Chapter 14: Oxygenation *skills lab NCLEX Q's*

The nurse is caring for a client whose respirations are supported by a ventilator. The nurse is preparing to suction the client's endotracheal tube using a closed suctioning system. Place the following steps in the correct order. Use all options - Turn the catheter safety cap to disable the suction button - Clear secretions from the sheath - Grasp the catheter and advance it to the predetermined length - Turn the catheter safety cap to enable the suction button - Depress the suction button to apply intermittent suction - Hyperventilate the client

1. Hyperventilate the client 2. Turn the catheter safety cap to enable the suction button 3. Grasp the catheter and advance it to the predetermined length 4. Depress the suction button to apply intermittent suction 5. Clear secretions from the sheath 6. Turn the catheter safety cap to disable the suction button

A nurse is caring for a client who stops breathing. The nurse must manually resuscitate the client using a bag and mask device. Place the nurse's steps in the correct order. Use all options - Turn on oxygen and adjust flow rate - Hyperextend client's neck - Place mask over client's face - Squeeze bag with non dominant hand - Press against mask to form a seal around face - Initiate CPR

1. Turn on oxygen and adjust flow rate 2. Initiate CPR 3. Hyperextend client's neck 4. Place mask over client's face 5. Press against mask to form a seal around face 6. Squeeze bag with non dominant hand

The nurse observes continuous vigorous bubbling in the water seal chamber of a chest drainage system. What should the nurse do next? A. Assess the tubing for loose connection and air leaks B. Document the finding, because it is expected C. Notify the health care provider of the finding D. Clamp the tubing on the chest drainage system

A.

the nurse is explaining the planned chest tube removal procedure to the client. What will the nurse instruct the client to do during the procedure? A. Take a deep breath and hold it while the tube is being removed B. Breathe in and out, in short rapid breaths during removal of the tube C. Take a deep breath and cough out forcefully during removal of the tube D. Breathe as he or she normally would during the removal of the chest tube

A.

The health care provider has prescribed an oropharyngeal airway for a client with a decreased level of consciousness. The health care provider has noted gurgling respirations and the client's tongue is in the posterior pharynx. The client vomits as the airway is inserted. Which actions should the nurse take? Select all that apply. A. Position client onto the side immediately B. Provide oral suctioning and mouth care C. Assess for bleeding in the mouth D. Remove oropharyngeal airway E. Raise the head of the bed to 90 degrees

A. B. D.

The nurse us preparing to replace a chest drainage system that has become full. What actions will the nurse implement for this procedure? Select all that apply. A. Add sterile water to the water seal chamber in the new system B. Remove the suction from the current drainage system C. Clamp the chest tube 1.5 to 2.5 inches (3.75 to 6.25 cm) from the insertion site D. keep the end of the chest tube sterile while inserting the end of the new insertion site E. Gently pull on the chest tube until the connections come apart

A. B. C. D.

The nurse has just completed system endotracheal suctioning on a client. The client now has decreased oxygen saturation readings. Which actions should the nurse take? Select all that apply. A. Auscultate lung sounds B. Hyperoxygenate the client C. Obtain an immediate portable chest x-ray D. Call the health care provider E. Remain with the client

A. B. E.

An intensive care nurse is receiving a female client from the emergency room. The client suffered head and facial trauma during a motor vehicle accident and requires an endotracheal tube and mechanical ventilation. What supplies should the nurse anticipate needing at the bedside? Select all that apply. A. An extra endotracheal tube of the same size B. Tape to secure the endotracheal tube to the face C. A bag-valve mask and suction equipment D. Commercially prepared endotracheal tube holder E. A can of shaving cream and a double blade razor

A. C. D.

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at FiO2 of 100%. Which oxygen delivery system should the nurse use? A. Nasal cannula B. nonrebreather mask C. Simple mask D. Venturi mask

B.

A nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant? A. Simple mask B. Oxygen hood C. Venturi mask D. Nasal cannula

B.

