Oxygenation

A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli's function will the nurse share with the patient? a. Carries out gas exchange b. Regulates tidal volume c. Produces hemoglobin d. Stores oxygen

ANS: A The alveolus is a capillary membrane that allows gas exchange of oxygen and carbon dioxide during respiration. The alveoli do not store oxygen, regulate tidal volume, or produce hemoglobin. OBJ: Describe the physiological processes of ventilation, perfusion, and exchange of respiratory gases. TOP: Teaching/Learning MSC: Physiological Adaptation

Which of the following is a recommended immunization for adults yearly? a. Pneumococcal b. Influenza c. Polio d. Tetanus

ANS: B Influenza vaccines are recommended yearly for adults.

26. A nurse is caring for a patient who is taking warfarin (Coumadin) and discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient? a. Increased cholesterol level b. Distended jugular vein c. Bleeding d. Angina

ANS: C Patients taking warfarin (Coumadin) for anticoagulation prolong the prothrombin time (PT)/international normalized ratio (INR) results if they are taking gingko biloba, garlic, or ginseng with the anticoagulant. The drug interaction can precipitate a life-threatening bleed. Increased cholesterol levels are associated with saturated fat dietary intake. A distended jugular vein and peripheral edema are associated with damage to the right side of the heart. Angina is temporary ischemia of the heart muscle. DIF:Apply (application)REF:883 OBJ: Discuss the effects of a patient's level of health, age, lifestyle, and environment on oxygenation.

A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli's function will the nurse share with the patient? a. carries out gas exchange b. regulates tidal volume c. produces hemoglobin d. stores oxygen

a. carries out gas exchange

The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires? a. stimulation of chemical receptors in the aorta b. reduction of arterial oxygen saturation levels c. requirement of elastic recoil lung properties d. enhancement of accessory muscle usage

a. stimulation of chemical receptors in the aorta

A nurse is teaching the patient with mitral valve problems about the valves in the heart. Starting on the right side of the heart, describe the sequence of the blood flow through these valves. 1. Mitral 2. Aortic 3. Tricuspid 4. Pulmonic a. 1,3,2,4 b. 4,3,2,1 c. 3,4,1,2 d. 2,4,1,3

c. 3,4,1,2

46. The nurse is caring for a patient who needs oxygen via a nasal cannula. Which task can the nurse delegate to the nursing assistive personnel? a. Applying the nasal cannula b. Adjusting the oxygen flow c. Assessing lung sounds d. Setting up the oxygen

ANS: A The skill of applying (not adjusting oxygen flow) a nasal cannula or oxygen mask can be delegated to nursing assistive personnel (NAP). The nurse is responsible for assessing the patient's respiratory system, response to oxygen therapy, and setup of oxygen therapy, including adjustment of oxygen flow rate. DIF:Apply (application)REF:900 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Planning

The finding of a barrel chest configuration in a patient may be related to which of the following disorders? a. Chronic obstructive pulmonary disease b. Acute asthma attack c. Cardiomyopathy d. Acute myocardial infarction

ANS: A The air trapping that occurs in chronic obstructive pulmonary disease over time causes the chest to expand, leaving a ratio of 1:1 from side to front ratio instead of the normal 1:2 ratio.

2. A nurse is teaching a community health promotion class and discusses the flu vaccine. Which information will the nurse include in the teaching session? (Select all that apply.) a. It is given yearly. b. It is given in a series of four doses. c. It is safe for children allergic to eggs. d. It is safe for adults with acute febrile illnesses. e. The nasal spray is given to people over 50. f. The inactivated flu vaccine is given to people over 50.

ANS: A, F Annual (yearly) flu vaccines are recommended for all people 6 months and older. The inactivated flu vaccine should be given to these individuals with chronic health problems and those 50 and older. People with a known hypersensitivity to eggs or other components of the vaccine should consult their health care provider before being vaccinated. There is a flu vaccine made without egg proteins that is approved for adults 18 years of age and older. Adults with an acute febrile illness should schedule the vaccination after they have recovered. The live, attenuated nasal spray vaccine is given to people from 2 through 49 years of age if they are not pregnant or do not have certain long-term health problems such as asthma; heart, lung, or kidney disease; diabetes; or anemia. DIF:Apply (application)REF:890-891 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Teaching/Learning

A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority? a. Pulse b. respirations c. Temperature d. Blood pressure

ANS: B Respirations and oxygen saturation are the priorities. Cervical trauma at C3 to C5 usually results in paralysis of the phrenic nerve. When the phrenic nerve is damaged, the diaphragm does not descend properly, thus reducing inspiratory lung volumes and causing hypoxemia. While pulse and blood pressure are important, respirations are the priority. Temperature is not a high priority in this situation. OBJ:Assess for the risk factors affecting a patient's oxygenation.

45. The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take? a. Set suction regulator at 150 to 200 mm Hg. b. Limit the length of suctioning to 10 seconds. c. Apply suction while gently rotating and inserting the catheter. d. Liberally lubricate the end of the suction catheter with a water-soluble solution.

ANS: B Suctioning passes should be limited to 10 seconds to avoid hypoxemia. Suction for a tracheostomy should be set at 100 to 150 mm Hg. Excessive lubrication can clog the catheter or occlude the airway; lubricant is not necessary for oropharyngeal or artificial airway (tracheostomy) suctioning. Suction should never be applied on insertion. DIF:Apply (application)REF:912 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Implementation

A nurse is teaching staff about the conduction of the heart. In which order will the nurse present the conduction cycle, starting with the first structure? 1. Bundle of His 2. Purkinje network 3. Intraatrial pathways 4. Sinoatrial (SA) node 5. Atrioventricular (AV) node a. 5, 4, 3, 2, 1 b. 4, 3, 5, 1, 2 c. 4, 5, 3, 1, 2 d. 5, 3, 4, 2, 1

ANS: B The conduction system originates with the SA node, the "pacemaker" of the heart. The electrical impulses are transmitted through the atria along intraatrial pathways to the AV node. It assists atrial emptying by delaying the impulse before transmitting it through the Bundle of His and the ventricular Purkinje network. DIF:Understand (comprehension)REF:875 OBJ: Describe the structure and function of the cardiopulmonary system.

37. A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority? a. Risk for skin breakdown b. Impaired gas exchange c. Activity intolerance d. Risk for infection

ANS: B The most important nursing intervention is to maintain airway and circulation for this patient; therefore, Impaired gas exchange is the first nursing priority. Activity intolerance is a concern but is not the priority in this case. Risk for skin breakdown and Risk for infection are also important but do not address an immediate impairment with physiologic integrity. DIF:Analyze (analysis)REF:886 | 888 OBJ: Develop a plan of care for a patient with altered need for oxygenation.

Which oxygen delivery setting places a patient in danger of not receiving adequate oxygen? a. Nasal cannula at a flow rate of 2 L/min b. Nasal cannula at a rate of 5 L/min c. Simple mask at a flow rate of 5 L/min d. Non-rebreather mask at a flow rate of 5 L/min

Answer: d A non-rebreather mask with a flow rate of 5 L/min does not give the patient adequate levels of oxygen in the reservoir bag and may result in the person developing hypoxemia. The accepted range of oxygen delivery with a non-rebreather mask is 10 to 15 L/min. The amount that can be delivered by nasal cannula is 1 to 6 L/min, and oxygen delivered at 2 or 5 L/min by nasal cannula is within the safe range. Oxygen delivered at 5 L/min by a simple face mask delivers adequate oxygen because the range for a face mask is 5 to 10 L/min.

Which position is the priority for a patient experiencing acute shortness of breath? a. Supine position b. Reverse Trendelenburg position c. Face-down position d. Upright position

Answer: d When a person is having difficulty breathing, placing her or him in an upright position helps to increase the effectiveness of breathing. The supine position may decrease respiratory efficiency, place pressure on the chest wall from the bed, and cause increased anxiety for the patient. The reverse Trendelenburg position increases the workload of breathing. The face-down (prone) position may inhibit the patient's ability to breathe.

Which questions are included in a focused history for a cardiac patient? (Select all that apply.) a. Are you having pain? b. Where is the pain located? c. Do you attend religious services regularly? d. Do you have increased fatigue? e. Do you have any episodes of dizziness?

Answers: a, b, d, e All pain assessment is important to determine a pattern of pain. Cardiac events can contribute to fatigue, and abnormal heart rhythms may contribute to dizziness. Although knowledge of a patient's religious affiliation may be important in certain settings, it is not part of a focused assessment of a cardiac patient.

Which of the following artificial airways would the nurse anticipate to have a cuff at the end? a. Nasotracheal airway b. Pharyngeal airway c. Oral pharyngeal airway d. An endotracheal tube

ANS: D An endotracheal tube enters the patient's trachea and has a cuff to prevent gastric contents from emptying into the lungs from the gastrointestinal tract.

Which of the following conditions would be associated with a wheezing sound on inspiration in a patient's lower posterior chest? a. Myocardial infarction b. Congestive heart failure c. Pulmonary edema d. Asthma

ANS: D Asthma causes a narrowing of small airways that results in a wheezing sound.

