Chapter 87 Oxygen Therapy and Respiratory Care Exam& ACTUAL EXAM

The nurse is using a simple mask on a client prescribed supplemental oxygen. Which is the minimum oxygen flow rate for oxygen delivery using a simple mask to prevent carbon dioxide buildup? A. 25 LPM B. 10 LPM C. 16 LPM D. 6 LPM

D. 6 LPM

While assessing a client who is admitted to the hospital with a diagnosis of pleurisy, the nurse would note which characteristic symptom of this disorder? A. Pain that worsens when the breath is held B. Early morning fatigue C. Dyspnea that is relieved by lying flat D. Knifelike pain that worsens on inspiration

D. Knifelike pain that worsens on inspiration

Venturi mask

High-flow oxygen delivery system that provides the most reliable & consistent oxygen enrichment

Avoiding use of a gas or electric stove while oxygen is in use Being careful to monitor for kinks in the tubing Posting "no smoking" signs at home

If Wallace Peterson is discharged with an order for home oxygen therapy, which instructions should be included in his discharge teaching? Select all that apply.

partial-rebreathing

Low-flow oxygen delivery sys with a bag attached, and no valves

Non-rebreather mask

Oygen delivery sys that has valves on the outside of the mask as well as valves between the mask and bag

True

Suctioning may be done through the nostril or the mouth?

Nasal cannula

Two short tubes that fit into each nostril to deliver low flow oxygen

Pale skin and mucous membranes Restlessness HTN

Which of the followng are early signs of hypoxemia?(Select all that apply.)

Liters per minute

A client after cardiac arrest is receiving oxygen therapy via a mask. What unit should the nurse use to document the amount of oxygen delivered?

related to smoking

A patient is discussing his diagnosis of emphysema with the nurse. The patient demonstrates an understanding of the disease when he states that emphysema:

A nurse is collecting date from a client who is receiving mechanical ventilation. Which of the following findings indicated that the client might have developed an infection? A. Change in sputum color B. Absent breath sounds over one lung area C. Decrease in blood pressure D. Increase in abdominal girth

A. Change in sputum color

A nurse is caring for a client who has pneumonia and has been receiving oxygen therapy for several days. When collecting data from the client, the nurse should identify which of the following findings as an indication of an adverse effect of oxygen therapy? A. Cracks in oral mucous membranes B. Excessive pulmonary secretions C. Tachycardia D. Poor skin turgor

A. Cracks in oral mucous membranes

What condition might occur if an endotracheal tube (ET) is incorrectly placed? A. Gastric distention B. Hyperventilation C. Anergy D. Pneumothorax

A. Gastric distention

Which of the following are early signs of hypoxemia? ( Select all that apply. ) A. Restlessness B. Bradycardia C. Hypertension D. Confusion or stupor E. Pale skin and mucous membranes

A. Restlessness C. Hypertension E. Pale skin and mucous membranes

A nurse is applying an oxygen mask for a client diagnosed with chronic obstructive pulmonary disease (COPD) that provides the most reliable and consistent oxygen enrichment. Which mask has the nurse chosen? A. Venturi mask B. Simple mask C. Partial-rebreathing mask D. Non-breathing mask

A. Venturi mask

short-acting beta-adrenergic agonist.

Albuterol is classified as a:

The nurse is using a pulse oximeter to determine the percentage of oxygen saturation in a client's blood. Which pulse oximetry reading indicates that the client needs immediate supplemental oxygen? A. 98& B. 80% C. 99% D. 100%

B. 80%

The nurse has assisted with the intubation of a client diagnosed with status asthmaticus. What should the nurse do to verify proper placement of the endotracheal tube ( ET )? A. Obtain an MRI. B. Obtain a chest x-ray. C. Slightly pull on the tubing. D. Palpate the neck.

B. Obtain a chest x-ray.

Which client would most likely require chronic mechanical ventilation? A. A client who experienced a drug overdose. B. A client who has extensive surgery. C. A client who has a spinal cord injury. D. A client who has pneumonia in both lungs.

C. A client who has a spinal cord injury.

Hyperbaric Chamber

Carbon monoxide poisoning

The nurse is performing nasotracheal suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made? A. Secretions are becoming bloody. B. Coughing occurs with suctioning. C. Skin color becomes cyanotic. D. Heart rate decreases from 78 beats/minute to 54 beats/minute.

