Gas exchange and oxygenation Test

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as risk factors for heart disease? (Select all that apply) A. A diet high in saturated fats B. A history of an overactive bladder C. A history of smoking for 25 years D. A sedentary lifestyle E. A waist cirucumference of 84 cm (33 in)

A, C, D

A nurse is reviewing the medical history of a client who has heart disease and a narrowed valve. Which of the following findings should the nurse expect? A. Regurgitation B. Stenosis C. Muscle Atrophy D. Hypotension

B. ***The nurse should expect a client who has heart disease and a narrowed valve to have stenosis. Stenosis is a narrowing or stiffening of the heart valve that causes backflow of the blood.

A nurse is performing chest percussion therapy on a client. Which of the following actions should the nurse take? A. Perform chest percussion therapy six times per day B. Listen for a hollow sound when performing chest percussion therapy C. Use flat hands to perform chest percussion therapy D. Apply chest percussion therapy over the client's ribs

B. ***The nurse should hear a hollow sound when performing chest percussion therapy. This indicates proper technique is being used to loosen the secretions.

A nurse is auscultating a client's heart sounds and hears a low-pitched whooshing or blowing sound over the apex of the heart. The nurse should identify that this indicates which of the following? A. Tachycardia B. Murmur C. Gallop D. Stroke volume

B. ***A whooshing or blowing sound indicates a murmur and can be low-, medium-, or high-pitched

A nurse is assessing a client who has COPD. The nurse should identify that which of the following is an expected finding? A. jugular vein distension B. clubbing of the fingers C. Heart murmur D. Paradoxical breathing

B. ***The nurse should identify that clubbing of the fingers is an expected finding for a client who has a chrnic pulmonary disease, such as COPD.

A nurse is assessing a client who is receiving oxygen therapy. The nurse should identify that which of the following findings can indicate oxygen toxicity? A. Hypertension B. Ringing in the ears C. Fever D. Dilated pupils

B. ***The nurse should identify that ringing in the ears, as well as headache, disorientation, and muscle twitching can indicate oxygen toxicity

A nurse is caring for a client who is receiving supplemental oxygen for hypoxia. The nurse should identify that which of the following can cause hypoxia? A. Diabetic ketoacidosis B. Smoke inhalation C. Administration of a stimulant medication D. Right-sided heart failure

B. ***The nurse should identify that smoke inhalation can cause hypoxia. Smoke inhalation can cause a client to become hypoxic due to a lack of oxygen and ventilation

A nurse is providing teaching for a client who has a new prescription for a continuous positive airway pressure (CPAP) machine to treat obstructive sleep apnea. Which of the following statements should the nurse include? A. Use the CPAP mask during the daytime B. Cover your nose with the CPAP mask C. Medications to assist with breathing can be administered through the CPAP machine D. You will need supplemental oxygen to use the CPAP machine

B. ***The nurse should instruct the client to cover their nose with the CPAP mask to create a seal to treat obstructive sleep apnea. CPAP is used for obstructive sleep apnea to keep the upper airway open and increase a client's oxygenation.

A nurse is planning care for a group of clients on a cardiopulmonary unit. Which of the following clients should the nurse plan to see first. A. A client who requires teaching about a new cholesterol-lowering medication B. A client who reports dyspnea when walking to the bathroom C. A client who has a new diagnosis of aortic valve stenosis and needs a referral to a cardiologist D. A client who has asthma and is being discharged to home

B. ***When using the urgent vs. nonurgent approach to client care, the nurse determines that the first client the nurse should see is the client who reports, dyspnea. The client might be experiencing hypoxia due to inadequate oxygenation, which requires further intervention by the nurse.

A nurse is discussing atrial fibrillation with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of atrial fibrillation? A. Atrial fib is caused by electrical signals that come from the ventricles B. Atrial fibrillation causes a lower-than-expected heart rate C. Atrial fibrillation is caused by electrical signals outside of the SA node D. Atrial fibrillation causes diaphoresis in most clients

C. ***This statement by the newly licensed nurse indicates an understanding of atrial fibrillation. Atrial fib is caused when electrical impulses start outside of the SA node, causing an irregular heart rate.

A nurse is suctioning a client's tracheostomy using an open system. Which of the following actions should the nurse take? A. Use clean technique to perform the procedure B. apply suction when inserting the catheter C. Administer 100% oxygen before the procedure D. Suction the tracheostomy for 20 seconds each time.

C. ' ***The nurse should administer 100% oxygen to the client before the procedure to reduce the risk for hypoxia

A nurse is caring for a client who has atelectasis. The nurse should identify that which of the following substance is required to keep the client's alveoli from collapsing and causing atelectasis? A. Lymphatic fluid B. Oxygenated blood, C. Synovial fluid D. Surfactant

D. *** The nurse should identify that surfactant is a lubricant required to keep alveoli in the lungs from collapsing during exhalation. A lack of surfactant can result in atelectasis.

