CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
A nurse prepares to perform postural drainage. How should the
nurse ascertain the best position to facilitate clearing the lungs?
Auscultation
The nurse is assisting a physician with an endotracheal intubation
for a client in respiratory failure. It is most important for the nurse
to assess for:
Symmetry of the client's chest expansion
A client is receiving supplemental oxygen. When determining the
effectiveness of oxygen therapy, which arterial blood gas value is
most important?
Partial pressure of arterial oxygen (PaO2)
For a client who has a chest tube connected to a closed water-seal
Measuring and documenting the drainage in the collection chamdrainage system, the nurse should include which action in the care
ber
plan?
The nurse suctions a patient through the endotracheal tube for 20
seconds and observes dysrhythmias on the monitor. What does
the nurse determine is occurring with the patient?
The patient is hypoxic from suctioning.
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360
degrees for which of the following time periods?
10 to 15 seconds
After lobectomy for lung cancer, a client receives a chest tube
connected to a disposable chest drainage system. The nurse
observes that the drainage system is functioning correctly when
she notes tidal movements or fluctuations in which compartment
of the system as the client breathes?
Water-seal chamber
Constant bubbling in the water seal of a chest drainage system
indicates which of the following problems?
Air leak
A nurse is assigned to care for a client with a tracheostomy tube.
How can the nurse communicate with this client?
By supplying a magic slate or similar device
A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10
breaths/minute. These signs are associated with which condition?
Hypoxia
A client is on a ventilator. Alarms are sounding, indicating an
increase in peak airway pressure. The nurse assesses first for
A kink in the ventilator tubing
The nurse is educating the patient in the use of a mini-nebulizer.
What should the nurse encourage the patient to do? (Select all
that apply.)
• Cough frequently.
• Hold the breath at the end of inspiration for a few seconds.
• Frequently evaluate progress.
Which of the following statements would not be considered an
appropriate intervention for a patient with an ET tube?
Routine cuff deflation is recommended
The nurse is assisting a client with postural drainage. Which of the
following demonstrates correct implementation of this technique?
Instruct the client to remain in each position of the postural
drainage sequence for 10 to 15 minutes.
Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?
Baseline arterial blood gas (ABG) levels
A patient has been receiving 100% oxygen therapy by way of a
nonrebreather mask for several days. Now the patient complains
of tingling in the fingers and shortness of breath, is extremely
restless, and describes a pain beneath the breastbone. What
should the nurse suspect?
Oxygen toxicity
For a client with an endotracheal (ET) tube, which nursing action
is the most important?
Auscultating the lungs for bilateral breath sounds
Which type of ventilator has a present volume of air to be delivered
with each inspiration?
Volume-controlled
A nurse observes constant bubbling in the water-seal chamber of
a closed chest drainage system. What should the nurse conclude?
The system has an air leak.
1 / 18
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
A patient is being educated in the use of incentive spirometry prior
Encourage the patient to take approximately 10 breaths per hour,
to having a surgical procedure. What should the nurse be sure to
while awake.
include in the education?
After undergoing a left thoracotomy, a client has a chest tube in
place. When caring for this client, the nurse must:
encourage coughing and deep breathing.
A client with COPD has been receiving oxygen therapy for an
extended period. What symptoms would be indicators that the
client is experiencing oxygen toxicity? Select all that apply.
• Dyspnea
• Substernal pain
• Fatigue
The nurse is transporting a patient with chest tubes to a treatment
Cut the contaminated tip of the tube and insert a sterile connector
room. The chest tube becomes disconnected and falls between
and reattach.
the bed rail. What is the priority action by the nurse?
The nurse is preparing to perform chest physiotherapy (CPT) on
a patient. Which of the following patient statements would indicate
the procedure is contraindicated.
"I just finished eating my lunch, I'm ready for my CPT now."
A client with a respiratory condition is receiving oxygen therapy.
While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?
84 mm Hg
The nurse is caring for a patient with an endotracheal tube (ET).
Which of the following nursing interventions is contraindicated?
Deflating the cuff routinely
A client is on a positive-pressure ventilator with a synchronized
intermittent mandatory ventilation (SIMV) setting. The ventilator
is set for 8 breaths per minute. The client is taking 6 breaths per
minute independently. The nurse
Continues assessing the client's respiratory status frequently
The nurse is caring for a patient being weaned from the mechanical ventilator. Which of the following patient findings would require
the termination of the weaning process?
Blood pressure increase of 20 mm Hg from baseline
A patient with COPD requires oxygen administration. What
method of delivery does the nurse know would be best for this
patient?
A Venturi mask
Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration?
Volume cycled
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?
Manual resuscitation bag
Of the following oxygen administration devices, which has the
advantage of providing high oxygen concentration?
Nonrebreather mask
A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and
endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator
sounds, the nurse starts to check for the cause. Which condition
triggers the high-pressure alarm?
Kinking of the ventilator tubing
A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy
is:
keeping his airway patent.
Which of the following is the most reliable and accurate method for
delivering precise concentrations of oxygen through noninvasive
means?
Venturi mask
A client with pneumonia develops respiratory failure and has a
partial pressure of arterial oxygen of 55 mm Hg. He's placed on
mechanical ventilation with a fraction of inspired oxygen (FIO2) of
0.5.
2 / 18
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
0.9. The nursing goal should be to reduce the FIO2 to no greater
than:
A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:
5 to 20 minutes.
Arterial blood gases should be obtained at which timeframe following the initiation of continuous mechanical ventilation?
20 minutes
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator
sounds, what should the nurse do?
Suction the client's artificial airway.
A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and
surgery" on the nursing care plan. Which of the following nursing
interventions would be appropriately aligned with this nursing
diagnosis? Select all that apply.
• Monitor pulmonary status as directed and needed.
• Regularly assess the client's vital signs every 2 to 4 hours.
• Encourage deep breathing exercises
Which of the following is a potential complication of a low pressure
in the ET cuff?
Aspiration pneumonia
Which of the following ventilator modes provides full ventilatory
support by delivering a present tidal volume and respiratory rate?
Assist control
A client is prescribed postural drainage because secretions are
building in the superior segment of the lower lobes. Which is the
best position to teach the client to use for postural drainage?
Lying prone
A patient with emphysema informs the nurse, "The surgeon will
be removing about 30% of my lung so that I will not be so short
of breath and will have an improved quality of life." What surgery
does the nurse understand the surgeon will perform?
A lung volume reduction
A client has a sucking stab wound to the chest. Which action
should the nurse take first?
Apply a dressing over the wound and tape it on three sides.
