Chapter 38 Oxygenation and Tissue Perfusion (Answers) - Elsevier PDF

**Chapter 38 Oxygenation and Tissue Perfusion** **Answers for Review Questions** 1\. The nurse assesses a patient with chronic obstructive pulmonary disease (COPD). Which significant finding does the nurse anticipate when inspecting the chest? **Answer:** b Chronic air trapping in COPD can cause...

**Chapter 38 Oxygenation and Tissue Perfusion** **Answers for Review Questions** 1\. The nurse assesses a patient with chronic obstructive pulmonary disease (COPD). Which significant finding does the nurse anticipate when inspecting the chest? **Answer:** b Chronic air trapping in COPD can cause a barrel-shaped chest. The intercostal spaces pull the chest out, and the accessory muscles of breathing may compensate to enlarge the chest cavity, causing the anteroposterior diameter of the chest to increase. The chest diameter ratio of 1:2 is the normal finding for a person who does not have hyperinflation of the lungs. A concave sternum is not an expected finding with COPD. A lateral curvature of the spine is consistent with scoliosis, which is not an expected finding for most patients with COPD. LO: 38.3 Bloom's: Understanding NCLEX Client Needs: Physiological Integrity: System Specific Assessments 2\. What is the desired outcome related to the nursing diagnosis of *Impaired Airway Clearance*? **Answer:** b The use of mucolytic agents may thin the secretions and allow easier removal. Thickened secretions in the airways can make it more difficult to cough effectively. The goal is to decrease the thickness of secretions. Improved range of motion is related to musculoskeletal problems. The normal respiratory rate is 12 to 20 breaths/min, and 28 breaths/min is considered tachypnea and is not desired. LO: 38.5 Bloom's: Applying NCLEX Client Needs: Physiological Integrity: Expected Actions/Outcomes 3\. The nurse is caring for a patient with severe chronic obstructive pulmonary disease (COPD). The patient has albuterol treatments scheduled every 6 hours and PRN and is on oxygen 2L/min via nasal cannula. Respiratory therapy (RT) administered the last breathing treatment 1 hour ago. When entering the patient's room to administer medications, the nurse notes that the patient is in acute respiratory distress. Which priority interventions would the nurse take to safely manage the care of this patient? (*Select all that apply*.) **Answer:** a, b, d, e When a person is having difficulty breathing, placing the individual in an upright position (Fowler or semi-Fowler) helps to increase the effectiveness of breathing by placing less pressure on the chest from the bed. The nurse would put the patient in an upright position to improve breathing. Respiratory therapy should come to assess the patient, to administer a second breathing treatment, and evaluate oxygen requirements depending on the facility. It is important to assess vital signs and lung sounds to determine what has changed with the patient since the last assessment. Do not administer oxygen through a simple nasal cannula at greater than 6 L/min. Medications are given only per order from the primary care provider. LO: 38.6 Bloom's: Analyzing NCLEX Client Needs: Physiological Integrity: Alterations in Body Systems 4\. When administering oxygen to a patient, the nurse recognizes that using which oxygen delivery system places a patient in danger of receiving inadequate oxygen? **Answer:** d A nonrebreather mask with a flow rate of 5 L/min does not give the patient adequate levels of oxygen in the reservoir bag and may result in the person developing hypoxemia. The accepted range of oxygen delivery with a nonrebreather mask is 10 to 15 L/min. The amount that can be delivered by nasal cannula is 1 to 6 L/min, and oxygen delivered at 2 or 5 L/min by nasal cannula is within the safe range. Oxygen delivered at 5 L/min by a simple face mask delivers adequate oxygen because the range for a face mask is 5 to 10 L/min. LO: 38.6 Bloom's: Applying NCLEX Client Needs: Physiological Integrity: Physiological Adaptation 5\. The nurse knows that which of the following nursing actions are indicated when suctioning a patient with a tracheostomy? (*Select all that apply*.) **Answer:** b, c, e, f Assess heart rate, respiratory rate, oxygen saturation, and lung sounds before suctioning to provide a baseline for detecting changes in the patient's condition. Reassess after suctioning to determine whether suctioning was beneficial to the patient. Oxygen is removed during the suctioning procedure, and the amount of time spent suctioning needs to be limited to 10 to 15 seconds. In