A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate? A. The client's respiratory rate is in the normal range B. The client's available hemoglobin is adequately saturated with oxygen C. The client's oxygen demands are being met D. The client's red blood cell (RBC) count is in the normal range

B.

The nurse is caring for a client who is receiving continuous oxygen at 4L/minute via nasal cannula. The client's oxygen saturation has consistently been 94% to 96%, but suddenly drops to 86% as the nurse palpates the client's abdomen. The client denies respiratory difficulty or other distress. Which is likely reason for the client's decreasing oxygen saturation? A. The client has developed a pulmonary embolism and has a ventilation-perfusion mismatch. B. the nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen C. The client is holding his or her breath D. The client's appendix has ruptured

B.

Which factors indicate that the nurse should stop delivery of breaths via a manual resuscitation bag and mask device? Select all that apply. A. The client's oxygen saturation has improved to 95% during use of the device B. The client has been intubated and is connected to a mechanical ventilator C. The client has a return of a spontaneous breathing at 15 breaths per minute D. The health care provider has ended the cardiopulmonary resuscitation effort E. Another nurse has begun chest compressions at a rate of 100 per minute

B. C. D.

A nurse is preparing to insert a nasopharyngeal airway in a client. Before doing so, however, the nurse assesses the client and reviews the client's health record. Which findings would contraindicate insertion of the airway? Select all that apply. A. Frequent nasopharyngeal suctioning required B. Deviated septum C. Traumatic brain injury D. Enlarged tongue E. Clenched teeth F. Recent nasal surgery

B. C. F.

A nurse is preparing to retape a client's endotracheal tube. What should the nurse do? Select all that apply A. Inspect the chest for any skin breakdown B. Provide pain medication to the client C. Assess the client's lung sounds D. Verify the endotracheal tube length E. Measure the client's oxygen saturation level

B. C. D. E.

A nurse is preparing to suction a client using an open system endotracheal tube. After removing the ventilator tubing from the endotracheal tube, what would the nurse do next? A. Advance the suction catheter no more than 1 cm past the endotracheal tube B. Open the adapter on the mechanical ventilator tubing with the dominant hand C. Attach the manual resuscitation bag to the endotracheal tube to hyperventilate the client D. Deliver three breaths with the manual resuscitation bag with the nondominant hand

C.

The nurse is suctioning a client on a mechanical ventilator using a closed system endotracheal tube. In the process of advancing the catheter, the nurse meets resistance. What should the nurse do? A. turn the catheter counterclockwise and then advance at least 0.5 inches (1.25cm) B. Remove the catheter and start the process over to prevent infection C. Withdraw the catheter at least 0.5 inches (1.25 cm) before applying suction D. Continue to apply suction as this means the catheter is in the carina

C.

A nurse must take a client's pulse oximetry reading. The nurse is explaining the technique to the client. Which statements about pulse oximetry are true? Select all that apply. A. Pulse oximeters display oxygen saturation and respiratory rate B. A range of 88% to 95% is considered normal oxygen saturation for infants C. Once the oximetry probe is correctly placed, a beam of red and infrared light travels through the tissue and blood vessels D. Pulse oximetry measurements requires insertion of an arterial line E. The pulse oximetry sensor can produce accurate results even if circulation to the sensor site is impaired F. Sensors are available for use on the finger, toe, foot, earlobe, forehead, and bridge of the nose

C. F.

The nurse is preparing to assist with removal of a chest tube. What action should the nurse take first? A. Provide reassurance to the client while the health care provider removes the tube. B. Anticipate a prescription for a postprocedure chest x-ray C. Premedicate the client with the prescribed analgesic D. Assess the client's breath sounds, oxygen saturation, and pain level

D.

The nurse is preparing to teach a client how to perform incentive spirometry. Which concepts should the nurse include? A. Oxygen saturation is expected to decrease during the first few minutes of incentive spirometry B. The client should forcefully exhale int the incentive spirometer and continue to exhale until unable to continue C. Proper, frequent use of incentive spirometry can improve pulmonary circulation D. Incentive spirometry provides visual reinforcement for deep breathing

D.