Oxygen Perfusion Questions ATI Necessary for Exam 3 Adult Health I (Plus a few extra questions related to other content)

The oncology nurse is caring for a client receiving chemotherapy. Which of the following statements would be a priority assessment for the nurse?

"Have you been experiencing any strange tastes or aftertastes lately?" Explanation: Clients receiving chemotherapy may have altered gustatory or olfactory sensations. Asking about taste would be an assessment for this condition. Repeating softly spoken words assesses auditory disturbances, feeling assesses tactile disturbances, and reading assesses visual disturbances.

The nursing student is studying the reticular activating system (RAS). Which statement indicates to the professor that the student has mastered the information?

"The RAS serves to monitor and regulate incoming sensory stimuli."

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 asses this client's oxygenation?

Arterial blood gas Explanation: Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.

Implanted CVAD =?

Chemotherapy

A client with closed-angle glaucoma and a cough has a prescription for a cough medicine. The nurse would question which cough medicine if prescribed for this client?

Cough medicine with an antihistamine Explanation: The client with closed-angle glaucoma should avoid cough medicine because of its anticholinergic action. The client with diabetes should avoid cough medicine with a high sugar content. The client with thyroid disorders should avoid cough medicine containing iodine. The client with hypertension should avoid cough medicine with decongestants.

Excessive diarrhea = ?

Hypokalemia

In which fluid compartment is most of the body's fluid located?

Intracellularly

When examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique?

Pattern of thoracic expansion Explanation: The nurse can assess patterns of thoracic expansion through palpation. Fluid-filled and consolidated portions of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation.

During the nurse's morning assessment of a client with a diagnosis of dementia, the client states that the year is 1949 and believing to be in a hotel. How should the nurse best respond to this client's disorientation?

Reorient the client to place and time Explanation: It is appropriate to reorient clients with dementia who are confused. Doing so in an effective and empathic manner requires the astute implementation of nursing skills. Engaging more deeply with the client's incorrect responses does not reorient the client. Attempting to reorient the client in a subtle and indirect manner is not likely to be effective. Documenting the client's response is necessary, but this should be followed by reorientation.

When caring for a client with a tracheostomy, the nurse would perform which recommended action?

Suction the tracheostomy tube using sterile technique Explanation: Sterile technique is required when suctioning a tracheostomy in order to prevent introduction of microorganisms into the respiratory tract. The area around a new tracheostomy may need to be assessed and cleaned every 1 to 2 hours. Gauze dressings that are not filled with cotton must be used to prevent aspiration of lint or cotton fibers into the trachea

Fluid I/Os should be approximately the same in order to maintain fluid balance? True or False?

TRUE

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

They are low-pitched, soft sounds heard over peripheral lung fields. Explanation: Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles afe soft, high-pitched discontinuous (intermittent) popping sounds.

Which guideline is recommended for determining suction catheter depth when suctioning endotracheal tube?

Using a suction catheter with centimeter increments on it, insert the suction catheter into endotracheal tube until the centimeter markings on both the endotracheal tube and catether align, and insert the suction catheter no further than an additional 1 cm.

The student is studying the sensory experience. Which statement indicates that the student understands the four conditions that must be met for a client to experience the world?

an agent, act, or other influence capable of initiating a response by the nervous system- must be present

A nursing instructor is speaking to a group of nursing students about proper care of the ears to promote hearing, as ho are hard-of-hearing as well as techniques to follow when working with clients wi. An appropriate nursing intervention discussed by the instructor includes:

demonstrating or pantomiming (dramatically expressing with physical expressions and exaggerative gestures) ideas. Explanation: For hard-of-hearing or deaf clients, demonstrating or pantomiming may assist in communication. Clients should be instructed to avoid cleaning the ear with cotton-tipped applicators or sharp objects as this can cause damage to the inner ear. While speaking directly may enhance communîcation, speaking loudly will not benefit the client. Clients should be discouraged from using earphones that concentrate loud noise in the ear canal causing acoustic damage.

The nurse is conducting health education with a group of older adults in the clinic. Which activity should the nurse include in the education that can prevent sensory loss in the older adult population?

good management of illness such as hypertension Explanation: Client education to promote sensory health and function focuses on ways to prevent sensory loss and to maintain general health. Education topics include the importance of frequent eye examinations (yearly) and close control of chronic illnesses such as hypertension and diabetes. Age related changes in eyesight and motor function may affect the ability to drive. Avoiding places full of people can prevent infection but may cause sensory overload in older adults.

