SHERPATH: Implementation and Evaluation of Interventions Related to Oxygenation and Perfusion

What is the priority nursing assessment to evaluate to the effectiveness of prescribed antihypertensive medications? A. Heart rate B. Pulse oximetry C. Blood pressure D. Respiratory rate

C. Blood pressure Evaluation of patient blood pressure is the priority assessment to monitor the effectiveness of antihypertensive medications.

When a patient with infectious bronchitis (inflammation of the bronchi) is admitted to the hospital, the nurse expects what medications to be added to the patient's drug regimen? Select all that apply. A. Corticosteroids B. Antibiotics C. Vaccines D. Anticholinergics E. Mucolytics

A. Corticosteroids Corticosteroids reduce inflammation, which helps patients with bronchitis. B. Antibiotics Antibiotics are given for infectious processes like bronchitis. D. Anticholinergics Anticholinergics decrease inflammation and secretions.

When effective, medications used for treatment of pulmonary disease should result in what changes in the patient's status?Select all that apply. A. Decrease in symptoms B. Fewer number of exacerbations C. Increased exercise tolerance D. Improved overall health status E. Lessens the number of laboratory tests

A. Decrease in symptoms Medications prescribed are used to decrease symptoms. B. Fewer number of exacerbations Medications are prescribed to decrease disease flare-ups. C. Increased exercise tolerance Medications relieve symptoms to improve the ability to exercise. D. Improved overall health status Medications that decrease symptoms also increase overall health.

When a patient with chronic cardiovascular disease is admitted to the unit, which medications should the nurse expect to be on the medication administration record? Select all that apply. A. Diuretics B. Anticoagulants C. Antiarrhythmics D. Calcium channel blockers E. Bronchodilators

A. Diuretics Diuretics increase the flow of urine, reducing excess water in the body and are often prescribed for a patient who is admitted with a cardiovascular disorder. B. Anticoagulants Anticoagulants prevent clot formation and are often prescribed for a patient who is admitted with a cardiovascular disorder. C. Antiarrhythmics Antiarrhythmics suppress abnormal heart rates and rhythms, and are often prescribed for a patient who is admitted with a cardiovascular disorder. D. Calcium channel blockers Calcium channel blockers lower arterial blood pressure and are often prescribed for a patient who is admitted with a cardiovascular disorder.

A nurse recognizes that daily, extended supplemental oxygen therapy leads to what potential outcomes for a COPD patient?Select all that apply. A. Increased level of daily function B. Slowed progression of the disease C. Improved mental status D. Increased tolerance to activity E. Decreased inflammation of the alveoli

A. Increased level of daily function Oxygen therapy improves oxygenation in the client and increased daily function. C. Improved mental status Oxygen therapy improves oxygenation in the patient and this improves mental status. D. Increased tolerance to activity Oxygen therapy improves tissue oxygenation thus improving tolerance to activity.

Following surgery, a patient states that performing incentive spirometry is uncomfortable and wants to know why it is necessary. The nurse would include what information in the response to this question? A. It facilitates gravity drainage of secretions. B. It prevents atelectasis. C. It removes mucus from the respiratory tract D. It drains fluid from the pleural space.

B. It prevents atelectasis. Incentive spirometry is an effective means of expanding the lungs; thereby reducing the risk of atelectasis and pneumonia.

What explanation would be appropriate when preparing a patient for the placement of an oropharyngeal tube? A. "There will be a small incision made to help you breathe" B. "This will help facilitate clearing secretions from your mouth and throat." C. "This will remain in place only as long as you are under general anesthesia" D. "Your nares will be lubricated to ease insertion."

B. "This will help facilitate clearing secretions from your mouth and throat." An oropharyngeal tube is used to help with suctioning secretions to keep the airway clear.

Which device would the nurse apply to a patient who has arrived in the emergency department unconscious and in respiratory arrest (is not breathing)? A. Venturi mask B. Ambu bag C. Nasal cannula D. CPAP device

B. Ambu bag The bag-valve-mask (BVM) device, also known as an Ambu bag, uses a one-way valve to support, ventilate, and oxygenate a patient in respiratory arrest.

What is the primary rationale for administering a corticosteroid (Methylprednisolone) to a patient with a pulmonary disease? A. It will treat the underlying infection. B. It will decrease inflammation C. It will increase the diameter of the bronchi. D. It will decrease the thickness of airway secretions.

