Question 1

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

Accepted Answer

A)  Brushing teeth with chlorhexidine at least every 8 hours 
B)  Maintaining the endotracheal pressure at 10 cm H2O 
C)  Positioning the patient flat during tube feedings 
D)  Repositioning the patient every 4 hours 
A)  Brushing teeth with chlorhexidine at least every 8 hours 
B)  Maintaining the endotracheal pressure at 10 cm H2O 
C)  Positioning the patient flat during tube feedings 
D)  Repositioning the patient every 4 hours

Question 2

The nurse suctions the patient's artificial airway.For which adverse effect related to suctioning should the nurse monitor during the procedure?

Accepted Answer

A)  Fatigue 
B)  Anxiety 
C)  Coughing 
D)  Dysrhythmias 
A)  Fatigue 
B)  Anxiety 
C)  Coughing 
D)  Dysrhythmias

Question 3

The nurse uses a closed-system (in-line)endotracheal (ET)suctioning system for the patient.Which does the nurse implement to prevent airway interference?

Accepted Answer

A)  Inserts the catheter between ventilator cycles to avoid airway interference 
B)  Inserts the catheter 25.4 cm (10 inches) and applies continuous suction during withdrawal 
C)  Visualizes the black line in the sheath of the catheter before completing the procedure 
D)  Withdraws the suction catheter and discards it after completing the procedure 
A)  Inserts the catheter between ventilator cycles to avoid airway interference 
B)  Inserts the catheter 25.4 cm (10 inches) and applies continuous suction during withdrawal 
C)  Visualizes the black line in the sheath of the catheter before completing the procedure 
D)  Withdraws the suction catheter and discards it after completing the procedure

Question 4

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

Accepted Answer

A)  Increased pulse rate 
B)  Increased restlessness 
C)  A complaint of slight lethargy 
D)  An oxygen saturation of 95% 
A)  Increased pulse rate 
B)  Increased restlessness 
C)  A complaint of slight lethargy 
D)  An oxygen saturation of 95%

Question 5

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?

Accepted Answer

A)  Creates a method for counting respirations 
B)  Compensates for leaks in tubing connections 
C)  Maintains up to 20 cm of intrapleural pressure 
D)  Facilitates bubbling for pressure over 20 mm Hg 
A)  Creates a method for counting respirations 
B)  Compensates for leaks in tubing connections 
C)  Maintains up to 20 cm of intrapleural pressure 
D)  Facilitates bubbling for pressure over 20 mm Hg

Question 6

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 should be taken by the nurse immediately?

Accepted Answer

A)  Notify the healthcare provider. 
B)  Perform a cardiopulmonary assessment. 
C)  Elevate the head of the bed to 60 degrees. 
D)  Provide the patient with pain medication. 
A)  Notify the healthcare provider. 
B)  Perform a cardiopulmonary assessment. 
C)  Elevate the head of the bed to 60 degrees. 
D)  Provide the patient with pain medication.

Question 7

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

Accepted Answer

A)  Assess breath sounds. 
B)  Discontinue suctioning. 
C)  Instruct the patient to cough. 
D)  Ventilate the patient manually. 
A)  Assess breath sounds. 
B)  Discontinue suctioning. 
C)  Instruct the patient to cough. 
D)  Ventilate the patient manually.

Question 8

2. A ____________ contains a one-way valve with a reservoir,which does not allow exhaled air to enter the reservoir bag.It prevents inhalation of room air.

Accepted Answer

Nonrebreathing mask
Device of

Question 9

A patient with chronic bronchitis is not responding well to the chest physiotherapy (CPT)and asks the nurse what might be done to help bring up more secretions.Which response by the nurse is most appropriate?

Accepted Answer

A)  "Your healthcare provider will probably increase the number of treatments but make them a little shorter." 
B)  "Your healthcare provider may try a nebulizer treatment 20 minutes before CPT to begin loosening the secretions." 
C)  "You'll probably need to do more coughing exercises; I'll help you with them." 
D)  "Your healthcare provider will probably order a sputum specimen to see what the problem is." 
A)  "Your healthcare provider will probably increase the number of treatments but make them a little shorter." 
B)  "Your healthcare provider may try a nebulizer treatment 20 minutes before CPT to begin loosening the secretions." 
C)  "You'll probably need to do more coughing exercises; I'll help you with them." 
D)  "Your healthcare provider will probably order a sputum specimen to see what the problem is."