Which of the following patients may need a pharyngeal airway? a. A patient who is alert and oriented b. A patient who has a tracheostomy c. A patient with a broken nose d. A patient with decreased level of consciousness

ANS: D Pharyngeal airways are needed most often when a patient has a decreased level of consciousness and loss of muscle tone.

When a person takes a breath in, what is the primary muscle of respiration? a. The intercostal muscles b. The neck muscles c. Muscles of the shoulder girdle d. The diaphragm

ANS: D The diaphragm is the primary muscle of respiration. When it contracts, the intrathoracic is increased, forcing atmospheric air into the airways.

A nurse is teaching the staff about conduction of the heart. In which order will the nurse present the conduction cycle, starting with the first structure? 1. Bundle of His 2.Purkinje network 3.Intraatrial pathways 4. Sinoatrial node (SA Node) 5. Atrioventricular node (AV Node) a. 5,4,3,2,1 b. 4,3,5,1,2 c. 4,5,3,1,2 d. 5,3,4,2,1

b. 4,3,5,1,2

The home health nurse recommends that a patient with respiratory problems install a carbon monoxide detector in the home. What is the rationale for the nurse's action? a. carbon monoxide detectors are required by law in the home b. carbon monoxide tightly binds to hemoglobin, causing hypoxia c. carbon monoxide signals the cerebral cortex to cease ventilations d. carbon monoxide combines with oxygen in the body and produces a deadly toxin

b. carbon monoxide tightly binds to hemoglobin, causing hypoxia

(**)A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority? a. pulse b. respirations c. temperature d. blood pressure

b. respirations

A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close? a. aortic and mitral b. mitral and tricuspid c. aortic and pulmonic d. mitral and pulmonic

c. aortic and pulmonic

The nurse administers intravenous morphine sulfate to a patient for pain control. She will need to monitor her patient for which of the following adverse effects? 1) Decreased heart rate 2) Muscle weakness 3) Decreased urine output 4) Respiratory depression

ANS: 4 Opioids are potent respiratory depressants. Patients receiving opioids should be monitored for decreased rate and depth of respirations. PTS:1DIF:ModerateREF:pp. 1299, 1305; critical-thinking and synthesis required KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension

A nurse is teaching a community health promotion class and discusses the flu vaccine. Which information will the nurse include in the teaching session? (Select all that apply.) a.It is given yearly. b.It is given in a series of four doses. c.It is safe for children allergic to eggs. d.It is safe for adults with acute febrile illnesses. e.The nasal spray is given to people over 50. f.The inactivated flu vaccine is given to people over 50.

A,F

10. A patient has a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia? a. Superior vena cava b. Pulmonary artery c. Coronary artery d. Carotid artery

ANS: C A myocardial infarction is the lack of blood flow due to obstruction to the coronary artery, which supplies the heart with blood. The superior vena cava returns blood back to the heart. The pulmonary artery supplies deoxygenated blood to the lungs. The carotid artery supplies blood to the brain.

What is the rationale for wrapping petroleum gauze around a chest tube insertion site? 1) Prevents air from leaking around the site 2) Prevents infection at the insertion site 3) Absorbs drainage from the insertion site 4) Protects the tube from becoming dislodged

ANS: 1 Petroleum gauze creates a seal around the insertion site. Collapse of the lung can occur if there is a leak around the insertion site that causes loss of negative pressure within the system. Air leaks are one common cause of loss of negative pressure. PTS:1DIF:EasyREF:p. 1322 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

(**) The nurse suspects the patient has increased after load. Which piece of equipment should the nurse obtain to determine the presence of this condition? a. pulse oximeter b. oxygen cannula c. blood pressure cuff d. yankauer suction tip catheter

c. blood pressure cuff

A nurse is following the Ventilator Bundle standards to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.) a.Head of bed elevation to 90 degrees at all times b.Daily oral care with chlorhexidine c.Cuff monitoring for adequate seal d.Clean technique when suctioning e.Daily "sedation vacations" f.Heart failure prophylaxis

B,C,E

(**)A patient has a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia? a. superior vena cava b. pulmonary artery c. coronary artery d. carotid artery

c. coronary artery

A patient's heart rate increased from 94 to 164 beats/min. What will the nurse expect? a. increase in diastolic filling time b. decrease in hemoglobin level c. decrease in cardiac output d. increase in stroke volume

c. decrease in cardiac output

A nurse is caring for a patient with sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.) a.Assist-control (AC) b.Pressure support ventilation (PSV) c.Bilevel positive airway pressure (BiPAP) d.Continuous positive airway pressure (CPAP) e.Synchronized intermittent mandatory ventilation (SIMV)

C,D

A patient has inadequate stroke volume related to decreased preload. which treatment does the nurse prepare to administer? a. diuretics b. vasodilators c. chest physiotherapy d. intravenous (IV) fluids

d. intravenous (IV) fluids

The patient has right-sided heart failure. Which finding will the nurse expect when performing an assessment? a. peripheral edema b. basilar crackles c. chest pain d. cyanosis

a. peripheral edema

A patient with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic? a. "Your disease doesn't send enough oxygen to your fingers." b. "Your disease affects both your lungs and your heart, and not enough blood is being pumped." c. "Your disease will be helped if you pursed-lip breathe." d. "Your disease often makes patients lose mental status."

a. "Your disease doesn't send enough oxygen to your fingers"

A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave? a. SA node b. AV node c. Bundle of His d. Purkinje fibers

a. SA node

A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest? a. A cup of nonfat yogurt with granola and a handful of dried apricots b. Whole wheat toast with butter and a side of bacon c. A bowl of cereal with whole milk and a banana d. Omelet with sausage, cheese, and onions

a. a cup of nonfat yogurt with granola and a handful of dried apricots

A nurse is caring for a group of patients. Which patient should the nurse see first? a. a patient with hypercapnia wearing an oxygen mask b. a patient with a chest tube ambulating with the chest tube unclamped c. a patient with thick secretions being tracheal suctioned first and then orally d. a patient with a new tracheostomy and tracheostomy obturator at the bedside

a. a patient with hypercapnia wearing an oxygen mask

(**)The nurse is caring for a patient who needs oxygen via a nasal cannula. Which task can the nurse delegate to the nursing assistive personnel? a. Applying the nasal cannula b.Adjusting the oxygen flow c. Assessing lung sounds d. Setting up the oxygen

a. applying the nasal cannula

The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination? a. Experiences chest pain after eating a heavy meal b. Experiences adequate oxygen saturation during exercise c. Experiences crushing chest pain for more than 20 minutes d. Experiences tingling in the left arm that lasts throughout the morning

a. experiences chest pain after eating a heavy meal

Which coughing technique will the nurse use to help a patient clear central airways? a. Huff b. Quad c. Cascade d. Incentive spirometry

a. huff

The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most likely expect? a. Increased preload b. Increased heart rate c. Decreased afterload d. Decreased tissue perfusion

a. increased preload

A patient has carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient? a. Low-carbohydrate b. Low-caffeine c. High-caffeine d. High-carbohydrate

a. low carbohydrate

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen? a. Nasal cannula b. Simple face mask c. Non-rebreather mask d. Partial non-rebreather mask

a. nasal cannula

(**)The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal the patient could achieve? a. Sleeping on two to three pillows at night b. Limiting the diet to 1500 calories a day c. Running 30 minutes every morning d. Stopping smoking immediately

a. sleeping on two or three pillows at night

(**)A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the nurse describe as modifiable? a. Stress b. Allergies c. Family history d. Gender

a. stress

The nurse is careful to monitor a patient's cardiac output. Which goal is the nurse trying to achieve? a. to determine peripheral extremity circulation b. to determine oxygenation requirements c. to determine cardiac dysrhythmias d. to determine ventilation status

a. to determine peripheral extremity circulation

A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately? a. Ventricular tachycardia b. Atrial fibrillation c. Sinus rhythm d. Paroxysmal supraventricular tachycardia

a. ventricular tachycardia

The nurse is educating a student nurse on caring for a patient with a chest tube. Which statement from the student nurse indicates successful learning? a. "I should clamp the chest tube when giving the patient a bed bath." b. "I should report if I see continuous bubbling in the water-seal chamber." c. "I should strip the drains on the chest tube every hour to promote drainage." d. "I should notify the health care provider first, if the chest tube becomes dislodged."

b. "I should report if I see continuous bubbling in the water-seal chamber"

(**) A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis? a. "Atelectasis affects only those with chronic conditions such as emphysema." b. "It is important to do breathing exercises every hour to prevent atelectasis." c. "If I develop atelectasis, I will need a chest tube to drain excess fluid." d. "Hyperventilation will open up my alveoli, preventing atelectasis."

b. "It is important to do breathing exercises every hour to prevent atelectasis."

