The nurse finds the patient in cardiopulmonary arrest b. Bag-valve-mask unit
with no pulse or respirations. Which oxygen delivery
device will the nurse use for this patient? The priority of the nurse is to ventilate the patient manually using a bag-valve-
mask (BVM) unit. This allows air to be forced into the patient's lungs when there
a. Non-rebreather mask are no spontaneous respirations. The non-rebreather mask and nasal cannula
b. Bag-valve-mask unit require the patient to breathe on his or her own. CPAP is used for patients who
c. Continuous positive airway pressure (CPAP) are awake, oriented, and in respiratory failure.
d. High-flow nasal cannula
The nurse is caring for a patient who is slow to awaken a. Insert an oral airway.
following general anesthesia. The patient is breathing
spontaneously but is minimally responsive and having An oral (oropharyngeal) airway will prevent the patient's tongue from falling
difficulty maintaining a patent airway. Which back and occluding the airway. Lowering the head of the bed will only increase
intervention is the most appropriate for the patient to airway occlusion and risk of aspiration. Turning the patient's head to the side will
improve oxygenation? not clear the back of the patient's tongue from the airway. Monitoring the
patient's pulse oximetry will not improve oxygenation or clear the airway.
a. Insert an oral airway.
b. Lower the head of the bed.
c. Turn the patient's head to the side.
d. Monitor the patient's pulse oximetry.
,The nurse is caring for a patient with a history of left- a. Administer the ordered intravenous diuretic.
sided congestive heart failure who is acutely short of
breath. The nurse hears fine crackles throughout both The patient's respiratory distress is due to pulmonary edema and fluid overload
lung fields and notes that the patient's pulse oximetry is from left-sided congestive heart failure. A patient with heart failure may be on
only 88% on 4 L of oxygen. What is the priority diuretics. A diuretic will pull the excess fluid out of the body through the urine
intervention of the nurse? and relieve the patient's distress. A chest tube is not needed as the fluid is within
the alveoli rather than between the lung and chest wall. Suctioning and use of an
a. Administer the ordered intravenous diuretic. incentive spirometer will not address fluid overload or improve the patient's
b. Prepare for insertion of a chest tube. symptoms.
c. Suction secretions from the patient's respiratory tract.
d. Have the patient use the ordered incentive spirometer.
The nurse is caring for a patient who has been intubated a. Placement of a tracheostomy tube
with an oral endotracheal tube for several weeks. The
physicians predict that the patient will need to remain on Placement of a tracheostomy tube will secure the patient's airway directly
a ventilator for at least several more weeks before he will through the trachea, eliminating the need for the endotracheal tube. This will
be able to maintain his airway and breathe on his own. make the patient more comfortable and may allow eating while minimizing
What procedure does the nurse anticipate will be planned damage to the oropharynx from the endotracheal tube.
for the patient to facilitate recovery?
a. Placement of a tracheostomy tube
b. Diagnostic thoracentesis
c. Pulmonary angiogram
d. Lung transplantation surgery
, The nurse is caring for a patient with a chest tube who a. Clamp the chest tube until the collection device is replaced.
was transported to radiology for testing. When the patient
returns to the nursing unit, the transporter shows the The broken collection device may no longer be used to collect chest tube
nurse the patient's chest tube collection device, which drainage. Clamping the chest tube until the collection device is replaced will
was badly damaged after being caught in the elevator prevent air from entering the lung space until the new collection device is
door. What is the priority action of the nurse? attached.
a. Clamp the chest tube until the collection device is
replaced.
b. Cover the insertion site with a new occlusive dressing.
c. Ensure that there is gentle bubbling in the water seal
chamber.
d. Check the patient's lung sounds and pulse oximetry.
