Chapter 32: Oxygenation

Which assessment findings indicate to the nurse that the patient is hypoxic? (select all that apply) a. Heart rate is 55 beats/minute and irregular. b. Urine output is 300 mL over the last 8 hours. c. The patient is drowsy and difficult to arouse. d. Hands and feet are pale and cool to the touch. e. Abdomen is soft with bowel sounds 4 quadrants

A,C,D

Which assessment findings indicate that the patient is at risk for developing ventricular fibrillation? (Select all that apply.) a. Serum potassium level 7.6 mEq/L b. Long history of coronary artery disease c. Impaired conduction through the SA node d. Recent incidents of ventricular tachycardia e. Vagal stimulation from removal of fecal impaction

A,B,D

Which interventions are appropriate for the patient with the nursing diagnosis decreased cardiac output related to reduced stroke volume and contractility? (Select all that apply.) a. Frequent lung sound assessment and continuous pulse oximetry. b. Strict intake and output monitoring with daily weights before breakfast. c. Administer oxygen to maintain pulse oximetry levels between 90% and 92%. d. Provide stool softeners and encourage dietary fiber to prevent constipation. e. Encourage the patient to consume additional salt to maintain blood pressure.

A,B,D

Which laboratory finding indicates that the body is attempting to compensate for the patient's end-stage chronic obstructive pulmonary disease (COPD)? a. Hemoglobin 22.1 g/dL b. Serum sodium 130 mEq/L c. Serum cholesterol 236 mg/dL d. Serum albumin level 4.8 g/dL

a. Hemoglobin 22.1 g/dL

The nurse is caring for a patient with a pulmonary embolism that prevents blood flow to the lower lobe of the right lung. Which breathing process is impaired for this patient? a. Perfusion b. Diffusion c. Respiration d. Ventilation

a. Perfusion

Which patient would benefit from education about pursed-lip breathing? a. A patient with emphysema after many years of smoking b. A patient with a pneumothorax and a chest tube to suction c. A patient with a tracheostomy following throat cancer surgery d. A patient with respiratory muscle paralysis after spinal cord injury

a. A patient with emphysema after many years of smoking

Which laboratory finding indicates that the patient is likely to experience hypoxemia? a. Hematocrit 31% b. Serum creatinine 0.8 mg/dL c. Glycosylated hemoglobin 7% d. White blood cell count 4600/mm3

a. Hematocrit 31%

Which respiratory problem is experienced by premature infants due to lack of surfactant in their lungs? a. The alveoli shrivel and are unable to exchange oxygen for carbon dioxide. b. Weakness of the respiratory muscles limits airflow in and out of the lungs. c. Swelling of abdominal organs limits expansion and contraction of the diaphragm. d. Insufficient hemoglobin impairs delivery of oxygen to tissues throughout the body.

a. The alveoli shrivel and are unable to exchange oxygen for carbon dioxide.

Which assessment finding explains the patient's tachycardia? a. The patient drinks at least eight cans of diet cola every day. b. The patient takes digoxin 0.125 mg PO daily. c. The patient has a history of untreated hypothyroid disease. d. The patient takes metoprolol 50 mg PO daily.

a. The patient drinks at least eight cans of diet cola every day.

Which is the priority outcome for the patient with pulmonary embolism and the nursing diagnosis impaired gas exchange related to impaired pulmonary perfusion? a. The patient's pulse oximetry will stay at least 93%. b. The patient's lung sounds will remain clear bilaterally. c. The patient will verbalize understanding of oxygen therapy. d. The patient will walk 50 feet in the hallway without dyspnea.

a. The patient's pulse oximetry will stay at least 93%.

The nurse assists a patient who collapsed in cardiac arrest. Which is the first action of the nurse? a. Determine the patient's cardiac rhythm. b. Administer fast, deep chest compressions. c. Ensure that a patent airway is maintained. d. Ventilate the patient using a barrier device.

b. Administer fast, deep chest compressions.

