Oxygenation (NCLEX)

A patient is brought to the emergency department unconscious following a barbiturate overdose. Which potential complication will the nurse include when developing the plan of care? a. Hypercapnic respiratory failure related to decreased ventilatory effort b. Hypoxemic respiratory failure related to diffusion limitations c. Hypoxemic respiratory failure related to shunting of blood d. Hypercapnic respiratory failure related to inc

A

Gina, a home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? a. Hypoxia b. Delirium c. Hyperventilation d. Semiconsciousness

A

An experienced LPN/LVN, under the supervision of the team leader RN, is assigned to provide nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/LVN? Select all that apply. 1.) Auscultating breath sounds 2.) Administering medications via metered-dose inhaler (MDI) 3.) Completing in-depth admission assessment 4.) Checking oxygen saturation using pulse oximetry 5.)Developing the nursing care plan 6.) Evaluating the pat

124 The experienced LPN/LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/LVN. Independently completing the admission assessment, developing the nursing care plan, and evaluating a patient's abilities require additional education and skills within the scope of practice of the professional RN.

A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse should implement which activities? Select all that apply. 1.Suctioning the client as needed 2.Encouraging coughing every 2 hours 3.Placing the bed in low Fowler's position 4.Supporting the neck incision when the client coughs 5.Monitoring the respiratory status frequently

1245

A patient admits to the E.D. with fractures of 3 lower ribs. Which of the following is the priority concern of the nurse caring for this patient? 1) infection risk 2) pain 3) hemorrhage risk 4) airway maintenance

3

The nurse enters the patient's room at the beginning of her shift. The patient is 3 days post-op right-sided pneumonectomy. Which of the following findings requires most immediate intervention by the nurse? 1) The patient is slowly sipping iced water. 2) The CNA reports that urinary output for the last 6 hours is 200 mL. 3) The patient is positioned on her left side with SCDs in place. 4) The patient reports pain at 9/10.

3 The post-op pneumonectomy patient should be positioned on the OPERATIVE (bad) side OR on the back. Sipping iced water in itself isn't harmful to this patient. Urinary output is sufficient. Pain is expected, although this would be the nurse's second concern.

The amount of air inspired and expired with each breath is called: a. tidal volume. b. residual volume. c. vital capacity. d. dead-space volume.

A

A nurse is caring for a 29 year-old patient on a med-surg unit with 3 lower rib fractures. Which of the following findings, if noted by the nurse, is most concerning? 1) Patient rates pain 8/10. 2) Patient reports feeling muscle spasms over the fracture area when he coughs. 3) Patient's temperature is 99.8F. 4) The nurse feels a crackling, grating sensation over the lower ribs.

3 This patient has spiked a fever which, even though it is slight, could be indicative of pneumonia or atelectasis. This needs to be further investigated. Crepitus and muscle spasms over the area are expected. Extreme pain is also expected, and would be the nurse's immediate concern after addressing the patient's elevated temperature.

The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the LPN? 1. The client with pneumonia who has a pulse oximeter reading of 91%. 2. The client with a hemothorax who has Hgb of 9 mg/dL and Hct of 20%. 3. The client with chest tubes who has jugular vein distention and BP of 96/60. 4. The client who is two (2) hours post-bronchoscopy procedure.

4

The critical care charge nurse is responsible for the care of four patients receiving mechanical ventilation. Which patient is most at risk for failure to wean and ventilator dependence? a. A 68-year-old patient with a history of smoking and emphysema b. A 57-year-old patient who experienced a cardiac arrest c. A 49-year-old postoperative patient who had a colectomy d. A 29-year-old patient who is recovering from flail chest

A

The nurse will monitor for clinical manifestations of hypercapnia when a patient in the emergency department has a. chest trauma and multiple rib fractures. b. carbon monoxide poisoning after a house fire. c. left-sided ventricular failure and acute pulmonary edema. d. tachypnea and acute respiratory distress syndrome (ARDS).

A

The unlicensed assistive personnel (UAP) is assisting with feeding for a patient with severe end-stage chronic obstructive pulmonary disease (COPD). Which instruction will the nurse provide the UAP? A.) Encourage the patient to eat foods that are high in calories and protein. B.) Feed the patient as quickly as possible to prevent early satiety. C.) Offer lots of fluids between bites of food. D.) Try to get the patient to eat everything on the tray

A

Which of the following statements is true regarding oxygen toxicity? A) It can occur in patients who inhale greater than 50% oxygen for more than 24 hours. B) It causes destruction of oxygen-free radicals. C) The most common presenting symptom is respiratory depression. D) Chest radiography is a useful tool for early diagnosis.

