Deck 62: Oxygenation

Question 1

The nurse has been asked to obtain a sputum specimen from a client who is in the first postoperative day after a surgical gastric resection for stomach cancer. The nurse will ensure that which item is provided to the client to ensure an effective sputum collection?

A)Supplemental oxygen
B)Folded bath blanket
C)Peak expiratory flow meter
D)Sterile applicator stick

Answer 1

Folded bath blanket

Question 2

The nurse has just completed insertion of a nasal trumpet to assist in protecting a responsive client's airway and should place the client in which position to maintain the airway?

A)Supine with the head to the side
B)Side-lying with chin positioned closest to the chest
C)Prone with head to the side
D)Side-lying with head slightly tilted up and centered on the pillow

Answer 2

Side-lying with head slightly tilted up and centered on the pillow

Question 3

The nurse observes a client using the incentive spirometer and s that further instruction is required when the client performs which action?

A)Exhales before placing the incentive spirometer to the lips
B)Seals the lips tightly around the mouthpiece of the incentive spirometer
C)Inhales quickly, causing the spirometer balls to snap to the top of the incentive spirometer
D)Attempts to cough productively after using the incentive spirometer

Answer 3

Inhales quickly, causing the spirometer balls to snap to the top of the incentive spirometer

Question 4

The nurse should know that which takes priority in assisting the client to effectively use a volume-oriented incentive spirometer?

A)The spirometer must be held in an upright position.
B)A nose clip must be used for effective inhalation.
C)The procedure must be repeated every 15 minutes to be effective.
D)Clean the spirometer in the dishwasher when used at home.

Question 5

The nurse should encourage the client to use incentive spirometry prior to which procedure?

A)Ambulating the client
B)Preparing the client for a rest period
C)Removing the client's meal tray
D)Obtaining a sputum specimen

Question 6

After completing instructions for collecting a sputum specimen to the client, the nurse observes the client remove the lid of the specimen container and spit into the cup. Which is the nurse's next best action?

A)Ask the client if the specimen obtained was sputum or saliva.
B)Explain to the client that the specimen will have to be obtained by suctioning.
C)Provide the client with a new specimen container and explain again how to obtain the specimen.
D)Send the specimen to the lab as obtained but label it as saliva.

Question 7

The nurse is caring for a group of clients with respiratory disorders and should know that which client should not be placed on continuous positive airway pressure (CPAP)to assist with respiratory distress?

A)The client with chronic obstructive pulmonary disease (COPD)who is complaining of shortness of breath
B)The client whose respirations have fallen to 8/minute after receiving morphine sulfate
C)The client who experiences apnea during sleep
D)The client who is experiencing wheezing and is having difficulty moving air adequately

Question 8

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD)who is receiving supplemental oxygen and should intervene if which delivery device is being used by the client?

A)Nasal cannula
B)Continuous positive airway pressure (CPAP)
C)Bilevel positive airway pressure (BiPAP)
D)Venturi face mask

Question 9

The nurse is caring for a client who is exhibiting severe respiratory distress and is receiving supplemental oxygen through a nonrebreather mask. While assessing the client, the nurse notes that the bag attached to the mask is deflated. Which is the nurse's best action?

A)Document it as functioning normally.
B)Decrease the flow of oxygen to the mask.
C)Increase the flow of oxygen to the mask.
D)Prepare for endotracheal intubation.

Question 10

The nurse is observing a new mother use a bulb syringe to suction her newborn's nose and mouth and should provide further instruction if the mother performs which action?

A)The mother begins the procedure by suctioning the infant's nose.
B)The mother deflates the bulb before placing the tip of the bulb syringe in the infant's nose.
C)The mother releases the bulb and removes the bulb syringe from the infant's nose.
D)The mother washes the bulb syringe with soap and water and then allows it to air dry.

Question 11

The nurse is preparing to assist a client in obtaining a sputum specimen and should place the client in which position?

A)Low Fowler's
B)Side-lying
C)Semi-Fowler's
D)Trendelenburg

Question 12

The nurse is caring for an older adult client who had a tracheostomy placed 3 days ago and should know that which issue will take priority when caring for this client?

A)Reducing the client's anxiety concerning self-care of the tracheostomy
B)Reassuring the client that the tracheostomy is a temporary measure
C)Ensuring that the skin around the client's tracheostomy stoma is assessed frequently
D)Referring the client to a support group for individuals with tracheostomies

Question 13

The nurse is assisting a client in obtaining a sputum specimen. After a deep cough, the client produces approximately 1/2 tsp of sputum. Which is the nurse's next action?

