Week 9 Oxygenation and Perfusion: Assess and Recognize Cues; Implement and Take Action; Evaluate

Which explanation would the nurse give when preparing a patient for placement of an oropharyngeal tube? -"There will be a small incision made to help you breathe" -"This will help facilitate clearing secretions from your mouth and throat." -"This will remain in place only as long as you are under general anesthesia." -"Your nares will be lubricated to ease insertion."

"There will be a small incision made to help you breathe"A tracheostomy involves an incision and is not part of oropharyngeal placement. Correct "This will help facilitate clearing secretions from your mouth and throat."An oropharyngeal tube is used to help with suctioning secretions to keep the airway clear. "This will remain in place only as long as you are under general anesthesia."An endotracheal tube is used for oxygenation during surgical procedures, not an oropharyngeal tube. "Your nares will be lubricated to ease insertion."A nasopharyngeal tube is lubricated before insertion through the nares. An oropharyngeal tube is placed in the mouth.

Which findings would prompt the nurse to perform a focused cardiopulmonary assessment? Select all that apply. 1-Medical history of a cardiovascular problem 2-Medical history of a respiratory problem 3-Signs and symptoms of decreased oxygenation 4-Signs and symptoms of activity intolerance 5-Signs and symptoms of increased peripheral perfusion

*1,2,3,4 Medical history of a cardiovascular problem A medical history of a cardiovascular problem would prompt the nurse to obtain more patient data by performing a focused cardiopulmonary assessment. Medical history of a respiratory problem A medical history of a respiratory problem would prompt the nurse to obtain more patient data by performing a focused cardiopulmonary assessment. Signs and symptoms of decreased oxygenation Development of signs and symptoms of decreased oxygenation indicates the need for a focused cardiopulmonary assessment. Signs and symptoms of activity intolerance Development of signs and symptoms of activity intolerance suggests a problem related to oxygenation and perfusion. This indicates the need for a focused cardiopulmonary assessment. Signs and symptoms of increased peripheral perfusion A focused cardiopulmonary assessment would be needed if the patient developed clinical manifestations of decreased (not increased) peripheral perfusion.

Which questions would the nurse include during the patient interview of a focused respiratory health assessment? Select all that apply. Have you ever smoked? Have you had recent weight gain? Do you use oxygen at home? Do you have difficulty clearing secretions? Do you have a cough? For how long?

*Have you ever smoked? This would be an appropriate question to ask during a focused respiratory health assessment. Smoking is linked to respiratory disorders that decrease oxygenation. Have you had recent weight gain? Asking about recent weight gain is a question the nurse would ask during a focused cardiovascular health assessment. Weight gain is often associated with heart failure. *Do you use oxygen at home? This would be an appropriate question to ask during a focused respiratory health assessment. Chronic lung conditions may require oxygen at home. *Do you have difficulty clearing secretions? This would be an appropriate question to ask during a focused respiratory health assessment. Some chronic lung conditions may be associated with difficulty clearing secretions. *Do you have a cough? For how long? This would be an appropriate question to ask during a focused respiratory health assessment.

The nurse would instruct a patient to hold each breath for seconds when explaining coughing/deep breathing chest physiotherapy? Record your answer as two whole numbers separated by a hyphen.

3-5 When coughing/deep breathing, the nurse would instruct the patient to take a series of deep breaths, holding each breath for 3 to 5 seconds, and then releasing the breath with a series of coughs.

Match the type of oxygen mask to its description. A-No reservoir bag; 1 L/min O2 ⇧ = ~5% O2 concentration ⇧ B-Reservoir bag present; room air is inspired with O2 delivered C-Reservoir bag present; one-way valve prevents entry of exhaled air D-No reservoir bag; ensures accuracy of O2 concentration; uses adaptors/dials 1-Simple face mask 2-Partial rebreather mask 3-Venturi mask 4-Nonrebreather mask

A-1 B-2 C-4 D-3

Match the artificial airway tube with the correct situation. A-Inserted in the patient's nose to facilitate ease of suctioning B-Inserted in mouth; maintains airway and breathing without ventilatory help C-Inserted through the mouth for positive pressure mechanical ventilation D-Inserted through trachea; provides ventilation when upper airway obstructed 1-Oropharyngeal tube 2-Endotracheal tube 3-Nasopharyngeal tube 4-Tracheostomy tube

A-3 B-1 C-2 D-4

Match the drug classification with the key assessment associated with evaluation of treatment. A-Blood pressure B-Daily weights, intake and output C-Heart rate and rhythm D-Bleeding 1-Diuretics 2-Anticoagulants 3-Antihypertensives 4-Antiarrhythmics

