Nursing Care Prep U (ch. 20, 21, 22, 30, 31)
Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? -Nasal cannula -Venturi mask -T-piece -Partial-rebreathing mask
Venturi mask
The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? -Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing -Promote the client's ability to take in oxygen -Promote the strengthening of the client's diaphragm -Promote more efficient and controlled ventilation and to decrease the work of breathing
improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing
Positive end-expiratory pressure (PEEP) therapy has which effect on the heart? -Reduced cardiac output -Increased blood pressure -Bradycardia -Tachycardia
reduced cardiac output
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? -Suction control chamber -Air-leak chamber -Collection chamber -Water-seal chamber
water seal chamber
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? -120 mm Hg -58 mm Hg -84 mm Hg -45 mm Hg
84 mm Hg
A client has a sucking stab wound to the chest. Which action should the nurse take first? -Prepare a chest tube insertion tray. -Draw blood for a hematocrit and hemoglobin level. -Apply a dressing over the wound and tape it on three sides. -Prepare to start an I.V. line.
Apply a dressing over the wound and tape it on three sides
Which is a potential complication of a low pressure in the endotracheal tube cuff? -Aspiration pneumonia -Pressure necrosis -Tracheal bleeding -Tracheal ischemia
Aspiration pneumonia
Which is a potential complication of a low pressure in the endotracheal tube cuff? -Pressure necrosis -Tracheal bleeding -Tracheal ischemia -Aspiration pneumonia
Aspiration pneumonia
For a client with an endotracheal (ET) tube, which nursing action is the most important? -Monitoring serial blood gas values every 4 hours -Turning the client from side to side every 2 hours -Auscultating the lungs for bilateral breath sounds -Providing frequent oral hygiene
Auscultate the lungs for bilateral breath sounds
What assessment method would the nurse use to determine the areas of the lungs that need draining? -Chest X-ray -Arterial blood gas (ABG) levels -Inspection -Auscultation
Auscultation
The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? -Circulatory hypoxia -Histotoxic hypoxia -Hypoxemic hypoxia -Anemic hypoxia
Circulatory Hypoxia
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? -Kinking of the ventilator tubing -A change in the oxygen concentration without resetting the oxygen level alarm -A disconnected ventilator circuit -An ET cuff leak
Kinking of the ventilator tubing
When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long?
No Longer than 10 seconds
The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber? -Milk the chest tube. -Disconnect the system and get another. -Notify the physician. -Place the head of the patient's bed flat.
Notify the physician
A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? -Surgery to remove the tonsils and adenoids -Bi-level positive airway pressure (BiPAP) -Medications to assist the patient with sleep at night -Continuous positive airway pressure (CPAP)
Continuous positive airway pressure (CPAP)
Which type of oxygen therapy includes the administration of oxygen at pressure greater than atmospheric pressure? -Hyperbaric -Low-flow systems -Transtracheal -High-flow systems
Hyperbaric
In general, chest drainage tubes are not indicated for a client undergoing which procedure? -Wedge resection -Lobectomy -Segmentectomy -Pneumonectomy
Pneumonectomy
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? -Check for an apical pulse. -Increase the oxygen percentage. -Ventilate the client with a handheld mechanical ventilator. -Suction the client's artificial airway.
Suction the client's artificial airway.
Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? -Partial-rebreathing mask -Nasal cannula -Venturi mask -T-piece
Venturi Mask
A nurse is caring for a client after a thoracotomy for a lung mass. What part of the client's care is the priority for the nurse? -Gas exchange -Home care -Anxiety -Impaired mobility
gas exchange
A client has a sucking stab wound to the chest. Which action should the nurse take first? -Apply a dressing over the wound and tape it on three sides. -Prepare to start an I.V. line. -Prepare a chest tube insertion tray. -Draw blood for a hematocrit and hemoglobin level.
Apply a dressing over the wound and tape it on three sides.
A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention? -Restrict intravenous fluids for at least 24 hours. -Assist with positioning the client on the right side. -Encourage coughing to mobilize secretions. -Make sure that a thoracotomy tube is linked to open chest drainage.
Encourage coughing to mobilize secretions.
