Deck 36: Oxygenation

Question 1

While a patient is receiving hygiene care,her chest tube becomes disconnected from the water-seal chest drainage unit (CDU).Which action should the nurse take immediately?

A) Clamp the chest tube close to the insertion site.
B) Set up a new drainage system, and connect it to the chest tube.
C) Have the patient take and then hold a deep breath while the nurse reconnects the tube to the CDU.
D) Place the disconnected end nearest the patient into a bottle of sterile water.

Answer 1

Place the disconnected end nearest the patient into a bottle of sterile water.

Question 2

The nurse is caring for a 6-month-old infant diagnosed with RSV,a viral infection causing copious airway secretions.What consideration will influence the nurse's plan of care most?

A) Infants breathe more rapidly than adults.
B) Infants' airways are narrower and more easily obstructed.
C) Infants have lower hemoglobin levels reducing oxygenation.
D) Infants have larger tonsils and adenoids.

Answer 2

Infants' airways are narrower and more easily obstructed.

Question 3

You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury.During your assessment,you notice that the patient's respirations follow a cycle progressively increasing in depth,then progressively decreasing in depth,followed by a period of apnea.Which of the following appropriately describes this respiratory pattern?

A) Biot's breathing
B) Kussmaul's respirations
C) Sleep apnea
D) Cheyne-Stokes respirations

Answer 3

Cheyne-Stokes respirations

Question 4

Which of the following blood levels normally provides the primary stimulus for breathing?

A) pH
B) Oxygen
C) Bicarbonate
D) Carbon dioxide

Question 5

The nurse is administering a purified protein derivative (PPD)test to a homeless client.Which of the following statements concerning PPD testing is true?

A) A positive reaction indicates that the client has active tuberculosis (TB).
B) A positive reaction indicates that the client has been exposed to the disease.
C) A negative reaction always excludes the diagnosis of TB.
D) The PPD can be read within 12 hours after the injection.

Question 6

The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis.Which of the following responses indicates to the nurse that the medication is effective?

A) The amount of sputum the patient expectorates decreases with each dose administered.
B) Cough is completely suppressed, and she is able to sleep through the night.
C) Dry, unproductive cough is reduced, but her voluntary coughing is more productive.
D) Involuntary coughing produces large amounts of thick yellow sputum.

Question 7

The nurse is providing care to a pregnant woman in preterm labor.The patient is 32 weeks pregnant.Initially,the patient states,"I've gained 30 pounds.That should be enough for the baby.Everything will be okay if I deliver now." After teaching the patient about fetal development,the nurse will know her teaching is effective if the patient makes which of the following statements?

A) "The baby's lungs are well developed now, but he will be at increased risk for SIDS if I deliver early."
B) "We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early."
C) "If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening."
D) "Thanks for reassuring me; I was pretty sure there isn't much risk to the baby this far along in my pregnancy."

Question 8

You are caring for an adult patient with a tracheostomy who is being mechanically ventilated.His pulse oximetry reading is 85%,heart rate is 113 beats/min,and respiratory rate is 30 breaths/min.The patient is very restless.His respirations are labored,and you hear gurgling sounds.You auscultate crackles and rhonchi in both lungs.What is the most appropriate action to take?

A) Call the respiratory therapist to check the ventilator settings.
B) Provide endotracheal suctioning.
C) Provide tracheostomy care.
D) Notify the physician of the patient's signs of fluid overload.

Question 9

The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure.The patient is complaining of shortness of breath,and the nurse observes conversational dyspnea.What is the first action the nurse should take?

A) Review and implement the primary care provider's prescriptions for treatments.
B) Perform a quick physical examination of breathing, circulation, and oxygenation.
C) Gather a thorough medical history, including current symptoms, from the family.
D) Administer oxygen to the patient through a nasal cannula.

Question 10

For which patient could the nurse collect a sputum specimen without using a suction catheter?

A) The patient with a newly placed tracheostomy
B) The patient with an endotracheal tube
C) The patient with late-stage amyotrophic lateral sclerosis
D) The patient admitted with chronic bronchitis

Question 11

A 62-year-old man with emphysema says,"My doctor wants me to quit smoking.It's too late now,though; I already have lung problems." Which of the following would be the best response to his statement?