A-3 B-1 C-4 D-2

Match the pulmonary function test (PFT) with the measured element. A-Air volume expelled with lungs maximally inflated B-Air volume expelled in 1 second from start of FVC C-Air volume left in lungs after forced expiration D-Air volume left in lungs after normal expiration E-Maximal flow rate in the middle of FVC maneuver 1-Residual volume (RV) 2-Forced expiratory volume in 1 second (FEV1) 3-Forced vital capacity (FVC) 4-Functional residual capacity (FRC) 5-Forced expiratory flow (FEF)

A-3 B-2 C-1 D-4 E-5

Match the pulmonary drug classification with the key principle of use. A-Increase the diameter of the bronchi B-Improve airway clearance C-Decrease inflammation D-Decrease the thickness of secretions 1-Mucolytics 2-Corticosteroids 3-Anticholinergics 4-Inhaled bronchodilators

A-4 B-3 C-2 D-1

Which type of chest physiotherapy involves percussion? Aerobic exercise Postural drainage Incentive spirometry Coughing/deep breathing

Aerobic exerciseAerobic exercise is not a type of chest physiotherapy but can be involved in rehabilitation of patients with oxygenation and perfusion dysfunction after acute management has been completed. Correct Postural drainagePostural drainage involves techniques such as percussion and vibration while a patient is placed in a series of specific positions that facilitate gravity drainage from a lung area. Incentive spirometryIncentive spirometry involves the use of a device by a patient to frequently expand the lungs and prevent atelectasis. Coughing/deep breathingCoughing/deep breathing is a technique that combines controlled coughing with deep breathing to maintain lung expansion and to prevent atelectasis and pneumonia.

Which interventions would the nurse implement when providing care for a patient prescribed a diuretic? Select all that apply. Applying antiembolic stockings Monitoring daily weight Monitoring intake and output Elevating the head of the bed to the semi-Fowler position Monitoring for bleeding tendencies

Applying antiembolic stockingsAntiembolic stockings are used to treat patients who are at risk for clot formation. Correct Monitoring daily weightPatients on diuretics are weighed daily to monitor fluid loss. Correct Monitoring intake and outputPatients on diuretics must have intake and output monitored closely to evaluate fluid balance. Elevating the head of the bed to the semi-Fowler positionElevating the head of the bed is not needed specifically for patients taking diuretics. Monitoring for bleeding tendenciesDiuretics do not cause bleeding tendencies.

Which peripheral vascular assessment would the nurse perform when admitting a patient with impaired cardiac function? Auscultating breath sounds Auscultating an apical pulse Inspecting skin color in the extremities Measuring the chest for expansion

Auscultating breath sounds Auscultating breath sounds is part of a respiratory assessment, not a peripheral vascular assessment. Auscultating an apical pulse Auscultating the apical pulse is part of a cardiovascular assessment, not a peripheral vascular assessment. Peripheral implies distant, rather than central. *Inspecting skin color in the extremities Inspecting extremities for skin color such as cyanosis, pallor, or pink skin tone is part of a peripheral vascular assessment. Measuring the chest for expansion Measuring chest expansion is an important part of a lung assessment, not a peripheral vascular assessment.

Which health problem risk would be evaluated by obtaining a lipid panel? Cardiac injury Atherosclerosis Fluid around heart Blood electrolyte imbalances

Cardiac injury Injury to heart muscle can be indirectly evaluated using ECG or cardiac enzymes, not a lipid panel. *Atherosclerosis Total cholesterol of greater than 200 mg/dL is a risk factor for atherosclerosis. This value is obtained in a lipid panel. Fluid around heart A chest x-ray is used to detect an abnormal accumulation of fluid around the heart. Blood electrolyte imbalances A basic metabolic panel is used to assess kidney function, blood glucose level, and electrolyte status.

Which objective data would the nurse focus on obtaining in a patient with signs of cardiac muscle hypoxia? Select all that apply. Chest pain Dyspnea Abnormal cardiac enzymes levels Irregular heartbeat Decreased breath sounds

Chest painThe patient's report of chest pain is an important finding but is subjective in nature rather than objective. DyspneaDyspnea, while important, is not measurable and is therefore subjective, rather than objective data. Correct Abnormal cardiac enzymes levelsCardiac enzymes are routinely prescribed for patients experiencing cardiac hypoxia. These laboratory tests are prescribed by the provider and are considered objective data. Correct Irregular heartbeatDevelopment of an irregular or abnormal heartbeat is an important objective finding in a patient who is having cardiac muscle hypoxia. Decreased breath soundsDecreased breath sounds are objective data but are associated with respiratory disorders.

