Medical Surgical Nursing 1st Edition Hoffman Test Bank

Medical Surgical Nursing 1st edition
Hoffman Test Bank

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-1st-edition-hoffman-test-bank/
Chapter 7: Oxygen Therapy Management
Multiple Choice
Identify the choice that best completes the statement or answers the question.
____ 1. The nurse is providing care to a patient who has a tracheostomy. The loss of which protective mechanism
does the nurse plan to monitor this patient for during the respiratory assessment process?
1) The ability to cough
2) The filtration and humidification of inspired air
3) A decrease in the oxygen-carrying capacity of the trachea
4) The sneeze reflex initiated by irritants in the nasal passages
____ 2. When conducting a respiratory assessment, the nurse notes a low-pitched sound that is continuous throughout
inspiration. Which does this lung sound indicate to the nurse?
1) Narrow bronchi
2) Narrow trachea passages
3) Inflamed pleural surfaces
4) Blocked large airway passages
____ 3. The nurse is providing care to a patient admitted with a respiratory disorder. Which laboratory finding would
be most significant?
1) Blood pH 7.32
2) Oxygen saturation 96%
3) Serum sodium 140 mg/dL
4) Hemoglobin level 12 mg/dL
____ 4. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) who is
prescribed 24% oxygen at 2 L/min. Which is the best method for the nurse to use in order to administer
oxygen to this patient?
1) Face mask
2) Venturi mask
3) Nasal cannula
4) Nonrebreather mask
____ 5. The nurse is providing care for a patient admitted with smoke inhalation injury who is developing acute
respiratory distress syndrome (ARDS). Which course of action regarding oxygen therapy does the nurse
anticipate for this patient?
1) Oxygen via a facial mask
2) Oxygen via a Venturi mask
3) Oxygen via a nasal cannula
4) Oxygen via mechanical ventilation
____ 6. The nurse is providing care to a patient, diagnosed with asthma, with a respiratory rate of 28 at rest who is
experiencing audible wheezing during inspiration. Which nursing diagnosis should the nurse use when
planning care for this patient?
1) Activity Intolerance
2) Impaired Tissue Perfusion
3) Ineffective Airway Clearance
4) Ineffective Breathing Pattern
Copyright © 2017 F. A. Davis Company

____ 7. The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease
(COPD). The nurse assesses the patient’s breathing rate at 32 breaths per minute. The patient is also
experiencing hypertension and fatigue. Which nursing diagnosis is a priority when planning care for this
patient?
1) Anxiety
2) Ineffective Coping
3) Ineffective Breathing Pattern
4) Ineffective Airway Clearance
____ 8. The nurse is providing care to a patient who is diagnosed with chronic obstructive pulmonary disease
(COPD). The patient’s pulse oximetry is 93% on room air with a current respiratory rate of 35 breaths per
minute. The most recent chest x-ray indicates a flattened diaphragm with infiltrates. The patient is currently
febrile with an increased number of white blood cells (WBCs) noted on the latest complete blood count
(CBC). Which prescription does the nurse question for this patient based on the current data?
1) Antibiotic therapy
2) Nonsteroidal anti-inflammatory therapy
3) Oxygen therapy via nasal cannula at 3-4 L/min
4) Bronchodilators therapy with adrenergic stimulating drugs
____ 9. The nurse is providing care to an infant diagnosed with respiratory syncytial virus (RSV). The infant is
grunting with expiration. Which action by the nurse is appropriate?
1) Limit fluid intake
2) Place the infant in a supine position
3) Perform chest physiotherapy to clear the nasal passages
4) Suction the airway to relieve the current obstruction that is noted
____ 10. Which nursing action determines the accuracy of the detected waveform when monitoring a patient’s oxygen
saturation via oximetry?
1) Using a site with adequate perfusion
2) Ensuring the any nail polish is removed
3) Leaving the sensor in place for a minimum of ten seconds
4) Assessing the heart rate and comparing it with the displayed pulse
____ 11. Which did the nurse auscultate when conducting a patient’s respiratory assessment if wheezing is
documented?
1) Snoring sounds
2) Gurgling sounds
3) Low-pitched bubbling
4) High-pitched squeaking
____ 12. Which did the nurse auscultate when conducting a patient’s respiratory assessment if rhonchi is documented?
1) Snoring sounds
2) Gurgling sounds
3) Low-pitched bubbling
4) High-pitched squeaking
____ 13. Which position should the nurse place a patient prior to performing in-line suctioning?
1) Prone
2) Supine

