NR224 Week 7 Oxygenation and Nursing Skill Questions with expert curated solutions with 100% Accuracy (PASSED)
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97 Terms
Which information does a pulse oximeter measure?
Saturation of hemoglobin with oxygen
3 multiple choice options
What percentage of the air we breathe is oxygen?
21%
3 multiple choice options
Which muscle group is primarily responsible for the inflation of the lungs?
Diaphragm
3 multiple choice options
When gas exchange is impaired, both the lungs and heart can (compensate/worsen) for a limited time by altering the respiratory rate, heart rate, or both, allowing the body to return to (disequilibrium/homeostasis.) When compensatory mechanisms fail, the result may lead to tissue and organ (damage/hypertrophy) or death.
- compensate
- homeostasis
- damage
For each underlying pathophysiologic change, specify if the change is associated with hypoxia or hypoxemia.
- Hypoventilation
- Oxygen is not reaching the alveoli
- Not enough functional red blood cells
- Diffusion impairment
- Blood is not reaching the tissues
- Cyanide poisoning
Hypoxia
- Not enough functional red blood cells
- Blood is not reaching the tissues
- Cyanide poisoning
Hypoxemia
- Hypoventilation
- Oxygen is not reaching the alveoli
- Diffusion impairment
Match each device with name and then identify the piece of gas exchange it measures:
Device Name:
- Spirometry
- Oximeter
- Lab Testing
- Chest X-Ray
Gas Exchange Measured:
- Ventilation
- Hypoxemia
Spirometry: Ventilation
Oximeter: Hypoxemia
Lab Testing: Hypoxemia
Chest X-Ray: Ventilation
Match each device with its name and then identify the piece of gas exchange it measures.
Type of Test:
Echocardiogram - Angina, Dysfunctional valves, VQ mismatch
Lab Testing - Myocarditis, Myocardial infarction, VQ mismatch
Electrocardiogram - Aortic aneurysm, Decreased blood flow, Dysrhythmia
Cardiac Catheterization - Decreased blood flow, Altered cardiac output; Infarction/Ischemia, Myocarditis
- Echocardiogram: Dysfunctional Valves
- Lab Testing: Myocardial infarction
- Electrocardiogram: Dysrhythmia
- Cardiac Catheterization: Altered cardiac output; Infarction/Ischemia
For each sign or symptom listed, specify the prioritized device for assistance: ventilation device, oxygen, or inhaled medication.
- Ventilation Device
- Oxygen
- Inhaled Medication
SIGN/SYMPTOM
Oxygen saturation 78%
Cannot take a deep breath
Asthmatic wheezing
Stopped breathing
Ventilation Device: Cannot take a deep breath, Stopped breathing
Oxygen: Oxygen saturation 78%
Inhaled Medication: Asthmatic wheezing
Situation: An older adult arrives at the emergency department (ED) with a productive cough, fatigue, and shortness of breath that has worsened over the last three days.
Background: No history of medical problems; takes no prescription medications; occasionally takes acetaminophen for pain; does not smoke.
Assessment: T 98.6°F (37°C), BP 155/85, P 120, R 30, oxygen saturation (O2 sat) 88% on room air; lung sounds diminished right lower lobe with rhonchi present; heart regular rhythm with no murmurs or extra heart sounds.
The client is admitted with dyspnea. They are tachypneic at 30 with a blood pressure of 160/90, pulse of 125 and regular, and oxygen saturation is 88%. What is the priority nursing diagnosis for this client?
Impaired gas exchange
3 multiple choice options
Situation: An older adult arrives at the emergency department (ED) with a productive cough, fatigue, and shortness of breath that has worsened over the last three days.
Background: No history of medical problems; takes no prescription medications; occasionally takes acetaminophen for pain; does not smoke.
Assessment: T 98.6°F (37°C), BP 155/85, P 120, R 30, oxygen saturation (O2 sat) 88% on room air; lung sounds diminished right lower lobe with rhonchi present; heart regular rhythm with no murmurs or extra heart sounds.
Which diagnostic test should the nurse anticipate being ordered?
Chest X-Ray
3 multiple choice options
Situation: An older adult arrives at the emergency department (ED) with a productive cough, fatigue, and shortness of breath that has worsened over the last three days.
Background: No history of medical problems; takes no prescription medications; occasionally takes acetaminophen for pain; does not smoke.
Assessment: T 98.6°F (37°C), BP 155/85, P 120, R 30, oxygen saturation (O2 sat) 88% on room air; lung sounds diminished right lower lobe with rhonchi present; heart regular rhythm with no murmurs or extra heart sounds.
