resp 1-3 Flashcards
<p>10. Which of the following skills can safely be delegated routinely to an NAP?
A. Oropharyngeal suctioning
B. Airway suctioning using a closed method
C. Endotracheal tube care
D. Tracheostomy care</p>
<p>A. Oropharyngeal suctioningRationaleAlthough an NAP may routinely handle oropharyngeal suctioning, the other skills require the training and judgment of an RN. The nurse is responsible for cardiopulmonary assessment and evaluation of the patient during the skill performance. Only in cases of a permanent tracheostomy or a well-established artificial airway in a stable patient may the skill of suctioning be delegated to an NAP.</p>
<p>11. Why is it important to assess a patient's understanding of a procedure?
A. Encourages cooperation of the patient during and after the procedure
B. Minimizes risks to the patient
C. Identifies teaching needs
D. All of the above</p>
<p>D. All of the aboveRationaleAll of these outcomes are applicable to assessing patient knowledge of the procedure. If the patient understands what will happen to him during a procedure and why this is important for his health, he tends to cooperate during and after the procedure. If the patient understands the procedure and what he needs to do afterward to remain safe and free of complications, risks will be minimized. Also, by discussing the procedure with the patient, the nurse can identify teaching needs.</p>
<p>12. If a patient is accidentally extubated, which of the following actions are appropriate?
A. Remain with the patient.
B. Assist respirations with bag-valve mask as needed.
C. Assess patient for airway patency, spontaneous breathing, and vital signs
.D. Prepare for reintubation.
E. All of the above.</p>
<p>E. All of the above.RationaleAll of the listed interventions are appropriate for unexpected extubation. The nurse should stay with the patient until assistance arrives to continually assess respiratory status and the need for any of the listed interventions.</p>
<p>13. Several factors affect the volume and consistency of endotracheal secretions. Which of the following causes an increase in the amount and thickness of secretions? Choose all that apply .A. Fluid intake B. Infection C. Respiratory rate D. Humidification</p>
<p>B. InfectionRationalePatients with respiratory infection, such as pneumonia, are prone to increased secretions that are thicker and sometimes are more difficult to expectorate. Fluid intake increases the amount of secretions but will thin them. Humidity loosens secretions, facilitating airway suctioning when the patient cannot clear secretions effectively. Rate of respirations will not effect the amount or viscosity of secretions.</p>
<p>15. Which chest tube placement location promotes the removal of air?
A. Apical (second or third intercostal space)
B. Mediastinal
C. Posterior (fifth or sixth intercostal space)
D. None of the above</p>
<p>A. Apical (second or third intercostal space)RationaleThe location of the chest tube indicates the type of drainage expected. Apical (second or third intercostal space) and anterior chest tube placement promote removal of air. Because air rises, these chest tubes are placed high, allowing evacuation of air from the intrapleural space and lung reexpansion.</p>
<p>17. Current evidence indicates that patients who have chest tubes longer than 20 days are at increased risk for health care–associated infection (HAI). Which of the following nursing interventions are appropriate for decreasing this risk? Choose all that apply.
A. Encouraging deep breathing exercises
B. Assisting patient with early mobility
C. Refraining from use of analgesia because this would depress respirations
D. Providing patient education regarding these practices</p>
<p>A. Encouraging deep breathing exercisesB. Assisting patient with early mobilityD. Providing patient education regarding these practicesRationaleResearchers have found that patients who have chest tubes longer than 20 days are at six times greater risk of developing an HAI than those who have chest tubes for a period shorter than 20 days. On the basis of this information, nurses should be vigilant regarding the need for a chest tube, should encourage deep breathing exercises and early mobility, as well as use of appropriate analgesia to promote activity, and should provide patient education regarding these practices. Patients should be given appropriate analgesia so they will be able to increase their mobility and to cough and deep breathe more effectively.</p>
<p>19. An unconscious patient with a head injury has an oral airway that has been taped in place for several days. Which assessment information obtained by the nurse is most critical because of the patient's status?
A. Frequency of mouth care with lemon glycerin swabs
B. Condition of the lips and surrounding skin
C. How often the patient is being repositioned
D. Status of the patient's oral airway</p>
<p>B. Condition of the lips and surrounding skinRationaleThe patient is unable to let the nursing staff know whether the lips or the skin around the mouth is hurting. An oral airway can cause significant lip and tongue erosion. Lemon glycerin swabs should not be used because they are drying to mucosal tissues. The other assessments are important but do not relate to the presence of the oral airway.</p>
<p>8. Before discharge, the nurse designs a patient teaching plan to help the patient and family correctly perform chest physiotherapy. Why is this teaching an important aspect of patient safety?
