Care of Patients Requiring Oxygen Therapy or Tracheostomy Chapter 30

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b. Package of cigarettes on the coffee table
c. Several decorative candles on the mantlepiece
e. Electric fan with a frayed cord in the bathroom

The patient requires home oxygen therapy. When the home health nurse enters the patient's home for the initial visit, he observes several issues that are safety hazards related to the patient's oxygen therapy. What hazards do these include? (Select all that apply)
a. Bottle of wine in the kitchen area
b. Package of cigarettes on the coffee table
c. Several decorative candles on the mantlepiece
d. Grounded outlet with a green dot on the plate
e. Electric fan with a frayed cord in the bathroom
f. Computer with a three-pronged plug

b. Patient must take a breath after every third or fourth word
d. Patien appears strained and fatigued
e. Pulse of 95 beats/min, respiratory rate of 30/min

Before completing the morining assessment, the nurse concludes that the patient is experiencing inadequate oxygenation and tissue perfusion as a result of respiratory problems. Which assessment findings support the nurse's conclusion? (Select all that apply)
a. Inspiratory and expiratory effort is shallow, even, and quiet.
b. Patient must take a breath after every third or fourth word
c. Skin is pale, pink, and dry
d. Patient appears strained and fatigued
e. Pulse of 95 beats/min, respiratory rate of 30/min
f. Patient does not want to eat

b. Take vital signs and check the pulse oximeter readings

The home health nurse has been caring for a patient with a chronic respiratory disorder. Today the patient seems confused when she is normally alert and oriented X 3. What is the priority nursing action?
a. Notify the physician about the mental status change
b. Take vital signs and check the pulse oximeter readings
c. Ask the patient's family when this behavior started
d. Perform a mental status examination

b. Valve replacement with increased cardiac output

The nurse is caring for several patients on a general medical-surgical unit. The nurse would question the necessity of oxygen therapy for the patient with which condition?
a. Pulmonary edema with decreased arterial PO2 levels
b. Valve replacement with increased cardiac output
c. Anemia with adecreased hemoglobin and hematocrit
d. Sustained fever with an increased metabolic demand

c. Why the patient is receiving oxygen, expected outcomes, and complications

When a patient is requiring oxygen therapy, what is important for the nurse to know?
a. Patients require 1 to 10L/min by nasal cannula in order for oxygen to be effective
b. Oxygen-induced hypoventilation is the priority when the PaCO2 levels are unknown
c. Why the patient is receiving oxygen, expected outcomes, and complications
d. The goal is the highest Fio2 possible for the particular device being used

c. Low level of carbon dioxide concentraton in the blood, as sensed by the chemoreceptors in the brain

The patient with chronic obstructive pulmonary disease (COPD) is admitted to the hospital with oxygen-induced hypoventilation. What is the respiratory stimulus t breathe for this patient?
a. High carbon dioxide (60 to 65 mm Hg) level in the blood that rose over time
b. Low level of carbon dioxide concentration in the blood, as sensed by the chemoreceptors in the brain
c. Low level of oxygen concentration in the blood, as sensed by the peripheral chemoreceptors
d. Oxygen narcosis which stimulates central chemoreceptors in the brain

c. Lower concentration of oxygen (1 to 2 L/min) per nasal cannula

The nurse is administering oxygen to the patient who is hypoxic and has chronic high levels of carbon dioxide. Which oxygen therapy prevents a respiratory complication for this patient?
a. FiO2 higher than the usual 2 to 4 L/min per nasal cannula
b. Venturi mask of 40% for the delivery of oxygen
c. Lower concentration of oxygen (1 to 2 L/min) per nasal cannula
d. Variable Fio2 via partial rebreather mask

d. Changes in level of consciousness, apnea, and respiratory pattern

The patient is at high risk or unknown risk for oxygen-induced hypoventilation. What must the nurse monitor for?
a. Signs of nonproductive cough, chest pain, crackles, and hypoxemia
b. Change of skin tone from pink to gray color after several minutes of oxygen therapy
c. Signs and symptoms of hypoventilation rather than hypoxemia
d. Changes in level of consciousness, apnea, and respiratory pattern

