Question 1

The nurse observes a client using the incentive spirometer and s that further instruction is required when the client performs which action?
A)Exhales before placing the incentive spirometer to the lips
B)Seals the lips tightly around the mouthpiece of the incentive spirometer
C)Inhales quickly,causing the spirometer balls to snap to the top of the incentive spirometer
D)Attempts to cough productively after using the incentive spirometer

Accepted Answer

The correct use of an incentive spirometer involves slow, steady inhalation rather than quick breaths. Inhaling quickly and causing the balls to snap to the top indicates the client is not using the device correctly, as it is designed to encourage slow, deep breathing to improve lung function.

Question 2

The nurse is caring for a group of clients with respiratory disorders and should know that which client should not be placed on continuous positive airway pressure (CPAP)to assist with respiratory distress?
A)The client with chronic obstructive pulmonary disease (COPD)who is complaining of shortness of breath
B)The client whose respirations have fallen to 8/minute after receiving morphine sulfate
C)The client who experiences apnea during sleep
D)The client who is experiencing wheezing and is having difficulty moving air adequately

Accepted Answer

CPAP is contraindicated for clients with a significantly decreased respiratory drive, as in the case of a client whose respirations have decreased to 8/minute after receiving morphine sulfate. CPAP assists with keeping the airways open but requires the patient to be able to initiate breaths on their own.

Question 3

The nurse is preparing to do tracheostomy care for a client and should know that which must be present at the bedside before beginning this procedure?
A)One pair of sterile gloves
B)Obturator
C)Full-strength hydrogen peroxide
D)Sterile water

Accepted Answer

The obturator is essential to have at the bedside during tracheostomy care because it is used to quickly reinsert the tracheostomy tube in case it becomes dislodged or needs to be replaced, ensuring the airway remains open.

Question 4

The nurse has just completed insertion of a nasal trumpet to assist in protecting a responsive client's airway and should place the client in which position to maintain the airway?
A)Supine with the head to the side
B)Side-lying with chin positioned closest to the chest
C)Prone with head to the side
D)Side-lying with head slightly tilted up and centered on the pillow

Accepted Answer

Side-lying with the head slightly tilted up and centered on the pillow is the best position to maintain an open airway and ensure proper drainage, reducing the risk of aspiration and promoting comfort while using a nasal trumpet.

Question 5

The nurse is assisting a client in obtaining a sputum specimen.After a deep cough,the client produces approximately 1/2 tsp of sputum.Which is the nurse's next action?
A)Assist the client to cough again and produce more sputum.
B)Send the specimen to the lab.
C)Allow the client to rest for one hour and then ask the client to cough again.
D)Ask the client to walk around for 30 minutes and try again to produce sputum.

Accepted Answer

For a sputum specimen to be adequate for analysis, it typically needs to be at least 1 to 2 teaspoons in volume. If the client produces less than this amount, the nurse should encourage the client to cough again to produce a sufficient sample for accurate testing.

Question 6

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD)who is experiencing increasing respiratory difficulty.The client has refused being placed on a mechanical ventilator and the nurse is aware that which would provide possible respiratory assistance to this client?
A)Place an endotracheal tube without the use of a mechanical ventilator.
B)Provide supplemental oxygen using a Venturi face mask.
C)Put a nonrebreather mask on the client to help him breathe.
D)Place the client on a bilevel positive airway pressure (BiPAP)machine.

Accepted Answer

BiPAP provides non-invasive ventilation support, helping to improve breathing by delivering pressurized air to keep airways open, which can be beneficial for COPD patients who refuse mechanical ventilation.

Question 7

The nurse is preparing to assist a client in obtaining a sputum specimen and should place the client in which position?
A)Low Fowler's
B)Side-lying
C)Semi-Fowler's
D)Trendelenburg

Accepted Answer

Semi-Fowler's position, where the head of the bed is raised to 30-45 degrees, helps facilitate breathing and the collection of sputum by allowing gravity to assist in the drainage of secretions from the lower to the upper respiratory tract.

Question 8

The nurse should encourage the client to use incentive spirometry prior to which procedure?
A)Ambulating the client
B)Preparing the client for a rest period
C)Removing the client's meal tray
D)Obtaining a sputum specimen

Accepted Answer

Incentive spirometry is used to help the patient take deep breaths, which can clear the lungs and prevent pneumonia. It is particularly useful before obtaining a sputum specimen to ensure the sample is deep from within the lungs, improving the quality of the specimen for diagnostic purposes.