A. Reduces readmission to a health care facility
B. Decreases the amount of medical equipment needed in the home care setting
C. Because patients and families need to know changes or effects associated with chest PT and when to notify the health care providerD. Decreases anxiety of the family caregiver</p>
<p>C. Because patients and families need to know changes or effects associated with chest PT and when to notify the health care providerRationaleThe patient and the caregiver need to know and recognize changes in the patient's respiratory or physiologic status to determine the effectiveness of therapy and to know when they should inform the health care provider of the need for additional therapy.</p>
<p>9. A patient is receiving chest physiotherapy in the home setting. The home health nurse observes the session and notes that the patient is not tolerating the procedure well. Which of the following is the best choice for modifying care?A. Reduce treatments by 2 per day.B. Suggest using an Acapella device.C. Let the patient select when treatment is given.D. Administer a bronchodilator therapy.</p>
<p>B. Suggest using an Acapella device.RationaleAn Acapella device in conjunction with CPT maneuvers provides airway vibration and assists in clearing the airways. Reducing treatment sessions at all is not acceptable because the patient needs the therapy. The nurse may shorten the session if the patient is able to clear the airway with a shorter session. Administering a bronchodilator requires an order from the health care provider; this would take some time, and the nurse can institute other therapies. Letting the patient select when to have CPT therapy may not be appropriate in that these therapies may have to be scheduled at specific time periods.</p>
<p>A cough generally becomes significant when it</p>
<p>persists, is recurring, or is productive.</p>
<p>A patient experiences severe dyspnea and hemoptysis during a session of chest physiotherapy (CPT). After stopping the CPT, what is the initial appropriate nursing intervention?o 1Notifying the health care providero 2Administering a bronchodilator to ease the dyspneao 3Assessing patiento 4Elevating the head of patient's bed</p>
<p>3 Rationale: A current assessment of the patient is needed before decisions regarding treatment can be made. There can be a number of causes for the dyspnea and the bleeding. The health care provider will be notified but will expect current patient information to be available.</p>
<p>A patient has a respiratory rate of 30 breaths/min that is rhythmic and moderate in depth. What term would you use to describe this breathing pattern?</p>
<p>Tachypnea</p>
<p>A patient hospitalized for acute pneumonia has a 10-year history of chronic lung disease and cannot clear her respiratory secretions from the posterior pharynx even with coughing. Which suctioning intervention is appropriate? o 1Oropharyngealo 2Nasopharyngealo 3Endotrachealo 4Tracheal</p>
<p>1 Rationale: Oropharyngeal suction uses a Yankauer or tonsillar tip suction device to remove large amounts of thick mucus. This would be most appropriate for a patient who cannot clear her airway by herself and does not have an artificial airway.</p>
<p>A patient is in the intensive care unit after a thoracotomy and has subsequent hypoxia. Which of the following manifestations is an associated symptom of hypoxia?o 1Increased mentationo 2Feeling of calmo 3Normal heart rate and rhythmo 4Lethargy</p>
<p>4 Rationale: The common symptom of hypoxia is lethargy. Patients exhibit anxiety and restlessness, not a feeling of calmness, with hypoxia. In addition, patients will have tachycardia and potential dysrhythmias secondary to hypoxia. Hypoxia can cause all patients to be confused with a diminished level of consciousness</p>
<p>A patient is receiving oxygen by nasal cannula. Which statement by the patient indicates that teaching regarding oxygen therapy has been effective?o 1“I was feeling better, so I removed my oxygen.”o 2“I asked my spouse not to put Vaseline on my lips.”o 3“I can take off my oxygen to walk to the bathroom.”o 4“I do not want to be oxygen dependent, so I need continuous pulse oximetry.”</p>
<p>2 Rationale: Petroleum jelly products should not be used around oxygen because of the possibility of friction, which can cause a fire. Options 1, 3, and 4 demonstrate that the patient needs education.</p>
<p>A patient is to be placed on a ventilator. Which nursing action has been found to be most effective in reducing ventilator-associated pneumonia?A. Performing mouth care at least four times a dayB. Repositioning the patient every 2 to 3 hoursC. Assessing lung sounds every shiftD. Performing range-of-motion exercises three times a day</p>
<p>A. Performing mouth care at least four times a dayRationaleStudies have shown that frequent mouth care decreases the incidence of ventilator-associated pneumonia. The other procedures are important to do, but they do not affect the incidence of ventilator-associated pneumonia.</p>
<p>A patient needing chest physiotherapy finished his lunch at 1 PM. When is the soonest that he should receive postural drainage?o 130 minutes latero 2At 2 PMo 3Before his next snacko 4Right after dinner</p>
<p>2 Rationale: Postural drainage should be avoided for 1 to 2 hours after meals. If he finished his lunch at 1 PM, the soonest that postural drainage can be done is at 2 PM.</p>
