Deck 40: Oxygenation

Question 1

The client is admitted to the emergency department with a pneumothorax.The nurse anticipates that the client will be experiencing:
1) Dyspnea
2) Eupnea
3) Fremitus
4) Orthopnea

Answer 1

1
The client with a pneumothorax (collapsed lung)will exhibit dyspnea and pain.Eupnea is normal,easy breathing.It would not be expected in the case of a pneumothorax.Fremitus is the vibration felt when the hand is placed on the client's chest and the client speaks (vocal fremitus).Fremitus would be decreased with a pneumothorax.Orthopnea is a condition in which the person must use multiple pillows when lying down or must sit with the arms elevated and leaning forward to breathe.The client with a pneumothorax would be exhibiting dyspnea.

Question 2

The nurse is working on a pulmonary unit at the local hospital.The nurse is alert to one of the early signs of hypoxia in the clients,which is:
1) Cyanosis
2) Restlessness
3) A decreased respiratory rate
4) A decreased blood pressure

Answer 2

2
Mental status changes are often the first signs of respiratory problems and may include restlessness and irritability.Cyanosis is a late sign of hypoxia.A decreased respiratory rate is not an early sign of hypoxia.The respiratory rate will increase as the body attempts to compensate for the decreased level of oxygen.As the hypoxia worsens,the respiratory rate may decline.During early stages of hypoxia the blood pressure is elevated unless the condition is caused by shock.

Question 3

The nurse identifies that the client is unable to cough to produce a sputum specimen,and the client's secretions must be suctioned.Which suctioning route is preferred for obtaining this specimen?
1) Nasopharyngeal
2) Nasotracheal
3) Oropharyngeal
4) Orotracheal

Answer 3

2
Nasotracheal suctioning is the preferred route for obtaining a sputum specimen when the client is unable to cough to produce a sputum specimen on his or her own.The nasopharyngeal route for suctioning is used when the client is able to cough but is unable to clear secretions by expectorating or swallowing.It is not the preferred route for obtaining a sputum specimen.The oropharyngeal route is used when the client is able to cough but is unable to clear secretions by expectorating or swallowing.It is not the preferred route for obtaining a sputum specimen.The orotracheal route is used when the client is unable to manage secretions by coughing.The nasotracheal route is preferred over the orotracheal route because stimulation of the gag reflex is minimal.

Question 4

The nurse is checking the client's overall oxygenation.In assessment of the presence of central cyanosis,the nurse will inspect the client's:
1) Palms and soles of the feet
2) Nail beds
3) Earlobes
4) Tongue

Question 5

The client has experienced a myocardial infarction resulting in damage to the left ventricle.A possible complication the client may experience that the nurse is alert to is:
1) Jugular neck vein distention
2) Pulmonary congestion
3) Peripheral edema
4) Liver enlargement

Question 6

A client with a suspected narcotic (heroin)overdose is brought to the emergency department by the police.The nurse anticipates that assessment findings will reveal:
1) Agitation
2) Hyperpnea
3) Restlessness
4) Decreased level of consciousness

Question 7

A 64-year-old client is seen in the emergency department for palpitations and mild shortness of breath.The electrocardiogram (ECG)reveals a normal P wave,P-R interval,and QRS complex with a regular rhythm and rate of 108 beats per minute.The nurse should recognize this cardiac dysrhythmia as:
1) Sinus dysrhythmia
2) Sinus tachycardia
3) Supraventricular tachycardia
4) Ventricular tachycardia

Question 8

The unit manager is orienting a new staff nurse and evaluates which of the following as an appropriate technique for nasotracheal suctioning?
1) Placing the client in a supine position
2) Preparing for a clean or nonsterile technique
3) Suctioning the oropharyngeal area first,then the nasotracheal area
4) Applying intermittent suction for 10 seconds during catheter removal