A hospital client has been awakened at night by the alarm on his roommate's intravenous pump. This client was aroused by brain action in his:

reticular activating system (RAS) Explanation: The RAS is the network that mediates arousal. The limbic system is a complex system of nerves and networks in the brain, involving several areas near the edge of the cortex concerned with instinct and mood. It controls the basic emotions (fear, pleasure, anger) and drives (hunger, sex, dominance, care of offspring). Cerebellum is the part of the brain that coordinates and regulates muscular activity. The prefrontal cortex is a part of the brain located at the front of the frontal lobe and is involved in a variety of complex behaviors and personality development.

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?

trauma to the tracheal mucosa Explanation: Occluding the Y-port on the suction tubing is what creates the suction. While suctioning would be difficult but possible, suctioning while advancing the tube would damage the tracheal mucosa and remove excessive amounts of oxygen, not carbon dioxide, from the respiratory tract. Suctioning during insertion of the catheter would not compromise sterility.

An older adult client who is in a long-term care facility tells the nurse, "I am not eating that, it is poisoned." Which is the best way for the nurse to address the client's statement?

"What makes you think the food is poisoned?" Explanation: The client is exhibiting delusional behavior. Delusions are beliefs not based on reality that reflect an unconscious need or fear. By asking an open-ended question the nurse can determine why the client is making the statement and create a strategy to change the client's perspective. Asking the client if he or she wants another meal or bringing the client another meal does not address the underlying issue. Telling the client it is okay to eat the meal is not recognizing the client's fear and could damage the nurse-client relationship.

What is the adequate hydration level?

2.5 L is adequate hydration.

The pediatric nurse is caring for four clients. Which client will receive the greatest benefit from the use of an oxygen analyzer to assure that the client is receiving the prescribed amount of oxygen?

3-year old in croup tent Explanation: An oxygen analyzer is used most commonly when caring for newborns in isolettes, children in croup tents, and clients who are mechanically ventilated.

In which of the following clients will the nurse document the presence of delusions?

A client who believes the hospital kitchen staff are poisoning her food Explanation: Delusions, beliefs not based in reality, reflect an unconscious need or fear. Hallucinations involve sensing something that does not exist. Becoming nonresponsive does not indicate delirium. Fear of wide open spaces suggests a phobia, not delirium.

A client who was admitted to the critical care unit is experiencing sensory overload. When developing this client's plan of care, which intervention would be appropriate for the nurse to include? Select all that apply. a). Provide varying levels of stimulation throughout the day. b). Offer simple explanations before a treatment or procedure. c). Set up a consistent schedule for routine care activities. d). Speak to the client in a loud tone of voice. e). Suggest the use of noise-reducing h

B, C and E Explanation: Sensory overload is excessive stimuli over which a person feels little control; the brain is unable to meaningfully respond to or ignore stimuli. Appropriate interventions include providing a consistent, predictable pattern of stimulation to help the client develop a sense of control over the environment; offering simple explanations before procedures, tests, and examinations; establishing a schedule with the client for routine care such as eating, bathing, turning. positioning, coughing, and exercising; speaking calmly with the client and moving slowly; communicating confidence; exploring with the client what stimuli are most distressing (e.g. incoming phone calls, visitors) and developing a plan to reduce or eliminate them using earplugs, pain medication, and/or noise-reducing headphones, as indicated.

Which actions would a nurse perform after selecting a site and palpating accessible veins in order to start an IV infusion? Select all that apply. a). Clean the entry site with saline, followed by an alcohol swab according to agency policy b). Place the dominant hand about 4 in (10 cm) below the entry site to hold the skin taut against the vein c). Enter the skin gently with the catheter held by the hub in the non-dominant hand, bevel side down, at a 10- to 30 degree angle. d). Advance the n

C, E and F

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. True or False?

TRUE Explanation: 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 nurse caring for a client with a chest tube should monitor tre client's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.

When inspecting the client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression. Explanation: The adult chest contour is slightly convex, with no sternal depression. The skin of the thorax should be warm and dry, and the anteroposterior diameter of the chest should be less than the transverse diameter. The contour of the intercostal spaces should be flat or depressed.

Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway?

When holding the airway on the side of the client's face, it should reach from the tragus of the ear to the tip of the nostril.

Which client is experiencing a disturbance in sensory perception as the primary nursing concern, rather than the etiology of another problem?

a client who is experiencing acute confusion as a result of a drug interaction Explanation: Acute confusion is a direct example of a disturbance in sensory perception, Sleep disturbances can impact sensory perception. but they are not a direct example, The feeling of powerlessness and unproductive coping are alterations in sensory perception.

