Nursing Chapter 38_WITH RATIONALE
The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which oxygen
delivery device will the nurse use for this patient?
a. Non-rebreather mask
b. Bag-valve-mask unit
c. Continuous positive airway pressure (CPAP)
d. High-flow nasal cannula - ✔✔ correct answer b. Bag-valve-mask unit
Rationale:
The priority of the nurse is to ventilate the patient manually using a bag-valve-mask unit (also called by
the proprietary name Ambu bag). This allows air to be forced into the patient's lungs when there are no
spontaneous respirations. The non-rebreather mask and nasal cannula require the patient to breathe on
his or her own. CPAP is used for patients who are awake, oriented, and in respiratory failure.
The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient is
breathing spontaneously but is minimally responsive and having difficulty maintaining a patent airway.
Which intervention is the most appropriate for the patient to improve oxygenation?
a.Insert an oral airway.
b.Lower the head of the bed.
c.Turn the patient's head to the side.
d.Monitor the patient's pulse oximetry. - ✔✔ correct answer a.Insert an oral airway.
Rationale:
An oral airway will prevent the patient's tongue from falling back and occluding the airway. Lowering the
head of the bed will only increase airway occlusion and risk of aspiration. Turning the patient's head to
the side will not clear the back of the patient's tongue from the airway. Monitoring the patient's pulse
oximetry will not improve oxygenation or clear the airway.
, Nursing Chapter 38_WITH RATIONALE
The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short
of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient's pulse
oximetry is only 88% on 4 L of oxygen. What is the priority intervention of the nurse?
a.Administer the ordered intravenous diuretic.
b.Prepare for insertion of a chest tube.
c.Suction secretions from the patient's respiratory tract.
d.Have the patient use the ordered incentive spirometer. - ✔✔ correct answer a.
Administer the ordered intravenous diuretic.
Rationale:
The patient's respiratory distress is due to pulmonary edema and fluid overload from left-sided
congestive heart failure. A diuretic will pull the excess fluid out of the body through the urine and relieve
the patient's distress. A chest tube is not needed as the fluid is within the alveoli rather than between
the lung and chest wall. Suctioning and use of an incentive spirometer will not address fluid overload or
improve the patient's symptoms.
The nurse is caring for a patient who has been intubated with an oral endotracheal tube for several
weeks. The physicians predict that the patient will need to remain on a ventilator for at least several
more weeks before he will be able to maintain his airway and breathe on his own. What procedure does
the nurse anticipate will be planned for the patient to facilitate recovery?
a.Placement of a tracheostomy tube
b.Diagnostic thoracentesis
c.Pulmonary angiogram
d.Lung transplantation surgery - ✔✔ correct answer a.Placement of a tracheostomy tube
Rationale:
The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which oxygen
delivery device will the nurse use for this patient?
a. Non-rebreather mask
b. Bag-valve-mask unit
c. Continuous positive airway pressure (CPAP)
d. High-flow nasal cannula - ✔✔ correct answer b. Bag-valve-mask unit
Rationale:
The priority of the nurse is to ventilate the patient manually using a bag-valve-mask unit (also called by
the proprietary name Ambu bag). This allows air to be forced into the patient's lungs when there are no
spontaneous respirations. The non-rebreather mask and nasal cannula require the patient to breathe on
his or her own. CPAP is used for patients who are awake, oriented, and in respiratory failure.
The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient is
breathing spontaneously but is minimally responsive and having difficulty maintaining a patent airway.
Which intervention is the most appropriate for the patient to improve oxygenation?
a.Insert an oral airway.
b.Lower the head of the bed.
c.Turn the patient's head to the side.
d.Monitor the patient's pulse oximetry. - ✔✔ correct answer a.Insert an oral airway.
Rationale:
An oral airway will prevent the patient's tongue from falling back and occluding the airway. Lowering the
head of the bed will only increase airway occlusion and risk of aspiration. Turning the patient's head to
the side will not clear the back of the patient's tongue from the airway. Monitoring the patient's pulse
oximetry will not improve oxygenation or clear the airway.
, Nursing Chapter 38_WITH RATIONALE
The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short
of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient's pulse
oximetry is only 88% on 4 L of oxygen. What is the priority intervention of the nurse?
a.Administer the ordered intravenous diuretic.
b.Prepare for insertion of a chest tube.
c.Suction secretions from the patient's respiratory tract.
d.Have the patient use the ordered incentive spirometer. - ✔✔ correct answer a.
Administer the ordered intravenous diuretic.
Rationale:
The patient's respiratory distress is due to pulmonary edema and fluid overload from left-sided
congestive heart failure. A diuretic will pull the excess fluid out of the body through the urine and relieve
the patient's distress. A chest tube is not needed as the fluid is within the alveoli rather than between
the lung and chest wall. Suctioning and use of an incentive spirometer will not address fluid overload or
improve the patient's symptoms.
The nurse is caring for a patient who has been intubated with an oral endotracheal tube for several
weeks. The physicians predict that the patient will need to remain on a ventilator for at least several
more weeks before he will be able to maintain his airway and breathe on his own. What procedure does
the nurse anticipate will be planned for the patient to facilitate recovery?
a.Placement of a tracheostomy tube
b.Diagnostic thoracentesis
c.Pulmonary angiogram
d.Lung transplantation surgery - ✔✔ correct answer a.Placement of a tracheostomy tube
Rationale:
