MULTIPLE CHOICE
1. The nurse performing tracheotomy care will:
a. raise the head of the bed to high Fowlers position.
b. remove the inner cannula with the ungloved hand.
c. suction tracheotomy before beginning care.
d. clean cannula with gauze and replace and lock.
ANS: C
Proper pro...
Chapter 20: Oxygenation
Fundamental Nursing Skills and Concepts 12th Edition, Timby
MULTIPLE CHOICE
1. The nurse performing tracheotomy care will:
a. raise the head of the bed to high Fowlers position.
b. remove the inner cannula with the ungloved hand.
c. suction tracheotomy before beginning care.
d. clean cannula with gauze and replace and lock.
ANS: C
Proper procedure includes suctioning the tracheotomy before beginning care.
DIF: Cognitive Level: Application REF: k 528, Skill 28-7 OBJ:
Clinical Practice #3 TOP: Tracheotomy Care KEY: Nursing
Process Step: Planning MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
2. The nurse caring for a patient with a disposable chest drainage system can promote
effective tube function and patient safety by:
a. taping all connections within the system.
b. keeping the system at the level of the patients chest.
c. turning on suction to 35 cm.
d. looping the tubing between the mattress and the bed rail to minimize length.
ANS: A
All connections in the system should be taped. Suction should be set at 20 cm unless
ordered otherwise. Looping the tubing encourages plugs in the tubing.
DIF: Cognitive Level: Application REF: k 531, Steps 28-1 OBJ:
Clinical Practice #4 TOP: Chest Tube Care KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
reduction of risk
3. The nurse takes into consideration that a pulse oximeter may not give an accurate reading
if the patient is:
a. dark skinned.
b. jaundiced.
c. obese.
d. febrile.
ANS: B
An accurate reading is dependent on light passing through the vascular bed. Jaundice
may cause an inaccurate reading.
DIF: Cognitive Level: Knowledge REF: k 505 OBJ: Theory #1
TOP: Pulse Oximetry KEY: Nursing Process Step:
Assessment MSC: NCLEX: Physiological Integrity: physiological
adaptation
4. The nurse clarifies that the cough mechanism is stimulated when:
, a. foreign substances are propelled by the cilia toward the respiratory tract.
b. dehumidified air enters the upper airway passages.
c. more than 250 mL of air moves in and out of the lungs with each breath.
d. the blood transports carbon dioxide to the lungs.
ANS: A
Cilia work to propel foreign substances toward the entrance of the respiratory tract,
and the cough reflex works to expel the secretions.
DIF: Cognitive Level: Knowledge REF: k 502 OBJ: Theory #1
TOP: Respiratory Structure Function KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
5. A nurse caring for a patient with a tracheostomy should determine whether the patient
needs suctioning by:
a. monitoring the rate of respirations.
b. determining the last time the patient was suctioned.
c. examining the character of the sputum.
d. auscultating the breath sounds.
ANS: D
Auscultating the patients breath sounds helps the nurse assess for retained secretions
and verifies the need for suctioning. The respiratory rate may rise when suctioning is
needed, but it could also rise for other reasons.
DIF: Cognitive Level: Application REF: k 526, Skill 26-6 OBJ:
Clinical Practice #1 TOP: Suctioning KEY: Nursing Process
Step: Implementation MSC: NCLEX: Physiological Integrity:
basic care and comfort
6. A patient requires suctioning via the nasotracheal route. In order to perform this
procedure safely, the nurse should:
a. apply suction while advancing the catheter into the airway.
b. suction the nasotracheal passage after suctioning the mouth.
c. hold the catheter with the dominant hand after donning sterile gloves.
d. insert the non-lubricated catheter into the nasal passage.
ANS: C
The suction catheter should be held with the dominant hand after donning sterile
gloves, because sterile technique must be adhered to when suctioning both the
nasopharyngeal and tracheal areas.
DIF: Cognitive Level: Application REF: k 526, Skill 26-6 OBJ:
Clinical Practice #1 TOP: Suctioning KEY: Nursing Process
Step: Implementation MSC: NCLEX: Safe Effective Care
Environment: safety and infection control
7. The nurse recognizes that, immediately before a tracheotomy cuff deflation, the patient
should:
a. be administered extra oxygen.
b. have the pharynx suctioned.
c. have the cuff pressure checked.
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