c. Monitor the prescribed oxygen level and length of therapy

The patient is receiving a high concentration of oxygen as a temporary emergency measure. Which nursing action is the most appropriate to prevent complications associated with high flow oxygen?
a. Auscultate the lungs every 4 hours for oxygen toxicity.
b. Increase the oxygen if the PaO2 level is less than 93 mm Hg.
c. Monitor the prescribed oxygen level and length of therapy
d. Decrease the oxygen if the patient's condition des not respond

a. Continuous delivery of oxygen at greater than 50% concentration
b. Delivery of high concentration of oxygen over 24 to 48 hours
c. The severity and extent of lung disease
d. Neglecting to monitor the patient's status and reducing oxygen concentration as soon as possible
e. Excluding measures such as continuous positive airway pressure (CPAP) or positive end-expiratory pressure (PEEP)

Increased risk for oxygen toxicity is related to which factors? (Select all that apply)
a. Continuous delivery of oxygen at greater than 50% concentration
b. Delivery of high concentration of oxygen over 24 to 48 hours
c. The severity and extent of lung disease
d. Neglecting to monitor the patient's status and reducing oxygen concentration as soon as possible
e. Excluding measures such as continuous positive airway pressure (CPAP) or positive end-expiratory pressure (PEEP)

b. Risk for infection related to the condensation in the tubing

The patient is receiving humidified oxygen which places the patient at high risk for which nursing diagnosis?
a. Risk for injury related to the moisture in the tube
b. Risk for infection related to the condensation in the tubing
c. Impaired physical mobility related to reliance on equipment
d. Risk for impaired skin integrity related to the mask

c. Change the humidifier every 24 hours

The patient is receiving warmed and humidified oxygen. The respiratory therapist informs the nurse that several other patients on other units have developed hospital-acquired infections and Pseudomonas aeruginosa has been identified as the organism. What does the nurse do?
a. Place the patient in respiratry isolation
b. Obtain an order for a sputum culture
c. Change the humidifier every 24 hours
d. Obtain an order to dicontinue the humidifier

c. Drain condensation from the water trap

Nursing interventions to prevent infection in patients with humidified oxygen include which actions?
a. Use sterile normal saline to provide moisture
b. Drain condensation into the humidifier
c. Drain condensation from the water trap
d. Maintain a sterile closed system at all times

a. Increased combustion
c. Oxygen toxicity
d. Absorption atelectasis
f. Oxygen-induced hypoventilation

Which factors are considered hazards associated with oxygen therapy? (Select all that apply)
a. Increased combustion
b. Oxygen narcosis
c. Oxygen toxicity
d. Absorption atelectasis
e. Hypoxic drive
f. Oxygen-induced hypoventilation

a. To prevent the patient from desaturating

The patient is receiving warmed and humidified oxygen. In discarding the moisture formed by condensation, why does the nurse minimize the time that the tubing is disconnected?
a. To prevent the patient from desaturating
b. To reduce the patient's riskk of infection
c. To minimize the disturbance to the patient
d. To facilitate overall time management

d. Being familiar with the devices and techniques used in order to provide proper care

What is the best description of the nurse's role in the deliver of oxygen therapy?
a. Receiving the therapy report from the respiratory therapist
b. Evaluating the response to oxygen therapy
c. Contacting respiratory therapy for the devices
d. Being familiar with the devices and techniques used in order to provide proper care

d. 50 feet

The patient with an oxygen delivery device would like to ambulate to the bathroom but the tubing is too short. Extension tubing is added. What is the maximum length of the tubing that can be added in order to deliver the amount of oxygen needed for that device?
a. 25 feet
b. 35 feet
c. 45 feet
d. 50 feet

c. "This special nasal cannula allows you to decrease the oxygen flow by 50%."

