be assessed frequently.
The postoperative client is receiving the low oxygen therapy typical for anyone having postoperative therapy who has no other respiratory problems. The client who meets discharge criteria does not require frequent assessment. Although the client with pneumonia will require more frequent assessment than a client who does not require oxygen therapy, the client wearing the Venturi mask must be assessed first.
Which problem does the nurse suspect when a client receiving 50% oxygen by Venturi mask for 2 days now has crackles and decreased breath sounds on auscultation?
New-onset asthma
Absorptive atelectasis
Bronchiolar infection
Stasis pneumonia
Absorptive atelectasis
Absorptive atelectasis occurs when high oxygen levels are delivered that causes nitrogen dilution when oxygen diffuses from the alveoli into the blood. The alveoli collapse, which is detected as crackles and decreased breath sounds on auscultation. The problem is in the alveoli, not the airways. Although decreased breath sounds accompany pneumonia, crackles are not present with the increased density.
Which best practice technique will the nurse use when suctioning a client’s tracheostomy tube place earlier today?
Applying suction only during insertion of the catheter
Hyperoxygenating the client before and after suctioning
Ensuring each suction pass lasts no longer 30 seconds
Suctioning repeatedly until the secretions are is clear
Hyperoxygenating the client before and after suctioning
The client needs to be preoxygenated/hyperoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning, the client needs to be hyperoxygenated for 1 to 5 minutes, or until the client’s baseline heart rate and oxygen saturation are within normal limits.
Repeat suctioning can be performed as needed for up to three total suction passes. Any additional suctioning will cause or worsen hypoxemia. Applying suction during insertion is inappropriate because suction makes advancement of the suction tube difficult and is traumatic to the airway. Suction is applied only when the suction tube is removed. Suctioning for 30 seconds is too long and can cause or worsen hypoxemia; a suction pass should last 10 to 15 seconds.
Which action will the nurse take to prevent harm from tracheal stenosis in a client after a tracheostomy?
Using commercial tube holders instead of standard tracheostomy ties
Securing the tube in a midline position
Assessing bilateral breath sound every 2 hours
Ensuring maximum cuff pressure
Securing the tube in a midline position
Tracheal stenosis, a narrowed tracheal lumen, is caused to scar tissue formation from irritation. Two methods of preventing this complication is to keep the tube from moving in the trachea and to maintain proper cuff pressure. Securing the tube in the midline position is critical regardless of whether the tube is secured with commercial tube holders or standard tape ties. Although assessing breath sounds bilateral is an important action whenever a client has a tracheostomy, but does not prevent harm from tracheal stenosis.
For which problem in a client with a tracheostomy will the nurse collaborate with the speech–language pathologist (SLP) member of the interprofessional team?
Ensuring effective communication
Determining the proper cuff pressure
Identifying early indications of infection
Assessing for vocal cord damage
Ensuring effective communication
One of the many roles of the SLP is helping health care professionals work with clients who have communication problems to find the most effective means of maintaining communication. They also may be involved in assessing clients for aspiration risk. They are not involved in vocal cord assessment (primary health care provider responsibility), infection assessment, or determining correct cuff pressure (respiratory therapist responsibility).
Which action will the nurse take first when a client has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure? Which nursing action must be taken first?
Cleaning the tracheostomy inner cannula and stoma
Observing for indications that suctioning is needed
Auscultating lung sounds
Changing the tracheostomy dressing immediately
Auscultating lung sounds
The first step of the nursing process and nursing action for a client following an airway procedure is to assess for a patent airway by auscultating the client’s lungs and assessing the client’s respiratory status.
Suction is not needed if the lungs and airways are clear to auscultation. Although cleanliness is important, the PACU nurse will not typically perform this procedure immediately after the tracheotomy is created, unless copious secretions are blocking the tube.
Performing a dressing change is done every 8 hours or per hospital policy. The PACU nurse will perform this if the dressing is soiled or bloody, but assessment of airway must be performed first.
What action does the nurse take first when a client who has a “do not resuscitate” (DNR) order and a nonrebreather oxygen mask, has labored breathing?
Only provide comfort to the client.
