Oxygenation Practice Questions Ch. 41

Questions and Answers

Which patterns did the nurse observe in a client with diabetic ketoacidosis experiencing Kussmaul's respirations? (Select all that apply)

Respirations that are abnormally slow

Respirations that are increased in rate (correct)

Respirations that cease for several seconds

Respirations that are shallow

Respirations that are abnormally deep (correct)

The client with several broken ribs is most likely to experience which type of acid-base imbalance?

Metabolic acidosis from calcium loss due to broken bones

Respiratory alkalosis from anxiety and hyperventilation

Metabolic alkalosis from taking analgesics containing base products

Respiratory acidosis from inadequate ventilation (correct)

The nurse should assess a client at risk for respiratory acidosis for which signs and symptoms?

Bradycardia and hyperactivity

Decreased respiratory rate and depth

Bradypnea, dizziness, and paresthesias

Headache, restlessness, and confusion (correct)

What other extrapulmonary causes can lead to respiratory failure in a client with Guillain-Barré syndrome? (Select all that apply)

Stroke Signup and view all the answers

If Guillain-Barré syndrome is severe enough, the client will be at risk for which acid-base imbalance?

Respiratory acidosis Signup and view all the answers

Which type of adventitious lung sounds should the nurse expect to hear from a client with asthma?

Wheezes Signup and view all the answers

Which statement is most appropriate for the nurse to make to the client about coughing and deep-breathing techniques?

Use of an incentive spirometer will help prevent pneumonia. Signup and view all the answers

What piece of information should the nurse include when teaching a client about the use of an incentive spirometer?

The best results are achieved when sitting up or with the head of the bed elevated 45 to 90 degrees. Signup and view all the answers

What action is most appropriate if continuous gentle bubbling is noted in the water seal chamber of a client with a pneumothorax?

Check for an air leak, because the bubbling should be intermittent. Signup and view all the answers

What is the most appropriate action when a 12-month-old infant's respiratory rate is 35 breaths/minute?

Document the findings. Signup and view all the answers

Limit the length of suctioning to ______ seconds.

10-15 Signup and view all the answers

Which finding would the nurse expect when assessing a patient with a right pneumothorax?

Absence of breath sounds on the right side Signup and view all the answers

A closed suction device would be most appropriate for which patient?

75-year-old with aspiration pneumonia following a stroke Signup and view all the answers

Which patient should the nurse see first?

A patient with hypercapnia wearing an oxygen mask Signup and view all the answers

Which statement by the patient indicates an understanding of atelectasis?

It is important to do breathing exercises every hour to prevent atelectasis. Signup and view all the answers

In which order will the nurse perform the steps for nasotracheal suctioning, beginning with the first step?

5, 3, 1, 2, 4, 6 Signup and view all the answers

Which type of diet will the nurse most likely suggest for a patient with carbon dioxide retention?

Low-carbohydrate Signup and view all the answers

Which condition will the nurse assess for in a patient taking warfarin (Coumadin) and garlic for hypertension?

Bleeding Signup and view all the answers

What does a whooshing sound at the fifth intercostal space indicate?

Regurgitation of the mitral valve Signup and view all the answers

Which oxygen delivery device is most appropriate for a patient with COPD receiving 2 L/min of oxygen?

Nasal cannula Signup and view all the answers

Which age-related change requires close monitoring of oxygen status during anesthesia for older adults?

Diminished respiratory muscle strength may cause poor chest expansion. Signup and view all the answers

Which assessment finding does the nurse expect when conducting a history and physical examination for a patient experiencing angina pectoris?

Experiences chest pain after eating a heavy meal Signup and view all the answers

Which risk factor for cardiopulmonary disease is modifiable?

Stress Signup and view all the answers

Which intervention best addresses a short-term goal for an obese patient suffering from fatigue related to ineffective breathing?

Sleeping on two to three pillows at night Signup and view all the answers

Which nursing diagnosis is a priority for a patient with left-sided hemiparesis who has developed bronchitis?

Impaired gas exchange Signup and view all the answers

Which response by the nurse is most therapeutic when a patient with COPD asks why clubbing occurs?

Your disease doesn't send enough oxygen to your fingers. Signup and view all the answers

Which finding requires immediate action by the nurse for a patient with a chest tube inserted on low constant suction?

No bubbling is present in the suction control chamber of the drainage device. Signup and view all the answers

Which nursing intervention is most effective in promoting effective airway clearance for a patient with a tracheostomy?

