Chapter 41: Oxygenation

The nurse is caring for a patient who was admitted to the hospital with a diagnosis of left-sided heart failure. While assessing the patient, which signs and symptoms would the nurse likely find? Select all that apply. 1 Dyspnea 2 Fatigue 3 Dizziness 4 Peripheral edema 5 Distended neck veins

1 Dyspnea 2 Fatigue 3 Dizziness

The nurse is teaching a patient about lifestyle practices to promote heart health. Which instructions should the nurse include in this teaching? Select all that apply. 1 Eat foods rich in fiber. 2 Eat foods rich in fats and proteins. 3 Have a daily calorie intake of 2000 calories. 4 Have a daily calorie intake of 3000 calories. 5 Exercise for at least 30-60 minutes every day.

1 Eat foods rich in fiber. 3 Have a daily calorie intake of 2000 calories. 5 Exercise for at least 30-60 minutes every day.

A patient wants to understand the mechanism of respiration. What should the nurse explain to the patient? Select all that apply. 1 Normal breathing is quiet with minimum or no effort. 2 Ventilation is the process of air moving in and out of lungs. 3 Normal breathing is noisy and requires all the chest muscles. 4 The diaphragm is an important muscle that helps in breathing. 5 Ventilation is the process of oxygenated blood flowing in the body.

1 Normal breathing is quiet with minimum or no effort. 2 Ventilation is the process of air moving in and out of lungs. 4 The diaphragm is an important muscle that helps in breathing.

A patient who reported chest pain was admitted to the hospital and is now ready to be discharged. The patient's blood pressure reading is 170/100 mm Hg and the serum cholesterol is 240 mg/dL. Which diet considerations should be included in the patient's diet plan? Select all that apply. 1 Restrict intake of salt. 2 Restrict intake of white beans. 3 Include saturated fats. 4 Include spinach. 5 Increase intake of omega-3 fatty acids.

1 Restrict intake of salt. 4 Include spinach. 5 Increase intake of omega-3 fatty acids.

The nurse is conducting a teaching session for a group of young adults. One of them wants to know if substance abuse affects respiratory functions. How should the nurse answer? Select all that apply. 1 The respiratory center is depressed and affects respiratory function in addicts. 2 Having alcohol and drugs causes a reduction in airflow to the lungs and affects respiration. 3 People who are addicted often have low nutritional status, which affects respiratory functions. 4 The oxygen-carrying capacity of blood is low in people who chronically abuse substances. 5 There is no relation between respiratory function and substance abuse as it affects the nervous system.

1 The respiratory center is depressed and affects respiratory function in addicts. 3 People who are addicted often have low nutritional status, which affects respiratory functions. 4 The oxygen-carrying capacity of blood is low in people who chronically abuse substances.

A patient with right ventricular failure asks the nurse about this condition. Which information should the nurse include in the explanation? Select all that apply. 1 The right ventricle doesn't function well, and fluid backs up in the systemic circulation. 2 There may be an enlargement of the liver and spleen. 3 The right ventricle doesn't function well, and fluid backs up in the lungs. 4 There is pulmonary edema and fluid accumulation in the lungs. 5 There may be peripheral edema of the hands and feet.

1 The right ventricle doesn't function well, and fluid backs up in the systemic circulation. 2 There may be an enlargement of the liver and spleen. 5 There may be peripheral edema of the hands and feet.

For which of the following health problems is a patient who has a 40-year history of smoking at risk? 1. Alcoholism and hypertension 2. Obesity and diabetes 3. Stress-related illness 4. Cardiopulmonary disease and lung cancer

4. Cardiopulmonary disease and lung cancer

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation as a result of the anemia? 1. Increased breathlessness but increased activity tolerance 2. Decreased breathlessness and decreased activity tolerance 3. Increased activity tolerance and decreased breathlessness 4. Decreased activity tolerance and increased breathlessness

4. Decreased activity tolerance and increased breathlessness

The nurse is educating a student nurse on caring for a patient with a chest tube. Which statement from the student nurse indicates successful learning? a. "I should clamp the chest tube when giving the patient a bed bath." b. "I should report if I see continuous bubbling in the water-seal chamber." c. "I should strip the drains on the chest tube every hour to promote drainage." d. "I should notify the health care provider first, if the chest tube becomes dislodged."

