OXYGEN ADMINISTRATION AND SUCTIONING: POST TESTFREIDA MICHELLE B. TAJA, RN, MAN

1. When should a nurse suction a client? A. As desired B. As needed C. Every 1 hour D. Every 4 hours

2. Ernest Arnold Hamilton, a 60 year old American client was mobbed by teen gangsters near New york, Cubao. He was rushed to John John Hopio Medical Center and was Unconscious. You are his nurse and you are to suction his secretions. In which position should you place Mr. Hamilton? A. High fowlers B. Semi fowlers C. Prone D. Side lying

3. You are about to set the suction pressure to be used to Mr. Hamilton. You are using a Wall unit suction machine. How much pressure should you set the valve before suctioning Mr. Hamilton? A. 50-95 mmHg B. 200-350 mmHg C. 100-120 mmHg D. 10-15 mmHg

4. The wall unit is not functioning; You then try to use the portable suction equipment available. How much pressure of suction equipment is needed to prevent trauma to mucus membrane and air ways in case of portable suction units? A. 2-5 mmHg B. 5-10 mmHg C. 10-15 mmHg D. 15-25 mmHg

5. There are four catheter sizes available for use, which one of these should you use for Mr. Hamilton? A. Fr. 18 B. Fr. 12 C. Fr. 10 D. Fr. 5

6. Which of the following, if done by the nurse, indicates incompetence during suctioning an unconscious client? A. Measure the length of the suction catheter to be inserted by measuring from the tip of the nose, to the earlobe, to the xiphoid process B. Use KY Jelly if suctioning nasopharyngeal secretion C. The maximum time of suctioning should not exceed 15 seconds D. Allow 30 seconds interval between suctioning

7. Which of the following is the initial sign of hypoxemia in an adult client? 1. Confusion 2. Tachycardia 3. Cyanosis 4. Pallor 5. Irritability 6. Flaring of Nares A. 1,2 B. 2,5 C. 2,6 D. 3,4

8. Which method of oxygenation least likely produces anxiety and apprehension? A. Nasal Cannula B. Simple Face mask C. Non Rebreather mask D. Partial Rebreather mask

9. Which of the following oxygen delivery method can deliver 100% Oxygen at 15 LPM? A. Nasal Cannula B. Simple Face mask C. Non Rebreather mask D. Partial Rebreather mask

10. Which of the following is not true about OXYGEN? A. Oxygen is odorless, tasteless and colorless gas. B. Oxygen can irritate mucus membrane C. Oxygen supports combustion D. Excessive oxygen administration results in respiratory acidosis

11. Roberto San Andres, A new nurse in the hospital is about to administer oxygen on patient with Respiratory distress. As his senior nurse, you should intervene if Roberto will: A. Use venturi mask in oxygen administration B. Put a non rebreather mask in the patient before opening the oxygen source C. Use a partial rebreather mask to deliver oxygen D. Check for the doctor s order for Oxygen administration

12. Which of the following will alert the nurse as an early sign of hypoxia? A. Client is tired and dyspneic B. The client is coughing out blood C. The client s heart rate is 50 BPM D. Client is frequently turning from side to side

13. The best method of oxygen administration for client with COPD uses: A. Cannula B. Simple Face mask C. Non rebreather mask D. Venturi mask

14. When teaching a family member of a home-based client how to suction his tracheostomy, the nurse includes which of the following instructions? a. b. c. d. Suction for 10-15 seconds at at time. Regulate the suction machine to -300 cm suction. Apply suction to the catheter during insertion only. Pass the suction catheter into the opening of the tracheostomy tube to (2 to 3 cm).

15. Which of the following interventions is most appropriate when suctioning a tracheostomy tube? a. Hypoventilate the child before suctioning. b. Repeat the suctioning process for two intervals. c. Insert the catheter 1 to 2 cm below the tracheostomy tube. d. Inject a small amount of normal saline solution into the tube before suctioning.

16. Which of the following actions is correct for performing tracheal suctioning? a. Apply suction during insertion of the catheter. b. Limit suctioning to 10 to 15 seconds duration. c. Resterilize the suction catheter in alcohol after use. d. Repeat suctioning intervals every 15 minutes until clear.