B. Coughing occurs with suctioning.

The nurse is gathering data for several clients. When obtaining pulse oximetry readings, the nurse determines that this method is ineffective for which client? A. A client with pneumonia B. A client on oxygen via non-rebreather mask C. A client with severe anemia D. A client with chronic obstructive pulmonary disease (COPD)

C. A client with severe anemia

A nurse is caring for an unconscious client who has undergone a tracheostomy. What measure should the nurse take while suctioning this client? A. Insert the suction catheter about an inch into the trachea B. Place the client in a semi- or high Fowlers position C. Avoid applying suction when inserting the suction catheter. D. Suction the tube continuously for at least 35 seconds.

C. Avoid applying suction when inserting the suction catheter.

A nurse is caring for clients in the ICU notices that a client is not breathing. What should me the immediate nursing intervention for this client? A. Initiate resipirations. B. Initiate chest compressions. C. Call for assistance. D. Stabilize the neck.

C. Call for assistance.

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which actions would the nurse take? Select all that apply. A. Contact the respiratory department to suction the client. B. Notify the Rapid Response Team. C. Discontinue suctioning until the client is stabilized. D. Finish the suctioning as quickly as possible. E. Notify the RN.

C. Discontinue suctioning until the client is stabilized. E. Notify the RN.

A nurse is caring for a client who has a new prescription for oxygen therapy of 4L/min using a nasal cannula. Which of the following actions should the nurse take? A. Lubricate the nares with a 0.9% sodium chloride. B. Establish an alternative means of communication. C. Provide humidification. D. Remove the cannula during meal times.

C. Provide humidification.

The nurse administering oxygen to clients with respiratory disorders is careful to monitor concentrations to prevent oxygen toxicity. How does this adverse reaction manifest itself? A. Change in blood pressure. B. Change in heart rate. C. Change in level of consciousness. D. Change in the lung tissue

D. Change in the lung tissue

The nurse reinforces instructing a client how to use an incentive spirometer. Which observation would indicate the ineffective use of this equipment by the client? A. The client removes the mouthpiece from the mouth to exhale. B. The client forms a tight seal around the mouthpiece with the lips. C. The client inhales slowly. D. The client is breathing through the nose.

D. The client is breathing through the nose.

1-5

What flow range are oxygen concentrators set at home and extended settings? _____LPM

Naloxone

What is an antidote for opiods?

Oxygen allows common flammable materials to burn faster and hotter.

What is the most important safety issue related to oxygen administration, that the nurse should consider?

Pale skin Elevated blood pressure

Which of the following is correct in regard to using a nasal cannula as a form of oxygen delivery?(Select all that apply.)

Oxygen stroller

administering portable liquid oxygen

Oxygen concentrator

home and extended care setting

Oxygen Cylinder

short term emergencies

draw the blood sample from his radial artery

A nurse informs a patient experiencing respiratory difficulty that the respiratory therapy department will be drawing arterial blood gases. The nurse is correct in informing the patient that the respiratory therapist will most likely:

Venturi mask

A nurse is applying an oxygen mask for a client diagnosed with chronic obstructive pulmonary disease (COPD) that provides the most reliable and consistent oxygen enrichment. Which mask has the nurse chosen?

Ensure that the cylinder is always kept away from heat.

A nurse is caring for a client receiving oxygen from a large oxygen cylinder. What measure should the nurse implement to minimize the risk of injury?

b. Perform airway suctioning

A nurse is caring for a client who is receiving IPPB treatment . Which measure should the nurse employ to ensure that mucus is removed? a. encourage forceful exhalation b. perform airway suctioning c. provide IPPB for 2 to 4 minutes d. assist the client to lie supine on the bed

PaCO2 of 51 mm Hg

A nurse is evaluating a patient's arterial blood gases. Which finding should be a concern?

Fingertip Earlobe

A physician orders her patient to have intermittent pulse oximetry monitoring. The nurse correctly applies the device by attaching the probe to the patient's _____. Select all that apply.

The patient's skin is bluish.

Which finding is a late clinical manifestation of respiratory distress?

Provide humidification

A nurse is caring for a client who has a new prescription for oxygen therapy of 4 L/min using a nasal cannula. Which of the following actions should the nurse take?

Fowler's

A nurse is caring for a client who has dyspnea. In which of the following positions should the nurse place the client?

A nurse is caring for a client who underwent a tracheostomy following throat surgery. Which is the rationale for swabbing the area around the outside of the trach tube with normal saline? A. To remove encrusted secretions B. To relieve bronchospasm C. To reduce inflammation D. To hydrate thick sputum

A. To remove encrusted secretions

The nurse is planning care for a client whose oxygenation is being monitored by a pulse oximeter. Which intervention is important to ensure accurate monitoring of the client's oxygenation status? A. Tape the sensor to the client's finger. B. Notify the primary health care provider immediately of an O2 saturation less than 90%. C. Place the sensor on a finger below the blood pressure cuff. D. Instruct the client not to move the sensor.

