Oxygenation Skills
The nurse is caring for a patient who is recovering from a left partial lobectomy. Which action would be most helpful in reexpanding the affected lung? A. Placing the patient in a right side-lying position B. Encouraging the patient to deep breathe and cough every hour C. Regularly assessing the patient's ability to breathe comfortably D. Providing medication to manage postoperative pain of greater than 3 on a 0-to-10 scale
A. Placing the patient in a right side-lying position Rationale: Placing the patient in a right side-lying position will facilitate reexpansion of the affected lung. The unaffected lung should be next to the bed, and the affected lung should be up. Encouraging the patient to breathe deeply and cough every hour, regularly assessing the patient's ability to breathe comfortably, and providing pain medication may be appropriate, but these would not be the most effective way of reexpanding the affected lung.
Which action by the nurse would most effectively reduce the patient's risk for injury when collecting a sputum specimen by means of nasotracheal suctioning? A. Lubricating the catheter with sterile water B. Performing the procedure using aseptic technique C. Positioning the patient in a semi- to high-Fowler's position D. Assessing the patient's degree of anxiety regarding the intervention
A. Lubricating the catheter with sterile water Rationale: Lubricating the catheter with sterile water minimizes trauma to the patient's respiratory mucosa during nasotracheal suctioning to obtain a sputum specimen. Using aseptic technique might reduce the risk for infection, but would have no effect on the patient's risk for injury during nasotracheal suctioning to obtain a sputum specimen. The semi- to high-Fowler's position is appropriate, but patient positioning is not as important as catheter lubrication in reducing the risk for injury during nasotracheal suctioning to obtain a sputum specimen. Assessing the patient's anxiety level is appropriate, and addressing the patient's apprehension might make him or her less tense during the procedure, thereby reducing the risk for injury. Assessing anxiety is not as important, however, as catheter lubrication in reducing the patient's risk for injury during nasotracheal suctioning to obtain a sputum specimen.
When caring for a patient for whom oxygen by nonrebreathing mask has been ordered, which action ensures appropriate oxygen delivery? A. Looping the oxygen tubing around the side rail of the bed B. Assessing breath sounds every shift C. Securing the tubing snugly to the patient's gown D. Assessing that the reservoir bag stays inflated
D. Assessing that the reservoir bag stays inflated Rationale: A mask that fits properly will deliver the prescribed amount of oxygen. The oxygen tubing should not be looped around the side rail of the bed. Assessing breath sounds does not ensure that the oxygen is being delivered appropriately. The tubing should have some slack so that the patient can move his or her head.
What can the nurse do to evaluate a patient's response to continuous oxygen therapy delivered at 4 L/min by nasal cannula? A. Regularly measure and trend the patient's pulse oximetry (SpO2) values. B. Evaluate venous blood levels every morning. C. Monitor the patient's arterial blood gas (ABG) levels hourly. D. Assess the patient for compliance with the prescribed therapy.
A. Regularly measure and trend the patient's pulse oximetry (SpO2) values. Rationale: Measuring and analyzing the patient's pulse oximetry values will provide objective information about the patient's response to oxygen therapy. Arterial blood monitors oxygen levels, therefore monitoring venous blood does not evaluate the patient's response to oxygen therapy. ABG levels should not be monitored every hour in a patient who is receiving oxygen at a rate of 4 L/min. Assessing the patient's compliance does not provide data regarding his or her response to oxygen therapy.
Why is it important for the nurse to set the correct flow rate for a patient to whom oxygen is prescribed? A. To provide the correct amount of oxygen to the patient B. To ensure the therapeutic effects of oxygen therapy C. To prevent any adverse reaction to the prescribed oxygen therapy D. To minimize the risk of combustion during oxygen delivery
A. To provide the correct amount of oxygen to the patient Rationale: The role of the flow regulator is to deliver the amount of oxygen indicated on the regulator. Although therapeutic effects are an expected outcome of the therapy, such effects cannot be ensured merely by properly setting the prescribed flow rate. Although adverse effects are not an expected outcome of the therapy, such effects cannot be prevented merely by properly setting the prescribed flow rate. The risk of combustion cannot be averted merely by properly setting the prescribed flow rate.