A young man incurred a spontaneous pneumothorax. The physician has just inserted a chest tube and has prescribed suction set
at 20 cm of water. The nurse instills the fluid to this level in the
appropriate chamber. Mark the level of fluid on the appropriate
chamber of the closed drainage system.
A (below the 2002 date number on picture)
The nurse is assessing a patient with chest tubes connected to a
drainage system. What should the first action be when the nurse
observes excessive bubbling in the water seal chamber?
Notify the physician.
The nurse is preparing to assist the health care provider with the
"When the tube is being removed, take a deep breath, exhale, and
removal of a patient's chest tube. Which of the following instrucbear down."
tions will the nurse correctly give the patient?
A client who must begin oxygen therapy asks the nurse why this
treatment is necessary? What would the nurse identify as the
goals of oxygen therapy? Select all that apply.
• To provide adequate transport of oxygen in the blood
• To decrease the work of breathing
• To reduce stress on the myocardium
A client on long-term mechanical ventilation becomes very frusAsk the client to write, use a picture board, or spell words with an
trated when he tries to communicate. Which intervention should
alphabet board.
the nurse perform to assist the client?
A patient with emphysema is placed on continuous oxygen at 2
L/min at home. Why is it important for the nurse to educate the
patient and family that they must have No Smoking signs placed
on the doors?
Oxygen supports combustion.
A nurse is caring for a client after a thoracotomy for a lung mass.
Which nursing diagnosis should be the first priority?
Impaired gas exchange
Which of the following ventilator modes provides a combination of
mechanically assisted breaths and spontaneous breaths?
Intermittent mandatory ventilation (IMV)
3 / 18
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
A client is postoperative and prescribed an incentive spirometer
(IS). The nurse instructs the client to:
Expect coughing when using the spirometer properly.
Which of the following is a potential complication of a low pressure
in the endotracheal tube (ET) cuff?
Aspiration pneumonia
A client with supraglottic cancer undergoes a partial laryngectomy.
Postoperatively, a cuffed tracheostomy tube is in place. When
removing secretions that pool above the cuff, the nurse should
instruct the client to:
cough as the cuff is being deflated.
A client is recovering from thoracic surgery needed to perform
a right lower lobectomy. Which of the following is the most likely
postoperative nursing intervention?
Encourage coughing to mobilize secretions.
A patient in the ICU has been orally intubated and on mechanical
ventilation for 2 weeks after having a severe stroke. What action
does the nurse anticipate the physician will take now that the
patient has been intubated for this length of time?
The patient will have an insertion of a tracheostomy tube.
A nurse is weaning a client from mechanical ventilation. Which
assessment finding indicates the weaning process should be
stopped?
Runs of ventricular tachycardia
A new ICU nurse is observed by her preceptor entering a patient's
room to suction the tracheostomy after performing the task 15
minutes before. What should the preceptor educate the new nurse
to do to ensure that the patient needs to be suctioned?
Auscultate the lung for adventitious sounds.
The nurse assesses a patient with a heart rate of 42 and a blood
pressure of 70/46. What type of hypoxia does the nurse determine
this patient is displaying?
Circulatory hypoxia
A nurse is planning care for a client after a tracheostomy. One
of the client's goals is to overcome verbal communication imEncourage the client's communication attempts by allowing him
pairment. Which intervention should the nurse include in the care time to select or write words.
plan?
A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation
with a preset tidal volume and number of breaths each minute.
The client has the ability to breathe spontaneously between the
ventilator breaths with no ventilator assistance. The nurse should
document the ventilator setting as:
synchronized intermittent mandatory ventilation (SIMV).
15 to 20 mm Hg
(Even though everything says 20-25)
Usually the pressure is maintained at less than 25 cm water
Which of the following ranges of water pressure identifies the
pressure to prevent injury and at more than 20 cm water pressure
amount of pressure within the endotracheal tube cuff that is beto prevent aspiration. High cuff pressure can cause tracheal bleedlieved to prevent both injury and aspiration?
ing, ischemia, and pressure necrosis, whereas low cuff pressure
can increase the risk of aspiration pneumonia. A measure of 0 to
5 mm Hg or 10 to 15 mm Hg of water pressure would indicate that
the cuff is underinflated. A measure of 30 to 35 mm Hg of water
pressure would indicate that the cuff is overinflated.
Of the following oxygen administration devices, which has the
advantage of providing high oxygen concentration?
Non-rebreather mask
A patient is diagnosed with mild obstructive sleep apnea after
having a sleep study performed. What treatment modality will be
the most effective for this patient?
Continuous positive airway pressure
Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate?
Assist-control
4 / 18
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
The nurse received a client from the post-anesthesia care unit
(PACU) who has a chest tube to a closed drainage system. Report
from the PACU nurse included drainage in the chest tube at 80 mL
of bloody fluid. Fifteen minutes after transfer from the PACU, the
chest tube indicates drainage as pictured. The client is reporting
pain at "8" on a scale of 0 to 10. The first action of the nurse is to:
Assess pulse and blood pressure.
In general, chest drainage tubes are not used for the patient
undergoing
pneumonectomy.
The nurse has instructed a patient on how to perform pursed-lip
Improve oxygen transport, induce a slow, deep breathing pattern,
breathing. The nurse recognizes the purpose of this type of
and assist the patient to control breathing
breathing is to accomplish which of the following?
Question: The nurse is teaching a postoperative client who had a
coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the
following order:
Sit in an upright position.
Place the mouthpiece of the spirometer in the mouth.
Breathe air in through the mouth.
Hold breath for about 3 seconds.
Exhale air slowly through the mouth.
Which type of oxygen therapy includes the administration of oxygen at pressure greater than 1 atmosphere?
Hyperbaric
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower
the client's arterial blood oxygen saturation?
Endotracheal
A client is prescribed postural drainage because secretions are
Take prescribed albuterol (Ventolin) before performing postural
accumulating in the upper lobes of the lungs. The nurse instructs
drainage.
the client to:
A client abruptly sits up in bed, reports having difficulty breathing
and has an arterial oxygen saturation of 88%. Which mode of
oxygen delivery is most likely to reverse these manifestations?
Nonrebreather mask
When performing endotracheal suctioning, the nurse applies suc10 to 15 seconds
tioning while withdrawing and gently rotating the catheter 360
degrees for which of the following time periods?