The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance? a. Suctioning respiratory secretions several times every hour b. Administering humidified oxygen through a tracheostomy collar c. Instilling normal saline into the tracheostomy to thin secretions before suctioning d. Deflating the tracheostomy cuff before allowing the patient to cough up secretions

b. administering humidified oxygen through a tracheostomy collar

The nurse needs to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change? a. Thinner heart valves cause lipid accumulation and fibrosis. b. Diminished respiratory muscle strength may cause poor chest expansion. c. Alterations in mental status prevent patients' awareness of ineffective breathing. d. An increased number of pacemaker cells make proper anesthesia induction more difficult.

b. diminished respiratory muscle strength may cause poor chest expansion

The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient? a. Inform the patient of the importance of finishing the entire dose of antibiotics. b. Encourage the patient to stay up-to-date on all vaccinations. c. Schedule patient to get annual tuberculosis skin testing. d. Create an exercise routine to run 45 minutes every day.

b. encourage the patient to stay up to date on all vaccinations

(**)A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority? a. Risk for skin breakdown b. Impaired gas exchange c. Activity intolerance d. Risk for infection

b. impaired gas exchange

While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first? a.Press the emergency response button. b.Insert a spare tracheostomy with the obturator. c.Manually occlude the tracheostomy with sterile gauze. d.Place a face mask delivering 100% oxygen over the nose and mouth.

b. insert a spare tracheostomy with the obturator

The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take? a. Set suction regulator at 150 to 200 mm Hg. b. Limit the length of suctioning to 10 seconds. c. Apply suction while gently rotating and inserting the catheter. d. Liberally lubricate the end of the suction catheter with a water-soluble solution.

b. limit the length of suctioning to 10 seconds

Upon auscultation of the patient's chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse? a. The beginning of the systolic phase b. Regurgitation of the mitral valve c. The opening of the aortic valve d. Presence of orthopnea

b. regurgitation of the mitral valve

A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step? 1. Insert catheter. 2. Apply suction and remove. 3. Have patient deep breathe. 4. Encourage patient to cough. 5. Attach catheter to suction system. 6. Rinse catheter and connecting tubing. a. 1, 2, 3, 4, 5, 6 b. 4, 5, 1, 2, 3, 6 c. 5, 3, 1, 2, 4, 6 d. 3, 1, 2, 5, 4, 6

c. 5,3,1,2,4,6

A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation? a. Anxiety over illness b. Decreased drive to breathe c. Increased metabolic demands d. Infection destroying lung tissues

c. Increased metabolic demands

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient? a. Discontinue the humidification delivery device to keep excess fluid from lungs. b. Monitor oxygen saturation, and frequently auscultate lung bases. c. Assist the patient to cough, turn, and deep breathe every 2 hours. d. Decrease fluid intake to 300 mL a shift.

c. assist the patient to cough, turn, and deep breathe every 2 hours

A nurse is caring for a patient who is taking warfarin (Coumadin) and discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient? a. Increased cholesterol level b. Distended jugular vein c. Bleeding d. Angina

c. bleeding

While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on 3 pillows to help with the difficult breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record? a. martial fibrillation b. myocardial ischemia c. left-sided heart failure d. right-sided heart failure

c. left-sided heart failure

A patient with a pneumothorax has a chest tube inserted and is placed on low constant suction. Which finding requires immediate action by the nurse? a. The patient reports pain at the chest tube insertion site that increases with movement. b. Fifty milliliters of blood gushes into the drainage device after the patient coughs. c. No bubbling is present in the suction control chamber of the drainage device. d. Yellow purulent discharge is seen leaking out from around the dressing site.

c. no bubbling is present in the suction control chamber of the drainage device

A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium? a. right ventricle, left ventricle, left atrium b. left atrium, right ventricle, left ventricle c. right ventricle, left atrium, left ventricle d. left atrium, left ventricle, right ventricle

c. right ventricle, left atrium, left ventricle

A patient has heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output? a. myocardial contractility x myocardial blood flow b. ventricular filling time/diastolic filling time c. stroke volume x heart rate d. preload/afterload

c. stroke volume x heart rate

(**) The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider? a. Increased anterior-posterior diameter of the chest b. Accessory muscle used for breathing c. Clubbing of the fingers d. Hemoptysis

d. Hemoptysis

A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning? a. pulse 75 b. pulse 80 c. O2 saturation 91% d. O2 saturation 88%

d. O2 saturation 88%

(**)The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method? a. A 5-year-old with excessive drooling from epiglottitis b. A 5-year-old with an asthma attack following severe allergies c. A 24-year-old with a right pneumothorax following a motor vehicle accident d. A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation

d. a 24-year old with acute respiratory distress syndrome requiring mechanical ventilation

(**) A nurse is caring for a patient with respiratory problems. which assessment finding indicates a late sign of hypoxia? a. elevated blood pressure b. increased pulse rate c. restlessness d. cyanosis

d. cyanosis

The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process? a. ventilation b. surfactant c. perfusion d. diffusion

d. diffusion

A patient has a history of COPD. His pulse oximetry reading is 97%. What other findings would indicate adequate tissue and organ oxygenation? Choose all that apply. 1) Normal urine output 2) Strong peripheral pulses 3) Clear breath sounds bilaterally 4) Normal muscle strength

ANS: 1, 2, 4 To determine adequacy of tissue oxygenation, assess respiration, circulation, and tissue/organ function. Good peripheral circulation is characterized by strong peripheral pulses. Impaired tissue oxygenation to the kidneys would result in abnormal kidney function (e.g., poor urine output). Hypoxic limb tissue would result in abnormal muscle functioning (e.g., muscle weakness and pain with exercise). Adequacy of tissue oxygenation cannot be determined by assessing pulmonary ventilation alone; circulation must also be assessed. PTS:1DIFgrinifficult REF: p. 1300; higher-order item, some of answer implied in text KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

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

ANS: 1, 3, 4 Normal lung volumes and capacities vary with body size, age, and exercise level. Volumes and capacities are higher in men, in large people, and in athletes. Race does not influence normal lung volumes and capacities. PTS:1DIF:EasyREF:p. 1305 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

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? Choose all that apply. 1) "Keep healthy snacks or gum available to chew instead of smoking a cigarette." 2) "Don't tell your friends and family you are trying to quit, until you feel confident that you'll be successful." 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."

ANS: 1, 3, 4 People who are trying to quit smoking often are more successful when they are accountable to other people who are encouraging and supportive. Having something to chew (e.g., carrot sticks, gum, nuts, or seeds) can distract from the desire to smoke a cigarette. Setting a date to stop smoking and choosing a time of low stress are two strategies that help people be more successful with smoking cessation. Self-reward for meeting goals is a form of positive reinforcement. PTS:1DIF:ModerateREF:p. 1311, ESG Self-Care: Smoking Cessation Tips KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension

Which of the following is/are accurate about nasotracheal suctioning? Choose all that apply. 1) Apply suction for no longer than 10-15 sec during a single pass. 2) Apply suction while inserting and removing the catheter. 3) Reapply oxygen between suctioning passes for ventilator patients. 4) Gently rotate the suction catheter as you remove it.

ANS: 1, 4 Limiting suctioning to 10 seconds or less and reapplying oxygen between suctioning passes prevent hypoxia. Suction should be applied only while withdrawing the catheter, using a continuous rotating motion to prevent trauma to the airway. Endotracheal suctioning is used when the patient is being mechanically ventilated, and most ventilator patients have in-line suctioning, so there is no need to reapply oxygen. PTS: 1 DIF: Moderate REF: p. 1347 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

The nurse is teaching a patient about her chest drainage system. Which of the following should the nurse include in the teaching? Choose 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 without assistance as much as possible. 4) Immediately notify the nurse if she experiences increased shortness of breath

ANS: 1, 4 Patients should regularly perform coughing and deep-breathing exercises to promote lung reexpansion. Also to promote lung reexpansion, the nurse should encourage the patient to be as active as her condition permits, rather than telling her not to walk. Chest drainage systems are bulky, but patients with disposable systems can still get out of bed and ambulate. However, the patient will need assistance from one or two staff members to protect and monitor the system and to monitor her responses to activity; she should not get out of bed on her own. If a patient with a chest drainage system becomes acutely short of breath, the patient should immediately notify the nurse so the nurse can check for occlusion of the system, which can result in a tension pneumothorax. PTS:1DIF:ModerateREF:pp. 1313, 1358 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

You are caring for an adult patient with a tracheostomy who is being mechanically ventilated. His pulse oximetry reading is 85%, heart rate is 113, and respiratory rate is 30. The patient is very restless. His respirations are labored, and you hear gurgling sounds. You auscultate crackles and rhonchi in both lungs. What is the most appropriate action to take? 1) Call the respiratory therapist to check the ventilator settings. 2) Provide endotracheal suctioning. 3) Provide tracheostomy care. 4) Notify the physician of the patient's signs of fluid overload.

