NSE221-Midterm MC Questions With Complete Solutions
atients with a tracheostomy or endotracheal tube need
suctioning. Which nursing interventions apply to proper
suctioning technique? Select all that apply
A. preoxygenate the patient for at least 30 seconds before
suctioning
B. Instruct the patient that he or she is going to be suctioned
C. quickly insert the suction catheter until resistance is met
D. suction the patient for at least 30 seconds to remove
secretions
E. repeat suctioning as needed for to five total suction passes
a (if the pt is on oxygen)
b
c
What are possible complications that can occur with suctioning
from an artificial airway? Select all that apply
A. infection
,B. coughing
C. hypoxia
D. tissue (mucosa) trauma
E. Vagal stimulation
F. bronchospasm
ACDEF
While the nursing student changes a patients trach dressing, the
nurse observes the student using a pair of scissors to cut a 4X4
gauze pad to make a split dressing that will fit around the trach
tube. What is the nurses best action?
A. give the student positive reinforcement for use of materials
and technique
B. report the student to the instructor for remediation of the skill
C. change the dressing immediately after the student has left the
room
D. direct the student in the correct use of materials and explain
the rationale
D. direct the student in the correct use of materials and explain
the rationale
,The nurse is caring for a patient with a tracheostomy who has
recently been transferred from the ICU. but he has no unusual
occurrences related to the tracheostomy or his oxygenation
status. What does the routine care for this patient include?
A. thorough respiratory assessment at least every 2 hours
B. maintaining the cuff pressure between 50 and 100 mm Hg
C. Suctioning as needed; maximum suction time of 20 seconds
D. changing the tracheostomy dressing once a day
A. thorough respiratory assessment at least every 2 hours
A patient with a permanent trach is interested in developing an
exercise regime. Which activity does the nurse advise the patient
to avoid?
A. aerobics
B. Tennis
C. golf
D. swimming
d. swimming
A patient with a trach who receives unnecessary suctioning can
experience which complications? Select all that apply
, A. bronchospasm
B. mucosal damage
C. impaired gag reflex
D. bronchodialation
E. bleeding
ABE
A patient who is breathing on his own has a fenestrated trach
tube with a cuff. Which precaution must the nurse instruct the
student about when caring for this patient?
A. always keep the cuff inflated to prevent secretions from
entering the lungs
B. suction the patient every 30 to 60 minutes
C. always deflate the cuff before capping the tube with the
decannulation cuff
D. To reduce the risk for tracheal damage, keep the cuff pressure
between 22 and 30 mm Hg
C. always deflate the cuff before capping the tube with the
decannulation cuff
A patient with a trach tube is currently alert and cooperative but
seems to be coughing more frequently and producing more
secretions than usual. The nurse determines there is a need for
suctioning. Which nursing intervention does the nurse use to
prevent hypoxia for this patient?
atients with a tracheostomy or endotracheal tube need
suctioning. Which nursing interventions apply to proper
suctioning technique? Select all that apply
A. preoxygenate the patient for at least 30 seconds before
suctioning
B. Instruct the patient that he or she is going to be suctioned
C. quickly insert the suction catheter until resistance is met
D. suction the patient for at least 30 seconds to remove
secretions
E. repeat suctioning as needed for to five total suction passes
a (if the pt is on oxygen)
b
c
What are possible complications that can occur with suctioning
from an artificial airway? Select all that apply
A. infection
,B. coughing
C. hypoxia
D. tissue (mucosa) trauma
E. Vagal stimulation
F. bronchospasm
ACDEF
While the nursing student changes a patients trach dressing, the
nurse observes the student using a pair of scissors to cut a 4X4
gauze pad to make a split dressing that will fit around the trach
tube. What is the nurses best action?
A. give the student positive reinforcement for use of materials
and technique
B. report the student to the instructor for remediation of the skill
C. change the dressing immediately after the student has left the
room
D. direct the student in the correct use of materials and explain
the rationale
D. direct the student in the correct use of materials and explain
the rationale
,The nurse is caring for a patient with a tracheostomy who has
recently been transferred from the ICU. but he has no unusual
occurrences related to the tracheostomy or his oxygenation
status. What does the routine care for this patient include?
A. thorough respiratory assessment at least every 2 hours
B. maintaining the cuff pressure between 50 and 100 mm Hg
C. Suctioning as needed; maximum suction time of 20 seconds
D. changing the tracheostomy dressing once a day
A. thorough respiratory assessment at least every 2 hours
A patient with a permanent trach is interested in developing an
exercise regime. Which activity does the nurse advise the patient
to avoid?
A. aerobics
B. Tennis
C. golf
D. swimming
d. swimming
A patient with a trach who receives unnecessary suctioning can
experience which complications? Select all that apply
, A. bronchospasm
B. mucosal damage
C. impaired gag reflex
D. bronchodialation
E. bleeding
ABE
A patient who is breathing on his own has a fenestrated trach
tube with a cuff. Which precaution must the nurse instruct the
student about when caring for this patient?
A. always keep the cuff inflated to prevent secretions from
entering the lungs
B. suction the patient every 30 to 60 minutes
C. always deflate the cuff before capping the tube with the
decannulation cuff
D. To reduce the risk for tracheal damage, keep the cuff pressure
between 22 and 30 mm Hg
C. always deflate the cuff before capping the tube with the
decannulation cuff
A patient with a trach tube is currently alert and cooperative but
seems to be coughing more frequently and producing more
secretions than usual. The nurse determines there is a need for
suctioning. Which nursing intervention does the nurse use to
prevent hypoxia for this patient?
