Respiratory Practice Questions
A 242-lb patient is being mechanically ventilated. To prevent lung injury, what setting should the nurse anticipate for tidal volume? (Record your answer using a whole number.) ___ mL
660
A nurse assesses a patient who is prescribed fluticasone (Flovent) and notes oral lesions. What action would the nurse take? A. Encourage oral rinsing after fluticasone administration. B. Obtain an oral specimen for culture and sensitivity. C. Start the patient on a broad-spectrum antibiotic. D. Document the finding as a known side effect.
A
A nurse cares for a patient with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process would the nurse correlate with this patient's history and clinical manifestations? A. Increased pulmonary pressure creating a higher workload on the right side of the heart B. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles C. Increased number and size of mucous glands producing large amounts of thick mucus D. Left ventricular hypertrophy creating a decrease in cardiac output
A
A nurse is caring for a patient on mechanical ventilation and finds the patient agitated and thrashing about. What action by the nurse is most appropriate? A. Assess the cause of the agitation. B. Reassure the patient that he or she is safe. C. Restrain the patient's hands. D. Sedate the patient immediately.
A
A patient in the emergency department has several broken ribs. What care measure will best promote comfort? A. Allowing the patient to choose the position in bed B. Humidifying the supplemental oxygen C. Offering frequent, small drinks of water D. Providing warmed blankets
A
A patient is receiving oxygen at 4 L per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)? A. Apply water-soluble ointment to nares and lips. B. Periodically turn the oxygen down or off. C. Remove the tubing from the patient's nose. D. Turn the patient every 2 hours or as needed.
A
A home health nurse is visiting a new patient who uses oxygen in the home. For which factors does the nurse assess when determining if the patient is using the oxygen safely? (Select all that apply.) A. The patient does not allow smoking in the house. B. Electrical cords are in good working order. C. Flammable liquids are stored in the garage. D. Household light bulbs are the fluorescent type. E. The patient does not have pets inside the home.
A, B, C
A nurse teaches a patient who has chronic obstructive pulmonary disease. Which statements related to nutrition would the nurse include in this patient's teaching? (Select all that apply.) A. "Avoid drinking fluids just before and during meals." B. "Rest before meals if you have dyspnea." C. "Have about six small meals a day." D. "Eat high-fiber foods to promote gastric emptying." E. "Increase carbohydrate intake for energy."
A, B, C
The nurse caring for mechanically ventilated patients uses best practices to prevent ventilator- associated pneumonia. What actions are included in this practice? (Select all that apply.) A. Adherence to proper hand hygiene B. Administering antiulcer medication C. Elevating the head of the bed D. Providing oral care per protocol E. Suctioning the patient on a regular schedule
A, B, C, D
A nurse is teaching a patient about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the patient? (Select all that apply.) A. Absorptive atelectasis B. Combustion C. Dried mucous membranes D. Oxygen-induced hyperventilation E. Toxicity
A, B, C, E
A patient with a new pulmonary embolism (PE) is anxious. What nursing actions are most appropriate? (Select all that apply.) A. Acknowledge the frightening nature of the illness. B. Delegate a back rub to the unlicensed assistive personnel (UAP). C. Give simple explanations of what is happening. D. Request a prescription for antianxiety medication. E. Stay with the patient and speak in a quiet, calm voice.
A, B, C, E
A nurse is caring for a patient who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) A. Applying water-soluble lip balm to the patient's lips B. Ensuring that the humidification provided is adequate C. Performing oral care with alcohol-based mouthwash D. Reminding the patient to cough and deep breathe often E. Suctioning excess secretions through the tracheostomy
A, D
A patient is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the patient maintain self-esteem? (Select all that apply.) A. Create a communication system. B. Don't go out in public alone. C. Find hobbies to enjoy at home. D. Try loose-fitting shirts with collars. E. Wear fashionable scarves.