B

The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take? a. Set suction regulator at 150 to 200 mm Hg. b. Limit the length of suctioning to 10 seconds. c. Apply suction while gently rotating and inserting the catheter. d. Liberally lubricate the end of the suction catheter with a water-soluble solution.

B

The nurse needs to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change? a. Thinner heart valves cause lipid accumulation and fibrosis. b. Diminished respiratory muscle strength may cause poor chest expansion. c. Alterations in mental status prevent patients' awareness of ineffective breathing. d. An increased number of pacemaker cells make proper anesthesia induction more difficult.

B

While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first? a. Press the emergency response button. b. Insert a spare tracheostomy with the obturator. c. Manually occlude the tracheostomy with sterile gauze. d. Place a face mask delivering 100% oxygen over the nose and mouth.

B

A nurse is following the Ventilator Bundle standards to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.) a. Head of bed elevation to 90 degrees at all times b. Daily oral care with chlorhexidine c. Cuff monitoring for adequate seal d. Clean technique when suctioning e. Daily "sedation vacations" f. Heart failure prophylaxis

B, C, E

A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close? a. Aortic and mitral b. Mitral and tricuspid c. Aortic and pulmonic d. Mitral and pulmonic

C

A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation? a. Anxiety over illness b. Decreased drive to breathe c. Increased metabolic demands d. Infection destroying lung tissues

C

A nurse is caring for a patient who is taking warfarin (Coumadin) and discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient? a. Increased cholesterol level b. Distended jugular vein c. Bleeding d. Angina

C

A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step? 1. Insert catheter. 2. Apply suction and remove. 3. Have patient deep breathe. 4. Encourage patient to cough. 5. Attach catheter to suction system. 6. Rinse catheter and connecting tubing. a. 1, 2, 3, 4, 5, 6 b. 4, 5, 1, 2, 3, 6 c. 5, 3, 1, 2, 4, 6 d. 3, 1, 2, 5, 4, 6

C

A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium? a. Right ventricle, left ventricle, left atrium b. Left atrium, right ventricle, left ventricle c. Right ventricle, left atrium, left ventricle d. Left atrium, left ventricle, right ventricle

C

A nurse is teaching the patient with mitral valve problems about the valves in the heart. Starting on the right side of the heart, describe the sequence of the blood flow through these valves. 1. Mitral 2. Aortic 3. Tricuspid 4. Pulmonic a. 1, 3, 2, 4 b. 4, 3, 2, 1 c. 3, 4, 1, 2 d. 2, 4, 1, 3

C

A patient has a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia? a. Superior vena cava b. Pulmonary artery c. Coronary artery d. Carotid artery

C

A patient has heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output? a. Myocardial contractility Myocardial blood flow b. Ventricular filling time/Diastolic filling time c. Stroke volume Heart rate d. Preload/Afterload

C

A patient with a pneumothorax has a chest tube inserted and is placed on low constant suction. Which finding requires immediate action by the nurse? a. The patient reports pain at the chest tube insertion site that increases with movement. b. Fifty milliliters of blood gushes into the drainage device after the patient coughs. c. No bubbling is present in the suction control chamber of the drainage device. d. Yellow purulent discharge is seen leaking out from around the dressing site.

C

A patient's heart rate increased from 94 to 164 beats/min. What will the nurse expect? a. Increase in diastolic filling time b. Decrease in hemoglobin level c. Decrease in cardiac output d. Increase in stroke volume

C

The nurse suspects the patient has increased afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition? a. Pulse oximeter b. Oxygen cannula c. Blood pressure cuff d. Yankauer suction tip catheter

C

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient? a. Discontinue the humidification delivery device to keep excess fluid from lungs. b. Monitor oxygen saturation, and frequently auscultate lung bases. c. Assist the patient to cough, turn, and deep breathe every 2 hours. d. Decrease fluid intake to 300 mL a shift.

