When is intermittent suction applied during the suctioning process

While withdrawing the suction catheter from the trachea

A client’s pulse ox is 85%. Which of the following actions should the nurse take first?

Assess for signs & symptoms of hypoxia.

All of the following demonstrate how nutrition can impact oxygenation except

Respiratory secretions are more easily mobilized

A client is receiving O2 via NC. This method of oxygen delivery:

Delivers a low concentration of oxygen

When performing Chestphysiotherapy (CPT) nurse should perform all except

Perform right after patient eats

A surgical procedure to create an opening into the neck.

When performing suctioning, which action should the nurse take first

Preoxygenate at 100% for up to 3min

Which is an example of a high flow oxygen system?

venturi mask with large-bore tubing

O2 in body tissues with pulse oximetry

A patient becomes suddenly anxious and agitated. The first thing the nurse should do is:

Assess patency of the airway and oxygenation

Most significant advantage of a venturi mask

Delivers the most precise amount of oxygen

When assessing for proper airway function the nurse should assess all except?

ability to move lower extremities

The primary purpose for the the cuff in a tracheostomy tube is to:

provide maximum sealing for airway

Which of the following instructions should the nurse include in the teaching about home oxygen?

"Check your pulse ox if SOB and call the HCP if <93%."

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Week 5 Oxygenation

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Questions 86

Answers

1
Oximetry is ordered for a bilateral hand amputee. Where may the nurse place the probe? (Select all that apply)
Index finger
Forehead
Earlobe
Toe
2
Ventilation in excess in which CO2 is blowed off
Hypoxia
Hypoventilation
Cyanosis
Hyperventilation
3
When is intermittent suction applied during the suctioning process
While inserting the suction catheter into the trachea
While withdrawing the suction catheter from the trachea
While advancing the suction catheter into the trachea
While the patient coughs
4
A client’s pulse ox is 85%. Which of the following actions should the nurse take first?
Assess for signs & symptoms of hypoxia.
Document the reading and call the physician.
Get the patient OOB.
Administer morphine sulfate to ease the work of breathing.
5
The external opening on the skin surface is the
Incision site
Ostomy
larynx
Stoma
6
All of the following demonstrate how nutrition can impact oxygenation except
Obesity causes decreased lung expansion
Increased body weight increases tissue oxygen demands
Respiratory secretions are more easily mobilized
Sodium restriction facilitates better heart function
7
A client is receiving O2 via NC. This method of oxygen delivery:
Delivers a low concentration of oxygen
Delivers a high concentration of oxygen
Delivers a constant rate of a specific concentration of O2
Restricts the client’s ability to eat, speak, or drink
8
Which position is best for promoting ventilation?
Prone
Supine
high fowler"s
Left lateral
9
Which resp rate would be the most concerning
18
15
12
44
10
Oxygen at 4 L/min via a nasal cannula delivers approximately what percentage of oxygen?
None of the above
100%
36%
28%
11
A nurse assessing a client who is hypoxic should expect to find which of the following?
Pallor
Somnolence
Tachycardia
Bradypnea
12
True or false, for a new Trach, Trach Care can be performed by Certified Nursing Assistant?
False, (only licensed nurse)
True
13
True or False; the old ties are removed first when replacing with new ties
True
False
14
What inspired oxygen concentration does 2L of NC deliver to a patient?
28%
38%
60%
80%
15
True or False; in health care facilities, trach care is a non sterile procedure.
True
False
16
A bluish discoloration of the skin and mucous membranes?
cyanosis
crepitus
jaundice
rhinnorhea
17
What is the oxygenation of tissues which involves the heart ?
Perfusion
Diffusion
Percussion
Ventilation
18
An age related change in older adults that impacts oxygenation is:
Increase in chest expansion
Increased immunity
Increased nutrition
Mental status changes
19
When performing Chestphysiotherapy (CPT) nurse should perform all except
Provide meds 1 hr prior
Perform right after patient eats
Percussion, Vibration, postural drainage
Auscultate Lungs
20
A Tracheotomy is?
A surgical procedure to remove the larynx?
A scope procedure.
to enhance swallowing.
A surgical procedure to create an opening into the neck.
21
True or False: A simple face mask delivers oxygen concentrations from 40% to 60% @ to 5-8 L/min
False
True
22
All of the following influence oxygenation except
LIfestyle
Skin color
Smoking
Stress
23
