Question 1

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

Accepted Answer

The suction catheter should be held with the dominant hand after donning sterile gloves, because sterile technique must be adhered to when suctioning both the nasopharyngeal and tracheal areas.

Question 2

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

Accepted Answer

A pharyngeal airway such as a nasopharyngeal or an oropharyngeal airway is useful for patients who can breathe on their own but tend to occlude the airway with the tongue.

Question 3

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

Accepted Answer

Auscultating the patient's breath sounds helps the nurse assess for retained secretions and verifies the need for suctioning. The respiratory rate may rise when suctioning is needed, but it could also rise for other reasons.

Question 4

The nurse clarifies that the condition in which there is a decreased amount of oxygen in the blood is:

Accepted Answer

Hypoxemia is a condition in which there is a decreased amount of oxygen in the blood, hypoxia is inadequate oxygen to meet cellular needs, hypercapnia is increased level of carbon dioxide in the blood, and dyspnea is difficulty breathing.

Question 5

A nurse is aware that adequate hydration is necessary to mobilize respiratory secretions. To thin respiratory secretions for easier expectoration, the patient should consume at least _____ mL/day.

Accepted Answer

A fluid intake of at least 1500 to 2000 mL/day is needed to thin respiratory secretions for easier removal by coughing.

Question 6

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

Accepted Answer

Postural drainage is best accomplished in the morning prior to eating, because more secretions accumulate while the patient is asleep.

Question 7

The nurse would determine that this patient is aware of how to use the incentive spirometer device properly when the patient:

Accepted Answer

Proper technique for use of an incentive spirometer is to take 10 slow, deep breaths every hour and to hold each breath for 3 seconds to enhance gas exchange.

Question 8

The nurse uses a diagram to show that when the diaphragm moves:

Accepted Answer

When the diaphragm moves down, increasing the size of the thoracic space, air is pulled into the lungs. The respiratory action is controlled by the spinal cord.

Question 9

A nurse performing oral suctioning on an adult patient should set the wall suction machine so that the suction pressure is between _____ mm Hg.

Accepted Answer

The range of suction pressure for an adult patient is between 80 and 120 mm Hg.

Question 10

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

Document findings. Constant bubbling in the suction chamber indicates that suction is on.

Question 11

The nurse loosens mucus plugs by using percussion on a patient over the area of the:

Accepted Answer

Percussion, a rhythmic clapping with cupped hands over the thoracic area, will loosen mucus plugs. This technique is both useless and painful when applied over bony areas.

Question 12

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

Accepted Answer

The sequence for resuscitative interventions is to check for responsiveness; if no response, activate emergency medical services, check for pulse at carotid, begin compressions, then open the airway and check for breathing.

Question 13

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

Accepted Answer

Sitting upright and leaning forward with arms supported on an over-the-bed table is best for this patient, because it allows for expansion of the thoracic cage in all four directions (front, back, and two sides).

Question 14

A patient requires a precise concentration of 40% oxygen. Which of the following devices would best allow for this?

Accepted Answer

A Venturi mask is useful when accuracy of delivery is essential.

Question 15

A patient who will begin oxygen therapy has a history of sinus disorders. This patient would benefit most from which oxygen setup?

Accepted Answer

If a patient suffers from sinus problems, it is best to add a humidifier to the oxygen setup.

Question 16

The nurse takes into consideration that while caring for a patient on oxygen therapy, safety precautions should be observed, which include:

Accepted Answer

All equipment in a room where oxygen is being administered should be in good working order without frayed or loose connections because of the possibility of fire.

Question 17

A patient has a history of chronic obstructive pulmonary disease. The patient's oxygen flow rate should be set to no more than _____ L/min.

Accepted Answer

Patients with obstructive lung disease are given only 2 to 3 L/min of oxygen, because over time they adjust to high carbon dioxide levels, and their stimulus to breathe comes from low arterial oxygen levels. Higher amounts of oxygen could reduce or eliminate the respiratory drive.

Question 18

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

Accepted Answer

Proper coughing procedure is to take in two deep breaths, inhale deeply again and to forcibly exhale (cough) at the end of the third breath. This technique is very effective in moving secretions up the bronchial tree.

Question 19

The nurse monitoring patients eating in the dining room of a skilled nursing facility notes that a patient begins choking. As the nurse prepares to deliver the Heimlich maneuver, the fist should be positioned:

Accepted Answer

Proper placement of the fist is halfway between the xiphoid process and the umbilicus.

Question 20

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

Accepted Answer

Immediately before deflating a cuff on a tracheotomy tube, the pharynx should be suctioned to prevent accumulated oral secretions from entering the bronchial tree once the cuff is deflated.

Quiz 28: Assisting with Respiration and Oxygen Delivery