3) Fowler’s
4) Semi-Fowler’s
____ 14. When conducting in-line suctioning, which is the maximum amount of time for each suctioning event?
1) 10 seconds
2) 30 seconds
3) 45 seconds
4) 60 seconds
____ 15. When conducting in-line suctioning on a patient, which amount of time should the nurse allow as a rest period
between suction procedures?
1) 5 to 15 seconds
2) 10 to 20 seconds
3) 15 to 25 seconds
4) 20 to 30 seconds
____ 16. The nurse is performing in-line suctioning when the patient experiences a drop in oxygen saturation and
bradycardia. Which nursing action is appropriate?
1) Continue suctioning and administer 50% oxygen
2) Discontinue suctioning and prepare for resuscitation
3) Discontinue suctioning and administer 100% oxygen
4) Continue suctioning and administer prescribed epinephrine
____ 17. The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm beeps and
the nurse notes a mucous plug in the endotracheal (ET) tube. Which action by the nurse is appropriate?
1) Suction, as needed
2) Insert an oral airway
3) Assess for asymmetric chest rise
4) Empty water from the ventilator tubing
the nurse notes the patient is biting down on the endotracheal (ET) tube. Which action by the nurse is
appropriate?
4) Empty water from the ventilator tubing
the nurse notes a collection of moisture in the ventilator tubing. Which action by the nurse is appropriate?
1) Empty the water
____ 20. The nurse is providing education to a patient who is prescribed oxygen in the home environment. Which
statement made by the patient indicates the need for further education?
1) “I will ensure that the oxygen is kept six feet away from the stove.”
2) “I placed a no smoking sign on the door and several places within the house.”
3) “I will store the oxygen on its side, per the instructions provided by the agency.”

4) “I will keep a fire extinguisher in the house and keep it close to where the oxygen is
stored.”
____ 21. The nurse is providing education to a patient regarding the use of an incentive spirometer. Which patient
statement indicates the need for further education?
1) “I should be in a sitting position when using this device.”
2) “I will use this device 20 times per hour while I am awake each day.”
3) “I will exhale completely prior to placing my lips around the mouthpiece.”
4) “I will hold my breath for 3 seconds after I feel like I cannot inhale any more breath.”
____ 22. The nurse is providing care to a patient who is mechanically ventilated. In order to decrease the risk for
aspiration, which action by the nurse is appropriate?
1) Elevate the head of the bed between 30 to 45 degrees
2) Limit each suctioning event to no more than 10 seconds
3) Perform chest physiotherapy as prescribed by the practitioner
4) Ensure an NPO status is maintained for the length of the prescribed treatment
____ 23. The nurse is providing care to a patient who is being weaned from mechanical ventilation. Which finding
would necessitate the continuation of mechanical ventilation if noted during the assessment process?
1) An FIO2 less than or equal to 0.4–0.5
2) A PEEP less than or equal to 5–8 cm H2O
3) A pH greater than 7.25 during spontaneous ventilation
4) A drop in blood pressure indicating a hypotensive state
____ 24. The nurse is providing care to a patient who is recovering from facial trauma who requires high-flow oxygen
therapy. Which method of oxygen delivery should the nurse plan for when providing care?
1) Face tent
2) Nasal cannula
3) Venturi mask
4) Nonrebreather mask
____ 25. The nurse is providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) who
requires supplemental oxygen. Which is the anticipated flow rate range by nasal cannula (NC) when
providing care for this patient?
1) 1-2 L/min
2) 2-3 L/min
3) 3-4 L/min
4) 4-5 L/min
Multiple Response
Identify one or more choices that best complete the statement or answer the question.
____ 26. Which independent nursing actions are appropriate to include in the plan of care for a patient who is
experiencing an alteration in oxygenation? Select all that apply.
1) Providing suctioning
2) Assisting with positioning
3) Prescribing bronchodilators
4) Monitoring activity tolerance
5) Encouraging deep breathing exercises