When performing suctioning, which action should the nurse take first
Have patient cough
Place patient on 2L via Nasal Cannula (NC)
Preoxygenate at 100% for up to 3min
Suction while inserting tube
24
This allows delivery of oxygen when the patient is eating.
face tent
simple face mask
partial rebreather
nasal cannula
25
You discover a COPD pt having SOB, what postion would assist breathing for this pt?
prone
semi-Fowler's
orthopneic position
supine
26
Late signs of hypoxemia include all except
Hypotension
Bradypnea
Bradycardia
Nasal flaring
27
Which device delivers high flow O2 from 10-15L and provides 60-90% O2?
Nasal cannula
Venturi mask
Simple mask
Nonrebreather
28
Best locations to use for a pulse ox if edema, dark nail polish, or thick toe/fingernails are present?
Finger
Skin fold
Earlobe
Toe
29
Which of the following is a nurses highest priority
Building a good rapport with patient
Thorough head to toe assessment
Protecting Airway
Ensuring patient is comfortable
30
Which is an example of a high flow oxygen system?
nasal canula
face tent
simple face mask
venturi mask with large-bore tubing
31
Nsg interventions to promote effective respirations and respiratory function include all except
Increase fluids to thin secretions
Encourage turning, coughing, deep breathing
Encourage mobility
Bedrest w/ HOB down
32
Which is an early sign of hypoxia?
Restlessness
confusion
Edema
cyanosis
33
SpO2 measures what?
O2 in body tissues with pulse oximetry
not sure
O2 in arteries
blood
34
Equipment used for trach care include all except
Obturator at bedside
Cotton balls
Saline
Split guaze dressing
35
A patient becomes suddenly anxious and agitated. The first thing the nurse should do is:
Assess patency of the airway and oxygenation
Suction the mouth and nose
Give him a sedative
Order a psych consult
36
Nasal cannula can provide up to how many liters of O2?
5
6
4
2
37
Most significant advantage of a venturi mask
Most inexpensive
Comfortable to wear
Pt can eat while wearing mask
Delivers the most precise amount of oxygen
38
Always monitor patients __________ when tracheostomy suctioning
Changes in pulse or cardiac monitor
Change in patient‘s color
All the above
Change in vital signs
39
When assessing oxygenation via Pulse Oximetry, which reading should the nurse expect
85-90%
90-95%
80-85%
95%-100%
40
What is an EARLY sign(s) that warrants additional assessment of respiratory status?
Pulse is slower than normal and is thready and weak.
Lips are cyanotic, fingers are cool, and capillary refill is sluggish.
Restlessness.
Respirations are slow and shallow.
41
When assessing for proper airway function the nurse should assess all except?
respiratory status
ability to clear secretions
ability to move lower extremities
cough/ gag reflex
42
A pt with COPD needs 35% oxygen, what will the nurse choose?
non-rebreather
fact tent
partial rebreather
Venturi mask
43
Which of the following is of most concern to a nurse caring for a post-operative patient?
Diaphoresis
Stridor
Fatigue
Incisional Pain
44
An Fi02 of 28% would indicate a patient is recieving the following amount of oxygen?
5L
1L
2L
RA
45
The primary purpose for the the cuff in a tracheostomy tube is to:
deflate and allow the client to talk
prevent the trachea from becoming irritated with the tube.
permit the nurses to suction without irritating the trachea
provide maximum sealing for airway
46
Which mask provides 35-50% Fi02 and 6-12L of O2
Nasal Cannula
Aerosol
Partial non-rebreather
Simple Mask
47
The nurse knows postural drainage can promote all of these EXCEPT...
decreases atelectasis
decreases bacterial growth and infections
facilitates drainage of secretions via gravity
improves pulmonary ventilation
48
The tracheostomy can be secured in place by?
Twill Ties
Bracket
Gauze
Threading string
49
What is the device used to keep the alveoli from collapsing and enhances gas exchange?
Tidal volume
Incentive spirometer
Simple Mask
Forced air capacity
50
I am strong, I am capable, I am going to be a nurse
False
True
51
Which of the following instructions should the nurse include in the teaching about home oxygen?
"Check your oxygen equipment once each week."
"Check your pulse ox if SOB and call the HCP if <93%."
"Store unused oxygen tanks horizontally."
"Use wool blankets on your bed."
52
Postural drainage is done when the patient is in what postion?
high-fowlers
on the right lateral
prone
upside-down
53
Warm_________ oxygen is administered to patients with a tracheostomy.
Humidified
Pressurized
Dry
Moist
54
An obturator is used with a tracheostomy when...
is placed during trach suctioning
the trach becomes dislodged & needs to be reinserted.
is placed during trach care to keep the trach in place.
is used to clean the trach
55
