C HAPTER 28: A SSISTING WITH R ESPIRATION
AND O XYGEN D ELIVERY
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. A patient requires suctioning via the nasotracheal route. In order to
perform this procedure safel y, the nurse should:
a. appl y suction while advancing the catheter i nto 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 nonlubricated 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: p. 525|Skill 28 -5
OBJ: Clinical Practice #1 TOP: Suctionin g
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Safe, Effective Care Environment: Safet y and Infection
Control
,2. The nurse recognizes that, immediatel y before a tracheotom y cuff
deflation, the patient should:
a. be administered extra ox ygen.
b. have the pharynx suctioned.
c. have the cuff pressure checked.
d. be monitored for respiratory rate.
ANS: B
Immediatel y before deflating a cuff on a tracheotom y 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: p. 529 OBJ:
Clinical Practice #3 TOP: Tracheostom y KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity: Reduction of Risk
3. The nurse takes into cons ideration 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 patient’s skin with acetone.
c. assessing equipment in room fo r frayed cords.
d. reducing humidification on the ox ygen 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 possibilit y of fire.
, DIF: Cognitive Level: Comprehension REF: p. 518
OBJ: Clinical Practice #5 TOP: Safet y Precautions
with Ox ygen KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safet y
and Infection Control
4. A nurse caring for a patient with a water seal t ype chest drainage that is
on low suction assesses that there is constant bubbling in the suction
container. The nurse should:
a. immediatel y turn the patient to the side of the insertion site.
b. check for air leaks in drainage system.
c. document findings.
d. clamp the chest tube and place the patient in high Fowler’s position.
ANS: C
Document findings. Constant bubbling in the suction chamber indicates
that suction is on.
DIF: Cognitive Level: Anal ysis REF: p. 521 OBJ:
Clinical Practice #4 TOP: Coughing and Deep Breathing
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrit y: Basic Care and Comfort
5. A nurse is aware that adequate hydration is necessary to mobilize
respiratory secretions. To thin respiratory secretions for easier
expectoration, the patient should consume at least:
a. 500 to 1000 mL/day.
b. 1000 to 1500 m L/day.
AND O XYGEN D ELIVERY
Williams: deWit's Fundamental Concepts and Skills for Nursing, 5th
Edition
MULTIPLE CHOICE
1. A patient requires suctioning via the nasotracheal route. In order to
perform this procedure safel y, the nurse should:
a. appl y suction while advancing the catheter i nto 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 nonlubricated 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: p. 525|Skill 28 -5
OBJ: Clinical Practice #1 TOP: Suctionin g
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Safe, Effective Care Environment: Safet y and Infection
Control
,2. The nurse recognizes that, immediatel y before a tracheotom y cuff
deflation, the patient should:
a. be administered extra ox ygen.
b. have the pharynx suctioned.
c. have the cuff pressure checked.
d. be monitored for respiratory rate.
ANS: B
Immediatel y before deflating a cuff on a tracheotom y 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: p. 529 OBJ:
Clinical Practice #3 TOP: Tracheostom y KEY: Nursing
Process Step: Implementation MSC: NCLEX:
Physiological Integrity: Reduction of Risk
3. The nurse takes into cons ideration 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 patient’s skin with acetone.
c. assessing equipment in room fo r frayed cords.
d. reducing humidification on the ox ygen 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 possibilit y of fire.
, DIF: Cognitive Level: Comprehension REF: p. 518
OBJ: Clinical Practice #5 TOP: Safet y Precautions
with Ox ygen KEY: Nursing Process Step: Planning
MSC: NCLEX: Safe, Effective Care Environment: Safet y
and Infection Control
4. A nurse caring for a patient with a water seal t ype chest drainage that is
on low suction assesses that there is constant bubbling in the suction
container. The nurse should:
a. immediatel y turn the patient to the side of the insertion site.
b. check for air leaks in drainage system.
c. document findings.
d. clamp the chest tube and place the patient in high Fowler’s position.
ANS: C
Document findings. Constant bubbling in the suction chamber indicates
that suction is on.
DIF: Cognitive Level: Anal ysis REF: p. 521 OBJ:
Clinical Practice #4 TOP: Coughing and Deep Breathing
KEY: Nursing Process Step: Implementation MSC:
NCLEX: Physiological Integrit y: Basic Care and Comfort
5. A nurse is aware that adequate hydration is necessary to mobilize
respiratory secretions. To thin respiratory secretions for easier
expectoration, the patient should consume at least:
a. 500 to 1000 mL/day.
b. 1000 to 1500 m L/day.
