Respiratory Disorders

Question 1

Manifestations of PE (11)

Answer 1

• Dyspnea
• Tachypnea
• Sharp, stabbing pain on inspiration
• Tachycardia
• Hypotension
• Sense of impending doom
• Diaphoresis
• Decreased SaO2
• Pleural effusion
• Crackles
• Cough

Question 2

Air leak in chest tube manifestation

Answer 2

Continuous rapid bubbling in the water seal chamber

Question 3

Air leak interventions (4)

Answer 3

• Start at chest and move down tubing to find leak
• Tighten connection
• Replace drainage system
• Keep connection taped securely

Question 4

Chest tube complication: no tidying in water seal chamber nursing interventions (2)

Answer 4

• Check for kinks in tubing
• Check breath sounds for lung re-expansion

Question 5

Chest tube complication: no bubbling in suction control chamber nursing interventions (3)

Answer 5

• Check that tubing is attached
• Check that water is filled to prescribed level
• Check wall suction regulator

Question 6

Chest tube complication: chest tube is disconnected from system nursing intervention

Answer 6

• Place open end of chest tube in sterile water until system can be replaced

Question 7

Chest tube complication: chest tube accidentally pulled from client nursing interventions (3)

Answer 7

• Cover insertion site with sterile dressing taped on 3 sides
• Contact provider
• Prepare for reinsertion

Question 8

Early signs of hypoxia/hypoxemia (8)

Answer 8

• Tachypnea
• Tachycardia
• Restlessness
• Pale skin/mucous membranes
• Elevated bp
• Use of accessory muscles
• Nasal flaring
• Adventitious lung sounds

Question 9

Late signs of hypoxia/hypoxemia (6)

Answer 9

• Bradypnea
• Bradycardia
• Confusion/stupor
• Cyanotic skin/mucous membranes
• Hypotension
• Cardiac dysrhythmias

Question 10

Nasal cannula FIO2/flow rate

Answer 10

• 24-44%
• 1-6 L/min

Question 11

Simple face mask FIO2/flow rate

Answer 11

• 40-60%
• 6-8 L/min

Question 12

Partial rebreather mask FIO2/flow rate

Answer 12

• 50-75%
• 8-11 L/min

Question 13

Non-rebreather mask FIO2/flow rate

Answer 13

• 80-100%
• 12 L/min

Question 14

Venturi mask FIO2/flow rate

Answer 14

• 24-40%
• 4-8 L/min

Question 15

Aerosol mask, face tent FIO2/flow rate

Answer 15

• 30-100%
• 8-10 L/min

Question 16

T-piece FIO2/flow rate

Answer 16

• 30-100%
• 8-10 L/min

Question 17

Steps for suctioning (11)

Answer 17

• Perform hand hygiene
• Explain procedure
• Put on required PPE
• Place client in semi/high fowler’s
• Take baseline vitals/lung sounds
• Use medical asepsis for oral suctioning
• Use surgical asepsis for all other types
• Hyperoxygenate patient
• Suction for 10-15 seconds with a rotating motion 2-3 times
• Wait 20-30 seconds between each suction
• Document amount, color, consistency of secretions and patient response

Question 18

Tracheostomy care steps (6)

Answer 18

• Explain procedure
• Place patient in semi/high fowler’s
• Keep 2 extra tracheostomy tubes at bedside, one that is the patient’s size and one that is smaller
• Suction patient as needed, not on routine schedule
• Assess for respiratory distress
• Provide care every 8 hours and as needed