Deck 36: Oxygenation

Question 1

The nurse is administering a purified protein derivative (PPD) test to a nursing student. Which of the following statements concerning PPD testing is true?
1)A positive reaction indicates that the client has active tuberculosis (TB).
2)A positive reaction indicates that the client has been exposed to the disease.
3)A negative reaction always excludes the diagnosis of TB.
4)The PPD can be read within 12 to 24 hours after the injection.

Answer 1

2

Question 2

A nurse is suctioning a client via an open system tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of:
1)5 seconds
2)15 seconds
3)30 seconds
4)45 seconds

Answer 2

2

Question 3

The nurse is preparing to administer medication to the client with an exacerbation of asthma. Which of the following medications would improve the respiratory function of the client?
1)Opioid
2)Vasodilator
3)Antianxiety medication
4)Bronchodilator

Answer 3

4

Question 4

The nurse is providing care for a client admitted with a diagnosis of muscular dystrophy resulting in inadequate muscle strength to draw enough air into the lungs. What nursing diagnosis would be most appropriate for this client?
1)Ineffective Breathing Pattern
2)Ineffective Airway Clearance
3)Impaired Gas Exchange
4)Impaired Spontaneous Ventilation

Question 5

The nurse is planning care for an older adult client newly admitted with a medical diagnosis of pneumonia and a nursing diagnosis of Ineffective Airway Clearance. Which of the following is the nurse's priority intervention?
1)Teach the importance of pneumonia immunization.
2)Teach coughing and deep breathing exercises.
3)Position the client to optimize maximum ventilation.
4)Encourage the use of incentive spirometer every hour.

Question 6

A nurse is preparing to obtain a sputum specimen from an adult client. Which of the following nursing actions will facilitate obtaining the specimen?
1)Limiting fluid intake prior to collection
2)Having the client take deep breaths
3)Asking the client to spit into the collection container
4)Asking the client to obtain the specimen after eating

Question 7

The nurse administers an antitussive/expectorant cough preparation to a client with bronchitis. Which of the following responses indicates to the nurse that the medication is effective?
1)The amount of sputum the client expectorates decreases with each dose administered.
2)Cough is completely suppressed, and the client is able to sleep through the night.
3)Dry, unproductive cough is reduced, but her voluntary coughing is more productive.
4)Involuntary coughing produces large amounts of thick yellow sputum.

Question 8

The nurse is admitting to the medical-surgical unit an older adult with a diagnosis of pulmonary hypertension and right-sided heart failure. The client is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take?
1)Review and implement the primary care provider's prescriptions for treatments.
2)Perform a quick physical examination of breathing, circulation, and oxygenation.
3)Gather a thorough medical history, including current symptoms, from the family.
4)Administer supplemental oxygen to the client through a nasal cannula.

Question 9

A client is unable to breathe independently and is now on mechanical ventilation. Which of the following is a correct nursing intervention for maintenance?
1)Keep the head of the bed flat for 6 hours.
2)Avoid using mouth rinses or mouthwashes.
3)Provide the client with a paper and pencil or letter board.
4)Drain condensation into the humidifier when it collects in the tubing.

Question 10

The nurse is preparing to obtain sputum specimens from several clients. Which of the following clients could the nurse collect a sputum specimen without using a suction catheter?
1)The client with a newly placed tracheostomy
2)The client with an endotracheal tube
3)The client with late-stage amyotrophic lateral sclerosis
4)The client admitted with chronic bronchitis

Question 11

The nurse is providing teachings on smoking cessation to an older client with emphysema. The client states, "My doctor wants me to quit smoking. It's too late now, though; I already have lung problems." Which of the following would be the best response to his statement?
1)"You should quit so your family does not get sick from exposure to secondhand smoke."
2)"You will need to use an oxygen tank, but remember it is a fire hazard to smoke with the oxygen tank in your home."
3)"Once you stop smoking, your body will begin to repair some of the damage to your lungs."
4)"You should ask your primary care provider for a prescription for a nicotine patch to help you quit."

Question 12

The nurse is providing care to a pregnant woman in preterm labor. The client is 32 weeks pregnant. Initially, the client states, "I've gained 30 pounds. That should be enough for the baby. Everything will be okay if I deliver now." After teaching the client about fetal development, the nurse will know her teaching is effective if the client makes which of the following statements?
1)"The baby's lungs are well developed now, but he will be at increased risk for sudden infant death syndrome (SIDS) if I deliver early."
2)"We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early."
3)"If I deliver this early, my baby is at risk for respiratory distress syndrome (RDS), a condition that can be life threatening."
4)"Thanks for reassuring me; I was pretty sure there isn't much risk to the baby this far along in my pregnancy."