Notify the chaplain and the family member of record.
Ensure that the tubing is patent and that oxygen flow is high.
Initiate the Rapid Response Team (RRT).
Ensure that the tubing is patent and that oxygen flow is high.
The nurse needs to first ensure that the tubing is patent and that the O2 flow is high. Labored breathing and ultimately suffocation can occur if the reservoir bag on a nonrebreather mask kinks, or if the oxygen source disconnects or is not set to high-flow levels.
The chaplain and the family member of record would not be notified until assessment confirms that death is imminent at this time. The RRT team can be called but the client may not want to be intubated, as indicated in the DNR orders. The RRT needs to know the client’s wishes when they arrive. Comforting the client must be done but is not the first action by the action.
For which situation will the nurse take immediate action to prevent harm for a client with pneumonia who is receiving 100% oxygen via a nonrebreather mask?
Sputum is now rust-colored.
Oxygen reservoir deflates during inspiration.
Crackles are present in the lung bases.
Skin is pink and flushed.
Oxygen reservoir deflates during inspiration.
The nurse takes action immediately if the reservoir bag is deflated. Suffocation can occur if the reservoir bag deflates, kinks, or if the oxygen source disconnects. The nurse needs to remove the device, refill the reservoir, and then reapply the mask.
It is anticipated that the client’s color is now pink. The client’s color is expected to improve (from ashen or gray to pink) because of an increase in PaO2 level. Crackles in lung bases are an expected finding in a client with pneumonia, as is expectorating rust-colored sputum.
Which assessment has the highest priority for the nurse to make when caring for a client who had a tracheostomy placed yesterday? Which of these assessments is essential for the nurse to make?
Examining the color and consistency of secretions
Measuring the cuff pressure
Observing for tachypnea
Checking arterial blood gas values
Observing for tachypnea
It is essential for the nurse to assess the client for tachypnea. Tachypnea can indicate hypoxia.
Assessing secretions, checking arterial blood gas values, and measuring cuff pressure are all appropriate interventions, after assessing airway and breathing.
Which actions will the nurse take to reduce risk for aspiration for a client with a tracheostomy? Select all that apply.
Inflating the tracheostomy cuff during meals
Encouraging water with meals
Teaching the client to “tuck” the chin down in the forward position to swallow
Maintaining the client upright for 30 minutes after eating
Encouraging frequent sipping from a cup
Providing small, frequent meals
Teaching the client to “tuck” the chin down in the forward position to swallow
Maintaining the client upright for 30 minutes after eating
Providing small, frequent meals
Interventions that must be noted in the client’s plan of care include having the client remain upright for at least 30 minutes after eating to reduce the chance of aspiration. Also, making sure that small frequent meals are available for the client. Shorter and more frequent intervals of eating tire the client less and also reduce the chance for aspiration. Teaching the client how to tuck the chin down in the forward position helps to open the upper esophageal sphincter and again reduces the risk of aspiration.
Sipping from a cup is contraindicated. Liquids are consumed using a spoon to ensure that the client is attempting to swallow only small volumes of liquid. Controlled small amounts of thickened liquids are given. Thin liquids such as water should be avoided because they are easily aspirated. The tracheostomy cuff needs to be deflated because an inflated tube narrows the upper esophageal sphincter opening, which increases the risk for aspiration.
Which statements regarding noninvasive positive-pressure ventilation (NPPV) are true? Select all that apply.
Can only be used safely by alert clients.
Risk for ventilator-associated pneumonia is reduced but still present.
An endotracheal tube is required for oxygen therapy.
Masks must have a tight seal for effective ventilation.
The system operates with either room air or oxygen.
Vomiting with potential aspiration can occur.
Can only be used safely by alert clients.
Masks must have a tight seal for effective ventilation.
The system operates with either room air or oxygen.
Vomiting with potential aspiration can occur.
Which statements made by a client going home with a tracheostomy indicate to the nurse the need for further teaching about correct tracheostomy care? (Select all that apply.)
Select all that apply.
“I can only take baths, but no showers.”
“I will be unable to wear a necklace.”
“I should put cotton or foam over the tracheostomy hole.”
