Question 1

The nurse is working with a nursing assistant to care for a patient with a new tracheostomy. Which tasks may the nurse delegate to the assistant? (Select all that apply.)
A) Obtaining masks, gloves, and suction supplies from the utility room
B) Helping to reassure the patient before, during, and after suctioning
C) Changing the Velcro or twill ties used to secure the tracheostomy
D) Transporting sputum specimens to the lab for culture and sensitivity testing
E) Assessing need for suctioning of the oropharynx or tracheostomy
F) Teaching the patient how to remove and clean the inner cannula

Accepted Answer

Care of a new tracheostomy may not be delegated to a nursing assistant. Obtaining supplies needed for care, helping to reassure the patient, and bringing specimens to the lab are tasks that may be assigned to the assistant.

Question 2

The nurse is performing a respiratory assessment on a patient. Which assessment findings indicate to the nurse that the patient has a history of long-standing chronic respiratory disease? (Select all that apply.)
A) All of the patient's fingernails are noticeably clubbed.
B) The patient needs to sleep on at least four to five pillows at night.
C) The patient's chest has equal antero-posterior and transverse diameters.
D) The patient's lower legs have large areas of brownish spotted discoloration.
E) The patient reports puffiness of both feet when standing for long periods.
F) The patient's forced vital capacity test result is 3.8 L of air.

Accepted Answer

Clubbing of fingernails, the need to sleep in an upright position, and a barrel chest are all indicative of long-standing chronic respiratory disease like COPD. Brownish spotted discoloration is indicative of venous insufficiency. Forced vital capacity of almost 4 L is found in patients with good respiratory function.

Question 3

The nurse notes the following findings when assessing a patient with COPD. Which require prompt nursing intervention? (Select all that apply.)
A) The patient is unable to count out loud past 15 after a deep breath.
B) The patient's nails are noticeably clubbed.
C) The patient's sputum has turned from yellow to greenish-brown.
D) The patient has stridor with wheezes heard in all lung fields.
E) The patient's forced vital capacity has increased from 2.8 to 3.4 L.
F) The patient has become confused and mildly disoriented.

Accepted Answer

A patient who is unable to count out loud past 15 after a deep breath is indicative of poor airflow through the airways, which must be addressed promptly. Greenish-brown sputum may indicate pneumonia requiring antibiotic treatment. Stridor and wheezes is indicative of an acute asthma attack. Confusion and disorientation in a patient with COPD may indicate retention of carbon dioxide.

Question 4

The preceptor is working with a new nurse to provide care for a patient with a new tracheostomy. Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.)
A) The outer cannula is cleaned with the brush and half-strength H S1U1B12S1U1B0OS1U1B12S1U1B0
B) The new tracheostomy holder is secured before the old soiled one is removed.
C) A Yankauer suction catheter is used to remove secretions from the patient's mouth.
D) Sterile gloves are applied before the soiled dressing is removed from the tracheostomy.
E) Half-strength HS1U1B12S1U1B0OS1U1B12S1U1B0 is used to remove crusted secretions around the tracheostomy site.
F) Pain medication is administered to the patient prior to suctioning.

Accepted Answer

Only the inner cannula of the tracheostomy is removed for cleaning. The outer cannula stays in the trachea to maintain airway patency. Clean gloves are applied before the soiled dressing is removed. Half-strength HS1U1B12S1U1B0OS1U1B12S1U1B0 is used to remove secretions that have built up on the inner cannula. Sterile saline should be used to clean the patient's skin as needed.

Question 5

The preceptor is working with a new nurse to suction a patient through his new tracheostomy. Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.)
A) The suction is not applied to the catheter until it is being withdrawn.
B) The patient is placed in the supine position prior to suctioning.
C) The suction catheter is twirled side to side as it is being withdrawn.
D) Suction is applied continuously as the catheter is withdrawn.
E) The patient's oxygen is reapplied between suction attempts.
F) Water-soluble lubricant is applied to the suction catheter before insertion.

Accepted Answer

The head of the patient's bed should be elevated prior to suctioning to facilitate coughing out secretions. Suction is always applied intermittently as the catheter is withdrawn. Water-soluble lubricant is used when suctioning the naris but not a tracheostomy because the secretions negate the need for additional lubrication.

Quiz 38: Oxygenation and Tissue Perfusion

The nurse is working with a nursing assistant to care for a patient with a new tracheostomy. Which tasks may the nurse delegate to the assistant? (Select all that apply.)

The nurse is performing a respiratory assessment on a patient. Which assessment findings indicate to the nurse that the patient has a history of long-standing chronic respiratory disease? (Select all that apply.)

The nurse notes the following findings when assessing a patient with COPD. Which require prompt nursing intervention? (Select all that apply.)

The preceptor is working with a new nurse to provide care for a patient with a new tracheostomy. Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.)

The preceptor is working with a new nurse to suction a patient through his new tracheostomy. Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.)