Oxygenation / Gas Exchange EAQ Quiz
A client undergoes an abdominal cholecystectomy with common duct exploration. In the immediate postoperative period the priority nursing action is: 1 Irrigating the T-tube every hour 2 Changing the dressing every two hours 3 Encouraging coughing and deep breathing 4 Promoting an adequate fluid and food intake
3 Encouraging coughing and deep breathing Self-splinting results in shallow breathing, which does not aerate the lungs adequately, particularly the lower right lobe. The T-tube is never irrigated; it drains by gravity until the edema in the operative area subsides; the physician then removes the tube. The nurse does not change the dressing in the immediate postoperative period; the client's respiratory status takes priority. The client will be nothing by mouth immediately after surgery.
A health care provider prescribes daily sputum specimens to be collected from a client. When is the most appropriate time for the nurse to collect these specimens? 1 After activity 2 Before meals 3 On awakening 4 Before a respiratory treatment
3 On awakening During sleep, mucous secretions in the respiratory tract move slowly toward the throat. On awakening, increased ciliary motion raises these secretions more vigorously, thus facilitating expectoration and the collection of sputum specimens. Although activity mobilizes secretions, no secretions may be present at the time of activity; sputum is most plentiful upon arising. The sputum may leave an unpleasant taste in the mouth, which may interfere with appetite. Sputum more likely would be collected after, not before, a respiratory treatment, because this mobilizes secretions.
A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? 1 Productive cough 2 Clubbing of the fingertips 3 Crackles at the height of inhalation 4 Diminished breath sounds on auscultation
4 Diminished breath sounds on auscultation Atelectasis refers to the collapse of alveoli; breath sounds over the area are diminished. A productive cough most often is associated with inflammation or infection, not atelectasis. Clubbing of the fingertips is a late sign of chronic hypoxia related to prolonged obstructive lung disease. Crackles at the height of inhalation are not specific to atelectasis. Crackles are associated with fluid in the alveoli, which occurs with heart failure and pulmonary edema. Test-Taking Tip: A psychological technique used to boost your test-taking confidence is to look into a mirror whenever you pass one and say out loud, "I know the material, and I'll do well on the test." Try it; many students have found that it works because it reduces "test anxiety."
A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's blood studies indicate pH 7.30, Po2 60 mm Hg, Pco2 55 mm Hg, and HCO3 23 mEq/L. The nurse concludes that the client is experiencing: 1 Hypocapnia 2 Hyperkalemia 3 Generalized anemia 4 Respiratory acidosis
4 Respiratory acidosis The pH is less than the norm of 7.35 to 7.45, indicating acidosis. The Po2 is less than the norm of 80 to 100 mm Hg. The Pco2 is increased more than the norm of 35 to 45 mm Hg. The HCO3 is within the norm of 23 to 28 mEq/L. These results indicate a respiratory etiology. The client's carbon dioxide level is increased, not decreased. These values are unrelated to hyperkalemia; a serum potassium level more than 5 mEq/L indicates hyperkalemia. These values are unrelated to anemia; decreased levels of red blood cells (RBCs), Hb, and Hct are related to anemia.
A nurse in the post-anesthesia care unit is caring for a client who just had a thyroidectomy. For which client response is it most important for the nurse to monitor? 1 Urinary retention 2 Signs of restlessness 3 Decreased blood pressure 4 Signs of respiratory obstruction
4 Signs of respiratory obstruction The first and most important observation should be for respiratory obstruction. If this occurs, treatment must be instituted immediately. Urinary retention is a later concern; urinary retention will not occur in the immediate postoperative period. Signs of restlessness may result from the anesthesia; however, it is not life-threatening and usually passes. The blood pressure is not significantly affected by this type of surgery; however, surgery itself can influence blood pressure. If the blood pressure significantly increases, other symptoms of thyroid crisis (storm) will be present.
