Fundamentals Test 2 Prep U Oxygenation
A nurse administers albuterol, as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect? A. Respiratory rate of 22 breaths/minute B. Dilated and reactive pupils C. Urine output of 40 ml/hour D. Heart rate of 100 beats/minute
A.
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? A. Endotracheal suctioning B. Encouragement of coughing C. Use of a cooling blanket D. Incentive spirometry
A.
The nurse is beginning the shift and is assessing the oxygen exchange on a neonate. The nurse reviews the medical record for pulse oximetry reading for the last 8 hours. The pulse oximetry reading at 1530 is 75%. What should the nurse do first? A. Administer oxygen via mask. B. Swaddle the neonate in heated blankets. C. Reassess the oximetry reading in 30 minutes. D. Draw blood gases for oxygen and carbon dioxide levels.
A.
The nurse is caring for a lethargic 4-year-old who is a victim of a near-drowning accident. The nurse should first: A. administer oxygen. B. institute rewarming. C. prepare for intubation. D. start an intravenous infusion.
A.
The nurse is providing care for a client with a tracheotomy whose pulse oximeter has recently alarmed, showing the oxygen saturation to be 77%. The nurse has repositioned the client and applied supplemental oxygen, interventions that have raised the oxygen levels to 80% and somewhat decreased work of breathing. The client is not in immediate distress, and level of consciousness remains high. The nurse should page which of the following practitioners? A. Respiratory therapist. B. Physical therapist. C. Physician. D. Occupational therapist.
A.
An unconscious client with multiple injuries arrives in the emergency department. What should the nurse do first? A. Establish an airway. B. Determine the identity of the client. C. Stop bleeding from open wounds. D. Check for a neck fracture.
A. (The highest priority for a client with multiple head and neck injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Determining the client's identify, blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established.)
A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer? A. An inhaled beta2-adrenergic agonist B. An inhaled corticosteroid C. An I.V. beta2-adrenergic agonist D. An oral corticosteroid
A. (An inhaled beta2-adrenergic agonist helps promote bronchodilation, which improves oxygenation. Although an I.V. beta2-adrenergic agonist can be used, the client needs be monitored because of the drug's greater systemic effects. The I.V. form is typically used when the inhaled beta2-adrenergic agonist doesn't work. A corticosteroid is slow acting, so its use won't reduce hypoxia in the acute phase.)
For a client with an endotracheal (ET) tube, which nursing action is the most important? A. Auscultating the lungs for bilateral breath sounds B. Turning the client from side to side every 2 hours C. Monitoring serial blood gas values every 4 hours D. Providing frequent oral hygiene
A. (For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.)
A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? A. Heart rate of 94 beats/minute B. Oxygen saturation (SaO2) of 89% C. Decreased cough and gag reflexes D. Blood-tinged stools
B.
A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first? A. Reduce the client's anxiety. B. Maintain adequate oxygenation. C. Decrease chest pain. D. Maintain adequate circulating volume.
B.
Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which problem should receive the highest priority during the acute phase? A. risk for infection due to altered immune system B. ineffective breathing pattern related to neuromuscular impairment C. impaired swallowing related to neuromuscular impairment D. fluid volume deficits related to total urinary incontinence
B.
The nurse is teaching a client with emphysema how to do pursed-lip breathing. What is the expected outcome of using pursed-lip breathing? A. increased oxygenation B. prolonged exhalation C. increased exercise tolerance D. relief from shortness of breath
B.
The nursing priority of care for a client exhibiting signs and symptoms of coronary artery disease should be which of the following? A. Decrease anxiety B. Enhance myocardial oxygenation C. Administer sublingual nitroglycerin D. Educate the client about his symptoms
B.
To help a client prevent atelectasis and pneumonia after surgery, what should the nurse do? A. Administer oxygen therapy as needed to maintain adequate oxygenation. B. Offer pain medication before having the client deep-breathe and use incentive spirometry. C. Instruct the client to cough, deep-breathe, and turn in bed once every 8 hours. D. Encourage the client to drink 1,000 mL of fluids in 24 hours.
B.
When assessing for oxygenation in a client with dark skin, the nurse should examine the client's: A. skin. B. buccal mucosa. C. nape of the neck. D. forehead.
B.
In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? A. Decreased heart rate B. Increased restlessness C. Increased blood pressure D. Decreased level of consciousness (LOC)
B. (In ALS, an early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress.)
A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first? A. Instruct the client to breathe into a paper bag. B. Administer oxygen by nasal cannula as ordered. C. Auscultate breath sounds bilaterally every 4 hours. D. Encourage the client to deep-breathe and cough every 2 hours.
