Podcast
Questions and Answers
When applying a nasal cannula, which action ensures proper placement?
When applying a nasal cannula, which action ensures proper placement?
- Positioning the tubing over the client's ears with the adjuster at the nape of the neck
- Placing the prongs of the nasal cannula in the client's nostrils, pointing downwards (correct)
- Ensuring the cannula is positioned loosely to prevent skin breakdown
- Placing the prongs of the nasal cannula in the client's nostrils, pointing upwards
What is the primary purpose of ensuring the reservoir bag on a non-rebreather mask does not completely collapse during client exhalation?
What is the primary purpose of ensuring the reservoir bag on a non-rebreather mask does not completely collapse during client exhalation?
- To prevent skin breakdown from the mask's pressure.
- To allow for accurate titration of oxygen flow rate.
- To ensure the client receives the maximum possible oxygen concentration. (correct)
- To facilitate carbon dioxide rebreathing and maintain acid-base balance.
In the context of closed-chest drainage, what does 'water seal chamber mark' refer to?
In the context of closed-chest drainage, what does 'water seal chamber mark' refer to?
- A level indicating the appropriate amount of sterile water to add to prevent air from re-entering the pleural space. (correct)
- A measurement used to determine the client's fluid balance and overall hydration status.
- A measurement indicating the amount of suction being applied to the drainage system.
- A marker for documenting the date and time the drainage system was last changed.
During the process of replacing a chest-tube drainage system, what immediate action should the nurse take after disconnecting the old system and prior to connecting the new system?
During the process of replacing a chest-tube drainage system, what immediate action should the nurse take after disconnecting the old system and prior to connecting the new system?
A nurse is preparing to perform nasotracheal suctioning on a client. What is the MOST appropriate suction pressure setting to use?
A nurse is preparing to perform nasotracheal suctioning on a client. What is the MOST appropriate suction pressure setting to use?
A client with a chest tube is being repositioned. The nurse notes a continuous bubbling in the water seal chamber. What should the nurse suspect?
A client with a chest tube is being repositioned. The nurse notes a continuous bubbling in the water seal chamber. What should the nurse suspect?
Which of the following nursing actions is MOST important when providing tracheostomy care to prevent infection?
Which of the following nursing actions is MOST important when providing tracheostomy care to prevent infection?
What is the MOST accurate method for a nurse to confirm correct placement of an endotracheal tube following insertion by a respiratory therapist?
What is the MOST accurate method for a nurse to confirm correct placement of an endotracheal tube following insertion by a respiratory therapist?
A client with COPD is prescribed home oxygen therapy. What should the nurse emphasize regarding safety?
A client with COPD is prescribed home oxygen therapy. What should the nurse emphasize regarding safety?
A client with a history of asthma exacerbations is prescribed a short acting beta-2 agonist (SABA) and an inhaled corticosteroid (ICS). How would you best instruct the client on how to take their medications?
A client with a history of asthma exacerbations is prescribed a short acting beta-2 agonist (SABA) and an inhaled corticosteroid (ICS). How would you best instruct the client on how to take their medications?
What is the primary reason a nurse should avoid applying suction during the insertion of a nasotracheal catheter?
What is the primary reason a nurse should avoid applying suction during the insertion of a nasotracheal catheter?
A nurse is caring for a client with COPD who is receiving oxygen at 2 L/min via nasal cannula. Which assessment finding would warrant immediate intervention?
A nurse is caring for a client with COPD who is receiving oxygen at 2 L/min via nasal cannula. Which assessment finding would warrant immediate intervention?
When preparing to replace a chest tube insertion site dressing, what is the MOST important nursing action to perform after exposing the insertion site?
When preparing to replace a chest tube insertion site dressing, what is the MOST important nursing action to perform after exposing the insertion site?
A client with a tracheostomy is being discharged home. Which instruction is MOST critical for the nurse to emphasize to the client and family regarding tracheostomy care?
A client with a tracheostomy is being discharged home. Which instruction is MOST critical for the nurse to emphasize to the client and family regarding tracheostomy care?
When administering oxygen via a Venturi mask, which of the following is essential for the nurse to verify?
When administering oxygen via a Venturi mask, which of the following is essential for the nurse to verify?
A nurse is caring for a client who is scheduled for nasotracheal suctioning. Which pre-procedure intervention is most important for the nurse to implement?
A nurse is caring for a client who is scheduled for nasotracheal suctioning. Which pre-procedure intervention is most important for the nurse to implement?
Which nursing intervention is MOST appropriate for a client experiencing dyspnea while lying flat in bed?
Which nursing intervention is MOST appropriate for a client experiencing dyspnea while lying flat in bed?
What is the primary rationale for ensuring that flammable liquids are kept away from oxygen equipment in a client's home?
What is the primary rationale for ensuring that flammable liquids are kept away from oxygen equipment in a client's home?
A client with a history of asthma exacerbations is prescribed a short-acting beta-2 agonist (SABA) PRN. What should the nurse instruct the client?
A client with a history of asthma exacerbations is prescribed a short-acting beta-2 agonist (SABA) PRN. What should the nurse instruct the client?
A nurse is caring for a client receiving oxygen via non-rebreather mask. Which of the following nursing actions are essential??
A nurse is caring for a client receiving oxygen via non-rebreather mask. Which of the following nursing actions are essential??
A client who is postoperative is using an incentive spirometer. The nurse is teaching the client how to use the device correctly. Which statement indicates the client understands the instructions?
