Chapter 39 oxygenation and perfusion

What assessments would a nurse make when auscultating the lungs? a. Cardiovascular function b. Abnormal chest structures c. Presence of edema d. Volume of air exhaled or inhaled

a. Cardiovascular function

A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nuise related to this occurrenee? a. Remove the catheter. b. Notify the primary care provider. c. Check that the airway is the appropriate size for the patient. d. Place the patient on his or her back.

a. Remove the catheter.

A nurse suctioning a patient through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur? a. Trauma to the tracheal mucosa b. Prevention of suctioning c. Loss of sterile field d. Suctioning of carbon dioxide

a. Trauma to the tracheal mucosa

The nurse sets up an oxygen tent for a patient. Which patient is the best candidate for this oxygen delivery system? a. An older adult patient who has COPD b. A child who has pneumonia c. An adult who is receiving oxygen at home d. An adolescent who has asthma

b. A child who has pneumonia

The nurse is teaching an adolescent with asthma how to use a metered dose inhaler. Which teaching point follows recommended guidelines? a. Inhale through the nose instead of the mouth. b. Be sure to shake the canister before using it. c. Inhale the medication rapidly. d. Inhale two sprays with one breath for faster action.

b. Be sure to shake the canister before using it.

A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation? a. Thoracentesis b. Pulse oximetry c. Diffusion capacity d. Maximal respiratory pressure

b. Pulse oximetry

The nurse is assessing the respiratory rates of patients in a community health care facility. Which patient exhibits an abnormal value? a. An infant with a respiratory rate of 20 bpm b. A 4-year-old with a respiratory rate of 40 bpm c. A 12-year-old with a respiratory rate of 20 bpm d. A 70-year-old with a respiratory rate of 18 bpm

a. An infant with a respiratory rate of 20 bpm

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? a. Checking the amount of oxygen in the cylinder before using it b. Using a cylinder for a patient transfer that indicates available oxygen is 500 psi c. Placing the oxygen cylinder on the stretcher next to the patient d. Discontinuing oxygen flow by turning the cylinder key counterclockwise until tight the chest

a. Checking the amount of oxygen in the cylinder before using it

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. a. Closely assess the patient before, during, and after the procedure. b. Hyperoxygenate the patient before and after suctioning. c. Limit the application of suction to 20 to 30 seconds. d. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. e. Use appropriate suction pressure (80 to 150 mm Hg). f. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.

a. Closely assess the patient before, during, and after the procedure. b. Hyperoxygenate the patient before and after suctioning. d. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. e. Use appropriate suction pressure (80 to 150 mm Hg).

A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? a. Dyspnea b. Hypotension c. Decreased respiratory rate d. Decreased pulse rate

a. Dyspnea

An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? a. Tilt the patient's head forward. b. Hold the mask tightly over the patient's nose and mouth. c. Pull the patient's jaw backward. d. Compress the bag twice the normal respiratory rate for the patient.

b. Hold the mask tightly over the patient's nose and mouth.

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a. Refrain from exercise. b. Reduce anxiety. c. Eat meals 1 to 2 hours prior to breathing treatments. d. Eat a high-protein/high-calorie diet. e. Maintain a high-Fowler's position when possible. f. Drink 2 to 3 pints of clear fluids daily.

b. Reduce anxiety. d. Eat a high-protein/high-calorie diet. e. Maintain a high-Fowler's

When percussing a normal lung, which sound would the nurse hear? a. Tympany b. Resonance c. Dullness d. Hyperresonance

b. Resonance

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter? a. The age of the patient b. The size of the endotracheal tube c. The type of secretions to be suctioned d. The height and weight of the patient

b. The size of the endotracheal tube

The nurse assesses a patient and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations? a. Hyperventilation b. Нуроxia c. Perfusion d. Atelectasis

b. Нуроxia

A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? a. A postoperative adult b. An adult with COPD c. A teenager with cystic fibrosis d. A child with pneumonia

c. A teenager with cystic fibrosis

A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? a. Instruct the assistant to notify the primary care provider. b. Assess the patient's vital signs. c. Remove the tape, adjust the depth to ordered depth and reapply the tape. d. No action is required as depth will adjust automatically.

c. Remove the tape, adjust the depth to ordered depth and reapply the tape.

