Chapter 21 Quiz

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Question #1

A patient with COPD requires oxygen administration. What method of delivery does the nurse know would be best for this patient?

A A nasal cannula

B A Venturi mask

C A nonrebreathing mask

D An oropharyngeal catheter

Question #2

The nurse is caring for a client in the ICU who is receiving mechanical ventilation. Which nursing measure is implemented in an effort to reduce the client’s risk of developing ventilator-associated pneumonia (VAP)?

A Maintaining the client in a high Fowler’s position

B Ensuring that the client remains sedated while intubated

C Turning and repositioning the client every 4 hours

D Cleaning the client’s mouth with chlorhexidine daily

Question #3

The nurse is preparing to perform chest physiotherapy (CPT) on a client. Which statement by the client tells the nurse that the procedure is contraindicated.

A “I just changed into my running suit; we can do my CPT now.”

B “I just finished eating my lunch, I’m ready for my CPT now.”

C “I received my pain medication 10 minutes ago, let’s do my CPT now.”

D “I have been coughing all morning and am barely bringing anything up.”

Question #4

A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply.,,

A Fatigue

B Dyspnea

C Bradycardia

D Substernal pain

E Mood swings

Question #5

A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to:

A Maintain a supine position to use the spirometer.

B Use the spirometer twice every hour

C Inhale and exhale rapidly with the spirometer.

D Expect coughing when using the spirometer properly.

Question #6

Which is a correct endotracheal tube cuff pressure?

A 16 mm Hg

B 19 mm Hg

C 13 mm Hg

D 22 mm Hg

Question #7

A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:

A hold the breath as the cuff is being reinflated.

B exhale deeply as the nurse reinflates the cuff.

C take a deep breath as the nurse deflates the cuff.

D cough as the cuff is being deflated.

Question #8

A hold the breath as the cuff is being reinflated.

B cough as the cuff is being deflated.

C exhale deeply as the nurse reinflates the cuff.

D take a deep breath as the nurse deflates the cuff.

Question #9

A client is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 28 mm Hg. The nurse is aware of what complications that can be caused by this pressure? Select all that apply.,,

A Hypoxia

B Tracheal ischemia

C Tracheal aspiration

D Tracheal bleeding

E Pressure necrosis

Question #10

The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique?

A It increases the respiratory rate to improve oxygenation.

B It prolongs exhalation.

C It will prevent the alveoli from overexpanding.

D It will assist with widening the airway.

Question #11

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result?

A Promote the strengthening of the client’s diaphragm

B Promote the client’s ability to take in oxygen

C Promote more efficient and controlled ventilation and to decrease the work of breathing

D Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing

Question #12

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply.,,

A To clear respiratory secretions

B To provide visual feedback to encourage the client to inhale slowly and deeply

C To reduce stress on the myocardium

D To provide adequate transport of oxygen in the blood

E To decrease the work of breathing

Question #13

A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client?

A Risk for trauma related to endotracheal intubation and cuff pressure

B Risk for infection related to endotracheal intubation and suctioning

C Impaired physical mobility related to being on a ventilator

D Impaired gas exchange related to ventilator setting adjustments

Question #14

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must:

A encourage coughing and deep breathing.

B clamp the chest tube once every shift.

C milk the chest tube every 2 hours.

D report fluctuations in the water-seal chamber.

Question #15

A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as:

A assist-control (AC) ventilation.

B pressure support ventilation (PSV).

C continuous positive airway pressure (CPAP).

D synchronized intermittent mandatory ventilation (SIMV).

Question #16

The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?

A Milk the chest tube.

B Disconnect the system and get another.

C Notify the physician.

D Place the head of the patient’s bed flat

Question #17

A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time?

A The patient will have an insertion of a tracheostomy tube.

B The patient will begin the weaning process.

C The patient will be extubated and another endotracheal tube will be inserted.

D The patient will be extubated and a nasotracheal tube will be inserted.

Question #18

A client is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which action first?

A Troubleshoot to identify the malfunction.

B Reposition the endotracheal tube.

C Manually ventilate the client.

D Notify the respiratory therapist.

Question #19

In general, chest drainage tubes are not indicated for a client undergoing which procedure?