A client who is postoperative is using an incentive spirometer. The nurse is teaching the client how to use the device correctly. Which statement indicates the client understands the instructions?
A client with a chest tube connected to a closed drainage system suddenly develops respiratory distress. What PRIORITIZED intervention should the nurse perform?
A client with a chest tube connected to a closed drainage system suddenly develops respiratory distress. What PRIORITIZED intervention should the nurse perform?
A nurse is providing discharge teaching to a client with COPD who will be using home oxygen therapy. In addition to not smoking, what other key safety measure should the nurse emphasize to the client?
A nurse is providing discharge teaching to a client with COPD who will be using home oxygen therapy. In addition to not smoking, what other key safety measure should the nurse emphasize to the client?
A nurse is caring for a client with a tracheostomy tube. During routine tracheostomy care, the nurse accidentally dislodges the tracheostomy tube. What is the nurse's MOST appropriate initial action?
A nurse is caring for a client with a tracheostomy tube. During routine tracheostomy care, the nurse accidentally dislodges the tracheostomy tube. What is the nurse's MOST appropriate initial action?
A patient receiving oxygen via nasal cannula at 4 L/min complains of nasal dryness and irritation. What should the nurse do FIRST?
A patient receiving oxygen via nasal cannula at 4 L/min complains of nasal dryness and irritation. What should the nurse do FIRST?
A client with COPD is on oxygen therapy at 2L/min via nasal cannula. Which assessment finding requires the nurse to most urgently collaborate with the respiratory therapist or physician?
A client with COPD is on oxygen therapy at 2L/min via nasal cannula. Which assessment finding requires the nurse to most urgently collaborate with the respiratory therapist or physician?
When teaching a client how to use a metered-dose inhaler (MDI) with a spacer, which instruction is MOST important for the nurse to emphasize?
When teaching a client how to use a metered-dose inhaler (MDI) with a spacer, which instruction is MOST important for the nurse to emphasize?
A client is being discharged home with oxygen therapy. Which statement made by the client indicates a need for further teaching regarding safety measures?
A client is being discharged home with oxygen therapy. Which statement made by the client indicates a need for further teaching regarding safety measures?
A nurse is preparing to perform tracheostomy suctioning on a client. What is the MOST important step to prevent hypoxia during the procedure?
A nurse is preparing to perform tracheostomy suctioning on a client. What is the MOST important step to prevent hypoxia during the procedure?
The nurse is caring for a client with a chest tube connected to a closed drainage system. The nurse notes tidaling has stopped in the water seal chamber. Which action should the nurse take first?
The nurse is caring for a client with a chest tube connected to a closed drainage system. The nurse notes tidaling has stopped in the water seal chamber. Which action should the nurse take first?
When changing a chest tube dressing, what would be the BEST way to ensure a sterile environment?
When changing a chest tube dressing, what would be the BEST way to ensure a sterile environment?
A nurse is caring for a client with an acute asthma exacerbation. After administering a short-acting beta-2 agonist (SABA) via nebulizer, which assessment finding indicates the medication was effective?
A nurse is caring for a client with an acute asthma exacerbation. After administering a short-acting beta-2 agonist (SABA) via nebulizer, which assessment finding indicates the medication was effective?
A client with a tracheostomy is being prepared for discharge. Which of the following instructions should the nurse emphasize to the client and family regarding stoma care at home?
A client with a tracheostomy is being prepared for discharge. Which of the following instructions should the nurse emphasize to the client and family regarding stoma care at home?
A postoperative client is using an incentive spirometer. What indicates that the client is using the device correctly?
A postoperative client is using an incentive spirometer. What indicates that the client is using the device correctly?
Which nursing intervention is MOST effective in promoting oxygenation for a client with pneumonia who is experiencing hypoxemia?
Which nursing intervention is MOST effective in promoting oxygenation for a client with pneumonia who is experiencing hypoxemia?
A nurse is caring for a client with a tracheostomy who is on a ventilator. What is the rationale for maintaining cuff pressure between 14 and 20 mm Hg?
A nurse is caring for a client with a tracheostomy who is on a ventilator. What is the rationale for maintaining cuff pressure between 14 and 20 mm Hg?
Which of the following actions should the nurse take to prevent accidental dislodgement of a newly placed tracheostomy tube?
Which of the following actions should the nurse take to prevent accidental dislodgement of a newly placed tracheostomy tube?
A nurse is educating a client on how to use an incentive spirometer. What indicates the patient needs further teaching?
A nurse is educating a client on how to use an incentive spirometer. What indicates the patient needs further teaching?
A nurse is caring for a client receiving oxygen therapy via a simple face mask. Which action is appropriate when the client's oxygen saturation is within normal limits?
A nurse is caring for a client receiving oxygen therapy via a simple face mask. Which action is appropriate when the client's oxygen saturation is within normal limits?
A nurse is caring for a client with COPD who is prescribed a Venturi mask. Which of the following is an advantage of using a Venturi mask for this client?
A nurse is caring for a client with COPD who is prescribed a Venturi mask. Which of the following is an advantage of using a Venturi mask for this client?
What nursing action is most important when caring for a client receiving oxygen therapy via nasal cannula?
What nursing action is most important when caring for a client receiving oxygen therapy via nasal cannula?
When performing closed-chest drainage, which finding requires immediate intervention from the nurse?
When performing closed-chest drainage, which finding requires immediate intervention from the nurse?
Which of the following indicates an acute exacerbation of COPD?
Which of the following indicates an acute exacerbation of COPD?
What is a critical step when performing oropharyngeal suctioning on a client?
