Question

A client reported slight shortness of breath and the nursing assessment reveals the presence of bilateral coarse crackles. The client's SaO2 is 90%. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

Answer 1

Correct Answers:

6 L/min.

Rationale :

💎The nasal cannula is a low-flow oxygen device that safely delivers 1–6 L/min, providing an FiO₂ range of 24–44%.

💎Exceeding 6 L/min can cause nasal mucosal dryness, irritation, and limited oxygen efficiency because higher flow disperses oxygen.

💎For patients with SaO₂ of 90% and bilateral crackles, this low-to-moderate range supports oxygenation without suppressing respiratory drive.

💎If more oxygen is needed, the nurse should transition to a simple mask or Venturi mask for controlled FiO₂.

💎Maintaining the proper flow preserves comfort and mucosal integrity, especially in long-term therapy.

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Answer 2

Correct Answers:

6 L/min.

Rationale :

💎The nasal cannula is a low-flow oxygen device that safely delivers 1–6 L/min, providing an FiO₂ range of 24–44%.

💎Exceeding 6 L/min can cause nasal mucosal dryness, irritation, and limited oxygen efficiency because higher flow disperses oxygen.

💎For patients with SaO₂ of 90% and bilateral crackles, this low-to-moderate range supports oxygenation without suppressing respiratory drive.

💎If more oxygen is needed, the nurse should transition to a simple mask or Venturi mask for controlled FiO₂.

💎Maintaining the proper flow preserves comfort and mucosal integrity, especially in long-term therapy.

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Answer 3

Correct Answers:

Raise the head of the bed.

Rationale :

🔵When oxygen saturation drops after surgery, the first nursing action is to improve ventilation by elevating the head of the bed (Fowler’s or semi-Fowler’s).

🔵This position expands lung capacity, enhances diaphragmatic movement, and promotes alveolar gas exchange.

🔵Hypoxemia following transfer can occur from atelectasis or hypoventilation due to anesthesia effects.

🔵Oxygen should be applied after positioning if saturation does not improve, following the airway–breathing–circulation (ABC) priority.

🔵Immediate positioning also prevents aspiration and facilitates effective chest expansion.

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Answer 4

Correct Answers:

The patient states, "I will not use my oxygen any flammable products"

Rationale :

🟢Oxygen supports combustion, so patients must avoid open flames, smoking, and oil-based substances near oxygen devices.

🟢This safety measure prevents fire hazards in the home or clinical setting.

🟢Education ensures patients understand oxygen itself is not explosive but makes fire burn faster and hotter.

🟢The statement demonstrates awareness of fire risk precautions, showing correct understanding of oxygen safety.

🟢Nurses should reinforce no smoking signs, secure tubing, and proper storage of oxygen tanks.

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Answer 5

Correct Answers:

The patient states, "I will not use my oxygen any flammable products"

Rationale :

🟢Oxygen supports combustion, so patients must avoid open flames, smoking, and oil-based substances near oxygen devices.

🟢This safety measure prevents fire hazards in the home or clinical setting.

🟢Education ensures patients understand oxygen itself is not explosive but makes fire burn faster and hotter.

🟢The statement demonstrates awareness of fire risk precautions, showing correct understanding of oxygen safety.

🟢Nurses should reinforce no smoking signs, secure tubing, and proper storage of oxygen tanks.

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Answer 6

Correct Answers:

Increase oral intake of fluids.

Rationale :

🩵 Adequate hydration keeps respiratory secretions thin and less viscous, promoting effective coughing and clearance.

🩵Fluids help moisturize mucous membranes and improve ciliary action, aiding airway defense mechanisms.

🩵In lung congestion, thick secretions hinder gas exchange and increase infection risk.

🩵Unless contraindicated (e.g., heart failure), 2–3 L/day of fluids is typically encouraged.

🩵This intervention enhances comfort and oxygenation through improved mucus expectoration.

