Airway Management
Which of the following is an inaccurate step in the implementation of closed inline suctioning? Hand hygiene and clean gloves have already been applied. A) Attach suction. Hyperoxygenate the patient. Unlock the suction control mechanism. Pick up the suction catheter in the enclosed plastic sleeve with your dominant hand. B) Wait until the patient inhales or the ventilator delivers a breath and then quickly but gently insert the catheter on the next inhalation. C) Apply suction by squeezing on the suction control mechanism while withdrawing the catheter. Be sure to withdraw the catheter completely into the plastic sheath. D) Close the saline port and attach the saline syringe or vial. Squeeze the vial or push the syringe. Turn off the suction. Document.
D) Close the saline port and attach the saline syringe or vial. Squeeze the vial or push the syringe. Turn off the suction. Document
Which of the following, if exhibited by the patient, would indicate late hypoxia? A) Restlessness. B) Anxiety. C) Eupnea. D) Cyanosis.
D) Cyanosis.
Which step in the sequence of nasopharyngeal suctioning requires correction? A) Perform hand hygiene. Connect suctioning tubing to the suction machine and turn it on. Have supplemental oxygen available. B) Maintaining sterile technique, open suction catheter. Fill the basin with 100 mL of sterile saline/water. Open the package of water-soluble lubricant. C) Apply sterile gloves. Attach suction catheter to connecting tubing. Test the assembled suctioning equipment. D) Lubricate the end of the catheter. Insert the catheter during expiration. Apply continuous suction for approximately 1 minute as the catheter is withdrawn.
D) Lubricate the end of the catheter. Insert the catheter during expiration. Apply continuous suction for approximately 1 minute as the catheter is withdrawn.
The nurse is orienting a newly hired nurse to a surgical intensive care unit. The newly hired nurse asks when endotracheal tube care is necessary. The correct response is: A) "Signs that endotracheal tube care must be performed include loosening of the tapes, soiled tapes, mobility of the tube, and alteration in skin or tissue integrity." B) "When the patient begins to cough continuously." C) "It should be done at least every 8 to 12 hours." D) "Indications for endotracheal tube care include wheezes, crackles, audible gurgling, secretions in the mouth, decreased pulse oximetry, tachypnea, and tachycardia."
A) "Signs that endotracheal tube care must be performed include loosening of the tapes, soiled tapes, mobility of the tube, and alteration in skin or tissue integrity
A discussion is taking place on the unit regarding the application of lubricant to the suction catheter before passing it through the nasal passage. Which statement is accurate? A) "Water-soluble lubricant should be used because oil based lubricants increase the risk for aspiration and pneumonia." B) "If the patient's fluid status is sufficient, lubricating the catheter is unnecessary." C) "Petroleum jelly can be used to lubricate the catheter as long as the patient is not on oxygen via nasal cannula." D) "Applying water-soluble lubricant to the suction catheter ensures that it is working properly prior to oropharyngeal or nasotracheal suctioning."
A) "Water-soluble lubricant should be used because oil based lubricants increase the risk for aspiration and pneumonia."
Which of the following would lead to an increase in oxygen demand? A) A fever. B) Sleep. C) Taking a narcotic. D) Postural drainage.
A) A fever.
After receiving report, which of the following patients should the nurse see first? A) A patient who is receiving an IV piggyback antibiotic and is complaining of shortness of breath and itching. B) A patient who is unable to explain the purpose and side effects of the medication. C) A patient who complained of "stinging" at the IV site when the previous nurse administered an IV push medication. D) A patient with IV fluids infusing without difficulty, but was reported to have no blood return upon aspiration.
A) A patient who is receiving an IV piggyback antibiotic and is complaining of shortness of breath and itching.
Which of the following is an unexpected outcome during or after endotracheal suctioning and endotracheal tube care? A) A sudden drop in oxygen saturation. B) Depth of tube is the same as when started or as ordered (same centimeter marking at gums or lips). C) Clean tape is firmly secured to cheeks, upper lip, top of nose, and tube only. D) Bilateral breath sounds are equal.
A) A sudden drop in oxygen saturation.
