Gas Exchange & Oxygenation

A client is diagnosed with pulmonary embolism. Which symptom would most likely be present? Chest pain and dyspnea Shallow respirations and wheezing Left arm pain and diaphoresis Cough and crackles

Correct response: Chest pain and dyspnea Explanation: The manifestations of pulmonary embolism depend on the size and location of the obstruction. Chest pain, dyspnea, and increased respiratory rate are the most frequent signs and symptoms of pulmonary embolism.

Dyspnea can best be described by which of the following? A subjective sensation felt when experiencing difficulty breathing Breathing that is rhythmic waxing and waning of the depth of respiration Very rapid respirations Abnormally fast and deep breathing that results in retaining carbon dioxide

Correct response: A subjective sensation felt when experiencing difficulty breathing Explanation: Dyspnea is described as a subjective sensation where a person feels that it is difficult to breathe. Cheyne-Stoke breathing involves waxing and waning of respiratory depth. Very rapid breathing explains tachypnea, while breathing that retains carbon dioxide describes hyperventilation.

The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication? Atelectasis Acute respiratory distress syndrome Metabolic alkalosis Respiratory acidosis

Correct response: Acute respiratory distress syndrome Explanation: Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Options A, C, and D are incorrect.

Which is the strongest predisposing factor for asthma? Congenital malformations Allergy Male gender Air pollution

Correct response: Allergy Explanation: Allergy is the strongest predisposing factor for asthma.

Which nursing intervention is the priority for a client in myasthenic crisis? Assessing respiratory effort Administering intravenous immunoglobin (IVIG) per orders Preparing for plasmapheresis Ensuring adequate nutritional support

Correct response: Assessing respiratory effort Explanation: A client in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early. Administering IVIG, preparing for plasmaphersis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium? Difficulty in breathing Hematoma Absent distal pulses Urge to cough

Correct response: Difficulty in breathing Explanation: Nurses must determine if the client has any allergies, particularly to iodine, shellfish, or contrast dye. During the procedure, the nurse should check for signs and symptoms of allergic reactions to the contrast medium, such as itching, hives, or difficulty in breathing. The nurses inspects for hematoma, absent distal pulses, after the procedure. When the contrast medium is infused, an urge to cough is often a sensation experienced by the client.

The nurse practitioner is working in an overnight sleep lab assessing and diagnosing clients with sleep apnea. During this diagnostic procedure, the nurse notes that a client's blood pressure is 162/97 mm Hg. The nurse explains this connection to the client based on which pathophysiologic principle? During apneic periods the client experiences hypoxemia, which stimulates chemoreceptors to induce vasoconstriction. When the client starts to snore, the epiglottis is closed over the trachea. Specialized cells are located in the back of the throat that signal when the airway is obstructed; this sends signals to the kidney to increase the pulse rate. When airways are obstructed, the body will retain extracellular fluid so that this fluid can be shifted to intravascular space to increase volume.

Correct response: During apneic periods the client experiences hypoxemia, which stimulates chemoreceptors to induce vasoconstriction. Explanation: People with sleep apnea also may experience an increase in BP because of the hypoxemia that occurs during the apneic periods. The specialized chemoreceptors are located in carotid bodies and aortic bodies of the aorta. Retention of fluid is not the cause of increased BP during sleep apnea episodes.

The nurse is caring for a client undergoing conscious sedation. The nurse knows the client is at risk for ineffective breathing patterns. What nursing intervention will help the client demonstrate a normal breathing pattern? Reinforce use of incentive spirometer. Encourage progressive activity. Encourage the client to drink plenty of fluids. Encourage the client to take deep breaths and cough at least every hour.

Correct response: Encourage the client to take deep breaths and cough at least every hour. Explanation: The nurse should encourage the client to take deep breaths and cough at least every hour. Deep breathing and coughing improve oxygenation and assist in clearing the effects of anesthesia. Drinking plenty of fluids and progressive activity will not help the client to demonstrate a normal breathing pattern. Use of incentive spirometer is not required until indicated.

