Med Surg 1 Chapter 28 – Flashcards
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Which prescription for oxygen delivery does the nurse question?
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48% O2 per nasal cannula As a low-flow rate system, oxygen concentrations of 24% to 44% (1-6 L/min) are recommended with the nasal cannula. It is not intended to deliver more than 44% Fio2 because at a higher rate, oxygenation doesn't increase due to the limitation of anatomic dead space. All other choices are valid prescriptions.
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A new graduate RN discovers that her patient, who had a tracheostomy placed the previous day, has completely dislodged both the obturator and the tracheostomy tube. Which action should the nurse take first?
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Direct someone to call the Rapid Response Team while using a resuscitation bag and facemask. Because a fresh tracheostomy stoma will collapse, the patient will lose airway patency, which will require the nurse to ventilate the patient through the mouth and nose while waiting for assistance to recannulate the patient. Directing someone else to call the Rapid Response Team allows the nurse to provide immediate care required by the patient. Auscultation of the patient's breath sounds at this time will not improve the patient's respiratory status and will be ineffective until airway patency is restored. Further, auscultation should not be done while a nasal cannula is simultaneously applied. Effective use of a 100% non-rebreather mask requires a patent airway. During the first 72 hours following a tracheostomy, reinsertion of the tube is difficult and should not be attempted by the nurse. Reinsertion of the tracheostomy tube should be done once a Rapid Response Team is available to accomplish this.
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Which factor is a manifestation of tracheoesophageal fistula (TEF)?
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Increased cough and choking while eating TEF causes excessive pressure on the cuff that leads to erosion of the posterior wall of the trachea which, in turn, leads to increased coughing and choking while eating. A manifestation of TEF is the presence of food particles in tracheal secretions. With TEF, the patient does not receive the set tidal volume on the ventilator and increasing air in the cuff is needed in order to achieve a seal.
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The older adult patient with degenerative arthritis is admitted for tracheostomy surgery. What is the best communication method for this patient during the postoperative period?
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Picture board A picture board does not require very much dexterity for communication. Dexterity can be limited to the extent the patient finds comfortable. A computer keyboard, Magic Slate, and pen and paper require dexterity that may be difficult and/or painful for a patient with degenerative arthritis.
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The risk of aspiration during oral intake with a tracheostomy is related to which factor?
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Proximity of the tracheostomy tube to the epiglottis Due to the normal close proximity of the trachea and the esophagus, a tracheostomy tube can potentially interfere with protecting the airway during swallowing. A pressurized cuff on a tracheostomy tube doesn't provide assurance against aspiration during swallowing. Although xerostomia will make eating more challenging, it doesn't directly cause an increased risk of aspiration.
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The nurse is caring for a patient who is using a non-rebreather mask. What action by the nurse is most important?
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Frequent assessment that the oxygen source is functioning One-way valves on the non-rebreather mask open on exhalation and close on inhalation so the patient receives the highest possible oxygen concentration. If the oxygen source is depleted or fails to function, the patient could suffocate. Frequent, close monitoring is essential for safety. Mask fit is important with all types of masks but not as important as oxygen availability. Patients may feel claustrophobic with a mask and should be provided with emotional support, but this does not pose a greater urgency than oxygenation. Patency of the nostrils is a priority when a patient is using a nasal cannula.
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A patient being discharged home after being diagnosed with chronic obstructive pulmonary disease (COPD) will require home oxygen therapy. Which statement by the patient's spouse indicates that further teaching is required?
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"Our grandson will blow out the birthday candles for her at the party."' Oxygen is combustible and open flames like matches and candles should not be used in the immediate vicinity. Smoking should not be allowed in the same room when oxygen is in use. Knowing how to use a fire extinguisher correctly is important. The patient should return to the hospital for further evaluation if respiratory distress develops.
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Which of the following conditions is caused by collapsed alveoli?
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Absorptive atelectasis Collapsed alveoli cause atelectasis (called absorptive atelectasis), which is detected as crackles and decreased breath sounds on auscultation. The manifestations of oxygen toxicity are the same as those for acute respiratory distress syndrome. Oxygen-induced hypoventilation is related to carbon dioxide retention. Collapsed alveoli is not the cause of pneumonia.
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. A patient who has a long-term tracheostomy communicates frustration to the nurse about not being able to talk. What does the nurse tell this patient?
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"A fenestrated tube is necessary to facilitate talking." Fenestrated tubes allow airflow across the vocal cords, thus allowing the patient to talk. Simply telling the patient that the tube is necessary does not offer the patient information as to why. Patients with cuffless tubes can also talk. Unless there is permanent damage to the vocal cords, patients will be able to speak.
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. During shift report, the nurse learns the assigned patient with chronic lung disease is receiving oxygen at 4 L/min per nasal cannula. When entering the patient's room, what is the nurse's initial action?
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Assess oxygen saturation with a pulse oximeter. A patient with chronic lung disease and hypercarbia loses sensitivity to elevated carbon dioxide levels as a stimulus for breathing. Instead, low oxygen levels become the primary stimulus. Patients with hypercarbia and hypoxemia usually require 1-2 L/min (no more than 2-3 L/min) to keep them from losing their hypoxic drive and developing oxygen-induced hypoventilation. In a patient receiving 4 L/min, oxygen-induced hypoventilation may be a concern, although inadequately treated hypoxemia is a greater priority. The lowest level of oxygen needed to maintain adequate oxygenation should be given. The nurse should evaluate oxygen saturation with a pulse oximeter before making a decision to reduce the O2 rate or requesting an order for ABGs. Auscultating lung sounds does not provide definitive assessment data on oxygenation.
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A patient has just arrived in the postanesthesia care unit (PACU) following a successful tracheostomy procedure. Which nursing action must be taken first?
