Chapter 28: Assisting with Respiration and Oxygen Delivery My Nursing Test Banks

Chapter 28: Assisting with Respiration and Oxygen Delivery

Test Bank

MULTIPLE CHOICE

1. The nurse uses a diagram to show that when the diaphragm moves:

a.

up, the increased negative pressure in the thoracic space forces air into the lungs.

b.

down, the intercostal muscles retract, forcing air out of the lungs.

c.

down, the negative pressure in the thoracic space pulls air into the lungs.

d.

up, the decreased negative pressure allows air to enter the lungs.

ANS: C

When the diaphragm moves down, increasing the size of the thoracic space, air is pulled into the lungs. The respiratory action is controlled by the spinal cord.

DIF: Cognitive Level: Knowledge REF: p. 501 OBJ: Theory #1

TOP: Respiratory Action KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

2. The nurse clarifies that the condition in which there is a decreased amount of oxygen in the blood is:

a.

hypoxia.

b.

hypercapnia.

c.

dyspnea.

d.

hypoxemia.

ANS: D

Hypoxemia is a condition in which there is a decreased amount of oxygen in the blood, hypoxia is inadequate oxygen to meet cellular needs, hypercapnia is increased level of carbon dioxide in the blood, and dyspnea is difficulty breathing.

DIF: Cognitive Level: Comprehension REF: p. 503 OBJ: Theory #1

TOP: Oxygen Levels KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

3. The nurse monitoring patients eating in the dining room of a skilled nursing facility notes that a patient begins choking. As the nurse prepares to deliver the Heimlich maneuver, the fist should be positioned:

a.

halfway between the xiphoid process and the umbilicus.

b.

directly over the sternum.

c.

between the umbilicus and the symphysis pubis.

d.

directly over the umbilicus.

ANS: A

Proper placement of the fist is halfway between the xiphoid process and the umbilicus.

DIF: Cognitive Level: Application REF: p. 507, Skill 28-2

OBJ: Clinical Practice #1 TOP: Heimlich Maneuver

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

4. A patient has collapsed and cannot be aroused by asking loudly, Are you okay? The next action should be to:

a.

position the fingers over the carotid artery to feel for a pulse.

b.

tilt the head by placing one hand on the forehead and lift the chin.

c.

call for help or, if there is assistance, have that person get help.

d.

deliver two quick short breaths into the patients airway.

ANS: C

The sequence for resuscitative interventions is to check for responsiveness; if no response, activate emergency medical services, check for pulse at carotid, begin compressions, then open the airway and check for breathing.

DIF: Cognitive Level: Application REF: p. 509, Skill 28-3

OBJ: Theory #3 TOP: Basic Life Support

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

5. The nurse instructing the patient to perform forceful exhalation coughing would teach the patient to take in:

a.

one deep breath and quickly exhale.

b.

two breaths and force the air out quickly.

c.

two deep breaths, then inhale deeply again and force out the air quickly.

d.

one breath, hold it for 3 seconds, then forcefully exhale three times with mouth open.

ANS: C

Proper coughing procedure is to take in two deep breaths, inhale deeply again and to forcibly exhale (cough) at the end of the third breath. This technique is very effective in moving secretions up the bronchial tree.

DIF: Cognitive Level: Knowledge REF: p. 511 OBJ: Clinical Practice #1

TOP: Effective Coughing KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

6. The nurse is aware that the best time to schedule a postural drainage treatment is:

a.

shortly after the patient arises in the morning, before breakfast.

b.

in the morning immediately after breakfast.

c.

30 minutes after lunch.

d.

1 hour after supper.

ANS: A

Postural drainage is best accomplished in the morning prior to eating, because more secretions accumulate while the patient is asleep.

DIF: Cognitive Level: Comprehension REF: p. 511 OBJ: Clinical Practice #1

TOP: Postural Drainage KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: basic care and comfort

7. A patient who will begin oxygen therapy has a history of sinus disorders. This patient would benefit most from which oxygen setup?

a.

High oxygen flow rate

b.

A humidifier

c.

A Venturi mask

d.

A nasal cannula

ANS: B

If a patient suffers from sinus problems, it is best to add a humidifier to the oxygen setup.

DIF: Cognitive Level: Application REF: p. 514, Table 28-4

OBJ: Clinical Practice #2 TOP: Oxygen Therapy

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

8. A patient has a history of chronic obstructive pulmonary disease. The patients oxygen flow rate should be set to no more than _____ L/min.

a.

5 to 10

b.

4 to 5

c.

2 to 3

d.

