Exam 16: Promoting Oxygenation

The nurse fills the suction-control chamber with water to the 20-cm line while setting up a water-seal chest drainage system.Which rationale does the nurse use to explain this intervention?

The nurse is attempting to prevent ventilator-associated pneumonia (VAP) in a newly intubated patient.Which activities would best support this goal?

The nurse notes that the patient's chest tube pulled out by 5.1 cm (2 inches) during turning and repositioning.Which is the initial action by the nurse?

The patient with a mediastinal tube placed 22 hours ago has produced 350 mL of drainage since insertion.Which action by the nurse would be most appropriate?

Nasotracheal suctioning is performed on a patient who is unable to take deep breaths.What action by the nurse would best meet the patient's needs before suctioning?

The patient uses continuous positive airway pressure (CPAP) at home and tells the home care nurse that the mask fits too tightly.Which action is most important for the nurse to take?

A patient admitted for asthma is weak and tired.Which patient position does the nurse use for patient performance of a peak expiratory flow rate (PEFR)?

A patient in respiratory distress is admitted to critical care.Which type of mask would the nurse anticipate using to deliver the highest FIO₂ without intubation?

The nurse sees that a patient with a chest tube has intermittent bubbling in the water-seal chamber 4 hours after the chest tube was inserted.What action by the nurse is most appropriate at this time?

The patient is lethargic and unable to clear oral secretions effectively.How does the nurse manage the suctioning of the oropharyngeal secretions from the patient?

An older-adult patient with a nasal cannula and extension tubing is able to get out of bed independently.What teaching by the nurse is indicated for this patient?

The nurse assesses the SaO₂ a patient who receives oxygen at 3 L/min by nasal cannula.The SaO₂ at 8 AM was 94 mm Hg, and at 10 AM it was 92 mm Hg.Which action by the nurse is most appropriate?

A home care patient receives oxygen by nonrebreather (NRB) mask.Which does the nurse include when teaching the caregiver about the oxygen-delivery system?

The nurse suctions the patient's endotracheal tube, and the patient becomes hypoxic.Which is the priority nursing intervention to increase patient oxygenation?

The nurse prepares to perform oropharyngeal suctioning on an adult.Nursing care is appropriate if which wall suction pressure is used?

A patient with newly diagnosed asthma is asking why peak flow measurements are being ordered.What is the best response by the nurse?

A nurse is suctioning a patient through a tracheostomy.Which change in the patient's status would cause the nurse to discontinue the procedure?

The nurse institutes oxygen therapy for the patient.Which goal should the nurse set as a positive patient outcome of airway maintenance?

The nurse is preparing to assist the physician in the removal of a chest tube.Which item does the nurse is available to be placed over the insertion site as soon as the chest tube is removed?

A patient with a major chest injury was originally alert and oriented after recovery from surgery but is now becoming apprehensive and dizzy.What action by the nurse takes priority?