You are preparing to perform oropharyngeal suctioning. Which of the following steps in the sequence is incorrect? A) Assist the patient into a supine position. Prepare supplies. Turn the suction unit on and set the suction control gauge to high. Connect the suction tubing to the suction machine and to the Yankauer suction catheter. B) Place the suction catheter in the container of water and apply suction. If the patient has an oxygen device, remove it, placing it near the patient's face. Insert the catheter gently into the mouth along the gingival border (gum line). C) Gently move the catheter around the patient's mouth until all of the secretions are cleared. Encourage the patient to cough. Replace the oxygen mask. Suction water from the basin through the catheter until the catheter is cleared of secretions. Reassess the patient's respiratory status and repeat the procedure if necessary. D) Turn off the suction source. Wipe the patient's face. Discard the water into an appropriate receptacle. Discard the Yankauer suction catheter or place it in a nonairtight container to ensure that it remains uncontaminated. Provide oral care. Remove the gloves and perform hand hygiene. Record the procedure.
A) Assist the patient into a supine position. Prepare supplies. Turn the suction unit on and set the suction control gauge to high. Connect the suction tubing to the suction machine and to the Yankauer suction catheter
The nurse is concerned the patient is developing atelectasis as a result of immobility. Crackles are noted upon auscultation. Which type of coughing technique is best for the nurse to teach the patient? A) Cascade. B) Huff. C) Quad. D) Chest percussion
A) Cascade.
Which of the following is a correct sequence for administering an IV piggyback through a saline lock? A) Cleanse the port with alcohol and assess the patency of the IV line by flushing it with 2 to 3 mL of sterile normal saline. Attach IV piggyback tubing to the saline lock, and administer the medication per order. When the infusion is completed, disconnect the tubing, cleanse the port with alcohol, and flush the IV line with 2 to 3 mL sterile normal saline. B) Cleanse the port with alcohol. Attach IV piggyback tubing to the saline lock, and administer the medication per order. When the infusion is completed, disconnect the tubing, cleanse the port with alcohol, and flush the IV line with 2 to 3 mL sterile normal saline. C) Cleanse the port with alcohol and assess the patency of the IV line by flushing it with 2 to 3 mL of sterile normal saline. Attach IV piggyback tubing to the saline lock, and administer the medication per order. When the infusion is completed, disconnect the tubing and document.
A) Cleanse the port with alcohol and assess the patency of the IV line by flushing it with 2 to 3 mL of sterile normal saline. Attach IV piggyback tubing to the saline lock, and administer the medication per order. When the infusion is completed, disconnect the tubing, cleanse the port with alcohol, and flush the IV line with 2 to 3 mL sterile normal saline.
A patient has clear oral secretions that are extremely copious and thick. What would be an appropriate response by the nurse? A) Oropharyngeal suctioning. B) Nasopharyngeal suctioning. C) Nasotracheal suctioning. D) Obtain a sputum specimen for culture and sensitivity.
A) Oropharyngeal suctioning.
The nurse is assessing the patient before administering a large-volume infusion with medication added. The nurse observes the IV site for signs of infiltration or phlebitis, looks at the patient's allergy band, assesses the patient's understanding of the medication therapy, determines drug compatibility, and collects medication reference information (e.g., rate of administration, side effects, nursing implications, etc.). Which assessment measure should the nurse have included but failed to? A) Patient's fluid balance B) Patient's mobility C) Patient's ability to perform self-care D) Location of the IV
A) Patient's fluid balance
You are busy performing routine assessments of the patients on the unit. You note audible gurgling on inspiration and expiration of the stable postoperative patient. Which of the following tasks can you delegate to competent NAP? A) Performing oral suctioning. B) Assessing the adequacy of respiratory functioning. C) Evaluating the outcome of oral suctioning. D) Performing nasotracheal suctioning.
A) Performing oral suctioning.
What should the nurse monitor in order to evaluate the presence of a possible complication of closed inline suctioning? A) Pulse oximetry. B) Presence of gag reflex. C) Peripheral edema. D) History of allergies.
A) Pulse oximetry
Which of the following would be an appropriate nursing diagnosis for the patient who has a tracheostomy tube? A) Risk of altered skin integrity. B) Impaired mobility. C) Fluid volume deficit. D) Risk of fluid volume excess.
A) Risk of altered skin integrity
A nurse takes precautions to prevent an undesirable outcome when administering medications by the intravenous route. Which of the following actions would require correction in order to prevent an undesirable outcome? A) The nurse adds a piggyback infusion of an antibiotic to a main line IV of parenteral nutrition. B) The nurse explores the patient's cultural beliefs regarding the use of alcohol, herbal remedies, and dietary preferences. C) The nurse verifies the prescribed dilution and rate of administration so that the medication is given over the appropriate amount of time in the appropriate concentration. D) The nurse verifies any medications added to IV fluids with another nurse and relies on the pharmacist or manufacturer to add high-alert medications to IV fluids
A) The nurse adds a piggyback infusion of an antibiotic to a main line IV of parenteral nutrition.
