CH21 - Resp. PrepU ?'s
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 nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs? a) Auscultation b) Chest X-ray c) Arterial blood gas (ABG) levels d) Inspection
a) Auscultation
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 a) Continues assessing the client's respiratory status frequently b) Consults with the physician about removing the client from the ventilator c) Contacts the respiratory therapy department to report the ventilator is malfunctioning d) Changes the setting on the ventilator to increase breaths to 14 per minute
a) Continues assessing the client's respiratory status frequently
The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated? a) Deflating the cuff routinely b) Ensuring that humidified oxygen is always introduced through the tube c) Deflating the cuff prior to tube removal d) Checking the cuff pressure every 6 to 8 hours
a) Deflating the cuff routinely
A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client? a) Impaired gas exchange related to ventilator setting adjustments b) Risk for infection related to endotracheal intubation and suctioning c) Risk for trauma related to endotracheal intubation and cuff pressure d) Impaired physical mobility related to being on a ventilator
a) Impaired gas exchange related to ventilator setting adjustments
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a) Partial pressure of arterial oxygen (PaO2) b) pH c) Bicarbonate (HCO3-) d) Partial pressure of arterial carbon dioxide (PaCO2)
a) Partial pressure of arterial oxygen (PaO2)
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.) a) Tracheal bleeding b) Tracheal ischemia c) Hypoxia d) Tracheal aspiration e) Pressure necrosis
a) Tracheal bleeding b) Tracheal ischemia e) Pressure necrosis
Which type of ventilator has a present volume of air to be delivered with each inspiration? a) Volume-controlled b) Time-cycled c) Pressure-cycled d) Negative-pressure
a) Volume-controlled
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? a) Water-seal chamber b) Collection chamber c) Suction control chamber d) Air-leak chamber
a) Water-seal chamber
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? a) "During the removal of the chest tube, do not move because it will make the removal more painful." b) "When the tube is being removed, take a deep breath, exhale, and bear down." c) "Exhale forcefully while the chest tube is being removed." d) "While the chest tube is being removed, raise your arms above your head."
b) "When the tube is being removed, take a deep breath, exhale, and bear down."
A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than: a) 0.21. b) 0.5. c) 0.7. d) 0.35
b) 0.5
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 30 to 35 seconds b) 10 to 15 seconds c) 20 to 25 seconds d) 0 to 5 seconds
b) 10 to 15 seconds
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? a) 45 mm Hg b) 84 mm Hg c) 120 mm Hg d) 58 mm Hg
b) 84 mm Hg
A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for a) A cut or slice in the tubing from the ventilator b) A kink in the ventilator tubing c) Malfunction of the alarm button d) Higher than normal endotracheal cuff pressure
b) A kink in the ventilator tubing
Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? a) Electrocardiogram (ECG) results b) Baseline arterial blood gas (ABG) levels c) Prior outcomes of weaning d) Fluid intake for the past 24 hours
b) Baseline arterial blood gas (ABG) levels
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? a) Inform the patient that using the spirometer is not necessary if the patient is experiencing pain. b) Encourage the patient to take approximately 10 breaths per hour, while awake. c) Encourage the patient to try to stop coughing during and after using the spirometer. d) Have the patient lie in a supine position during the use of the spirometer.
b) Encourage the patient to take approximately 10 breaths per hour, while awake
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? a) An ET cuff leak b) Kinking of the ventilator tubing c) A disconnected ventilator tube d) A change in the oxygen concentration without resetting the oxygen level alarm
b) 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? a) Tracheostomy cleaning kit b) Manual resuscitation bag c) Oxygen analyzer d) Water-seal chest drainage set-up
b) Manual resuscitation bag
Choice Multiple question - Select all answer choices that apply. 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? Select all that apply. a) Mood swings b) Substernal pain c) Dyspnea d) Bradycardia e) Fatigue
b) Substernal pain c) Dyspnea e) Fatigue
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: a) A scheduled time for deflation of the tracheal cuff b) Symmetry of the client's chest expansion c) Cool air humidified through the tube d) Tracheal cuff pressure set at 30 mm Hg
b) Symmetry of the client's chest expansion
Which type of ventilator has a present volume of air to be delivered with each inspiration? a) Negative-pressure b) Volume-controlled c) Time-cycled d) Pressure-cycled
b) Volume-controlled
A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for: a) 45 to 60 minutes. b) 30 to 40 minutes. c) 5 to 20 minutes. d) 15 to 60 seconds.
c) 5 to 20 minutes
Constant bubbling in the water seal of a chest drainage system indicates which of the following problems? a) Tension pneumothorax b) Tidaling c) Air leak d) Increased drainage
c) Air leak
A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority? a) Posting a "No smoking" sign over the client's bed b) Applying an oil-based lubricant to the client's mouth and nose c) Assessing the client's respiratory status, orientation, and skin color d) Changing the mask and tubing daily
c) Assessing the client's respiratory status, orientation, and skin color
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? a) Encouragement of coughing b) Use of a cooling blanket c) Endotracheal suctioning d) Incentive spirometry
c) Endotracheal suctioning
The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated. a) "I received my pain medication 10 minutes ago, let's do my CPT now." b) "I just changed into my running suit; we can do my CPT now." c) "I have been coughing all morning and am barely bringing anything up." d) "I just finished eating my lunch, I'm ready for my CPT now."
d) "I just finished eating my lunch, I'm ready for my CPT now."
For a client with an endotracheal (ET) tube, which nursing action is the most important? a) Turning the client from side to side every 2 hours b) Providing frequent oral hygiene c) Monitoring serial blood gas values every 4 hours d) Auscultating the lungs for bilateral breath sounds
d) Auscultating the lungs for bilateral breath sounds
A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? a) By placing the call button under the client's pillow b) By suctioning the client frequently c) By providing a tracheostomy plug to use for verbal communication d) By supplying a magic slate or similar device
d) By supplying a magic slate or similar device
The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique? a) Use aerosol sprays to deodorize the client's environment after postural drainage. b) Administer bronchodilators and mucolytic agents following the sequence. c) Perform this measure with the client once a day. d) Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.
d) Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.
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? a) A disconnected ventilator tube b) An ET cuff leak c) A change in the oxygen concentration without resetting the oxygen level alarm d) Kinking of the ventilator tubing
d) Kinking of the ventilator tubing
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? a) Add more air to the cuff. b) Call the physician. c) Remove the malfunctioning cuff. d) Suction the client, withdraw residual air from the cuff, and reinflate it.
d) Suction the client, withdraw residual air from the cuff, and reinflate it.
A client with end-stage chronic obstructive pulmonary disease (COPD) requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is associated with restraint use in the client who requires BiPAP? a) The client will maintain adequate urine output. b) The client will remain infection-free. c) The client will remain pain-free. d) The client will maintain adequate oxygenation.
d) The client will maintain adequate oxygenation.
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? a) The patient is having a myocardial infarction. b) The patient is in a hypermetabolic state. c) The patient is having a stress reaction. d) The patient is hypoxic from suctioning.
d) The patient is hypoxic from suctioning.
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? a) Collection chamber b) Suction control chamber c) Air-leak chamber d) Water-seal chamber
d) Water-seal chamber