Concept of Oxygenation

A nurse is administering moderate sedation to a client with chronic obstructive pulmonary disease (COPD). The nurse bases her next action on the principle that:

It may be necessary to raise the head of this client's bed.

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for receiving oxygenated blood from the lungs?

Left atrium

After surgical repair of a cleft lip, an infant exhibits difficulty breathing. Which measure should the nurse institute first?

Open the infant's airway.

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?

PaO2

A client in her 29th week of gestation reports dizziness and clamminess when assuming a supine position. During the assessment, the nurse observes there is a marked decrease in the client's blood pressure. Which intervention should the nurse implement to help alleviate this client's condition?

Place the client in the left lateral position.

A client has a central venous catheter inserted into the subclavian vein. The nurse assesses the client immediately following the insertion of the catheter and notes a sudden onset of chest pain and shortness of breath. Which of the following complications should the nurse be prepared to treat?

Pneumothorax

A client with a history of allergy-induced asthma, hypertension, and mitral valve prolapse is admitted to an acute care facility for elective surgery. The nurse obtains a complete history and performs a thorough physical examination. When percussing the client's chest wall, the nurse expects to elicit:

Resonant sounds

A nurse is caring for a client who has been administered an epidural block. Which should the nurse assess next?

Respiratory rate

A newborn has been diagnosed with a congenital heart disease. Which congenital heart disease is associated with cyanosis?

Tetralogy of Fallot

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.

Which of the following is the most important consideration when performing tracheotomy suctioning?

The client should be hyper-oxygenated, then suctioned for the duration of 10 to 15 seconds.

A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth?

The pons

A nurse advises a patient with a casted femur fracture to check for signs of a fat embolism. She tells the patient that the onset of symptoms for FES occur:

W/in 12-48 hours

The nurse has administered oral penicillin as ordered for prophylaxis of endocarditis. The nurse instructs the parents to immediately report which reaction?

Wheezing

A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure? Select all that apply.

Withhold food and fluids until the client's gag reflex returns. Assess for hemoptysis and frank bleeding. Monitor the client's vital signs.

On the second postoperative day after an abdominal hysterectomy, the client develops a temperature of 100.4° F (38° C). The nurse's first action should be to:

ensure that the client takes at least 10 deep breaths every hour.

A nurse is reviewing the medications used by a client who has chronic bronchitis and a history of high blood pressure and prostate enlargement. The nurse should verify that the client understands how to use which medications? Select all that apply.

guaifenesin with dextromethorphan liquid generic pseudoephedrine tablets

The nurse is assisting with spirometry testing for a 6-year-old child with asthma. Which of the following instructions is most important for the nurse to give the child to obtain an accurate reading?

"Breathe out as hard as possible, and then breathe in deeply."

A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) who is being discharged after treatment for an acute exacerbation. Which statement by the client indicates proper understanding of the discharge instructions?

"I should try to eat several small meals during the day."

Which action should the nurse take first in caring for a client during an acute asthma attack?

Administer bronchodilator as ordered.

The nurse observes that a client who has received midazolam for conscious sedation is having shallow respirations. The nurse should do all except:

Administer naloxone

The nurse examines a 26-week-old premature infant. The skin temperature is lowered. What could be a consequence of the infant being cold?

Apnea

Which nursing intervention is the priority for a client in myasthenic crisis?

Assessing respiratory effort

Which medication is used for symptomatic bradycardia unresponsive to ventilation and oxygenation?

Atropine

The nurse is assessing a client who has just given birth and notes her pre-labor vital signs reveal a temperature 98.8oF (37.1oC), blood pressure 120/70 mm Hg, HR 80, and RR 20. Which current vital sign assessment should the nurse prioritize now?

Blood pressure 90/50 mm Hg, pulse 120 beats/min, respirations 24 breaths/min.

Which practice should a nurse recommend to a client who has had a cesarean birth?

Coughing and deep-breathing exercises

The nurse is obtaining data on an older adult client. What finding may indicate to the nurse the early symptom of heart failure?

Dyspnea on exertion

A patient is admitted to the hospital and is being evaluated for heart failure. Which diagnostic study is usually performed to confirm the diagnosis of heart failure?

