Test bank for davis advantage for medical surgical nursing making connections to practice 2nd editio

Test Bank for Davis Advantage for Medical-Surgical Nursing: Making Connections to Practice,

Test Bank for Davis Advantage for Medical-Surgical Nursing: Making Connections to Practice, 2nd Edition, Janice J. Hoffman Nancy J. Sullivan To download the complete and accurate content document, go to: https://testbankbell.com/download/test-bank-for-davis-advantage-for-medical-surgical -nursing-making-connections-to-practice-2nd-edition-janice-j-hoffman-nancy-j-sullivan /

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Chapter 7: Oxygen Therapy Management Multiple Choice Identify the choice that best completes the statement or answers the question. ____

1. The nurse is providing care to a patient admitted with a respiratory disorder. Which laboratory finding would be most significant?

1. Blood pH 7.32 2. Oxygen saturation 96% 3. PaO2 80 mm Hg 4. Hemoglobin level 12 mg/dL

____

2. The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease (COPD). The patient’s pulse oximetry is 93% on room air with a current respiratory rate of 35 breaths per minute. The most recent chest x-ray indicates a flattened diaphragm with infiltrates.

The patient is currently febrile with an increased number of white blood cells (WBCs) noted on the latest complete blood count (CBC). Which order does the nurse question for this patient based on the current data?

1. Raise the head of the patient’s bed 2. Add humidification to the oxygen source 3. Oxygen therapy via nasal cannula at 3 to 4 L/min 4. Chest physiotherapy (CPT) every 4 hours while awake

____

3. Which nursing action best determines the accuracy of the detected waveform when monitoring a patient’s oxygen saturation via oximetry?

1. Using a site with adequate perfusion 2. Ensuring the any nail polish is removed 3. Leaving the sensor in place for a minimum of 10 seconds 4. Assessing the heart rate and comparing it with the displayed pulse

____

4. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) who is prescribed 24% oxygen at 2 L/min. Which is the best method for the nurse to use to administer oxygen to this patient?

1. Face mask 2. Venturi mask 3. Nasal cannula 4. Nonrebreather mask

____

5. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) who requires supplemental oxygen. Which is the correct flow rate range by nasal cannula (NC) when providing care for this patient?

1. 1 to 2 L/min 2. 2 to 3 L/min 3. 3 to 4 L/min 4. 4 to 5 L/min

Copyright © 2020 F. A. Davis Company

____

6. The nurse is providing care to a patient who is recovering from facial trauma who requires high-flow oxygen therapy. Which method of oxygen delivery does the nurse recognize as best for this patient?

1. Face tent 2. Nasal cannula 3. Venturi mask 4. Nonrebreather mask

____

7. The nurse is providing education to a patient who is prescribed oxygen in the home environment.

Which statement made by the patient indicates the need for further education?

1. “I will ensure that the oxygen is kept 6 feet away from the stove.”

2. “I placed a no smoking sign on the door and several places within the house.”

3. “I will store the oxygen on its side, per the instructions provided by the agency.”

4. “I will keep a fire extinguisher in the house and keep it close to where the oxygen is stored.”

____

8. The nurse provides education to a patient who is going to be discharged from the hospital with oxygen. Which patient statement indicates the need for further education?

1. “I have two fire extinguishers in my home.”

2. “I will activate emergency medical services if I lose power.”

3. “I will check my oxygen tank daily and order new tanks well in advance of needing them.”

4. “I told my husband to stack the oxygen tanks in the closet so that they aren’t cluttering the room.”

____

9. The nurse assists the healthcare provider with a patient intubation. What is the priority action by the nurse?

1. Ensure suction is available.

2. Place the intubation tray at the bedside for the procedure.

3. Explain each step of the procedure to the patient and family.

4. Administer manual breaths to the patient using a resuscitation bag and mask.

____

10. The nurse is providing care to a patient who is mechanically ventilated. Which nursing action is most effective in decreasing the risk for aspiration?

1. Elevate the head of the bed between 30 to 45 degrees 2. Limit each suctioning event to no more than 10 seconds 3. Perform chest physiotherapy as prescribed by the practitioner 4. Ensure an NPO status is maintained for the length of the prescribed treatment

____

11. When conducting a respiratory assessment, the nurse notes a low-pitched sound that is continuous throughout inspiration. Which does this lung sound indicate to the nurse?

1. Narrow bronchi 2. Narrow trachea passages 3. Inflamed pleural surfaces 4. Blocked large airway passages

____

12. During auscultation of breath sounds, the nurse hears wheezing and correlates to which sound?

1. Snoring sounds Copyright © 2020 F. A. Davis Company

2. Gurgling sounds 3. Low-pitched bubbling 4. High-pitched squeaking ____

13. Which sound heard during auscultation of the breath sounds does the nurse correlate to rhonchi?

1. Snoring sounds 2. Gurgling sounds 3. Low-pitched bubbling 4. High-pitched squeaking

____

14. The nurse places the patient in which position before performing in-line suctioning?

1. Prone 2. Supine 3. Fowler’s 4. Semi-Fowler’s

____

15. When conducting in-line suctioning, the nurse recognizes which of the following is the maximum amount of time for each suctioning event?

1. 10 seconds 2. 30 seconds 3. 45 seconds 4. 60 seconds

____

16. When conducting in-line suctioning on a patient, which amount of time does the nurse allow as a rest period between suction procedures?

1. 5 to 15 seconds 2. 10 to 20 seconds 3. 15 to 25 seconds 4. 20 to 30 seconds

____

17. The nurse is performing in-line suctioning when the patient experiences a decrease in oxygen saturation and bradycardia. Which nursing action is best?

