Deck 30: Oxygenation

Question 1

The nurse is educating a patient who has recently been diagnosed with chronic obstructive pulmonary disease (COPD).The nurse explains how the gasses in the lungs move between the air spaces and the bloodstream.Which process is the nurse describing?

A) Ventilation
B) Diffusion
C) Respiration
D) Perfusion

Answer 1

Diffusion

Question 2

The guardians of a premature infant who was delivered at 31-weeks' gestation is expected to be discharged from the hospital within the next few days.The guardians have voiced concern regarding how to prevent respiratory syncytial virus (RSV)exposure to the baby.What is the best response from the nurse?

A) "You will need to limit the baby's exposure to crowds of people."
B) "You need to make sure that the car seat is facing backward in the back seat of your car."
C) "You do not need to be concerned; the baby has a natural protection against this disease."
D) "You must sterilize all the bottles for the first 6 months."

Answer 2

"You will need to limit the baby's exposure to crowds of people."

Question 3

The patient is experiencing shortness of breath.Which of the following lab tests indirectly indicates the oxygen level in the blood system?

A) Hemoglobin
B) White blood cell count
C) Electrolytes
D) Creatinine

Answer 3

Hemoglobin

Question 4

A patient was admitted to the surgical unit after surgical removal of an abdominal tumor.As the nurse performs a postsurgical assessment,the patient's blood pressure is 90/54,heart rate is 94,and respiratory rate is 22.Based on these values,the nurse should be most concerned with which of the following conditions?

A) Hypovolemia
B) Left-sided heart failure
C) Right-sided heart failure
D) Hypervolemia

Question 5

The exchange of oxygen and carbon dioxide during cellular metabolism is best described as which of the following?

A) Ventilation
B) Diffusion
C) Respiration
D) Perfusion

Question 6

A patient who is 7 months pregnant with her first child is visiting the health care provider for her scheduled prenatal checkup.She tells the nurse that she is short of breath and fatigued.What is the best response from the nurse?

A) "You should have let us know immediately instead of waiting until your appointment."
B) "I'll make a note of it on your chart."
C) "That is normal; your uterus is causing pressure on your diaphragm, making it more difficult to breathe."
D) "Oxygen is needed for you and the baby. I will give you some oxygen to help you."

Question 7

A 58-year-old Caucasian woman is at the clinic for her annual check-up.She tells the nurse that she noticed her blood pressure is higher than it was when she was younger.She asks the nurse why this would happen.What is the nurse's best response?

A) "Your race and gender are predisposing factors for heart disease."
B) "Well, if you stop smoking your blood pressure would go down."
C) "As we age, our blood vessels become less elastic, which causes higher blood pressure."
D) "I don't think it's anything to worry about."

Question 8

A patient on the surgical unit is 1 day postoperative for surgery to remove stomach cancer.In addition to the physiological stress this patient has undergone,the nurse recognizes that this patient will have to deal with the psychological stress of finding out that the cancer has metastasized to the liver.Which physiological change would the nurse expect to see as a response to stress?

A) Decreased heart rate
B) Increased hemoptysis output
C) Increased respiratory rate
D) Decreased cardiac output

Question 9

A 36-year-old patient diagnosed with meningitis has a fever of 102.3° F.A family member verbalizes a concern that the patient is "breathing fast." Upon assessment,the nurse notes a respiratory rate of 20 breaths/min,pulse oximetry is 92% on 2L/O?,and lungs clear to auscultation.What is the best explanation for the rapid respiratory rate that the nurse can give the family member?

A) "He is most likely anxious because he is in the hospital."
B) "His fever has increased his metabolic rate and is causing him to breathe faster."
C) "He is hyperventilating because he needs more oxygen."
D) "He has an acid-base imbalance, which is causing him to hyperventilate."

Question 10

Which term should the nurse use to best describe the movement of air in and out of the patient's lungs?

A) Ventilation
B) Diffusion
C) Respiration
D) Perfusion

Question 11

A 3-month-old infant is being seen for a well-child check at the pediatric clinic.The nurse is assessing the guardian's knowledge level about the infant's growth and development.One of the topics that the nurse has chosen to address in this session is the risk for airway obstruction.What is the main reason that the nurse has chosen this topic?

A) Infants can have severe allergic reactions to food based on exposure to secondhand smoke.
B) Infants are prone to lower airway infections that can become obstructive.
C) Infants have a tendency to place foreign objects in their mouths.
D) Infants can have airway obstruction from excessive drooling associated with teething.

Question 12

The family member of a 73-year-old patient with chronic obstructive pulmonary disease (COPD)is concerned about the patient's recent weight loss.When questioned by the nurse,the patient denies any change in diet or activity,but admits to losing 10 lb in the past 6 weeks.What is the nurse's best response to the family member's concern?

