Exam 4 Foundations Davis Edge Questions

The nurse is reinforcing teaching with a patient about the incentive spirometry. Which statement by the patient indicates a correct understanding of the teaching? I should do this every other hour." "I should blow into the device." "I should inhale at least ten times an hr." "I should breathe fast to raise the platform."

"I should inhale at least ten times an hr."

The nurse contributes to the staff education program about respirations. Which statement by the staff members indicates successful teaching? "The respiratory center of the brain is in the hypothalamus." "Oxygen and carbon dioxide move by filtration in the lungs." "Normally, respirations are regulated by increases in carbon dioxide levels." "Internal respiration occurs between the alveoli and the capillaries."

"Normally, respirations are regulated by increases in carbon dioxide levels."

Which statement by the nurse indicates a correct understanding of the respiratory system? "Oxygen moves from an area of lower concentration to an area of higher concentration." "There is air in the pleural space around the lungs." "The parietal pleura lines the chest cavity." "Capillaries are two-cells thick."

"The parietal pleura lines the chest cavity."

The nurse is making the beginning of shift assessments and notices the chest tube drainage at 355. At the end of the shift, the nurse observes the amount in the collection chamber at 480. How many milliliters (mL) would the nurse record on the intake and output record for chest tube drainage? Record answer as a whole number.

125

Which patient would cause the nurse to question the health-care provider's prescription of percussion? A patient with excess mucus production in the lungs. A patient with lung congestion from pneumonia. A patient with thick mucus buildup in the lungs. A patient with broken ribs from a vehicle accident.

A patient with broken ribs from a vehicle accident

The nurse is cleaning and replacing a reusable cannula for a patient with a tracheostomy. Which techniques should the nurse use? Select all that apply. After removing the old tracheostomy dressing, clean hands and apply sterile gloves. Use the sterilized small bottle brush to clean the inside and outside of the inner cannula. Rinse the inner cannula with sterile saline. Use sterile gauze 4×4 to dry the inside of the inner cannula. Use one hydrogen peroxide-soaked, cotton-tipped applicator to clean around the stoma.

After removing the old tracheostomy dressing, clean hands and apply sterile gloves. Use the sterilized small bottle brush to clean the inside and outside of the inner cannula. Rinse the inner cannula with sterile saline.

Which action would the nurse take for a nebulizer treatment? Notifies the health-care provider for the patient's heartbeat of 90 bpm at the beginning of the treatment Rinses equipment in cold water after the treatment Allows the equipment to air dry after the treatment Notifies the health-care provider for the patient's heartbeat of 95 bpm at the beginning of the treatment and is 106 bpm after the treatment

Allows the equipment to air dry after the treatment

A patient tires after trying to obtain a sputum specimen; only 3 mL was obtained. Which action should the nurse take? Place the specimen in a dark plastic container. Obtain 20 mL of sputum. Keep sputum specimen on counter for 1 hr. Attach a sputum trap and suction the trachea.

Attach a sputum trap and suction the trachea.

The nurse is monitoring a patient for hypoxia. Which are late signs of hypoxia? Select all that apply. Bluish skin tones Restlessness Slow heartbeat Increased respirations Substernal retractions

Bluish skin tones Slow heartbeats Substernal retractions

The nurse is explaining structures in the airway. In which sequence would the nurse place the structures of the airway?

Bronchioles Trachea Alveoli Nostrils Right and left bronchus Pharynx

The nurse is caring for the patient shown in the image. Which action should the nurse take? Check for pooled water in the tubing before turning. Insert an artificial airway into the patient's mouth. Notify the health-care provider if the drainage is greater than 100 mL/hr. Remind patient to use incentive spirometry five times every hr.

Check for pooled water in the tubing before turning.

Which findings in a patient's history would alert the nurse to possible impaired oxygenation? Select all that apply. Chest hit the steering wheel during an accident. Chest x-ray indicates loss of alveoli. Chest area received a stab wound. Airway is patent. Airway is blocked by a swallowed coin.

Chest hit the steering wheel during an accident Chest x-ray indicates loss of alveoli Chest area received a stab wound Airway is blocked by a swallowed coin

Which action would indicate to the nurse a patient is coughing effectively? Breaths in through nose and holds breath for ten seconds Coughs three times upon exhalation. Deep breaths two times then coughs. Slowly exhales through mouth with lips in "smiling" position.

Cough three times upon exhalation.

A patient has a weak cough. Which action would the nurse take to obtain a sputum culture? Obtain 20 mL of sputum. Encourage splinting of the abdomen. Do not allow the patient to rinse mouth. Have the patient cough while inhaling.

Encourage splinting of the abdomen

The nurse is caring for patients with respiratory needs. Which actions should the nurse take? Select all that apply. Ensure that one finger fits between the tracheostomy tie and the patient's skin. Cut a 4×4 to make a tracheostomy dressing to place under the patient's faceplate. Make certain a nonrebreathing mask remains at least half full. Check the patient's arterial blood gas to determine alkalosis or acidosis. Prepare the patient for a pulmonary function test to visualize the trachea and bronchi

Ensure that one finger fits between the tracheostomy tie and the patient's skin. Make certain a nonrebreathing mask remains at least half full. Check the patient's arterial blood gas to determine alkalosis or acidosis.

