Skills Lab 4 Oxygen & Airway

Question 1

When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to help maintain good skin integrity?

A. Frequently applying moisturizing lotion to facial areas that come into contact with the cannula.
B. Removing the cannula every 2 hours for no longer than 10 minutes.
C. Assessing the skin of the patient’s outer ears, nares, and nasal mucosa for breakdown at least once per shift.
D. Instructing the patient to inform staff of any problems with facial dryness or cracking.

Answer 1

C

Question 2

When caring for a patient who is receiving oxygen by simple face mask, which action ensures that the rate of oxygen being delivered is appropriate?

A. Frequently asking the patient how he or she is breathing.
B. Ensuring that the oxygen tubing is pulled tight, with little or no slack.
C. Securing the oxygen tubing to the patient’s clothing to prevent tugging.
D. Assessing for proper placement of the mask on the patient’s face.

Answer 2

D

Question 3

When caring for a patient for whom oxygen by nonrebreathing mask has been ordered, which action ensures appropriate oxygen delivery?

A. Looping the oxygen tubing around the side rail of the bed
B. Assessing breath sounds every shift
C. Securing the tubing snugly to the patient’s gown
D. Assessing that the reservoir bag stays inflated

Answer 3

D

Question 4

When caring for a patient who is receiving supplemental oxygen by face tent, which action ensures that the oxygen is flowing?

A. Testing the closing capacity of the mask’s valves
B. Routinely monitoring the seal over the patient’s mouth and nose
C. Ensuring that a mist is always present
D. Regularly verifying that the mask is positioned loosely

Answer 4

C

Question 5

What would the nurse do when receiving an order to increase the delivery rate of a patient’s oxygen per nasal cannula from 1 L/min to 3 L/min?

A. Encourage the patient to take deeper breaths in order to get more oxygen
B. Change the device from nasal cannula to simple face mask
C. Ensure that humidification is present
D. Adjust the float ball on the flow meter to 3 L/min

Answer 5

D

Question 6

What would the nurse do first when preparing to begin oxygen therapy for a patient?

A. Educate the NAP about the oxygen orders.
B. Review the medical prescription for delivery method and flow rate.
C. Place a “No Smoking” sign outside of the hospital room.
D. Ensure that suction equipment is present in the room.

Answer 6

B

Question 7

When preparing the patient’s environment for safe oxygen therapy, which intervention is a priority to minimize the patient’s risk for injury?

A. Place appropriate signage to alert staff and visitors to the presence of oxygen in the patient’s room.
B. Instruct nursing assistive personnel (NAP) to immediately correct or report safety hazards.
C. Inspect all electrical equipment in the patient’s room for the presence of safety-check tags.
D. Ensure that the patient receives the prescribed amount of oxygen via the appropriate method.

Answer 7

C

Question 8

When a patient is receiving oxygen at home, which instruction to the family would help them understand how to use the oxygen safely?

A. Increase the oxygen level as needed for the patient’s comfort.
B. Store extra oxygen cylinders horizontally.
C. Place a “No Smoking” sign at the entrance to the house.
D. Keep oxygen 5 feet (about 1.5 meters) away from anything that could generate a spark.

Answer 8

C

Question 9

What would the nurse do first when preparing to educate the patient about safe administration of oxygen therapy at home?

A. Evaluate the patient’s understanding of the combustible nature of oxygen.
B. Arrange for a capable family member to be present during the initial discussion.
C. Collect written information to present to the patient as supplemental instructional materials.
D. Assess the patient’s emotional readiness and physical ability to provide autonomous care.

Answer 9

D

Question 10

Which statement by the patient would indicate that he or she understands the safe use of oxygen?

A. “The nurse told me that my oxygen saturation must be maintained at 85% or above.”
B. “I know that oxygen is a medication I can adjust whenever I need to.”
C. “I’ll alert the nurse immediately if I have any increased difficulty breathing.”
D. “I often experience difficulty breathing for no apparent reason, but that is expected.”

Answer 10

C

Question 11

What would the nurse do first to ease breathing for a patient with mild dyspnea?

A. Administer oxygen at 2 L/min by nasal cannula.
B. Help the patient into an upright sitting position.
C. Monitor the patient’s pulse oximetry level.
D. Determine if the patient has a history of respiratory pathology.

Answer 11

B

Question 12

During an admission interview, a patient who is required to stay in the supine position reports, “I can’t breathe well while I’m lying down.” What would the nurse do first to help this patient?

A. Notify the health care provider of the patient’s complaint.
B. Request that the health care provider prescribe oxygen therapy.
C. Interview the patient concerning the onset of this problem.
D. Instruct the patient to use two bed pillows when lying supine.

Answer 12

D

Question 13

The nurse is caring for a patient who is recovering from a left partial lobectomy. Which action would be most helpful in reexpanding the affected lung?

A. Placing the patient in a right side-lying position
B. Encouraging the patient to deep breathe and cough every hour
C. Regularly assessing the patient’s ability to breathe comfortably
D. Providing medication to manage postoperative pain of greater than 3 on a 0-to-10 scale

Answer 13

A

Question 14

What is the purpose of splinting the abdomen with a small pillow during controlled coughing?

A. To minimize chest discomfort caused by the coughing
B. To expand lung capacity during the inspiratory phase of the cough
C. To maximize transdiaphragmatic pressure during the expiratory phase of the cough
D. To focus the patient’s attention on the abdominal muscles used during the cough

Answer 14

C

Question 15

What would the nurse do routinely to monitor oxygenation in a patient receiving BiPAP?