A) "Maybe the patient has a higher metabolic rate than you."
B) "It doesn't seem fair that some people can lose weight so easily."
C) "This disease affects the respiratory system and causes the body to burn more calories to supply the energy to breathe."
D) "You need to discuss this with the health care provider so testing can be ordered for tuberculosis."

Question 13

A 47-year-old woman with a history of diabetes and hypertension calls the clinic complaining of epigastric pain and shortness of breath with activity.She has taken antacids with no relief.What type of pain is the patient experiencing?

A) Pericardial pain
B) Pleuritic chest pain
C) Musculoskeletal pain
D) Cardiac pain

Question 14

The nurse is admitting a patient with chronic obstructive pulmonary disease (COPD).During the initial head-to-toe assessment the patient's pulse oximetry reading is 89% on room air.What is the nurse's first priority?

A) Administer oxygen immediately @ 4L/NC.
B) Call the primary health care provider for an order for oxygen.
C) Assist the patient into a recumbent position.
D) Determine the patient's normal pulse oximetry reading.

Question 15

When giving CPR,compressions are causing the heart to pump blood into and out of the lungs to the body's organs.This movement of oxygenated blood is best described as which of the following?

A) Ventilation
B) Diffusion
C) Respiration
D) Perfusion

Question 16

A 45-year-old patient was diagnosed with an anterior myocardial infarction.The patient asks the nurse why his chest hurt when he had his heart attack.What is the best response from the nurse?

A) "One of your heart valves wasn't working properly and caused an obstructed blood flow."
B) "One of your coronary arteries had a spasm, and your heart muscle wasn't able to get enough blood."
C) "Your heart muscle was deprived of oxygen, which caused chest pain."
D) "The heart muscle is sensitive to changes in electrical conduction."

Question 17

What is the best indicator the nurse can use to determine the adequacy of a patient's cardiac output?

A) Stroke volume
B) Myocardial contractility
C) Afterload
D) Cardiac index

Question 18

A healthy 33-year-old mother of three children reports "having no energy." She asks the nurse,how she could increase her energy level.What is the best response for the nurse to give?

A) "You should decrease iron intake."
B) "Daily exercise has been shown to increase a person's energy level."
C) "Energy caffeinated drinks are a good substitute for exercise."
D) "Try to exercise 90 minutes every other day."

Question 19

A college student who smokes asks a healthcare professional if there really is a connection between smoking and lung cancer.What is the healthcare worker's best response?

A) The risk for lung cancer for smokers than for nonsmokers is 5 times greater.
B) The risk for lung cancer for smokers than for nonsmokers is 10 times greater.
C) The risk for lung cancer for smokers than for nonsmokers is 50 times greater.
D) Lung cancer affects smokers and non-smokers equally due to occupational hazards.

Question 20

A patient has been admitted to the cardiac unit with the diagnosis of bradycardia.The patient states "I am confused about what the doctor said is wrong with me,he said my pacemaker is not working.I don't have a pacemaker." What is the nurse's best response?

A) "The sinoatrial node is the 'pacemaker' of your heart."
B) "Myocardial contractility determines your heart rate."
C) "The atrioventricular node is the 'pacemaker' of your heart."
D) "The ventricular Purkinje network determines your heart rate."

Question 21

A patient with a tracheostomy is experiencing thick and tenacious secretions.To maintain this patient's airway,what is the most appropriate action for the nurse?

A) Tracheal suctioning
B) Oropharyngeal suctioning
C) Nasotracheal suctioning
D) Orotracheal suctioning

Question 22

The RN and nursing assistive personnel (NAP)are caring for six patients on the pulmonary unit.Which of the following tasks would be most appropriate for the nurse to delegate to the NAP?

A) Taking vital signs on a 56-year-old man with severe dyspnea
B) Suctioning a patient with hemoptysis
C) Encouraging a postoperative patient to use the incentive spirometer
D) Performing chest percussion on a patient with atelectasis

Question 23

The assistive personnel reports that an older patient is complaining of shortness of breath and palpitations.The nurse connects the patient to an electrocardiogram monitor and analyzes the rhythm with normal P wave and normal QRS and T waves.The rate is 116 beats per minute and regular.The nurse identifies this rhythm as which of the following?

A) Sinus bradycardia
B) Ventricular tachycardia
C) Sinus tachycardia
D) Normal sinus rhythm

Question 24

The nurse is evaluating a patient who has a chest tube.To properly maintain chest tube function,what is the nurse's best action?

A) Strip the tube every hour to maintain drainage.
B) Place the device below the patient's chest.
C) Double clamp the tubes except during assessments.
D) Remove the tubing from the drainage device to check for proper suctioning.