What is a critical step when performing oropharyngeal suctioning on a client?
Which nursing intervention is essential immediately after endotracheal suctioning?
Which nursing intervention is essential immediately after endotracheal suctioning?
What is priority nursing action for a client who has a productive cough and is able to expectorate sputum?
What is priority nursing action for a client who has a productive cough and is able to expectorate sputum?
A nurse is caring for a client with a chest tube. For which of the following findings should the nurse notify the physician?
A nurse is caring for a client with a chest tube. For which of the following findings should the nurse notify the physician?
What is the correct sequence when performing closed-chest drainage system replacement?
What is the correct sequence when performing closed-chest drainage system replacement?
A nurse is caring for a client at risk for developing airway compromise. Which of the following is an early indication of hypoxemia?
A nurse is caring for a client at risk for developing airway compromise. Which of the following is an early indication of hypoxemia?
What is the correct positioning for postural drainage of the anterior basal segments of both lower lobes?
What is the correct positioning for postural drainage of the anterior basal segments of both lower lobes?
A nurse is caring for a client with a tracheostomy who requires frequent suctioning. What does frequent suctioning put the client at risk for?
A nurse is caring for a client with a tracheostomy who requires frequent suctioning. What does frequent suctioning put the client at risk for?
A client has a tracheostomy tube with an inflated cuff. What does the inflated cuff prevent?
A client has a tracheostomy tube with an inflated cuff. What does the inflated cuff prevent?
A nurse is providing discharge instructions to a client with COPD who will be using home oxygen therapy. Which of the following statements by the client indicates a need for further teaching?
A nurse is providing discharge instructions to a client with COPD who will be using home oxygen therapy. Which of the following statements by the client indicates a need for further teaching?
A nurse is preparing to perform nasopharyngeal suctioning on a client with a respiratory infection. Which action will reduce the risk of trauma to the nasal mucosa?
A nurse is preparing to perform nasopharyngeal suctioning on a client with a respiratory infection. Which action will reduce the risk of trauma to the nasal mucosa?
A nurse is caring for a client receiving oxygen via a non-rebreather mask. Which of the following is a critical nursing action related to this specific oxygen delivery system?
A nurse is caring for a client receiving oxygen via a non-rebreather mask. Which of the following is a critical nursing action related to this specific oxygen delivery system?
A nurse is preparing to collect a sputum specimen from a client with suspected pneumonia. When is the BEST time to collect the specimen to ensure an accurate diagnosis?
A nurse is preparing to collect a sputum specimen from a client with suspected pneumonia. When is the BEST time to collect the specimen to ensure an accurate diagnosis?
A client with an artificial airway is being prepared for discharge. Which of the following instructions should the nurse prioritize for the family?
A client with an artificial airway is being prepared for discharge. Which of the following instructions should the nurse prioritize for the family?
A nurse is caring for a client with hypoxemia. What position should the nurse place the client in?
A nurse is caring for a client with hypoxemia. What position should the nurse place the client in?
A nurse assesses a client's SpO2 and obtains a reading of 88%. The client is prescribed oxygen. What should the nurse do FIRST?
A nurse assesses a client's SpO2 and obtains a reading of 88%. The client is prescribed oxygen. What should the nurse do FIRST?
A client with a tracheostomy is being discharged home. What should you teach them about showering?
A client with a tracheostomy is being discharged home. What should you teach them about showering?
A client is diagnosed with oxygen-induced hypoventilation. Which delivery system is the safest for this client?
A client is diagnosed with oxygen-induced hypoventilation. Which delivery system is the safest for this client?
What is the purpose of chest physiotherapy?
What is the purpose of chest physiotherapy?
A patient has a single-lumen tracheostomy. Which client population is this contraindicated in?
A patient has a single-lumen tracheostomy. Which client population is this contraindicated in?
A nurse is preparing to provide tracheostomy care. What is the appropriate order?
A nurse is preparing to provide tracheostomy care. What is the appropriate order?
What is the correct flow rate for a simple face mask?
What is the correct flow rate for a simple face mask?
Which pre-existing condition is a contraindication of chest physiotherapy?
Which pre-existing condition is a contraindication of chest physiotherapy?
A nurse is caring for a client with a tracheostomy. What should they do if the client shows signs of hypoxemia during tracheostomy care?
A nurse is caring for a client with a tracheostomy. What should they do if the client shows signs of hypoxemia during tracheostomy care?
A client with asthma is prescribed home oxygen therapy. What is key client education?
A client with asthma is prescribed home oxygen therapy. What is key client education?
A nurse is suctioning a client and notes the heart rate decreases significantly. What is the next step?
A nurse is suctioning a client and notes the heart rate decreases significantly. What is the next step?
What indicates the resolution of an asthma exacerbation?
What indicates the resolution of an asthma exacerbation?
What is a manifestation of oxygen toxicity?
What is a manifestation of oxygen toxicity?
How long should postural drainage positions be maintained?
How long should postural drainage positions be maintained?
What is the most appropriate intervention for a client with a history of asthma exacerbations who is wheezing?
What is the most appropriate intervention for a client with a history of asthma exacerbations who is wheezing?
A nurse is caring for a client with an uncuffed tracheostomy tube. What does this mean for the client?
A nurse is caring for a client with an uncuffed tracheostomy tube. What does this mean for the client?
A client with COPD is receiving oxygen via nasal cannula. Which finding indicates the oxygen flow rate may be too high?