The patient is being discharged and requires home oxygen therapy with a reservoir-type nasal cannula. He asks the nurse, "Why can't I just take this nasal cannula that I hve been using in the hospital?" What is the nurse's best response?
a. "The doctor ordered the cannula, so your insurance company should cover the cost."
b. "With the used cannula there is a risk of a hospital-acquired infection."
c. "This special nasal cannula allows you to decrease the oxygen flow by 50%."
d. "This nasal cannula is much better. It is more flexible and comfortable to wear.

c. Ensure that valves and rubber flaps are patent, functional, and not stuck

The patient is receiving oxygen therapy through a non-rebreather mask. What is the correct nursing intervention?
a. Maintain liter flow so tat the reservoir bag is up to one-half full
b. Maintain 60% to 75% FiO2 at 6 to 11 L/min
c. Ensure that valves and rubber flaps are patent, functional, and not stuck
d. Assess for effctiveness and switch to partial rebreather for more precise FiO2.

c. Obtain a physician order for a nasal cannula at 5 L/min

The patient with a face mask at 5 L/min is able to eat. Which nursing intervention is performed at mealtimes?
a. Change the mask to a nasal cannula of 6 L/min or more
b. Have the patient work around the face mask as best as possible
c. Obtain a physician order for a nasal cannula at 5 L/min
d. Obtain a physician order to remove the mask at meals

a. Delivers oxygen directly into the lungs

The physician orders transtracheal oxygen therapy for the patient with respiratory difficulty. What does the nurse tell the patient's family is the purpose of this type oxygen deliver system?
a. Delivers oxygen directly into the lungs
b. Keeps the small air sacs open to improve gas exchange
c. Prevents the need for an endotracheal tube
d. Provides high humidity with oxygen delivery

a. Assess the patient's ears, back of neck, and face at least every 4 to 8 hours for irritation
b. Apply padding on tubing to prevent pressure on skin
d. Assess nasal and mucous membranes for dryness and cracks
e. Obtain an order for humidification when oxygen is being delivered at 6 L/min or more
f. Provide mouth care every 8 hours and as needed
g. Position tubing so it will not pull on patient's ears

The nursing diagnosis for the patient receiving oxygen therapy is risk for impaired skin integrity. Which nursing interventions are related to prevention of skin breakdown? (Select all that apply)
a. Assess the patient's ears, back of neck, and face at least every 4 to 8 hours for irritation
b. Apply padding on tubing to prevent pressure on skin
c. Use petroleum jelly on nostrils, face, and lips to relieve dryness
d. Assess nasal and mucous membranes for dryness and cracks
e. Obtain an order for humidification when oxygen is being delivered at 6 L/min or more
f. Provide mouth care every 8 hours and as needed
g. Position tubing so it will not pull on patient's ears

b. Monitor for signs of oxygen toxicity and absorption atelectasis

The patient is receiving oxygen therapy for respiratory problems. According to NIC interventions for administration and monitoring of its effectiveness, what does the nurse do?
a. Monitor the effectivenss of oxygen therapy at least once every 8 hours
b. Monitor for signs of oxygen toxicity and absorption atelectasis
c. Instruct the patient to replace the oxygen mask when the device is removed
d. Ask the respiratory therapist to monitor the oxygen flow and patient response

a. Tracheostomy tube

The patient requires long-term airway maintenance following surgery for cancer of the neck. The nurse is using a piece of equipment to explain the procedure nd mechanism that are associated with this long-term therapy. Which piece of equipment does the nurse most likely use for this patient teaching session?
a. Tracheostomy tube
b. Nasal trumpet
c. Endotracheal tube
d. Nasal cannula

a. Opening in the trachea that enables breathing

The patient is receiving preoperative teaching for a partial laryngectomy and will have a tracheostomy postoperatively. How does the nurse define a tracheostomy to the patient?
a. Opening in the trachea that enables breathing
b. Temporary procedure that will be reversed at a later date
c. Technique using positive pressure to improve gas exchange
d. Procedure that holds open the upper airways

c. Inspecting and palpating for air under the skin

The patient returns from the operating room and the nurse assessfor subcutaneous emphysema which is a potential complication associated with tracheostomy. How does the nurse assess for this complication?
a. Checking the volume of the pilot balloon
b. Listening for airflow through the tube
c. Inspecting and palpating for air under the skin
d. Assessing the tube for patency