A Wedge resection

B Lobectomy

C Pneumonectomy

D Segmentectomy

Question #20

A client has a sucking stab wound to the chest. Which action should the nurse take first?

A Draw blood for a hematocrit and hemoglobin level.

B Prepare to start an I.V. line.

C Apply a dressing over the wound and tape it on three sides.

D Prepare a chest tube insertion tray.

Question #21

A client has a sucking stab wound to the chest. Which action should the nurse take first?

A Prepare to start an I.V. line.

B Draw blood for a hematocrit and hemoglobin level.

C Apply a dressing over the wound and tape it on three sides.

D Prepare a chest tube insertion tray.

Question #22

A client has a tracheostomy but doesn’t require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:

A 30 to 40 minutes.

B 45 to 60 minutes.

C 5 to 20 minutes.

D 15 to 60 seconds.

Question #23

A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?

A Suction the client, withdraw residual air from the cuff, and reinflate it.

B Remove the malfunctioning cuff.

C Add more air to the cuff.

D Call the physician.

Question #24

A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?

A They help prevent pulmonary edema.

B They help prevent pneumothorax.

C They help prevent cardiac arrhythmias.

D They help prevent subcutaneous emphysema.

Question #25

The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse?

A Heart rate, 112 bpm

B Pain of 5 on a 1-to-10 scale

C Moderate amounts of colorless sputum

D Chest tube drainage, 190 mL/hr

Question #26

A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention?

A Assist with positioning the client on the right side.

B Restrict intravenous fluids for at least 24 hours.

C Make sure that a thoracotomy tube is linked to open chest drainage.

D Encourage coughing to mobilize secretions.

Question #27

Which type of oxygen therapy includes the administration of oxygen at pressure greater than atmospheric pressure?

A High-flow systems

B Low-flow systems

C Transtracheal

D Hyperbaric

Question #28

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which oxygen delivery method would give the greatest level of inspired oxygen?

A Simple mask

B Nonrebreather mask

C Nasal cannula

D Face tent

Question #29

A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do?

A Clamp the chest tube immediately.

B Secure the chest tube with tape.

C Place the end of the chest tube in a container of sterile saline.

D Apply an occlusive dressing and notify the physician.

Question #30

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?

A “Don’t use the incentive spirometer more than 5 times every hour.”

B “Breathe in and out quickly.”

C “Before you do the exercise, I’ll give you pain medication if you need it.”

D “You need to start using the incentive spirometer 2 days after surgery.”

Question #31

Hyperbaric oxygen therapy increases the blood’s capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:

A a compromised skin graft.

B a malignant tumor.

C hyperthermia.

D pneumonia.

Question #32

The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?

A Histotoxic hypoxia

B Circulatory hypoxia

C Anemic hypoxia

D Hypoxic hypoxia

Question #33

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?

A The patient is hypoxic from suctioning.

B The patient is having a myocardial infarction.

C The patient is in a hypermetabolic state.

D The patient is having a stress reaction

Question #34

A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?

A Hypoxia

B Oxygen-induced hypoventilation

C Oxygen toxicity

D Oxygen-induced atelectasis

Question #35

The nurse is preparing to assist the health care provider to remove a client’s chest tube. Which instruction will the nurse correctly give to the client?

A “Exhale forcefully while the chest tube is being removed.”

B “While the chest tube is being removed, raise your arms above your head.”

C “Do not move during the removal of the chest tube because moving will make it more painful.”

D “When the tube is being removed, take a deep breath, exhale, and bear down.”

Question #36

Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate?

A Assist control

B SIMV

C Pressure support

D IMV

Question #37

Which is a potential complication of a low pressure in the endotracheal tube cuff?

A Tracheal bleeding

B Pressure necrosis

C Tracheal ischemia

D Aspiration pneumonia

Question #38

Which is a potential complication of a low pressure in the endotracheal tube cuff?

A Pressure necrosis

B Tracheal bleeding

C Aspiration pneumonia

D Tracheal ischemia

Question #39

Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?

A T-piece

B Partial-rebreathing mask

C Nasal cannula

D Venturi mask

Question #40

Which oxygen administration device has the advantage of providing a high oxygen concentration?

A Venturi mask

B Nonrebreathing mask

C Catheter

D Face tent

Question #41

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

A Suction the client’s artificial airway.

