Respiratory failure Flashcards
(42 cards)
The nurse is planning care with a client who 2 days earlier had a total laryngectomy with creation of a new tracheostomy. Which is a priority goal for the client?
a. Learn to care for the tracheostomy.
b, Maintain a patent airway.
c, Decrease secretions.
d. Relieve anxiety related to the tracheostomy.
b. maintain a patent airway.
The main goal for a client with a new tracheostomy is to maintain a patent airway. A fresh tracheostomy frequently causes bleeding and excess secretions, and clients may require frequent suctioning to maintain patency. Decreasing secretions may be a component of a client’s care after laryngectomy and tracheostomy, and relieving anxiety is always an important goal; however, the primary goal is to maintain a patent airway. Instruction on how to care for a tracheostomy is a priority later in the client’s recovery.
The nurse is planning care for a client with acute respiratory distress syndrome (ARDS). Which action will be most helpful to promote effective airway clearance?
a. Administer oxygen every 2 hours.
b, Turn the client every 4 hours.
c. Administer sedatives to promote rest.
d. Suction if cough is ineffective.
d. suction if cough is ineffective.
The nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned every 2 hours to help move secretions; every 4 hours is not often enough. Administering sedatives to promote rest is contraindicated in ARDS because sedatives can depress respirations.
Immediately following an automobile accident, a 21-year-old client has severe pain in the right chest from hitting the steering wheel, a compound fracture of the right tibia and fibula, and multiple lacerations and contusions. What is the priority nursing goal for this client?
a. Reduce the client’s anxiety.
b. Maintain adequate oxygenation.
c. Decrease chest pain.
d, Maintain adequate circulating volume.
b. maintain adequate oxygenation.
Blunt chest trauma can lead to respiratory failure. Maintenance of adequate oxygenation is the priority for the client. Decreasing the client’s anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation, as is maintaining adequate circulatory volume.
After suctioning a client’s tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent which outcome?
a. stimulating the client’s cough reflex
b. depriving the client of sufficient oxygen supply
c. dislodging the tracheostomy tube
d. obstructing the suctioning catheter with secretions
b. depriving the client of sufficient oxygen supply.
After suctioning, the client should rest for at least 3 minutes or until respirations return to normal before suctioning is repeated, unless secretions interfere with breathing. Intermittent suctioning prevents oxygen deprivation. Hypoxia can lead to cardiac arrhythmias and cardiac arrest. The client should receive 100% oxygen between suctionings.
The nurse should not prevent stimulating the cough reflex as it helps mobilize secretions.
Intermittent suction does not prevent dislodgment of the tracheostomy tube.
Intermittent suction does not keep the suction catheter from becoming obstructed; clearing the catheter with normal saline will keep the catheter clear.
Which complication is associated with mechanical ventilation?
a. gastrointestinal hemorrhage
b, immunosuppression
c. increased cardiac output
d. pulmonary emboli
a. gastrointestinal hemorrhage
Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged mechanical ventilation because of the development of stress ulcers. Clients who are receiving steroid therapy and those with a previous history of ulcers are most likely to be at risk. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis.
A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?
a. “Clean the tracheostomy tube with alcohol and water.”
b, “Family members should continue to talk to the client.”
c. “Oral intake of fluids should be limited for 1 week only.”
d. “Limit the amount of protein in the diet.”
b. “Family members should continue to talk to the client.”
Commonly, family members are reluctant to talk to the client who has had a total laryngectomy and can no longer speak. To promote a supportive environment, the nurse should encourage family members to continue normal communication. The nurse should teach the client to clean the tracheostomy tube with hydrogen peroxide and rinse it with sterile saline solution, to consume oral fluids as desired, and to eat protein-rich foods to promote healing.
The nurse is caring for a client who has experienced severe multiple trauma. The client’s arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. This finding is an indicator of the development of which of the following conditions?
a. Hospital-acquired pneumonia.
b. Hypovolemic shock.
c, Acute respiratory distress syndrome (ARDS).
d. Asthma.
c. Acute respiratory distress syndrome (ARDS)
ARDS frequently develops after a major insult to the body. The major diagnostic indicator is low arterial oxygen levels that are not responsive to the administration of high concentrations of oxygen. Early recognition of ARDS is important to increase the client’s chances of recovery. The oxygen levels of clients with hospital-acquired pneumonia, hypovolemic shock, or asthma would be expected to improve with oxygen administration.
For a client with an endotracheal (ET) tube, which nursing action is the most important?
a. auscultating the lungs for bilateral breath sounds
b. turning the client from side to side every 2 hours
c. monitoring serial blood gas values every 4 hours
d. providing frequent oral hygiene
a. auscultating the lungs for bilateral breath sounds.
For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they’re secondary to ensuring adequate oxygenation.
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
a. Hypotension, hyperoxemia, and hypercapnia
b. Hyperventilation, hypertension, and hypocapnia
c. Hyperoxemia, hypocapnia, and hyperventilation
d. Hypercapnia, hypoventilation, and hypoxemia
d. hypercapnia, hypoventilation, and hypoxemia.
The cardinal physiologic abnormalities of acute respiratory failure are hypercapnia, hypoventilation, and hypoxemia. The nurse should focus on resolving these problems.
The nurse is conducting a focused assessment of a client at risk for acute respiratory distress syndrome (ARDS). Which finding indicates the client is becoming hypoxemic?
a. elevated carbon dioxide level
b. hypoxia not responsive to oxygen therapy
c. metabolic acidosis
d. severe, unexplained electrolyte imbalance
b. hypoxia not responsive to oxygen therapy.