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Answer 7

Correct Answers:

Increase oral intake of fluids.

Rationale :

🩵 Adequate hydration keeps respiratory secretions thin and less viscous, promoting effective coughing and clearance.

🩵Fluids help moisturize mucous membranes and improve ciliary action, aiding airway defense mechanisms.

🩵In lung congestion, thick secretions hinder gas exchange and increase infection risk.

🩵Unless contraindicated (e.g., heart failure), 2–3 L/day of fluids is typically encouraged.

🩵This intervention enhances comfort and oxygenation through improved mucus expectoration.

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Answer 8

Correct Answers:

dyspnea, arrhythmia, cyanosis

Rationale :

💠Hypoxia leads to impaired tissue oxygenation, manifesting as dyspnea (shortness of breath), cyanosis (bluish skin/mucosa), and irregular heart rhythms from cardiac strain.

💠Early symptoms include restlessness, tachycardia, and anxiety as compensatory mechanisms fail.

💠Cyanosis occurs once deoxygenated hemoglobin exceeds 5 g/dL, signaling critical oxygen deficiency.

💠Arrhythmias result from myocardial hypoxia, potentially leading to cardiac arrest if untreated.

💠Recognizing these classic signs enables prompt oxygen therapy and monitoring.

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Answer 9

Correct Answers:

Instruct the patient to exhale normally and then place lips securely around the mouthpiece.
Encourage the patient to complete breathing exercises about 5 to 10 times every 1 to 2 hours.

Rationale :

Exhale normally, then place lips securely around the mouthpiece

🌬️Exhaling to a normal baseline first resets lung volume so the next breath is a slow, deep inspiration that truly expands alveoli.

🌬️A tight lip seal on the mouthpiece prevents air leaks, ensuring the device measures the actual inspired volume and not room-air bypass.

🌬️The patient then inhales slowly through the mouthpiece (not the nose), watching the piston/indicator rise to the prescribed target volume.

🌬️A 3–5-second inspiratory hold at peak volume promotes alveolar recruitment and collateral ventilation, reducing atelectasis risk.

🌬️After several efforts, instruct the patient to cough and splint the incision (if post-op) to mobilize and clear secretions effectively.

Complete 5–10 breaths every 1–2 hours while awake

🌬️Performing 5–10 coached inspirations every 1–2 hours provides the repetition and frequency needed to prevent postoperative atelectasis and pneumonia.

🌬️Regular practice increases functional residual capacity and inspiratory capacity, improving ventilation–perfusion matching and oxygenation.

🌬️Pairing sessions with pain control (analgesia timed before IS), upright positioning, and early ambulation maximizes lung expansion.

🌬️Teach patients to stop if dizzy or light-headed, rest, and then resume to avoid hyperventilation.

🌬️Consistent scheduling (e.g., every 1–2 hours while awake) builds habit and ensures sustained alveolar recruitment throughout recovery.

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Answer 10

Correct Answers:

It helps clear the airways of excessive secretions.

Rationale :

💎Percussion, vibration, and postural drainage move secretions from peripheral → central airways for cough/suction.

💎This improves ventilation–perfusion matching, reduces shunt, and relieves obstruction-related hypoxemia.

💎Indicated in retentive conditions (CF, bronchiectasis, mucus-plugging pneumonia) to lower infection risk.

💎Time sessions before meals/bronchodilators to maximize tolerance and airway caliber.

💎Monitor for contraindications (e.g., unstable hemodynamics, rib fractures) and oxygen trends during therapy.

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NUR321_Exam3_FA_2023_Fundamentals

No.

1 :
A client reported slight shortness of breath and the nursing assessment reveals the presence of bilateral coarse crackles. The client's SaO2 is 90%. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

2 :
A client reported slight shortness of breath and the nursing assessment reveals the presence of bilateral coarse crackles. The client's SaO2 is 90%. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

4 :
A nurse is educating a patient about oxygen therapy via a nasal cannula. How does the nurse know the teaching was effective?

