NURS 310- Fundamentals of Nursing- CH 41.- EAQs- Oxygenation

Which artificial airway is the simplest type? 1 Pharyngeal tube 2 Endotracheal tube 3 Tracheostomy tube 4 Oropharyngeal airway

An oropharyngeal airway is the simplest type of artificial airway. It prevents obstruction of the trachea by displacement of the tongue into the oropharynx. A pharyngeal tube is used to clear the pharynx. An endotracheal tube is a short-term artificial airway that is used to administer invasive mechanical ventilation. A tracheostomy tube is a used to perform tracheal suctioning.

Which complication would the nurse suspect if an endotracheal tube cuff is underinflated? Correct1 Aspiration 2 Impaired skin integrity 3 Impaired oxygenation 4 Necrosis of tracheal tissu

An underinflated cuff increases the patient's risk of aspiration. An inability to control secretions and pressure from airway devices may increase the risk of impaired skin integrity and infection. A buildup of secretions in the airways is responsible for impaired oxygenation. An overinflated cuff may result in ischemia or necrosis of the tracheal tissue

A patient is intubated and mechanically ventilated. Upon assessment, the nurse finds that the endotracheal tube cuff is underinflated and adds air until normal cuff pressure is reached. Which statement is true regarding the rationale behind the nursing intervention? Correct1 To prevent aspiration 2 To reduce tracheal tissue necrosis 3 To decrease impairment of the skin 4 To diminish the chances of infection

An underinflated cuff may increase the risk of aspiration. Therefore the nurse must replace it with a properly inflated cuff. An overinflated cuff may cause ischemia and necrosis of tracheal tissue. The patient would require reintubation with a new tube to prevent the complication. Intubation and deep endotracheal suctioning require strict aseptic technique, which reduces the chance of infection. Ventilator-associated protocols are used to prevent pneumonia in patients who are intubated and mechanically ventilated.

Which nursing skill is categorized in the planning phase while delivering care to a patient with an artificial airway? 1 Preparing for oropharyngeal suctioning 2 Reinforcing the information given to the patient and family 3 Assisting the patient to attain a semi-Fowler's position 4 Providing a baseline measure of ventilation and ease of breathing

Assisting the patient to attain a semi-Fowler's position provides access to the site and facilitates completion of the procedure without causing the nurse muscle strain or the patient discomfort. This intervention is performed in the planning phase of the nursing process. Preparing for oropharyngeal suctioning by connecting the Yankauer suction catheter to a suction source is performed during the implementation phase. The information given to the patient and family is reinforced in the assessment phase. Providing a baseline measure of ventilation and ease of breathing by auscultating the lung sounds is performed during the assessment phase.

A nurse auscultates a patient's lung sounds before inserting an endotracheal tube to maintain the artificial airway. Which rationale explains this nursing intervention? 1 To prevent aspiration 2 To prevent tube dislodgment 3 To prevent ischemia of the tracheal tissue Correct4 To provide a baseline measure of ventilation

Auscultating the lung sounds and observing the respiratory rate and depth will provide a baseline measure of ventilation and ease of breathing. Underinflating the cuff may increase the risk of aspiration. The tube may dislodge because of inadequate tube size. Overinflating the cuff may lead to ischemia and necrosis of the tracheal tissue.

Which statement is true regarding endotracheal and tracheal airways? Select all that apply. One, some, or all responses may be correct. 1 An endotracheal tube is a long-term artificial airway. Correct2 A specially trained clinician should insert the endotracheal tube. Correct3 Tracheostomy suctioning should be performed only when necessary. Incorrect4 An endotracheal tube is inserted by making a surgical insertion into the trachea. Correct5 The most common complication associated with a tracheostomy tube is partial or complete obstruction.

Endotracheal tube insertion is a complex technique that requires specialized skills. Therefore a specially trained clinician should insert the endotracheal tube to ensure the patient's safety. Tracheostomy suctioning should be performed to clear the secretions only when necessary because suctioning too frequently may lead to hypoxemia, hypotension, and arrhythmias. Tracheostomy tube insertion may cause complications such as partial or complete airway obstruction because of a buildup of respiratory secretions. An endotracheal tube is a short-term artificial airway; it is not used for long-term assistance. An endotracheal tube is passed directly through the patient's mouth, past the pharynx, and into the trachea; it is not inserted by making a surgical insertion in the trachea.

Which step in the nursing process is the nurse performing when suctioning the tracheostomy in a patient? 1 Planning 2 Evaluation 3 Assessment Correct4 Implementation

Implementation involves executing the intubation and related activities. Therefore suctioning the tracheostomy is considered part of the implementation stage of the nursing process. Planning would involve the health care team deciding the steps involved with the intubation. Assessment includes gathering data about the patient; these data may be what leads the health care team to decide to intubate the patient. Evaluation involves assessing the success of a procedure.

The nurse is reviewing the medical records of a patient with decreased oxygenation due to increased secretions. Which finding would prevent the nurse from performing nasotracheal suctioning for the patient? 1 Croup 2 Asthma 3 Obesity 4 Heart failure

It is contraindicated to perform nasotracheal suctioning in patients with croup because of the risk of bronchospasm. It is appropriate to perform nasotracheal suctioning in patients with asthma, obesity, and heart failure.

Which information would the nurse provide to a patient's family who asks about the rationale for noninvasive ventilation (NIV) that has been prescribed for the patient? Select all that apply. One, some, or all responses may be correct. 1 It corrects atelectasis. 2 It breathes for the patient. 3 It improves oxygenation. 4 It promotes adequate sleep. 5 It decreases pulmonary edema.

NIV corrects atelectasis because it keeps the alveoli partially inflated as it improves oxygenation, promotes adequate sleep, and improves gas exchange. NIV also decreases pulmonary edema because of the improved gas exchange. NIV does not breathe for the patient.

Which complication occurs in a patient with noninvasive ventilation? Select all that apply. One, some, or all responses may be correct. Incorrect1 Sinusitis Correct2 Facial injury Correct3 Skin breakdown Correct4 Dry mucous membranes Incorrect5 Ventilator-associated pneumonia

Noninvasive ventilation causes complications that include facial injury, skin breakdown, and dry mucous membranes. Sinusitis and ventilator-associated pneumonia are avoided with noninvasive ventilation.

Which purpose does noninvasive ventilation serve? Select all that apply. One, some, or all responses may be correct. Correct1 Treats atelectasis Correct2 Improves alveolar ventilation 3 Reduces intracranial pressure 4 Decreases oxygen consumption Correct5 Maintains positive airway pressure

Noninvasive ventilation is used to treat atelectasis by inflating the alveoli and reducing pulmonary edema by forcing fluid out of the lungs back into the circulation. It also improves alveolar ventilation and maintains positive airway pressure. Invasive mechanical ventilation reduces intracranial pressure and decreases oxygen consumption.

Which assessment by the nurse is least likely to support the suspicion of an accumulation of secretions in a patient with an artificial airway? 1 Auscultating lung sounds 2 Observing patency of the airway 3 Observing respiratory rate and depth 4 Observing the condition of the surrounding tissues

Observing the condition of the surrounding tissues determines whether the patient is at risk of potentially impaired skin integrity and infection. This assessment may not support the suspicion of secretions impairing artificial airway care. Auscultating lung sounds and observing the patency of the airways and respiratory rate and depth helps to assess for the presence of secretions by the diminished breath sounds, which are signs of airway obstruction. These assessments can determine the effect of airway obstruction on the patient's oxygenation while receiving artificial airway care.

Which age population displays an enlarged and calcified trachea and bronchi on an x-ray? 1 Toddlers 2 School-age children 3 Young adults 4 Older adults

Older adults display these x-ray findings. The trachea and large bronchi in older adults may become enlarged from calcification of the airways. Toddlers have smaller airways, not enlarged. School-age children do not experience calcified trachea and bronchi. Young adults do not have enlarged or calcified airways.

What is the disadvantage of using an oxygen-conserving cannula? Select all that apply. One, some, or all responses may be correct. 1 Increases risk of aspiration 2 Cannula cannot be cleaned 3 May induce feelings of claustrophobia 4 More expensive than standard cannula 5 Contraindicated in patients who retain carbon dioxide

Oxygen-conserving cannulas cannot be cleaned and are more expensive. Simple face masks may increase the risk of aspiration and induce feelings of claustrophobia. Simple face masks are contraindicated in patients who retain carbon dioxide.

The nurse is developing the plan of care for a patient with a well-established tracheostomy tube. Which action is safe to delegate to the assistive personnel (AP)? 1 Perform oral suctioning. 2 Clean tracheostomy stoma. 3 Suction tracheostomy tube. 4 Increase oxygen administration.

Perform oral suctioning.

Which nursing intervention maintains the patient's supply of oxygen? 1 Hyperventilating the patient 2 Rinsing the inner cannula with normal saline solution 3 Placing the tracheostomy tube over the outer cannula 4 Securing the inner cannula with a "locking" mechanism

Placing the tracheostomy tube over the outer cannula Placing a tracheostomy tube over the outer cannula will help maintain the patient's supply of oxygen. Hyperventilating the patient and securing the "locking" mechanism helps secure the inner cannula and reestablish the oxygen supply. Rinsing the inner cannula with normal saline solution will remove secretions from the inner cannula

While performing endotracheal tube care, which action by the nurse reduces anxiety, encourages cooperation, and reduces risks associated with the treatment? Select all that apply. One, some, or all responses may be correct. 1 Placing the patient in the supine position 2 Obtaining assistance from available staff 3 Placing a towel across the patient's chest 4 Providing reassurance during the procedure 5 Explaining the importance of trying not to cough

Providing reassurance by comforting the patient by explaining the procedure helps reduce the patient's anxiety and encourages cooperation, thereby reducing the risks associated with the treatment. Coughing may cause complications in a patient who is receiving endotracheal tube care. Explaining to the patient the risks associated with coughing helps reduce the risks associated with it. Placing the patient in the supine position provides access to the site and facilitates completion of the procedure without causing the nurse or patient discomfort. Obtaining assistance from available staff reduces the risk of accidental extubation. Placing a towel across the patient's chest helps reduce the transmission of microorganisms to linens and bedclothes.

Which aspect of care for a patient with a tracheostomy can be safely delegated to assistive personnel? Select all that apply. One, some, or all responses may be correct. 1 Providing stoma care 2 Cleaning the inner cannula 3 Reporting a change in the color of the stoma 4 Reporting the patient's respiratory status 5 Reporting unexpected drainage from the tracheostomy tube

Reporting a change in the color of the stoma Reporting unexpected drainage from the tracheostomy tube

which finding is the nurse least likely to observe in a client receiving invasive mechanical ventilation? Correct1 Sinusitis 2 Total airway obstruction 3 A pressure area around the tube Incorrect4 Ventilator-associated pneumonia

Sinusitis is a complication associated with noninvasive ventilation (such as continuous positive airway pressure [CPAP]) versus invasive ventilation. A pressure area around the tube is possible. The nurse must perform care of the airway tube routinely to prevent a pressure area from forming. Airway obstruction and pneumonia are potential complications of invasive mechanical ventilation.

