Question 1

A patient with newly diagnosed asthma is asking why peak flow measurements are being ordered.What is the best response by the nurse?

Accepted Answer

The peak expiratory flow measurements are objective indicators of the patient's current status and the effectiveness of the treatment.Decreased peak expiratory flow rate (PEFR)may indicate the need for further interventions such as increased doses of bronchodilators or antiinflammatory medications.The measurements focus on expiration,not inspiration,and do not reflect the amount of circulating oxygen in the alveoli.The peak expiratory flow measurements reflect only the respiratory system,not the overall health.

Question 2

While the nurse prepares to suction the patient's tracheostomy tube,the patient coughs up mucus,which is visible at the opening of the tube.Which action by the nurse is most appropriate at this time?

Accepted Answer

The secretions need to be suctioned to remove them; then the patient would be hyperoxygenated.There is no reason to push secretions into the patient.Listening to the lung sounds will be done after suctioning to determine the effectiveness and whether the patient's airway is clear.Wiping the secretions with a tissue would bring nonsterile tissue to the opening of the tube,which is contraindicated.The fibers could also go down the tube.

Question 3

The nurse is working with a patient receiving oxygen.What can the nurse delegate to nursing assistive personnel (NAP)during the administration of oxygen?

Accepted Answer

The NAP needs to be instructed to report to the nurse changes in vital signs or pulse oximetry and changes in the patient's anxiety or behavior.The nurse should adjust the flow rate of the oxygen since oxygen is considered a medication.The nurse must also provide the patient teaching.The nurse assists the provider during endotracheal intubation because the procedure is sterile,can require the nurse to administer emergency medication,and requires critical thinking and clinical judgment.

Question 4

A patient just had his tracheostomy suctioned.Which change in the patient's status would the nurse expect to see immediately after suctioning was completed?

Accepted Answer

Suctioning significantly increases the heart rate for 4 to 5 minutes following the procedure.The respiratory rate varies normally,and there would be a variation from before the procedure when the patient needed suctioning and afterward.There is a significant decrease in the oxygen saturation for 4 to 5 minutes following the procedure.The patient's respiratory effort would be easier after suctioning.

Question 5

An oxygen cylinder is turned on,and the gauge registers in the green range.What action should the nurse take at this time?

Accepted Answer

The gauge should register in the green range,which indicates that there is an adequate amount of oxygen in the cylinder.The respiratory therapy department oversees oxygen administration,but there is no reason to contact them because there is no problem.The cylinder of oxygen being used is fine and does not need to be replaced at this time.The oxygen rate is considered medication and should not be changed.

Question 6

The nurse is preparing to assist the physician in the removal of a chest tube.Which item would the nurse anticipate being placed over the insertion site as soon as the chest tube is removed?

Accepted Answer

First the petroleum gauze is placed over the wound to prevent any leakage of air.Gauze with Elastoplast would be used at the end of the dressing of the wound.Steri-Strips and 2 × 2-inch gauze with tincture of benzoin are not used during the removal of a chest tube.

Question 7

The nurse suctions the patient's endotracheal tube,and the patient becomes hypoxic.Which is the priority nursing intervention to increase patient oxygenation?

Accepted Answer

If the patient becomes hypoxic,the nurse ventilates him or her manually with supplemental oxygen to increase oxygenation.The nurse implements measures to oxygenate the patient quickly to avoid adverse and potentially life-threatening complications,including arrhythmias and cardiopulmonary arrest.He or she assesses the patient after providing supplemental oxygen and before seeking assistance because the hypoxia is most likely transient.The nurse discontinues suctioning to stop the decline in patient oxygen saturation; however,this action alone does not increase oxygenation.Instructing the patient to cough is a reasonable response to hypoxia,especially if the patient has pulmonary secretions; however,manual ventilation provides supplemental oxygen in addition to ventilation to increase patient oxygenation.

Question 8

The nurse prepares to perform oropharyngeal suctioning on an adult.Nursing care is appropriate if which wall suction pressure is used?

Accepted Answer

The wall suction setting for adults is 100 to 150 mm Hg.The wall suction setting for infants is 40 to 60 mm Hg.The wall suction setting for children is 60 to 100 mm Hg.The setting of 100 to 150 mm Hg is not specifically indicated for any age group.

