EAQ - Oxygenation (Mastery)
The nurse caring for a patient who is experiencing a cardiac dysrhythmia would monitor the patient's oxygen saturation for which reason? 1. An abnormal conduction system decreases perfusion. 2. The fluid overload that occurs with a dysrhythmia decreases oxygenation. 3. The irregular cardiac rhythm causes changes to the thoracic cage, which interferes with breathing. 4. Inadequate red blood cell production associated with a dysrhythmia lowers oxygen levels.
1
The nurse expects which assessment finding in a patient with a long history of substance abuse? 1. Vasoconstriction of peripheral blood vessels 2. Elevated respiratory rate 3. Increased amount of inhaled oxygen 4. Increased hemoglobin production
1
The nurse identifies that which central nerve system alteration must be considered when caring for a patient who sustained a fracture of the C4 vertebrae? 1. Cervical trauma at C3 to C5 usually results in paralysis of the phrenic nerve. 2. Phrenic nerve paralysis may prevent anteroposterior chest expansion. 3. The vagus nerve may be paralyzed because of a fracture of the C4 vertebrae. 4. The vagus nerve may be paralyzed, reducing inspiratory lung volumes.
1
The nurse suspects which condition when a patient's assessment findings include increased blood pressure, tachycardia, dizziness, a decreased level of consciousness, and the need to sit in a high Fowler's position? 1. Hypoxia 2. Hyperlipidemia 3. Hypovolemia 4. Hyperventilation
1
When comparing invasive mechanical ventilation and noninvasive ventilation, the nurse identifies which advantage of the noninvasive type? 1. Noninvasive ventilation avoids the complication of sinusitis. 2. It is not associated with a feeling of claustrophobia. 3. A clinical indication for noninvasive ventilation is reversing atelectasis. 4. It can be used to either fully or partially replace spontaneous breathing.
1
Which action would the nurse perform first for a patient who is lying supine in bed and experiencing shortness of breath? 1. Raise the head of the bed to 45 degrees. 2. Assess the oxygen saturation with a pulse oximeter. 3. Obtain the blood pressure and respiratory rate. 4. Notify the health care provider of the patient's condition.
1
Which clinical manifestation is a late sign of hypoxia? 1. Cyanosis 2. Xanthelasma 3. Periorbital edema 4. Splinter hemorrhages
1
Which condition can cause reduced circulating blood volume and extracellular fluid loss? 1. shock 2. Pneumonia 3. Chest trauma 4. Multiple rib fractures
1
Which condition causes bluish discoloration of the skin and mucous membranes? 1. Нурохіа 2. Dehydration 3. Hyperlipidemia 4. Right-sided cardiac failure
1
Which laboratory value does the nurse assess to determine adequate oxygenation in a patient who is hospitalized with respiratory failure? 1. Arterial blood gases (ABGs) 2. Glycosylated hemoglobin Alc (HbAIc) 3. Complete blood count (CBC) 4. Comprehensive metabolic panel (CMP)
1
Which phrase defines hypoxia? 1. Inadequate tissue oxygenation at the cellular level 2. Decreased amount of arterial oxygen 3. Loss of extracellular fluid and reduced circulating blood volume 4. Rapid removal of carbon dioxide faster than it is produced by cellular metabolism
1
Which physiological process explains why a patient who has chills and a temperature of 104° F (40° C) is at risk of developing dyspnea? 1. Fever increases metabolic demands, requiring increased oxygen need. 2. Blood glucose stores are depleted, and the cells do not have energy to use oxygen. 3. Carbon dioxide production increases as a result of hyperventilation. 4. The small chest and lungs decrease the production of carbon dioxide and oxygen.
1
Which recommendation would the nurse make when teaching patients about preventing airborne allergen respiratory problems? 1. Discourage the patients from having an indoor cat or dog. 2. Encourage patients to restrict their activities. 3. Instruct patients to stay away from insects, especially bees. 4. Tell patients to limit their dietary intake of eggs.
1
Which statement by a patient indicates the need for further teaching regarding diaphragmatic breathing? 1. " should practice the exercise initially in the sitting position and then in the supine position." 2. "I should place one hand flat below the breastbone and the other hand flat on the abdomen." 3. "I should inhale slowly, making the abdomen push out and moving the lower hand outward." 4. "I should practice these exercises often with the pursed-lip breathing technique."
