Question 1

The nurse is providing care to a client admitted to the emergency department with the diagnosis of acute respiratory distress syndrome (ARDS).When educating the client's family,what should the nurse say is the expected progression of the disease process?
A)Initiation of ARDS
B)Onset of pulmonary edema
C)End-stage ARDS
D)Alveolar collapse
E)None of above

Accepted Answer

A,B,D,C

Question 2

Which clinical manifestation does the nurse correctly attribute to hypoxia in a client with acute respiratory distress syndrome (ARDS)?
A)Fluid imbalance
B)Hypertension
C)Bradycardia
D)Dyspnea

Accepted Answer

Dyspnea (difficulty breathing) is a common manifestation of hypoxia in ARDS, as the respiratory system is unable to fully oxygenate the blood. Fluid imbalance, hypertension, and bradycardia are not typically associated with hypoxia in this condition.

Question 3

When auscultating the lungs of a client experiencing dyspnea,the nurse hears a low-pitched sound that is continuous throughout inspiration.What does this lung sound indicate to the nurse?
A)Narrow bronchi
B)Narrow trachea passages
C)Blocked large airway passages
D)Inflamed pleural surfaces

Accepted Answer

A low-pitched sound that is continuous throughout inspiration is typically indicative of a blocked large airway passage. This sound is often described as a wheeze and is commonly heard in clients with asthma or chronic obstructive pulmonary disease (COPD). Narrow bronchi or trachea passages would result in a high-pitched wheezing sound, while inflamed pleural surfaces would produce a rubbing or grating sound.

Question 4

Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation? Select all that apply.
A)Encouraging deep breathing exercises
B)Assisting with positioning
C)Providing suctioning
D)Prescribing bronchodilators
E)Monitoring activity intolerance

Accepted Answer

A)Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.
B)Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.
C)Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.
D)Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.
E)Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.

Question 5

A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%.Which nursing diagnosis is a priority for this client?
A)Risk for Infection
B)Impaired Spontaneous Ventilation
C)Risk for Acute Confusion
D)Decreased Cardiac Output

Accepted Answer

A respiratory rate of 8 breaths per minute is significantly below the normal range of 12-20 breaths per minute, indicating impaired spontaneous ventilation. Additionally, the low oxygen saturation level of 82% indicates hypoxemia, or low levels of oxygen in the blood. This can result in tissue damage and organ dysfunction, making impaired spontaneous ventilation a priority nursing diagnosis to address the client's respiratory status. The other options may also be relevant to the client's care but are not the priority at this time.

Question 6

The nurse is reviewing the results of laboratory tests conducted on a client admitted with an alteration in respiratory function.Which laboratory finding would be most significant for this client?
A)Hemoglobin level 14 g/dL
B)Oxygen saturation 96%
C)Serum sodium 140 mg/dL
D)Blood pH 7.32

Accepted Answer

The blood pH of 7.32 indicates that the client may be experiencing respiratory acidosis, which is consistent with an alteration in respiratory function. The other laboratory findings are within normal ranges and may not be directly related to the respiratory issue.

Question 7

While performing nasotracheal suctioning,the nurse notes the older adult client with an alteration in oxygenation is moving the head around and pulling at the nurse's hand to remove the suction catheter.Which actions by the nurse are appropriate? Select all that apply.
A)Remove the suction catheter
B)Lower the head of the bed
C)Decrease the suction pressure
D)Apply restraints to the client's arms and legs
E)Hyperoxygenate the client

Accepted Answer

A)The older adult client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, decrease the suction pressure, and hyperoxygenate the client. Restraining the patient does not address the hypoxemia. The client should be in the Fowler or high-Fowler position.
B)The older client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, decrease the suction pressure, and hyperoxygenate the client. Restraining the patient does not address the hypoxemia. The client should be in the Fowler or high-Fowler position.
C)The older client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, decrease the suction pressure, and hyperoxygenate the client. Restraining the patient does not address the hypoxemia. The client should be in the Fowler or high-Fowler position.
D)The older client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, decrease the suction pressure, and hyperoxygenate the client. Restraining the patient does not address the hypoxemia. The client should be in the Fowler or high-Fowler position.
E)The older client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, decrease the suction pressure, and hyperoxygenate the client. Restraining the patient does not address the hypoxemia. The client should be in the Fowler or high-Fowler position.