A client with COPD is receiving oxygen via nasal cannula. Which finding indicates the oxygen flow rate may be too high?
A nurse is teaching a client with asthma about using a peak flow meter. What instruction is MOST important to ensure accurate readings?
A nurse is teaching a client with asthma about using a peak flow meter. What instruction is MOST important to ensure accurate readings?
A client has a tracheostomy with a cuffed tube. Prior to oral feeding, what nursing intervention is MOST important to implement?
A client has a tracheostomy with a cuffed tube. Prior to oral feeding, what nursing intervention is MOST important to implement?
A nurse assesses a client receiving mechanical ventilation via a tracheostomy and notes the cuff pressure is 28 mm Hg. What is the appropriate nursing action?
A nurse assesses a client receiving mechanical ventilation via a tracheostomy and notes the cuff pressure is 28 mm Hg. What is the appropriate nursing action?
When performing closed-chest drainage, what action is most appropriate to maintain system integrity when the drainage system is momentarily full?
When performing closed-chest drainage, what action is most appropriate to maintain system integrity when the drainage system is momentarily full?
A nurse is caring for a client with a chest tube. The client reports a burning sensation when breathing. What actions should the nurse take first?
A nurse is caring for a client with a chest tube. The client reports a burning sensation when breathing. What actions should the nurse take first?
A nurse is preparing to perform nasotracheal suctioning on a client. What is the most important assessment to make prior to initiating the procedure?
A nurse is preparing to perform nasotracheal suctioning on a client. What is the most important assessment to make prior to initiating the procedure?
A client is receiving oxygen via a simple face mask. What assessment finding would indicate the need to switch to a different oxygen delivery system?
A client is receiving oxygen via a simple face mask. What assessment finding would indicate the need to switch to a different oxygen delivery system?
A client with COPD is being discharged home with oxygen therapy. What home safety measure is MOST important for the nurse to emphasize?
A client with COPD is being discharged home with oxygen therapy. What home safety measure is MOST important for the nurse to emphasize?
A nurse is caring for a client with a tracheostomy. What intervention helps prevent the formation of a mucous plug?
A nurse is caring for a client with a tracheostomy. What intervention helps prevent the formation of a mucous plug?
A nurse is teaching a client how to use an incentive spirometer. What indicates the client understands the instructions?
A nurse is teaching a client how to use an incentive spirometer. What indicates the client understands the instructions?
A client is using a metered-dose inhaler (MDI) with a spacer. What is the rationale for using a spacer with the MDI?
A client is using a metered-dose inhaler (MDI) with a spacer. What is the rationale for using a spacer with the MDI?
A client has a chest tube connected to a closed drainage system. The nurse notes bubbling in the water seal chamber only during coughing. What does this usually indicate?
A client has a chest tube connected to a closed drainage system. The nurse notes bubbling in the water seal chamber only during coughing. What does this usually indicate?
A nurse is preparing to change a chest tube insertion site dressing. What supplies are MOST important to have at the bedside?
A nurse is preparing to change a chest tube insertion site dressing. What supplies are MOST important to have at the bedside?
A nurse is caring for a client with a tracheostomy. Which intervention is MOST important to prevent skin breakdown around the stoma?
A nurse is caring for a client with a tracheostomy. Which intervention is MOST important to prevent skin breakdown around the stoma?
A nurse is educating a client on using a metered-dose inhaler (MDI). What statement by the client indicates a need for further teaching?
A nurse is educating a client on using a metered-dose inhaler (MDI). What statement by the client indicates a need for further teaching?
A client is being discharged home with oxygen therapy via nasal cannula. Which instruction is MOST important to include in the discharge teaching?
A client is being discharged home with oxygen therapy via nasal cannula. Which instruction is MOST important to include in the discharge teaching?
A nurse is caring for a client with a chest tube. The drainage system is accidentally disconnected. What is the nurse's immediate action?
A nurse is caring for a client with a chest tube. The drainage system is accidentally disconnected. What is the nurse's immediate action?
A nurse assesses a client with pneumonia. Which finding indicates the client needs airway suctioning?
A nurse assesses a client with pneumonia. Which finding indicates the client needs airway suctioning?
What information is most important client education for a client with frequent asthma exacerbations?
What information is most important client education for a client with frequent asthma exacerbations?
What is the most important information to teach clients with home oxygen?
What is the most important information to teach clients with home oxygen?
What is the maximum length of time you should suction a client?
What is the maximum length of time you should suction a client?
Which statement indicates more education is required for a client using an incentive spirometer?
Which statement indicates more education is required for a client using an incentive spirometer?
Which complication is associated with long-term mechanical ventilation?
Which complication is associated with long-term mechanical ventilation?
What should a tracheostomy cuff pressure be?
What should a tracheostomy cuff pressure be?
After suctioning a client, what is the first action a nurse should take?
After suctioning a client, what is the first action a nurse should take?
A client has a new tracheostomy. What equipment must be readily available at the bedside?
A client has a new tracheostomy. What equipment must be readily available at the bedside?
What does a double-lumen tracheostomy have that a single-lumen does not?
What does a double-lumen tracheostomy have that a single-lumen does not?
What is the FiO2 range for a simple face mask?
What is the FiO2 range for a simple face mask?
What patient position is correct for postural drainage of the posterior segments of both lower lobes?
What patient position is correct for postural drainage of the posterior segments of both lower lobes?
Which mask delivers the most precise oxygen concentration with humidity added?
Which mask delivers the most precise oxygen concentration with humidity added?
What oxygen-delivery device delivers the highest concentration of oxygen?