The student nurse is observing the staff nurse perform routine tracheostomy care. Which of the following actions, if made by the staff nurse, would be inappropriate? A) The nurse removes the soiled tracheostomy ties, cleans the flange, and applies new tracheostomy ties, securing them tightly behind the patient's neck. B) The nurse oxygenates the patient, suctions the tracheostomy tube, and removes the soiled tracheostomy dressing before removing gloves. C) The nurse cleans around the tracheostomy faceplate and stoma with hydrogen peroxide, then rinses with normal saline-saturated gauze and cotton-tipped applicators. D) The nurse removes the inner cannula and places it in a sterile basin of hydrogen peroxide to soak.
A) The nurse removes the soiled tracheostomy ties, cleans the flange, and applies new tracheostomy ties, securing them tightly behind the patient's neck
The primary purpose of an oral airway is: A) To prevent obstruction of the trachea by displacement of the tongue into the oropharynx. B) To provide a route for suctioning the patient. C) To enable the patient to speak. D) To allow the health care professional to inflate or deflate the cuff as needed.
A) To prevent obstruction of the trachea by displacement of the tongue into the oropharynx.
What is one advantage of a tracheostomy tube over an endotracheal tube? A) With a tracheostomy tube, the amount of anatomic dead space is decreased and thereby increases the patient's oxygen levels. B) The fenestration in the tracheostomy tube prevents the aspiration of gastric contents. C) Tracheostomy tubes can be placed by physicians and other specially trained health care personnel (e.g., physician assistants, licensed respiratory personnel, and paramedics). D) Tracheostomy tubes require less suctioning, whereas endotracheal tubes require suctioning every 1-2 hours.
A) With a tracheostomy tube, the amount of anatomic dead space is decreased and thereby increases the patient's oxygen levels.
You perform nasotracheal suctioning. Which of the following is an incorrect sequence for this procedure? A) You apply sterile gloves, pick up the suction catheter with your dominant hand, secure the catheter to the tubing, connect the tubing to the suction machine, and turn the suction on. B) Wearing sterile gloves, you suction a small amount of sterile normal saline from the basin and lightly coat 6 to 8 cm of the catheter with water-soluble lubricant. C) Using your dominant hand, you gently but quickly insert the catheter into the patient's nares and intermittently suction and rotate the catheter while withdrawing the catheter. D) You rinse the catheter and connecting tubing with normal saline and allow the patient to rest 1 to 2 minutes between catheter passes. You encourage the patient to cough, and when suctioning is complete, you appropriately discard used equipment and perform oral care.
A) You apply sterile gloves, pick up the suction catheter with your dominant hand, secure the catheter to the tubing, connect the tubing to the suction machine, and turn the suction on
Which of the following can be removed for cleaning, especially if the patient has copious or tenacious secretions? A) The outer cannula of the tracheostomy tube. B) The inner cannula of the tracheostomy tube. C) The obturator. D) The flange.
B) The inner cannula of the tracheostomy tube
You are teaching the spouse of a patient how to perform oral suctioning for when they return home. Which of the following statements, if made by the spouse, indicates further instruction is needed? A) "It would be abnormal to obtain bloody secretions." B) "Because oral secretions are thick, suction settings should be set on high." C) "I should be careful to avoid touching the back of the throat with the tip of the suction catheter." D) "I should encourage fluids to help keep secretions thin."
B) "Because oral secretions are thick, suction settings should be set on high."
6. The patient's wife asks why the nurse turns the oxygen all the way up before suctioning the patient. The nurse's best response is: A) "It is necessary in order to create the pressure needed to make the suction machine work effectively." B) "Because suctioning will remove oxygen, the flow rate is increased to prevent a decrease in oxygen available to tissues." C) "As secretions are removed, they need to be replaced with oxygen." D) "A high concentration of oxygen stimulates the respiratory center so the patient will continue breathing during the suctioning procedure."
B) "Because suctioning will remove oxygen, the flow rate is increased to prevent a decrease in oxygen available to tissues."
