Nokea
A nurse in the emergency department is caring for a patient who was brought in by fire rescue due to a heroin overdose. The nurse notes the patient is not breathing. What action will the nurse take immediately?
- A. Tilt the patient's head forward.
- B. Begin ventilation using a manual resuscitation bag (Ambu bag).
- C. Place the mask tightly over the patient's nose and mouth.
- D. Pull the patient's jaw backward.
- E. Compress the bag twice the normal respiratory rate for the patient.
- F. Recommend that a sputum culture for cytology is obtained.
Correct Answer: B,C
Rationale: The priority is to establish ventilation using the manual resuscitation bag to provide emergency or rescue breathing. The nurse tilts the head back, pulls the jaw forward, and positions the mask tightly over the patient's nose and mouth. The bag is compressed at a rate that approximates normal respiratory rate (e.g., 12 to 20 breaths/min in adults). Sputum for cytology is done primarily to detect cells that may be malignant, determine organisms causing infection, and identify blood or pus in the sputum. Note that the bag, with the mask removed, also fits easily over tracheostomy and endotracheal tubes.
You may also like to solve these questions
A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly?
- A. Making sure the oxygen is flowing into the prongs
- B. Maintaining oxygen saturation between 94% and 98%
- C. Encouraging the patient to breathe through their nose with their mouth closed
- D. Initiating the oxygen flow rate at 6 L/min or more
- E. Protecting the patient's skin from irritation by the oxygen tubing
Correct Answer: A,C,E
Rationale: The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should encourage the patient to breathe through their nose with the mouth closed. The nurse should adjust the flow rate and maintain the patient's oxygen saturation as prescribed. The nurse should implement pressure injury prevention strategies; pressure from the tubing could result in medical device-related alterations in skin integrity.
A nurse plans to suction a patient's endotracheal tube using the open suction technique. Which intervention is appropriate for this technique?
- A. Using a suction catheter that is the diameter of the endotracheal tube
- B. Maintaining the patient in the supine position
- C. Administering oxygen prior to suctioning
- D. Changing the inline suction device every 24 hours
Correct Answer: C
Rationale: To prevent hypoxemia, prior to endotracheal suctioning, the nurse provides 100% oxygen for a minimum of 30 seconds. This is referred to as hyperoxygenation. The nurse limits the application of suction to no more than 10 to 15 seconds. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. An inline suction device is considered a closed, self-contained system used for a 'closed technique' for suction; these are changed every 24 hours.
A nurse is caring for a patient admitted for an acute asthma exacerbation. The patient reports extreme dyspnea, stating, 'Turn up the oxygen, I'm not getting enough air.' Which actions would the nurse take first?
- A. Suction the airway.
- B. Assess the pulse oximetry reading.
- C. Obtain a peak flow meter reading.
- D. Assess for cyanosis of the lips.
Correct Answer: B
Rationale: Using the nursing process, the nurse first assesses the oxygen saturation via pulse oximetry before changing the oxygen flow rate. Suctioning is provided to remove respiratory secretions; the nurse would note adventitious breath sounds or phlegm with cough indicating a need for suction. A peak flow meter is used to assess the point of highest flow during forced expiration. It is routinely used for patients with moderate or severe asthma to measure the severity of the disease and degree of disease management. While cyanosis of the lips is a late sign of hypoxemia, the nurse can quickly begin to alleviate or lessen dyspnea by simply repositioning the patient.
A nursing student attending clinical on a medical-surgical unit receives report from the off-going nurse stating the patient has adventitious breath sounds that clear after expectorating sputum. Which adventitious breath sound will the student expect to auscultate?
- A. Bronchial
- B. Bronchovesicular
- C. Vesicular
- D. Wheezing
Correct Answer: D
Rationale: Wheezing and crackles represent adventitious or abnormal breath sounds. Bronchial, bronchovesicular, and vesicular breath sounds are normal.
A nurse is teaching a patient how to use a metered-dose inhaler for asthma. Which comments from the patient assure the nurse that the teaching has been effective?
- A. I'll be careful not to shake the canister before using it.
- B. It's important to hold the canister upside down when using it.
- C. I have to remember to inhale the medication through my nose.
- D. I will continue to inhale when the cold propellant is in my throat.
- E. I won't inhale more than one spray with one breath.
- F. I will activate the device while continuing to inhale.
Correct Answer: D,E,F
Rationale: Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, inhaling two sprays with one breath, and not activating the device while inhaling.