All of the following demonstrate how nutrition can impact oxygenation except

Respiratory secretions are more easily mobilized

What is positioned around the outer Cannula to prevent skin irritation?

Lint free composite 4x 4 sponge

When performing suctioning which action should the nurse take first?

preoxygenate at 100% for 3 mins

Chest Physiotherapy (PT) is used to:

mobilize secretions and clear the airway

An obturator is used with a tracheostomy when...

the trach becomes dislodged & needs to be reinserted.

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%."

A surgical procedure to create an opening into the neck.

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

Assess for signs & symptoms of hypoxia.

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

ability to move lower extremities

Most significance of venturi mask

delivers the most precise amount of oxygen

Postural drainage is done when the patient is in what postion?

high-fowlers, prone, on the right lateral

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

Delivers a low concentration of oxygen

Who do you see first?

The patient with tracheostomy that needs suctioning

studbud

Exam 1 Review NRS2024

100 termsStudBud Administration95 plays

Imported from external platform

Flashcards100 cardsFPractice quizPHost liveL

Questions 100

Answers

1
Oxygen at 4 L/min via a nasal cannula delivers approximately what percentage of oxygen?
None of the above
36%
100%
28%
2
You're performing ROM with a patient when they express pain. What do you do?
Contact the provider
Slowly release muscle tension
Hold the position that caused pain while you assess the patient
Stop and assess the patient
3
Early signs of hypoxemia include all except
Restlessness
Cyanosis
Tachypnea
Tachycardia
4
What is an EARLY sign(s) that warrants additional assessment of respiratory status?
Respirations are slow and shallow.
Pulse is slower than normal and is thready and weak.
Lips are cyanotic, fingers are cool, and capillary refill is sluggish.
Restlessness.
5
All of the following demonstrate how nutrition can impact oxygenation except
Respiratory secretions are more easily mobilized
Increased body weight increases tissue oxygen demands
Sodium restriction facilitates better heart function
Obesity causes decreased lung expansion
6
Nsg interventions to promote effective respirations and respiratory function include all except
Encourage turning, coughing, deep breathing
Increase fluids to thin secretions
Encourage mobility
Bedrest w/ HOB down
7
Which of the following is of most concern to a nurse caring for a post-operative patient?
Stridor
Diaphoresis
Incisional Pain
Fatigue
8
What inspired oxygen concentration does 2L of NC deliver to a patient?
38%
80%
28%
60%
9
To administer 100% FiO2 @ 15 LPM, the nurse should use:
simple face mask
venturi mask
nasal cannula
non-rebreather mask
10
True or False; the old ties are removed first when replacing with new ties
False
True
11
The external opening on the skin surface is the
Ostomy
larynx
Stoma
Incision site
12
Which infection is healthcare acquired?
UTI after a Foley Catheter
Bronchitis after working in a nursing home
Yeast infection after antibiotics
13
Late signs of hypoxemia include all except
Bradypnea
Hypotension
Nasal flaring
Bradycardia
14
What is positioned around the outer Cannula to prevent skin irritation?
Lint free composite 4x 4 sponge
Faceplate
Adhesive sponge
Gauze
15
The tracheostomy can be secured in place by?
Threading string
Bracket
Twill Ties
Gauze
16
When performing suctioning which action should the nurse take first?
Apply Sterile gloves
suctioning while inserting tube
Place patient on 2 L via Nasal canula
preoxygenate at 100% for 3 mins
17
Most appropriate time to collect sputum sample
After breakfast
Late evening
While pt is sleeping
Early morning
18
This masks provides the patient with the highest concentration of oxygen
Non Rebreather
Simple Mask
Nasal Cannula
Venturi
19
Chest Physiotherapy (PT) is used to:
stop coughing
limit the production of mucus
mobilize secretions and clear the airway
help the lungs absorb secretions
20
A patient has had back surgery and would like to get cleaned up. What kind of bath?
The patient should not bathe post up
Partial bed bath
Full bed bath
Independent bath
21
You discover a COPD pt having SOB, what postion would assist breathing for this pt?
supine
prone
semi-Fowler's
orthopneic position
22
What is the oxygenation of tissues which involves the heart ?
Ventilation
Perfusion
Percussion
Diffusion
23
The indwelling tube inserted through the stoma is?
Cannula
None of the above
Air pipe
Obturator
24
Which is NOT a sign of inadequate oxygenation?
warm and dry skin
mottling
altered mental status
cyanosis
25
When assessing oxygenation via Pulse Oximetry, which reading should the nurse expect
90-95%
80-85%
95%-100%
85-90%
26
An Fi02 of 28% would indicate a patient is recieving the following amount of oxygen?
5L
2L
RA
1L
27
An obturator is used with a tracheostomy when...
is placed during trach suctioning
the trach becomes dislodged & needs to be reinserted.
is used to clean the trach
is placed during trach care to keep the trach in place.
28
This is used when high humidity is needed & other oxygen delivery systems are not tolerated.
Nasal canula
Non-rebreather
