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 was brought in by fire rescue due to a heroin overdose. The nurse notes the patient is not breathing. What action will the nurse take immediately?
Correct Answer: B,C
Rationale: The priority is to establish ventilation using the manual resuscitation bag to provide emergency or rescue breathing. The nurse tilts the head back, pulls the jaw forward, and positions the mask tightly over the patient's nose and mouth. The bag is compressed at a rate that approximates normal respiratory rate (e.g., 12 to 20 breaths/min in adults). Sputum for cytology is done primarily to detect cells that may be malignant, determine organisms causing infection, and identify blood or pus in the sputum. Note that the bag, with the mask removed, also fits easily over tracheostomy and endotracheal tubes.
Question 2 of 5
Which assessments and interventions should the nurse consider when performing tracheal suctioning?
Correct Answer: A,B,D,E,F
Rationale: Close assessment of the patient before, during, and after the procedure is necessary to identify complications such as hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. In addition, monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis caused by excessive negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage.
Question 3 of 5
A nurse is monitoring a patient with a pleural effusion after a thoracentesis removing 1,400 mL of dark yellow liquid. What is the expected outcome of this procedure?
Correct Answer: C
Rationale: Thoracentesis involves inserting a needle into the pleural space to aspirate pleural fluid, air, or both. A thoracentesis may be performed to obtain a specimen for diagnostic purposes, to remove fluid or air that has accumulated in the pleural cavity and is causing respiratory difficulty and discomfort, or to instill medications.
Question 4 of 5
A nursing student attending clinical on a medical-surgical unit receives report from the off-going nurse stating the patient has adventitious breath sounds that clear after expectorating sputum. Which adventitious breath sound will the student expect to auscultate?
Correct Answer: D
Rationale: Wheezing and crackles represent adventitious or abnormal breath sounds. Bronchial, bronchovesicular, and vesicular breath sounds are normal.
Question 5 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.