In general, the nurse should apply suction no longer than 10
to 15 seconds because hypoxia and dysrhythmias may develop,
leading to cardiac arrest. Applying suction for 30 to 35 seconds
a) 30 to 35 seconds
is hazardous and may result in the patient's developing hypoxia,
which can lead to dysrhythmias and, ultimately, cardiac arrest. Apb) 20 to 25 seconds
plying suction for 20 to 25 seconds is hazardous and may result in
the patient's developing hypoxia, which can lead to dysrhythmias
c) 0 to 5 seconds
and, ultimately, cardiac arrest. Applying suction for 0 to 5 seconds
would provide too little time for effective suctioning of secretions.
d) 10 to 15 seconds
A client is receiving supplemental oxygen. When determining the
effectiveness of oxygen therapy, which arterial blood gas value is
most important?
Partial pressure of arterial oxygen (PaO2)
a) Partial pressure of arterial oxygen (PaO2)
b) Bicarbonate (HCO3-)
c) Partial pressure of arterial carbon dioxide (PaCO2)
The most significant and direct indicator of the effectiveness of
oxygen therapy is the PaO2 value. Based on the PaO2 value, the
nurse may adjust the type of oxygen delivery (cannula, Venturi
mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not
oxygenation. The pH, HCO3-, and PaCO2 (less)
d) pH
After lobectomy for lung cancer, a client receives a chest tube
connected to a disposable chest drainage system. The nurse
Water-seal chamber
observes that the drainage system is functioning correctly when
she notes tidal movements or fluctuations in which compartment Fluctuations in the water-seal compartment are called tidal moveof the system as the client breathes?
5 / 18
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
ments and indicate normal function of the system as the pressure
in the tubing changes with the client's respirations. The air-leak
meter — not chamber — detects air leaking from the pleural space.
The collection chamber connects the chest tube from the client to
the system. Drainage from the tube drains into and collects in a
series of calibrated columns in this chamber. The suction control
chamber provides the suction, which can be controlled to provide
negative pressure to the chest. (less)
a) Collection chamber
b) Air-leak chamber
c) Suction control chamber
d) Water-seal chamber
The nurse is caring for a patient with an endotracheal tube (ET).
Which of the following nursing interventions is contraindicated?
Deflating the cuff routinely
a) Checking the cuff pressure every 6 to 8 hours
Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before
b) Ensuring that humidified oxygen is always introduced through
the ET is removed. Cuff pressures should be checked every 6 to
the tube
8 hours. Humidified oxygen should always be introduced through
the tube.
c) Deflating the cuff prior to tube removal
d) Deflating the cuff routinely
A client is on a positive-pressure ventilator with a synchronized
intermittent mandatory ventilation (SIMV) setting. The ventilator
is set for 8 breaths per minute. The client is taking 6 breaths per
Continues assessing the client's respiratory status frequently
minute independently. The nurse
The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra
a) Continues assessing the client's respiratory status frequently
breaths. Data in the stem suggest that the ventilator is working
correctly. The nurse would continue making frequent respiratory
b) Consults with the physician about removing the client from the
assessments of the client. There are not sufficient data to suggest
ventilator
the client could be removed from the ventilator. There is no reason
to increase the ventilator's setting to 14 breaths per minute or to
c) Contacts the respiratory therapy department to report the
contact respiratory therapy to report the machine is not working
ventilator is malfunctioning
properly.
d) Changes the setting on the ventilator to increase breaths to 14
per minute
A nurse is weaning a client from mechanical ventilation. Which
assessment finding indicates the weaning process should be
stopped?
Runs of ventricular tachycardia
Ventricular tachycardia indicates that the client isn't tolerating
the weaning process. The weaning process should be stopped
before lethal ventricular arrhythmias occur. A respiratory rate of 16
breaths/minute and an oxygen saturation of 93% are normal findings. Although the client's blood pressure has increased, it hasn't
increased more than 20% over baseline, which would indicate that
the client isn't tolerating the weaning process.
a) Runs of ventricular tachycardia
b) Oxygen saturation of 93%
c) Respiratory rate of 16 breaths/minute
d) Blood pressure increase from 120/74 mm Hg to 134/80 mm Hg
A client has a sucking stab wound to the chest. Which action
should the nurse take first?
a) Prepare to start an I.V. line.
b) Apply a dressing over the wound and tape it on three sides.
c) Prepare a chest tube insertion tray.
Apply a dressing over the wound and tape it on three sides.
The nurse should immediately apply a dressing over the stab
wound and tape it on three sides to allow air to escape and to
prevent tension pneumothorax (which is more life-threatening than
an open chest wound). Only after covering and taping the wound
should the nurse draw blood for laboratory tests, assist with chest
tube insertion, and start an I.V. line.
6 / 18
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
d) Draw blood for a hematocrit and hemoglobin level.
A patient is being mechanically ventilated in the ICU. The ventilator
alarms begin to sound. The nurse should complete which of the
following actions first?
Troubleshoot to identify the malfunction.
The nurse should first immediately attempt to identify and correct
the problem and, if the problem cannot be identified and/or corrected, the patient must be manually ventilated with an Ambu bag.
The respiratory therapist may be notified, but this is not the first
action by the nurse. The nurse should not reposition the ET tube
as a first response to an alarm.
a) Notify the respiratory therapist.
b) Troubleshoot to identify the malfunction.
c) Reposition the endotracheal (ET) tube.
d) Manually ventilate the patient.
Of the following oxygen administration devices, which has the
advantage of providing high oxygen concentration?
Non-rebreather mask
The non-rebreather mask provides high oxygen concentration but
it is usually poor fitting. The Venturi mask provides low levels of
supplemental oxygen. The catheter is an inexpensive device that
provides a variable fraction of inspired oxygen and may cause
gastric distention. A face tent provides a fairly accurate fraction of
inspired oxygen, but is bulky and uncomfortable. It would not be
the device of choice to provide high oxygen concentration.
a) Catheter
b) Venturi mask
c) Face tent
d) Non-rebreather mask
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower
Endotracheal suctioning
the client's arterial blood oxygen saturation?
Endotracheal suctioning removes secretions as well as gases
from the airway and lowers the arterial oxygen saturation (SaO2)
level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because
of superficial vasoconstriction, using a cooling blanket can lower
peripheral oxygen saturation readings, but SaO2 levels wouldn't
be affected.
a) Encouragement of coughing
b) Use of a cooling blanket
c) Incentive spirometry
d) Endotracheal suctioning
The nurse is caring for a patient who is scheduled for a lobectomy.
Following the procedure, the nurse will plan care based on which
of the following?
The patient will return to the nursing unit with two chest tubes.