Which of the following is true regarding pulmonary circulation? The system functions with an increased arterial pressure to circulate through the distal parts of the body. It is a low-pressure system that allows for improved gas exchange. It is the larger of the two circulatory systems. It consists of the left side of the heart, the aorta, and its branches.

Correct response: It is a low-pressure system that allows for improved gas exchange. Explanation: The pulmonary circulation consists of the right heart and the pulmonary artery, capillaries, and veins. It is the smaller of the systems and functions at a lower pressure to assist with gas exchange.

After a client receives morphine sulfate for pain in the postanesthesia care unit (PACU), which assessment finding would the nurse obtain as a priority? Auscultate bowel sounds. Obtain temperature. Measure respiratory rate. Check the neurologic status.

Correct response: Measure respiratory rate. Explanation: The client who is receiving morphine sulfate for pain has a potential for decreased respiratory effort because of the side effect of respiratory depression; the client may also have constipation as a side effect, but this would not be a priority over respiratory depression. The postoperative client needs to be monitored for changes in their neurologic status and temperature, but this would not be a priority over the respiratory status.

Which structure in the brain controls respiration? Medulla Pons Thalamus Hypothalamus

Correct response: Medulla Explanation: The central nervous system controls respiration, or the act of breathing to allow gas exchange. The respiratory center in the medulla stimulates the inspiratory muscles, diaphragm, external intercostals, and abdominal muscles to contract.

A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest? Respiratory acidosis Paradoxical chest movement Chest pain on inspiration Clubbing of fingers and toes

Correct response: Paradoxical chest movement Explanation: Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chestwall movement. Respiratory acidosis and chest pain are symptoms that can occur with flail chest but is not as significant in the diagnosis as paradoxical chest movement. Clubbing of fingers and toes are sign of prolonged tissue hypoxia.

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? Pleurisy Pneumonia Hypoxemia Pulmonary edema

Correct response: Pneumonia Explanation: Older clients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Delirium, pneumonia, decline in functional ability, exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and falls are all threats to recovery in the older adult.

A client has been diagnosed with deep vein thrombosis (DVT). The nurse is planning care and recognizes that the client is most at risk for: Pulmonary embolism Vasculitis Polyarteritis nodosa Arterial insufficiency

Correct response: Pulmonary embolism Explanation: Deep venous thrombosis (DVT) most commonly occurs in the lower extremities. DVT of the lower extremity is a serious disorder, complicated by pulmonary embolism, recurrent episodes of DVT, and development of chronic venous insufficiency. Isolated calf thrombi often are asymptomatic. If left untreated, they may extend to the larger, more proximal veins, with an increased risk of pulmonary emboli.

Pulmonary hypertension is usually caused by long-term exposure to hypoxemia. When pulmonary vessels are exposed to hypoxemia, what is their response? Pulmonary vessels dilate Pulmonary vessels constrict Pulmonary vessels spasm Pulmonary vessels infarct

Correct response: Pulmonary vessels constrict Explanation: Continued exposure of the pulmonary vessels to hypoxemia is a common cause of pulmonary hypertension. Unlike blood vessels in the systemic circulation, most of which dilate in response to hypoxemia and hypercapnia, the pulmonary vessels constrict.

The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign? Apical pulse Orthostatic blood pressure Respiratory rate and depth Urinary intake and output

Correct response: Respiratory rate and depth Explanation: The client receiving narcotics/opioids needs monitoring of the respiratory rate and depth to ensure that respiratory depression does not result in progressive respiratory issues, physiologic damage from respiratory depression, or loss of consciousness. The pulse, blood pressure, and urinary intake and output are not as important as respiratory status when administering narcotics.