The nursing staff is caring for a patient who collapsed in cardiac arrest. When will breaths be delivered via the bag-valve mask device? a. After the patient is intubated b. After every 30 chest compressions c. When the patient's lips start to become cyanotic d. When another nurse takes over chest compressions

b. After every 30 chest compressions

The nurse is caring for a patient who has shallow breaths following abdominal surgery. Which respiratory complication is most likely to occur as a result of the patient's breathing pattern? a. Aspiration b. Atelectasis c. Cor pulmonale d. Pulmonary fibrosis

b. Atelectasis

Which intervention will most effectively maintain breathing function for a patient with muscle weakness due to amyotrophic lateral sclerosis (ALS)? a. Teaching pursed-lip breathing exercises b. BiPAP (bi-level positive airway pressure) c. Administration of oxygen via nasal cannula d. CPAP (continuous positive airway pressure)

b. BiPAP (bi-level positive airway pressure)

The nurse has orders to titrate the patient's oxygen to maintain a pulse oximetry level greater than 94%. The patient's pulse oximetry will not rise above 90% despite use of a nonrebreather mask. Which is the appropriate action of the nurse? a. Insert an oral airway and apply a full face oxygen mask. b. Call respiratory therapy to consider BiPAP support for the patient. c. Remove the nonrebreather mask and replace it with a Venturi mask. d. Place an oxygen nasal cannula underneath the patient's non rebreather mask.

b. Call respiratory therapy to consider BiPAP support for the patient.

The nurse is caring for a patient who has pneumonia and chronic bronchitis. The patient is very congested, coughing up copious amounts of thick green sputum. Which breath sounds will the nurse expect to hear? a. Fine crackles b. Coarse rhonchi c. Diminished bases d. Scattered wheezes

b. Coarse rhonchi

The nurse assesses a patient during suctioning. Which finding indicates that the procedure should be stopped immediately? a. Pulse oximetry decreases from 98% to 92%. b. Heart rate decreases from 78 to 40 beats/minute. c. Respiratory rate increases from 16 to 20 breaths/minute. d. Blood pressure increases from 110/70 to 120/80 mm Hg.

b. Heart rate decreases from 78 to 40 beats/minute.

The patient's blood pressure is 180/100. Why does the patient's heart have to work harder due to the high blood pressure? a. Increased preload b. Increased afterload c. Decreased contractility d. Increased stroke volume

b. Increased afterload

Which is the highest priority nursing diagnosis for the patient admitted with pneumonia? a. Activity intolerance related to increased oxygen demand with exertion b. Ineffective airway clearance related to inability to cough up thick secretions c. Risk for fluid volume deficit related to inadequate intake of fluids with fever d. Imbalanced nutrition related to loss of appetite and increased metabolic demand

b. Ineffective airway clearance related to inability to cough up thick secretions

Which assessment finding is expected for a patient with a chest tube for treatment of hemothorax? a. Constant bubbling in the water-seal chamber b. Presence of bloody drainage from the chest tube c. The patient denies having pain at the chest tube site d. Subcutaneous emphysema is present around the chest tube site

b. Presence of bloody drainage from the chest tube

Which assessment finding indicates that the patient is experiencing hypercapnia during sleep? a. The patient sleeps in the lateral position with at least two pillows. b. The patient wakes up feeling hung over after consuming no alcohol. c. The patient has difficulty falling asleep and wakes up early each morning. d. The patient works the night shift and is unable to sleep well during the day.

b. The patient wakes up feeling hung over after consuming no alcohol.

Which assessment finding indicates that the sinoatrial node was damaged as a result of the patient's heart attack? a. The patient's jugular vein is distended. b. The patient's heart rate is 34 beats/minute. c. Faint wheezes are heard in the patient's lungs. d. The patient has developed a new heart murmur.

b. The patient's heart rate is 34 beats/minute.

When will the nurse clamp the patient's chest tube? a. When the patient ambulates in the hallway b. When changing the drainage collection unit c. Before assisting the patient to take a shower d. When disconnecting the chest tube from suction

b. When changing the drainage collection unit

The nurse is caring for a patient with end-stage chronic obstructive pulmonary disease (COPD). The patient's pulse oximetry reading is 90% on room air. What is the priority action of the nurse? a. Administer 4L/NC oxygen immediately. b. Assist the patient into a recumbent position. c. Determine the patient's normal pulse oximetry values. d. Obtain an order for STAT arterial blood gases (ABGs).

c. Determine the patient's normal pulse oximetry values.