Which statement by the licensed practical nurse indicates the need for further teaching regarding the insertion of artificial oral airways? 1 "Insert the airway by placing it over the tongue." 2 "Insert the airway in such a way that the flange rests against the patient's teeth." 3 "Turn the airway so that the opening points upward when the airway is in the oropharynx." 4 "Insert the airway by initially pointing the curved end upward and turning it downward upon reaching the back of the mouth."

The airway should be inserted by initially pointing the curved end upward, and once it reaches the back of the mouth, it should be turned downward to follow the natural curve of the tongue. The airway should be inserted by placing it over the tongue. Inserting the airway in such a way that the flange rests against the patient's teeth is a correct insertion technique that helps prevent airway obstruction. When the airway is in the oropharynx, turn the airway in such a way that the opening points downward to prevent airway obstruction.

Which initial dressing application is required for endotracheal tube care? Select all that apply. One, some, or all responses may be correct. Incorrect1 Scissors 2 Twill tape 3 Small sterile brush Correct4 Tincture of benzoin and liquid adhesive Correct5 0.12% to 0.20% chlorhexidine mouthwash

The initial dressing application of endotracheal tube care requires tincture of benzoin, liquid adhesive, and 0.12% to 0.20% chlorhexidine mouthwash. Scissors, twill tape, and a small sterile brush are required for tracheostomy care

Which action requires correction regarding endotracheal tube care? 1 Holding the endotracheal tube firmly 2 Cleaning the oral airway with plain water 3 Keeping the endotracheal tube cuff inflated 4 Cleaning the face and neck with a soapy washcloth

The nurse should clean the oral airway with warm, soapy water, not plain water, to promote hygiene and reduce the transmission of microorganisms. The nurse should hold the endotracheal tube firmly at the patient's lips to maintain proper tube positioning and to prevent accidental extubation. The nurse should keep the endotracheal tube cuff inflated to reduce the risk of aspiration and accidental extubation. The nurse should clean the patient's face and neck with a soapy washcloth to prevent adhesive tape adherence.

Which statement by the patient indicates the need for further teaching regarding diaphragmatic breathing? Correct1 "I should practice the exercise initially in the sitting position and then in the supine position." 2 "I should place one hand flat below the breastbone and the other hand flat on the abdomen." 3 "I should inhale slowly, making the abdomen push out and moving the lower hand outward." 4 "I should practice these exercises often with the pursed-lip breathing technique."

The patient should practice the exercise initially in the supine position because it is easier to perform and then switch to a sitting or standing position. The patient should place one hand flat below the breastbone and the other hand flat on the abdomen. The patient should inhale slowly, making the abdomen push out and moving the lower hand outward. The patient should practice these exercises often with the pursed-lip breathing technique.

Which statement by the patient indicates the need for further teaching regarding diaphragmatic breathing? 1 "I should practice the exercise initially in the sitting position and then in the supine position." 2 "I should place one hand flat below the breastbone and the other hand flat on the abdomen." 3 "I should inhale slowly, making the abdomen push out and moving the lower hand outward." 4 "I should practice th

The steps involved in disposing of the inner cannula in a tracheostomy tube are to remove the cannula from its packaging and then withdraw the inner cannula and replace it with the new cannula. The nurse then disposes of the contaminated cannula in an appropriate receptacle and applies an oxygen source or ventilator.

Which statement if made by the nursing student indicates the need for further teaching regarding factors increasing the risk of complications associated with endotracheal intubation? Select all that apply. One, some, or all responses may be correct. 1 "I should avoid prolonged endotracheal intubation." 2 "I should avoid placing an endotracheal tube in a patient with diminished nutrition." 3 "I should avoid overinflating the cuff because it causes aspiration of secretions." 4 "I should avoid underinflating the cuff because it may result in ischemia of the tracheal mucosa." 5 "I should avoid placing an endotracheal tube in a patient who has undergone radiotherapy for oral cancer."

Underinflating the cuff may increase the risk of aspiration because of a buildup of negative pressure. Overinflating the cuff may lead to ischemia and necrosis of the tracheal tissue. Prolonged placement of an endotracheal tube may result in the risk of infections. The placement of an endotracheal tube in a patient with malnutrition or radiation may result in tissue breakdown.

Which intervention in a patient with a tracheostomy pulls mucus and other contaminants from the stoma? 1 Cleaning the outer tracheostomy tube flange 2 Using dry 4 × 4-inch gauze and patting the skin lightly 3 Maintaining a secure hold on the tracheostomy tube 4 Cleaning in a circular motion from the stoma site outward

Using normal saline-saturated, cotton-tipped sterile swabs and 4 × 4-inch gauze, the nurse should clean in a circular motion from the stoma site outward. This pulls mucus and other contaminants from the stoma. Cleaning the outer tracheostomy tube flange will remove secretions that can be a source of infection. Using dry 4 × 4-inch gauze and patting the skin lightly will prohibit the formation of a moist environment for microorganism growth and skin excoriation. Maintaining a secure hold on the tracheostomy tube will keep the tube in place.

The nurse manager is implementing a program to decrease the incidence of ventilator-associated pneumonia (VAP) by 25% on a nursing unit. Which action would be classified as beneficial to meeting this goal? Select all that apply. One, some, or all responses may be correct. 1 Perform sterile endotracheal suctioning. 2 Assess bilateral lung fields every 2 hours. 3 Provide daily oral care with chlorhexidine. 4 Give prophylactic intravenous antibiotics. 5 Elevate the head of the bed greater than 30 degrees.

VAP can lead to patient deaths and is a major complication of ventilator-dependent patients. Therefore the nurse should implement ways to decrease VAP. These would include sterile suctioning, cleaning the oral cavity with chlorhexidine, and elevating the head of the bed greater than 30 degrees. Lung sounds should be auscultated every 4 hours unless changes occur. Prophylactic antibiotics can lead to drug-resistant microorganisms, which also have a high mortality rate.

Which complication is associated with invasive mechanical ventilation? Select all that apply. One, some, or all responses may be correct. 1 Nasal injury 2 Volutrauma 3 Skin breakdown 4 Gastrointestinal disturbances 5 Ventilator-associated pneumonia

Volutrauma, gastrointestinal disturbances, and ventilator-associated pneumonia are complications associated with invasive mechanical ventilation. Skin breakdown and nasal injury are the complications associated with noninvasive mechanical ventilation.

Which nursing action is most appropriate to prevent biting while inserting an oropharyngeal airway into an unconscious patient? 1 Keeping the oropharyngeal airway insertion cuff inflated 2 Holding the oropharyngeal airway insertion firmly while inserting the oropharyngeal airway 3 Placing adhesive tape around the head from cheek to cheek below the ears 4 Pushing the tongue into the oropharynx when placing an oropharyngeal airway

When placing an oropharyngeal airway in an unconscious patient, the nurse should push the tongue into the oropharynx to prevent the patient from biting the tube. Keeping the oropharyngeal airway insertion cuff inflated prevents aspiration. Holding the endotracheal tube firmly while inserting it and placing adhesive tape around the head from cheek to cheek below the ears will help maintain proper tube position.

The nurse would be concerned about which patient regarding the development of ischemia and necrosis of the tracheal tissue? Select all that apply. One, some, or all responses may be correct. 1 A patient with a long endotracheal tub 2 A patient with an underinflated cuff Correct3 A patient with an overinflated cuff Correct4 A patient who underwent thoracic radiation Correct5 A patient with prolonged period of intubation

While caring for a patient with an endotracheal tube, the nurse should continuously monitor for factors that increase the risk of complications. A patient with an overinflated cuff and a patient who underwent thoracic radiation are at risk of ischemia and necrosis of tracheal tissue caused by hypoxia. A patient with a prolonged period of intubation is also at increased risk of complications such as tracheal tissue breakdown that leads to necrosis and ischemia. A patient with a long endotracheal tube and a patient with an underinflated cuff have an increased risk of aspiration.

During an assessment, which finding indicates the presence of a pneumothorax? 1 Tracheal deviation toward the affected side 2 Inability to auscultate tracheal breath sounds Correct3 Pleuritic pain that worsens on inspiration 4 Pursed-lip breathing

A finding that indicates a pneumothorax is pleuritic pain that worsens on inspiration. Pneumothorax is caused by a rapid accumulation of air in the pleural space, causing severely high intrapleural pressure. Patients will report sudden onset of sharp pleuritic pain that worsens with inspiration. The trachea will deviate toward the unaffected side (the side with lower intrapleural pressure), not the affected side. With a pneumothorax, absent breath sounds on the affected side occur, not an inability to auscultate tracheal breath sounds. Pursed-lip breathing is associated with chronic lung diseases, not with a pneumothorax.

Which diagnostic test does the nurse anticipate will be used to rule out a pulmonary blood clot in a patient? 1 Lung scan 2 Bronchoscopy 3 Pulmonary function test (PFT) 4 Peak expiratory flow rate (PEFR)

A lung scan will be prescribed for a patient to rule out a pulmonary blood clot. Bronchoscopy is an invasive study in which a lighted camera is inserted into the pulmonary system for direct visualization and to remove mucous plugs or foreign bodies but not to rule out a pulmonary blood clot. A PFT is used to evaluate the inhalation and exhalation quality for patients experiencing shortness of breath or possible asthma but not for a pulmonary blood clot. PEFR is a measurement of the patient's maximum speed of expiration for patients with asthma, not for detecting a pulmonary blood clot.

Which diagnostic test is beneficial for a patient who is coughing up blood-tinged sputum? Select all that apply. One, some, or all responses may be correct. 1 Lung scan 2 Bronchoscopy 3 Sputum specimen 4 Pulmonary function test 5 Chest x-ray examination

A lung scan, bronchoscopy, sputum specimen, and chest x-ray examination are used to diagnose the cause of hemoptysis. Blood-tinged sputum indicates the presence of hemoptysis, which is associated with coughing and bleeding from the upper respiratory tract and sinus drainage. Pulmonary function tests are used for basic ventilation studies, not for blood-tinged sputum.

Which nursing action is likely responsible for the patient's blood pressure being low and finding that the patient has hypoxemia and arrhythmias? 1 Rotating the catheter 2 Performing too-frequent suctioning 3 Applying negative pressure during the withdrawal of the catheter 4 Maintaining pressure at 125 mm Hg while withdrawing the catheter

A patient is at risk of developing hypoxemia, hypotension (blood pressure being low), and arrhythmias with too-frequent suctioning. The rotation of the catheter enhances the removal of secretions that have adhered to the sides of the endotracheal tube; it does not cause low blood pressure, hypoxemia, or arrhythmias. Applying negative pressure during the withdrawal of the catheter is a correct nursing action; it would not cause low blood pressure, hypoxemia, or arrhythmias. While suctioning, maintaining pressures between 100 and 150 mm Hg for adults is a correct nursing action and should be applied during the withdrawal of the catheter; a correct action does not cause low blood pressure, hypoxemia, and arrhythmias.

