Chapter 35. Oxygenation My Nursing Test Banks

Chapter 35. Oxygenation

Multiple Choice

Identify the choice that best completes the statement or answers the question.

____ 1. The nurse is providing care to a pregnant woman in preterm labor. The patient is 32 weeks pregnant. Initially, the patient states, Ive gained 30 pounds. That should be enough for the baby. Everything will be OK if I deliver now. After teaching the patient about fetal development, the nurse will know her teaching is effective if the patient makes which of the following statements?

1)

The babys lungs are well developed now, but he will be at increased risk for sudden infant death syndrome if I deliver early.

2)

We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early.

3)

If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening.

4)

Thanks for reassuring me; I was pretty sure there isnt much risk to the baby this far along in my pregnancy.

____ 2. The nurse is caring for a patient who is experiencing dyspnea. Which of the following positions would be most effective if incorporated into the patients care?

1)

Supine

2)

Head of bed elevated 80

3)

Head of bed elevated 30

4)

Lying on left side

____ 3. While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal drainage system (CDU). Which action should the nurse take immediately?

1)

Clamp the chest tube close to the insertion site.

2)

Set up a new drainage system, and connect it to the chest tube

3)

Have the patient take and hold a deep breath while the nurse reconnects the tube to the CDU.

4)

Place the disconnected end nearest the patient into a bottle of sterile water.

____ 4. The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which of the following responses indicates to the nurse that the medication is effective?

1)

The amount of sputum the patient expectorates decreases with each dose administered.

2)

Cough is completely suppressed, and she is able to sleep through the night.

3)

Dry, unproductive cough is reduced, but her voluntary coughing is more productive.

4)

Involuntary coughing produces large amounts of thick yellow sputum.

____ 5. A patient diagnosed with hypertension is taking an angiotensin-converting enzyme (ACE) inhibitor. When planning care, which of the following outcomes would be appropriate for the patient?

1)

BP will be lower than 135/85 on all occasions.

2)

BP will be normal after 2 to 3 weeks on medication.

3)

Patient will not experience dizziness on rising.

4)

Urine output will increase to at least 50 ml/hr

____ 6. The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure. The patient is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take?

1)

Review and implement the primary care providers prescriptions for treatments.

2)

Perform a quick physical examination of breathing, circulation, and oxygenation.

3)

Gather a thorough medical history, including current symptoms, from the family.

4)

Administer oxygen to the patient through a nasal cannula.

____ 7. You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patients respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern?

1)

Biots breathing

2)

Kussmauls respirations

3)

Sleep apnea

4)

Cheyne-Stokes respirations

____ 8. You are preparing the nursing care plan for a middle-aged patient admitted to the intensive care unit for an acute myocardial infarction (heart attack). His symptoms include tachycardia, palpitations, anxiety, jugular vein distention, and fatigue. Which of the following nursing diagnoses is most appropriate?

1)

Decreased Cardiac Output

2)

Impaired Tissue Perfusion

3)

Impaired Cardiac Contractility

4)

Impaired Activity Tolerance

____ 9. You are to connect a patient to a cardiac monitor. Which of the following actions should you take to ensure an accurate electrocardiogram tracing?

1)

Select electrode placement sites over bony prominences.

2)

Apply the electrodes immediately after cleansing the skin, before the alcohol evaporates.

3)

Before applying the electrodes, rub the placement sites with gauze until the skin reddens.

4)

Ensure that the gel on the back of the electrodes is dry.

____ 10. You are admitting a 54-year-old patient with chronic obstructive pulmonary disease (COPD). The physician prescribes O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient?

1)

Nonrebreather mask

2)

Nasal cannula

3)

Partial rebreather mask

4)

Venturi mask

____ 11. Which of the following provide the most reliable data about the effectiveness of airway suctioning?

1)

The amount, color, consistency and odor of secretions

2)

The patients tolerance for the procedure

3)

Breath sounds, vital signs, and pulse oximetry before and after suctioning

4)

The number of suctioning passes required to clear secretions

____ 12. What is the rationale for wrapping petroleum gauze around a chest tube insertion site?

1)

Prevents air from leaking around the site

2)

Prevents infection at the insertion site

3)

Absorbs drainage from the insertion site

4)

Protects the tube from becoming dislodged

____ 13. You are caring for an adult patient with a tracheostomy who is on a mechanical ventilator. His pulse oximetry reading of 85%, heart rate is 113, and respiratory rate is 30. The patient is very restless. His respirations are labored, and you hear gurgling sounds. You auscultate crackles and rhonchi in both lungs. What is the most appropriate action to take?

1)

Call the respiratory therapist to check the ventilator settings.

2)

Provide endotracheal suctioning.

3)

Provide tracheostomy care.

4)

Notify the physician of signs of fluid overload.

____ 14. Chest percussion and postural drainage would be an appropriate intervention for which of the following conditions?

1)

Congestive heart failure

2)

Pulmonary edema

3)

Pneumonia

4)

Pulmonary embolus

____ 15. For a patient with peripheral venous insufficiency, which of the following interventions would help to promote peripheral circulation?

1)

Have the patient sit in a recliner, with legs lower than the heart.

2)

Teach the patient to avoid sitting with the legs crossed.

3)

Be sure intravenous medications are adequately diluted.

4)

Regularly assess skin color and temperature of the legs.

____ 16. Which of the following blood levels normally provides the primary stimulus for breathing?

1)

pH

2)

Oxygen

3)

Bicarbonate

4)

Carbon dioxide

____ 17. Chronic stress may lead directly to cardiovascular disease because of the repeated release of which of the following?

1)

Histamine

2)

Catecholamines

3)

Cortisol

4)

Protease

____ 18. The nurse is teaching a pregnant woman about the increased oxygen demand that develops during pregnancy. The nurse knows the patient comprehends the teaching when she makes the following statement:

1)

I may need to drink more fluids in order to make more oxygen.

2)

I may need to take an iron supplement so that I am not anemic.

3)

I will need a multivitamin supplement for several months.

4)

I will need to eat more fruits and vegetables.

____ 19. A 62-year-old man with emphysema says, My doctor wants me to quit smoking. Its too late now, though; I already have lung problems. Which of the following would be the best response to his statement?

1)

You should quit so your family does not get sick from exposure to secondhand smoke.

2)

You will need to use oxygen, but remember it is a fire hazard to smoke with oxygen in your home.

3)

Once you stop smoking, your body will begin to repair some of the damage to your lungs.

4)

You should ask your primary care provider for a prescription for a nicotine patch so that you can quit.

____ 20. The nurse administers intravenous morphine sulfate to a patient for pain control. She will need to monitor her patient for which of the following adverse effects?

1)

Decreased heart rate

2)

Muscle weakness

3)

Decreased urine output

4)

Respiratory depression

____ 21. When using sterile technique to perform tracheostomy care of a new tracheostomy, which of the following is correct?

1)

You will need a single pair of sterile gloves.

2)

Place the patient in semi-Fowlers position, if possible

3)

Clean the stoma under the faceplate with hydrogen peroxide.

4)

Cut a slit in sterile 4 x 4 gauze halfway through to make a dressing.

____ 22. A patient has just had a chest tube inserted to dry-seal suction drainage. Which of the following is a correct nursing intervention for maintenance?

1)

Keep the head of the bed flat for 6 hours.

2)

Avoid using mouth rinses or mouthwashes.

3)

Provide the patient with a paper and pencil or letter board.

4)

Drain condensation into the humidifier when it collects in the tubing.

Multiple Response

Identify one or more choices that best complete the statement or answer the question.

____ 1. The nurse is counseling a 17-year-old girl on smoking cessation. The nurse should include which of the following helpful tips in her education? Choose all that apply.

1)

Keep healthy snacks or gum available to chew instead of smoking a cigarette.

2)

Dont tell your friends and family you are trying to quit, until you feel comfortable youll be successful.

3)

Plan a time to quit when you will not have many other demands or stressors in your life.

4)

Reward yourself with an activity you enjoy when you quit smoking.

____ 2. A patient has a history of COPD. His pulse oximetry reading is 97%. What other findings would indicate adequate tissue and organ oxygenation? Choose all that apply.

1)

Normal urine output

2)

Strong peripheral pulses

3)

Clear breath sounds bilaterally

4)

Normal muscle strength

____ 3. The nurse is teaching a patient about her chest drainage system. Which of the following should the nurse include in the teaching? Choose all that apply.

1)

Perform frequent coughing and deep-breathing exercises

2)

Sit up in a chair but not walk while the drainage system is in place

3)

Get out of bed on her own as much as possible

4)

Immediately notify the nurse if she experiences increased shortness of breath

____ 4. Nursing interventions to reduce the risk of thromboembolism include which of the following activities? Choose all that apply.

1)

Keep the patients hips and knees flexed while the patient is in bed.

2)

Apply compression devices (e.g., sequential compression devices).

3)

Turn the patient frequently or encourage frequent position changes.

4)

Promote adequate hydration by encouraging oral intake.

____ 5. When providing safety education to the mother of a toddler, you would inform the mother that, based on the childs developmental stage, he is at high risk for which of the following factors that influence oxygenation? Choose all that apply.

1)

Frequent, serious respiratory infections

2)

Airway obstruction from aspiration of small objects

3)

Drowning in small amounts of water around the home

4)

Development of asthma

____ 6. Obesity is associated with higher risk for which of the following conditions that affect the pulmonary and cardiovascular systems? Choose all that apply.

1)

Reduced alveolar-capillary gas exchange

2)

Lower respiratory tract infections

3)

Sleep apnea

4)

Hypertension

____ 7. Which of the following is/are accurate about nasotracheal suctioning? Choose all that apply.

1)

Apply suction for no longer than 10 sec during a single pass.

2)

Apply suction while inserting and removing the catheter.

3)

Reapply oxygen between suctioning passes for ventilator patients.

4)

Gently rotate the suction catheter as you remove it.

____ 8. Which of the following medications would you expect to be included in the treatment of a patient with congestive heart failure? Choose all that apply.

1)

Nitrates

2)

Beta-adrenergic agents

3)

Diuretics

4)

Anticoagulants

____ 9. Which of the following factors influence normal lung volumes and capacities? Choose all that apply.

1)

Age

2)

Race

3)

Body size

4)

Activity level

____ 10. As the nurse caring for a patient who has suffered a myocardial infarction that has damaged the sinoatrial (SA) node, you should plan to monitor for which of the following potential complications? Choose all that apply.

1)

Decreased heart rate

2)

Increased heart rate

3)

Decreased cardiac output

4)

Decreased strength of ventricular contractions

____ 11. Of the following interventions, which is/are likely to reduce the risk of postoperative atelectasis? Choose all that apply.

1)

Administer bronchodilators.

2)

Apply low-flow oxygen.

3)

Encourage coughing and deep breathing.

4)

Administer pain medication.

Completion

Complete each statement.

1. ____________________ is the movement of air into and out of the lungs through the act of breathing. ____________________ refers to the exchange of gases (oxygen and carbon dioxide) in the lungs.

2. Prolonged use of high oxygen concentrations reduces ____________________ production, which leads to alveolar collapse and reduced lung elasticity.

3. The amount of air moved into and out of the lungs with each normal breath is known as the ____________________. Normally, this volume is around ____________________ ml.

4. A positive TB skin test indicates that a patient has active tuberculosis.

5. Nicotine increases the risk for thrombus (blood clot) formation.

6. A troponin level is a laboratory test performed to determine how well the cells, tissues, and organs are supplied with oxygen.

Chapter 35. Oxygenation

Answer Section

MULTIPLE CHOICE

1. ANS: 3

Premature infants (younger than 33 weeks gestation) are born before the alveolar surfactant system is fully developed. Therefore, they are at high risk for respiratory distress syndrome (RDS). RDS is characterized by widespread atelectasis (collapse of alveoli), usually related to a deficiency of surfactant that keeps air sacs open.

PTS: 1 DIF: Moderate REF: V1, p. 871

KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

2. ANS: 2

Position affects ventilation. An upright or elevated position pulls abdominal organs down, thus allowing maximum diaphragm excursion and lung expansion.

PTS: 1 DIF: Easy REF: V1, p. 878

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

3. ANS: 4

Recollapse of the lung can occur because of loss of negative pressure within the system. This is commonly caused by air leaks, disconnections, or cracks in the bottles or chambers. If any of these occur, the nurse should immediately place the disconnected end nearest the patient into a bottle of sterile water or saline to a depth of 2 cm to serve as an emergency water seal until a new system can be connected. Do not clamp the chest tube because this can rapidly lead to a tension pneumothorax. A new drainage system should be set up to decrease the risk of infection, but the immediate action is to place the disconnected end into a bottle of sterile water.

PTS: 1 DIF: Moderate REF: V2, p. 890

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis

4. ANS: 3

Antitussives are cough suppressants that reduce the frequency of an involuntary, dry, nonproductive cough. Antitussives are useful for adults when coughing is unproductive and frequent, leading to throat irritation or interrupted sleep. Expectorants help make coughing more productive. The goal of an antitussive/expectorant combination is to reduce the frequency of dry, unproductive coughing while making voluntary coughing more productive.

PTS: 1 DIF: Difficult REF: V1, p. 883

KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

5. ANS: 1

Goals must be clearly stated so that it is easy to evaluate if they have been met. BP . . . lower than 135/85 . . . is clearly stated and easily evaluated. In contrast, BP will be normal . . .) does not clearly state the desired endpoint. Freedom from dizziness on rising is probably not achievable because ACE inhibitors are vasodilating agents, which may cause vessel dilation and hypotension, especially when the patient arises from a seated or lying position. Patients should be warned of this effect. The expected/desired effect of the ACE inhibitor is to lower the blood pressure; the urine output is minimally relevant in determining that outcome, if at all.

PTS: 1 DIF: Difficult REF: V1, p. 908

KEY: Nursing process: Planning | Client need: PHSI | Cognitive level: Application

6. ANS: 2

The first action the nurse should take is to make a quick assessment of the adequacy of breathing, circulation, and oxygenation in order to determine the type of immediate intervention required. The nurses assessment should include simple questions about current symptoms. A more thorough medical history can be gathered once the patients oxygenation needs are addressed. Following a quick assessment, the nurse should then review and implement physicians orders. Administering oxygen is not appropriate without knowing what treatments the primary care provider has prescribed.

PTS: 1 DIF: Moderate REF: V1, p. 877

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

7. ANS: 4

This respiratory pattern is known as Cheyne-Stokes respirations. It is often associated with damage to the medullary respiratory center or high intracranial pressure due to brain injury.

PTS: 1 DIF: Easy REF: V2, pp. 886-887

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

8. ANS: 1

The patients symptoms reflect altered cardiac preload, a component of cardiac output. Acute myocardial infarction is often associated with decreased cardiac output as a result of altered cardiac pumping ability. Although the other nursing diagnoses might be associated with Decreased Cardiac Output, these diagnoses cannot be determined from the symptoms presented. Additionally, Impaired Cardiac Contractility is not a NANDA nursing diagnosis.

PTS: 1 DIF: Difficult REF: V1, p. 908 | V2, pp. 895-896

KEY: Nursing process: Diagnosis | Client need: PHSI | Cognitive level: Analysis

9. ANS: 3

Electrodes should be placed over soft tissues or close to bone in order to obtain accurate waveforms. Sites over bony prominences, thick muscles, and skinfolds can produce artifact; therefore, they should not be used. Alcohol removes skin oils that may prevent the electrodes from adhering. However, the alcohol should be allowed to dry before the electrodes are placed. Rubbing the skin with gauze or a washcloth removes dead skin cells and promotes better electrical contact. A dry electrode will not conduct electrical activity; gel should not be dry.

PTS: 1 DIF: Moderate REF: V2, p. 842

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Comprehension

10. ANS: 4

The Venturi mask is capable of delivering 24% to 50% FIO2. The cone-shaped adapter at the base of the mask allows a precise FIO2 to be delivered. This is very useful for patients with chronic lung disease. Rebreather masks are used when high concentrations of oxygen are required. A nasal cannula administers oxygen in liters per minute and does not allow administration of a precise FIO2.

PTS: 1 DIF: Difficult REF: V2, p. 852

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

11. ANS: 3

Breath sounds, vital signs, and oxygen saturation levels before and after suctioning provide data about the effectiveness of suctioning. Information about the amount and appearance of secretions provides data about the likelihood of airway infection and/or inflammation. Data about the patients tolerance of suctioning provide information about the patients overall condition. The number of suctioning passes required to clear the secretions provides information about the amount of secretions present.

PTS: 1 DIF: Moderate REF: V2, p. 863 | V2, p. 868 | V2, p. 872

KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

12. ANS: 1

Petroleum gauze creates a seal around the insertion site. Collapse of the lung can occur if there is a leak around the insertion site that causes loss of negative pressure within the system. Air leaks are one common cause of loss of negative pressure.

PTS: 1 DIF: Easy REF: V2, p. 880

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

13. ANS: 2

Increased pulse and respiratory rates, decreased oxygen saturation, gurgling sounds during respiration, auscultation of adventitious breath sounds, and restlessness are signs that indicate the need for suctioning. Airways are suctioned to remove secretions and maintain patency. The patients symptoms should subside once the airway is cleared.

PTS: 1 DIF: Moderate REF: V1, p. 891 | V2, p. 899

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

14. ANS: 3

Chest physiotherapy moves secretions to the large, central airways for expectoration or suctioning. This treatment is not effective for conditions that do not involve the development of airway secretions, including congestive heart failure, pulmonary edema, and pulmonary embolus.

PTS: 1 DIF: Moderate REF: V1, pp. 887-888

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

15. ANS: 2

Sitting with the legs crossed interferes with blood flow to the lower extremities, and should be avoided. The patient should sit or lie with the legs above the level of the heart to promote venous return via gravity. Adequate dilution of IV medications helps prevent chemical irritation of veins, but does not promote venous return from the lower extremities. Assessing skin color and temperature provides information about circulation, but does nothing to promote circulation.

PTS: 1 DIF: Difficult REF: V1, p. 909

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

16. ANS: 4

Carbon dioxide (CO2) level provides the primary stimulus to breathe. High CO2 levels stimulate breathing to eliminate the excess CO2. A secondary, although important, drive to breathe is hypoxemia. Low blood O2 levels stimulate breathing to bring more oxygen into the lungs.

PTS: 1 DIF: Moderate REF: V1, p. 870

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

17. ANS: 2

The stress response stimulates release of catecholamines from the sympathetic nervous system. This results in increased heart rate and contractility, vasoconstriction, and increased tendency of blood to clot. Cortisol is also released in the stress response, but it is more indirectly related to development of cardiovascular disease through altered glucose, fat, and protein metabolism.

PTS: 1 DIF: Moderate REF: V1, p. 903

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Recall

18. ANS: 2

During pregnancy, oxygen demand increases dramatically. To compensate, the mothers blood volume increases by 30%. The woman requires additional iron to produce this blood as well as to meet fetal requirements. Failure to meet these iron demands can result in maternal anemia, reducing tissue oxygenation of the mother.

PTS: 1 DIF: Moderate REF: V1, p. 904

KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Application

19. ANS: 3

The nurses response should focus on correcting the patients misinformation rather than on convincing him to stop smoking. Once a person stops smoking, the body begins to repair the damage. During the first few days, the person will cough more as the cilia begin to clear the airways. Then the coughing subsides, and breathing becomes easier. Even long-time smokers can benefit from smoking cessation. The suggestions that the patients family will become ill and that oxygen is a fire hazard appear to be scare tactics, which can be seen as coercive, and would not be effective in motivating the patient to stop smoking. Although asking the primary care provider for a prescription may help the patient to stop smoking, it does not address his incorrect belief that it is too late for him to do so.

PTS: 1 DIF: Moderate REF: V1, pp. 873-874

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

20. ANS: 4

Opioids are potent respiratory depressants. Patients receiving opioids should be monitored for decreased rate and depth of respirations.

PTS: 1 DIF: Moderate REF: V1, p. 874

KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension

21. ANS: 2

Semi-Fowlers position promotes lung expansion and prevents back strain for the nurse. You will need two pairs of sterile gloves: one pair for dressing removal, and a clean pair for the rest of the procedure. You should clean the stoma under the faceplate with sterile saline. Never cut a 4 x 4 gauze for the dressing because lint and fibers from the cut edge could enter the trachea and cause respiratory distress.

PTS: 1 DIF: Easy REF: V1, p. 896 | V2, pp. 853-858

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

22. ANS: 3

Maintain patient in semirecumbent position (head of bed elevated 30 to 45 degrees). This is extremely important to promote lung expansion, reduce gastric reflux, and prevent ventilator-associated pneumonia (VAP). Patients being mechanically ventilated are at high risk for developing VAP, which is associated with high mortality rates. Mouth rinses and mouthwashes are a part of the recommended routine for preventing VAP. They also provide comfort and preserve integrity of the mucous membranes. The patient on a mechanical ventilator is unable to speak. This can produce extreme anxiety. An alternative method of communication must be used so the patient can express her needs and concerns. You should check the ventilator tubing frequently for condensation. Drain the fluid into a collection device or waste receptacle because condensation in the ventilator tubing can cause resistance to airflow. Moreover, the patient can aspirate it if it backflows down into the endotracheal tube. The fluid should not be drained into the humidifier because the patients secretions may have contaminated it.

PTS: 1 DIF: Difficult REF: V1, p. 898 | V2, p. 876

KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

MULTIPLE RESPONSE

1. ANS: 1, 3, 4

People who are trying to quit smoking should tell several supportive people that they plan to quit and ask them to help them to be successful. Having something to chew on (e.g., carrot sticks, gum, nuts, or seeds) can distract from the desire to have a cigarette. Setting a date to stop smoking and choosing a time of low stress are two strategies that help people be more successful with smoking cessation. Self-reward for meeting goals is a form of positive reinforcement.

PTS: 1 DIF: Moderate REF: V1, p. 886

KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension

2. ANS: 1, 2, 4

To determine adequacy of tissue oxygenation, assess respiration, circulation, and tissue/organ function. Good peripheral circulation is characterized by strong peripheral pulses. Impaired tissue oxygenation to the kidneys would result in abnormal kidney function (e.g., poor urine output). Hypoxic limb tissue would result in abnormal muscle functioning (e.g., muscle weakness and pain with exercise). Adequacy of tissue oxygenation cannot be determined by assessing pulmonary ventilation alone; circulation must also be assessed.

PTS: 1 DIF: Difficult

REF: V1, p. 870; higher-order item, some of answer implied in text | V1, p. 875; higher-order item, some of answer implied in text

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

3. ANS: 1, 4

Patients should regularly perform coughing and deep-breathing exercises to promote lung reexpansion. Also to promote lung reexpansion, the nurse should encourage the patient to be as active as her condition permits, rather than telling her not to walk. Chest drainage systems are bulky, but patients with disposable systems can still get out of bed and ambulate. However, the patient will need assistance from one or two staff members to protect and monitor the system and to monitor her responses to activity; she should not get out of bed on her own. If a patient with a chest drainage system becomes acutely short of breath, the patient should immediately notify the nurse so the nurse can check for occlusion of the system, which can result in a tension pneumothorax.

PTS: 1 DIF: Moderate REF: V2, p. 889

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

4. ANS: 2, 3, 4

Adequate circulation ensures that oxygenated blood reaches tissues and organs and that venous blood returns to the heart. Compression devices, frequent position changes, and hydration are interventions that promote venous return and reduce the risk of clot formation. Flexion of the hips, legs, and knees constricts the veins, slows venous blood flow, and increases the risk of thromboembolism.

PTS: 1 DIF: Moderate REF: V1, p. 909

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

5. ANS: 2, 3

As a toddlers respiratory and immune systems mature, the risk for frequent and serious infections is less than in infanthood. Most children recover from upper respiratory infections without difficulty. Toddlers airways are relatively short and small and may be easily obstructed, and they often put objects in their mouth as part of exploring their environment, thus increasing their risk for aspiration. In addition, toddlers are at high risk for drowning in very small amounts of water around the home (e.g., in a bucket of water or toilet bowl). The risk for developing asthma is not significantly influenced by the childs developmental stage.

PTS: 1 DIF: Moderate REF: V1, p. 871

KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension

6. ANS: 2, 3, 4

Obesity causes multiple health problems, many of which affect the lungs, heart, and circulation. Large abdominal fat stores press upward on the diaphragm, preventing full chest expansion and leading to hypoventilation and dyspnea on exertion. The risk for respiratory infection increases because lower lung segments are poorly ventilated, and secretions are not removed effectively. When an obese person lies down, chest expansion is limited even more. Excess neck girth and fat stores in the upper airway often lead to obstructive sleep apnea. Obesity also increases the risk of developing atherosclerosis and hypertension. Obesity does not cause reduced alveolar-capillary gas exchange.

PTS: 1 DIF: Easy REF: V1, p. 873 | V1, p. 904

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension

7. ANS: 1, 4

Limiting suctioning to 10 sec or less and reapplying oxygen between suctioning passes prevent hypoxia. Suction should be applied only while withdrawing the catheter, using a continuous rotating motion to prevent trauma to the airway. Endotracheal suctioning is used when the patient is being mechanically ventilated, and most ventilator patients have in-line suctioning, so there is no need to reapply oxygen.

PTS: 1 DIF: Moderate REF: V2, pp. 865869

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

8. ANS: 2, 3

Beta-adrenergic agents block stimulation of beta receptors in the heart, lungs, and blood vessels and decrease heart rate, slow conduction through the AV node, and decrease myocardial oxygen demand by reducing myocardial contractility. Diuretics increase removal of sodium and water from the body through increased urine output. Diuretics reduce the volume of circulating blood and prevent accumulation of fluid in the pulmonary circulation.

PTS: 1 DIF: Moderate REF: V1, p. 910; ESG Supplemental Materials

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

9. ANS: 1, 3, 4

Normal lung volumes and capacities vary with body size, age, and exercise level. Volumes and capacities are higher in men, in large people, and in athletes. Race does not influence normal lung volumes and capacities.

PTS: 1 DIF: Easy REF: V1, p. 880

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

10. ANS: 1, 3

Normally, the SA node is the primary pacemaker for the heart and initiates a rate of 60 to 100 beats per minute. If the SA node fails, the atrioventricular node can take over as the pacemaker, but it generally triggers a slower heart rate. Cardiac output will decrease as a result of the decrease in heart rate. Damage to the SA node interferes with the electrical activity of the heart but does not affect the pumping action of the heart.

PTS: 1 DIF: Difficult REF: V1, p. 900

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Application

11. ANS: 3, 4

Pain alters the rate and depth of respirations. Often, patients in pain breathe shallowly and are at risk for atelectasis. Regularly assess all patients for pain. Once you have medicated the patient, reassess breath sounds, and encourage the patient to cough and breathe deeply.

PTS: 1 DIF: Moderate

REF: V1, pp. 876-877; critical thinking item that requires synthesis of information

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

COMPLETION

1. ANS:

Ventilation; Respiration

Pulmonary ventilation (breathing) is the movement of air into and out of the lungs. Oxygenation of the blood, and ultimately of organs and tissues, depends on adequate ventilation. Respiration refers to gas exchange, that is, the oxygenation of blood and elimination of carbon dioxide in the lungs. Although the plural form respirations is used to mean breaths when taking vital signs, this is a misnomer: You cannot measure gas exchange by counting breaths per minute.

PTS: 1 DIF: Easy REF: V1, p. 868

KEY: Client need: HPM | Cognitive level: Comprehension

2. ANS:

surfactant

Oxygen toxicity can develop when oxygen concentrations of more than 50% are administered for longer than 48 to 72 hours.

PTS: 1 DIF: Moderate REF: V1, p. 889

KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Recall

3. ANS: tidal volume; 500

PTS: 1 DIF: Easy REF: V2, p. 892

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension

4. ANS:

F

Patients with positive TB skin tests must undergo further testing (chest x-ray and sputum cultures) to determine whether they have merely been exposed to the tuberculosis bacillus or whether they have active disease.

PTS: 1 DIF: Easy REF: V1, p. 879

KEY: Nursing process: Evaluation | Client need: HPM | Cognitive level: Recall

5. ANS:

T

Nicotine increases the risk for thrombus formation because of its constricting effects on blood vessel walls.

PTS: 1 DIF: Easy REF: V1, p. 909

KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension

6. ANS:

F

Troponin is a serum evaluation used to detect myocardial infarction (MI). Levels of these contractile proteins remain elevated for up to 7 days after MI. Organ function indirectly evaluates the extent to which oxygen demands have been met in the cells, organs, and tissues.

PTS: 1 DIF: Difficult REF: V2, p. 893

KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

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