A, D, E
A nurse administers medications to a patient who has asthma. Which medication classification is paired correctly with its physiologic response to the medication? A. Bronchodilator—stabilizes the membranes of mast cells and prevents the release of inflammatory mediators B. Cholinergic antagonist—causes bronchodilation by inhibiting the parasympathetic nervous system C. Corticosteroid—relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors D. Cromone—disrupts the production of pathways of inflammatory mediators
B
A nurse is caring for a patient on the medical stepdown unit. The following data are related to this patient: Subjective Info S.O.B. for 20 minutes, Feels frightened, "Can't catch my breath" Lab Analysis pH: 7.12, PaCO2: 28 mm Hg, PaO2: 58 mm Hg, SaO2: 88% Physical Assessment Pulse: 120 beats/min, RR: 34 breaths/min, BP: 158/92 mm Hg, Lungs have crackles What action by the nurse is most appropriate? A. Call respiratory therapy for a breathing treatment. B. Facilitate a STAT pulmonary angiography. C. Prepare for immediate endotracheal intubation. D. Prepare to administer intravenous anticoagulants.
B
A nurse is caring for a patient using oxygen while in the hospital. What assessment finding indicates that outcomes for patient safety with oxygen therapy are being met? A. 100% of meals being eaten by the patient B. Intact skin behind the ears C. The patient understanding the need for oxygen D. Unchanged weight for the past 3 days
B
A patient has a tracheostomy tube in place. When the nurse suctions the patient, food particles are noted. What action by the nurse is best? A. Elevate the head of the patient's bed. B. Measure and compare cuff pressures. C. Place the patient on NPO status. D. Request that the patient have a swallow study.
B
A patient is being discharged soon on warfarin. What menu selection for dinner indicates that the patient needs more education regarding this medication? A. Hamburger and French fries B. Large chef's salad and muffin C. No selection; spouse brings pizza D. Tuna salad sandwich and chips
B
While assessing a patient who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action by the nurse is best? A. Assess for drainage from the site. B. Cover the insertion site with sterile gauze. C. Contact the provider and obtain a suture kit. D. Reinsert the tube using sterile technique.
B
A nurse assesses a patient who has a chest tube. For which manifestations would the nurse immediately intervene? (Select all that apply.) A. Production of pink sputum B. Tracheal deviation C. Sudden onset of shortness of breath D. Pain at insertion site E. Drainage of 75 mL/hr
B, C
A nurse assesses a patient with chronic obstructive pulmonary disease. Which questions would the nurse ask to determine the patient's activity tolerance? (Select all that apply.) A. "What color is your sputum?" B. "Do you have any difficulty sleeping?" C. "How long does it take to perform your morning routine?" D. "Do you walk upstairs every day?" E. "Have you lost any weight lately?"
B, C, E
A nurse is teaching a patient how to perform pursed-lip breathing. Which instructions would the nurse include in this teaching? (Select all that apply.) A. "Open your mouth and breathe deeply." B. "Use your abdominal muscles to squeeze air out of your lungs." C. "Breath out slowly without puffing your cheeks." D. "Focus on inhaling and holding your breath as long as you can." E. "Exhale at least twice the amount of time it took to breathe in."
B, C, E
A nurse cares for a patient who tests positive for alpha1-antitrypsin (AAT) deficiency. The patient asks, "What does this mean?" How would the nurse respond? A. "Your children will be at high risk for the development of chronic obstructive pulmonary disease." B. "I will contact a genetic counselor to discuss your condition." C. "Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke." D. "This is a recessive gene and would have no impact on your health."
C
A patient is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? A. Assess the patient for sedation needs. B. Get family permission for restraints. C. Provide frequent oral care per protocol. D. Use nonverbal pain assessment tools.
C
A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? A. Holding the device securely when changing ties B. Suctioning the patient first if secretions are present C. Tying a square knot at the back of the neck D. Using half-strength peroxide for cleansing
C
After teaching a patient who is prescribed a long-acting beta2 agonist medication, a nurse assesses the patient's understanding. Which statement indicates that the patient comprehends the teaching? A. "I will carry this medication with me at all times in case I need it." B. "I will take this medication when I start to experience an asthma attack." C. "I will take this medication every morning to help prevent an acute attack." D. "I will be weaned off this medication when I no longer need it."
C
When working with women who are taking hormonal birth control, what health promotion measures does the nurse teach to prevent possible pulmonary embolism (PE)? (Select all that apply.) A. Avoid drinking alcohol. B. Eat more omega-3 fatty acids. C. Exercise on a regular basis. D. Maintain a healthy weight. E. Stop smoking cigarettes.
C, D, E
A nurse assesses a patient with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. What actions would the nurse take? (Select all that apply.) A. Administer prescribed salmeterol (Serevent) inhaler. B. Assess the patient for a tracheal deviation. C. Administer oxygen to keep saturations greater than 94%. D. Perform peak expiratory flow readings. E. Administer prescribed albuterol (Proventil) inhaler.
C, E
A nurse assesses several patients who have a history of asthma. Which patient would the nurse assess first? A. A 66-year-old patient with a barrel chest and clubbed fingernails B. A 48-year-old patient with an oxygen saturation level of 92% at rest C. A 35-year-old patient who has a longer expiratory phase than inspiratory phase D. A 27-year-old patient with a heart rate of 120 beats/min
D
A nurse cares for a patient who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. What action would the nurse take? A. Ambulate the patient in the hallway to promote deep breathing. B. Auscultate the patient's anterior and posterior lung fields. C. Encourage the patient to take shallow breaths to help with the pain. D. Administer pain medication and encourage the patient to take deep breaths.
D
A nurse cares for a patient who has a chest tube. When would this patient be at highest risk for developing a pneumothorax? A. When the insertion site becomes red and warm to the touch B. When the tube drainage decreases and becomes sanguineous C. When the patient experiences pain at the insertion site D. When the tube becomes disconnected from the drainage system
D
A patient is on mechanical ventilation and the patient's spouse wonders why ranitidine (Zantac) is needed since the patient "only has lung problems." What response by the nurse is best? A. "It will increase the motility of the gastrointestinal tract." B. "It will keep the gastrointestinal tract functioning normally." C. "It will prepare the gastrointestinal tract for enteral feedings." D. "It will prevent ulcers from the stress of mechanical ventilation."
D
A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best? A. "It is chronic hypoxemia that accompanies restrictive airway disease." B. "It is hypoxemia from lung damage due to mechanical ventilation." C. "It is hypoxemia that continues even after the patient is weaned from oxygen." D. "It is hypoxemia that persists even with 100% oxygen administration."
D
The nurse is caring for a patient who is prescribed a long-acting beta2 agonist. The patient states, "The medication is too expensive to use every day. I only use my inhaler when I have an attack." How would the nurse respond? A. "You are using the inhaler incorrectly. This medication should be taken daily." B. "If you decrease environmental stimuli, it will be okay for you to use the inhaler only for asthma attacks." C. "Tell me more about your fears related to feelings of breathlessness." D. "It is important to use this type of inhaler every day. Let's identify potential community services to help you."
D
A patient appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? A. Assess for other manifestations of hypoxia. B. Change the sensor on the pulse oximeter. C. Obtain a new oximeter from central supply. D. Tell the patient to take slow, deep breaths.
A
A patient has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the patient's face is puffy and the eyelids are swollen. What action by the nurse takes priority? A. Assess the patient's oxygen saturation. B. Notify the Rapid Response Team. C. Oxygenate the patient with a bag-valve-mask. D. Palpate the skin of the upper chest.
A
A patient has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the patient will need as the priority? A. Alteplase B. Enoxaparin C. Unfractionated heparin D. Warfarin sodium
A
A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? A. Applying suction while inserting the catheter B. Preoxygenating the patient prior to suctioning C. Suctioning for a total of three times if needed D. Suctioning for only 10 to 15 seconds each time
A
An unlicensed assistive personnel (UAP) was feeding a patient with a tracheostomy. Later that evening, the UAP reports that the patient had a coughing spell during the meal. What action by the nurse takes priority? A. Assess the patient's lung sounds. B. Assign a different UAP to the patient. C. Report the UAP to the manager. D. Request thicker liquids for meals.
A
The nurse instructs a patient on the steps needed to obtain a peak expiratory flow rate. In which order would these steps occur? 1. "Take as deep a breath as possible." 2. "Stand up (unless you have a physical disability)." 3. "Place the meter in your mouth, and close your lips around the mouthpiece." 4. "Make sure the device reads zero or is at base level." 5. "Blow out as hard and as fast as possible for 1 to 2 seconds." 6. "Write down the value obtained." 7. "Repeat the process two additional times, and record the highest number in your chart." A. 4, 2, 1, 3, 5, 6, 7 B. 3, 4, 1, 2, 5, 7, 6 C. 2, 1, 3, 4, 5, 6, 7 D. 1, 3, 2, 5, 6, 7, 4
A
The nurse caring for mechanically ventilated patients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) A. Chest wall stiffness B. Decreased muscle strength C. Inability to cooperate D. Less lung elasticity E. Poor vision and hearing
A, B, D
A nurse is caring for a patient who is on mechanical ventilation. What actions will promote comfort in this patient? (Select all that apply.) A. Allow visitors at the patient's bedside. B. Ensure that the patient can communicate if awake. C. Keep the television tuned to a favorite channel. D. Provide back and hand massages when turning. E. Turn the patient every 2 hours or more.