The nurse should plan for the patient to return to the nursing
unit with two chest tubes intact. During a lobectomy, the lobe is
removed, and the remaining lobes of the lung are re-expanded.
b) The patient will require mechanical ventilation following
Usually, two chest catheters are inserted for drainage. The upper
surgery.
tube is for air removal; the lower one is for fluid drainage. Sometimes, only one catheter is needed. The chest tube is connected
c) The patient will return to the nursing unit with two chest tubes.
to a chest drainage apparatus for several days.
a) The patient will return from surgery with no drainage tubes.
d) The patient will require sedation until the chest tube (s) are
removed.
A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and
surgery" on the nursing care plan. Which of the following nursing
interventions would be appropriately aligned with this nursing
diagnosis? Select all that apply.
7 / 18
• Monitor pulmonary status as directed and needed.
• Regularly assess the client's vital signs every 2 to 4 hours.
• Encourage deep breathing exercises.
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
a) Encourage deep breathing exercises.
Interventions to improve the client's gas exchange include monitoring pulmonary status as directed and needed, assessing vital
signs every 2 to 4 hours, and encouraging deep breathing exercises. Maintainin an open airway is appropriate for improving the
client's airway clearance. Monitoring and recording hourly intake
and output are essential interventions for ensuring appropriate
fluid balance.
b) Monitor and record hourly intake and output.
c) Regularly assess the client's vital signs every 2 to 4 hours.
d) Maintain an open airway.
e) Monitor pulmonary status as directed and needed.
Hyperbaric oxygen therapy increases the blood's capacity to carry
and deliver oxygen to compromised tissues. This therapy may be
used for a client with:
a compromised skin graft.
a) a malignant tumor.
A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the
wound site promotes wound healing. Hyperbaric oxygen therapy
isn't indicated for malignant tumors, pneumonia, or hyperthermia.
b) a compromised skin graft.
c) hyperthermia.
d) pneumonia.
The nurse is preparing to assist the health care provider with the
removal of a patient's chest tube. Which of the following instructions will the nurse correctly give the patient?
"When the tube is being removed, take a deep breath, exhale, and
bear down."
a) "Exhale forcefully while the chest tube is being removed."
When assisting in the chest tube's removal, instruct the patient
to perform a gentle Valsalva maneuver or to breathe quietly. The
b) "While the chest tube is being removed, raise your arms above
chest tube is then clamped and quickly removed. Simultaneously,
your head."
a small bandage is applied and made airtight with petrolatum
gauze covered by a 4 × 4-inch gauze pad and thoroughly covered
c) "During the removal of the chest tube, do not move because it
and sealed with nonporous tape. The other options are incorrect
will make the removal more painful."
instructions for the patient.
d) "When the tube is being removed, take a deep breath, exhale,
and bear down."
The nurse assesses a patient with a heart rate of 42 and a blood
pressure of 70/46. What type of hypoxia does the nurse determine
Circulatory hypoxia
this patient is displaying?
a) Hypoxic hypoxia
b) Circulatory hypoxia
c) Histotoxic hypoxia
Given this patient's vital signs, he appears to be in shock. Circulatory hypoxia is hypoxia resulting from inadequate capillary
circulation. It may be caused by decreased cardiac output, local
vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced,
arterial oxygen (PaO2) remains normal. Circulatory hypoxia is
corrected by identifying and treating the underlying cause. (less)
d) Anemic hypoxia
The nurse is caring for a patient following a thoracotomy. Which
of the following findings requires immediate intervention by the
nurse?
Chest tube drainage of 190 mL/hr
a) Heart rate: 112 bpm
b) Chest tube drainage of 190 mL/hr
The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse will notify the primary
provider if drainage is 150 mL/hr or greater. The other findings are
normal following a thoracotomy; no intervention is required.
c) Moderate amounts of colorless sputum
8 / 18
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
d) Pain of 5 on a 1 to 10 pain scale
After undergoing a left thoracotomy, a client has a chest tube in
place. When caring for this client, the nurse must:
encourage coughing and deep breathing.
When caring for a client who's recovering from a thoracotomy, the
nurse should encourage coughing and deep breathing to prevent
pneumonia. Fluctuations in the water-seal chamber are normal.
Clamping the chest tube could cause a tension pneumothorax.
Chest tube milking is controversial and should be done only to
remove blood clots that obstruct the flow of drainage.
a) report fluctuations in the water-seal chamber.
b) milk the chest tube every 2 hours.
c) clamp the chest tube once every shift.
d) encourage coughing and deep breathing.
A client with COPD has been receiving oxygen therapy for an
extended period. What symptoms would be indicators that the
client is experiencing oxygen toxicity? Select all that apply.
• Dyspnea
• Substernal pain
• Fatigue
a) Substernal pain
b) Fatigue
Oxygen toxicity can occur when clients receive too high a concentration of oxygen for an extended period. Symptoms include
dyspnea, substernal pain, restlessness, fatigue, and progressive
respiratory difficulty. Bradycardia and mood swings are not symptoms of oxygen toxicity.
c) Dyspnea
d) Bradycardia
e) Mood swings
A client has a tracheostomy but doesn't require continuous me- 5 to 20 minutes.
chanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for: Initially, the nurse should plug the opening in the tracheostomy
tube for 5 to 20 minutes, then gradually lengthen this interval
according to the client's respiratory status. A client who doesn't
a) 30 to 40 minutes.
require continuous mechanical ventilation already is breathing
without assistance, at least for short periods; therefore, plugging
b) 5 to 20 minutes.
the opening of the tube for only 15 to 60 seconds wouldn't be
long enough to reveal the client's true tolerance to the procedure.
c) 15 to 60 seconds.
Plugging the opening for more than 20 minutes would increase
the risk of acute respiratory distress because the client requires
d) 45 to 60 minutes.
an adjustment period to start breathing normally.
The nurse is transporting a patient with chest tubes to a treatment
room. The chest tube becomes disconnected and falls between
the bed rail. What is the priority action by the nurse?
Cut the contaminated tip of the tube and insert a sterile connector
and reattach.
a) Immediately reconnect the chest tube to the drainage apparaIf the patient is lying on a stretcher and must be transported to
tus.
another area, place the drainage system below the chest level. If
the tubing disconnects, cut off the contaminated tips of the chest
b) Cut the contaminated tip of the tube and insert a sterile
tube and tubing, insert a sterile connector in the cut ends, and
connector and reattach.
reattach to the drainage system. Do not clamp the chest tube
during transport. (less)
c) Clamp the chest tube close to the connection site.
d) Call the physician.