Question 9

A client has recently had mitral valve replacement surgery.To prevent excess serosanguineous fluid buildup,the nurse anticipates that care will include:
1) Increased oxygen therapy
2) Frequent chest physiotherapy
3) Incentive spirometry on a regularly scheduled basis
4) Chest tube placement in the thoracic cavity

Question 10

All of the following clients are experiencing increased respiratory secretions and require intervention to assist in their removal.Chest percussion is indicated and appropriate for the client experiencing:
1) Thrombocytopenia
2) Cystic fibrosis
3) Osteoporosis
4) Spinal fracture

Question 11

The client has chest tubes in place following thoracic surgery.In working with a client who has a chest tube,the nurse should:
1) Clamp the tubes except during client assessments
2) Remove the tubing from the connection to check for adequate suction power
3) Milk or strip the tubes every 15 to 30 minutes to maintain drainage
4) Coil and secure excess tubing next to the client

Question 12

A client develops acute renal failure and a resulting metabolic acidosis.The nurse recognizes that the respiratory system compensates through:
1) Hypoventilation and increase of bicarbonate levels in the bloodstream
2) Alternating periods of deep versus shallow breaths to maintain homeostasis of the serum pH
3) Hyperventilation to decrease the serum CO₂ level and thereby raise the pH
4) Expansion of the lung tissues to their fullest,which increases the inspiratory reserve volumes to provide more oxygen to the tissues

Question 13

On admitting a client,the nurse finds that there is a history of myocardial ischemia.The most disconcerting dysrhythmia for electrocardiography to reveal is:
1) Sinus bradycardia
2) Sinus dysrhythmia
3) Ventricular tachycardia
4) Atrial fibrillation

Question 14

At a community health fair the nurse informs the residents that the influenza vaccine is recommended for clients:
1) Only older than age 65
2) 40 to 60 years of age
3) In any age-group who have a chronic disease
4) Who have an acute febrile illness

Question 15

A client recently fractured his spinal cord at the C3 level and is at great risk for developing pneumonia primarily because the:
1) Resulting paralysis immobilizes him,and secretions will increase in his lungs
2) Innervation to the phrenic nerve is absent,preventing chest expansion
3) Resulting abnormal chest shape disallows efficient ventilatory movement
4) Trauma decreases the ability of his red blood cells to carry oxygen

Question 16

The client with a chronic obstructive respiratory disease is receiving oxygen via a nasal cannula.Which of the following interventions does the nurse plan to include in the client's care?
1) Assess nares for skin breakdown every 6 hours.
2) Check patency of the cannula every 2 hours.
3) Inspect the mouth every 6 hours.
4) Check oxygen flow every 24 hours.

Question 17

The nurse is working on a respiratory care unit in the hospital.Upon entering the room of a client with emphysema,it is noted that the client is experiencing respiratory distress.The nurse should:
1) Instruct the client to breathe rapidly
2) Provide 20% oxygen at 2 L/min via nasal cannula
3) Place the client in the supine position
4) Go to contact the health care provider

Question 18

The nurse has reviewed information about the cardiovascular system before caring for a client with heart disease.The nurse knows that which of the following statements is true concerning the physiology of the cardiovascular system?
1) Stimulating the parasympathetic system would cause the heart rate to go up.
2) When a person has heart muscle disease,the heart muscles stretches as far as is necessary to maintain function.
3) The QRS interval on the electrocardiogram represents the electrical impulses passing through the ventricles.
4) When stroke volume decreases,there is a resultant decrease in heart rate.

Question 19

It is suspected that the client's oxygenation status is deteriorating.The nurse is aware that the abnormal assessment finding that represents the most serious indication of the client's decreased oxygenation is:
1) Poor skin turgor
2) Clubbing of the nails
3) Central cyanosis
4) Pursed-lip breathing

Question 20

In teaching a client about an upcoming diagnostic test,the nurse identifies that which one of the following uses an injection of contrast material?
1) Holter monitor
2) Echocardiography
3) Cardiac catheterization
4) Exercise stress test