A student is giving a brief review in clinical post-conference on the different types of artificial airways and how to perform open suctioning. Which statement would require correction? A) "Oral airways are frequently used for patients returning from surgery who are able to breathe spontaneously but are not fully awake." B) "You should not hyperoxygenate the patient with a head injury prior to suctioning." C) "Tracheostomy tubes can be used long term or permanently." D) "Pediatric tracheostomy tubes are cuffless."
B) "You should not hyperoxygenate the patient with a head injury prior to suctioning."
Which of the following patients would have the greatest potential for an alteration in respiration? A) A 15-year-old male with a migraine headache. B) A 44-year-old female with anemia. C) A 19-year-old female with diarrhea. D) A 32-year-old male with an ear ache.
B) A 44-year-old female with anemia.
Which situation can be delegated to NAP in regard to endotracheal tube care? A) Endotracheal care may be delegated to NAP only if the patient is on a ventilator. B) Assisting the nurse during a tape change by holding the endotracheal tube. C) Performing respiratory assessments before and after endotracheal tube care. D) If the tapes are soiled, the NAP may change the tapes.
B) Assisting the nurse during a tape change by holding the endotracheal tube.
The nurse is performing closed inline suctioning of a patient. The nurse's pre-procedure assessment indicated a pulse oximetry reading of 92%, heart rate 90 beats per minute, respirations 20 per minute and crackles and wheezes upon auscultation. After making two suction passes, the nurse determines the patient's pulse oximetry reading is 95%, heart rate is 80 beats per minute, respiratory rate is 20, and lungs are clear upon auscultation. What is the nurse's best action at this time? A) Stop suctioning immediately and administer supplemental oxygen at 100%. B) Clear the inner cannula of secretions with saline, lock the suction mechanism, turn off the suction, remove gloves, perform hand hygiene, and document. C) Allow the patient to rest 1 to 2 minutes before making a third suction pass. D) Consult with the physician regarding the need for an inhaled bronchodilator or to reduce the frequency and duration of suctioning.
B) Clear the inner cannula of secretions with saline, lock the suction mechanism, turn off the suction, remove gloves, perform hand hygiene, and document
Which of the following would be an inappropriate intervention for the patient who cannot stop coughing while being suctioned? A) Stop suctioning and allow the patient to rest. B) Determine the need for chest physiotherapy. C) Consult with the physician regarding the need for an inhaled bronchodilator. D) Administer supplemental oxygen.
B) Determine the need for chest physiotherapy.
The nurse is to administer 5 mg of Morphine sulfate IV push. The drug is available as 10 mg/mL. What is the nurse's best action? A) Assess the patient's IV site for patency, and administer 2 mL of morphine sulfate. B) Dilute the amount of morphine sulfate to be given in 5 to 10 mL of 0.9% sodium chloride and administer at the correct rate. C) Administer 0.5 mL of morphine sulfate at the correct rate by IV push without further dilution. system. D) Flush the IV line with 1 mL of normal saline, administer the correct amount of morphine sulfate at the correct rate, and flush with 2 to 3 mL of normal saline.
B) Dilute the amount of morphine sulfate to be given in 5 to 10 mL of 0.9% sodium chloride and administer at the correct rate.
What nursing intervention is appropriate for the patient with a large amount of sputum? A) Perform nasotracheal suctioning every hour. B) Encourage the patient to cough every hour while awake. C) Place the patient on fluid restriction. D) Avoid all milk products.
B) Encourage the patient to cough every hour while awake.
Which of the following is a potential danger of a continuous intravenous infusion? A) Cardiac dysrhythmias B) Fluid volume overload C) Precipitate formation or clouding of the IV fluid D) Vein irritation
B) Fluid volume overload
Which of the following should NOT be delegated to NAP? A) Oropharyngeal suctioning. B) Nasotracheal suctioning on a stable patient. C) Pulse oximetry. D) Oral care.
B) Nasotracheal suctioning on a stable patient.
A patient has an endotracheal tube inserted orally. When should the nurse expect to perform endotracheal tube care? A) Whenever the patient begins to cough. B) On a routine schedule every 24 to 48 hours to reposition the tube. C) Only when the depth of the tube has changed from its original position (as indicated by a marking at the lip or gum line). D) According to physician orders.
B) On a routine schedule every 24 to 48 hours to reposition the tube.
