Oxygenation and Perfusion

The nurse understands that client education related to antihypertensive medication should include which of the following? a. inform client that recommended lifestyle changes are not necessary b. inform client if a dosage of medication is missed , to double the next scheduled dose c. inform client to avoid over-the-counter cold and sinus medications d. inform client to discontinue antihypertensives once blood pressure is normal

c. inform client to avoid over-the-counter cold and sinus medications

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client? a. Nasal cannula b. Face tent c. Simple mask d. Non-rebreather mask

a. Nasal cannula

A nurse is admitting a 6-year-old child status post tonsillectomy to the surgical unit. The nurse obtains his weight and places EKG and a pulse oximeter on the client's left finger. His heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate: a. adequate tissue perfusion b. diminished stroke volume c. heart failure d. high cardiac output

a. adequate tissue perfusion

Which of the following assessment factors would indicate a need for oropharyngeal suctioning? a. Thin sputum and a weak cough. b. Breathing rate of 36 breaths/min; noisy, gurgling respirations. c. Auscultation of fluid (rales and rhonchi) in the lower lobes of the lungs. d. Oxygen saturation levels of 95%; use of diaphragmatic breathing.

b. Breathing rate of 36 breaths/min; noisy, gurgling respirations.

When treating hypertensive emergencies, the nurse identifies the most appropriate route of administration for antihypertensive agents as being which of the following? a. Oral b. Continuous IV infusion c. Intramuscular d. Sublingual

b. Continuous IV infusion

Which would a nurse expect to assess if a client is experiencing right-sided heart failure? a. Wheezing b. Peripheral edema c. Hemoptysis d. Dyspnea

b. Peripheral edema

The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier? a. mineral oil b. normal saline c. tap water d. distilled water

d. distilled water

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation? a. Arterial blood gas b. Hemoglobin levels c. Hematocrit values d. Pulmonary function

a. Arterial Blood Gases (ABG)

A nurse caring for a patient with chronic obstructive pulmonary disease (COPD) knows that hypoxia may occur in patients with respiratory problems. What are signs of this serious condition? Select all answers that apply. a. Dyspnea b. Hypotension c. Small pulse pressure d. Decreased respiratory rate e. Pallor f. Increased pulse rate

a. Dyspnea c. Small pulse pressure e. Pallor f. Increased pulse rate

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client? a. Flow meter b. Nasal cannula c. Nasal strip d. Oxygen analyzer

a. Flow meter A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician.

The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client? a. Nasal cannula b. Tracheostomy collar c. Simple mask d. Face tent

a. Nasal cannula A nasal cannula is ideal for administering low concentrations of oxygen to clients who are not extremely hypoxic or have chronic lung disease.

What structural changes to the respiratory system should a nurse observe when caring for older adults? a. respiratory muscles become weaker b. diminished coughing and gag reflexes c. increased use of accessory muscles for breathing d. increased mouth breathing and snoring

a. respiratory muscles become weaker

A nurse is teaching a client who is newly diagnosed with hypertension and diabetes mellitus. For a client without diabetes mellitus, the target blood pressure is 140/90 or lower. Because this client has diabetes mellitus, the target blood pressure will be which of the following? a. 25/85 or lower b. 130/80 or lower c. 145/95 or lower d. 150/95 or lower

b. 130/80 or lower

The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner? a. 10 L/min oxygen via Venturi mask b. 8 L/min oxygen via nasal cannula c. 12 L/min oxygen via nonrebreather mask d. 8 L/min oxygen via partial rebreather mask

b. 8 L/min oxygen via nasal cannula The correct amount delivered FiO2 for a nonrebreather mask is 12 L/min; 8-11 L/min for partial rebreather mask; 4-10 L/min for Venturi mask; and 1-6 L/min for nasal cannula. However, per nasal cannula it may be no more than 2-3 L/min to for a client with chronic lung disease.