A) "You should quit so your family does not get sick from exposure to secondhand smoke."
B) "You will need to use oxygen, but remember it is a fire hazard to smoke with oxygen in your home."
C) "Once you stop smoking, your body will begin to repair some of the damage to your lungs."
D) "You should ask your primary care provider for a prescription for a nicotine patch to help you quit."

Question 12

A patient has just had a chest tube inserted to dry-seal suction drainage.Which of the following is a correct nursing intervention for maintenance?

A) Keep the head of the bed flat for 6 hours.
B) Avoid using mouth rinses or mouthwashes.
C) Provide the patient with a paper and pencil or letter board.
D) Drain condensation into the humidifier when it collects in the tubing.

Question 13

A nurse is suctioning a male client via a tracheostomy tube.When suctioning,the nurse must limit the suctioning time to a maximum of:

A) 1 minute
B) 5 seconds
C) 15 seconds
D) 30 seconds

Question 14

The patient was admitted to the ICU in respiratory acidosis secondary to smoke inhalation and exposure to caustic gases.After placement of an endotracheal tube and connection to a mechanical ventilator,the arterial blood gas results are pH = 7.28,PaO? = 85,PaCO? = 60.What changes to care does the nurse anticipate?

A) Wean the patient from the ventilator.
B) Increase the concentration of oxygen delivered.
C) Decrease the concentration of oxygen delivered.
D) Increase the number of breaths per minute on the ventilator.

Question 15

A nurse is preparing to obtain a sputum specimen from a male client.Which of the following nursing actions will facilitate obtaining the specimen?

A) Limiting fluid
B) Having the client take deep breaths
C) Asking the client to spit into the collection container
D) Asking the client to obtain the specimen after eating

Question 16

The nurse is planning care for a 70-year-old patient newly admitted with a medical diagnosis of pneumonia and a nursing diagnosis of Ineffective Airway Clearance.Which is the nurse's priority intervention?

A) Teach the importance of pneumonia immunization.
B) Teach coughing and deep breathing exercises.
C) Position to optimize maximum ventilation.
D) Encourage use of incentive spirometer to increase deep breathing.

Question 17

The nurse is caring for a patient diagnosed with pneumonia,teaching him or her how to cough and deep-breathe.The patient asks,"Why is drinking fluids so important?" What is the nurse's best response?

A) "The doctor ordered increased fluid intake."
B) "Fluids prevent pathogens from growing in your lungs."
C) "Fluids help to flush infection away so it doesn't grow in your lungs."
D) "Fluids make secretions thin, making them easier to cough up."

Question 18

When using sterile technique to perform tracheostomy care of a new tracheostomy,which of the following is correct?

A) You will need a single pair of sterile gloves.
B) Place the patient in semi-Fowler's position, if possible.
C) Clean the stoma under the faceplate with hydrogen peroxide.
D) Cut a slit in sterile 4 in. ´ 4 in. gauze halfway through to make a dressing.

Question 19

The nurse is caring for a patient admitted with a diagnosis of muscular dystrophy resulting in inadequate muscle strength to draw enough air into the lungs.What nursing diagnosis would be most appropriate for this patient?

A) Ineffective Breathing Pattern
B) Ineffective Airway Clearance
C) Impaired Gas Exchange
D) Impaired Spontaneous Ventilation

Question 20

The nurse administers intravenous morphine sulfate to a patient for pain control.She will need to monitor her patient for which of the following adverse effects?

A) Decreased heart rate
B) Muscle weakness
C) Decreased urine output
D) Respiratory depression

Question 21

Obesity is associated with higher risk for which of the following conditions that affect the pulmonary and cardiovascular systems? Select all that apply.

A) Reduced alveolar-capillary gas exchange
B) Lower respiratory tract infections
C) Sleep apnea
D) Hypertension

Question 22

The nurse is caring for a patient with an acute asthma event.What classification of medications would the nurse anticipate administering to this patient? Select all that apply.

A) Expectorant
B) Corticosteroid
C) Bronchodilator
D) Cough suppressant
E) Antibiotic

Question 23

Which procedure can the nurse safely delegate to the certified nursing assistant who is knowledgeable and experienced in the procedure?