Question 9

The nurse assesses arterial blood gas results from the 88-year-old patient who receives oxygen at 3 L/min by nasal cannula.The PaO₂ at 8 AM was 84 mm Hg,and at 10 AM it was 82 mm Hg.Which action should the nurse take?

Accepted Answer

The nurse continues with the current therapy and nursing care because the difference between oxygen values is insignificant,probably representing a normal variation in patient PaO₂occurring from minute to minute.The nurse continues to monitor the patient closely because the PaO₂ is approaching the lower limit for an acceptable arterial blood oxygen tension.Collaborating for a mask is unnecessary because the patient's PaO₂ is within normal limits.The patient's oxygen tension is at the lower acceptable range for arterial blood.

Question 10

A patient with a major chest injury was originally alert and oriented after recovery from surgery but is now becoming apprehensive and dizzy.What action should be taken by the nurse immediately?

Accepted Answer

Apprehension,dizziness,anxiety,a decreased ability to concentrate,and fatigue are indicators of impaired gas exchange.The nurse needs to assess the patient's cardiopulmonary status,including vital signs and pulse oximeter.The healthcare provider will be notified if there is a need for additional intervention.Elevating the head of the bed may be helpful,but the patient needs to be assessed immediately.Pain medication could decrease the respiratory system,which is already showing an adverse status.

Question 11

The nurse hears the patient's stridor from the hallway and notes that the patient's oxygen saturation has decreased to 92%.Which nursing intervention does the nurse implement first?

Accepted Answer

The nurse implements a noninvasive intervention to enhance the patient's airway before instituting an invasive measure because,although the patient's airway is impaired,he or she continues to oxygenate fairly well but is working very hard to do so.By quickly adjusting the patient's position to maximize gas exchange and chest expansion,the nurse intervenes and gains additional valuable data for planning additional nursing care.Suctioning is contraindicated for stridor because it can aggravate stridor to laryngospasm.The nurse avoids inserting an airway because the patient has stridor,an airway impairment in the trachea.If the patient needs an artificial airway,the nurse needs to provide an endotracheal tube or tracheostomy to restore his or her airway because the obstruction is beyond the reach of an oral airway.The nurse avoids ABGs because valuable data are already available for patient assessment; ABGs are not necessary yet.

Question 12

A patient with chronic bronchitis is not responding well to the chest physiotherapy (CPT)and asks the nurse what might be done to help bring up more secretions.Which response by the nurse is most appropriate?

Accepted Answer

Scheduling the CPT after bronchodilator enhances movement of secretions out of airways.Making the treatments shorter and more frequent won't help bring up more secretions.Coughing exercises alone won't help produce more secretions.Obtaining a sputum specimen is used to identify organisms and would not help the patient's toleration of the CPT.

Question 13

An older adult patient with a nasal cannula and extension tubing is able to get out of bed independently.What teaching by the nurse is indicated for this patient?

Accepted Answer

This older patient is at risk for tripping and falling over the extension tubing.Slippers need to be worn when ambulating,but the risk for tripping and falling is priority.The patient should keep the oxygen on as long as the extension tubing reaches.The oxygen rate is considered medication and should not be changed by the patient.

Question 14

Nasotracheal suctioning is performed on a patient who is unable to take deep breaths.What action by the nurse would best meet the patient's needs before suctioning?

Accepted Answer

Hyperoxygenating before suctioning can minimize postsuctioning hypoxemia if a patient is unable to take a deep breath.The oxygen rate cannot be changed without an order from the healthcare provider.Elevating the head of the bed can allow lung expansion but does little if the patient is unable to take deep breaths.Hyperextending the neck opens the airway; flexing the neck closes the airway.

Question 15

A patient in respiratory distress is admitted to critical care.Which type of mask would the nurse anticipate using to deliver the highest FIO₂ without intubation?

Accepted Answer

The nonrebreather is the mask that can deliver the highest possible FIO₂ without intubation.

Question 16

A home care patient receives oxygen by nonrebreather (NRB)mask.Which does the nurse include when teaching the caregiver about the oxygen delivery system?