CPAP
Face Tent
29
Which of the following instructions should the nurse include in the teaching about home oxygen?
"Store unused oxygen tanks horizontally."
"Use wool blankets on your bed."
"Check your pulse ox if SOB and call the HCP if <93%."
"Check your oxygen equipment once each week."
30
A Tracheotomy is?
A scope procedure.
A surgical procedure to remove the larynx?
A surgical procedure to create an opening into the neck.
to enhance swallowing.
31
Nasal cannula can provide up to how many liters of O2?
6
4
5
2
32
A client’s pulse ox is 85%. Which of the following actions should the nurse take first?
Administer morphine sulfate to ease the work of breathing.
Assess for signs & symptoms of hypoxia.
Get the patient OOB.
Document the reading and call the physician.
33
A term used to describe a patient who has difficulty lying flat?
Apnea
Dyspnea
Tachypnea
Orthopnea
34
I am strong, I am capable, I am going to be a nurse
True
False
35
When assessing for proper airway function the nurse should assess all except?
cough/ gag reflex
ability to move lower extremities
respiratory status
ability to clear secretions
36
What medications put patients at risk for falls?
Antibiotics
Antivirals
Cholinergics
Opiates
37
Which position is best for promoting ventilation?
Prone
high fowler"s
Supine
Left lateral
38
This allows delivery of oxygen when the patient is eating.
simple face mask
partial rebreather
face tent
nasal cannula
39
Which device delivers high flow O2 from 10-15L and provides 60-90% O2?
Venturi mask
Nasal cannula
Nonrebreather
Simple mask
40
A nurse assessing a client who is hypoxic should expect to find which of the following?
Tachycardia
Bradypnea
Pallor
Somnolence
41
How many fingers should be able fit between the tape and neck once trach is secure?
1
3
2
No fingers
42
Most significance of venturi mask
pt can eat while wearing mask
comfortable to wear
delivers the most precise amount of oxygen
mose inexpensive
43
The nurse should include a client’s oxygen saturation level in which part of the SBAR report?
Assessment
Recommendation
Background
Situation
44
Which of the following does not contribute to falls in the older adult?
unsteady balance
increased endurance
decreased strength
slow reflexes
45
Which is a late sign of hypoxia?
hypertension
tachycardia
extreme restlessness
RR 30
46
Which is NOT a component of oxygenation?
perfusion
gas exchange
ventilation
peristalsis
47
True or False: A simple face mask delivers oxygen concentrations from 40% to 60% @ to 5-8 L/min
False
True
48
Postural drainage is done when the patient is in what postion?
upside-down
high-fowlers
prone
on the right lateral
49
A client is receiving O2 via NC. This method of oxygen delivery:
Delivers a low concentration of oxygen
Delivers a constant rate of a specific concentration of O2
Delivers a high concentration of oxygen
Restricts the client’s ability to eat, speak, or drink
50
Ventilation in excess in which CO2 is blowed off
Hypoxia
Hyperventilation
Cyanosis
Hypoventilation
51
Who do you see first?
The patient who has had a change in mental status
The patient with rales and a moist cough
The patient with new chest pain
The patient with tracheostomy that needs suctioning
52
Which of these is not a contributing factor of aspiration pneumonia
Use of Incentive Spirometry
Immobility
Age
Decreased gag reflex
53
Nursing interventions to promote effective respirations and respiratory function include all the following except?
encourage mobility
encourage turning, coughing, and deep breathing
increase fluids to thin secretions
Bedrest with bed flat
54
A patient becomes suddenly anxious and agitated. The first thing the nurse should do is:
Give him a sedative
Suction the mouth and nose
Order a psych consult
Assess patency of the airway and oxygenation
55
Which is an early sign of hypoxia?
Restlessness
Edema
cyanosis
confusion
56
Which is an example of a high flow oxygen system?
venturi mask with large-bore tubing
nasal canula
simple face mask
face tent
57
The caption shows what part of the Trach?
Inner Catheter
outer Cannula
Obturator
Inner Cannula
58
Oximetry is ordered for a bilateral hand amputee. Where may the nurse place the probe? (Select all that apply)
Index finger
Earlobe
Forehead
Toe
59
True or false, for a new Trach, Trach Care can be performed by Certified Nursing Assistant?
False, (only licensed nurse)
True
60
What does dehissence mean?
A wound that is reddened and swollen
A wound that has an abcess under it
A wound that is opening
Visible internal organs
61
When is intermittent suction applied during the suctioning process
While the patient coughs
While advancing the suction catheter into the trachea
While withdrawing the suction catheter from the trachea
While inserting the suction catheter into the trachea
62
Which mask provides 35-50% Fi02 and 6-12L of O2
Nasal Cannula
Simple Mask
Aerosol
Partial non-rebreather
63
When assessing for effective airway function and patency the nurse should assess all except
Respiratory status
Cough/Gag reflex
Ability to handle oral secretions
Ability to move lower extremities
64
The use of an incentive spirometer can...
expand collapsed alveoli
reduce respiratory gas exchange
reduce pulmonary ventilation
provide hyperventilation
65
A pt is obtunded after a seizure & the tongue is obstructing the airway, what should be used?
