EAQ 3: Oxygenation and Homeostasis

Which explanation will the nurse give when a client asks about what causes varicose veins? 1 "Abnormal configurations of the veins." 2 "Incompetent valves of superficial veins." 3 "Decreased pressure within the deep veins." 4 "Atherosclerotic plaque formation in the veins."

2 Incompetent valves result in retrograde venous flow and subsequent dilation of veins. Abnormal configurations of the veins are considered a result of, rather than a cause of, varicose veins. Pressure within the deep veins is increased, not decreased. Plaque formation is considered an arterial, rather than a venous, problem and is associated with atherosclerosis.

Which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema? 1 Prevents bronchial spasm 2 Decreases air trapping in lung 3 Improves alveolar surface area 4 Strengthens diaphragmatic contraction

2 Pursed-lip breathing provides positive pressure in the airways during expiration, prolonging expiration and decreasing the air trapping, which is characteristic of emphysema. Pursed-lip breathing will not decrease bronchospasm, which is characteristic of asthma. Alveolar surface area is not changed by pursed-lip expiration. Diaphragmatic contraction is not strengthened by pursed-lip breathing.

Which would be the respiratory rate in a 2-year-old child? 1 20 breaths/min 2 30 breaths/min 3 40 breaths/min 4 50 breaths/min

2 The normal range for the respiratory rate in a 2-year-old child (toddler) is between 25 and 32 breaths/min. Twenty breaths per minute is the normal respiratory rate in adolescents and adults. The normal respiratory rate in newborns is 40 breaths/min. The normal respiratory rate in infants is 50 breaths/min.

After the nurse has finished teaching a client about sickle cell anemia, which statement indicates that the client has a correct understanding of the condition? 1 "I have abnormal platelets." 2 "I have abnormal hemoglobin." 3 "I have abnormal hematocrit." 4 "I have abnormal white blood cells."

2 The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle. Although it can affect hematocrit, it is really a result of the abnormal hemoglobin. The disorder affects hemoglobin rather than platelets or white blood cells.

Which is the purpose of a vitamin K injection in a newborn? 1 It promotes conjugation of bilirubin. 2 It promotes formation of red blood cells. 3 It prevents destruction of red blood cells. 4 It provides protection from hemorrhage.

4 Vitamin K prevents hemorrhagic disease of the newborn because it activates coagulation factors in the liver. Its role in the liver is to activate blood coagulation, not bilirubin conjugation. The mechanism by which vitamin K prevents hemorrhage is unrelated to formation or destruction of red blood cells, for which vitamin K does not have a role.

Which is the minimum heart rate of a 14-year-old? Record your answer using a whole number. ________ beats per minute

60

Which complication is the priority for the nurse to assess in a child with smoke inhalation? 1 Systemic infection 2 Tracheobronchial edema 3 Post-traumatic stress disorder 4 Generalized adaptation to stress

2 Heat and inhaled smoke-related irritants may cause fluid to shift from the intravascular compartment into the interstitial compartment, resulting in edema, which obstructs the airway. Although monitoring for infection is important, a patent airway is the priority. Although monitoring for post-traumatic stress disorder is important because the condition could occur later, maintaining a patent airway is the priority. Although monitoring for physical and emotional responses to stress is important, maintaining a patent airway is the priority.

A client is extubated in the postanesthesia care unit after surgery. For which common response would the nurse be alert when monitoring the client for acute respiratory distress? 1 Bradycardia 2 Restlessness 3 Constricted pupils 4 Clubbing of the fingers

2 Inadequate oxygenation of the brain from acute respiratory distress may produce restlessness or behavioral changes. The pulse increases with cerebral hypoxia from acute respiratory distress. The pupils dilate with cerebral hypoxia. Clubbing of the fingers is the result of prolonged hypoxia.

At which interval are humidified oxygen systems replaced to prevent infection? 1 1 day 2 3 days 3 5 days 4 7 days

1 Humidified oxygen delivery needs to be changed out daily to prevent infection. Every 3 to 5 days is too long to wait and may promote infection. Oxygen delivery without humidification will need to be changed out every 7 days.