ANS: 2 Increased pulse and respiratory rates, decreased oxygen saturation, gurgling sounds during respiration, auscultation of adventitious breath sounds, and restlessness are signs that indicate the need for suctioning. Airways are suctioned to remove secretions and maintain patency. The patient's symptoms should subside once the airway is cleared. PTS: 1 DIF: Moderate REF: p. 1318, 1342 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

The nurse is caring for a patient who is experiencing dyspnea. Which of the following positions would be most effective if incorporated into the patient's care? 1) Supine 2) Head of bed elevated 80° 3) Head of bed elevated 30° 4) Lying on left side

ANS: 2 Position affects ventilation. An upright or elevated position pulls abdominal organs down, thus allowing maximum diaphragm excursion and lung expansion. PTS:1DIF:EasyREF:p. 1303 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

When using sterile technique to perform tracheostomy care of a new tracheostomy, which of the following is correct? 1) You will need a single pair of sterile gloves. 2) Place the patient in semi-Fowler's position, if possible. 3) Clean the stoma under the faceplate with hydrogen peroxide. 4) Cut a slit in sterile 4 × 4 gauze halfway through to make a dressing

ANS: 2 Semi-Fowler's position promotes lung expansion and prevents back strain for the nurse. You will need two pairs of sterile gloves: one pair for dressing removal, and a clean pair for the rest of the procedure. You should clean the stoma under the faceplate with sterile saline. Never cut a 4 × 4 gauze for the dressing because lint and fibers from the cut edge could enter the trachea and cause respiratory distress. PTS: 1 DIF: Easy REF: p. 1338 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure. The patient 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 oxygen to the patient through a nasal cannula.

ANS: 2 The first action the nurse should take is to make a quick assessment of the adequacy of breathing, circulation, and oxygenation in order to determine the type of immediate intervention required. The nurse's assessment should include simple questions about current symptoms. A more thorough medical history can be gathered once the patient's oxygenation needs are addressed. Following a quick assessment, the nurse should then review and implement physician's orders. Administering oxygen is not appropriate without knowing what treatments the primary care provider has prescribed. PTS:1DIF:ModerateREF:pp. 1301-1302 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

When providing safety education to the mother of a toddler, you 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? Choose all that apply. 1) Frequent, serious respiratory infections 2) Airway obstruction from aspiration of small objects 3) Drowning in small amounts of water around the home 4) Development of asthma

ANS: 2, 3 As a toddler's respiratory and immune systems mature, the risk for frequent and serious infections is less than in infanthood. Most children recover from upper respiratory infections without difficulty. Toddlers' airways are relatively short and small and may be easily obstructed, and they often put objects in their mouth as part of exploring their environment, thus increasing their risk for aspiration and airway obstruction. In addition, toddlers are at high risk for drowning in very small amounts of water around the home (e.g., in a bucket of water or toilet bowl). The risk for developing asthma is not significantly influenced by the child's developmental stage. PTS:1DIF:ModerateREF:p. 1297 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension

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

ANS: 2, 3, 4 Obesity causes multiple health problems, many of which affect the lungs, heart, and circulation. Large abdominal fat stores press upward on the diaphragm, preventing full chest expansion and leading to hypoventilation and dyspnea on exertion. The risk for respiratory infection increases because lower lung segments are poorly ventilated, and secretions are not removed effectively. When an obese person lies down, chest expansion is limited even more. Excess neck girth and fat stores in the upper airway often lead to obstructive sleep apnea. Obesity also increases the risk of developing atherosclerosis and hypertension. Obesity does not cause reduced alveolar-capillary gas exchange. PTS: 1 DIF: Easy REF: p. 1299 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension

The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which of the following responses indicates to the nurse that the medication is effective? 1) The amount of sputum the patient expectorates decreases with each dose administered. 2) Cough is completely suppressed, and she 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.

ANS: 3 Antitussives are cough suppressants that reduce the frequency of an involuntary, dry, nonproductive cough. Antitussives are useful for adults when coughing is unproductive and frequent, leading to throat irritation or interrupted sleep. Expectorants help make coughing more productive. The goal of an antitussive/expectorant combination is to reduce the frequency of dry, unproductive coughing while making voluntary coughing more productive. PTS:1DIFgrinifficultREF:p. 1310 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

Which of the following provide the most reliable data about the effectiveness of airway suctioning? 1) The amount, color, consistency, and odor of secretions 2) The patient's tolerance for the procedure 3) Breath sounds, vital signs, and pulse oximetry before and after suctioning 4) The number of suctioning passes required to clear secretions

ANS: 3 Breath sounds, vital signs, and oxygen saturation levels before and after suctioning provide data about the effectiveness of suctioning. Information about the amount and appearance of secretions provides data about the likelihood of airway infection and/or inflammation. Data about the patient's tolerance of suctioning provide information about the patient's overall condition. The number of suctioning passes required to clear the secretions provides information about the amount of secretions present. PTS: 1 DIF: Moderate REF: p. 1351 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

Chest percussion and postural drainage would be an appropriate intervention for which of the following conditions? 1) Congestive heart failure 2) Pulmonary edema 3) Pneumonia 4) Pulmonary embolus

ANS: 3 Chest physiotherapy moves secretions to the large, central airways for expectoration or suctioning. This treatment is not effective for conditions that do not involve the development of airway secretions, including congestive heart failure, pulmonary edema, and pulmonary embolus. PTS:1DIF:ModerateREF:p. 1313 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

A patient has just had a chest tube inserted to dry-seal suction drainage. Which of the following is a correct nursing intervention for maintenance? 1) Keep the head of the bed flat for 6 hours. 2) Immobilize the patient's arm on the affected side. 3) Keep the drainage system lower than the insertion site. 4) Drain condensation into the humidifier when it collects in the tubing.

ANS: 3 The drainage system must be below the insertion site to prevent fluid flowing back into the pleural cavity and compromising the patient's respiratory status. Maintain patient in semirecumbent position (head of bed elevated 30 to 45 degrees), not flat. This is extremely important to promote lung expansion, reduce gastric reflux, and prevent ventilator-associated pneumonia (VAP), if the person is being mechanically ventilated. Patients being mechanically ventilated are at high risk for developing VAP, which is associated with high mortality rates. Mouth rinses and mouthwashes are a part of the recommended routine for preventing VAP. They also provide comfort and preserve integrity of the mucous membranes. Encourage the patient to move the arm on the affected side; if he cannot, perform passive range-of-motion. You should check the ventilator tubing frequently for condensation, and drain the fluid into a collection device or waste receptacle because condensation in the ventilator tubing can cause resistance to airflow. Moreover, the patient can aspirate it if it backflows down into the endotracheal tube. The fluid should not be drained into the humidifier because the patient's secretions may have contaminated it. PTS: 1 DIF: Difficult REF: p. 1353 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

A 62-year-old man with emphysema says, "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 oxygen, but remember it is a fire hazard to smoke with oxygen 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."

ANS: 3 The nurse's response should focus on correcting the patient's misinformation rather than on convincing him to stop smoking. Once a person stops smoking, the body begins to repair the damage. During the first few days, the person will cough more as the cilia begin to clear the airways. Then the coughing subsides, and breathing becomes easier. Even long-time smokers can benefit from smoking cessation. The suggestions that the patient's family will become ill and that oxygen is a fire hazard appear to be scare tactics, which can be seen as coercive, and would not be effective in motivating the patient to stop smoking. Although asking the primary care provider for a prescription may help the patient to stop smoking, it does not address his incorrect belief that it is "too late" for him to do so. PTS:1DIF:ModerateREF:p. 1299 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

Of the following interventions, which is/are likely to reduce the risk of postoperative atelectasis? Choose all that apply. 1) Administer bronchodilators. 2) Apply low-flow oxygen. 3) Encourage coughing and deep breathing. 4) Administer pain medication.

ANS: 3, 4 Pain alters the rate and depth of respirations. Often, patients in pain breathe shallowly, which puts them at risk for atelectasis. Regularly assess all patients for pain. Once you have medicated the patient, reassess breath sounds, and encourage the patient to cough and breathe deeply. This will help to open air sacs and mobilize secretions in the airways. PTS: 1 DIF: Moderate REF: pp. 1303, 1313 ; critical-thinking item that requires synthesis of information KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Synthesis

Which of the following blood levels normally provides the primary stimulus for breathing? 1) pH 2) Oxygen 3) Bicarbonate 4) Carbon dioxide

ANS: 4 Carbon dioxide (CO2) level provides the primary stimulus to breathe. High CO2 levels stimulate breathing to eliminate the excess CO2. A secondary, although important, drive to breathe is hypoxemia. Low blood O2 levels stimulate breathing to bring more oxygen into the lungs. PTS:1DIF:ModerateREF:p. 1296 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

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

ANS: 4 Recollapse of the lung can occur because of loss of negative pressure within the system. This is commonly caused by air leaks, disconnections, or cracks in the bottles or chambers. If any of these occur, the nurse should immediately place the disconnected end nearest the patient into a bottle of sterile water or saline to a depth of 2 cm to serve as an emergency water seal until a new system can be connected. Do not clamp the chest tube because this can rapidly lead to a tension pneumothorax. A new drainage system should be set up to decrease the risk of infection, but the immediate action is to place the disconnected end into a bottle of sterile water. PTS:1DIF:ModerateREF:p. 1322 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis

You are admitting a 54-year-old patient with chronic obstructive pulmonary disease (COPD). The physician prescribes O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient? 1) Nonrebreather mask 2) Nasal cannula 3) Partial rebreather mask 4) Venturi mask

ANS: 4 The Venturi mask is capable of delivering 24% to 50% FIO2. The cone-shaped adapter at the base of the mask allows a precise FIO2 to be delivered. This is very useful for patients with chronic lung disease. Rebreather masks are used when high concentrations of oxygen are required. A nasal cannula administers oxygen in liters per minute and does not allow administration of a precise FIO2. PTS:1DIFgrinifficultREF:p. 1335 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patient'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