1. Continue suctioning and administer 50% oxygen 2. Discontinue suctioning and prepare for resuscitation 3. Discontinue suctioning and administer 100% oxygen 4. Continue suctioning and administer prescribed epinephrine

____

18. The nurse suctions a patient’s tracheostomy tube. During the procedure, the patient’s heart rate drops to the low 50s and oxygen saturation falls to 85%. Which is the priority action by the nurse?

1. Tell the patient to relax and continue the procedure.

2. Stop the suctioning procedure and administer oxygen.

3. Notify the healthcare provider at the end of the procedure.

4. Document the patient’s reaction to the procedure in the medical record.

____

19. The nurse is providing care to a patient who has a tracheostomy. The nurse plans to monitor this patient for the loss of which protective mechanism during the respiratory assessment process?

1. The ability to cough 2. The filtration and humidification of inspired air Copyright © 2020 F. A. Davis Company

3. A decrease in the oxygen-carrying capacity of the trachea 4. The sneeze reflex initiated by irritants in the nasal passages ____

20. The nurse is providing education to a patient regarding the use of an incentive spirometer. Which patient statement indicates the need for further education?

1. “I should be in a sitting position when using this device.”

2. “I will use this device 20 times per hour while I am awake each day.”

3. “I will exhale completely before placing my lips around the mouthpiece.”

4. “I will hold my breath for 3 seconds after I feel like I cannot inhale any more breath.”

____

21. The nurse instructs a patient on the use of incentive spirometry. Which patient statement indicates the need to provide additional instruction?

1. “I will use the device 5 to 10 times per day.”

2. “I will take in a slow, deep breath, like inhaling through a straw.”

3. “I will exhale completely before I begin this breathing exercise.”

4. “I will sit up in bed as this allows my lungs to expand during the exercise.”

____

22. Which statement by the patient receiving intermittent positive-pressure breathing (IPPB) treatments indicates that the nurse’s teaching was effective?

1. “I will need to have a breathing tube placed.”

2. “I will get my aerosolized medications with this treatment.”

3. “This will decrease my need to cough.”

4. “This will require me to be on oxygen permanently.”

____

23. The nurse is providing care for a patient on a mechanical ventilator in the assist-control mode. If the ventilator rate is set at 10 breaths per minute, and the patient is breathing 16 times per minute, how many ventilator breaths is the patient receiving?

1. 6 2. 10 3. 12 4. 16

____

24. The nurse recognizes that the patient on which mode of mechanical ventilation is at greatest risk for developing respiratory alkalosis?

1. Assist-control 2. Intermittent mandatory ventilation 3. Synchronized intermittent mandatory ventilation 4. Pressure support

____

25. The patient is admitted to the Intensive Care Unit and placed on Synchronized Intermittent Mandatory Ventilation (SIMV) mode. The nurse notes that the patient is breathing 12 times per minute, and the ventilator is set at 8 breaths per minute. How many ventilator breaths is the patient receiving?

1. 4 2. 8 3. 12 4. 20 Copyright © 2020 F. A. Davis Company

____

26. The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm sounds and the nurse notes a mucous plug in the endotracheal (ET) tube. Which action by the nurse is indicated?

1. Suctioning as needed 2. Inserting an oral airway 3. Assessing for asymmetrical chest rise 4. Emptying water from the ventilator tubing

____

27. The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm sounds and the nurse notes the patient is biting down on the endotracheal (ET) tube. Which action by the nurse is appropriate?

1. Suctioning as needed 2. Inserting an oral airway 3. Assessing for asymmetrical chest rise 4. Emptying water from the ventilator tubing

____

28. The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm is activated, and the nurse notes a collection of moisture in the ventilator tubing. Which action by the nurse is appropriate?

1. Emptying the water from the ventilator tubing 2. Suctioning as needed 3. Inserting an oral airway 4. Assessing for asymmetrical chest rise

____

29. The nurse is providing care to a patient who is being weaned from mechanical ventilation. Which finding would necessitate the continuation of mechanical ventilation if noted during the weaning process?

1. An FIO2 less than or equal to 0.4 to 0.5 2. A positive end-expiratory pressure (PEEP) less than or equal to 5 to 8 cm H2O 3. A pH greater than 7.25 during spontaneous ventilation 4. Decreased blood pressure

Multiple Response Identify one or more choices that best complete the statement or answer the question. ____

30. Which information does the nurse document when monitoring a patient’s oxygen saturation via oximetry? Select all that apply.

1. SpO2 result 2. Current vital signs 3. Last time the patient ate or drank 4. Type and amount of oxygen therapy in use 5. Education provided to the patient and family

____

31. Which intervention does the nurse include in the plan of care for a patient being mechanically ventilated who is receiving care based on a ventilator bundle focused on reducing the risk of ventilator-associated pneumonia? Select all that apply.

Copyright © 2020 F. A. Davis Company

1.

2.

3.

4.

5.

Elevating the head of the bed Ensuring a sedation vacation each day Minimizing ambulation Administering a prescribed peptic ulcer prophylactic regimen Restricting family visitation

____

32. In providing care to a patient on a mechanical ventilator, the nurse suctions the patient using in-line suctioning. Which information does the nurse document in the medical record after the procedure is completed? Select all that apply.

1. Amount of secretions 2. Color of the secretions 3. Consistency of the secretions 4. Patient’s response to the procedure 5. Number of times that the suction catheter was introduced

____

33. Which actions by the nurse are considered best practice when providing tracheostomy care? Select all that apply.

1. Setting the suction to 150 mm Hg 2. Suctioning as the catheter is introduced into the airway 3. Applying appropriate personal protective equipment 4. Inspecting the trach stoma for signs of infection, irritation, and skin breakdown 5. Rinsing a disposable inner cannula with sterile water and drying

____

34. The nurse provides care to a patient who is intubated and receiving mechanical ventilation. Which actions are appropriate for the nurse to implement if the high-pressure alarm sounds? Select all that apply.