Question 8

The nurse is conducting an assessment for a client on a medical-surgical unit.Which findings are indicative of a client who is experiencing tachypnea? Select all that apply.
A)Excessive rapid breathing
B)Chest pain
C)Rapid breathing at rest
D)Shallow breathing
E)Cyanosis

Accepted Answer

Tachypnea is defined as excessive rapid breathing, which can be assessed by observing the client's respiratory rate and depth. Rapid breathing at rest and shallow breathing can both indicate tachypnea. Chest pain and cyanosis are not necessarily indicative of tachypnea specifically.

Question 9

The nurse is providing care to a client with arterial blood gas analysis as follows: PaO₂ of 82,PaCO₂ of 49,HCO₃ of 26,and pH of 7.31.Which assessment by the nurse is correct? A)Respiratory acidosis B)Respiratory alkalosis C)Metabolic alkalosis D)Metabolic acidosis

Accepted Answer

The PaCO2 value of 49 indicates respiratory acidosis. The pH value of 7.31 also supports this diagnosis as it is below the normal range (7.35-7.45) indicating acidosis. The HCO3- value of 26 is within the normal range (22-28) and does not indicate metabolic acidosis or alkalosis.

Question 10

The nurse is providing care for a client admitted during an acute exacerbation of asthma.Which medication does the nurse anticipate to relieve the acute symptoms exhibited by the client?
A)Inhaled short-acting beta-agonists
B)Oral corticosteroids
C)Inhaled long-acting beta-agonists
D)Oral anticholinergics

Accepted Answer

Inhaled short-acting beta-agonists are the first-line medication for relieving acute symptoms of asthma, such as wheezing and shortness of breath. They work quickly to relax the smooth muscles in the airways, allowing for easier breathing. Oral corticosteroids may be used in addition to inhaled beta-agonists in severe cases, but they are not the initial choice for acute symptom relief. Inhaled long-acting beta-agonists are used for long-term control of asthma symptoms, not for immediate relief of acute exacerbations. Oral anticholinergics may be used for chronic obstructive pulmonary disease (COPD) but are not usually used for asthma exacerbations.

Question 11

The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance.Which action by the nurse is the most appropriate?
A)Encourage strenuous activity.
B)Consult a dietitian for low-calorie meals.
C)Space periods of activity with periods of rest.
D)Encourage dependence with activities of daily living.

Accepted Answer

Dyspnea and subsequent activity intolerance indicate that the client may have difficulty with physical activity. It is essential to space periods of activity with periods of rest to prevent exhaustion and promote adequate oxygenation. Encouraging strenuous activity would be inappropriate, as it could exacerbate dyspnea. Consulting a dietitian for low-calorie meals may be appropriate for clients with obesity, but it is not indicated in this case. Encouraging dependence with activities of daily living would undermine the clients' sense of autonomy and could lead to further deconditioning.

Question 12

The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client with asthma.Which action by the newly licensed nurse requires immediate intervention?
A)The newly licensed nurse is observed obtaining the pulse oximetry reading 10 minutes after the client used an albuterol inhaler.
B)The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment.
C)The newly licensed nurse is observed assessing the client's thoracic wall,skin,and nail beds.
D)The newly licensed nurse is observed auscultating breath sounds with a stethoscope.

Accepted Answer

The newly licensed nurse should intervene immediately if they observe the nurse continuing to ask the client questions while the client exhibits difficulty breathing and signs of respiratory impairment. This indicates a lack of understanding of the urgency of addressing the client's breathing distress, and could lead to delayed interventions that could worsen the client's condition. The other actions, such as obtaining pulse oximetry readings, assessing the client's thoracic wall and breath sounds, are appropriate and necessary components of a respiratory assessment.