ANS: 4 This respiratory pattern is known as Cheyne-Stokes respirations. It is often associated with damage to the medullary respiratory center or high intracranial pressure due to brain injury. PTS:1DIF:EasyREF:p. 1303 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

27. A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest? a. A cup of nonfat yogurt with granola and a handful of dried apricots b. Whole wheat toast with butter and a side of bacon c. A bowl of cereal with whole milk and a banana d. Omelet with sausage, cheese, and onions

ANS: A A 2000-calorie diet of fruits, vegetables, and low-fat dairy foods that are high in fiber, potassium, calcium, and magnesium and low in saturated and total fat helps prevent and reduce the effects of hypertension. Nonfat yogurt with granola is a good source of calcium, fiber, and potassium; dried apricots add a second source of potassium. Although cereal and a banana provide fiber and potassium, skim milk should be substituted for whole milk to decrease fat. An omelet with sausage and cheese is high in fat. Butter and bacon are high in fat. DIF:Analyze (analysis)REF:879-880

25. A patient has carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient? a. Low-carbohydrate b. Low-caffeine c. High-caffeine d. High-carbohydrate

ANS: A A low-carbohydrate diet is best. Diets high in carbohydrates play a role in increasing the carbon dioxide load for patients with carbon dioxide retention. As carbohydrates are metabolized, an increased load of carbon dioxide is created and excreted via the lungs. A low- or high-caffeine diet is not as important as the carbohydrate load. DIF:Understand (comprehension)REF:879 OBJ: Discuss the effects of a patient's level of health, age, lifestyle, and environment on oxygenation.

34. The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination? a. Experiences chest pain after eating a heavy meal b. Experiences adequate oxygen saturation during exercise c. Experiences crushing chest pain for more than 20 minutes d. Experiences tingling in the left arm that lasts throughout the morning

ANS: A Angina pectoris is chest pain that results from limited oxygen supply. Often pain is precipitated by activities such as exercise, stress, and eating a heavy meal and lasts 3 to 5 minutes. Symptoms of angina pectoris are relieved by rest and/or nitroglycerin. Adequate oxygen saturation occurs with rest; inadequate oxygen saturation occurs during exercise. Pain lasting longer than 20 minutes or arm tingling that persists could be a sign of myocardial infarction. DIF:Apply (application)REF:878 OBJ: Assess for the physical manifestations that occur with alterations in oxygenation.

15. The nurse is careful to monitor a patient's cardiac output. Which goal is the nurse trying to achieve? a. To determine peripheral extremity circulation b. To determine oxygenation requirements c. To determine cardiac dysrhythmias d. To determine ventilation status

ANS: A Cardiac output indicates how much blood is being circulated systemically throughout the body to the periphery. The amount of blood ejected from the left ventricle each minute is the cardiac output. Oxygen status would be determined by pulse oximetry and the presence of cyanosis. Cardiac dysrhythmias are an electrical impulse monitored through ECG results. Ventilation status is measured by respiratory rate, pulse oximetry, and capnography. Capnography provides instant information about the patient's ventilation. Ventilation status does not depend solely on cardiac output. DIF:Apply (application)REF:875 | 903 OBJ: Describe the relationship of cardiac output, preload, afterload, contractility, and heart rate to the process of oxygenation

40. A patient with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic? a. "Your disease doesn't send enough oxygen to your fingers." b. "Your disease affects both your lungs and your heart, and not enough blood is being pumped." c. "Your disease will be helped if you pursed-lip breathe." d. "Your disease often makes patients lose mental status."

ANS: A Clubbing of the nail bed can occur with COPD and other diseases that cause prolonged oxygen deficiency or chronic hypoxemia. Pursed-lipped breathing helps the alveoli stay open but is not the cause of clubbing. Loss of mental status is not a normal finding with COPD and will not result in clubbing. Low oxygen and not low circulating blood volume is the problem in COPD that results in clubbing. DIF:Apply (application)REF:884 OBJ: Identify the clinical outcomes occurring as a result of hyperventilation, hypoventilation, and hypoxemia. TOP: Teaching/Learning MSC: Physiological Adaptation

The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires? a.Stimulation of chemical receptors in the aorta b.Reduction of arterial oxygen saturation levels c. Requirement of elastic recoil lung properties d. Enhancement of accessory muscle usage

ANS: A Inspiration is an active process, stimulated by chemical receptors in the aorta. Reduced arterial oxygen saturation levels indicate hypoxemia, an abnormal finding. Expiration is a passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work. Prolonged use of the accessory muscles does not promote effective ventilation and causes fatigue. DIF:Understand (comprehension)REF:872 OBJ: State the process of the neural and chemical regulation of respiration.

29. A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen? a. Nasal cannula b. Simple face mask c. Non-rebreather mask d. Partial non-rebreather mask

ANS: A Nasal cannulas deliver oxygen from 1 to 6 L/min. All other devices (simple face mask, non-rebreather mask, and partial non-rebreather mask) are intended for flow rates greater than 6 L/min. DIF:Apply (application)REF:903 OBJ: Develop a plan of care for a patient with altered need for oxygenation.

32. The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most likely expect? a. Increased preload b. Increased heart rate c. Decreased afterload d. Decreased tissue perfusion

ANS: A Preload refers to the amount of blood in the left ventricle at the end of diastole; an increase in circulating volume would increase the preload of the heart. Afterload refers to resistance; increased pressure would lead to increased resistance, and afterload would increase. A decrease in tissue perfusion would be seen with hypovolemia. A decrease in fluid volume would cause an increase in heart rate as the body is attempting to increase cardiac output.

19. The patient has right-sided heart failure. Which finding will the nurse expect when performing an assessment? a. Peripheral edema b. Basilar crackles c. Chest pain d. Cyanosis

ANS: A Right-sided heart failure results from inability of the right side of the heart to pump effectively, leading to a systemic backup. Peripheral edema, distended neck veins, and weight gain are signs of right-sided failure. Basilar crackles can indicate pulmonary congestion from left-sided heart failure. Cyanosis and chest pain result from inadequate tissue perfusion. DIF:Apply (application)REF:878 OBJ: Assess for the physical manifestations that occur with alterations in oxygenation.

20. A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave? a. SA node b. AV node c. Bundle of His d. Purkinje fibers

ANS: A The P wave represents the electrical conduction through both atria; the SA node initiates electrical conduction through the atria. The AV node conducts down through the bundle of His and the Purkinje fibers to cause ventricular contraction. DIF:Apply (application)REF:875-876 OBJ: Describe the relationship of cardiac output, preload, afterload, contractility, and heart rate to the process of oxygenation. TOP: Evaluation MSC: Physiological Adaptation

44. Which coughing technique will the nurse use to help a patient clear central airways? a. Huff b. Quad c. Cascade d. Incentive spirometry

ANS: A The huff cough stimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the word huff. The quad cough technique is for patients without abdominal muscle control such as those with spinal cord injuries. While the patient breathes out with a maximal expiratory effort, the patient or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough. With the cascade cough the patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then he or she opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in patients with large volumes of sputum. Incentive spirometry encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It promotes deep breathing and prevents or treats atelectasis in the postoperative patient. DIF:Understand (comprehension)REF:892 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Implementation

16. A nurse is caring for a group of patients. Which patient should the nurse see first? a. A patient with hypercapnia wearing an oxygen mask b. A patient with a chest tube ambulating with the chest tube unclamped c. A patient with thick secretions being tracheal suctioned first and then orally d. A patient with a new tracheostomy and tracheostomy obturator at bedside

ANS: A The mask is contraindicated for patients with carbon dioxide retention (hypercapnia) because retention can be worsened; the nurse must see this patient first to correct the problem. All the rest are using correct procedures and do not need to be seen first. A chest tube should not be clamped when ambulating. Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a tension pneumothorax. Use nasotracheal suctioning before pharyngeal suctioning whenever possible. The mouth and pharynx contain more bacteria than the trachea. Keep tracheostomy obturator at bedside with a fresh (new) tracheostomy to facilitate reinsertion of the outer cannula if dislodged. DIF:Analyze (analysis)REF:902 OBJ:Assess for the risk factors affecting a patient's oxygenation.

36. The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal the patient could achieve? a. Sleeping on two to three pillows at night b. Limiting the diet to 1500 calories a day c. Running 30 minutes every morning d. Stopping smoking immediately

ANS: A To achieve a short-term goal, the nurse should plan a lifestyle change that the patient can make immediately that will have a quick effect. Sleeping on several pillows at night will immediately relieve orthopnea and open the patient's airway, thereby reducing fatigue. Running 30 minutes a day will improve cardiopulmonary health, but a patient needs to build up exercise tolerance. Smoking cessation is another process that many people have difficulty doing immediately. A more realistic short-term goal would be to gradually reduce the number of cigarettes smoked. Limiting caloric intake can help a patient lose weight, but this is a gradual process and is not reasonable for a short-term goal. DIF:Apply (application)REF:882 OBJ: Develop a plan of care for a patient with altered need for oxygenation.