17. While performing nasopharyngeal suction, a nurse hears a client s pulse oximeter alarm. The pulse oximeter indicates the client s oxygen saturation reading is 86%. Which of the following nursing actions should the nurse take? a. Stop suctioning and give oxygen to the client. b. Withdraw the suction catheter and tell the client to cough several times. c. Continue suctioning for 10 to 15 more seconds and then withdraw the suction catheter. d. Keep the suction catheter inserted and wait a few seconds before beginning suctioning.

18. A child is intubated and placed on a ventilator after a near drowning. The physician s order is to suction every 3 to 4 hours. Which phrase describes the purpose of suctioning? a. To keep the client free of infection. b. To keep the client from experiencing cardiac arrythmias. c. To keep the client s airway patent. d. To maintain fluid and electrolyte balance.

19. The best position to promote maximum lung expansion is: A. B. C. D. Supine B. Lateral C. Prone D. Semi-fowler s

20. Which of the following is inappropriate nursing action when performing oropharyngeal suctioning? a. Place the client in a semi-fowler s or lateral position. b. Measure the length of the catheter from the tip of the nose to the earlobe. c. Lubricate suction catheter tip with alcohol. d. Apply suction during withdrawal of the suction catheter tip.

21. The maximum interval before applying another suction: a. b. c. d. 2-3 seconds 10-20 minutes 20-30 minutes 60 seconds

22. To evaluate the effectiveness of suctioning, the nurse should primarily: a. b. c. d. Auscultate the chest for clear breath sounds. Assess the respiratory rate. Check the skin color. Palpate the pulse rate.

23. The oxygen administration device preferred for patients with COPD is: A. Nasal Cannula B. Oxygen Tent C. Venturi Mask D. Oxygen Hood

24. Which of the following is not to be included in the nursing interventions for a client receiving oxygen therapy? A. Place a No Smoking sign at the bedside. B. Place the client in semi-fowler s position. C. Place sterile water into the oxygen humidifier. D. Lubricate nares with oil to prevent dryness of the mucous membrane.

24. Which of the following is not to be included in the nursing interventions for a client receiving oxygen therapy? A. Place a No Smoking sign at the bedside. B. Place the client in semi-fowler s position. C. Place sterile water into the oxygen humidifier. D. Lubricate nares with oil to prevent dryness of the mucous membrane.

25. The following are appropriate nursing diagnoses for clients with oxygenation problems: a. Ineffective airway clearance related to tracheobronchial secretions. b. Ineffective breathing pattern related to decreased energy and fatigue. c. Impaired gas exchange related to altered oxygen-carrying capacity of the blood. d. All of these.

26. A client with Chronic Pulmonary Disease has a bluish tinge around the lips. This would most accurately be documented as: A. Hypoxia B. Hypoxemia C. Dyspnea D. Cyanosis

27. A client with a chronic lung disorder requires some supplemental oxygen. The nurse anticipates that safe delivery would be oxygen: a. b. c. d. 2 L/min per nasal cannula 6 L/min per face mask 8 L/min per partial rebreathing mask 10 L/min per nonrebreathing mask

28. Which of the following represents proper nasopharyngeal suction technique? a. Lubricate the suction catheter with Vaseline before and between insertions. b. Apply suction intermittently while inserting the suction catheter. c. Rotate the catheter while applying the suction. d. Hyperoxygenate the client with 100% oxygen for 30 minutes before and after suctioning.

29. It is a condition of insufficient oxygen anywhere in the body, from the inspired gas to the tissues. Hypoxia C. Herpercapnia A. Hypoxemia D. Hypercarbia 30. A condition where carbon dioxide is accumulated in the blood. A. Hypoxia C. Hypercapnia B. Hypoxemia D. Hyperventilation

31. This refers to reduced oxygen in the blood characterized by a low partial pressure in the arterial blood or low hemoglobin saturation. A. Hypoxia C. Hypercapnia B. Hypoxemia D. Hyperventilation 32. The nurse should be aware of the late clinical sign of hypoxemia which is: A. Restlessness C. Confusion B. Orthopnea D. Irritability