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Listen to lung sounds The first nursing action for a patient following an airway procedure is to assess the patient's respiratory status; this requires auscultation of the lungs. Suction is not needed if the lungs are clear to auscultation. Although cleanliness is a priority, the nurse must assess the patient's respiratory status before cleaning or performing a dressing change.
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To prevent aspiration during swallowing in a patient with a tracheostomy, what does the nurse suggest?
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Thicken all liquids to increase consistency. Thickening the consistency of all liquids will facilitate swallowing with a decreased risk of aspiration. The patient should actually "tuck" the chin down and move the forehead forward when swallowing. Consecutive swallows of liquid will likely increase the risk of aspiration as would consuming moisture-producing fruits.
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When providing suctioning through an endotracheal or tracheostomy tube, what alerts the nurse to stop suctioning?
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Oxygen saturation by pulse oximetry is less than 90%. Oxygen saturation below 90% indicates hypoxemia and is a reason to stop suctioning. The cough reflex is an expected response to suctioning; it does not preclude the necessity to clear the airway, although excessive coughing would prompt the nurse to allow the patient to rest. The suction catheter can be irrigated to empty thick secretions and restore suction. An increased heart rate from 72 to 78 is not substantial to cause concern.
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Which action is a priority safety precaution when performing tracheostomy care?
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Securing new ties before removing the old ones Keeping the tube in place to prevent accidental decannulation is critical. Old ties or Velcro should be kept in place until the new ones are secure. Cleaning the stoma, replacing the disposable cannula, and assessing for skin breakdown are important, but maintaining the placement of the tube is the priority.
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The nurse assesses a patient who has begun receiving oxygen therapy of 40% via Venturi mask and notes pink lips and nailbeds and a pulse oximetry value of 98%. The patient is sleeping and has a heart rate of 76 beats per minute, a respiratory rate of 6 breaths per minute, and breaths are nonlabored and shallow. What is the nurse's correct initial response?
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Notify the provider of the patient's respiratory rate and breathing pattern The nurse should closely monitor patients receiving oxygen therapy for decreased rate and depth, which can indicate oxygen-induced hypoventilation. The nurse should notify the provider that this patient has a lower-than-normal respiratory rate and shallow respirations, which can precipitate respiratory arrest. The nurse may auscultate breath sounds and awaken the patient after notifying the provider. The facemask does not safely deliver oxygen at a rate less than 40%.
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For patient safety and quality care, which technique is best for the nurse to use when suctioning the patient with a tracheostomy tube?
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Hyperoxygenate before and after suctioning The patient should be preoxygenated with 100% oxygen for 30 seconds to 3 minutes to prevent hypoxemia. After suctioning , the patient should be hyperoxygenated for 1-5 minutes, or until the patient's baseline heart rate and oxygen saturation are within normal limits. Repeat suctioning as needed for up to three total suction passes; additional suctioning will cause or worsen hypoxemia. Applying suction during insertion is inappropriate because suction makes advancement of the suction tube difficult/traumatic. Suction is applied only when the suction tube is removed. Suctioning for 30 seconds is too long and can cause or worsen hypoxemia; never suction longer than 10-15 seconds.
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What is the cause of subcutaneous emphysema in a patient with a new tracheostomy?
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Trapping of air escaped into the tissues Subcutaneous emphysema occurs when there is an opening or tear in the trachea and air escapes into the fresh tissue planes of the neck. Air can also progress throughout the chest and other tissues into the face.
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A patient has a fenestrated tracheostomy tube in place. Which of the following multidisciplinary team members should be involved in the discharge planning process?
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Speech therapy A vital member of the multidisciplinary team for the patient with a fenestrated tracheostomy tube is Speech Therapy. Speech therapy can teach the patient about swallowing and communication. Helping communication is an important nursing action and is National Patient Safety Goal set forth by The Joint Commission. Physical therapy and occupational therapy may be beneficial to the patient for conditioning and strengthening. The patient may utilize a patient care assistant as well.
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A chest x-ray is ordered for an ambulatory patient receiving nasal oxygen. What does the nurse do when transport personnel come to get the patient?
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Ensure portable oxygen is in place before transport to radiology. Oxygen is a drug and should not be interrupted. It is the nurse's responsibility to ensure that the patient has an oxygen source during periods of transport so that oxygen delivery is not disrupted. A portable x-ray is not necessary if the patient is ambulatory. Neither hyperoxygenating nor disconnecting the oxygen is safe practice.
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A comatose patient is receiving oxygen via a simple facemask. Which nursing action is a priority for this patient?
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Assessing the oropharynx for secretions and vomitus Patients receiving oxygen via facemask have a limited ability to clear the mouth and thus have an increased risk for aspiration. Keeping the oropharynx clear is a priority for this patient. The other actions are all important but are not the top priority.
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What is one of the purposes of oxygen therapy?
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To have an acceptable blood oxygen level One of the purposes of oxygen therapy is to have an acceptable blood oxygen level without causing harmful side effects. Oxygen therapy cannot cure a problem or stop a disease process. The lowest fraction of inspired oxygen is used.
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The patient with a tracheostomy who is using a T-piece mask reports a feeling of suffocation to the nurse. What is the first intervention that the nurse adopts in order to provide relief to the patient?
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Check that the exhalation port is open and uncovered The possible reason for the patient's feeling of suffocation could be occlusion of the exhalation port. So, to stabilize the patient's condition, the nurse should open the port and keep the port uncovered. The flow rate delivery of fraction of inspired oxygen (FiO2) is affected by condensation. The humidifier should create enough mist to be visible during inspiration and expiration. If the weight of the T-piece pulls on the tracheostomy, it causes pain or erosion of skin at the insertion site; therefore, it is essential to see to it that it does not pull on the tracheostomy.