1. Inserting an oral airway 2. Assessing the ventilator connections 3. Checking the patient’s cuff pressure 4. Suctioning the patient’s endotracheal tube 5. Emptying water from the ventilator tubing

____

35. The nurse provides care to a patient who is intubated and receiving mechanical ventilation. Which actions are appropriate for the nurse to implement if the low-pressure alarm sounds? Select all that apply.

1. Inserting an oral airway 2. Assessing the ventilator connections 3. Checking the patient’s cuff pressure 4. Suctioning the patient’s endotracheal tube 5. Assessing the patient’s respiratory rate

Copyright © 2020 F. A. Davis Company

Chapter 7: Oxygen Therapy Management Answer Section MULTIPLE CHOICE 1. ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 1. Reviewing concepts of oxygenation Chapter page reference: 83 Heading: Overview of Oxygen Therapy/Oxygen Monitoring and Measurement/Table 7.1 – Normal Arterial Blood Gas Values Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1 2 3 4

Normal blood pH is 7.35 to 7.45. A decreased pH indicates that the patient is experiencing acidosis, which indicates an alteration in oxygenation.

Oxygen saturation of 96% is within normal limits.

The normal PaO2 (partial pressure of oxygen in arterial blood) level, the part of total blood gas pressure exerted by oxygen gas, is 80 to 95 mm Hg. The hemoglobin level affects the amount of oxygen that can be carried in the blood; however, the value is within normal limits.

PTS: 1 CON: Oxygenation 2. ANS: 3 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 3. Describing methods of oxygen delivery Chapter page reference: 83 Heading: Overview of Oxygen Therapy/Contraindications to Oxygen Administration Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 2 3

Raising the head of the bed decreases the work of breathing and is not contraindicated.

This is an appropriate order for this patient.

The nurse needs to be concerned about the order for oxygen to be provided at 3 to 4 L/min. This amount of oxygen is too much for a patient with COPD because the patient's breaths are stimulated by a hypoxic drive and this disease

Copyright © 2020 F. A. Davis Company

4

process causes the body to retain carbon dioxide. Providing this much oxygen can result in an increase in carbon dioxide levels, leading to respiratory failure.

Oxygen for this patient should be at a lower rate, such as 1 to 2 L/min, with close assessments of the patient's breathing status.

Chest physiotherapy (CPT) is ordered when the patient requires assistance in removing pulmonary secretions. CPT consists of percussion, vibration, and postural drainage. This is not contraindicated in the patient with COPD.

PTS: 1 CON: Oxygenation 3. ANS: 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 1. Reviewing concepts of oxygenation Chapter page reference: 84 Heading: Non-Invasive Oxygen Delivery Methods/Low-Flow Delivery Devices/Table 7.2 – Obtaining an Oxygen Saturation Reading Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1

2

3

4

Although using a site with adequate perfusion is important, this action does not determine the accuracy of the detected waveform when monitoring a patient’s oxygen saturation via oximetry.

Although ensuring that any nail polish is removed is important, this action does not determine the accuracy of the detected waveform when monitoring a patient’s oxygen saturation via oximetry.

Although leaving the sensor in place for a minimum of 10 seconds is important, this action does not determine the accuracy of the detected waveform when monitoring a patient’s oxygen saturation via oximetry.

Assessing the heart rate and comparing it with the displayed pulse is the nursing action that determines the accuracy of the wave form when monitoring a patient’s oxygen saturation via oximetry.

PTS: 1 CON: Oxygenation 4. ANS: 3 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 3. Describing methods of oxygen delivery Chapter page reference: 84 Heading: Noninvasive Oxygen Delivery Methods/Low-Flow Delivery Devices/Nasal Cannula Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Comprehension [Understanding] Concept: Oxygenation Copyright © 2020 F. A. Davis Company

Difficulty: Moderate Feedback 1 2 3 4

A face mask is better suited to deliver oxygen at higher percentages and flow rates.

A Venturi mask is better suited to deliver oxygen at higher percentages and flow rates.

The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2 L/min is through nasal cannula.

A nonrebreather mask is better suited to deliver oxygen at higher percentages and flow rates.

PTS: 1 CON: Oxygenation 5. ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 3. Describing methods of oxygen delivery Chapter page reference: 84 Heading: Noninvasive Oxygen Delivery Methods/Low-Flow Delivery Devices/Nasal Cannula Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge [Remembering] Concept: Oxygenation Difficulty: Easy Feedback 1

2

3

4

A low flow rate of 1 to 2 L/min via NC is anticipated for a patient with COPD. The patient who retains CO2, such as the patient with COPD, will use the lower amount of oxygen (1–2 L/min) so the patient does not lose his or her hypoxic drive to breathe.

This flow rate is higher than anticipated when providing care for a patient with COPD who requires supplement oxygen via NC. This level may suppress the hypoxic drive to breathe.

This flow rate is higher than anticipated when providing care for a patient with COPD who requires supplement oxygen via NC. This level may suppress the hypoxic drive to breathe.

This flow rate is higher than anticipated when providing care for a patient with COPD who requires supplement oxygen via NC. This level may suppress the hypoxic drive to breathe.

PTS: 1 CON: Oxygenation 6. ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 3. Describing methods of oxygen delivery Chapter page reference: 87 Heading: Noninvasive Oxygen Delivery Methods/High-Flow Delivery Devices/Face Tent Copyright © 2020 F. A. Davis Company

Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 2

3 4

A face tent is a high-flow delivery device of oxygen that is appropriate for the patient who requires supplemental oxygen if facial trauma is experienced.

Although a nasal cannula might be appropriate for a patient who needs a low-flow delivery device, this is not appropriate for the patient who requires a high-flow delivery device.