Echocardiogram

Fetal circulation differs from the circulatory path of the newborn infant. In utero the fetus has a hole connecting the right and left atria of the heart. This allows oxygenated blood to quickly pass to the major organs of the body. What is this hole called?

Foramen ovale

A patient has a hemoglobin level of 7 g/dL. What should the nurse be alert to assess for?

Hypoxia

A client with chest pain, dyspnea, and an irregular heartbeat comes to the emergency department. An electrocardiogram shows a heart rate of 110 beats/minute (sinus tachycardia) with frequent premature ventricular contractions. Shortly after admission, the client has ventricular tachycardia and becomes unresponsive. After successful resuscitation, the client is taken to the intensive care unit (ICU). Which nursing diagnosis is the priority at this time?

Ineffective tissue perfusion (cardiopulmonary) related to arrhythmia

The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that apply.

A client who is on complete bed rest following extensive spinal surgery. A client who has a large venous stasis ulcer on the right ankle area. A client who has recently been admitted with a broken femur and is awaiting surgery. A client who has undergone a total vaginal hysterectomy and is now on estrogen replacement

The parents of a 30-month-old girl have brought her into the emergency department because she had a seizure. During the health history, the nurse suspects the child had a breath-holding spell. Which parental report suggests breath-holding?

A tantrum preceded the event.

Which of the following would be inconsistent as criterion of extubation in the patient who has undergone a coronary artery bypass graft (CABG)?

Inability to speak

A client has a chest tube inserted for the treatment of a pneumothorax. While turning in the bed, the client dislodges the tube and it is found in the bed. As the registered nurse is directing the health care team, place the actions of the registered nurse in the correct order. All options must be used.

Apply an occlusive dressing over the puncture site Tape the dressing on three sides Direct the licensed practical/vocational nurse (LPN/VN) to notify the health care provider. Assess the client's respiratory status. Assess vital signs and await further medical orders

In a patient who is to be given vecuronium (Norcuron), anesthesia is induced before neuromuscular blockade is started. What is the reason for this?

Because it helps prevent the patient from undergoing the frightening experience of paralysis and the inability to breathe

A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated?

Dull

The nurse enters a client's room and finds the client slumped over in a chair. What actions should the nurse take? Place in sequential order. Use all the options.

Establish unresponsiveness. Activate resuscitation team. Place the client on a firm surface. Check pulse. Begin cycles of 30 compressions and 2 breaths.

The client with a fractured left humerus reports dyspnea and chest pain. Pulse oximetry is 88%. Temperature is 100.2 degrees Fahrenheit (38.5 degrees Centigrade); heart rate is 110 beats per minute; respiratory rate is 32 breaths per minute. The nurse suspects the client is experiencing:

Fat embolism syndrome

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?

Increased intracranial pressure (ICP)

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

Partial pressure of arterial oxygen (PaO2)

Which is an infection-related cause of delirium?

Pneumonia

The nurse caring for a client in preterm labor observes abnormal fetal heart rate (FHR) patterns. Which nursing intervention should the nurse perform next?

administration of oxygen by mask

A client has been admitted to the coronary care unit. The nurse observes third-degree heart block at a rate of 35 bpm on the client's cardiac monitor. The client has a blood pressure of 90/60 mm Hg. The nurse should first:

prepare for transcutaneous pacing.

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?

High-protein

When assessing a client with partial-thickness burns over 60% of the body, which finding should the nurse report immediately?

Hoarseness of the voice

Which cells release erythropoietin and renin in response a decrease in the pressure of the blood entering the glomerulus?

Juxtaglomerular cells

A nurse is assessing a child brought to the emergency department. The child has a fever of 102.4 degrees F. The nurse continues the assessment, integrating knowledge that which of the following reflects the effect of fever on the basal metabolic rate?

Tachypenea

A G2P1 woman is in labor attempting a VBAC, when she suddenly complains of light-headedness and dizziness. An increase in pulse and decrease in blood pressure is noted as a change from the vital signs obtained 15 minutes prior. The nurse should investigate further for additional signs or symptoms of which complication?

Uterine rupture