Question 13

The nurse is providing care to the adult client with mechanically ventilated client who has a tracheostomy. The client has a pulse oximetry reading at 85%, heart rate at 113 beats/min, and respiratory rate at 30 breaths/min. The client has become restless and has labored gurgling respirations. The nurse auscultates bilateral crackles and rhonchi. What is the most appropriate nursing action at this time?
1)Call the respiratory therapist for ventilator assessment.
2)Provide sterile endotracheal suctioning.
3)Provide sterile tracheostomy and stoma care.
4)Notify the physician of the client's signs of fluid overload.

Question 14

Which of the following best describes the function of type 1 alveolar cells?
1)They add moisture to the inhaled air in the lungs.
2)They open the airway during breathing to allow air to move.
3)They facilitate gas exchange in the lungs.
4)They produce surfactant to lubricate the lungs.

Question 15

The nurse is caring for a client diagnosed with pneumonia, teaching him or her how to cough and deep-breathe. The client asks, "Why is drinking fluids so important?" What is the nurse's best response?
1)"The doctor ordered increased fluid intake."
2)"Fluids prevent pathogens from growing in your lungs."
3)"Fluids help to flush infection away so it doesn't grow in your lungs."
4)"Fluids make secretions thin, making them easier to cough up."

Question 16

The client was admitted to the intensive care unit (ICU) for respiratory acidosis secondary to smoke inhalation and exposure to caustic gases. After placement of an endotracheal tube and connection to a mechanical ventilator, the arterial blood gas results are pH = 7.28; partial pressure of oxygen (PaO₂) = 85; partial pressure of carbon dioxide (PaCO₂) = 60. What changes to care does the nurse anticipate?
1)Wean the client from the ventilator.
2)Increase the concentration of oxygen delivered.
3)Decrease the concentration of oxygen delivered.
4)Increase the number of breaths per minute on the ventilator.

Question 17

The nurse is caring for a 6-month-old infant diagnosed with respiratory syncytial virus (RSV) infection. What consideration will most influence the nurse's plan of care?
1)Infants breathe more rapidly than adults.
2)Infants' airways are narrower and easily obstructed.
3)Infants' lower hemoglobin (HgB) levels reduce oxygenation.
4)Infants have larger tonsils and adenoids.

Question 18

While a client is receiving hygiene care, the chest tube becomes disconnected from the water-seal chest drainage unit (CDU). Which action should the nurse take immediately?
1)Clamp the chest tube close to the insertion site with rubber-shod hemostats.
2)Set up a new drainage system, and quickly connect it to the chest tube.
3)Have the client take a deep breath while the nurse reconnects the tube to the CDU.
4)Place the disconnected end nearest the client into a bottle of sterile water.

Question 19

When using sterile technique to perform care of a new tracheostomy, which of the following is correct?

A)Cleanse the area with hot soapy water, and rinse well.
B)Place the client in semi-Fowler's position, if possible.
C)Clean the stoma under the faceplate with hydrogen peroxide.
D)Cut a slit in sterile 4 * 4 inch gauze halfway through to make a dressing.

Question 20

The nurse is providing care for a young adult client with an intracranial hemorrhage secondary to a closed head injury. During the assessment, the nurse notices that the client's respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern?
1)Biot's breathing
2)Kussmaul's respirations
3)Sleep apnea
4)Cheyne-Stokes respirations

Question 21

Of the following interventions, which of the following may reduce the risk of postoperative atelectasis? Select all that apply.
1)Administer bronchodilators.
2)Apply low-flow oxygen.
3)Encourage coughing and deep breathing.
4)Administer pain medication.
5)Suction the airway prn (as needed).

