Chapter 20: Oxygenation
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. The nurse performing tracheotomy care will:
a. raise the head of the bed to high Fowlers position.
b. remove the inner cannula with the ungloved hand.
c. suction tracheotomy before beginning care.
d. clean cannula with gauze and replace and lock.
ANS: C
Proper procedure includes suctioning the tracheotomy before beginning care.
DIF: Cognitive Level: Application REF: k 528, Skill 28-7 OBJ:
Clinical Practice #3 TOP: Tracheotomy Care KEY: Nursing
Process Step: Planning MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
2. The nurse caring for a patient with a disposable chest drainage system can promote
effective tube function and patient safety by:
a. taping all connections within the system.
b. keeping the system at the level of the patients chest.
c. turning on suction to 35 cm.
d. looping the tubing between the mattress and the bed rail to minimize length.
ANS: A
All connections in the system should be taped. Suction should be set at 20 cm unless
ordered otherwise. Looping the tubing encourages plugs in the tubing.
DIF: Cognitive Level: Application REF: k 531, Steps 28-1 OBJ:
Clinical Practice #4 TOP: Chest Tube Care KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
reduction of risk
3. The nurse takes into consideration that a pulse oximeter may not give an accurate reading
if the patient is:
a. dark skinned.
b. jaundiced.
c. obese.
d. febrile.
ANS: B
An accurate reading is dependent on light passing through the vascular bed. Jaundice
may cause an inaccurate reading.
DIF: Cognitive Level: Knowledge REF: k 505 OBJ: Theory #1
TOP: Pulse Oximetry KEY: Nursing Process Step:
Assessment MSC: NCLEX: Physiological Integrity: physiological
adaptation
4. The nurse clarifies that the cough mechanism is stimulated when:
, a. foreign substances are propelled by the cilia toward the respiratory tract.
b. dehumidified air enters the upper airway passages.
c. more than 250 mL of air moves in and out of the lungs with each breath.
d. the blood transports carbon dioxide to the lungs.
ANS: A
Cilia work to propel foreign substances toward the entrance of the respiratory tract,
and the cough reflex works to expel the secretions.
DIF: Cognitive Level: Knowledge REF: k 502 OBJ: Theory #1
TOP: Respiratory Structure Function KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
5. A nurse caring for a patient with a tracheostomy should determine whether the patient
needs suctioning by:
a. monitoring the rate of respirations.
b. determining the last time the patient was suctioned.
c. examining the character of the sputum.
d. auscultating the breath sounds.
ANS: D
Auscultating the patients breath sounds helps the nurse assess for retained secretions
and verifies the need for suctioning. The respiratory rate may rise when suctioning is
needed, but it could also rise for other reasons.
DIF: Cognitive Level: Application REF: k 526, Skill 26-6 OBJ:
Clinical Practice #1 TOP: Suctioning KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
6. A patient requires suctioning via the nasotracheal route. In order to perform this
procedure safely, the nurse should:
a. apply suction while advancing the catheter into the airway.
b. suction the nasotracheal passage after suctioning the mouth.
c. hold the catheter with the dominant hand after donning sterile gloves.
d. insert the non-lubricated catheter into the nasal passage.
ANS: C
The suction catheter should be held with the dominant hand after donning sterile
gloves, because sterile technique must be adhered to when suctioning both the
nasopharyngeal and tracheal areas.
DIF: Cognitive Level: Application REF: k 526, Skill 26-6 OBJ:
Clinical Practice #1 TOP: Suctioning KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
7. The nurse recognizes that, immediately before a tracheotomy cuff deflation, the patient
should:
a. be administered extra oxygen.
b. have the pharynx suctioned.
c. have the cuff pressure checked.
, d. be monitored for respiratory rate.
ANS: B
Immediately before deflating a cuff on a tracheotomy tube, the pharynx should be
suctioned to prevent accumulated oral secretions from entering the bronchial tree once
the cuff is deflated.