Question 13

The nurse recognizes that which pathophysiologic changes are occurring when caring for the client with respiratory acidosis? Select all that apply. A)Increased CO₂ B)Vasoconstriction C)Decreased O₂ D)Decreased intracranial pressure (ICP) E)Increased pulse rate

Accepted Answer

A)Respiratory acidosis is an alteration of acid-base imbalance that is caused by decreased oxygen intake, resulting in an excess of dissolved carbon dioxide (increased CO₂). Vasodilatation, not vasoconstriction, occurs as a low pH results in relaxation of vascular smooth muscle by interrupting the normal function of calcium channels. Cerebral vasodilation results in increased intracranial pressure. The pulse rate increases in an attempt to compensate for oxygen deprivation. B)Respiratory acidosis is an alteration of acid-base imbalance that is caused by decreased oxygen intake, resulting in an excess of dissolved carbon dioxide (increased CO₂). Vasodilatation, not vasoconstriction, occurs as a low pH results in relaxation of vascular smooth muscle by interrupting the normal function of calcium channels. Cerebral vasodilation results in increased intracranial pressure. The pulse rate increases in an attempt to compensate for oxygen deprivation. C)Respiratory acidosis is an alteration of acid-base imbalance that is caused by decreased oxygen intake, resulting in an excess of dissolved carbon dioxide (increased CO₂). Vasodilatation, not vasoconstriction, occurs as a low pH results in relaxation of vascular smooth muscle by interrupting the normal function of calcium channels. Cerebral vasodilation results in increased intracranial pressure. The pulse rate increases in an attempt to compensate for oxygen deprivation. D)Respiratory acidosis is an alteration of acid-base imbalance that is caused by decreased oxygen intake, resulting in an excess of dissolved carbon dioxide (increased CO₂). Vasodilatation, not vasoconstriction, occurs as a low pH results in relaxation of vascular smooth muscle by interrupting the normal function of calcium channels. Cerebral vasodilation results in increased intracranial pressure. The pulse rate increases in an attempt to compensate for oxygen deprivation. E)Respiratory acidosis is an alteration of acid-base imbalance that is caused by decreased oxygen intake, resulting in an excess of dissolved carbon dioxide (increased CO₂). Vasodilatation, not vasoconstriction, occurs as a low pH results in relaxation of vascular smooth muscle by interrupting the normal function of calcium channels. Cerebral vasodilation results in increased intracranial pressure. The pulse rate increases in an attempt to compensate for oxygen deprivation.

Question 14

A client with chronic obstructive pulmonary disease (COPD)is prescribed oxygen 24% 2 L/min.Which is the best method to administer oxygen to this client?
A)Face mask
B)Nasal cannula
C)Nonrebreather mask
D)Venturi mask

Accepted Answer

Nasal cannula is the best method to administer oxygen to a client with COPD because it delivers a low flow of oxygen (2 L/min) and still allows the client to exhale some carbon dioxide, which is important for clients with COPD who have retained CO2 levels. A face mask or nonrebreather mask can cause the client to rebreathe CO2, worsening their condition. A Venturi mask may provide too much oxygen and decrease their respiratory drive.

Question 15

Vaccinations can help promote healthy oxygenation by
A)reducing the transmission of preventable diseases.
B)increasing the exchange of oxygen for carbon dioxide in the lungs.
C)promoting adequate blood circulation to organs and tissues.
D)preventing all respiratory infections.

Accepted Answer

Vaccinations can reduce the transmission of preventable diseases, such as influenza or pneumonia, which can cause respiratory infections and compromise oxygenation. By preventing these diseases, vaccinations can help ensure healthy oxygenation. However, vaccinations do not directly increase oxygen exchange in the lungs or blood circulation to organs and tissues.

Question 16

The nurse assigned to the newborn nursery is conducting shift assessments.While assessing one newborn,the nurse notes the respiratory rate is 52 breaths per minute.Which action by the nurse is appropriate?
A)Notify the healthcare provider of this assessment finding.
B)Obtain an arterial blood gas for further respiratory assessment.
C)Begin monitoring the respiratory rate every 5 minutes.
D)Continue to monitor the newborn per facility policy.