B. It will decrease inflammation Methylprednisolone, a corticosteroid, is used to decrease inflammation.

A student nurse includes which intervention when caring for a patient taking a diuretic? Select all that apply. A. Application of anti-embolic stockings B. Daily weight monitoring C. Intake and output monitoring D. Increase the head of the bed to semi-Fowlers E. Monitor for bleeding tendencies

B. Daily weight monitoring Patients on diuretics are weighed daily to monitor fluid loss. C. Intake and output monitoring Patients on diuretics need to have intake and output monitored closely to evaluate fluid balance.

After administering a prescribed bronchodilator to a patient with COPD, which assessment finding indicates the drug has been effective? A. Decreased secretions B. Decreased wheezing C. Increased heart rate D. Decreased body temperature

B. Decreased wheezing A decrease in wheezing after the administration of a prescribed inhaled bronchodilator indicates the drug has been effective by the patient opening airway.

A patient prescribed anticoagulant therapy is about to be discharged for home; which instruction should be included during patient education? A. Expect bleeding and bruising while taking the medication B. Dietary advice on limiting foods intake of green, leafy vegetables C. Blood pressure should be monitored daily D. Encourage daily weights at the same time every day

B. Dietary advice on limiting foods intake of green, leafy vegetables Vitamin K, found in green, leafy vegetables can alter the effects of anticoagulant therapy and should be limited.

A student nurse attending a lecture on pulmonary medications learns that bronchodilators have which primary action that relieves wheezing? A. Decrease inflammation B. Increase the diameter of the bronchi C. Decrease the thickness of secretions D. Protect against disease

B. Increase the diameter of the bronchi Bronchodilators increase the diameter of the bronchi and bronchioles.

Which actions are the nurse's responsibilities during a chest tube insertion procedure? Select all that apply. A. Explain procedure to patient B. Position the patient C. Assure that the drainage system is working properly D. Administer a prescribed bronchodilator E. Initiate oxygen therapy directly before tube insertion

B. Position the patient Position the patient: The patient is positioned as directed at the beginning of the procedure to facilitate insertion of the chest tube. C. Assure that the drainage system is working properly Assure that the drainage system is working properly: Promptly checking to see that the drainage system is working properly is needed to validate correct placement and an intact system.

When inserting a nasopharyngeal tube, what guidelines will the student nurse need to remember?Select all that apply. A. The airway is inserted into the mouth over the tongue. B. The length is measured from tragus to nostril plus one inch. C. The airway is removed and changed at least every 24 hours. D. Gentle to moderate force is applied when resistance is encountered. E. The airway is lubricated before attempting insertion and inserted gently.

B. The length is measured from tragus to nostril plus one inch. The correct way to measure is from the ear tragus to the nostril plus 1 inch. C. The airway is removed and changed at least every 24 hours. The airway is removed and changed every 8 to 24 hours along with alternating nares to prevent skin irritation. E. The airway is lubricated before attempting insertion and inserted gently. The airway is lubricated before attempting insertion to ease passage.

What benefits are important for the nurse to include when educating a patient about antihypertensive medications? A. They control an irregular heart rate. B. They reduce the risk of stroke. C. They reduce the risk of blood clots. D. They control swelling of the feet.

B. They reduce the risk of stroke. Antihypertensive agents reduce blood pressure which reduces risk of complications of hypertension such as stroke and heart disease.

Match the drug classification with associated key assessments. Blood pressure Daily weights, intake and output Heart rate and rhythm Bleeding Diuretics Antiarrhythmics Anticoagulants Antihypertensives

Blood pressure-Antihypertensives Daily weights, intake and output-Diuretics Heart rate and rhythm-Antiarrhythmics Bleeding-Anticoagulants

While caring for a patient with pneumonia, the nurse receives an order for a common low-flow system to deliver continuous oxygen at 2 L/min. The nurse anticipates using which system? A. Non-rebreather mask B. BiPAP C. Nasal cannula D. Ambu bag

C. Nasal cannula A nasal cannula is used as a low-flow system used to deliver a continuous flow of supplemental oxygen at 2L per minute.

The nurse manager observes a nurse stripping the tubing of a chest tube on a patient who recently arrived in the unit following chest surgery. Based on the evidence, how should the nurse manager respond? A. Demonstrate the proper technique to be used with stripping to prevent injury. B. Take no action as long as the procedure is being performed correctly. C. Stop the procedure and inform the nurse that tube stripping is not to be performed. D. Assist the nurse by turning the patient to the side with the chest tube.