The chest x-ray results confirm community-acquired pneumonia. Both the electrocardiogram and echocardiogram are normal. Based on these results, what is the most likely cause of the client’s increased respirations?
Hypoxemia
3 multiple choice options
Situation: An older adult arrives at the emergency department (ED) with a productive cough, fatigue, and shortness of breath that has worsened over the last three days.
Background: No history of medical problems; takes no prescription medications; occasionally takes acetaminophen for pain; does not smoke.
Assessment: T 98.6°F (37°C), BP 155/85, P 120, R 30, oxygen saturation (O2 sat) 88% on room air; lung sounds diminished right lower lobe with rhonchi present; heart regular rhythm with no murmurs or extra heart sounds.
Which priority order from the healthcare provider should the nurse anticipate receiving?
Oxygen
3 multiple choice options
George (preferred pronouns: he, him, his) is currently in the emergency department. A nursing assessment reveals the following: T 98.6°F (37°C), BP 90/60, P 125 and regular, R 22; oxygen saturation (O2 sat) 86% on room air; lung sounds clear with good symmetrical expansion; heart rate regular rhythm.
What is the priority nursing diagnosis for this client?
Impaired gas exchange
3 multiple choice options
George (preferred pronouns: he, him, his) is current in the emergency department. A nursing assessment reveals the following: T 98.6°F (37°C), BP 90/60, P 125 and regular, R 22; oxygen saturation (O2 sat) 86% on room air; lung sounds clear with good symmetrical expansion; heart rate regular rhythm.
Based on the assessment findings, the client's impaired gas exchange is most likely a result of which system?
Cardiac
3 multiple choice options
George (preferred pronouns: he, him, his) is current in the emergency department. A nursing assessment reveals the following: T 98.6°F (37°C), BP 90/60, P 125 and regular, R 22; oxygen saturation (O2 sat) 86% on room air; lung sounds clear with good symmetrical expansion; heart rate regular rhythm.
Based on the assessment findings, which diagnostic tests should the nurse anticipate will be ordered? (SATA)
- Cardiac catheterization
- Blood work
- Echocardiogram
- Electrocardiogram
- Spirometry
- Cardiac catheterization
- Blood work
- Echocardiogram
- Electrocardiogram
George (preferred pronouns: he, him, his) is current in the emergency department. A nursing assessment reveals the following: T 98.6°F (37°C), BP 90/60, P 125 and regular, R 22; oxygen saturation (O2 sat) 86% on room air; lung sounds clear with good symmetrical expansion; heart rate regular rhythm.
The following tests were completed with results as follows:
Blood work shows Troponin I is abnormally elevated and B-Type naturetic peptide is normal.
Electrocardiogram shows ST elevation in the inferior leads.
Cardiac catheterization shows 100% blockage of the right coronary artery.
Echocardiogram shows normal valve function with an inferior wall motion abnormality.
Which pathophysiological condition is causing this impaired gas exchange?
Myocardial infarction
3 multiple choice options
What is the color of an oxygen cylinder designated as the standard in the United States?
Green
3 multiple choice options
When using supplemental oxygen, what equipment determines the amount of oxygen the client receives?
Regulator
3 multiple choice options
Which statement about oxygen is accurate?
Oxygen is a medication requiring an order to administer.
3 multiple choice options
The nurse comes across an oxygen tank that is not in use but is making a loud "hissing" sound. What is the best course of action?
Turn the valve on the top of the tank clockwise (to the right) until it cannot be turned anymore.
3 multiple choice options
During a shift assessment, the nurse notices that a client receiving 4 L of oxygen by nasal cannula has bloody tissues in their hand. The client reports that their nose is sore and has been bleeding for the last 20 minutes. What should the nurse do next?
Contact the healthcare provider.
3 multiple choice options
What is the main difference between continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BiPAP)?
One machine offers a static pressure for inspiration and expiration, while the other offers a different pressure for each.
3 multiple choice options
The nurse enters an adult client’s room and notices they have stopped breathing. Which three priority actions should the nurse take first?
- Call for help.
- Notify the client’s healthcare provider.
- Ventilate the client with a bag-valve-mask device.
- Gently shake the client and call their name.
- Leave to get the emergency cart.
- Call for help.
- Ventilate the client with a bag-valve-mask device.
- Gently shake the client and call their name.
Match the oxygen percentage delivered with the type of oxygen delivery in the table.