What is the purpose of splinting the abdomen with a small pillow during controlled coughing? A. To minimize chest discomfort caused by the coughing B. To expand lung capacity during the inspiratory phase of the cough C. To maximize transdiaphragmatic pressure during the expiratory phase of the cough D. To focus the patient's attention on the abdominal muscles used during the cough
C. To maximize transdiaphragmatic pressure during the expiratory phase of the cough Rationale: Splinting the abdomen will increase transdiaphragmatic pressure. Applying a small pillow to the abdomen will not help to reduce chest discomfort, expand lung capacity during the inspiratory phase or to focus the patient's attention on the abdominal muscles used while coughing.
During an admission interview, a patient who is required to stay in the supine position reports, "I can't breathe well while I'm lying down." What would the nurse do first to help this patient? A. Notify the health care provider of the patient's complaint. B. Request that the health care provider prescribe oxygen therapy. C. Interview the patient concerning the onset of this problem. D. Instruct the patient to use two bed pillows when lying supine.
D. Instruct the patient to use two bed pillows when lying supine. Rationale: Instructing the patient to use two bed pillows when lying supine is an appropriate intervention at this time. Although it is appropriate to notify the patient's health care provider of the patient's complaint, doing so is not the first action the nurse would take. Although it may be appropriate to request that the health care provider prescribe oxygen therapy, doing so is not the first action the nurse would take. Although it may be appropriate to interview the patient concerning the onset of this problem, doing so is not the first action the nurse would take.
Which of the following is a risk factor for decreased oxygen saturation level in a patient? A. Chest wall injury B. Restlessness C. Hypotension D. Prescribed bronchodilators
A. Chest wall injury Rationale: Chest wall injury is a risk factor for decreased oxygen saturation level in a patient. Restlessness is a symptom of altered oxygen saturation, not a risk factor for it. Hypotension will influence measurement of the oxygen saturation level but is not a risk factor for decreased oxygen saturation. Prescribed bronchodilators will influence measurement of the oxygen saturation level, but use of such agents is not a risk factor for decreased oxygen saturation.
A patient is prescribed continuous oxygen saturation monitoring. The nurse would confirm that the alarms have been set to which limits? A. Low of 85% and high of 100% B. Low of 80% and high of 100% C. Low of 75% and high of 90% D. Low of 82% and high of 95%
A. Low of 85% and high of 100% Rationale: A low of 85% and a high of 100% are the alarm limits that are usually preset by the manufacturer of the monitoring device, and these limits must be confirmed. The alarm for the lower limit must be set at 85%, and the alarm for the higher limit should be set at 100%.
What should the nurse teach nursing assistive personnel (NAP) about selecting the appropriate site for measuring a patient's oxygen saturation level? A. "Do not use the fingers if her nails are polished." B. "I've checked her capillary refill, and it's acceptable in both her hands and feet." C. "Please review the patient's previously documented pulse oximetry readings for the site used." D. "Ask the patient to keep her finger motionless while you are monitoring her oxygen saturation."
B. "I've checked her capillary refill, and it's acceptable in both her hands and feet." Rationale: Checking the capillary refill is the correct option, because it provides NAP with specific direction regarding the appropriate sites for this particular patient. The finger can be used if the patient's nails have been polished; the nail polish will simply need to be removed. Previously documented pulse oximetry readings do not pertain to the selection of an appropriate site for the current measurement of peripheral oxygen saturation. Patient teaching does not pertain to site selection.
What would the nurse do first to ease breathing for a patient with mild dyspnea? A. Administer oxygen at 2 L/min by nasal cannula. B. Help the patient into an upright sitting position. C. Monitor the patient's pulse oximetry level. D. Determine if the patient has a history of respiratory pathology.
B. Help the patient into an upright sitting position. Rationale: The nurse would first try to ease the patient's breathing using a noninvasive intervention such as this one. Placing the patient in a sitting position improves lung expansion. The nurse would not provide oxygen first. Monitoring the patient with pulse oximetry would not help the patient's manifestations of dyspnea. Determining if the patient has a history of respiratory pathology would not help the patient's current manifestations of dyspnea.
What would the nurse do routinely to monitor oxygenation in a patient receiving BiPAP? A. Assess the patient's level of consciousness every 4 hours. B. Monitor the patient's pulse oximetry readings. C. Verify the pressure settings for both inspiratory and expiratory pressure. D. Evaluate daily arterial blood gases (ABGs)
B. Monitor the patient's pulse oximetry readings. Rationale: The nurse would routinely monitor the patient's pulse oximetry readings, because these values may reveal gradual changes in oxygenation status. Level of consciousness is subjective and may not adequately reflect the patient's oxygenation level. Verifying inspiratory and expiratory pressure settings is not useful in detecting oxygenation. Unless the patient is in critical condition, ABGs are not drawn routinely.
