Multiple Choice Questions

Which of the following are indicators that a client is ready to be weaned from a ventilator? Select all that apply. a) Tidal volume of 8.5 mL/kg b) Rapid/shallow breathing index of 112 breaths/min c) Vital capacity of 13 mL/kg d) FiO2 45% e) PaO2 of 64 mm Hg
  • • Dyspnea• Substernal pain• Fatigue Oxygen toxicity can occur when clients receive too high a concentration of oxygen for an extended period. Symptoms include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia and mood swings are not symptoms of oxygen toxicity.
  • Intermittent mandatory ventilation (IMV)
  • a compromised skin graft. A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.
  • • PaO2 of 64 mm Hg• Tidal volume of 8.5 mL/kg• Vital capacity of 13 mL/kg Weaning criteria for clients are as follows: Vital capacity 10 to 15 mL/kg; Maximum inspiratory pressure at least -20 cm H2; Tidal volume: 7 to 9 mL/kg; Minute ventilation: 6 L/min; Rapid/shallow breathing index below 100 breaths/min; PaO2 > 60 mm Hg; FiO2 < 40%
A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply. a) Substernal pain b) Fatigue c) Dyspnea d) Bradycardia e) Mood swings
  • cough as the cuff is being deflated.
  • • PaO2 of 64 mm Hg• Tidal volume of 8.5 mL/kg• Vital capacity of 13 mL/kg Weaning criteria for clients are as follows: Vital capacity 10 to 15 mL/kg; Maximum inspiratory pressure at least -20 cm H2; Tidal volume: 7 to 9 mL/kg; Minute ventilation: 6 L/min; Rapid/shallow breathing index below 100 breaths/min; PaO2 > 60 mm Hg; FiO2 < 40%
  • • Dyspnea• Substernal pain• Fatigue Oxygen toxicity can occur when clients receive too high a concentration of oxygen for an extended period. Symptoms include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia and mood swings are not symptoms of oxygen toxicity.
  • a compromised skin graft. A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.
Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with: a) a malignant tumor. b) a compromised skin graft. c) hyperthermia. d) pneumonia.
  • a compromised skin graft. A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.
  • • Dyspnea• Substernal pain• Fatigue Oxygen toxicity can occur when clients receive too high a concentration of oxygen for an extended period. Symptoms include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia and mood swings are not symptoms of oxygen toxicity.
  • Continues assessing the client's respiratory status frequently
  • Water-seal chamber
A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply. a) Encourage deep breathing exercises. b) Monitor and record hourly intake and output. c) Regularly assess the client's vital signs every 2 to 4 hours. d) Maintain an open airway. e) Monitor pulmonary status as directed and needed.
  • • Monitor pulmonary status as directed and needed.• Regularly assess the client's vital signs every 2 to 4 hours.• Encourage deep breathing exercises. Interventions to improve the client's gas exchange include monitoring pulmonary status as directed and needed, assessing vital signs every 2 to 4 hours, and encouraging deep breathing exercises. Maintainin an open airway is appropriate for improving the client's airway clearance. Monitoring and recording hourly intake and output are essential interventions for ensuring appropriate fluid balance.
  • "When the tube is being removed, take a deep breath, exhale, and bear down."
  • Endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.
  • Cut the contaminated tip of the tube and insert a sterile connector and reattach.
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? a) Encouragement of coughing b) Use of a cooling blanket c) Incentive spirometry d) Endotracheal suctioning
  • The patient will return to the nursing unit with two chest tubes.
  • Endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.
  • Cut the contaminated tip of the tube and insert a sterile connector and reattach.
  • Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.
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Multiple Choice Questions
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