A, B, D, E
A nurse is planning discharge teaching on tracheostomy care for an older patient. What factors does the nurse need to assess before teaching this particular patient? (Select all that apply.) A. Cognition B. Dexterity C. Hydration D. Range of motion E. Vision
A, B, D, E
A home health nurse evaluates a patient who has chronic obstructive pulmonary disease. Which assessments would the nurse include in this patient's evaluation? (Select all that apply.) A. Examination of mucous membranes and nail beds B. Measurement of rate, depth, and rhythm of respirations C. Auscultation of bowel sounds for abnormal sounds D. Check peripheral veins for distention while at rest E. Determine the patient's need and use of oxygen
A, B, E
A nurse plans care for a patient who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions would the nurse include in this patient's plan of care? (Select all that apply.) A. Ask the patient to drink 2 L of fluids daily. B. Add humidity to the prescribed oxygen. C. Suction the patient every 2 to 3 hours. D. Use a vibrating positive expiratory pressure device. E. Encourage diaphragmatic breathing.
A, B, E
A nurse cares for a patient who is prescribed an intravenous prostacyclin agent. What actions would the nurse take to ensure the patient's safety while on this medication? (Select all that apply.) A. Keep an intravenous line dedicated strictly to the infusion. B. Teach the patient that this medication increases pulmonary pressures. C. Ensure that there is always a backup drug cassette available. D. Start a large-bore peripheral intravenous line. E. Use strict aseptic technique when using the drug delivery system.
A, C, E
A nurse answers a call light and finds a patient anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg. What action by the nurse takes priority? A. Assess the patient's lung sounds. B. Notify the Rapid Response Team. C. Provide reassurance to the patient. D. Take a full set of vital signs.
B
A nurse cares for a patient with arthritis who reports frequent asthma attacks. What action would the nurse take first? A. Review the patient's pulmonary function test results. B. Ask about medications the patient is currently taking. C. Assess how frequently the patient uses a bronchodilator. D. Consult the provider and request arterial blood gases.
B
A nurse is caring for four patients on intravenous heparin therapy. Which laboratory value possibly indicates that a serious side effect has occurred? A. Hemoglobin: 14.2 g/dL (142 g/L) B. Platelet count: 82,000/L (82 × 109/L) C. Red blood cell count: 4.8/mm3 (4.8 × 1012/L) D. White blood cell count: 8700/mm3 (8.7 × 109/L)
B
A nurse is preparing to admit a patient on mechanical ventilation from the emergency department. What action by the nurse takes priority? A. Assessing that the ventilator settings are correct. B. Ensuring that there is a bag-valve-mask in the room. C. Obtaining personal protective equipment. D. Planning to suction the patient upon arrival to the room.
B
A nurse is teaching a patient about warfarin. What assessment finding by the nurse indicates a possible barrier to self-management? A. Poor visual acuity B. Strict vegetarian C. Refusal to stop smoking D. Wants weight loss surgery
B
A nursing student caring for a patient removes the patient's oxygen as prescribed. The patient is now breathing what percentage of oxygen in the room air? A. 14% B. 21% C. 28% D. 31%
B
A patient is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals that the patient has an alteration in the gene CYP2C19. What action by the nurse is best? A. Instruct the patient to eliminate all vitamin K from the diet. B. Prepare preoperative teaching for an inferior vena cava (IVC) filter. C. Refer the patient to a chronic illness support group. D. Teach the patient to use a soft-bristled toothbrush.
B
A patient is on intravenous heparin to treat a pulmonary embolism. The patient's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? A. Decrease the heparin rate. B. Increase the heparin rate. C. No change to the heparin rate. D. Stop heparin; start warfarin.