Accepted Answer

A) A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate or newborn is 30-60 breaths per minute.
B) A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate or newborn is 30-60 breaths per minute.
C) A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate or newborn is 30-60 breaths per minute.
D) A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate or newborn is 30-60 breaths per minute.

Question 17

The nurse is providing care to a client with sepsis due to a severely infected leg wound.The client states that he is having trouble breathing.Upon assessment,the nurse notes dyspnea,a respiratory rate of 32,the use of accessory muscles to breathe,and rales and rhonchi upon auscultation of the lungs.The nurse recognizes these findings as characteristic of what condition?
A)Allergic response from antibiotic therapy
B)Deep vein thrombosis
C)Acute respiratory distress syndrome
D)Anemia

Accepted Answer

The client's symptoms suggest acute respiratory distress syndrome (ARDS), a severe lung condition that can occur as a complication of sepsis. Dyspnea, tachypnea (rapid breathing), use of accessory muscles, and abnormal lung sounds like rales and rhonchi are all indicative of ARDS. Allergic responses to antibiotics may cause respiratory symptoms, but they typically include coughing or wheezing, rather than rales and rhonchi. Deep vein thrombosis and anemia are not typically associated with these respiratory symptoms.

Question 18

The nurse is providing care to an adult client with a long history of chronic obstructive pulmonary disease (COPD).The client is admitted to the intensive care unit with a pneumothorax.Which interventions are appropriate for this client? Select all that apply.
A)Elevate head of the bed
B)Administer a high rate of oxygen by nasal cannula
C)Prepare for a chest tube insertion
D)Administer prescribed antihypertensive medications
E)Administer intravenous caffeine per order

Accepted Answer

A)The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed because of the client's dyspnea and orthopnea and prepare for a chest tube insertion. Because clients with COPD have a decreased response to hypercarbia, which stimulates breathing, a high rate of oxygen by nasal cannula is inappropriate. There is no indication that the client is experiencing hypertension. IV caffeine is administered to premature infants as a respiratory stimulant. This intervention is not appropriate for an adult client diagnosed with COPD and a pneumothorax.
B)The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed due to the client's dyspnea and orthopnea and prepare for a chest tube insertion. Because clients with COPD have a decreased response to hypercarbia, which stimulates breathing, a high rate of oxygen by nasal cannula is inappropriate. There is no indication that the client is experiencing hypertension. IV caffeine is administered to premature infants as a respiratory stimulant. This intervention is not appropriate for an adult client diagnosed with COPD and a pneumothorax.
C)The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed due to the client's dyspnea and orthopnea and prepare for a chest tube insertion. Because clients with COPD have a decreased response to hypercarbia, which stimulates breathing, a high rate of oxygen by nasal cannula is inappropriate. There is no indication that the client is experiencing hypertension. IV caffeine is administered to premature infants as a respiratory stimulant. This intervention is not appropriate for an adult client diagnosed with COPD and a pneumothorax.
D)The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed due to the client's dyspnea and orthopnea and prepare for a chest tube insertion. Because clients with COPD have a decreased response to hypercarbia, which stimulates breathing, a high rate of oxygen by nasal cannula is inappropriate. There is no indication that the client is experiencing hypertension. IV caffeine is administered to premature infants as a respiratory stimulant. This intervention is not appropriate for an adult client diagnosed with COPD and a pneumothorax.
E)The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed due to the client's dyspnea and orthopnea and prepare for a chest tube insertion. Because clients with COPD have a decreased response to hypercarbia, which stimulates breathing, a high rate of oxygen by nasal cannula is inappropriate. There is no indication that the client is experiencing hypertension. IV caffeine is administered to premature infants as a respiratory stimulant. This intervention is not appropriate for an adult client diagnosed with COPD and a pneumothorax.