<p>A patient needs an FiO2 of 80%. Which of these oxygen delivery devices can deliver oxygen at this FiO2 level? (Select all that apply.)o 1Nasal cannula at 6 L/mino 2Venturi mask at 12 L/mino 3Nonrebreathing mask at 6 L/mino 4Partial rebreathing mask at 6 L/min</p>
<p>2 Rationale: A Venturi mask is the only method of delivering an FiO2 of 80% with the stated liters per minute. The nasal cannula delivers 44% at most, the partial rebreather must be set at a minimum of 8 liters, and the nonrebreather must be set at a minimum of 6 liters.</p>
<p>A patient needs both the trachea and the oral pharynx suctioned. In which order should the nurse suction these areas and why? Place in correct order. o 1Suction the oral cavity lasto 2Suction the oral cavity firsto 3Suction nasotracheally firsto 4Suction nasotracheally last</p>
<p>1, 3 Rationale: There are usually fewer infectious microorganisms in the trachea compared with the mouth. Suction from the least contaminated to the most contaminated.</p>
<p>A patient with pneumonia has a major significant accumulation of thick secretions and requires chest physiotherapy (CPT). Which action by the nurse will help the patient clear respiratory secretions following CPT?o 1Set up a fluid intake schedule with a goal of 1500 mL/dayo 2Have patient use his incentive spirometer twice each shifto 3Ambulate patient as much as possible to prevent stasiso 4Encourage patient to take several warm showers every day</p>
<p>1 Rationale: To help liquefy secretions, patients need a minimum of 1500 mL daily unless contraindicated by other physiologic problems. Setting up a fluid intake schedule would best help alleviate this problem</p>
<p>A patient with pulmonary edema had BiPAP started 30 minutes ago. The nurse should inform the patient that he will undergo which diagnostic test shortly?A. Arterial blood gasB. Chest X-rayC. Pulmonary function testD. Pulse oximetry reading</p>
<p>A. Arterial blood gasRationaleWhen a patient is placed on noninvasive positive-pressure ventilation (BiPAP), it is necessary to evaluate the oxygenation and ventilation status of the patient. Although an arterial blood gas is an invasive procedure, it is important to know the patient's oxygen and carbon dioxide levels. Chest X-ray will provide information on fluid overload, and a pulmonary function test is inappropriate when a patient is acutely ill. A pulse oximetry reading would yield information on oxygenation.</p>
<p>At the beginning of the shift, you have only one critical care bed available. During your shift, you receive calls for assistance on the following patients:• Patient A has burns on her face, scalp, and chest and is coughing up sputum with black streaks.• Patient B has pneumonia and has suddenly become confused.• Patient C is short of breath and complaining that he can’t breathe. His skin is cool and moist, and he is coughing up clear sputum with small bubbles in it.• Which patient would you admit to the critical care bed? Why?</p>
<p>All of these patients have problems affecting oxygenation that may require admission to a critical care bed. Consider which patient is at immediate risk. When immediate risk isconsidered, patient C is the correct answer.</p>
<p>begins when the diaphragm contractsand the chest cavity is pulled downward.</p>
<p>Inhalation</p>
<p>both \_\_\_\_\_\_\_\_\_ and \_\_\_\_\_\_\_\_ report to the respiratory center in the brainstem</p>
<p>chemoreceptors and lung receptors</p>
<p>causes a low level of dissolved carbon dioxide in the blood, called hypocarbia (also called hypocapnia).</p>
<p>Hyperventilation</p>
<p>causes an excess of dissolved carbon dioxide in the blood, called hypercarbia (also called hypercapnia).</p>
<p>Hypoventilation</p>
<p>Chemoreceptors</p>
<p>detect changes in blood pH, O2, and CO2 levels,</p>
<p>Chemoreceptors located</p>
<p>medulla of the brainstem, the carotid arteries, and the aorta</p>
<p>During chest physiotherapy (CPT) the patient's oxygen saturation goes from 96 to 90. Which action should the nurse take initially? o 1Check patient's vital signso 2Stop the CPT session for that timeo 3Stop and ask patient how he feelso 4Listen to patient's lungs</p>
<p>3 Rationale: The oxygen saturation levels are reasonable considering what is being done to the patient. If the patient says he feels all right, continue with the therapy while continuing to monitor him. If the patient doesn't feel well, stop the session and assess further.</p>
<p>How can you ensure that the suction catheter enters the trachea and not the esophagus?</p>
<p>• Insert the catheter into the pharynx.• Advance it into the trachea during inspiration.• Once the suction catheter enters the trachea, it will stimulate coughing. If the catheter is not advanced on inspiration, it will enter the esophagus and may trigger gagging or vomiting.</p>
<p>Humidification is added to a nasal cannula when the flow is set at:o 11 L/min.o 22 L/min.o 33 L/min.o 44 L/min.</p>
<p>4 Rationale: When the oxygen rate is 4 L/min or greater, humidification is needed to prevent drying of the nasal mucous membrane. Under 4 L the moisture can be provided by the nasal passages.</p>
<p>Hypoventilation severe enough to cause hypercarbia is usually associated with hypoxemia because</p>
<p>inadequate amounts of oxygen are inhaled.</p>
<p>hypoxic central nervous system tissue causes</p>
<p>abnormal brain functioning (e.g., altered level of consciousness),</p>
<p>hypoxic limb tissue results in</p>
<p>abnormal muscle functioning (e.g., muscle weakness and pain with exercise).</p>
<p>hypoxic renal tissue causes</p>
<p>abnormal kidney functioning (e.g., poor urine output</p>