A. Assess the patient’s level of consciousness every 4 hours.
B. Monitor the patient’s pulse oximetry readings.
C. Verify the pressure settings for both inspiratory and expiratory pressure.
D. Evaluate daily arterial blood gases (ABGs)

Answer 15

B

Question 16

Which action is part of the preparation for nasotracheal suctioning?

A. Place the patient in a supine position.
B. Preoxygenate the patient with 100% oxygen.
C. Suction 100 mL of warm tap water to flush the suction catheter.
D. Place water-soluble lubricant onto the open sterile catheter package.

Answer 16

D

Question 17

Which response would the nurse report immediately if it occurred in association with nasotracheal suctioning?

A. Patient complains of discomfort during the procedure.
B. Patient has a severe bout of nonproductive coughing and complains of sore throat.
C. After oxygen delivery device has been reapplied on completion of the procedure, patient’s pulse oximetry reading falls to 88%.
D. Patient’s pulse rate increases by 10 bpm.

Answer 17

C

Question 18

While suctioning the nasotracheal airway, the nurse notes that a patient’s pulse rate has fallen from 102 bpm to 80 bpm. What is the best course of action?

A. Encourage the patient to take several deep breaths.
B. Interrupt suction to the catheter for at least 10 seconds.
C. Discontinue suctioning by removing the suction catheter.
D. Assess the patient’s pulse oximetry reading to see if oxygenation is adequate.

Answer 18

C

Question 19

As a nasotracheal catheter is inserted to suction the airway, a patient begins to gag and says, “I feel like I’m going to throw up.” What is the nurse’s best response?

A. Complete the catheter insertion in 5 seconds or less.
B. Remove the catheter.
C. Encourage the patient to take several deep breaths to minimize the nausea.
D. Stop advancing the catheter, and allow the patient to rest for several minutes.

Answer 19

B

means that the catheter is in the esophagus

Question 20

How does the nurse evaluate the effect of nasotracheal suctioning on a patient’s respiratory status?

A. Asking the patient about symptoms of respiratory difficulty.
B. Comparing respiratory assessment data from before and after the suctioning procedure.
C. Confirming that the patient’s pulse oximetry value is >90%.

Answer 20

B

Question 21

Which action would the nurse perform when preparing to suction a patient’s oropharynx?

A. Apply sterile gloves.
B. Place the patient in a semi-Fowler’s or sitting position.
C. Remove the nasal cannula.
D. Flush the suction catheter with 200 mL of warm tap water.

Answer 21

B

Question 22

After oropharyngeal suctioning, what does the nurse do with the supplies?

A. Place the rigid catheter in a clean, dry area.
B. Place all disposable equipment into the wrapper of the suction catheter before discarding it in a trash receptacle.
C. Fold the paper drape with the outer surface inward, and dispose of it in a biohazard receptacle.
D. Place dirty gloves in the biohazard receptacle in the patient’s room.

Answer 22

A

Question 23

When preparing to suction a patient’s oral cavity, why would the nurse first suction a small amount of sterile water through the catheter?

A. To moisten the exterior of the plastic catheter
B. To ensure that the catheter’s suction is functioning properly
C. To minimize friction as the catheter moves within the oral cavity
D. To avoid startling the patient with the sound created by the suction

Answer 23

B

Question 24

What is a priority intervention when performing oropharyngeal suctioning for a patient who is receiving oxygen by face mask?

A. Complete the suctioning process in 20 seconds or less.
B. Keep the oxygen mask near the patient’s face during the suctioning procedure.
C. Encourage the patient to take several deep breaths before suctioning begins.
D. Increase the oxygen flow rate by 1 L/min for 3 minutes before suctioning.

Answer 24

B

Question 25

Which action is most useful in evaluating the effectiveness of oropharyngeal suctioning?

A. Comparing presuctioning and postsuctioning respiratory assessment data
B. Confirming that the patient’s pulse oximetry value is >90%
C. Asking the patient to report any symptoms of dyspnea
D. Assessing the patient’s skin for signs of cyanosis

Answer 25

A

Question 25

Why is it important for the nurse to set the correct flow rate for a patient to whom oxygen is prescribed?

A. To provide the correct amount of oxygen to the patient
B. To ensure the therapeutic effects of oxygen therapy
C. To prevent any adverse reaction to the prescribed oxygen therapy
D. To minimize the risk of combustion during oxygen delivery

Answer 25

A

Question 26

What would be the nurse’s priority in order to minimize a patient’s risk for injury during oxygen therapy?

A. Advising the patient to call for assistance before getting out of bed.
B. Instructing nursing assistive personnel (NAP) to immediately correct the flow rate if the oxygen regulator is not set as prescribed.
C. Observing the six rights of medication administration.
D. Monitoring the patient for signs of hypoxia.

Answer 26

C

Question 27

What can the nurse do to evaluate a patient’s response to continuous oxygen therapy delivered at 4 L/min by nasal cannula?

A. Regularly measure and trend the patient’s pulse oximetry (SpO2) values.
B. Evaluate venous blood levels every morning.
C. Monitor the patient’s arterial blood gas (ABG) levels hourly.
D. Assess the patient for compliance with the prescribed therapy.

Answer 27

A

Question 28

What should the nurse do when a patient is ordered to receive 4 L/min oxygen by nasal cannula?

A. Encourage oral fluids.
B. Restrict fluids.
C. Ensure that humidification is present.
D. Measure blood pressure every hour.

Answer 28

C

Question 29

What would the nurse monitor frequently to ensure that the prescribed amount of oxygen is being delivered to a patient?

A. Arterial blood gas (ABG) levels
B. Oxygen flow meter setting
C. Respiratory rate
D. Temperature

Answer 29

B