Chapter 41: Oxygenation Potter & Perry
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51 Terms
A nurse is teaching staff about the conduction of the heart. In which order will the nurse present the conduction cycle, starting with the first structure?
1. Bundle of His
2. Purkinje network
3. Intraatrial pathways
4. Sinoatrial (SA) node
5. Atrioventricular (AV) node
a.
5, 4, 3, 2, 1
b.
4, 3, 5, 1, 2
c.
4, 5, 3, 1, 2
d.
5, 3, 4, 2, 1
B
A nurse is teaching the patient with mitral valve problems about the valves in the heart. Starting on the right side of the heart, describe the sequence of the blood flow through these valves.
1. Mitral
2. Aortic
3. Tricuspid
4. Pulmonic
a.
1, 3, 2, 4
b.
4, 3, 2, 1
c.
3, 4, 1, 2
d.
2, 4, 1, 3
C
A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli's function will the nurse share with the patient?
a.
Carries out gas exchange
b.
Regulates tidal volume
c.
Produces hemoglobin
d.
Stores oxygen
A
A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?
a.
Aortic and mitral
b.
Mitral and tricuspid
c.
Aortic and pulmonic
d.
Mitral and pulmonic
C
The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process?
a.
Ventilation
b.
Surfactant
c.
Perfusion
d.
Diffusion
D
A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority?
a.
Pulse
b.
Respirations
c.
Temperature
d.
Blood pressure
B
The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires?
a.
Stimulation of chemical receptors in the aorta
b.
Reduction of arterial oxygen saturation levels
c.
Requirement of elastic recoil lung properties
d.
Enhancement of accessory muscle usage
A
The home health nurse recommends that a patient with respiratory problems install a carbon monoxide detector in the home. What is the rationale for the nurse's action?
a.
Carbon monoxide detectors are required by law in the home.
b.
Carbon monoxide tightly binds to hemoglobin, causing hypoxia.
c.
Carbon monoxide signals the cerebral cortex to cease ventilations.
d.
Carbon monoxide combines with oxygen in the body and produces a deadly toxin.
B
While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record?
a.
Atrial fibrillation
b.
Myocardial ischemia
c.
Left-sided heart failure
d.
Right-sided heart failure
C
A patient has a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia?
a.
Superior vena cava
b.
Pulmonary artery
c.
Coronary artery
d.
Carotid artery
C
A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium?
a.
Right ventricle, left ventricle, left atrium
b.
Left atrium, right ventricle, left ventricle
c.
Right ventricle, left atrium, left ventricle
d.
Left atrium, left ventricle, right ventricle
C
The nurse suspects the patient has increased afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition?
a.
Pulse oximeter
b.
Oxygen cannula
c.
Blood pressure cuff
d.
Yankauer suction tip catheter
C
A patient has heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output?
a.
Myocardial contractility Myocardial blood flow
b.
Ventricular filling time/Diastolic filling time
c.
Stroke volume Heart rate
d.
Preload/Afterload
C
A patient's heart rate increased from 94 to 164 beats/min. What will the nurse expect?
a.
Increase in diastolic filling time
b.
Decrease in hemoglobin level
c.
Decrease in cardiac output
d.
Increase in stroke volume
C
The nurse is careful to monitor a patient's cardiac output. Which goal is the nurse trying to achieve?
a.
To determine peripheral extremity circulation
b.
To determine oxygenation requirements
c.
To determine cardiac dysrhythmias
d.
To determine ventilation status
A
A nurse is caring for a group of patients. Which patient should the nurse see first?
a.
A patient with hypercapnia wearing an oxygen mask
b.
A patient with a chest tube ambulating with the chest tube unclamped
c.
A patient with thick secretions being tracheal suctioned first and then orally
d.
A patient with a new tracheostomy and tracheostomy obturator at bedside
A
A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer?
a.
Diuretics
b.
Vasodilators
c.
Chest physiotherapy
d.
Intravenous (IV) fluids
D
A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning?
a.
Pulse 75
b.
Pulse 80
c.