Which dietary restriction will the nurse expect to be included in the plan for a client with left ventricular failure? 1 Sodium 2 Calcium 3 Potassium 4 Magnesium

1 Restriction of sodium reduces the amount of water retention, thus reducing cardiac workload. Calcium is restricted in individuals who develop renal calculi. Potassium is not restricted, especially if a diuretic is prescribed, because diuresis facilitates the loss of potassium in the urine. Magnesium is not restricted.

A client has delivered her infant by cesarean birth. The nurse monitors the newborn's respiration closely, because infants born via the cesarean method are prone to atelectasis. Why does this occur? 1 The ribcage is not compressed and released during birth. 2 The sudden temperature change at birth causes aspiration. 3 There is usually oxygen deprivation after a cesarean birth. 4 There is no gravity during the birth to promote drainage from the lungs.

1 The release after compression of the chest during a vaginal birth is the mechanism for expansion of the newborn's lungs; because this does not occur during a cesarean birth, lung expansion may be incomplete, and atelectasis may result. Temperature change is not implicated in aspiration. The infant is monitored closely to prevent oxygen deprivation. The newborn's head may be held lower than the chest to allow gravity to promote drainage from the lungs after a cesarean birth.

In comparing assessment findings in clients with vascular dementia and dementia of the Alzheimer type, which factor is unique to vascular dementia? 1 Memory impairment 2 Abrupt onset of symptoms 3 Difficulty making decisions 4 Inability to use words to communicate

2 The signs and symptoms associated with vascular dementia have an abrupt onset (days to weeks) because of the occlusion of small arteries or arterioles in the cortex of the brain. Dementia of the Alzheimer type is associated with a gradual (years), progressive loss of function. Memory impairment and difficulty making decisions may or may not be a symptom of vascular dementia; it depends on which part of the brain is affected. Alzheimer disease usually results in memory impairment and difficulty with decision-making, but not abruptly. Inability to use words to communicate is a typical symptom of Alzheimer disease, but with vascular dementia, the client may have trouble speaking or understanding speech.

Which parameter describes the maximum volume of air a client's lungs may contain? 1 Vital capacity 2 Total lung capacity 3 Inspiratory capacity 4 Functional residual capacity

2 Total lung capacity is the maximum volume of air that the lungs can contain. Vital capacity is the maximum volume of air that can be exhaled after maximum inspiration. Inspiratory capacity is the maximum volume of air that can be inhaled after maximum expiration. Functional residual capacity is the volume of air remaining in the lungs at the end of normal exhalation.

A beta blocker is prescribed for the client with persistent ventricular tachycardia. Which response indicates that the beta blocker is working effectively? 1 Decreased anxiety 2 Reduced chest pain 3 Decreased heart rate 4 Increased blood pressure

3 A decreased heart rate is the expected response to a beta blocker. Beta blockers inhibit the activity of the sympathetic nervous system and of adrenergic hormones, decreasing the heart rate, conduction velocity, and workload of the heart. A beta blocker is not an anxiolytic and does not reduce anxiety. A beta blocker is not an analgesic and does not reduce chest pain. Beta blockers reduce blood pressure.

The nurse is preparing to administer a transdermal medication to an infant. To administer the medication safely, the nurse would recognize which as the reason absorption is more rapid via the transdermal route in infants than in older children? 1 Thinner dermis 2 Larger skin pores 3 Increased blood flow 4 Minimal subcutaneous fat

3 Blood flow to the skin is greater in infants than in older children and adults. The dermis, pores of the skin, and subcutaneous fat are not considered factors affecting transdermal absorption in the infant.

The nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. Which would the nurse document these sounds as? 1 Vesicular 2 Bronchial 3 Crackles 4 Rhonchi

3 Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli. Vesicular breath sounds are normal. They are quiet, soft, and inspiration sounds that are short and almost silent on expiration. They are heard over the lung periphery. Bronchial breath sounds are normal and consist of a full inspiration and expiratory phase with the expiratory phase being louder. They are heard over the trachea and large bronchi of the lungs. Rhonchi are abnormal breath sounds heard over the large airways of the lungs. They consist of a low pitch and are caused by the movement of secretions in the larger airways; they usually clear with coughing.

