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 OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Simple b. Venturi mask c. Partial rebreather d. Nonrebreather

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?

ANS: D

The nonrebreather is the mask that can deliver the highest possible FIO2 without intubation.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning 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.

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?

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.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Assessment a. Put on slippers whenever walking. b. Take off the oxygen if only going to the bathroom. c. Be careful not to trip over the extra oxygen tubing. d. Increase the flow rate a little before getting out of bed.

4. An older-adult patient with a nasal cannula and extension tubing is able to get out of bed independently. What teaching by the nurse is indicated for this patient?

ANS: C

This older patient is at risk for tripping and falling over the extension tubing. Slippers need to be worn when ambulating, but the risk for tripping and falling is the priority. The patient should keep the oxygen on as long as the extension tubing reaches. If not, the nurse will help the patient by getting a portable oxygen cylinder. The oxygen rate is considered medication and should not be changed by the patient.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Apply the oxygen as ordered. b. Notify the respiratory therapy department. c. Obtain a new cylinder of oxygen. d. Adjust the flowmeter slightly below what is ordered.

5. An oxygen cylinder is turned on, and the gauge registers in the green range. What action does the nurse take at this time?

ANS: A

The gauge should register in the green range, which indicates that there is an adequate amount of oxygen in the cylinder. The respiratory therapy department oversees oxygen administration, but there is no reason to contact them because there is no problem. The cylinder of oxygen being used is fine and does not need to be replaced at this time. The oxygen rate is considered medication and should not be changed.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. They measure the minimum force used to breathe in during the breathing process. b. They measure the maximum flow that occurs during one quick, forced expiration. c. They measure the amount of circulating oxygen in the alveoli during breathing. d. They indicate the stability of your overall health.

6. A patient with newly diagnosed asthma is asking why peak flow measurements are being ordered. What is the best response by the nurse?

ANS: B

The peak expiratory flow measurements are objective indicators of the patient’s current status and the effectiveness of the treatment. Decreased peak expiratory flow rate (PEFR) may indicate the need for further interventions such as increased doses of bronchodilators or antiinflammatory medications. The measurements focus on expiration, not inspiration, and do not reflect the amount of circulating oxygen in the alveoli. The peak expiratory flow measurements reflect only the respiratory system, not the overall health.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. 40–60 mm Hg b. 60–80 mm Hg c. 80–100 mm Hg d. 100–150 mm Hg

7. The nurse prepares to perform oropharyngeal suctioning on an adult. Nursing care is appropriate if which wall suction pressure is used?

ANS: D

The wall suction setting for adults is 100–150 mm Hg. The wall suction setting for infants is 40–60 mm Hg. The wall suction setting for children is 60–100 mm Hg. The setting of 80-100 mm Hg is not specifically indicated for any age-group.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Increase the oxygen rate of the nasal cannula. b. Elevate the head of the patient’s bed. c. Hyperoxygenate with oxygen attached to a mask. d. Gently flex the patient’s neck.

8. Nasotracheal suctioning is performed on a patient who is unable to take deep breaths. What action by the nurse would best meet the patient’s needs before suctioning?

ANS: C

Hyperoxygenating before suctioning can minimize postsuctioning hypoxemia if a patient is unable to take a deep breath. The oxygen rate cannot be changed without an order from the health care provider. Elevating the head of the bed can allow lung expansion but does little if the patient is unable to take deep breaths. Hyperextending the neck opens the airway; flexing the neck closes the airway.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Hyperoxygenate this patient. b. Suction the visible secretions. c. Listen to the lung sounds. d. Wipe the mucus off with tissue.

9. While the nurse prepares to suction the patient’s tracheostomy tube, the patient coughs up mucus, which is visible at the opening of the tube. Which action by the nurse is most appropriate at this time?