d. Tracheal stenosis

The patient with a tracheostomy develops increased coughing, inability to expectorate secretions, and difficulty breathing. What are these assessment findings related to?
a. Overinflation of the pilot balloon
b. Tracheoesophageal fistula
c. Cuff leak and rupture
d. Tracheal stenosis

c. Skin is puffy at the neck area with a crackling sensation

The patient returns from the operating room after having a tracheostomy. While assessing the patient, which observations made by the nurse warrant immediate notification of the physician?
a. Patient is alert but unable to speak and has difficulty communicating his needs.
b. Small amount of bleeding present at the incision
c. Skin is puffy at the neck area with a crackling sensation
d. Respirations are audible and noisy with an increased respiratory rate.

c. Suction the airway with the oral suction equipment

The patient was intubated for acute respiratory failure, and there is an endotracheal tube in place. Which nursing intervention is not appropriate for this patient?
a. Ensure that the oxygen is warme and humidified
b. Suction the airway, then the mouth, and give oral care
c. Suction the airway with the oral suction equipment
d. Position the tubing so it does not pull on the airway.

b. Secure te tube in place using ties or fabric fasteners

To prevent accidental decannulation of a tracheostomy rube, what does the nurse do?
a. Obtain an order for continuous upper extremity restraints
b. Secure te tube in place using ties or fabric fasteners
c. Allow some flexibility in motion of the tube while coughing
d. Instruct the patient to hold the tube with a tissue while coughing

d. Tracheostomy tube with obturator

The patient has a recent tracheostomy. What necessary equipment does the nurse ensure is kept at the bedside?
a. Pair of wire cutters
b. Pocket mask and code cart
c. Ambu bag and oxygen tubing
d. Tracheostomy tube with obturator

a. "The cuff is deflated to allow the patient to speak."

Which statement by the nursing student indicates an understanding of the deflation of the tracheostomy cuff?
a. "The cuff is deflated to allow the patient to speak."
b. "The cuff is deflated to permit suctioning more easily."
c. "The cuff should never be deflated because the patient will choke."
d. "The cuff should be deflated to facilitate access for tracheostomy care."

a. Provide tracheal suctioning when there are noisy respirations

The patient has a temporary tracheostomy folling surgery to the neck area to remove a benign tumor. Which nursing intervention is performed to prevent obstruction f the tracheostomy tube?
a. Provide tracheal suctioning when there are noisy respirations
b. Provide oxygenation to maintain pulse oximeter readings
c. Inflate the cuff to maximum pressure and check it once per shift.
d. Suction regularly and PRN with a Yankauer suction

b. Quickly and gently replace the tube wth a clean cannula kept at the bedside

The patient sustained a serious crush injury to the neck and had a tracheostomy tube placed yesterday. As the nurse is performing tracheostomy care, the patient suddenly sneezes very forcefully and the tracheostomy tube falls out onto the bed linens. What does the nurse do?
a. Ventilate the patient with 100% oxygen and notify the physician
b. Quickly and gently replace the tube wth a clean cannula kept at the bedside
c. Quickly rinse the tube with sterile solution and gently replace it
d. Give the patient oxygen; call for assistance and a new tracheostomy kit.

a. Helps prevent tracheal damage

The patient required emergency intubation and currently has an artificial airway in place. Oxygen is being administered directly from the wall source. Why would warmed and humidified oxygen be a more appropriate choice for this patient?
a. Helps prevent tracheal damage
b. Promotes thick secretions
c. Is more comfortable for the patient
d. Is less likely to cause oxygen toxicity

b. Hypoxia

The patient has an endotracheal tube and requires frequent suctioning for copious secretions. What is a complication of tracheal suctioning?
a. Atelectasis
b. Hypoxia
c. Hypercarbia
d. Bronchodilation

d. Direct the student in the correct use of materials and explain the rationale

While the nursing student changes the patient's tracheostomy dressing, the nurse observes the student using a pair of scissors to cut a 4 X 4 gauze pad to make a split dressing that will fit around the tracheostomy tube. What is the nurse's best action?
a. Give the student positive reinforcement for use of materials and technique
b. Report the student to the instructor for remediation of the skill
c. Change the dressing immediately after the student has left the room
d. Direct the student in the correct use of materials and explain the rationale