some cases, the nurse provides extra oxygen before and during suctioning procedures, and decreasing the oxygen is contraindicated, therefore it would not be appropriate to decrease the flow rate. Documentation ensures that changes are noticed and that other members of the interprofessional team are aware of the patient's condition. Evidence-based practice shows that flushing with sterile NSS has no benefit because saline does not mix with secretions and the procedure may have negative effects for the patient. LO: 38.6 Bloom's: Analyzing NCLEX Client Needs: Physiological Integrity: Potential for Complications of Diagnostic Tests/Treatments/Procedures 6\. A patient admitted with a history of chronic obstructive pulmonary disease (COPD) admits to smoking 1 pack of cigarettes per day for the last 40 years. When developing a plan of care for the patient, the nurse includes smoking cessation as a priority education goal. Which interventions would the nurse include in the patient education? (*Select all that apply*.) **Answer:** a, b, c, e, g Providing the patient with alternative therapy---such as meditation or relaxation techniques, nicotine replacement therapy, support groups, and counseling---are all tools to help a person quit smoking. Education about the risks of smoking gives the patient factual information about the long-term effects. Changing to e-cigarettes and decreasing the amount of cigarettes by half does not eliminate inhalation of nicotine and other harmful substances. LO: 38.6 Bloom's: Applying NCLEX Client Needs: Health Promotion and Maintenance: Health Promotion/Disease Prevention 7\. The nurse understands that which of the following is most likely occurring when caring for a pulmonary patient who has bluish discoloration around the lips? **Answer:** b Cyanosis occurs due to hypoxemia, which is a low level of oxygen in the blood. Hemoglobin that is not saturated with oxygen causes a bluish discoloration of the skin. Increased or decreased levels of carbon dioxide (CO~2~) may indicate an acid-base imbalance. An elevated white blood cell count may indicate an infection. LO: 38.6 Bloom's: Analyzing NCLEX Client Needs: Physiological Integrity: Alterations in Body Systems 8\. During handoff to the oncoming shift, the nurse includes in the SBAR report that the patient needs to be evaluated by speech therapy for which of the following reasons? **Answer:** a Aspiration pneumonia results from abnormal entry of material from the mouth and stomach into the trachea and lungs. Patients should be evaluated for whether they have a decreased gag reflex or decreased level of consciousness. The speech therapist can perform a swallow study to determine whether thin liquids are being aspirated into the lung and recommend a regimen of thickened liquids and swallow exercises to prevent aspiration. A speech therapist would not be consulted in cases of hypoventilation or hyperventilation. Nursing measures and consulting the primary care practitioner are proper steps for these findings. A physical therapist may be consulted if scoliosis is hampering the patient's respirations. LO: 38.6 Bloom's: Applying NCLEX Client Needs: Physiological Integrity: Reduction of Risk Potential 9\. A patient with chronic obstructive pulmonary disease (COPD) uses which drive to breathe? **Answer:** c Chronically elevated level of carbon dioxide in the chemoreceptors become tolerant of high levels. The carbon dioxide ceases to be the patient's trigger to breathe; therefore, what drives the patient to breathe is the hypoxic (low oxygen) drive. A person normally uses increased PaCO~2~ levels as the drive to breathe. A patient with COPD has chronic elevation of PaCO~2~ and has lost sensitivity to it as a drive to breathe. Instead, a decreased PaO~2~ level becomes the drive to breathe. LO: 38.6 Bloom's: Analyzing NCLEX Client Needs: Physiological Integrity: Alterations in Body Systems 10\. Which questions would be included during a focused history on a cardiac patient to help the nurse determine the significance of the cues? *(Select all that apply.)* **Answer:** a, b, d, e Asking questions and providing time for the patient to answer is essential to helping determine what is occurring. Pain assessment is important to determine a pattern of pain. Cardiac events can contribute to fatigue and abnormal heart rhythms may contribute to dizziness. Although knowledge of a patient's religious affiliation may be important in certain settings, it is not part of a focused assessment of a cardiac patient. LO: 38.3 Bloom's: Applying NCLEX Client Needs: Physiological Integrity: System Specific Assessments