Question 21

The primary reason a client with chronic obstructive pulmonary disease (COPD)often experiences fatigue and activity intolerance is related to:
1) The increased presence of surfactant that results in "sticky" alveoli
2) The presence of chronic infections in the lungs and bronchial tree
3) The extra energy that is needed to exhale the air from the damaged lungs
4) The client's elevated anxiety level related to the air hunger being experienced

Question 22

The client is admitted to the medical center with a diagnosis of right-sided heart failure.In assessment of this client,the nurse expects to find:
1) Dyspnea
2) Confusion
3) Dizziness
4) Peripheral edema

Question 23

A client with a chest tube in place is being transported via stretcher to another room closer to the nurses' station.During the transport the collection unit bangs against the wall and breaks open.The nurse immediately:
1) Clamps the tube
2) Tells the client to hyperventilate
3) Raises the tubing above the client's chest level
4) Places the end of the tube in a container of sterile water

Question 24

The nurse is preparing to teach a group of adult women about the signs and symptoms of a myocardial infarction (heart attack).The nurse will include in the teaching plan the results of research that demonstrate women may experience specific symptoms,such as:
1) Visual difficulties
2) Epigastric pain
3) Loss of motor function unilaterally
4) Right scapular discomfort and stiffness

Question 25

The electrical activity of the client's heart is being continuously monitored while the client is on the coronary care unit.Suddenly the nurse finds that the client is experiencing ventricular fibrillation.The nurse will prepare to:
1) Administer atropine
2) Prepare for cardiopulmonary resuscitation (CPR)
3) Prepare the client for surgical placement of a pacemaker
4) Instruct the client to perform the Valsalva maneuver

Question 26

The nurse observes that a client's pulse rate is 58 beats per minute and regular in rhythm.Which of the following statements made by the nurse shows the appropriate understanding of the client's further need for assessment?
1) "I'll wait 15 minutes and reevaluate the client's pulse rate."
2) "Her pulse rate is usually in the mid 60s,so there isn't a problem."
3) "I'll need to assess her for the presence of chest pain and/or dizziness."
4) "You run an electrocardiogram,and I'll notify her health care provider."

Question 27

The nurse is preparing to discuss myocardial infarctions (MIs)with a women's group.Which of the following assessment findings should be included when discussing the typically observed signs and symptoms in females experiencing an MI?
1) Originates both at rest and upon exertion
2) Pain lasting longer than 30 minutes
3) Pain radiating up into left jaw
4) Significant gastric indigestion

Question 28

The nurse is assessing a client with a history of chronic obstructive pulmonary disease.When assessing for the presence of air hunger,the nurse should:
1) Monitor the client's pulse oximetry reading
2) Measure the movement of air by counting respirations
3) Auscultate breath sounds both anteriorly and posteriorly
4) Observe for the elevation of the client's clavicles during inspiration

Question 29

A client asks the nurse,"I was told that my heart is beating in normal sinus rhythm (NSR).What does that mean?" The nurse replies most therapeutically when responding with which of the following?
1) "Are you worried about how your heart is working?"
2) "It means your heart is working just the way it is supposed to work."
3) "A damaged heart doesn't beat in normal sinus rhythm like yours does."
4) "Each beat starts in the SA node and then causes the chambers to contract."

Question 30

The client is experiencing a sinus dysrhythmia with a pulse rate of 82 beats per minute.Upon entering the room,the nurse expects to find the client:
1) Extremely fatigued
2) Complaining of chest pain
3) Experiencing a "fluttering" sensation in the chest
4) Having no clinical signs based on the assessment

Question 31

The nurse is caring for a client who experienced a flailed chest injury (multiple rib fractures)as a result of a motorcycle accident.The nurse realizes that pain management for this client will directly impact the effectiveness of his respiratory functioning primarily because:
1) Pain increases metabolic needs,thus increasing oxygen consumption
2) Pain increases emotional distress,which can lead to hyperventilation
3) Pain will decrease the client's motivation to deep breathe,contributing to shallow,diminished inspirations
4) Pain will decrease the client's ability to both relax and recuperate,thus extending the period of recovery