Question 10

The nurse teaches the patient controlled coughing.Which should the nurse include in patient teaching for effective coughing?

Accepted Answer

A)  Cough in a low-Fowler's position hourly. 
B)  Inhale and cough deeply with the mouth open. 
C)  Self-reposition and cough every 4 hours. 
D)  Breathe in quickly 3 to 4 times vigorously. 
A)  Cough in a low-Fowler's position hourly. 
B)  Inhale and cough deeply with the mouth open. 
C)  Self-reposition and cough every 4 hours. 
D)  Breathe in quickly 3 to 4 times vigorously.

Question 11

The nurse performs tracheostomy care for the patient.Which instruction does the nurse give to nursing assistive personnel (NAP)to implement while changing the ties of the tracheostomy tube?

Accepted Answer

A)  Prevent the patient from coughing out the tube. 
B)  Don sterile gloves before providing assistance. 
C)  Inject sterile saline solution into the tracheostomy. 
D)  Hold the tracheostomy tube securely in place. 
A)  Prevent the patient from coughing out the tube. 
B)  Don sterile gloves before providing assistance. 
C)  Inject sterile saline solution into the tracheostomy. 
D)  Hold the tracheostomy tube securely in place.

Question 12

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

Accepted Answer

A)  Instruct the nursing assistive personnel (NAP) to apply pressure for 5 minutes. 
B)  Replace the water-seal drainage system with a sterile waterless unit quickly. 
C)  Hold a towel firmly over the site and send for petrolatum gauze. 
D)  Push the tube into place and apply an occlusive sterile dressing. 
A)  Instruct the nursing assistive personnel (NAP) to apply pressure for 5 minutes. 
B)  Replace the water-seal drainage system with a sterile waterless unit quickly. 
C)  Hold a towel firmly over the site and send for petrolatum gauze. 
D)  Push the tube into place and apply an occlusive sterile dressing.

Question 13

A patient with a water-sealed chest tube unit is connected to suction.Patient care is correct if the nurse takes which action?

Accepted Answer

A)  Monitors the bubbling of sterile water in the water-seal chamber 
B)  Strips the tube every 2 hours for 15 seconds to prevent clots 
C)  Clamps the chest tube when transporting the patient 
D)  Keeps two toothed clamps at the bedside for an emergency 
A)  Monitors the bubbling of sterile water in the water-seal chamber 
B)  Strips the tube every 2 hours for 15 seconds to prevent clots 
C)  Clamps the chest tube when transporting the patient 
D)  Keeps two toothed clamps at the bedside for an emergency

Exam 14: Promoting Oxygenation

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

The nurse suctions the patient's artificial airway.For which adverse effect related to suctioning should the nurse monitor during the procedure?

The nurse uses a closed-system (in-line)endotracheal (ET)suctioning system for the patient.Which does the nurse implement to prevent airway interference?

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

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?

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 should be taken by the nurse immediately?

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

2. A ____________ contains a one-way valve with a reservoir,which does not allow exhaled air to enter the reservoir bag.It prevents inhalation of room air.

A patient with chronic bronchitis is not responding well to the chest physiotherapy (CPT)and asks the nurse what might be done to help bring up more secretions.Which response by the nurse is most appropriate?

The nurse teaches the patient controlled coughing.Which should the nurse include in patient teaching for effective coughing?

The nurse performs tracheostomy care for the patient.Which instruction does the nurse give to nursing assistive personnel (NAP)to implement while changing the ties of the tracheostomy tube?

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

A patient with a water-sealed chest tube unit is connected to suction.Patient care is correct if the nurse takes which action?

Using Evidence in Nursing Practice

Communication and Collaboration

Documentation and Informatics

Patient Safety and Quality Improvement

Infection Control

Vital Signs

Health Assessment

Specimen Collection

Diagnostic Procedures

Bathing and Personal Hygiene

Care of the Eye and Ear

Promoting Nutrition

Pain Management

Safe Patient Handling, transfer, and Positioning

Exercise Mobility

Traction, cast Care, and Immobilization Devices

Urinary Elimination

Bowel Elimination and Gastric Intubation

Ostomy Care

Preparation for Safe Medication Administration

Administration of Nonparenteral Medications

Administration of Parenteral Medications

Wound Care and Irrigation

Pressure Ulcers

Dressings,bandages,and Binders

Intravenous and Vascular Access Therapy

Preoperative and Postoperative Care

Emergency Measures for Life Support in the Hospital Setting

Palliative Care

Home Care Safety

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