Administering humidified oxygen through a tracheostomy collar Signup and view all the answers

Which patient is most appropriate for a closed suction device?

A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation Signup and view all the answers

Which information should be included in a teaching session about the flu vaccine?

It is given yearly. Signup and view all the answers

Which types of ventilator support should the nurse be prepared to administer for a patient with sleep apnea?

Continuous positive airway pressure (CPAP) Signup and view all the answers

What electrolyte imbalance does profuse diaphoresis, dry sticky mucous membranes, weakness, disorientation, and decreased levels of consciousness support?

Hypernatremia Signup and view all the answers

Which oxygen-delivery system should the nurse select for a patient with a precise oxygen level prescribed?

Venturi Mask Signup and view all the answers

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient?

Incentive spirometer Signup and view all the answers

What is the appropriate action for the nurse when there is 200 mL of dark-red drainage in the chest tube two hours post-surgery?

Record the amount and continue to monitor drainage Signup and view all the answers

Which priority assessments should the nurse perform for a patient exhibiting labored breathing and using accessory muscles?

Amount of sputum production Signup and view all the answers

What action should the nurse perform first for a patient feeling short of breath while lying supine?

Raise the head of the bed to 45 degrees Signup and view all the answers

Which statement indicates a need for further education in a patient with emphysema?

If I get short of breath, I'll turn up my oxygen level to 6 L/min. Signup and view all the answers

What are the signs/symptoms of secondary pneumothorax?

Sharp pleuritic pain that worsens on inspiration Signup and view all the answers

Which assessment finding indicates a patient with pneumonia needs airway suctioning?

Decreased independent ability to cough Signup and view all the answers

Which intervention is a simple method for reducing the risks of stasis of pulmonary secretions?

Frequent change of position Signup and view all the answers

Which adventitious lung sounds should the nurse expect to auscultate in a patient with severe left-sided heart failure?

Inspiratory crackles in lung bases Signup and view all the answers

What physiological process explains why a child with a fever is at risk for developing dyspnea?

Fever increases metabolic demands, requiring increased oxygen need Signup and view all the answers

What symptoms should the nurse assess for to determine the oxygen status of a patient diagnosed with severe iron deficiency anemia?

Decreased activity intolerance and increased breathlessness Signup and view all the answers

What disorder is a patient at increased risk for if they have smoked since adolescence?

Cardiopulmonary disease and lung cancer Signup and view all the answers

Do you use a clean or sterile technique with nasopharyngeal suctioning?

Sterile Signup and view all the answers

Do you use a clean or sterile technique with oropharyngeal suctioning?

Clean Signup and view all the answers

Which assessment finding indicates a patient with severe lobar pneumonia needs airway suctioning?

Decreased ability to clear airway through coughing Signup and view all the answers

Which of the following results falls within expected or normal limits?

Arterial oxygen tension (PaO2) of 95 mmHg Signup and view all the answers

What is the primary function of the alveoli?

Carry out gas exchange Signup and view all the answers

What condition will anemia result in?

Hypoxemia Signup and view all the answers

What is the process of exchanging gases through the alveolar capillary membrane called?

Diffusion Signup and view all the answers

What would a nurse expect to find in a patient with a C4 injury?

Decreased tidal volume Signup and view all the answers

In which situation would a nurse expect to see increased ventilation?

Decreased pH Signup and view all the answers

Why should a patient install a carbon monoxide detector at home?

Carbon monoxide tightly bonds to hemoglobin, causing hypoxia Signup and view all the answers

What does crackles in lung fields and a patient sleeping on three pillows most likely indicate?

Left-sided heart failure Signup and view all the answers

What would a nurse expect in a patient with ischemia to the left coronary artery?

Decreased afterload Signup and view all the answers

What formula should be used to calculate normal cardiac output?

Stroke volume x heart rate Signup and view all the answers

If a patient's heart rate increased from 80 bpm to 160 bpm, what is expected to follow?

Decrease in cardiac output Signup and view all the answers

Why does a nurse monitor a patient's cardiac output?

Peripheral extremity circulation Signup and view all the answers

What should a nurse's first priority be for a patient complaining of sharp chest pain and shortness of breath?

Have the patient sit down in the nearest chair Signup and view all the answers

If a patient has inadequate stroke volume related to decreased preload, what should the nurse anticipate?

Verifying that the blood consent form has been signed Signup and view all the answers

Which vital sign is a nurse most concerned with when caring for a patient with atrial fibrillation?