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A patient has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially?
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Face tent A patient with smoke inhalation and facial burns who requires high-flow oxygen should initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue. Although a Venturi mask and a non-rebreather mask are high-flow oxygen delivery devices, they require snug fitting on the face, which can be painful and can introduce infection to compromised facial skin. A nasal cannula is not a high-flow device.
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What should the nurse include when instructing a patient about safe practice for home-care oxygen therapy? Select all that apply.
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Safety precautions Maintenance of equipment Equipment needed for home oxygen therapy When a patient is taught about self-management of home-care oxygen therapy, it includes safety precautions and how to maintain the equipment. The nurse should also instruct the patient about the equipment required for home oxygen therapy, which may include the oxygen source, delivery devices, and humidity sources. Re-evaluation of the need for home oxygen therapy is required on a periodic basis. It is vital to have a community health nursing agency available for follow-up care in the home.
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Which patient has the most urgent need for frequent nursing assessment?
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An older adult patient who was admitted 2 hours ago with emphysema and dyspnea, has a 45-year 2-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask The older adult with a long history of smoking and chronic lung disease is at elevated risk for respiratory depression owing to the hypoxic drive of respirations countered by high levels of oxygen; this patient must be assessed frequently while receiving high-flow oxygen. The young patient with no signs or symptoms of respiratory compromise and the patient who meets discharge criteria do not require frequent assessment. Although the middle-aged patient with pneumonia will require more frequent assessment than a patient who does not require oxygen therapy, the older patient on higher-flow oxygen is at greater risk for respiratory demise and therefore needs frequent assessment more urgently.
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A patient who smokes is being discharged home on oxygen. The patient states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response?
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"You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous." The nurse should use this opportunity to educate the patient about the dangers of smoking in the presence of oxygen, as well as the benefits of quitting. Telling the patient it is OK to quit when ready, or that it's never too late to quit, do not address the safety issue of smoking in the presence of oxygen. Recommending that the patient turn off the oxygen when smoking encourages the patient to remove his or her oxygen source, which could harm the patient.
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To minimize hypoxia during suctioning of a tracheostomy, which action must the nurse perform?
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Preoxygenate for 30 seconds to 3 minutes before suctioning Applying and/or increasing the oxygen level before suctioning a tracheostomy can improve presuctioning levels and thus decrease hypoxia with the procedure. Suction should be applied to the catheter only during withdrawal, or it increases hypoxia. Suctioning frequently for at least 20 seconds would be a safety risk for the patient. Suctioning may trigger coughing; however, this will not decrease hypoxia.
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Which symptom indicates tube obstruction in a patient with tracheostomy?
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Difficulty breathing As a result of tube obstruction, a patient with tracheostomy has difficulty breathing. The respirations may become noisy, rather than quiet, and are accompanied with thick, dry secretions, rather than thick, wet secretions. There are also unexplained peak pressures noted.
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When assessing the adequacy of a patient's oxygenation, which information is important for the nurse to note?
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Partial pressure of arterial oxygen (Pao2) Pao2is a measure of the amount of oxygen in the arterial blood. Fio2is a measure of the inspired oxygen, which may not all be absorbed. PEEP is a measure of positive expiratory pressure for a patient on a ventilator. CPAP is a delivery system, not a measure of oxygenation.
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A patient has developed subcutaneous emphysema after surgery for a tracheostomy. Why must the nurse notify the health care provider immediately?
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There is an opening or tear in the trachea allowing air leakage into the tissues. Subcutaneous emphysema occurs when there is an opening or tear in the trachea adjacent to the tracheostomy, allowing air to leak into the surrounding tissues. Air can also progress throughout the chest and other tissues into the face. This requires immediate action to maintain adequate oxygenation. A pneumothorax may occur in the apex of the lung; however, this is not likely to cause subcutaneous emphysema. When ventilator pressures are too high, lung damage may occur from this, rather than from subcutaneous emphysema. Some bleeding after surgery is not abnormal, and the incision area should be monitored for hematoma, leakage, or evidence of bruising; this is not related to the subcutaneous emphysema.
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The nurse is assisting a patient with a tracheostomy to eat. Which is an important nursing action to help the patient swallow and avoid aspiration?
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Elevate the head of the bed for at least 30 minutes after eating The nurse should elevate the head of the bed during eating and for at least 30 minutes after eating to prevent aspiration and reflux. The patient should be encouraged to take "dry swallows" between bites of food to clear the esophagus. Increasing the pressure puts pressure on the esophagus. Patients should take small amounts of fluids from a spoon to facilitate swallowing.
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After surgical placement of a tracheostomy tube, what is the recommended method to verify placement?
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Chest x-ray Chest x-ray is the recommended standard to verify placement. Noting asymmetry of lung sounds and chest expansion gives valuable information but is not definitive for tracheostomy placement. A bronchoscopy is not used to verify placement of a tracheostomy tube.
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Which of these are causative factors for hypoxia in a patient with tracheostomy? Select all that apply.
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Frequent suctioning Excessive suction pressure Ineffective oxygenation before, during, and after suctioning In a patient with tracheostomy, hypoxia may be caused by frequent suctioning, excessive suction pressure, and ineffective oxygenation before, during, and after suctioning. Limited suctioning time is recommended. The standard catheter size is 12 Fr or 14 Fr; using 14 Fr sized catheter reduces the risk of hypoxia.
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Which of these oxygen delivery systems is known to deliver low-flow fraction of inspired oxygen (FiO2)?
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Nasal cannula The nasal cannula is the only type of oxygen delivery system which delivers low-flow FiO2. Face tents, Venturi masks, and tracheostomies are examples of oxygen delivery systems that deliver high-flow FiO2.