____ 27. Which should the nurse include in the plan of care for a mechanically ventilated patient who is receiving care
based on a ventilator bundle? Select all that apply.
1) Elevating the head of the bed
2) Ensuring a sedation vacation each day
3) Conducting a readiness to wean assessment
4) Administering a prescribed peptic ulcer prophylactic regimen
5) Avoiding the use of compression stockings during immobility
____ 28. Which information should the nurse document when monitoring a patient’s oxygen saturation via oximetry?
Select all that apply.
1) The SpO2 result
2) The current vital signs
3) The presence of family or visitors at the patient’s bedside
4) The type and amount of oxygen therapy in use
5) The education provided to the patient and family
____ 29. The nurse suctions a mechanically ventilated patient using in-line suctioning. Which information should the
nurse document in the medical record after the procedure is completed? Select all that apply.
1) The amount of secretions
2) The color of the secretions
3) The consistency of the secretions
4) The patient’s response to the procedure
5) The amount of oxygen the patient received during the procedure
____ 30. Which actions by the nurse are considered best practice when providing tracheostomy care? Select all that
apply.
1) Asking the family to leave the bedside
2) Suctioning at the start and finish of the procedure
3) Applying appropriate personal protective equipment
4) Inspecting the site of infection, irritation, and skin breakdown
5) Rinsing a disposable inner cannula with sterile water and drying

Chapter 7: Oxygen Therapy Management
Answer Section
MULTIPLE CHOICE
1. ANS: 2
Chapter number and title: 7, Oxygen Therapy Management
Chapter learning objective: Explaining indications, management, and complications of artificial airways
Chapter page reference: 085-092
Heading: Tracheostomy
Integrated Processes: Nursing Process – Assessment
Client Need: Physiological Integrity – Physiological Adaptation
Cognitive level: Application [Applying]
Concept: Oxygenation
Difficulty: Moderate
Feedback
1 The client can still cough and sneeze, and there is no decrease in the oxygen-carrying
capacity of the trachea.
2 When the nasal passages are bypassed, as they would be in the case of a client with a
tracheostomy, the filtration, humidification, and warming of the nasal passages are also
bypassed.
PTS: 1 CON: Oxygenation

2. ANS: 4
Chapter learning objective: Reviewing concepts of oxygenation
Heading: ETT Management
Feedback
1 Wheezing is created by narrow bronchi.
2 Stridor is the sound created by narrow tracheal passages.
3 A low-pitched grating sound is created by inflamed pleural surfaces.
4 The nurse auscultated rhonchi, which are low-pitched sounds that are continuous
throughout inspiration. Rhonchi suggests blockage of large airway passages, which may
be cleared with coughing.

3. ANS: 1
Chapter page reference: 076
Heading: Oxygen Monitoring and Measurement
Integrated Processes: Nursing Process – Evaluation
Client Need: Physiological Integrity – Reduction of Risk Potential
Cognitive level: Comprehension [Understanding]
Difficulty: Easy
Feedback
1 Normal blood pH is 7.35–7.45. A decreased pH indicates that the client is experiencing
acidosis, which indicates an alteration in oxygenation.
2 Oxygen saturation of 96% is within normal limits.
3 The serum sodium does not impact the oxygen capacity of the body.
4 The hemoglobin level affects the amount of oxygen that can be carried in the blood;
however, the value is within normal limits.

4. ANS: 3
Chapter learning objective: Describing methods of oxygen delivery
Heading: Nasal Cannula
Integrated Processes: Nursing Process – Planning
Client Need: Physiological Integrity – Basic Care and Comfort
Feedback
1 A face mask is better suited to deliver oxygen at higher percentages and flow rates.
2 A Venturi mask is better suited to deliver oxygen at higher percentages and flow rates.
3 The oxygen delivery device that would safely administer 24% oxygen at the flow rate
of 2 liters per minute is through nasal cannula.
4 A nonrebreather mask is better suited to deliver oxygen at higher percentages and flow
rates.