Oxygen saturation Signup and view all the answers

What would a nurse expect to find in a patient with right-sided heart failure?

Peripheral edema Signup and view all the answers

Which part of the conduction system represents the P wave?

SA node Signup and view all the answers

Which statement by a patient indicates understanding of atelectasis?

It is important to do breathing exercises every hour to prevent atelectasis Signup and view all the answers

Where is the best location to assess for hypoxia in an African American patient with COPD?

Oral mucosa Signup and view all the answers

Why should a nurse expect a patient with a temperature of 100.2 F to hyperventilate?

Increased metabolic demands Signup and view all the answers

What is the earliest sign of hypoxia?

Restlessness Signup and view all the answers

What change in respiratory pattern should a nurse expect in a 5-year-old with strep throat given aspirin?

Hyperventilation to decrease serum levels of carbon dioxide Signup and view all the answers

What would a nurse anticipate finding in a patient who suffered a myocardial infarction to the left coronary artery?

Crackles in the lungs Signup and view all the answers

What should a nurse recommend for breakfast to a patient managing hypertension?

Cup of nonfat yogurt with granola, and a handful of dried apricots Signup and view all the answers

What does a whooshing sound at the fifth intercostal space indicate?

Regurgitation of the mitral valve Signup and view all the answers

Which oxygen delivery device is most appropriate for a patient with COPD?

Nasal cannula Signup and view all the answers

What age-related change requires monitoring of oxygen status during anesthesia in the elderly?

Decreased lung defense mechanisms may cause ineffective airway clearance Signup and view all the answers

What is the best plan of care for an elderly patient at risk for infection due to decreased immunity?

Encourage the patient to stay up to date on all vaccinations Signup and view all the answers

What change in cardiac output is expected in a patient with fluid volume overload?

Increased preload Signup and view all the answers

What is the priority nursing action for a patient with COPD recovering from a myocardial infarction?

Place the patient on continuous cardiac monitoring Signup and view all the answers

What should the nurse expect a patient with angina pectoris to experience?

Experience feelings of indigestion after eating a heavy meal Signup and view all the answers

What is a nonmodifiable risk factor for lung disease?

Allergies Signup and view all the answers

What short-term goal could be achieved by an obese patient suffering from fatigue related to ineffective breathing?

Sleeping on 2-3 pillows at night Signup and view all the answers

What nursing diagnosis is the priority for a patient with left-sided hemiparesis who developed bronchitis?

Impaired gas exchange Signup and view all the answers

What nursing intervention is most effective in preventing hospital-acquired pneumonia in an elderly patient?

Assist patient to cough, turn, and deep breathe every 2 hours Signup and view all the answers

Which assessment finding requires further follow-up in a patient with emphysema?

Hemoptysis Signup and view all the answers

What response is most therapeutic for a patient with COPD asking about difficulty with fine motor skills?

Your body isn't receiving enough oxygen to send down to your fingers; this causes them to club and makes dexterity difficult Signup and view all the answers

Which nursing intervention is most effective for promoting effective airway clearance in a patient with a tracheostomy tube?

Administering humidified oxygen through a tracheostomy collar Signup and view all the answers

What statement indicates that teaching has been effective regarding caring for a patient with a chest tube?

I should report if I see continuous bubbling in the water-seal chamber Signup and view all the answers

What is the priority nursing diagnosis for a patient with a tracheostomy post-traumatic brain injury?

Ineffective airway clearance Signup and view all the answers

Study Notes

Gas Exchange and Respiratory Physiology

Alveoli primarily function in gas exchange, allowing oxygen and carbon dioxide to move between the air and bloodstream.
Anemia decreases oxygen-carrying capacity, leading to hypoxemia due to inadequate tissue oxygenation.
Diffusion is the process where gases are exchanged through the alveolar capillary membrane.

Neuromuscular Impact on Breathing

A C4 spinal cord injury can lead to decreased tidal volume due to impaired diaphragm function.
Decreased pH from CO2 retention signals increased ventilation, while normal or increased oxygen saturation may not reflect respiratory issues.

Heart and Circulation

Cardiac output in healthy adults ranges from 4 to 6 L/min and can be calculated using stroke volume multiplied by heart rate.
An increase in heart rate often results in decreased cardiac output due to reduced diastolic filling time.
Left-sided heart failure manifests as pulmonary congestion and is indicated by crackles in lung fields.