Which intervention will relieve dryness of the mucous membranes for a patient having a chronic dry cough in the mornings, with occasional production of thick, yellow-green sputum in small quantities? 1 Giving a nebulizer treatment Correct2 Offering plenty of oral fluids 3 Administering 2 L/min of oxygen 4 Instilling normal saline into artificial airwa

A patient with chronic dry cough would be offered plenty of oral fluids. Fluids help moisten the secretions and promote secretion removal. Adequate hydration helps treat dryness of oral mucosa. A nebulizer treatment maintains open airways but does not help in the treatment of mucous membrane dryness. Oxygen therapy treats dyspnea associated with exercise or hypoxemia, not dry mucous membranes; oxygen therapy could make the mucous membranes more dry. The evidence supporting the use of normal saline instillation in improving artificial airway secretion removal may be harmful and is not recommended.

The nurse is caring for a patient who presents with an oxygen saturation 85% on room air. Which assessment finding is most likely affecting this patient's oxygenation? 1 Heart rate 48 beats/min 2 Blood pressure 100/62 mm Hg 3 Alert and oriented to name only 4 Urinary output 500 mL/24 hours

Bradycardia (heartbeat less than 60 beats/min) can decrease cardiac output, which decreases oxygenation. The patient has a heart rate of 48 beats/min, which can cause the oxygen saturation of 85%. The patient's blood pressure is the result of the decreased heart rate and cardiac output. The low oxygenation could lead to decreased orientation. The decreased cardiac output from the bradycardia can decrease urinary output.

Based on the laboratory reports, which nursing intervention would benefit the patient who has chronic obstructive pulmonary disease (COPD)? 1 Encouraging oral fluids Correct2 Administering 2 L/min of oxygen therapy 3 Administering oral antibiotics 4 Encouraging aggressive ambulation

Administering 2 L/min of oxygen therapy is an appropriate nursing intervention that can benefit this patient. Increased respiratory rate and heart rate, decreased SpO2, diminished diaphragmatic movement, and abnormal lung sounds upon auscultation may indicate altered gas exchange. The other interventions are more appropriate for other patients. If the patient has an elevated body temperature, providing oral fluids and antibiotics may be helpful. Aggressive ambulation, at this time, can cause more harm and should be avoided.

Which information does the nurse document after performing endotracheal suctioning for a patient with cystic fibrosis? Select all that apply. One, some, or all responses may be correct. 1 Color of secretions 2 Amount of secretions 3 Respiratory assessments before and after suctioning 4 Consistency of secretions 5 Pulse oximetry values

After performing endotracheal suctioning, the nurse should document the respiratory assessments before and after suctioning; size of catheter used; and the consistency, amount, and color of secretions obtained. The nurse should also document patient tolerance of the suctioning procedure, including changes in vital signs and pulse oximetry values.

Which tracheostomy complication is the most serious? 1 Hypoxemia 2 Arrhythmia 3 Hypotension 4 Airway obstruction

An airway obstruction is the most serious complication of a tracheostomy. Hypoxemia, arrhythmia, and hypotension are caused by too-frequent suctioning; they are not the most serious complications of a tracheostomy.

The nurse is caring for a patient experiencing an exacerbation of asthma. Which intervention does the nurse perform to immediately improve oxygenation? Select all that apply. One, some, or all responses may be correct. 1 Give intravenous fluids. 2 Identify asthma triggers. 3 Administer bronchodilators. 4 Provide supplemental oxygen. 5 Instruct on a weight-loss regimen

An asthma exacerbation involves narrowing of the airways. It usually is related to an action or something that triggers the inflammatory response such as exercise, allergies, or cold. Therefore the nurse would work with the patient to identify what triggers the asthma attacks. Bronchodilators would be given to open the airways. The nurse would provide supplemental oxygen to improve oxygen levels. Intravenous fluids would be administered if the patient had hypovolemia. Weight loss would help a patient with asthma, but it will not immediately improve oxygen levels.

Which condition causes decreased tissue oxygenation because of the decreased oxygen-carrying capacity of the blood? 1 Obesity 2 Anemia 3 Pregnancy 4 Neuromuscular disease

Anemia decreases the oxygen-carrying capacity of blood by reducing the amount of available hemoglobin to transport oxygen. The other conditions cause decreased oxygenation for other reasons. Decreased oxygenation may result from reduced lung volumes (not from the decreased oxygen-carrying capacity) in patients who are obese. An increased metabolic rate and pressure on the diaphragm from the growing fetus (not the decreased oxygen-carrying capacity) may result in decreased oxygenation in patients who are pregnant. An impaired ability to expand and contract the chest wall (not the decreased oxygen-carrying capacity) may result in decreased tissue oxygenation in patients who have neuromuscular diseases.

The nurse reviews a patient's cardiopulmonary health history and identifies that which diagnosis impacts cardiac oxygenation? 1 Hypovolemia 2 Cystic fibrosis 3 Angina pectoris 4 Atrial fibrillation

Angina pectoris occurs when the heart is not receiving adequate oxygen, leading to chest pain. Hypovolemia would decrease cardiac output, causing peripheral hypoxia. Cystic fibrosis affects oxygenation because of thickened pulmonary secretions. Atrial fibrillation decreases cardiac output, leading to peripheral hypoxia.

n elderly patient reports to a health care provider office for a routine physical examination. The patient tells the nurse, "I experience shortness of breath with activity." The nurse recognizes that which normal physiological change accounts for the patient's condition? Select all that apply. One, some, or all responses may be correct. 1 Enlarged alveoli 2 Calcified airways 3 Altered mental status 4 Increased lung elasticity 5 Changed thoracic shape

As a person ages, changes occur to the respiratory tract that can increase a patient's risk of breathing difficulties and infections. These include enlarged alveoli, which diminish the surface area for gas exchange. Calcified airways decrease lung elasticity. Osteoporosis changes the shape of the thorax. Mental status changes are not a normal part of aging. Lung elasticity decreases with aging.

Which action would the nurse take first for the patient with chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min and becomes short of breath while in the supine position during a bath? 1 Increase the flow of oxygen. 2 Perform tracheal suctioning. 3 Report this to the health care provider. 4 Assist the patient to a semi-Fowler's position.

Assist the patient to a semi-Fowler's position.

Which condition involves collapsed alveoli that prevent the normal exchange of oxygen and carbon dioxide? 1 Ventricular fibrillation 2 Kyphosis Correct3 Atelectasis 4 Myocardial infarction

Atelectasis is a pulmonary condition that leads to a collapse of the alveoli, which prevents a normal exchange of oxygen and carbon dioxide. Ventricular fibrillation is a life-threatening abnormal heart rhythm, not alveoli collapsing. Kyphosis is a structural abnormality that alters the ability of the lungs to distend (compliance), resulting in increased intraalveolar pressure, but not collapsed alveoli. A myocardial infarction may affect pulmonary circulation and may result in dyspnea, but not collapsed alveoli

A patient experiences impaired oxygenation due to postoperative atelectasis. When planning care for the patient, which goal does the nurse prioritize to resolve the condition? 1 Reduce oxygen to 2 L/nasal cannula. 2 Use incentive spirometer hourly as instructed. 3 Decrease respiratory rate to 18 breaths/min. 4 Perform nebulizer treatments independently.

Atelectasis occurs when lungs are not expanding to their full capacity, causing alveolar collapse. The way to improve oxygenation with atelectasis is deep breathing and incentive spirometry. Therefore an appropriate goal is to use the incentive spirometer every hour as instructed by the nurse. Reducing oxygen and decreasing the respiratory rate shows improvement, but not that a goal is met. Performing nebulizer treatments independently would be a goal toward self-management.

The nurse monitors the oxygen saturation of a patient who is experiencing a cardiac dysrhythmia. Which is the rationale for the nurse's action? Correct1 An irregular cardiac rhythm decreases perfusion. 2 The fluid overload that occurs with a dysrhythmia decreases oxygenation. 3 The irregular cardiac rhythm causes changes to the thoracic cage, which interferes with breathing. 4 Inadequate red blood cell production associated with a dysrhythmia lowers oxygen levels.

Bundle branch block affects the cardiac rhythm, which in turn decreases cardiac output, perfusion, and oxygenation. The nurse would monitor the weight for fluid overload. Kyphosis causes changes in the thoracic change. Anemia causes inadequate red blood cell production.

Which information is correct regarding physiological factors that affect oxygenation? 1 Metabolic rate decreases normally in pregnancy, wound healing, and exercise. 2 The physiological response to chronic hypoxemia is an increase in white blood cell production. Correct3 Carbon monoxide (CO) poisoning decreases the oxygen-carrying capacity of the blood. 4 The oxygen-carrying capacity of the blood increases when there is a decline in inspired oxygen concentration.

CO poisoning decreases the oxygen-carrying capacity of blood. The metabolic rate increases (not decreases) normally during pregnancy, wound healing, and exercise because the body is using energy or building tissue. The physiological response to chronic hypoxemia is the production of red blood cells, not white blood cells. When there is a decrease in inspired oxygen concentration, the oxygen-carrying capacity of the blood decreases (not increases).

Which goal would be the primary motive behind administering continuous positive airway pressure (CPAP) to a patient with a diagnosis of sleep apnea? Incorrect1 To facilitate gas exchange Correct2 To prevent airway collapse 3 To increase pulmonary edema 4 To improve contractility of the cardiac musculature

CPAP prevents airway collapse. In obstructive sleep apnea, the upper airway collapses, causing obstruction that leads to shallow or absent breathing; the use of CPAP prevents this from occurring. CPAP does not facilitate gas exchange in sleep apnea. CPAP reduces (not increases) pulmonary edema by forcing fluid out of the lungs. CPAP plays no role in improving the contractility of the cardiac musculature.

Which information is true regarding chest percussion? 1 Involves slow striking of the chest wall 2 Is performed over multilayers of clothing 3 Involves rhythmically clapping on the chest wall 4 Is commonly performed on patients who have osteoporosis

Chest percussion involves rhythmically clapping on the chest wall. It involves striking the chest wall vigorously, not slowly striking the chest wall. It is performed over a single layer (not multilayers) of clothing. Chest percussion is contraindicated in patients who have osteoporosis, and it is not commonly performed.

A patient requires endotracheal suctioning due to increased secretions. Which rationale supports the use of a closed system for suctioning? Correct1 Decreased infection risk Incorrect2 Increased desaturation risk 3 Improved secretion removal 4 Diminished risk of dysrhythmias

Closed system suctioning decreases the risk for infection because the suction catheter is maintained in a plastic sheath and is unable to touch other objects during the procedure. It allows for continued oxygen administration because the oxygen does not have to be removed between suction passes. Therefore it does not pose a risk of desaturation. Both methods remove secretions; one is not better than the other. Frequent endotracheal suctioning of any kind can cause dysrhythmias.