Oxygen Delivery
Flow Rate Setting
Oxygen Percentage
Room air: N/A
Nasal cannula1: 4 L/min
Simple face mask: 6 - 12 L/min
Venturi mask: 15 L/min
Partial non-rebreather: 10 - 15 L/min
Full non-rebreather - 15 L/min
Room air: N/A: 21%
Nasal cannula1: 4 L/min: 24-40%
Simple face mask: 6 - 12 L/min: 35-50%
Venturi mask: 15 L/min: 24-50%
Partial non-rebreather: 10 - 15 L/min: 60-80%
Full non-rebreather - 15 L/min: 100%
A client using oxygen at 2 L/min via nasal cannula to keep their oxygen saturation greater than 92% needs to be transported to the x-ray department. The nurse is assessing the client and the oxygen equipment. Select the statement that best describes the assessment findings.
The oxygen saturation is adequate.
The flow rate should be decreased by 1 L/min.
There is enough oxygen to transport the client.
The client is wearing the correct oxygen delivery device.
Which oxygen equipment is needed to implement a healthcare provider order for oxygen, 5 L/min per nasal cannula? (SATA)
- wall plug for O2
- nasal cannula
- regulator (with humidifier)
A client with no spontaneous respirations is being supported on a ventilator with 40% oxygen being delivered. When the ventilator stops working, which device should the nurse select to support the client until a replacement ventilator arrives?
Bag-valve-mask delivering 50% oxygen
3 multiple choice options
During report, the nurse learns that a client is wearing a mask that delivers 90% oxygen with a flow rate of 15 L/min. Which type of oxygen mask should the nurse anticipate the client is using?
Full non-rebreather mask
3 multiple choice options
Which items are needed to complete the healthcare provider’s order for a client to receive supplemental oxygen at 50%? Select all that apply.
- wall plug for O2
- simple face mask
- regulator (with humidifier)
While assessing a client with the healthcare provider's order to receive 100% oxygen via a non-rebreather mask, the nurse notes the equipment as shown in the image. What should the nurse do next?
Replace the mask with a full non-rebreather mask.
3 multiple choice options
What are some reasons for tracheostomy placement? (SATA)
- Long-term ventilator use
- Brain aneurysm repair
- Laryngectomy
- Heart surgery
- Trauma-causing upper airway obstruction
- Trauma-causing upper airway obstruction
- Laryngectomy
- Long-term ventilator use
How often should routine tracheostomy care be completed?
Every shift
3 multiple choice options
What is the purpose of a pilot balloon?
It signals if the cuff is inflated or deflated.
3 multiple choice options
What is the priority concern for the nurse working with a client who breathes through a tracheotomy?
The tube could accidentally fall out.
3 multiple choice options
Which supplies are required when performing tracheostomy care? (SATA)
- Twill tape
- Saline
- Sterile gloves
- Scissors
- Cotton-tipped applicators
- Cleaning brush
- Gauze 4x4
- Basin
- Betadine swabs
- Split 4x4
- Twill tape
- Saline
- Sterile gloves
- Scissors
- Cotton-tipped applicators
- Cleaning brush
- Gauze 4x4
- Basin
- Split 4x4
The nurse is performing tracheostomy care on a client and notices that behind the neck plate there is some redness and skin breakdown. Which action will reduce further complications?
Add a drain sponge (split 4x4) between the stoma and neck plate.
3 multiple choice options
The nurse is preparing to perform tracheostomy care on a client who is receiving 50% oxygen via a trach collar and coughing. The nurse notes that the client's oxygen saturation levels have decreased over the last hour. What is the priority action the nurse should take first?
Suction through the tracheostomy tube.
3 multiple choice options
Gustavo, Gus for short (pronouns: he, him, his), is an older adult male who has viral pneumonia. He was hospitalized and placed on a ventilator two weeks ago. Gus is scheduled for tracheostomy surgery in the morning.
Gus' spouse asks why he needs a tracheostomy. What is the best response by the nurse?
This will reduce some of his discomfort and helps support his airway.
3 multiple choice options
Gustavo, Gus for short (pronouns: he, him, his), is an older adult male who has viral pneumonia. He was hospitalized and placed on a ventilator two weeks ago. Gus is scheduled for tracheostomy surgery in the morning.