a. Thorough respiratory ssessment at least every 2 hours

The nurse is caring for a patient with a tracheostomy who has recently been transferred from the ICU, but he has had no unusual occurrences related to the tracheostomy or his oxygenation status. What does the routine care for this patient include?
a. Thorough respiratory ssessment at least every 2 hours
b. Maintainin the cuff pressure between 50 and 100 mm Hg
c. Suctioning as needed; maximum suction time of 20 seconds
d. Changing the tracheostomy dressing once a day

d. Increase the humidity in the home

The patient with a tracheostomy is being discharged to home. In patient teaching, what does the nurse instruct the patient to do?
a. Use sterile technique when suctioning
b. Instill tap water into the artificial airway
c. Clean the tracheostomy tube with soap and water
d. Increase the humidity in the home

a. Open the suction kit
b. Pour sterile saline into sterile contaier
e. Put on sterile gloves
f. Keep catheter sterile; attach to suction
i. Lubricate catheter tip in sterile saline solution
c. Preoxygenate the patient
h. Insert catheter into trachea without suctionin
g. Withdraw catheter, applying suction and twirling catheter
d. Discard supplies, wash hands, and document

The nurse has explained the endotracheal suctioning procedure to the patient, gathered equipment, washed hands, and set low wall suction. Indicate the correct steps of completing the suctioning procedure in order.
a. Open the suction kit
b. Pour sterile saline into sterile contaier
c. Preoxygenate the patient
d. Discard supplies, wash hands, and document
e. Put on sterile gloves
f. Keep catheter sterile; attach to suction
g. Withdraw catheter, applying suction and twirling catheter
h. Insert catheter into trachea without suctionin
i. Lubricate catheter tip in sterile saline solution

c. Suction tracheostomy tube if necessary
a. Remove old dressing and excess secretions
f. Open tracheostomy kit and pour peroxide into one side of container and saline into another
d. Put on sterile gloves
i. Remove inner cannula; place it in peroxide solution use brush to clean
h. Rinse inner cannula in sterile saline
e. Reinsert inner cannula into outer cannula
g. Clean stoma site and plate
j. Change tracheostomy ties if needed and place new tracheostomy dressing
b. Wash hands, dispose of equipment, and document

The nurse has explained the tracheostomy care procedure to the patient, gathered equipment, and wased hands. Indicate the correct stops of completing the tracheostomy care procedure
a. Remove old dressing and excess secretions
b. Wash hands, dispose of equipment, and document
c. Suction tracheostomy tube if necessary
d. Put on sterile gloves
e. Reinsert inner cannula into outer cannula
f. Open tracheostomy kit and pour peroxide into one side of container and saline into another
g. Clean stoma site and plate
h. Rinse inner cannula in sterile saline
i. Remove inner cannula; place it in peroxide solution use brush to clean
j. Change tracheostomy ties if needed and place new tracheostomy dressing

d. Swimming

The patient with a permanent tracheostomy is interested in developing an exercise regimen. Which activity does the nurse advise the patient to avoid?
a. Aerobics
b. Tennis
c. Golf
d. Swimming

d. Uses toothettes or a soft-bristled brush moistened in water

The patient with an endotracheal tube in place has dry mucous membranes and lips related to the tube and the partial open mouth position. What techniques does the nurse use to provide this patient with frequent oral care?
a. Cleanses the mouth with glycerin swabs
b. Provides alcohol-based mouth rinse and oral suction
c. Cleanses with a mixture of hydrogen peroxide and water
d. Uses toothettes or a soft-bristled brush moistened in water

c. Cuffed fenestrated tube

The patient with a tracheostomy tube is able to speak and is no longer on mechanical ventilation. Which type of tracheostomy tube does this patient have?
a. Cuffless tube
b. Standard cuffed tube
c. Cuffed fenestrated tube
d. Tube without an obturator

c. Talking tracheostomy tube

Tracheostomy tube that is used with patients who can speak while on a ventilator for a long-term basis.
a. Double-lumen tube
b. Cuffed fenestrated tube
c. Talking tracheostomy tube
d. Cuffed tube