Which abnormality is caused by chronic hypoxemia? 1 Edema 2 Clubbing 3 Cyanosis 4 Splinter hemorrhages

Clubbing in the fingertips is associated with chronic hypoxemia. Edema is associated with right-sided heart failure, not hypoxemia. Neck vein distention is caused by right-sided heart failure, not chronic hypoxemia. Splinter hemorrhages are caused by infective endocarditis, not chronic hypoxemia.

While performing oropharyngeal suctioning, which intervention performed by the nurse helps move secretions from the lower to the upper airway and then into the mouth? Correct1 Encouraging the patient to cough 2 Lubricating the catheter before insertion Incorrect3 Keeping the oxygen mask near the patient's face 4 Applying suction pressure while introducing the catheter

Coughing moves secretions from lower to upper airways into the mouth. Therefore the nurse encourages the patient to cough. Lubricating the catheter may ease the insertion of the catheter but does not move secretions. An oxygen mask is kept near the patient's face, which allows access to the patient's mouth while having access to the oxygen-delivery system, but does not move secretions from the lungs into the mouth. Applying suction pressure while introducing the catheter increases the risk of damage to the mucosa and should not be performed, and it does not mobilize secretions from the lungs into the mouth.

Which clinical manifestation is a late sign of hypoxia? 1 Cyanosis 2 Xanthelasma 3 Periorbital edema 4 Splinter hemorrhages

Cyanosis is a late sign of hypoxia and indicates decreased tissue oxygenation (hypoxia). Xanthelasma is an ophthalmic abnormality indicative of hyperlipidemia; it is not a late sign of hypoxia. Periorbital edema is a clinical manifestation of renal disease; it is not a late sign of hypoxia. Splinter hemorrhages are a clinical manifestation of bacterial endocarditis; they are not a late sign of hypoxia.

Which intervention would the nurse include in a teaching session to patients about preventing airborne allergen respiratory problems? 1 Discourage the patients from playing with pets. 2 Encourage patients to restrict their activities. 3 Instruct patients to stay away from insects, especially bees. 4 Tell patients to limit dietary intake of eggs.

Discourage the patients from playing with pets.

Which terminology would the nurse chart to document the patient saying, "It's hard for me to breathe, and I feel short-winded all the time?" 1 Apnea Correct2 Dyspnea 3 Tachypnea 4 Ventilatory fatigue

Dyspnea is a subjective description reflective of the patient's statement indicating a difficulty in breathing. Apnea refers to an absence of breathing, not a difficulty in breathing. Tachypnea refers to an increased rate of breathing, usually greater than 20 breaths per minute, not a difficulty in breathing. Ventilatory fatigue is a subjective description of laborious breathing, use of accessory muscles, and clavicles elevating during inspiration, not a difficulty in breathing.

The nurse identifies that which event indicates the need to perform oropharyngeal suctioning? 1 There is evidence of hypoxia. 2 Assessment findings of a patient include rhonchi auscultated throughout all lung fields. 3 Gurgling lung sounds are present. Correct4 The patient is able to cough effectively but is unable to clear secretions by expectorating.

Oropharyngeal or nasopharyngeal suctioning is used when a patient is able to cough effectively but is unable to clear secretions by expectorating. Endotracheal suctioning is performed when the patient is hypoxic because of secretions, rhonchi, or gurgling lung sounds are noted.

Which nursing intervention may be beneficial for a patient who has thick pulmonary secretions? Select all that apply. One, some, or all responses may be correct. 1 Encouraging fluid intake 2 Teaching cascade coughing 3 Administering antipyretic drugs 4 Giving intravenous antibiotics 5 Placing the patient in a low-Fowler's position

For a patient with thick pulmonary secretions, encouraging fluid intake and teaching cascade coughing are beneficial. Antipyretics and intravenous antibiotics are administered when the body temperature is elevated and if infection exists, but these interventions will not immediately improve the thick secretions. Patients who have thick secretions should be kept in a high-, not low-, Fowler's position to enhance lung expansion and prevent aspiration.

How far would the nurse insert a nasopharyngeal suction catheter into a young child? Correct1 4 to 7.5 cm (1.5 to 3 inches) 2 8 to 12 cm (3 to 5 inches) 3 16 cm (6.5 inches) 4 18 cm (7 inches)

For nasopharyngeal suctioning in a young child, the catheter is inserted 4 to 7.5 cm (1.5 to 3 inches). For an older (not younger) child, the catheter is inserted 8 to 12 cm (3 to 5 inches). For adults (not a younger child), the catheter is inserted 16 cm (6.5 inches). 18 cm (7 inches) is too far for nasopharyngeal suctioning in any patient.

Which intervention is a simple and cost-effective method for reducing pulmonary secretions stasis and reduced chest wall expansion in a patient who has decreased mobility? 1 Antibiotics 2 Frequent change of position 3 Oxygen humidification 4 Chest physiotherap

Frequent change of position is a simple and cost-effective method for reducing pulmonary secretions stasis and reduced chest wall expansion, both of which increase the risk of pneumonia. Antibiotics and oxygen humidification do not help mobilize secretions or chest wall expansion. Chest physiotherapy can help mobilize pulmonary secretions but does not directly help chest wall expansion.

Which nursing intervention, if performed before suctioning, minimizes hypoxemia after suctioning? 1 Lubricating the catheter 2 Applying suctioning during the insertion 3 Performing suctioning too frequently Correct4 Hyperoxygenating the patient before suctioning

Hyperoxygenating the patient before suctioning minimizes the risk of hypoxemia after suctioning. Lubricating the catheter permits easier insertion and reduces mucosal surface trauma but does not minimize hypoxemia. The nurse never applies suctioning during the insertion; suctioning is applied while withdrawing the catheter. The risk of developing hypoxemia (not minimizing hypoxemia) increases with too-frequent suctioning.

Which condition causes the patient to have cyanotic conjunctivae? 1 Fat embolus Correct2 Hypoxemia 3 Hyperlipidemia 4 Bacterial endocarditis

Hypoxemia may cause cyanotic conjunctivae. A fat embolus causes petechiae on the conjunctivae, not cyanotic conjunctivae. Hyperlipidemia may cause xanthelasma, not cyanotic conjunctivae. Bacterial endocarditis may cause petechiae on the conjunctivae, not cyanotic conjunctivae

Which condition causes bluish discoloration of the skin and mucous membrane? Correct1 Hypoxia 2 Dehydration 3 Hyperlipidemia 4 Right-sided cardiac f

Hypoxia causes a bluish discoloration of the skin and mucous membrane. Bluish discoloration of the skin and mucous membrane is cyanosis, which is a clinical manifestation of hypoxia, or reduced tissue oxygenation. Decreased skin turgor (not bluish discoloration of the skin and mucous membrane) is a clinical manifestation of dehydration. Xanthelasma (yellow lipid lesions on the eyelids) is a clinical manifestation of hyperlipidemia; hyperlipidemia does not cause bluish discoloration of the skin and mucous membrane. Distention of the veins of the neck and peripheral edema (not bluish discoloration of the skin and mucous membrane) is associated with right-sided cardiac failure.

In which condition do the lungs remove carbon dioxide faster than it is produced by cellular metabolism? 1 Hypoxia 2 Hypoxemia 3 Hypovolemia Correct4 Hyperventilation

In hyperventilation, the lungs remove carbon dioxide faster than it is produced by cellular metabolism. Hypoxia is inadequate tissue oxygenation at the cellular level that results from a deficiency in oxygen delivery or oxygen use at the cellular level, not from removing carbon dioxide faster than it is produced. Hypoxemia refers to a decrease in the amount of arterial oxygen, not removing carbon dioxide faster than it is produced. Hypovolemia is described as extracellular fluid loss and reduced circulating blood volume, not removing carbon dioxide faster than it is produced.

Which nursing action is appropriate during suctioning? 1 Picking up the connecting tubing with the dominant hand 2 Applying clean gloves to both hands for oropharyngeal suctioning 3 Applying a sterile glove to the nondominant hand for artificial airway suctioning 4 Picking up a suction catheter with the nondominant hand and not letting the catheter touch nonsterile surfaces

In oropharyngeal suctioning, the nurse applies clean gloves to both hands. Connecting tubing is picked up with the nondominant hand, not the dominant hand. Sterile gloves are worn on the dominant hand (not nondominant) for artificial airway suctioning. The suction catheter is picked up with the dominant hand (not the nondominant), and the catheter should not be allowed to touch nonsterile surfaces.

Which information would the nurse share with the patient about the normal mechanism of respiration? Select all that apply. One, some, or all responses may be correct. Correct1 Normal breathing is quiet with minimum or no effort. Correct2 Ventilation is the process of air moving in and out of the lungs. 3 Normal breathing is noisy and requires all the chest muscles. Correct4 The diaphragm is an important muscle that helps in breathing. 5 Ventilation is the process of oxygenated blood flowing in the body

Information the nurse would share includes the following: normal breathing is quiet with minimum or no effort, ventilation is the process of air moving in and out of the lungs, and the diaphragm is an important muscle that helps in breathing. Normal breathing is a quiet process, which requires minimum effort. Ventilation is the process of air moving in and out of the lungs. A major muscle in breathing is the diaphragm. Noisy breathing occurs in diseased conditions or in the presence of some obstruction; noisy breathing is not normal. All chest muscles, such as the pectorals and sternocleidomastoid, are used in labored breathing, which is not a normal mechanism of respiration. Perfusion (not ventilation) is the process of oxygenated blood flowing in the body. Perfusion is a process by which the cardiovascular system delivers oxygen-rich blood to the tissues and returns deoxygenated blood to the lungs.

Which instruction would the nurse include in a teaching session about lifestyle practices to promote heart health? Select all that apply. One, some, or all responses may be correct. Correct1 Eat foods rich in fiber. 2 Eat foods rich in fats and proteins. Correct3 Participate in aerobic exercises. 4 Have a daily calorie intake of 3000 calories. Correct5 Exercise for at least 150 minutes a week

Lifestyle practices include eating foods rich in fiber, participating in aerobic exercises, and exercising for at least 150 minutes a week. A diet rich in fiber has cardioprotective properties. Aerobic exercise is necessary to improve lung and heart function and strengthen muscles. Exercising for at least 150 minutes a week will help promote circulation of the blood and a healthy heart. Diets high in fats and proteins will lead to cardiac disorders, not promote heart health. A calorie intake of 3000 calories may lead to weight gain and obesity and have an adverse effect on the heart, not a positive effect.

Which purpose does asking the patient to say "ahh" while performing suctioning accomplish? 1 Facilitates breathing 2 Elevates the bronchial passage 3 Assists in opening the glottis 4 Permits the flow of secretions into the mouth

Making sounds such as "ahh" assists in opening the glottis to permit passage of the catheter into the trachea. Making sounds such as "ahh" does not facilitate breathing. Turning the patient's head to the side (not saying "ahh") elevates the bronchial passage on the opposite side. Directed coughing (not saying "ahh") may permit the flow of secretions into the mouth from the upper respiratory tract.

