Respiratory Chapters Questions from Med Surg Study Guide Flashcards
What is an advantage of a tracheostomy over an endotracheal (ET) tube for long-term management of an upper airway obstruction?
a. A tracheostomy is safer to perform in an emergency.
b. An ET tube has a higher risk of tracheal pressure necrosis.
c. A tracheostomy tube allows for more comfort and mobility.
d. An ET tube is more likely to lead to lower respiratory tract infection.
C. With a tracheostomy (versus an endotracheal [ET]
tube), patient comfort is increased because there is no
tube in the mouth. Because the tube is more secure,
mobility is improved. The ET tube is more easily inserted
in an emergency situation. It is preferable to perform a tracheostomy in the operating room because it requires careful dissection but it can be performed with local anesthetic in the intensive care unit (ICU) or in an emergency. With a cuff, tracheal pressure necrosis is as much a risk with a tracheostomy tube as with an ET tube and infection is also as likely to occur because the defenses of the upper airway are bypassed.
What are the characteristics of a fenestrated tracheostomy tube (select all that apply)?
a. The cuff passively fills with air.
b. Cuff pressure monitoring is not required.
c. It has two tubings with one opening just above the cuff.
d. Patient can speak with an attached air source with the cuff inflated.
e. Airway obstruction is likely if the exact steps are not followed to produce speech.
f. Airflow around the tube and through the window allows speech when the cuff is deflated and the plug is inserted.
e, f. The fenestrated tracheostomy tube has openings on the outer cannula to allow air to pass over the vocal cords to allow speaking. If the steps of using the fenestrated tracheostomy tube are not completed in the correct order, severe respiratory distress may result. The cuff of the tracheostomy tube with a foam-filled cuff passively fills with air and does require pressure monitoring, although cuff integrity must be assessed daily. The speaking tracheostomy tube has two tubes attached. One tube allows air to pass over the vocal cords to enable the person to speak with the cuff inflated.
During care of a patient with a cuffed tracheostomy, the nurse notes that the tracheostomy tube has an inner cannula.
To care for the tracheostomy appropriately, what should the nurse do?
a. Deflate the cuff, then remove and suction the inner cannula.
b. Remove the inner cannula and replace it per institutional guidelines.
c. Remove the inner cannula if the patient shows signs of airway obstruction.
d. Keep the inner cannula in place at all times to prevent dislodging the tracheostomy tube
b. An inner cannula is a second tubing that fits inside the outer tracheostomy tube. Disposable inner cannulas are frequently used but nondisposable ones can be removed and cleaned of mucus that has accumulated on the inside of the tube. Many tracheostomy tubes do not have inner cannulas because when humidification is adequate, accumulation of mucus should not occur.
Which actions prevent the dislodgement of a tracheostomy tube in the first 3 days after its placement (select all that apply)?
a. Provide tracheostomy care every 24 hours.
b. Keep the patient in the semi-Fowler position at all times.
c. Keep a same size or larger replacement tube at the bedside.
d. Tracheostomy ties are not changed for 24 hours after tracheostomy procedure.
e. Suction the tracheostomy tube when there is a moist cough or a decreased SpO2.
f. A physician performs the first tube change, no sooner than 7 days after the tracheostomy.
d, e, f. Changing the tracheostomy tapes or the tube too
soon will be irritating to the trachea and could contribute to dislodgement of the tracheostomy tube. Suctioning should be done when increased secretions are evident in the tube to prevent the patient from severe coughing, which could cause tube dislodgement. Tracheostomy care is done every 8 hours. Keeping the patient in a semi-Fowler position will not prevent dislodgement. Keeping an extra tube at the bedside will speed reinsertion if the tracheostomy tube is dislodged but it will not prevent dislodgement.
Delegation Decision: In planning the care for a patient with a tracheostomy who has been stable and is to be
discharged later in the day, the RN may delegate which interventions to the licensed practical nurse (LPN) (select all that apply)?
a. Suction the tracheostomy.
b. Provide tracheostomy care.
c. Determine the need for suctioning.
d. Assess the patient’s swallowing ability.
e. Teach the patient about home tracheostomy care.
a, b, c. LPNs may determine the need for suctioning, suction the tracheostomy, and determine whether the patient has improved after the suctioning when caring for stable patients. They also may perform tracheostomy care using sterile technique. The patient’s swallowing ability is assessed by a speech therapist, videofluoroscopy, or fiberoptic endoscopic evaluations. The RN will teach the patient about home tracheostomy care.
What is included in the nursing care of the patient with a cuffed tracheostomy tube?
a. Change the tube every 3 days.
b. Monitor cuff pressure every 8 hours.
c. Perform mouth care every 12 hours.
d. Assess arterial blood gases every 8 hours.
b. Cuff pressure should be monitored every 8 hours to ensure that an air leak around the cuff does not occur and that the pressure is not too high to allow adequate tracheal capillary perfusion. Respiratory therapists in some institutions will record the cuff pressure but the nurse must be able to assess cuff pressure and identify if there is a problem maintaining cuff pressure. Tracheostomy tubes are not usually changed sooner than 7 days after a tracheotomy. Mouth care should be performed a minimum of every 8 hours and more often as needed to remove dried secretions. ABGs are not routinely assessed with tracheostomy tube placement unless symptoms of respiratory distress continue.
Priority Decision: A patient’s tracheostomy tube becomes dislodged with vigorous coughing. What should be the
nurse’s first action?
a. Attempt to replace the tube.
b. Notify the health care provider.
c. Place the patient in high Fowler position.
d. Ventilate the patient with a manual resuscitation bag until the health care provider arrives.
a. If a tracheostomy tube is dislodged, the nurse should immediately attempt to replace the tube by grasping the retention sutures (if available) and spreading the opening. The obturator is inserted in the replacement tube, water- soluble lubricant is applied to the tip, and the tube is inserted in the stoma at a 45-degree angle to the neck. The obturator is immediately removed to provide an airway. If the tube cannot be reinserted, the health care provider should be notified and the patient should be assessed for the level of respiratory distress, positioned in semi-Fowler position, and ventilated with a manual resuscitation bag (MRB) only if necessary until assistance arrives.