B
A patient is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? A. Administer prescribed anxiolytic medication. B. Ensure that informed consent is on the chart. C. Reinforce any teaching done previously. D. Start the preoperative antibiotic infusion.
B
A patient is wearing a venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? A. Assess the patient's oxygen saturation and, if normal, turn off the oxygen. B. Determine if the patient can switch to a nasal cannula during the meal. C. Have the patient lift the mask off the face when taking bites of food. D. Turn the oxygen off while the patient eats the meal and then restart it.
B
A patient with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis of impaired self-esteem are being met? A. The patient demonstrates good understanding of stoma care. B. The patient has joined a book club that meets at the library. C. Family members take turns assisting with stoma care. D. Skin around the stoma is intact without signs of infection.
B
A pulmonary nurse cares for patients who have chronic obstructive pulmonary disease (COPD). Which patient would the nurse assess first? A. A 46-year-old with a 30-pack-year history of smoking B. A 52-year-old in a tripod position using accessory muscles to breathe C. A 68-year-old who has dependent edema and clubbed fingers D. A 74-year-old with a chronic cough and thick, tenacious secretions
B
A student nurse is preparing to administer enoxaparin to a patient. What action by the student requires immediate intervention by the supervising nurse? A. Assessing the patient's platelet count B. Choosing an 18-gauge, 2-inch (5 cm) needle C. Not aspirating prior to injection D. Swabbing the injection site with alcohol
B
After teaching a patient how to perform diaphragmatic breathing, the nurse assesses the patient's understanding. Which action demonstrates that the patient correctly understands the teaching? A. The patient lays on his or her side with his or her knees bent. B. The patient places his or her hands on his or her abdomen. C. The patient lays in a prone position with his or her legs straight. D. The patient places his or her hands above his or her head.
B
A nurse is caring for five patients. For which patients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) A. Patient who had a reaction to contrast dye yesterday B. Patient with a new spinal cord injury on a rotating bed C. Middle-aged man with an exacerbation of asthma D. Older patient who is 1 day post-hip replacement surgery E. Young obese patient with a fractured femur
B, D, E
A nurse assesses a patient who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.) A. Production of pink sputum B. Tracheal deviation C. Pain at insertion site D. Sudden onset of shortness of breath E. Drainage greater than 70 mL/hr F. Disconnection at Y site
B, D, E, F
A nurse cares for a female patient who has a family history of cystic fibrosis. The patient asks, "Will my children have cystic fibrosis?" How would the nurse respond? A. "Since many of your family members are carriers, your children will also be carriers of the gene." B. "Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder." C. "Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested." D. "Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder."
C
A nurse cares for a patient who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection would the nurse provide for this patient? A. Spaghetti with meat sauce, ice cream B. Chicken soup, grilled cheese sandwich C. Omelet, soft whole-wheat bread D. Pasta salad, custard, orange juice
C
A nurse cares for a patient who is infected with Burkholderia cepacia. What action would the nurse take first when admitting this patient to a pulmonary care unit? A. Instruct the patient to wash his or her hands after contact with other people. B. Implement droplet precautions and don a surgical mask. C. Keep the patient isolated from other patients with cystic fibrosis. D. Obtain blood, sputum, and urine culture specimens.
C
A nurse cares for a patient with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question would the nurse ask first? A. "Do you have a strong support system?" B. "What do you understand about your disease?" C. "Do you experience shortness of breath with basic activities?" D. "What medications are you prescribed to take each day?"
C
A nurse cares for a patient with chronic obstructive pulmonary disease (COPD). The patient states that he no longer enjoys going out with his friends. How would the nurse respond? A. "There are a variety of support groups for people who have COPD." B. "I will ask your provider to prescribe you with an antianxiety agent." C. "Share any thoughts and feelings that cause you to limit social activities." D. "Friends can be a good support system for patients with chronic disorders."
C
A nurse is assisting the healthcare provider who is intubating a patient. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? A. Ensure that the patient has adequate sedation. B. Find another provider to intubate. C. Interrupt the procedure to give oxygen. D. Monitor the patient's oxygen saturation.
C
A nurse is teaching a patient who has cystic fibrosis (CF). Which statement would the nurse include in this patient's teaching? A. "Take an antibiotic each day." B. "Contact your provider to obtain genetic screening." C. "Eat a well-balanced, nutritious diet." D. "Plan to exercise for 30 minutes every day."