The nurse identifies that which event indicates the need to perform oropharyngeal suctioning? 1 There is evidence of hypoxia. 2 Assessment findings of a patient include rhonchi auscultated throughout all lung fields. 3 Gurgling lung sounds are present. Correct4 The patient is able to cough effectively but is unable to clear secretions by expectorating

Oropharyngeal or nasopharyngeal suctioning is used when a patient is able to cough effectively but is unable to clear secretions by expectorating. Endotracheal suctioning is performed when the patient is hypoxic because of secretions, rhonchi, or gurgling lung sounds are noted.

Which age-related change in the older adult may result in decreased tissue oxygenation caused by impaired chest expansion? Select all that apply. One, some, or all responses may be correct. 1 Change in cough mechanism 2 Impairment of the immune system 3 Ossification of costal cartilage 4 Decreased intervertebral space 5 Diminished respiratory muscle strength

Ossification of costal cartilage, decreased intervertebral space, and diminished respiratory muscle strength will all impair chest expansion, which leads to decreased tissue oxygenation. A change in the cough mechanism may lead to atelectasis because of retained pulmonary secretions; however, it does not impair chest expansion. An impaired immune system can predispose to respiratory infections but will not impair chest expansion.

Which complication is the most common in a patient with a tracheostomy? 1 Pneumonia 2 Nasal injury 3 Pneumothorax Correct4 Partial airway obstruction

Partial airway obstruction is the most common complication in a patient with a tracheostomy. Pneumonia and pneumothorax also occur in patients with a tracheostomy but are not common. Nasal injury is associated with noninvasive ventilation.

Which information would the nurse include in an educational session for a group of nurses regarding physiological factors that prevent adequate oxygenation in patients? Select all that apply. One, some, or all responses may be correct. Anemia Obesity Kyphosis Pregnancy High altitude

Physiological factors that prevent patients from maintaining adequate oxygen levels would include an inability to carry sufficient oxygen, such as a patient with anemia or high altitudes. Obesity, kyphosis, and pregnancy are conditions that affect how the chest wall moves.

Which explanation is the likely rationale for teaching pursed-lip breathing to a patient with chronic obstructive pulmonary disease (COPD)? 1 To optimize ventilation perfusion mismatch 2 To prevent collapse of the alveoli 3 To enhance perfusion of the airways 4 To improve the ability to cough

Preventing the collapse of the alveoli is the rationale for pursed-lip breathing. Pursed-lip breathing involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse. Pursed-lip breathing is a breathing exercise that involves deep inspiration and prolonged expiration through a narrow outlet (pursed lips). Slow expiration creates a backpressure in the airways, which prevents the alveoli from collapsing. Although pursed-lip breathing improves ventilation, it does not optimize ventilation perfusion mismatch. It does not improve the perfusion of the airways; circulation improves perfusion. Pursed-lip breathing does not increase the individual's ability to cough; splinting improves the ability to cough.

Which goal is the primary motive for why a nurse would perform pulse oximetry on a patient who is cyanotic? 1 To monitor ventilation Correct2 To assess the oxygenation level 3 To obtain a biopsy specimen 4 To visualize the tracheobronchial tree

Pulse oximetry is a diagnostic test done to assess the oxygenation level. If the nurse wanted to assess the patient's ventilation, the nurse would perform capnography, not obtain a pulse oximetry reading. To obtain a biopsy specimen, the patient would undergo a thoracentesis or bronchoscopy, not a pulse oximetry reading. To visualize the tracheobronchial tree, a bronchoscopy would be performed, not a pulse oximetry reading.

Which diagnostic test provides instant feedback about a patient's oxygenation status? 1 Capnography 2 Bronchoscopy 3 Thoracentesis 4 Pulse oximetr

Pulse oximetry is a diagnostic test that provides instant feedback about a patient's oxygenation level. Capnography is a diagnostic test that provides instant information about the patient's ventilation and perfusion, not oxygenation status. Bronchoscopy allows for visual examination of the tracheobronchial tree; it does not provide instant feedback about oxygenation status. Thoracentesis is a procedure done on the chest wall and pleural space to drain fluid, not provide instant feedback about oxygenation status.

Which intervention would help a patient who is gasping and unable to breathe and has a tracheostomy tube? 1 Removal of the tracheostomy tube from the airway 2 Replacement of the inner tube with a temporary spare one 3 Administration of oxygen therapy through a nasal cannula 4 Immediate transportation to surgery for a repeat tracheostomy

Replacement of the inner tube with a temporary spare one would help this patient. A tracheostomy is performed when a patient needs an artificial airway for a long time. It involves inserting a large tracheostomy tube that has a small plastic inner tube, which fits inside the larger tube. The most common complication of a tracheostomy is blockage of the inner tube because of secretions. Total removal of the tracheostomy tube is not required because it can cause blockage of the airway. Administration of oxygen to the patient will not help because the airway is blocked. No major damage to the tracheostomy tube has occurred, and therefore a repeat tracheostomy is not required.

Which risk is associated with suctioning when performed in an appropriate time interval on a patient who has a head injury? 1 Irregular heartbeat 2 Decreased blood pressure 3 Increased intracranial pressure 4 Abnormal decrease in oxygen concentration

Suctioning increases intracranial pressure even when provided in the appropriate time interval. Therefore hyperventilation should be performed before suctioning to reduce the risk of intracranial pressure. Providing suctioning frequently, not performing it in an appropriate time interval, increases the risk of an irregular heartbeat (arrhythmias), decreased blood pressure (hypotension), and an abnormal decrease in oxygen concentration (hypoxemia).

Which diagnostic test prescribed by the health care provider is less reliable when used on a patient with human immunodeficiency virus (HIV)? 1 Hemoglobin 2 Sputum cytology 3 Complete blood count (CBC) 4 Tuberculosis skin testing (TST

TST is less reliable when used on a patient with HIV. However, hemoglobin, sputum cytology, and CBC tests are still reliable for patients with HIV.

Which statement made by the new nurse about suctioning a patient with an endotracheal tube indicates the charge nurse needs to intervene? 1 "I'll use a sterile technique to suction the patient." 2 "I'll apply suction while rotating and withdrawing the suction catheter." 3 "I'll suction the mouth after I suction the endotracheal tube." 4 "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."

The charge nurse would intervene when the new nurse says, "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient." Saline instillation has been found to cause harm, is not recommended when suctioning, and does not increase the amount of secretions removed. The charge nurse would not need to intervene with the other statements because they are correct. The nurse would use a sterile technique. The nurse would apply suction while rotating and withdrawing the suction catheter, and the nurse would suction the mouth after suctioning the endotracheal tube.

Which clinical manifestation would the nurse likely observe in a patient diagnosed with a pneumothorax? Select all that apply. One, some, or all responses may be correct. 1 Chest pain on expiration Correct2 Dyspnea Correct3 Tachycardia 4 Absence of coughing Correct5 Sharp pain in the chest

The nurse would observe dyspnea, tachycardia, and sharp pain in the chest. Pneumothorax is the collection of air in the pleural cavity. Pneumothorax also leads to dyspnea and resultant tachycardia. A sharp pain is common and occurs because of irritation of the pleura. The chest pain is experienced during inspiration, not during expiration. Absence of coughing does not occur with a pneumothorax

Which condition causes a patient's inability to lie flat, increased blood pressure, increased pulse, and experience dizziness and a decreased level of consciousness? 1 Hypoxia 2 Hyperlipidemia 3 Hypovolemia 4 Hyperventilation

The condition is hypoxia. Patients with hypoxia are unable to lie flat. Patients with hypoxia have an increased blood pressure and an increased pulse rate. The clinical signs and symptoms of hypoxia include a decreased level of consciousness and dizziness. Hyperlipidemia is elevated levels of fat/triglycerides in the blood; it can cause xanthelasma, not the signs and symptoms in the scenario. Hypovolemia does not cause the blood pressure to increase; it causes it to decrease, usually from shock or severe dehydration. Hyperventilation causes rapid respirations, sighing breaths, numbness and tingling of hands/feet, not the signs and symptoms in the scenario.

Which consideration would be included in a diet plan for the patient whose baseline blood pressure is 170/100 mm Hg and serum cholesterol is 240 mg/dL? Select all that apply. One, some, or all responses may be correct. Correct1 Restrict intake of salt. 2 Restrict intake of potassium. Incorrect3 Include saturated fats. Correct4 Include chicken. Correct5 Increase intake of omega-3 fatty acids

The diet plan would restrict the intake of salt, include chicken, and increase the intake of omega-3 fatty acids. A diet low in sodium helps control hypertension. Chicken is a lean meat and is included in a diet for hypertension and high cholesterol. A diet high in omega-3 fatty acids is considered cardioprotective. A diet high (not restricted) in potassium is advised for hypertension. Avoiding, not including, saturated fat in the diet is known to prevent and/or reduce the effects of hypertension.

Which statement is true about the various patterns of respiration? Select all that apply. One, some, or all responses may be correct. 1 Apnea is the absence of respirations for 15 seconds or longer. 2 Apnea is the increase in rate and depth of respiration. 3 Kussmaul respiration is the increase in rate and depth of breathing. 4 Kussmaul respiration is the body's attempt to compensate by increasing carbon dioxide levels. 5 Cheyne-Stokes breathing is a period of apnea following a period of deep breathing and then shallow breathin

The following statements are true: apnea is the absence of respirations for 15 seconds or longer; Kussmaul respiration is the increase in rate and depth of breathing; and Cheyne-Stokes breathing is a period of apnea following a period of deep breathing and then shallow breathing. Apnea is the absence of breathing, not an increase in rate and depth of respiration. Kussmaul respiration is the body's attempt to compensate by decreasing (not increasing) carbon dioxide levels.

Which information about breathing patterns is true? Select all that apply. One, some, or all responses may be correct. 1 Bradypnea is less than 12 breaths per minute. 2 Tachypnea is greater than 20 breaths per minute. 3 Paradoxical breathing is the increased number of breaths per minute. 4 Apnea is the absence of respirations for a period of time. 5 Cheyne-Stokes respiration is caused by increased blood flow to the brain

The following statements are true: bradypnea is less than 12 breaths per minute; tachypnea is greater than 20 breaths per minute; and apnea is the absence of respirations for a period of time. At rest, the breathing rate for normal adults is 12 to 20 regular breaths per minute. Bradypnea occurs when the respiratory rate decreases below 12 breaths per minute. Tachypnea occurs when the respiratory rate increases above 20 breaths per minute. Apnea is the absence of respiration for a period of time and when the patient will not have any breath sounds. Paradoxical breathing is when the chest wall contracts during inspiration and expands during exhalation; it is not an increased number of breaths per minute. Cheyne-Stokes respiration is caused by a decreased (not increased) blood flow or an injury to the brainstem and is characterized by periods of apnea followed by periods of deep breathing, then shallow breathing, followed by more apnea.

