1. The nurse finds the patient in cardiopulmonary arrest with no pulse or
jk jk jk jk jk jk jk jk jk jk jk
respirations. Which oxygen delivery device will the nurse use for this
jk j k j k j k j k j k j k j k j k j k j k
patient?
j k
a. Non-rebreather mask j k
b. Bag-valve-mask unit jk
c. Continuous positive airway pressure (CPAP) j k j k j k j k
d. High-flow nasal cannula: b. Bag-valve-mask unit jk jk jk jk jk
The priority of the nurse is to ventilate the patient manually using a bag-valve-mask (BVM) unit. This allows air to be
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
forced into the patient's lungs when there are no spontaneous respirations. The non-rebreather mask and nasal
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
cannula require the patient to breathe on his or her own. CPAP is used for patients who are awake, oriented, and in
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
respiratory failure.
jk jk
2. The nurse is caring for a patient who is slow to awaken following
j k j k j k j k j k j k j k j k j k j k j k j k
general
j k
anesthesia. The patient is breathing spontaneously but is minimally j k j k j k j k j k j k j k j k
respon-sive and having difficulty maintaining a patent airway. Which
j k j k j k j k j k j k j k j k j k
intervention is the most appropriate for the patient to improve oxygenation?
j k j k jk jk jk jk jk jk jk jk jk
a. Insert an oral airway. jk jk jk
b. Lower the head of the bed. jk jk jk jk jk
c. Turn the patient's head to the side. j k jk j k jk jk j k
d. Monitor the patient's pulse oximetry.: a. Insert an oral airway.
jk jk jk jk jk jk jk jk jk
An oral (oropharyngeal) airway will prevent the patient's tongue from falling back and occluding the airway. Lowering the
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
head of the bed will only increase airway occlusion and risk of aspiration. Turning the patient's head to the side will
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
not clear the back of the patient's tongue from the airway. Monitoring the patient's pulse oximetry will not improve oxygenation
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
or clear the airway.
jk jk jk jk
3. The nurse is caring for a patient with a history of left-sided congestive
j k j k j k j k j k j k j k j k j k j k j k j k
heart failure who is acutely short of breath. The nurse hears fine crackles
k
j k
j k
j k
j k
j k
j k
j k
j k
j k
j k
j k
j
throughoutbothlungfieldsandnotesthatthepatient'spulseoximetryisonly 88%
jk k
j k
j k
j k
j k
j k
j k
j k
j k
j k
j k
j k
j jk
on 4 L of oxygen. What is the priority intervention of the nurse?
j k j k j k j k j k j k j k j k j k j k j k j k j k
,a. Administer the ordered intravenous diuretic.
j k j k j k j k
b. Prepare for insertion of a chest tube.
j k j k j k j k j k j k
, c. Suction secretions from the patient's respiratory tract. j k j k j k j k j k j k
d. Have the patient use the ordered incentive spirometer.: a.Administertheordered
jk jk jk jk jk jk jk jk jk jk jk
intravenous diuretic.
jk jk
The patient's respiratory distress is due to pulmonary edema and fluid overload from left-sided congestive heart
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
failure. A patient with heart failure may be on diuretics. A diuretic will pull the excess fluid out of the body through
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
j the urine and relieve the patient's distress. A chest tube is not needed as the fluid is within the alveoli rather than
k jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
between the lung and chest wall. Suctioning and use of an incentive spirometer will not address fluid overload or
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
improve the patient's symptoms.
jk jk jk jk
4. The nurse is caring for a patient who has been intubated with an oral
j k j k j k j k j k j k j k j k j k j k j k j k j k
endotracheal tube for several weeks. The physicians predict that the j k j k j k j k j k j k j k j k j k
patient will need to remain on a ventilator for at least several more
j k jk j k j k j k j k j k j k j k j k j k j k j k
weeks before he
j k j k j k
will be able to maintain his airway and breathe on his own. What procedure does
jk jk jk jk jk jk jk k
j k
j k
j jk jk jk jk jk
jkthe nurse anticipate will be planned for the patient to facilitate recovery?
jk jk jk jk jk jk jk jk jk jk jk
a. Placement of a tracheostomy tube j k j k j k j k
b. Diagnostic thoracentesis jk
c. Pulmonary angiogram j k
d. Lung transplantation surgery: a. Placement of a tracheostomy tube
jk jk jk jk jk jk jk jk
Placement of a tracheostomy tube will secure the patient's airway directly through the trachea, eliminating the need for the
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
endotracheal tube. This will make the patient more comfortable and may allow eating while minimizing damage to
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
the oropharynx from the endotracheal tube.
jk jk jk jk jk jk
5. The nurse is caring for a patient with a chest tube who was transported
jk jk jk jk jk jk jk jk jk jk jk jk jk
to radiology for testing. When the patient returns to the nursing unit, the
jk jk jk jk jk jk jk jk jk jk jk jk
transporter shows the nurse the patient's chest tube collection device,
jk j k j k j k j k j k j k j k j k j k
which was badly damaged after being caught in the elevator door. What is the
j k jk k
j k
j jk k
j k
j k
j jk k
j k
j k
j k
j k
j
priority action of the nurse?
jk jk jk jk jk
a. Clamp the chest tube until the collection device is replaced. j k j k j k j k j k j k j k j k j k
b. Cover the insertion site with a new occlusive dressing. j k j k j k j k j k j k j k j k
c. Ensure that there is gentle bubbling in the water seal chamber. j k j k j k j k j k j k j k j k j k j k
jk jk jk jk jk jk jk jk jk jk jk
respirations. Which oxygen delivery device will the nurse use for this
jk j k j k j k j k j k j k j k j k j k j k
patient?
