AH Exam 1: Chapter 21
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?
"Before you do the exercise, I'll give you pain medication if you need it."
The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated.
"I just finished eating my lunch, I'm ready for my CPT now."
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?
10 to 15 seconds
The nurse is caring for a patient in the ICU who required emergent endotracheal (ET) intubation with mechanical ventilation. The nurse receives an order to obtain arterial blood gases (ABGs) following the procedure. The nurse recognizes that ABGs should be obtained at which timeframe following the initiation of mechanical ventilation?
20 minutes
A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?
84mmHg
A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for:
A kink in the ventilator tubing
A patient with emphysema informs the nurse, "The surgeon will be removing about 30% of my lung so that I will not be so short of breath and will have an improved quality of life." What surgery does the nurse understand the surgeon will perform?
A lung volume reduction (20-30% removed)
A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration?
A partial rebreathing mask
A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for?
Anemic hypoxia
A client has a sucking stab wound to the chest. Which action should the nurse take first?
Apply a dressing over the wound and tape it on three sides
A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse
Assesses the client's tracheostomy and lung sounds every 15 minutes
A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?
Assessing the client's respiratory status, orientation, and skin color
An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure?
At bedtime
For a client with an endotracheal (ET) tube, which nursing action is the most important?
Auscultating the lungs for bilateral breath sounds
A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?
Auscultation
Which of the following is an adverse reaction that would require termination of the weaning process from the ventilator?
BP increase of 20 mmHg
Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain
Baseline arterial blood gas (ABG) levels
A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?
By supplying a magic slate or similar device
The nurse is caring for a patient in the ICU who is receiving mechanical ventilation. Which of the following nursing measures are implemented in an effort to reduce the patient's risk of developing ventilator-associated pneumonia (VAP)?
Cleaning the patient's mouth with chlorhexidine daily
A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse
Continues assessing the client's respiratory status frequently
The nurse is transporting a patient with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse?
Cut the contaminated tip of the tube and insert a sterile connector and reattach.
The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined?
Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?
Endotracheal suctioning
A client is receiving mechanical ventilation. How frequently should the nurse auscultate the client's lungs to check for secretions?
Every 2 to 4 hours
A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to:
Expect coughing when using the spirometer properly
A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity?
Fatigue Dyspnea Substernal pain
The nurse should monitor a client receiving mechanical ventilation for which of the following complications?
Gastrointestinal hemorrhage
The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do?
Hold the breath at the end of inspiration for a few seconds. Cough frequently. Frequently evaluate progress
A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?
Hypoxia
A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority?
Impaired gas exchange
The nurse has instructed a patient on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which of the following?
Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing
The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?
Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes
The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique?
It prolongs exhalation
A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:
Keeping his airway patent
A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?
Kinking of the ventilator tubing
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?
Manual resuscitation bag
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?
Measuring and documenting the drainage in the collection chamber
A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to reverse these manifestations?
Nonrebreather mask
Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration?
Nonrebreather mask
A patient has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the patient complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?
Oxygen toxicity
A patient has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the patient complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?
Oxygen toxicity
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?
Partial pressure of arterial oxygen (PaO2)
A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do?
Place the end of the chest tube in a container of sterile saline
A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to:
Prescribed albuterol before performing postural drainage
Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?
Reduced cardiac output
Which of the following statements would not be considered an appropriate intervention for a patient with an ET tube?
Routine cuff deflation is recommended
A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped?
Runs of ventricular tachycardia
The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:
Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?
Suction the client's artificial airway. (high pressure alarm means obstruction of airway)
A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?
Suction the client, withdraw residual air from the cuff, and reinflate it
The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:
Symmetry of the client's chest expansion
A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to:
Take prescribed albuterol (Ventolin) before performing postural drainage
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?
The patient is hypoxic from suctioning
A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time?
The patient will have an insertion of a tracheostomy tube. (ET tube can last up to 21 days)
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
The system has an air leak
A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply.
To provide adequate transport of oxygen in the blood To decrease the work of breathing To reduce stress on the myocardium
A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mm Hg. The nurse is aware of what complications that can be caused by this pressure? (Select all that apply.)
Tracheal ischemia Tracheal bleeding Pressure necrosis
A patient with COPD requires oxygen administration. What method of delivery does the nurse know would be best for this patient
Venturi mask
Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration?
Volume cycled
A client is prescribed postural drainage because secretions are building in the superior segment of the lower lobes. Which is the best position to teach the client to use for postural drainage?
Was a picture: guy lying on his stomach facing down to drain
A client has been placed on a ventilator, and the spouse is visiting for the first time. The spouse begins to cry. The best statement by the nurse is
"Tell me what you are feeling"
The nurse is preparing to assist the health care provider with the removal of a patient's chest tube. Which of the following instructions will the nurse correctly give the patient?
"When the tube is being removed, take a deep breath, exhale, and bear down."
The nurse is preparing to assist the health care provider with the removal of a patient's chest tube. Which of the following instructions will the nurse correctly give the patient?
"When the tube is being removed, take a deep breath, exhale, and bear down."
The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to:
Assess pulse and blood pressure
A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?
Auscultate the lung for adventitious sounds
A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?
Auscultate the lung for adventitious sounds
A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?
Encourage the patient to take approximately 10 breaths per hour, while awake.