Which assessment finding would the nurse observe in a patient with a pneumothorax after a blunt injury to the chest? Select all that apply. One, some, or all responses may be correct. 1 Sharp pain in the chest 2 Difficulty in breathing 3 Oozing from the chest wall 4 Excessive expectoration of mucus 5 Pain that increases on inspiration

The nurse would observe the following: sharp pain in the chest, difficulty in breathing, and pain that increases on inspiration. Pneumothorax is the accumulation of air between the parietal and visceral pleura. It causes sharp pain in the chest as atmospheric air irritates the pleura. The pain makes it difficult for the patient to breathe normally. The pain occurs more often during inspiration. There is no external wound or oozing with a pneumothorax from a blunt injury. There is no overproduction of mucus in a pneumothorax.

Which information about breathing patterns is true? Select all that apply. One, some, or all responses may be correct. 1 Bradypnea is less than 12 breaths per minute. 2 Tachypnea is greater than 20 breaths per minute. 3 Paradoxical breathing is the increased number of breaths per minute. 4 Apnea is the absence of respirations for a period of time. 5 Cheyne-Stokes respiration is caused by increased blood flow to the brain.

The following statements are true: bradypnea is less than 12 breaths per minute; tachypnea is greater than 20 breaths per minute; and apnea is the absence of respirations for a period of time. At rest, the breathing rate for normal adults is 12 to 20 regular breaths per minute. Bradypnea occurs when the respiratory rate decreases below 12 breaths per minute. Tachypnea occurs when the respiratory rate increases above 20 breaths per minute. Apnea is the absence of respiration for a period of time and when the patient will not have any breath sounds. Paradoxical breathing is when the chest wall contracts during inspiration and expands during exhalation; it is not an increased number of breaths per minute. Cheyne-Stokes respiration is caused by a decreased (not increased) blood flow or an injury to the brainstem and is characterized by periods of apnea followed by periods of deep breathing, then shallow breathing, followed by more apnea.

Which family member would receive the pneumococcal vaccine in a family consisting of a grandfather, 70 years old; the mother, 46; the daughter, 22; and the son who smokes, 18? Select all that apply. One, some, or all responses may be correct. 1 Grandfather 2 Mother 3 Daughter 4 Son 5 None of the family members

The grandfather and son who smokes would receive the vaccine. The pneumococcal vaccine is recommended for all adults older than 65 years; therefore the grandfather would receive the vaccine. It is also indicated for patients with a history of asthma, smokers, and patients having any chronic illnesses irrespective of their age. Therefore the son would also receive the pneumococcal vaccine. The mother and daughter do not need the vaccine because they are younger than 65 years and do not have asthma or any other chronic illnesses.

Which instruction would the nurse include when teaching a patient about the procedure for diaphragmatic breathing? Select all that apply. One, some, or all responses may be correct. Correct1 "Inhale slowly to make the abdomen push out." 2 "Exhale rapidly to make the abdomen go in." Correct3 "Start practicing the technique in a supine position initially." 4 "Perform the technique in a prone position once you have learned it." Correct5 "Place one hand on the breastbone and the other hand on the abdomen."

The instructions the nurse would include are "inhale slowly to make the abdomen push out," "start practicing the technique in a supine position initially," and "place one hand on the breastbone and the other hand on the abdomen." In diaphragmatic breathing, the patient inhales slowly, making the abdomen push out. During this process, the diaphragm flattens out. Initially the technique is performed in a supine position. The patient places one hand flat below the breastbone and the other hand on the abdomen to feel the movement of the abdomen. The patient exhales (but not quickly) so that the abdomen goes in and the diaphragm goes up. This procedure is performed initially in a supine position and later sitting or standing, not in the prone position.

Which type of suctioning can the nurse delegate to assistive personnel (AP)? Correct1 Oral 2 Orotracheal 3 Nasotracheal 4 Endotrachea

The nurse can delegate oral suctioning with a Yankauer suction device to an AP. Orotracheal, nasotracheal, and endotracheal suctioning must be performed by a registered nurse or respiratory therapist.

Which amount is the maximum time for the nurse to apply suction when performing endotracheal suctioning of a patient? 1 5 seconds Correct2 10 seconds 3 15 seconds 4 20 seconds

The nurse cannot apply intermittent suction for longer than 10 seconds, because any longer can cause hypoxemia. Five seconds is allowed, but it is not the maximum amount of time. Fifteen and 20 seconds are too long of time frames to perform the procedure.

Which assessment would the nurse perform before providing endotracheal tube care? Select all that apply. One, some, or all responses may be correct. 1 Oral cavity 2 Lung sounds 3 Peristomal skin 4 Airway patency 5 Color of secretions

The nurse should assess the oral cavity for lesions related to the tube irritating the mucosa. Lung sounds should be auscultated to determine the need for suctioning. The nurse would assess airway patency, and the color of secretions because green or yellow secretions would indicate an infection. The peristomal skin would be assessed if the patient had a tracheostomy, not an endotracheal tube.

Which diagnostic study would the nurse anticipate for a patient who has chest pain from cardiac problems? Select all that apply. One, some, or all responses may be correct. Correct1 Serum cholesterol Correct2 Electrocardiogram 3 Bronchoscopy Correct4 Serum cardiac enzymes 5 Ultrasonography of pelvis

The nurse would anticipate the following diagnostic tests: serum cholesterol, electrocardiogram, and serum cardiac enzymes. Excessive cholesterol can lead to atherosclerosis, which further leads to myocardial infarction or angina. Determining the cholesterol level is essential. An electrocardiogram helps assess the electrical activity of the heart and helps diagnose disturbances in cardiac activity. Cardiac enzymes are essential in determining any ischemic heart disorder or myocardial injury. Bronchoscopy is used to determine abnormalities of the tracheobronchial tree, not the heart. Ultrasonography of the pelvis helps assess disorders of organs in the pelvic region, not the heart region.

Which pertinent question would the nurse ask to assess the history of allergies in a patient? Select all that apply. One, some, or all responses may be correct. 1 "What are you allergic to?" 2 "Who is with you when you have an allergic reaction?" 3 "What measures do you take to obtain relief from allergies?" 4 "How many times have you had allergic reactions to date?" 5 "What happens when you come in contact with the allergen?"

The nurse would ask the following questions: "what are you allergic to," "what measures do you take to obtain relief from allergies," and "what happens when you come in contact with the allergen?" Allergies are manifested in various ways. They may involve minor symptoms such as a runny nose or rash or a life-threatening condition such as anaphylaxis. To assess a patient's history for allergies, it is extremely important for the nurse to know the allergen ("What are you allergic to?"). It is also important to know the relief measures and medications that the patient takes for allergies. Allergy symptoms vary from person to person. Hence it is important to understand what symptoms this patient suffers ("What happens when you come in contact with the allergen?"). Who the patient is with is not a pertinent question; the focus is on the patient, not others. A patient may have multiple allergy attacks; hence the question about the number of reactions is not of prime importance.

Which action would the nurse take for a patient with chronic bronchitis who has blood in the sputum? Select all that apply. One, some, or all responses may be correct. 1 Assess for the source of bleeding. 2 Request a chest x-ray and bronchoscopy. 3 Request pH testing of the sputum specimen. 4 Confirm hematemesis if the pH test is alkaline. 5 Consider blood-stained sputum as hematemesis.

The nurse would assess for the source of bleeding; request a chest x-ray and bronchoscopy; and request pH testing of the sputum specimen. Find the source of bleeding by determining whether the blood-stained sputum is associated with cough and upper respiratory tract bleeding or whether the bleeding is from the gastrointestinal tract. A chest x-ray and bronchoscopy can help confirm the diagnosis in the case of blood-stained sputum. Testing the pH of the sputum specimen can help determine whether the source of the hemoptysis has an alkaline pH or an acidic pH. Hematemesis has an acidic, not alkaline, pH. Blood-stained sputum is hemoptysis, whereas hematemesis is blood in vomitus; thus blood-stained sputum would be hemoptysis, not hematemesis.

Which action would the nurse take first for the patient with chronic obstructive pulmonary disease (COPD) who is receiving oxygen at 2 L/min and becomes short of breath while in the supine position during a bath? 1 Increase the flow of oxygen. 2 Perform tracheal suctioning. 3 Report this to the health care provider. 4 Assist the patient to a semi-Fowler's position

The nurse would first assist the patient to a semi-Fowler's position. Breathing is easier in a semi-Fowler's position because it permits greater expansion of the chest cavity. If repositioning does not improve the situation, then oxygenation and contacting the health care provider might be appropriate. The patient would not benefit from tracheal suctioning.

Which guideline would the nurse follow when administering chest physiotherapy? 1 Chest physiotherapy is contraindicated in patients with cystic fibrosis. 2 Patients on long-term steroids should not undergo chest physiotherapy. 3 Chest physiotherapy is contraindicated in patients with increased tolerance to exercise. 4 Patients with increased intracranial pressure should undergo chest physiotherapy.

The nurse would follow this guideline: patients on long-term steroids should not undergo chest physiotherapy. Patients on long-term steroids are susceptible to pathological rib fractures, so chest physiotherapy would likely be contraindicated. Patients with cystic fibrosis need chest physiotherapy; it is not contraindicated. Increased exercise tolerance allows a patient to better sustain chest physiotherapy, which may be strenuous on the patient; thus chest physiotherapy would not be contraindicated. Patients with increased intracranial pressure should not undergo chest physiotherapy. Patients who have increased intracranial pressure may not tolerate postural changes or postural drainage, so chest physiotherapy should be avoided.

Which immediate action would the nurse take for a patient with chronic obstructive pulmonary disorder (COPD) who is receiving oxygen therapy using a simple face mask whose blood analysis reveals abnormally high levels of carbon dioxide? 1 Remove the mask and apply a new oxygen mask. 2 Reset the mask to cover the patient's nose only. 3 Remove the mask and use a nasal cannula as an oxygen supply. 4 Reset the mask to cover the patient's mouth and nose.

The nurse would immediately remove the mask and use a nasal cannula as an oxygen supply. Simple face masks are designed to deliver 6 L/min or more of oxygen. However, in patients with COPD, this results in hypoventilation. These patients have adapted to a high level of carbon dioxide, so their carbon dioxide-sensitive chemoreceptors are essentially not functioning. Because the stimulus to breathe is a decreased arterial oxygen (PaO2) level, administration of oxygen greater than 1 to 3 L/min prevents the PaO2 from falling to a level that stimulates the peripheral receptors. This destroys the stimulus to breathe. The resulting hypoventilation causes excessive retention of carbon dioxide. Additionally, the patient may inhale exhaled carbon dioxide retained in the mask. Therefore masks are contraindicated in patients with COPD. However, a nasal cannula does not cause rebreathing of exhaled carbon dioxide and allows for safe delivery of lower rates of oxygen. Hence the nurse would immediately remove the mask and use a nasal cannula as an oxygen supply. Applying a new mask or resetting the mask to cover the nose or mouth and nose will not improve the patient's condition. In fact, it will make it worse.