The nurse is caring for a patient with a tracheostomy who has audible gurgling and requests to be suctioned. Assessment prior to suctioning indicates pulse 84, respirations 24, and pulse oximetry 93%. Which of the following is an indication that the nurse should stop suctioning and oxygenate the patient? A) The patient's pulse oximetry decreases to 90%. B) The patient's pulse decreases to 60 beats per . C) The patient's pulse rate increases to 100 beats/minute. D) Thick pale yellow secretions are obtained.
B) The patient's pulse decreases to 60 beats per minute.
What is the purpose of having a fenestrated tube in an artificial airway? A) To decrease the likelihood of aspiration of stomach contents. B) To allow a patient to talk. C) To prevent dislodgment. D) To prevent trauma to the trachea
B) To allow a patient to talk.
Why is it recommended to add medications to new IV fluid containers whenever possible? A) To maintain asepsis B) To be able to determine the exact concentration of the medication in the IV solution C) To make it easier for the medication to dissolve D) To prevent leaking of IV fluid (i.e., the seal on an existing infusion is already broken, making its leaking more perceptible)
B) To be able to determine the exact concentration of the medication in the IV solution
Why is it important to be sure the colored indicator line on the catheter is visible in the sheath when suctioning is complete? A) To ensure retained secretions in the catheter do not "drain" into the patient's airway. B) To prevent airway reduction with the presence of the suction catheter. C) To reduce the risk of infection by removing the secretions from the inner lumen. D) To ensure that suctioning of the patient's airway does not occur accidentally.
B) To prevent airway reduction with the presence of the suction catheter.
Which task could be delegated to NAP? A) Nasotracheal suctioning. B) Tracheostomy care of a well-established tracheostomy. C) Closed inline suctioning if a patient is on a mechanical ventilator. D) Endotracheal tube care
B) Tracheostomy care of a well-established tracheostomy.
Which of the following is an inaccurate statement in regard to performing endotracheal tube care? A) Cut first piece of tape approximately 1 to 2 feet (24 to 48 cm) in length; lay adhesive-side-up on table. B) When rotating the endotracheal tube from one side of the mouth to the other, deflate the cuff. . C) Have assistant hold tube in place and note the markings on the tube indicating depth of tube insertion before removing old tape. D) To secure the tapes around the tube, place the top side of the torn tape across the patient's upper lip and tightly wrap the lower side around the tube. .
B) When rotating the endotracheal tube from one side of the mouth to the other, deflate the cuff. .
The nurse is orienting a new graduate nurse to common procedures performed on the unit. Which statement, if made by the graduate nurse, indicates understanding of nasotracheal suctioning? A) "The maximum duration to suction is 20 seconds." B) "The bacterial count in the nasotracheal pathway is higher than in the oral cavity, so whenever possible, you should suction the trachea through the mouth." C) "A 1- to 2- minute interval should be allowed between suctioning passes." D) "Intermittent suction is applied during insertion of the catheter."
C) "A 1- to 2- minute interval should be allowed between suctioning passes."
The nursing instructor is reviewing IV medication administration with the nursing students. Which of the following statements, if made by a student, indicates further instruction is needed? A) "The nurse should never administer IV medications through tubing that is infusing blood, blood products, or parenteral nutrition solutions." B) "The 6 rights of medication administration include the right medication, the right dose, the right patient, the right route, the right time, and the right documentation." C) "The three additional rights for administering a medication by IV bolus are the right flush or dilution, the right syringe, and the right monitoring." D) "The administration of hyperosmolar drugs by the intravenous route increases the risk of phlebitis."
C) "The three additional rights for administering a medication by IV bolus are the right flush or dilution, the right syringe, and the right monitoring."
A nurse is trying to determine whether or not a patient's artificial airway should be suctioned. Which of the following fails to be an indication for suctioning? A) Pulse oximetry 89%. B) Pulmonary secretions. C) 2 hours have elapsed since patient was last suctioned. D) Patient has audible gurgling and appears restless.
C) 2 hours have elapsed since patient was last suctioned
Which of the following is a correct sequence for administering a medication by IV bolus through a saline lock? A) Clean injection port with antiseptic swab, insert syringe containing prepared medication into port, and inject over recommended time period. Remove syringe, clean port, and flush port with normal saline at same rate as medication administration. B) Clean injection port with antiseptic swab, insert syringe with normal saline, aspirate for blood return, and flush with saline. Remove syringe, clean port, administer medication over recommended time period, withdraw syringe, clean port, discard gloves, and document. C) Clean injection port, insert syringe of normal saline, aspirate for blood return, and flush with saline. Remove syringe, clean port, administer medication over recommended time period, withdraw syringe, clean port, and flush port with normal saline at same rate as medication administration. D) Clean injection port, insert syringe of medication, pinch tubing above port and aspirate for a blood return, release the tubing and administer the medication at the recommended rate, remove syringe, and verify infusion rate.