A Venturi mask delivers a high flow of oxygen; however, facial trauma makes this an unrealistic choice.

A nonrebreather mask is not an appropriate for the high-flow delivery of oxygen.

PTS: 1 CON: Oxygenation 7. ANS: 3 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 3. Describing methods of oxygen delivery Chapter page reference: 88 Heading: Long-Term Oxygen Therapy/Oxygen Delivery/Box 7.1 – Educating for Patients Receiving Home Oxygen Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment: Safety and Infection Control Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 2 3 4

Oxygen needs to be kept at least 6 feet from sources of heat, such as the stove.

This statement indicates correct understanding of the information presented.

A no smoking sign needs to be placed in the home if oxygen is stored, or in use.

This statement indicates correct understanding of the information presented.

Oxygen needs to be stored upright, not on its side. This statement indicates the need for further education.

A fire extinguisher needs to be maintained in the home and stored close to where the oxygen is stored. This statement indicates correct understanding of the information presented.

PTS: 1 CON: Safety 8. ANS: 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 3. Describing Methods of Oxygen Delivery Copyright © 2020 F. A. Davis Company

Chapter page reference: 88 Heading: Long-Term Oxygen Therapy/Oxygen Delivery/ Box 7.1 – Educating for Patients Receiving Home Oxygen Integrated Processes: Teaching and Learning Client Need: Safe and Effective Care Environment Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Moderate Feedback 1

2

3

4

The patient is taught to keep a fire extinguisher in the house located close to the source of oxygen. This statement indicates a correct understanding of the information presented regarding oxygen safety in the home.

The nurse discusses the importance of having an emergency plan and tells the patient to call 911 in case of power failure. This statement indicates a correct understanding of the information presented regarding oxygen safety in the home.

The nurse educates the patient to check the amount of oxygen in the tank and order more in advance so it does not run out. This statement indicates a correct understanding of the information presented regarding oxygen safety in the home.

The nurse educates the patient to store and keep oxygen tanks in an upright position. This patient statement indicates a need for additional education regarding oxygen safety in the home.

PTS: 1 CON: Safety 9. ANS: 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 4. Explaining indications, management, and complications of artificial airways Chapter page reference: 91-93 Heading: Invasive Oxygen Therapy/Artificial Airways/Endotracheal Tube/Nursing Considerations Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Moderate Feedback 1

2

Suction is available throughout the procedure to ensure a patent airway.

However, suction may or may not be needed and is dependent on the patient’s condition. Therefore, this is not the priority nursing action.

Although it is important for the intubation tray to be placed at bedside, this task can be delegated to another member of the healthcare team. The nurse’s priority is to maintain the patient's airway, breathing, and circulation (ABCs).

Copyright © 2020 F. A. Davis Company

3

4

The nurse explains the procedure and the reason for intubation to the patient (if the patient is able to understand) and family members. Teaching is a psychosocial need and is not the priority in this situation. Maintaining the patient’s ABCs is the priority.

The nurse prioritizes care using the ABCs. During a patient intubation, the nurse maintains proper airway management using a manual resuscitation bag with face mask connected to a 100% oxygen source throughout the intubation procedure.

This action maintains the patient’s airway and breathing.

PTS: 1 CON: Oxygenation 10. ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 5. Discussing the rationale, methods, and complications for mechanical ventilation Chapter page reference: 91-93 Heading: Invasive Oxygen Therapy/Artificial Airways /Endotracheal Tube/Nursing Considerations/Table 7.3 – Process for Endotracheal Intubation Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1

2 3 4

Unless contraindicated, any patient who is mechanically ventilated should have the head of the bed elevated at 30 to 45 degrees to decrease the risk for aspiration.

Although it is important to limit each suctioning event to 10 seconds in length, this is not an action to decrease the risk for aspiration.

Although chest physiotherapy is often prescribed, this action is not intended to decrease the risk for aspiration.

Although many patients who are mechanically ventilated will receive parenteral or enteral nutrition, an NPO status is unnecessary to decrease the risk for aspiration.

PTS: 1 CON: Safety 11. ANS: 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 1. Reviewing concepts of oxygenation Chapter page reference: 93-94 Heading: Invasive Oxygen Therapy/Artificial Airways/Endotracheal Tube/ ETT Management/Table 7.4 – Characteristics of Breath Sounds Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Copyright © 2020 F. A. Davis Company

Concept: Assessment Difficulty: Moderate Feedback 1 2 3 4

Wheezing is created by narrow bronchi.

Stridor is the sound created by narrow tracheal passages.

A low-pitched grating sound is created by inflamed pleural surfaces.

The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout inspiration. Rhonchi suggests blockage of large airway passages, which may be cleared with coughing.

PTS: 1 CON: Assessment 12. ANS: 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 4. Explaining indication, management, and complications pf artificial airways Chapter page reference: 93-94 Heading: Invasive Oxygen Therapy/Artificial Airways/Endotracheal Tube/ETT Management/ Table 7.4 – Characteristics of Breath Sounds Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Moderate Feedback 1 2 3 4

Snoring sounds indicate rhonchi, caused by airflow obstruction from thick secretions or fluid in the large airways.

Gurgling sounds indicate crackles. On inhalation, air comes in contact with secretions in the trachea and large bronchi.

Loud, low-pitched bubbling sounds indicate crackles. On inhalation, air comes in contact with secretions in the trachea and large bronchi.

Wheezing is characterized as musical, high-pitched squeaking that indicates narrowed passages caused by secretions, bronchospasm, edema, and inflammation.