Which point would the nurse include when teaching a patient about coughing and deep breathing techniques? Select all that apply. One, some, or all responses may be correct. 1 Perform deep inhalation followed by a deep cough. 2 Perform deep breathing and coughing every 2 hours. 3 Perform shallow inhalations followed by a deep cough. 4 Avoid coughing and hold the breath when the cough is stimulated. 5 Hold a deep breath for 2 to 3 seconds and then forcefully exhale, saying, "huff.

The nurse would include the following points: perform deep inhalation followed by a deep cough; perform deep breathing and coughing every 2 hours; and hold a deep breath for 2 to 3 seconds and then forcefully exhale, saying, "huff." Patients are advised to take a deep breath and then cough deeply. This allows mucus to be expectorated. Patients with upper and lower respiratory tract infections are asked to perform deep-breathing exercises and cough every 2 hours while awake. While practicing a "huff" cough, the patient takes a deep breath and holds it for 2 to 3 seconds followed by forcefully exhaling while saying the word, "huff." This ensures that the tissues are oxygenated well before the cough is induced. Breaths should be deep; shallow inhalation is not advised. Coughing should never be suppressed or avoided. The mucus should be expectorated as much as possible.

Which instruction given by the nurse is appropriate for a patient who has intermittent episodes of cough accompanied with thick, yellow sputum and crackles in the lungs? Select all that apply. One, some, or all responses may be correct. 1 "Drink plenty of water." 2 "Walk around as much as you can." 3 "Place a hot-water bag on your chest." 4 "Try to spend most of your time in the prone position." 5 "Perform deep-breathing exercises once every 2 hours."

The nurse would instruct the patient to "Drink plenty of water," "Walk around as much as you can," and "Perform deep-breathing exercises once every 2 hours." All of these would help promote lung expansion and rid the body of the thick sputum. The nurse's instructions aim to optimize ventilation and facilitate airway clearance to prevent atelectasis. Drinking water will help loosen and mobilize the secretions. Ambulation also helps improve airway ventilation and clearance. Deep breathing is encouraged to improve ventilation. Placing hot-water bags on the chest wall is not an appropriate instruction. Anterior chest wall movement is hampered in the prone position, so the patient would not be instructed to lie down. The prone position would allow the sputum to accumulate.

Which action would the nurse take when performing tracheal suctioning in a patient who has a history of respiratory distress? 1 Apply suctioning before the patient has coughed. 2 Use suction pressure while inserting the catheter. 3 Continue suctioning without allowing rests in between passes of the catheter. 4 Maintain the suction pressure between 80 and 120 mm Hg while withdrawing the catheter.

The nurse would maintain the suction pressure between 80 and 120 mm Hg while withdrawing the catheter. In tracheal suctioning, once the catheter is inserted to the necessary distance, the suction pressure is maintained between 80 and 120 mm Hg while being withdrawn. Oropharyngeal and nasopharyngeal suctioning (not tracheal) is used when the patient is able to cough effectively but is unable to clear secretions by expectorating; oropharyngeal and nasopharyngeal suctioning is applied after the patient has coughed. Suction pressure is not applied while the catheter is being inserted. If the patient has respiratory distress, then the nurse would allow the patient to rest between passes of the catheter; not allowing rests in between passes of the catheter causes hypoxia and fatigue.

Which parameter would the nurse monitor in a patient who has developed hypoxia as a result of severe anemia? Select all that apply. One, some, or all responses may be correct. 1 Pulse rate 2 Skin turgor 3 Natriuretic peptide 4 Respiratory rate 5 Skin color change

The nurse would monitor pulse rate, respiratory rate, and skin color change. Hypoxia presents as an increase in pulse rate and a rise in respiratory rate and depth of respiration. In late stages of hypoxia, the skin and mucous membrane may become bluish in color. Skin turgor is a hydration parameter, so it is less significant when monitoring a patient with hypoxia. A natriuretic peptide indicates the severity of congestive heart failure, so it is less significant when monitoring a patient with hypoxia.

Which action would the nurse take for a patient who has a chest tube to drain a pneumothorax? Select all that apply. One, some, or all responses may be correct. 1 Clamp the chest tube when the patient is moving about. 2 Keep the drainage below the chest level of the patient. 3 Routinely milk the chest tube to increase drainage. 4 Fill the water-seal chamber to the mark given by the manufacturer and observe it. 5 If the tube disconnects, crimp tubing with a gloved hand.

The nurse would perform the following actions: keep the drainage below the chest level of the patient; fill the water-seal chamber to the mark given by the manufacturer and observe it; and if the tube disconnects, crimp the tubing with a gloved hand. The chest tube's drainage is kept below the patient's chest level because it is facilitated by gravity. It is essential to fill the water-seal chamber to the level given by the manufacturer. If the tube disconnects, crimp the tubing with a gloved hand or clamp the tubing with a shodded hemostat to prevent air from entering the pleural space. The drainage tube should not be clamped because it can result in a tension pneumothorax. Routine milking of the chest tube is not recommended because it can increase intrathoracic pressure and cause tissue damage. Milking the chest tube helps remove blood clots in the tube from a hemothorax (must have proper assessment), but it is not required in a pneumothorax.

In which position would the nurse place a patient with a right lung abscess? 1 Supine position with both lungs at the same level 2 45-degree semi-Fowler's position with left lung down Correct3 45-degree semi-Fowler's position with right lung down 4 Supine position with left lung at slightly lower level than the right

The nurse would place the patient in a 45-degree semi-Fowler's position with right lung down. In patients with a pulmonary abscess, the affected lung should be positioned down to prevent the flow of secretions to the healthy lung. A semi-Fowler's position with the patient at 45 degrees is the best position to use to promote lung expansion. It also helps relieve the pressure from the abdomen onto the diaphragm. The supine position with both lungs at the same level does not help lung expansion nor address the abscess. In cases of bilateral lung diseases (the patient has right lung disease), the position should be determined by the severity of the disease. Having the left lung lower than the right would allow the abscess to drain into the healthy lung (left).

In which position would the nurse place the patient to drain the apical segments of the lungs? 1 Prone with thorax and abdomen elevated 2 Supine with head elevated 3 Sitting on side of bed 4 Side-lying in Trendelenburg's

The nurse would place the patient sitting on the side of bed to drain the apical segments of the lungs. The prone position with thorax and abdomen elevated drains the posterior segment of the right middle lobe, not the apical segments. The supine with head elevated position is used to drain the anterior segments of the right and left upper lobes, not the apical segments. The side-lying Trendelenburg's position is used to drain the lateral (not apical) segments of the lungs.

Which nursing action would the nurse perform first for the patient lying supine in bed, short of breath? Correct1 Raise the head of the bed to 45 degrees. 2 Take the patient's oxygen saturation with a pulse oximeter. 3 Obtain the patient's blood pressure and respiratory rate. 4 Notify the health care provider of the patient's shortness of breath

The nurse would raise the head of the bed first. Raising the head of the bed brings the diaphragm down and allows for better chest expansion, thus improving ventilation. Taking the oxygen saturation, blood pressure, and respiratory rate would be included in the assessment, but raising the head of the bed would be the priority action. Depending on the situation, the nurse may need to notify the health care provider but only after completing an in-depth assessment; it is not the first action the nurse would take.

Which nursing action would the nurse perform first for the patient lying supine in bed, short of breath? Correct1 Raise the head of the bed to 45 degrees. 2 Take the patient's oxygen saturation with a pulse oximeter. 3 Obtain the patient's blood pressure and respiratory rate. 4 Notify the health care provider of the patient's shortness of breath.

The nurse would raise the head of the bed first. Raising the head of the bed brings the diaphragm down and allows for better chest expansion, thus improving ventilation. Taking the oxygen saturation, blood pressure, and respiratory rate would be included in the assessment, but raising the head of the bed would be the priority action. Depending on the situation, the nurse may need to notify the health care provider but only after completing an in-depth assessment; it is not the first action the nurse would take.

Which response would the nurse make to a patient with chronic obstructive pulmonary disease (COPD) who is trying to do diaphragmatic breathing exercises for the first time in a sitting position? 1 "You need to do diaphragmatic breathing exercises in a standing posture initially." 2 "You need to stop immediately because diaphragmatic breathing exercises are contraindicated for you." 3 "You have to tighten your chest muscles while taking deep inspirations in this exercise." 4 "You have to practice these exercises first in the supine position and then in the sitting position."

The nurse would say, "You have to practice these exercises first in the supine position and then in the sitting position." For diaphragmatic exercises, a patient needs to relax the chest muscles during inspiration. The patient needs to practice these exercises first in a posture in which it is easy to do and then move on to difficult postures. Therefore the patient needs to perform these exercises first in a supine, then a sitting, and finally in a standing position. These exercises are not performed initially in the standing position. Diaphragmatic breathing exercises are not contraindicated for patients with COPD; they are helpful in promoting lung expansion. During diaphragmatic breathing, the abdominal muscles, not the chest muscles, are tightened up.

Which oxygen-delivery system would the nurse select to administer oxygen at 4 L/min to a patient needing a low-flow delivery device? 1 Nasal cannula 2 Venturi mask 3 Simple face mask without inflated reservoir bag 4 Simple face mask with inflated reservoir bag

The nurse would select a nasal cannula. A nasal cannula can deliver 4 L/min of oxygen via a low-flow delivery device. A Venturi mask delivers at precise rates but is a high-flow delivery system, not a low-flow. A simple face mask without an inflated reservoir bag delivers oxygen at 6 to 12 L/min, not 4 L/min. A simple face mask with an inflated reservoir bag delivers oxygen at 10 to 15 L/min, not 4 L/min.

Which assessment finding would alert the nurse to stop suctioning a patient? 1 Pulse oximetry of 90% 2 Body temperature of 99° F (37.2° C) Correct3 Heart rate of 40 beats per minute 4 Respiratory rate of 20 breaths/min

The nurse would stop if the heart rate is 40 beats per minute. If there is a change in heart rate of 20 beats per minute (either increase or decrease), suctioning is stopped. The nurse would stop if the pulse oximetry is below 90%, not 90%. A body temperature of 99° F (37.2° C) is considered normal and would not cause suctioning to stop. Twenty breaths/min is normal, so this would not cause the nurse to stop suctioning.

Which statement by the nurse indicates a correct understanding about the assessment of a patient who has decreased tissue oxygenation? Select all that apply. One, some, or all responses may be correct. 1 "I should ask the patient about any history of cardiovascular problems." 2 "I should obtain pulse oximetry readings to obtain the patient's oxygenation level." 3 "I will advise the patient to undergo a thoracentesis to obtain the rate of perfusion." 4 "I will obtain accurate results if I perform capnography during the start of exhalation." 5 "I should perform capnography to obtain instant information about the patient's ventilation status."