Oxygen saturation 91%
d.
Oxygen saturation 88%
D
The patient has right-sided heart failure. Which finding will the nurse expect when performing an assessment?
a.
Peripheral edema
b.
Basilar crackles
c.
Chest pain
d.
Cyanosis
A
A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave?
a.
SA node
b.
AV node
c.
Bundle of His
d.
Purkinje fibers
A
A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis?
a.
"Atelectasis affects only those with chronic conditions such as emphysema."
b.
"It is important to do breathing exercises every hour to prevent atelectasis."
c.
"If I develop atelectasis, I will need a chest tube to drain excess fluid."
d.
"Hyperventilation will open up my alveoli, preventing atelectasis."
B
The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia?
a.
Elevated blood pressure
b.
Increased pulse rate
c.
Restlessness
d.
Cyanosis
D
A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation?
a.
Anxiety over illness
b.
Decreased drive to breathe
c.
Increased metabolic demands
d.
Infection destroying lung tissues
C
A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step?
1. Insert catheter.
2. Apply suction and remove.
3. Have patient deep breathe.
4. Encourage patient to cough.
5. Attach catheter to suction system.
6. Rinse catheter and connecting tubing.
a.
1, 2, 3, 4, 5, 6
b.
4, 5, 1, 2, 3, 6
c.
5, 3, 1, 2, 4, 6
d.
3, 1, 2, 5, 4, 6
C
A patient has carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient?
a.
Low-carbohydrate
b.
Low-caffeine
c.
High-caffeine
d.
High-carbohydrate
A
A nurse is caring for a patient who is taking warfarin (Coumadin) and discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient?
a.
Increased cholesterol level
b.
Distended jugular vein
c.
Bleeding
d.
Angina
C
A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest?
a.
A cup of nonfat yogurt with granola and a handful of dried apricots
b.
Whole wheat toast with butter and a side of bacon
c.
A bowl of cereal with whole milk and a banana
d.
Omelet with sausage, cheese, and onions
A
Upon auscultation of the patient's chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse?
a.
The beginning of the systolic phase
b.
Regurgitation of the mitral valve
c.
The opening of the aortic valve
d.
Presence of orthopnea
B
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen?
a.
Nasal cannula
b.
Simple face mask
c.
Non-rebreather mask
d.
Partial non-rebreather mask
A
The nurse needs to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change?
a.
Thinner heart valves cause lipid accumulation and fibrosis.
b.
Diminished respiratory muscle strength may cause poor chest expansion.
c.
Alterations in mental status prevent patients' awareness of ineffective breathing.
d.
An increased number of pacemaker cells make proper anesthesia induction more difficult.
B
The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient?
a.
Inform the patient of the importance of finishing the entire dose of antibiotics.
b.
Encourage the patient to stay up-to-date on all vaccinations.
c.
Schedule patient to get annual tuberculosis skin testing.
d.
Create an exercise routine to run 45 minutes every day.
B
The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most likely expect?
a.
Increased preload
b.
Increased heart rate
c.
Decreased afterload
d.
Decreased tissue perfusion
A
A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately?
a.
Ventricular tachycardia
b.
Atrial fibrillation
c.
Sinus rhythm
d.
Paroxysmal supraventricular tachycardia
A
The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination?
a.
Experiences chest pain after eating a heavy meal
b.
Experiences adequate oxygen saturation during exercise
c.
Experiences crushing chest pain for more than 20 minutes
d.
Experiences tingling in the left arm that lasts throughout the morning
A
A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the nurse describe as modifiable?
a.
Stress
b.
Allergies
c.
Family history
d.
Gender
A
The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal the patient could achieve?
a.
Sleeping on two to three pillows at night
b.
Limiting the diet to 1500 calories a day
c.
Running 30 minutes every morning
d.
Stopping smoking immediately
A
A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority?
a.
Risk for skin breakdown
b.
Impaired gas exchange
c.
Activity intolerance
d.
Risk for infection
B
Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient?
a.
Discontinue the humidification delivery device to keep excess fluid from lungs.
b.