B Ventilate the client with a handheld mechanical ventilator

C Increase the oxygen percentage.

D Check for an apical pulse.

Question #42

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?

A Inform the patient that using the spirometer is not necessary if the patient is experiencing pain

B Have the patient lie in a supine position during the use of the spirometer.

C Encourage the patient to try to stop coughing during and after using the spirometer.

D Encourage the patient to take approximately 10 breaths per hour, while awake.

Question #43

Which type of ventilator has a preset volume of air to be delivered with each inspiration?

A Pressure cycled

B Time cycled

C Volume cycled

D Negative pressure

Question #44

A client is on a positive–pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse

A Consults with the physician about removing the client from the ventilator

B Contacts the respiratory therapy department to report the ventilator is malfunctioning

C Continues assessing the client’s respiratory status frequently

D Changes the setting on the ventilator to increase breaths to 14 per minute

Question #45

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

A Bicarbonate (HCO3–)

B pH

C Partial pressure of arterial oxygen (PaO2)

D Partial pressure of arterial carbon dioxide (PaCO2)

Question #46

The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?

A Routinely deflating the cuff

B Deflating the cuff before removing the tube

C Checking the cuff pressure every 6 to 8 hours

D Ensuring that humidified oxygen is always introduced through the tube

Question #47

A new ICU nurse is observed by her preceptor entering a patient’s room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?

A Auscultate the lung for adventitious sounds.

B Have the patient inform the nurse of the need to be suctioned.

C Have the patient cough.

D Assess the CO2 level to determine if the patient requires suctioning.

Question #48

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?

A pH

B PCO2

C HCO3

D PaO2

Question #49

The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if preformed by the nurse, indicates the need for further review of the procedure?

A Cleans the wound and the plate with a sterile cotton tip moistened with hydrogen peroxide

B Places clean tracheostomy ties then removes soiled ties after the new ties are in place

C Dries and reinserts the inner cannula or replaces it with a new disposable inner cannula

D Puts on clean gloves; removes and discards the soiled dressing in a biohazard container

Question #50

A client with a respiratory condition is receiving oxygen therapy. While assessing the client’s PaO2, the nurse knows that the therapy has been effective based on which of the following readings?

A 84 mm Hg

B 45 mm Hg

C 58 mm Hg

D 120 mm Hg

Question #51

Which ventilator mode provides full ventilatory support by delivering a preset tidal volume and respiratory rate?

A IMV

B Pressure support

C Assist control

D SIMV

Question #52

Which type of ventilator has a preset volume of air to be delivered with each inspiration?

A Negative-pressure

B Volume-controlled

C Time-cycled

D Pressure-cycled

Question #53

For a client with an endotracheal (ET) tube, which nursing action is the most important?

A Turning the client from side to side every 2 hours

B Auscultating the lungs for bilateral breath sounds

C Providing frequent oral hygiene

D Monitoring serial blood gas values every 4 hours

Question #54

A client suffers acute respiratory distress syndrome as a consequence of shock. The client’s condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

A A disconnected ventilator circuit

B Kinking of the ventilator tubing

C A change in the oxygen concentration without resetting the oxygen level alarm

D An ET cuff leak

Question #55

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?

A Collection chamber

B Water-seal chamber

C Suction control chamber

D Air-leak chamber

Question #56

The nurse is assigned to care for a client with a chest tube. The nurse should ensure that which item is kept at the client’s bedside?

A A bottle of sterile water

B An Ambu bag

C An incentive spirometer

D A set of hemostats

Question #57

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for

A A kink in the ventilator tubing

B Higher than normal endotracheal cuff pressure

C A cut or slice in the tubing from the ventilator

D Malfunction of the alarm button

Question #58

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for how long?

A 30 to 35 seconds

B 20 to 25 seconds

C 10 to 15 seconds

D 0 to 5 seconds

Question #59

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

A The client has a pneumothorax.

B The chest tube is obstructed.

C The system is functioning normally.

D The system has an air leak.

Question #60

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?

A Keeping the collection chamber at chest level

B Measuring and documenting the drainage in the collection chamber

C Stripping the chest tube every hour

D Maintaining continuous bubbling in the water-seal chamber

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