The nurse is providing immediate postoperative care to a client who had a thyroidectomy. The nurse should monitor the client for which clinical manifestation? 1 Urinary retention 2 Signs of restlessness 3 Decreased blood pressure 4 Signs of respiratory obstruction
4 Signs of respiratory obstruction The first and most important observation should be for signs of respiratory obstruction. Tracheal compression can occur because of edema in the surgical area. Tracheal compression is exhibited by decreased inspiratory/expiratory pressure, decreased ventilation, dyspnea, shortness of breath, tachypnea, tachycardia, nasal flaring, use of accessory muscles to breathe, cyanosis, reduced oxygen saturation, and altered arterial blood gases. Although urinary retention is a concern after anesthesia, it is not life threatening. Signs of restlessness may be a result of the anesthesia; however, if it is because of a lack of oxygenation, assessing for respiratory obstruction is a more direct and objective assessment associated with this surgery. The blood pressure is not significantly affected by this type of surgery unless thyroid storm occurs; when assessing for thyroid storm all the vital signs will increase.
A client is to undergo amniocentesis at 38 weeks' gestation to determine fetal lung maturity. What lecithin/sphingomyelin ratio (L/S ratio) is adequate for the nurse to conclude that the fetus' lungs are mature enough to sustain extrauterine life? 1 2:1 2 1:1 3 1:4 4 3:4
1 2:1 The lecithin concentration increases abruptly at 35 weeks, reaching a level that is twice the amount of sphingomyelin, which decreases concurrently. At 30 to 32 weeks' gestation, the amounts of lecithin and sphingomyelin are equal, indicating lung immaturity. A ratio of 1:4 does not reflect fetal lung maturity; nor does a ratio of 3:4. Test-Taking Tip: Read every word of each question and option before responding to the item. Glossing over the questions just to get through the examination quickly can cause you to misread or misinterpret the real intent of the question.
A person's bathrobe ignites while the individual is cooking in the kitchen on a gas stove. What is the priority intervention after the flames are extinguished? 1 Assess the person's breathing 2 Offer the person sips of water 3 Cover the person with a warm blanket 4 Calculate the extent of the person's burns
1 Assess the person's breathing A patent airway is most vital; if the person is not breathing, cardiopulmonary resuscitation (CPR) should be initiated. The person should be kept nothing by mouth because extensive burns decrease intestinal peristalsis and the person may vomit and aspirate. Covering the person with a warm blanket is not done until the assessment for breathing is completed. Calculating the extent of the person's burns is not the priority; this assessment is done after transfer to a medical facility. Test-Taking Tip: Watch for grammatical inconsistencies. If one or more of the options is not grammatically consistent with the stem, the alert test taker can identify it as a probable incorrect option. When the stem is in the form of an incomplete sentence, each option should complete the sentence in a grammatically correct way.
A client with a history of closed-angle glaucoma is scheduled for abdominal surgery. Because the client is extremely anxious, surgery is to be performed under general anesthesia. What should the nurse teach the client to do to prevent respiratory complications postoperatively? 1 Deep-breathing techniques 2 Performing productive coughing 3 Turning from side to side frequently 4 Pant breathing while gently closing the eyelids
1 Deep-breathing techniques Deep breathing is an intervention to prevent respiratory complications that does not increase intraocular pressure. Coughing is contraindicated because it increases intraocular pressure. Although turning from side to side is permitted, it is not as effective as deep breathing in preventing respiratory complications. Pant breathing is shallow breathing and will not prevent respiratory complications.
The nurse is caring for a school-aged child with cystic fibrosis. Which pathophysiological factor has the greatest impact on the child's health status and is of priority in the care plan? 1 Extremely thick mucus causes obstructed airways. 2 There is acute inflammation of the lung parenchyma. 3 Endocrine glands secrete increased levels of hormones. 4 Increased irritability of the airways results in obstruction.
1 Extremely thick mucus causes obstructed airways. Dysfunction of the exocrine glands leads to an excessive accumulation of thick mucus, a slower flow rate of mucus, and incomplete expectoration of mucus, all of which contribute to airway obstruction. Acute inflammation of the lung parenchyma is associated with pneumonia, not cystic fibrosis. The endocrine glands are not affected in cystic fibrosis. Increased irritability of the airways causes obstruction and is associated with asthma, not cystic fibrosis.