Which set of values would the nurse review to determine whether heart muscle injury has occurred? Complete blood count (CBC) with differential Lipid panel Basic metabolic panel Cardiac enzymes

Complete blood count (CBC) with differential A CBC provides information on red blood cells and white blood cells but cannot measure heart muscle injury. A CBC provides important information about infections and anemia. Lipid panel A lipid panel gives information on cholesterol and triglycerides but cannot measure heart muscle injury. Elevated levels may indicate coronary artery disease risk. Basic metabolic panel A basic metabolic panel gives information on glucose, renal function, and electrolytes but cannot measure heart muscle injury. A basal metabolic panel is used to monitor renal function as well as fluid and electrolyte balance. *Cardiac enzymes Elevated cardiac enzyme levels are indicative of cardiac muscle injury. Cardiac enzymes and proteins are released when myocardial necrosis (death of heart muscle cells) occurs.

Which benefit is important for the nurse to include when educating a patient about antihypertensive medications? Control an irregular heart rate Reduce the risk for stroke Reduce the risk for blood clots Control swelling of the feet

Control an irregular heart rateAntiarrhythmics control irregular heart rates. Correct Reduce the risk for strokeAntihypertensives reduce blood pressure, which reduces the risk for complications associated with hypertension such as stroke and heart disease. Reduce the risk for blood clotsAnticoagulants reduce the occurrence of blood clots. Control swelling of the feetDiuretics reduce and control edema.

Which questions would the nurse include during the patient interview of a focused cardiovascular health assessment? Select all that apply. Are you having chest pain? Have you had recent weight gain? What type of work do you do? How many pillows do you sleep with? Do you ever experience dizziness?

Correct Are you having chest pain?Asking about chest pain is an appropriate question to ask during a focused cardiovascular health assessment. Chest pain is associated with myocardial hypoxia. Correct Have you had recent weight gain?Asking about recent weight gain is an appropriate question to ask during a focused cardiovascular health assessment. Weight gain is often associated with heart failure. What type of work do you do?Asking where the patient works is not an appropriate question to ask during a focused cardiovascular health assessment. This would be a part of a focused respiratory health assessment as exposure to certain inhaled chemicals may cause respiratory damage. Correct How many pillows do you sleep with?Asking about how many pillows the patient sleeps with is an appropriate question to ask during a focused cardiopulmonary health assessment. Sleeping with multiple pillows is often associated with heart failure. Correct Do you ever experience dizziness?Asking if the patient ever experiences dizziness is an appropriate question to ask during a focused cardiovascular health assessment. Dizziness can be associated with some cardiac arrhythmias.

Which medications would the nurse expect to be added to the patient's drug regimen when a patient with infectious bronchitis (inflammation of the bronchi) is admitted to the hospital? Select all that apply. Corticosteroids Antibiotics Vaccines Anticholinergics Mucolytics

Correct CorticosteroidsCorticosteroids reduce inflammation, which helps patients with bronchitis. Correct AntibioticsAntibiotics are given for infectious processes like bronchitis. VaccinesVaccines are not given for bronchitis. Correct AnticholinergicsAnticholinergics decrease inflammation and secretions. MucolyticsUnless there is evidence of thick mucus, mucolytics are not used for bronchitis.

Which medications would the nurse expect to be on the medication administration record for a patient with chronic cardiovascular disease? Select all that apply. Diuretics Anticoagulants Antiarrhythmics Calcium channel blockers Bronchodilators

Correct DiureticsDiuretics increase urine production, reducing excess water in the body, and they are often prescribed for a patient who is admitted with a cardiovascular disorder. Correct AnticoagulantsAnticoagulants prevent clot formation and are often prescribed for a patient who is admitted with a cardiovascular disorder. Correct AntiarrhythmicsAntiarrhythmics suppress abnormal heart rates and rhythms and are often prescribed for a patient who is admitted with a cardiovascular disorder. Correct Calcium channel blockersCalcium channel blockers lower arterial blood pressure and are often prescribed for a patient who is admitted with a cardiovascular disorder. BronchodilatorsBronchodilators increase the diameter of the bronchi and would be anticipated for a patient who is admitted with a pulmonary, not cardiovascular, disorder.