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Which is an example of a low-flow oxygen delivery system used for long-term therapy?
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Nasal Cannula A nasal cannula is an example of a low-flow oxygen delivery system that is used to treat chronic lung disease and for any patient in need of long-term oxygen therapy. A T-piece and face tent are examples of high-flow oxygen delivery systems. A simple facemask is used to deliver oxygen concentrations of 40% to 60% for short-term oxygen therapy or in an emergency.
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. Which principle should guide the nurse's decision regarding oral care for a patient with a tracheostomy during the first 24 hours postoperative?
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Oral care is indicated to decrease the accumulation of organisms Oral care helps decrease the accumulation of organisms present in the mouth that can contribute to pneumonia and should be a regular part of postoperative care. Good oral care is important even if the patient is not eating, which actually serves to facilitate cleansing of the oral cavity. Protein will aid healing, but does not negate the need for oral care.
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The nurse is caring for a patient with facial burns from a house fire. Which mode of oxygen delivery is recommended for this patient?
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Face tent The face tent allows oxygen delivery without touching the face. It is recommended for facial trauma and facial burns to reduce the risk of pressure-related complications and to promote healing. Because a simple facemask, Venturi mask, and nasal cannula rest on the face, they would not provide this benefit.
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A patient with chronic obstructive pulmonary disease (COPD) has a physician's prescription stating, "Adjust oxygen to keep SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN?
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Adjust the position of the oxygen tubing The scope of a nursing assistant's work includes positioning of oxygen tubing for patient comfort. Assessing for signs and symptoms of hypoventilation, choosing which O2 delivery device to use, and changing the O2 flow rate are actions that are beyond the scope of practice for unlicensed personnel.
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A patient who has been receiving high-flow oxygen via a Venturi mask for several days is reporting respiratory difficulty and that the mask doesn't seem right. What cause could be contributing to this sensation?
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When the mask was changed at the end of the previous shift, a simple facemask was initiated for oxygen delivery. The Venturi mask is for high-flow oxygen therapy; if it was switched to a simple facemask, the patient would likely notice the difference in oxygen delivery. A Venturi mask does not have a rebreather bag or a nonrebreather bag. The reported problem is most likely related to not using a high-flow oxygen delivery system, rather than the size of the mask.
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Which action does the nurse take if a patient develops bradycardia during nasopharyngeal suctioning?
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Administer 100% oxygen by bag-valve-mask Hyperoxygenating the patient can reverse bradycardia caused by vagal stimulation during suctioning. Bronchodilators are used if it becomes difficult to pass a suction tube to open the airways. Asking the patient to hold the breath will worsen the bradycardia because it will increase vagal stimulation. The nurse should oxygenate the patient before resuming suctioning.
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. What are typical postoperative concerns after a new tracheostomy? Select all that apply.
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Tube obstruction Tube dislodgement Accidental decannulation Maintaining patency of the airway is a primary concern after a new tracheostomy. Tube obstruction, dislodgement, or decannulation can cause an airway emergency. Plugging the tube for communication will not be a priority in the immediate postoperative period. Communication should rely on nonverbal techniques such as sign boards, etc. This patient would most likely not have an endotracheal tube.
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The patient coughs and expels the tracheostomy tube. The nurse inserts a new tracheostomy tube and auscultates the lungs, but cannot hear breath sounds. What is the nurse's next best action?
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Ventilate with a bag-valve-mask and ensure the Rapid Response Team is notified The nurse may request assistance from another nurse, a respiratory therapist, or a health care provider if needed and should ventilate the patient with a bag-valve-mask until the airway can be secured. The Rapid Response Team should be notified by another nurse. A simple facemask should not be used because the patient has a tracheostomy. Ordering a chest x-ray for a pneumothorax is not an appropriate intervention. Assessing for air under the tracheostomy should be done, but is not a priority.
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When administering oxygen to a patient at 5 L/min per nasal cannula, which intervention does the nurse include in the patient's plan of care?
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Ensure that oxygen bubbles through the water in the humidifier. When the oxygen flow rate is greater than 4 L/min, humidification should be used to prevent drying of the nasal mucosa. The nurse should ensure that there is adequate water in the humidifier chamber and that oxygen is bubbling through it. The nasal cannula should be cleaned as needed, but it does not require routine cleaning. Measurement of oxygen saturation using pulse oximetry should be done at intervals and does not need to be monitored continuously. Elevating the head of the bed 45 degrees is not necessary when administering nasal O2.
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What cuff pressure should be maintained in a tracheostomy or endotracheal tube to prevent mucosal ischemia?
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14-20 mm/hg A pressure range of 14-20 mm Hg is recommended to prevent an air leak around the cuff yet not be excessive to cause ischemia of the tracheal mucosa.
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The nurse has an order to begin weaning a patient from supplemental oxygen. The patient is currently receiving oxygen via facemask at a flow rate of 5 L/min, and the oxygen saturation is 97%. Which action by the nurse is correct?
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Change the equipment to a nasal cannula with a flow rate of 4 L/min A facemask must have a minimum flow rate of 5 L/min, so the nurse should change the equipment to a nasal cannula before slowing the flow rate. Decreasing the flow rate without changing to a nasal cannula can lead to rebreathing of CO2. Weaning from oxygen should be gradual and not abrupt. Patients with chronic obstructive pulmonary disease (COPD) may have oxygen saturations of 94% or greater, so there is no need to wait for higher oxygen saturations before weaning.
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Which factors should be taken into consideration when determining the type of oxygen delivery system to be used for a patient? Select all that apply.