Which of these is not a contributing factor of aspiration pneumonia?
immobility
decreased gag reflex
use of incentive spirometer
age
56
How many fingers should be able fit between the tape and neck once trach is secure?
1
No fingers
3
2
57
A pt is obtunded after a seizure & the tongue is obstructing the airway, what should be used?
non-rebreather
oropharyngeal airway
face tent
nasopharyngeal airway
58
When assessing for effective airway function and patency the nurse should assess all except
Ability to handle oral secretions
Respiratory status
Cough/Gag reflex
Ability to move lower extremities
59
What effect does hemoglobin amount have on oxygenation status?
Low hemoglobin levels cause increased O2-carrying capacity.
More hemoglobin reduces the client’s respiratory rate
No effect
Low hemoglobin levels cause reduced oxygen-carrying capacity
60
What is positioned around the outer Cannula to prevent skin irritation?
Adhesive sponge
Lint free composite 4x 4 sponge
Gauze
Faceplate
61
The use of an incentive spirometer can...
reduce pulmonary ventilation
expand collapsed alveoli
reduce respiratory gas exchange
provide hyperventilation
62
A term used to describe a patient that has difficulty breathing when lying flat
Apnea
Orthopnea
Dyspnea
Tachypnea
63
This mask provides the patient with the highest concentration of oxygen
simple mask
venturi
non rebreather
nasal canula
64
This is used when high humidity is needed & other oxygen delivery systems are not tolerated.
Nasal canula
Non-rebreather
CPAP
Face Tent
65
The nurse should include a client’s oxygen saturation level in which part of the SBAR report?
Assessment
Background
Situation
Recommendation
66
A second ______ tracheostomy set is to be kept by bedside at all times.
Same size
Larger
It’s not necessary
Smaller
67
Which is NOT a sign of inadequate oxygenation?
mottling
cyanosis
warm and dry skin
altered mental status
68
This masks provides the patient with the highest concentration of oxygen
Simple Mask
Venturi
Nasal Cannula
Non Rebreather
69
Which of the following is the nurses highest priority?
Building a good rapport
Thorough head to toe assessment
Ensuring patient has no pain
Protecting airway
70
Nursing interventions to promote effective respirations and respiratory function include all the following except?
encourage mobility
encourage turning, coughing, and deep breathing
Bedrest with bed flat
increase fluids to thin secretions
71
Early signs of hypoxemia include all except
Tachycardia
Cyanosis
Restlessness
Tachypnea
72
The indwelling tube inserted through the stoma is?
Cannula
Obturator
Air pipe
None of the above
73
Chest Physiotherapy (PT) is used to:
mobilize secretions and clear the airway
limit the production of mucus
help the lungs absorb secretions
stop coughing
74
When performing suctioning which action should the nurse take first?
Place patient on 2 L via Nasal canula
Apply Sterile gloves
preoxygenate at 100% for 3 mins
suctioning while inserting tube
75
Which of these is not a contributing factor of aspiration pneumonia
Decreased gag reflex
Use of Incentive Spirometry
Age
Immobility
76
Which finding requires immediate action?
A patient who gets tired after walking around the unit
Cold, pale feet with hair loss and weak pedal pulses
A visitor holding his hands around his throat during lunch
Patient with pneumonia whose O2 sat is 95% on room air
77
Most appropriate time to collect sputum sample
While pt is sleeping
After breakfast
Late evening
Early morning
78
Most significance of venturi mask
mose inexpensive
delivers the most precise amount of oxygen
pt can eat while wearing mask
comfortable to wear
79
A term used to describe a patient who has difficulty lying flat?
Tachypnea
Orthopnea
Dyspnea
Apnea
80
A nursing intervention that promotes effective circulation includes:
assisting with intubation
Providing information and support for smoking cessation
administering vasodilators
offering the influenza vaccine
81
The caption shows what part of the Trach?
outer Cannula
Inner Catheter
Inner Cannula
Obturator
82
When suctioning a trach, you suction for no more than
10 seconds
5 seconds
15 seconds
20 seconds
83
Which is a late sign of hypoxia?
RR 30
hypertension
tachycardia
extreme restlessness
84
Which is NOT a component of oxygenation?
perfusion
gas exchange
ventilation
peristalsis
85
To administer 100% FiO2 @ 15 LPM, the nurse should use:
venturi mask
non-rebreather mask
simple face mask
nasal cannula
86
All of the following relate to smoking and oxygenation except:
Birth control pills counteract damage due to smoking
First and second hand smoke are related to lung cancer
Second hand smoke may be damaging to an adult
Lung cancer is 10 x greater for a smoker

Week 5 Oxygenation Flashcards | StudBud