While assessing a client's neurological status, the nurse asks the client to close the eyes and identify the object placed into the hand. The nurse explains that this test if the client is able to identity the solidity, size, shape, and texture of the object. The nurse documents this ability as?

stereognosis Explanation: Stereognosis is the sense that perceives the solidity of objects and their size, shape, and texture. Proprioception is the term used to describe the sense, usually at a subconscious level, of the movements and position of the body and especially its limbs, independent of vision. Kinesthesia refers to awareness of positioning of body parts and body movement. Sensory perception is the conscious process of selecting, organizing, and interpreting data from the senses into meaninghal information.

When the nurse reviews the client's laboratory reports revealing sodium, 140 mEq/L (140 mmol/L); potassium, 4.1 mEq/L (4.1 mmol/L); calcium 7.9 mg/dL (1.975 mmol/L), and magnesium 1.9 mg/dL (0.781 mmol/L); the nurse should notify the health care provider of what abnormal value?

Low calcium Explanation: Normal total serum calcium levels range between 8.9 and 10.1 mg/dL (2.225 to 2.525 mmol/L). The other values are within reference ranges.

The community health nurse wants to identify clients who have lifestyle factors that may place them at risk for sensory disturbances. Which question will the nurse ask?

"Do you work around loud noises at work?" Explanation: Clients may be at risk for sensory disturbances for different reasons. Lifestyle factors include work or leisure activities that are potentially harmful to the eyes and ears, such as loud noises. Physiologic factors, such as diabetes and use of medications (chemotherapy), place clients at risk for sensory disturbances as well. Social and environmental factors include human and environmental stimulation (living by oneself).

What signs of complications and their probable causes may occur when administering an IV solution to a patient? (Select all that apply.) a) Swelling, pain, coolness, or pallor at the insertion site may indicate infiltration of the IV. b) Engorged neck veins, increased blood pressure, and dyspnea occur when a thrombus is present. c) Bleeding at the site when the IV is discontinued indicates an infection is present. d) A pounding headache, fainting, rapid pulse rate, increased blood pressure,

A, E and F

The nurse writes a problem-based care plan, citing the client's excess fluid volume. What risk factor does the nurse expect to assess in this client?

Acute kidney injury Explanation: Excess fluid volume may result from increased fluid intake or from decreased excretions, such as occurs with progressive acute kidney failure. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit.

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?

Ambu bag Explanation: 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. Oxygen masks may cover only the nose and mouth and can vary in the amount of oxygen delivered. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostril. An oxygen tent is a tentlike enclosure within which the air supply can be enriched with oxygen to aid a client's breathing. Oxygen masks, nasal cannula, and oxygen tents are used for clients who have a respiratory drive.

The nurse is caring for an older adult client that recently lost total vision in both eyes due to macular degeneration. Which interventions will the nurse add to the client's plan of care to assist with the with vision loss? Choose all that apply. a). Hold tightly to the client's arm during ambulation. b). Inform the client when the nurse is leaving the room c). Acknowledge presence when entering the room. d). Speak in a louder tone than usual. e). Clear the room of clutter and do not

B, C, E and F Explanation: When communicating with clients with reduced vision, the nurse should follaw these guidelines ackngwledge presence in the client's room, Identify oneself by name, speak in a normal tone or voice, remember that the blind person is unable to pick up most nonverbal cues during communication, explain the reason for touching the person before doing so, keep the caflight or bell within easy reach of the person and place the bed in the lowest position, orient the person to sounds in the environment, orient the person to the arrangement of the room and its furnishings, clear pathways for the person and do not rearrange furnishings and clarify this fact with housekeeping personnel, assist with ambulation by walking sightly ahead of the person, allowing the person to grasp nurse's arm, stay in the person's field of vision if she has partial or reduced peripheral vision, provide diversions using other senses, and indicate to the person when the conversation has ended

A nurse is providing care in an area which is plagued by high levels of air pollutants from industry and motor vehicles. The nurse will expect a high incidence and prevalence of what respiratory disease?

Bronchitis Explanation: Bronchitis refers to a condition in which the airways become inflamed, commonly due to respiratory irritants such as air pollution and high humidity. Exposure to such irritants leads to the release of inflammatory mediators, which in turn, lead to inflammation and narrowing of the airways and increased mufus production. Atelectasis refers to the partial or complete collapse of the small air sacs in the lungs, common after surgery or with obstruction or compression of the airways or lungs. Bronchiectasis results from chronic inflammation or infection causing an excess accumulation of mucus. Croup is an infection of the airways, most commonly viral in origin.