C. Stop the procedure and inform the nurse that tube stripping is not to be performed. Research has shown that stripping (milking) tubing on a chest tube to free a possible occlusion is not a safe practice and can result in damage to lung tissue, increase bleeding, or may alter pressures within the chest.

A nursing student observes the insertion of a chest tube in a patient injured in a car crash. What should the student understand about the purpose of chest tubes? A. They provide oxygenation when respirations are impaired. B. They can be used for removal of excessive airway secretions. C. They drain blood and fluid to promote full lung expansion. D. They can keep the airway open when there is airway damage.

C. They drain blood and fluid to promote full lung expansion Chest tubes drain fluid or blood from the pleural space so lungs can fully expand.

Based on evaluation of the different types of tubes used to maintain oxygenation, which one would a patient receiving general anesthesia require? A. Nasopharyngeal B. Tracheostomy C. Oropharyngeal D. Endotracheal

D. Endotracheal An endotracheal tube is used for delivering oxygen under pressure when ventilation must be totally controlled and in general anesthetic procedures.

When visiting a patient who was discharged recently with orders to use a CPAP machine, the nurse finds the patient is refusing to use it due to claustrophobia. Which course of action should the nurse initiate? A. Teaching deep breathing exercises B. Seeking re-admission to the hospital for oxygen therapy C. Suggesting counseling to overcome the unreasonable fear D. Requesting an order for a high-flow nasal cannula

D. Requesting an order for a high-flow nasal cannula For patients who are noncompliant, high-flow nasal cannulas are used to mimic positive airway pressure while promoting patient comfort by reducing a feeling of claustrophobia

After palpating the skin around the stoma site during tracheostomy care, the nurse calls the primary care provider and checks the tube for placement suspecting which alteration? A. Excessive secretions B. Reddened incision C. Respiratory infection D. Subcutaneous emphysema

D. Subcutaneous emphysema Subcutaneous emphysema indicates air trapped in the skin surrounding the stoma from improper tube placement, and the primary care provider is notified.

Match the pulmonary drug classification with the key principle of use. Increase the diameter of the bronchi Improve airway clearance Decrease inflammation Decrease the thickness of secretions - Inhaled bronchodilators - Corticosteroids - Mucolytics - Anticholinergics

Increase the diameter of the bronchi - Inhaled bronchodilators Improve airway clearance - Anticholinergics Decrease inflammation - Corticosteroids Decrease the thickness of secretions - Mucolytics

Match the artificial airway tube with the correct situation. Inserted in the patient's nose to facilitate ease of suctioning Inserted in mouth; maintains airway; patient breathing w/o ventilatory help Inserted through the mouth for positive pressure mechanical ventilation Inserted through trachea; provides ventilation when upper airway obstructed Endotracheal tube Tracheostomy tube Nasopharyngeal tube Oropharyngeal tube

Inserted in the patient's nose to facilitate ease of suctioning- Nasopharyngeal tube Inserted in mouth; maintains airway; patient breathing w/o ventilatory help- Oropharyngeal tube Inserted through the mouth for positive pressure mechanical ventilation- Endotracheal tube Inserted through trachea; provides ventilation when upper airway obstructed- Tracheostomy tube

Match the type of oxygen mask to its description. - No reservoir bag; 1 L/min increase O2 equal to 5% increase O2 concentration - Reservoir bag present; room air is inspired with O2 delivered - Reservoir bag present; one-way valve prevents entry of exhaled air - No reservoir bag; ensures accuracy of O2 concentration; uses adaptors/dials Partial rebreather mask Non-rebreather mask Simple face mask Venturi mask

No reservoir bag; 1 L/min increase O2 equal to 5% increase O2 concentration - Simple Face mask Reservoir bag present; room air is inspired with O2 delivered- Partial rebreather mask Reservoir bag present; one-way valve prevents entry of exhaled air- Non-rebreather mask No reservoir bag; ensures accuracy of O2 concentration; uses adaptors/dials- Venturi mask

Match the type of chest physiotherapy to its description. Therapeutic positioning that facilitates gravity drainage from the lungs Combines controlled coughing with deep breathing to maintain lung expansion Helps a patient reach a set inhalation volume Postural drainage Incentive spirometry Coughing/Deep breathing

Therapeutic positioning that facilitates gravity drainage from the lungs - Postural drainage Combines controlled coughing with deep breathing to maintain lung expansion - Coughing/Deep breathing Helps a patient reach a set inhalation volume - Incentive spirometry