1 to 2

ANS: C

Patients with obstructive lung disease are given only 2 to 3 L/min of oxygen, because over time they adjust to high carbon dioxide levels, and their stimulus to breathe comes from low arterial oxygen levels. Higher amounts of oxygen could reduce or eliminate the respiratory drive.

DIF: Cognitive Level: Comprehension REF: p. 514, Safety Alert

OBJ: Theory #5 TOP: Oxygen Therapy

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk

9. The nurse loosens mucus plugs by using percussion on a patient over the area of the:

a.

sternum.

b.

thorax.

c.

spine between the scapulae.

d.

midaxillary line on the rib cage.

ANS: B

Percussion, a rhythmic clapping with cupped hands over the thoracic area, will loosen mucus plugs. This technique is both useless and painful when applied over bony areas.

DIF: Cognitive Level: Knowledge REF: p. 511 OBJ: Clinical Practice #1

TOP: Oxygen Therapy: Percussion KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

10. A patient requires a precise concentration of 40% oxygen. Which of the following devices would best allow for this?

a.

A simple face mask

b.

A non-rebreather mask

c.

A partial rebreathing mask

d.

A Venturi mask

ANS: D

A Venturi mask is useful when accuracy of delivery is essential.

DIF: Cognitive Level: Comprehension REF: p. 517, Table 28-3

OBJ: Clinical Practice #2 TOP: Oxygen Therapy: Venturi Mask

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

11. The nurse recognizes that a post-operative patient who can breathe independently but has trouble maintaining an airway because of the tongue falling back into the throat would be best benefited by a(n):

a.

pharyngeal airway.

b.

endotracheal tube.

c.

tracheostomy.

d.

partial rebreather oxygen mask.

ANS: A

A pharyngeal airway such as a nasopharyngeal or an oropharyngeal airway is useful for patients who can breathe on their own but tend to occlude the airway with the tongue.

DIF: Cognitive Level: Analysis REF: p. 516 OBJ: Theory #4

TOP: Airway KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: prevention and early detection of disease

12. A nurse performing oral suctioning on an adult patient should set the wall suction machine so that the suction pressure is between _____ mm Hg.

a.

25 and 50

b.

50 and 75

c.

80 and 120

d.

120 and 180

ANS: C

The range of suction pressure for an adult patient is between 80 and 120 mm Hg.

DIF: Cognitive Level: Application REF: p. 517, Table 28-3

OBJ: Clinical Practice #1 TOP: Suctioning

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

13. A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:

a.

monitoring the rate of respirations.

b.

determining the last time the patient was suctioned.

c.

examining the character of the sputum.

d.

auscultating the breath sounds.

ANS: D

Auscultating the patients breath sounds helps the nurse assess for retained secretions and verifies the need for suctioning. The respiratory rate may rise when suctioning is needed, but it could also rise for other reasons.

DIF: Cognitive Level: Application REF: p. 526, Skill 26-6

OBJ: Clinical Practice #1 TOP: Suctioning

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

14. A patient requires suctioning via the nasotracheal route. In order to perform this procedure safely, the nurse should:

a.

apply suction while advancing the catheter into the airway.

b.

suction the nasotracheal passage after suctioning the mouth.

c.

hold the catheter with the dominant hand after donning sterile gloves.

d.

insert the non-lubricated catheter into the nasal passage.

ANS: C

The suction catheter should be held with the dominant hand after donning sterile gloves, because sterile technique must be adhered to when suctioning both the nasopharyngeal and tracheal areas.

DIF: Cognitive Level: Application REF: p. 526, Skill 26-6

OBJ: Clinical Practice #1 TOP: Suctioning

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

15. The nurse recognizes that, immediately before a tracheotomy cuff deflation, the patient should:

a.

be administered extra oxygen.

b.

have the pharynx suctioned.

c.

have the cuff pressure checked.

d.

be monitored for respiratory rate.

ANS: B

Immediately before deflating a cuff on a tracheotomy tube, the pharynx should be suctioned to prevent accumulated oral secretions from entering the bronchial tree once the cuff is deflated.

DIF: Cognitive Level: Application REF: p. 527, Skill 28-6

OBJ: Clinical Practice #3 TOP: Tracheostomy

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk

16. The nurse takes into consideration that while caring for a patient on oxygen therapy, safety precautions should be observed, which include:

a.

using clothing of synthetic cloth for the patient.

b.

removing any adhesive from the patients skin with acetone.

c.

assessing equipment in room for frayed cords.

d.

reducing humidification on the oxygen delivery device.