1
Which statement is true regarding respiratory physiology? 1. Ventilation is the process of moving gases into and out of the lungs. 2. The diaphragm is the major expiratory muscle of respiration. 3. Ventilation requires muscular properties irrespective of the elastic properties of the lungs. 4. The diaphragm is innervated by the phrenic nerve that exits the cranium.
1
Which statement made by a patient's caregiver indicates the need for further teaching regarding tracheostomy care at home? 1. "I should remove the outer cannula and perform the care." 2. "I should cover the tracheostomy when the patient is outside." 3. "I should perform tracheostomy care at least once a day." 4. " should report to the health care provider pain that persists longer than a week after insertion."
1
Which clinical manifestation occurs with right-sided heart failure? Select all that apply. One, some, or all responses may be correct. 1. Weight gain 2. Distended neck veins 3. Pedal edema 4. Heart murmur 5. Lung crackles
1, 2, 3
While assessing the patient with left-sided heart failure, which symptom would the nurse likely find? Select all that apply. One, some, or all responses may be correct. 1. Dyspnea 2. Fatigue 3. Dizziness 4. Peripheral edema 5. Distended neck veins
1, 2, 3
Which information about breathing patterns is true? Select all that apply. One, some, or all responses may be correct. 1. Bradypnea is less than 12 breaths per minute. 2. Tachypnea is greater than 20 breaths per minute. 3. Paradoxical breathing is asynchronous breathing. 4. Apnea is the absence of respirations for a period of time. 5. Cheyne-Stokes respiration is caused by increased blood flow.
1, 2, 3, 4
Which instruction would the nurse include in a teaching session about lifestyle practices to promote heart health? Select all that apply. One, some, or all responses may be correct. 1. Eat foods rich in fiber. 2. Participate in a muscle-strengthening activity at least 2 days a week. 3. Participate in aerobic exercise. 4. Consume a daily calorie intake of 3000 calories. 5. Exercise for at least 150 minutes a week.
1, 2, 3, 5
The nurse expects which pulmonary manifestation in a patient with underlying left-sided heart failure? Select all that apply. One, some, or all responses may be correct. 1. Paroxysmal nocturnal dyspnea 2. Difficulty breathing 3. Green-colored sputum 4. Bibasilar crackles 5. Crackles in apex of lungs on auscultation
1, 2, 4
Which information would the nurse share with the patient about the normal mechanism of respiration? Select all that apply. One, some, or all responses may be correct. 1. Normal breathing is quiet and accomplished with minimal effort. 2. Ventilation is the process of air moving in and out of the lungs. 3. Normal breathing requires all of the chest muscles. 4. The diaphragm is the major inspiratory muscle of respiration. 5. Ventilation is the process of oxygenated blood flowing in the body.
1, 2, 4
Which common symptom would the nurse find in a patient who experiences a myocardial infarction? Select all that apply. One, some, or all responses may be correct. 1. Crushing or squeezing chest pain 2. Pain that lasts less than 20 minutes 3. Pain not relieved by nitroglycerin 4. Spasms of the extremities 5. Pain at rest or exertion
1, 3, 5
Which instruction would the nurse include when teaching a patient about the procedure for diaphragmatic breathing? Select all that apply. One, some, or all responses may be correct. 1. "Inhale slowly to make the abdomen push out." 2. "Exhale rapidly to make the abdomen go in." 3. "Start practicing the technique in a supine position initially." 4. "Perform the technique in a prone position once you have learned it." 5. "Place one hand flat below the breastbone and the other hand flat on the abdomen."
1, 3, 5
Which statement is true about the various patterns of respiration? Select all that apply. One, some, or all responses may be correct. 1. Apnea is the absence of respirations for 15 seconds or longer. 2. Apnea is an example of paradoxical breathing. 3. Kussmaul respiration is the increase in rate and depth of breathing. 4. Kussmaul respiration is the body's attempt to compensate by increasing carbon dioxide levels. 5. Cheyne-Stokes breathing is a period of apnea following a period of deep breathing and then shallow breathing.
1, 3, 5
Which parameter would the nurse monitor in a patient who has developed hypoxia as a result of severe anemia? Select all that apply. One, some, or all responses may be correct. 1. Pulse rate 2. Skin turgor 3. Natriuretic peptide 4. Respiratory rate 5. Skin color change
1, 4, 5
Which physiological factor is a cause of hypoxia? Select all that apply. One, some, or all responses may be correct. 1. Anemia 2. Obesity 3. Kyphosis 4. Pregnancy 5. High altitude
1, 5
Carbon monoxide (CO) toxicity causes decreased oxygen-carrying capacity of the blood because of which physiological event? 1. It stimulates hyperventilation, causing respiratory alkalosis. 2. CO forms a strong bond with hemoglobin, creating a functional anemia. 3. It leads to hypoventilation, causing metabolic acidosis. 4. CO causes alveoli to overinflate, leading to atelectasis.
