Question 1

The nurse has been asked to obtain a sputum specimen from a client who is in the first postoperative day after a surgical gastric resection for stomach cancer. The nurse will ensure that which item is provided to the client to ensure an effective sputum collection?
A)Supplemental oxygen
B)Folded bath blanket
C)Peak expiratory flow meter
D)Sterile applicator stick

Accepted Answer

A folded bath blanket will be used by the client to hold against the abdomen to allow for effective coughing.

Question 2

The nurse has just completed insertion of a nasal trumpet to assist in protecting a responsive client's airway and should place the client in which position to maintain the airway?
A)Supine with the head to the side
B)Side-lying with chin positioned closest to the chest
C)Prone with head to the side
D)Side-lying with head slightly tilted up and centered on the pillow

Accepted Answer

The client should be positioned in a side-lying position with the head slightly tilted up to maintain and open airway and to allow for adequate drainage of secretions.

Question 3

The nurse observes a client using the incentive spirometer and s that further instruction is required when the client performs which action?
A)Exhales before placing the incentive spirometer to the lips
B)Seals the lips tightly around the mouthpiece of the incentive spirometer
C)Inhales quickly, causing the spirometer balls to snap to the top of the incentive spirometer
D)Attempts to cough productively after using the incentive spirometer

Accepted Answer

The client should inhale slowly, not quickly, and deeply to ensure maximal lung expansion.

Question 4

The nurse should know that which takes priority in assisting the client to effectively use a volume-oriented incentive spirometer?
A)The spirometer must be held in an upright position.
B)A nose clip must be used for effective inhalation.
C)The procedure must be repeated every 15 minutes to be effective.
D)Clean the spirometer in the dishwasher when used at home.

Accepted Answer

A volume-oriented incentive spirometer must be used in an upright position to function correctly.

Question 5

The nurse should encourage the client to use incentive spirometry prior to which procedure?
A)Ambulating the client
B)Preparing the client for a rest period
C)Removing the client's meal tray
D)Obtaining a sputum specimen

Accepted Answer

The deep breathing that is completed with incentive spirometry may help a client prepare for obtaining a sputum specimen.

Question 6

After completing instructions for collecting a sputum specimen to the client, the nurse observes the client remove the lid of the specimen container and spit into the cup. Which is the nurse's next best action?
A)Ask the client if the specimen obtained was sputum or saliva.
B)Explain to the client that the specimen will have to be obtained by suctioning.
C)Provide the client with a new specimen container and explain again how to obtain the specimen.
D)Send the specimen to the lab as obtained but label it as saliva.

Accepted Answer

The nurse should explain again how to obtain the specimen and give the client a new specimen container.

Question 7

The nurse is caring for a group of clients with respiratory disorders and should know that which client should not be placed on continuous positive airway pressure (CPAP)to assist with respiratory distress?
A)The client with chronic obstructive pulmonary disease (COPD)who is complaining of shortness of breath
B)The client whose respirations have fallen to 8/minute after receiving morphine sulfate
C)The client who experiences apnea during sleep
D)The client who is experiencing wheezing and is having difficulty moving air adequately

Accepted Answer

CPAP should never be used on clients receiving opioids because it causes the pharynx to relax and contributes to further airway obstruction.

Question 8

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD)who is receiving supplemental oxygen and should intervene if which delivery device is being used by the client?
A)Nasal cannula
B)Continuous positive airway pressure (CPAP)
C)Bilevel positive airway pressure (BiPAP)
D)Venturi face mask

Accepted Answer

A Venturi face mask provides oxygen concentrations from 24% to 50% with flow rates from 4-10 L/min, which would be too high for a client with COPD and may cause the client's breathing stimuli to be suppressed.

Question 9

The nurse is caring for a client who is exhibiting severe respiratory distress and is receiving supplemental oxygen through a nonrebreather mask. While assessing the client, the nurse notes that the bag attached to the mask is deflated. Which is the nurse's best action?
A)Document it as functioning normally.
B)Decrease the flow of oxygen to the mask.
C)Increase the flow of oxygen to the mask.
D)Prepare for endotracheal intubation.