What oxygen-delivery device delivers the highest concentration of oxygen?
How often should tracheostomy care be performed?
How often should tracheostomy care be performed?
What action is contraindicated with placement of a single-lumen tracheostomy?
What action is contraindicated with placement of a single-lumen tracheostomy?
If a patient is experiencing hypoxemia, what position should the nurse put them in?
If a patient is experiencing hypoxemia, what position should the nurse put them in?
A nurse is caring for a client with COPD. Which of the following is an expected finding?
A nurse is caring for a client with COPD. Which of the following is an expected finding?
What is a priority nursing intervention for a client who has a productive cough and is able to expectorate sputum?
What is a priority nursing intervention for a client who has a productive cough and is able to expectorate sputum?
A client receiving oxygen via a simple face mask at 6 L/min reports feeling claustrophobic. Which intervention is the MOST appropriate initial action for the nurse?
A client receiving oxygen via a simple face mask at 6 L/min reports feeling claustrophobic. Which intervention is the MOST appropriate initial action for the nurse?
The nurse is providing discharge teaching to a client with COPD who is starting home oxygen therapy. Which statement indicates the client correctly understands a key safety measure?
The nurse is providing discharge teaching to a client with COPD who is starting home oxygen therapy. Which statement indicates the client correctly understands a key safety measure?
While performing closed-chest drainage, the nurse observes continuous bubbling in the water-seal chamber of the chest tube drainage system. What is the MOST appropriate initial nursing intervention?
While performing closed-chest drainage, the nurse observes continuous bubbling in the water-seal chamber of the chest tube drainage system. What is the MOST appropriate initial nursing intervention?
A client with a tracheostomy is being prepared for discharge. Which instruction should the nurse emphasize to the client and their family to ensure effective communication?
A client with a tracheostomy is being prepared for discharge. Which instruction should the nurse emphasize to the client and their family to ensure effective communication?
A nurse is caring for a client with an endotracheal tube who requires suctioning. After preoxygenating the client, which action demonstrates the MOST appropriate technique for suctioning?
A nurse is caring for a client with an endotracheal tube who requires suctioning. After preoxygenating the client, which action demonstrates the MOST appropriate technique for suctioning?
Flashcards
Beginning steps for Oxygen therapy
Beginning steps for Oxygen therapy
Provides privacy, introduce yourself, hand hygiene and PPE, patient ID, allergies, educate, gather equipment at the bedside
Applying nasal cannula
Applying nasal cannula
Place the prongs of nasal cannula in the client's nostrils, with the prongs pointing down. Place the tubing over the client's ears and position the adjuster under the client's chin. Ensure that the cannula is snug, but not tight
Applying nonrebreather mask
Applying nonrebreather mask
Position the mask over the client's nose and mouth. Stretch the elastic straps over the client's head. Adjust the elastic straps so the mask sits snugly against the client's face. Ensure that the reservoir bag does not completely collapse with exhalation
Replacing a closed-chest drainage system - beginning
Replacing a closed-chest drainage system - beginning
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Clamping the Drainage tube
Clamping the Drainage tube
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Assess Insertion Site
Assess Insertion Site
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Positioning for Oxygenation
Positioning for Oxygenation
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Safe Suctioning Parameters
Safe Suctioning Parameters
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COPD basics
COPD basics
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Asthma long-term treatment basics
Asthma long-term treatment basics
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Oxygen Flow Rate Adjustment
Oxygen Flow Rate Adjustment
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Applying Simple Mask
Applying Simple Mask
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Applying Venturi Mask
Applying Venturi Mask
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Chest Tube Insertion
Chest Tube Insertion
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Post-connection checklist
Post-connection checklist
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Dressing Application Post-Care
Dressing Application Post-Care
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Assess Respiratory Status
Assess Respiratory Status
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Breathing Exercises
Breathing Exercises
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Airway & Activity Management
Airway & Activity Management
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Promote Effective Coughing
Promote Effective Coughing
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Optimize Environment
Optimize Environment
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Nasopharyngeal/tracheal Suctioning
Nasopharyngeal/tracheal Suctioning
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Risks of Suctioning
Risks of Suctioning
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COPD Chronic Management
COPD Chronic Management
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Oxygenation Improvement (No Order)
Oxygenation Improvement (No Order)
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Oxygen deficit:Assess & Communication
Oxygen deficit:Assess & Communication
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Incentive Spirometer
Incentive Spirometer
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Metered Dose Inhaler (MDI)
Metered Dose Inhaler (MDI)
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Respiratory Assessment
Respiratory Assessment
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Breathing Techniques
Breathing Techniques
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FiO2 and Flow Rates by Device
FiO2 and Flow Rates by Device
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Home Oxygen Safety
Home Oxygen Safety
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Pulse Oximeter
Pulse Oximeter
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Fraction of Inspired Oxygen (FiO2)
Fraction of Inspired Oxygen (FiO2)
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Hypoxemia Definition
Hypoxemia Definition
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Tachypnea
Tachypnea
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Cyanosis Definition
Cyanosis Definition