d. Cuffed tube

Tracheostomy tube that has a cuff that seals airway when inflated.
a. Fenestrated tube
b. Metal tracheostomy tube
c. Single-lumen tube
d. Cuffed tube

a. Cuffless tube

Tracheostomy tube that is used for long-term management of patients not on mechanical ventilation or at high risk for aspiration
a. Cuffless tube
b. Single-lumen tube
c. Talking tracheostomy tube
d. Double-lumen tube

b. Double-lumen tube

Tracheostomy tube that has three parts - outer cannula, inner cannula, and obturator
a. Cuffed fenestrated tube
b. Double-lumen tube
c. Cuffless tube
d. Metal tracheostomy tube

c. Metal tracheostomy tube

Tracheostomy tube that is used for permanent tracheostomy
a. Fenestrated tube
b. Single-lumen tube
c. Metal tracheostomy tube
d. Talking traheostomy tube

c. Cuffed fenestrated tube

Tracheostomy tube that is used often with patients with spinal cord paralysis or muscular disease who do not require a ventilator all the time.
a. Cuffed tube
b. Double-lumen tube
c. Cuffed fenestrated tube
d. Cuffless tube

b. Single-lumen tube

Tracheostomy tube that has no inner cnnula and is used for patients with long or extra-thick necks
a. Cuffed tube
b. Single-lumen tube
c. Fenestrated tube
d. Metal tracheostomy tube

a. Fenestrated tube

Tracheostomy tube that is used when weaning a patient from a ventilator; allows the patient to speak
a. Fenestrated tube
b. Talking tracheostomy tube
c. Double-lumen tube
d. Cuffless tube

d. Assess and record cuff pressures each shift using minimal leak technique

The patient has a cuffed tracheostomy tube without a pressure relief valve. To prevent tissue damage of the tracheal mucosa, what does the nurse do?
a. Deflate the cuff every 2 to 4 hours and maintain as needed
b. Change the tracheostomy tube every 3 days or per hospital policy
c. Assess and record cuff pressures each shift using the occlusive technique
d. Assess and record cuff pressures each shift using minimal leak technique

b. Provide close supervision if the patient is self-feeding

An older adult patient is at risk for aspirating food or fluids. What is the most appropriate nursing action to assess for and prevent this problem?
a. Monitor for increased amount of secretions when patient is coughing
b. Provide close supervision if the patient is self-feeding
c. Obtain an order for a clear liquid diet and offer small but frequent amounts
d. Obtain an order for a chest x-ray to determine the presence of aspiration pneumonia.

c. Encourage "dry swallowing" after each bite to clear residue from the throat

An older adult patient sustained a stroke several weeks ago and is having difficulty swallowing. To prevent aspiration during mealtimes, what does the nurse do?
a. Hyperextend the head to allow food to enter the stomach and not the lungs
b. Give thin liquids after each bite of food to help "wash the food down."
c. Encourage "dry swallowing" after each bite to clear residue from the throat
d. Maintain a low Fowler's position during eating and for 2 hours afterwards

b. Avoid prolonged suctioning time

The patient with a tracheostomy tube is currently alert and cooperative but seems to be coughing more frequently and producing more secretions than usual. The nurse determines that there is a need for suctioning. Which nursing intervention does the nurse use to prevent hypoxia for this patient?
a. Allow the patient to breathe room air prior to suctioning
b. Avoid prolonged suctioning time
c. Suction frequently when the patient is coughing
d. Use the largest available catheter

c. Oxygenate with 100% oxygen and monitor the patient

The nurse is suctioning the secretions from a patient's endotracheal tube. The patient demonstrates a vagal response by a drop in heart rate to 54 and a drop in blood pressure to 90/50. After stopping suctioning, what is the nurse's priority action?
a. Allow the patient to rest for at least 10 minutes
b. Monitor the patient and call the Rapid Response Team
c. Oxygenate with 100% oxygen and monitor the patient
d. Administer atropine according to standing orders