C

While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record? a. Atrial fibrillation b. Myocardial ischemia c. Left-sided heart failure d. Right-sided heart failure

C

A nurse is caring for a patient with sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.) a. Assist-control (AC) b. Pressure support ventilation (PSV) c. Bilevel positive airway pressure (BiPAP) d. Continuous positive airway pressure (CPAP) e. Synchronized intermittent mandatory ventilation (SIMV)

C, D

A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning? a. Pulse 75 b. Pulse 80 c. Oxygen saturation 91% d. Oxygen saturation 88%

D

A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer? a. Diuretics b. Vasodilators c. Chest physiotherapy d. Intravenous (IV) fluids

D

The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider? a. Increased anterior-posterior diameter of the chest b. Accessory muscle used for breathing c. Clubbing of the fingers d. Hemoptysis

D

The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia? a. Elevated blood pressure b. Increased pulse rate c. Restlessness d. Cyanosis

D

The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process? a. Ventilation b. Surfactant c. Perfusion d. Diffusion

D

The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method? a. A 5-year-old with excessive drooling from epiglottitis b. A 5-year-old with an asthma attack following severe allergies c. A 24-year-old with a right pneumothorax following a motor vehicle accident d. A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation

D

14. Two hours after surgery, the nurse assess a patient who had a chest tube inserted during surgery. There is 200 mL if dark red drainage in the chest tube at this time. What is appropriate action for the nurse to preform? a. Record amount and continue to monitor drainage b. Notify physician c. Strip the chest tube starting at the chest d. Increase suctioning by 10 mmHg

a. Record amount and continue to monitor drainage

8. A patient was admitted following a motor vechicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common findings in pneumothorax? (Select All that apply) a. Sharp pleuritic pain that worsens on inspiration b. Crackles over lung bases of affected lung c. Tracheal deviation toward affected lung d. Worsening dyspnea e. Absent lung sounds to auscultation on affected side

a. Sharp pleuritic pain that worsens on inspiration d. Worsening dyspnea e. Absent lung sounds to auscultation on affected side

11. The nursing is caring for a patient who has labored breathing, is using accessory muscles, and is coughing of pink frothy sputum. The patient has diminished breath sounds In bilateral lung bases. What are the priority nursing assessments for the nuse to preform prior to notifying the patient's healthcare provider? (Select all that apply) a. SpO2 levels b. Amount, color, and consistency of sputum production c. Fluid status d. Change in RR and pattern e. Pain in lower leg

a. SpO2 levels b. Amount, color, and consistency of sputum production d. Change in RR and pattern

6. The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication? a. Antibiotics b. Frequent change of position c. Oxygen humidification d. Chest physiotherapy

b. Frequent change of position

13. Which of the following skills can the nurse delegate to NAP? (Select all that apply) a. Nasotracheal suction b. Oropharyngeal suctioning of stable patient c. Suctioning of new artificial airway d. Permanent tracheostomy tube suctioning e. Care of endotracheal tube

b. Oropharyngeal suctioning of stable patient d. Permanent tracheostomy tube suctioning

7. A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicated that the patient needs airway suctioning? a. Coughing up sputum occasionally b. Coughing up thin, watery sputum after nebulization c. Decreased ability to clear airway through coughing d. Lung sounds clear after coughing

c. Decreased ability to clear airway through coughing

15. The nurse is reviewing the results of the patient's diagnostic testing. Of the following results, the finding that falls within the expected normal limits is: a. Palpable, elevated hardened area around tuberculosis skin testing site b. Sputum for culture and sensitivity identifies mycobacterium tuberculosis c. Presence of acid-fast bacilli in sputum d. Arterial Oxygen tension (PaO2) of 95 mmHg

d. Arterial Oxygen tension (PaO2) of 95 mmHg

9. A patient has been newly diagnosed with chronic lung disease. In discussing the lung disease with the nurse, which of the patient's statements would indicate a need for further teaching? a. "I will make sure that I rest between activities so I don't get so short of breath." b. "I will practice the pursed-lip breathing technique to improve my exercise tolerance" c. "If I have trouble breathing at night, I will use two or three pillows to prop up" d. If I get short of breath, I will turn up my oxygen level to 6 L/Min"

d. If I get short of breath, I will turn up my oxygen level to 6 L/Min"