ANS: C

All equipment in a room where oxygen is being administered should be in good working order without frayed or loose connections because of the possibility of fire.

DIF: Cognitive Level: Comprehension REF: p. 514, Safety Alert

OBJ: Clinical Practice #5 TOP: Safety Precautions with Oxygen

KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

17. A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should:

a.

immediately turn the patient to the side of the insertion site.

b.

check for air leaks in drainage system.

c.

include findings in documentation.

d.

clamp the chest tube and place the patient in high Fowlers position.

ANS: C

Document findings. Constant bubbling in the suction chamber indicates that suction is on.

DIF: Cognitive Level: Analysis REF: p. 531, Steps 28-1

OBJ: Clinical Practice #4 TOP: Coughing and Deep Breathing

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

18. A nurse is aware that adequate hydration is necessary to mobilize respiratory secretions. To thin respiratory secretions for easier expectoration, the patient should consume at least _____ mL/day.

a.

500 to 1000

b.

1000 to 1500

c.

1500 to 2000

d.

2500 to 3000

ANS: C

A fluid intake of at least 1500 to 2000 mL/day is needed to thin respiratory secretions for easier removal by coughing.

DIF: Cognitive Level: Comprehension REF: p. 522 OBJ: Clinical Practice #1

TOP: Mobilizing Secretions KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

19. The nurse would determine that this patient is aware of how to use the incentive spirometer device properly when the patient:

a.

took 10 slow, deep breaths every hour.

b.

took five quick huffs and then coughed vigorously.

c.

exhaled deeply and then inhaled quickly and forcefully three times.

d.

took five deep breaths slowly every 4 hours.

ANS: A

Proper technique for use of an incentive spirometer is to take 10 slow, deep breaths every hour and to hold each breath for 3 seconds to enhance gas exchange.

DIF: Cognitive Level: Knowledge REF: p. 524 OBJ: Clinical Practice #1

TOP: Incentive Spirometer KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: basic care and comfort

20. The nurse assists the patient with emphysema into the most beneficial position to facilitate respiration, which is:

a.

semi-Fowlers position with a single pillow behind the head.

b.

high Fowlers position without a pillow behind the head.

c.

right lateral with the head of the bed elevated 45 degrees.

d.

sitting upright and forward with arms supported on an over-the-bed table.

ANS: D

Sitting upright and leaning forward with arms supported on an over-the-bed table is best for this patient, because it allows for expansion of the thoracic cage in all four directions (front, back, and two sides).

DIF: Cognitive Level: Application REF: p. 524, Figure 28-20

OBJ: Clinical Practice #1 TOP: Positioning

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

21. The nurse performing tracheotomy care will:

a.

raise the head of the bed to high Fowlers position.

b.

remove the inner cannula with the ungloved hand.

c.

suction tracheotomy before beginning care.

d.

clean cannula with gauze and replace and lock.

ANS: C

Proper procedure includes suctioning the tracheotomy before beginning care.

DIF: Cognitive Level: Application REF: p. 528, Skill 28-7

OBJ: Clinical Practice #3 TOP: Tracheotomy Care

KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe Effective Care Environment: safety and infection control

22. The nurse caring for a patient with a disposable chest drainage system can promote effective tube function and patient safety by:

a.

taping all connections within the system.

b.

keeping the system at the level of the patients chest.

c.

turning on suction to 35 cm.

d.

looping the tubing between the mattress and the bed rail to minimize length.

ANS: A

All connections in the system should be taped. Suction should be set at 20 cm unless ordered otherwise. Looping the tubing encourages plugs in the tubing.

DIF: Cognitive Level: Application REF: p. 531, Steps 28-1

OBJ: Clinical Practice #4 TOP: Chest Tube Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk

23. The nurse takes into consideration that a pulse oximeter may not give an accurate reading if the patient is:

a.

dark skinned.

b.

jaundiced.

c.

obese.

d.

febrile.

ANS: B

An accurate reading is dependent on light passing through the vascular bed. Jaundice may cause an inaccurate reading.

DIF: Cognitive Level: Knowledge REF: p. 505 OBJ: Theory #1

TOP: Pulse Oximetry KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

24. The nurse clarifies that the cough mechanism is stimulated when:

a.

foreign substances are propelled by the cilia toward the respiratory tract.

b.

dehumidified air enters the upper airway passages.

c.

more than 250 mL of air moves in and out of the lungs with each breath.

d.

the blood transports carbon dioxide to the lungs.

ANS: A

Cilia work to propel foreign substances toward the entrance of the respiratory tract, and the cough reflex works to expel the secretions.