Question 32

Several nursing students are discussing cardiac conduction with their clinical instructor.When asked where a heart rate of 56 beats per minute most likely originates,the most informed student replies:
1) The atrioventricular (AV)node
2) The sinoatrial (SA)node
3) The Purkinje network
4) The bundle of His

Question 33

The nurse is completing a physical examination for a client who is anemic.In assessing the client's eyes,a sign assessed by the nurse that is consistent with the diagnosis is:
1) Xanthelasma
2) Petechiae
3) Corneal arcus
4) Pale conjunctiva

Question 34

The primary effect of chronic fevers on the body's respiratory functioning is seen in:
1) Increased oxygen requirements that exceed the body's ability to satisfy its needs
2) Increased respiratory rates that tax the body's reserves of stored energy
3) Breakdown of muscle mass,causing ineffective intercostal muscle function
4) The presence of a sense of general malaise that stresses the immune system

Question 35

The nurse is reviewing the results of the client's diagnostic testing.Of the following results,the finding that falls within expected or normal limits is:
1) Palpable,elevated hardened area around a tuberculosis skin testing site.
2) Sputum for culture and sensitivity identifies Mycobacterium tuberculosis
3) Presence of acid fast bacilli in sputum
4) Arterial oxygen tension (PaO₂)of 95 mm Hg

Question 36

When assisting with PM care for an 82-year-old client recuperating from pneumonia,the nurse observes that the client appears to be uncharacteristically confused,asking "Where am I?" Which of the following interventions is the most therapeutic for this particular client?
1) Listen for lung sounds.
2) Reorient the client to place.
3) Ask some simple questions to confirm the confusion.
4) Assess the client's pulse oximetry reading on room air.

Question 37

Pregnancy affects a woman's oxygenation needs primarily because of:
1) The increased metabolic demands required to support the fetus
2) The increased tendency to develop anemia as a result of low iron reserves
3) The decreased ability to engage in the physical exercise required to promote circulation
4) The decreased lung capacity resulting from the pressure of the uterus on the diaphragm

Question 38

The client has supplemental oxygen in place and requires suctioning to remove excess secretions from the airway.To promote maximum oxygenation,an appropriate action by the nurse is to:
1) Suction continuously for 30-second intervals
2) Replace the oxygen and allow rest in between suctioning passes
3) Increase the amount of suction pressure to 200 mm Hg
4) Complete a number of suctioning passes until the catheter comes back clear

Question 39

The nurse suspects that a 59-year-old client has experienced angina pectoris.Which of the following assessment questions will most likely produce information that will assist in the diagnosis?
1) "How long did the pain last?"
2) "Can you describe the pain for me?"
3) "Did the pain radiate into your left arm?"
4) "What were you doing when the pain started?"

Question 40

When the nurse is reviewing a client's laboratory results,a low calcium level is noted.When the nurse then reviews the client's electrocardiogram,the most likely change noted will be a(n):
1) Increased Q-T interval
2) Increased P-R interval
3) Q-T interval less than 0.12 seconds
4) QRS interval greater than 0.12 seconds

Question 41

A client diagnosed with chronic bronchitis is awakened from sleep experiencing shortness of breath.The nurse suspects that he is experiencing orthopnea and suggests positioning him to minimize the dyspnea so he can sleep more peacefully.The nurse best describes this position to the client as:
1) "I'll use pillows to take the pressure off your lungs so that they can expand more effectively."
2) "By leaning forward and resting on these pillows,you will be least likely to be short of breath."
3) "This is an upright position that you will be comfortable in and able to breathe more effectively."
4) "We'll place two pillows behind your back so you are sitting more upright;that will let you rest better."

