ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 40 Questions
Question 1 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 2 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 3 of 5
A nurse working in the pulmonary clinic is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend?
Correct Answer: B,D,E
Rationale: When caring for patients with COPD, it is important to help create an environment that is likely to reduce anxiety, which increases oxygen demand. A high-protein/high-calorie diet is recommended to meet increased energy needs due to the work of breathing. People with dyspnea and orthopnea are most comfortable in a high-Fowler (upright) position because accessory muscles can easily be used to facilitate respiration and lung expansion. Meals should be eaten 1 to 2 hours after breathing treatments; exercise and drinking 2 to 3 quarts (1.9 to 2.9 L) of clear fluids daily is recommended, rather than 2 to 3 pints.
Question 4 of 5
A nurse plans to suction a patient's endotracheal tube using the open suction technique. Which intervention is appropriate for this technique?
Correct Answer: C
Rationale:
To prevent hypoxemia, prior to endotracheal suctioning, the nurse provides 100% oxygen for a minimum of 30 seconds. This is referred to as hyperoxygenation. The nurse limits the application of suction to no more than 10 to 15 seconds. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. An inline suction device is considered a closed, self-contained system used for a 'closed technique' for suction; these are changed every 24 hours.
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.