12. Place the following in correct sequence for suctioning a patient. a. Open Kit & Basin b. Apply gloves c. Lub catheter d. Verify functioning of suction device and pressure e. Connect suction tubing to suction catheter f. Increase supplemental O2 g. Reapply O2 h. Suction airway

d. Verify functioning of suction device and pressure f. Increase supplemental O2 a. Open Kit & Basin c. Lube catheter b. Apply gloves e. Connect suction tubing to suction catheter h. Suction airway g. Reapply O2

Which abnormality change in the fingertips iscaused by chronic hypoxemia? 1 Edema 2 Clubbing 3 Distention 4 Splinter hemorrhages

2 Clubbing

A patient who has hypoxia is hospitalized. The nurse observes central cyanosis on the patient's tongue, soft palate, and conjunctiva. What should the nurse suspect based on this observation? 1 Atelectasis 2 Hypoxemia 3 Hypovolemia 4 Hyperventilation

2 Hypoxemia

In which condition do the lungs remove carbon dioxide faster than it is produced by cellular metabolism? 1 Hypoxia 2 Hypoxemia 3 Hypovolemia 4 Hyperventilation

4 Hyperventilation

The nurse is careful to monitor a patient's cardiac output. Which goal is the nurse trying to achieve? a. To determine peripheral extremity circulation b. To determine oxygenation requirements c. To determine cardiac dysrhythmias d. To determine ventilation status

A

Which coughing technique will the nurse use to help a patient clear central airways? a. Huff b. Quad c. Cascade d. Incentive spirometry

A

A nurse is teaching a community health promotion class and discusses the flu vaccine. Which information will the nurse include in the teaching session? (Select all that apply.) a. It is given yearly. b. It is given in a series of four doses. c. It is safe for children allergic to eggs. d. It is safe for adults with acute febrile illnesses. e. The nasal spray is given to people over 50. f. The inactivated flu vaccine is given to people over 50.

A, F

A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority? a. Pulse b. Respirations c. Temperature d. Blood pressure

B

Upon auscultation of the patient's chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse? a. The beginning of the systolic phase b. Regurgitation of the mitral valve c. The opening of the aortic valve d. Presence of orthopnea

B

A nurse counsels a patient with a pulmonary disorder and anemia about self-care. Which statement if made by the patient during evaluation indicates a need for correction? 1 "I should eat a diet rich in carbohydrates." 2 "I should exercise for 30 to 60 minutes daily." 3 "I should use varenicline (Chantix) or nicotine patches." 4 "I should use a face mask while going out during a smoggy day."

1 "I should eat a diet rich in carbohydrates."

A patient reports fatigue and an inability to lie flat. During anassessment, the nurse finds the patient has an increased blood pressure and an increased pulse rate. Further assessment reveals that the patient is dizzy, unable to concentrate, and has a decreased level of consciousness. Which condition does the nurse suspect? 1 Hypoxia 2 Hypoxemia 3 Hypovolemia 4 Hyperventilation

1 Hypoxia

The nurse goes to assess a new patient and finds the patient lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first? 1 Raise the head of the bed to 45 degrees. 2 Take the patient's oxygen saturation with a pulse oximeter. 3 Take the patient's blood pressure and respiratory rate. 4 Notify the health care provider of the patient's shortness of breath.