Which of the following are indicators that a client is ready to be
weaned from a ventilator? Select all that apply.
a) Tidal volume of 8.5 mL/kg
9 / 18
• PaO2 of 64 mm Hg
• Tidal volume of 8.5 mL/kg
• Vital capacity of 13 mL/kg
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
b) Rapid/shallow breathing index of 112 breaths/min
Weaning criteria for clients are as follows: Vital capacity 10 to 15
mL/kg; Maximum inspiratory pressure at least -20 cm H2; Tidal
volume: 7 to 9 mL/kg; Minute ventilation: 6 L/min; Rapid/shallow
breathing index below 100 breaths/min; PaO2 > 60 mm Hg; FiO2
< 40%
c) Vital capacity of 13 mL/kg
d) FiO2 45%
e) PaO2 of 64 mm Hg
Which ventilator mode provides a combination of mechanically
assisted breaths and spontaneous breaths?
a) Assist-control
b) Synchronized intermittent mandatory ventilation (SIMV)
c) Pressure support
d) Intermittent mandatory ventilation (IMV)
Intermittent mandatory ventilation (IMV)
Intermittent mandatory ventilation (IMV) provides a combination
of mechanically assisted breaths and spontaneous breaths. Assist-control ventilation provides full ventilator support by delivering
a preset tidal volume and respiratory rate. SIMV delivers a preset
tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with
no assistance from the ventilator for those extra breaths. Pressure
support ventilation assists SIMV by applying a pressure plateau to
the airway throughout the patient-triggered inspiration to decrease
resistance within the tracheal tube and ventilator tubing.
A client with supraglottic cancer undergoes a partial laryngectomy.
Postoperatively, a cuffed tracheostomy tube is in place. When
removing secretions that pool above the cuff, the nurse should
cough as the cuff is being deflated.
instruct the client to:
The nurse should instruct the client to cough during cuff deflation.
If the client can't cough, the nurse should perform suctioning to
a) hold the breath as the cuff is being reinflated.
prevent aspiration of secretions. Because the cuff should be deflated during expiration, the client shouldn't take a deep breath as
b) take a deep breath as the nurse deflates the cuff.
the nurse deflates the cuff. Likewise, because the cuff is reinflated
during inspiration, the client shouldn't hold the breath or exhale
c) cough as the cuff is being deflated.
deeply during reinflation.
d) exhale deeply as the nurse reinflates the cuff.
The nurse suctions a patient through the endotracheal tube for 20
seconds and observes dysrhythmias on the monitor. What does
the nurse determine is occurring with the patient?
The patient is hypoxic from suctioning.
a) The patient is in a hypermetabolic state.
b) The patient is hypoxic from suctioning.
Apply suction while withdrawing and gently rotating the catheter
360 degrees (no longer than 10-15 seconds). Prolonged suctioning may result in hypoxia and dysrhythmias, leading to cardiac
arrest.
c) The patient is having a myocardial infarction.
d) The patient is having a stress reaction.
Instruct the client to remain in each position of the postural
The nurse is assisting a client with postural drainage. Which of the drainage sequence for 10 to 15 minutes.
following demonstrates correct implementation of this technique?
Postural drainage is usually performed two to four times daily,
before meals (to prevent nausea, vomiting, and aspiration) and
a) Instruct the client to remain in each position of the postural
at bedtime. Prescribed bronchodilators, water, or saline may be
drainage sequence for 10 to 15 minutes.
nebulized and inhaled before postural drainage to dilate the bronchioles, reduce bronchospasm, decrease the thickness of mucus
b) Administer bronchodilators and mucolytic agents following the and sputum, and combat edema of the bronchial walls. The nurse
sequence.
instructs the client to remain in each position for 10 to 15 minutes
and to breathe in slowly through the nose and out slowly through
c) Use aerosol sprays to deodorize the client's environment after pursed lips to help keep the airways open so that secretions can
postural drainage.
drain while in each position. If the sputum is foul-smelling, it is
important to perform postural drainage in a room away from other
10 / 18
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
patients or family members. (Deodorizers may be used to counteract the odor. Because aerosol sprays can cause bronchospasm
and irritation, they should be used sparingly and with caution.)
d) Perform this measure with the client once a day.
A nurse observes constant bubbling in the water-seal chamber of
a closed chest drainage system. What should the nurse conclude?
The system has an air leak.
Constant bubbling in the water-seal chamber indicates an air leak
and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber.
Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop
fluctuating in the water-seal chamber. (less)
a) The client has a pneumothorax.
b) The system has an air leak.
c) The chest tube is obstructed.
d) The system is functioning normally.
A client is on a positive-pressure ventilator with a synchronized
intermittent mandatory ventilation (SIMV) setting. The ventilator
is set for 8 breaths per minute. The client is taking 6 breaths per
Continues assessing the client's respiratory status frequently
minute independently. The nurse
The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra
a) Consults with the physician about removing the client from the
breaths. Data in the stem suggest that the ventilator is working
ventilator
correctly. The nurse would continue making frequent respiratory
assessments of the client. There are not sufficient data to suggest
b) Continues assessing the client's respiratory status frequently
the client could be removed from the ventilator. There is no reason
to increase the ventilator's setting to 14 breaths per minute or to
c) Changes the setting on the ventilator to increase breaths to 14
contact respiratory therapy to report the machine is not working
per minute
properly.
d) Contacts the respiratory therapy department to report the
ventilator is malfunctioning
Which type of ventilator has a present volume of air to be delivered
with each inspiration?
Volume-controlled
With volume-controlled ventilation, the volume of air to be delivered with each inspiration is present. Negative pressure ventilators
exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When
the pressure-cycled ventilator cycles on, it delivers a flow of air
(inspiration) until it reaches a present pressure, and then cycles
off, and expiration occurs passively.
a) Pressure-cycled
b) Negative-pressure
c) Time-cycled
d) Volume-controlled
The nurse is preparing to perform chest physiotherapy (CPT) on
a patient. Which of the following patient statements would indicate
the procedure is contraindicated.
"I just finished eating my lunch, I'm ready for my CPT now."
When performing CPT, the nurse ensures that the patient is
comfortable, is not wearing restrictive clothing, and has not just
eaten. The nurse gives medication for pain, as prescribed, before
percussion and vibration and splints any incision and provides
b) "I just finished eating my lunch, I'm ready for my CPT now."
pillows for support, as needed. A goal of CPT is for the patient
to be able to mobilize secretions; the patient who is having an
c) "I just changed into my running suit; we can do my CPT now."
unproductive cough is a candidate for CPT.
a) "I received my pain medication 10 minutes ago, let's do my
CPT now."
d) "I have been coughing all morning and am barely bringing
anything up."
For a client with an endotracheal (ET) tube, which nursing action
is the most important?
