Question 1

A patient with a tracheostomy is experiencing thick and tenacious secretions.To maintain this patient's airway,what is the most appropriate action for the nurse?

Accepted Answer

Tracheal suctioning is performed through an artificial airway such as a tracheostomy.Oropharyngeal suctioning clears secretions from the mouth and upper airway.Nasotracheal suctioning introduces the catheter through the naris into the trachea.Orotracheal suctioning introduces the catheter through the mouth into the trachea.

Question 2

The RN and nursing assistive personnel (NAP)are caring for six patients on the pulmonary unit.Which of the following tasks would be most appropriate for the nurse to delegate to the NAP?

Accepted Answer

Base your decision to delegate responsibility to nursing assistive personnel (NAP)on your assessment of the patient and the type of care the patient will receive.Consider which tasks are safe to delegate within the skill set of the NAP and how the patient will feel about the care that you have delegated.Incentive spirometry is a method of encouraging voluntary deep breathing by providing visual feedback to patients about inspiratory volume.It is an effective method for promoting deep breathing to prevent or treat atelectasis in the postoperative patient.Incentive spirometry encourages patients to breathe to their normal inspiratory capacities and can be delegated to a NAP.The priority is to maintain or improve the patient's oxygenation and meet the patient's needs.You are ultimately responsible for all the total patient care.In all the other responses the patient is experiencing difficulties that require the nurse's attention: severe dyspnea (difficulty breathing),hemoptysis (bloody sputum),and chest percussion (done by nurses or respiratory therapists).

Question 3

The assistive personnel reports that an older patient is complaining of shortness of breath and palpitations.The nurse connects the patient to an electrocardiogram monitor and analyzes the rhythm with normal P wave and normal QRS and T waves.The rate is 116 beats per minute and regular.The nurse identifies this rhythm as which of the following?

Accepted Answer

Sinus tachycardia is a rate between 100 and 180 beats per minute with normal P,QRS,and T waves.Ventricular Tachycardia has a rhythm slightly irregular,rate 100 to 200 beats/min,P wave absent,QRS complex wide and bizarre,greater than 0.12 sec.Sinus bradycardia is a rate less than 60 beats per minute with normal P,QRS,and T waves.Normal sinus rhythm is a rate between 60 and 100 beats per minute with normal P,QRS,and T waves.

Question 4

The nurse is evaluating a patient who has a chest tube.To properly maintain chest tube function,what is the nurse's best action?

Accepted Answer

Observe the chest drainage system to be sure it is upright and below the level of tube insertion.Most institution have stopped stripping the chest tube because this greatly increases intrapleural pressure unless the patient is fresh from postoperative thoracic surgery or has chest trauma.Chest tubes are only clamped under specific circumstances per health care provider's order or nursing policy to assess for an air leak,to quickly empty or change disposable drainage systems,or to assess if the chest tube is ready to be removed.Clamping the chest tube is not recommended because it may result in a tension pneumothorax,a life-threatening event.Removing the tubing would cause a disruption in the suctioning of the chest tube and should not be done.

Question 5

The home care nurse is admitting a patient with COPD.The primary healthcare provider has ordered O? /nasal cannula at 3 L/min.To promote safety,the nurse would instruct the patient on which of the following safety measures? (Select all that apply.)

Accepted Answer

Promote safety by using the following measures:
•Place "No smoking" signs on the patient's room door,over the bed,and in every room of the home where oxygen is used.Inform the patient,visitors,roommates,and all personnel that smoking is not permitted in areas where oxygen is in use.
•Determine that all electrical equipment in a health facility room or patient's home is functioning correctly and is properly grounded.
•Know the fire procedures and the location of the closest fire extinguisher.
•Check the oxygen level of portable tanks before transporting to ensure that there is enough oxygen in the tank.
•Store oxygen tanks in secure holders to prevent them from being knocked over.
•Store oxygen tanks 6 feet away from toys with electric motors,electric space heaters,fireplaces,electric blankets,hair dryers,or other appliances.Do not store in a trunk box or small closet.

Question 6

The nursing student is formulating a nursing care plan for a patient with pneumonia.The care plan is directed toward meeting the potential oxygenation needs of the patient.Which of the following examples would be the best way for the nursing student to write an expected outcome for the care plan?

Accepted Answer

All goals need to have measurable outcomes for you to be able to determine whether they have been met.These include objective data,such as oxygen saturation levels,arterial blood gas levels,laboratory findings,chest radiographs,electrocardiogram patterns,blood pressure,and pulse.Quantify subjective findings,such as the reported degree of breathlessness or pain on visual analog scales.Less pain,breathe better,and normal interactions do not include objective data,making them hard to measure.

Question 7

A nurse is being oriented to work for an intensive care unit.The hemodynamic data indicate that the patient has a decreased preload.Which information indicates the nurse has a correct understanding of the concept of preload?

Accepted Answer

Preload is the amount of blood at the end of ventricular diastole.Cardiac output is the amount of blood ejected from the left ventricle each minute.Cardiac conduction is the rhythmic relaxation and contraction of the atria and ventricles dependent on transmission of electrical impulses.Afterload is the resistance of the ejection of blood from the left ventricle.

Question 8

A patient presents with an acute myocardial infarction that resulted in right ventricular damage.The nurse needs to assess the patient for right-sided heart failure,which includes which of the following?

Accepted Answer

Right-sided heart failure causes distended jugular veins and peripheral edema.Right-sided heart failure results from impaired functioning of the right ventricle,which is typically caused by pulmonary disease or pulmonary hypertension.An increase in pressure in the pulmonary system causes increased resistance in the right ventricle.The right ventricle fails as a result of this pressure.Left-sided heart failure results in crackles on auscultation and patient complaints of fatigue,dyspnea,and orthopnea.Increased myocardial perfusion does not occur.