5. ANS: 4
Chapter learning objective: Discussing the rationale, methods, and complications for mechanical ventilation
Heading: Overview of Mechanical Ventilation

Feedback
1 With ARDS, it is rarely possible to maintain adequate tissue oxygenation with oxygen
therapy alone; therefore, oxygen via face mask is not anticipated.
therapy alone; therefore, oxygen via a Venturi mask is not anticipated.
therapy alone; therefore, oxygen via nasal cannula is not anticipated.
4 With mechanical ventilation, the FiO2 (fraction of inspired oxygen–the percentage of
oxygen administered) is set at the lowest possible level to maintain a PaO2 higher than
60 mmHg and oxygen saturation of approximately 90%. It is important to remember
that mechanical ventilation does not cure ARDS; it simply supports respiratory function
while the underlying problem is identified and treated.

6. ANS: 4
Heading: Nursing Diagnoses
Integrated Processes: Nursing Process – Diagnosis
Feedback
1 There is not enough information to determine if this nursing diagnosis is appropriate.
4 The patient is experiencing tachypnea and wheezing; therefore, the patient is
experiencing an ineffective breathing pattern necessitating the use of this nursing
diagnosis when planning care.

7. ANS: 3
Heading: Nursing Diagnoses
Integrated Processes: Nursing Process – Diagnosis
Cognitive level: Analysis [Analyzing]
Difficulty: Hard
Feedback
1 There is no information to support Anxiety or Ineffective Coping.
2 There is no information to support Anxiety or Ineffective Coping.

3 The patient's respiratory rate of 32 per minute is an indication of an ineffective
breathing pattern. The elevated blood pressure and fatigue are indications of a
compromised respiratory status. The diagnosis of Ineffective Breathing Pattern would
be the priority for the patient at this time.
4 There is no information to support Ineffective Airway Clearance, as there is no mention
that the client is coughing.

8. ANS: 3
Heading: Contraindications to Oxygen Administration
Integrated Processes: Nursing Process – Implementation
Feedback
1 This is an appropriate prescription for this patient.
3 The nurse should be concerned about the order for oxygen to be provided at 3-4
liters/minute. This amount of oxygen is too much for a patient with COPD because the
patient's breaths are stimulated by a hypoxic drive and this disease process causes the
body to retain carbon dioxide. Providing this much oxygen can result in an increase in
carbon dioxide levels, leading to respiratory failure. Oxygen for this patient should be
at a lower rate, such as 1-2 liters/minute, with close assessments of the patient's
breathing status.

9. ANS: 4
Feedback
1 Fluids should be increased to thin secretions.
2 Laying the child on his back will not improve the child's ability to breathe.
3 Performing chest physiotherapy is not an appropriate action to assist the child to clear
the nasal passages.
4 Grunting is seen with partial airway obstruction caused by increased secretions and

edema. The nurse should suction the airway to relieve the obstruction.

10. ANS: 4
Feedback
1 While using a site with adequate perfusion is important, this action does not determine
the accuracy of the detected waveform when monitoring a patient’s oxygen saturation
via oximetry.
2 While ensuring that any nail polish is removed is important, this action does not
determine the accuracy of the detected waveform when monitoring a patient’s oxygen
saturation via oximetry.
3 While leaving the sensor in place for a minimum of ten seconds is important, this action
does not determine the accuracy of the detected waveform when monitoring a patient’s
oxygen saturation via oximetry.
4 Assessing the heart rate and comparing it with the displayed pulse is the nursing action
that determines the accuracy of the wave form when monitoring a patient’s oxygen
saturation via oximetry.

11. ANS: 4
Feedback
1 Snoring sounds indicate rhonchi, caused by airflow obstruction from thick secretions or
fluid in the large airways.
2 Gurgling sounds indicate crackles. On inhalation, air comes in contact with secretions
in the trachea and large bronchi.
3 Loud, low-pitched bubbling sounds indicate crackles. On inhalation, air comes in
contact with secretions in the trachea and large bronchi.
4 Wheezing is characterized as musical, high-pitched squeaking that indicates narrowed

passages caused by secretions, bronchospasm, edema, and inflammation.

