220 chapter 14: oxygenation

an intensive care nurse is placing an endotracheal tube and mechanical ventilation on a client. What supplies should the nurse anticipate needing at the bed side?

-a bag-valve mask and suction equipment -commercially prepared endotracheal tube holder -an extra endotracheal tube of the same sixe

the nurse has just completed open system endotracheal suctioning on a client. The client now has decreased oxygen saturation readings. which actions should the nurse take? Select all that apply.

-hyperoxygenate the client -remain with the client -auscultate lung sounds

the health care provider has prescribed an oropharyngeal airway for a client with a decreased level on consciousness. The health care provider has noted gurgling respirations and the clients tongue is in the posterior pharynx. The client vomits as the airway is inserted. Which actions should the nurse take? select all that apply

-position client onto the side immediately -provide oral suctioning and mouth care -remove oropharyngeal airway

the nurse is preparing to replace a chest drainage system that has become full. What actions should the nurse implement for this procedure? Select all that apply

-remove the suction from the current drainage system -add sterile water to the water seal chamber in the new system -keep the end of the chest tube sterile while inserting the end of the new drainage system -clamp the chest tube 1.5 to 2.5 in (3.75 to 6.25 cm) from teh insertion site

the nurse is preparing to assist with the removal of a chest tube. What action should the nurse take first?

assess the clients breath sounds, oxygen saturation, and pain level

the nurse observes continuous vigorous bubbling in the water seal chamber of a chest drainage system. What should the nurse do next?

assess the tubing for loose connections and air leaks

a nurse is preparing to suction a client using an open system endotracheal tube. After removing the ventilator tubing from the endotracheal tube, what would the nurse do next?

attach the manual resuscitation bag to the endotracheal tube to hyperventilate the client

the nurse is preparing to teach a client how to perform incentive spirometry. Which concepts should the nurse include?

incentive spirometry provides visual reinforcement for deep breathing

a nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system would the nurse use?

nonrebreather mask

a nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant?

oxygen hood

the nurse is explaining the planned chest tube removal procedure to the client. What will the nurse instruct the client to do during this procedure?

take a deep breath and hold it while the tube is being removed

a nurse is caring for a client who is receiving continuous oxygen at 3 L/min via nasal cannula. The clients oxygen saturations has consistently been 94% to 96%, but suddenly drops to 86% as the nurse palpates the clients abdomen. The client denies respiratory difficulty or other distress. which is a likely reason for the client't decreasing oxygen saturation.

the nurse has inadvertently stepped on the clients oxygen tubing, occluding the flow of oxygen.

a nurse is preparing to re-tape a clients endotracheal tube. What should the nurse do? Select all that apply

-assess the clients lung sounds -measure the clients oxygen saturation level -verify the endotracheal tube length -provide pain medication to the client

a nurse is preparing to insert a nasopharyngeal airway in a client. Before doing so, however, the nurse assesses the client and reviews the clients health record. Which findings would contraindicate insertion of the airway? Select all that apply

-deviated septum -recent nasal surgery -traumatic brain injury

a nurse must take a clients pulse oximetry reading. The nurse is explaining the technique to the client. Which statements about pulse oximetry is true? select all that apply

-once the oximetry probe is placed correctly, a beam of red infrared light travels through the tissue and blood vessels -sensors are available for use on the finger, toe, foot, earlobe, forehead, and bridge of nose

a nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate?

the clients available hemoglobin is adequately saturated with oxygen

the nurse is suctioning a client on a mechanical ventilator using a closed system endotracheal tube. In the process of advancing the catheter, the nurse meets resistance. What should the nurse do?

withdraw the catheter at least 0.5in (1.25 cm) before applying suction