oropharyngeal airway
face tent
non-rebreather
nasopharyngeal airway
66
Which lab is important assessing wound healing capacity?
Albumin
ESR
Calcium
WBC
67
Warm_________ oxygen is administered to patients with a tracheostomy.
Pressurized
Humidified
Dry
Moist
68
This mask provides the patient with the highest concentration of oxygen
venturi
simple mask
non rebreather
nasal canula
69
What is the device used to keep the alveoli from collapsing and enhances gas exchange?
Tidal volume
Simple Mask
Forced air capacity
Incentive spirometer
70
An age related change in older adults that impacts oxygenation is:
Increase in chest expansion
Increased nutrition
Increased immunity
Mental status changes
71
All of the following influence oxygenation except
Stress
Smoking
LIfestyle
Skin color
72
A nursing intervention that promotes effective circulation includes:
assisting with intubation
administering vasodilators
offering the influenza vaccine
Providing information and support for smoking cessation
73
Always monitor patients __________ when tracheostomy suctioning
All the above
Change in patient‘s color
Change in vital signs
Changes in pulse or cardiac monitor
74
Best locations to use for a pulse ox if edema, dark nail polish, or thick toe/fingernails are present?
Earlobe
Skin fold
Toe
Finger
75
The nurse knows postural drainage can promote all of these EXCEPT...
improves pulmonary ventilation
decreases atelectasis
decreases bacterial growth and infections
facilitates drainage of secretions via gravity
76
When suctioning a trach, you suction for no more than
10 seconds
20 seconds
5 seconds
15 seconds
77
A term used to describe a patient that has difficulty breathing when lying flat
Orthopnea
Dyspnea
Apnea
Tachypnea
78
Select All: What impacts wound healing?
Protein levels
Tissue oxygenation
Gender
Blood sugar
79
When performing Chestphysiotherapy (CPT) nurse should perform all except
Percussion, Vibration, postural drainage
Perform right after patient eats
Auscultate Lungs
Provide meds 1 hr prior
80
Which finding requires immediate action?
Patient with pneumonia whose O2 sat is 95% on room air
A patient who gets tired after walking around the unit
A visitor holding his hands around his throat during lunch
Cold, pale feet with hair loss and weak pedal pulses
81
Risk factors for pressure wound formation? Select all:
Occupation
Cannabis use
Advanced age
Immobility
82
Which of these is not a contributing factor of aspiration pneumonia?
decreased gag reflex
use of incentive spirometer
immobility
age
83
Equipment used for trach care include all except
Split guaze dressing
Cotton balls
Saline
Obturator at bedside
84
How should we dress a stage 1 pressure ulcer?
Dry dressing
Moist dressing
Open to air
Hydrocolloid dressing
85
A bluish discoloration of the skin and mucous membranes?
jaundice
cyanosis
crepitus
rhinnorhea
86
Which of the following is the nurses highest priority?
Ensuring patient has no pain
Thorough head to toe assessment
Protecting airway
Building a good rapport
87
What happens to a patient's metabolism when they are immobile?
It is increased
The require more fats
It is decreased
They require less protein
88
True or False; in health care facilities, trach care is a non sterile procedure.
True
False
89
SpO2 measures what?
O2 in arteries
O2 in body tissues with pulse oximetry
blood
not sure
90
A second ______ tracheostomy set is to be kept by bedside at all times.
Larger
Smaller
Same size
It’s not necessary
91
A pt with COPD needs 35% oxygen, what will the nurse choose?
fact tent
non-rebreather
partial rebreather
Venturi mask
92
The primary purpose for the the cuff in a tracheostomy tube is to:
provide maximum sealing for airway
prevent the trachea from becoming irritated with the tube.
permit the nurses to suction without irritating the trachea
deflate and allow the client to talk
93
What effect does hemoglobin amount have on oxygenation status?
Low hemoglobin levels cause reduced oxygen-carrying capacity
More hemoglobin reduces the client’s respiratory rate
Low hemoglobin levels cause increased O2-carrying capacity.
No effect
94
Which resp rate would be the most concerning
12
18
15
44
95
Which of the following is a nurses highest priority
Protecting Airway
Ensuring patient is comfortable
Thorough head to toe assessment
Building a good rapport with patient
96
All of the following relate to smoking and oxygenation except:
Second hand smoke may be damaging to an adult
Lung cancer is 10 x greater for a smoker
Birth control pills counteract damage due to smoking
First and second hand smoke are related to lung cancer
97
How do you contaminate your sterile field? Select all:
Set it up below waist level
Turn your back on it
Add sterile supplies to it
Touch it with clean gloves
98
Most significant advantage of a venturi mask
Pt can eat while wearing mask
Most inexpensive
Delivers the most precise amount of oxygen
Comfortable to wear
99
In a mobile obese adult, where does the nurse assess for skin breakdown?
The heels
The sacrum
The back of the head
The skin folds
100
When performing suctioning, which action should the nurse take first
Have patient cough
Place patient on 2L via Nasal Cannula (NC)
Suction while inserting tube
Preoxygenate at 100% for up to 3min

Exam 1 Review NRS2024 Flashcards | StudBud