12. ANS: 1
Feedback
1 Snoring sounds indicate rhonchi, caused by airflow obstruction from thick secretions or
fluid in the large airways.
2 Gurgling sounds indicate crackles. On inhalation, air comes in contact with secretions
in the trachea and large bronchi.
3 Loud, low-pitched bubbling sounds indicate crackles. On inhalation, air comes in
contact with secretions in the trachea and large bronchi.
4 Wheezing is characterized as musical, high-pitched squeaking that indicates narrowed
passages caused by secretions, bronchospasm, edema, and inflammation.

13. ANS: 4
Feedback
1 A prone position is not appropriate for a patient who requires in-line suctioning.
2 A supine position is not appropriate for a patient who requires in-line suctioning.
3 A Fowler’s position is not appropriate for a patient who requires in-line suctioning.
4 A high-Fowler’s position is appropriate for a patient who requires in-line suctioning.
Elevating the head of bed will allow for easier ventilation for the patient.

14. ANS: 1

Cognitive level: Knowledge [Remembering]
Difficulty: Easy
Feedback
1 Each suctioning event should last no longer than 10 seconds. Suctioning lasting longer
than 10 seconds causes hypoxia, cardiopulmonary compromise, and a vagal response.
2 Each suctioning event should not last 30 seconds as this can cause hypoxia,
cardiopulmonary compromise, and a vagal response.

15. ANS: 2
Difficulty: Easy
Feedback
1 A rest period of 5 to 15 seconds is not adequate between suction procedures.
2 A rest period of 10 to 20 seconds is an appropriate time frame between suction
procedures. This time frame decreases the risk for hypoxia, dysrhythmia, and
bronchospasm.
3 A rest period of 15 to 25 seconds is not appropriate between suction procedures.
4 A rest period of 20 to 30 seconds is not appropriate between suction procedures.

16. ANS: 3
Feedback

1 The nurse should not continue suctioning and administer 50% oxygen if in-lining
suctioning causes a drop in oxygen saturation and bradycardia.
2 While the nurse should discontinue suctioning, it is not necessary to prepare for
resuscitation.
3 When in-line suctioning causes a drop in oxygen saturation and bradycardia, the nurse
discontinues suctioning and administers 100% oxygen.
4 The nurse should not continue suctioning and administer prescribed epinephrine if
in-lining suctioning causes a drop in oxygen saturation and bradycardia.

17. ANS: 1
Heading: Pressure Support Ventilation
Feedback
1 A mucous plug often causes a high-pressure alarm when a patient is being mechanically
ventilated. The appropriate action by the nurse is to suction the ET tube in order to
remove the mucous plug.
2 An oral airway is inserted if the patient is biting on the ET tube, which can cause a
high-pressure alarm for a patient who is being mechanically ventilated.
3 Assessing for asymmetric chest rise is an appropriate action if the high-pressure alarm
is caused by a pneumothorax, not a mucous plug.
4 Emptying water in the ventilator tubing is an appropriate action if the high-pressure
alarm is caused by water collection, not a mucous plug.

18. ANS: 2
Feedback

is caused by a pneumothorax, not when the patient is biting down on the ET tube.
alarm is caused by water collection, not when the patient is biting down on the ET tube.

19. ANS: 1
Feedback
alarm is caused by moisture collection.
is caused by a pneumothorax, not a collection of moisture in the ventilator tubing.

20. ANS: 3
Heading: Oxygen Delivery
Integrated Processes: Teaching and Learning
Client Need: Safe and Effective Care Environment – Safety and Infection Control
Concept: Safety
Difficulty: Hard
Feedback
1 Oxygen should be kept at least 6 feet from sources of heat, such as the stove. This
statement indicates correct understanding of the information presented.
2 A “no smoking” sign should be placed in the home if oxygen is stored, or in use. This
3 Oxygen should be stored upright, not on its side. This statement indicates the need for
further education.
4 A fire extinguisher should be maintained in the home and stored close to where the

oxygen is stored. This statement indicates correct understanding of the information
presented.
PTS: 1 CON: Safety