A

Which of the following nursing diagnoses would be the most important yet relevant nursing diagnosis for the patient diagnosed with having a pulmonary contusion? A) Fluid Volume Overload B) Imbalanced Nutrition: Less than body requirements C) Acute Pain D) Risk for Infection

A Fluid volume overload would be appropriate for this client because of the fluid build-up occurring in the lungs (AEB: Crackles, decreased breath sounds, etc.). This build-up is caused by the bruising and edema pulling fluid from the vascular spaces.

The unlicensed assistive personnel (UAP) tells the nurse that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should the nurse suggest to the UAP to improve the patient's comfort for this problem? A.) Humidify the patient's oxygen. B.) Use a simple face mask instead of a nasal cannula. C.) Provide the patient with an extra pillow. D.) Have the patient sit up in a chair at the bedside.

A When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Applying water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.

Which of the following would the nurse anticipate being ordered for the patient with pulmonary contusion? SATA: A) IV fluids B) Intubation/mechanical ventilation C) Opioids D) Antibiotics E) Albumin

ABCD IV fluids would be necessary to prevent hypovolemia because of the fluid that is leaving the vascular spaces into the lungs/pleural spaces. This must be administered judiciously to prevent fluid volume overload or worsening lung function. Intubation or mechanical ventilation may be ordered, if pulmonary contusion is severe. Opioids are often used for pain relief. Antibiotics would be administered prophylactically to prevent infection from arising. Albumin would not be given in this disorder.

A black male client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the: a. lips. b. mucous membranes. c. nail beds. d. earlobes

B

A female client with interstitial lung disease is prescribed prednisone (Deltasone) to control inflammation. During client teaching, the nurse stresses the importance of taking prednisone exactly as prescribed and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience: a. hyperglycemia and glycosuria. b. acute adrenocortical insufficiency. c. GI bleeding. d. restlessness and seizures.

B

A male adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? a. Immediately before a meal b. At least 2 hours after a meal c. When bronchospasms occur d. When secretions have mobilized

B

A patient has been on a non-rebreathing mask at 10 L/min for 4 days and is complaining of a dry cough, a stuffy nose, and substernal chest pain (pain score, 6 of 10) that increases with deep breathing. The chest radiograph shows no changes, and the 12-lead electrocardiography (ECG) findings are normal. The nurse suspects the patient is experiencing: A) hypercapnia. B) oxygen toxicity. C) unstable angina. D) absorption atelectasis.

B

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? a. Position the patient so that the left chest is dependent. b. Tape a nonporous dressing on three sides over the chest wound. c. Cover the sucking chest wound firmly with an occlusive dressing. d. Keep the head of the patient's bed at no more than 30 degrees elevation.

B

A patient with hypercapnic respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. Which collaborative intervention will the nurse anticipate? a. Administration of 100% oxygen by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of bilevel positive pressure ventilation (BiPAP)

B

Mr. J, a 26-year-old patient with diabetes, is admitted to the unit in severe diabetic ketoacidosis. His pH is 7.29. Understanding the principles of the oxyhemoglobin dissociation curve, you would expect which finding when you measure his SaO2? A) The SaO2 may be higher than normal. B) The SaO2 may be lower than normal. C) The SaO2 is not affected because he does not have pulmonary disease. D) You must know the HCO3- before you can predict changes in the SaO2.

B

The RN is teaching an unlicensed assistive personnel (UAP) to check oxygen saturation by pulse oximetry. What will the nurse be sure to tell the UAP about patients with darker skin? A.) "Be aware that patients with darker skin usually show a 3% to 5% higher oxygen saturation compared with light-skinned patients." B.) "Usually dark-skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients." C.) "With a dark-skinned patient, you may get more accurate r

B

The nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns the nurse immediately? A.) Fine bibasilar crackles B.) Respiratory rate of 8 breaths/min C.) The patient sitting up and leaning over the nightstand D.) A large barrel chest

B

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled b. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath c. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temp

B

Which of the following would be most appropriate for a male client with an arterial blood gas (ABG) of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3 24 mEq/L, and PaO2 94 mm Hg? a. Administer a prescribed decongestant. b. Instruct the client to breathe into a paper bag. c. Offer the client fluids frequently. d. Administer prescribed supplemental oxygen.