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Hypercarbia Definition
Hypercarbia Definition
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Low-Flow Oxygen Systems
Low-Flow Oxygen Systems
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Nasal Cannula Details
Nasal Cannula Details
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Simple Face Mask Details
Simple Face Mask Details
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Partial Rebreather Mask Details
Partial Rebreather Mask Details
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Non-Rebreather Mask Details
Non-Rebreather Mask Details
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Venturi Mask Details
Venturi Mask Details
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Aerosol Mask/Face Tent
Aerosol Mask/Face Tent
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Oxygen Toxicity Manifestations
Oxygen Toxicity Manifestations
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Oxygen-Induced Hypoventilation Nursing
Oxygen-Induced Hypoventilation Nursing
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Oxygen Safety Measures
Oxygen Safety Measures
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Nebulization Definition
Nebulization Definition
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Chest Physiotherapy Definition
Chest Physiotherapy Definition
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Percussion Definition
Percussion Definition
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Vibration Definition
Vibration Definition
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Postural Drainage Definition
Postural Drainage Definition
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Suctioning Indications
Suctioning Indications
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Suction Catheter Types
Suction Catheter Types
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Suction Pressure
Suction Pressure
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Tracheotomy Definition
Tracheotomy Definition
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Tracheostomy Definition
Tracheostomy Definition
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Double-Lumen Cannula
Double-Lumen Cannula
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Cuffed Tracheostomy Tube
Cuffed Tracheostomy Tube
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Cuffless Tracheostomy Tube
Cuffless Tracheostomy Tube
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Fenestrated Tracheostomy Tube
Fenestrated Tracheostomy Tube
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Tracheostomy Equipment
Tracheostomy Equipment
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Tracheostomy and Eating
Tracheostomy and Eating
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Accidental Decannulation (<72hr)
Accidental Decannulation (<72hr)
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Accidental Decannulation (>72hr)
Accidental Decannulation (>72hr)
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Tracheal Stenosis Definition
Tracheal Stenosis Definition
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Study Notes
Pulse Oximetry and Oxygen Therapy
- Oxygen maintains cellular oxygenation for respiratory problems like bronchitis, cystic fibrosis, and asthma, and prevents hypoxia in respiratory or circulatory impairments.
- Patent airway maintenance is a nursing priority, involving secretion mobilization, suctioning, and artificial airway management.
Pulse Oximetry
- Measures pulse saturation (SpO2) using infrared light to determine oxygenated and deoxygenated hemoglobin levels.
- SpO2 reflects hemoglobin saturation percentage when SaO2 is above 70%.
Pulse Oximetry Indications
- Increased breathing effort
- Wheezing or coughing
- Cyanosis
- Changes in respiratory rate or rhythm
- Adventitious breath sounds
- Restlessness, irritability, confusion
- Dyspnea or orthopnea
Considerations for Low Pulse Oximetry Readings (Below 90%)
- Confirm probe placement and proper function of oxygen delivery system.
- Place client in semi-Fowler’s or Fowler’s position to promote chest expansion.
- Encourage deep breathing and provide emotional support to reduce anxiety.
Interpretation of Pulse Oximetry Findings
- Expected range: 95%–100%. Acceptable levels: 91%–100%. Some illnesses allow for 85%–89%.
- Readings below 90% indicate hypoxemia.
- Slightly lower values may be acceptable for older adults and clients with dark skin.
- Hypothermia, poor peripheral blood flow, excessive light, low hemoglobin, jaundice, movement, edema, nail polish, and metal studs can cause inaccurate readings.
Oxygen Therapy
- Oxygen treats hypoxemia, but requires a prescription for administration and adjustment.
- Oxygen flow rates maintain SpO2 at 95% to 100% using the lowest effective amount to prevent complications.
- Fraction of inspired oxygen (FiO2) is the oxygen percentage a client receives.
Manifestations of Hypoxia
- Early signs: Tachypnea, tachycardia, restlessness, anxiety, confusion, pale skin, elevated blood pressure, use of accessory muscles, nasal flaring, adventitious lung sounds.
- Late signs: Stupor, cyanotic skin, bradypnea, bradycardia, hypotension, cardiac dysrhythmias.
Nursing Actions for Hypoxia
- Monitor respiratory rate, pattern, level of consciousness, SpO2, and ABGs.
- Provide oxygen at the lowest effective flow.
- Ensure mask creates a secure seal; assess for hypoxia and hypercarbia.
- Auscultate lungs for breath sounds and monitor oxygenation with pulse oximetry and ABGs.
- Encourage turning, coughing, deep breathing, incentive spirometry, and suctioning.
- Promote rest, reduce stimuli, provide emotional support, nutritional support, and assess skin integrity.
- Document response to oxygen therapy; titrate oxygen and discontinue gradually; monitor for respiratory depression.
Low-Flow Oxygen Delivery Systems
- Deliver varying oxygen amounts depending on delivery method and breathing pattern.
Nasal Cannula
- Delivers FiO2 of 24% to 44% at 1 to 6 L/min.
- Safe, simple, easy to apply, comfortable, and allows eating, talking, and ambulation.
- FiO2 varies with flow rate and breathing; extended use can cause skin breakdown and dry mucous membranes; tubing easily dislodged.
- Assess nares patency, ensure proper prong fit, use water-soluble gel, and provide humidification for flows above 4 L/min.
Simple Face Mask
- Delivers FiO2 of 35% to 60% at 5 to 10 L/min; minimum flow is 5 L/min to flush CO2.
- Easy to apply, more comfortable than nasal cannula, simple delivery method, provides humidified oxygen.
- Flow rates below 5 L/min can cause CO2 rebreathing; poorly tolerated by anxious or claustrophobic clients; impairs eating, drinking, and talking; risk of aspiration.
- Ensure proper fit, use nasal cannula during meals, use cautiously with aspiration risk, and monitor for skin breakdown.
Partial Rebreather Mask
- Delivers FiO2 of 60% to 90% at 10 to 15 L/min.