Which term would the nurse use in report to describe a patient who gets short of breath walking down the hall? Subcutaneous emphysema Air hunger Orthopnea Exertional dyspnea

Exertional dyspnea

The nurse is contributing to a staff educational program about chronic lung disease. Which information should the nurse recommend including in the presentation? Higher levels of oxygen should be used for maintenance of the disease. Higher levels of oxygen can be used for short-term management of severe dyspnea. Higher levels of oxygen are what stimulates these patients to breathe. Higher levels of oxygen above 3 L/min are used for routine care.

Higher levels of oxygen can be used for short-term management of severe dyspnea.

The nurse is contributing to a staff educational program about chronic lung disease. Which information should the nurse recommend including in the presentation? Higher levels of oxygen should be used for maintenance of the disease. Higher levels of oxygen can be used for short-term management of severe dyspnea. Higher levels of oxygen are what stimulates these patients to breathe. Higher levels of oxygen above 3 L/min are used for routine care.

Higher levels of oxygen can be used for short-term management of severe dyspnea.

A patient needs to be suctioned. Which technique should the nurse use? Set suction regulator at 120 to 160 mm Hg. Hold the suction catheter in gloved dominant hand, which is sterile. Test suction by placing nasal prongs in water and watching for bubbles. Apply suction upon insertion of catheter.

Hold the suction catheter in gloved dominant hand, which is sterile.

The nurse is observing changes in a patient's mental functioning and skin color. Which condition is causing these changes? Hypoxemia Hypoxia Cyanosis Crepitus

Hypoxia

The nurse is describing to a patient how the oxygen moves from the bloodstream to the body's cells. Which process is the nurse discussing? Internal respiration. External respiration. Inhalation. Exhalation.

Internal respiration

The nurse is caring for a patient with a chest tube. Which actions should the nurse take? Select all that apply. Keep wet suction set up and upright at all times. Observe for kinks and loops in the tubing. Keep all connections securely taped. Keep petroleum gauze dressings covered with regular gauze around insertion site. Empty the drainage bottle at the end of each shift.

Keep wet suction set up and upright at all times. Observe for kinks and loops in the tubing. Keep all connections securely taped. Keep petroleum gauze dressings covered with regular gauze around insertion site.

A patient is having tachypnea and dyspnea. Which action should the nurse take? Leave to go get help Speak loudly to get patient's attention Say, "Follow me and my breathing" Keep silent to focus on breathing

Leave to go get help

The nurse is using this suction catheter (shown in the image). The nurse is suctioning which area on the patient? Nose Mouth Lungs Down the throat

Mouth

A patient has dark skin. Which area is best for the nurse to check for cyanosis? Tip of nose Tops of ears Mucous membranes Nailbeds

Mucous membranes

The nurse is preparing to administer a bronchodilator nebulizer treatment. Which action should the nurse take? Check the medication two times. Assist to a side-lying position. Obtain pulse before administering the treatment. Stop the nebulizer when vapor is slightly visible.

Obtain pulse before administering the treatment

The nurse must obtain a sputum culture. Which action is best for the nurse to take? Obtain the culture early in the morning. Obtain the culture after breakfast. Obtain the culture after giving medications. Obtain the culture right before bedtime.

Obtain the culture early in the morning

A patient is using a nebulizer with a mouthpiece. Which technique would the nurse observe for in this patient? Patient breathes fast and shallow throughout the treatment. Patient securely holds mouthpiece with teeth. Patient breathes in through mouth and out through nose. Patient opens mouth to exhale.

Patient breaths in through mouth and out through nose.

Which sputum finding would concern the nurse the most? Thick yellow sputum. Thin green sputum. Pink frothy sputum. Rust-colored sputum.

Pink frothy sputum

The nurse is collecting data about a patient with respiratory problems. Which technique would the nurse perform to check for excursion? Palpate for the feeling of crispy rice cereal beneath the patient's skin. Place hands on both sides of the chest and watch as patient breathes in and out. Auscultate lung sounds, comparing the right side to the left side. Notice if accessory muscles in the neck and shoulders are being used to breathe.

Place hands on both sides of the chest and watch as patient breaths in and out.

A patient's chest tube becomes disconnected from the drainage unit when the patient was transferred from the bed to the chair. Which action is the nurse's first priority? Check for bubbles in the water seal chamber. Milk the tubing of the chest tube system. Place the end of the tube in water. Clamp the chest tube with padded hemostats.

Place the end of the tube in water.

Which findings indicate the nurse needs to suction a patient? Select all that apply. Rattling sound in throat. Coughing up and expelling mucus. Crackles heard upon auscultation. Drooling secretions from mouth. Respirations are even and regular.