A mediastinal shift occurs in which type of chest disorder? Tension pneumothorax Traumatic pneumothorax Simple pneumothorax Cardiac tamponade

Correct response: Tension pneumothorax Explanation: A tension pneumothorax causes the lung to collapse and the heart, the great vessels, and the trachea to shift toward the unaffected side of the chest (mediastinal shift). A traumatic pneumothorax occurs when air escapes from a laceration in the lung itself and enters the pleural space or enters the pleural space through a wound in the chest wall. A simple pneumothorax most commonly occurs as air enters the pleural space through the rupture of a bleb or a bronchopleural fistula. Cardiac tamponade is compression of the heart resulting from fluid or blood within the pericardial sac.

A nurse observes a new environmental services employee enter the room of a client with severe acute respiratory syndrome. Which action by the employee requires immediate intervention by the nurse? The employee wears a gown, gloves, N95 respirator, and eye protection when entering the room. The employee doesn't remove the stethoscope, blood pressure cuff, and thermometer that are kept in the room. The employee removes all personal protective equipment and washes his hands before leaving the client's room. The employee enters the room wearing a gown, gloves, and a mask.

Correct response: The employee enters the room wearing a gown, gloves, and a mask. Explanation: The nurse should tell the employee to wear the proper personal protective equipment, including a gown, gloves, N95 respirator, and eye protection, when entering the client's room. To prevent the spread of infection, a stethoscope, blood pressure cuff, and thermometer for single client use should be kept in the room of a client who requires isolation. Removing all personal protective equipment and washing hands before leaving the client's room are correct procedures.

The nurse has just taken the blood pressure of a 13-year-old, and the percentile rank is 88%. Why would the nurse categorize the child as prehypertensive? The teenager's blood pressure was 122/83. The teenager was born at 33 weeks' gestation. The teen gets no regular exercise. The teenager eats a high-fat diet.

Correct response: The teenager's blood pressure was 122/83. Explanation: A blood pressure greater than 120/80 is categorized as prehypertensive regardless of the percentile. Preterm birth is a risk factor for hypertension and does not indicate prehypertension itself. A high-fat diet and lack of exercise are risks for cardiovascular disease. Both require the nurse's attention to promote health but are not factors in categorizing the adolescent as prehypertensive.

A nursing diagnosis of Risk for impaired tissue integrity would be most appropriate for which client? client with endometriosis client taking oral contraceptives client with a vaginal packing in place client having reconstructive breast surgery

Correct response: client having reconstructive breast surgery Explanation: Reconstructive breast surgery places the client at risk for insufficient blood supply to the muscle graft and skin, which can lead to tissue necrosis. Endometriosis or oral contraceptives are not generally associated with altered tissue perfusion. Pressure from vaginal packing can sometimes put pressure on the bladder neck and interfere with voiding.

The health care provider has prescribed beclomethasone for long term control of asthma. The nurse is most correct to advise the client that beclomethasone is a: mast cell stabilizer. xanthine derivative. corticosteroid. leukotriene inhibitor.

Correct response: corticosteroid. Explanation: Beclomethasone is a corticosteroid prescribed for long term asthma control. Mast cell stabilizers help to decrease bronchospasm and mucous membrane inflammation. A xanthine derivative such as theophylline is a time released bronchodilator. Leukotriene inhibitors help with bronchodilation and decrease airway edema.

The nurse is explaining to new parents that a potential complication of a cesarean birth is transient tachypnea. The nurse explains that this is due to which occurrence? lack of thoracic compressions during birth loss of blood volume due to hemorrhage inadequate suctioning of the mouth and nose of the newborn prolonged unsuccessful vaginal birth

Correct response: lack of thoracic compressions during birth Explanation: A baby born by cesarean birth does not have the same benefit of the birth canal squeeze as does the newborn born by vaginal birth. This may result in the fluid in the lungs being removed too slowly or incompletely. Research findings support the need for thoracic compression to assist with the removal of the fluid and facilitate adequate breathing in the newborn.