C) Clean injection port, insert syringe of normal saline, aspirate for blood return, and flush with saline. Remove syringe, clean port, administer medication over recommended time period, withdraw syringe, clean port, and flush port with normal saline at same rate as medication administration.
Which of the following is a correct sequence for administering an IV piggyback through an existing IV infusion that uses a needleless system? A) Connect infusion tubing to medication bag and prime tubing, hang piggyback medication bag at same level as primary fluid bag, wipe off lower Y-port of primary infusion line with an alcohol swab and insert tip of piggyback infusion tubing, then regulate flow rate of IV piggyback. B) Cleanse the port with alcohol and assess the patency of the IV line by flushing it with 2 to 3 mL of sterile normal saline. Attach appropriate IV tubing to the saline lock, and administer the medication via piggyback. When the infusion is completed, disconnect the tubing, cleanse the port with alcohol, and flush the IV line with 2 to 3 mL sterile normal saline. C) Connect infusion tubing to medication bag and prime tubing, hang piggyback medication bag above level of primary fluid bag, wipe off upper Y-port of primary infusion line with an alcohol swab and insert tip of piggyback infusion tubing, regulate flow rate of IV piggyback.
C) Connect infusion tubing to medication bag and prime tubing, hang piggyback medication bag above level of primary fluid bag, wipe off upper Y-port of primary infusion line with an alcohol swab and insert tip of piggyback infusion tubing, regulate flow rate of IV piggyback.
3. For the patient who extubated himself, what is the priority action the nurse should take? A) Apply a sterile dressing to the site. B) Notify the physician. C) Determine whether the patient is breathing spontaneously. D) Medicate the patient for pain and assess for tissue damage
C) Determine whether the patient is breathing spontaneously.
You have a 36-year-old female patient with severe asthmatic bronchitis after a short course of influenza. The patient was admitted to your unit and intubated with an oral endotracheal tube. She was placed on mechanical ventilation for respiratory support and the instillation of aerosolized medication. Which of the following demonstrates correct understanding of endotracheal tubes? A) Endotracheal tubes are designed for long-term use. B) Endotracheal tubes are fenestrated so that she will be able to talk when she is feeling better. C) Endotracheal tubes for adults are cuffed and must be inflated for mechanical ventilation to be effective. D) The patient with an endotracheal tube will require less attention to airway patency than the patient who is without an endotracheal tube.
C) Endotracheal tubes for adults are cuffed and must be inflated for mechanical ventilation to be effective
A patient may go home with a tracheostomy tube. Prior to discharge, the patient and the patient's family should be taught all of the following routine tracheostomy tube care measures except: A) Recognizing signs and symptoms of hypoxia and how to prevent hypoxia. B) How to suction the tracheostomy tube. C) How to remove the tracheostomy tube. D) Expected drainage from the tracheostomy and when to notify the physician
C) How to remove the tracheostomy tube
The nurse is preparing to perform nasotracheal suctioning on a patient. Which of the following would be an appropriate nursing action? A) To effectively suction the left main stem bronchus, turn the patient's head to the left. B) When suctioning artificial airways, it is important to apply suction during insertion. C) Hyperoxygenate the patient prior to suctioning and allow 1 to 2 minutes between suction passes. D) For open nasotracheal suctioning, clean gloves are appropriate.
C) Hyperoxygenate the patient prior to suctioning and allow 1 to 2 minutes between suction passes
The nurse is caring for a patient who has an endotracheal tube inserted orally. The nurse instructs the NAP to report if the patient indicates signs of pain. Because the patient cannot communicate verbally, what signs of pain should the NAP report? A) Coughing, or audible gurgling. B) Foul-smelling breath or remaining secretions in the mouth. C) Increased restlessness or a sudden change in vital signs. D) Ability of the patient to move the tube with the tongue or to bite down on the tube.
C) Increased restlessness or a sudden change in vital signs.
A patient with a weak cough has secretions in the lower airway. What would be an appropriate response by the nurse? A) Oropharyngeal suctioning. B) Nasopharyngeal suctioning. C) Nasotracheal suctioning. D) Quad cough.