Which major subjective symptom is associated with both chronic obstructive pulmonary disease (COPD) and pneumonia? Dyspnea Elevated arterial carbon dioxide level Irregular heart rhythm Chest pain

Correct DyspneaDyspnea is the subjective feeling of difficulty breathing and is common to many respiratory problems including COPD and pneumonia. Elevated arterial carbon dioxide levelElevated arterial carbon dioxide levels are considered objective data and are associated primarily with obstructive disorders. Irregular heart rhythmAn irregular heart rhythm is measurable data and is therefore objective. It is also not a common sign of respiratory problems. Chest painChest pain is reported by the patient and is therefore subjective. It is not, however, a common symptom of respiratory diseases.

Which questions would the nurse include as part of a focused respiratory health assessment? Have you ever been exposed to hazardous materials at work? Have you had recent weight gain? Have you ever lost consciousness? Do you take medications to prevent blood clots?

Correct Have you ever been exposed to hazardous materials at work?Asking about exposure to hazardous materials at work is an appropriate question to ask during a focused respiratory health assessment. Have you had recent weight gain?Asking about recent weight gain is an appropriate question to ask during a focused cardiovascular health assessment. Have you ever lost consciousness?Asking about loss of consciousness is an appropriate question to ask during a focused cardiovascular health assessment. Do you take medications to prevent blood clots?Asking about medications to prevent blood clots is an appropriate question to ask during a focused cardiovascular health assessment.

When assessing a patient with low hemoglobin, the nurse looks for symptoms of fluid retention, understanding that the patient may have which condition? Hemodilution Hypoxia Infection Hyperlipidemia

Correct HemodilutionHemodilution occurs in cardiac failure patients when excess fluid is retained. HypoxiaHypoxia causes a long-term increase in hemoglobin in an attempt to enhance oxygen-carrying capacity. InfectionInfection causes increased or decreased white blood cells, not red blood cells. HyperlipidemiaElevated lipid levels do not alter hemoglobin or fluid status.

Which cautions would the nurse include when discussing home oxygen therapy with a patient who has chronic obstructive pulmonary disease (COPD)? Select all that apply. High oxygen levels can be toxic. Use oxygen therapy only as absolutely needed. Limit oxygen concentration to low-flow. Do not smoke while using oxygen. Avoid humidified oxygen.

Correct High oxygen levels can be toxic.High concentrations of oxygen are toxic to lung tissue and can result in tissue damage. Use oxygen therapy only as absolutely needed.Instructions about use of oxygen therapy should reflect the health care provider's prescription. This instruction would not be appropriate. Correct Limit oxygen concentration to low-flow.COPD patients can be harmed by breathing in too high of an oxygen concentration. Correct Do not smoke while using oxygen.Oxygen is flammable and should never be used around flames. Avoid humidified oxygen.When possible, humidification is recommended, especially for higher concentrations of oxygen.

Which potential outcomes for a patient with chronic obstructive pulmonary disease (COPD) are associated with daily extended supplemental oxygen therapy? Select all that apply. Increased level of daily function Slowed progression of the disease Improved mental status Increased activity tolerance Decreased inflammation of the alveoli

Correct Increased level of daily functionOxygen therapy improves oxygenation, which increases the level of daily function. Slowed progression of the diseaseOxygen therapy does not affect the progression of COPD. Correct Improved mental statusOxygen therapy improves oxygenation, which improves the patient's mental status. Correct Increased activity toleranceOxygen therapy improves tissue oxygenation, which improves activity tolerance. Decreased inflammation of the alveoliOxygen therapy does not alter inflammation of the alveoli.

Which assessment techniques would the nurse include when performing a physical assessment on a patient with an oxygenation problem? Select all that apply. Inspection Palpation Auscultation Reflexes Vital signs

Correct InspectionThe nurse inspects the chest for abnormalities and observes chest movement during inspiration and expiration. Correct PalpationThe nurse palpates for tenderness and turbulent blood flow within the heart (thrill) and may note displacement of the apical pulse position, which can occur with heart enlargement. Correct AuscultationThe nurse auscultates the heart for normal and abnormal heart sounds and the lungs for normal breath sounds or the presence of decreased or absent sounds. ReflexesReflex tests are not commonly used in the assessment of oxygenation and perfusion. Correct Vital signsMeasurement of vital signs is a vital part of the assessment of the patient's oxygenation and perfusion status.

Which emergency preparedness equipment would the nurse need to confirm is available in the room of a patient with a tracheostomy tube? Select all that apply. Obturator Inner cannula Bag-valve-mask (BVM) device Blood pressure equipment Tracheostomy care kit

Correct ObturatorAn obturator is definitely needed as emergency equipment . Correct Inner cannulaFor any tracheostomy tube with an inner cannula, an extra inner cannula is definitely needed as emergency equipment. Correct Bag-valve-mask (BVM) deviceA BVM device should always be available for emergency use. Blood pressure equipmentBlood pressure equipment is not generally a part of required emergency equipment. Correct Tracheostomy care kitThe tracheostomy care kit is used to secure the tube to prevent it from being dislodged during care.