Accepted Answer

If the bag is completely deflated, the nurse should increase the flow of oxygen to the mask and then contact the healthcare provider.

Question 10

The nurse is observing a new mother use a bulb syringe to suction her newborn's nose and mouth and should provide further instruction if the mother performs which action?
A)The mother begins the procedure by suctioning the infant's nose.
B)The mother deflates the bulb before placing the tip of the bulb syringe in the infant's nose.
C)The mother releases the bulb and removes the bulb syringe from the infant's nose.
D)The mother washes the bulb syringe with soap and water and then allows it to air dry.

Accepted Answer

The mother should be taught to suction the infant's mouth before suctioning the infant's nose to prevent aspiration of secretions in the throat.

Question 11

The nurse is preparing to assist a client in obtaining a sputum specimen and should place the client in which position?
A)Low Fowler's
B)Side-lying
C)Semi-Fowler's
D)Trendelenburg

Accepted Answer

Semi-Fowler's position allows for maximum lung ventilation and expansion. Other positions that would be effective would be high Fowler's, or sitting on the side of a bed or in a chair.

Question 12

The nurse is caring for an older adult client who had a tracheostomy placed 3 days ago and should know that which issue will take priority when caring for this client?
A)Reducing the client's anxiety concerning self-care of the tracheostomy
B)Reassuring the client that the tracheostomy is a temporary measure
C)Ensuring that the skin around the client's tracheostomy stoma is assessed frequently
D)Referring the client to a support group for individuals with tracheostomies

Accepted Answer

The nurse should place priority on caring for the skin around the client's stoma because older adults are more prone to skin breakdown.

Question 13

The nurse is assisting a client in obtaining a sputum specimen. After a deep cough, the client produces approximately 1/2 tsp of sputum. Which is the nurse's next action?
A)Assist the client to cough again and produce more sputum.
B)Send the specimen to the lab.
C)Allow the client to rest for one hour and then ask the client to cough again.
D)Ask the client to walk around for 30 minutes and try again to produce sputum.

Accepted Answer

A sputum specimen requires 1-2 tsp of sputum, so the nurse should assist the client to repeat the coughing to produce additional sputum.

Question 14

The nurse is caring for a 4-year-old postoperative client who has been unable to understand the use of the incentive spirometer. The nurse should choose which activity that will assist the child to perform the same action as the spirometer?
A)Blowing out candles
B)Sucking on a straw
C)Filling up a balloon
D)Using bubbles

Accepted Answer

Incentive spirometry focuses on inhalation, which is the action that sucking on a straw will imitate.

Question 15

The nurse is caring for a client with pneumonia and should be most concerned about which assessment?
A)The client cannot remember which day it is.
B)The client's heart rate has risen from 72 to 78 bpm.
C)The client's pulse oximetry has decreased from 99% to 97%.
D)The client respiratory rate has risen from 16 to 20 breaths per minute.

Accepted Answer

One of the early signs of hypoxia is confusion and should be reported immediately.

Question 16

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD)who is experiencing increasing respiratory difficulty. The client has refused being placed on a mechanical ventilator and the nurse is aware that which would provide possible respiratory assistance to this client?
A)Place an endotracheal tube without the use of a mechanical ventilator.
B)Provide supplemental oxygen using a Venturi face mask.
C)Put a nonrebreather mask on the client to help him breathe.
D)Place the client on a bilevel positive airway pressure (BiPAP)machine.

Accepted Answer

The use of a CPAP or BiPAP machine may provide an appropriate alternative to intubation.

Question 17

The nurse is caring for a client with a respiratory disorder and should alert the healthcare provider if the client displays which signs or symptoms that indicate early hypoxia? Select all that apply.
A)Headache
B)Nausea
C)Heart rate of 52
D)Respiratory rate of 30
E)Blurred vision
F)Hemoglobin of 17.3 mg/dl

Accepted Answer

Headache is an early sign of hypoxia.
Tachypnea is an early sign of hypoxia.
Visual disturbances are an early sign of hypoxia.