C) Nasotracheal suctioning.
After the NAP performs routine vital signs on the patient, the NAP reports to the nurse that the patient is restless, and it sounds like the patient is gurgling. Vital sign readings indicate a pulse of 72, respiratory rate of 20 breaths per minute, and a pulse oximetry of 89%. What is the most appropriate action at this time? A) Document the normal findings. B) Consult with the physician regarding need for a bronchodilator. C) Suction the patient's airway. D) Have the patient take a deep breath and reassess pulse oximetry.
C) Suction the patient's airway.
Which of the following actions, if performed by the nurse, may be considered negligence? A) The nurse leaves the tubing connected to the primary line after the infusion is completed. B) The nurse stops the piggyback infusion when the insertion site appears red, swollen, and tender to the touch. C) The nurse administers a large volume IV containing potassium chloride by gravity. D) The nurse hangs the IV piggyback higher than the primary line, swabs the upper Y-port with alcohol, connects the tubing with a needleless adapter, opens the clamp, and adjusts the IV pump infusion rate.
C) The nurse administers a large volume IV containing potassium chloride by gravity.
Which of the following is a correct sequence for adding a medication to a new intravenous fluid container? (The nurse has performed hand hygiene and prepared the syringe of medication to be added to the new IV fluid container.) A) The nurse gently rotates the bag of IV fluids end to end, places it on the IV pole, wipes off the injection port with an alcohol swab, inserts the needle into the port, injects the medication, and checks the rate of the infusion. B) The nurse prepares the prescribed medication, wipes off the port for tubing insertion with an alcohol swab, injects the medication, withdraws the syringe, and starts the infusion. C) The nurse wipes off the medication injection port with an alcohol swab, inserts the needle of the syringe with the prepared medication into the port, injects the medication, turns the bag end to end, completes the medication label, and applies it to the IV bag. D) The nurse wipes off the medication injection port with an alcohol swab; inserts the needle of the syringe; withdraws an amount of IV solution equivalent to the amount of medication to be added; removes the needle and syringe, discarding it appropriately; inserts the needle of the syringe with the prepared medication into the port; injects the medication; withdraws the syringe; and turns the IV bag end to end.
C) The nurse wipes off the medication injection port with an alcohol swab, inserts the needle of the syringe with the prepared medication into the port, injects the medication, turns the bag end to end, completes the medication label, and applies it to the IV bag
Which of the following patients is most likely to experience some difficulty with effective coughing? A) The elderly patient who had outpatient foot surgery. B) The middle-age man who is postoperative for knee arthroplasty. C) The patient who is postoperative for abdominal surgery. D) The patient who preoperatively practiced cascade coughing.
C) The patient who is postoperative for abdominal surgery
The nurse is planning to administer medication by IV bolus through a saline lock. After the medication is delivered, why is it necessary to flush the port with 2 to 3 mL of normal saline at the same rate as the medication was delivered? A) In order to ensure patency of the IV site while observing for puffiness. B) To prevent dislodging a blood clot into the bloodstream. C) To ensure that any medication remaining within the IV is delivered at the correct rate. D) To avoid causing circulatory compromise from fluid volume excess.
C) To ensure that any medication remaining within the IV is delivered at the correct rate.
The nurse needs to administer an IV push medication for a patient who is complaining of pain. The medication is incompatible with the IV fluid that is infusing. What is the nurse's best initial action? A) Initiate a saline lock in a different location (proximal to the present IV site) to be used for IV push medications. B) Wait until the infusion is complete and then administer the pain medication. C) Contact the physician and request the pain medication be given by a different route, or request a different pain medication that would be compatible with the IV fluids. D) Stop the infusion, flush with 10 mL of 0.9% sodium chloride, give the IV pain medication over the appropriate amount of time, flush with another 10 mL of 0.9% sodium chloride at the same rate as the medication was administered, and restart the IV fluids.
D) Stop the infusion, flush with 10 mL of 0.9% sodium chloride, give the IV pain medication over the appropriate amount of time, flush with another 10 mL of 0.9% sodium chloride at the same rate as the medication was administered, and restart the IV fluids.
The nurse wants to take appropriate precautions when administering IV medications in order to provide safe and effective nursing care. Which of the following indicate misunderstanding and may impede the nurse from reaching the goal of safe, effective care? (Select one correct answer) A) The nurse is aware the presence of diseases that impair drug absorption, metabolism, or excretion increase the risk of an adverse drug reaction. B) Clean gloves are worn during administration of an IV bolus. C) The nurse adds medications to new IV fluid containers only. D) The nurse continues a large volume infusion containing medication on a patient with crackles, dyspnea, and an elevated blood pressure and pulse rate.