ANS: B

The secretions need to be suctioned to remove them; then the patient would be hyperoxygenated. Listening to the lung sounds will be done after suctioning to determine the effectiveness and whether the patient’s airway is clear. Wiping the secretions with a tissue would bring nonsterile tissue to the opening of the tube, which is contraindicated. The fibers could also go down the tube.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Brushing teeth with chlorhexidine at least every 8 hours b. Maintaining the endotracheal pressure at 10 cm H2O c. Positioning the patient flat during tube feedings d. Repositioning the patient every 4 hours

10. The nurse is attempting to prevent ventilator-associated pneumonia (VAP) in a newly intubated patient. Which activities would best support this goal?

ANS: A

Oral care with chlorhexidine decreases the colonization of bacteria. Brushing the teeth also helps remove plaque, which can harbor bacteria. The endotracheal cuff pressure should be at 20

25 cm H2O to decrease movement of secretions to the lower airways. The patient should be elevated during tube feedings to prevent aspiration, which can lead to VAP. The patient needs to be repositioned every 2 hours.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Monitors the bubbling of sterile water in the water-seal chamber. b. Strips the tube every 2 hours for 15 seconds to prevent clots. c. Clamps the chest tube when transporting the patient. d. Keeps two toothed clamps at the bedside for an emergency.

11. A patient with a water-sealed chest tube unit is connected to suction. Patient care is correct if the nurse takes which action?

ANS: A

Intermittent bubbling is normal during expiration when the air is being evacuated from the pleural cavity. Continuous bubbling during both inspiration and expiration indicates a leak in the system. Stripping the tube increases negative pressure within the tube and is generally not recommended. The chest tube system is kept unclamped when transporting the patient. The clamps must be toothless or have guards on them to prevent puncture of the chest tube or tubing.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Notify the health care provider of excessive bleeding. b. Document the drainage output in the patient record. c. Place extra dressings and tape over the insertion site. d. Clamp the mediastinal tube to test tolerance for removal.

12. The patient with a mediastinal tube placed 22 hours ago has produced 350 mL of drainage since insertion. Which action by the nurse would be most appropriate?

ANS: B

The amount of drainage is within normal range and should be documented in the patient record. A total of approximately 500 mL in the first 24 hours is within expectations. There is no excessive bleeding; therefore the health care provider does not need to be notified. There is no need to reinforce the insertion site with extra dressing material. Clamping the mediastinal tube is not indicated since it has only been in 22 hours and has an expected amount of drainage.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Petroleum gauze or Xeroform gauze b. Gauze with Elastoplast c. 2  2–inch gauze with tincture of benzoin d. Steri-Strips under a bioclusive dressing

13. The nurse is preparing to assist the physician in the removal of a chest tube. Which item does the nurse is available to be placed over the insertion site as soon as the chest tube is removed?

ANS: A

First the petroleum gauze or Xeroform gauze is placed over the wound to prevent any leakage of air. Gauze with Elastoplast would not be used nor would Steri-Strips, 2  2–inch gauze, or tincture of benzoin.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Notify the physician. b. Check for an air leak. c. Listen to the lung sounds. d. Document the findings.

14. The nurse sees that a patient with a chest tube has intermittent bubbling in the water-seal chamber 4 hours after the chest tube was inserted. What action by the nurse is most appropriate at this time?

ANS: D

Intermittent bubbling is expected while air is being evacuated from the pleural cavity. The actions of notifying the physician, checking for an air leak, and listening to the lung sounds are not required since the chest tubes appear to be functioning correctly.

DIF: Cognitive Level: Remembering OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Collaborate with the provider to use an oxygen mask. b. Plan follow-up nursing care for patient hypoxemia. c. Request that the laboratory confirm the patient’s results. d. Continue with the current therapy and nursing care.

15. The nurse assesses the SaO2 a patient who receives oxygen at 3 L/min by nasal cannula. The SaO2 at 8 AM was 94 mm Hg, and at 10 AM it was 92 mm Hg. Which action by the nurse is most appropriate?