What equipment should be placed in Gus' room before he returns from surgery? (SATA)
- Oxygen regulator
- Suction kit (sterile)
- #8 disposable inner cannula
- Bag-valve-mask - adult
- #8 tracheostomy tube non-cuffed with disposable inner cannula
- Tracheostomy dressing kit
- Oxygen tank
- #8 tracheostomy tube cuffed with disposable inner cannula
- #8 tracheostomy tube cuffed with disposable inner cannula
- Suction kit (sterile)
- Tracheostomy dressing kit
- #8 disposable inner cannula
- Bag-valve-mask - adult
One hour after providing tracheostomy (trach) care, the nurse returns to assess Gus, who is resting comfortably. Gus is not coughing, his lungs are clear to auscultation, and his oxygen saturation (O2 sat) is 96% on 10 L/min of humidified oxygen via a trach collar. Which priority action should the nurse take at this time?
Inform Gus that they will return in an hour.
3 multiple choice options
Sort the available supplies based on if they are needed for tracheostomy care or must be available at the bedside for emergency use.
Supplies
- Scissors
- Basin
- Split 4x4
- Sterile gloves
- Suction tubing and oral suctioning tool
- Gauze 4x4
- Cleaning brush
- Saline
- Tracheostomy tube in package
- Working suction unit
- Twill tape
- Cotton-tipped applicators
Needed for Tracheostomy Care
- Scissors
- Basin
- Split 4x4
- Sterile gloves
- Gauze 4x4
- Cleaning brush
- Saline
- Twill tape
- Cotton-tipped applicators
Available at Bedside for Emergency Use
- Suction tubing and oral suctioning tool
- Working suction unit
- Tracheostomy tube in package
When changing the tracheostomy ties and no assistance is available, which is the proper sequence to follow?
After postoperative day 1, the client will no longer need ties. They can be removed carefully using scissors and a cross-cut motion to reduce the chance of skin injury or breakdown.
Apply the new ties while the old ties are still intact, ensuring a double knot is used to secure the ties to the neck plate with the twill traveling around the back of the neck, then remove the old ties.
3 multiple choice options
The nurse is performing routine tracheostomy care on a client. There is a supply shortage of drain sponges (split 4x4). What can be used in place of the drain sponge?
Use a regular 4x4 folded on either side of the stoma.
3 multiple choice options
Which technique is followed when performing open tracheal suctioning in an acute care facility?
Sterile technique with a sterile catheter
3 multiple choice options
Which procedure is the proper way to perform open tracheal suctioning?
Insert the tube without suctioning, then begin intermittent suctioning with the catheter completely inserted and continue while withdrawing the catheter.
3 multiple choice options
Which statement accurately describes a closed suction system?
A system that is attached to a tracheostomy or endotracheal tube and is reused frequently
3 multiple choice options
What are some indications that suctioning is necessary? (SATA)
- Fever
- Increased respiratory rate
- Frequent coughing
- Decreased oxygen saturation
- As part of routine suctioning
- Increased respiratory rate
- Frequent coughing
- Decreased oxygen saturation
What is the maximum amount of time that suction can be applied while suctioning a tracheostomy?
10 seconds
3 multiple choice options
Which statement is accurate when communicating with a client with a tracheostomy tube?
Use a pencil and paper to allow the client to write responses.
3 multiple choice options
What are the advantages to using a closed suction system? (SATA)
- Automatically delivers oxygen throughout the suction process
- Ideal for frequent suctioning in someone with heavy secretions
- Maintains sterile environment continuously
- Takes two people to complete
- The catheter is disposed of with each use
- Automatically delivers oxygen throughout the suction process
- Ideal for frequent suctioning in someone with heavy secretions
- Maintains sterile environment continuously
Place the suctioning steps in the correct order, from first to last.
- Apply intermittent suction while withdrawing the catheter.
- Explain the procedure to the client.
- Increase supplemental oxygen.
- Insert suction catheter with the dominant hand.
- Reapply oxygen and rinse the suction catheter.
- Remove oxygen device with the non-dominant hand.
- Set suction regulator between 80 mmHg and 150 mmHg.
- Wait 30-60 seconds before suctioning again.
1. Explain the procedure to the client.
2. Set suction regulator between 80 mmHg and 150 mmHg.
3. Increase supplemental oxygen.
4. Remove oxygen device with the non-dominant hand.
5. Insert suction catheter with the dominant hand.
6. Apply intermittent suction while withdrawing the catheter.
7. Reapply oxygen and rinse the suction catheter.
8. Wait 30-60 seconds before suctioning again.
The nurse is caring for an adult female client admitted with community-acquired pneumonia who has been on a ventilator for 14 days. Earlier in the day, the client had a 7.5 mm French cuffed tracheostomy tube inserted for ongoing ventilatory support. After receiving the report and reviewing the chart, the nurse enters the room and finds the client coughing with audible gurgling when she breathes.