A client with a history of pheochromocytoma is admitted to the hospital in an acute hypertensive crisis. To reverse hypertensive crisis caused by pheochromocytoma, the nurse expects to administer: phentolamine (Regitine). methyldopa (Aldomet). mannitol (Osmitrol). felodipine (Plendil).

Correct response: phentolamine (Regitine). Explanation: Pheochromocytoma causes excessive production of epinephrine and norepinephrine, natural catecholamines that raise the blood pressure. Phentolamine, an alpha-adrenergic given by I.V. bolus or drip, antagonizes the body's response to circulating epinephrine and norepinephrine, reducing blood pressure quickly and effectively. Although methyldopa is an antihypertensive agent available in parenteral form, it isn't effective in treating hypertensive emergencies. Mannitol, a diuretic, isn't used to treat hypertensive emergencies. Felodipine, an antihypertensive agent, is available only in extended-release tablets and therefore doesn't reduce blood pressure quickly enough to correct hypertensive crisis.

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as pleural effusion. pneumothorax. hemothorax. consolidation.

Correct response: pleural effusion. Explanation: Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process.

When assessing fetal heart rate patterns, which finding would alert the nurse to a possible problem? variable decelerations prolonged decelerations early decelerations accelerations

Correct response: prolonged decelerations Explanation: Prolonged decelerations are associated with prolonged cord compression, abruptio placentae, cord prolapse, supine maternal position, maternal seizures, regional anesthesia, or uterine rupture. Variable decelerations are the most common deceleration pattern found. They are usually transient and correctable. Early decelerations are thought to be the result of fetal head compression. They are not indicative of fetal distress and do not require intervention. Fetal accelerations are transitory increases in FHR and provide evidence of fetal well-being.

What does decreased pulse pressure reflect? tachycardia reduced distensibility of the arteries reduced stroke volume elevated stroke volume

Correct response: reduced stroke volume Explanation: Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.

A nurse is monitoring a female client with an epidural block. Which complication would be the most important for the nurse to monitor in the client? accidental intrathecal block respiratory depression postdural puncture headache a failed block

Correct response: respiratory depression Explanation: Respiratory depression is a complication of epidural anesthesia and should be closely monitored in laboring clients. A failed block, accidental intrathecal block, and a postdural headache are all side effects of a spinal epidural block.

An expectant mother of twins has been told there is a strong chance that she will go into labor early and her babies will be premature. In order to increase the chances of having healthy infants, she is given a dose of steroids to stimulate the production of surfactant in the infants' lungs. Surfactant is important for survival of the babies because it reduces: surface tension of the respiratory membrane. oxygen/carbon dioxide diffusion through the membrane. carbon dioxide distribution in tissues. surface viscosity for alveolar macrophage movement.

Correct response: surface tension of the respiratory membrane. Explanation: Surfactant disrupts surface tension by breaking hydrogen bonds in water, thus allowing a reduction of surface tension in smaller alveoli, making lung inflation easier. Surfactant does not directly affect gas distribution or alveolar macrophage movement.

The term for the volume of air inhaled and exhaled with each breath is residual volume. tidal volume. vital capacity. expiratory reserve volume.

Correct response: tidal volume. Explanation: Tidal volume is the volume of air inhaled and exhaled with each breath. Residual volume is the volume of air remaining in the lungs after a maximum expiration. Vital capacity is the maximum volume of air exhaled from the point of maximum inspiration. Expiratory reserve volume is the maximum volume of air that can be exhaled after a normal inhalation.

Which hollow tube transports air from the laryngeal pharynx to the bronchi? trachea larynx bronchioles pharynx

Correct response: trachea Explanation: The trachea is a hollow tube composed of smooth muscle and supported by C-shaped cartilage. The trachea transports air from the laryngeal pharynx to the bronchi and lungs. This is a cartilaginous framework between the pharynx and trachea that produces sound. The bronchioles are smaller subdivisions of bronchi within the lungs. The pharynx, or throat, carries air from the nose to the larynx and food from the mouth to the esophagus.