A client with supraventricular tachycardia (SVT) has a heart rate of 170 beats/minute. After treatment with diltiazem, which assessment indicates to the nurse that the diltiazem is effective? 1 Increased urine output 2 Blood pressure of 90/60 mm Hg 3 Heart rate of 98 beats/minute 4 No longer complaining of heart palpations

3 Diltiazem hydrochloride's purpose is to slow down the heart rate. SVT has a heart rate of 150 to 250 beats/minute. A heart rate of 110 beats/minute indicates that the diltiazem hydrochloride is having the desired effect. Hypotension is a side effect of diltiazem hydrochloride, not a desired effect. Heart palpations are experienced by some with various dysrhythmias. A decreased sensation of heart palpations is a positive finding but is not present in all clients. Increased urine output may occur over a period of time because of the increased ventricular filling time but would not occur until after the heart rate had stabilized.

Which teratogenic effect is seen because of lithium? 1 Stillbirth 2 Shortened limbs 3 Ebstein anomaly 4 Neural tube defects

3 Ebstein anomaly (cardiac defects) in the newborn occurs because of taking lithium during pregnancy. Stillbirth may occur because of alcohol use. Shortened limbs may occur because of thalidomide. Neural tube defects are due to antiseizure medications.

Which medication would the nurse expect to administer to control bleeding in a child with hemophilia A? 1 Albumin 2 Fresh frozen plasma 3 Factor VIII concentrate 4 Factors II, VII, IX, X complex

3 Factor VIII is the missing plasma component necessary to control bleeding in a child with hemophilia A. Factor VIII is not provided by albumin. Although fresh frozen plasma does contain factor VIII, there is an insufficient amount in a plasma transfusion; a higher volume is required. A complex of factors II, VII, IX, and X is not useful in this situation.

An older client with a history of congestive heart failure expresses concern about potential exposure to tuberculosis (TB) from his or her roommate at the extended care facility. The roommate coughs a great deal and sometimes spits up blood. Which is the primary reason that the nurse pursues more information about the roommate? 1 Death from TB is on the increase in older populations. 2 The roommate is causing increased anxiety and stress in the client. 3 TB adversely affects older adults with chronic illness. 4 Most likely, the roommate prevents the client from getting proper sleep.

3 The client's cardiac condition and age make the client vulnerable to communicable diseases. In the United States, death from TB is declining because of improved medication therapy. (Canada: According to the Public Health Agency of Canada, 1607 new active and retreatment (latent) TB cases were reported to the Canadian Tuberculosis Reporting System in 2011, but TB is no longer common in the overall Canadian population.) The nurse's primary concern is to prevent the spread of infection. The issues of client anxiety and potential sleep disturbance should be addressed later; they are not the greatest concern at this time.

Which part of the electrocardiogram (ECG) represents depolarization of the ventricles? 1 P wave 2 T wave 3 PR interval 4 QRS interval

4 Atrial and ventricular depolarization and repolarization are represented on the ECG as a series of waves: the P wave followed by the QRS complex and the T wave. The QRS represents ventricular depolarization. The P wave occurs with depolarization of the atria. The T wave represents ventricular repolarization. The PR interval represents depolarization of the atria and of the atrioventricular node.

The weight of a 3-month-old infant with tetralogy of Fallot has declined from the 25th percentile to the 5th. Which mechanism would the nurse suspect is the reason for this inadequate weight gain? 1 Cyanosis resulting in cerebral changes 2 Decreased arterial oxygen level resulting in polycythemia 3 Pulmonary hypertension resulting in recurrent respiratory infections 4 Inadequate oxygen perfusion leading to activity intolerance, resulting in diminished energy to nurse

4 Because of quick fatigue, it is difficult for the infant to consume sufficient calories for adequate weight gain. Increased caloric intake is needed to meet the infant's nutritional needs. Although cyanosis is present, it may not lead to cerebral changes. Cyanosis is not directly related to inadequate weight gain. Although decreased Po2 does lead to polycythemia, it does not affect the infant's ability to gain adequate weight. Although there is pulmonary hypertension, it is not directly related to inadequate weight gain or respiratory infections.