D) The nurse continues a large volume infusion containing medication on a patient with crackles, dyspnea, and an elevated blood pressure and pulse rate.
The staff nurse instructs the student nurse to keep the obturator of the tracheostomy tube at the patient's bedside. How does the student nurse know which is the obturator? A) The obturator is the part which can be removed and discarded or cleaned and replaced. B) The obturator is the part which must remain inserted to ensure patency of the tube. C) The obturator remains visible at the site of the insertion and aids in securing the entire system to the patient's neck. D) The obturator is more slender and longer than the inner or outer cannula, and is rounded at the tip.
D) The obturator is more slender and longer than the inner or outer cannula, and is rounded at the tip
Which of the following patients should be assessed for a worsening clinical situation? A) The COPD patient whose pulse oximetry remains the same after oropharyngeal suctioning. B) The patient with absence of adventitious lung sounds on inspiration and expiration. C) The patient who demonstrates less drooling after being suctioned. D) The patient with presence of blood in the secretions.
D) The patient with presence of blood in the secretions.
The nurse is performing closed inline suctioning. Pre-procedure assessment indicated crackles and wheezes bilaterally, pulse rate 72, respiratory rate 20 breaths per minute, and pulse oximetry 89%. Which of the following indicates the nurse should stop suctioning and administer oxygen? A) The patient's respiratory rate remains unchanged. B) The patient's pulse oximetry increases to 94%. C) Thick clear sputum is obtained during suctioning. D) The patient's pulse increases to 114 beats per minute
D) The patient's pulse increases to 114 beats per minute.
The nurse desires to suction the patient's left main stem bronchus. In what position should the patient be placed? A) Keep the patient's head in a neutral position and rotate the catheter counter-clockwise upon insertion. B) Keep the patient's head in a neutral position and rotate the catheter clockwise upon insertion. C) Turn the patient's head to the left. D) Turn the patient's head to the right.
D) Turn the patient's head to the right.
The nurse is performing endotracheal tube care. Which step is an appropriate nursing action for performing this skill? A) Fold the tape that holds the endotracheal tube in place lengthwise to prevent it from sticking to the patient's head/hair. B) Use the tongue blades to inspect the patient's oral cavity for sores. C) Rotate the endotracheal tube to the opposite side of the mouth only if a lesion has developed under the tube. D) Use two people to carry out the procedure.
D) Use two people to carry out the procedure.
The nurse is going to perform inline tracheostomy suctioning followed by tracheostomy tube care (using a disposable inner cannula). Which of the following is an incorrect step in the sequence for these procedures? A) Perform hand hygiene. Connect the suctioning tubing to the suction machine. Set on low. Hyperoxygenate the patient. Unlock the suction catheter. Insert the catheter during inspiration. B) Apply suction. Withdraw the catheter to the point indicated. Lock the suction catheter. Turn off the suction machine. Provide oral care. C) Remove existing tracheostomy dressing. Using sterile technique, open the tracheostomy kit. Prepare the supplies: open 4-by-4 gauze, saline, and hydrogen peroxide. Place cotton swabs in saline solution. D) Apply clean gloves. Remove the existing inner cannula. Insert the new inner cannula. Clean around the stoma and flange. Have another family member hold the tracheostomy tube. E) Cut the existing tracheostomy ties and remove them. Install new tracheostomy ties. Insert new tracheostomy dressing. Discard the used equipment and supplies. Reposition the patient.
E) Cut the existing tracheostomy ties and remove them. Install new tracheostomy ties. Insert new tracheostomy dressing. Discard the used equipment and supplies. Reposition the patient.
What additional supplies are required for administering a medication by IV bolus through a saline lock versus an existing infusion of IV fluids? A) The necessary supplies are the same regardless of whether a medication is administered by IV bolus through a saline lock or through an existing infusion of IV fluids. B) Two syringes with 2 to 3 mL of normal saline C) A watch D) Nonsterile gloves
Two syringes with 2 to 3 mL of normal saline
8. What is the increased risk for the patient if the nurse suctions for more than 15 seconds? A) Pulmonary embolus. B) Infection. C) Hypoxia. D) Dehydration
hypoxia