Question 18

The nurse is preparing to do tracheostomy care for a client and should know that which must be present at the bedside before beginning this procedure?
A)One pair of sterile gloves
B)Obturator
C)Full-strength hydrogen peroxide
D)Sterile water

Accepted Answer

The nurse must have an obturator at the bedside in case the trach tube is inadvertently dislodged. The obturator will allow the tube to be reinserted immediately.

Question 19

The nurse is caring for a client who was just placed on supplemental oxygen per nasal cannula and should contact the healthcare provider if which assessment data are noted at the next assessment? Select all that apply.
A)The client complains of feeling anxious and restless.
B)Skin color is pink and warm to touch.
C)The heart rate is 82.
D)The respiratory rate is 36.
E)The client is using accessory muscles to breathe.

Accepted Answer

Feelings of anxiety and restlessness are signs of hypoxia and should be reported.
A respiratory rate of 36 indicates the client is breathing abnormally fast and it should be reported.
The use of accessory muscles to breathe indicates difficulty breathing and should be reported.

Question 20

The nurse is preparing to insert an oropharyngeal airway in an unresponsive client and should do which to ensure the airway is inserted correctly?
A)Using a tongue depressor, push the tongue to the side of the mouth when inserting the airway.
B)Begin the procedure by inserting the airway upside down and then rotating it to the correct position.
C)Position the airway in a downward position and then rotate it upward as it passes by the back of the throat.
D)Refrain from taping the bottom of the airway to prevent esophageal injury when the client swallows.

Accepted Answer

The procedure is begun with the airway curved upward (upside down)and then rotated 180 degrees.

Quiz 62: Oxygenation

The nurse has been asked to obtain a sputum specimen from a client who is in the first postoperative day after a surgical gastric resection for stomach cancer. The nurse will ensure that which item is provided to the client to ensure an effective sputum collection?

The nurse has just completed insertion of a nasal trumpet to assist in protecting a responsive client's airway and should place the client in which position to maintain the airway?

The nurse observes a client using the incentive spirometer and s that further instruction is required when the client performs which action?

The nurse should know that which takes priority in assisting the client to effectively use a volume-oriented incentive spirometer?

The nurse should encourage the client to use incentive spirometry prior to which procedure?

After completing instructions for collecting a sputum specimen to the client, the nurse observes the client remove the lid of the specimen container and spit into the cup. Which is the nurse's next best action?

The nurse is caring for a group of clients with respiratory disorders and should know that which client should not be placed on continuous positive airway pressure (CPAP) to assist with respiratory distress?

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen and should intervene if which delivery device is being used by the client?

The nurse is caring for a client who is exhibiting severe respiratory distress and is receiving supplemental oxygen through a nonrebreather mask. While assessing the client, the nurse notes that the bag attached to the mask is deflated. Which is the nurse's best action?

The nurse is observing a new mother use a bulb syringe to suction her newborn's nose and mouth and should provide further instruction if the mother performs which action?

The nurse is preparing to assist a client in obtaining a sputum specimen and should place the client in which position?

The nurse is caring for an older adult client who had a tracheostomy placed 3 days ago and should know that which issue will take priority when caring for this client?

The nurse is assisting a client in obtaining a sputum specimen. After a deep cough, the client produces approximately 1/2 tsp of sputum. Which is the nurse's next action?

The nurse is caring for a 4-year-old postoperative client who has been unable to understand the use of the incentive spirometer. The nurse should choose which activity that will assist the child to perform the same action as the spirometer?

The nurse is caring for a client with pneumonia and should be most concerned about which assessment?

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is experiencing increasing respiratory difficulty. The client has refused being placed on a mechanical ventilator and the nurse is aware that which would provide possible respiratory assistance to this client?

The nurse is caring for a client with a respiratory disorder and should alert the healthcare provider if the client displays which signs or symptoms that indicate early hypoxia? Select all that apply.

The nurse is preparing to do tracheostomy care for a client and should know that which must be present at the bedside before beginning this procedure?

The nurse is caring for a client who was just placed on supplemental oxygen per nasal cannula and should contact the healthcare provider if which assessment data are noted at the next assessment? Select all that apply.

The nurse is preparing to insert an oropharyngeal airway in an unresponsive client and should do which to ensure the airway is inserted correctly?