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Importance of humidity Oxygen concentration required by the patient Oxygen concentration achieved by a delivery system The humidity level needs to be maintained in any oxygen delivery system to prevent dry nose and throat. Oxygen concentration required by the patient and the level of oxygen concentration achieved would determine the kind of delivery system to be used. The patient should be mobile. The patient's body temperature is not a deciding factor for the type of oxygen delivery system to be used.
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The nurse is preparing to change a cuffed tube tracheostomy to a fenestrated tracheostomy tube. Which action is most important prior to cuff deflation?
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Suction the patient's oropharynx before deflating the cuff Before deflating a cuff, the nurse should suction the airway above the cuff to remove any secretions that might be aspirated into the lungs. It is not necessary for the patient to perform the Valsalva maneuver or for the nurse to insert an oral airway. An incentive spirometer is not indicated.
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. The nurse is educating a patient about oral hygiene. Which is the best oral hygiene practice to help keep the airway patent in a patient with a tracheostomy?
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Use of normal saline for rinsing Rinsing the oral cavity every 4 hours with normal saline is recommended. It prevents dryness in the oral cavity. Glycerin swabs should not be used since it may cause dryness. Hydrogen peroxide may be used for removing crusted matter but it may result in a breakdown of healing tissue. A mouthwash containing alcohol should not be used because this will dry the mouth, alter the pH, and promote bacterial growth.
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Which relevant psychosocial issues should the nurse address with a patient who has a new tracheostomy? Select all that apply.
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Using scarves and other approaches for covering the tracheostomy site Having the patient use a mirror to view the appearance of the tracheostomy A tracheostomy is a significant change in appearance and body image. Nurses can facilitate adjustment to this change by encouraging the patient to view the site early and by providing information for ways to cover the site without interfering with oxygenation. The spread of infection is a safety concern, not a psychosocial one. Teaching about oxygen equipment does not address a psychosocial issue. Oxygen levels should be monitored; however, this is for safety rather than psychosocial concerns.
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When caring for a patient with a Venturi mask, one strategy to reduce the fraction of inspired oxygen (Fio2) yet maintain oxygenation is to convert to which device?
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Continuous positive airway pressure mask The continuous positive airway pressure (CPAP) mask administers continuous positive airway pressure, which increases ventilation by increasing volume and pressure of inhalation. This prevents alveolar collapse, thereby enhancing gas exchange/oxygenation, which would allow for lower Fio2. Other delivery systems do not enhance ventilation.
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A patient who has thick, sticky respiratory secretions requires high-flow, humidified oxygen delivery. Which oxygen delivery equipment does the nurse use for this patient?
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Aerosol Mask An aerosol mask is used when high humidity is n needed, as with thick secretions. A face tent is used for patients with burns or facial trauma. A nonrebreather mask is a low-flow oxygen delivery system. The Venturi mask is not the best method to deliver high-humidity oxygen.
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In caring for a patient during the first few days after tracheostomy placement, what nursing action is included in wound care?
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Folding standard gauze 4 × 4s to fit around the tube It is recommended that intact 4 × 4s be folded and placed around the tube. Cutting the 4 × 4 gauze might release small pieces of gauze that may be aspirated. The stoma site should be assessed every shift. Steri-Strips are not used to stabilize the tube.
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What is recommended as safe nursing practice when caring for a patient with a tracheostomy and T-piece?
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Ensure that aerosol continuously comes out of the exhalation side of the T-piece. When oxygen flow rates are adequate through the humidifier, a mist or aerosol should continuously be seen from the exhalation port both during inhalation and exhalation. The exhalation port should be kept open and uncovered; draping it might occlude the airway. The T-piece does not touch the skin so it does not need to be padded. An oral suctioning device should never be used to suction the T-piece because it is contaminated with oral flora and will introduce infection.
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Which assessment findings may indicate a tracheostomy tube is obstructed? Select all that apply.
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Noisy respirations Dyspnea Difficulty inserting a suction catheter Noisy respirations are heard when secretions accumulate and obstruct air flow in the tube. Dyspnea will occur if the airway is obstructed. Dried secretions may make it difficult to pass a suction catheter through the tube. Asymmetry of chest movement does not indicate an obstructed airway. If the tracheostomy is obstructed, tachypnea would result, not bradypnea. Edema around the stoma is external to the tracheostomy tube and would not obstruct the tube.
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The spouse of a patient who is scheduled for a tracheostomy is expressing concern regarding the surgery's impact on their quality of life. What should the focus of the nurse be at this time?
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Addressing approaches for the patient to communicate with the tracheostomy Various methods of nonverbal communication should be tried to determine the best approach to allow the couple to discuss their concerns and approaches for maintaining quality of life. Although it is important for the spouse to learn tracheostomy care and emergency procedures like resuscitation, concern for quality of life will potentially interfere with mastery of the content and skills.
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When the inner cannula is removed from a fenestrated tracheostomy tube, what is an expected patient function?
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The patient will be able to speak A fenestrated tube has holes that allow air to pass during exhalation through the vocal cords, enabling speech. Removing the inner cannula enables this feature. The patient is at risk for aspiration until determined to be safe with a swallow study, so removal of the inner cannula does not mean it is safe to sip water. Removal of the inner cannula does not affect range of motion of the neck nor the patient's ability to cough more effectively.
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The nurse is suctioning a patient who has a tracheostomy and notes a pulse oximetry reading of 90% during the procedure. Which action does the nurse take?
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Use a manual resuscitation bag to deliver 100% oxygen before resuming If hypoxia occurs while suctioning, the nurse should stop suctioning and reoxygenate the patient with 100% oxygen and manual resuscitation until hypoxia improves before resuming suctioning. It may be necessary to provide oxygen during the procedure to prevent hypoxia, but this should not be done if hypoxia is present and not via a facemask if a tracheostomy is the airway for this patient. In general, a larger-diameter tube increases the risk of hypoxia. It is not correct to ask the patient to cough to improve hypoxia.