The nurse is caring for a patient who is hospitalized for c. Impaired airway clearance r/t thick secretions in trachea and bronchi.
pneumonia. Which nursing diagnosis has the highest
priority? Airway maintenance and patency is the highest priority for all patients,
especially patients with respiratory disorders. Oxygenation is the most important
a. Activity intolerance r/t generalized weakness and human need. The other diagnoses can apply once the patient's airway is kept
hypoxemia patent.
b. Impaired nutritional intake r/t poor appetite and
increased metabolic needs
c. Impaired airway clearance r/t thick secretions in
trachea and bronchi
d. Lack of knowledge r/t use of nebulizer and inhaled
bronchodilators
with no pulse or respirations. Which oxygen delivery
device will the nurse use for this patient? The priority of the nurse is to ventilate the patient manually using a bag-valve-
mask (BVM) unit. This allows air to be forced into the patient's lungs when there
a. Non-rebreather mask are no spontaneous respirations. The non-rebreather mask and nasal cannula
b. Bag-valve-mask unit require the patient to breathe on his or her own. CPAP is used for patients who
c. Continuous positive airway pressure (CPAP) are awake, oriented, and in respiratory failure.
d. High-flow nasal cannula
The nurse is caring for a patient who is slow to awaken a. Insert an oral airway.
following general anesthesia. The patient is breathing
spontaneously but is minimally responsive and having An oral (oropharyngeal) airway will prevent the patient's tongue from falling
difficulty maintaining a patent airway. Which back and occluding the airway. Lowering the head of the bed will only increase
intervention is the most appropriate for the patient to airway occlusion and risk of aspiration. Turning the patient's head to the side will
improve oxygenation? not clear the back of the patient's tongue from the airway. Monitoring the
patient's pulse oximetry will not improve oxygenation or clear the airway.
a. Insert an oral airway.
b. Lower the head of the bed.
c. Turn the patient's head to the side.
d. Monitor the patient's pulse oximetry.
,The nurse is caring for a patient with a history of left- a. Administer the ordered intravenous diuretic.
sided congestive heart failure who is acutely short of
breath. The nurse hears fine crackles throughout both The patient's respiratory distress is due to pulmonary edema and fluid overload
lung fields and notes that the patient's pulse oximetry is from left-sided congestive heart failure. A patient with heart failure may be on
only 88% on 4 L of oxygen. What is the priority diuretics. A diuretic will pull the excess fluid out of the body through the urine
intervention of the nurse? and relieve the patient's distress. A chest tube is not needed as the fluid is within
the alveoli rather than between the lung and chest wall. Suctioning and use of an
a. Administer the ordered intravenous diuretic. incentive spirometer will not address fluid overload or improve the patient's
b. Prepare for insertion of a chest tube. symptoms.
c. Suction secretions from the patient's respiratory tract.
d. Have the patient use the ordered incentive spirometer.
The nurse is caring for a patient who has been intubated a. Placement of a tracheostomy tube
with an oral endotracheal tube for several weeks. The
physicians predict that the patient will need to remain on Placement of a tracheostomy tube will secure the patient's airway directly
a ventilator for at least several more weeks before he will through the trachea, eliminating the need for the endotracheal tube. This will
be able to maintain his airway and breathe on his own. make the patient more comfortable and may allow eating while minimizing
What procedure does the nurse anticipate will be planned damage to the oropharynx from the endotracheal tube.
for the patient to facilitate recovery?
a. Placement of a tracheostomy tube
b. Diagnostic thoracentesis
c. Pulmonary angiogram
d. Lung transplantation surgery
, The nurse is caring for a patient with a chest tube who a. Clamp the chest tube until the collection device is replaced.
was transported to radiology for testing. When the patient
returns to the nursing unit, the transporter shows the The broken collection device may no longer be used to collect chest tube
nurse the patient's chest tube collection device, which drainage. Clamping the chest tube until the collection device is replaced will
was badly damaged after being caught in the elevator prevent air from entering the lung space until the new collection device is
door. What is the priority action of the nurse? attached.
a. Clamp the chest tube until the collection device is
replaced.
b. Cover the insertion site with a new occlusive dressing.
c. Ensure that there is gentle bubbling in the water seal
chamber.
d. Check the patient's lung sounds and pulse oximetry.
The nurse is caring for a patient who is hospitalized for c. Impaired airway clearance r/t thick secretions in trachea and bronchi.
pneumonia. Which nursing diagnosis has the highest
priority? Airway maintenance and patency is the highest priority for all patients,
especially patients with respiratory disorders. Oxygenation is the most important
a. Activity intolerance r/t generalized weakness and human need. The other diagnoses can apply once the patient's airway is kept
hypoxemia patent.
b. Impaired nutritional intake r/t poor appetite and
increased metabolic needs
c. Impaired airway clearance r/t thick secretions in
trachea and bronchi
d. Lack of knowledge r/t use of nebulizer and inhaled
bronchodilators