The nurse's statements that indicate a correct understanding include: "I should ask the patient about any history of cardiovascular problems," "I should obtain pulse oximetry readings to obtain the patient's oxygenation level," and "I should perform capnography to obtain instant information about the patient's ventilation status."Capnography, not thoracentesis, will provide the patient's perfusion rate, and performing capnography at the end, not the beginning, of exhalation will provide the most accurate results.

Which nursing diagnosis presents with a cough producing thick, yellow-green sputum, which is aggravated when lying down flat, along with dry mucous membranes and crackles in the lower lobes bilaterally? 1 Geriatric health problems 2 Impaired airway clearance 3 Risk of tuberculosis infection 4 Risk of pulmonary aspiration

The nursing diagnosis is impaired airway clearance. A cough producing thick, yellow-green sputum, which is aggravated when lying down flat, along with dry mucous membranes and crackles, indicates impaired airway clearance of secretions. Geriatric health problems are not an appropriate diagnosis because presence of crackles is not an age-related change, nor is thick, yellow-green sputum. The patient's history is not suggestive of tuberculosis, so the risk of tuberculosis is an unlikely diagnosis. The patient is not debilitated to be at risk of aspiration. Thus risk of pulmonary aspiration is not an appropriate diagnosis.

Which condition would a patient with a respiratory rate of 25 breaths/min have? 1 Apnea 2 Bradypnea 3 Tachypnea 4 Orthopnea

The patient has tachypnea because the rate is 25 breaths/min. Tachypnea is a condition in which the respiratory rate is greater than 20 breaths/min. Apnea is a condition in which there is an absence of respirations lasting for 15 seconds or more, not a respiratory rate of 25 breaths/min. Bradypnea is a condition in which the respiratory rate generally ranges below 12 breaths/min, not for a respiratory rate of 25 breaths/min. Orthopnea is an abnormal condition in which a patient struggles to breathe when lying flat, not having a respiratory rate of 25 breaths/min.

Which type of breathing pattern causes the patient's respiratory rate to be 40 breaths/min and deep? 1 Apnea 2 Bradypnea 3 Kussmaul 4 Cheyne-Stokes

The patient is experiencing Kussmaul respirations. In some conditions, such as metabolic acidosis, the acidic pH stimulates an increase in the rate of respiration that exceeds 35 breaths/min, resulting in decreased carbon dioxide levels. This action causes Kussmaul respirations. Apnea is an absence of respirations lasting 15 seconds or longer, not when the rate is 40. Bradypnea occurs when the respiratory rate is fewer than 12 breaths per minute, not when the respiratory rate is 40. Cheyne-Stokes respirations are abnormal respiratory patterns that occur when there is decreased blood flow or injury to the brainstem, causing periods of apnea followed by periods of deep breathing and then shallow breathing followed by more apnea, not deep respirations of 40 per minute.

Which patient would be experiencing hypoxia caused by increased metabolic rates? Select all that apply. One, some, or all responses may be correct. Correct1 Patient who has a fever 2 Patient who is in shock 3 Patient who has anemia 4 Patient who has myasthenia gravis Correct5 Patient in the third trimester of pregnancy

The patient who has a fever and the patient in the third trimester of pregnancy are the patients with increased metabolic rates. Increased metabolic rates increase the oxygen demand, which can cause hypoxia. Fever and pregnancy can increase a patient's metabolic rate. Hypovolemia (not increased metabolic rates) causes hypoxia in patients who are in shock. A decreased oxygen-carrying capacity (not increased metabolic rates) causes hypoxia in patients who have anemia. Decreased chest wall movements (not increased metabolic rates) cause hypoxia in patients who have myasthenia gravis

Which patient would be experiencing hypoxia caused by increased metabolic rates? Select all that apply. One, some, or all responses may be correct. 1 Patient who has a fever 2 Patient who is in shock 3 Patient who has anemia 4 Patient who has myasthenia gravis 5 Patient in the third trimester of pregnancy

The patient who has a fever and the patient in the third trimester of pregnancy are the patients with increased metabolic rates. Increased metabolic rates increase the oxygen demand, which can cause hypoxia. Fever and pregnancy can increase a patient's metabolic rate. Hypovolemia (not increased metabolic rates) causes hypoxia in patients who are in shock. A decreased oxygen-carrying capacity (not increased metabolic rates) causes hypoxia in patients who have anemia. Decreased chest wall movements (not increased metabolic rates) cause hypoxia in patients who have myasthenia gravis.

Which intervention would the nurse perform for a patient with a nursing diagnosis of impaired airway clearance? Select all that apply. One, some, or all responses may be correct. 1 Give antibiotics. 2 Perform chest physiotherapy. 3 Provide flu vaccination. 4 Administer expectorants. 5 Provide supplemental oxygen.

The patient with impaired airway clearance would benefit from chest physiotherapy and expectorants to loosen secretions to facilitate removal. The nurse may provide supplemental oxygen if the secretions are blocking airways. Antibiotics would be administered if the patient has an infection. A flu vaccination would be given to patients with chronic diseases to prevent influenza A/B.

Which assessment finding would indicate the patient needs airway suctioning? 1 Coughing thick sputum only occasionally 2 After nebulization, coughing up thin sputum Correct3 Decreased independent ability to cough 4 Clear lung sounds only after coughing

The patient would need airway suctioning when there is a decreased independent ability to cough. Impaired ability to cough up mucus caused by weakness or very thick secretions indicates a need for suctioning. The other choices indicate that the patient has the ability to cough and does not need airway suctioning. Even though it is occasionally, the patient can cough up the thick sputum. Coughing up thin sputum after nebulization also indicates an ability to cough; the patient does not need suctioning. If the lung sounds are clear after the patient coughs, then coughing is effective and suctioning is not needed.

Which physiological process explains why a child who has chills and a temperature of 104° F (40° C) is at risk of developing dyspnea? 1 Fever increases metabolic demands, requiring increased oxygen need. 2 Blood glucose stores are depleted, and the cells do not have energy to use oxygen. 3 Carbon dioxide production increases as a result of hyperventilation. 4 The small chest and lungs decrease the production of carbon dioxide and oxygen.

The physiological process is as follows: fever increases metabolic demands, requiring increased oxygen need. When the body cannot meet the increased oxygenation need, the increased metabolic rate causes the breakdown of protein and the wasting of respiratory muscles, increasing the work of breathing. Although blood glucose stores can become depleted, this is not the physiological process that occurs in a fever. Carbon dioxide production increases because of an increased metabolism stemming from the fever, not as a result of hyperventilation. The small chest and lungs do not affect the production of carbon dioxide and oxygen. The carbon dioxide increases (not decreases) in a fever

Which topic discussed by the nurse with the patient is about orthopnea? 1 Exposure of patient to passive smoking 2 Shortness of breath affecting daily activities 3 Rating the shortness of breath on a scale of 0 to 10 4 Feeling of comfort when sleeping in a reclining chair

The question about feeling of comfort when sleeping in a reclining chair is about orthopnea. Orthopnea is an abnormal condition in which a patient uses multiple pillows when reclining to breathe easier or sits leaning forward with arms elevated. The question about exposure to passive smoking gives information about predisposing factors, not orthopnea. The question about shortness of breath affecting daily activities indicates the severity of the symptoms, not about orthopnea. The question to rate shortness of breath gives information about severity, not about orthopnea.

Which respiratory assessment would the nurse perform for a patient who exhibits labored breathing, uses accessory muscles, and has rhonchi and diminished breath sounds? Select all that apply. One, some, or all responses may be correct. SpO2 levels Correct2 Amount of sputum production Correct3 Change in respiratory rate and pattern 4 Pain in lower calf area 5 Pitting edema in the ankles

The respiratory assessment includes SpO2 levels, amount of sputum production, and change in respiratory rate and pattern. Pain in the lower calf area and pitting edema in the ankles indicate vascular/circulatory, not respiratory, status.

intermittent suctioning

The step illustrated is applying intermittent suctioning for 10 seconds. The figure depicts suctioning a tracheostomy. Intermittent suctioning is applied for no more than 10 seconds. For hyperoxygenating the patient before suctioning, the nurse would be attaching or squeezing a manual resuscitation bag connected to an oxygen source or a mechanical ventilator, not applying suctioning with the thumb. In artificial airway suctioning, when the patient begins to cough, the catheter is pulled back by 1 cm (0.4 inches), not 3 cm (1.2 inches), before applying suctioning. Picking up the suction catheter with the nondominant hand without touching nonsterile surfaces is not the step depicted in the image; picking up the suction catheter uses the dominant hand, not nondominant hand.

Which statement is true regarding respiratory physiology? 1 Ventilation is the process of moving gases into and out of the lungs. 2 The diaphragm is the major expiratory muscle of respiration. 3 Ventilation requires muscular properties irrespective of the elastic properties of the lungs. 4 The diaphragm is innervated by the phrenic nerve that exits the cranium.

The true statement is ventilation is the process of moving gases into and out of the lungs. The diaphragm is the major muscle of inspiration, but not expiration. Ventilation requires both the muscular and elastic properties of the lungs, not just muscular. The diaphragm is innervated by the phrenic nerve, which exits the spinal cord at the fourth cervical vertebrae, not the cranium.

hich condition is the consequence of using an artificial airway that is too large? 1 Hypotension 2 Thick secretions 3 Airway obstruction 4 Aspiration of gastric contents

The use of an airway that is too large forces the tongue toward the epiglottis and obstructs the airway. Suctioning respiratory secretions too frequently may lead to hypotension. Thick secretions and aspiration of gastric contents are complications of noninvasive ventilation.

While performing tracheal suctioning, which nursing action is appropriate in removing secretions adhered to the sides of the endotracheal (ET) tube? Correct1 Rotating the catheter 2 Applying the suction pressure while inserting the catheter 3 Advancing the catheter tip farther into the patient's trachea 4 Maintaining the suction pressure between 130 and 160 mm Hg

To remove the secretions that are adhered to the sides of the ET tube, the nurse rotates the catheter. The suction pressure is never applied while inserting the catheter, even if secretions are adhered to the sides. In tracheal suctioning, the catheter tip is advanced farther into the patient's trachea. However, this action will not remove the adhered secretions. The suction pressures maintained while inserting the catheter should be between 80 and 120 mm Hg, not 130 and 160 mm Hg.

Which action would the nurse take to perform suctioning in a patient who has chronic obstructive pulmonary disorder (COPD) and is spontaneously breathing? 1 Hyperventilate the patient prior to suctioning. 2 Administer oxygen at a rate of no more than 3 L/min. 3 Ensure that the patient receives high levels of oxygen. 4 Limit the introduction of the catheter to 3 times with each suctioning procedure.

While suctioning, the nurse would administer oxygen at a rate of no more than 3 L/min to a patient who has COPD and who is breathing spontaneously. For a patient with COPD and who is breathing spontaneously, the nurse would not hyperventilate the patient prior to suctioning or ensure that the patient receives high levels of oxygen because high levels of oxygen decrease the stimulus to breathe in a COPD patient. The nurse would limit the introduction of the catheter to 2 (not 3) times with each suctioning procedure.