What should the nurse do first?
Suction the client with a sterile suction catheter.
3 multiple choice options
The nurse is caring for an adult female client admitted with community-acquired pneumonia who has been on a ventilator for 14 days. Earlier in the day, the client had a 7.5 mm French cuffed tracheostomy tube inserted for ongoing ventilatory support. After receiving the report and reviewing the chart, the nurse enters the room and finds the client coughing with audible gurgling when she breathes.
What size suction catheter would be appropriate?
12 French suction catheter
3 multiple choice options
The nurse is caring for an adult female client admitted with community-acquired pneumonia who has been on a ventilator for 14 days. Earlier in the day, the client had a 7.5 mm French cuffed tracheostomy tube inserted for ongoing ventilatory support. After receiving the report and reviewing the chart, the nurse enters the room and finds the client coughing with audible gurgling when she breathes.
To what value should the nurse adjust the suction regulator?
100 mmHg
3 multiple choice options
The nurse is caring for an adult female client admitted with community-acquired pneumonia who has been on a ventilator for 14 days. Earlier in the day, the client had a 7.5 mm French cuffed tracheostomy tube inserted for ongoing ventilatory support. After receiving the report and reviewing the chart, the nurse enters the room and finds the client coughing with audible gurgling when she breathes.
After the suction device is set, which nursing action should the nurse perform next?
Apply sterile gloves.
3 multiple choice options
The nurse is caring for an adult female client admitted with community-acquired pneumonia who has been on a ventilator for 14 days. Earlier in the day, the client had a 7.5 mm French cuffed tracheostomy tube inserted for ongoing ventilatory support. After receiving the report and reviewing the chart, the nurse enters the room and finds the client coughing with audible gurgling when she breathes.
Once the suction catheter is connected to suction, which action should the nurse perform next?
Advance the catheter down the tube before applying suction.
3 multiple choice options
The nurse is caring for an adult female client admitted with community-acquired pneumonia who has been on a ventilator for 14 days. Earlier in the day, the client had a 7.5 mm French cuffed tracheostomy tube inserted for ongoing ventilatory support. After receiving the report and reviewing the chart, the nurse enters the room and finds the client coughing with audible gurgling when she breathes.
As the nurse advances the suction catheter to the carina, the client begins to cough. What action should the nurse take?
Apply intermittent suction as the catheter is withdrawn from the tube.
3 multiple choice options
The nurse is caring for an adult female client admitted with community-acquired pneumonia who has been on a ventilator for 14 days. Earlier in the day, the client had a 7.5 mm French cuffed tracheostomy tube inserted for ongoing ventilatory support. After receiving the report and reviewing the chart, the nurse enters the room and finds the client coughing with audible gurgling when she breathes.
After the first suctioning pass, the nurse hears gurgling from the tracheostomy tube. What should the nurse do next?
Wait at least 30 to 60 seconds before performing another suction attempt.
3 multiple choice options
Which items are required for the nurse to initiate supplemental oxygen therapy for a client? (SATA)
- Medical diagnosis
- Order from a prescribing provider
- Oxygen delivery device
- Flow rate
- Safety signs
- Order from a prescribing provider
- Oxygen delivery device
- Flow rate
- Safety signs
Which nursing diagnoses may be appropriate for a client who is short of breath? (SATA)
- Altered skin integrity
- Ineffective breathing pattern
- Ineffective airway clearance
- Electrolyte imbalance
- Endocrine imbalance
- Ineffective breathing pattern
- Ineffective airway clearance
Which nursing actions can improve impaired gas exchange? (SATA)
- Strategies to open the airway
- Oxygen delivery
- Fluid administration
- Supine positioning
- Ventilation assistance
- Strategies to open the airway
- Oxygen delivery
- Ventilation assistance
In both the Nursing Assessment and the Vital Signs sections of the EHR, select the cues that indicate this client is experiencing impaired gas exchange.
- shortness of breath with a history of asthma
- scattered wheezes in the lungs
- increased respiratory rate
- decreased oxygen saturation.
An adult arrived at the emergency department at 15:30 with shortness of breath.
After completing the assessment, the nurse contacted the healthcare provider with the information below.
Situation: adult presenting with shortness of breath, increasingly worse over the last 2 days and a productive cough
Background: history of asthma
Assessment: lungs with scattered sonorous wheezes, symmetrical chest expansion with no temperature, slightly elevated blood pressure, respiratory rate of 28, and an oxygen saturation of 88% on room air.