Insertion of a pharyngeal airway may be considered for a patient for which reasons? Select all that apply. A. A decreased level of consciousness B. The patient is unable to breathe effectively C. Frequent suctioning needs D. Loss of muscle tone E. The patient requires mechanical ventilation

A. A decreased level of consciousness Decreased or loss of consciousness are often the reasons for insertion of a pharyngeal airway. C. Frequent suctioning needs Frequent suctioning needs is an excellent reason to consider use of a pharyngeal tube. D. Loss of muscle tone Loss of muscle tone is one indication for insertion of a pharyngeal tube.

A nurse is preparing to discuss home oxygen therapy with a patient who has COPD. What cautions should be included in the discussion? Select all that apply. A. High oxygen levels can be toxic B. Use oxygen therapy only as absolutely needed C. Limit oxygen concentration to low-flow D. Do not smoke while using oxygen E. Humidified oxygen should be avoided

A. High oxygen levels can be toxic High concentrations of oxygen are toxic to lung tissue and can result in tissue damage. C. Limit oxygen concentration to low-flow COPD patients can be harmed by breathing in too high of an oxygen concentration. D. Do not smoke while using oxygen Oxygen is flammable and should never be used around flames

When assessing a patient's respiratory system, which alteration may require supplemental oxygen therapy? Select all that apply. A. Increased respiratory rate B. Decreased heart rate C. Low oxygen saturation D. Cyanosis E. Elevated hemoglobin

A. Increased respiratory rate Increased respiratory (tachypnea) rate is a sign of hypoxia and the possible need for supplemental oxygen therapy. C. Low oxygen saturation Low oxygen saturation is a sign that suggests reduced blood oxygen levels (hypoxemia). D. Cyanosis Cyanosis results from decreased tissue oxygenation and may be an indication for supplemental oxygen therapy.

The nurse is taking care of a patient with a tracheostomy tube. What emergency preparedness equipment should the nurse confirm is available in the patient's room? Select all that apply. A. Obturator B. Inner cannula C. BVM device D. Blood pressure equipment E. Tracheostomy care kit

A. Obturator An obturator is definitely needed as emergency equipment. B. Inner cannula For any tracheostomy tube with an inner cannula, this is definitely needed as emergency equipment. C. BVM device A bag-valve-mask (BVM) device should always be available for emergency use. E. Tracheostomy care kit The tube is secured to prevent it from being dislodged during care.

A nurse assesses a suspected blockage in the chest tube of a patient and prepares to strip or milk the tube to clear it, but is stopped by another nurse. What can happen if the nurse strips or milks the tube? Select all that apply. A. Pleural damage B. Increased bleeding C. Blood clot formation D. Increased intrathoracic pressure

A. Pleural damage Evidence shows milking or stripping can cause pleural damage. B. Increased bleeding Evidence shows milking or stripping can result in increased bleeding. D. Increased intrathoracic pressure Evidence shows milking or stripping can result in increased intrathoracic pressure.

When the supervisor observes a new nurse suctioning a patient using normal saline to facilitate the procedure, what action should be taken? A. Caution the nurse to limit the amount of saline to less than 1 mL. B. Remind the nurse that only sterile normal saline can be used. C. Encourage the nurse to use it frequently to facilitate secretion removal. D. Inform the nurse that normal saline should not be instilled.

D. Inform the nurse that normal saline should not be instilled. Normal saline is no longer used as a method to facilitate the removal of secretions and has no benefit because saline does not mix with the secretions.

When administering medication to a patient with non-life-threatening lower airway inflammation, which route would the nurse expect to be used? A. Subcutaneous B. Nasal C. Intravenous D. Inhalation

D. Inhalation The preferred route for administering pulmonary medications for non-life threatening airway inflammation is inhalation. It is routinely provided by respiratory therapists with an order from the patient's primary care provider.

When a patient experiencing an abnormally rapid heartbeat asks what the purpose of an antiarrhythmic medication is, what explanation would the nurse give? A. It promotes increased urine flow. B. Low doses prevent blood clot formation. C. It is needed to reduce high blood pressure. D. It suppresses abnormal rhythms of the heart.

D. It suppresses abnormal rhythms of the heart. Antiarrhythmics treat or prevent tachyarrhythmias (heart arrhythmias with a rapid rate) including ventricular tachycardia and atrial fibrillation.