oxygenation passpoint

C

A 7-year-old boy is hospitalized with cystic fibrosis. To help him manage secretions and avoid respiratory distress, the nurse should: a)serve a high-calorie diet. b) place the child in an oxygen tent and have oxygen administered continuously. c) perform chest physiotherapy every 4 hours. d) give pancreatic enzymes as ordered.

C

A client has had a left chest tube in place for several days. The nurse assesses the client and notes that there is no bubbling in the water seal chamber. Auscultation of the left lower lung reveals vesicular breath sounds. What is the most appropriate action by the nurse? a) Clamp the chest tube and document the response. b)Connect the client to a new chest tube system. c) Further assess the client for reinflation of the lung. d) Increase the suction level of the chest tube.

A

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? a)Light-headedness or paresthesia b) Hallucinations or tinnitus c) Nausea or vomiting d) Abdominal pain or diarrhea

B

A client is brought to the emergency department following an automobile accident. Physical assessment reveals tachycardia, dyspnea, and absent breath sounds over the right lung. Which of the following actions is the nurse's most appropriate action? a) Preparing the client for a tracheostomy b)Preparing the client for a chest tube insertion c) Preparing the client for an emergency thoracotomy d) Preparing the client for a pericardiocentesis

C

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a) pH b) Partial pressure of arterial carbon dioxide (PaCO2) c) Partial pressure of arterial oxygen (PaO2) d) Bicarbonate (HCO3-)

A

A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure? a) Bibasilar crackles b) Right upper quadrant pain c) Jugular vein distention d) Dependent edema

C

A client receiving hemodialysis treatments arrives at the hospital with a blood pressure of 200/100 mmHg, a heart rate of 110 bpm, and a respiratory rate of 36 breaths/min. Oxygen saturation on room air is 89%. The client reports shortness of breath, and has + 2 pedal edema. The last hemodialysis treatment was yesterday. Which intervention should be done first? a) Elevate the foot of the bed b) Restrict the client's fluids c) Administer oxygen d) Prepare the client for hemodialysis

A

A client with a history of asthma is brought to the emergency department in respiratory distress. Which is the priority action by the nurse? a) Position in Fowler's position, initiate oxygen, and administer bronchodilators as ordered. b) Place in supine position, initiate oxygen, and administer bronchodilators as ordered. c) Position in high Fowler's position and administer bronchodilators as ordered. d) Encourage ambulation and administer bronchodilators and steroids as ordered.

D

A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which statement is true concerning oxygen administration to a client with COPD? a) High oxygen concentrations will cause coughing and dyspnea. b) Administration of oxygen is contraindicated in clients who are using bronchodilators. c) Increased oxygen use will cause the client to become dependent on the oxygen. d)High oxygen concentrations may inhibit the hypoxic stimulus to breathe.

A

A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He reports shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include: a)diminished or absent breath sounds on the affected side. b)diminished or absent breath sounds on the affected side. c)muffled or distant heart sounds. d)paradoxical chest wall movement with respirations.

B

A nurse is caring for a client with bronchogenic carcinoma. Which nursing intervention takes highest priority? a) Offering frequent rest periods b)Removing pulmonary secretions c) Improving nutritional status d)Allowing the client to express concerns

D

A preschool child immobilized in a hip spica cast has trouble breathing after meals. Which action would be best? a) Teach the child pursed-lip breathing. b) Give the child a laxative after meals. c) Encourage the child to drink more between meals. d) Offer the child small feedings several times a day.

D

A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first? a) Maintain adequate circulating volume. b)Reduce the client's anxiety. c) Decrease chest pain. d)Maintain adequate oxygenation.

D

After a thoracotomy, the nurse instructs the client to perform deep-breathing exercises. What is an expected outcome of these exercises? a) There is increased blood flow to the lungs to allow them to recover from the trauma of surgery. b)The rate of air flow to the remaining lobe is controlled so that it will not become hyperinflated. c)The elevated diaphragm enlarges the thorax and increases the lung surface available for gas exchange d)The alveoli expand and increase the lung surface available for ventilation.

C

In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to what acid-base imbalance? a) Metabolic alkalosis b) Metabolic acidosis c)Respiratory acidosis d)Respiratory alkalosis

D

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The decrease in pH exists because the client's lungs: a) are unable to inspire sufficient oxygen. b) are unable to exchange oxygen and carbon dioxide. c) have ineffective cilia from years of smoking. d) are not able to blow off carbon dioxide.

B

The nurse is caring for a lethargic 4-year-old who is a victim of a near-drowning accident. The nurse should first: a) prepare for intubation. b) administer oxygen. c) institute rewarming. d) start an intravenous infusion.

A

The nurse on the previous night shift documented that the lungs of a client with lung cancer were CTA (clear to auscultation) in all fields. While doing the shift assessment the dayshift nurse noticed decreased breath sounds, especially in the right lower lobe. The nurse's best action is to do which of the following? a)Notify the MD of the change in client status. b)Report findings to the charge nurse for follow up with the previous shift's nurse regarding the documentation. c) Document the findings as the only action as this is expected in clients with lung cancer. d) Call radiology for an X-ray to confirm findings.

C

Which complication is common in neonates who receive prolonged mechanical ventilation at birth? a)Hydrocephalus b) Esophageal atresia c) Bronchopulmonary dysplasia d) Renal failure

A

Which finding would suggest pneumothorax in a trauma victim? a)absent breath sounds b) inspiratory wheezing c) pronounced crackles d) dullness on percussion

B

While assessing a 2-hour-old neonate, a nurse observes that the neonate has acrocyanosis. Which nursing action should the nurse perform at this time? a)Activate the code emergency response system. b) Do nothing — acrocyanosis is normal in the neonate. c)Notify the physician that a cardiac consult is needed. D)Take the neonate's temperature immediately according to hospital policy.