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A patient is scheduled to undergo insertion of a catheter for transtracheal oxygen (TTO) therapy. Which statement by the patient indicates a need for further teaching about the procedure?
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"I can use this method only when I am at home." The TTO delivery system involves passing the catheter into an incision in the trachea; it may be concealed more easily than the nasal cannula, making it a more acceptable option for some patients. It may be used at home or when out in public. Many patients require less oxygen with TTO and the flow rate may need to be adjusted for activity and rest. The procedure to insert the catheter requires local anesthesia.
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The peak pressure alarm is sounding on the ventilator of a patient with a recent tracheostomy. What intervention should be done first?
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Assess the patient's respiratory status The patient must always be assessed before attention is turned to equipment. If the alarm is sounding as an indicator of worsening patient condition, reducing the sensitivity is harmful. Suctioning the patient may not even be needed; the patient's respiratory status must be assessed before such a determination can be reached.
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Which finding indicates a need for low-flow oxygen delivery for a patient?
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Chronic hypercarbia Patients with chronic hypercarbia need lower levels of oxygen delivery since a low Pao2 level is this patient's primary stimulus for breathing. High-flow oxygen delivery will cause oxygen-induced hypoventilation and CO2 narcosis. Patients with any level of hypoxia should have oxygen flow levels of 2-4 L/min. Patients with acute hypercarbia may have high-flow oxygen without a risk of oxygen-induced hypoventilation.
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The nurse assesses a patient who is receiving oxygen using a partial rebreather facemask at a flow rate of 12 L/min. The nurse notes the patient's oxygen saturation level is 90%. What is the nurse's next action?
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Changing the mask to a non-rebreather mask Patients receiving oxygen by mask are prone to rebreathing exhaled air containing carbon dioxide and room air that has a lower oxygen concentration. A non-rebreather mask can deliver an Fio2 greater than 90% and a flow rate of 10-15 L/min. The partial rebreather only allows an oxygen flow rate of 6-11 L/min.
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A patient with sleep apnea has a new prescription for a BiPAP device to be worn at night. What does the nurse include in the teaching for this assistive device? Select all that apply.
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The mask must fit tightly to form a proper seal. BiPAP provides positive pressure during inhalation and exhalation to keep alveoli open BiPAP improves airflow during sleep and promotes comfort by reducing dyspnea To ensure delivery of prescribed positive-pressure breaths, the mask must fit snugly with no leakage. The BiPAP device delivers positive-pressure ventilation to keep alveoli open and prevent atelectasis. It promotes rhythmic breathing and prevents apneic episodes, which cause dyspnea thereby promoting comfort and restful sleep. It delivers oxygen as well as room air. The difference and benefit of BiPAP over the CPAP machine is that exhalation pressure is less than inspiratory pressure in BiPAP, providing less resistance and enhanced comfort.
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What can be inferred from finding that the tracheostomy tube is pulsating in synchrony with the heartbeat in a patient brought to the health care unit in a critical state?
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The patient is having trachea-innominate artery fistula Tracheostomy tube pulsating in synchrony with the heartbeat is a manifestation of trachea-innominate artery fistula, which results in a critical and life-threatening situation. In tracheomalacia, there is constant pressure exerted by the cuff, causing tracheal dilation and erosion of the cartilage. In tracheal stenosis, there is narrowed lumen due to scar formation. TEF causes excess pressure on the cuff that leads to erosion of the posterior wall of the trachea.
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A patient has been receiving 60% oxygen per simple facemask since admission 3 days ago. Which initial findings alert the nurse to oxygen toxicity? Select all that apply.
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Nonproductive cough Chest Pain Gastrointestinal GI upset Initial symptoms of oxygen toxicity include dyspnea, nonproductive cough, chest pain beneath the sternum, and GI upset. Hemoptysis would be a later symptom as the condition worsens. Bradycardia and fever are not present with oxygen toxicity.
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Which principles are important for the nurse to remember about oxygen administration? Select all that apply.
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Nitrogen helps prevent alveolar collapse, as it doesn't cross over capillary membranes High levels of oxygen dilute the nitrogen in the lungs leading to alveolar collapse Nitrogen, which is 79% of room air, helps to prevent alveolar collapse because it doesn't cross over the capillary membranes into the blood. High levels of oxygen administration dilute the nitrogen when it diffuses across the membrane into the circulation, and the alveoli collapse, leading to atelectasis. Oxygen administration can cause toxicity and must be monitored closely. An increased PaCO2 will result when the patient is retaining CO2; this is not a desirable state. PaO2 levels of greater than 90 mm Hg should be reported to the health care provider.
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Which technique or action does the nurse use to prevent a tracheoesophageal fistula (TEF) in a patient after a tracheotomy has been performed?
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Maintain proper cuff pressure A TEF is a hole created between the trachea and the anterior esophagus due to excessive cuff pressure. Three methods of preventing this complication are to progress to a deflated cuff or cuffless tube as soon as possible, maintain proper cuff pressure, and monitor the amount of air needed for inflation for any change. Manually administering oxygen by mask is an appropriate intervention once the fistula has formed, but it does not prevent the formation. Applying direct pressure is an intervention for a trachea-innominate artery fistula. Preventing pulling of and traction on the tracheostomy tube is a prevention measure for tracheal stenosis.
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Which instance would make the treatment with continuous positive airway pressure (CPAP) ineffective?
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Respiratory failure following extubation CPAP has been found ineffective for patients with respiratory failure following extubation. Atelectasis is commonly seen in patients who have undergone surgery. Patients with cardiac-induced pulmonary edema and COPD may benefit from this form of oxygen or air delivery.