A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client? a. Oxygen mask b. Ambu bag c. Oxygen tent d. Nasal cannula

b. Ambu bag If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube.

A nurse is educating about lifestyle modifications for a group of clients with newly diagnosed hypertension. While discussing dietary changes, which of the following points would the nurse emphasize? a. A person with hypertension should never consume alcohol. b. It takes 2 to 3 months for the taste buds to adapt to decreased salt intake. c. There is usually no need to change alcohol consumption for clients with hypertension. d. The taste buds never adapt to decreased salt intake.

b. It takes 2 to 3 months for the taste buds to adapt to decreased salt intake.

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? a. "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." b. "Take in a small amount of air very quickly and then exhale as quickly as possible." c. "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." d. "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling."

c. "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

A client is admitted to the intensive care unit (ICU) with a diagnosis of hypertension emergency/crisis. The client's blood pressure (BP) is 200/130 mm Hg. The nurse is preparing to administer IV nitroprusside. Upon assessment, which finding requires immediate intervention by the nurse? a. Nausea and severe headache b. Urine output of 40 mL over the past hour c. Numbness and weakness in the left arm d. Chest pain score of 3 (on a scale of 1 to 10)

c. Numbness and weakness in the left arm The finding of numbness and weakness in left arm may indicate the client is experiencing neurological symptoms associated with an ischemic stroke because of the severely elevated BP; immediate intervention is required.

The nurse is caring for a client who was had a percutaneous tracheostomy (PCT) following a motor vehicle accident, and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? a. Simple mask b. Nasal cannula c. Tracheostomy collar d. Face tent

c. Tracheostomy collar A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT.

A client with chronic obstructive pulmonary disease (COPD) reports severe shortness of breath when it is raining. The nurse says to the client: a. "The airway becomes occluded during periods of rain." b. "Have you had a stress test to determine if your airway is obstructed?" c. "You should use your inhaler as often as necessary during this time to help your breathing." d. "The air is thicker or more viscous with humidity, thus it is harder for you to breathe."

d. "The air is thicker or more viscous with humidity, thus it is harder for you to breathe."

A patient has been admitted to the hospital with exacerbation of heart failure (HF) that has resulted in pulmonary and peripheral edema. The nurse has been carefully monitoring the trajectory of the patient's signs and symptoms of HF. How can the nurse best monitor the patient's fluid balance? a. By monitoring the patient's blood urea nitrogen (BUN) and creatinine levels b. By measuring and recording the patient's oral fluid intake c. By assessing the patient's skin turgor at several different sites d. By performing daily weights at the same time each day

d. By performing daily weights at the same time each day

The nursing instructor is teaching their clinical group how to assess a client for congestive heart failure. How would the instructor teach the students to assess a client with congestive heart failure for nocturnal dyspnea? a. By observing the client's diet during the day b. By collecting the client's urine output c. By measuring the client's abdominal girth d. By questioning how many pillows the client normally uses for sleep

d. By questioning how many pillows the client normally uses for sleep

Mr. Faulkner is a 69-year-old man who has enjoyed generally good health for his entire adult life. As a result, he has been surprised to receive a new diagnosis of hypertension after a series of visits to his primary care provider. The nurse who is working with Mr. Faulkner should recognize which of the following aspects of aging and hypertension? a. Older adults are less vulnerable to the pathophysiological effects of hypertension than are younger adults. b. The diagnostic criteria for hypertension in adults over 65 differ from those for younger adults. c. Blood pressure remains stable throughout adulthood but tends to be assessed more often by health care providers of older adults. d. The incidence and prevalence of hypertension increase with age.

d. The incidence and prevalence of hypertension increase with age.

The nurse is awaiting results of cardiac biomarkers for a patient with severe chest pain. The nurse would identify which cardiac biomarker as remaining elevated the longest when myocardial damage has occurred? a. Myoglobin b. CK-MB c. Brain natriuretic peptide (BNP) d. Troponin T and I

d. Troponin T and I