oxygenation practice questions - Sheet1

Question 1

1. The nurse is preparing to perform nasotracheal suctioning on a patient. Arrange the steps in order.
2. Apply suction.
3. Assist patient to semi-Fowler’s or high Fowler’s position, if able.
4. Advance catheter through nares and into trachea.
5. Have patient take deep breaths.
6. Lubricate catheter with water-soluble lubricant.
7. Apply sterile gloves.
8. Perform hand hygiene.
9. Withdraw catheter.

Answer 1

Answer: 7, 2, 6, 4, 5, 3, 1, 8
Rationale: Performing hand hygiene ensures asepsis. Positioning aids airway access, and sterile technique with lubrication protects the mucosa. Proper sequencing optimizes suctioning.

Question 2

2. Which skills can the nurse delegate to assistive personnel (AP)? (Select all that apply.)
3. Initiate oxygen therapy via nasal cannula.
4. Perform nasotracheal suctioning of a patient.
5. Educate the patient about the use of an incentive spirometer.
6. Assist with care of an established tracheostomy tube.
7. Reposition a patient with a chest tube.

Answer 2

Answer: 4, 5
Rationale: APs can assist with routine tracheostomy care and repositioning but cannot perform invasive procedures or provide patient education.

Question 3

3. 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?
4. Start oxygen at 2 L/min via nasal cannula.
5. Elevate the head of the bed to 45 degrees.
6. Encourage the patient to use the incentive spirometer.
7. Notify the health care provider.

Answer 3

Answer: 2
Rationale: Elevating the head of the bed improves lung expansion and helps the patient clear secretions. Oxygen and other actions follow if necessary.

Question 4

4. 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?
5. “Pursed-lip breathing is like exercise for my lungs and will help me strengthen my breathing muscles.”
6. “When I am sick, I should limit the amount of fluids I drink so that I don’t produce excess mucus.”
7. “I will ensure that I receive an influenza vaccine every year, preferably in the fall.”
8. “I will look for a smoking-cessation support group in my neighborhood.”

Answer 4

Answer: 2
Rationale: Limiting fluids is incorrect; staying hydrated thins mucus, which aids clearance in COPD. Other statements are correct for COPD management.

Question 5

5. Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention? (Select all that apply.)
6. SpO2 value of 95%
7. Chest retractions
8. Respiratory rate of 28 breaths per minute
9. Nasal flaring
10. Clubbing of fingers

Answer 5

Answer: 2, 3, 4
Rationale: Chest retractions, tachypnea, and nasal flaring signal respiratory distress. SpO2 of 95% is normal; clubbing indicates chronic hypoxia, not acute distress.

Question 6

6. The nurse is caring for a patient with an artificial airway. What are reasons to suction the patient? (Select all that apply.)
7. The patient has visible secretions in the airway.
8. There is a sawtooth pattern on the patient’s EtCO2 monitor.
9. The patient has clear breath sounds.
10. It has been 3 hours since the patient was last suctioned.
11. The patient has excessive coughing.

Answer 6

Answer: 1, 2, 5
Rationale: Visible secretions, sawtooth EtCO2 patterns, and excessive coughing indicate a need for suctioning. Clear breath sounds and routine intervals do not justify suctioning.

Question 7

7. The nurse is caring for a patient with a chest tube for treatment of a right pneumothorax. Which assessment finding necessitates immediate notification of the health care provider?
8. New, vigorous bubbling in the water-seal chamber.
9. Scant amount of sanguineous drainage noted on the dressing.
10. Clear but slightly diminished breath sounds on the right side of the chest.
11. Pain score of 2 one hour after the administration of the prescribed analgesic.

Answer 7

Answer: 1
Rationale: New, vigorous bubbling may indicate an air leak and requires prompt intervention. The other findings are expected or manageable.

Question 8

8. 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.)
9. Perform chest compressions.
10. Ask someone to bring the automatic external defibrillator (AED) to the room for immediate defibrillation.
11. Apply oxygen via nasal cannula.
12. Place the patient supine.
13. Educate the family about the need for CPR.

Answer 8

Answer: 1, 2, 4
Rationale: Chest compressions, using an AED, and ensuring a supine position are critical actions during cardiac arrest. Education can occur later.

Question 9

9. The nurse is performing tracheostomy care on a patient. What finding would indicate that the tracheostomy tube has become dislodged?
10. Clear breath sounds
11. Patient speaking to nurse
12. SpO2 reading of 96%
13. Respiratory rate of 18 breaths/minute

Answer 9

Answer: 2
Rationale: A tracheostomy patient speaking indicates dislodgement as airflow bypasses the tracheostomy tube. Other findings suggest normal function.