A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?

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Question 1 of 9

A nurse is orienting a newly licensed nurse on performing a routine assessment of a client who is receiving mechanical ventilation via an endotracheal tube. Which of the following information should the nurse include in the teaching?

Correct Answer: D

Rationale: Assessing breath sounds every 1 to 2 hours is crucial in monitoring the client's respiratory status and identifying any potential complications promptly. Monitoring ventilator settings every 8 hours is important for overall ventilation management. Documenting the endotracheal tube placement accurately is essential to ensure proper positioning. Using a vest restraint if self-extubation is attempted is not a recommended intervention as it can lead to complications and should be avoided.

Question 2 of 9

A client has left homonymous hemianopsia. Which of the following is an appropriate nursing intervention?

Correct Answer: B

Rationale: In a client with left homonymous hemianopsia, there is a loss of vision on the right side of both eyes. Placing the bedside table on the right side of the bed ensures that essential items are within the client's field of vision, minimizing the risk of injury or accidents. Teaching the client to scan to the right and orienting them using the clock method may be helpful strategies, but placing the bedside table on the right side of the bed is a more direct and immediate intervention to enhance the client's safety and independence.

Question 3 of 9

A client is scheduled for a thoracentesis. Which of the following supplies should NOT be in the client's room?

Correct Answer: B

Rationale: During a thoracentesis procedure, the focus is on draining fluid or air from the pleural space. An incentive spirometer, which helps improve lung function, is not a necessary supply for this specific procedure. Oxygen equipment, pulse oximeter for monitoring oxygen saturation levels, and sterile dressing for wound care may be needed during or after the procedure.

Question 4 of 9

When a chest tube is accidentally removed from a client, which of the following actions should the nurse NOT take first?

Correct Answer: B

Rationale: When a chest tube is accidentally removed, the priority action for the nurse is to immediately seal the insertion site with a gloved hand, a sterile occlusive dressing, or petroleum gauze to prevent air from entering the pleural space and causing a pneumothorax. Applying sterile gauze to the insertion site is not the correct initial action. The first step is to prevent respiratory compromise by ensuring the site is sealed. Therefore, the nurse should not apply sterile gauze to the insertion site first.

Question 5 of 9

A client is being cared for by a nurse 2 hours after admission. The client has an SaO2 of 91%, exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medication should the nurse expect to administer?

Correct Answer: D

Rationale: The client's presentation with an SaO2 of 91%, audible wheezes, and use of accessory muscles indicates respiratory distress, likely due to bronchoconstriction. Beta2 agonists are the appropriate class of medications to administer in this situation as they act as bronchodilators, helping to relieve the bronchoconstriction and improve airflow to the lungs. Antibiotics, beta-blockers, and antivirals are not indicated for this client's respiratory distress symptoms.

Question 6 of 9

A client experiencing dyspnea will receive continuous oxygen. Which oxygen device should be used to deliver a precise amount of oxygen?

Correct Answer: B

Rationale: A Venturi mask is the most appropriate choice for delivering a precise amount of oxygen to a client with dyspnea. Unlike other oxygen delivery devices, the Venturi mask allows for accurate oxygen concentration delivery by controlling the amount of air entrained. This feature is crucial in ensuring the client receives the prescribed oxygen concentration, especially in cases where precise oxygen delivery is required.

Question 7 of 9

When assessing a client with a history of asthma, which of the following factors should the nurse identify as a risk for asthma?

Correct Answer: B

Rationale: When assessing a client with a history of asthma, the nurse should identify environmental allergies as a risk factor for asthma. Environmental allergens such as pollen, dust mites, mold, and pet dander can trigger asthma symptoms and exacerbate the condition. Gender, alcohol consumption, and other factors may not directly contribute to the development or exacerbation of asthma.

Question 8 of 9

During an assessment, a healthcare provider observes a client with a chest tube and drainage system. What is an expected finding?

Correct Answer: B

Rationale: When assessing a client with a chest tube and drainage system, gentle constant bubbling in the suction control chamber is an expected finding. This indicates that the system is functioning properly. Continuous bubbling in the water seal chamber would suggest an air leak, the drainage system should be positioned upright at chest level to promote proper drainage, and exposed sutures without dressing would be an incorrect finding as they should be covered to prevent infection.

Question 9 of 9

When planning care for a client on mechanical ventilation, which mode of ventilation that increases the effort of the client's respiratory muscles should NOT be included in the plan of care?

Correct Answer: A

Rationale: Assist-control ventilation mode delivers a preset tidal volume at a set rate; however, it may not be suitable for clients who need to maintain some level of respiratory muscle activity. This mode provides full support for each breath, potentially leading to decreased respiratory muscle strength over time. Therefore, it is important to avoid using assist-control mode for clients who require increased effort of respiratory muscles to prevent muscle atrophy and promote optimal respiratory function.

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