b. Ask questions that can be answered with a "yes" or "no" response

The patient with a tracheostomy is unable to speak. He is not in acute distress, but is gesturing and trying to communicate with the nurse. Which nursing intervention is the best approach in this situation?
a. Rely on the family to interpret for the patient
b. Ask questions that can be answered with a "yes" or "no" response
c. Obtain an immediate consult with the speech therapist
d. Encourage the patient to rest rather than struggle with communication

c. Pulsating traheostomy tube in synchrony with the heartbeat

Which clinical finding in the patient with a recent tracheostomy is the most serious and requires immediate intervention?
a. Increased cough and difficulty expectorating secretions
b. Food particles in the tracheal secretions
c. Pulsating traheostomy tube in synchrony with the heartbeat
d. Set tidal volume on the ventilator not being received by the patient

c. "You have been brave and cheerful, but there is something that is worrying you."

The nurse is providing discharge instructions for the patient who must perform self-care of a tracheostomy. The patient has been cheerful and cooperative during the hospital stay and has demonstrated interest and capability in performing self-care. But now the patient begins crying and refuses to leave the hospital. What is the nurse's best response?
a. "You have done so well with your self-care. I am sure that you will be okay."
b. "Let me call your family. They can help you to get home and get settled."
c. "You have been brave and cheerful, but there is something that is worrying you."
d. "We'll delay this teaching until later. Let's choose a scarf for you to wear home."

a. Absence of breath sounds

Following a motor-vehicle crash a client is admitted with multiple trauma, including significant bruising of the left chest from striking the steering wheel. The client is alert and reports severe left chest pain on inspiration. The nurse should assess the client for manifestations of pneumothorax, including which of the following?
a. Absence of breath sounds
b. Expiratory wheezing
c. Inspiratory stridor
d. Rhonchi

c. Reinsert the tracheostomy tube

While changing soiled velcro ties for a client with a tracheostomy, the client suddenly coughs, dislodging a tracheostomy tube. Which of the following is the appropriate nursing action?
a. Provide ventilation with a manual resiscitation bag and face mask
b. Have a coworker call the emergency response team
c. Reinsert the tracheostomy tube
d. Cover the tracheostomy opening with a sterile dressing

d. Sitting while leaning forward over the bedside table

A client is scheduled for a thoracentesis. Into what position should the nurse assist the client for the procedure?
a. Lying flat on the affected side
b. Prone with the arms raised over the head
c. Supine with the head of the bed elevated
d. Sitting while leaning forward over the bedside table

c. Have the client breathe slowly into a paper bag

A nurse is caring for a client who is admitted in an extremely anxious state. The client's arterial blood gas (ABG) values are pH 7.47, PO2 94, PCO2 30, and HCO3 25. What should the nurse do?
a. Give supplemental oxygen via nasal cannula
b. Monitor the client's fluid and electrolyte balance closely.
c. Have the client breathe slowly into a paper bag
d. Administer sodium bicarbonate

b. Decreased exhalation of carbon dioxide

An older adult client is admitted with respiratory acidosis as a complication of chronic obstruction pulmonary disease (COPD). The nurse suspects that this is related to which of the following?
a. Increased mucous secretions
b. Decreased exhalation of carbon dioxide
c. Increased respiratory rate
d. Recent vomiting and diarrhea

d. "I will show you how to splint your incision while coughing."

While the nurse is reinforcing preoperative teaching for a client scheduled for a right pneumonectomy, the client tells the nurse, "I cough all the time, and I'm really afraid it will hurt when I cough after the surgery." Which of the following is an appropriate nursing response?
a. "After the surgeon removes the lung, you will not need to cough."
b. "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough."
c. "Intravenious pain medication will keep you free of pain when you cough after the surgery."
d. "I will show you how to splint your incision while coughing."

b. Explain the procedure to the client
c. Increase the flow of oxygen via the tracheostomy collar
d. Insert the suction catheter into the tracheostomy
a. Apply Suction

