Question 1

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 in order to administer oxygen to this patient?

Accepted Answer

The best method for administering oxygen to a patient with COPD who is prescribed 24% oxygen at 2 L/min is a nasal cannula. This device delivers low to moderate oxygen concentrations of 24-45% and is ideal for patients with COPD who need supplemental oxygen at lower flow rates. A face mask may be too uncomfortable for the patient as they can cause claustrophobia and also CO2 retention. A venturi mask is most effective for delivering high flow rates of oxygen in patients with severe COPD or acute respiratory distress. A nonrebreather mask is used for delivering high concentrations of oxygen in emergencies or for critically ill patients.

Question 2

Which nursing action determines the accuracy of the detected waveform when monitoring a patient's oxygen saturation via oximetry?

Accepted Answer

Assessing the heart rate and comparing it with the displayed pulse ensures that the oximeter is accurately detecting the patient's pulse, which is crucial for the accuracy of the oxygen saturation reading.

Question 3

Which did the nurse auscultate when conducting a patient's respiratory assessment if wheezing is documented?

Accepted Answer

Wheezing is a high-pitched, musical sound that is caused by air passing through narrowed airways, typically heard during expiration.

Question 4

When conducting in-line suctioning on a patient,which amount of time should the nurse allow as a rest period between suction procedures?

Accepted Answer

The answer of When conducting in-line suctioning on a patient,which...

Question 5

When conducting in-line suctioning,which is the maximum amount of time for each suctioning event?

Accepted Answer

The maximum amount of time for each suctioning event during in-line suctioning is recommended to be 10 seconds to minimize the risk of complications such as hypoxemia and cardiac arrhythmias.

Question 6

Which did the nurse auscultate when conducting a patient's respiratory assessment if rhonchi is documented?

Accepted Answer

Rhonchi are low-pitched, snoring sounds that occur when air is blocked or airflow becomes rough through the large airways.

Question 7

Which position should the nurse place a patient prior to performing in-line suctioning?

Accepted Answer

The patient should be placed in a semi-Fowler's position prior to performing in-line suctioning to promote optimal lung expansion and oxygenation. This position also helps to prevent aspiration.

Question 8

The nurse is providing care to a patient,diagnosed with asthma,with a respiratory rate of 28 at rest who is experiencing audible wheezing during inspiration.Which nursing diagnosis should the nurse use when planning care for this patient?

Accepted Answer

The answer of The nurse is providing care to a...

Question 9

The nurse is performing in-line suctioning when the patient experiences a drop in oxygen saturation and bradycardia.Which nursing action is appropriate?

Accepted Answer

Discontinue suctioning and administer 100% oxygen is appropriate because the drop in oxygen saturation and bradycardia indicate the patient is not tolerating the procedure well, and immediate oxygenation is necessary to stabilize the patient.

Question 10

The nurse is providing care for a patient admitted with smoke inhalation injury who is developing acute respiratory distress syndrome (ARDS).Which course of action regarding oxygen therapy does the nurse anticipate for this patient?

Accepted Answer

Patients with ARDS typically require mechanical ventilation with positive end-expiratory pressure (PEEP). This helps to keep the airways open and improve oxygenation. Oxygen via a facial mask, Venturi mask, or nasal cannula may not provide enough oxygenation support for a patient with severe respiratory distress.

Question 11

The nurse is providing care to an infant diagnosed with respiratory syncytial virus (RSV).The infant is grunting with expiration.Which action by the nurse is appropriate?

Accepted Answer

Suctioning the airway to relieve the current obstruction is appropriate for an infant with grunting during expiration, as it may be a sign of increased work of breathing and airway obstruction. Limiting fluid intake and placing the infant in a supine position may exacerbate the situation. Chest physiotherapy may be indicated in some cases but is not the first-line intervention for a potentially critical situation such as this.

Question 12

The nurse is providing care to a patient who is mechanically ventilated.The high-pressure alarm beeps and the nurse notes the patient is biting down on the endotracheal (ET)tube.Which action by the nurse is appropriate?

Accepted Answer

If the patient is biting down on the ET tube, inserting an oral airway may help prevent further biting and damage to the tube. Suctioning may be needed after the airway is secured, but it is important to address the biting first. Assessing for asymmetric chest rise and emptying water from tubing are not relevant to the issue of the patient biting down on the ET tube.

Question 13

The nurse is providing care to a patient who is mechanically ventilated.The high-pressure alarm beeps and the nurse notes a collection of moisture in the ventilator tubing.Which action by the nurse is appropriate?

Accepted Answer

Emptying the water from the ventilator tubing is appropriate as moisture can cause increased resistance and trigger the high-pressure alarm.

Question 14

The nurse is providing care to a patient who has a tracheostomy.The loss of which protective mechanism does the nurse plan to monitor this patient for during the respiratory assessment process?

Accepted Answer

With a tracheostomy, the upper airway is bypassed, which eliminates the natural filtration and humidification of inspired air provided by the nose and upper airway. The loss of these protective mechanisms can cause irritation and dryness of the lower airway. Therefore, the nurse needs to monitor for signs of airway irritation and dryness such as cough, sore throat, and thick secretions. decreasing the oxygen carrying capacity of the trachea and the sneeze reflex are not relevant to the loss of the protective mechanism in this case.

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 prescription does the nurse question for this patient based on the current data?

Accepted Answer

Oxygen therapy at 3-4 L/min may lead to CO2 retention in COPD patients, as they rely on hypoxic drive to breathe.

Question 16

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?

Accepted Answer

Oxygen should not be stored on its side as it can cause leaks and increase the risk of fire. The other statements indicate appropriate understanding of oxygen safety measures.

Question 17

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?

Accepted Answer

The answer of When conducting a respiratory assessment,the nurse notes...

Question 18

The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease (COPD).The nurse assesses the patient's breathing rate at 32 breaths per minute.The patient is also experiencing hypertension and fatigue.Which nursing diagnosis is a priority when planning care for this patient?

Accepted Answer

The patient's breathing rate of 32 breaths per minute indicates an ineffective breathing pattern, which is a priority nursing diagnosis for a patient with COPD. This condition can cause fatigue and hypertension, along with other symptoms. Anxiety and ineffective coping may also be secondary diagnoses but addressing the ineffective breathing pattern is the priority. Ineffective airway clearance may also be a concern but not the priority in this patient.

Question 19

The nurse is providing care to a patient admitted with a respiratory disorder.Which laboratory finding would be most significant?

Accepted Answer

A blood pH of 7.32 indicates that the patient may be experiencing respiratory acidosis, which could be related to their respiratory disorder. This laboratory finding is the most significant in terms of assessing the patient's respiratory function and acid-base balance. The other options are also important and should be monitored, but they are not as directly related to the respiratory disorder.

Question 20

The nurse is providing care to a patient who is mechanically ventilated.The high-pressure alarm beeps and the nurse notes a mucous plug in the endotracheal (ET)tube.Which action by the nurse is appropriate?

Accepted Answer

The high-pressure alarm indicates a blockage in the ET tube, and the most common cause is a mucous plug. Suctioning is the appropriate intervention to clear the airway and remove the obstruction. Inserting an oral airway is not necessary as the patient already has an ET tube in place. Assessing for asymmetric chest rise is important, but it is not the priority at this time. Emptying water from the ventilator tubing is also not related to this situation.

Quiz 7: Oxygen Therapy Management

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 in order to administer oxygen to this patient?