D. Instruct the client not to move the sensor.

The nursing student and clinical instructor are performing tracheotomy suction at the bedside of an adult client with a tracheostomy. Which action by the nursing student is incorrect, causing the clinical instructor to intervene? A. The student uses wall suction unit pressure of 100 mm Hg. B. The student inserts the catheter into the tracheostomy without applying suction. C. The student places the client in semi-Fowler's position before suctioning. D. The student suctions the client's tracheotomy tube for 15 seconds.

D. The student suctions the client's tracheotomy tube for 15 seconds.

The nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. Based on this finding, the nurse makes which determination? A. An air leak is present. B. The system is functioning as expected. C. The tubing is kinked. D. The lung has reexpanded.

B. The system is functioning as expected.

D. change in lung tissue

The nurse administering oxygen to clients with respiratory disorders is careful to monitor concentrations to prevent oxygen toxicity. How does this adverse reaction manifest itself? A)Changes in heart rate B)Changes in level of consciousness C)Changes in lung structure D)Changes in lung tissue

Call for assistance

The nurse caring for clients in the ICU notices that a client is not breathing. What should be the immediate nursing intervention for this client?

C. Continuous positive airway pressure (CPAP

The nurse is facilitating the weaning of a client from mechanical ventilation. The nurse uses ventilation that allows inspiratory and expiratory airway pressures to be maintained above atmospheric pressure and helps keep the client's lungs inflated. This method tends to improve lung function, even though breathing is spontaneous. What is the term for this mode of ventilation? A) Synchronized intermittent mandatory ventilation (SIMV). B) Pressure support ventilation (PSV). C) Continuous positive airway pressure (CPAP) D) Volume ventilation

90

The nurse is preparing a care plan for Wallace Peterson. An appropriate goal is for Mr. Peterson's oxygen saturation to remain at ____% or above at all times.

"I should hold it up to my lips and blow out as hard as I can."

The nurse is teaching Kimberly Dunning how to use the incentive spirometer. Which statement indicates that further teaching is required?

6 LPM

The nurse is using a simple mask on a client prescribed supplemental oxygen. What is the minimum oxygen flow rate for oxygen delivery using a simple mask to prevent carbon dioxide buildup?

Delivery of desired concentration

The nurse knows that when administering oxygen to an individual who is having difficulty breathing, the type of device that is used is critically important. What is the primary concern when delivering oxygen to a client?

Change in sputum color

A nurse is collecting data from a client who is receiving mechanical ventilation. Which of the following findings indicates that the client might have developed an infection?

A nurse is caring for a client who is receiving IPPB treatment. Which measure should the nurse employ to ensure the mucus is removed? A. Perform airway suctioning B. Provide IPPD for 2-4 minutes. C. Encourage forceful exhalation. D. Assist the client to lie supine on the bed.

A. Perform airway suctioning

The nurse is explaining to a client diagnosed with cystic fibrosis the goals of the oxygen therapy being prescribed. Which is a therapeutic effect of oxygen administration? A. It affects the ventilatory drive control mechanisms and increases the stimulus to breathe, B. It decreases the heart's work in pumping blood and eases the heart's load. C. It increases the work of the respiratory system, allowing it to work more efficiently. D. It reverses high and low oxygen concentrations in the blood.

B. It decreases the heart's work in pumping blood and eases the heart's load.

Encourage the client to cough Perform oral suctioning as needed Position the client on his left side. Provide emotional support to the client.

The nurse is caring for a client with an endotracheal tube. Which of the following indicate that the client needs suctioning?(Select all that apply.)

D. To remove encrusted secretions

A nurse is caring for a client who underwent a tracheostomy following throat surgery. What is the rationale for swabbing the area around the outside of the tracheostomy tube with hydrogen peroxide? A) To relieve bronchospasm B) To hydrate thick sputum C) To reduce inflammation D) To remove encrusted secretions

"I'm allergic to dogs and I had to catch my neighbor's dog after she got out"

A nurse is caring for a patient with a diagnosis of asthma. Which patient statement indicates that the patient developed an asthma attack as a result of exposure to a known trigger?

A client after cardiac arrest is receiving oxygen therapy via a mask. What unit should the nurse use to document the amount of oxygen delivered? A. Milliliters per minute B. Liters per minute C. Pounds per square inch D. Liters per square inch

B. Liters per minute

What is most important safety issue related to oxygen administration, that the nurse should consider? A. Decrease oxygen concentration weakens stimulus to breathe. B. Oxygen should be to all clients postoperatively to prevent nonsocomial infections. C. Oxygen allows common flammable material to burn faster and hotter. D. Oxygen can increase the heart's work of pumping blood.