- Reservoir bag allows rebreathing of exhaled air with room air, easier humidification.
- Deflation of reservoir bag causes CO2 buildup; FiO2 varies with breathing pattern; poorly tolerated by anxious clients; bag can twist.
- Keep reservoir bag one-third to one-half full during inspiration, assess fit, and use cautiously with aspiration risk.
Non-rebreather Mask
- Delivers FiO2 of 80% to 95% at 10 to 15 L/min to keep reservoir bag two-thirds full during inspiration and expiration.
- Delivers highest possible O2 concentration without intubation; one-way valve maximizes O2 intake.
- Valve must be intact; poorly tolerated by anxious clients; impairs eating, drinking, and talking; use cautiously with aspiration risk.
- Perform hourly valve/flap assessment; ensure secure seal; use nasal cannula during meals.
High-Flow Oxygen Delivery Systems
- Deliver precise oxygen concentrations with added humidity.
Venturi Mask
- Delivers FiO2 of 24% to 60% at 4 to 15 L/min via adapters for specific air/oxygen mix.
- Delivers most precise oxygen concentration, best for chronic lung disease.
- Expensive; impairs eating, drinking, and talking; mask and humidity can cause skin breakdown.
- Frequently assess flow rate and proper fit; keep tubing free of kinks; use nasal cannula during meals.
Aerosol Mask
- Delivers FiO2 of 24% to 100% at >10 L/min, provides high humidification. Face tent fits loosely; tracheostomy collar covers surgical opening.
- Useful for mask intolerance, facial trauma, burns, thick secretions.
- High humidification requires frequent monitoring.
- Empty condensation, ensure adequate water in canister, verify aerosol mist, and prevent tracheostomy tube pull.
Complications of Oxygen Therapy
- Oxygen toxicity can result from high O2 concentrations (> 50%), long duration (> 24-48 hours), and lung disease severity.
- Manifestations: Nonproductive cough, substernal pain, nausea, vomiting, fatigue, dyspnea, restlessness, paresthesias.
- Use lowest necessary oxygen level, monitor ABGs, decrease FiO2 as SpO2 improves.
- Oxygen-induced hypoventilation occurs in clients with alveolar hypoventilation.
- Monitor respiratory rate, pattern, level of consciousness, behavior, and SpO2. Use Venturi mask if tolerated, and notify provider of impending respiratory depression.
- Oxygen is combustible.
- Post "No Smoking" signs; know fire extinguisher location; educate on fire hazards; use cotton gowns; ensure electrical devices are working and grounded; avoid flammable materials.
Airway Clearance
- Mucosal secretion buildup or aspiration can obstruct the airway.
- Hydration and coughing maintain airway patency.
- Includes assistance with coughing, hydration, positioning, humidification, nebulizer therapy, chest physiotherapy, and suctioning.
- Promotes adequate gas exchange and lung expansion.
Airway Clearance Indications
- Infants
- Neuromuscular disorders
- Quadriplegics
- Cystic fibrosis
- Hypoxia (restlessness, irritability, tachypnea, tachycardia, cyanosis, decreased level of consciousness, decreased SpO2 levels)
- Adventitious breath sounds
- Visible secretions
- Absence of spontaneous cough
Airway Clearance Considerations
- Humidification moistens and loosens secretions.
- Nebulization breaks up medications (bronchodilators, mucolytic agents) for better clearance.
- Chest physiotherapy (percussion, vibration, postural drainage) mobilizes secretions.
- Early-morning postural drainage mobilizes secretions accumulated overnight.
Airway Clearance - Nursing Actions
- Encourage coughing (more effective than suctioning).
- Suction orally, nasally, or endotracheally only when needed.
- Maintain surgical asepsis for tracheal suctioning.
Suctioning Precautions
- Wear PPE
- Assist client to high-Fowler's, if able
- Encourage deep breathing
- Obtain baseline breath sounds and vital signs (SaO2)
- Yankauer catheter used for oropharyngeal suctioning
- Flexible catheters used for nasopharyngeal or nasotracheal suctioning
- Catheter should not exceed one half of the internal diameter of the endotracheal tube
- Hyperoxygenate if using endotracheal suctioning
- Use medical asepsis for mouth, surgical for all other suctioning
- Use suction pressure no higher than 120 to 150 mm Hg
- Limit each suction attempt to 10 to 15 seconds, with total suctioning time to 5 min
Nasopharyngeal and Nasotracheal Suctioning Additional Guidelines
- Insert during inhalation
- No suctioning on insertion
- Slant catheter downward and advance 6 to 8 in
- Apply intermittent suction for 10 to 15 seconds while withdrawing, rotate catheter
- Two passes max, 1 min rest between passes
Endotracheal Suctioning Additional Guidelines
- Remove bag or ventilator, insert catheter until resistance met
- Pull back catheter 1 cm before suctioning to prevent damage
- Apply intermittent suction for 10 to 15 seconds while withdrawing, rotate catheter
- Reattach bag/ventilator, administer 100% oxygen
- Rinse catheter with sterile saline
- Don't reuse catheter
Sputum Specimen Collection
- Collect sputum for cytology to identify aberrant cells or cancer.
- Collect sputum for culture and sensitivity to identify micro-organisms and effective antibiotics.
- Collect sputum to identify acid-fast bacilli (AFB) to diagnose tuberculosis (requires three consecutive morning samples).
Sputum Specimen - Nursing Actions
- Obtain specimens in the early morning, 1 to 2 hours after eating.