Which order should the nurse anticipate receiving?
Chest x-ray
3 multiple choice options
An adult arrived at the emergency department at 15:30 with shortness of breath.
The chest x-ray results revealed bronchial wall thickening with mild hyperinflation, consistent with asthma. No pneumonia is present.
Based on these findings, which nursing actions should the nurse include in the client's plan of care? (SATA)
- Encouraging frequent rest periods
- Preparing to administer supplemental oxygen
- Working with respiratory therapy to administer inhaled medications
- Positioning the client in a semi-Fowler's position
- Administering antibiotics
- Positioning in a supine position
- Positioning the client in a semi-Fowler's position
- Preparing to administer supplemental oxygen
- Working with respiratory therapy to administer inhaled medications
- Encouraging frequent rest periods
An adult arrived at the emergency department at 15:30 with shortness of breath. Review the "Provider Orders" tab before answering the question.
Which statements below are accurate concerning starting supplemental oxygen therapy? (SATA)
PROVIDER ORDERS: Oxygen 4 L/min per nasal cannula ----- Douglas Eubanks, MD
- No provider order is required to start supplemental oxygen.
- This will deliver about 37% oxygen.
- If the flow is higher, humidification is recommended for comfort.
- A flow meter is not needed to deliver oxygen this way.
- It is safe to smoke when using oxygen by this delivery method.
- This will deliver about 37% oxygen.
- If the flow is higher, humidification is recommended for comfort.
An adult arrived at the emergency department at 15:30 with shortness of breath.
The client has responded well to the treatment and is preparing for discharge to home. Which statement, regarding the use of supplemental oxygen at home, made by the client leads the nurse to believe that more discharge teaching is needed?
"I don't smoke, but vaping is safe with oxygen."
3 multiple choice options
Nasal cannula
It delivers a small to moderate amount of oxygen comfortably and is usually the first device used when oxygen is needed.
Simple face mask
It is usually used for a temporary need for increased oxygen. It can deliver up to 50% oxygen with a flow rate of 6 to 12 L/min.
Venturi mask
It is used for accurate oxygen delivery by changing the flow valve. It is good for accurate oxygen delivery for a longer period of time.
Partial non-rebreather
It is used when high amounts of oxygen are needed. There is a reservoir bag with a one-way valve preventing oxygen from flowing back into the bag.
Full non-rebreather
It is used when high amounts of oxygen are needed. There is a reservoir bag with three one-way valves in the mask. Delivers up to 100% oxygen.
Continuous positive airway pressure (CPAP) machine
It delivers oxygen along with a constant pressure to help with ventilation. It can be difficult to exhale due to the continuous pressure.
Bilevel positive airway pressure (BiPAP) machine
It delivers oxygen or air along with a pressure that increases with inspiration and decreases with expiration. It helps with ventilation.
Ventilator
It delivers oxygen and ventilation when a client is unable to. It is used for urgent life support until underlying problems can be treated.
An adult client who uses oxygen, 2 L/min via nasal cannula at home, is admitted to the hospital with pneumonia. They have a history of chronic obstructive pulmonary disease (COPD) and have a productive cough with a moderate amount of yellowish sputum. The first dose of antibiotics was administered 2 hours ago.
What is this client's priority nursing diagnosis?
Ineffective airway clearance
3 multiple choice options
An adult client who uses oxygen, 2 L/min via nasal cannula at home, is admitted to the hospital with pneumonia. They have a history of chronic obstructive pulmonary disease (COPD) and a productive cough with a moderate amount of yellowish sputum. The first dose of antibiotics was administered 2 hours ago.
Which finding about a full non-rebreather mask ensures it is delivering the highest level of oxygen?
The oxygen regulator is set at 15 L/min.
3 multiple choice options
An adult client who uses oxygen, 2 L/min via nasal cannula at home, is admitted to the hospital with pneumonia. They have a history of chronic obstructive pulmonary disease (COPD) and a productive cough with a moderate amount of yellowish sputum. The first dose of antibiotics was administered 2 hours ago.
After 45 minutes on 100% oxygen via a non-rebreather mask, the client's respirations are 36 per minute and oxygen saturation is 86%. Which action should the nurse anticipate taking next?
Using a bag-valve-mask to assist with ventilation
3 multiple choice options
The client was intubated and transferred to the intensive care unit by the rapid response team (RRT). Two weeks later, a temporary tracheostomy was placed because the client remained dependent on the ventilator for breathing. The client is being transferred to a step-down unit.
