Deck 7: Oxygen Therapy Management

Question 1

The nurse is providing care to a patient admitted with a respiratory disorder. Which laboratory finding would be most significant?
1)Blood pH 7.32
2)Oxygen saturation 96%
3)PaO₂ 80 mm Hg
4)Hemoglobin level 12 mg/dL

Answer 1

1

Question 2

The nurse is performing in-line suctioning when the patient experiences a decrease in oxygen saturation and bradycardia. Which nursing action is best?
1)Continue suctioning and administer 50% oxygen
2)Discontinue suctioning and prepare for resuscitation
3)Discontinue suctioning and administer 100% oxygen
4)Continue suctioning and administer prescribed epinephrine

Answer 2

3

Question 3

The nurse is providing education to a patient regarding the use of an incentive spirometer. Which patient statement indicates the need for further education?
1)"I should be in a sitting position when using this device."
2)"I will use this device 20 times per hour while I am awake each day."
3)"I will exhale completely before placing my lips around the mouthpiece."
4)"I will hold my breath for 3 seconds after I feel like I cannot inhale any more breath."

Answer 3

2

Question 4

The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) who is prescribed 24% oxygen at 2 L/min. Which is the best method for the nurse to use to administer oxygen to this patient?
1)Face mask
2)Venturi mask
3)Nasal cannula
4)Nonrebreather mask

Question 5

The nurse is providing care to a patient who is mechanically ventilated. Which nursing action is most effective in decreasing the risk for aspiration?
1)Elevate the head of the bed between 30 to 45 degrees
2)Limit each suctioning event to no more than 10 seconds
3)Perform chest physiotherapy as prescribed by the practitioner
4)Ensure an NPO status is maintained for the length of the prescribed treatment

Question 6

The nurse provides education to a patient who is going to be discharged from the hospital with oxygen. Which patient statement indicates the need for further education?
1)"I have two fire extinguishers in my home."
2)"I will activate emergency medical services if I lose power."
3)"I will check my oxygen tank daily and order new tanks well in advance of needing them."
4)"I told my husband to stack the oxygen tanks in the closet so that they aren't cluttering the room."

Question 7

The nurse is providing care to a patient who is recovering from facial trauma who requires high-flow oxygen therapy. Which method of oxygen delivery does the nurse recognize as best for this patient?
1)Face tent
2)Nasal cannula
3)Venturi mask
4)Nonrebreather mask

Question 8

The nurse places the patient in which position before performing in-line suctioning?
1)Prone
2)Supine
3)Fowler's
4)Semi-Fowler's

Question 9

The nurse assists the healthcare provider with a patient intubation. What is the priority action by the nurse?
1)Ensure suction is available.
2)Place the intubation tray at the bedside for the procedure.
3)Explain each step of the procedure to the patient and family.
4)Administer manual breaths to the patient using a resuscitation bag and mask.

Question 10

During auscultation of breath sounds, the nurse hears wheezing and correlates to which sound?
1)Snoring sounds
2)Gurgling sounds
3)Low-pitched bubbling
4)High-pitched squeaking

Question 11

The nurse suctions a patient's tracheostomy tube. During the procedure, the patient's heart rate drops to the low 50s and oxygen saturation falls to 85%. Which is the priority action by the nurse?
1)Tell the patient to relax and continue the procedure.
2)Stop the suctioning procedure and administer oxygen.
3)Notify the healthcare provider at the end of the procedure.
4)Document the patient's reaction to the procedure in the medical record.

Question 12

The nurse is providing education to a patient who is prescribed oxygen in the home environment. Which statement made by the patient indicates the need for further education?
1)"I will ensure that the oxygen is kept 6 feet away from the stove."
2)"I placed a no smoking sign on the door and several places within the house."
3)"I will store the oxygen on its side, per the instructions provided by the agency."
4)"I will keep a fire extinguisher in the house and keep it close to where the oxygen is stored."

Question 13

The nurse is providing care to a patient who has a tracheostomy. The nurse plans to monitor this patient for the loss of which protective mechanism during the respiratory assessment process?
1)The ability to cough
2)The filtration and humidification of inspired air
3)A decrease in the oxygen-carrying capacity of the trachea
4)The sneeze reflex initiated by irritants in the nasal passages

Question 14

Which nursing action best determines the accuracy of the detected waveform when monitoring a patient's oxygen saturation via oximetry?
1)Using a site with adequate perfusion
2)Ensuring the any nail polish is removed
3)Leaving the sensor in place for a minimum of 10 seconds
4)Assessing the heart rate and comparing it with the displayed pulse

Question 15

The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease (COPD). The patient's pulse oximetry is 93% on room air with a current respiratory rate of 35 breaths per minute. The most recent chest x-ray indicates a flattened diaphragm with infiltrates. The patient is currently febrile with an increased number of white blood cells (WBCs) noted on the latest complete blood count (CBC). Which order does the nurse question for this patient based on the current data?
1)Raise the head of the patient's bed
2)Add humidification to the oxygen source
3)Oxygen therapy via nasal cannula at 3 to 4 L/min
4)Chest physiotherapy (CPT) every 4 hours while awake

Question 16

When conducting a respiratory assessment, the nurse notes a low-pitched sound that is continuous throughout inspiration. Which does this lung sound indicate to the nurse?
1)Narrow bronchi
2)Narrow trachea passages
3)Inflamed pleural surfaces
4)Blocked large airway passages

Question 17

When conducting in-line suctioning, the nurse recognizes which of the following is the maximum amount of time for each suctioning event?
1)10 seconds
2)30 seconds
3)45 seconds
4)60 seconds