PTS: 1 CON: Assessment 13. ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 4. Explaining indication, management, and complications pf artificial airways Chapter page reference: 93-94 Heading: Invasive Oxygen Therapy/Artificial Airways/Endotracheal Tube/ETT Management/ Table 7.4 – Characteristics of Breath Sounds Integrated Processes: Nursing Process: Assessment Copyright © 2020 F. A. Davis Company

Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Assessment Difficulty: Moderate Feedback 1 2 3 4

Snoring sounds indicate rhonchi, caused by airflow obstruction from thick secretions or fluid in the large airways.

Gurgling sounds indicate crackles. On inhalation, air comes in contact with secretions in the trachea and large bronchi.

Loud, low-pitched bubbling sounds indicate crackles. On inhalation, air comes in contact with secretions in the trachea and large bronchi.

Wheezing is characterized as musical, high-pitched squeaking that indicates narrowed passages caused by secretions, bronchospasm, edema, and inflammation.

PTS: 1 CON: Assessment 14. ANS: 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 4. Explaining indications, management, and complications of artificial airways Chapter page reference: 93-94 Heading: Invasive Oxygen Therapy/Artificial Airways/Endotracheal Tube/ETT Management / Table 7.5 – Suctioning Using In-Line or Closed Suction Catheters Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 2 3 4

A prone position is not appropriate for a patient who requires in-line suctioning.

A supine position is not appropriate for a patient who requires in-line suctioning.

Fowler’s position is not appropriate for a patient who requires in-line suctioning.

Semi-Fowler’s position is appropriate for a patient who requires in-line suctioning. Elevating the head of bed will allow for easier ventilation for the patient.

PTS: 1 CON: Oxygenation 15. ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 4. Explaining indications, management, and complications of artificial airways Chapter page reference: 93-94 Copyright © 2020 F. A. Davis Company

Heading: Invasive Oxygen Therapy/Artificial Airways/Endotracheal Tube/ETT Management/Table 7.5 – Suctioning Using In-Line or Closed Suction Catheters Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Oxygenation Difficulty: Easy Feedback 1

2 3 4

Each suctioning event should last no longer than 10 seconds. Suctioning lasting longer than 10 seconds causes hypoxia, cardiopulmonary compromise, and a vagal response.

Each suctioning event should not last 30 seconds because this can cause hypoxia, cardiopulmonary compromise, and a vagal response.

Each suctioning event should not last 45 seconds because this can cause hypoxia, cardiopulmonary compromise, and a vagal response.

Each suctioning event should not last 60 seconds because this can cause hypoxia, cardiopulmonary compromise, and a vagal response.

PTS: 1 CON: Oxygenation 16. ANS: 2 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 4. Explaining indications, management, and complications of artificial airways Chapter page reference: 93-94 Heading: Invasive Oxygen Therapy/Artificial Airways/Endotracheal Tube/ETT Management/ Table 7.5 – Suctioning Using In-Line or Closed Suction Catheters Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Knowledge [Remembering] Concept: Oxygenation Difficulty: Easy Feedback 1 2

3 4

A rest period of 5 to 15 seconds is not adequate between suction procedures.

A rest period of 10 to 20 seconds is an appropriate time frame between suction procedures. This time frame decreases the risk for hypoxia, dysrhythmia, and bronchospasm.

A rest period of 15 to 25 seconds is not appropriate between suction procedures.

A rest period of 20 to 30 seconds is not appropriate between suction procedures.

PTS: 1 CON: Oxygenation 17. ANS: 3 Chapter number and title: 7, Oxygen Therapy Management Copyright © 2020 F. A. Davis Company

Chapter learning objective: 4. Explaining indications, management, and complications of artificial airways Chapter page reference: 97 Heading: Invasive Oxygen Therapy/Artificial Airways/ Tracheostomy/Tracheostomy Care/Suctioning a Tracheostomy: Safety Alert Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 2 3 4

The nurse does not continue suctioning and administer 50% oxygen if in-line suctioning causes a decrease in oxygen saturation and bradycardia.

Although the nurse does discontinue suctioning, it is not necessary to prepare for resuscitation.

When in-line suctioning causes a decrease in oxygen saturation and bradycardia, the nurse discontinues suctioning and administers 100% oxygen.

The nurse does not continue suctioning and administer prescribed epinephrine if in-line suctioning causes a decrease oxygen saturation and bradycardia.

PTS: 1 CON: Oxygenation 18. ANS: 2 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 4. Explaining indications, management and complications of artificial airways Chapter page reference: 97-99 Heading: Invasive Oxygen Therapy/Artificial Airways/ Tracheostomy/Tracheostomy Care/Suctioning a Tracheostomy Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Moderate Feedback 1

2

3 4

Although the nurse provides reassurance during the procedure, it is unsafe to continue suctioning when the patient experiences bradycardia and decreased oxygen saturation.

Bradycardia and a decreased oxygen saturation during tracheostomy suctioning require the nurse to stop the procedure and administer 100% oxygen. The priority is to restore homeostasis.

Although it may be necessary to notify the healthcare provider of the patient’s reaction to the suctioning, this is not the priority action.

Although is it important to document the patient’s reaction to the procedure in

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the medical record, this is not the priority action at this time.

PTS: 1 CON: Oxygenation 19. ANS: 2 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 4. Explaining indications, management, and complications of artificial airways Chapter page reference: 95-97 Heading: Invasive Oxygen Therapy/Artificial Airways/Tracheostomy Integrated Processes: Nursing Process: Assessment Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Oxygenation Difficulty: Moderate Feedback 1 2

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The patient can still cough and sneeze, and there is no decrease in the oxygen-carrying capacity of the trachea.

The inspired air through the tracheostomy is not warmed, filtered, and humidified through the nose and mouth as with normal breathing, and this can lead to thick, dry secretions.

The patient can still cough and sneeze, and there is no decrease in the oxygen-carrying capacity of the trachea.

The patient can still cough and sneeze, and there is no decrease in the oxygen-carrying capacity of the trachea.