A)Assist the client to cough again and produce more sputum.
B)Send the specimen to the lab.
C)Allow the client to rest for one hour and then ask the client to cough again.
D)Ask the client to walk around for 30 minutes and try again to produce sputum.

Question 14

The nurse is caring for a 4-year-old postoperative client who has been unable to understand the use of the incentive spirometer. The nurse should choose which activity that will assist the child to perform the same action as the spirometer?

A)Blowing out candles
B)Sucking on a straw
C)Filling up a balloon
D)Using bubbles

Question 15

The nurse is caring for a client with pneumonia and should be most concerned about which assessment?

A)The client cannot remember which day it is.
B)The client's heart rate has risen from 72 to 78 bpm.
C)The client's pulse oximetry has decreased from 99% to 97%.
D)The client respiratory rate has risen from 16 to 20 breaths per minute.

Question 16

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD)who is experiencing increasing respiratory difficulty. The client has refused being placed on a mechanical ventilator and the nurse is aware that which would provide possible respiratory assistance to this client?

A)Place an endotracheal tube without the use of a mechanical ventilator.
B)Provide supplemental oxygen using a Venturi face mask.
C)Put a nonrebreather mask on the client to help him breathe.
D)Place the client on a bilevel positive airway pressure (BiPAP)machine.

Question 17

The nurse is caring for a client with a respiratory disorder and should alert the healthcare provider if the client displays which signs or symptoms that indicate early hypoxia? Select all that apply.

A)Headache
B)Nausea
C)Heart rate of 52
D)Respiratory rate of 30
E)Blurred vision
F)Hemoglobin of 17.3 mg/dl

Question 18

The nurse is preparing to do tracheostomy care for a client and should know that which must be present at the bedside before beginning this procedure?

A)One pair of sterile gloves
B)Obturator
C)Full-strength hydrogen peroxide
D)Sterile water

Question 19

The nurse is caring for a client who was just placed on supplemental oxygen per nasal cannula and should contact the healthcare provider if which assessment data are noted at the next assessment? Select all that apply.

A)The client complains of feeling anxious and restless.
B)Skin color is pink and warm to touch.
C)The heart rate is 82.
D)The respiratory rate is 36.
E)The client is using accessory muscles to breathe.

Question 20

The nurse is preparing to insert an oropharyngeal airway in an unresponsive client and should do which to ensure the airway is inserted correctly?

A)Using a tongue depressor, push the tongue to the side of the mouth when inserting the airway.
B)Begin the procedure by inserting the airway upside down and then rotating it to the correct position.
C)Position the airway in a downward position and then rotate it upward as it passes by the back of the throat.
D)Refrain from taping the bottom of the airway to prevent esophageal injury when the client swallows.

Question 21

The nurse is preparing to perform tracheostomy care on an alert, cooperative adult client and should request an assistant prior to which step?

A)An assistant is not required when performing tracheostomy care in a cooperative, alert adult client.
B)The assistant is required prior to pouring liquids into the sterile container.
C)The assistant is required prior to removing the inner cannula.
D)The assistant is required prior to removing and placing new tracheostomy ties.

Question 22

The nurse is caring for a client who has a chest tube. Upon assessment, the nurse notes that there is continuous bubbling of water in the suction container of the chest tube but very little if any bubbling in the water seal chamber. Which is the nurse's best action at this time?

A)Contact respiratory therapy for immediate assistance.
B)Reposition the client to the affected side.
C)Auscultate the client's lungs, paying close attention to the area near the chest tube.
D)Wait 15 minutes and reassess the client.

Question 23

The nurse is caring for a client who had a chest tube inserted 48 hours ago. During the first AM assessment, the nurse noted there was intermittent bubbling of the water in the water-seal chamber. When assessing the client 2 hours later, the nurse notes that the water is now continuously bubbling. Which is the nurse's priority action at this time?

A)Document the presence of the bubbling.
B)Immediately contact the healthcare provider.
C)Instruct the client to perform deep-breathing exercises.
D)Disconnect the chest tube from the drainage system and place the chest tube in a new chest tube drainage system.

Question 24

The nurse is preparing to provide tracheostomy care to a 6-month-old infant and should know that which takes priority when performing this procedure?

A)Teaching the parents how to perform the procedure
B)Ensuring that a second person is available to assist with the procedure
C)Completing the procedure while the infant is asleep to minimize traumatizing the infant
D)Use clean rather than sterile procedure because the infant will be going home with the tracheostomy