C
A patient has a pulmonary embolism and is started on oxygen. The student nurse asks why the patient's oxygen saturation has not significantly improved. What response by the nurse is best? A. "Breathing so rapidly interferes with oxygenation." B. "Maybe the patient has respiratory distress syndrome." C. "The blood clot interferes with perfusion in the lungs." D. "The patient needs immediate intubation and mechanical ventilation."
C
A patient has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? A. Apply oxygen at 100%. B. Assess the respiratory rate. C. Ensure a patent airway. D. Start two large-bore IV lines.
C
A patient is admitted with a pulmonary embolism (PE). The patient is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? A. Encourage the patient to walk 5 minutes each hour. B. Refer the patient to smoking cessation classes. C. Teach the patient about factor V Leiden testing. D. Tell the patient that sometimes no cause for disease is found.
C
After teaching a patient who is prescribed salmeterol (Serevent), the nurse assesses the patient's understanding. Which statement by the patient indicates a need for additional teaching? A. "I will be certain to shake the inhaler well before I use it." B. "It may take a while before I notice a change in my asthma." C. "I will use the drug when I have an asthma attack." D. "I will be careful not to let the drug escape out of my nose and mouth."
C
An intubated patient's oxygen saturation has dropped to 88%. What action by the nurse takes priority? A. Determine if the tube is kinked. B. Ensure that all connections are patent. C. Listen to the patient's lung sounds. D. Suction the endotracheal tube.
C
The nurse assesses the patient using the device pictured below to deliver 50% O2: (It's a pic of a High-Flow Venturi Mask). The nurse finds that the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best? A. Assess the patient's oxygen saturation. B. Document these findings in the chart. C. Immediately increase the flow rate. D. Turn the flow rate down to 2 L/min.
C
The nurse instructs a patient on how to correctly use an inhaler with a spacer. In which order would these steps occur? 1. "Press down firmly on the canister to release one dose of medication." 2. "Breathe in slowly and deeply." 3. "Shake the whole unit vigorously three or four times." 4. "Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer." 5. "Place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece." 6. "Remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds." A. 2, 3, 4, 5, 6, 1 B. 3, 4, 5, 1, 6, 2 C. 4, 3, 5, 1, 2, 6 D. 5, 3, 6, 1, 2, 4
C
A nurse cares for a patient who has a pleural chest tube. What action would the nurse take to ensure safe use of this equipment? A. Strip the tubing to minimize clot formation and ensure patency. B. Secure tubing junctions with clamps to prevent accidental disconnections. C. Connect the chest tube to wall suction at the level prescribed by the provider. D. Keep padded clamps at the bedside for use if the drainage system is interrupted.
D
A nurse evaluates the following arterial blood gas and vital sign results for a patient with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results and Vital Signs pH = 7.32 Heart rate = 110 beats/min PaCO2 = 62 mm Hg Respiratory rate = 12 breaths/min PaO2 = 46 mm Hg Blood pressure = 145/65 mm Hg HCO3- = 28 mEq/L (28 mmol/L) Oxygen saturation = 76% What action would the nurse take first? A. Administer a short-acting beta2 agonist inhaler. B. Document the findings as normal for a patient with COPD. C. Teach the patient diaphragmatic breathing techniques. D. Initiate oxygenation therapy to increase saturation to 92%.
D
A nurse is assessing a patient who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the patient's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? A. Call the operating room to inform them of a pending emergency case. B. No action is needed at this time; this is a normal finding in some patients. C. Remove the tracheostomy tube; ventilate the patient with a bag-valve-mask. D. Stay with the patient and have someone else call the provider immediately.
D
A nurse is caring for a patient on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? A. The patient is able to initiate spontaneous breaths. B. The inspired oxygen has adequate humidification. C. The upper peak airway pressure limit alarm is off. D. The upper peak airway pressure limit alarm is on.
D
A patient is brought to the emergency department after sustaining injuries in a severe car crash. The patient's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the patient is cyanotic. What action by the nurse is the priority? A. Administer oxygen and reassess. B. Auscultate the patient's lung sounds. C. Facilitate a portable chest x-ray. D. Prepare to assist with intubation.
D