Which data would be obtained by the nurse preparing to perform a cough assessment on a patient with a respiratory disorder? Sputum characteristics Pulse oximetry Capillary refill Respiratory rate

Correct Sputum characteristicsObtaining information about the amount and characteristics (e.g., color, odor, consistency) of sputum is an important part of a cough assessment. Pulse oximetryPulse oximetry is a vital sign but is not part of a cough assessment. Capillary refillAssessing capillary refill is part of a peripheral vascular assessment, not a cough assessment. Respiratory rateWhile an important vital sign, measuring respiratory rate is not part of a cough assessment.

Which information would the nurse be aware of when using cardiac enzyme measurements for assessment of myocardial infarction? Select all that apply. They are released when death of cardiac cells occurs. Elevated serum levels suggest cardiac damage. There are "good" and "bad" types of cardiac enzymes. Alterations in enzyme types may indicate infection. Abnormally low levels are seen with decreased oxygenation.

Correct They are released when death of cardiac cells occurs.Cardiac enzymes and certain proteins are normally located inside of cardiac cells. When the cell dies, the enzymes and proteins escape into the blood, where they can be measured. Correct Elevated serum levels suggest cardiac damage.Cardiac enzymes and certain proteins are normally located inside of cardiac cells. When the cell dies, the enzymes and proteins escape into the blood, where they can be measured as elevated serum levels. There are "good" and "bad" types of cardiac enzymes.While there are lipid types that are considered good and bad, there are no good and bad cardiac enzymes. Alterations in enzyme types may indicate infection.Elevated levels of white blood cells in the complete blood count are indicative of infection; however, this is not so with cardiac enzyme levels. Abnormally low levels are seen with decreased oxygenation.Cardiac enzyme elevations are specific to heart muscle damage rather than decreased oxygenation as a whole.

Which situations would indicate a need for the nurse to consider insertion of a pharyngeal airway? Select all that apply. Decreased level of consciousness Inability to breathe effectively Frequent suctioning needs Loss of muscle tone Requires mechanical ventilation

Decreased level of consciousness Decreased or loss of consciousness is often the reason for insertion of a pharyngeal airway. Inability to breathe effectively An inability to breathe effectively would require placement of a tracheal tube rather than a pharyngeal tube. Frequent suctioning needs Frequent suctioning needs is an excellent reason to consider use of a pharyngeal tube. Loss of muscle tone Loss of muscle tone is one indication for insertion of a pharyngeal tube. Requires mechanical ventilation The need for positive pressure mechanical ventilation would require placement of a tracheal tube rather than a pharyngeal tube.

Which finding indicates that the prescribed inhaled bronchodilator administered to a patient with chronic obstructive pulmonary disease (COPD) has been effective? Decreased secretions Decreased wheezing Increased heart rate Decreased body temperature

Decreased secretions Administration of a prescribed inhaled bronchodilator does not decrease secretions. Decreased wheezing A decrease in wheezing after administration of a prescribed inhaled bronchodilator indicates that the drug has been effective. Increased heart rate An increase in heart rate after administration of a prescribed inhaled bronchodilator does not indicate that the drug has been effective. Increased heart rate is a known side effect of inhaled bronchodilators. Decreased body temperature A decrease in temperature after administration of a prescribed inhaled bronchodilator does not indicate that the drug has been effective.

Which patient changes would the nurse expect when medications used to treat pulmonary disease are effective? Select all that apply. Decreased symptoms Fewer exacerbations Increased exercise tolerance Improved overall health status Reduced laboratory testing requirements

Decreased symptoms Pulmonary medications are used to decrease symptoms. Fewer exacerbations Pulmonary medications are prescribed to decrease disease flareups. Increased exercise tolerance Pulmonary medications relieve symptoms to improve the ability to exercise. Improved overall health status Pulmonary medications that decrease symptoms also increase overall health. Reduced laboratory testing requirements Pulmonary medications are not prescribed to decrease the number of required laboratory tests. Blood draws are often required to monitor the effectiveness of pharmacologic therapy.