PTS: 1 CON: Oxygenation 20. ANS: 2 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 7. Clarifying indications and nursing implications for the following respiratory care modalities: Incentive Spirometry Chapter page reference: 100 Heading: Therapeutic Modalities/Incentive Spirometry: Nursing Implications Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Communication Difficulty: Moderate Feedback 1

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A sitting, or high-Fowler’s, position is recommended when using an incentive spirometer. This statement indicates correct understanding of the information presented.

The device needs to be used 5 to 10 times each hour while awake. This statement indicates the need for further education.

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The patient exhales completely before placing the mouth on the device. This statement indicates correct understanding of the information presented.

The patient needs to hold the breath for 3 seconds and then exhale completely.

This statement indicates correct understanding of the information presented.

PTS: 1 CON: Communication 21. ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 7. Clarifying indications and nursing implications for the following respiratory care modalities: Incentive Spirometry Chapter page reference: 100 Heading: Therapeutic Modalities/Incentive Spirometry: Nursing Implications Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Comprehension [Understanding] Concept: Communication Difficulty: Moderate Feedback 1

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This statement indicates the need for additional instruction. The nurse encourages the patient to use the device 5 to 10 times per hour while awake or as directed by the healthcare provider. Have the patient rest a few seconds between exercises and cough after each session. This repeated exercise improves lung expansion and promotes airway clearance of the secretions.

This statement indicates a correct understanding of what the patient does after placing the mouth on the mouthpiece. The nurse instructs the patient to take in a slow, smooth, deep breath, like inhaling through a straw. When the patient reaches maximal inspiration and cannot inhale any more, the patient holds his or her breath for approximately 3 seconds. Then the patient exhales smoothly and slowly. This allows for good expansion of the alveoli to prevent or treat atelectasis.

The nurse instructs the patient to exhale completely before placing the mouth on the mouthpiece of the incentive spirometer.

The patient is instructed to sit up (semi-Fowler’s is best) if no contraindications are noted. This allows for optimal lung expansion during this breathing exercise.

PTS: 1 CON: Communication 22. ANS: 2 Chapter number and title: 6, Geriatric Implications for Medical-Surgical Nursing Chapter learning objective: 7. Clarifying indications and nursing implications for the following respiratory care modalities: Intermittent positive pressure breathing (IPPB) Chapter page reference: 102 Heading: Therapeutic Modalities/Intermittent Positive Pressure Breathing Integrated Processes: Teaching and Learning Client Need: Physiological Integrity: Physiological Adaptation Copyright © 2020 F. A. Davis Company

Cognitive Level: Analysis [Analyzing] Concept: Nursing Roles Difficulty: Moderate Feedback 1

Intubation is not required for IPPB treatments.

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Intermittent positive-pressure breathing (IPPB) devices are prescribed by the healthcare provider to improve lung expansion, to deliver aerosol medications, or to assist the patient in ventilation. IPPB is indicated for patients who need to improve lung expansion.

IPPB treatments do not decrease need to cough, and with treatments that decrease viscosity of secretions, the patient may have increased need to cough to clear secretions.

Oxygen therapy is not administered via IPPB, and these treatments are intended to increase lung expansion and assist in ventilation.

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PTS: 1 CON: Nursing Roles 23. ANS: 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 6. Contrasting various mechanical ventilator modalities Chapter page reference: 104 Heading: Overview of Mechanical Ventilation/Modes/Assist-Control Ventilation, Also Known as Continuous Mandatory Ventilation (CMV) Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis Concept: Oxygenation Difficulty: Difficult Feedback 1

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In assist-control mode the respiratory rate and tidal volume are preset and each breath initiated by the patient is supported. Because the patient is initiating 6 breaths above the set rate of 10, the patient will receive 16 breaths.

The ventilator rate is set at 10, but because in assist-control mode the ventilator supports (assists) all breaths initiated by the patient, the patient will receive 16 breaths.

The ventilator rate is set at 10, but because in assist-control mode the ventilator supports (assists) all breaths initiated by the patient, the patient will receive 16 breaths.

In assist-control mode the respiratory rate and volume of breaths are preset. If the patient does not initiate a breath, the ventilator delivers the breaths at the preset rate and volume. If the patient does initiate a breath, the ventilator delivers the preset volume (assisted breath), allowing the patient to control the rate of breaths. Because the patient is breathing 16 times, that is the number of

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breaths the ventilator will deliver.

PTS: 1 CON: Oxygenation 24. ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 5. Discussing the rationale, methods, and complications for mechanical ventilation Chapter page reference: 104-105 Heading: Overview of Mechanical Ventilation/Modes Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis Concept: pH regulation Difficulty: Difficult Feedback 1

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The disadvantage of assist-control mode is that in the hyperventilating patient, respiratory alkalosis can develop if the respiratory rate increases above a normal rate because the ventilator continues to deliver a preset volume with each initiated breath.

In intermittent mandatory ventilation there is a preset rate and volume and the ventilator only delivers the set rate, decreasing the risk of respiratory alkalosis.

In synchronized intermittent mandatory ventilation there is a preset rate and volume and the ventilator only delivers the set rate, synchronized with the patient’s breathing. This decreases the risk of respiratory alkalosis.

Pressure support is a continuous positive pressure that is delivered during respiration. Because this mode does not impact rate or volume, there is less risk of respiratory alkalosis that in the patient on assist-control.

PTS: 1 CON: pH Regulation 25. ANS: 2 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 6. Contrasting various mechanical ventilator modalities Chapter page reference: 104 Heading: Overview of Mechanical Ventilation/Modes/Synchronized Intermittent Mandatory Ventilation Integrated Processes: Nursing Process: Analysis Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis Concept: Oxygenation Difficulty: Difficult Feedback 1

The patient is receiving 8 ventilator breaths because in synchronized intermittent

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mandatory ventilation the rate is set to deliver the set rate.