B

After receiving change-of-shift report, which patient will the nurse assess first? a. A patient with cystic fibrosis who has thick, green-colored sputum b. A patient with pneumonia who has coarse crackles in both lung bases c. A patient with emphysema who has an oxygen saturation of 91% to 92% d. A patient with septicemia who has intercostal and suprasternal retractions

D

After the respiratory therapist performs suctioning on a patient who is intubated, the unlicensed assistive personnel (UAP) measures vital signs for the patient. Which vital sign value should the UAP be instructed to report to the RN immediately? a. Heart rate of 98 beats/min b. Respiratory rate of 24 breaths/min c. Blood pressure of 168/90 mm Hg d. Tympanic temperature of 101.4°F (38.6°C)

D

A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of: A. Pulmonary Embolism B. Right pneumothorax C. Displaced endotracheal tube D. Acute respiratory distress syndrome

B Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi.

When the nurse is caring for an obese patient with left lower lobe pneumonia, gas exchange will be best when the patient is positioned a. on the left side. b. on the right side. c. in the tripod position. d. in the high-Fowler's position.

B The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions.

Before seeing a newly assigned female client with respiratory alkalosis, the nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? a. Myasthenia gravis b. Type 1 diabetes mellitus c. Extreme anxiety d. Narcotic overdose

C

Mr. D, a 28-year-old man, has been admitted to the intensive care unit for monitoring after a motor vehicle accident (MVA). Your physical assessment reveals multiple abrasions and bruising across the chest but an otherwise healthy young man. Suddenly, Mr. D complains of difficulty breathing. You quickly perform an assessment of his respiratory status and observe that his O2 saturation has dropped dramatically, there are decreased breath sounds on the left, and it appears that there is some trach

C

The nurse is caring for a 22-year-old patient who came to the emergency department with acute respiratory distress. Which information about the patient requires the most rapid action by the nurse? a. Respiratory rate is 32 breaths/min. b. Pattern of breathing is shallow. c. The patient's PaO2 is 45 mm Hg. d. The patient's PaCO2 is 34 mm Hg.

C

The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patients airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed? A) Continue suctioning the patient until no more secretions are obtained. B) Perform chest physiotherapy rather than nasotracheal suctioning. C) Wait several minutes and then repeat suctioning. D) Perform postural drainage and then repeat suctioning.

C

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.

C

The patient arrives to the ED and you are told by the reporting nurse that the patient is suspected of having flail chest. Which of the following would the nurse assess for first? A) Palpate the thorax for a crackling, grating sound B) Ask pt. pain level and location C) Monitor respirations D) Assess blood pressure and heart rate

C In order to look for s/s of flail chest, the most important assessment sign to watch for is paradoxical chest movement, which could be found by monitoring respirations. Palpating the thorax could cause further damage to the ribs. It would be very important to assess pain and bp and hr (bleeding) but these will not help confirm the suspected diagnosis.

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months of experience) floated from the surgical unit to the medical unit? A.) A 58-year-old patient on airborne precautions for tuberculosis (TB) B.) A 65-year-old patient who just returned from bronchoscopy and biopsy C.) A 72-year-old patient who needs teaching about the use of incentive spirometry D.)A 69-year-old patient with chronic obstructive pulmonary disease (COPD) who

C Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. Also, a fairly new nurse should be assigned more stable and less complicated patients. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized and careful assessment and monitoring after the procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.

The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? a. Administer the scheduled IV antibiotic. b. Give the PRN acetaminophen (Tylenol) 650 mg. c. Obtain oxygen saturation using pulse oximetry. d. Notify the health care provider of the patient's vital signs.

C The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Administration of the scheduled antibiotic and administration of Tylenol also will be done, but they are not the highest priority for a patient who may be developing ARDS.

At 11 p.m., a male client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86% and he's still wheezing. The nurse should plan to administer: a. alprazolam (Xanax). b. propranolol (Inderal) c. morphine. d. albuterol (Proventil).

D

A female client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range? a. 1 to 2 mcg/ml b. 2 to 5 mcg/ml c. 5 to 10 mcg/ml d. 10 to 20 mcg/ml

D

A male client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? a. pH, 5.0; PaCO2 30 mm Hg b. pH, 7.40; PaCO2 35 mm Hg c. pH, 7.35; PaCO2 40 mm Hg d. pH, 7.25; PaCO2 50 mm Hg

D

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.

D

After change-of-shift report, which patient should the nurse assess first? a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C) c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

D

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."

D

When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first? a. Check pupil reaction to light. b. Notify the health care provider. c. Attempt to calm and reassure the patient. d. Assess oxygenation using pulse oximetry.

D

Which of the following statements is true about intrapleural (the space between the parietal and visceral or pulmonary pleurae) pressure under normal conditions? A. It is always positive B. It is negative during inhalation; positive during exhalation C. It is positive during inhalation; negative during exhalation D. It is always negative

D