The nurse is providing care for a patient admitted with smoke inhalation injury who is developing acute respiratory distress syndrome (ARDS). Which course of action regarding oxygen therapy does the nurse anticipate for this patient?
1) Oxygen via a facial mask
2) Oxygen via a Venturi mask
3) Oxygen via a nasal cannula
4) Oxygen via mechanical ventilation

4) Oxygen via mechanical ventilation

The nurse is providing care to a patient, diagnosed with asthma, with a respiratory rate of 28 at rest who is experiencing audible wheezing during inspiration. Which nursing diagnosis should the nurse use when planning care for this patient?
1) Activity Intolerance
2) Impaired Tissue Perfusion
3) Ineffective Airway Clearance
4) Ineffective Breathing Pattern

4) Ineffective Breathing Pattern

The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease (COPD). The nurse assesses the patient's breathing rate at 32 breaths per minute. The patient is also experiencing hypertension and fatigue. Which nursing diagnosis is a priority when planning care for this patient?
1) Anxiety
2) Ineffective Coping
3) Ineffective Breathing Pattern
4) Ineffective Airway Clearance

3) Ineffective Breathing Pattern

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 prescription does the nurse question for this patient based on the current data?
1) Antibiotic therapy
2) Nonsteroidal anti-inflammatory therapy
3) Oxygen therapy via nasal cannula at 3-4 L/min
4) Bronchodilators therapy with adrenergic stimulating drugs

3) Oxygen therapy via nasal cannula at 3-4 L/min

The nurse is providing care to an infant diagnosed with respiratory syncytial virus (RSV). The infant is grunting with expiration. Which action by the nurse is appropriate?
1) Limit fluid intake
2) Place the infant in a supine position
3) Perform chest physiotherapy to clear the nasal passages
4) Suction the airway to relieve the current obstruction that is noted

4) Suction the airway to relieve the current obstruction that is noted

Which nursing action 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 ten seconds
4) Assessing the heart rate and comparing it with the displayed pulse

4) Assessing the heart rate and comparing it with the displayed pulse

Which did the nurse auscultate when conducting a patient's respiratory assessment if wheezing is documented?
1) Snoring sounds
2) Gurgling sounds
3) Low-pitched bubbling
4) High-pitched squeaking

4) High-pitched squeaking

Which did the nurse auscultate when conducting a patient's respiratory assessment if rhonchi is documented?
1) Snoring sounds
2) Gurgling sounds
3) Low-pitched bubbling
4) High-pitched squeaking

1) Snoring sounds

Which position should the nurse place a patient prior to performing in-line suctioning?
1) Prone
2) Supine
3) Fowler's
4) Semi-Fowler's

4) Semi-Fowler's

When conducting in-line suctioning, which is the maximum amount of time for each suctioning event?
1) 10 seconds
2) 30 seconds
3) 45 seconds
4) 60 seconds

1) 10 seconds

When conducting in-line suctioning on a patient, which amount of time should 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

2) 10 to 20 seconds

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

3) Discontinue suctioning and administer 100% oxygen

The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm beeps and the nurse notes a mucous plug in the endotracheal (ET) tube. Which action by the nurse is appropriate?
1) Suction, as needed
2) Insert an oral airway
3) assess for asymmetric chest rise
4) Empty water from the ventilator tubing

1) Suction, as needed

The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm beeps and the nurse notes the patient is biting down on the endotracheal (ET) tube. Which action by the nurse is appropriate?
1) Suction, as needed
2) Insert an oral airway
3) Assess for asymmetric chest rise
4) Empty water from the ventilator tubing

2) Insert an oral airway

The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm beeps and the nurse notes a collection of moisture in the ventilator tubing. Which action by the nurse is appropriate?
1) Empty the water
2) Suction, as needed
3) Insert an oral airway
4) Assess for asymmetric chest rise

1) Empty the water

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 six 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."

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

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 prior to 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."

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

The nurse is providing care to a patient who is mechanically ventilated. In order to decrease the risk for aspiration, which action by the nurse is appropriate?
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

1) Elevate the head of the bed between 30 to 45 degrees

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 assessment process?
1) An FIO2 less than or equal to 0.4-0.5
2) A PEEP less than or equal to 5-8 cm H2O
3) A pH greater than 7.25 during spontaneous ventilation
4) A drop in blood pressure indicating a hypotensive state

4) A drop in blood pressure indicating a hypotensive state

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 should the nurse plan for when providing care?
1) Face tent
2) Nasal cannula
3) Venturi mask
4) Nonrebreather mask

1) Face tent

The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) who requires supplemental oxygen. Which is the anticipated flow rate range by nasal cannula (NC) when providing care for this patient?
1) 1-2 L/min
2) 2-3 L/min
3) 3-4 L/min
4) 4-5 L/min

1) 1-2 L/min

Which independent nursing actions are appropriate to include in the plan of care for a patient who is experiencing an alteration in oxygenation? Select all that apply.
1) Providing suctioning
2) Assisting with positioning
3) Prescribing bronchodilators
4) Monitoring activity tolerance
5) Encouraging deep breathing exercises

1) Providing suctioning
2) Assisting with positioning

4) Monitoring activity tolerance
5) Encouraging deep breathing exercises

Which should the nurse include in the plan of care for a mechanically ventilated patient who is receiving care based on a ventilator bundle? Select all that apply.
1) Elevating the head of the bed
2) Ensuring a sedation vacation each day
3) Conducting a readiness to wean assessment
4) Administering a prescribed peptic ulcer prophylactic regimen
5) Avoiding the use of compression stockings during immobility

1) Elevating the head of the bed
2) Ensuring a sedation vacation each day
3) Conducting a readiness to wean assessment
4) Administering a prescribed peptic ulcer prophylactic regimen

Which information should the nurse document when monitoring a patient's oxygen saturation via oximetry? Select all that apply.
1) The SpO2 result
2) The current vital signs
3) The presence of family or visitors at the patient's bedside
4) The type and amount of oxygen therapy in use
5) The education provided to the patient and family

1) The SpO2 result
2) The current vital signs

4) The type and amount of oxygen therapy in use
5) The education provided to the patient and family

The nurse suctions a mechanically ventilated patient using in-line suctioning. Which information should the nurse document in the medical record after the procedure is completed? Select all that apply.
1) The amount of secretions
2) The color of the secretions
3) The consistency of the secretions
4) The patient's response to the procedure
5) The amount of oxygen the patient received during the procedure

1) The amount of secretions
2) The color of the secretions
3) The consistency of the secretions
4) The patient's response to the procedure

Which actions by the nurse are considered best practice when providing tracheostomy care? Select all that apply.
1) Asking the family to leave the bedside
2) Suctioning at the start and finish of the procedure
3) Applying appropriate personal protective equipment
4) Inspecting the site of infection, irritation, and skin breakdown
5) Rinsing a disposable inner cannula with sterile water and drying

3) Applying appropriate personal protective equipment
4) Inspecting the site of infection, irritation, and skin breakdown