Question 9

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD)who is receiving supplemental oxygen and should intervene if which delivery device is being used by the client?
A)Nasal cannula
B)Continuous positive airway pressure (CPAP)
C)Bilevel positive airway pressure (BiPAP)
D)Venturi face mask

Accepted Answer

Venturi face mask delivers a precise concentration of oxygen, and the nurse must monitor the client closely to ensure that the desired oxygen concentration is being delivered.

Question 10

The nurse is preparing to provide tracheostomy care to a 6-month-old infant and should know that which takes priority when performing this procedure?
A)Teaching the parents how to perform the procedure
B)Ensuring that a second person is available to assist with the procedure
C)Completing the procedure while the infant is asleep to minimize traumatizing the infant
D)Use clean rather than sterile procedure because the infant will be going home with the tracheostomy

Accepted Answer

Ensuring that a second person is available to assist with the procedure takes priority to ensure safety and efficiency, especially in a potentially unstable situation like tracheostomy care in an infant.

Question 11

The nurse should know that which takes priority in assisting the client to effectively use a volume-oriented incentive spirometer?
A)The spirometer must be held in an upright position.
B)A nose clip must be used for effective inhalation.
C)The procedure must be repeated every 15 minutes to be effective.
D)Clean the spirometer in the dishwasher when used at home.

Accepted Answer

Holding the spirometer in an upright position is crucial for accurate measurement and effectiveness of the exercise, ensuring the patient can see the volume marker and aim for a target volume during inhalation.

Question 12

After completing instructions for collecting a sputum specimen to the client,the nurse observes the client remove the lid of the specimen container and spit into the cup.Which is the nurse's next best action?
A)Ask the client if the specimen obtained was sputum or saliva.
B)Explain to the client that the specimen will have to be obtained by suctioning.
C)Provide the client with a new specimen container and explain again how to obtain the specimen.
D)Send the specimen to the lab as obtained but label it as saliva.

Accepted Answer

The nurse should provide the client with a new specimen container and explain again how to obtain the specimen properly. This ensures that the correct type of specimen is collected for accurate testing.

Question 13

The nurse is caring for a 4-year-old postoperative client who has been unable to understand the use of the incentive spirometer.The nurse should choose which activity that will assist the child to perform the same action as the spirometer?
A)Blowing out candles
B)Sucking on a straw
C)Filling up a balloon
D)Using bubbles

Accepted Answer

The answer of The nurse is caring for a 4-year-old...

Question 14

The nurse is observing a new mother use a bulb syringe to suction her newborn's nose and mouth and should provide further instruction if the mother performs which action?
A)The mother begins the procedure by suctioning the infant's nose.
B)The mother deflates the bulb before placing the tip of the bulb syringe in the infant's nose.
C)The mother releases the bulb and removes the bulb syringe from the infant's nose.
D)The mother washes the bulb syringe with soap and water and then allows it to air dry.

Accepted Answer

The correct procedure for using a bulb syringe involves starting with suctioning the infant's mouth before the nose to prevent the risk of inhaling any secretions into the lungs if the baby gasps during the suctioning of the nose.

Question 15

The nurse is preparing to insert an oropharyngeal airway in an unresponsive client and should do which to ensure the airway is inserted correctly?
A)Using a tongue depressor,push the tongue to the side of the mouth when inserting the airway.
B)Begin the procedure by inserting the airway upside down and then rotating it to the correct position.
C)Position the airway in a downward position and then rotate it upward as it passes by the back of the throat.
D)Refrain from taping the bottom of the airway to prevent esophageal injury when the client swallows.

Accepted Answer

The correct technique for inserting an oropharyngeal airway involves starting with the airway upside down and then rotating it to the correct position as it is inserted. This method helps guide the airway past the tongue and into the correct position without causing trauma.

Question 16

The nurse is caring for a client who was just placed on supplemental oxygen per nasal cannula and should contact the healthcare provider if which assessment data are noted at the next assessment? Select all that apply.
A)The client complains of feeling anxious and restless.
B)Skin color is pink and warm to touch.
C)The heart rate is 82.
D)The respiratory rate is 36.
E)The client is using accessory muscles to breathe.

Accepted Answer

Anxiety and restlessness (A), a high respiratory rate (D), and use of accessory muscles (E) can indicate respiratory distress or inadequate oxygenation, requiring further evaluation by a healthcare provider.

Question 17

The nurse has been asked to obtain a sputum specimen from a client who is in the first postoperative day after a surgical gastric resection for stomach cancer.The nurse will ensure that which item is provided to the client to ensure an effective sputum collection?
A)Supplemental oxygen
B)Folded bath blanket
C)Peak expiratory flow meter
D)Sterile applicator stick

Accepted Answer

The answer of The nurse has been asked to obtain...