When obtaining a health history from a patient with possible cancer of the mouth, what would the nurse expect the patient to report?
a. Long-term denture use
b. Heavy tobacco and/or alcohol use
c. Persistent swelling of the neck and face
d. Chronic herpes simplex infections of the mouth and lips
b. The primary risk factors associated with head and neck cancers are heavy tobacco and alcohol use and family history. Chronic infections are not known to be risk factors, although cancers in patients younger than age 50 have been associated with human papillomavirus (HPV) infection. Oral cancer may cause a change in the fit of dentures but denture use is not a risk factor for oral cancer.
The patient has been diagnosed with an early vocal cord malignancy. The nurse explains that usual treatment
includes
a. radiation therapy that preserves the quality of the voice.
b. a hemilaryngectomy that prevents the need for a tracheostomy.
c. a radical neck dissection that removes possible sites of metastasis.
d. a total laryngectomy to prevent development of second primary cancers
a. If laryngeal tumors are small, radiation is the treatment of choice because it can be curative and can preserve voice quality. Surgical procedures are used if radiation treatment is not successful or if larger or advanced lesions are present.
During preoperative teaching for the patient scheduled for a total laryngectomy, what should the nurse include?
a. The postoperative use of nonverbal communication techniques
b. Techniques that will be used to alleviate a dry mouth and prevent stomatitis
c. The need for frequent, vigorous coughing in the first 24 hours postoperatively
d. Self-help groups and community resources for patients with cancer of the larynx
a. With removal of the larynx, the patient will not be able
to communicate verbally and it is important to arrange
with the patient a method of communication before surgery so that postoperative communication can take place. Dry mouth and stomatitis result from radiation therapy. Vigorous coughing is not encouraged immediately postoperatively and information related to community resources is usually introduced during the postoperative period.
When assessing the patient on return to the surgical unit following a total laryngectomy and radical neck dissection,
what would the nurse expect to find?
a. A closed-wound drainage system
b. A nasal endotracheal tube in place
c. A nasogastric tube with orders for tube feedings
d. A tracheostomy tube and mechanical ventilation
a. Following a radical neck dissection, drainage tubes are often used to prevent fluid accumulation in the wound as well as possible pressure on the trachea. The patient has placement of a nasogastric tube to suction immediately after surgery, which will later be used to administer tube feedings until swallowing can be accomplished. A tracheostomy tube is in place but mechanical ventilation is usually not indicated.
Following a supraglottic laryngectomy, the patient is taught how to use the supraglottic swallow to minimize the risk of aspiration. In teaching the patient about this technique, what should the nurse instruct the patient to do?
a. Perform Valsalva maneuver immediately after swallowing.
b. Breathe between each Valsalva maneuver and cough sequence.
c. Cough after swallowing to remove food from the top of the vocal cords.
d. Practice swallowing thin, watery fluids before attempting to swallow solid foods.
c. A supraglottic laryngectomy involves removal of the epiglottis and false vocal cords and the removal of the epiglottis allows food to enter the trachea. Supraglottic swallowing protects the trachea from aspiration by taking a deep breath, putting the food or fluid in the mouth, swallowing while holding the breath, coughing immediately after swallowing to remove the food from the top of the vocal cord, swallowing again, then breathing. Super-supraglottic swallowing requires performance of the Valsalva maneuver before placing food in the mouth and swallowing. See Table 27-9.
What should the nurse include in discharge teaching for the patient with a total laryngectomy?
a. How to use esophageal speech to communicate
b. How to use a mirror to suction the tracheostomy
c. The necessity of never covering the laryngectomy stoma
d. The need to use baths instead of showers for personal hygiene
b. Suctioning of the tracheostomy with the use of a mirror is a self-care activity taught to the patient before discharge. Voice rehabilitation is usually managed by a speech therapist or speech pathologist but the nurse should discuss the various types of voice rehabilitation and the advantages and disadvantages of each option. The laryngectomy stoma should be covered with a shield during showering and covered with light scarves or fabric when aspiration of foreign materials is likely.
What is the most normal functioning method of speech restoration in the patient with a total laryngectomy?
a. Esophageal speech
b. A transesophageal puncture
c. An electrolarynx held to the neck
d. An electrolarynx placed in the mouth
b. Transesophageal puncture provides the most normal voice reproduction but requires a surgical fistula made between the esophagus and the trachea and possibly a valve prosthesis. Esophageal speech involves trapping air in the esophagus and releasing it to form sound but only 10% of patients can develop fluent speech with this method. The electrolarynx, whether placed in the mouth or held to the neck, allows speech that has a metallic or robotic sound.
A male patient has chronic obstructive pulmonary disease (COPD) and is a smoker. The nurse notices respiratory distress and no breath sounds over the left chest. Which type of pneumothorax should the nurse suspect is occurring?
a. Tension pneumothorax
b. Iatrogenic pneumothorax
c. Traumatic pneumothorax
d. Spontaneous pneumothorax
d. Spontaneous pneumothorax is seen from the rupture of small blebs on the apex of the lung in patients with lung disease or smoking, as well as in tall, thin males with a family history of or a previous spontaneous pneumothorax. Tension pneumothorax occurs with mechanical ventilation and with blocked chest tubes. Iatrogenic pneumothorax occurs due to the laceration or puncture of the lung during medical procedures. Traumatic pneumothorax can occur with penetrating or blunt chest trauma.
