Chapter 14: Promoting Oxygenation

Nursing Interventions & Clinical Skills, 6th Edition- by Anne Griffin Perry - Potter - Ostendorf

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Chapter 14: Promoting Oxygenation

 

Complete Chapter Questions With Answers

 

Sample Questions Are Posted Below

 

MULTIPLE CHOICE

 

  1. A patient just had his tracheostomy suctioned. Which change in the patient’s status would the nurse expect to see immediately after suctioning was completed?
a. The heart rate changes from 84 to 92.
b. The respiratory rate remains the same.
c. The oxygenation saturation changes from 92 to 98.
d. The patient’s respiratory effort increases gradually.

 

 

ANS:  A

Suctioning significantly increases the heart rate for 4 to 5 minutes following the procedure. The respiratory rate varies normally, and there would be a variation from before the procedure when the patient needed suctioning and afterward. There is a significant decrease in the oxygen saturation for 4 to 5 minutes following the procedure. The patient’s respiratory effort would be easier after suctioning.

 

DIF:    Cognitive Level: Apply                   REF:   Page 377| Page 380

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Assessment

 

  1. 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
c. Partial rebreather
d. Nonrebreather

 

 

ANS:  D

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

 

DIF:    Cognitive Level: Apply                   REF:   Page 358| Page 360

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Planning

 

  1. 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 should be taken by the nurse immediately?
a. Notify the healthcare 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 healthcare 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.

 

DIF:    Cognitive Level: Apply                   REF:   Page 359

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Assessment

 

  1. 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?
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.

 

 

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 priority. The patient should keep the oxygen on as long as the extension tubing reaches. The oxygen rate is considered medication and should not be changed by the patient.

 

DIF:    Cognitive Level: Apply                   REF:   Page 356| Page 357

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Assessment

 

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

 

 

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: Apply                   REF:   Page 359-360

OBJ:   NCLEX: Physiological Integrity      TOP:   Nursing Process: Implementation

 

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