- Perform chest physiotherapy to help mobilize secretions.
- Use sterile specimen container, label, laboratory requisition slip, and biohazard bag.
- Use container with preservative for cytology specimens.
- Collect sputum specimens by suctioning during coughing.
- If a client cannot cough effectively, collect the specimen by endotracheal suctioning.
- Older adults may require suctioning due to weak cough reflex and decreased muscle strength.
Chest Physiotherapy
- Techniques loosen respiratory secretions and move them to central airways for removal by coughing or suctioning.
- Administer a bronchodilator medication or nebulizer treatment 30 min to 1 hr prior to postural drainage.
Chest Physiotherapy - Contraindications
- Pregnancy
- Rib, chest, head, or neck injury
- Increased intracranial pressure
- Recent abdominal surgery
- Pulmonary embolism
- Bleeding disorders or osteoporosis
Chest Physiotherapy - Nursing Actions
- Schedule treatments 1 hour before or 2 hours after meals, and at bedtime.
- Offer emesis basin and tissues; use cupped hands for chest percussion.
- Tense hand and arm muscles to create vibration during client exhalation.
- Have the client remain in each position for 10 to 15 min for percussion, vibration, and postural drainage.
- Discontinue if client reports faintness or dizziness.
- Position client properly to promote drainage of specific lung areas.
Positioning for Lung Drainage
- Both lobes in general: High Fowler’s
- Apical segments of both lobes: Sitting on the side of the bed
- Right upper lobe, anterior segment: Supine with head elevation
- Right upper lobe, posterior segment: on the left side with a pillow under the right side of the chest
- Right middle lobe, anterior segment: three-quarters supine with dependent lung in Trendelenburg
- Right middle lobe, posterior segment: prone with thorax and abdomen elevation
- Right lower lobe, lateral segment: on the left side in Trendelenburg
- Left upper lobe, anterior segment: supine with head elevation
- Left upper lobe, posterior segment: on the right side with a pillow under the left side of the chest
- Left lower lobe, lateral segment: on the right side in Trendelenburg
- Both lower lobes, anterior segments: supine in Trendelenburg
- Both lower lobes, posterior segments: prone in Trendelenburg
Tracheal Suctioning
- Tracheal suctioning is indicated for early signs of hypoxemia.
- Hypoxemia signs may be: restlessness, confusion, tachypnea/tachycardia, decreased SpO2 levels, adventitious breath sounds, cyanosis, and absence of spontaneous cough
Artificial Airways and Tracheostomy Care
- A tracheotomy is a sterile surgical incision into the trachea to establish an airway, can be emergency or scheduled, temporary or permanent.
- A tracheostomy is the stoma from a tracheotomy, providing a patent airway.
Tracheostomy Indications
- Acute or chronic upper airway obstruction
- Edema
- Anaphylaxis
- Burns
- Trauma
- Head/neck surgery
- Copious secretions
- Obstructive sleep apnea
- Long-term mechanical ventilation
- Laryngeal trauma or cancer surgery
Single-Lumen (Cannula) Tracheostomy Tube
- Long, single-cannula tube, for clients with long or thick necks.
- Do not use with clients who have excessive secretions.
Double-Lumen (Cannula) Tracheostomy Tube
- Includes outer cannula, inner cannula, and obturator.
- Facilitates inner cannula removal, cleaning, replacement.
- Useful for clients who have excessive secretions.
Cuffed Tracheostomy Tube
- Balloon inflates around the distal segment, protecting the lower airway.
- Permits mechanical ventilation, prevents aspiration, but inhibits speech.
- Cuff pressures must be monitored to prevent tracheal tissue necrosis.
Cuffless Tracheostomy Tube
- For long-term airway management
- Requires low aspiration risk
- Not for mechanical ventilation
- Allows speech
Fenestrated Tracheostomy Tube with Cuff
- Openings in the posterior wall with a balloon, includes inner cannula
- Allows ventilation with speech
Fenestrated Tracheostomy Tube without Cuff
- Openings in the posterior wall with no balloon, includes inner cannula.
- Helps wean from tracheostomy, facilitates speech.
Tracheostomy Care - Nursing Actions
- Keep spare tracheostomy tubes, obturator, oxygen source, suction catheters, and BVM at bedside.
- Provide communication methods.
- Use emergency call system.
- Maintain humidification and hydration.
- Provide oral care every 2 hours, tracheostomy care every 8 hours, and suction if necessary.
- Apply oxygen loosely during the procedure if SpO2 decreases.
- Use surgical asepsis to clean the inner cannula, replace soiled dressings, and clean the stoma site.
- Secure new tracheostomy ties before removing soiled ones; ensure one or two fingers fit between the tie and the neck.
- Change nondisposable tubes every 6 to 8 weeks, reposition the client every 2 hours, and minimize dust in the room.
- If the client is permitted to eat, position them upright and tip the chin to the chest to enable swallowing. Assess for aspiration.
- Accidental decannulation within 72 hours is an emergency. Ventilate with BVM, call for assistance.
- If unable to replace the tracheostomy tube, administer oxygen through the stoma or through the nose and mouth.
Damage to Trachea
- Tracheal stenosis: Narrowing of the tracheal lumen due to scar formation resulting from irritation of the tracheal mucosa from the tracheal tube cuff.
- Keep the cuff pressure between 14 and 20 mm Hg.
- Tracheal wall necrosis: Tissue damage that results when the pressure of the inflated cuff impairs blood flow to the tracheal wall.
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