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? -Endotracheal suctioning -Encouragement of coughing -Incentive spirometry -Use of a cooling blanket
Endotracheal suctioning
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? -The patient is having a stress reaction. -The patient is in a hypermetabolic state. -The patient is having a myocardial infarction. -The patient is hypoxic from suctioning.
The patient is hypoxic from suctioning
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: -clamp the chest tube once every shift. -milk the chest tube every 2 hours. -encourage coughing and deep breathing. -report fluctuations in the water-seal chamber.
encourage coughing and deep breathing
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? -"Breathe in and out quickly." -"You need to start using the incentive spirometer 2 days after surgery." -"Don't use the incentive spirometer more than 5 times every hour." -"Before you do the exercise, I'll give you pain medication if you need it."
"Before you do the exercise, I'll give you pain medication if you need it."
A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped? -Oxygen saturation of 93% -Runs of ventricular tachycardia -Respiratory rate of 16 breaths/minute -Blood pressure remains stable
runs of ventricular tachycardia
A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client. -1"Slowly count to 7." -2"Inhale through your nose." -3"Exhale slowly through pursed lips." -4"Slowly count to 3."
2"Inhale through your nose." 4"Slowly count to 3." 3"Exhale slowly through pursed lips." 1"Slowly count to 7."
A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply. -Request order for patient-controlled analgesia pump -Monitor and record hourly intake and output. -Regularly assess the client's vital signs every 2 to 4 hours. -Encourage deep breathing exercises. -Monitor pulmonary status as directed and needed.
Monitor pulmonary status as directed and needed. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises.
A patient with emphysema is placed on continuous oxygen at 2 L/min at home. Why is it important for the nurse to educate the patient and family that they must have No Smoking signs placed on the doors? -Oxygen is explosive. -Oxygen supports combustion. -Oxygen is combustible. -Oxygen prevents the dispersion of smoke particles.
Oxygen supports combustion.
A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect? -Hypoxia -Oxygen-induced atelectasis -Oxygen-induced hypoventilation -Oxygen toxicity
Oxygen toxicity
A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect? -Oxygen toxicity -Oxygen-induced hypoventilation -Oxygen-induced atelectasis -Hypoxia
Oxygen toxicity
Positive end-expiratory pressure (PEEP) therapy has which effect on the heart? -Increased blood pressure -Bradycardia -Tachycardia -Reduced cardiac output
Reduced cardiac output
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated? -Routinely deflating the cuff -Checking the cuff pressure every 6 to 8 hours -Deflating the cuff before removing the tube -Ensuring that humidified oxygen is always introduced through the tube
Routinely deflating the cuff
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? -Partial pressure of arterial carbon dioxide (PaCO2) -Partial pressure of arterial oxygen (PaO2) -Bicarbonate (HCO3-) -pH
Partial pressure of arterial oxygen (PaO2)
The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure? -Puts on clean gloves; removes and discards the soiled dressing in a biohazard container -Cleans an infected wound and the plate with a sterile cotton tip moistened with hydrogen peroxide -Dries and reinserts the inner cannula or replaces it with a new disposable inner cannula -Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting
Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting
The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? -Circulatory hypoxia -Hypoxemic hypoxia -Anemic hypoxia -Histotoxic hypoxia
Circulatory hypoxia
Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with: -pneumonia. -a malignant tumor. -hyperthermia. -a compromised skin graft.
a compromised skin graft
A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to: -Maintain a supine position to use the spirometer. -Expect coughing when using the spirometer properly. -Use the spirometer twice every hour. -Inhale and exhale rapidly with the spirometer.
expect coughing when using the spirometer properly.
A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply. -Request order for patient-controlled analgesia pump -Monitor and record hourly intake and output. -Monitor pulmonary status as directed and needed. -Regularly assess the client's vital signs every 2 to 4 hours. -Encourage deep breathing exercises.
monitor pulmonary status as directed and needed. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises.
Which type of ventilator has a preset volume of air to be delivered with each inspiration? -Time cycled -Pressure cycled -Volume cycled -Negative pressure
olume cycled
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? -"Before you do the exercise, I'll give you pain medication if you need it." -"Don't use the incentive spirometer more than 5 times every hour." -"Breathe in and out quickly." -"You need to start using the incentive spirometer 2 days after surgery."
"Before you do the exercise, I'll give you pain medication if you need it."