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) and administers a bronchodilator. Which primary action would the nurse conclude is relieving the wheezing? Decreases inflammation Increases the diameter of the bronchi Decreases the thickness of secretions Protects against disease

Decreases inflammationCorticosteroids reduce inflammation. Correct Increases the diameter of the bronchiBronchodilators increase the diameter of the bronchi and bronchioles. Decreases the thickness of secretionsMucolytics decrease secretion thickness. Protects against diseaseVaccines protect against communicable disease.

Which rationale explains why a patient with a recent myocardial infarction would have a basic metabolic panel drawn to monitor serum electrolytes? Elevated levels increase the risk for atherosclerosis. Abnormal levels can cause cardiac arrhythmias. Reduced levels can result in decreased oxygen levels. Normal levels suggest healing of muscle tissue.

Elevated levels increase the risk for atherosclerosis.Serum electrolyte disturbances do not increase the risk for atherosclerosis. Correct Abnormal levels can cause cardiac arrhythmias.Increased or decreased electrolytes, such as potassium and magnesium, can cause cardiac arrhythmias. Reduced levels can result in decreased oxygen levels.Serum electrolyte disturbances do not lead to decreased oxygen levels. Normal levels suggest healing of muscle tissue.Serum electrolytes do not directly heal muscle tissue.

Which alteration resulting from improper tube placement and found by palpating the skin around the stoma site during tracheostomy care would prompt the nurse to call the primary health care provider? Excessive secretions Reddened incision Respiratory infection Subcutaneous emphysema

Excessive secretionsExcessive secretions are not a cause for immediate primary health care provider notification. Reddened incisionA reddened incision is a sign of irritation and not a cause for immediate primary health care provider notification. Respiratory infectionSkin palpation at the tracheostomy site would not assess for a respiratory infection. Correct Subcutaneous emphysemaSubcutaneous emphysema indicates air trapped in the skin surrounding the stoma from improper tube placement, and the nurse would notify the primary health care provider.

Which discharge instruction would be included during patient education of a patient prescribed anticoagulant therapy? Expect bleeding and bruising while taking the medication. Limit intake of green, leafy vegetables. Monitor blood pressure daily. Take daily weights at the same time every day.

Expect bleeding and bruising while taking the medication.Bleeding and bruising are adverse, not expected, effects associated with anticoagulant therapy. Correct Limit intake of green, leafy vegetables.Vitamin K, found in green, leafy vegetables, can alter the effects of anticoagulant therapy and should be limited. Monitor blood pressure daily.Blood pressure monitoring is not a part of anticoagulant therapy patient education. Take daily weights at the same time every day.Taking daily weights is not a routine part of anticoagulant therapy patient education.

The complete blood count results for a patient with chronic obstructive pulmonary disease (COPD) show an elevated red blood cell count. Which clinical manifestation would the nurse associate with this finding? Hyperlipidemia Hypoxia Infection Hemodilution

HyperlipidemiaHyperlipidemia is related to atherosclerosis, not elevated red blood cell counts. Correct HypoxiaLong-term hypoxia results in stimulation of red blood cell production for increased oxygen-carrying capacity. InfectionInfection causes increased or decreased white blood cells, not red blood cells. HemodilutionHemodilution is related to an increase in circulating fluid in the blood that dilutes the concentration of red blood cells, as might be seen with heart failure.

Which information would the nurse expect to obtain from a chest x-ray prescribed for a patient with a cough and shortness of breath? Select all that apply. Hypoxia from diminished lung function Areas of increased lung tissue density Impaired electrical activity in the heart Size of the heart Atherosclerosis in heart blood vessels

Hypoxia from diminished lung function Arterial blood gases are used to assess hypoxia. *Areas of increased lung tissue density Chest x-rays show areas of increased density in the lungs. Impaired electrical activity in the heart Information on impaired electrical activity can be obtained by an echocardiogram (ECG or EKG). *Size of the heart Chest x-rays are used to examine the lungs, heart, and bones of the chest, including heart size. The heart may be enlarged in the case of heart failure. Atherosclerosis in heart blood vessels Chest x-rays do not visualize atherosclerosis within blood vessels.

Which alterations of oxygenation and perfusion may require supplemental oxygen therapy? Select all that apply. Increased respiratory rate Decreased heart rate Low oxygen saturation Cyanosis Elevated hemoglobin

Increased respiratory rate Increased respiratory rate (tachypnea) is a sign of hypoxia and indicates the possible need for supplemental oxygen therapy. Decreased heart rate Decreased heart rate (bradycardia) is a slow heart rate and is not a clinical indication for supplemental oxygen therapy. Low oxygen saturation Low oxygen saturation is a sign that suggests reduced blood oxygen levels (hypoxemia) and indicates the possible need for supplemental oxygen therapy. Cyanosis Cyanosis results from decreased tissue oxygenation and indicates the possible need for supplemental oxygen therapy. Elevated hemoglobin Elevated hemoglobin is sometimes present in certain types of respiratory diseases but does not indicate the need for supplemental oxygen therapy.