2
The nurse expects which assessment finding in a patient with anemia? 1. Flushed face 2. Increased heart rate 3. Irritability 4. Decreased breathlessness
2
The nurse loosens the tubing of a patient's nasal cannula to prevent which complication? 1. Epistaxis 2. Skin irritation 3. Нурохіа 4. Dry upper airway mucosa
2
When addressing orthopnea with a patient, which topic would the nurse discuss? 1. Exposure of patient to passive smoking 2. Shortness of breath affecting daily activities 3. Rating the shortness of breath on a scale of 0 to 10 4. The need to sleep in a recliner chair to breathe easier
2
Which cardiopulmonary abnormality is associated with chronic hypoxemia? 1. Dependent edema 2. Clubbing of nail beds 3. Neck vein distention 4. Splinter hemorrhages
2
Which condition causes a patient to experience cyanotic conjunctivae? 1. Fat embolus 2. Hypoxemia 3. Hyperlipidemia 4. Bacterial endocarditis
2
Which condition causes reduced tissue oxygenation because of decreased hemoglobin production? 1. Obesity 2. Anemia 3. Cystic fibrosis 4. Muscular dystrophy
2
Which intervention will relieve dryness of the mucous membranes for a patient having a chronic cough and an inability to expectorate secretions? 1. Giving a nebulizer treatment 2. Offering plenty of oral fluids 3. Administering 2 L/min of oxygen 4. Instilling normal saline into the patient's artificial airway
2
Which is the rationale for performing pulse oximetry on a patient who is cyanotic? 1. To monitor ventilation 2. To assess the oxygenation level 3. To obtain a biopsy specimen 4. To visualize the tracheobronchial tree
2
Which underlying physiological process is occurring in a patient who has severe dehydration and reports dizziness? 1. Impaired movement of the chest 2. Reduced circulating blood volume 3. Increased metabolic rate of the body 4. Decreased oxygen-carrying capacity of the blood
2
Peripheral cyanosis is seen in which body structure? Select all that apply. One, some, or all responses may be correct. 1. Sclera 2. Earlobe 3. Nail beds 4. Chest 5. Conjunctiva of the eye
2, 3
Which information would the nurse include when teaching a health awareness program on the ill effects of smoking? Select all that apply. One, some, or all responses may be correct. 1. Inhaled nicotine causes vasodilation of peripheral and coronary blood vessels. 2. Smoking has been linked to the development of lung cancer and myeloid leukemia. 3. Inhaled nicotine causes hypertension. 4. Exposure to secondhand smoke increases the risk of cardiovascular disease in the nonsmoker. 5. Smoking during pregnancy can cause low-birth-weight
2, 3, 4, 5
In which position would the nurse place a patient with a right lung abscess? 1. Supine position with both lungs at the same level 2. 45-degree semi-Fowler position with left lung down 3. 45-degree semi-Fowler position with right lung down 4. Supine position with left lung at slightly lower level than the right
3
In which position would the nurse place the patient to drain the apical segments of the lungs? 1. Prone with the thorax and abdomen elevated 2. Supine with the head elevated 3. Sitting on the side of the bed 4. Side-lying in the Trendelenburg position
3
The nurse recognizes which type of breathing pattern in a patient whose respirations are deep and at a rate of 40 breaths/min? 1. Apnea 2. Bradypnea 3. Kussmaul respiration 4. Cheyne-Stokes respiration
3
The nurse reviews a patient's cardiopulmonary health history and identifies that which diagnosis impacts cardiac oxygenation? 1. Hypovolemia 2. Cystic fibrosis 3. Angina pectoris 4. Atrial fibrillation
3
The nurse would report that a patient with a respiratory rate of 25 breaths/min has which condition? 1. Apnea 2. Bradypnea 3. Tachypnea 4. Orthopnea
3
Which assessment finding would indicate that a patient needs airway suctioning? 1. Occasionally coughing up thick sputum 2. After nebulization, coughing up thin sputum 3. Decreased independent ability to cough 4. Clear lung sounds only after coughing
3
Which condition involves collapsed alveoli that prevent the normal exchange of oxygen and carbon dioxide? 1. Acute pulmonary embolism 2. Kyphosis 3. Atelectasis 4. Myocardial infarction
3
Which condition is the consequence of using an oral airway that is too large? 1. Hypotension 2. Thick secretions 3. Airway obstruction 4. Aspiration of gastric contents
3
Which environmental factor would the nurse assess when evaluating a patient's respiratory status? 1. Stress 2. Substance abuse 3. Occupation 4. Usual daily fluid intake
3
Which information is correct regarding physiological factors that affect oxygenation? 1. Metabolic rate decreases normally in pregnancy, wound healing, and exercise. 2. The physiological response to chronic hypoxemia is an increase in white blood cell production. 3. Carbon monoxide (CO) poisoning decreases the oxygen-carrying capacity of the blood. 4. The oxygen-carrying capacity of the blood increases when there is a decline in inspired oxygen concentration.