DIF: Cognitive Level: Application REF: k 527, Skill 28-6 OBJ:
Clinical Practice #3 TOP: Tracheostomy KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
reduction of risk
8. The nurse takes into consideration that while caring for a patient on oxygen therapy,
safety precautions should be observed, which include:
a. using clothing of synthetic cloth for the patient.
b. removing any adhesive from the patients skin with acetone.
c. assessing equipment in room for frayed cords.
d. reducing humidification on the oxygen delivery device.
ANS: C
All equipment in a room where oxygen is being administered should be in good
working order without frayed or loose connections because of the possibility of fire.
DIF: Cognitive Level: Comprehension REF: k 514, Safety Alert
OBJ: Clinical Practice #5 TOP: Safety Precautions with Oxygen
KEY: Nursing Process Step: Planning MSC: NCLEX:
Safe Effective Care Environment: safety and infection control
9. A nurse caring for a patient with a water seal type chest drainage that is on low suction
assesses that there is constant bubbling in the suction container. The nurse should:
a. immediately turn the patient to the side of the insertion site.
b. check for air leaks in drainage system.
c. include findings in documentation.
d. clamp the chest tube and place the patient in high Fowlers position.
ANS: C
Document findings. Constant bubbling in the suction chamber indicates that suction is
on.
DIF: Cognitive Level: Analysis REF: k 531, Steps 28-1 OBJ:
Clinical Practice #4 TOP: Coughing and Deep Breathing KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity: basic care and comfort
10. A nurse is aware that adequate hydration is necessary to mobilize respiratory secretions.
Tothin respiratory secretions for easier expectoration, the patient should consume at least
_____ mL/day.
a. 500 to 1000
b. 1000 to 1500
c. 1500 to 2000
d. 2500 to 3000
ANS: C
, A fluid intake of at least 1500 to 2000 mL/day is needed to thin respiratory secretions
for easier removal by coughing.
DIF: Cognitive Level: Comprehension REF: k 522 OBJ: Clinical
Practice #1 TOP: Mobilizing Secretions KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
11. The nurse would determine that this patient is aware of how to use the incentive
spirometer device properly when the patient:
a. took 10 slow, deep breaths every hour.
b. took five quick huffs and then coughed vigorously.
c. exhaled deeply and then inhaled quickly and forcefully three times.
d. took five deep breaths slowly every 4 hours.
ANS: A
Proper technique for use of an incentive spirometer is to take 10 slow, deep breaths
every hour and to hold each breath for 3 seconds to enhance gas exchange.
DIF: Cognitive Level: Knowledge REF: k 524 OBJ: Clinical Practice #1
TOP: Incentive Spirometer KEY: Nursing Process Step:
Evaluation MSC: NCLEX: Physiological Integrity: basic care and comfort
12. The nurse assists the patient with emphysema into the most beneficial position to
facilitate respiration, which is:
a. semi-Fowlers position with a single pillow behind the head.
b. high Fowlers position without a pillow behind the head.
c. right lateral with the head of the bed elevated 45 degrees.
d. sitting upright and forward with arms supported on an over-the-bed table.
ANS: D
Sitting upright and leaning forward with arms supported on an over-the-bed table is
best for this patient, because it allows for expansion of the thoracic cage in all four
directions (front, back, and two sides).
DIF: Cognitive Level: Application REF: k 524, Figure 28-20 OBJ:
Clinical Practice #1 TOP: Positioning KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
13. The nurse uses a diagram to show that when the diaphragm moves:
a. up, the increased negative pressure in the thoracic space forces air into the lungs.
b. down, the intercostal muscles retract, forcing air out of the lungs.
c. down, the negative pressure in the thoracic space pulls air into the lungs.
d. up, the decreased negative pressure allows air to enter the lungs.
ANS: C
When the diaphragm moves down, increasing the size of the thoracic space, air is
pulled into the lungs. The respiratory action is controlled by the spinal cord.
DIF: Cognitive Level: Knowledge REF: k 501 OBJ: Theory #1
TOP: Respiratory Action KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity: physiological
adaptation
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. The nurse performing tracheotomy care will:
a. raise the head of the bed to high Fowlers position.
b. remove the inner cannula with the ungloved hand.
c. suction tracheotomy before beginning care.
d. clean cannula with gauze and replace and lock.