33. A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately? a. Ventricular tachycardia b. Atrial fibrillation c. Sinus rhythm d. Paroxysmal supraventricular tachycardia

ANS: A Ventricular tachycardia and ventricular fibrillation are life-threatening rhythms that require immediate intervention. Ventricular tachycardia is a life-threatening dysrhythmia because of the decreased cardiac output and the potential to deteriorate into ventricular fibrillation or sudden cardiac death. Atrial fibrillation is a common dysrhythmia in older adults and is not as serious as ventricular tachycardia. Sinus rhythm is normal. Paroxysmal supraventricular tachycardia is a sudden, rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously. DIF:Apply (application)REF:878 OBJ: Identify the clinical outcomes occurring as a result of disturbances in conduction, altered cardiac output, impaired valvular function, myocardial ischemia, and impaired tissue perfusion.

35. A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the nurse describe as modifiable? a. Stress b. Allergies c. Family history d. Gender

ANS: A Young and middle-age adults are exposed to multiple cardiopulmonary risk factors: an unhealthy diet, lack of exercise, stress, over-the-counter and prescription drugs not used as intended, illegal substances, and smoking. Reducing these modifiable factors decreases a patient's risk for cardiac or pulmonary diseases. A nonmodifiable risk factor is family history; determine familial risk factors such as a family history of lung cancer or cardiovascular disease. Other nonmodifiable risk factors include allergies and gender. DIF:Understand (comprehension)REF:879 OBJ:Assess for the risk factors affecting a patient's oxygenation.

31. The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient? a. Inform the patient of the importance of finishing the entire dose of antibiotics. b. Encourage the patient to stay up-to-date on all vaccinations. c. Schedule patient to get annual tuberculosis skin testing. d. Create an exercise routine to run 45 minutes every day.

ANS: B A nursing care plan for preventative health measures should be reasonable and feasible. Keeping up-to-date on vaccinations is important because vaccine reduces the severity of illnesses and serious complications. Determine if and when the patient has had a pneumococcal or influenza (flu) vaccine. This is especially important when assessing older adults because of their increased risk for respiratory disease. Although it is important to finish the full course of antibiotics, it is not a preventative health measure. Scheduling annual tuberculosis skin tests does not address prevention and is an unreliable indictor of tuberculosis in older patients. The exercise routine should be reasonable to increase compliance; exercise is recommended only 3 to 4 times a week for 30 to 60 minutes, and walking, rather than running, is an efficient method. DIF:Apply (application)REF:879 | 890-891 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Planning

30. The nurse needs to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change? a. Thinner heart valves cause lipid accumulation and fibrosis. b. Diminished respiratory muscle strength may cause poor chest expansion. c. Alterations in mental status prevent patients' awareness of ineffective breathing. d. An increased number of pacemaker cells make proper anesthesia induction more difficult.

ANS: B Age-related changes in the thorax that occur from ossification of costal cartilage, decreased space between vertebrae, and diminished respiratory muscle strength lead to problems with chest expansion and oxygenation,whereby the patient will have difficulty excreting anesthesia gas. The nurse needs to monitor the patient's oxygen status carefully to make sure the patient does not retain too much of the drug. Older adults experience alterations in cardiac function as a result of calcification of the conduction pathways, thicker and stiffer heart valves caused by lipid accumulation and fibrosis, and a decrease in the number of pacemaker cells in the SA node. Altered mental status is not a normal age-related change; it indicates possible cardiac and/or respiratory problems. DIF:Understand (comprehension)REF:879 OBJ: Discuss the effects of a patient's level of health, age, lifestyle, and environment on oxygenation. TOP: Assessment MSC: Health Promotion and Maintenance

21. A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis? a. "Atelectasis affects only those with chronic conditions such as emphysema." b. "It is important to do breathing exercises every hour to prevent atelectasis." c. "If I develop atelectasis, I will need a chest tube to drain excess fluid." d. "Hyperventilation will open up my alveoli, preventing atelectasis."

ANS: B Atelectasis develops when alveoli do not expand. Breathing exercises, especially deep breathing and incentive spirometry, increase lung volume and open the airways, preventing atelectasis. Deep breathing also opens the pores of Kohn between alveoli to allow sharing of oxygen between alveoli. Atelectasis can affect anyone who does not deep breathe. A chest tube is for pneumothorax or hemothorax. It is deep breathing, not hyperventilation, that prevents atelectasis. DIF:Apply (application)REF:872 | 892 | 896 OBJ: Identify the clinical outcomes occurring as a result of hyperventilation, hypoventilation, and hypoxemia.

The home health nurse recommends that a patient with respiratory problems install a carbon monoxide detector in the home. What is the rationale for the nurse's action? a. carbon monoxide detectors are required by law in the home. b.Carbon monoxide tightly binds to hemoglobin, causing hypoxia. c.Carbon monoxide signals the cerebral cortex to cease ventilations. d.Carbon monoxide combines with oxygen in the body and produces a deadly toxin.

ANS: B Carbon monoxide binds tightly to hemoglobin; therefore, oxygen is not able to bind to hemoglobin and be transported to tissues, causing hypoxia. A carbon monoxide detector is not required by law, does not signal the cerebral cortex to cease ventilations, and does not combine with oxygen but with hemoglobin to produce a toxin. DIF:Apply (application)REF:876 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care setting

43. The nurse is educating a student nurse on caring for a patient with a chest tube. Which statement from the student nurse indicates successful learning? a. "I should clamp the chest tube when giving the patient a bed bath." b. "I should report if I see continuous bubbling in the water-seal chamber." c. "I should strip the drains on the chest tube every hour to promote drainage." d. "I should notify the health care provider first, if the chest tube becomes dislodged."

ANS: B Correct care of a chest tube involves knowing normal and abnormal functioning of the tube. A constant or intermittent bubbling in the water-seal chamber indicates a leak in the drainage system, and the health care provider must be notified immediately. Stripping the tube is not routinely performed as it increases pressure. If the tubing disconnects from the drainage unit, instruct the patient to exhale as much as possible and to cough. This maneuver rids the pleural space of as much air as possible. Temporarily reestablish a water seal by immersing the open end of the chest tube into a container of sterile water. The chest tube should not be clamped unless necessary; if so, the length of time clamped would be minimal to reduce the risk of pneumothorax. DIF:Apply (application)REF:899 | 922 | 926 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Evaluation

42. The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance? a. Suctioning respiratory secretions several times every hour b. Administering humidified oxygen through a tracheostomy collar c. Instilling normal saline into the tracheostomy to thin secretions before suctioning d. Deflating the tracheostomy cuff before allowing the patient to cough up secretions

ANS: B Humidification from air humidifiers or humidified oxygen tracheostomy collars can help prevent drying of secretions that cause occlusion. Suctioning should be done only as needed; too frequent suctioning can damage the mucosal lining, resulting in thicker secretions. Normal saline should not be instilled into a tracheostomy; research showed no benefit with this technique. The purpose of the tracheostomy cuff is to keep secretions from entering the lungs; the nurse should not deflate the tracheostomy cuff unless instructed to do so by the health care provider. DIF:Apply (application)REF:896 OBJ: Develop a plan of care for a patient with altered need for oxygenation.

48. While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first? a. Press the emergency response button. b. Insert a spare tracheostomy with the obturator. c. Manually occlude the tracheostomy with sterile gauze. d. Place a face mask delivering 100% oxygen over the nose and mouth.

ANS: B The nurse's first priority is to establish a stable airway by inserting a spare trach into the patient's airway; ideally an obturator should be used. The nurse could activate the emergency response team if the patient is still unstable after the tracheostomy is placed. A patient with a tracheostomy breathes through the tube, not the nose or mouth; a face mask would not be an effective method of getting air into the lungs. Manually occluding pressure over the tracheostomy site is not appropriate and would block the patient's only airway. DIF:Apply (application)REF:921-922 OBJ: Develop a plan of care for a patient with altered need for oxygenation.

28. Upon auscultation of the patient's chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse? a. The beginning of the systolic phase b. Regurgitation of the mitral valve c. The opening of the aortic valve d. Presence of orthopnea

ANS: B When regurgitation occurs, there is a backflow of blood into an adjacent chamber. For example, in mitral regurgitation the mitral leaflets do not close completely. When the ventricles contract, blood escapes back into the atria, causing a murmur, or "whooshing" sound. The systolic phase begins with ventricular filling and closing of the aortic valve, which is heard as the first heart sound, S1. Orthopnea is an abnormal condition in which a patient uses multiple pillows when reclining to breathe easier or sits leaning forward with arms elevated. DIF:Understand (comprehension)REF:878 OBJ: Identify the clinical outcomes occurring as a result of disturbances in conduction, altered cardiac output, impaired valvular function, myocardial ischemia, and impaired tissue perfusion.

The exchange of oxygen and carbon dioxide occurs in the alveoli. How is oxygen carried in the blood? a. The white blood cells b. The hemoglobin c. The platelets d. The neutrophils

ANS: B Oxygen is carried on the hemoglobin to the tissues where some is released.