Question 42

When obtaining vital signs,a nursing assistive personnel is concerned that the heart rate of 56 is too low for a 23-year-old client who has been training for a marathon.The nurse explains that:
1) A low heart rate is normal in well-conditioned athletes
2) The health care provider needs to be notified immediately
3) The heart rate needs to be rechecked before taking any action
4) The heart rate could be caused by hyperthyroidism

Question 43

A client with coronary artery disease is being prepared for a coronary arterial bypass graft surgery.The nurse knows that the coronary artery that carries the most blood and can cause the most harm when blocked is the:
1) Left coronary artery
2) Posterior interventricular artery
3) Circumflex artery
4) Anterior interventricular artery

Question 44

A client has been admitted to the emergency department with an aspirin overdose.The nurse anticipates that the client will be experiencing respiratory complications because the nurse knows that aspirin (salicylate)poisoning causes excessive stimulation of the respiratory system as the body attempts to compensate for:
1) Decreased hemoglobin
2) Excess carbon monoxide
3) Decreased oxygen
4) Excess carbon dioxide

Question 45

A 45-year-old male client shares with the nurse that he has noticed that when he is anxious he feels short of breath.The nurse shares with the client that dyspnea can be caused by many conditions and that the client can make an objective assessment of the severity of the dyspnea by using which of the following?
1) Peak expiratory flow rate meter (PEFR)
2) Chest x-ray examination
3) Pulmonary function test
4) Visual analog scale from 1 to 10

Question 46

A client who has a history of a major myocardial infarction is taking digoxin.The nurse explains this medication helps increase cardiac output by:
1) Increasing the heart rate
2) Reducing the resistance of pulmonary circulation
3) Increasing the force of the myocardial contraction
4) Increasing cardiac conduction

Question 47

A humidity tent is frequently used for infants and young children to liquefy secretions and help reduce a fever.The nurse knows that humidified air puts the client at risk for:
1) Respiratory distress
2) Infection
3) Skin breakdown
4) Hypothermia

Question 48

A 47-year-old female client tells the nurse that her heart feels as though it is racing.The client's pulse is 160 beats per minute.The nurse knows that a vagal response will stimulate the parasympathetic nervous system to slow the heart rate and instructs the client to:
1) Bear down as though she is having a bowel movement
2) Take a hot shower
3) Take a cold bath
4) Hold her breath

Question 49

The nurse is preparing an educational handout for older adults with chronic respiratory diseases.To best minimize the risk for infection,the nurse should include which of the following guidelines in the material?
1) Remember to take your respiratory medication on schedule.
2) If you are prescribed breathing treatments,take them as ordered.
3) Avoid large,crowded places,especially during the winter months.
4) Remember to talk with your health care provider about a flu vaccination.

Question 50

The nurse working on the cardiac unit notes that the client has an S₂ murmur,which the nurse understands is caused by:
1) Pulmonic or aortic valve backflow or regurgitation
2) Mitral valve backflow or regurgitation
3) Tricuspid valve backflow or regurgitation
4) Poor coronary arterial circulation

Question 51

When interviewing a newly admitted client,the nurse learns that the client is a cigarette smoker.It is determined that the client has a 50 pack-year history.This means that the client has smoked:
1) 2 packs of cigarettes a day for 25 years
2) 50 cigarettes a week for the last year
3) 1 pack a week for the last year
4) 50 packs within the last year

Question 52

The nurse knows that the client who smokes is how much more likely to develop lung cancer than a nonsmoker?
1) Twice
2) Three times
3) Five times
4) Ten times

Question 53

The nurse working on the pulmonary unit is asked to obtain an acid-fast bacillus (AFB)sputum specimen from a client.The nurse knows that this test is used to screen for:
1) Cancer
2) Tuberculosis (TB)
3) Cystic fibrosis
4) Histoplasmosis

Question 54

During pretesting for an elective surgery,it is discovered that the older adult client has atrial fibrillation.The nurse knows that this is a common dysrhythmia in older people and can cause:
1) Fatigue,a fluttering in the chest,or shortness of breath if the ventricular response is rapid
2) Acute loss of pulse and respiration
3) Severe hypotension and loss of pulse and consciousness
4) Dizziness,syncope,or chest pain