Ch. 39 Oxygenation and Perfusion NCLEX Questions

Ch. 39 Oxygenation and Perfusion NCLEX Questions ScienceMedicineNursing hcps-rockechrr Save

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70 terms nurseathrtPreview Prioritization NCLEX questions 28 terms madisoncastello Preview Practice Perfusion NCLEX Questions...28 terms dawn_h_carroll Preview Fluid a 33 terms Ale 1. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). What would be an expected finding upon assessment of this patient?

• Dyspnea
• Hypotension
• Decreased respiratory rate
• Decreased pulse rate
• Dyspnea

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet?

• The patient vomits during suctioning.
• The secretions appear to be stomach contents.
• The catheter touches an unsterile surface.
• A nosebleed is noted with continued suctioning
• A nosebleed is noted with continued suctioning

A nurse is inserting an oropharyngeal airway for a patient who vomits when it is inserted. Which action would be the first that should be taken by the nurse related to this occurrence?

• Remove the catheter
• Notify the primary care provider
• Check that the airway is the appropriate size for the patient
• Place the patient on his or her back
• Remove the catheter

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the catheter to use?

• The age of the patient
• The size of the endotracheal tube
• The type of secretions to be suctioned
• The height and weight of the patient

b.The nurse would base the size of the suctioning catheter on the size of the endotracheal tube. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. Larger catheters can contribute to trauma and hypoxemia.A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing methods might the nurse use to measure the patient's oxygen saturation? Select all that apply.

• Thoracentesis
• Pulse oximetry
• Diffusion capacity
• Maximal respiratory pressure
• Pulse oximetry

A patient with COPD is unable to perform personal hygiene without becoming exhausted. Which nursing intervention would be appropriate for this patient?

• Assist with bathing and hygiene tasks even if patient feels capable of performing them alone.
• Teach the patient not to talk about the procedure, just to perform it at the best of his/her ability.
• Teach the patient to take short shallow breaths when performing hygiene measures
• Group personal care activities into smaller steps, allowing rest periods between activities
• Group personal care activities into smaller steps, allowing rest periods between activities

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply.

• Refrain from exercise.
• Reduce anxiety.
• Eat meals 1 to 2 hours prior to breathing treatments.
• Eat a high-protein/high-calorie diet.
• Maintain a high-Fowler's position when possible.
• Drink 2 to 3 pints of clear fluids daily.

b, d, e.When caring for patients with COPD, it is important to create an environment that is likely to reduce anxiety and ensure that they eat a high- protein/high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high Fowler's position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises, and drinking 2 to 3 quarts (1.9-2.9 L) of clear fluids daily is recommended.

A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended?

• A postoperative adult
• An adult with COPD
• A teenager with cystic fibrosis
• A child with pneumonia
• A teenager with cystic fibrosis

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply.

• "I will be careful not to shake up the canister before using it."
• "I will hold the canister upside-down when using it."
• "I will inhale the medication through my nose."
• "I will continue to inhale when the cold propellant is in my throat."
• "I will only inhale one spray with one breath."
• "I will activate the device while continuing to inhale."

d, e, f.Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, and inhaling two sprays with one breath.A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly?

• The nurse assures that the oxygen is flowing into the prongs.
• The nurse adjusts the fit of the cannula so it fits snug and tight against the skin.
• The nurse encourages the patient to breathe through the nose with the mouth closed.
• The nurse adjusts the flow rate to 6L/min or more.
• The nurse encourages the patient to breathe through the nose with the mouth closed.

A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident?

• Instruct assistant to notify the primary care provider.
• Assess the patient's vital signs.
• Remove the tape, adjust the depth to ordered depth and reapply the tape.
• No action is required as depth will adjust automatically.

c.The tube depth should be maintained at the same level unless otherwise ordered by the physician. If the depth changes, the nurse should remove the tape, adjust the tube to ordered depth, and reapply the tape.

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder?

• Checking the amount of oxygen in the cylinder before using it
• Using a cylinder for a patient transfer that indicates available oxygen is 500 psi
• Placing the oxygen cylinder on the stretcher next to the patient
• Discontinuing oxygen flow by turning cylinder key counterclockwise until tight

a.The cylinder must always be checked before use to ensure that enough oxygen is available for the patient. It is unsafe to use a cylinder that reads 500 psi or less because not enough oxygen remains for a patient transfer. A cylinder that is not secured properly may result in injury to the patient. Oxygen flow is discontinued by turning the valve clockwise until it is tight.A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation?

• Notify the physician.
• Apply an occlusive dressing on the site.
• Assess the patient for signs of respiratory distress.
• Put on gloves and insert the chest tube in a bottle of sterile saline.

d.When a chest tube becomes separated from the drainage device, the nurse should first put on gloves, open a sterile bottle of normal saline or water, and insert the chest tube into the bottle without contaminating the chest tube. This creates a water seal until a new drainage unit can be attached. Then the nurse should assess vital signs and notify the physician.An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure?

• Tilt the patient's head forward.
• Hold the mask tightly over the patient's nose and mouth.
• Pull the patient's jaw backward.
• Compress the bag twice the normal respiratory rate for the patient.

b.With the patient's head tilted back, jaw pulled forward, and airway cleared, the mask is held tightly over the patient's nose and mouth. The bag also fits easily over tracheostomy and endotracheal tubes. The operator's other hand compresses the bag at a rate that approximates normal respiratory rate (e.g., 16-20 breaths/min in adults).