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A "do not resuscitate" (DNR) patient has a non-rebreather oxygen mask, and breathing appears to be labored. What does the nurse do first?
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Ensure that the tubing is patent and that oxygen flow is high Labored breathing and ultimately suffocation can occur if the reservoir bag on a non-rebreather mask kinks or if the oxygen source disconnects or is not set to high flow levels. The chaplain and the family member of record should not be notified because death is not imminent at this time. Equipment malfunction must be ruled out before intubation of the patient is performed. Additionally, the patient may not want to be intubated, as indicated in the DNR orders. Troubleshooting and reversal of nonresuscitative equipment is the standard of care; DNR does not mean "do not treat."
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The primary health care provider has written an order to resume the diet for a patient with a tracheostomy following a laryngectomy. What does the nurse include when teaching the patient about prevention of aspiration?
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All liquids will need to be thickened, including water. Thickening all liquids gives the patient more control over aspiration when swallowing. The patient should be sitting upright when eating and should tuck the chin down and lower the forehead while swallowing to prevent aspiration. Due to the close proximity of the cuffed tube to the esophagus, it may interfere with the passage of food; the cuff should therefore be deflated to facilitate swallowing and prevent aspiration.
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Family members of a patient with chronic lung disease report increasing the level of oxygen administration for the patient because of increased sleepiness and decreased responsiveness, but it did not seem to help. What is the most likely reason for this?
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Decreased sensitivity to increased Paco2 levels Hypoxia (decreased oxygen levels in the blood) serves as the main driver for ventilation in the patient with chronic lung disease; administering increased levels of oxygen can interfere with this stimulus. Consequently, carbon dioxide levels will increase; this can then cause the increased sleepiness and decreased responsiveness seen in this patient. Although pain medications can lead to sleepiness and alter responsiveness, that is not the concern with this patient at this time
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The nurse is preparing a patient with a permanent tracheostomy to be discharged home. While providing teaching, the nurse notes that the patient's secretions are thick and sticky. What does the nurse include in this patient's teaching?
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Increase daily fluid intake until secretions are thinner and easily mobilized Thick and sticky mucus indicates that the patient is inadequately hydrated and the fluid intake should be increased. Normal saline drops are sometimes used with questionable benefit and should only be administered if the provider orders them. Suctioning the tracheostomy may increase secretions because of localized irritation to the airway. Over-the-counter expectorants will not help with dehydration.
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Which nursing interventions should the nurse follow when providing low-flow oxygen to a patient through a nasal cannula? Select all that apply.
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Assess the patency of the nostrils Ensure secure fitting of the prongs Applying water-soluble jelly to nares An assessment for the patency of the nostrils is important because congestion or a deviated septum prevents effective delivery of oxygen through the nares. A poorly fitting nasal cannula leads to hypoxemia and skin breakdown. Application of water-soluble jelly on the nares should be done as needed, or when necessary. This jelly prevents mucosal irritation related to the drying effect of oxygen and promotes comfort. It is more important for the nurse to provide emotional support for a patient wearing a face mask than to a patient using a nasal cannula. Monitoring the patient's blood pressure regularly may not help as a nursing intervention.
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Which of these instructions reflects best practices for suctioning the artificial airway? Select all that apply.
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"Wash hands." "Don protective eyewear." "Maintain standard precaution" Best practices for patient safety and quality care while suctioning the artificial airway include washing hands, donning proper eyewear for protection, and maintaining standard precautions. Suction should not be applied during insertion or for longer than 10 to 15 seconds.
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. While performing care for a patient who had a tracheostomy placed 24 hours ago, the tube is accidentally dislodged. What action is the highest priority for the nurse?
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Ventilate with a resuscitation bag and mask The highest priority is to oxygenate the patient with a bag and facemask while another nurse calls the Rapid Response Team. Assessing for bilateral breath sounds is done after the tube is replaced to ensure proper tube placement. The nurse should not attempt to replace the tube himself or herself because damage may occur.
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The lunch tray is served to a patient wearing a Venturi mask. What does the nurse do to facilitate eating?
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Request a prescription for a nasal cannula to only be used during mealtime It is recommended that a nasal cannula be obtained during mealtime to allow the patient to be comfortable when eating while maintaining adequate oxygenation. The other choices do not maintain consistency in oxygen blood levels nor promote comfort.
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A patient's family is asking about the comparative risks with a ventilator versus noninvasive positive pressure ventilation (NPPV). Which principle should guide the nurse's response?
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NPPV should be used only in patients with intact mental status who can protect their airway Both the ventilator and NPPV have advantages and risks. A major concern in patients on NPPVs is that they must be alert enough to protect their own airway; mental status would be a key determining factor. Either system can be used to treat dyspnea or hypercarbia. The need for PEEP is not known at this time.
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An older adult patient is being discharged home with a tracheostomy. Which nursing action is an acceptable assignment for an experienced LPN/LVN?
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Suction the tracheostomy using sterile technique Complex sterile procedures are within the education and scope of practice of the experienced LPN/LVN. Completion of patient referral forms, patient and family teaching, and consulting with the health care provider are all actions that must be performed by an RN.
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The nurse discovers that a patient's tracheostomy tube has an air leak and notes a cuff pressure of 20 mm Hg. Which action by the nurse is correct?
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Contact the provider to request a larger-diameter tracheostomy tube. The tracheostomy cuff should be inflated to a pressure of 14-20 mm Hg, or 20-30 cm H2O. If the patient continues to show signs of an air leak after properly inflating the cuff, a larger-diameter tube should be used. A range of 20-30 is the range of cm H2O, not mm Hg. Securing the cannula with tape or suctioning the patient frequently does not prevent an air leak.
