Exam 3 Adaptive Quizzing
A health care provider prescribes oropharyngeal suctioning as needed A nurse is caring for a client who is receiving mechanical ventilation
for a client in a coma. Which assessment made by the nurse indicates via an endotracheal tube with a high-volume, low-pressure cuff.
What
the need for suctioning? problem is prevented when the nurse uses a high-volume, low-
pressure cuff?
Gurgling sounds with each breath
Fine crackles at the base of the lungs Air leakage
Cyanosis in the nail beds of the Lung infection
fingers
Dry cough at increasingly frequent intervals
Mucosal necrosis
Secretions in the upper airway produce gurgling sounds that interfere Tracheal secretion
with the free flow of air with each breath. Oropharyngeal suction will Mucosal necrosis is prevented because these cuffs do not compress
not address fine crackles at the base of the lungs. Cyanosis can the capillary beds. A minimal air leak is desirable to ensure the lowest
result from a variety of problems unrelated to the presence of possible pressure in the cuff while placement of the tube is
secretions; suctioning should be done only when secretions are maintained. Surgical asepsis, not use of these cuffs, prevents
blocking the airway. Suctioning is not needed in the absence of infection. Secretions will be increased because the cuff is a foreign
accumulated oropharyngeal secretions. body in the trachea.
A client with a pulmonary embolus is intubated, and mechanical A postoperative client is being weaned from mechanical ventilation.
ventilation is instituted. What should the nurse do when suctioning What is the most important factor for the nurse to consider when
the endotracheal tube? organizing activities?
Apply suction while inserting the catheter.
Remain with the client to assess
responses.
Hyperoxygenate with 100% Allow family members to participate in the process.
oxygen before and after Permit the client more extended times alone for independence.
suctioning.
Use short, jabbing movements of the catheter to loosen secretions.
Suction two to three times in quick succession to remove most of the Observe monitoring devices at the control panel of the ventilator.
secretions. This is a critical time; the client's response to reduction of ventilator
support must be observed closely and evaluated for signs of
Suctioning also removes oxygen, which can cause cardiac
dysrhythmias; the nurse attempts to prevent this by hyperoxygenatingrespiratory distress (e.g., shallow breathing, restlessness, use of
the client before and after suctioning. To prevent trauma to the removal. Using short, jabbing movements of the catheter may cause
trachea and hypoxia, suction should be applied only during catheter tracheal damage and therefore is contraindicated. Suctioning should
[DOCUMENT TITLE] | [Document subtitle]
,Exam 3 Adaptive Quizzing
be performed only as needed; excessive suctioning irritates the accessory respiratory muscles, tachycardia, pallor, and tachypnea).
mucosa, which increases secretion production. Allowing family members to participate in the process delegates
professional responsibility inappropriately. Permitting the client more
extended times alone for independence will not ensure the client's
What nursing action will limit hypoxia when suctioning a client's safety. Observing monitoring devices at the control panel of the
airway? ventilator will not provide the client with support and professional
assistance.
Apply suction only after catheter is inserted.
Limit suctioning with catheter to half a minute.
Lubricate the catheter with saline before When caring for a client on mechanical ventilation, the nurse should
insertion. monitor for which signs of hyperventilation?
Use a sterile suction catheter for each suctioning episode. Hypoxia
The negative pressure from suctioning removes oxygen as well as Hypercapnia
secretions; suction should be applied only after the catheter is Metabolic acidosis
inserted and is being withdrawn. Limiting suctioning with catheter Respiratory alkalosis
to half a minute is too long; suctioning should be limited to 10
Increased rate and depth of breathing result in excessive elimination
seconds. Lubrication will facilitate insertion and minimize trauma; it
of CO2, and respiratory alkalosis can result. Hypoxia is associated with
will not
respiratory acidosis, not respiratory alkalosis, which is related to
hyperventilation. With hyperventilation, CO2 levels will be decreased
prevent hypoxia. The use of a sterile catheter helps prevent infection, (hypocapnia), not elevated. Metabolic acidosis results from excess
not hypoxia.
Administer oxygen via
a ventilation bag Insert
A client has an endotracheal tube and is receiving mechanical
ventilation. Periodic suctioning is necessary and the nurse follows a
the catheter without
specific protocol when performing this procedure. Select in order applying suction Rotate
of priority the nursing actions that should be taken when
suctioning. Assess client's vital signs and lung sounds the catheter while
suction is applied
[DOCUMENT TITLE] | [Document subtitle]
, Exam 3 Adaptive Quizzing
hydrogen ions caused by a metabolic problem, not a respiratory being administered at 3 L/nasal cannula. Four hours after admission,
problem. the client has increased restlessness and confusion followed by a
decreased respiratory rate and lethargy. The nurse should:
Question the client about the
A client with a history of emphysema is admitted with a diagnosis
confusion Change the method of
of acute respiratory failure with respiratory acidosis. Oxygen is
oxygen delivery
The nurse should first assess the client's vital signs and lung sounds to Percuss and vibrate the client's chest wall
determine if suctioning is needed. Then 100% oxygen should be
administered to compensate for the lack of oxygen intake during
the suctioning process. Suctioning should not be applied during Discontinue or decrease the
catheter insertion to limit trauma. Rotating the catheter during
withdrawal ensures thorough removal of secretions.
oxygen flow rate
With emphysema it is believed that the respiratory center no longer
responds to elevated carbon dioxide as the stimulus to breathe but
rather to lowered oxygen levels; therefore, the oxygen being
delivered must be lowered to supply enough for oxygenation without
being so elevated that it negates the stimulus to breathe. However,
[DOCUMENT TITLE] | [Document subtitle]
A health care provider prescribes oropharyngeal suctioning as needed A nurse is caring for a client who is receiving mechanical ventilation
for a client in a coma. Which assessment made by the nurse indicates via an endotracheal tube with a high-volume, low-pressure cuff.