11 / 18
Auscultating the lungs for bilateral breath sounds
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
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.
a) Monitoring serial blood gas values every 4 hours
b) Turning the client from side to side every 2 hours
c) Providing frequent oral hygiene
d) Auscultating the lungs for bilateral breath sounds
A client is recovering from thoracic surgery needed to perform
a right lower lobectomy. Which of the following is the most likely
postoperative nursing intervention?
a) Make sure that a thoracotomy tube is linked to open chest
drainage.
b) Restrict intravenous fluids for at least 24 hours.
c) Assist with positioning the client on the right side.
Encourage coughing to mobilize secretions.
The client is encouraged to cough frequently to mobilize secretions. The client will be placed in the semi-Fowler's position. Thoracotomy tubes are always attached to closed, sealed drainage to
re-expand lung tissue and prevent pneumothorax. Restricting IV
fluids in a client who is NPO while recovering from surgery would
lead to dehydration. (less)
d) Encourage coughing to mobilize secretions.
A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and
endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator Kinking of the ventilator tubing
sounds, the nurse starts to check for the cause. Which condition
triggers the high-pressure alarm?
Conditions that trigger the high-pressure alarm include kinking of
the ventilator tubing, bronchospasm, pulmonary embolus, mucus
plugging, water in the tube, and coughing or biting on the ET tube.
a) A change in the oxygen concentration without resetting the
The alarm may also be triggered when the client's breathing is
oxygen level alarm
out of rhythm with the ventilator. A disconnected ventilator tube or
an ET cuff leak would trigger the low-pressure alarm. Changing
b) Kinking of the ventilator tubing
the oxygen concentration without resetting the oxygen level alarm
would trigger the oxygen alarm, not the high-pressure alarm.
c) An ET cuff leak
d) A disconnected ventilator tube
A client is receiving supplemental oxygen. When determining the
effectiveness of oxygen therapy, which arterial blood gas value is
most important?
Partial pressure of arterial oxygen (PaO2)
a) Partial pressure of arterial carbon dioxide (PaCO2)
b) Bicarbonate (HCO3-)
c) Partial pressure of arterial oxygen (PaO2)
The most significant and direct indicator of the effectiveness of
oxygen therapy is the PaO2 value. Based on the PaO2 value, the
nurse may adjust the type of oxygen delivery (cannula, Venturi
mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not
oxygenation. The pH, HCO3-, and PaCO2.
d) pH
A nurse is assigned to care for a client with a tracheostomy tube.
How can the nurse communicate with this client?
By supplying a magic slate or similar device
a) By suctioning the client frequently
b) By placing the call button under the client's pillow
c) By supplying a magic slate or similar device
The nurse should use a nonverbal communication method, such
as a magic slate, note pad and pencil, and picture boards (if the
client can't write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy;
it doesn't enable the client to communicate. The call button, which
should be within reach at all times for all clients, can summon at12 / 18
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
d) By providing a tracheostomy plug to use for verbal communi- tention but doesn't communicate additional information. Suctioncation
ing clears the airway but doesn't enable the client to communicate.
After lobectomy for lung cancer, a client receives a chest tube
connected to a disposable chest drainage system. The nurse
Water-seal chamber
observes that the drainage system is functioning correctly when
she notes tidal movements or fluctuations in which compartment
Fluctuations in the water-seal compartment are called tidal moveof the system as the client breathes?
ments and indicate normal function of the system as the pressure
in the tubing changes with the client's respirations. The air-leak
meter — not chamber — detects air leaking from the pleural space.
a) Collection chamber
The collection chamber connects the chest tube from the client to
the system. Drainage from the tube drains into and collects in a
b) Water-seal chamber
series of calibrated columns in this chamber. The suction control
chamber provides the suction, which can be controlled to provide
c) Air-leak chamber
negative pressure to the chest. (less)
d) Suction control chamber
For a client who has a chest tube connected to a closed water-seal
drainage system, the nurse should include which action in the care Measuring & documenting the drainage in the collection chamber
plan?
Positive end-expiratory pressure (PEEP) therapy has which effect
on the heart?
Reduced cardiac output
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?
Manual Resuscitation bag
A nurse observes constant bubbling in the water-seal chamber of
a closed chest drainage system. What should the nurse conclude?
The system has an air leak
A client has been placed on a ventilator, and the spouse is visiting
for the first time. The spouse begins to cry. The best statement by
the nurse is
Tell me what you are feeling
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator
sounds, what should the nurse do?
Suction the client's artificial airway
Which of the following ventilator modes provides full ventilatory
support by delivering a present tidal volume and respiratory rate?
assist control
Fluctuations in the ______ are called tidal movements and indicate normal function of the system as the pressure in the tubing
changes with the client's respiration
water-seal compartment
Which of the following would indicate a decrease in pressure with
mechanical ventilation?
increase in compliance
A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with
the cuff inflated to 15 mm Hg. The nurse has suctioned the client
with return of small amounts of thin white mucus. Lung sounds
are clear. Oxygen saturation levels are 91%. What is the priority
nursing diagnosis for this client?
impaired gas exchange related to ventilator settings adjusted
The nurse is assisting a client with postural drainage. Which of the
following demonstrates correct implementation of this technique?
instruct the client to remain in each position of the postural
drainage sequence for 10 to 15 minutes
The nurse is caring for a patient with an endotracheal tube (ET).
Which of the following nursing interventions is contraindicated?
deflating the cuff prior to removal
n general, chest drainage tubes are not indicated for a patient
undergoing which of the following procedures?
Pneumonectomy
client has a sucking stab wound to the chest. Which action should
the nurse take first?
apply a dressing and tape down 3 sides
13 / 18
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
Which of the following is a correct endotracheal tube cuff pressure?
17mmhg
The nurse is caring for a patient in the ICU who is receiving mechanical ventilation. Which of the following nursing measures are
implemented in an effort to reduce the patient's risk of developing
ventilator-associated pneumonia (VAP)?
cleaning the pts mouth with chlorhexidine daily
Of the following oxygen administration devices, which has the
advantage of providing high oxygen concentration?
non re breather mask
In general, chest drainage tubes are not used for the patient
undergoing
pneumonectomy
The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse will notify the primary
provider if drainage is _____ or greater.
50 mL/hr
using the minimal-leak technique with cuff pressure less than 25
cm H2O.
A nurse is caring for a client who has a tracheostomy tube and who To prevent tracheal dilation, a minimal-leak technique should be
is undergoing mechanical ventilation. The nurse can help prevent used and the pressure should be kept at less than 25 cm H2O.
tracheal dilation, a complication of tracheostomy tube placement, Suctioning is vital but won't prevent tracheal dilation. Use of a
by:
cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.
Which of the following ranges of water pressure identifies the
amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration?