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The nurse is performing wound care on a tracheostomy placed 48 hours ago. While replacing the ties, the patient becomes agitated and moves unexpectedly, causing the tube to come out. Which actions does the nurse immediately take? Select all that apply.
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Ventilate the patient using a manual resuscitation bag with facemask Call Rapid Response Team When a newly placed tracheostomy tube comes out, the priority is to reestablish the airway. The nurse should manually ventilate the patient while another nurse calls the Rapid Response Team. The nurse should not attempt to manually replace the tube. A nasal airway is not indicated in this situation. A nonrebreather mask does not provide ventilation, which is vital.
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The nurse is suctioning a patient's tracheostomy and notes a heart rate of 98 and an oxygen saturation of 89% during the procedure. Which action by the nurse is correct?
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Reoxygenate the patient with a 100% oxygen delivery system. If a patient becomes hypoxic during suctioning, the nurse should reoxygenate the patient with 100% oxygen. Patients are asked to take three to four deep breaths, if possible, prior to beginning suctioning. Continuing suctioning will increase the hypoxia.
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The nurse is teaching a patient with a tracheostomy who is to be discharged about home tracheostomy management. Which statement by the patient indicates that further instruction may be needed?
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"I should sleep in a room with a dehumidifier. Patients with tracheostomies should be taught to humidify (not dehumidify) homes to prevent drying of secretions. White spots may indicate Candida infection and should be reported. Patients should be upright to at least 30 degrees after eating to prevent aspiration. The tape ties or Velcro holder should be changed once daily and as needed if it becomes soiled.
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Respirations of a sedated patient with a new tracheostomy have become noisy, and the ventilator alarms indicate high peak pressures. The ventilator tube is clear. What is the best immediate action by the nurse?
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Suctioning the patient Suctioning the patient will likely result in clear lung sounds and lower peak pressure, and the appearance of the sputum will indicate whether bleeding is a concern. Humidifying the oxygen source will help mobilize secretions, but an active cough response is also required to clear the airway; a sedated patient has a weak cough. Increasing oxygenation does nothing to clear the airway of whatever is making it noisy and is elevating peak pressures. Removing the inner cannula of a ventilated patient is contraindicated.
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A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at a flow rate of 2 L/min via nasal cannula. The nurse notes an oxygen saturation of 89% after a previous level of 92% and assesses swelling of both nares along with copious nasal discharge. What is the nurse's next action?
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Change the nasal cannula to a Venturi mask The patient is not getting enough oxygen through the nasal cannula because the nares are narrowed and full of secretions. The nurse should change the delivery system to see if this improves. Increasing the flow rate will not help if the delivery route is compromised. Arterial blood gases may be performed if the patient does not improve after changes in oxygen delivery. Suctioning the nares will increase irritation and narrowing of the nares.
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Which of these are valuable instructions for the nurse regarding best practices for patient safety during oxygen therapy? Select all that apply.
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"Lubrication of the patient's nostrils, face, and lips is essential to prevent drying." "Ensure that the oxygen and humidification equipment are functioning properly." "Position the tubing so it does not pull on the patient's face or the artificial airway." During oxygen therapy, lubrication of the patient's nostrils, face, and lips with nonpetroleum cream is essential to relieve the drying effects of oxygen. For effective oxygen therapy, the oxygen and humidification equipment should be functioning properly. The tubing should be positioned in such a way that it does not pull on the patient's face or artificial airway. Mouth care is an integral part of caring for a patient who is undergoing oxygen therapy, and should be provided every 8 hours or as needed. Care should be taken that smoking, lit matches, and candles are not present in the immediate vicinity of the oxygen therapy room or area because oxygen is combustible.
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The nurse is discharging a patient with a prescription for continuous oxygen therapy via nasal cannula at home. What does the nurse include in the discharge teaching?
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Pad the tubing behind the ears. Because the tubing creates pressure that may lead to skin breakdown (especially behind the ears), padding the tubing prevents this complication. Smoking is prohibited in a room where oxygen therapy is being administered. Petroleum jelly is flammable and should not be used on the patient's face, nose, or lips; a nonpetroleum cream should be used.
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Which medical emergency can lead to a life-threatening situation?
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Trachea-innominate artery fistula In trachea-innominate artery fistula, a malpositioned tube triggers its distal tip to push against the lateral wall of the tracheostomy. This pressure causes necrosis and erosion of the innominate artery, resulting in massive bleeding, which is life-threatening. In tracheomalacia, there is constant pressure exerted by the cuff, which results in tracheal dilation and erosion of cartilage. Tracheal stenosis is characterized by narrowed tracheal lumen. It is formed due to scar formation from irritation of tracheal mucosa by the cuff. TEF is caused by excessive cuff pressure that leads to erosion of the posterior wall of the trachea.
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What is the greatest priority while providing care to a patient with a tracheostomy?
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When changing the ties, having someone assist by holding the tube until it is securely stable Unless the tube is well-secured when providing tracheostomy care and changing the ties, dislodgement or decannulation may occur. Potential loss of airway is a priority over potential for skin breakdown or patient/family teaching.
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A patient with an artificial airway is receiving oxygen at a rate of 4 L/min. The nurse notes that a humidifier bottle between the oxygen source and the patient is half-full of sterile water and that the water is bubbling. Which action by the nurse is correct?
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Change the humidification device to a heated nebulizer. All patients receiving oxygen should have humidification to help minimize tissue trauma. Patients receiving oxygen through an artificial airway should have heated humidification to increase the humidity level. If the patient were receiving oxygen without an artificial airway, the water would be at an appropriate level and should be bubbling to be effective. Even though humidity increases the risk of infection, the correct action is to follow protocol for changing the equipment to prevent infection.