Oropharyngeal Tube

Inserted through the mouth with the airway going over the tongue Should be removed from the airway every 4 to 8 hours Secured in place with a holder or tape

Nasopharyngeal

Inserted through the nose Protects nares and provides a guide for catheter insertion when frequent suctioning is required

Which information would the nurse give to a postsurgical patient who states that performing incentive spirometry is uncomfortable and wants to know why it is necessary? It facilitates gravity drainage of secretions. It prevents atelectasis. It removes mucus from the respiratory tract. It drains fluid from the pleural space.

It facilitates gravity drainage of secretions.Postural drainage, not incentive spirometry, uses therapeutic positioning, percussion, and vibration to facilitate gravity drainage of secretions. Correct It prevents atelectasis.Incentive spirometry is an effective means of expanding the lungs, thereby reducing the risk for atelectasis and pneumonia. It removes mucus from the respiratory tract.Removing mucus from the respiratory tract is a purpose for airway suctioning, not performing incentive spirometry. It drains fluid from the pleural space.Draining fluid from the pleural space is a purpose for placing a chest tube, not performing incentive spirometry.

Which explanation would the nurse give to a patient experiencing an abnormally rapid heartbeat who asks about the purpose of an antiarrhythmic medication? It promotes increased urine flow. Low doses prevent blood clot formation. It is needed to reduce high blood pressure. It suppresses abnormal rhythms of the heart.

It promotes increased urine flow.Diuretics increase urine flow, reducing excess water in the body. Low doses prevent blood clot formation.Anticoagulants prevent blood clot formation, reducing the risk for thrombi and emboli. It is needed to reduce high blood pressure.Antihypertensives reduce blood pressure, reducing the risk for complications associated with high blood pressure. Correct It suppresses abnormal rhythms of the heart.Antiarrhythmics treat or prevent tachyarrhythmias (heart arrhythmias with a rapid rate) including ventricular tachycardia and atrial fibrillation.

Which type of tube would a patient receiving general anesthesia require to maintain oxygenation? Nasopharyngeal Tracheostomy Oropharyngeal Endotracheal

Nasopharyngeal A nasopharyngeal tube is inserted through the nose and is used for frequent suctioning. Tracheostomy A tracheostomy tube is inserted for a blocked upper airway. Oropharyngeal An oropharyngeal tube is used for oral (mouth) suctioning and keeps the tongue from blocking the airway. Endotracheal An endotracheal tube is used for delivering oxygen under pressure when ventilation must be totally controlled and during procedures requiring general anesthesia.

Which delivery system would the nurse use when the health care provider prescribes a common low-flow system to deliver continuous oxygen at 2 L/min for a patient with pneumonia? Nonrebreather mask Bilevel positive airway pressure (BiPAP) Nasal cannula Ambu bag

Nonrebreather mask The flow rate for nonbreather masks must be at least 10 L/min to maintain reservoir inflation; however, the flow rate can range from 10 L/min to 15 L/min. Bilevel positive airway pressure (BiPAP) Supplemental oxygen is not automatically provided with BiPAP. Use of supplemental oxygen therapy with BiPAP requires an additional oxygen prescription. Nasal cannula A nasal cannula is used as a low-flow system to deliver a continuous flow of supplemental oxygen at 2 L/min. Ambu bag An Ambu bag uses a one-way valve to support, ventilate, and oxygenate a patient with high-flow oxygen who is unable to breathe without assistance.

What type of airway is indicated? Decreased levels of consciousness Loss of muscle tone Frequent suctioning needs

Pharyngeal Airways

Tracheostomy Tube

Plastic polymer or metal tube that fits through a stoma in the neck Most have an outer cannula with an attached flange and cuff and a removable inner cannula Based on facility policy, specific items are kept at the bedside in case of tracheostomy dislodgement (e.g., BVM device, O2 and suction equipment, extra inner and outer cannulas with obturators, extra tracheostomy care kit)

Endotracheal Tube

Semirigid, curved tube with a cuff at the distal end Inflated cuff prevents aspiration of gastric contents into the lungs Placed through the mouth Sealed with a balloon at the end of the tube

Which route would the nurse use when administering medication to a patient with non-life-threatening lower airway inflammation? Subcutaneous Nasal Intravenous Inhalation

SubcutaneousSubcutaneous administration is not the preferred route for pulmonary medications. NasalNasal administration is not used for the delivery of lower airway treatment. IntravenousIntravenous would be the preferred route for medication administration in life-threatening airway inflammation. Correct InhalationThe preferred route for administering pulmonary medications for non-life-threatening airway inflammation is inhalation. It is routinely provided by respiratory therapists with a prescription from the patient's primary health care provider.