The patient's tuberculosis test appears red and flat after the injection 48 hours ago. Which is the appropriate action of the nurse? a. Repeat the tuberculosis test because the results are inconclusive. b. Measure the reddened area in millimeters and document the result. c. Document the results as a negative reaction to the tuberculosis test. d. Contact the state health department about the patient's positive test.

c. Document the results as a negative reaction to the tuberculosis test.

How can the parents best protect their premature infant from developing respiratory syncytial virus (RSV)? a. Immunize the infant against RSV. b. Ensure that the infant's bottles are sterilized. c. Limit the baby's exposure to crowds of people. d. Daily administration of prophylactic antibiotics.

c. Limit the baby's exposure to crowds of people.

Which patient would benefit from BiPAP therapy? a. Surgical patient under general anesthesia b. Confused, agitated patient with no gag reflex c. Patient with pulmonary edema due to CHF exacerbation d. Stroke patient who frequently aspirates fluids and saliva

c. Patient with pulmonary edema due to CHF exacerbation

Which type of sterile dressing will be applied to the chest wall after removal of the patient's chest tube? a. Dry gauze dressing b. Absorbent foam dressing c. Petroleum gauze dressing d. Non Adherent gauze dressing

c. Petroleum gauze dressing

Which is the priority action of the nurse for a patient with ventricular tachycardia? a. Assess the patient for signs of digoxin toxicity. b. Draw serum electrolytes to check for hyperkalemia. c. Start chest compressions if there is no palpable pulse. d. Check the patient's BP and administer sublingual nitroglycerin.

c. Start chest compressions if there is no palpable pulse.

Which assessment finding is expected for a patient with impaired lung compliance? a. The patient's respirations are very deep and rapid. b. The patient reports sharp left-sided rib and chest pain. c. The patient struggles to take a deep breath and exhale. d. The patient's breathing pattern is irregular with periods of apnea.

c. The patient struggles to take a deep breath and exhale.

The nurse assesses distended neck veins in a patient sitting in a chair to eat. Which is the priority intervention of the nurse? a. Document the observation in the chart. b. Assess the patient's deep tendon reflexes. c. Measure urine specific gravity and volume. d. Check the patient's pulse and blood pressure.

d. Check the patient's pulse and blood pressure.

The nurse is caring for a dying patient in hospice. The patient's respirations are slow and uneven with deep breaths and long periods of apnea. Which term best describes this breathing pattern? a. Rhonchal bradypnea b. Forrest-Shiley breaths c. Kussmaul's respirations d. Cheyne-Stokes breathing

d. Cheyne-Stokes breathing

The nurse is caring for a patient a serum potassium level of 7.4 mEq/L. Which is the highest priority nursing diagnosis for this patient? a. Nausea related to side effects from medications b. Ineffective tissue perfusion related to altered mental status c. Fluid volume excess related to increased isotonic fluid retention d. Risk for decreased cardiac output related to altered heart rhythm

d. Risk for decreased cardiac output related to altered heart rhythm

Which nursing diagnosis is appropriate for a patient using CPAP therapy to treat sleep apnea? a. Readiness for enhanced sleep related to desire for restful sleep b. Disturbed body image related to use of CPAP mask for sleeping c. Risk for disuse syndrome related to discomfort from CPAP mask d. Risk for impaired skin integrity related to tight-fitting mask on face

d. Risk for impaired skin integrity related to tight-fitting mask on face

Which assessment finding indicates why the patient does not have signs of respiratory alkalosis despite a respiratory rate of 30 breaths/minute? a. The patient's hematocrit is 28%. b. The patient's oral temperature is 99.2° F. c. The patient is experiencing a panic attack. d. The patient has a large pulmonary embolism.

d. The patient has a large pulmonary embolism.

Which assessment finding explains why the patient developed right-sided heart failure? a. The patient's resting heart rate is usually 55 to 60 beats/minute. b. The patient's resting heart rate is usually 58 to 60 beats/minute. c. The patient has 2+ pitting edema of the legs, feet, and abdomen. d. The patient was diagnosed with cystic fibrosis at 2 years of age.

d. The patient was diagnosed with cystic fibrosis at 2 years of age.

Which term is used to describe a machine that helps to move air in and out of the patient's lungs? a. Aerator b. Diffuser c. Respirator d. Ventilator

d. Ventilator