In the second stage of labor the nurse should plan to discourage a client from holding her breath longer than 6 seconds while pushing with each contraction. What complication does this prevent? 1 Fetal hypoxia 2 Perineal lacerations 3 Carpopedal spasms 4 Maternal hypertension
1 Fetal hypoxia Prolonged breath holding at this stage of labor can result in decreased placental/fetal oxygenation, which could lead to fetal hypoxia. Perineal lacerations occur with rapid, uncontrolled expulsion of the fetus. Carpopedal spasms and maternal hypertension are not caused by prolonged holding of the breath.
The nurse is developing a plan of care for a client that had a chest tube removed. To promote respiratory exchange, the plan should include: 1 Careful monitoring for crepitus 2 Coughing and deep breathing every hour 3 Bed rest with range-of-motion exercises 4 Covering the chest tube site with a sterile dressing
2 Coughing and deep breathing every hour Encouraging coughing and deep breathing every hour prevents atelectasis and collection of secretions and promotes respiratory exchange. Observing for dyspnea is important, but crepitus is unlikely to occur with stabilization of respiratory status. Activity should be promoted within limits of physical ability; bed rest is unnecessary. Covering the chest tube site does not promote respiratory exchange.
A nurse is providing morning hygiene to a bedridden client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). What is the priority nursing intervention when the client becomes short of breath during the care? 1 Obtain a pulse oximeter to determine the client's oxygen saturation level. 2 Put the client in a high-Fowler's position. 3 Darken the lights and provide a rest period of at least 15 minutes. 4 Continue the hygiene activities while reassuring the client
2 Put the client in a high-Fowler's position. Putting the client in the high-Fowler's position will help to expand lungs and decrease severity of shortness of breath. Leaving the client to obtain a pulse oximeter while the client is experiencing shortness of breath places the client in danger. Providing a rest period for at least 15 minutes may be appropriate but is not the priority. The nurse needs to acknowledge the change in the client's condition such as shortness of breath and take care of this immediate client need prior to continuing the hygiene activities.
A client is admitted to the emergency department with a stab wound of the chest. What is the priority when the nurse performs a focused assessment of the client's response to this injury? 1 Level of pain 2 Quality and depth of respirations 3 Amount of serosanguineous drainage 4 Blood pressure and pupillary response
2 Quality and depth of respirations The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is applicable in all clinical emergencies for immediate assessment and treatment. The approach likely improves outcomes by helping health care providers focus on the most life-threatening clinical problems. The rate and characteristics of respirations, in addition to the presence or absence of breath sounds, oxygen saturation, and unilateral chest movements, should be assessed so that the client's respiratory status can be determined. The concern is to identify a pneumothorax caused by the injury, which can be life threatening. Although important, pain is not a life-threatening symptom. Bleeding may accumulate in the pleural space, but it is inaccessible to direct observation. Excessive blood loss will cause a decreased blood pressure, but bleeding is indicated first by respiratory changes because the blood will accumulate in the pleural space; pupillary response is unaffected.
A nurse plans to set up emergency equipment at the bedside of a client in the immediate postoperative period after a thyroidectomy. What should the nurse include in the bedside setup? 1 Crash cart with bed board 2 Tracheostomy set and oxygen 3 Ampule of sodium bicarbonate 4 Airway and nonrebreather mask
2 Tracheostomy set and oxygen A tracheostomy set and oxygen are necessary if the client experiences an acute respiratory obstruction as a result of postoperative edema, nerve damage, or tetany. A cardiac arrest is not an expected response after thyroid surgery. Acidosis requiring sodium bicarbonate and cardiac arrest are not expected responses after a thyroidectomy. If the airway is obstructed by postoperative edema, the use of a mechanical airway will be ineffective because it will not reach beyond the point of the obstruction. A nonrebreather mask is designed to deliver high concentrations of oxygen. In the event of an airway obstruction, the client's need is to circumvent the obstruction, not deliver high concentrations of oxygen.