j k
a. Non-rebreather mask j k
b. Bag-valve-mask unit jk
c. Continuous positive airway pressure (CPAP) j k j k j k j k
d. High-flow nasal cannula: b. Bag-valve-mask unit jk jk jk jk jk
The priority of the nurse is to ventilate the patient manually using a bag-valve-mask (BVM) unit. This allows air to be
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
forced into the patient's lungs when there are no spontaneous respirations. The non-rebreather mask and nasal
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
cannula require the patient to breathe on his or her own. CPAP is used for patients who are awake, oriented, and in
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
respiratory failure.
jk jk
2. The nurse is caring for a patient who is slow to awaken following
j k j k j k j k j k j k j k j k j k j k j k j k
general
j k
anesthesia. The patient is breathing spontaneously but is minimally j k j k j k j k j k j k j k j k
respon-sive and having difficulty maintaining a patent airway. Which
j k j k j k j k j k j k j k j k j k
intervention is the most appropriate for the patient to improve oxygenation?
j k j k jk jk jk jk jk jk jk jk jk
a. Insert an oral airway. jk jk jk
b. Lower the head of the bed. jk jk jk jk jk
c. Turn the patient's head to the side. j k jk j k jk jk j k
d. Monitor the patient's pulse oximetry.: a. Insert an oral airway.
jk jk jk jk jk jk jk jk jk
An oral (oropharyngeal) airway will prevent the patient's tongue from falling back and occluding the airway. Lowering the
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
head of the bed will only increase airway occlusion and risk of aspiration. Turning the patient's head to the side will
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
not clear the back of the patient's tongue from the airway. Monitoring the patient's pulse oximetry will not improve oxygenation
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
or clear the airway.
jk jk jk jk
3. The nurse is caring for a patient with a history of left-sided congestive
j k j k j k j k j k j k j k j k j k j k j k j k
heart failure who is acutely short of breath. The nurse hears fine crackles
k
j k
j k
j k
j k
j k
j k
j k
j k
j k
j k
j k
j
throughoutbothlungfieldsandnotesthatthepatient'spulseoximetryisonly 88%
jk k
j k
j k
j k
j k
j k
j k
j k
j k
j k
j k
j k
j jk
on 4 L of oxygen. What is the priority intervention of the nurse?
j k j k j k j k j k j k j k j k j k j k j k j k j k
,a. Administer the ordered intravenous diuretic.
j k j k j k j k
b. Prepare for insertion of a chest tube.
j k j k j k j k j k j k
, c. Suction secretions from the patient's respiratory tract. j k j k j k j k j k j k
d. Have the patient use the ordered incentive spirometer.: a.Administertheordered
jk jk jk jk jk jk jk jk jk jk jk
intravenous diuretic.
jk jk
The patient's respiratory distress is due to pulmonary edema and fluid overload from left-sided congestive heart
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
failure. A patient with heart failure may be on diuretics. A diuretic will pull the excess fluid out of the body through
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
j the urine and relieve the patient's distress. A chest tube is not needed as the fluid is within the alveoli rather than
k jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
between the lung and chest wall. Suctioning and use of an incentive spirometer will not address fluid overload or
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
improve the patient's symptoms.
jk jk jk jk
4. The nurse is caring for a patient who has been intubated with an oral
j k j k j k j k j k j k j k j k j k j k j k j k j k
endotracheal tube for several weeks. The physicians predict that the j k j k j k j k j k j k j k j k j k
patient will need to remain on a ventilator for at least several more
j k jk j k j k j k j k j k j k j k j k j k j k j k
weeks before he
j k j k j k
will be able to maintain his airway and breathe on his own. What procedure does
jk jk jk jk jk jk jk k
j k
j k
j jk jk jk jk jk
jkthe nurse anticipate will be planned for the patient to facilitate recovery?
jk jk jk jk jk jk jk jk jk jk jk
a. Placement of a tracheostomy tube j k j k j k j k
b. Diagnostic thoracentesis jk
c. Pulmonary angiogram j k
d. Lung transplantation surgery: a. Placement of a tracheostomy tube
jk jk jk jk jk jk jk jk
Placement of a tracheostomy tube will secure the patient's airway directly through the trachea, eliminating the need for the
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
endotracheal tube. This will make the patient more comfortable and may allow eating while minimizing damage to
jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk jk
the oropharynx from the endotracheal tube.
jk jk jk jk jk jk
5. The nurse is caring for a patient with a chest tube who was transported
jk jk jk jk jk jk jk jk jk jk jk jk jk
to radiology for testing. When the patient returns to the nursing unit, the
jk jk jk jk jk jk jk jk jk jk jk jk
transporter shows the nurse the patient's chest tube collection device,
jk j k j k j k j k j k j k j k j k j k
which was badly damaged after being caught in the elevator door. What is the
j k jk k
j k
j jk k
j k
j k
j jk k
j k
j k
j k
j k
j
priority action of the nurse?
jk jk jk jk jk
a. Clamp the chest tube until the collection device is replaced. j k j k j k j k j k j k j k j k j k
b. Cover the insertion site with a new occlusive dressing. j k j k j k j k j k j k j k j k
c. Ensure that there is gentle bubbling in the water seal chamber. j k j k j k j k j k j k j k j k j k j k