Accepted Answer

To prevent inhalation of carbon dioxide,the nurse instructs the caregiver to maintain an inflated bag at the end of the mask because it serves as an oxygen reservoir for the patient.If the bag deflates,the patient is at risk of inhaling excessive levels of carbon dioxide.The nurse regulates the oxygen flow rate by adjusting the flowmeter on the oxygen source; the NRB mask does not have a mixing valve.It does not dehydrate the patient.It requires a tight seal for effective therapy.

Question 17

A patient with a water-sealed chest tube unit is connected to suction.Patient care is correct if the nurse takes which action?

Accepted Answer

Intermittent bubbling is normal during expiration when the air is being evacuated from the pleural cavity.Continuous bubbling during both inspiration and expiration indicates a leak in the system.Stripping the tube increases negative pressure within the tube and is generally not recommended.The chest tube system is kept unclamped when transporting the patient.The clamps must be toothless or have guards on them to prevent puncture of the chest tube or tubing.

Question 18

The patient with a mediastinal tube placed 22 hours ago has produced 350 mL of drainage since insertion.Which action by the nurse would be most appropriate?

Accepted Answer

The amount of drainage is within normal range and should be documented in the patient record.A total of approximately 500 mL in the first 24 hours is within expectations.There is no excessive bleeding; therefore the healthcare provider does not need to be notified.There is no need to reinforce the insertion site with extra dressing material.Clamping the mediastinal tube is not indicated.

Question 19

The nurse is attempting to prevent ventilator-associated pneumonia (VAP)in a newly intubated patient.Which activities would best support this goal?

Accepted Answer

Oral care with chlorhexidine decreases the colonization of bacteria.Brushing the teeth also helps removes plaque,which can harbor bacteria.The endotracheal cuff pressure should be at 20 cm H₂O to decrease movement of secretions to the lower airways.The patient should be elevated during tube feedings to prevent aspiration,which can lead to VAP.The patient needs to be repositioned every 2 hours.

Question 20

The nurse sees that a patient with a chest tube has intermittent bubbling in the water-seal chamber 4 hours after the chest tube was inserted.What action by the nurse is most appropriate at this time?

Accepted Answer

Intermittent bubbling is expected while air is being evacuated from the pleural cavity.The actions of notifying the physician,checking for an air leak,and listening to the lung sounds are not required since the chest tubes appear to be functioning correctly.

Quiz 14: Promoting Oxygenation

A patient with newly diagnosed asthma is asking why peak flow measurements are being ordered.What is the best response by the nurse?

While the nurse prepares to suction the patient's tracheostomy tube,the patient coughs up mucus,which is visible at the opening of the tube.Which action by the nurse is most appropriate at this time?

The nurse is working with a patient receiving oxygen.What can the nurse delegate to nursing assistive personnel (NAP) during the administration of oxygen?

A patient just had his tracheostomy suctioned.Which change in the patient's status would the nurse expect to see immediately after suctioning was completed?

An oxygen cylinder is turned on,and the gauge registers in the green range.What action should the nurse take at this time?

The nurse is preparing to assist the physician in the removal of a chest tube.Which item would the nurse anticipate being placed over the insertion site as soon as the chest tube is removed?

The nurse suctions the patient's endotracheal tube,and the patient becomes hypoxic.Which is the priority nursing intervention to increase patient oxygenation?

The nurse prepares to perform oropharyngeal suctioning on an adult.Nursing care is appropriate if which wall suction pressure is used?

The nurse assesses arterial blood gas results from the 88-year-old patient who receives oxygen at 3 L/min by nasal cannula.The PaO₂ at 8 AM was 84 mm Hg,and at 10 AM it was 82 mm Hg.Which action should the nurse take?

A patient with a major chest injury was originally alert and oriented after recovery from surgery but is now becoming apprehensive and dizzy.What action should be taken by the nurse immediately?

The nurse hears the patient's stridor from the hallway and notes that the patient's oxygen saturation has decreased to 92%.Which nursing intervention does the nurse implement first?

A patient with chronic bronchitis is not responding well to the chest physiotherapy (CPT) and asks the nurse what might be done to help bring up more secretions.Which response by the nurse is most appropriate?

An older adult patient with a nasal cannula and extension tubing is able to get out of bed independently.What teaching by the nurse is indicated for this patient?