21. ANS: 2
Chapter learning objective: Clarifying indications and nursing implications for the following respiratory care
modalities: Incentive Spirometry.
Heading: Nursing Implications
Integrated Processes: Teaching and Learning
Difficulty: Hard
Feedback
1 A sitting, or high-Fowler’s, position is recommended when using an incentive
spirometer. This statement indicates correct understanding of the information presented.
2 The device should be used 5 to 10 times each hour while awake. This statement
indicates the need for further education.
3 The patient exhales completely prior to placing the mouth on the device. This statement
indicates correct understanding of the information presented.
4 The patient should hold the breath for three seconds and then exhale completely. This

22. ANS: 1
Heading: Ventilator-Associated Pneumonia
Feedback
1 Unless contraindicated, any patient who is mechanically ventilated should have the
head of the bed elevated at 30 to 45 degrees to decrease the risk for aspiration.
2 While it is important to limit each suctioning event to 10 seconds in length, this is not
an action to decrease the risk for aspiration.
3 While chest physiotherapy is often prescribed, this action is not intended to decrease the
risk for aspiration.
4 While many patients who are mechanically ventilated will receive parenteral or enteral
nutrition, an NPO status is unnecessary to decrease the risk for aspiration.

23. ANS: 4
Heading: Patient Criteria for Weaning
Integrated Processes: Nursing Process – Evaluation
Cognitive level: Comprehension [Understanding]
Difficulty: Easy
Feedback
1 An FIO2 less than or equal to 0.4–0.5 indicates the patient is able to be weaned from
mechanical ventilation.
2 A PEEP less than or equal to 5–8 cm H2O indicates the patient is able to be weaned
from mechanical ventilation.
3 A pH greater than 7.25 during spontaneous ventilation indicates the patient is able to be
weaned from mechanical ventilation.
4 Hemodynamic instability, such as a drop in blood pressure to a hypotensive state,
indicates the patient is not a candidate for being weaned from mechanical ventilation.

24. ANS: 1
Heading: High-Flow Delivery Devices
Feedback
1 A face-tent is a high-flow delivery device of oxygen that is appropriate for the patient
who requires supplemental oxygen if facial trauma is experienced.
2 While a nasal cannula might be appropriate for a patient who needs a low-flow delivery
device, this is not appropriate for the patient who requires a high-flow delivery device.
3 A Venturi mask delivers a high-flow of oxygen; however, facial trauma makes this an
unrealistic choice.
4 A nonrebreather mask is not an appropriate for the high-flow delivery of oxygen.

25. ANS: 1

Heading: Nasal Cannula
Difficulty: Easy
Feedback
1 A low flow rate of 1-2 L/min via NC is anticipated for a patient with COPD. The
patient who retains CO2, such as the patient with COPD, will use the lower amount of
oxygen (1–2 L/min) so the patient does not lose his or her hypoxic drive to breathe.
2 This flow rate is higher than anticipated when providing care for a patient with COPD
who requires supplement oxygen via NC.
MULTIPLE RESPONSE
26. ANS: 1, 2, 4, 5
Heading: Overview of Oxygen Therapy
Client Need: Safe and Effective Care Environment – Management of Care
Feedback
1. This is correct. Suctioning is an independent nursing action.
2. This is correct. Repositioning is an independent nursing action.
3. This is incorrect. Prescribing bronchodilators is outside the scope of nursing practice.
4. This is correct. Monitoring activity tolerance is an independent nursing action.
5. This is correct. Encouraging deep breathing exercises is an independent nursing action.

27. ANS: 1, 2, 3, 4
Heading: Nursing Management for a Mechanically Ventilated Patient

Concept: Evidence-Based Practice
Feedback
1. This is correct. Elevation of the head of the bed is included in the plan of care for a patient
who is receiving care based on a ventilator bundle.
2. This is correct. A sedation vacation each day is included in the plan of care for a patient who
is receiving care based on a ventilator bundle.
3. This is correct. Assessing for readiness to be weaned is included in the plan of care for a
patient who is receiving care based on a ventilator bundle.
4. This is correct. Administering the prescribed peptic ulcer prophylactic regimen is included in
the plan of care for a patient who is receiving care based on a ventilator bundle.
5. This is incorrect. The patient is placed on deep vein thrombosis prophylaxis, which should
include the use of compression stockings during immobility.
PTS: 1 CON: Evidence-Based Practice