What facts should the nurse consider when preparing the room? (SATA)
- Sterile suction catheters should be kept in the room along with a working suction unit.
- Tracheostomy dressing change kits will need to be ordered for tracheostomy care once daily.
- Since the client is still on the ventilator, a cuffless tracheostomy tube will still be used.
- Knowing the tracheostomy tube brand and size will be needed so an additional one can be kept in the room in case of decanulation.
- Trach ties are not needed until the tracheostomy tube heals.
- Sterile suction catheters should be kept in the room along with a working suction unit.
- Knowing the tracheostomy tube brand and size will be needed so an additional one can be kept in the room in case of decanulation.
The client requires frequent suctioning. When suctioning, which statements are accurate concerning safe care? (SATA)
- The catheter does not need to be sterile as long as it is clean.
- If suctioning needs to be repeated, it should be done immediately as waiting will cause the secretions to dry.
- Suctioning should be done while inserting the catheter, and no suctioning should be done while removing the catheter.
- Closed system suctioning is preferable while the client is still on a ventilator, especially if suctioning is required frequently.
- The total suction time should be no more than 10 seconds from start to finish.
- Closed system suctioning is preferable while the client is still on a ventilator, especially if suctioning is required frequently.
- The total suction time should be no more than 10 seconds from start to finish.
The client began breathing on their own and was removed from the ventilator. They are currently receiving supplemental oxygen via a tracheostomy collar and will be discharged to home with the oxygen.
What information about using home oxygen should the nurse include in the client's discharge teaching? (SATA)
- An oxygen tank may cause or intensify a fire.
- An oxygen tank is usually painted yellow, indicating that there is oxygen inside.
- The tank should be secured to a mobile holder to prevent it from falling.
- A regulator is needed to dial in the oxygen flow rate.
- A key or tank valve should be used to shut the tank off when not in use.
- An oxygen tank may cause or intensify a fire.
- The tank should be secured to a mobile holder to prevent it from falling.
- A regulator is needed to dial in the oxygen flow rate.
- A key or tank valve should be used to shut the tank off when not in use.
The client asks the nurse what options, besides a large oxygen tank, are available for use at home.
Match the oxygen source to its correct description.
It needs to be filled, primarily used for transport - Tank
It is used in hospitals to deliver oxygen through wall outlets - Liquid oxygen
It makes oxygen and is best used in the home environment - Concentrator
Before performing tracheostomy care and suctioning, what factors would be important for the nurse to consider? (SATA)
- Respiratory assessment
- Lack of humidity
- Abdominal assessment
- Fluid balance
- Presence of infection
- Peripheral pulses
- Respiratory assessment
- Lack of humidity
- Fluid balance
- Presence of infection
The nurse knows it is best practice to remove the old tracheostomy ties (before/after) the new ties have been secured in place. This helps to prevent (aspiration/dislodgment) of the tracheostomy tube.
- after
- dislodgment
When preparing to suction a tracheostomy tube, hyperoxygenation is (recommended/not recommended) before, during, and after suctioning to reduce suction-induced (hypoxemia/coughing.)
- recommended
- hypoxemia
When reviewing the client chart, what cues indicate sterile tracheal suctioning is needed? (SATA)
- Rhonchi
- Audible secretions
- Oxygen saturation
- Fatigue
- Blood pressure
- Rhonchi
- Audible secretions
- Oxygen saturation
Review the table and indicate whether the supplies/equipment are indicated or not indicated for performing the return demonstration of tracheostomy care and suctioning.
- Suction catheter kit
- Sterile alcohol
- Sterile saline
- Pulse oximeter
- Blood pressure cuff
- Face mask with shield or face mask and eye protection
Indicated
- Suction catheter kit
- Sterile saline
- Pulse oximeter
- Face mask with shield or face mask and eye protection
Not Indicated
- Sterile alcohol
- Blood pressure cuff
While performing tracheostomy care, the nurse accidentally dislodges the tracheostomy tube. What actions should the nurse take? (SATA)
- Ventilate client as needed
- Suction the stoma site
- Stay with the client while calling for help
- Leave the room to get help
- Assess for airway patency
- Ventilate client as needed
- Stay with the client while calling for help
- Assess for airway patency
Reflect on the nurse in the skill video you just viewed. The nurse in the skill video documented the following after performing tracheostomy care and suctioning. Highlight the incorrect information they documented.