ANS: D

The nurse continues with the current therapy and nursing care because the difference between oxygen values is insignificant, probably representing a normal variation occurring from minute to minute. The nurse continues to monitor the patient closely because the SaO2 is approaching the lower limit for an acceptable reading. Collaborating for a mask is unnecessary because the patient’s SaO2 is close to normal limits and there is no indication that the patient is exhibiting signs of hypoxemia.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Adjusting the flow rate of the oxygen b. Reporting changes in patient’s behavior c. Instructing the patient about oxygen at home d. Assisting during endotracheal intubation

16. The nurse is working with a patient receiving oxygen. What can the nurse delegate to nursing assistive personnel (NAP) during the administration of oxygen?

ANS: B

The NAP needs to be instructed to report to the nurse changes in vital signs or pulse oximetry and changes in the patient’s anxiety or behavior. The nurse should adjust the flow rate of the oxygen since oxygen is considered a medication. The nurse must also provide the patient teaching. The nurse assists the provider during endotracheal intubation because the procedure is sterile, can require the nurse to administer emergency medication, and requires critical thinking and clinical judgment.

DIF: Cognitive Level: Applying OBJ: NCLEX: Safe and Effective Care Environment

TOP: Nursing Process: Implementation a. Keep the plastic bag at the end of the mask inflated continually. b. Adjust the oxygen flow rate with the valve in front of the mask. c. Offer fluids frequently and apply moisturizer to prevent dry skin. d. Remove the elastic head strap to prevent skin breakdown at the ears.

17. A home care patient receives oxygen by nonrebreather (NRB) mask. Which does the nurse include when teaching the caregiver about the oxygen-delivery system?

ANS: A

To prevent inhalation of carbon dioxide, the nurse instructs the caregiver to maintain an inflated bag at the end of the mask because it serves as an oxygen reservoir for the patient. If the bag deflates, the patient is at risk of inhaling excessive levels of carbon dioxide. The nurse regulates the oxygen flow rate by adjusting the flowmeter on the oxygen source; the NRB mask does not have a mixing valve. It does not dehydrate the patient. It requires a tight seal for effective therapy.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Place the patient in high Fowler’s position. b. Suction the oropharynx. c. Insert an artificial airway. d. Review the last arterial blood gases (ABGs).

18. The nurse hears the patient’s wheezing and gasping from the hallway and notes that the patient’s oxygen saturation has decreased to 92%. Which nursing intervention does the nurse implement first?

ANS: A

The nurse implements a noninvasive intervention to enhance the patient’s airway before instituting an invasive measure because, although the patient’s airway is impaired, he or she continues to oxygenate fairly well but is working very hard to do so. By quickly adjusting the patient’s position to maximize gas exchange and chest expansion, the nurse intervenes and gains additional valuable data for planning additional nursing care. There is no indication the patient needs suctioning or an artificial airway at this time. ABGs are not necessary yet.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Assess breath sounds. b. Discontinue suctioning. c. Instruct the patient to cough. d. Ventilate the patient manually.

19. The nurse suctions the patient’s endotracheal tube, and the patient becomes hypoxic. Which is the priority nursing intervention to increase patient oxygenation?

ANS: D

If the patient becomes hypoxic, the nurse ventilates him or her manually with supplemental oxygen to increase oxygenation. The nurse implements measures to oxygenate the patient quickly to avoid adverse and potentially life-threatening complications, including arrhythmias and cardiopulmonary arrest. He or she assesses the patient after providing supplemental oxygen and before seeking assistance because the hypoxia is most likely transient. The nurse discontinues suctioning to stop the decline in patient oxygen saturation; however, this action alone does not increase oxygenation. Instructing the patient to cough is a reasonable response to hypoxia, especially if the patient has pulmonary secretions; however, manual ventilation provides supplemental oxygen in addition to ventilation to increase patient oxygenation.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Changing the mask to a simple face mask b. Teaching the patient the rationale for a tight c. Enlarging several of the air holes on the mask d. Loosening the straps of the mask for the patient’s comfort

20. The patient uses continuous positive airway pressure (CPAP) at home and tells the home care nurse that the mask fits too tightly. Which action is most important for the nurse to take?