ANS: C
Proper procedure includes suctioning the tracheotomy before beginning care.
DIF: Cognitive Level: Application REF: k 528, Skill 28-7 OBJ:
Clinical Practice #3 TOP: Tracheotomy Care KEY: Nursing
Process Step: Planning MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
2. The nurse caring for a patient with a disposable chest drainage system can promote
effective tube function and patient safety by:
a. taping all connections within the system.
b. keeping the system at the level of the patients chest.
c. turning on suction to 35 cm.
d. looping the tubing between the mattress and the bed rail to minimize length.
ANS: A
All connections in the system should be taped. Suction should be set at 20 cm unless
ordered otherwise. Looping the tubing encourages plugs in the tubing.
DIF: Cognitive Level: Application REF: k 531, Steps 28-1 OBJ:
Clinical Practice #4 TOP: Chest Tube Care KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
reduction of risk
3. The nurse takes into consideration that a pulse oximeter may not give an accurate reading
if the patient is:
a. dark skinned.
b. jaundiced.
c. obese.
d. febrile.
ANS: B
An accurate reading is dependent on light passing through the vascular bed. Jaundice
may cause an inaccurate reading.
DIF: Cognitive Level: Knowledge REF: k 505 OBJ: Theory #1
TOP: Pulse Oximetry KEY: Nursing Process Step:
Assessment MSC: NCLEX: Physiological Integrity: physiological
adaptation
4. The nurse clarifies that the cough mechanism is stimulated when:
, a. foreign substances are propelled by the cilia toward the respiratory tract.
b. dehumidified air enters the upper airway passages.
c. more than 250 mL of air moves in and out of the lungs with each breath.
d. the blood transports carbon dioxide to the lungs.
ANS: A
Cilia work to propel foreign substances toward the entrance of the respiratory tract,
and the cough reflex works to expel the secretions.
DIF: Cognitive Level: Knowledge REF: k 502 OBJ: Theory #1
TOP: Respiratory Structure Function KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
5. A nurse caring for a patient with a tracheostomy should determine whether the patient
needs suctioning by:
a. monitoring the rate of respirations.
b. determining the last time the patient was suctioned.
c. examining the character of the sputum.
d. auscultating the breath sounds.
ANS: D
Auscultating the patients breath sounds helps the nurse assess for retained secretions
and verifies the need for suctioning. The respiratory rate may rise when suctioning is
needed, but it could also rise for other reasons.
DIF: Cognitive Level: Application REF: k 526, Skill 26-6 OBJ:
Clinical Practice #1 TOP: Suctioning KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
6. A patient requires suctioning via the nasotracheal route. In order to perform this
procedure safely, the nurse should:
a. apply suction while advancing the catheter into the airway.
b. suction the nasotracheal passage after suctioning the mouth.
c. hold the catheter with the dominant hand after donning sterile gloves.
d. insert the non-lubricated catheter into the nasal passage.
ANS: C
The suction catheter should be held with the dominant hand after donning sterile
gloves, because sterile technique must be adhered to when suctioning both the
nasopharyngeal and tracheal areas.
DIF: Cognitive Level: Application REF: k 526, Skill 26-6 OBJ:
Clinical Practice #1 TOP: Suctioning KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
7. The nurse recognizes that, immediately before a tracheotomy cuff deflation, the patient
should:
a. be administered extra oxygen.
b. have the pharynx suctioned.
c. have the cuff pressure checked.
, d. be monitored for respiratory rate.
ANS: B
Immediately before deflating a cuff on a tracheotomy tube, the pharynx should be
suctioned to prevent accumulated oral secretions from entering the bronchial tree once
the cuff is deflated.