1. A nurse is following the Ventilator Bundle standards to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.) a. Head of bed elevation to 90 degrees at all times b. Daily oral care with chlorhexidine c. Cuff monitoring for adequate seal d. Clean technique when suctioning e. Daily "sedation vacations" f. Heart failure prophylaxis

ANS: B, C, E The key components of the Institute for Healthcare Improvement (IHI) Ventilator Bundle are: Elevation of the head of the bed (HOB)—elevation is 30 to 45 degrees Daily "sedation vacations" and assessment of readiness to extubate Peptic ulcer disease prophylaxis Deep venous thrombosis prophylaxis Daily oral care with chlorhexidine Monitor cuff pressure frequently to ensure that there is an adequate seal to prevent aspiration of secretions is also included. Sterile technique is used for suctioning when on ventilators. Heart failure prophylaxis is not a component. DIF:Apply (application)REF:898 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Implementation

12. The nurse suspects the patient has increased afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition? a. Pulse oximeter b. Oxygen cannula c. Blood pressure cuff d. Yankauer suction tip catheter

ANS: C A blood pressure cuff is needed. The diastolic aortic pressure is a good clinical measure of afterload. Afterload is the resistance to left ventricular ejection. In hypertension the afterload increases, making cardiac workload also increase. A pulse oximeter is used to monitor the level of arterial oxygen saturation; it will not help determine increased afterload. While an oxygen cannula may be needed to help decrease the effects of increased afterload, it will not help determine the presence of afterload. A Yankauer suction tip catheter is used to suction the oral cavity. DIF:Analyze (analysis)REF:875 OBJ: Describe the relationship of cardiac output, preload, afterload, contractility, and heart rate to the process of oxygenation. TOP: Planning MSC: Physiological Adaptation

A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close? a. Aortic and mitral b. Mitral and tricuspid c. Aortic and pulmonic d. Mitral and pulmonic

ANS: C As the ventricles empty, the ventricular pressures decrease, allowing closure of the aortic and pulmonic valves, producing the second heart sound, S2. The mitral and tricuspid produce the first heart sound, S1. The aortic and mitral do not close at the same time. The mitral and pulmonic do not close at the same time. DIF:Apply (application)REF:874 OBJ: Describe the structure and function of the cardiopulmonary system.

13. A patient has heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output? a. Myocardial contractility × Myocardial blood flow b. Ventricular filling time/Diastolic filling time c. Stroke volume × Heart rate d. Preload/Afterload

ANS: C Cardiac output can be calculated by multiplying the stroke volume and the heart rate. The other options are not measures of cardiac output. DIF:Understand (comprehension)REF:875 OBJ: Differentiate among the physiological processes of cardiac output, myocardial blood flow, and coronary artery circulation.

23. A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation? a. Anxiety over illness b. Decreased drive to breathe c. Increased metabolic demands d. Infection destroying lung tissues

ANS: C Increased body temperature (fever) increases the metabolic rate, thereby increasing carbon dioxide production. The increased carbon dioxide level stimulates an increase in the patient's rate and depth of respiration, causing hyperventilation. Anxiety can cause hyperventilation, but this is not the direct cause from a fever. Sleep causes a decreased respiratory drive; hyperventilation speeds up breathing. The cause of the fever in this question is unknown. DIF:Understand (comprehension)REF:877 OBJ: Discuss the effects of a patient's level of health, age, lifestyle, and environment on oxygenation.

9. While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record? a. Atrial fibrillation b. Myocardial ischemia c. Left-sided heart failure d. Right-sided heart failure

ANS: C Left-sided heart failure results in pulmonary congestion, the signs and symptoms of which include shortness of breath, cough, crackles, and paroxysmal nocturnal dyspnea (difficulty breathing when lying flat). Right-sided heart failure is systemic and results in peripheral edema, weight gain, and distended neck veins. Atrial fibrillation is often described as an irregularly irregular rhythm; rhythm is irregular because of the multiple pacemaker sites. Myocardial ischemia results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet myocardial oxygen demands, producing angina or myocardial infarction. DIF:Apply (application)REF:878 OBJ: Assess for the physical manifestations that occur with alterations in oxygenation.

41. A patient with a pneumothorax has a chest tube inserted and is placed on low constant suction. Which finding requires immediate action by the nurse? a. The patient reports pain at the chest tube insertion site that increases with movement. b. Fifty milliliters of blood gushes into the drainage device after the patient coughs. c. No bubbling is present in the suction control chamber of the drainage device. d. Yellow purulent discharge is seen leaking out from around the dressing site.

ANS: C No bubbling in the suction control chamber indicates an obstruction of the drainage system. An obstruction causes increased pressure, which can cause a tension pneumothorax, which can be life threatening. The nurse needs to determine whether the leak is inside the thorax or in the tubing and act from there. Occasional blood gushes from the lung owing to lung expansion, as during a cough; this is reserve drainage. Drainage over 100 mL/hr after 3 hours of chest tube placement is cause for concern. Yellow purulent drainage indicates an infection that should be reported to the health care provider but is not as immediately life threatening as the lack of bubbling in the suction control chamber. DIF:Apply (application)REF:899 | 925 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Implementation

A nurse is teaching the patient with mitral valve problems about the valves in the heart. Starting on the right side of the heart, describe the sequence of the blood flow through these valves. 1. Mitral 2. Aortic 3. Tricuspid 4. Pulmonic a. 1, 3, 2, 4 b. 4, 3, 2, 1 c. 3, 4, 1, 2 d. 2, 4, 1, 3

ANS: C The blood flows through the valves in the following direction: tricuspid, pulmonic, mitral, and aortic. DIF:Understand (comprehension)REF:874 OBJ: Describe the structure and function of the cardiopulmonary system.

38. Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient? a. Discontinue the humidification delivery device to keep excess fluid from lungs. b. Monitor oxygen saturation, and frequently auscultate lung bases. c. Assist the patient to cough, turn, and deep breathe every 2 hours. d. Decrease fluid intake to 300 mL a shift.

ANS: C The goal of the nursing action should be the prevention of pneumonia; the action that best addresses this is to cough, turn, and deep breathe to keep secretions from pooling at the base of the lungs. Humidification thins respiratory secretions, making them easier to expel and should be used. Monitoring oxygen status is important but is not a method of prevention. Hydration assists in preventing hospital-acquired pneumonia. The best way to maintain thin secretions is to provide a fluid intake of 1500 to 2500 mL/day unless contraindicated by cardiac or renal status. Restricting fluids is contraindicated in this situation since there is no data indicating cardiac or renal disease. DIF:Apply (application)REF:892 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Implementation

24. A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step? 1. Insert catheter. 2. Apply suction and remove. 3. Have patient deep breathe. 4. Encourage patient to cough. 5. Attach catheter to suction system. 6. Rinse catheter and connecting tubing. a. 1, 2, 3, 4, 5, 6 b. 4, 5, 1, 2, 3, 6 c. 5, 3, 1, 2, 4, 6 d. 3, 1, 2, 5, 4, 6

ANS: C The steps for nasotracheal suctioning are as follows: Verify that catheter is attached to suction; have patient deep breathe; insert catheter; apply intermittent suction for no more than 10 seconds and remove; encourage patient to cough; and rinse catheter and connecting tubing with normal saline. DIF:Understand (comprehension)REF:907-911 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Implementation

11. A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium? a. Right ventricle, left ventricle, left atrium b. Left atrium, right ventricle, left ventricle c. Right ventricle, left atrium, left ventricle d. Left atrium, left ventricle, right ventricle

ANS: C Unoxygenated blood flows through the venae cavae into the right atrium, where it is pumped down to the right ventricle; the blood is then pumped out the pulmonary artery and is returned oxygenated via the pulmonary vein to the left atrium, where it flows to the left ventricle and is pumped out to the rest of the body via the aorta. DIF:Understand (comprehension)REF:874 OBJ: Describe the structure and function of the cardiopulmonary system.

14. A patient's heart rate increased from 94 to 164 beats/min. What will the nurse expect? a. Increase in diastolic filling time b. Decrease in hemoglobin level c. Decrease in cardiac output d. Increase in stroke volume

ANS: C With a sustained heart rate greater than 160 beats/min, diastolic filling time decreases, decreasing stroke volume and cardiac output. The hemoglobin level would not be affected. DIF:Understand (comprehension)REF:875 OBJ: Describe the relationship of cardiac output, preload, afterload, contractility, and heart rate to the process of oxygenation.

Which of the chambers of the heart becomes enlarged when mitral valve stenosis occurs? a. Right atrium b. Right ventricle c. Left atrium d. Left ventricle

Answer: c When the mitral valve is narrowed as in mitral stenosis, the left atrium has to generate more force to empty its contents, and left atrial enlargement may occur. The other three chambers of the heart may also enlarge, depending on where in the cardiovascular system the problem is occurring.

Which of the following oxygen masks has holes at the side that allow air to enter the mask? a. Partial rebreathing mask b. Nonrebreathing mask c. Simple face mask d. Nebulizer mask

ANS: C The holes in the mask allow the CO2 to escape on expiration, and if the oxygen is turned off, room air can be breathed through the holes.