A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? a. The nurse assures that the oxygen is flowing into the prongs. b. The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. c. The nurse encourages the patient to breathe through the nose with the mouth closed. d. The nurse adjusts the flow rate to 6 L/min or more.

c. The nurse encourages the patient to breathe through the nose with the mouth closed.

6. The nurse is auscultating the lungs of a patient and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? a. They are loud, high-pitched sounds heard primarily over the trachea and larynx. b. They are medium-pitched blowing sounds heard over the major bronchi. c. They are low-pitched, soft sounds heard over peripheral lung fields. d. They are soft, high-pitched discontinuous (intermittent) popping lung sounds.

c. They are low-pitched, soft sounds heard over peripheral lung fields.

A nurse auscultates the lungs of a patient with asthma. Which lung sound is characteristic of this condition? a. Crackles b. Bronchial sounds c. Wheezes d. Vesicular sounds

c. Wheezes

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. a. "I will be careful not to shake up the canister before using it." b. "I will hold the canister upside down when using it." c. "I will inhale the medication through my nose. d. "I will continue to inhale when the cold propellant is in my throat." e. "I will only inhale one spray with one breath." f. "I will activate the device while continuing to inhale."

d. "I will continue to inhale when the cold propellant is in my throat." e. "I will only inhale one spray with one breath." f. "I will activate the device while continuing to inhale."

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? a. The patient vomits during suctioning. b. The secretions appear to be stomach contents. c. The catheter touches an unsterile surface. d. A nosebleed is noted with continued suctioning.

d. A nosebleed is noted with continued suctioning.

A nurse is performing CPR on a patient who is in cardiac arrest. What action would the nurse perform second? a. Check the victim for a response. b. Begin CPR with the CAB sequence. c. Get an automated external defibrillator (AED) or Defibrillator d. Activate the emergency response system

d. Activate the emergency response system.

Parks has chronic obstructive pulmonary disease. His nurse has taught him pursed lip breathing, which helps him in which of the following ways? a. Increases carbon dioxide, which stimulates breathing b. Teaches him to prolong inspiration and shorten expiration c. Helps liquefy his secretions d. Decreases the amount of air trapping and resistance

d. Decreases the amount of air trapping and resistance.

The nurse is caring for a patient who complains of difficulty breathing. In what position would the nurse place this patient? a. Prone position b. Lateral position c. Supine position d. Fowler's position

d. Fowler's position

A patient with COPD is unable to perform personal hygiene and is becoming exhausted. What nursing intervention would be appropriate for this patient? a. Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone. b. Teach the patient not to talk about the procedure, just to perform it at the best of his or her ability. c. Teach the patient to take short shallow breaths when performing hygiene measures. d. Group personal care activities into smaller steps, allowing rest periods between activities.

d. Group personal care activities into smaller steps, allowing rest periods between activities.

A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first aclion that should be taken by the nurse in this situation? a. Notify the health care provider. b. Apply an occlusive dressing on the site. c. Assess the patient for signs of respiratory distress. d. Put on gloves and insert the chest tube in a bottle of sterile saline.

d. Put on gloves and insert the chest tube in a bottle of sterile saline.

The nurse schedules a pulmonary function test to measure the amount of air left in a patient's lungs at maximal expiration. What test does the nurse order? a. Tidal volume (TV) b. Total lung capacity (TLC) c. Forced expiratory volume (FEV) d. Residual volume (RV)

d. Residual volume (RV)

When caring for a patient with a tracheostomy, the nurse would perform which recommended action? a. Clean the wound around the tube and inner cannula at least every 24 hours. b. Assess a newly inserted tracheostomy every 3 to 4 hours, c. Use gauze dressings over the tracheostomy that are filled with cotton d. Suction the tracheostomy tube using sterile technique.

d. Suction the tracheostomy tube using sterile technique.

When inspecting a patient's chest to assess respiratory status, the nurse should be aware of which normal finding? a. The contour of the intercostal spaces should be rounded. b. The skin at the thorax should be cool and moist. c. The anteroposterior diameter should be greater than the transverse diameter. d. The chest should be slightly convex with no sternal depression.

d. The chest should be slightly convex with no sternal depression.