Patient Monitoring and Interventions

Continuous cardiac monitoring is essential for patients post-myocardial infarction, especially those with comorbidities like COPD.
Inadequate stroke volume due to decreased preload requires verification of blood consent before transfusion.
Patients with COPD may have altered mental status affecting their awareness of breathing difficulties.

Infection Prevention and Respiratory Care

Vaccination is vital for elderly patients to prevent infections due to decreased immunity.
Effective coughing and deep breathing exercises can help prevent hospital-acquired pneumonia.
Administering humidified oxygen through a tracheostomy collar improves airway clearance.

Diagnosis and Signs of Hypoxia

Restlessness is typically the first sign of hypoxia, leading to more severe symptoms as condition worsens.
A patient with COPD and bronchitis may be assessed for impaired gas exchange, especially if displaying increased respiratory rates.

Surgical and Emergency Responses

In cases of pneumothorax, absence of breath sounds on the affected side is expected.
A closed suction device is most suitable for patients with aspiration pneumonia, particularly in the elderly.

Nutritional Guidance and Lifestyle Considerations

Dietary recommendations for patients managing hypertension should emphasize low-fat, high-potassium, and high-fiber foods.
Making small adjustments, like sleeping with elevated pillows, can alleviate breathing difficulties in obese patients experiencing fatigue.

Atrial Fibrillation and Monitoring

In patients with atrial fibrillation, oxygen saturation is the most critical vital sign due to the risk of emboli formation.
Hemoptysis in a patient with emphysema necessitates further evaluation, as it may indicate serious complications.

Patient Education

Understanding the importance of regular breathing exercises can help prevent atelectasis in at-risk patients.
During evaluation of a new tracheostomy, awareness of suctioning techniques and signs of airway obstruction is vital for patient safety.### Breathing Exercises
Performing breathing exercises every hour is critical to prevent atelectasis.

Nasotracheal Suctioning Steps

Correct sequence for nasotracheal suctioning:
Attach catheter to suction system → Have patient deep breathe → Insert catheter → Apply suction and remove → Encourage patient to cough → Rinse catheter and connecting tubing.

Carbon Dioxide Retention Diet

A low-carbohydrate diet is recommended for patients with carbon dioxide retention due to lung issues.

Anticoagulant Interaction

Monitor for bleeding in patients taking warfarin (Coumadin) who also use garlic for hypertension management.

Heart Auscultation Findings

A whooshing sound at the fifth intercostal space indicates mitral valve regurgitation.

Oxygen Delivery for COPD

A nasal cannula is the most appropriate oxygen delivery device for COPD patients receiving 2 L/min of oxygen.

Anesthesia Monitoring in Older Adults

Diminished respiratory muscle strength can lead to inadequate chest expansion in older adults undergoing anesthesia.

Angina Pectoris Symptoms

Patients often report chest pain after consuming heavy meals when experiencing angina pectoris.

Modifiable Risk Factors

Stress is identified as a modifiable risk factor for cardiopulmonary disease.

Short-term Goal for Fatigue

Using two to three pillows at night can help alleviate fatigue related to ineffective breathing for obese patients.

Prioritizing Nursing Diagnoses

Impaired gas exchange is the priority nursing diagnosis for patients with chronic bronchitis and abnormal vital signs.

Clubbing in Lung Disease

Clubbing occurs due to insufficient oxygen supply to peripheral areas, commonly seen in lung disease.

Chest Tube Care

Absence of bubbling in the suction control chamber after chest tube insertion indicates potential blockage needing immediate evaluation.

Promoting Airway Clearance

Administering humidified oxygen via a tracheostomy collar effectively promotes airway clearance for patients with tracheostomy tubes.

Closed Suction Device Use

The most suitable patients for closed suction devices include those on mechanical ventilation, such as a 24-year-old with ARDS.

Flu Vaccine Teaching

Important points about the flu vaccine include its yearly administration and its safety for children allergic to eggs.

Ventilator Support for Sleep Apnea

CPAP and BiPAP are effective ventilator support options for patients with sleep apnea.

Hypernatremia Indicator

Indicators of hypernatremia include symptoms like profuse diaphoresis and dry mucous membranes alongside decreased consciousness.

Precise Oxygen Delivery

A Venturi mask is the ideal system for administering precise oxygen levels to patients.

Incentive Spirometer in Postoperative Care

Incentive spirometry is essential for preventing atelectasis in postoperative patients.