B. (When a pulmonary embolus places a client at risk for oxygen deprivation, the body compensates by hyperventilating. This causes respiratory alkalosis, as reflected in the client's ABG values. However, the most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia. To manage hypoxemia, the nurse should increase oxygenation by administering oxygen via nasal cannula as ordered. Instructing the client to breathe into a paper bag would cause depressed oxygenation when the client reinhaled carbon dioxide. Auscultating breath sounds or encouraging deep breathing and coughing wouldn't improve oxygenation.)
A nurse, assigned to a client with emphysema, is providing shift report. Which nursing interventions would be appropriate to include? Select all that apply. A. Reduce fluid intake to less than 850 ml per shift. B. Teach diaphragmatic, pursed-lip breathing. C. Administer low-flow oxygen as needed. D. Maintain the client in a supine position as much as possible. E. Encourage alternating client activity with rest periods. F. Teach the use of postural drainage and chest physiotherapy.
B. C. E. F.
A 39-year-old multigravid client at 39 weeks' gestation admitted to the hospital in active labor has been diagnosed with class II heart disease. To ensure cardiac emptying and adequate oxygenation during labor, the nurse plans to encourage the client to: A. breathe slowly after each contraction. B. avoid the use of analgesics for the labor pain. C. remain in a side-lying position with the head elevated. D. request local anesthesia for vaginal birth.
C.
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? A. pH B. Bicarbonate (HCO3-) C. Partial pressure of arterial oxygen (PaO2) D. Partial pressure of arterial carbon dioxide (PaCO2)
C.
A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? A. Tracheostomy cleaning kit B. Water-seal chest drainage set-up C. Manual resuscitation bag D. Oxygen analyzer
C.
On the first day after surgery, a client has been breathing room air. Vital signs are normal and O2 saturation is 89%. The nurse should first: A. lower the head of the bed. B. notify the health care provider (HCP). C. assist the client to take several deep breaths and cough. D. administer oxygen by nasal cannula as prescribed at 2L per minute.
C.
Which action will be most helpful to the nurse when determining the need for oxygen therapy in a client with chronic obstructive pulmonary disease? A. Ask the client to tell the nurse when oxygen is needed. B. Assess the client's fatigue level. C. Use a pulse oximeter to determine oxygen saturation. D. Evaluate the client's hemoglobin level daily.
C.
A 10-month-old infant with tetralogy of Fallot (TOF) experiences an cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which position? A. Knee-to-chest B. Fowler's C. Trendelenburg's D. Prone
A.
A client has had an incisional cholecystectomy. Which of the following nursing interventions has the highest priority in postoperative care for this client? A. Using incentive spirometry every 2 hours while awake. B. Performing leg exercises every shift. C. Maintaining a weight-reduction diet. D. Promoting incisional healing.
A.
A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Prescriptions include: oxygen 2 to 4 L/min per nasal cannula, oximetry at all times, and IV administration of 5% dextrose in water at 100 mL/h. The client has increasing dyspnea and has a respiratory rate of 32 breaths/min. The oxygen flow rate is set at 2 L/min. The nurse should first: A. increase the oxygen flow rate from 2 to 4 L/min. B. call the health care provider (HCP) immediately. C. provide reassurance to the client. D. obtain a sample for arterial blood gas analysis.
A.
A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases, and the respirations are shallow at a rate of 28 breaths/min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? Select all that apply. A. Monitor serum creatinine and blood urea nitrogen levels. B. Administer a sedative. C. Keep the head of the bed flat. D. Administer humidified oxygen. E. Auscultate the lungs.
A. D. E.
A client has an adrenal tumor and is scheduled for a bilateral adrenalectomy. During prepoperative teaching, the nurse teaches the client how to do deep breathing exercises after surgery by telling the client to: A. "Sit in an upright position, and take a deep breath." B. "Hold your abdomen firmly with a pillow, and take several deep breaths." C. "Tighten your stomach muscles as you inhale, and breathe normally." D. "Raise your shoulders to expand your chest."
B.
A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions? A. They help prevent subcutaneous emphysema. B. They help prevent pneumothorax. C. They help prevent cardiac arrhythmias. D. They help prevent pulmonary edema.
C.
A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately? A. Absent cough and gag reflexes B. Blood-tinged secretions C. Oxygen saturation of 90% D. Respiratory rate of 13 breaths/min
C.