ANS: B

The nurse teaches the patient that the mask of the CPAP must fit tightly to prevent collapse of the upper airway because the device is unable to establish positive airway pressure without a tight seal. The nurse cannot make the decision to change the type of mask used. Loosening the straps allows air to leak from the system so positive pressure never builds. If the CPAP has holes, they are integrated into the system so the nurse should not enlarge them because it alters the function of the mask.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Increased pulse rate b. Increased restlessness c. A complaint of slight lethargy d. An oxygen saturation of 95%

21. The nurse institutes oxygen therapy for the patient. Which goal should the nurse set as a positive patient outcome of airway maintenance?

ANS: D

Oxygen saturation at 95% is a positive patient outcome of oxygen therapy because it indicates a PaO2 between 80 and 100 mm Hg, which is within normal limits. The nurse expects normal sinus rhythm, heart rate between 60 and 100 beats/min, and a calm patient, indicating adequate oxygenation. Patients can become tachycardic as a compensatory mechanism for hypoxemia; older patients exhibit restlessness as an initial indicator of hypoxemia.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Planning a. Uses a Yankauer suction device. b. Loosens oral secretions with normal saline solution. c. Suctions the nose, mouth, and throat with a catheter. d. Uses a clean catheter to suction the nose and mouth.

22. The patient is lethargic and unable to clear oral secretions effectively. How does the nurse manage the suctioning of the oropharyngeal secretions from the patient?

ANS: A

A Yankauer suction device is a strawlike tube that can effectively suction oral secretions. The nurse avoids instilling saline solution into the patient’s oropharynx to prevent aspiration. Suctioning the nose and throat is not indicated. A sterile catheter is used for nasopharyngeal suctioning to prevent contamination of the nasal passages or trachea.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Fatigue b. Anxiety c. Coughing d. Dysrhythmias

23. The nurse suctions the patient’s artificial airway. Which adverse effect related to suctioning does the nurse monitor as the priority during the procedure?

ANS: D

Artificial airways require airway suctioning, which poses risks such as cardiac dysrhythmias; laryngeal spasm; and bradycardia, which is associated with stimulation of the vagus nerve. The onset of dysrhythmias indicates that the patient is physiologically not tolerating the procedure and the nurse would stop. Fatigue can occur after suctioning because suctioning induces coughing and transient hypoxemia. Suctioning is often unsettling for patients because it takes the patient’s breath away, literally, and usually induces coughing and gagging. But the priority is the dysrhythmias because they can lower cardiac output.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Inserts the catheter between ventilator cycles to avoid airway interference. b. Inserts the catheter 25.4 cm (10 inches) and applies continuous suction during withdrawal. c. Visualizes the colored indicator line in the sheath of the catheter before completing the procedure. d. Withdraws the suction catheter and discards it after completing the procedure.

24. The nurse uses a closed-system (in-line) endotracheal (ET) suctioning system for the patient. Which does the nurse implement to prevent airway interference?

ANS: C

The nurse visualizes the colored indicator line of the catheter after withdrawing the suction catheter from the ET because it indicates that the catheter is completely removed from the airway. The nurse inserts the catheter for suctioning during patient inhalation to avoid respiratory cycle interference for suctioning. The catheter is inserted until resistance is met to avoid suctioning in the main left or right bronchi. The closed-system suctioning system allows the nurse to use the same catheter for repeated patient suctioning by using sterile technique.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Prevent the patient from coughing out the tube. b. Don sterile gloves before providing assistance. c. Inject sterile saline solution into the tracheostomy. d. Hold the tracheostomy tube securely in place.