Chest Tube Drainage Monitoring

A chest tube with dark-red drainage post-surgery should be monitored and documented without immediate action unless excessive.

Priority Assessments for Dyspnea

When assessing a patient with breathing difficulties, prioritize measuring SpO2 levels, sputum production, and changes in respiratory patterns.

Initial Action for Dyspnea

Elevating the head of the bed to 45 degrees is the first action for a patient reporting shortness of breath.

Education on Emphysema

Statements indicating a need for further education include misconceptions about increasing oxygen flow when experiencing dyspnea.

Symptoms of Pneumothorax

Sharp pleuritic pain worsening on inspiration is a symptom indicative of a pneumothorax.

Indicators for Airway Suctioning

A decreased ability to clear airways through coughing suggests a need for airway suctioning.

Reducing Risks of Pulmonary Secretions

Regular position changes are a straightforward, cost-effective method to mitigate the risk of pulmonary secretions and enhance chest wall expansion.

Adventitious Lung Sounds in Heart Failure

Inspiratory crackles in lung bases are expected in patients with severe left-sided heart failure.

Dyspnea in Febrile Children

Increased metabolic demands due to fever significantly raise the oxygen requirement, elevating the risk of dyspnea in children.

Iron Deficiency Anemia Symptoms

Patients may demonstrate decreased activity tolerance and increased breathlessness as indicators of oxygen status.

Smoking Risks

Long-term smokers face heightened risks for developing cardiopulmonary diseases and lung cancer.

Nasopharyngeal vs. Oropharyngeal Suctioning Techniques

Nasopharyngeal suctioning requires a sterile technique; oropharyngeal suctioning involves a clean technique.

Diagnostic Testing Normal Limits

Arterial oxygen tension of 95 mmHg falls within normal limits for oxygen status; other tuberculosis-related tests indicate abnormal results.

Kussmaul's Respirations

Characteristics of Kussmaul's respirations include increased rate and abnormally deep breaths.

Respiratory Acidosis from Rib Fractures

Patients with multiple rib fractures are at risk of respiratory acidosis due to inadequate ventilation.

Signs of Respiratory Acidosis

Symptoms characteristic of respiratory acidosis include headaches, restlessness, and confusion.

Causes of Respiratory Failure

Potential extrapulmonary causes of respiratory failure include strokes, sleep apnea, myasthenia gravis, and effects of opioids or sedatives.

Guillain-Barré Syndrome Risks

Patients with Guillain-Barré syndrome are susceptible to respiratory acidosis due to potential respiratory muscle paralysis.

Asthma Assessment Findings

Wheezes are the typical adventitious lung sounds a nurse would expect in an asthmatic patient during respiratory assessment.

Teaching Coughing and Deep Breathing

Use of an incentive spirometer is vital in preventing pneumonia and should be emphasized in patient education regarding respiratory post-operative care.### Pulmonary Embolus
Blockage of the pulmonary artery affects blood flow to one or more lung lobes.
Most common cause is clot formation.
Early ambulation and blood thinners help prevent this complication.
Coughing and deep-breathing techniques are not related to prevention.

Incentive Spirometer Use

Optimal results achieved while sitting up or at a 45 to 90-degree angle.
Inhale slowly with a tight seal around the mouthpiece.
Maximum inspiration should be held for 5 seconds before exhaling.
Client should assume a semi Fowler's or high Fowler's position for lung expansion.

Continuous Bubbling in Water Seal Chamber

Continuous gentle bubbling indicates a potential air leak; should be intermittent.
Fluctuation may occur with inspiration/expiration, diminishing as pneumothorax resolves.
Bubbling observed in the suction control chamber of a wet drainage system, not the water seal chamber.
Increasing suction pressure is not typically advised unless prescribed, as it can be harmful.
Chest tubes should only be clamped with a healthcare provider's order.

Vital Signs in Infants

Normal respiratory rate for a 12-month-old is 20 to 40 breaths/minute.
A recorded respiratory rate of 35 breaths/minute falls within normal limits.
Other normal vital signs: apical heart rate of 90 to 130 beats/minute, and average blood pressure of 90/56 mm Hg.
Appropriate action is to document the findings.

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Test your knowledge with these practice questions focusing on Chapter 41 related to oxygenation. Each question offers multiple-choice options, requiring you to identify the correct answers related to gas exchange and the impact of anemia. Perfect for nursing students looking to reinforce their understanding of respiratory health.