Question 1

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

A)   Notify the healthcare provider of excessive bleeding.
B)   Document the drainage output in the patient record.
C)   Place extra dressings and tape over the insertion site.
D)   Clamp the mediastinal tube once each shift. B

Question 2

3. Use of _____________ or ___________ will help prevent nasal irritation from a nasal cannula.

Accepted Answer

isotonic saline nasal spray,water-soluble lubricant
water-soluble lubricant,isotonic saline nasal spray
The nurse should cleanse the area,observe for skin breakdown and apply isotonic saline nasal spray or a water-soluble lubricant to the area.

Question 3

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

A)   Increase the oxygen rate of the nasal cannula.
B)   Elevate the head of the patient's bed.
C)   Hyperoxygenate with ventilation attached to a mask.
D)   Gently flex the patient's neck. C

Question 4

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

A)   Adjust the patient's position.
B)   Suction the oropharynx.
C)   Insert an artificial airway.
D)   Review the last arterial blood gases (ABGs) .

Question 5

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

A)   Petroleum gauze on a pressure dressing
B)   Gauze with Elastoplast
C)   2 × 2-inch gauze with tincture of benzoin
D)   Steri-Strips under a bioclusive dressing

Question 6

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

A)   Apply the oxygen as ordered.
B)   Notify the respiratory therapy department.
C)   Obtain a new cylinder of oxygen.
D)   Adjust the flowmeter slightly below what is ordered.

Question 7

A patient admitted for asthma is weak and tired.Which patient position should the nurse use for patient performance of a peak expiratory flow rate (PEFR)?

Accepted Answer

A)   Standing
B)   Side lying
C)   High-Fowler's
D)   Reclining in chair

Question 8

1. When patients require respiratory support such as artificial airways,they are often unable to speak.A(n)_________ is a useful tool to aid in communication.

Accepted Answer

The answer of 1. When patients require respiratory support such...

Question 9

The patient uses continuous positive airway pressure (CPAP)at home and tells the home care nurse that the mask fits too tightly.Which action is most important for the nurse to take?

Accepted Answer

A)   Changing the mask to a simple face mask
B)   Teaching the patient about maintaining a tight fit to face
C)   Enlarging several of the air holes on the mask
D)   Loosening the straps of the mask for the patient's comfort

Question 10

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

A)   They measure the minimum force used to breathe in during the breathing process.
B)   They measure the maximum flow that occurs when one quick, forced expiration is taken.
C)   They measure the amount of circulating oxygen in the alveoli during breathing.
D)   They indicate the stability of your overall health.

Question 11

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

A)   Adjusting the flow rate of the oxygen
B)   Reporting changes in patient's behavior
C)   Instructing the patient about oxygen at home
D)   Assisting during endotracheal intubation

Question 12

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

A)   Keep the plastic bag at the end of the mask inflated continually.
B)   Adjust the oxygen flow rate with the valve in front of the mask.
C)   Offer fluids frequently and apply moisturizer to prevent dry skin.
D)   Remove the elastic head strap to prevent skin breakdown at the ears.

Question 13

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

A)   Collaborate with the provider to use an oxygen mask.
B)   Plan follow-up nursing care for patient hypoxemia.
C)   Request that the laboratory confirm the patient's results.
D)   Continue with the current therapy and nursing care.

Question 14

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

A)   Simple
B)   Venturi
C)   Partial rebreather
D)   Nonrebreather

Question 15

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

A)   The heart rate changes from 84 to 92.
B)   The respiratory rate remains the same.
C)   The oxygenation saturation changes from 92 to 98.
D)   The patient's respiratory effort increases gradually.

Question 16

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

A)   Put on slippers whenever walking.
B)   Take off the oxygen if only going to the bathroom.
C)   Be careful not to trip over the extra oxygen tubing.
D)   Increase the flow rate a little before getting out of bed.

Question 17

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

Accepted Answer

A)   40 to 60 mm Hg
B)   60 to 80 mm Hg
C)   80 to 100 mm Hg
D)   100 to 150 mm Hg

Question 18

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

A)   Hyperoxygenate this patient.
B)   Suction the visible secretions.
C)   Listen to the lung sounds.
D)   Wipe the mucus off with tissue.

Question 19

The patient is lethargic and unable to clear oral secretions effectively.How does the nurse manage the suctioning of the oropharyngeal secretions from the patient?

Accepted Answer

A)   Uses a Yankauer suction device
B)   Loosens oral secretions with normal saline solution
C)   Suctions the nose, mouth, and throat with a catheter
D)   Uses a clean catheter to suction the nose and mouth

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

A)   Notify the physician.
B)   Check for an air leak.
C)   Listen to the lung sounds.
D)   Document the findings.

Exam 14: Promoting Oxygenation

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?

3. Use of ___ or _ will help prevent nasal irritation from a nasal cannula.

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?

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?

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?

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

A patient admitted for asthma is weak and tired.Which patient position should the nurse use for patient performance of a peak expiratory flow rate (PEFR) ?

1. When patients require respiratory support such as artificial airways,they are often unable to speak.A(n)_________ is a useful tool to aid in communication.

The patient uses continuous positive airway pressure (CPAP) at home and tells the home care nurse that the mask fits too tightly.Which action is most important for the nurse to take?

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

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

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?