Oxygenation

Which intervention would the nurse perform to ensure that the correct amount of oxygen is delivered to the patient receiving 35% oxygen via a Venturi mask?

Place the mask over the patient's mouth and nose to form a tight seal

Which statement by the nurse indicates a correct understanding of suctioning safety guidelines?

"The mouth is suctioned with a separate oral suction device when there is an abundance of oral secretions."

Which amount is the maximum time for the nurse to apply suction when performing endotracheal suctioning of a patient?

10 seconds

How far would the nurse insert a nasopharyngeal suction catheter into a young child?

4 to 7.5 cm (1.5 to 3 inches)

Which action would the nurse take to perform suctioning in a patient who has chronic obstructive pulmonary disorder (COPD) and is spontaneously breathing?

Administer oxygen at a rate of no more than 3 L/min

Which action would the nurse take if having difficulty passing the catheter while suctioning a patient because of incomplete opening of the glottis?

Advise the patient to cough

Which tracheostomy complication is the most serious?

Airway obstruction

Which statement is true about the various patterns of respiration?

Apnea is the absence of respirations for 15 seconds or longer Kussmaul respiration is the increase in rate and depth of breathing Cheyne-Stokes breathing is a period of apnea following a period of deep breathing and then shallow breathing

Which nursing action is appropriate during suctioning?

Applying clean gloves to both hands for oropharyngeal suctioning

Which condition may be observed in a patient who receives frequent suctioning?

Arrhythmias

Which purpose does asking the patient to say "ahh" while performing suctioning accomplish?

Assists in opening the glottis

Which device helps reestablish normal intrapleural and intrapulmonic pressures while promoting lung reexpansion?

Chest tube

Which statement is true regarding chest tubes?

Chest tubes are used in the treatment of pneumothorax

Which abnormality is caused by chronic hypoxemia?

Clubbing

Which information does the nurse document after performing endotracheal suctioning for a patient with cystic fibrosis?

Color of secretions Amount of secretions Respiratory assessments before and after suctioning Consistency of secretions Pulse oximetry values

Which statement about home oxygen storage systems indicates a need for correction?

Compressed gas cylinder systems are the choice for high-volume users

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?

Croup

Which assessment finding would indicate the patient needs airway suctioning?

Decreased independent ability to cough

A patient requires endotracheal suctioning due to increased secretions. Which rationale supports the use of a closed system for suctioning?

Decreased infection risk

Which situation would cause the nurse to ask the patient to say "ahh" while guiding the suction catheter?

Difficulty in passing the suction catheter in the first attempt

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?"

Dyspnea

Which instruction would the nurse include in a teaching session about lifestyle practices to promote heart health?

Eat foods rich in fiber Participate in aerobic exercises Exercise for at least 150 minutes a week

While caring for a patient who has a chest tube, the nurse monitors the vital signs and pulse oximetry as prescribed by the health care provider. Which nursing skill does this demonstrate?

Evaluation

Which nursing intervention may be beneficial for a patient who has thick pulmonary secretions?

Encouraging fluid intake Teaching cascade coughing

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?

Encouraging the patient to cough

Which nursing intervention is appropriate if the nurse observes the return of bloody secretions while performing suctioning?

Evaluating suctioning frequency

Which topic discussed by the nurse with the patient is about orthopnea?

Feeling of comfort when sleeping in a reclining chair

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?

Frequent change of position

Which action would the nurse take when the patient gags and becomes nauseated upon inserting the suction catheter into the trachea?

Gently remove the catheter and wait until the patient breathes normally

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?

Grandfather Son

Which assessment finding would alert the nurse to stop suctioning a patient?

Heart rate of 40 beats per minute

Which disorder is treated by using chest tubes?

Hemothorax Pneumothorax Pulmonary embolism

Which position is appropriate in a patient who has a chest tube drainage system to drain fluid from the chest?

High-Fowler's

Which nursing intervention, if performed before suctioning, minimizes hypoxemia after suctioning?

Hyperoxygenating the patient before suctioning

Which statement made by the caregiver indicates successful teaching about safety measures for oxygen?