C. Oxygen allows common flammable material to burn faster and hotter.

The respiratory therapist explains to the nurse that the positive pressure ventilator pushes air into the lungs of a client through a circuit that joins the machine and the client. Which mode of operation breathes for the client, forcing the breath at set time intervals? A. Volume ventilation B. Pressure ventilation C. Assisted-breath ventilation D. Controlled-breath ventilation

D. Controlled-breath ventilation

B. Monitoring respiratory status. D. Monitor placement of the endotracheal tube. A. Reposition client frequently to minimize the risk of developing pneumonia.

The nurse is caring for a client who is intubated following trauma to the chest. Which nursing measures should the nurse perform while the client is intubated?(Select all that apply.) A. Reposition the client frequently. B. Monitor respiratory status. C. Provide oral care every 4 hours. D. Monitor placement of the endotracheal tube E. Keep the client lying flat to prevent tube slippage.

The nurse applies oxygen at 2L/min via nasal cannula as prescribed for a client with dyspnea and an oxygen saturation of 90%. What is a priority nursing action after oxygen administration for this client? A. Continually monitor the client's respiratory status. B. Remove the oxygen cannula when ambulating in the room. C. Maintain the client in the supine position. D. Adjust the amount of oxygen flow every 4 hours.

A. Continually monitor the client's respiratory status.

The nurse knows that when administering oxygen to an individual who is having difficulty breathing, the type of device that is used is critically important. Which is the primary concern when delivering oxygen to a client? A. Delivery of desired concentration B. Ease of oxygen delivery C. Comfort of the client D. Monitoring of ABGs

A. Delivery of desired concentration

d. Attach the cannula with the connecting tube to the adapter on the humidifier.

A nurse is caring for an asthmatic client who is receiving oxygen via a nasal cannula. What is the first step the nurse should take before administering oxygen? a. adjust the flow meter to the recommended flow rate b. insert the prongs of the nasal cannula into the client's nostrils c. encourage the client to breathe through the nose rather than the smooth d. attach the cannula with the connecting tube to the adapter on the humidifier

"Oxygen saturation levels can be monitored with a pulse oximeter" "The oxygen saturation is documented as the SaO2." "The oxygen saturation level represents the amount of oxygen bound to hemoglobin."

A nurse is evaluating her patient's oxygen saturation level. Which statement is correct? Select all that apply.

Respiratory acidosis

A patient is admitted with an acute lower respiratory tract disorder. Arterial blood gas results include pH 7.32, PaCO2 46 mm Hg, and HCO3 22 mEq/L. Based on these results, which acid-base imbalance is the patient experiencing?

The nurse is teaching a student nurse the use of mechanical ventilators for clients in ventilatory failure. Which teaching point regarding this procedure is accurate? A. A mechanical ventilator is a machine that can be connected to the client via an endotracheal tube ( ET ). B. Mechanical ventilation is used if a client can achieve adequate tissue oxygenation. C. A mechanical ventilator is a machine that forces carbon dioxide into the lungs. D. In all settings, the nurse is responsible for adjusting the settings on the ventilator.

A. A mechanical ventilator is a machine that can be connected to the client via an endotracheal tube ( ET ).

A nurse is caring for asthmatic client who is receiving oxygen via a nasal cannula. What is the first step the nurse should take before administering oxygen? A. Attach the cannula with the connecting tube to the adapter on the humidifier. B. Encourage the client to breathe through the nose rather than the mouth. C. Insert prongs of the nasal cannula into the client's nostrils. D. Adjust the flow meter to the recommended flow rate.

A. Attach the cannula with the connecting tube to the adapter on the humidifier.

A nurse is caring for a client receiving oxygen from a large oxygen cylinder. What measure should the nurse implement to minimize the risk for injury? A. Ensure that the cylinder is always kept away from heat. B. Remember to keep the valve of the cylinder turned on at all times. C. Roll the cylinder in a horizontal position when moving it. D. Connect the cylinder to the client without changing pressure.

A. Ensure that the cylinder is always kept away from heat.

The nurse is determining the need for suctioning in a client with an endotracheal tube (ETT) attached to a mechanical ventilator. Which observations are consistent with the need for suctioning? Select all that apply. A. Gurgling sounds with respiration B. Restlessness C. Presence of congestion in the lungs D. Low peak inspiratory pressure on the ventilator E. Increased pulse and respiratory rates

A. Gurgling sounds with respiration B. Restlessness C. Presence of congestion in the lungs E. Increased pulse and respiratory rates

The nurse is applying an oxygen cannula to a client with pneumonia. What information should the nurse be sure to include when reinforcing education about oxygen administration? Select all that apply. A. No smoking around oxygen. B. Discontinue the oxygen if there is nasal dryness. C. Do not adjust the cannula after it is applied. D. Use an electric razor instead of a straight razor around oxygen. E. Do not use oils around the oxygen, especially on hands.

