ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 40 : Oxygenation and Perfusion Questions
Question 1 of 5
A nurse in the emergency department is caring for a patient who had eaten shellfish and is now wheezing. The nurse explains to the patient that the health care provider has prescribed a bronchodilator, which will have what action?
Correct Answer: B
Rationale: A bronchodilator opens narrowed airways which result in wheezing. An expectorant encourages cough to clear secretions. A cough suppressant reduces, treats, or stops a cough. Medications that block histamine (antihistamine) are often used for allergy but are not specific bronchodilators.
Question 2 of 5
A nurse is planning to suction a patient's tracheostomy tube the day after its placement. Which action by the nurse is absolutely essential?
Correct Answer: D
Rationale: Sterile technique is used for tracheal suctioning, to reduce the risk of introduction of disease-causing organisms. Aseptic technique is imperative to avoid introducing organisms into the lower airway. An obturator, which guides the direction of the outer cannula, is inserted into the tube during placement and removed once the outer cannula of the tube is in place. In the home setting, clean technique is used.
Question 3 of 5
A nurse is assessing a patient with COPD who is experiencing dyspnea. What action will the nurse take first?
Correct Answer: A
Rationale: Patients with COPD experience dyspnea related to problems with ventilation and/or hypoxemia. One of the most common symptoms of hypoxia is dyspnea (difficulty breathing). Elevating the head of the bed will improve respiratory expansion and oxygenation. Coughing to facilitate secretion removal, pursed-lip breathing, and/or diaphragmatic breathing may be indicated, after sitting the patient up. Suction is indicated for patients demonstrating the presence of secretions, such as adventitious breath sounds or moist cough with phlegm; there is no indication this patient requires suctioning at this time.
Question 4 of 5
A nurse is maintaining airway patency in an unconscious patient by providing frequent nasopharyngeal suction. When would the nurse anticipate inserting a nasopharyngeal airway (nasal trumpet)?
Correct Answer: D
Rationale: Repeated suctioning may injure or traumatize the nares, resulting in nosebleed (epistaxis). The nurse would recommend insertion of a nasal trumpet, which will facilitate suction while protecting the nasal mucosa from further trauma.
Question 5 of 5
A nurse in the PACU is performing oral suctioning for a patient with an oropharyngeal airway, when the patient begins to vomit. What is the nurse's priority nursing action at this time?
Correct Answer: A
Rationale: The nurse discontinues suctioning, elevates the head of the bed, and turns the patient to the side to prevent aspiration. Airway protection takes priority; after positioning the patient, the nurse continues to suction the airway and oropharynx. Once airway patency has been established, the nurse will notify the provider of vomiting. There is no indication the oral airway is too large. Placing the patient supine while vomiting is inappropriate, as that could promote aspiration.