Question 25

The home care nurse is admitting a patient with COPD.The primary healthcare provider has ordered O? /nasal cannula at 3 L/min.To promote safety,the nurse would instruct the patient on which of the following safety measures? (Select all that apply.)

A) Place "No smoking" signs in all areas where oxygen will be used.
B) Instruct family and visitors who smoke that they must smoke a minimum of 10 feet from the patient.
C) Store tanks in a small closet, trunk of a car, or near the hot water heater.
D) Oxygen tanks should stay a minimum of 6 feet from space heaters, fireplaces, and appliances with an electric motor.
E) Know the exit routes and where the fire extinguisher are located in the home.

Question 26

The nursing student is formulating a nursing care plan for a patient with pneumonia.The care plan is directed toward meeting the potential oxygenation needs of the patient.Which of the following examples would be the best way for the nursing student to write an expected outcome for the care plan?

A) "The patient will have less pain."
B) "The patient will be able to breathe better."
C) "The patient's pulse oximetry reading will remain greater than 92%."
D) "The patient's interactions will be normal."

Question 27

A nurse is being oriented to work for an intensive care unit.The hemodynamic data indicate that the patient has a decreased preload.Which information indicates the nurse has a correct understanding of the concept of preload?

A) It is the amount of blood ejected from the left ventricle each minute.
B) It is the amount of blood in the heart at the end of ventricular diastole.
C) It is the resistance to the ejection of blood from the left ventricle.
D) It is the rhythmic relaxation and contraction of the heart chambers.

Question 28

A patient presents with an acute myocardial infarction that resulted in right ventricular damage.The nurse needs to assess the patient for right-sided heart failure,which includes which of the following?

A) Crackles on auscultation
B) Jugular neck vein distention
C) Increased myocardial perfusion
D) Orthopnea

Question 29

An adult collapsed at the grocery store.Before being transported to the emergency department,an automated external defibrillator (AED)was used.The nurse remembers learning that the AED is effective in saving a life because of which factors? (Select all that apply.)

A) Use of an AED strengthens the chain of survival.
B) The AED can be used by nonmedical personnel.
C) The AED sends heart rhythm to the closest emergency room (ER) for the physician to analyze and give orders.
D) Every minute without defibrillation decreases the survival rate by 7% to 10%.
E) The AED will automatically deliver a shock to the victim after announcing, "Everyone stand back."

Question 30

A patient reports chest pain.The nurse is attempting to assess the pain to differentiate the pain as cardiac,respiratory,or gastrointestinal.The nurse can properly identify the pain as cardiac in origin when the patient states that the cardiac pain:

A) does not occur with respiratory variations.
B) is peripheral and may radiate to the scapular areas.
C) is aggravated by inspiratory movements.
D) is nonradiating and occurs during inspiration.

Question 31

On entering the room,a nurse finds the patient sitting upright in bed with the upper torso resting on the over-bed table.The nurse assesses that this patient is experiencing acute hypoxemia.Which of the following are symptoms of acute hypoxemia? (Select all that apply.)

A) Cyanosis
B) Arrhythmias
C) Eupnea
D) Restlessness
E) Diaphoresis

Question 32

A patient has been admitted to the pulmonary unit of the hospital with right lower lobe pneumonia and history of chronic obstructive pulmonary disease (COPD).During the initial assessment the nurse notes that the patient has a respiration rate of 18 with retractions,tachycardia,and complains of dyspnea and dizziness.The nurse identifies that these are clinical signs of which condition?

A) Paroxysmal nocturnal dyspnea
B) Orthopnea
C) Hemoptysis
D) Hypoxia

Question 33

A student nurse caring for a patient with a chest tube has been asked what equipment should be at the bedside to assess for an air leak.Which information indicates the student nurse has a correct understanding of the equipment needed?

A) Suction equipment wrapped in plastic to keep instrument clean
B) Hemostat covered with gauze to prevent penetration of the chest tube
C) Cup of water to place the end of the chest tube
D) Petroleum gauze to use as a dressing

Question 34

A health care worker received an annual tuberculosis test administered 56 hours ago.The injection site is very red and flat.The certified nurse who is reading the test should take which action?

A) Advise the health care worker another test must be done because the test was not read within the proper time.
B) Tell the health care worker the results are positive and cannot return to work.
C) Document the results as a negative reaction.
D) Measure the area in millimeters.

Question 35

A patient with pulmonary congestion needs to cough to clear secretions.The nurse instructs the patient to inhale and perform a series of coughs during exhalation.What type of cough did the nurse teach the patient?

A) Quad
B) Huff
C) Cascade
D) Splinting