Ch 41 review quiz etc Flashcards
Which skills can the nurse delegate to assistive personnel (AP)?
(Select all that apply.)
1. Initiate oxygen therapy via nasal cannula.
2. Perform nasotracheal suctioning of a patient.
3. Educate the patient about the use of an incentive spirometer.
4. Assist with care of an established tracheostomy tube.
5. Reposition a patient with a chest tube.
Answer: 4, 5. Assistive personnel (AP) are not allowed to initiate oxygen therapy, provide education, or perform NT suctioning on a patient. They are allowed to assist the nurse in performing tracheostomy tube care and with repositioning patients.
The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first?
1. Start oxygen at 2 L/min via nasal cannula.
2. Elevate the head of the bed to 45 degrees.
3. Encourage the patient to use the incentive spirometer.
4. Notify the health care provider.
Answer: 2. The HOB (head of bed) needs to be elevated to help increase lung expansion and ease work of breathing. Also, this makes it easier for the patient to expectorate.
The nurse is performing discharge teaching for a patient with
chronic obstructive pulmonary disease (COPD). What statement,
made by the patient, indicates the need for further teaching?
1. “Pursed-lip breathing is like exercise for my lungs and will help
me strengthen my breathing muscles.”
2. “When I am sick, I should limit the amount of fluids I drink so
that I don’t produce excess mucus.”
3. “I will ensure that I receive an influenza vaccine every year,
preferably in the fall.”
4. “I will look for a smoking-cessation support group in my neighborhood.”
Answer: 2. Patients need to make sure that they are adequately hydrated to liquefy secretions, making it easier to expectorate. Fluids should not be limited or else the mucus will become too thick. All the other answers indicate an understanding of the discharge plan.
Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention? (Select all that apply.)
1. SpO2 value of 95%
2. Chest retractions
3. Respiratory rate of 28 breaths per minute
4. Nasal flaring
5. Clubbing of fingers
Answer: 2, 3, and 4, found in Table 41.2. SpO2 of 95% is normal and requires no intervention. Clubbed fingers are an assessment finding associated with chronic hypoxia; this does not require immediate intervention.
The nurse has just witnessed her patient go into cardiac arrest.
The family is in the patient’s room at the time the cardiac arrest
occurs. What priority interventions should the nurse perform at
this time? (Select all that apply.)
1. Perform chest compressions.
2. Ask someone to bring the automatic external defibrillator
(AED) to the room for immediate defibrillation.
3. Apply oxygen via nasal cannula.
4. Place the patient supine.
5. Educate the family about the need for CPR.
Answer: 1, 2, and 4. The nurse needs to initiate CPR and chest compressions. The patient needs to be in a supine position for chest compressions to be effective. Applying a nasal cannula is ineffective as rescue breathing must be implemented. The family does need to be educated, but this is not the priority for the nurse at this time. The nurse should delegate escorting the family from the room to an assistive personnel. Educating the family about CPR can be delegated to
another nurse who is not actively engaged in the resuscitation.