The nurse has placed the intubated client with acute respiratory distress syndrome (ARDS) in prone position for 30 minutes. Which factors would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. A. The family is coming in to visit. B. The client has increased secretions requiring frequent suctioning. C. The SpO2 and PO2 have decreased. D. The client is tachycardic with drop in blood pressure. E. The face has increased skin breakdown and edema.
C. D. E.
A client is admitted to the hospital with a diagnosis of a pulmonary embolism. Which problem should the nurse address first? A. nonproductive cough B. activity intolerance C. difficulty breathing D. impaired gas exchange
D. (Emboli obstruct blood flow, leading to a decreased perfusion of the lung tissue. Because of the decreased perfusion, a ventilation-perfusion mismatch occurs, causing hypoxemia to develop. Arterial blood gas analysis typically will indicate hypoxemia and hypocapnia. A priority objective in the treatment of pulmonary emboli is maintaining adequate oxygenation. A productive cough and activity intolerance do not indicate impaired gas exchange. The client does not demonstrate an ineffective breathing pattern; rather, the problem of impaired gas exchange is caused by the inability of blood to flow through the lung tissue.)
A 2½-year-old child is being treated for left lower lobe pneumonia. In what position should the nurse position the toddler to maximize oxygenation? A. Prone B. Left lateral C. Supine D. Right lateral
D.
The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following? A. Decreased cardiac output. B. Pleural effusion. C. Inadequate peripheral circulation. D. Decreased oxygenation of the blood.
D.
The nurse is planning care for a group of clients. Which client should the nurse identify as needing the most assistance in accepting being ill? A. an 8-year-old boy who alternately cries for his mother and is angry with the nurse about being hospitalized after a bike accident B. a 32-year-old woman diagnosed with depression related to lupus erythematosus who discusses her medication's adverse effects with the nurse C. a 45-year-old man who just suffered a severe myocardial infarction and talks to the nurse about concerns regarding resuming sexual relations with his wife D. a 60-year-old woman diagnosed with chronic obstructive pulmonary disease who refuses to wear an oxygen mask even though poor oxygenation makes her confused
D.
Which is an expected outcome of pursed-lip breathing for clients with emphysema? A. to promote oxygen intake B. to strengthen the diaphragm C. to strengthen the intercostal muscles D. to promote carbon dioxide elimination
D.
A 5-year-old child is brought to the emergency department after being stung multiple times on the face by yellow jackets. Which symptom of anaphylaxis requires priority medical intervention? A. Blood pressure of 95/50 mm Hg B. Diffuse facial urticaria C. Respiratory rate of 20 breaths/minute D. Heart rate less than 60 beats/minute
D. (Bradycardia, a slow but steady heartbeat at a rate less than 60 beats/minute, is an ominous sign in children. Older children experiencing anaphylaxis initially demonstrate tachycardia in response to hypoxemia. When tachycardia can no longer maintain tissue oxygenation, bradycardia follows. The development of bradycardia usually precedes cardiopulmonary arrest.)
During morning assessment, a nurse assesses four clients. Which client is the priority for follow up? A. An 84-year-old client with heart failure who's on telemetry and 2 L/minute of oxygen. B. A 42-year-old client who has left lower lobe pneumonia and an I.V. line. C. A 48-year-old client with chronic obstructive pulmonary disease with occasional atrial fibrillation. D. A 73-year-old client who has pneumonia with coarse crackles, is receiving 2 L/minute of oxygen, and has an I.V. line.
D. (The 73-year-old client with pneumonia should be the nurse's priority because of the oxygenation complications and the audible crackles that may result from fluid overload from the I.V. line. The 42-year-old client is younger and more mobile than the others. The 84-year-old client doesn't have pressing needs at this time. The nurse should evaluate the 48-year-old client if he goes into atrial fibrillation, but he isn't a priority at this time.)
A child with asthma has a heart rate of 160 bpm and a respiratory rate of 36 breaths/minute. The child appears restless and anxious and is given albuterol via nebulizer. Which finding would indicate that the nebulizer treatment has been effective? A. pulse oximeter reading of 91% B. nonproductive cough C. expiratory wheezing D. increase in peak expiratory flow rate
D. (The best indicator of the effectiveness of the albuterol is an increase in peak expiratory flow rate. Albuterol, a bronchodilator, opens and relaxes the airways, allowing a greater exchange of air, which is reflected as a higher peak expiratory flow rate.)