Rattling sound in throat Crackles heard upon auscultation Drooling secretions from mouth

A patient is having tachypnea and dyspnea. Which action should the nurse take? Leave to go get help Speak loudly to get patient's attention Say, "Follow me and my breathing" Keep silent to focus on breathing

Say, "Follow me and my breathing"

A patient has a pneumothorax. In which area would the nurse look for the insertion site of the chest tube? Second to fourth intercostal space Eighth and ninth intercostal space Posterior superior chest area Posterior inferior chest area

Second to fourth intercostal space

The nurse is caring for a patient who needs an endotracheal tube suctioned. Which technique should the nurse use? Clean Medical asepsis Sterile Hygienic

Sterile

The nurse is explaining inhalation. In which order would the nurse describe the process?

Stimulus from phrenic nerve occurs Lungs expand Chest cavity increases Diaphragm contracts Air is pulled into lungs Pressure in lungs becomes negative pressure

The nurse is performing oropharyngeal suctioning after nasopharyngeal suctioning. Which actions should the nurse take? Select all that apply. Remove glove over the nasopharyngeal catheter to discard. Put on sterile gloves. Reuse tonsil tip. Suction each side of the throat, cheek pouches, and around tongue. Suction mouth one time.

Suction each side of the throat, cheek pouches, and around tongue. Reuse tonsil tip Remove glove over the nasopharyngeal catheter to discard

The nurse is suctioning a patient for secretions. Which action should the nurse take? Suction the mouth first, then the nose Use suction by placing thumb on valve continuously Suction no longer than 10-15 seconds Use the dominant to control the suction

Suction no longer than 10-15 seconds

The nurse is contributing to the plan of care for a patient with chronic lung disease. Which intervention should the nurse recommend including in the patient's plan of care? Suggest eating fast. Eat breads and pasta for ease of chewing. Suggest a high-protein, caloric supplement. Eat three meals a day evenly spaced throughout the day.

Suggest a high-protein, caloric supplement.

A patient is receiving oxygen at 2 L/min per nasal cannula. Which strategies would the home health nurse use? Select all that apply. Apply petroleum jelly for the patient's chapped lips. Suggest cotton gown for sleeping. Ensure no one smokes in the house. Remove candles from the patient's room. Encourage polyester nonslip socks.

Suggest cotton gown for sleeping Ensure no one smokes in the house Remove candles from the patient's room

Which technique should the nurse use to obtain a throat specimen from a patient? Leave the capsule at the end of the tube intact. Touch the cheeks with the swab. Use gloved hands to swab one side of the throat. Swab the tonsils that have white exudate.

Swab the tonsils that have white exudate.

The nurse caring for a patient with a chest tube notifies the health-care provider and registered nurse (RN) for suspected hemorrhage in the patient. What did the nurse observe to make this conclusion? Tidaling in the second chamber stops abruptly. The total chest tube output is 300, and 1 hr later the total output is 550. There is one bright red clot in the tubing. A friction rub is heard upon auscultation of the lungs.

The total chest tube output is 300, and 1 hr later the total output is 550

The nurse hears in a report that a patient has pleural effusion. How should the nurse interpret this finding? There is air in the pleural space. The patient has a productive cough. There is fluid in the chest cavity. The patient has blood and fluid in the lungs.

There is fluid in the chest cavity

The health-care provider has written a prescription for supplemental oxygen via a Venturi mask. Which piece of equipment should the nurse obtain?

Thick tube mask

The nurse is assisting respiratory therapy in positioning a patient for postural drainage of the middle lobes. In which position would the nurse place the patient? Orthopneic. High Fowler's. Trendelenburg and side lying. Trendelenburg and prone.

Trendelenburg and side lying

The nurse is suctioning a patient's endotracheal tube while on a ventilator. Which strategies should the nurse use? Select all that apply. Apply clean gloves. Turn suction on to between 100 to 150 mm Hg. Insert suction catheter until met with resistance. Use a circular motion to withdraw the suction catheter. If repeated suction is needed, wait 15 seconds.

Turn suction on to between 100 to 150 mmHg Insert suction catheter until met with resistance Use a circular motion to without the suction catheter.

The nurse is suctioning a patient who has an established tracheostomy. Which actions should the nurse take? Select all that apply. Turn the suction on to between 80 and 120 mm Hg. Give three to five breaths with the Ambu bag attached to the tracheostomy. Apply suction upon insertion in the tracheostomy tube. Don sterile gloves. Pull suction catheter straight out of tracheostomy tube.

Turn the suction on to between 80 and 120 mmHg Give three to five breaths with the Ambu bag attached to the tracheostomy Don sterile gloves

Which suggestion to conserve energy would the nurse make to a patient with chronic lung disease? Stand while shaving. Use a terrycloth robe after bathing. Try to finish brushing teeth without resting After showering, obtain several small towels to dry body.

Use a terrycloth robe after bathing.

The nurse is cleaning the patient's tracheostomy. Which technique should the nurse use? Apply suction during insertion. Change the old ties and then apply the new ones. Use half-strength hydrogen peroxide with saline. Clean the tube q12h.

Use half-strength hydrogen peroxide with saline.