Oxygen Delivery
The nurse is performing a respiratory assessment. Which finding best supports the nursing diagnosis of ineffective airway clearance? a. Basilar crackles b. Oxygen saturation of 85% c. Presence of greenish sputum d. Respiratory rate of 28 breaths/min
A
The nurse is caring for a patient with an alteration in airway clearance. What nursing actions would be a priority to promote airway clearance (select all that apply.)? Select all that apply. a. Maintain adequate fluid intake. b. Maintain a 30-degree elevation. c. Splint the chest when coughing. d. Maintain a semi-Fowler's position. e. Instruct patient to cough at end of exhalation.
A, C, E
A patient is receiving 35% O2 via a Venturi mask. To ensure the correct amount of O2 delivery, which action by the nurse is important? a. Teach the patient to keep the mask on during meals. B. Keep the air entrainment ports clean and unobstructed. C. Give a high enough flow rate to keep the bag from collapsing. D. Drain moisture condensation from the corrugated tubing every hour.
B
An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed? A. Face tent B. Venturi mask C. Aerosol mask D. Tracheostomy collar
B
A patient is scheduled for spirometry. Which action should the nurse take to prepare the patient for this procedure? a. Give the rescue medication immediately before testing. B. Administer oral corticosteroids 2 hours before the procedure. C. Withhold bronchodilators for 6 to 12 hours before the examination. D. Ensure that the patient has been NPO for several hours before the test.
C
The nurse is caring for a group of patients. Which patient is at risk of aspiration? a. A 58-yr-old patient with absent bowel sounds 12 hours after abdominal surgery b. A 67-yr-old patient who had a cerebrovascular accident with expressive dysphasia c. A 26-yr-old patient with continuous enteral tube feedings through a nasogastric tube d. A 92-yr-old patient with viral pneumonia and coarse crackles throughout the lung fields
C
Which finding by the nurse for a patient with a nursing diagnosis of impaired gas exchange will be most useful in evaluating the effectiveness of treatment? a. Even, unlabored respirations b. Absence of wheezes or crackles c. Pulse oximetry reading of 92% d. Respiratory rate of 18 breaths/min
C
The nurse is caring for a patient with ineffective airway clearance. What is the priority nursing action to assist this patient expectorate thick lung secretions? a. Humidify the oxygen as able. b. Administer cough suppressant q4hr. c. Teach patient to splint the affected area. d. Increase fluid intake to 3 L/day if tolerated.
D
The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which patient statement indicates that teaching has been effective? A. "I am going to buy a rib binder to wear during the day." B. "I can take shallow breaths to prevent my chest from hurting." C. "I should plan on taking the pain pills only at bedtime so I can sleep." D. "I will use the incentive spirometer every hour or two during the day."
D
When assessing a 22-year-old patient who required emergency surgery and multiple transfusions 3 days ago, the nurse finds that the patient looks anxious and has labored respirations at a rate of 38 breaths/min. The oxygen saturation is 90% with the oxygen delivery at 6 L/min via nasal cannula. Which action is most appropriate? A. Increase the flow rate on the oxygen to 10 L/min and reassess the patient after about 10 minutes. B. Assist the patient in using the incentive spirometer and splint his chest with a pillow while he coughs. C. Administer the ordered morphine sulfate to the patient to decrease his anxiety and reduce the hyperventilation. D. Switch the patient to a nonrebreather mask at 95% to 100% fraction of inspired oxygen (FIO2) and call the health care provider to discuss the patient's status.
D