- Lungs clear in bilateral upper lobes
- Nasal cannula
- Disposable outer cannula
What information should be recorded in the Respiratory portion of the I-SBAR's Assessment section? (SATA)
- No oxygen needed after suctioning
- No secretions noted
- Bilateral upper lobe breath sounds clear
- Tracheostomy care and suctioning performed
- Continuous oxygen via trach collar
- Bilateral upper lobe breath sounds clear
- Tracheostomy care and suctioning performed
- Continuous oxygen via trach collar
A nurse is caring for a postoperative client. The client is 48 hours post tracheostomy.
The nurse is preparing to perform tracheostomy care. Which of these assessment findings require further follow-up before performing tracheostomy care?
Assessment Findings
- Client communicates they are having trouble breathing
- Visualization of thick secretions in tracheostomy tube
- Spouse at bedside
- SpO2 86% on 50% O2 via trach collar
Tracheostomy ties securely fastened
Assessment Findings That Require Further Follow-Up
- Client communicates they are having trouble breathing
- Visualization of thick secretions in tracheostomy tube
- SpO2 86% on 50% O2 via trach collar
Upon assessment, the nurse noted all the following cues. Match each cue with its associated risk for the client:
CUE:
- Thick secretions visible in the tracheostomy tube
- Client confused and picking at tracheostomy tube
- Client has a temperature of 101.7 °F (38.7 °C) Oral
- Client lying flat in bed
RISK:
- Risk for airway obstruction
- Risk for tube dislodgement
- Risk for infection
- Risk for aspiration
1. Thick secretions visible in the tracheostomy tube - Risk for airway obstruction
2. Client confused and picking at tracheostomy tube - Risk for tube dislodgement
3. Client has a temperature of 101.7 °F (38.7 °C) Oral - Risk for infection
4. Client lying flat in bed - Risk for aspiration
When suctioning the client's tracheostomy tube, the nurse meets resistance, and the client begins to cough. This is a sign of (tube dislodgment/proper technique). The nurse should now (pull the catheter back/push the catheter down) a 1/2 inch and apply (intermittent/continuous) suction.
- proper technique
- pull the catheter back
- intermittent
As the nurse is suctioning the client's tracheostomy tube, the client develops significant respiratory distress. Which of the potential interventions are indicated or contraindicated for the client at this time?
- Withdraw suction catheter
- Remove tracheostomy tube
- Administer oxygen
- Lay client flat
- Notify healthcare provider
Indicated
- Withdraw suction catheter
- Administer oxygen
- Notify healthcare provider
Contraindicated
- Remove tracheostomy tube
- Lay client flat
Arrange the steps in the order they should be performed in tracheostomy suctioning. Please note these are not inclusive steps of tracheostomy suctioning.
- Don sterile gloves
- Place client into semi-Fowler's or Fowler's position
- Adjust regulator to 80-150 mmHg
- Withdraw suction catheter approximately 1/2 inch then apply suction intermittently and gently rotate the catheter while withdrawing the catheter
- Open suction kit
- Pour sterile normal saline into sterile basin
- Dip the tip of the catheter into the basin to flush and moisten for easier insertion
- Insert the suction catheter into the tracheostomy until resistance is met or the client coughs
- Increase supplemental oxygen flow following facility policy for hyperoxygenation protocol
1. Place client into semi-Fowler's or Fowler's position
2. Adjust regulator to 80-150 mmHg
3. Increase supplemental oxygen flow following facility policy for hyperoxygenation protocol
4. Open suction kit
5. Don sterile gloves
6. Pour sterile normal saline into sterile basin
7. Dip the tip of the catheter into the basin to flush and moisten for easier insertion
8. Insert the suction catheter into the tracheostomy until resistance is met or the client coughs
9. Withdraw suction catheter approximately 1/2 inch then apply suction intermittently and gently rotate the catheter while withdrawing the catheter
Review the nurses' notes and indicate whether the assessment findings are improved, no change, or declined.
IMPROVED:
- HR 90
- RR 20
- SpO2 99%
NO CHANGE:
- BP 126/78
- Rhonchi auscultated
When educating a client and caregiver about home suctioning of a tracheostomy tube, it is important to teach the client/caregiver to never apply suction during (removal/insertion) of the suction catheter. Suggest caregivers hold their breath during the application of suction to help them remember to keep suction intervals )(brief/prolonged).
- insertion
- brief
The nurse knows it is important to (stabilize/remove) the tracheostomy tube during tracheostomy care to prevent (dislodgement/infection) of the tracheostomy tube.
- stabilize
- dislodgement