TEST BANK FOR NURSING INTERVENTIONS AND CLINICAL SKILLS 7TH EDITION BY POTTER
Chapter 16: Promoting Oxygenation Perry et al.: Nursing Interventions & Clinical Skills, 7th Edition MULTIPLE CHOICE 1. A nurse is suctioning a patient through a tracheostomy. Which change in the patient’s status
would cause the nurse to discontinue the procedure? a. The heart rate changes from 84 to 106 beats/min. b. The respiratory rate does not improve. c. The oxygenation saturation changes from 96 to 91. d. The patient’s respiratory effort increases gradually. ANS: A
The nurse monitors the patient’s vital signs and SpO2 continuously during suctioning. If the patient’s heart rate changes by 20 or more beats/min, the nurse stops suctioning. If the SpO2 drops below 90% (or 5% from baseline) the nurse would also stop. The patient’s respiratory rate would not be expected to improve during the procedure itself. A gradual increase in respiratory effort would indicate the patient still needs to be suctioned. DIF: Cognitive Level: Applying TOP: Nursing Process: Assessment
OBJ: NCLEX: Physiological Integrity
2. A patient in respiratory distress is admitted to critical care. Which type of mask would the
nurse anticipate using to deliver the highest FIO2 without intubation? a. Simple b. Venturi mask N c. Partial rebreather d. Nonrebreather ANS: D
The nonrebreather is the mask that can deliver the highest possible FIO2 without intubation. DIF: Cognitive Level: Remembering TOP: Nursing Process: Planning
OBJ: NCLEX: Physiological Integrity
3. A patient with a major chest injury was originally alert and oriented after recovery from
surgery but is now becoming apprehensive and dizzy. What action by the nurse takes priority? a. Notify the health care provider. b. Perform a cardiopulmonary assessment. c. Elevate the head of the bed to 60 degrees. d. Provide the patient with pain medication. ANS: B
Apprehension, dizziness, anxiety, a decreased ability to concentrate, and fatigue are indicators of impaired gas exchange. The nurse needs to assess the patient’s cardiopulmonary status, including vital signs and pulse oximeter. The health care provider will be notified if there is a need for additional intervention. Elevating the head of the bed may be helpful, but the patient needs to be assessed immediately. Pain medication could decrease the respiratory system, which is already showing an adverse status, and there is no indication that the patient specifically needs pain medication.
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