15-20
Hyperbaric oxygen therapy increases the blood's capacity to carry
and deliver oxygen to compromised tissues. This therapy may be
used for a client with:
a compromised skin graft
neg pressure ventilator
This client needs ventilatory support. His PaO2 is low despite receiving a high dose of oxygen. The iron lung or drinker respiratory
tank is an example of a negative-pressure ventilator. This type of
A young male client has muscular dystrophy. His PaO2 is 42 mm ventilator is used mainly with chronic respiratory failure associated
Hg with a FiO2 of 80%. Which of the following treatments would with neurological disorders, such as muscular dystrophy. It does
be least invasive and most appropriate for this client?
not require intubation of the client. The most common ventilator is
the positive-pressure ventilator, but this involves intubation with an
endotracheal tube or tracheostomy. CPAP is used for obstructive
sleep apnea. Bi-PAP is used for those with severe COPD or sleep
apnea who require ventilatory assistance at night.
Which of the following is a potential complication of a low pressure
in the endotracheal tube (ET) cuff?
aspiration pneumonia
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower
the client's arterial blood oxygen saturation?
ET suctioning
A client is postoperative and prescribed an incentive spirometer
(IS). The nurse instructs the client to:
expect coughing when using the IS properly
A client is on a positive-pressure ventilator with a synchronized
intermittent mandatory ventilation (SIMV) setting. The ventilator
is set for 8 breaths per minute. The client is taking 6 breaths per
minute independently. The nurse
continues assessing the pt respiratory status frequently
Arterial blood gases should be obtained at which timeframe following the initiation of continuous mechanical ventilation?
20 min
For a client with an endotracheal (ET) tube, which nursing action
is the most important?
auscultate lungs for bilateral breath sounds
14 / 18
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
Which ventilator mode provides a combination of mechanically
assisted breaths and spontaneous breaths?
intermittent mandatory ventilation
The nurse is caring for a patient who is scheduled for a lobectomy.
Following the procedure, the nurse will plan care based on which
of the following?
pt will return with 2 chest tubes
The nurse is caring for a patient following a wedge resection. While
the nurse is assessing the patient's chest tube drainage system,
constant bubbling is noted in the water seal chamber. This finding
indicates which of the following problems?
Air leak
The nurse is preparing to perform chest physiotherapy (CPT) on
a patient. Which of the following patient statements would indicate
the procedure is contraindicated.
I just finished eating my lunch, I'm ready for my CPT now."
The nurse is educating the patient in the use of a mini-nebulizer.
What should the nurse encourage the patient to do? (Select all
that apply.)
Hold the breath at the end of inspiration for a few seconds.
Cough frequently.
Frequently evaluate progress.
A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation
with a preset tidal volume and number of breaths each minute.
The client has the ability to breathe spontaneously between the
ventilator breaths with no ventilator assistance. The nurse should
document the ventilator setting as:
synchronized intermittent mandatory ventilation (SIMV)
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower
the client's arterial blood oxygen saturation?
Endotracheal suctioning
Which of the following is the most reliable and accurate method for
delivering precise concentrations of oxygen through noninvasive
means
Venturi mask
A young male client has muscular dystrophy. His PaO2 is 42 mm
Hg with a FiO2 of 80%. Which of the following treatments would
be least invasive and most appropriate for this client?
Negative-pressure ventilator
The nurse is admitting a patient with COPD. The decrease of what
substance in the blood gas analysis would indicate to the nurse
that the patient is experiencing hypoxemia?
PaO2
After undergoing a left thoracotomy, a client has a chest tube in
place. When caring for this client, the nurse must:
encourage coughing and deep breathing
A nurse is planning care for a client after a tracheostomy. One
of the client's goals is to overcome verbal communication imEncourage the client's communication attempts by allowing him
pairment. Which intervention should the nurse include in the care time to select or write words
plan?
Which of the following is an adverse reaction that would require
termination of the weaning process from the ventilator?
Blood pressure increase of 20 mm Hg
A client in acute respiratory distress is brought to the emergency
department. After endotracheal (ET) intubation and initiation of
mechanical ventilation, the client is transferred to the intensive
care unit. Before suctioning the ET tube, the nurse hyperventilates
and hyperoxygenates the client. What is the rationale for these
interventions?
They help prevent cardiac arrhythmias.
A client with end-stage chronic obstructive pulmonary disease
(COPD) requires bi-level positive airway pressure (BiPAP). While
caring for the client, the nurse determines that bilateral wrist
restraints are required to prevent compromised care. Which client
care outcome is associated with restraint use in the client who
requires BiPAP?
The client will maintain adequate oxygenation.
15 / 18
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
A client has been placed on a ventilator, and the spouse is visiting
for the first time. The spouse begins to cry. The best statement by
the nurse is
"Tell me what you are feeling."
A client with COPD has been receiving oxygen therapy for an
extended period. What symptoms would be indicators that the
client is experiencing oxygen toxicity? Select all that apply.
Substernal pain
Dyspnea
Fatigue
The nurse is caring for a patient in the ICU who required emergent endotracheal (ET) intubation with mechanical ventilation. The
nurse receives an order to obtain arterial blood gases (ABGs) following the procedure. The nurse recognizes that ABGs should be
obtained at which timeframe following the initiation of mechanical
ventilation?
20 minutes
The nurse is assigned the care of a patient with a chest tube. The
nurse should ensure that which of the following items is kept at
the patient's bedside?
A bottle of sterile water
The nurse should monitor a client receiving mechanical ventilation
for which of the following complications?
Gastrointestinal hemorrhage
A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and
surgery" on the nursing care plan. Which of the following nursing
interventions would be appropriately aligned with this nursing
diagnosis? Select all that apply
Monitor pulmonary status as directed and needed.
Regularly assess the client's vital signs every 2 to 4 hours.
Encourage deep breathing exercises.
After suctioning a tracheostomy tube, the nurse assesses the
client to determine the effectiveness of the suctioning. Which
findings indicate that the airway is now patent?
Effective breathing at a rate of 16 breaths/minute through the
established airway
A nurse is teaching a client about using an incentive spirometer.
Which statement by the nurse is correct?
"Before you do the exercise, I'll give you pain medication if you
need it."
A client who must begin oxygen therapy asks the nurse why this
treatment is necessary? What would the nurse identify as the
goals of oxygen therapy? Select all that apply.
To provide adequate transport of oxygen in the blood
To decrease the work of breathing
To reduce stress on the myocardium
The nurse is teaching a postoperative client who had a coronary
artery bypass graft about using the incentive spirometer. The
nurse instructs the client to perform the exercise in the following
order:
Sit in an upright position.