A hallmark of early ARDS is refractory hypoxemia. The client’s partial pressure of arterial oxygen (PaO2) level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS.
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client’s bedside?
a. tracheostomy cleaning kit
b. water-seal chest drainage set-up
c. manual resuscitation bag
d. oxygen analyzer
c. manual resuscitation bag
The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn’t have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn’t necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.
A client with a nasotracheal tube needs to be suctioned. What is the length of time the nurse should apply the suction for each pass of the catheter?
a. 1 to 5 seconds
b. 20 to 25 seconds
c. 10 to 15 seconds
d. 40 to 45 seconds
c. 10-15 seconds
Suction should be applied for 10 to 15 seconds for each pass of the catheter. Suctioning for longer than 15 seconds removes oxygen from the respiratory tract and cause hypoxemia. Suctioning less than 10 seconds would not be adequate to remove the secretions.
A client has a tracheostomy. Which nursing action would prevent complications of suctioning?
a. Suction for at least 15 seconds.
b. Keep a replacement cuff at the bedside.
c. Maintain sterility of the suction catheter.
d. Record time, amount, character of secretions.
c. maintain sterility of the suction catheter.
Trach suction should be limited to 10 seconds. Although a replacement cuff must be at the bedside and it is important to record secretions, these will not prevent complications. Trach suctioning is a sterile procedure and rinsing the catheter will be the priority to prevent infections.
A client who is intubated on mechanical ventilation develops subcutaneous emphysema. Which ventilator setting should the nurse anticipate being adjusted for this client?
a. ventilator rate
b. oxygen concentration
c. number of assisted breaths
d. positive end-expiratory pressure (PEEP)
d. positive end-expiratory pressure (PEEP)
For a client being mechanically ventilated, subcutaneous emphysema occurs because the alveoli are overdistended and rupture, permitting air to escape into the surrounding tissues. PEEP keeps the alveoli open between breaths. Because subcutaneous emphysema has developed, the PEEP setting should be adjusted. The development of subcutaneous emphysema did not occur because of the ventilator rate, oxygen concentration, or number of assisted breaths set on the ventilator.
A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. They’re placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than
a. 0.21.
b. 0.35.
c. 0.5.
d. 0.7.
c. 0.5
An FIO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. The ideal oxygen source is room air FIO2 0.18 to 0.21.
While changing the tapes on a tracheostomy tube, the client coughs and the tube is dislodged. which is the initial nursing action?
a. call the health care provider to reinsert the tube.
b. grasp the retention sutures to spread the opening.
c. call the respiratory therapy department to reinsert the tracheostomy.
d. cover the tracheostomy site with sterile dressing to prevent infection.
c.
the nurse is caring for a client immediately after removal of the endotracheal tube. the nurse should report which sign immediately if experienced by the client?
a. stridor
b. occasional pink-tinged sputum
c. respiratory rate of 24 breaths/minute
d. a few basilar lung crackles on the right
a. stridor
the nurse is suctioning a client via an endotracheal tube. during the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. which nursing intervention is most appropriate?
a. continue to suction.
b. notify the health care provider immediately.
c. stop the procedure and reoxygenate the client.
d. ensure that the suction is limited to 15 sections.
c.
the low-pressure alarm sounds on a ventilator. the nurse assess the client and then attempts to determine the cause of the alarm. if unsuccessful in determining the cause of the alarm, the nurse should take what initial action?
a. administer oxygen.
b. check the client’s vital signs
c. ventilate the client manually
d. start cardiopulmonary resuscitation
c. ventilate the client manually
the nurse is preparing to care for a client who will be weaned from a cuffed tracheostomy tube. the nurse is planning to use a tracheostomy plug and plans to insert it into the opening in the outer cannula. which nursing action is required before plugging the tube?
a. deflate the cuff on the tube.
b. place the inner cannula into the tube.
c. ensure that the client is able to speak
d. ensure that the client is able to swallow.
a. deflate the cuff on the tube.
the nurse caring for a client who is mechanically ventilated is monitoring for complications of mechanical ventilation. which assessment finding, if noted by the nurse, indicates the need for follow-up?
a. muscle weakness in the arms and legs
b. a temperature of 98.6ºF decreased from 99.0F
c. a blood pressure of 90/60 mmHg decreased from 112/78 mmHg
d. a heart rate of 80 beats per minute decreased from 85 beats per minute
c.
the nurse has assisted the health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. what is the initial nursing action to evaluate proper ET tube placement?
a. tape the ET tube in place, and note the centimeter marking at the lip line.
b. ask the radiology department to obtain a stat portable radiograph at the client’s bedside.
c. use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds.
d. attach the ET tube to the ventilator and determine whether the client is able to tolerate the tidal volume prescribed.
c.
the nurse is preparing to perform suctioning for a client with a tracheostomy tube and gathers the supplies needed for the procedure. what is the initial nursing action?
a. hyperoxygenate the client
b. set the suction pressure range at 150 mmHg
c. place the catheter into the tracheostomy tube.
d. apply suction on the catheter, and insert it into the tracheostomy tube.
a.
the nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. which observation by the nursing instructor indicates an action by the student requiring the need for further instruction?
a. suctioning the client every hour.
b. applying suction only during withdrawal of the catheter.
c. hyperventilating the client with 100% oxygen before suctioning
d. applying suction intermittently during withdrawal of the catheter.
a. suctioning the client every hour.
