Nokea
The home care nurse is assessing a patient who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the patient in the home environment?
- A. The patient desires a low-maintenance oxygen delivery system that delivers oxygen flow rates up to 6 L/min
- B. The patient requires a high-flow system for use with a tracheostomy collar
- C. The patient desires a portable oxygen delivery system that can deliver 2 L/min
- D. The patient's respiratory status requires a system that provides an FiO2 of 65%
Correct Answer: C
Rationale: The use of oxygen concentrators is another means of providing varying amounts of oxygen, especially in the home setting. They can deliver oxygen flows from 1 to 10 L/min and provide an FiO2 of about 40%. They require regular maintenance and are not used for high-flow applications. The patient desiring a portable oxygen delivery system of 2 L/min will benefit from the use of an oxygen concentrator.
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The acute medical nurse is preparing to wean a patient from the ventilator. Which assessment parameter is most important for the nurse to assess?
- A. Fluid intake for the last 24 hours
- B. Baseline arterial blood gas (ABG) levels
- C. Prior outcomes of weaning
- D. Electrocardiogram (ECG) results
Correct Answer: B
Rationale: Before weaning a patient from mechanical ventilation, it is most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the patient is tolerating the procedure. Other assessment parameters are relevant, but less critical. Measuring fluid volume intake and output is always important when a patient is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the patients record, and the nurse can refer to them before the weaning process begins.
The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system?
- A. 20 cm H2O
- B. 15 cm H2O
- C. 10 cm H2O
- D. 5 cm H2O
Correct Answer: A
Rationale: The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity?
- A. Bradycardia and frontal headache
- B. Dyspnea and substernal pain
- C. Peripheral cyanosis and restlessness
- D. Hypotension and tachycardia
Correct Answer: B
Rationale: Oxygen toxicity can occur when patients receive too high a concentration of oxygen for an extended period. Symptoms of oxygen toxicity include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia, frontal headache, cyanosis, hypotension, and tachycardia are not symptoms of oxygen toxicity.
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a patient who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?
- A. Deflate the cuff overnight to prevent tracheal tissue trauma
- B. Inflate the cuff to the highest possible pressure in order to prevent aspiration
- C. Monitor the pressure in the cuff at least every 8 hours
- D. Keep the tracheostomy tube plugged at all times
Correct Answer: C
Rationale: Cuff pressure must be monitored by the respiratory therapist or nurse at least every 8 hours by attaching a handheld pressure gauge to the pilot balloon of the tube or by using the minimal leak volume or minimal occlusion volume technique. Plugging is only used when weaning the patient from tracheal support. Deflating the cuff overnight would be unsafe and inappropriate. High cuff pressure can cause tissue trauma.
The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the patient has what diagnosis?
- A. Asthma
- B. Pneumonia
- C. Lung cancer
- D. COPD
Correct Answer: D
Rationale: Breathing retraining is especially indicated in patients with COPD and dyspnea. Breathing retraining may be indicated in patients with other lung pathologies, but not to the extent indicated in patients with COPD.