Question 19

The structure of the respiratory system that serves as the site of gas exchange is the
A)macrophage.
B)bronchi.
C)alveoli.
D)bronchiole.

Accepted Answer

The alveoli are the tiny air sacs in the lungs where gas exchange occurs. Oxygen from inhaled air diffuses into the bloodstream and carbon dioxide from the bloodstream diffuses into the alveoli to be exhaled. The other choices (macrophage, bronchi, bronchioles) are structures within the respiratory system but do not directly participate in gas exchange.

Question 20

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD).Which clinical manifestations are the direct result of altered perfusion? Select all that apply.
A)Bounding pulse
B)Pink nail beds
C)Cyanosis
D)Confusion
E)Wheezing

Accepted Answer

A)A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include cyanosis and confusion. A weak pulse and blue nail beds would also indicate poor perfusion. Wheezing is an abnormal breath sound that is the result of excess mucus in the airways.
B)A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include cyanosis and confusion. A weak pulse and blue nail beds would also indicate poor perfusion. Wheezing is an abnormal breath sound that is the result of excess mucus in the airways.
C)A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include cyanosis and confusion. A weak pulse and blue nail beds would also indicate poor perfusion. Wheezing is an abnormal breath sound that is the result of excess mucus in the airways.
D)A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include cyanosis and confusion. A weak pulse and blue nail beds would also indicate poor perfusion. Wheezing is an abnormal breath sound that is the result of excess mucus in the airways.
E)A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include cyanosis and confusion. A weak pulse and blue nail beds would also indicate poor perfusion. Wheezing is an abnormal breath sound that is the result of excess mucus in the airways.

Quiz 15: Oxygenation

The nurse is providing care to a client admitted to the emergency department with the diagnosis of acute respiratory distress syndrome (ARDS) .When educating the client's family,what should the nurse say is the expected progression of the disease process?

Which clinical manifestation does the nurse correctly attribute to hypoxia in a client with acute respiratory distress syndrome (ARDS) ?

When auscultating the lungs of a client experiencing dyspnea,the nurse hears a low-pitched sound that is continuous throughout inspiration.What does this lung sound indicate to the nurse?

Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation? Select all that apply.

A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%.Which nursing diagnosis is a priority for this client?

The nurse is reviewing the results of laboratory tests conducted on a client admitted with an alteration in respiratory function.Which laboratory finding would be most significant for this client?

While performing nasotracheal suctioning,the nurse notes the older adult client with an alteration in oxygenation is moving the head around and pulling at the nurse's hand to remove the suction catheter.Which actions by the nurse are appropriate? Select all that apply.

The nurse is conducting an assessment for a client on a medical-surgical unit.Which findings are indicative of a client who is experiencing tachypnea? Select all that apply.

The nurse is providing care to a client with arterial blood gas analysis as follows: PaO₂ of 82,PaCO₂ of 49,HCO₃ of 26,and pH of 7.31.Which assessment by the nurse is correct?

The nurse is providing care for a client admitted during an acute exacerbation of asthma.Which medication does the nurse anticipate to relieve the acute symptoms exhibited by the client?

The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance.Which action by the nurse is the most appropriate?

The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client with asthma.Which action by the newly licensed nurse requires immediate intervention?

The nurse recognizes that which pathophysiologic changes are occurring when caring for the client with respiratory acidosis? Select all that apply.

A client with chronic obstructive pulmonary disease (COPD) is prescribed oxygen 24% 2 L/min.Which is the best method to administer oxygen to this client?

Vaccinations can help promote healthy oxygenation by

The nurse assigned to the newborn nursery is conducting shift assessments.While assessing one newborn,the nurse notes the respiratory rate is 52 breaths per minute.Which action by the nurse is appropriate?

The nurse is providing care to an adult client with a long history of chronic obstructive pulmonary disease (COPD) .The client is admitted to the intensive care unit with a pneumothorax.Which interventions are appropriate for this client? Select all that apply.

The structure of the respiratory system that serves as the site of gas exchange is the

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD) .Which clinical manifestations are the direct result of altered perfusion? Select all that apply.