A nurse is caring for a patient with sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.) a. Assist-control (AC) b. Pressure support ventilation (PSV) c. Bilevel positive airway pressure (BiPAP) d. Continuous positive airway pressure (CPAP) e. Synchronized intermittent mandatory ventilation (SIMV)

ANS: C, D Ventilatory support is achieved using a variety of modes, including continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). The purpose of CPAP and BiPAP is to maintain a positive airway pressure and improve alveolar ventilation. This prevents or treats atelectasis by inflating the alveoli, reducing pulmonary edema by forcing fluid out of the lungs back into circulation, and improving oxygenation in those with sleep apnea. AC, PSV, and SIMV are invasive mechanical ventilation and are not routinely used on patients with sleep apnea. AC delivers a set tidal volume (VT) with each breath, regardless of whether the breath was triggered by the patient or the ventilator. Synchronized intermittent mandatory ventilation like AC delivers a minimum number of fully assisted breaths per minute that are synchronized with the patient's respiratory effort. Any breaths taken between volume-cycled breaths are not assisted; the volume of these breaths is determined by the patient's strength, effort, and lung mechanics. PSV mode is often combined with SIMV mode: inspiratory pressure is added to spontaneous breaths to overcome the resistance of the endotracheal tube or to help increase the volume of the patient's spontaneous breaths. DIF:Apply (application)REF:897 OBJ: Describe nursing care interventions used to promote oxygenation in the primary care, acute care, and restorative and continuing care settings. TOP: Planning

47. The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method? a. A 5-year-old with excessive drooling from epiglottitis b. A 5-year-old with an asthma attack following severe allergies c. A 24-year-old with a right pneumothorax following a motor vehicle accident d. A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation

ANS: D Closed suctioning is most often used on patients who require invasive mechanical ventilation to support their respiratory efforts because it permits continuous delivery of oxygen while suction is performed and reduces the risk of oxygen desaturation. In this case, the acute respiratory distress syndrome requires mechanical ventilation. In the presence of epiglottitis, croup, laryngospasm, or irritable airway, the entrance of a suction catheter via the nasal route causes intractable coughing, hypoxemia, and severe bronchospasm, necessitating emergency intubation or tracheostomy. The 5-year-old child with asthma would benefit from an inhaler. A chest tube is needed for the pneumothorax. DIF:Analyze (analysis)REF:895 OBJ: Discuss the effects of a patient's level of health, age, lifestyle, and environment on oxygenation. TOP: Implementation MSC: Physiological Adaptation

22. The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia? a. Elevated blood pressure b. Increased pulse rate c. Restlessness d. Cyanosis

ANS: D Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. Elevated blood pressure, increased pulse rate, and restlessness are early signs of hypoxia. DIF:Understand (comprehension)REF:877 OBJ: Assess for the physical manifestations that occur with alterations in oxygenation.

exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process? a.Ventilation b.Surfactant c.Perfusion d.Diffusion

ANS: D Diffusion is the process of gases exchanging across the alveoli and capillaries of body tissues. Ventilation is the process of moving gases into and out of the lungs. Surfactant is a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing. Perfusion is the ability of the cardiovascular system to carry oxygenated blood to tissues and return deoxygenated blood to the heart. DIF:Understand (comprehension)REF:873 OBJ: Describe the physiological processes of ventilation, perfusion, and exchange of respiratory gases. TOP: Teaching/Learning MSC: Physiological Adaptation

39. The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider? a. Increased anterior-posterior diameter of the chest b. Accessory muscle used for breathing c. Clubbing of the fingers d. Hemoptysis

ANS: D Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies are needed to determine the cause of blood in the sputum. Clubbing of the fingers, barrel chest (increased anterior-posterior chest diameter), and accessory muscle use are all normal findings in a patient with emphysema. DIF:Apply (application)REF:882 OBJ: Assess for the physical manifestations that occur with alterations in oxygenation.

17. A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer? a. Diuretics b. Vasodilators c. Chest physiotherapy d. Intravenous (IV) fluids

ANS: D Preload is affected by the circulating volume; if the patient has decreased fluid volume, it will need to be replaced with fluid or blood therapy. Preload is the amount of blood in the left ventricle at the end of diastole, often referred to as end-diastolic volume. Giving diuretics and vasodilators will make the situation worse. Diuretics causes fluid loss; the patient is already low on fluids or the preload would not be decreased. Vasodilators reduced blood return to the heart, making the situation worse; the patient does not have enough blood and fluid to the heart or the preload would not be decreased. Chest physiotherapy is a group of therapies for mobilizing pulmonary secretions. Chest physiotherapy will not help this cardiovascular problem. DIF:Apply (application)REF:875 OBJ: Describe the relationship of cardiac output, preload, afterload, contractility, and heart rate to the process of oxygenation.

18. A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning? a. Pulse 75 b. Pulse 80 c. Oxygen saturation 91% d. Oxygen saturation 88%

ANS: D Stop when oxygen saturation is 88%. Monitor patient's vital signs and oxygen saturation during procedure; note whether there is a change of 20 beats/min (either increase or decrease) or if pulse oximetry falls below 90% or 5% from baseline. If this occurs, stop suctioning. A pulse rate of 75 is only 10 beats different from the start of the procedure. A pulse rate of 80 is 15 beats different from the start of suctioning. Oxygen saturation of 91% is not 5% from baseline or below 90%. DIF:Apply (application)REF:911 OBJ: Identify the clinical outcomes occurring as a result of hyperventilation, hypoventilation, and hypoxemia.

A patient with chronic pneumonia may be evaluated by a speech therapist for which cause? a. Chronic aspiration of liquids b. Hypoventilation due to smoking c. Hyperventilation due to anxiety d. Decreased respiratory effort due to scolioses

Answer: a. The speech therapist can perform a swallow study to determine whether thin liquids are being aspirated into the lung and recommend a regimen of thickened liquids and swallow exercises to prevent aspiration. A speech therapist would not be consulted in cases of hypoventilation or hyperventilation. Nursing measures and consulting the primary care practitioner are proper steps for these problems. A physical therapist may be consulted if scoliosis is hampering the patient's respirations.

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD). Which finding does the nurse anticipate when inspecting the chest? a. A ratio of 1:2 when comparing the side and front views of the chest b. A barrel chest c. A concave shape to the sternum d. A severe lateral curvature of the spine

Answer: b Chronic air trapping in COPD can cause a barrel-shaped chest. The intercostal spaces pull the chest out, and the accessory muscles of breathing may compensate to enlarge the chest cavity. The chest diameter ratio of 1:2 is the normal finding for a person who does not have overinflation of the lungs. A concave sternum is not an expected finding with COPD. A lateral curvature of the spine is consistent with scoliosis, which is not an expected finding for most patients with COPD.

Which situation contributes to cyanosis in the pulmonary patient? a. Increased PaCO2 levels b. Hemoglobin that is not saturated with oxygen c. Elevated white blood cell count d. Decreased PaCO2 levels

Answer: b Hemoglobin that is not saturated with oxygen causes a bluish decolorization of the skin. Increased or decreased levels of carbon dioxide (CO2) may indicate an acid-base imbalance. An elevated white blood cell count may indicate an infection.

Which is a goal for a patient with the nursing diagnosis of Ineffective Airway Clearance? a. Patient's respiratory secretions will become thicker so they are not moved when coughing. b. Patient's respiratory secretions will have a thinner consistency after being given a mucolytic agent. c. Patient will have improved range of motion while in bed. d. Patient's respiratory rate will increase to 28 breaths/min during hospitalization.

Answer: b The use of mucolytic agents may thin the secretions and allow easier removal. Thickened secretions in the airways can make it more difficult to cough effectively. The goal is to decrease the thickness of secretions. Improved range of motion relates to musculoskeletal problems. The normal respiratory rate is 12 to 20 breaths/min, and 28 breaths/min is considered tachypnea and is not desired.

A patient with chronic obstructive pulmonary disease (COPD) uses which drive to breathe? a. Increased PaCO2 b. Decreased hemoglobin c. Decreased PaO2 levels d. Increased PaO2 levels

Answer: c A person normally uses increased PaCO2 levels as the drive to breathe. A patient with COPD has chronic elevation of PaCO2 and has lost sensitivity to it as a drive to breathe. Instead, a decreased PaO2 level becomes the drive to breathe.

Which action does a nurse anticipate when suctioning a patient with excessive secretions? a. Decrease the patient's oxygen flow rate before beginning the deep suctioning. b. Avoid lubricating the catheter tip to prevent getting the substance in the lung tissues. c. Limit the time that the catheter is suctioning to prevent excessive loss of oxygen during the process. d. Flush the artificial airway with 3 mL of tap water to loosen secretions before suctioning.

Answer: c Oxygen is removed during the suctioning procedure, and the amount of time needs to be limited. In some cases, the nurse provides extra oxygen during suctioning procedures, and decreasing the oxygen is contraindicated. Lubrication of the catheter tip with normal saline solution (NSS) is indicated and does not damage the lungs. Tap water is not sterile and should not be introduced into the airway. Evidence-based practice show that flushing with sterile NSS has no benefit, because saline does not mix with secretions, and the procedure may have negative emotional effects for the patient.