Which course of action would the nurse initiate on discovering a recently discharged patient refuses to use a CPAP machine because of claustrophobia? Teaching deep breathing exercises Seeking readmission to the hospital for oxygen therapy Suggesting counseling to overcome the unreasonable fear Requesting a prescription for a high-flow nasal cannula

Teaching deep breathing exercisesDeep breathing exercises will not maintain a patent airway. Seeking readmission to the hospital for oxygen therapyReadmission does not address the problem of nonadherence. Suggesting counseling to overcome the unreasonable fearCounseling is not appropriate for this situation. Correct Requesting a prescription for a high-flow nasal cannulaFor patients who are nonadherent, high-flow nasal cannulas are used to mimic positive airway pressure while promoting patient comfort by reducing the feeling of claustrophobia.

Which guidelines would the nurse recall when inserting a nasopharyngeal tube? Select all that apply. The airway is inserted into the mouth over the tongue. The length is measured from the tragus to the nostril plus 1 inch. The airway is removed and changed at least every 24 hours. Gentle to moderate force is applied when resistance is encountered. The airway is lubricated before attempting insertion and inserted gently.

The airway is inserted into the mouth over the tongue. This is how an oropharyngeal airway is inserted, not a nasopharyngeal airway. The length is measured from the tragus to the nostril plus 1 inch. The correct way to measure is from the ear tragus to the nostril plus 1 inch. The airway is removed and changed at least every 24 hours. The airway is removed and changed every 8 to 24 hours along with alternating nares to prevent skin irritation. Gentle to moderate force is applied when resistance is encountered. If resistance is encountered, the other nostril is tried as force can cause tissue damage. The airway is lubricated before attempting insertion and inserted gently. The airway is lubricated before attempting insertion to ease passage.

Which postoperative complication can be prevented by regularly performing deep-breathing exercises? Thrombus formation Bronchospasm Alveolar enlargement Atelectasis

Thrombus formationThrombus formation is caused by altered blood flow and is not prevented by deep breathing. Early ambulation and adequate hydration are interventions to help prevent thrombus formation. BronchospasmExposure to certain irritants, allergens, pollutants, or cold air causes the muscles surrounding the airways to spasm, and this is not prevented by deep breathing. Alveolar enlargementAlveolar enlargement occurs in emphysema and is a chronic condition. Correct AtelectasisPatients who have had abdominal or chest surgery are especially at risk for atelectasis because postsurgical pain causes them to breathe more shallowly, limiting the flow of air required to clear the airways.

What type of airway is indicated? Inability to breathe effectively Need for positive pressure mechanical ventilation Long-term airway patency problems Need for general anesthesia Blocked upper airway

Tracheal Airways

Which action describes the primary rationale for administering a corticosteroid (methylprednisolone) to a patient with a pulmonary disease? Treats the underlying infection Decreases inflammation Increases the diameter of the bronchi Decreases the thickness of airway secretions

Treats the underlying infection Corticosteroids are not used to treat infection. They can weaken the immune system and lead to infection. Decreases inflammation Methylprednisolone, a corticosteroid, is used to decrease inflammation. Increases the diameter of the bronchi Corticosteroids do not increase the size of the bronchi. This is the action of bronchodilators. Decreases the thickness of airway secretions Corticosteroids do not alter the thickness of secretions. This is the action of mucolytics.

Which device would the nurse apply to a patient who has arrived unconscious and in respiratory arrest (is not breathing)? Venturi mask Ambu bag Nasal cannula Continuous positive airway pressure (CPAP) device

Venturi mask A Venturi mask is used to administer supplemental oxygen to a conscious patient. Ambu bag The bag-valve-mask (BVM) device, also known as an Ambu bag, uses a one-way valve to support, ventilate, and oxygenate a patient in respiratory arrest. Nasal cannula A nasal cannula is a low-flow system commonly used to deliver a continuous flow of supplemental oxygen but does not provide ventilator support to an unconscious patient. Continuous positive airway pressure (CPAP) device CPAP provides the same pressure during both inhalation and exhalation but does not provide oxygen support to an unconscious patient.

Hemoptysis

the presence of blood in the sputum