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 An oropharyngeal catheter

B A nasal cannula

C A Venturi mask

D A nonrebreathing mask

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 Ensuring that the client remains sedated while intubated

B Turning and repositioning the client every 4 hours

C Maintaining the client in a high Fowler’s position

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

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

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

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

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 Bradycardia

C Substernal pain

D Mood swings

E Dyspnea

Question #5

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

A Use the spirometer twice every hour

B Expect coughing when using the spirometer properly.

C Inhale and exhale rapidly with the spirometer.

D Maintain a supine position to use the spirometer.

Question #6

Which is a correct endotracheal tube cuff pressure?

A 16 mm Hg

B 19 mm Hg

C 22 mm Hg

D 13 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 take a deep breath as the nurse deflates the cuff.

B hold the breath as the cuff is being reinflated.

C exhale deeply as the nurse reinflates the cuff.

D cough as the cuff is being deflated.

Question #8

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

B hold the breath as the cuff is being reinflated.

C exhale deeply as the nurse reinflates the cuff.

D cough as the cuff is being deflated.

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 Tracheal aspiration

B Tracheal bleeding

C Hypoxia

D Tracheal ischemia

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 will assist with widening the airway.

C It prolongs exhalation.

D It will prevent the alveoli from overexpanding.

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

B Promote the client’s ability to take in oxygen

C Promote the strengthening of the client’s diaphragm

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 reduce stress on the myocardium

B To provide adequate transport of oxygen in the blood

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

D To clear respiratory secretions

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 Impaired physical mobility related to being on a ventilator

B Risk for infection related to endotracheal intubation and suctioning

C Risk for trauma related to endotracheal intubation and cuff pressure

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 report fluctuations in the water-seal chamber.

B encourage coughing and deep breathing.

C milk the chest tube every 2 hours.

D clamp the chest tube once every shift.

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 synchronized intermittent mandatory ventilation (SIMV).

C pressure support ventilation (PSV).

D continuous positive airway pressure (CPAP).

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 Disconnect the system and get another.

B Place the head of the patient’s bed flat

C Milk the chest tube.

D Notify the physician.

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 be extubated and a nasotracheal tube will be inserted.

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

D The patient will begin the weaning process.

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 Manually ventilate the client.

C Notify the respiratory therapist.

D Reposition the endotracheal tube.

Question #19

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

A Wedge resection

B Pneumonectomy

C Lobectomy

D Segmentectomy

Question #20

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

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

B Draw blood for a hematocrit and hemoglobin level.

C Prepare a chest tube insertion tray.

D Prepare to start an I.V. line.

Question #21

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

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

B Prepare a chest tube insertion tray.

C Prepare to start an I.V. line.

D Draw blood for a hematocrit and hemoglobin level.

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 15 to 60 seconds.

B 30 to 40 minutes.

C 45 to 60 minutes.

D 5 to 20 minutes.

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 Call the physician.

B Remove the malfunctioning cuff.

C Add more air to the cuff.

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

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 cardiac arrhythmias.

C They help prevent subcutaneous emphysema.

D They help prevent pneumothorax.

Question #25

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

A Moderate amounts of colorless sputum

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

C Chest tube drainage, 190 mL/hr

D Heart rate, 112 bpm

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 Restrict intravenous fluids for at least 24 hours.

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

C Assist with positioning the client on the right side.

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 Hyperbaric

B Low-flow systems

C Transtracheal

D High-flow systems

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 Nasal cannula

C Face tent

D Nonrebreather mask

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

B Apply an occlusive dressing and notify the physician.

C Secure the chest tube with tape.

D Clamp the chest tube immediately.

Question #30

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

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

B “Breathe in and out quickly.”

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

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

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 hyperthermia.

B a malignant tumor.

C pneumonia.

D a compromised skin graft.

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 Hypoxic hypoxia

B Circulatory hypoxia

C Anemic hypoxia

D Histotoxic 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 having a stress reaction

B The patient is hypoxic from suctioning.

C The patient is in a hypermetabolic state.

D The patient is having a myocardial infarction.

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-induced atelectasis

D Oxygen toxicity

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

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

Question #36

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

A Assist control

B IMV

C SIMV

D Pressure support

Question #37

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

A Tracheal ischemia

B Tracheal bleeding

C Aspiration pneumonia

D Pressure necrosis

Question #38

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

A Tracheal bleeding

B Tracheal ischemia

C Pressure necrosis

D Aspiration pneumonia

Question #39

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

A Partial-rebreathing mask

B Venturi mask

C Nasal cannula

D T-piece

Question #40

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

A Face tent

B Venturi mask

C Catheter

D Nonrebreathing mask

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 Negative pressure

B Volume cycled

C Time cycled

D Pressure cycled

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 Continues assessing the client’s respiratory status frequently

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

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

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

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 carbon dioxide (PaCO2)

D Partial pressure of arterial oxygen (PaO2)

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 cough.

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

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

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

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

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

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 58 mm Hg

B 45 mm Hg

C 84 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 Assist control

B IMV

C Pressure support

D SIMV

Question #52

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

A Time-cycled

B Negative-pressure

C Pressure-cycled

D Volume-controlled

Question #53

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

A Auscultating the lungs for bilateral breath sounds

B Turning the client from side to side every 2 hours

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

C Kinking of the ventilator tubing

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 Suction control chamber

B Air-leak chamber

C Water-seal chamber

D Collection 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 set of hemostats

B An Ambu bag

C An incentive spirometer

D A bottle of sterile water

Question #57

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

A Higher than normal endotracheal cuff pressure

B Malfunction of the alarm button

C A kink in the ventilator tubing

D A cut or slice in the tubing from the ventilator

Question #58

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

A 10 to 15 seconds

B 30 to 35 seconds

C 0 to 5 seconds

D 20 to 25 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 system is functioning normally.

B The system has an air leak.

C The chest tube is obstructed.

D The client has a pneumothorax.

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 Measuring and documenting the drainage in the collection chamber

B Maintaining continuous bubbling in the water-seal chamber

C Keeping the collection chamber at chest level

D Stripping the chest tube every hour

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