Therapeutics Chapter 38: Oxygenation and Perfusion
Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? A. Eat smaller meals that are high in protein. B. Eat one large meal at noon. C. Snack on high-carbohydrate foods frequently. D. Contact the physician for nutrition shake.
Eat smaller meals that are high in protein. Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1418.
During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? A. Oxygen analyzer B. Humidifier C. Flow meter D. Nasal cannula
Flow meter Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1414.
A nurse is percussing the thorax of a client with chronic emphysema. What percussion sound would most likely be assessed? A. Hyperresonance B. Tympany C. Resonance D. Flat
Hyperresonance Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015,
The nurse assesses a client 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. Atelectasis B. Perfusion C. Hypoxia D. Hyperventilation
Hypoxia Explanation: Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 38, Oxygenation and Perfusion, p. 1401.
A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention? A. Explain uses of BiPAP masks versus CPAP masks. B. Inquire about factors that contribute to non-adherence. C. Document assessment and plan for intervention. D. Notify the healthcare provider of the client's current status.
Inquire about factors that contribute to non-adherence. Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 38: Oxygenation and Perfusion, p. 1429-1430.
Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen? A. It prescribes oxygen concentration. B. It determines whether the client is getting enough oxygen. C. It decreases dry mucous membranes via delivering small water droplets. D. It regulates the amount of oxygen received.
It regulates the amount of oxygen received. Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 38: Oxygenation and Perfusion, p. 1414
During assessment of a 4-year-old client, the nurse notes a respiratory rate of 35 breaths/min and a loud, harsh expiration that is longer than inspiration. The nurse would implement which appropriate nursing intervention next? A. Administer oxygen therapy B. Notify the health care provider C. Proceed with the assessment D. Obtain arterial blood sampling
Proceed with the assessment Explanation: Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1405.
When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom? A. Rapid respirations B. Mental alertness C. Weight loss D. Increased urine output
Rapid respirations Explanation: Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1402.
The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order? A. Forced Expiratory Volume (FEV) B. Total lung capacity (TLC) C. Tidal volume (TV) D. Residual Volume (RV)
Residual Volume (RV) Explanation: Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 38, Oxygenation and Perfusion, p. 1414.
The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign? A. Apical pulse B. Orthostatic blood pressure C. Respiratory rate and depth D. Urinary intake and output
Respiratory rate and depth Explanation: Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1465.
What is the action of codeine when used to treat a cough? A. Expectorant B. Antisuppressant C. Antihistamine D. Suppressant
Suppressant Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1422.
The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include the humidifier? A. "The humidifier prescribes the concentration of oxygen." B. "This is a gauge used to regulate the amount of oxygen that a client receives." C. "Small water droplets come from this, thus preventing dry mucous membranes." D. "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed."
"Small water droplets come from this, thus preventing dry mucous membranes." Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 38: Oxygenation and Perfusion, p. 1425-1429.
The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach? A. "Take in a little air, hold your breath 15 seconds, and exhale slowly." B. "Take in as much air as possible, hold your breath briefly, and exhale slowly." C. "Take in a small amount of air and exhale quickly." D. "Take in a large volume of air and hold your breath as long as you can."
"Take in as much air as possible, hold your breath briefly, and exhale slowly." Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 38: Oxygenation and Perfusion, p. 1420.
A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response? A. "Call your oxygen supplier immediately." B. "That will help the oxygen flow more freely." C. "That will make it easier to carry with you." D. "The caregiver will need to place the oxygen tank back into the secure carrier."
"The caregiver will need to place the oxygen tank back into the secure carrier." Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 38: Oxygenation and Perfusion, p. 1425-1429.
The nurse is caring for a client with a nonhealing wound who has been prescribed hyperbaric oxygen therapy (HBOT). When the client asks, "How will this help me?" what is the appropriate nursing response? A. "HBOT treats aerobic infections." B. "Wounds heal because HBOT helps to regenerate new tissue quickly." C. "You will be treated for decompression sickness." D. "It will help you breathe much easier, and feel better."
"Wounds heal because HBOT helps to regenerate new tissue quickly." Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 38: Oxygenation and Perfusion, p. 992.
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? A. "Oxygen is a flammable gas." B. "I understand; I used to be a smoker also." C. "You should never smoke when oxygen is in use." D. "An occasional cigarette will not hurt you."