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? -Impaired physical mobility related to being on a ventilator -Risk for trauma related to endotracheal intubation and cuff pressure -Impaired gas exchange related to ventilator setting adjustments -Risk for infection related to endotracheal intubation and suctioning
Impaired gas exchange related to ventilator setting adjustments
A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as: -assist-control (AC) ventilation. -synchronized intermittent mandatory ventilation (SIMV). -pressure support ventilation (PSV). -continuous positive airway pressure (CPAP).
synchronized intermittent mandatory ventilation (SIMV).
The nurse is preparing to assist the health care provider to remove a client's chest tube. Which instruction will the nurse correctly give to the client? -"When the tube is being removed, take a deep breath" -"Do not move during the removal of the chest tube because moving will make it more painful." -"Exhale forcefully while the chest tube is being removed." -"While the chest tube is being removed, raise your arms above your head."
"When the tube is being removed, take a deep breath"
The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated? -Ensuring that humidified oxygen is always introduced through the tube -Routinely deflating the cuff -Deflating the cuff before removing the tube -Checking the cuff pressure every 6 to 8 hours
-Routinely deflating the cuff
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: 1Sit in an upright position. 3Place the mouthpiece of the spirometer in the mouth. 5Breathe air in through the mouth. 2Hold breath for about 3 seconds. 4Exhale air slowly through the mouth.
1Sit in an upright position. 3Place the mouthpiece of the spirometer in the mouth. 5Breathe air in through the mouth. 2Hold breath for about 3 seconds. 4Exhale air slowly through the mouth.
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 -Contacts the respiratory therapy department to report the ventilator is malfunctioning -Continues assessing the client's respiratory status frequently -Changes the setting on the ventilator to increase breaths to 14 per minute -Consults with the physician about removing the client from the ventilator
Continues assessing the client's respiratory status frequently
The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined? -Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved. -Call respiratory therapy and wait until they arrive to determine what is happening. -Stop the ventilator by pressing the off button, wait 15 seconds, and then turn it on again to see if the alarm stops. -Suction the patient since the patient may be obstructed by secretions.
Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.
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? -Encourage the patient to try to stop coughing during and after using the spirometer. -Inform the patient that using the spirometer is not necessary if the patient is experiencing pain. -Have the patient lie in a supine position during the use of the spirometer. -Encourage the patient to take approximately 10 breaths per hour, while awake.
Encourage the patient to take approximately 10 breaths per hour, while awake.
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? -Incentive spirometry -Use of a cooling blanket -Encouragement of coughing -Endotracheal suctioning
Endotracheal suctioning
The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? -Promote the client's ability to take in oxygen -Promote more efficient and controlled ventilation and to decrease the work of breathing -Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing -Promote the strengthening of the client's diaphragm
Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing
The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique? -It will assist with widening the airway. -It will prevent the alveoli from overexpanding. -It prolongs exhalation. -It increases the respiratory rate to improve oxygenation.
It prolongs exhalation.
Which oxygen administration device has the advantage of providing a high oxygen concentration? -Face tent -Catheter -Venturi mask -Nonrebreathing mask
Nonrebreathing mask
The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia? -HCO3 -PCO2 -pH -PaO2
PaO2
The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure? -Cleans an infected wound and the plate with a sterile cotton tip moistened with hydrogen peroxide -Dries and reinserts the inner cannula or replaces it with a new disposable inner cannula -Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting -Puts on clean gloves; removes and discards the soiled dressing in a biohazard container
Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting
A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped? -Respiratory rate of 16 breaths/minute -Oxygen saturation of 93% -Blood pressure remains stable -Runs of ventricular tachycardia
Runs of ventricular tachycardia
A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? -The client has a pneumothorax. -The system is functioning normally. -The chest tube is obstructed. -The system has an air leak.
The system has an air leak
Which type of ventilator has a preset volume of air to be delivered with each inspiration? -Negative pressure -Volume cycled -Pressure cycled -Time cycled
Volume cycled
The nurse is caring for a client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client -returning to the nursing unit with two chest tubes. -requiring mechanical ventilation following surgery. -returning from surgery with no drainage tubes. -requiring sedation until the chest tube(s) are removed.
returning to the nursing unit with two chest tubes.