25. The nurse performs tracheostomy care for the patient. Which instruction does the nurse give to nursing assistive personnel (NAP) to implement while changing the ties of the tracheostomy tube?

ANS: D

The nurse instructs the NAP to hold the tracheostomy tube firmly in place to prevent accidental dislodgement and to maintain a gentle hold because excessive pressure can induce patient coughing. The NAP wears clean gloves to hold the tracheostomy tube in place. Injecting sterile saline solution into the tracheostomy tube is contraindicated.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Standing b. Side lying c. High-Fowler’s d. Reclining in chair

26. A patient admitted for asthma is weak and tired. Which patient position does the nurse use for patient performance of a peak expiratory flow rate (PEFR)?

ANS: C

The nurse uses high-Fowler’s position to promote optimum lung expansion. Standing for patient performance of PEFR to facilitate chest expansion would be unsafe. Side lying and reclining in a chair for PEFR measurement are not ideal because these positions impair chest expansion.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Cough in a low-Fowler’s position hourly. b. Inhale and cough deeply with the mouth open. c. Self-reposition and cough every 4 hours. d. Breathe in quickly 3–4 times vigorously.

27. The nurse teaches the patient controlled coughing. Which will the nurse include in patient teaching for effective technique?

ANS: B

The nurse teaches the patient to inhale deeply to mobilize pulmonary secretions and to cough deeply to expectorate the secretions. Low-Fowler’s position is contraindicated for coughing because it is too low to facilitate expectoration and because many patients are unable to tolerate a low position. Coughing and repositioning every 4 hours are inadequate. The patient should be taught to inhale slowly and cough with force.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Creates a method for counting respirations. b. Compensates for leaks in tubing connections. c. Maintains up to 20 cm of intrapleural pressure. d. Facilitates bubbling for pressure over 20 mm Hg.

28. The nurse fills the suction-control chamber with water to the 20-cm line while setting up a water-seal chest drainage system. Which rationale does the nurse use to explain this intervention?

ANS: C

Lungs inflate as a result of negative intrapleural pressure pulling parenchymal tissue to the chest wall and a thin layer of serous fluid holding it to the chest wall. A 20-cm amount of water in the water-seal chamber limits negative intrapleural pressure to 20 cm and prevents parenchymal tissue damage; the water prevents positive pressure from entering the intrapleural space and compressing the lungs. Positive pressure destroys negative intrapleural pressure. Respirations are counted by watching the chest rise and fall. Compensatory mechanisms for leaking within the system do not exist; the only remedy is to tighten the connections. Bubbling occurs with an air leak in the water-seal drainage system.

DIF: Cognitive Level: Understanding OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation a. Instruct the nursing assistive personnel (NAP) to apply pressure for 5 minutes. b. Replace the water-seal drainage system with a sterile waterless unit quickly. c. Hold a towel firmly over the site and send for petrolatum gauze. d. Push the tube into place and apply an occlusive sterile dressing.

29. The nurse notes that the patient’s chest tube pulled out by 5.1 cm (2 inches) during turning and repositioning. Which is the initial action by the nurse?

ANS: C

The nurse secures the tube in place with a clean towel (or closest handy clean material) and sends the NAP for sterile petroleum gauze. The nurse securely wraps the gauze around the base of the chest tube insertion to re-create an airtight seal so negative intrapleural pressure can be restored. The nurse applies pressure to the site to prevent the wound from drawing in room air because this intervention requires clinical judgment and critical thinking to seal the wound completely. A standard or a waterless system is suitable for the patient’s water-seal drainage; however, neither system is effective therapy until the airtight insertion site is reestablished. The portion of the tubing pulled out is now contaminated and should not be pushed into place. The nurse should collaborate with the health care provider for a chest x-ray film to evaluate the status of the lung after the accident.

DIF: Cognitive Level: Applying OBJ: NCLEX: Physiological Integrity

TOP: Nursing Process: Implementation