"You should never smoke when oxygen is in use." Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 38: Oxygenation and Perfusion, p. 1426.
The nurse is educating a client on the proper use of inhaled medications. What are appropriate education points to include? Select all that apply. A. Bronchodilators are used to liquefy or loosen thick secretions or reduce inflammation in airways. B. Nebulizers are used to deliver a controlled dose of medication with each compression of the canister. C. Dry powder inhalers (DPIs) are actuated by the client's inspiration, so there is no need to coordinate the delivery of puffs with inhalation. D. When using a metered-dose inhaler (MDI) , the client must activate the device before and after inhaling. E. MDIs deliver a controlled dose of medications with each compression of the canister.
- When using a metered-dose inhaler (MDI) , the client must activate the device before and after inhaling. - Dry powder inhalers (DPIs) are actuated by the client's inspiration, so there is no need to coordinate the delivery of puffs with inhalation. - MDIs deliver a controlled dose of medications with each compression of the canister. Explanation: Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 38, Oxygenation and Perfusion, p. 1433.
A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention? A. Contact the healthcare provider to report the client's current status. B. Explain the use of a BiPAP mask instead of a CPAP mask. C. Document outcomes of modifications in care. D. Ask the client what factors contribute to nonadherence.
Ask the client what factors contribute to nonadherence. Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 38: Oxygenation and Perfusion, p. 1407.
The nurse is caring for an older adult client on home oxygen who has dentures, but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate? A. Check fit of oxygen mask. B. Contact the oxygen supplier to request an oxygen tent. C. Increase the flow of oxygen. D. Discontinue oxygen therapy until the client is reassessed by the healthcare provider.
Check fit of oxygen mask. Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 38: Oxygenation and Perfusion, p. 1426-1428.
Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body? A. Parkinson's disease B. Pancreatitis C. Chronic anemia D. Graves' disease
Chronic anemia Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1402. Chapter 38: Oxygenation and Perfusion - Page 1402
The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client? A. "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." B. "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." C. "If you breathe through the mouth first, you will swallow germs into your stomach." D. "Breathing through your nose first will warm, filter, and humidify the air you are breathing."
"Breathing through your nose first will warm, filter, and humidify the air you are breathing." Explanation: Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1420.
The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse would cause the charge nurse to intervene? A. The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). B. The newly hired nurse assesses the client's pain and administers pain medication. C. The newly hired nurse explains what she is doing and the reason to the client, even though the client does not appear to be alert. D. The newly hired nurse adjusts the bed to a comfortable working position.
The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). Explanation: Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins, 2015, p. 1455.
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A. False B. True
True Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1431.
A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing: A. bronchiolitis. B. bronchitis. C. a bronchospasm. D. bronchiectasis.
a bronchospasm. Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015,
In which client would the nurse assess for a depressed respiratory system? A. a client taking amlodipine for hypertension B. a client taking opioids for cancer pain C. a client taking antibiotics for a urinary tract infection D. a client taking insulin for diabetes
a client taking opioids for cancer pain Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, pp. 1401, 1404.
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. tap water B. mineral oil C. normal saline D. distilled water
distilled water Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 38: Oxygenation and Perfusion, p. 1449.
The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal? A. fine crackles to the bases of the lungs bilaterally B. respiratory rate of 18 breaths per minute C. resonance on percussion of lung fields D. vesicular breath sounds audible over peripheral lung fields
fine crackles to the bases of the lungs bilaterally Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, p. 1416.
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. tracheostomy collar B. nasal cannula C. face tent D. simple mask
nasal cannula Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 38: Oxygenation and Perfusion, p. 1426.
The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly? A. drainage system is positioned slightly above chest level B. dressing is moist and intact C. respirations are at 20 breaths per minute D. small amount of subcutaneous air is detected at the sit of tube insertion
respirations are at 20 breaths per minute Explanation: Reference: Taylor, C., et al. Fundamentals of Nursing, 8th ed. Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins; 2015, Chapter 38: Oxygenation and Perfusion, p. 1430-1431.
A nurse suctioning a client 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. suctioning of carbon dioxide C. loss of sterile field D. prevention of suctioning
trauma to the tracheal mucosa Explanation: Reference: Taylor, C.R. Fundamentals of Nursing, 8th ed., Philadelphia: Wolters Kluwer Health, 2015, Chapter 38, Oxygenation and Perfusion, p. 1446-1447.