Nasotracheal suctioning is performed on a patient who is unable to take deep breaths.What action by the nurse would best meet the patient's needs before suctioning?

A patient in respiratory distress is admitted to critical care.Which type of mask would the nurse anticipate using to deliver the highest FIO₂ without intubation?

A home care patient receives oxygen by nonrebreather (NRB) mask.Which does the nurse include when teaching the caregiver about the oxygen delivery system?

A patient with a water-sealed chest tube unit is connected to suction.Patient care is correct if the nurse takes which action?

The patient with a mediastinal tube placed 22 hours ago has produced 350 mL of drainage since insertion.Which action by the nurse would be most appropriate?

The nurse is attempting to prevent ventilator-associated pneumonia (VAP) in a newly intubated patient.Which activities would best support this goal?

The nurse sees that a patient with a chest tube has intermittent bubbling in the water-seal chamber 4 hours after the chest tube was inserted.What action by the nurse is most appropriate at this time?

Quiz 14: Promoting Oxygenation

A patient with newly diagnosed asthma is asking why peak flow measurements are being ordered.What is the best response by the nurse?

While the nurse prepares to suction the patient's tracheostomy tube,the patient coughs up mucus,which is visible at the opening of the tube.Which action by the nurse is most appropriate at this time?

The nurse is working with a patient receiving oxygen.What can the nurse delegate to nursing assistive personnel (NAP) during the administration of oxygen?

A patient just had his tracheostomy suctioned.Which change in the patient's status would the nurse expect to see immediately after suctioning was completed?

An oxygen cylinder is turned on,and the gauge registers in the green range.What action should the nurse take at this time?

The nurse is preparing to assist the physician in the removal of a chest tube.Which item would the nurse anticipate being placed over the insertion site as soon as the chest tube is removed?

The nurse suctions the patient's endotracheal tube,and the patient becomes hypoxic.Which is the priority nursing intervention to increase patient oxygenation?

The nurse prepares to perform oropharyngeal suctioning on an adult.Nursing care is appropriate if which wall suction pressure is used?

The nurse assesses arterial blood gas results from the 88-year-old patient who receives oxygen at 3 L/min by nasal cannula.The PaO2 at 8 AM was 84 mm Hg,and at 10 AM it was 82 mm Hg.Which action should the nurse take?

A patient with a major chest injury was originally alert and oriented after recovery from surgery but is now becoming apprehensive and dizzy.What action should be taken by the nurse immediately?

The nurse hears the patient's stridor from the hallway and notes that the patient's oxygen saturation has decreased to 92%.Which nursing intervention does the nurse implement first?

A patient with chronic bronchitis is not responding well to the chest physiotherapy (CPT) and asks the nurse what might be done to help bring up more secretions.Which response by the nurse is most appropriate?

An older adult patient with a nasal cannula and extension tubing is able to get out of bed independently.What teaching by the nurse is indicated for this patient?

Nasotracheal suctioning is performed on a patient who is unable to take deep breaths.What action by the nurse would best meet the patient's needs before suctioning?

A patient in respiratory distress is admitted to critical care.Which type of mask would the nurse anticipate using to deliver the highest FIO2 without intubation?

A home care patient receives oxygen by nonrebreather (NRB) mask.Which does the nurse include when teaching the caregiver about the oxygen delivery system?

A patient with a water-sealed chest tube unit is connected to suction.Patient care is correct if the nurse takes which action?

The patient with a mediastinal tube placed 22 hours ago has produced 350 mL of drainage since insertion.Which action by the nurse would be most appropriate?

The nurse is attempting to prevent ventilator-associated pneumonia (VAP) in a newly intubated patient.Which activities would best support this goal?

The nurse sees that a patient with a chest tube has intermittent bubbling in the water-seal chamber 4 hours after the chest tube was inserted.What action by the nurse is most appropriate at this time?

The nurse assesses arterial blood gas results from the 88-year-old patient who receives oxygen at 3 L/min by nasal cannula.The PaO₂ at 8 AM was 84 mm Hg,and at 10 AM it was 82 mm Hg.Which action should the nurse take?

A patient in respiratory distress is admitted to critical care.Which type of mask would the nurse anticipate using to deliver the highest FIO₂ without intubation?