1 Raise the head of the bed to 45 degrees.

Which predisposing condition might be responsible for a patient having both reduced circulating blood volume and extracellular fluid? 1 Shock 2 Pneumonia 3 Chest trauma 4 Multiple rib fractures

1 Shock

What are the symptoms of hypoventilation? Select all that apply. 1 Convulsions 2 Dysrhythmias 3 Sighing breaths 4 Changes in mental status 5 Numbness and tingling of hands

1 Convulsions 2 Dysrhythmias 4 Changes in mental status

What parameters should the nurse monitor in a patient who has developed hypoxia due to severe anemia? Select all that apply. 1 Pulse rate 2 Blood urea 3 Serum bilirubin 4 Respiratory rate 5 Skin color change

1 Pulse rate 4 Respiratory rate 5 Skin color change

An 86-year old woman is admitted to the unit with chills and a fever of 104*F. What physiological process explains why she is at risk for dyspnea? 1. Fever increases metabolic demands, requiring increased oxygen need 2. Blood glucose stores are depleted and the cells do not have energy to use oxygen 3. Carbon dioxide production increases due to hyperventilation 4. Carbon dioxide production decreases due to hypoventilation

1. Fever increases metabolic demands, requiring increased oxygen need

A patient with chronic obstructive pulmonary disease (COPD) is on oxygen therapy. The arterial blood gas analysis after some time reveals that the carbon dioxide levels are high. The patient's condition improves when the amount of oxygen administered (fraction of inspired oxygen) is reduced. Which is the most probable reason for high levels of carbon dioxide in the patient? 1 Hypoxia 2 Hypoventilation 3 Hyperventilation 4 Respiratory alkalosis

2 Hypoventilation

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy and not cyanotic, the nurse understands the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following? 1. Stimulates hyperventilation, causing respiratory alkalosis 2. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs 3. Stimulates hypoventilation, causing respiratory acidosis 4. Causes alveoli to overinflate, leading to atelectasis

2. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs

A registered nurse discusses physiological factors that affect oxygenation with a group of nursing students. Which statement if made by the nursing student is correct? 1 "The metabolic rate decreases normally in pregnancy, wound healing, and exercise." 2 "The physiological response to chronic hypoxia is an increase in white blood cell production." 3 "Carbon monoxide is the most common toxic inhalant; it decreases the oxygen-carrying capacity of the blood." 4 "The oxygen carrying capacity of the blood increases when there is a decline in inspired oxygen concentration."

3 "Carbon monoxide is the most common toxic inhalant; it decreases the oxygen-carrying capacity of the blood."

The chest x-ray of a patient with a respiratory infection shows an enlarged and calcified trachea and bronchi. What would be the patient's age? 1 2 years old 2 12 years old 3 43 years old 4 78 years old

4 78 years old

A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation? 1. Sonorous wheezes in left lower lung 2. Rhonchi mid sternum 3. Crackles only in apex of lungs 4. Inspiratory crackles at lung bases

4. Inspiratory crackles at lung bases

A patient reports chest pain and shortness of breath on exertion. On auscultation, the heart rate is found to be 70 beats per minute. If the stroke volume of the patient's heart is 75 mL, what is the cardiac output in mL per minute? Record your answer using a whole number and please note that no comma is needed. ______ mL/minute

75 × 70 = 5250 mL/minute.

A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli's function will the nurse share with the patient? a. Carries out gas exchange b. Regulates tidal volume c. Produces hemoglobin d. Stores oxygen

A

A nurse is caring for a group of patients. Which patient should the nurse see first? a. A patient with hypercapnia wearing an oxygen mask b. A patient with a chest tube ambulating with the chest tube unclamped c. A patient with thick secretions being tracheal suctioned first and then orally d. A patient with a new tracheostomy and tracheostomy obturator at bedside

A

A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest? a. A cup of nonfat yogurt with granola and a handful of dried apricots b. Whole wheat toast with butter and a side of bacon c. A bowl of cereal with whole milk and a banana d. Omelet with sausage, cheese, and onions

A

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen? a. Nasal cannula b. Simple face mask c. Non-rebreather mask d. Partial non-rebreather mask

A

A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately? a. Ventricular tachycardia b. Atrial fibrillation c. Sinus rhythm d. Paroxysmal supraventricular tachycardia