The patient is receiving 8 ventilator breaths. If the patient does not initiate a breath, the ventilator delivers the preset volume and rate per minute to the patient. This mode allows the patient to breathe spontaneously at his or her own volume and rate between the breaths given by the ventilator. This mode synchronizes with the patient’s efforts to breathe.

The patient is receiving 8 ventilator breaths. This mode allows the patient to breathe spontaneously at his or her own volume and rate between the breaths given by the ventilator. This mode synchronizes with the patient’s efforts to breathe.

The patient is receiving 8 ventilator breaths. This mode allows the patient to breathe spontaneously at his or her own volume and rate between the breaths given by the ventilator. This mode synchronizes with the patient’s efforts to breathe.

PTS: 1 CON: Oxygenation 26. ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 5. Discussing the rationale, methods, and complications for mechanical ventilation Chapter page reference: 106 Heading: Overview of Mechanical Ventilation/Complications Associated With Mechanical Ventilation/Table 7.8 – Mechanical Ventilation Alarms Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1

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A mucous plug often causes a high-pressure alarm when a patient is being mechanically ventilated. The appropriate action by the nurse is to suction the endotracheal (ET) tube to remove the mucous plug.

An oral airway is inserted if the patient is biting on the ET tube, which can cause a high-pressure alarm for a patient who is being mechanically ventilated.

Assessing for asymmetrical chest rise is an appropriate action if the high-pressure alarm is caused by a pneumothorax, not a mucous plug.

Emptying water in the ventilator tubing is an appropriate action if the high-pressure alarm is caused by water collection, not a mucous plug.

PTS: 1 CON: Safety 27. ANS: 2 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 5. Discussing the rationale, methods, and complications for mechanical ventilation Copyright © 2020 F. A. Davis Company

Chapter page reference: 106 Heading: Overview of Mechanical Ventilation/Complications Associated With Mechanical Ventilation/Table 7.8 - Mechanical Ventilation Alarms Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1

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A mucous plug often causes a high-pressure alarm when a patient is being mechanically ventilated and would require the nurse is to suction the ET tube to remove the mucous plug. Suctioning does not address the patient biting the ET tube.

An oral airway is inserted if the patient is biting on the ET tube, which can cause a high-pressure alarm for a patient who is being mechanically ventilated.

Assessing for asymmetrical chest rise is an appropriate action if the high-pressure alarm is caused by a pneumothorax, not when the patient is biting down on the ET tube.

Emptying water in the ventilator tubing is an appropriate action if the high-pressure alarm is caused by water collection, not when the patient is biting down on the ET tube.

PTS: 1 CON: Safety 28. ANS: 1 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 5. Discussing the rationale, methods, and complications for mechanical ventilation Chapter page reference: 106 Heading: Overview of Mechanical Ventilation/Complications Associated With Mechanical Ventilation/Table 7.8 - Mechanical Ventilation Alarms Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate Feedback 1 2

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Emptying water in the ventilator tubing is an appropriate action if the high-pressure alarm is caused by moisture collection.

A mucous plug often causes a high-pressure alarm when a patient is being mechanically ventilated. The appropriate action by the nurse is to suction the ET tube to remove the mucous plug.

An oral airway is inserted if the patient is biting on the ET tube, which can cause a high-pressure alarm for a patient who is being mechanically ventilated.

Copyright © 2020 F. A. Davis Company

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Assessing for asymmetrical chest rise is an appropriate action if the high-pressure alarm is caused by a pneumothorax, not a collection of moisture in the ventilator tubing.

PTS: 1 CON: Safety 29. ANS: 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 5. Discussing the rationale, methods, and complications for mechanical ventilation Chapter page reference: 107-108 Heading: Overview of Mechanical Ventilation/Weaning from Mechanical Ventilation /Patient Criteria for Weaning/Box 7.5 – Weaning Criteria Integrated Processes: Nursing Process: Evaluation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Analysis [Analyzing] Concept: Oxygenation Difficulty: Moderate Feedback 1 2 3 4

PTS:

An FIO2 less than or equal to 0.4 to 0.5 indicates the patient is able to be weaned from mechanical ventilation.

A positive end-expiratory pressure less than or equal to 5 to 8 cm H2O indicates the patient is able to be weaned from mechanical ventilation.

A pH greater than 7.25 during spontaneous ventilation indicates the patient is able to be weaned from mechanical ventilation.

Hemodynamic instability, such as a decrease blood pressure to a hypotensive state, indicates the patient is not a candidate for being weaned from mechanical ventilation.

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CON: Oxygenation

MULTIPLE RESPONSE 30. ANS: 1, 2, 4, 5 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 2. Discussing indications for oxygen therapy Chapter page reference: 84-85 Heading: Noninvasive Oxygen Delivery Methods/Low-Flow Delivery Devices/Table 7.2 – Maintaining an Oxygen Saturation Reading Integrated Processes: Communication and Documentation Client Need: Safe and Effective Care Environment: Management of Care Cognitive Level: Application [Applying] Concept: Nursing Roles Difficulty: Moderate Copyright © 2020 F. A. Davis Company

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Feedback This is correct. The SpO2 result is documented in the medical record when monitoring a patient’s oxygen saturation via oximetry.

This is correct. The current vital signs are documented in the medical record when monitoring a patient’s oxygen saturation via oximetry.

This is incorrect. The last time the patient ate or drank is not information that is documented in the medical record when monitoring oxygenation saturation via oximetry.

This is correct. The type and amount of oxygen therapy in use is documented in the medical record when monitoring a patient’s oxygen saturation via oximetry.

This is correct. The education provided to the patient and family is documented in the medical record when monitoring a patient’s oxygen saturation via oximetry.