5 :
A nurse is educating a patient about oxygen therapy via a nasal cannula. How does the nurse know the teaching was effective?

6 :
A nurse is taking care of a patient with lung congestion. The nurse needs to teach the patient how to keep secretions thin so the patient can easily cough up and expectorate it. What would be important for the nurse to teach the patient?

7 :
A nurse is taking care of a patient with lung congestion. The nurse needs to teach the patient how to keep secretions thin so the patient can easily cough up and expectorate it. What would be important for the nurse to teach the patient?

8 :
The student nurse recognizes the patient is exhibiting signs of hypoxia. What would you expect the student to have found during their assessment?

9 :
The medical-surgical nurse is reviewing the use of an incentive spirometer. Which instructions will the nurse include in the client's teaching plan? (Select all that apply)

10 :
A provider orders chest physiotherapy (chest PT) for a patient. After the provider leaves, the patient says, "I still don't understand the purpose of this therapy. Which reply below would be the best reply by the nurse?

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NUR321_Exam3_FA_2023_Fundamentals

No.

1 : A client reported slight shortness of breath and the nursing assessment reveals the presence of bilateral coarse crackles. The client's SaO2 is 90%. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

2 : A client reported slight shortness of breath and the nursing assessment reveals the presence of bilateral coarse crackles. The client's SaO2 is 90%. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

4 : A nurse is educating a patient about oxygen therapy via a nasal cannula. How does the nurse know the teaching was effective?

5 : A nurse is educating a patient about oxygen therapy via a nasal cannula. How does the nurse know the teaching was effective?

6 : A nurse is taking care of a patient with lung congestion. The nurse needs to teach the patient how to keep secretions thin so the patient can easily cough up and expectorate it. What would be important for the nurse to teach the patient?

7 : A nurse is taking care of a patient with lung congestion. The nurse needs to teach the patient how to keep secretions thin so the patient can easily cough up and expectorate it. What would be important for the nurse to teach the patient?

8 : The student nurse recognizes the patient is exhibiting signs of hypoxia. What would you expect the student to have found during their assessment?

9 : The medical-surgical nurse is reviewing the use of an incentive spirometer. Which instructions will the nurse include in the client's teaching plan? (Select all that apply)

10 : A provider orders chest physiotherapy (chest PT) for a patient. After the provider leaves, the patient says, "I still don't understand the purpose of this therapy. Which reply below would be the best reply by the nurse?

1 :
A client reported slight shortness of breath and the nursing assessment reveals the presence of bilateral coarse crackles. The client's SaO2 is 90%. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

2 :
A client reported slight shortness of breath and the nursing assessment reveals the presence of bilateral coarse crackles. The client's SaO2 is 90%. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

4 :
A nurse is educating a patient about oxygen therapy via a nasal cannula. How does the nurse know the teaching was effective?

5 :
A nurse is educating a patient about oxygen therapy via a nasal cannula. How does the nurse know the teaching was effective?

6 :
A nurse is taking care of a patient with lung congestion. The nurse needs to teach the patient how to keep secretions thin so the patient can easily cough up and expectorate it. What would be important for the nurse to teach the patient?

7 :
A nurse is taking care of a patient with lung congestion. The nurse needs to teach the patient how to keep secretions thin so the patient can easily cough up and expectorate it. What would be important for the nurse to teach the patient?

8 :
The student nurse recognizes the patient is exhibiting signs of hypoxia. What would you expect the student to have found during their assessment?

9 :
The medical-surgical nurse is reviewing the use of an incentive spirometer. Which instructions will the nurse include in the client's teaching plan? (Select all that apply)

10 :
A provider orders chest physiotherapy (chest PT) for a patient. After the provider leaves, the patient says, "I still don't understand the purpose of this therapy. Which reply below would be the best reply by the nurse?