A. No smoking around oxygen.\ C. Do not adjust the cannula after it is applied. E. Do not use oils around the oxygen, especially on hands.

The nurse is caring for a client who is intubated and mechanically ventilated. What is a priority nursing intervention? A. Provide oral care every 2 hours. B. Suction the client every hour. C. Deflate the cuff and reposition the tube. D. Apply petroleum jelly to the lips to prevent dryness.

A. Provide oral care every 2 hours.

A client with chronic obstructive pulmonary disease (COPD) is admitted with an exacerbation of the disease and requires a low-level consistent oxygen concentration. What method of oxygen delivery will the nurse apply? A. Venturi mask B. Partial-rebreathing mask C. Non-rebreather mask D. Nasal cannula

A. Venturi mask

Fatigue

As the nurse continues to complete the nursing care plan, the student identifies ______ as the nursing diagnosis that most relates to Wallace Peterson's signs and symptoms of pneumonia and emphysema.

The nurse knows that when administering oxygen to an individual who is having difficulty breathing, the type of device that is used in critically important. What is the primary concern when delivering oxygen to a client? A. Monitor ABG's B. Delivery of desired concentration C. Ease of oxygen delivery. D. Comfort the client.

B. Delivery of desired concentration

Which of the following is correct in regards to using a nasal cannula as a form of oxygen delivery? ( Select all that apply. ) A. Hypotension B. Confusion C. Pale skin D. Bradycardia E. Elevated blood pressure

C. Pale skin E. Elevated blood pressure

A nurse is caring for a client receiving oxygen through a portable liquid-oxygen stroller. Which measure should the nurse implement when operating the stroller? A. Reduce the pressure in the stroller before connecting it to the client. B. Refill the stroller using small oxygen cylinders. C. Take measures to keep the stroller upright at all times. D. Connect the tubing of the stroller to an electric plug.

C. Take measures to keep the stroller upright at all times.

The nurse is facilitating the weaning of a client from mechanical ventilation. The nurse uses ventilation that allows inspiratory and expiratory airway pressures to be maintained above atmospheric pressure and helps keep the client's lungs inflated. This method tends to improve lung function, even though breathing is spontaneous. What is the term for this mode of ventilation? A. Synchronized Intermittent Mandatory Ventilation (SIMV) B. Pressure Support Ventilation (PSV) C. Volume ventilation D. Continuous Positive Airway Pressure (CPAP)

D. Continuous Positive Airway Pressure (CPAP)

The nurse is selecting an oxygen mask for a client diagnosed with pneumonia who requires an oxygen concentration of 75% with a flow rate around 10 LPM. Which mask would be a good choice for this client? A. Venturi mask B. Simple mask C. Non-breathing mask D. Partial-rebreathing mask

D. Partial-rebreathing mask

"It sounds like a high-pitched whistling sound."

The student nurse is auscultating Kimberly Dunning's lung fields. Which statement is the best description of wheezes?

Respiratory acidosis

Kimberly Dunning was admitted to the hospital with dyspnea related to an asthma attack. Which acid-base imbalance is she at the highest risk for developing based on her condition?

simple mask

Low-flow oxygen delivery system that fits over the client's nose, mouth and chin

provide oral care every 4 hrs reposition monitor Respiratory staturs monitor placement

The nurse is caring for a client who is intubated following trauma to the chest. Which nursing measures should the nurse perform while the client is intubated?(Select all that apply.)

It decreases the heart's work in pumping blood and eases the heart's load.

The nurse is explaining to a client diagnosed with cystic fibrosis the goals of the oxygen therapy being prescribed. Which is a therapeutic effect of oxygen administration?

"This mask is able to get the oxygen deeper into your lungs while you breathe in."

The nurse receives an order from Kimberly Dunning's physician to administer oxygen via a BiPAP (bi-level positive airway pressure) mask. The patient wants to know how this type of mask will help her breathe better. Which is the best response?

A patient is complaining of feeling short of breath. A nurse determines the presence of wheezes. A patient's respiratory rate is 32 breaths per minute.

Which findings are typically associated with an asthma attack? Select all that apply.

Deep breathing and coughing

Which of the following is the most effecting method for clearing secretions in the airway?