What
the need for suctioning? problem is prevented when the nurse uses a high-volume, low-
pressure cuff?
Gurgling sounds with each breath
Fine crackles at the base of the lungs Air leakage
Cyanosis in the nail beds of the Lung infection
fingers
Dry cough at increasingly frequent intervals
Mucosal necrosis
Secretions in the upper airway produce gurgling sounds that interfere Tracheal secretion
with the free flow of air with each breath. Oropharyngeal suction will Mucosal necrosis is prevented because these cuffs do not compress
not address fine crackles at the base of the lungs. Cyanosis can the capillary beds. A minimal air leak is desirable to ensure the lowest
result from a variety of problems unrelated to the presence of possible pressure in the cuff while placement of the tube is
secretions; suctioning should be done only when secretions are maintained. Surgical asepsis, not use of these cuffs, prevents
blocking the airway. Suctioning is not needed in the absence of infection. Secretions will be increased because the cuff is a foreign
accumulated oropharyngeal secretions. body in the trachea.
A client with a pulmonary embolus is intubated, and mechanical A postoperative client is being weaned from mechanical ventilation.
ventilation is instituted. What should the nurse do when suctioning What is the most important factor for the nurse to consider when
the endotracheal tube? organizing activities?
Apply suction while inserting the catheter.
Remain with the client to assess
responses.
Hyperoxygenate with 100% Allow family members to participate in the process.
oxygen before and after Permit the client more extended times alone for independence.
suctioning.
Use short, jabbing movements of the catheter to loosen secretions.
Suction two to three times in quick succession to remove most of the Observe monitoring devices at the control panel of the ventilator.
secretions. This is a critical time; the client's response to reduction of ventilator
support must be observed closely and evaluated for signs of
Suctioning also removes oxygen, which can cause cardiac
dysrhythmias; the nurse attempts to prevent this by hyperoxygenatingrespiratory distress (e.g., shallow breathing, restlessness, use of
the client before and after suctioning. To prevent trauma to the removal. Using short, jabbing movements of the catheter may cause
trachea and hypoxia, suction should be applied only during catheter tracheal damage and therefore is contraindicated. Suctioning should
[DOCUMENT TITLE] | [Document subtitle]
,Exam 3 Adaptive Quizzing
be performed only as needed; excessive suctioning irritates the accessory respiratory muscles, tachycardia, pallor, and tachypnea).
mucosa, which increases secretion production. Allowing family members to participate in the process delegates
professional responsibility inappropriately. Permitting the client more
extended times alone for independence will not ensure the client's
What nursing action will limit hypoxia when suctioning a client's safety. Observing monitoring devices at the control panel of the
airway? ventilator will not provide the client with support and professional
assistance.
Apply suction only after catheter is inserted.
Limit suctioning with catheter to half a minute.
Lubricate the catheter with saline before When caring for a client on mechanical ventilation, the nurse should
insertion. monitor for which signs of hyperventilation?
Use a sterile suction catheter for each suctioning episode. Hypoxia
The negative pressure from suctioning removes oxygen as well as Hypercapnia
secretions; suction should be applied only after the catheter is Metabolic acidosis
inserted and is being withdrawn. Limiting suctioning with catheter Respiratory alkalosis
to half a minute is too long; suctioning should be limited to 10
Increased rate and depth of breathing result in excessive elimination
seconds. Lubrication will facilitate insertion and minimize trauma; it
of CO2, and respiratory alkalosis can result. Hypoxia is associated with
will not
respiratory acidosis, not respiratory alkalosis, which is related to
hyperventilation. With hyperventilation, CO2 levels will be decreased
prevent hypoxia. The use of a sterile catheter helps prevent infection, (hypocapnia), not elevated. Metabolic acidosis results from excess
not hypoxia.
Administer oxygen via
a ventilation bag Insert
A client has an endotracheal tube and is receiving mechanical
ventilation. Periodic suctioning is necessary and the nurse follows a
the catheter without
specific protocol when performing this procedure. Select in order applying suction Rotate
of priority the nursing actions that should be taken when
suctioning. Assess client's vital signs and lung sounds the catheter while
suction is applied
[DOCUMENT TITLE] | [Document subtitle]
, Exam 3 Adaptive Quizzing
hydrogen ions caused by a metabolic problem, not a respiratory being administered at 3 L/nasal cannula. Four hours after admission,
problem. the client has increased restlessness and confusion followed by a
decreased respiratory rate and lethargy. The nurse should:
Question the client about the
A client with a history of emphysema is admitted with a diagnosis
confusion Change the method of
of acute respiratory failure with respiratory acidosis. Oxygen is
oxygen delivery
The nurse should first assess the client's vital signs and lung sounds to Percuss and vibrate the client's chest wall
determine if suctioning is needed. Then 100% oxygen should be
administered to compensate for the lack of oxygen intake during
the suctioning process. Suctioning should not be applied during Discontinue or decrease the
catheter insertion to limit trauma. Rotating the catheter during
withdrawal ensures thorough removal of secretions.
oxygen flow rate
With emphysema it is believed that the respiratory center no longer
responds to elevated carbon dioxide as the stimulus to breathe but
rather to lowered oxygen levels; therefore, the oxygen being
delivered must be lowered to supply enough for oxygenation without
being so elevated that it negates the stimulus to breathe. However,
[DOCUMENT TITLE] | [Document subtitle]