DIF: Cognitive Level: Application REF: k 527, Skill 28-6 OBJ:
Clinical Practice #3 TOP: Tracheostomy KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
reduction of risk
8. The nurse takes into consideration that while caring for a patient on oxygen therapy,
safety precautions should be observed, which include:
a. using clothing of synthetic cloth for the patient.
b. removing any adhesive from the patients skin with acetone.
c. assessing equipment in room for frayed cords.
d. reducing humidification on the oxygen delivery device.
ANS: C
All equipment in a room where oxygen is being administered should be in good
working order without frayed or loose connections because of the possibility of fire.
DIF: Cognitive Level: Comprehension REF: k 514, Safety Alert
OBJ: Clinical Practice #5 TOP: Safety Precautions with Oxygen
KEY: Nursing Process Step: Planning MSC: NCLEX:
Safe Effective Care Environment: safety and infection control
9. A nurse caring for a patient with a water seal type chest drainage that is on low suction
assesses that there is constant bubbling in the suction container. The nurse should:
a. immediately turn the patient to the side of the insertion site.
b. check for air leaks in drainage system.
c. include findings in documentation.
d. clamp the chest tube and place the patient in high Fowlers position.
ANS: C
Document findings. Constant bubbling in the suction chamber indicates that suction is
on.
DIF: Cognitive Level: Analysis REF: k 531, Steps 28-1 OBJ:
Clinical Practice #4 TOP: Coughing and Deep Breathing KEY:
Nursing Process Step: Implementation MSC: NCLEX:
Physiological Integrity: basic care and comfort
10. A nurse is aware that adequate hydration is necessary to mobilize respiratory secretions.
Tothin respiratory secretions for easier expectoration, the patient should consume at least
_____ mL/day.
a. 500 to 1000
b. 1000 to 1500
c. 1500 to 2000
d. 2500 to 3000
ANS: C
, A fluid intake of at least 1500 to 2000 mL/day is needed to thin respiratory secretions
for easier removal by coughing.
DIF: Cognitive Level: Comprehension REF: k 522 OBJ: Clinical
Practice #1 TOP: Mobilizing Secretions KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
11. The nurse would determine that this patient is aware of how to use the incentive
spirometer device properly when the patient:
a. took 10 slow, deep breaths every hour.
b. took five quick huffs and then coughed vigorously.
c. exhaled deeply and then inhaled quickly and forcefully three times.
d. took five deep breaths slowly every 4 hours.
ANS: A
Proper technique for use of an incentive spirometer is to take 10 slow, deep breaths
every hour and to hold each breath for 3 seconds to enhance gas exchange.
DIF: Cognitive Level: Knowledge REF: k 524 OBJ: Clinical Practice #1
TOP: Incentive Spirometer KEY: Nursing Process Step:
Evaluation MSC: NCLEX: Physiological Integrity: basic care and comfort
12. The nurse assists the patient with emphysema into the most beneficial position to
facilitate respiration, which is:
a. semi-Fowlers position with a single pillow behind the head.
b. high Fowlers position without a pillow behind the head.
c. right lateral with the head of the bed elevated 45 degrees.
d. sitting upright and forward with arms supported on an over-the-bed table.
ANS: D
Sitting upright and leaning forward with arms supported on an over-the-bed table is
best for this patient, because it allows for expansion of the thoracic cage in all four
directions (front, back, and two sides).
DIF: Cognitive Level: Application REF: k 524, Figure 28-20 OBJ:
Clinical Practice #1 TOP: Positioning KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
13. The nurse uses a diagram to show that when the diaphragm moves:
a. up, the increased negative pressure in the thoracic space forces air into the lungs.
b. down, the intercostal muscles retract, forcing air out of the lungs.
c. down, the negative pressure in the thoracic space pulls air into the lungs.
d. up, the decreased negative pressure allows air to enter the lungs.
ANS: C
When the diaphragm moves down, increasing the size of the thoracic space, air is
pulled into the lungs. The respiratory action is controlled by the spinal cord.
DIF: Cognitive Level: Knowledge REF: k 501 OBJ: Theory #1
TOP: Respiratory Action KEY: Nursing Process Step:
Implementation MSC: NCLEX: Physiological Integrity: physiological
adaptation