The nurse is preparing to initiate an infusion of packed red blood cells (PRBCs). While observing the information on the blood bag, it is essential to verify which information with another nurse? Select all that apply. a). Patency of the client's venous access device b). Client's room number c). Client's vital signs d). Number on the client's identification band e). Name on the client's identification band

D and E

A nurse who has diagnosed a client as having "fluid volume excess" related to compromised regulatory mechanism (kidneys) may have been alerted by what symptom?

Distended neck veins Explanation: Fluid volume excess causes the heart and lungs to work harder, leading to the veins in the neck becoming distended. Muscle twitching, and nausea and vomiting may signify electrolyte imbalances. The sternum is not an area assessed during fluid volume excess.

The nurse is assessing a neonate whose breathing ceased for 4 to 5 seconds on three different occasions. What is the nurse's best action?

Document these expected apneic episodes Explanation: The newborn's breathing pattern is characterized by occasional pauses of several seconds between breaths. This periodic breathing is normal during the first 3 months of life, but frequent or prolonged periods of apnea (cessation of breathing 20 seconds or longer) are abnormal. In the absence of symptoms of hypoxia, referrals and further interventions such as suctioning are unnecessary.

The nurse has just successfully inserted an intravenous (IV) catheter and initiated IV fluids. Which items should the nurse document? Select all that apply. 47s a). Rate of the IV solution b). Manufacturer of the IV catheter c). Location of the IV catheter access d). Client's reaction to the procedure e). Type of IV solution f). Gauge and length of the IV catheter

Everything but answer B.

The nurse has received the arterial blood gas (ABG) results. The ABG drawn on a client who has been receiving oxygen via partial rebreather mask. Which assessment findings should the nurse act upon after reviewing the ABG? Select all that apply. Headache Sore Throat Fatigue Nasal Flaring Tachycardia

Headache, sore throat, fatigue Explanation: The ABG results indicate possible hyperventilation and hyperoxygenation which could indicate oxygen toxicity. A headache, sore throat, and fatigue are possible indicators of oxygen toxicity. The client has an increased risk for oxygen toxicity due to the type of mask. The nasal flaring and tachycardia are possible signs of the opposite, inadequate oxygenation. ABG normal results are pH 7.35-7.45, Pa02 80 to 100 mm Hg (10.64 to 13.30 kPa), PaCO2 35 to 45 mm Hg (4.66 to 5.99 kPa), Sa0, 95% to 100% (0.95 to 1.0), and HCO3 22 to 26 mEq/l (22 to 36 mmol/l).

A client has received morphine for reports of pain at a recent surgical incision site. After receiving the medication, the client starts picking at the bedsheets and saying, "Get the bugs off my bed, I can feel them crawling on me! Which nursing diagnosis is apropriate for this client?

Impaired tactile perception related to side effects of medication as evidenced by client statement of "Get the bugs off my bed, I can feel them crawling on me." Explanation: The correctly written nursing diagnosis is Impaired tactile perception related to side effects of medication as evidence by client statement of "Get the bugs off my bed, I can feel them crawling on me." This client does not have a sensory deficit, but rather a sensory impairment. Hallucination and delirium are not nursing diagnoses.

A parents brings their 2-year-old to the emergency department in respiratory distress. SThe child's oxygen saturation is 81% and there is audible stridor. What intervention will the nurse anticipate?

Placement in an oxygen tent Explanation: Stridor often accompanies croup in young children. Due to the child's age, an oxygen tent would be an appropriate oxygen delivery device. The child is too young for metered-dose inhalers or deep breathing and coughing exercises.

When reviewing the data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom?

Rapid respirations Explanation: Normal cardiac output averages from 3.5 to 8.0 liter/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing the respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display a thready pulse.

A health care provider has prescribed oxygen to be delivered at 8 L/minute for a client who does not have a tracheostomy. Which oxygen delivery device(s) will the nurse consider using? Select all that apply. Simple Mask Partial Rebreather Venturi Mask Nonrebreather Mask T-piece

Simple mask, partial rebreather mask Explanation: A simple mask, and partial rebreather mask accommodate a flow of 8 L/min. A venturi mask accommodates 4-6 L/min, and a nonrebreather mask accommodates 10-15 L/min. The client does not have a tracheostomy so a T-piece is inappropriate.