Question 1

The nurse recognizes that a postoperative patient who can breathe independently but has trouble maintaining an airway because of the tongue falling back into the throat would be best benefitted by a(n):

Accepted Answer

A)  pharyngeal airway. 
B)  endotracheal tube. 
C)  tracheostomy. 
D)  partial rebreather oxygen mask.

Question 2

When a patient with a tracheostomy tube is taken care of at home by family, tracheostomy care instructions from the nurse include: (Select all that apply.)

Accepted Answer

A)  use sterile gloves during suctioning. 
B)  avoid going to crowded theaters and malls. 
C)  change catheters every 8 hours. 
D)  keep the home environment free of dust. 
E)  use bleach to clean suction equipment.

Question 3

The nurse assists the patient with emphysema into the most beneficial position to facilitate respiration, which is:

Accepted Answer

A)  semi-Fowler's position with a single pillow behind the head. 
B)  high Fowler's position without a pillow behind the head. 
C)  right lateral with the head of the bed elevated 45 degrees. 
D)  sitting upright and forward with arms supported on an over the bed table.

Question 4

A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:

Accepted Answer

A)  monitoring the rate of respirations. 
B)  determining the last time the patient was suctioned. 
C)  examining the character of the sputum. 
D)  auscultating the breath sounds.

Question 5

The multiple causes for hypoxia include: (Select all that apply.)

Accepted Answer

A)  extreme fright. 
B)  aspirated vomit. 
C)  pulmonary fibrosis. 
D)  hiccoughs. 
E)  high altitude.

Question 6

A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should:

Accepted Answer

A)  immediately turn the patient to the side of the insertion site. 
B)  check for air leaks in drainage system. 
C)  document findings. 
D)  clamp the chest tube and place the patient in high Fowler's position.

Question 7

A patient requires suctioning via the nasotracheal route. In order to perform this procedure safely, the nurse should:

Accepted Answer

A)  apply suction while advancing the catheter into the airway. 
B)  suction the nasotracheal passage after suctioning the mouth. 
C)  hold the catheter with the dominant hand after donning sterile gloves. 
D)  insert the nonlubricated catheter into the nasal passage.

Question 8

The nurse clarifies that the cough mechanism is stimulated when:

Accepted Answer

A)  foreign substances are propelled by the cilia toward the respiratory tract. 
B)  dehumidified air enters the upper airway passages. 
C)  more than 250 mL of air moves in and out of the lungs with each breath. 
D)  the blood transports carbon dioxide to the lungs.

Question 9

The nurse recognizes that, immediately before a tracheotomy cuff deflation, the patient should:

Accepted Answer

A)  be administered extra oxygen. 
B)  have the pharynx suctioned. 
C)  have the cuff pressure checked. 
D)  be monitored for respiratory rate.

Question 10

A patient has collapsed and cannot be aroused by asking loudly, "Are you okay?" The next action should be to:

Accepted Answer

A)  position the fingers over the carotid artery to feel for a pulse. 
B)  tilt the head by placing one hand on the forehead and lift the chin. 
C)  call for help or, if there is assistance, have that person get help. 
D)  deliver two quick short breaths into the patient's airway.

Question 11

The nurse instructing the patient to perform forceful exhalation coughing would instruct the patient to take in:

Accepted Answer

A)  one deep breath and quickly exhale. 
B)  two breaths and force the air out quickly. 
C)  two deep breaths, then inhale deeply again and force out the air quickly. 
D)  one breath, hold it for 3 seconds, then forcefully exhale three times with mouth open.

Question 12

The nurse is aware that the best time to schedule a postural drainage treatment is:

Accepted Answer

A)  shortly after the patient arises in the morning, before breakfast. 
B)  in the morning immediately after breakfast. 
C)  30 minutes after lunch. 
D)  1 hour after supper.

Exam 28: Assisting with Respiration and Oxygen Delivery

The nurse recognizes that a postoperative patient who can breathe independently but has trouble maintaining an airway because of the tongue falling back into the throat would be best benefitted by a(n) :