Question 18

Which sound heard during auscultation of the breath sounds does the nurse correlate to rhonchi?
1)Snoring sounds
2)Gurgling sounds
3)Low-pitched bubbling
4)High-pitched squeaking

Question 19

When conducting in-line suctioning on a patient, which amount of time does the nurse allow as a rest period between suction procedures?
1)5 to 15 seconds
2)10 to 20 seconds
3)15 to 25 seconds
4)20 to 30 seconds

Question 20

The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) who requires supplemental oxygen. Which is the correct flow rate range by nasal cannula (NC) when providing care for this patient?
1)1 to 2 L/min
2)2 to 3 L/min
3)3 to 4 L/min
4)4 to 5 L/min

Question 21

The nurse provides care to a patient who is intubated and receiving mechanical ventilation. Which actions are appropriate for the nurse to implement if the high-pressure alarm sounds? Select all that apply.
1)Inserting an oral airway
2)Assessing the ventilator connections
3)Checking the patient's cuff pressure
4)Suctioning the patient's endotracheal tube
5)Emptying water from the ventilator tubing

Question 22

The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm is activated, and the nurse notes a collection of moisture in the ventilator tubing. Which action by the nurse is appropriate?
1)Emptying the water from the ventilator tubing
2)Suctioning as needed
3)Inserting an oral airway
4)Assessing for asymmetrical chest rise

Question 23

Which information does the nurse document when monitoring a patient's oxygen saturation via oximetry? Select all that apply.
1)SpO₂ result
2)Current vital signs
3)Last time the patient ate or drank
4)Type and amount of oxygen therapy in use
5)Education provided to the patient and family

Question 24

The nurse instructs a patient on the use of incentive spirometry. Which patient statement indicates the need to provide additional instruction?
1)"I will use the device 5 to 10 times per day."
2)"I will take in a slow, deep breath, like inhaling through a straw."
3)"I will exhale completely before I begin this breathing exercise."
4)"I will sit up in bed as this allows my lungs to expand during the exercise."

Question 25

The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm sounds and the nurse notes the patient is biting down on the endotracheal (ET) tube. Which action by the nurse is appropriate?
1)Suctioning as needed
2)Inserting an oral airway
3)Assessing for asymmetrical chest rise
4)Emptying water from the ventilator tubing

Question 26

The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm sounds and the nurse notes a mucous plug in the endotracheal (ET) tube. Which action by the nurse is indicated?
1)Suctioning as needed
2)Inserting an oral airway
3)Assessing for asymmetrical chest rise
4)Emptying water from the ventilator tubing

Question 27

The nurse provides care to a patient who is intubated and receiving mechanical ventilation. Which actions are appropriate for the nurse to implement if the low-pressure alarm sounds? Select all that apply.
1)Inserting an oral airway
2)Assessing the ventilator connections
3)Checking the patient's cuff pressure
4)Suctioning the patient's endotracheal tube
5)Assessing the patient's respiratory rate

Question 28

The patient is admitted to the Intensive Care Unit and placed on Synchronized Intermittent Mandatory Ventilation (SIMV) mode. The nurse notes that the patient is breathing 12 times per minute, and the ventilator is set at 8 breaths per minute. How many ventilator breaths is the patient receiving?
1)4
2)8
3)12
4)20

Question 29

Which statement by the patient receiving intermittent positive-pressure breathing (IPPB) treatments indicates that the nurse's teaching was effective?
1)"I will need to have a breathing tube placed."
2)"I will get my aerosolized medications with this treatment."
3)"This will decrease my need to cough."
4)"This will require me to be on oxygen permanently."

Question 30

In providing care to a patient on a mechanical ventilator, the nurse suctions the patient using in-line suctioning. Which information does the nurse document in the medical record after the procedure is completed? Select all that apply.
1)Amount of secretions
2)Color of the secretions
3)Consistency of the secretions
4)Patient's response to the procedure
5)Number of times that the suction catheter was introduced

Question 31

Which intervention does the nurse include in the plan of care for a patient being mechanically ventilated who is receiving care based on a ventilator bundle focused on reducing the risk of ventilator-associated pneumonia? Select all that apply.
1)Elevating the head of the bed
2)Ensuring a sedation vacation each day
3)Minimizing ambulation
4)Administering a prescribed peptic ulcer prophylactic regimen
5)Restricting family visitation

Question 32

The nurse recognizes that the patient on which mode of mechanical ventilation is at greatest risk for developing respiratory alkalosis?
1)Assist-control
2)Intermittent mandatory ventilation
3)Synchronized intermittent mandatory ventilation
4)Pressure support

Question 33

The nurse is providing care for a patient on a mechanical ventilator in the assist-control mode. If the ventilator rate is set at 10 breaths per minute, and the patient is breathing 16 times per minute, how many ventilator breaths is the patient receiving?
1)6
2)10
3)12
4)16

Question 34

Which actions by the nurse are considered best practice when providing tracheostomy care? Select all that apply.
1)Setting the suction to 150 mm Hg
2)Suctioning as the catheter is introduced into the airway
3)Applying appropriate personal protective equipment
4)Inspecting the trach stoma for signs of infection, irritation, and skin breakdown
5)Rinsing a disposable inner cannula with sterile water and drying

Question 35

The nurse is providing care to a patient who is being weaned from mechanical ventilation. Which finding would necessitate the continuation of mechanical ventilation if noted during the weaning process?
1)An FIO₂ less than or equal to 0.4 to 0.5
2)A positive end-expiratory pressure (PEEP) less than or equal to 5 to 8 cm H₂O
3)A pH greater than 7.25 during spontaneous ventilation
4)Decreased blood pressure