A

A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave? a. SA node b. AV node c. Bundle of His d. Purkinje fibers

A

10. The nurse assess a new patient and finds the patient short of breath with a respiratory rate of 32 in lying supine in bed. What is the priority nursing action? a. Raise the head of the bed to 45 degrees or higher b. Get the oxygen saturation with a pulse oximeter c. Take the BP and RR d. Notify the healthcare provider of the shortness of breath

a. Raise the head of the bed to 45 degrees or higher

The nurse assesses a patient who is short of breath and fatigued. The nurse finds that the oxygen saturation of the blood is reduced. The lab report indicates that the patient's red blood cell count is increased. What do these findings suggest? 1 The patient has anemia. 2 The patient has chronic hypoxemia. 3 The patient has hypoventilation. 4 The patient has an acute infection.

2 The patient has chronic hypoxemia.

Which patients are at risk of hyperventilation? Select all that apply. 1 A patient who has atelectasis 2 A patient who has acute anxiety 3 A patient who has salicylate poisoning 4 A patient who has diabetic ketoacidosis 5 A patient who has cardiac dysrhythmias

2 A patient who has acute anxiety 3 A patient who has salicylate poisoning 4 A patient who has diabetic ketoacidosis

A patient is suffering from hypoxia. Which symptoms should the nurse expect in this patient? Select all that apply. 1 Bluish discoloration of the sclera 2 Bluish discoloration of the earlobe 3 Bluish discoloration of the nail bed 4 Bluish discoloration of the chest 5 Bluish discoloration of the conjunctiva

2 Bluish discoloration of the earlobe 3 Bluish discoloration of the nail bed 5 Bluish discoloration of the conjunctiva

A patient's laboratory report shows the presence of blood-tinged sputum. Which diagnostic tests are beneficial for the patient in this situation? Select all that apply. 1 Lung scan 2 Bronchoscopy 3 Sputum specimen 4 Pulmonary function test 5 Chest x-ray examination

2 Bronchoscopy 3 Sputum specimen 5 Chest x-ray examination

The nurse is conducting a teaching workshop for new mothers. A woman asks the nurse about the reasons for increased risk of respiratory tract infections in infants. Which reasons should the nurse cite? Select all that apply. 1 Smaller volume of lungs 2 Immature immune system 3 Frequent nasal congestion 4 Softer bones and low mobility 5 Exposure to secondhand smoke

2 Immature immune system 3 Frequent nasal congestion 5 Exposure to secondhand smoke

A patient has a condition in which the lungs remove carbon dioxide faster than it is produced by cellular metabolism. Which predisposing factors contribute to this condition? Select all that apply. 1 Cyanosis 2 Infection 3 Severe anxiety 4 Acid-base imbalance 5 Multiple rib fracture

2 Infection 3 Severe anxiety 4 Acid-base imbalance

What condition involves collapsed alveoli that prevent the normal exchange of oxygen and carbon dioxide? 1 Asthma 2 Kyphosis 3 Atelectasis 4 Myocardial infarction

3 Atelectasis

Which statement is true regarding chest percussion? 1 Chest percussion involves slow striking of the chest wall. 2 Chest percussion is performed over a multilayer of clothing. 3 Chest percussion involves rhythmically clapping on the chest wall. 4 Chest percussion is commonly performed on patients who have osteoporosis.

3 Chest percussion involves rhythmically clapping on the chest wall.

A patient reports having shortness of breath and fatigue on brisk walking for the past 2 weeks. The patient has also experienced menorrhagia for the past 2 months. The patient's blood reports show decreased hemoglobin and an increased red blood cell count. Which condition is the patient most likely experiencing? 1 Decreased surfactant in the lungs 2 Decreased lung compliance 3 Decreased oxygenation of blood 4 Decreased fraction of inspired oxygen concentration

3 Decreased oxygenation of blood

In what position should the nurse place the patient in to examine the apical segments of the lungs? 1 Prone 2 Supine 3 Fowler's (Sitting) 4 High-Fowler's

