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A nurse plans to suction a patient's endotracheal tube using the open suction technique. Which intervention is appropriate for this technique?
- A. Using a suction catheter that is the diameter of the endotracheal tube
- B. Maintaining the patient in the supine position
- C. Administering oxygen prior to suctioning
- D. Changing the inline suction device every 24 hours
Correct Answer: C
Rationale: To prevent hypoxemia, prior to endotracheal suctioning, the nurse provides 100% oxygen for a minimum of 30 seconds. This is referred to as hyperoxygenation. The nurse limits the application of suction to no more than 10 to 15 seconds. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. An inline suction device is considered a closed, self-contained system used for a 'closed technique' for suction; these are changed every 24 hours.
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A nurse in the emergency department is caring for a patient who had eaten shellfish and is now wheezing. The nurse explains to the patient that the health care provider has prescribed a bronchodilator, which will have what action?
- A. Helping the patient cough up thick mucus
- B. Opening narrowed airways and relieving wheezing
- C. Acting as a cough suppressant
- D. Blocking the effects of histamine
Correct Answer: B
Rationale: A bronchodilator opens narrowed airways which result in wheezing. An expectorant encourages cough to clear secretions. A cough suppressant reduces, treats, or stops a cough. Medications that block histamine (antihistamine) are often used for allergy but are not specific bronchodilators.
A nursing student attending clinical on a medical-surgical unit receives report from the off-going nurse stating the patient has adventitious breath sounds that clear after expectorating sputum. Which adventitious breath sound will the student expect to auscultate?
- A. Bronchial
- B. Bronchovesicular
- C. Vesicular
- D. Wheezing
Correct Answer: D
Rationale: Wheezing and crackles represent adventitious or abnormal breath sounds. Bronchial, bronchovesicular, and vesicular breath sounds are normal.
A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient?
- A. Assisting with all bathing and hygiene
- B. Telling the patient to avoid speaking during hygiene
- C. Teaching the patient to take short shallow breaths during activity
- D. Taking rest periods between activities
Correct Answer: D
Rationale: To prevent fatigue during activities including hygiene, the nurse should group (personal care) activities into smaller steps and encourage rest periods between activities. The nurse promotes and maintains dignity, independence, and strength by assisting with activities when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits and teach the patient to coordinate pursed-lip or diaphragmatic breathing with the activity.
A student with a history of asthma visits the school nurse reporting difficulty breathing and wheezing. Which tool would the nurse use to assess the severity of airway resistance?
- A. Peak flow meter
- B. End-tidal CO2 monitor
- C. Chest tube
- D. Arterial blood gas
Correct Answer: A
Rationale: A peak flow meter is used to assess the point of highest flow during forced expiration. It is routinely used by and for patients with moderate or severe asthma to measure the severity of the disease and degree of disease management. Capnography or end-tidal CO2 monitoring is used for assessing and monitoring ventilation and placement of artificial airways, predicting patients who are at risk for respiratory compromise, are experiencing partial or complete airway obstruction, or are experiencing hypoventilation. A chest tube is used to remove air or fluid from the pleural space. The arterial blood gas (ABG) is used to assess oxygenation, ventilation, and acid-base status; it is invasive and not performed in the school setting.
Which assessments and interventions should the nurse consider when performing tracheal suctioning?
- A. Closely assessing the patient before, during, and after the procedure
- B. Hyperoxygenating the patient before and after suctioning
- C. Limiting the application of suction to 20 to 30 seconds
- D. Monitoring the pulse to detect effects of hypoxia and stimulation of the vagus nerve
- E. Using an appropriate suction pressure (80 to 150 mm Hg)
- F. Inserting the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube
Correct Answer: A,B,D,E,F
Rationale: Close assessment of the patient before, during, and after the procedure is necessary to identify complications such as hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. In addition, monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis caused by excessive negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage.