Chapter 33 My Nursing Test Banks

Wagner, High Acuity Nursing, 6e
Chapter 33

Question 1

Type: MCSA

The nurse assessing a patient with multiple injuries is concerned about the patients ability to maintain adequate oxygenation. Which explanation would the nurse provide for this increased concern?

1. The patients bowel sounds are hypoactive.

2. The patient has a hemoglobin level of 14 mg/dL.

3. The patient suffered a cervical neck injury and slight concussion.

4. The patient had an arm injury from flying glass.

Correct Answer: 3

Rationale 1: Hypoactive bowel sounds would not necessarily indicate an injury that would impact the patients ability to maintain adequate oxygenation.

Rationale 2: A hemoglobin level of 14 mg/dL would be sufficient for oxygenation to the tissues and would not cause the nurse concern.

Rationale 3: Since the respiratory system requires constant input from the nervous system, the assessment findings of a cervical neck injury and slight concussion would be the ones that concern the nurse about the patients ability to maintain adequate oxygenation.

Rationale 4: An arm injury due to flying glass would likely have little impact on the patients ability to maintain oxygenation.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-1

Question 2

Type: MCSA

A patient has a hemoglobin level of 8.6 mg/dL. The nurse is concerned that which oxygenation component will be affected in this patient?

1. Oxygen delivery

2. Diffusion of oxygen

3. Pulmonary gas exchange

4. Oxygen consumption

Correct Answer: 1

Rationale 1: The concept of oxygenation involves three physiologic components for the intake, delivery, and use of oxygen for energy: pulmonary gas exchange, oxygen delivery, and oxygen consumption. Adequacy of oxygenation depends on the integration of these physiologic components. Oxygen delivery is the process of transportation of oxygen to cells and is dependent on cardiac output, hemoglobin saturation with oxygen, and the partial pressure of oxygen in arterial blood.

Rationale 2: Diffusion is part of pulmonary gas exchange. The actual process of diffusion will not be affected by low hemoglobin.

Rationale 3: The concept of oxygenation involves three physiologic components for the intake, delivery, and use of oxygen for energy: pulmonary gas exchange, oxygen delivery, and oxygen consumption. Adequacy of oxygenation depends on the integration of these physiologic components. Pulmonary gas exchange involves the intake of oxygen from the external environment into the internal environment.

Rationale 4: The concept of oxygenation involves three physiologic components for the intake, delivery, and use of oxygen for energy: pulmonary gas exchange, oxygen delivery, and oxygen consumption. Adequacy of oxygenation depends on the integration of these physiologic components. Oxygen consumption involves the use of oxygen at the cellular level to generate energy for cells to use to perform their specific functions.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-1

Question 3

Type: MCSA

A patient is being started on oxygen therapy for an oxygen saturation level of 84% on room air. The nurse expects that this therapy will be effective if oxygen enters the blood through which physiological process?

1. Osmosis

2. Fluid shift

3. Diffusion

4. Concentration gradient

Correct Answer: 3

Rationale 1: Osmosis is a passive exchange and is not the primary mechanism by which oxygen crosses the alveolarcapillary membrane.

Rationale 2: Fluid shifts are not involved in the physiologic process in which oxygen crosses the alveolarcapillary membrane.

Rationale 3: Oxygen crosses alveolarcapillary membranes by diffusion, combines with hemoglobin, and is transported via the pulmonary vein to the left side of the heart. After the heart pumps oxygenated blood into the vascular system where it is transported to cells, oxygenated blood then leaves the capillaries by diffusion and enters cells.

Rationale 4: Movement of oxygen across the alveolarcapillary membrane is not dependent upon a concentration gradient. It does depend upon the presence of a pressure gradient.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-2

Question 4

Type: MCSA

The nurse, caring for a patient with hypovolemic shock is primarily concerned that which change could occur in this patients pulmonary gas exchange?

1. Insufficient distribution of oxygen

2. Buildup of electrolytes in the blood

3. Over-oxygenation

4. Oxygen delivery shift to osmosis

Correct Answer: 1

Rationale 1: Since adequate blood flow must exist to distribute the oxygenated blood to the left side of the heart and the systemic circulation, the patient with hypovolemic shock is not going to have sufficient blood flow, which can lead to an insufficient distribution of oxygen to the tissues.

Rationale 2: A buildup of electrolytes in the blood is not of primary concern in this patients oxygenation.

Rationale 3: Hypovolemic shock will not result in over-oxygenation.

Rationale 4: Oxygen delivery is through diffusion and not osmosis. Hypovolemic shock does not cause an alteration to a different process.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-1

Question 5

Type: MCSA

The nurse is caring for a patient diagnosed with uncontrolled asthma. The nurse implements interventions to help control the effects of asthma on which element of the patients pulmonary gas exchange?

1. Removal

2. Diffusion

3. Ventilation

4. Perfusion

Correct Answer: 3

Rationale 1: Removal is not an element of pulmonary gas exchange.

Rationale 2: Diffusion impairments are seen in pneumonia, lung cancer, and conditions that cause pulmonary edema.

Rationale 3: Restrictive pulmonary disorders, such as uncontrolled asthma, will impair ventilation, the actual movement of air between the atmosphere and lungs.

Rationale 4: Perfusion impairments are seen in anemia, carbon dioxide poisoning, hemorrhage, and pulmonary embolism.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-2

Question 6

Type: MCSA

The nurse is caring for a patient with pneumonia that has impaired diffusion of oxygen. Assessment findings related to this impairment are similar to those the nurse would see in patients with which other disease states?

1. Spinal cord injuries

2. Flail chest

3. Atelectasis

4. Carbon monoxide poisoning

Correct Answer: 3

Rationale 1: The underlying pathophysiology of respiratory system changes in spinal cord injuries is associated with inability to ventilate.

Rationale 2: The underlying pathophysiology of respiratory system changes in flail chest is associated with inability to ventilate.

Rationale 3: Atelectasis results in decreased lung surface area and decreased ability to diffuse oxygen.

Rationale 4: Carbon dioxide poisoning affects the affinity of oxygen to hemoglobin, therefore affecting perfusion.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-2

Question 7

Type: MCSA

A nurse reviewing arterial blood gas results identifies the oxygen saturation level as low. The nurse interprets this information to reflect changes in which process?

1. Ratio of oxygenated hemoglobin to total hemoglobin

2. Percentage of cardiac output

3. Content of oxygen in arterial blood

4. Autoregulation

Correct Answer: 1

Rationale 1: The measurement of SaO2 or oxygen saturation by arterial blood gas analysis is a measurement of the ratio of oxygenated hemoglobin to total hemoglobin.

Rationale 2: Oxygen saturation level does not provide evidence about percentage of cardiac output.

Rationale 3: The content of oxygen in arterial blood is expressed as CaO2.

Rationale 4: Oxygen saturation level within the arterial blood gas analysis is not evidence of autoregulation.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-3

Question 8

Type: MCSA

A patient is diagnosed with iron deficiency anemia. The nurse plans interventions for a patient with which most likely complication?

1. Impaired oxygen delivery

2. Bleeding

3. Multisystem organ failure

4. Reduced lung function

Correct Answer: 1

Rationale 1: Oxygen delivery can be significantly reduced in a patient with a decrease in hemoglobin level, which would occur in a patient with iron deficiency anemia.

Rationale 2: Iron deficiency anemia should not increase the patients risk of bleeding.

Rationale 3: This patient has some risk for organ failure, but this is not the most likely complication.

Rationale 4: Anemia should not affect this patients ability to breath.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 33-3

Question 9

Type: MCSA

A patient tells the nurse that he feels more energetic when he wears oxygen. What would the nurse consider prior to responding to this statement?

1. The patients ability to extract oxygen is increased by wearing oxygen.

2. Increasing oxygen availability has shifted the oxyhemoglobin dissociation curve to the left.

3. Increasing availability of oxygen has produced more adenosine triphosphate.

4. Increased oxygen increases energy by breaking down carbohydrates.

Correct Answer: 3

Rationale 1: Oxygen extraction is the ability to take oxygen into the cells. The process of extraction is not improved by increased delivery.

Rationale 2: Shifting the oxyhemoglobin dissociation curve to the left will increase the bodys hemoglobin carrying capacity of oxygen, but will also decrease the release of oxygen to the tissues.

Rationale 3: Oxygen consumption is the process by which cells use oxygen to generate energy. Oxygen enables the energy contained in food to be broken down into elements that are converted into energy in the form of adenosine triphosphate. The primary value of oxygen is its ability to develop adenosine triphosphate, which would explain why the patient feels more energetic when he wears oxygen.

Rationale 4: The breakdown of carbohydrates is done without oxygen.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-4

Question 10

Type: MCSA

A patient is diagnosed with diabetic ketoacidosis. The nurse plans to provide care to a patient whose energy is being produced through which process?

1. Affinity

2. Aerobic metabolism

3. Extraction

4. Anaerobic metabolism

Correct Answer: 4

Rationale 1: Affinity refers to the hemoglobins ability to release oxygen to the tissues.

Rationale 2: Aerobic metabolism would not cause diabetic ketoacidosis.

Rationale 3: Extraction refers to the body cells ability to extract oxygen from hemoglobin.

Rationale 4: Carbohydrates are the only food substrates that can be broken down to generate adenosine triphosphate without the use of oxygen. Anaerobic metabolism produces the by-products pyruvate and lactate, causes lactate to accumulate in the body, and leads to lactic acidosis.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 33-4

Question 11

Type: MCSA

The nurse is planning essential activities for a critically ill patient. In order to provide the least impact on oxygen consumption, the nurse would be certain the patient rests before and after which activity?

1. Abdominal wound dressing change

2. Bed bath

3. Daily weight using bed sling scale

4. Turning and repositioning

Correct Answer: 3

Rationale 1: Changing the abdominal wound dressing will increase the patients oxygen consumption by 10%. This is not the activity with the greatest impact on oxygen status.

Rationale 2: A bed bath will increase the patients oxygen consumption by 20%. This is not the activity with the greatest impact on oxygen status.

Rationale 3: A daily weight with a bed sling scale will increase a patients oxygen consumption by 40% and is the activity that the nurse should do separately and then permit the patient to rest.

Rationale 4: Turning and repositioning will increase the patients oxygen consumption by 30%. This is not the activity with the greatest impact on oxygen status.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Planning

Learning Outcome: 33-4

Question 12

Type: MCSA

A patients PaO2 level is 48 mm Hg. The nurse would plan care to prevent development of which condition?

1. Hypoxemia

2. Intrapulmonary shunt

3. Hypoxia

4. Hyperventilation

Correct Answer: 3

Rationale 1: Hypoxemia, an inadequate amount of oxygen in the blood, is frequently quantified as a PaO2 of less than 60 mm Hg. This condition already exists.

Rationale 2: There is not enough information to identify whether the current condition is related to intrapulmonary shunt.

Rationale 3: If this condition is allowed to progress, hypoxia may result. The nurses interventions are directed at reversing this progression.

Rationale 4: There is not enough information to determine if the patient is hyperventilating.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-2

Question 13

Type: MCSA

A patient is going to be assessed for oxygen consumption level. Which parameter will the nurse identify for this assessment?

1. Serum potassium level

2. Hemoglobin level

3. Creatinine level

4. Serum lactate level

Correct Answer: 4

Rationale 1: Serum potassium is not used in determining oxygen consumption.

Rationale 2: Hemoglobin is not used in determining oxygen consumption.

Rationale 3: Creatinine is not used in determining oxygen consumption.

Rationale 4: Current methods of assessing oxygen consumption are limited to indirect measurement techniques including measurement of serum lactate levels, base deficit, and mixed venous oxygen saturation monitoring; therefore, the serum lactate level will be used to assess the patients oxygen consumption level.

Global Rationale: 

Cognitive Level: Applying

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-4

Question 14

Type: MCSA

A patients mixed venous oxygen saturation level is 56%. What evaluation would the nurse make of this reading?

1. The cells are taking more oxygen to meet needs.

2. The cells are not receiving enough oxygen.

3. The cells are releasing more carbon dioxide.

4. There isnt enough oxyhemoglobin to meet the patients needs.

Correct Answer: 2

Rationale 1: The level of 56% does not mean that the cells are taking more oxygen to meet needs.

Rationale 2: Venous blood from all body systems is considered mixed when it has reached the pulmonary artery. Normal mixed venous oxygen saturation is 60%80%. If the oxygen delivery to tissues is adequate for tissue demands, oxygen saturation of the blood in the pulmonary artery will be 60%80%. A low mixed venous oxygen saturation level means that less oxygen is returning to the right heart and the cells are not getting enough oxygen to meet their needs.

Rationale 3: The level of 56% does not mean that the cells are releasing more carbon dioxide.

Rationale 4: There is not enough information to determine the cause of this reading.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-4

Question 15

Type: MCSA

A patient with COPD says, I have to rest a lot. It just wears me out trying to breath. The nurse interprets this statement to mean the patient has difficulty with which respiratory process?

1. Perfusion

2. Diffusion

3. Ventilation

4. Consumption

Correct Answer: 3

Rationale 1: There is nothing in this statement that indicates the patient is not perfusing the lungs adequately.

Rationale 2: Oxygen is moved across the alveoli and into pulmonary capillaries by diffusion. This process does not require work on the part of the patient.

Rationale 3: Ventilation is movement of air between the atmosphere and the lungs. It involves the actual work of breathing. In a patient with COPD the movement of air into and out of the lungs is impaired.

Rationale 4: Oxygen consumption involves the use of oxygen at the cellular level and does not require work on the patients part.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-2

Question 16

Type: MCMA

A patient injured in an explosion has a flail chest and crushing injuries to his left arm and leg. He is unconscious and is losing blood rapidly. Laboratory testing reveals impaired oxygenation. Nursing interventions should be implemented to improve which components of oxygenation disrupted by this injury?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Ventilation

2. Thickness of the alveolarcapillary membrane

3. Oxygen affinity

4. Hemoglobin concentration

5. Blood flow to the lungs

Correct Answer: 1,4,5

Rationale 1: Since the patient has a flail chest, ventilation, or the movement of air between the atmosphere and the lungs, will be impaired.

Rationale 2: These injuries should not have a significant initial impact on thickness of the alveolarcapillary membrane. Should the flail chest result in pneumothorax or hemothorax, the effective surface area of the lungs will be decreased, but the thickness of the membrane will not be affected initially.

Rationale 3: Nothing in this scenario will affect hemoglobin affinity for oxygen.

Rationale 4: As the patient continues to bleed, the amount of available hemoglobin will continue to reduce.

Rationale 5: Since the patient has massive blood loss, the body has shunted blood to core organs in an attempt to maintain blood flow. This compensation is short lived as bleeding continues.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-2

Question 17

Type: MCMA

A nurse is preparing a patient for pulmonary functioning testing (PFT). Which nursing statements will help to reinforce teaching about the purposes of these tests?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. These tests can help in the diagnosis of any pulmonary diseases you may have.

2. We can monitor how well therapies are working by comparing the results of your tests.

3. Insurance companies require these tests be done before you can be discharged from the hospital.

4. By testing you frequently we can identify changes occurring in your pulmonary health before they become severe.

5. The tests give us numbers so we can make accurate assessments of your pulmonary health.

Correct Answer: 1,2,4,5

Rationale 1: PFT are helpful in diagnosing pulmonary diseases.

Rationale 2: These tests are often used for monitoring the effects of therapies.

Rationale 3: The results of the tests may be used to satisfy discharge screens but saying they are required by insurance companies is not accurate.

Rationale 4: Identifying changes in pulmonary status is a valid rationale for these tests.

Rationale 5: Because the results of these tests are reported in numbers, the trending of results is easy and useful.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-2

Question 18

Type: MCMA

A patient who is receiving chemotherapy is anemic and has low CaO2 levels. Which nursing interventions offer the best support for this patient?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. Monitor the administration of blood products.

2. Administer diuretics as ordered.

3. Keep the patients oxygen cannula in place.

4. Keep the patient on bedrest

5. Monitor the patients pulmonary artery wedge pressure (PAWP).

Correct Answer: 1,3

Rationale 1: One of the methods for increasing the amount of oxygen in arterial blood is to increase the amount of hemoglobin in the blood. If the patient is severely anemic, blood transfusion is an option.

Rationale 2: Diuretics will not increase CaO2 but might increase hematocrit.

Rationale 3: Supplementing oxygen to increase SaO2 and PaO2 will help increase CaO2.

Rationale 4: Keeping the patient on bedrest would decrease the effects of low CaO2 by decreasing metabolic demand, but will not increase CaO2.

Rationale 5: Monitoring the PAWP will not improve oxygenation of arterial blood.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Implementation

Learning Outcome: 33-3

Question 19

Type: MCMA

Arterial blood gases were drawn when a patient was discovered in cardiopulmonary arrest. Which results would the nurse evaluate as indicating global lactic acidosis?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. pH 7.21

2. HCO3 24 mEq/L

3. Base excess 12 mmol/L

4. PaO2 82 mm Hg

5. PaCO2 37 mmHg

Correct Answer: 1,3

Rationale 1: The patient in global lactic acidosis will have an acidotic pH (less than 7.35).

Rationale 2: HCO3 of 24 mEq/L is normal. In global lactic acidosis the HCO3 would be low.

Rationale 3: A base deficit will be seen in global lactic acidosis.

Rationale 4: This is a normal PaO2 and is not an expected finding in the global hypoxia that results in global lactic acidosis.

Rationale 5: This is a normal PaCO2.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-4

Question 20

Type: MCMA

A nurse is monitoring trends of a patients SvO2 as a measure of oxygen delivery to tissues. The nurse would be concerned about the accuracy of this trending if which patient condition develops?

Note: Credit will be given only if all correct choices and no incorrect choices are selected.

Standard Text: Select all that apply.

1. The patients heart rate drops.

2. The patient develops a high fever.

3. The patient develops gastrointestinal bleeding.

4. The patients SaO2 improves with antibiotic therapy.

5. The patient is receiving multivitamins in intravenous infusions.

Correct Answer: 1,2,3,4

Rationale 1: Dropping heart rate would change cardiac output. SvO2 is influenced by cardiac output.

Rationale 2: High fever will increase oxygen consumption, which affects SvO2.

Rationale 3: If the patients hemoglobin level changes it will change SvO2.

Rationale 4: Improvement of SaO2 will change SvO2.

Rationale 5: The presence of vitamins in intravenous infusions will not change SvO2.

Global Rationale: 

Cognitive Level: Analyzing

Client Need: Physiological Integrity

Client Need Sub: Physiological Adaptation

Nursing/Integrated Concepts: Nursing Process: Assessment

Learning Outcome: 33-4

Wagner, High Acuity Nursing, 6/E Test Bank

Copyright 2014 by Pearson Education, Inc.

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