A) Suctioning the newly placed tracheostomy tube
B) Suctioning the endotracheal tube
C) Suctioning the laryngopharynx
D) Suctioning the oropharynx

Question 24

When providing safety education to the mother of a toddler,you would inform the mother that,based on the child's developmental stage,he is at high risk for which of the following factors that influence oxygenation? Select all that apply.

A) Frequent, serious respiratory infections
B) Airway obstruction from aspiration of small objects
C) Drowning in small amounts of water around the home
D) Development of asthma

Question 25

Which of the following factors influence normal lung volumes and capacities? Select all that apply.

A) Age
B) Race
C) Body size
D) Activity level

Question 26

The nurse admits a patient to the surgical unit from the postanesthesia care unit.The patient has an oral airway in place and awakens only to painful stimuli.What is the priority nursing action?

A) Remove the oral airway and elevate the head of the bed.
B) Position the patient with the head turned to the side.
C) Measure vital signs and check surgical dressing.
D) Call the surgeon and obtain postoperative prescriptions.

Question 27

Which of the following is/are accurate about nasotracheal suctioning? Select all that apply.

A) Apply suction for no longer than 15 sec during a single pass.
B) Apply suction while inserting and removing the catheter.
C) Reapply oxygen between suctioning passes for ventilator patients.
D) Gently rotate the suction catheter as you remove it.

Question 28

The student nurse observes the staff nurse providing care to a patient with a chest tube.Which of the nurse's actions should the student recognize as incorrect and report to the nursing instructor?

A) Recording drainage from chest tube as output
B) Securing the chest tube to the chest tube dressing
C) Checking the water seal chamber for bubbling
D) Milking the chest tube to promote drainage

Question 29

The nurse,working in the postanesthesia care unit inserts an oral airway into the semiconscious patient to prevent airway obstruction.When should the airway be removed?

A) When the patient can be aroused
B) When the patient is 24 hours postoperative
C) When the patient removes it
D) When the provider prescribes that it be removed

Question 30

The nurse is teaching a patient about her chest drainage system.Which of the following should the nurse include in the teaching? Select all that apply.

A) Perform frequent coughing and deep-breathing exercises.
B) Sit up in a chair but do not walk while the drainage system is in place.
C) Get out of bed without assistance as often as possible.
D) Immediately notify the nurse if she experiences increased shortness of breath.

Question 31

The nurse is caring for a patient requiring a mechanical ventilator.When checking the inline thermometer,the nurse finds what temperature acceptable?

A) 78°F
B) 96°F
C) 105°F
D) 84°F

Question 32

Of the following interventions,which is/are likely to reduce the risk of postoperative atelectasis? Select all that apply.

A) Administer bronchodilators.
B) Apply low-flow oxygen.
C) Encourage coughing and deep breathing.
D) Administer pain medication.

Question 33

The nurse is caring for a patient with a chest tube.What outcome would indicate the chest tube can be discontinued?

A) No further bubbling is seen in the water seal chamber.
B) No further drainage is measured from the chest tube.
C) Chest x-ray shows the lungs are fully inflated.
D) The patient's respirations are regular and unlabored.

Question 34

The nurse admits a patient diagnosed with pneumonia.Which data findings indicate that the patient is not oxygenating adequately? Select all that apply.

A) Oxygen saturation 87%
B) Arterial blood gas pH 7.33
C) Respiratory rate 52 breaths/min
D) Fine rales in the left lower lobe
E) Cyanosis of the nailbeds and lips

Question 35

A patient has a history of COPD.His pulse oximetry reading is 97%.What other findings would indicate adequate tissue and organ oxygenation? Select all that apply.

A) Normal urine output
B) Strong peripheral pulses
C) Clear breath sounds bilaterally
D) Normal muscle strength

Question 36

The nurse is counseling a 17-year-old girl on smoking cessation.The nurse should include which of the following helpful tips in her education? Select all that apply.

A) "Keep healthy snacks or gum available to chew instead of smoking a cigarette."
B) "Don't tell your friends and family you are trying to quit, until you feel confident that you'll be successful."
C) "Plan a time to quit when you will not have many other demands or stressors in your life."
D) "Reward yourself with an activity you enjoy when you quit smoking."