Monitor oxygen saturation, and frequently auscultate lung bases.
c.
Assist the patient to cough, turn, and deep breathe every 2 hours.
d.
Decrease fluid intake to 300 mL a shift.
C
The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider?
a.
Increased anterior-posterior diameter of the chest
b.
Accessory muscle used for breathing
c.
Clubbing of the fingers
d.
Hemoptysis
D
A patient with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic?
a.
"Your disease doesn't send enough oxygen to your fingers."
b.
"Your disease affects both your lungs and your heart, and not enough blood is being pumped."
c.
"Your disease will be helped if you pursed-lip breathe."
d.
"Your disease often makes patients lose mental status."
A
A patient with a pneumothorax has a chest tube inserted and is placed on low constant suction. Which finding requires immediate action by the nurse?
a.
The patient reports pain at the chest tube insertion site that increases with movement.
b.
Fifty milliliters of blood gushes into the drainage device after the patient coughs.
c.
No bubbling is present in the suction control chamber of the drainage device.
d.
Yellow purulent discharge is seen leaking out from around the dressing site.
C
The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance?
a.
Suctioning respiratory secretions several times every hour
b.
Administering humidified oxygen through a tracheostomy collar
c.
Instilling normal saline into the tracheostomy to thin secretions before suctioning
d.
Deflating the tracheostomy cuff before allowing the patient to cough up secretions
B
The nurse is educating a student nurse on caring for a patient with a chest tube. Which statement from the student nurse indicates successful learning?
a.
"I should clamp the chest tube when giving the patient a bed bath."
b.
"I should report if I see continuous bubbling in the water-seal chamber."
c.
"I should strip the drains on the chest tube every hour to promote drainage."
d.
"I should notify the health care provider first, if the chest tube becomes dislodged."
B
Which coughing technique will the nurse use to help a patient clear central airways?
a.
Huff
b.
Quad
c.
Cascade
d.
Incentive spirometry
A
The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take?
a.
Set suction regulator at 150 to 200 mm Hg.
b.
Limit the length of suctioning to 10 seconds.
c.
Apply suction while gently rotating and inserting the catheter.
d.
Liberally lubricate the end of the suction catheter with a water-soluble solution.
B
The nurse is caring for a patient who needs oxygen via a nasal cannula. Which task can the nurse delegate to the nursing assistive personnel?
a.
Applying the nasal cannula
b.
Adjusting the oxygen flow
c.
Assessing lung sounds
d.
Setting up the oxygen
A
The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method?
a.
A 5-year-old with excessive drooling from epiglottitis
b.
A 5-year-old with an asthma attack following severe allergies
c.
A 24-year-old with a right pneumothorax following a motor vehicle accident
d.
A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation
D
While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first?
a.
Press the emergency response button.
b.
Insert a spare tracheostomy with the obturator.
c.
Manually occlude the tracheostomy with sterile gauze.
d.
Place a face mask delivering 100% oxygen over the nose and mouth.
B
A nurse is following the Ventilator Bundle standards to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.)
a.
Head of bed elevation to 90 degrees at all times
b.
Daily oral care with chlorhexidine
c.
Cuff monitoring for adequate seal
d.
Clean technique when suctioning
e.
Daily "sedation vacations"
f.
Heart failure prophylaxis
B, C, E
A nurse is teaching a community health promotion class and discusses the flu vaccine. Which information will the nurse include in the teaching session? (Select all that apply.)
a.
It is given yearly.
b.
It is given in a series of four doses.
c.
It is safe for children allergic to eggs.
d.
It is safe for adults with acute febrile illnesses.
e.
The nasal spray is given to people over 50.
f.
The inactivated flu vaccine is given to people over 50.
A, F
A nurse is caring for a patient with sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.)
a.
Assist-control (AC)
b.
Pressure support ventilation (PSV)
c.
Bilevel positive airway pressure (BiPAP)
d.
Continuous positive airway pressure (CPAP)
e.
Synchronized intermittent mandatory ventilation (SIMV)
C, D