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 is teaching a patient how to use a metered-dose inhaler for asthma. Which comments from the patient assure the nurse that the teaching has been effective?
Correct Answer: D,E,F
Rationale: Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, inhaling two sprays with one breath, and not activating the device while inhaling.
Question 2 of 5
A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly?
Correct Answer: A,C,E
Rationale: The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should encourage the patient to breathe through their nose with the mouth closed. The nurse should adjust the flow rate and maintain the patient's oxygen saturation as prescribed. The nurse should implement pressure injury prevention strategies; pressure from the tubing could result in medical device-related alterations in skin integrity.
Question 3 of 5
A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident?
Correct Answer: C
Rationale: The tube depth should be maintained at the same level unless otherwise prescribed. If the depth changes, the nurse should remove the tape or securement device, adjust the tube to the ordered depth, and reapply the tape or securement device.
Question 4 of 5
A nurse is providing teaching for a patient who will undergo cardiac surgery and return to the intensive care unit with an endotracheal tube. What education is most important for the nurse to provide?
Correct Answer: B
Rationale: Patients with an endotracheal tube are unable to speak. Explaining this to the patient preoperatively, along with information that they will be closely monitored, can help decrease anxiety. The endotracheal tube is used during anesthesia or for mechanical ventilation; it is not a surgical drain. A tracheostomy, located in the neck area, is a surgically placed artificial airway. While pulse oximetry will be used to monitor oxygenation, to prevent undue anxiety, it is most important that the patient understands speech will not be possible.
Question 5 of 5
A nurse is caring for a patient who has a pleural chest tube attached to a disposable chest drainage system. Which nursing actions are indicated for this patient?
Correct Answer: B,C,E,F
Rationale: The chest drainage collection device must be positioned below the tube's insertion site. Maintaining an occlusive dressing helps prevent air leak; assess for crepitus around the chest tube site indicating air leak. Avoid dependent loops or kinks in the tubing, which could impede drainage. Assess for bubbling in the water seal, maintaining the water level at the 2-cm mark. When a chest tube becomes separated from the drainage device, the nurse should submerge the tube's end in water, creating a temporary water seal and allowing air to escape until a new drainage unit can be attached.