Chapter 28: Assisting with Respiration and Oxygen Delivery

The nurse uses a diagram to show that when the diaphragm moves:

down, the negative pressure in the thoracic space pulls air into the lungs

The nurse clarifies that the condition in which there is a decreased amount of oxygen in the blood is:

hypoxemia

The nurse monitoring patients eating in the dining room of a skilled nursing facility notes that a patient begins choking. As the nurse prepares to deliver the Heimlich maneuver, the fist should be positioned:

halfway between the xiphoid process and the umbilicus.

A patient has collapsed and cannot be aroused by asking loudly, "Are you okay?" The next action should be to:

call for help or, if there is assistance, have that person get help.

The nurse instructing the patient to perform forceful exhalation coughing would teach the patient to take in:

two deep breaths, then inhale deeply again and force out the air quickly.

The nurse is aware that the best time to schedule a postural drainage treatment is:

shortly after the patient arises in the morning, before breakfast.

A patient who will begin oxygen therapy has a history of sinus disorders. This patient would benefit most from which oxygen setup?

A humidifier

A patient has a history of chronic obstructive pulmonary disease. The patient's oxygen flow rate should be set to no more than _____ L/min.

2 to 3

The nurse loosens mucus plugs by using percussion on a patient over the area of the:

thorax

A patient requires a precise concentration of 40% oxygen. Which of the following devices would best allow for this?

A Venturi mask

The nurse recognizes that a post-operative patient who can breathe independently but has trouble maintaining an airway because of the tongue falling back into the throat would be best benefited by a(n):

pharyngeal airway.

A nurse performing oral suctioning on an adult patient should set the wall suction machine so that the suction pressure is between _____ mm Hg.

80 and 120

A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:

auscultating the breath sounds.

A patient requires suctioning via the nasotracheal route. In order to perform this procedure safely, the nurse should:

hold the catheter with the dominant hand after donning sterile gloves.

The nurse recognizes that, immediately before a tracheotomy cuff deflation, the patient should:

have the pharynx suctioned.

The nurse takes into consideration that while caring for a patient on oxygen therapy, safety precautions should be observed, which include:

assessing equipment in room for frayed cords.

A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should:

include findings in documentation.

A nurse is aware that adequate hydration is necessary to mobilize respiratory secretions. To thin respiratory secretions for easier expectoration, the patient should consume at least _____ mL/day.

1500 to 2000

The nurse would determine that this patient is aware of how to use the incentive spirometer device properly when the patient:

took 10 slow, deep breaths every hour.

The nurse assists the patient with emphysema into the most beneficial position to facilitate respiration, which is:

sitting upright and forward with arms supported on an over-the-bed table.

The nurse performing tracheotomy care will:

suction tracheotomy before beginning care.

The nurse caring for a patient with a disposable chest drainage system can promote effective tube function and patient safety by:

taping all connections within the system.

The nurse takes into consideration that a pulse oximeter may not give an accurate reading if the patient is:

jaundiced

The nurse clarifies that the cough mechanism is stimulated when:

foreign substances are propelled by the cilia toward the respiratory tract.

When assessing the lungs of a patient, the nurse assesses a wheezing sound on inspiration. This finding is documented as:

stridor

A sputum specimen is best obtained just after the patient ________ or after a _________ treatment because this is when there is more mucus available or when it is easier to cough up.

awakens, nebulizer

When obtaining a sputum specimen, the nurse should provide the patient with a sterile sputum cup and teach the patient to rinse her mouth with _____________.

water

The nurse explains that the rate of respiration is triggered when the medulla senses a change in the level of ________ ions in the blood.

hydrogen

The nurse administering cardiopulmonary resuscitation (CPR) would administer chest compressions at the rate of ________ compressions/minute.

100

When a patient with a tracheostomy tube is taken care of at home by family, tracheostomy care instructions from the nurse include: (Select all that apply.)

avoid going to crowded theaters and malls.

change catheters every 8 hours.

keep the home environment free of dust.

use bleach to clean suction equipment.

The nurse is aware that changes occur in the respiratory system after the age of 70 that put the elderly more at risk for respiratory problems. These changes include: (Select all that apply.)

decreased oxygen saturation

incomplete expirations.

impaired cilia.

The multiple causes for hypoxia include: (Select all that apply.)

aspirated vomit.

pulmonary fibrosis.

high altitude.