Question 22

Which procedure can the nurse safely delegate to the certified nursing assistant who is knowledgeable and experienced in the procedure?
1)Suctioning the newly placed tracheostomy tube
2)Suctioning the endotracheal tube
3)Suctioning the laryngopharynx
4)Suctioning the oropharynx

Question 23

Obesity is associated with higher risk for which of the following conditions that affect the pulmonary and cardiovascular systems? Select all that apply.
1)Reduced alveolar-capillary gas exchange
2)Lower respiratory tract infections
3)Sleep apnea
4)Hypertension
5)Arthrosclerosis

Question 24

The student nurse observes the staff nurse providing care to a client with a chest tube. Which of the nurse's actions should the student recognize as incorrect and report to the nursing instructor?
1)Recording drainage from chest tube as output
2)Securing the chest tube to the chest tube dressing
3)Checking the water seal chamber for bubbling
4)Milking the chest tube to promote drainage

Question 25

When providing safety education to the mother of a toddler, the nurse would inform the mother that based on the child's developmental stage, he is at high risk for which of the following factors that influence oxygenation? Select all that apply.
1)Frequent, serious respiratory infections
2)Airway obstruction from aspiration of small objects
3)Drowning in small amounts of water
4)Development of asthma
5)Frequent bouts of tonsillitis

Question 26

The nurse admits a client to the surgical unit from the postanesthesia care unit. The client has an oral airway in place and awakens only to painful stimuli. What is the priority nursing action?
1)Remove the oral airway, and elevate the head of the bed.
2)Position the client with the head turned to the side.
3)Measure vital signs, and check surgical dressing.
4)Call the surgeon, and obtain postoperative prescriptions.

Question 27

The nurse is caring for a client who had experienced an acute asthma event. What classification of medications would the nurse anticipate administering to this client? Select all that apply.
1)Expectorant
2)Corticosteroid
3)Bronchodilator
4)Cough suppressant
5)Antibiotic

Question 28

The nurse is teaching a client about her chest drainage system. Which of the following should the nurse include in the teaching? Select all that apply.
1)Perform frequent coughing and deep-breathing exercises.
2)Sit up in a chair, but do not walk while the drainage system is in place.
3)Get out of bed independently as often as possible.
4)Immediately notify the nurse of any increased shortness of breath.
5)If the tube becomes disconnected, pinch it off, and use your call light to get help.

Question 29

The nurse, working in the postanesthesia care unit inserts an oral airway into the semiconscious client to prevent airway obstruction. When should the airway be removed?
1)When the client can be aroused
2)When the client is 24 hours postoperative
3)When the client removes it
4)When the provider prescribes that it be removed

Question 30

Which of the following factors influence normal lung volumes and capacities? Select all that apply.
1)Age
2)Race
3)Body size
4)Activity level
5)Environment

Question 31

The nurse is assessing the client has a history of chronic obstructive pulmonary disease (COPD). At this time, the client's pulse oximetry reading is 97%. What other findings would indicate adequate tissue and organ oxygenation? Select all that apply.
1)Normal urine output
2)Strong peripheral pulses
3)Clear breath sounds bilaterally
4)Normal muscle strength
5)Abnormal muscle twitching

Question 32

Which of the following is/are accurate about nasotracheal suctioning? Select all that apply.
1)Apply suction for no longer than 15 sec during a single pass.
2)Apply suction while inserting and removing the catheter.
3)Reapply oxygen between suctioning passes for clients on a ventilator.
4)Gently rotate the suction catheter as you remove it.
5)This may be delegated to an LPN on the unit.

Question 33

The nurse is caring for a client with a chest tube. What outcome would indicate the chest tube can be discontinued?
1)No further bubbling is seen in the water seal chamber.
2)No further drainage is measured from the chest tube.
3)Chest x-ray shows the lungs are fully inflated.
4)The client's respirations are regular and unlabored.

Question 34

The nurse is caring for a client requiring a mechanical ventilator. When checking the inline thermometer, the nurse finds what temperature acceptable?
1)78°F
2)84°F
3)96°F
4)105°F

Question 35

The nurse is counseling a 17-year-old girl on smoking cessation. The nurse should include which of the following helpful tips in her education? Select all that apply.
1)"Keep healthy snacks or gum available to chew instead of smoking a cigarette."
2)"Don't tell anyone that you are trying to quit until you are confident of your success."
3)"Plan a time to quit when you will not have many other demands or stressors in your life."
4)"Reward yourself with an activity you enjoy when you quit smoking."
5)"Ask your physician for a prescription for smoking cessation medications."

Question 36

The nurse assesses a client diagnosed with pneumonia. Which data findings indicate that the client is not oxygenating adequately? Select all that apply.
1)Oxygen saturation 87%
2)Arterial blood gas pH 7.33
3)Respiratory rate 52 breaths/min
4)Fine rales in the left lower lobe
5)Cyanosis of the nailbeds and lips