PTS: 1 CON: Nursing Roles 31. ANS: 1, 2, 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 5. Discussing the rationale, methods, and complications for mechanical ventilation Chapter page reference: 93 Heading: EBP Box: What Is the ABCDEF Bundle?

Integrated Processes: Nursing Process: Planning Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Nursing Roles Difficulty: Moderate

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Feedback This is correct. Elevation of the head of the bed is included in the plan of care for a patient who is receiving care based on a ventilator bundle.

This is correct. A sedation vacation each day is included in the plan of care for a patient who is receiving care based on a ventilator bundle.

This is incorrect. Early ambulation and exercise are important to preventing ventilator-associated pneumonia.

This is correct. Administering the prescribed peptic ulcer prophylactic regimen is included in the plan of care for a patient who is receiving care based on a ventilator bundle.

This is incorrect. Family engagement and empowerment are important interventions in the management of a patient on a mechanical ventilator.

PTS: 1 CON: Nursing Roles 32. ANS: 1, 2, 3, 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 5. Discussing the rationale, methods, and complications for mechanical ventilation Chapter page reference: 93-94 Copyright © 2020 F. A. Davis Company

Heading: Invasive Oxygen Therapy/Artificial Airways/Endotracheal Tube/ETT Management/ Table 7.5 Suctioning Using In-line or Closed Suction Catheters Integrated Processes: Communication and Documentation Client Need: Physiological Integrity: Physiological Adaptation Cognitive Level: Application [Applying] Concept: Communication Difficulty: Moderate

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Feedback This is correct. The amount of secretions collected during in-line suctioning is documented in the patient’s medical record.

This is correct. The color of secretions collected during in-line suctioning is documented in the patient’s medical record.

This is correct. The consistency of secretions collected during in-line suctioning is documented in the patient’s medical record.

This is correct. The patient’s response to the procedure is documented in the medical record.

This is incorrect. The number of times the suction catheter is introduced into the trachea is not a required component of the documentation of inline suctioning.

PTS: 1 CON: Communication 33. ANS: 3, 4 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 4. Explaining indications, management, and complications of artificial airways Chapter page reference: 97-99 Heading: Invasive Oxygen Therapy/Artificial Airways/ Tracheostomy/Tracheostomy Care/ Table 7.7 Suctioning the Tracheostomy Tube Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Application [Applying] Concept: Safety Difficulty: Moderate

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Feedback This is incorrect. The suction needs to be set at level up to 120 mm Hg. This is incorrect. Applying suction during catheter insertion increases the risk of hypoxia and trauma to mucosa.

This is correct. Personal protective equipment is applied to decrease the risk for infection.

This is correct. The tracheostomy site is assessed for infection, irritation, and skin breakdown.

This is incorrect. A reusable, not disposable, inner cannula is rinsed with sterile water and dried before reinsertion.

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PTS: 1 CON: Safety 34. ANS: 1, 4, 5 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 5. Discussing the rationale, methods and complications for mechanical ventilation Chapter page reference: 105-106 Heading: Overview of Mechanical Ventilation/Complications Associated with Mechanical Ventilation/Table 7.8 – Mechanical Ventilator Alarms Integrated Processes: Nursing Process: Implementation Client Need: Physiological Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult

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Feedback This is correct. If the patient is biting the endotracheal tube, a high-pressure alarm occurs. An appropriate nursing action is to insert an oral airway to prevent the biting.

This is incorrect. A leak in the ventilator circuit causes a low-pressure, not high-pressure, alarm. An appropriate nursing action in this instance is to assess the ventilator connections and tubing.

This is incorrect. A cuff leak causes a low-pressure, not high-pressure alarm.

Appropriate nursing interventions when this occurs are to assess for cuff leak, check cuff pressure, and call for respiratory assistance from the healthcare provider.

This is correct. A mucous plug or increased secretions cause a high-pressure alarm. When this occurs, the nurse suctions the patient’s endotracheal tube.

This is correct. Water may collect in the ventilator tubing causing a high-pressure alarm to occur. An appropriate nursing action is to empty the water from the ventilator tubing.

PTS: 1 CON: Safety 35. ANS: 2, 3, 5 Chapter number and title: 7, Oxygen Therapy Management Chapter learning objective: 5. Discussing the rationale, methods and complications for mechanical ventilation Chapter page reference: 105-106 Heading: Overview of Mechanical Ventilation/Complications Associated with Mechanical Ventilation/ Table 7.8?4 Mechanical Ventilator Alarms Integrated Processes: Nursing Process: Implementation Client Need: Physiologic Integrity: Reduction of Risk Potential Cognitive Level: Analysis [Analyzing] Concept: Safety Difficulty: Difficult Copyright © 2020 F. A. Davis Company

Test Bank for Davis Advantage for Medical-Surgical Nursing: Making Connections to Practice,

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PTS:

Feedback This is incorrect. If the patient is biting the endotracheal tube, a high-pressure, not low-pressure, alarm occurs. An appropriate nursing action is to insert an oral airway to prevent the biting.

This is correct. A leak in the ventilator circuit causes a low-pressure alarm. An appropriate nursing action in this instance is to assess the ventilator connections and tubing.

This is correct. A cuff leak causes a low-pressure alarm. Appropriate nursing interventions when this occurs are to assess for cuff leak, check cuff pressure, and call for respiratory assistance from the healthcare provider.

This is incorrect. A mucous plug or increased secretions cause a high-pressure, not low-pressure, alarm. When this occurs, the nurse suctions the patient’s endotracheal tube.

This is correct. If the patient is in synchronized intermittent mandatory ventilation (SIMV) or pressure-support modes and stops breathing, the low-pressure alarm sounds. The patient needs to be assessed and the healthcare provider notified immediately.

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CON: Safety

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