28. ANS: 1, 2, 4, 5
Integrated Processes: Communication and Documentation
Concept: Communication; Oxygenation
Feedback
1. This is correct. The SpO2 result is documented in the medical record when monitoring a
patient’s oxygen saturation via oximetry.
2. This is correct. The current vital signs are documented in the medical record when monitoring
a patient’s oxygen saturation via oximetry.
3. This is incorrect. The presence of family or visitors at the patient’s bedside is not information
that is documented in the medical record when monitoring oxygenation saturation via
oximetry.
4. This is correct. The type, and amount, of oxygen therapy in use is documented in the medical
record when monitoring a patient’s oxygen saturation via oximetry.
5. This is correct. The education provided to the patient and family is documented in the medical
record when monitoring a patient’s oxygen saturation via oximetry.
PTS: 1 CON: Communication | Oxygenation

29. ANS: 1, 2, 3, 4

Integrated Processes: Communication and Documentation
Concept: Communication; Oxygenation
Feedback
1. This is correct. The amount of secretions collected during in-line suctioning is documented in
the patient’s medical record.
2. This is correct. The color of secretions collected during in-line suctioning is documented in the
patient’s medical record.
3. This is correct. The consistency of secretions collected during in-line suctioning is
documented in the patient’s medical record.
4. This is correct. The patient’s response to the procedure is documented in the medical record.
5. This is incorrect. The amount of oxygen the patient received during the suctioning procedure
is documented on a separate flow sheet, not the medical record.
PTS: 1 CON: Communication | Oxygenation

30. ANS: 3, 4
Heading: Tracheostomy Care
Feedback
1. This is incorrect. The family should be educated about the procedure but there is no need to
ask the family to leave the bedside.
2. This is incorrect. The tracheostomy should be suctioned at the start of the procedure and as
needed.
3. This is correct. Personal protective equipment is applied to decrease the risk for infection.
4. This is correct. The tracheostomy site is assessed for infection, irritation, and skin breakdown.
5. This is incorrect. A reusable, not disposable, inner cannula is rinsed with sterile water and
dried prior to reinsertion.

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Copyright © 2017 F. A. Davis Company

Copyright © 2017 F. A. Davis Company

Copyright © 2017 F. A. Davis Company

Copyright © 2017 F. A. Davis Company

PTS: 1 CON: Oxygenation

PTS: 1 CON: Oxygenation

Copyright © 2017 F. A. Davis Company

PTS: 1 CON: Oxygenation

PTS: 1 CON: Oxygenation

Copyright © 2017 F. A. Davis Company

PTS: 1 CON: Oxygenation

PTS: 1 CON: Oxygenation

Copyright © 2017 F. A. Davis Company

PTS: 1 CON: Oxygenation

PTS: 1 CON: Oxygenation

Copyright © 2017 F. A. Davis Company

PTS: 1 CON: Oxygenation

PTS: 1 CON: Oxygenation

Copyright © 2017 F. A. Davis Company

PTS: 1 CON: Oxygenation

PTS: 1 CON: Oxygenation

PTS: 1 CON: Oxygenation

Copyright © 2017 F. A. Davis Company

PTS: 1 CON: Oxygenation

PTS: 1 CON: Oxygenation

Copyright © 2017 F. A. Davis Company

PTS: 1 CON: Oxygenation

PTS: 1 CON: Oxygenation

Copyright © 2017 F. A. Davis Company

PTS: 1 CON: Oxygenation

PTS: 1 CON: Oxygenation

Copyright © 2017 F. A. Davis Company

PTS: 1 CON: Safety

PTS: 1 CON: Oxygenation

PTS: 1 CON: Oxygenation

Copyright © 2017 F. A. Davis Company

PTS: 1 CON: Oxygenation

PTS: 1 CON: Oxygenation

Copyright © 2017 F. A. Davis Company

PTS: 1 CON: Oxygenation

PTS: 1 CON: Oxygenation

Copyright © 2017 F. A. Davis Company

PTS: 1 CON: Evidence-Based Practice

PTS: 1 CON: Communication | Oxygenation

Copyright © 2017 F. A. Davis Company

PTS: 1 CON: Communication | Oxygenation

PTS: 1 CON: Oxygenation

Copyright © 2017 F. A. Davis Company

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