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A nurse working in the pulmonary clinic is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend?
- A. Avoid exercise.
- B. Take steps to manage or reduce anxiety.
- C. Eat meals 1 to 2 hours prior to breathing treatments.
- D. Eat a high-protein/high-calorie diet.
- E. Maintain a high-Fowler position when possible.
- F. Drink 2 to 3 pints of clear fluids daily.
Correct Answer: B,D,E
Rationale: When caring for patients with COPD, it is important to help create an environment that is likely to reduce anxiety, which increases oxygen demand. A high-protein/high-calorie diet is recommended to meet increased energy needs due to the work of breathing. People with dyspnea and orthopnea are most comfortable in a high-Fowler (upright) position because accessory muscles can easily be used to facilitate respiration and lung expansion. Meals should be eaten 1 to 2 hours after breathing treatments; exercise and drinking 2 to 3 quarts (1.9 to 2.9 L) of clear fluids daily is recommended, rather than 2 to 3 pints.
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A nurse in the emergency department is caring for a patient who was brought in by fire rescue due to a heroin overdose. The nurse notes the patient is not breathing. What action will the nurse take immediately?
- A. Tilt the patient's head forward.
- B. Begin ventilation using a manual resuscitation bag (Ambu bag).
- C. Place the mask tightly over the patient's nose and mouth.
- D. Pull the patient's jaw backward.
- E. Compress the bag twice the normal respiratory rate for the patient.
- F. Recommend that a sputum culture for cytology is obtained.
Correct Answer: B,C
Rationale: The priority is to establish ventilation using the manual resuscitation bag to provide emergency or rescue breathing. The nurse tilts the head back, pulls the jaw forward, and positions the mask tightly over the patient's nose and mouth. The bag is compressed at a rate that approximates normal respiratory rate (e.g., 12 to 20 breaths/min in adults). Sputum for cytology is done primarily to detect cells that may be malignant, determine organisms causing infection, and identify blood or pus in the sputum. Note that the bag, with the mask removed, also fits easily over tracheostomy and endotracheal tubes.
A nurse is caring for a patient admitted for an acute asthma exacerbation. The patient reports extreme dyspnea, stating, 'Turn up the oxygen, I'm not getting enough air.' Which actions would the nurse take first?
- A. Suction the airway.
- B. Assess the pulse oximetry reading.
- C. Obtain a peak flow meter reading.
- D. Assess for cyanosis of the lips.
Correct Answer: B
Rationale: Using the nursing process, the nurse first assesses the oxygen saturation via pulse oximetry before changing the oxygen flow rate. Suctioning is provided to remove respiratory secretions; the nurse would note adventitious breath sounds or phlegm with cough indicating a need for suction. A peak flow meter is used to assess the point of highest flow during forced expiration. It is routinely used for patients with moderate or severe asthma to measure the severity of the disease and degree of disease management. While cyanosis of the lips is a late sign of hypoxemia, the nurse can quickly begin to alleviate or lessen dyspnea by simply repositioning the patient.
A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident?
- A. Instructing the assistant to notify the health care team
- B. Assessing the patient's vital signs
- C. Removing the tape, adjusting the depth to the ordered depth, and retaping securely
- D. Taking no action, as the depth will adjust automatically
Correct Answer: C
Rationale: The tube depth should be maintained at the same level unless otherwise prescribed. If the depth changes, the nurse should remove the tape or securement device, adjust the tube to the ordered depth, and reapply the tape or securement device.
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.
A nurse is monitoring a patient with a pleural effusion after a thoracentesis removing 1,400 mL of dark yellow liquid. What is the expected outcome of this procedure?
- A. Tachycardia
- B. Hypotension
- C. Reduced dyspnea
- D. Pulse oximetry of 88%
Correct Answer: C
Rationale: Thoracentesis involves inserting a needle into the pleural space to aspirate pleural fluid, air, or both. A thoracentesis may be performed to obtain a specimen for diagnostic purposes, to remove fluid or air that has accumulated in the pleural cavity and is causing respiratory difficulty and discomfort, or to instill medications.