3
Which information would the nurse include in a teaching session about substance abuse by teenagers? 1. Alcohol stimulates the respiratory center. 2. To produce a calming effect, paint thinner is huffed. 3. Nail polish remover is used for huffing. 4. With substance abuse, hemoglobin production increases.
3
Which physiological factor is directly responsible for a patient whose assessment findings include low hemoglobin, weakness, tachycardia, and pallor? 1. Increased metabolic rate 2. Altered electrical conduction 3. Decreased oxygen-carrying capacity 4. Reduced inspired oxygen concentration
3
Which physiological process occurs in anemia? 1. Decreased surfactant in the lungs 2. Decreased lung compliance 3. Decreased oxygenation of blood 4. Decreased fraction of inspired oxygen concentration
3
In which condition do the lungs remove carbon dioxide faster than it is produced by cellular metabolism? 1. Нурохіа 2. Hypoxemia 3. Hypovolemia 4. Hyperventilation
4
The nurse would expect to see an enlarged and calcified trachea and bronchi on the chest x-ray of which age population? 1. Toddlers 2. School-age children 3. Young adults 4. Older adults
4
Which action would the nurse take when a supine patient who has chronic obstructive pulmonary disease (COPD) and who is receiving oxygen at 2 L/min becomes short of breath? 1. Increase the flow of oxygen. 2. Perform tracheal suctioning. 3. Contact the health care provider. 4. Assist the patient to a semi-Fowler position.
4
Which adventitious lung sounds would the nurse hear upon auscultation of a patient with severe left-sided heart failure? 1. Sonorous wheezes in the left lower lung • 2. Rhonchi midsternum 3. Crackles in the apex of the lungs 4. Inspiratory crackles in the lung bases
4
Which condition causes central cyanosis on the patient's tongue, soft palate, and conjunctiva of the eye? 1. Dehydration 2. Kidney disease 3. Hyperlipidemia 4. Hypoxemia
4
Which condition causes hypoventilation in a patient who has a history of chronic obstructive pulmonary disease (COPD)? 1. Salicylate poisoning 2. Diabetic ketoacidosis 3. Amphetamine use 4. Administration of excessive oxygen
4
Which condition is likely induced by salicylate poisoning? 1. Atelectasis 2. Polycythemia 3. Hypovolemia 4. Hyperventilation
4
Which diagnostic test is used in the daily measurement for early detection of asthma exacerbations? 1. Lung scan 2. Thoracentesis 3. Pulmonary function test 4. Peak expiratory flow rate
4
Which diagnostic test provides instant feedback about a patient's oxygenation status? 1. Capnography 2. Bronchoscopy 3. Thoracentesis 4. Pulse oximetry
4
Which instruction would the nurse give to a patient with chronic obstructive pulmonary disease (COPD) who is sitting in a chair, attempting to perform diaphragmatic breathing exercises for the first time? 1. "You need to place your upper hand just above the breastbone." 2. "Because of your COPD, this type of exercise is contraindicated for you." 3. "You need to tighten your chest muscles while taking deep inspirations." 4. "You need to practice these exercises initially in the supine position."
4
Which reason would the nurse cite for increased risk of respiratory tract infections in school-age children? 1. Smaller volume of lungs 2. Narrow alveoli 3. Carbon monoxide poisoning 4. Secondhand smoke exposure
4
Which step of the nursing process is the nurse performing when suctioning a patient's tracheostomy? 1. Planning 2. Evaluation 3. Assessment 4. Implementation
4
