Deck 16: Promoting Oxygenation

Question 1

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) Petroleum gauze or Xeroform gauze
B) Gauze with Elastoplast
C) 2 * 2-inch gauze with tincture of benzoin
D) Steri-Strips under a bioclusive dressing

Answer 1

Petroleum gauze or Xeroform gauze

Question 2

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

A) 40-60 mm Hg
B) 60-80 mm Hg
C) 80-100 mm Hg
D) 100-150 mm Hg

Answer 2

100-150 mm Hg

Question 3

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?

A) Notify the health care provider of excessive bleeding.
B) Document the drainage output in the patient record.
C) Place extra dressings and tape over the insertion site.
D) Clamp the mediastinal tube to test tolerance for removal.

Answer 3

Document the drainage output in the patient record.

Question 4

While the nurse prepares to suction the patient's tracheostomy tube, the patient coughs up mucus, which is visible at the opening of the tube.Which action by the nurse is most appropriate at this time?

A) Hyperoxygenate this patient.
B) Suction the visible secretions.
C) Listen to the lung sounds.
D) Wipe the mucus off with tissue.

Question 5

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

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

Question 6

The nurse is working with a patient receiving oxygen.What can the nurse delegate to nursing assistive personnel (NAP) during the administration of oxygen?

A) Adjusting the flow rate of the oxygen
B) Reporting changes in patient's behavior
C) Instructing the patient about oxygen at home
D) Assisting during endotracheal intubation

Question 7

The nurse hears the patient's wheezing and gasping from the hallway and notes that the patient's oxygen saturation has decreased to 92%.Which nursing intervention does the nurse implement first?

A) Place the patient in high Fowler's position.
B) Suction the oropharynx.
C) Insert an artificial airway.
D) Review the last arterial blood gases (ABGs).

Question 8

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

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 9

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) Collaborate with the provider to use an oxygen mask.
B) Plan follow-up nursing care for patient hypoxemia.
C) Request that the laboratory confirm the patient's results.
D) Continue with the current therapy and nursing care.

Question 10

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?

A) Notify the physician.
B) Check for an air leak.
C) Listen to the lung sounds.
D) Document the findings.

Question 11

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

A) The heart rate changes from 84 to 106 beats/min.
B) The respiratory rate does not improve.
C) The oxygenation saturation changes from 96 to 91.
D) The patient's respiratory effort increases gradually.

Question 12

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?

A) Put on slippers whenever walking.
B) Take off the oxygen if only going to the bathroom.
C) Be careful not to trip over the extra oxygen tubing.
D) Increase the flow rate a little before getting out of bed.

Question 13

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?

A) Simple
B) Venturi mask
C) Partial rebreather
D) Nonrebreather

Question 14

An oxygen cylinder is turned on, and the gauge registers in the green range.What action does the nurse take at this time?

A) Apply the oxygen as ordered.
B) Notify the respiratory therapy department.
C) Obtain a new cylinder of oxygen.
D) Adjust the flowmeter slightly below what is ordered.

Question 15

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?

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

Question 16

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

A) Keep the plastic bag at the end of the mask inflated continually.
B) Adjust the oxygen flow rate with the valve in front of the mask.
C) Offer fluids frequently and apply moisturizer to prevent dry skin.
D) Remove the elastic head strap to prevent skin breakdown at the ears.

Question 17

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) Changing the mask to a simple face mask
B) Teaching the patient the rationale for a tight
C) Enlarging several of the air holes on the mask
D) Loosening the straps of the mask for the patient's comfort

Question 18

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

A) They measure the minimum force used to breathe in during the breathing process.
B) They measure the maximum flow that occurs during one quick, forced expiration.
C) They measure the amount of circulating oxygen in the alveoli during breathing.
D) They indicate the stability of your overall health.

Question 19

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?

A) Increase the oxygen rate of the nasal cannula.
B) Elevate the head of the patient's bed.
C) Hyperoxygenate with oxygen attached to a mask.
D) Gently flex the patient's neck.

Question 20

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

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.

Question 21

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

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 colored indicator line in the sheath of the catheter before completing the procedure.
D) Withdraws the suction catheter and discards it after completing the procedure.

Question 22

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

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 3-4 times vigorously.

Question 23

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) 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 24

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

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

Question 25

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?

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 26

The nurse suctions the patient's artificial airway.Which adverse effect related to suctioning does the nurse monitor as the priority during the procedure?

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

Question 27

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) Standing
B) Side lying
C) High-Fowler's
D) Reclining in chair

Question 28

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?

A) Uses a Yankauer suction device.
B) Loosens oral secretions with normal saline solution.
C) Suctions the nose, mouth, and throat with a catheter.
D) Uses a clean catheter to suction the nose and mouth.

Question 29

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?

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.