3 Fowler's (Sitting)

A patient has been newly diagnosed with emphysema. In discussing the condition with the nurse, which statement would indicate that the patient needs further education? 1 "I'll make sure that I rest between activities so I don't get so short of breath." 2 "I'll rest for 30 minutes before I eat my meal." 3 "If I have trouble breathing at night, I'll use two to three pillows to prop up." 4 "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

4 "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder? 1 Alcoholism and hypertension 2 Obesity and diabetes 3 Stress-related illnesses 4 Cardiopulmonary disease and lung cancer

4 Cardiopulmonary disease and lung cancer

The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires? a. Stimulation of chemical receptors in the aorta b. Reduction of arterial oxygen saturation levels c. Requirement of elastic recoil lung properties d. Enhancement of accessory muscle usage

A

The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination? a. Experiences chest pain after eating a heavy meal b. Experiences adequate oxygen saturation during exercise c. Experiences crushing chest pain for more than 20 minutes d. Experiences tingling in the left arm that lasts throughout the morning

A

A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the nurse describe as modifiable? a. Stress b. Allergies c. Family history d. Gender

A

A patient has carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient? a. Low-carbohydrate b. Low-caffeine c. High-caffeine d. High-carbohydrate

A

A patient with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic? a. "Your disease doesn't send enough oxygen to your fingers." b. "Your disease affects both your lungs and your heart, and not enough blood is being pumped." c. "Your disease will be helped if you pursed-lip breathe." d. "Your disease often makes patients lose mental status."

A

The nurse is caring for a patient who needs oxygen via a nasal cannula. Which task can the nurse delegate to the nursing assistive personnel? a. Applying the nasal cannula b. Adjusting the oxygen flow c. Assessing lung sounds d. Setting up the oxygen

A

The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most likely expect? a. Increased preload b. Increased heart rate c. Decreased afterload d. Decreased tissue perfusion

A

The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal the patient could achieve? a. Sleeping on two to three pillows at night b. Limiting the diet to 1500 calories a day c. Running 30 minutes every morning d. Stopping smoking immediately

A

The patient has right-sided heart failure. Which finding will the nurse expect when performing an assessment? a. Peripheral edema b. Basilar crackles c. Chest pain d. Cyanosis

A

A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority? a. Risk for skin breakdown b. Impaired gas exchange c. Activity intolerance d. Risk for infection

B

A nurse is teaching staff about the conduction of the heart. In which order will the nurse present the conduction cycle, starting with the first structure? 1. Bundle of His 2. Purkinje network 3. Intraatrial pathways 4. Sinoatrial (SA) node 5. Atrioventricular (AV) node a. 5, 4, 3, 2, 1 b. 4, 3, 5, 1, 2 c. 4, 5, 3, 1, 2 d. 5, 3, 4, 2, 1

B

A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis? a. "Atelectasis affects only those with chronic conditions such as emphysema." b. "It is important to do breathing exercises every hour to prevent atelectasis." c. "If I develop atelectasis, I will need a chest tube to drain excess fluid." d. "Hyperventilation will open up my alveoli, preventing atelectasis."

B

The home health nurse recommends that a patient with respiratory problems install a carbon monoxide detector in the home. What is the rationale for the nurse's action? a. Carbon monoxide detectors are required by law in the home. b. Carbon monoxide tightly binds to hemoglobin, causing hypoxia. c. Carbon monoxide signals the cerebral cortex to cease ventilations. d. Carbon monoxide combines with oxygen in the body and produces a deadly toxin.

B

The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient? a. Inform the patient of the importance of finishing the entire dose of antibiotics. b. Encourage the patient to stay up-to-date on all vaccinations. c. Schedule patient to get annual tuberculosis skin testing. d. Create an exercise routine to run 45 minutes every day.

B

The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance? a. Suctioning respiratory secretions several times every hour b. Administering humidified oxygen through a tracheostomy collar c. Instilling normal saline into the tracheostomy to thin secretions before suctioning d. Deflating the tracheostomy cuff before allowing the patient to cough up secretions

B