A nurse is teaching a client who has an abdominal incision about coughing and deep breathing. In which order should the nurse instruct the client to perform the following steps? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)

1- Take a deep breath 2- Hold your breath for several seconds 3. Exhale slowly 4. Brace the incision with a pillow and try to cough deeply

A nurse is providing teaching for a client who has a prescription for home oxygen. Which of the following instructions should the nurse include? A. Post a "No Smoking" sign inside the home B. Attach oxygen containers to a fixed object C. Store spare oxygen containers in a closet D. Notify the fire department that oxygen is used in the home E. Ensure oxygen tubing is no longer than 60 feet in length

A, B, D,

A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Crackles in the lungs B. Edema of the lower extremities C. A rapid, irregular HR D. A systolic murmur

A. ***The nurse should expect the client who has left-sided heart failure to have crackles in the lungs. Left-sided heart failure causes the blood to back up into the pulmonary circulation, causing crackles in the lungs

A nurse is assessing a client who is being discharged. The nurse notes the client has regular and quiet breathing. The nurse should identify this breathing pattern as which of the following? A. Normal breathing B. Kussmaul breathing C. Cheyne-Stokes breathing D. Apnea

A. ***A normal breathing pattern is regular, quiet, and shows no manifestations of discomfort.

A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take? A. Monitor the client for subcutaneous emphysema B. Expect continuous bubbling in the water seal chamber C. Keep the drainage system above the level of the client's chest D. Clamp the chest tube tubing when the client ambulates

A. ***The nurse should monitor the client for subcutaneous emphysema, which can indicate a leak or blockage of the system.

A nurse is caring for a client who requires 1L of oxygen. Which of the following oxygen delivery devices should the nurse expect to use? A. Nasal cannula B. Nonrebreather mask C. Partial rebreather mask D. Simple face mask

A. ***The nurse should plan to use a nasal cannula because oxygen via nasal cannula can be delivered at low concentrations of 1 to 4 L/ min.

A nurse is providing teaching for a client who has a new prescription for an incentive spirometer. Which of the following instructions should the nurse include? A. "Exhale into the incentive spirometer" B. "Use the incentive spirometer every hour while awake" C. "Hold your breath for 10 secs. when using the incentive spirometer" D. Use the incentive spirometer two times each session

B ***The nurse should instruct the client to use the incentive spirometer every hour while awake to promote lung expansion and mobilize secretions.

A nurse is explaining the sequence of electrical conduction in the heart to a newly license nurse. What should the nurse include as the correct sequence of the transmission of electrical impulses? A. AV node B. SA node C. Purkinje fibers D. Right and left bundle branches E. Bundle of His

B, A, E, D, C

A nurse is discussing ventilation and perfusion with a newly licensed nurse. The nurse should include in the discussion that the exchange of oxygen and carbon dioxide occurs at which of the following locations? A. Trachea B. Alveoli C. Diaphragm D. Bronchial tubes

B. ***The alveoli are air filled sacs where the exchange of oxygen and carbon dioxide occurs

A nurse is teaching a newly licensed nurse about pulmonary function tests. The nurse should include that which of the following is the vital capacity? A. The volume of air inspired and expired with a regular breath B. The maximum volume of air that is expired after a maximum inspiration C. The amount of additional air that can be inspired after a regular inspiration D. The amount of air in the lung after maximal inspiration

B. ***The vital capacity is the amount of air that is forcibly expelled after a maximal inspiration

A nurse is planning to measure the cardiac output of a client who had a myocardia infarction. Which of the following data should the nurse use to calculate the client's cardiac output? A. Respiratory rate B. Blood pressure c. Stroke volume D. vital capacity

C. ***The nurse should use stroke volume to calculate the client's cardiac output. Cardiac output is a measurement of the volume of blood pumped by the left ventricle in 1 min. Cardiac output is calculated by multiplying the client's heart rate by the client's stroke volume

A nurse is caring for a client who has a history of asthma and is wheezing. Which of the following actions should the nurse take first? A. Auscultate the lung sounds. B. Document the respiratory rate C. Obtain the oxygen saturation. D. Check the capillary refill

C. ***The greatest risk to this client is injury from hypoxia; therefore, the first action the nurse should take is to obtain the client's oxygen saturation. Obtaining the client's oxygen saturation will assist the nurse in determining the next intervention.

A nurse is caring for a client who requires 7 L of oxygen to maintain oxygen saturation. Which of the following oxygen delivery devices should the nurse expect to use? A. Nasal cannula B. Nonrebreather mask C. Partial rebreathe mask D. Simple face mask

D. *** The nurse should expect to use a simple face mask because it can deliver oxygen at medium concentrations of 5 to 8 L/min.