I should check the oxygen level of portable tanks before transporting

Which statement by the new nurse indicates the charge nurse needs to intervene?

I will apply negative pressure while inserting the catheter

Which statement made by the new nurse about suctioning a patient with an endotracheal tube indicates the charge nurse needs to intervene?

I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient

Which nursing process involves clamping the chest tubes under specific circumstances as per the health care provider's prescription?

Implementation

Which risk is associated with suctioning when performed in an appropriate time interval on a patient who has a head injury?

Increased intracranial pressure

Which information is true regarding chest percussion?

Involves rhythmically clapping on the chest wall

Why is clamping a chest tube contraindicated while ambulating a patient?

It causes tension pneumothorax

Which statement is true regarding an oxygen mask?

It is a device that fits snugly over the mouth and nose and is secured in place with a strap

Which action would the nurse take for a patient who has a chest tube to drain a pneumothorax?

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 If the tube disconnects, crimp tubing with a gloved hand

Which diagnostic test does the nurse anticipate will be used to rule out a pulmonary blood clot in a patient

Lung scan

Which action would the nurse take when performing tracheal suctioning in a patient who has a history of respiratory distress?

Maintain the suction pressure between 80 and 120 mm Hg while withdrawing the catheter

Which oxygen-delivery system would the nurse select to administer oxygen at 4 L/min to a patient needing a low-flow delivery device?

Nasal cannula

Which type of suctioning can the nurse delegate to assistive personnel (AP)?

Oral suctioning

Which age-related change in the older adult may result in decreased tissue oxygenation caused by impaired chest expansion?

Ossification of costal cartilage Decreased intervertebral space Diminished respiratory muscle strength

Which oxygen delivery system is indicated for long-term oxygen use at home?

Oxygen-conserving cannula

Which guideline would the nurse follow when administering chest physiotherapy?

Patients on long-term steroids should not undergo chest physiotherapy

Which intervention would the nurse perform for a patient with a nursing diagnosis of impaired airway clearance?

Perform chest physiotherapy Administer expectorants Provide supplemental oxygen

Which nursing action is likely responsible for the patient's blood pressure being low and finding that the patient has hypoxemia and arrhythmias?

Performing too-frequent suctioning

Which action would the nurse take when performing endotracheal tube suctioning on a patient with thick secretions?

Pick up the suction catheter with the dominant hand

During an assessment, which finding indicates the presence of a pneumothorax?

Pleuritic pain that worsens on inspiration

Which situation leads to tracheal mucosa trauma from artificial airway suctioning?

Providing deep tracheal suctioning

Which diagnostic test provides instant feedback about a patient's oxygenation status?

Pulse oximetry

Which action would the nurse take for a patient 2 hours after surgery for insertion of a chest tube who has 100 mL of dark-red drainage in the chest tube?

Record the amount and continue to monitor drainage

While performing tracheal suctioning, which nursing action is appropriate in removing secretions adhered to the sides of the endotracheal (ET) tube?

Rotating the catheter

Which diagnostic study would the nurse anticipate for a patient who has chest pain from cardiac problems?

Serum cholesterol Electrocardiogram Serum cardiac enzymes

Which type of oxygen mask is contraindicated for patients who have carbon dioxide retention?

Simple face mask

While caring for a patient who has a nasal cannula, the nurse loosens the elastic strap. Which unexpected patient outcome is responsible for the nurse's action?

Skin irritation

Which condition would a patient with a respiratory rate of 25 breaths/min have?

Tachypnea

The nurse identifies that which event indicates the need to perform oropharyngeal suctioning?

The patient is able to cough effectively but is unable to clear secretions by expectorating

For which reason would the water-seal chamber have continuous bubbling?

There is a leak between the patient and the chamber

Which statement is true regarding oxygen concentrators?

They provide large sources of oxygen

Which goal is the primary motive for why a nurse would perform pulse oximetry on a patient who is cyanotic?

To assess the oxygenation level

Which rationale explains the nurse not applying suction pressure while inserting the catheter?

To avoid traumatizing the lung mucosa

Which device provides high-flow oxygen delivery?

Venturi mask

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?

You have to practice these exercises first in the supine position and then in the sitting position.