Place the mouthpiece of the spirometer in the mouth.
Breathe air in through the mouth.
Hold breath for about 3 seconds.
Exhale air slowly through the mouth.
Hyperbaric oxygen therapy increases the blood's capacity to carry
and deliver oxygen to compromised tissues. This therapy may be
used for a client with:
a compromised skin graft.
A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating
thick yellow mucus through the tracheostomy tube frequently. The
nurse
Assesses the client's tracheostomy and lung sounds every 15
minutes
A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with
the cuff inflated to 15 mm Hg. The nurse has suctioned the client
Impaired gas exchange related to ventilator setting adjustments
with return of small amounts of thin white mucus. Lung sounds
are clear. Oxygen saturation levels are 91%. What is the priority
nursing diagnosis for this client?
Which ventilator mode provides a combination of mechanically
assisted breaths and spontaneous breaths?
Intermittent mandatory ventilation (IMV)
Which of the following are indicators that a client is ready to be
weaned from a ventilator? Select all that apply.
Vital capacity of 13 mL/kg
Tidal volume of 8.5 mL/kg
PaO2 of 64 mm Hg
16 / 18
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
The nurse is caring for a patient who is scheduled for a lobectomy.
Following the procedure, the nurse will plan care based on which
of the following?
The patient will return to the nursing unit with two chest tubes
Routine cuff deflation is recommended
Which of the following statements would not be considered an
appropriate intervention for a patient with an ET tube?
Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the endotracheal tube is removed. Cuff pressures should be
checked every 6 to 8 hours. Humidified oxygen should always be
introduced through the tube.
A client undergoes a tracheostomy after many failed attempts at
weaning him from a mechanical ventilator. Two days after traSuction the client, withdraw residual air from the cuff, and reinflate
cheostomy, while the client is being weaned, the nurse detects a
it.
mild air leak in the tracheostomy tube cuff. What should the nurse
do first?
A patient with emphysema is placed on continuous oxygen at 2
L/min at home. Why is it important for the nurse to educate the
patient and family that they must have No Smoking signs placed
on the doors?
Oxygen supports combustion
A client with COPD has been receiving oxygen therapy for an
extended period. What symptoms would be indicators that the
client is experiencing oxygen toxicity? Select all that apply.
• Substernal pain
• Dyspnea
• Fatigue
The client is postoperative for a total laryngectomy and has
recovered from anesthesia. The client's respirations are 32
breaths/minute, blood pressure is 102/58, and pulse rate is 104
beats/minute. Pulse oximetry is 90%. The client is receiving humidified oxygen. To aid in the client's respiratory status, the nurse
places the client in
Semi-Fowlers
The nurse is using an in-line suction kit to suction a patient who
is intubated and on a mechanical ventilator. What benefits does
inline suction have for the patient? (Select all that apply.)
• Decreases hypoxemia
• Decreases patient anxiety
• Sustains positive end expiratory pressure (PEEP)
Volume cycled
With volume-cycled ventilation, the volume of air to be delivered
Which type of ventilator has a pre-sent volume of air to be deliv- with each inspiration is present. Negative pressure ventilators
ered with each inspiration?
exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When
the pressure-cycled ventilator cycles on, it delivers a flow of air
(inspiration) until it reaches a present pressure, and then cycles
off, and expiration occurs passively.
Assist-control
Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. Intermittent
Which ventilator mode provides full ventilatory support by deliv- mandatory ventilation (IMV) provides a combination of mechanering a present tidal volume and respiratory rate?
ically assisted breaths and spontaneous breaths. SIMV delivers
a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra
breaths.
Anemic hypoxia
A patient is brought into the emergency department with carbon
Anemic hypoxia is a result of decreased effective hemoglobin
monoxide poisoning after escaping a house fire. What should the
concentration, which causes a decrease in the oxygen-carrying
nurse monitor this patient for?
capacity of the blood. It is rarely accompanied by hypoxemia. Carbon monoxide poisoning, because it reduces the oxygen-carrying
17 / 18
CC Ch. 21, Ch 21 Respiratory Care Modalities, PrepU Resp AH, MedSurg
Chapter 21 Respiratory Care Modalities, Ch 21 - Respiratory Care Modalities, Ex. 4-Ch. 21 (Med Surg) Resp. Care Modalities
Study online at https://quizlet.com/_8xcz3b
capacity of hemoglobin, produces similar effects but is not strictly
anemic hypoxia, because hemoglobin levels may be normal.
"Before you do the exercise, I'll give you pain medication if you
need it."
The nurse should assess the client's pain level before the client
A nurse is teaching a client about using an incentive spirometer. does incentive spirometry exercises and administer pain medicaWhich statement by the nurse is correct?
tion as needed. Doing so helps the client take deeper breaths and
help prevents atelectasis. The client should breathe in slowly and
steadily, and hold his breath for 3 seconds after inhalation. The
client should start doing incentive spirometry immediately after
surgery and aim to do 10 incentive spirometry breaths every hour.
The nurse is teaching a postoperative client who had a coronary
artery bypass graft about using the incentive spirometer. The
nurse instructs the client to perform the exercise in the following
order:
Sit in an upright position.
Place the mouthpiece of the spirometer in the mouth.
Breathe air in through the mouth.
Hold breath for about 3 seconds.
Exhale air slowly through the mouth.
A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?
Assessing the client's respiratory status, orientation, and skin
color
A nurse is caring for a client who has a tracheostomy tube and who
is undergoing mechanical ventilation. The nurse can help prevent using the minimal-leak technique with cuff pressure less than 25
tracheal dilation, a complication of tracheostomy tube placement, cm H2O.
by:
A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is
25 mm Hg. The nurse is aware of what complications that can be
caused by this pressure? (Select all that apply.)
• Pressure necrosis
• Tracheal bleeding
• Tracheal ischemia
The nurse is preparing to perform tracheostomy care on a patient
with a newly inserted tracheostomy tube. Which of the following Places clean tracheostomy ties, and removes soiled ties after the
actions, if preformed by the nurse, indicates the need for further new ties are in place
review of the procedure?
A client who must begin oxygen therapy asks the nurse why this
treatment is necessary? What would the nurse identify as the
goals of oxygen therapy? Select all that apply.
• To reduce stress on the myocardium
• To provide adequate transport of oxygen in the blood
• To decrease the work of breathing
The nurse is educating the patient in the use of a mini-nebulizer.
What should the nurse encourage the patient to do? (Select all
that apply.)
• Hold the breath at the end of inspiration for a few seconds.
• Cough frequently.
• Frequently evaluate progress.
18 / 18