What would the nurse monitor frequently to ensure that the prescribed amount of oxygen is being delivered to a patient? A. Arterial blood gas (ABG) levels B. Oxygen flow meter setting C. Respiratory rate D. Temperature
B. Oxygen flow meter setting Rationale: The oxygen flow meter setting is directly related to the rate of oxygen delivery. ABG levels would indicate the patient's response to oxygen therapy. Respiratory rate would indicate the patient's response to oxygen therapy. Oxygen delivery has little effect on body temperature.
What would the nurse do first when preparing to begin oxygen therapy for a patient? A. Educate the NAP about the oxygen orders. B. Review the medical prescription for delivery method and flow rate. C. Place a "No Smoking" sign outside of the hospital room. D. Ensure that suction equipment is present in the room.
B. Review the medical prescription for delivery method and flow rate. Rationale: The nurse's initial action when preparing to begin oxygen therapy would be to review the delivery method and flow rate specified on the medical order. The NAP is not able to complete oxygen orders. Smoking is not permitted inside hospitals. This sign would need to be put up at the patient's home. Suction equipment is not needed for oxygen therapy.
Why might the collection of a sputum specimen be delayed up to 2 hours? A. The patient is taking an afternoon nap. B. The patient has just finished eating lunch. C. Pain medication has just been administered. D. The family is visiting.
B. The patient has just finished eating lunch. Rationale: Specimen collection must be postponed for 1 to 2 hours after eating or the administration of a tube feeding, so the procedure would have to be delayed if the patient has just finished having lunch. The patient could be awakened to obtain the specimen. The administration of pain medication would not necessitate a delay in the collection of a sputum specimen. The presence of visitors would not necessitate a delay in the collection of a sputum specimen. They could be asked to step out of the room during the procedure.
Which statement by the patient would indicate that he or she understands the safe use of oxygen? A. "The nurse told me that my oxygen saturation must be maintained at 85% or above." B. "I know that oxygen is a medication I can adjust whenever I need to." C. "I'll alert the nurse immediately if I have any increased difficulty breathing." D. "I often experience difficulty breathing for no apparent reason, but that is expected."
C. "I'll alert the nurse immediately if I have any increased difficulty breathing." Rationale: The patient should let the nurse know without delay if he or she has increased difficulty breathing. Oxygen saturation should be 90% or higher in a patient on oxygen, although the level may vary depending on the patient's situation and medical history. Oxygen is considered to be a medication, but the patient may not adjust it himself or herself. A health care provider must write an order for initiation of oxygen therapy and for any change in oxygen administration thereafter. The patient should not experience difficulty breathing for no reason; this complaint would need to be reported to the nurse or to the provider.
When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to help maintain good skin integrity? A. Frequently applying moisturizing lotion to facial areas that come into contact with the cannula. B. Removing the cannula every 2 hours for no longer than 10 minutes. C. Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift. D. Instructing the patient to inform staff of any problems with facial dryness or cracking.
C. Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift. Rationale: Frequent assessment is a priority and will help the nurse identify early signs of skin breakdown. Although applying lotion is appropriate, this option is not the best way to maintain good skin integrity. It may not be appropriate to remove the cannula in a patient for whom oxygen therapy has been ordered. The patient may be unaware of facial skin areas that are dry or cracking.
What should the nurse do when a patient is ordered to receive 4 L/min oxygen by nasal cannula? A. Encourage oral fluids. B. Restrict fluids. C. Ensure that humidification is present. D. Measure blood pressure every hour.
C. Ensure that humidification is present. Rationale: If the oxygen flow rate is 4 L/min or higher, add humidification and verify that water is bubbling in the humidifier. Fluids need not be encouraged in the patient receiving 4 L/min oxygen by nasal cannula. Fluids need not be restricted in the patient receiving 4 L/min oxygen by nasal cannula. Blood pressure need not be measured every hour in a patient receiving 4 L/min oxygen by nasal cannula.