Question 18

The nurse is caring for a client with pneumonia and should be most concerned about which assessment?
A)The client cannot remember which day it is.
B)The client's heart rate has risen from 72 to 78 bpm.
C)The client's pulse oximetry has decreased from 99% to 97%.
D)The client respiratory rate has risen from 16 to 20 breaths per minute.

Accepted Answer

The client not being able to remember which day it is could indicate confusion or altered mental status, which can be a sign of decreased oxygenation or worsening condition in a patient with pneumonia. This is more concerning than the slight changes in heart rate, pulse oximetry, or respiratory rate, which are within normal variations or expected responses to illness.

Question 19

The nurse is caring for a client who is exhibiting severe respiratory distress and is receiving supplemental oxygen through a nonrebreather mask.While assessing the client,the nurse notes that the bag attached to the mask is deflated.Which is the nurse's best action?
A)Document it as functioning normally.
B)Decrease the flow of oxygen to the mask.
C)Increase the flow of oxygen to the mask.
D)Prepare for endotracheal intubation.

Accepted Answer

The bag attached to a nonrebreather mask should be inflated to ensure that the client is receiving the highest possible concentration of oxygen. If the bag is deflated, it indicates that the flow of oxygen is insufficient, and the nurse should increase the flow to properly inflate the bag and ensure adequate oxygen delivery.

Question 20

The nurse is caring for an older adult client who had a tracheostomy placed 3 days ago and should know that which issue will take priority when caring for this client?
A)Reducing the client's anxiety concerning self-care of the tracheostomy
B)Reassuring the client that the tracheostomy is a temporary measure
C)Ensuring that the skin around the client's tracheostomy stoma is assessed frequently
D)Referring the client to a support group for individuals with tracheostomies

Accepted Answer

Ensuring that the skin around the client's tracheostomy stoma is assessed frequently is a priority to prevent infection and skin breakdown, which are immediate concerns following tracheostomy placement.

Quiz 11: Oxygenation

The nurse observes a client using the incentive spirometer and s that further instruction is required when the client performs which action?

The nurse is caring for a group of clients with respiratory disorders and should know that which client should not be placed on continuous positive airway pressure (CPAP) to assist with respiratory distress?

The nurse is preparing to do tracheostomy care for a client and should know that which must be present at the bedside before beginning this procedure?

The nurse has just completed insertion of a nasal trumpet to assist in protecting a responsive client's airway and should place the client in which position to maintain the airway?

The nurse is assisting a client in obtaining a sputum specimen.After a deep cough,the client produces approximately 1/2 tsp of sputum.Which is the nurse's next action?

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is experiencing increasing respiratory difficulty.The client has refused being placed on a mechanical ventilator and the nurse is aware that which would provide possible respiratory assistance to this client?

The nurse is preparing to assist a client in obtaining a sputum specimen and should place the client in which position?

The nurse should encourage the client to use incentive spirometry prior to which procedure?

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen and should intervene if which delivery device is being used by the client?

The nurse is preparing to provide tracheostomy care to a 6-month-old infant and should know that which takes priority when performing this procedure?

The nurse should know that which takes priority in assisting the client to effectively use a volume-oriented incentive spirometer?

After completing instructions for collecting a sputum specimen to the client,the nurse observes the client remove the lid of the specimen container and spit into the cup.Which is the nurse's next best action?

The nurse is caring for a 4-year-old postoperative client who has been unable to understand the use of the incentive spirometer.The nurse should choose which activity that will assist the child to perform the same action as the spirometer?

The nurse is observing a new mother use a bulb syringe to suction her newborn's nose and mouth and should provide further instruction if the mother performs which action?

The nurse is preparing to insert an oropharyngeal airway in an unresponsive client and should do which to ensure the airway is inserted correctly?

The nurse is caring for a client who was just placed on supplemental oxygen per nasal cannula and should contact the healthcare provider if which assessment data are noted at the next assessment? Select all that apply.

The nurse has been asked to obtain a sputum specimen from a client who is in the first postoperative day after a surgical gastric resection for stomach cancer.The nurse will ensure that which item is provided to the client to ensure an effective sputum collection?

The nurse is caring for a client with pneumonia and should be most concerned about which assessment?

The nurse is caring for a client who is exhibiting severe respiratory distress and is receiving supplemental oxygen through a nonrebreather mask.While assessing the client,the nurse notes that the bag attached to the mask is deflated.Which is the nurse's best action?

The nurse is caring for an older adult client who had a tracheostomy placed 3 days ago and should know that which issue will take priority when caring for this client?