lesson 9 Flashcards
Nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? SATA
a. restlessness
b. tachypnea
c. bradycardia
d. confusion
e. hypertention
a. restlessness
b. tachypnea
d. confusion
e. hypertention
INCORRECT
c. bradycardia -
late stage of hypoxia , along with stupor, cyanotic skin & mucous membranes , bradypnea, hypotension, and cardiac dysrhythmias
provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. client and family teaching by the nurse should include which of the following instructions? SATA
a. apply petroleum jelly around the inside the nares
b. remove the nasal cannula during mealtimes
c. check the position of the cannula frequently
d. report any nausea or difficulty breathing
e. post “no smoking” signs in prominent locations
c. check the position of the cannula frequently
- teach the client that a disadvantage of the nasal cannula is that it dislodges easily. the client should form the habit of checking its position periodically and readjusting it as necessary .
d. report any nausea or difficulty breathing
- teach the client about oxygen toxicity , which is a complication of oxygen therapy , usually from high concentrations or long durations. manifestations include a nonproductive cough, substernal pain, nausea and vomitting. the client should report any of these promptly.
e. post “no smoking” signs in prominent locations
-nobody in the house should smoke or use any device that may generate sparks in the area where the oxygen is in use.
Nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. which of the following interventions is the nurse’s priority?
a. increase the oxygen flow
b. assist the client to fowler’s position
c. promote removal of pulmonary secretions
d. obtain a specimen for arterial blood gases
b. assist the client to fowler’s position
- The priority action to be taken when using the airway, breathing, circulation (ABC) approach to care delivery is to relieve dyspnea. fowlers position facilitates maximum lung expansion and thus optimizes breathing. when the client in this position, the cause of the client’s dyspnea can better assessed and determined .
INCORRECT:
a. increase the oxygen flow
- there may be a need to increase the client’s oxygen flow, as hypoxia can be the cause of a client’s difficulty breathing. However, another action is the priority.
c. promote removal of pulmonary secretions
- there may be a need to suction that client’s airway of encourage expectoration of pulmonary secretions . However, another action is a priority.
d. obtain a specimen for arterial blood gases
- check the client’s oxygenation status. However, another action is the priority .
Nurse is preparing to perform endotracheal suctioning for a client. the nurse should fools which of the following guidelines? SATA
a. apply the oxygen source loosely if the sp02 decreases during the procedure.
b. perform suctioning on a routine basis every 2 to 3 hr.
c. maintain medial asepsis during suctioning
d. use a new catheter of each suctioning attempt
e. apply suction for 10 to 15 seconds
a. apply the oxygen source loosely if the sp02 decreases during the procedure.
-apply suction pressure only while withdrawing the catheter to prevent damaging the tracheal tissue.
d. use a new catheter of each suctioning attempt
-use a new catheter , unless an in line suctioning system is in place, to prevent contamination with micro-organisms that can cause an infection .
e. apply suction for 10 to 15 seconds
- to prevent hypoxemia, apply suction for only 10-15 seconds and allow 2-3 min between passes for ventilation and oxygenation
Nurse is caring for a client who has a tracheostomy. which of the following actions should the nurse take when providing tracheostomy care? SATA
a. apply the oxygen source loosely if the sp02 decreases during the procedure
b. use surgical asepsis to remove and clean the inner cannula
c. clean the outer cannula surfaces in a circular motion form the stoma site outward.
d. replace the tracheostomy ties with new ties
e. cut a slit in gauze squares to place beneath the tube holder
a. apply the oxygen source loosely if the sp02 decreases during the procedure
- provide supplemental oxygen in response to any decline in oxygen saturation while performing trach care.
b. use surgical asepsis to remove and clean the inner cannula
-use a sterile disposable trach cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure.
c. clean the outer cannula surfaces in a circular motion form the stoma site outward.
-cleanse the exposed surfaces of the outer cannula and the area around and under the faceplate in a circular motion from the stoma outward. cleansing in this manner helps move mucous and contaminated material away from the stoma for easy removal.
INCORRECT:
d. replace the tracheostomy ties with new ties
- replace the tracheostomy ties if they are wet or soiled . there is a risk of tube dislodgment with replacing the ties, do not replace them, routinely.
e. cut a slit in gauze squares to place beneath the tube holder
-use a commercially-prepared tracheostomy dressing with a slit in it. cutting gauze squares can loosen lint or gauze fibers the client could aspirate.
Nurse is delivering an enternal feeding to a client who has a NG tube in place for intermittent feedings. when the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why they water is necessary. which of he following responses should the nurse make?
A. Water helps clear the tube so it dont get clogged
B. flushing helps make sure the tube stays in place
c. this will help you get enough fluids
d. adding water makes the formula less concentrated
A. Water helps clear the tube so it dont get clogged
Nurse is caring for a client who is receiving continuous enternal feedings. which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding?
a. auscultate breath sounds
b. stop the feeding’
c. obtain a chest xray
d. initiate oxygen therapy
b. stop the feeding’
The greatest risk to the client is aspiration pneumonia the 1st action to take is to stop the feeding so that no more formula can enter the lungs. 🫁
Nurse is preparing to instill an enternal feeding for a client who has a NG tube in place. which of the following actions is the nurse’s highest assessment priority before performing this procedure?
a. check how long the feeding container has been open
b. verify the placement of the NG tube
c. confirm that the client does not have diarrhea
d. make sure the client is alert and oriented
b. verify the placement of the NG tube
-the greatest risk to the client receiving enternal feedings is injury from aspiration. The priority nursing assessment before initiating an enternal feeding is to verify proper placement of the NG tube.
a nurse is caring for a client in a long term care facility who is receiving enternal feedings via NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding? SATA
a. auscultate the bowel sounds
b. assist the client to an upright position
c. test the ph of gastric aspirate
d. warm the formula to body temperature
e. discard any residual gastric contents
a. auscultate the bowel sounds
-because the client’s gastrointestinal tract might not be able to absorb nutrients.
b. assist the client to an upright position
-atleast 30 degree elevation of the head of bed. upright positioning helps prevent aspiration.
c. test the ph of gastric aspirate
-before administering enternal feedings verify the placement of the NG tube. the only reliable method is X-ray confirmation, which is impractical prior to every feeding. Testing the ph of gastric aspirate is an acceptable method between X-ray confirmations.
INCORRECT
d. warm the formula to body temperature
- have the enternal formula at room temperature before administering the enternal feeding.
e. discard any residual gastric contents
- return the residual to the client’s stomach, unless the volume of gastric contents is more than 250mL or the facility has other guidelines in place.
nurse is preparing to insert an NG tube for a client who requires gastric decompression. which of the following actions should the nurse perform before beginning the procedure? SATA
a.Review a signal the client can use if feeling any distress
b. lay a towel across the client’s chest
c. admin a oral pain med
d. obtain a dobhoff tube for insertion
e. have a petroleum based lubricant avail
a.Review a signal the client can use if feeling any distress
-establish means for the client to communicate that they want to stop the procedure before inserting the NG tube
b. lay a towel across the client’s chest
- place a disposable towel across the client’s chest to provide for a clean environment and protect the clients gown from being soiled.
INCORRECT
c. admin a oral pain med
-the purpose of the procedure is to remove contents of stomach, the procedure would also remove the oral pain med
d. obtain a dobhoff tube for insertion
- plan to use the prescribed type of tube for gastric decompression, which is a Salem sump, Miller-abbott, or Levin.
a Dobhoff tube is for feeding.
e. have a petroleum based lubricant avail
-plan to use a waterbased lubricant to reduce complications from aspiration.