Question 9

An adult collapsed at the grocery store.Before being transported to the emergency department,an automated external defibrillator (AED)was used.The nurse remembers learning that the AED is effective in saving a life because of which factors? (Select all that apply.)

Accepted Answer

The following is information on the use of an automated external defibrillator (AED):
•The automated external defibrillator (AED)is a device used to administer an electrical shock through the chest wall to the heart.
•The AED has a built-in computer that assesses the victim's heart rhythm and determines if defibrillation is needed.
•The rescuer delivers a shock to the victim after announcing,"Everyone stand back."
•The AED can be used by nonmedical personnel.
•Use of an AED strengthens the chain of survival.Every minute of a sudden cardiac death without defibrillation decreases the survival rate by 7% to 10% (American Heart Association,2005).

Question 10

A patient reports chest pain.The nurse is attempting to assess the pain to differentiate the pain as cardiac,respiratory,or gastrointestinal.The nurse can properly identify the pain as cardiac in origin when the patient states that the cardiac pain:

Accepted Answer

Cardiac pain does not occur with respiratory variations.Cardiac chest pain is most often substernal and radiates to the left arm and jaw in men,but some women have epigastric pain,complaints of indigestion,or a choking feeling and dyspnea.Pericardial pain results from an inflammation of the pericardial sac and is usually nonradiating and often occurs with inspiration.Pleuritic chest pain is peripheral and usually radiates to the scapular region.Inspiratory maneuvers aggravate pleuritic chest pain.

Question 11

On entering the room,a nurse finds the patient sitting upright in bed with the upper torso resting on the over-bed table.The nurse assesses that this patient is experiencing acute hypoxemia.Which of the following are symptoms of acute hypoxemia? (Select all that apply.)

Accepted Answer

Symptoms of acute hypoxemia include changes in respiration (tachypnea,dyspnea); blood pressure (hypertension,hypotension); color (pallor,cyanosis); mental status (headache,anxiety,impaired judgment,confusion,euphoria,lethargy); motor function (loss of coordination,weakness,tremors,hyperactive reflexes,restlessness,stupor,coma [around 30 mm Hg],death); arrhythmias (tachycardia,bradycardia),diaphoresis,blurred or tunnel vision,and nausea/vomiting.Eupnea is a normal breathing rate.

Question 12

A patient has been admitted to the pulmonary unit of the hospital with right lower lobe pneumonia and history of chronic obstructive pulmonary disease (COPD).During the initial assessment the nurse notes that the patient has a respiration rate of 18 with retractions,tachycardia,and complains of dyspnea and dizziness.The nurse identifies that these are clinical signs of which condition?

Accepted Answer

Dyspnea is a clinical sign of hypoxia.Dyspnea is the subjective sensation of breathlessness as perceived by the patient.Hypoxia is inadequate tissue oxygenation with a deficiency in oxygen delivery or oxygen utilization at the cellular level.Signs and symptoms of hypoxia include tachycardia,peripheral vasoconstriction,dizziness,and mental confusion.Dyspnea that occurs when a patient is sleeping is called paroxysmal nocturnal dyspnea.The patient awakens in a panic,feels as if he or she is suffocating,and has a strong need to sit up to relieve the breathlessness.Orthopnea is an abnormal condition in which a patient has difficulty breathing when lying down and has to use multiple pillows or sit to breathe.Hemoptysis is bloody sputum.It is associated with coughing and bleeding from the upper respiratory tract,from sinus drainage,or from the gastrointestinal tract.

Question 13

A student nurse caring for a patient with a chest tube has been asked what equipment should be at the bedside to assess for an air leak.Which information indicates the student nurse has a correct understanding of the equipment needed?

Accepted Answer

Covered hemostats are used to assess for air leaks,not a cup of water,suction equipment,or petroleum gauze.Hemostats have a covering to prevent hemostat from penetrating the chest tube.The use of these hemostats or other clamp prevents air from re-entering the pleural space.Suctioning does not determine an air leak; it is used to clear secretions.If there is a break in the chest drainage device,place the end of the chest tube in a bottle of sterile saline,not water.If a chest tube becomes dislodged apply pressure to chest tube site wound using petroleum gauze,a dry gauze dressing,and adhesive tape.

Question 14

A health care worker received an annual tuberculosis test administered 56 hours ago.The injection site is very red and flat.The certified nurse who is reading the test should take which action?

Accepted Answer

A reddened flat area is not a positive reaction,and you do not need to measure it.
Tuberculosis skin testing positive results is a palpable,elevated,hardened area around the injection site,caused by edema and inflammation from the antigen-antibody reaction,measured in millimeters.Tuberculin skin tests are read between 48 and 72 hours so the health care worker came at the right time (56 hours).

Question 15

A patient with pulmonary congestion needs to cough to clear secretions.The nurse instructs the patient to inhale and perform a series of coughs during exhalation.What type of cough did the nurse teach the patient?

Accepted Answer

With the cascade cough a patient takes a slow,deep breath and holds it for 2 seconds while contracting expiratory muscles.He or she then opens the mouth and performs a series of coughs throughout exhalation,thereby coughing at progressively lowered lung volumes.This technique promotes airway clearance and a patent airway in patients with large volumes of sputum.A quad cough is used for patients who have a spinal cord injury and no use of their abdominal muscles.While the patient breathes out with a maximal expiratory effort,the patient or you push inward and upward on the abdominal muscles toward the diaphragm,causing the cough.A huff cough stimulates a natural cough reflex.While exhaling,a patient opens the glottis by saying the word huff.Splinting occurs when the patient supports the abdomen when coughing; it is not a type of cough.

Quiz 30: Oxygenation