When caring for a patient who is receiving supplemental oxygen by face tent, which action ensures that the oxygen is flowing? A. Testing the closing capacity of the mask's valves B. Routinely monitoring the seal over the patient's mouth and nose C. Ensuring that a mist is always present D. Regularly verifying that the mask is positioned loosely
C. Ensuring that a mist is always present Rationale: It is appropriate to ensure that a mist is always present when oxygen is delivered by face tent. Testing the closing capacity of the mask's valves is appropriate only for a nonrebreathing mask. Monitoring the seal over the patient's mouth and nose is appropriate only for a nonrebreathing mask. Such an assessment is appropriate, but correct positioning of the mask does not indicate that oxygen is flowing from it.
When preparing the patient's environment for safe oxygen therapy, which intervention is a priority to minimize the patient's risk for injury? A. Place appropriate signage to alert staff and visitors to the presence of oxygen in the patient's room. B. Instruct nursing assistive personnel (NAP) to immediately correct or report safety hazards. C. Inspect all electrical equipment in the patient's room for the presence of safety-check tags. D. Ensure that the patient receives the prescribed amount of oxygen via the appropriate method.
C. Inspect all electrical equipment in the patient's room for the presence of safety-check tags. Rationale: Inspecting electrical equipment would take priority among the other interventions in providing environmental safety. Placing appropriate signage to alert others to the presence of oxygen and instructing the NAP to immediately correct or report safety hazards do not take priority regarding environmental safety. Ensuring the patient receives the prescribed amount of oxygen does not pertain to environmental safety.
What would be the nurse's priority in order to minimize a patient's risk for injury during oxygen therapy? A. Advising the patient to call for assistance before getting out of bed. B. Instructing nursing assistive personnel (NAP) to immediately correct the flow rate if the oxygen regulator is not set as prescribed. C. Observing the six rights of medication administration. D. Monitoring the patient for signs of hypoxia.
C. Observing the six rights of medication administration. Rationale: Oxygen is considered a medication and must be administered following the six rights of medication administration. Although a patient should call before getting out of bed, since the oxygen tubing may pose a trip hazard, it is more important for the nurse to ensure that the oxygen is administered correctly. The skill of setting and adjusting the oxygen flow rate may not be delegated to NAP. This option is directed toward evaluating the patient's response to oxygen therapy, not toward minimizing his or her risk for injury.
When a patient is receiving oxygen at home, which instruction to the family would help them understand how to use the oxygen safely? A. Increase the oxygen level as needed for the patient's comfort. B. Store extra oxygen cylinders horizontally. C. Place a "No Smoking" sign at the entrance to the house. D. Keep oxygen 5 feet (about 1.5 meters) away from anything that could generate a spark.
C. Place a "No Smoking" sign at the entrance to the house. Rationale: "No Smoking" signs should be placed throughout the house as well as at the entrance. Oxygen may not be increased based on the patient's comfort. Extra cylinders should be stored vertically. Keep oxygen at least 10 feet (about 3 meters) away from anything that could generate a spark.
Which criterion makes it appropriate for the nurse to delegate to nursing assistive personnel (NAP) the skill of collecting a sputum specimen? A. The skill takes little time to complete. B. The likelihood of infection is minimal. C. The patient can produce the specimen by coughing. D. The agency offers training in this skill for NAP.
C. The patient can produce the specimen by coughing. Rationale: The skill of collecting a sputum specimen may be delegated only if the specimen is produced by the noninvasive means of expectoration (the patient's coughing). The amount of time it takes to complete the skill of collecting a sputum specimen, the likelihood of infection, and the availability of training at the agency are not criterion used to determine whether the skill may be delegated.
What would the nurse do when receiving an order to increase the delivery rate of a patient's oxygen per nasal cannula from 1 L/min to 3 L/min? A. Encourage the patient to take deeper breaths in order to get more oxygen B. Change the device from nasal cannula to simple face mask C. Ensure that humidification is present D. Adjust the float ball on the flow meter to 3 L/min
D. Adjust the float ball on the flow meter to 3 L/min Rationale: The nurse would increase the flow rate by moving the ball on the oxygen delivery system from 1 L/min to 3 L/min. Taking deeper breaths will not change the flow rate from 1 L/min to 3 L/min. There is no need to change the delivery device. The provider has ordered oxygen to be administered per nasal cannula, not per simple face mask. If the flow rate of oxygen is 4 L/min or higher, humidification is added. Oxygen delivered at the rate of 3 L/min need not be humidified.