Which action would the nurse take after having difficulty in palpating the pedal pulse of a client with venous insufficiency? 1 Count the pulse at another site. 2 Notify the primary health care provider. 3 Lower the legs to increase blood flow. 4 Verify the pulse by using a Doppler.

4 Clients with venous insufficiency often have edema, which may make palpation of an arterial pulse difficult. A Doppler uses sound waves so that the pulse can be heard. The nurse is assessing for pulse presence and quality, not pulse rate, when checking pedal pulses. Because there is no indication that the client has arterial insufficiency, the nurse would not notify the primary health care provider about difficulty in palpating the distal pulses. Lowering the legs will increase edema and make palpation of pulses more difficult.

The nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise? 1 Decreases chest pain 2 Conserves energy 3 Increases oxygen saturation 4 Promotes elimination of CO2

4 Pursed-lip breathing increases positive pressure within the alveoli and makes it easier for clients to expel air from the lungs. This in turn promotes elimination of CO2. It also helps clients slow their breathing pattern and depth with respirations. It does not decrease chest pain, conserve energy, or increase oxygen saturation. 73%

In which area would the nurse place the stethoscope when taking an apical pulse? 1 a 2 b 3 c 4 d

4 The apex of the heart is at the mitral area, which is located where the fifth intercostal space intersects the midclavicular line (point d). Point a is the aortic area. Point b is the epigastric area. Point c is the pulmonic area. 88%

Which client response is most important for the nurse in the postanesthesia care unit to monitor when caring for a client who had a thyroidectomy? 1 Urinary retention 2 Signs of restlessness 3 Decreased blood pressure 4 Signs of respiratory obstruction

4 The first and most important observation should be for respiratory obstruction. If this occurs, treatment must be instituted immediately. Urinary retention is a later concern; urinary retention will not occur in the immediate postoperative period. Signs of restlessness may result from the anesthesia; however, it is not life threatening and usually passes. The blood pressure is not significantly affected by this type of surgery; however, surgery itself can influence blood pressure. If the blood pressure significantly increases, other symptoms of thyroid crisis (storm) will be present.

When calculating a client's heart rate on an electrocardiogram (ECG) strip, which action would the nurse take? 1 Count the P waves. 2 Count the T waves. 3 Count the PR interval. 4 Count the QRS complexes.

4 The heart rate is calculated by counting QRS complexes, which represent ventricular depolarization. The P wave represents atrial depolarization and would be used if the atrial rate was being calculated. The T wave represents ventricular repolarization and is not used to calculate heart rate. The PR interval represents depolarization of the atria and atrioventricular node and is not used in heart rate calculation.

A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? 1 Dull sound on percussion 2 Vocal fremitus on palpation 3 Rales with rhonchi on auscultation 4 Absence of breath sounds on auscultation

4 The left lung is collapsed; therefore there are no breath sounds. A tympanic, not a dull, sound will be heard with a pneumothorax. There is no vocal fremitus because there is no airflow into the left lung as a result of the pneumothorax. Rales with rhonchi will not be heard because there is no airflow into the left lung as a result of the pneumothorax.

Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax? Select all that apply. One, some, or all responses may be correct. 1 Emptying the drainage system when full 2 Keeping the drainage system at heart level 3 Notifying the health care provider of drainage greater than 50 mL/h 4 Marking the time on the drainage unit every shift 5 Laying the drainage system on its side during transport

4 The nurse would mark the drainage system every shift to determine the amount of drainage. The drainage system is a closed system, so the nurse would switch out the drainage system when it is full. Emptying the system would break sterility. The drainage system should remain below chest level to prevent fluid from backing up into the lungs. The nurse would notify the health care provider if drainage is greater than 100 mL/h. The nurse would keep the drainage system upright.

The nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. Which aspect of counseling would the nurse focus on? 1 Teaching how to make a room allergy-free 2 Referring to a support group for individuals with asthma 3 Arranging with the college to ensure a speedy return to classes 4 Evaluating whether the necessary lifestyle changes are understood

4 Understanding the disorder and the details of care are essential for the client to be self-sufficient. Although teaching is important, a perceived understanding of the need for specific interventions must be expressed before there is a readiness for learning. Referring to a support group is premature; this may be done eventually. Although ensuring a speedy return to classes is important, involving the college should be the client's decision.