“I will have to learn to suction myself.”
“I will notify my primary health care provider if my secretions develop a foul odor.”
“I can put normal saline in my tracheostomy to keep the secretions from getting thick.”
“I can only take baths, but no showers.”
“I will be unable to wear a necklace.”
“I should put cotton or foam over the tracheostomy hole.”
“I can put normal saline in my tracheostomy to keep the secretions from getting thick.”
Need for teaching is indicated when the client says that only baths and no showers can be taken. The client is permitted to shower with the use of a shower shield over the tracheostomy, which prevents water from entering the airway. Also, the client does not instill anything into the artificial airway unless prescribed. The client would not put cotton or foam over the tracheostomy hole; this action may cause airway obstruction. The stoma may be covered loosely with a small cotton cloth or light scarf to protect it during the day. This filters the air entering the stoma, keeps humidity in the airway, and enhances appearance.
The client is correct when commenting about learning to suction self, and will be taught clean suction technique to use at home. Also, foul-smelling secretions or drainage indicates possible infection and needs to be reported to the primary health care provider.
24.1 How will the nurse expect a client’s age-related decreased skeletal muscle strength to affect gas exchange?
Reduced gas exchange as a result of decreased alveolar surface
Reduced gas exchange as a result of longer relaxation of bronchiolar smooth muscles
Reduced gas exchange as a result of decreased changes in pressures of the chest cavity
Reduced gas exchange as a result of failure of pulmonary circulation to fully perfuse lung tissue
Reduced gas exchange as a result of decreased changes in pressures of the chest cavity
Breathing occurs through changes in the size of and pressure within the chest cavity. Contraction and relaxation of chest muscles (and the diaphragm) cause changes in the size and pressure of the chest cavity. When skeletal muscle strength is decreased in these muscles, pressure changes are decreased and less air moves in and out of the lungs. This reduced airflow limits gas exchange at the alveolar-capillary membrane. The alveolar surface itself is not decreased by weaker skeletal muscles, nor does this cause any relaxation of bronchiolar smooth muscle. Weaker skeletal muscles do not directly affect pulmonary circulation.
How will the nurse document the client’s respiratory assessment findings on auscultation that are heard as popping, discontinuous, high-pitched sounds at the end of exhalation?
Coarse crackles
Rhonchi
Wheezes
Fine crackles
Fine crackles
Fine crackles are heard as popping, discontinuous sounds that are high-pitched heard at the end of inhalation. Squeaky, musical continuous sounds heard when the client inhales and exhales are abnormal (adventitious) and described as wheezes. Coarse crackles are a rattling sound. Rhonchi are heard as low-pitched continuous snoring sounds.
What is the most relevant technique for the nurse to use when assessing a client for dyspnea?
Checking oxygen saturation by pulse oximetry
Observing the client’s rate, depth, and ease of inhalation and exhalation
Comparing previous respiratory assessment information with current data
Asking the client about whether any breathlessness is present
Asking the client about whether any breathlessness is present
Dyspnea, difficulty in breathing or breathlessness, is a subjective perception and varies among clients. Thus, only the client can rate his or her level of dyspnea.
The other measures listed for assessment of respiratory status and adequacy of ventilation and oxygenation are objective measures.
What is the nurse’s interpretation of a 50-year-old client’s respiratory assessment findings when hearing bronchial breath sounds over the left lower lobe and noting decreased fremitus and dullness to percussion in the same area?
Obstruction of the larger airways
Normal physical exam for a 50-year-old
An area of increased density
Subcutaneous emphysema
An area of increased density
Peripheral bronchial breath sounds are abnormal and can indicate atelectasis, tumor, or pneumonia. Decreased fremitus and dullness to percussion may indicate pleural effusion, which is more dense than air.
Bronchial breath sounds are normally heard only over the large airways in patients of any age, not in the periphery. An obstructed airway would have reduced bronchial breath sounds, and they would not be present in the periphery. Subcutaneous emphysema is a condition in which air is trapped within or beneath the skin. It is felt and heard as a “crackling” in the skin and subcutaneous tissues, not within any part of the respiratory tract.