The nurse measures a patient's oxygen saturation level as being 83%. What would the nurse do first? A. Reassess the oxygen saturation in a different location. B. Promptly report the assessment data to the charge nurse. C. Encourage the patient to rest quietly in bed for 30 minutes. D. Ask the patient whether he or she is having trouble breathing.
D. Ask the patient whether he or she is having trouble breathing. Rationale: Asking the patient whether he or she is having trouble breathing is the appropriate response, because the nurse must assess the patient for respiratory problems. Reassessing the oxygen saturation in a different location is not the priority action, because a deficiency has already been determined. Reporting the assessment data is not the priority action, because the nurse must first assess the patient for respiratory problems. Encouraging the patient to rest quietly is not the appropriate response, because the patient is not receiving enough oxygen. The patient must be assessed for respiratory problems without delay.
What would the nurse do first when preparing to educate the patient about safe administration of oxygen therapy at home? A. Evaluate the patient's understanding of the combustible nature of oxygen. B. Arrange for a capable family member to be present during the initial discussion. C. Collect written information to present to the patient as supplemental instructional materials. D. Assess the patient's emotional readiness and physical ability to provide autonomous care.
D. Assess the patient's emotional readiness and physical ability to provide autonomous care. Rationale: The nurse would first assess the patient's emotional readiness and physical ability to provide self-care, since these attributes are necessary in order to teach a patient effectively about oxygen administration. Information about oxygen's combustibility will be provided during patient education. The nurse might or might not need to arrange for a capable family member to be present during the initial discussion. The patient may be entirely capable of handling the oxygen equipment himself or herself. Although written information is a part of patient education, the nurse must first assess the patient's emotional readiness and physical ability to provide self-care.
When caring for a patient who is receiving oxygen by simple face mask, which action ensures that the rate of oxygen being delivered is appropriate? A. Frequently asking the patient how he or she is breathing. B. Ensuring that the oxygen tubing is pulled tight, with little or no slack. C. Securing the oxygen tubing to the patient's clothing to prevent tugging. D. Assessing for proper placement of the mask on the patient's face.
D. Assessing for proper placement of the mask on the patient's face. Rationale: Monitoring placement of the cannula tips helps ensure that the patient receives the oxygen prescribed. Asking the patient if he or she is having trouble breathing does not address oxygen delivery. Oxygen tubing should not be pulled tight. There should be enough slack in the tubing to allow the patient to turn his or her head comfortably. Securing the oxygen tubing to keep the patient from pulling out the cannula does not address oxygen delivery.
Which action would help to ensure that the results of a suctioned sputum specimen culture are reliable? A. Placing the specimen in a biohazard bag B. Obtaining the specimen when the patient coughs without prompting C. Wearing sterile gloves to suction the patient D. Refrigerating the specimen until it can be taken to the lab
D. Refrigerating the specimen until it can be taken to the lab Rationale: Refrigerating the specimen until it can be transported to the lab will help to ensure reliable results. Placing the specimen in a biohazard bag would ensure that no one comes into contact with the specimen during transport, but would have little bearing on the reliability of the specimen culture. The method of specimen collection has no bearing on the reliability of the specimen culture. In any case, it would be impractical for the nurse to stand by and wait until the patient begins to cough on his or her own. The nurse must wear sterile gloves to suction the patient.
What is the role of nursing assistive personnel (NAP) when a sputum specimen is collected by means of nasotracheal suctioning? A. Manipulating the suction catheter B. Setting up the sterile field C. Applying sterile gloves D. Transporting the specimen to the lab
D. Transporting the specimen to the lab Rationale: The nurse may delegate to NAP the task of transporting the sputum specimen to the lab. The nurse may not delegate to NAP any portion of the skill of collecting a sputum specimen by means of nasotracheal suctioning.
The nurse is preparing to measure the oxygen saturation level of a patient with obesity. Which action would help ensure an adequate measurement? A. Place the sensor on the ear. B. Place the sensor on the bridge of the nose. C. Place the sensor on a finger. D. Use a disposable tape-on sensor.
D. Use a disposable tape-on sensor. Rationale: Use of a disposable tape-on sensor is recommended for patients with obesity. The ear would be an appropriate site for sensor placement in a patient who has tremors. The bridge of the nose would be an appropriate site for sensor placement in a patient with peripheral vascular compromise. A finger is a usual site for sensor placement; however, it may not be adequate for a patient with obesity.