DIF: Cognitive Level: Knowledge REF: p. 502 OBJ: Theory #1

TOP: Respiratory Structure Function KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

25. When assessing the lungs of a patient, the nurse assesses a wheezing sound on inspiration. This finding is documented as:

a.

apnea.

b.

dyspnea.

c.

stridor.

d.

retractions.

ANS: C

Stridor is a wheezing sound that can be heard on auscultation or even with the naked ear and indicates respiratory obstruction.

DIF: Cognitive Level: Knowledge REF: p. 503 OBJ: Theory #1

TOP: Stridor KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: physiological adaptation

COMPLETION

26. A sputum specimen is best obtained just after the patient ________ or after a _________ treatment because this is when there is more mucus available or when it is easier to cough up.

ANS:

awakens, nebulizer

A sputum specimen is best obtained just after the patient awakens or after a nebulizer treatment because this is when there is more mucus available or when it is easier to cough up.

DIF: Cognitive Level: Application REF: p. 510, Patient Teaching

OBJ: Clinical Practice #1 TOP: Specimen Collection

KEY: Nursing Process Step: N/A MSC: NCLEX: N/A

27. When obtaining a sputum specimen, the nurse should provide the patient with a sterile sputum cup and teach the patient to rinse her mouth with _____________.

ANS:

water

When obtaining a sputum specimen, the nurse should provide the patient with a sterile sputum cup and teach the patient to rinse her mouth with water.

DIF: Cognitive Level: Application REF: p. 510, Patient Teaching

OBJ: Clinical Practice #1 TOP: Specimen Collection

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

28. The nurse explains that the rate of respiration is triggered when the medulla senses a change in the level of ________ ions in the blood.

ANS:

hydrogen

When there is an increase in hydrogen ions in the blood (pH), the medulla signals the spinal nerves to increase and deepen respirations. A drop in the pH reverses the process causing a slowing of the respirations.

DIF: Cognitive Level: Knowledge REF: p. 502 OBJ: Theory #1

TOP: pH Effect on Respiration KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: physiological adaptation

29. The nurse administering cardiopulmonary resuscitation (CPR) would administer chest compressions at the rate of ________ compressions/minute.

ANS:

100

The CPR guidelines require that there be 100 chest compressions/minute

DIF: Cognitive Level: Knowledge REF: p. 502, Skill 28-3

OBJ: Theory #3 TOP: CPR KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: reduction of risk

MULTIPLE RESPONSE

30. When a patient with a tracheostomy tube is taken care of at home by family, tracheostomy care instructions from the nurse include: (Select all that apply.)

a.

use sterile gloves during suctioning.

b.

avoid going to crowded theaters and malls.

c.

change catheters every 8 hours.

d.

keep the home environment free of dust.

e.

use bleach to clean suction equipment.

ANS: B, C, D, E

The patient should avoid crowded places to decrease the chance of respiratory infections; use household bleach, hydrogen peroxide, or soap and water to clean equipment; change catheter every 8 hours; and maintain the home environment free of air pollutants to decrease irritation to airway passages.

DIF: Cognitive Level: Comprehension REF: p. 532, Home Care

OBJ: Clinical Practice #3 TOP: Home Care of Tracheostomy Patient

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: basic care and comfort

31. The nurse is aware that changes occur in the respiratory system after the age of 70 that put the elderly more at risk for respiratory problems. These changes include: (Select all that apply.)

a.

decreased oxygen saturation.

b.

increased elasticity in thorax and respiratory tissues.

c.

incomplete expirations.

d.

thinning of alveolar membrane.

e.

impaired cilia.

ANS: A, C, E

After the age of 70, changes in the respiratory system that put the elderly at risk for respiratory disorders are decreased oxygen saturation and elasticity of the thorax and respiratory tissues, incomplete respirations, thickening of the alveolar membranes, impaired cilia, and a lessened respiratory reserve.

DIF: Cognitive Level: Comprehension REF: p. 502 OBJ: Theory #1

TOP: Age-Related Changes KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: physiological adaptation

32. The multiple causes for hypoxia include: (Select all that apply.)

a.

extreme fright.

b.

aspirated vomit.

c.

pulmonary fibrosis.

d.

hiccoughs.

e.

high altitude.

ANS: B, C, E

Among the many causes of hypoxia are aspirated vomit, pulmonary fibrosis, and high altitude.

DIF: Cognitive Level: Comprehension REF: p. 503, Box 28-1

OBJ: Theory #2 TOP: Causes for Hypoxia KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

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