A nurse is assisting with the care of a client who has a tracheostomy in place. The nurse determines that the client's airway secretions require suctioning afte auscultating the lung fields and prepares to apply suction using the open method. Put the following steps in order:
a. Apply Suction
b. Explain the procedure to the client
c. Increase the flow of oxygen via the tracheostomy collar
d. Insert the suction catheter into the tracheostomy

c. Crepitus

A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation when palpating the skin on the client's right chest. The nurse notifies the charge nurse and documents the presence of which of the following?
a. A friction rub
b. Crackles
c. Crepitus
d. Tactle fremitus

d. The nurse auscultates coarse crackles in the lung fields

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following indicates that the nurse should suction the client's airway secretions?
a. The client is unable to speak
b. The client's airway secretions were last suctioned 2 hr. ago
c. The client coughs and expectorates a large mucous plug
d. The nurse auscultates coarse crackles in the lung fields

a. Promote carbon dioxide elimination

A nurse is reinforcing teaching for a client with emphysema about pursed-lip breathing. The nurse reminds the client that pursed-lip breathing will help do which of the following?
a. Promote carbon dioxide elimination
b. Increase oxygen intake
c. Use the intercostal muscles
d. Strengthen the diaphragm

c. Check the client's gag reflex

Following a bronchoscopy, a client is sleepy but asks for a drink. Which of the following should be the nurse's first action?
a. Auscultate the client's bowel sounds
b. Find out if a diet has been prescribed
c. Check the client's gag reflex
d. Ask the client which clear liquid she prefers

b. the client's perception of the disease process and what may have triggered the current attack

A nurse is reviewing the discharge teaching plan with a client hospitalized following an acute exacerbation of reactive airway disease. When reminding the client how to prevent acute asthma attacks, what should the nurse plan to discuss first?
a. Triggers that can precipitate an attack and how to eliminate them from the client's environment
b. the client's perception of the disease process and what may have triggered the current attack
c. The client's medication regimen, including the proper use of metered-dose inhalers
d. Manifestations of respiratory infections and the importance of avoiding people who have infections

a. An expiratory wheeze

When collecting data from a client with reactive airway disease who is experiencing an acute asthma attack, the nurse should expect to auscultate for which of the following?
a. An expiratory wheeze
b. A pleural friction rub
c. Inspiratory stridor
d. Subcutaneous emphysema

a. Provide oral hygiene care after respiratory aerosol therapy treatments and before meals

To meet the goal of maintaining an adequate nutritional status for a client who has pneumonia, which measure should the nurse include when assisting in planning care to promote oral intake?
a. Provide oral hygiene care after respiratory aerosol therapy treatments and before meals
b. Serve nutritious foods at mealtimes and discourage between-meal snacking
c. Schedule respiratory aerosol treatments and chest physiotherapy just before meals
d. Select meals for the client to ensure that the meals are well-balanced

b. Mobilize secretions in the airways

A client diagnosed with pneumonia is prescribed chest physiotherapy (CPT) every 4 hrs. In planning the client's care, the nurse understands that the purpose of CPT is which of the following?
a. Encourage deep breaths
b. Mobilize secretions in the airways
c. Dilate the bronchioles
d. Stimulate the cough reflex

b. Increased restlessness

A pulse oximeter reading from a client diagnosed with smoke inhalation is 85% with a 40% face mask. The provider prescribes an increase of the oxygen to 50%. Because the client is a high risk for adult respiratory distress syndrome (ARDS), the nurse must observe the client for which of the following?
a. Substernal chest pain
b. Increased restlessness
c. Apnea
d. Oxygen saturation of 95%

b. Look for loose connections

A nurse is caring for a client who has acute respiratory failure and is being treated with mechanical ventilation. The low-pressure alarm on the ventilator begins to sound continuously. Which of the following is an appropriate nursing action?
a. Call the respiratory therapist
b. Look for loose connections
c. Suction the client's airway secretions
d. Increase the oxygen concentration

c. Flail chest

While observing a client who is unconscious following major trauma, the nurse notes that a portion of the client's chest pulls inward on inspiration. On expiration, the same portion expands outward. The nurse documents the presence of which of the following?
a. Symmetrical chest movement
b. Intercostal retractions
c. Flail chest
d. Cheyne-Stokes respirations

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