Chapter 37. Oxygenation My Nursing Test Banks

Chapter 37. 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 SIDS 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.

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:1DIF:ModerateREF:p. 1297

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

____ 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

ANS: 2

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

PTS:1DIF:EasyREF:p. 1303

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

____ 3. While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal chest 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.

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:1DIF:ModerateREF:p. 1322

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

____ 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.

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:1DIFifficultREF:p. 1310

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

____ 5. 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.

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:1DIF:ModerateREF:pp. 1301-1302

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

____ 6. 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

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:1DIF:EasyREF:p. 1303

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

____ 7. 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

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:1DIFifficultREF:p. 1335

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

____ 8. 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

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: p. 1351

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

____ 9. 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

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:1DIF:EasyREF:p. 1322

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

____ 10. You are caring for an adult patient with a tracheostomy who is being mechanically ventilated. His pulse oximetry reading is 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 the patients signs of fluid overload.

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: p. 1318, 1342

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

____ 11. 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

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:1DIF:ModerateREF:p. 1313

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

____ 12. Which of the following blood levels normally provides the primary stimulus for breathing?

1)

pH

2)

Oxygen

3)

Bicarbonate

4)

Carbon dioxide

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:1DIF:ModerateREF:p. 1296

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

____ 13. 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 to help you quit.

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:1DIF:ModerateREF:p. 1299

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

____ 14. 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

ANS: 4

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

PTS:1DIF:ModerateREF:pp. 1299, 1305; critical-thinking and synthesis required

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

____ 15. 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 4 gauze halfway through to make a dressing.

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 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: p. 1338

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

____ 16. 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)

Immobilize the patients arm on the affected side.

3)

Keep the drainage system lower than the insertion site.

4)

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

ANS: 3

The drainage system must be below the insertion site to prevent fluid flowing back into the pleural cavity and compromising the patients respiratory status.  Maintain patient in semirecumbent position (head of bed elevated 30 to 45 degrees), not flat. This is extremely important to promote lung expansion, reduce gastric reflux, and prevent ventilator-associated pneumonia (VAP), if the person is being mechanically ventilated. 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. Encourage the patient to move the arm on the affected side; if he cannot, perform passive range-of-motion. You should check the ventilator tubing frequently for condensation, and 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: p. 1353

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

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 confident that 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.

ANS: 1, 3, 4

People who are trying to quit smoking often are more successful when they are accountable to other people who are encouraging and supportive. Having something to chew (e.g., carrot sticks, gum, nuts, or seeds) can distract from the desire to smoke 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:1DIF:ModerateREF:p. 1311, ESG Self-Care: Smoking Cessation Tips

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

____ 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

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:1DIFifficult

REF: p. 1300; higher-order item, some of answer implied in text

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

____ 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 do not walk while the drainage system is in place.

3)

Get out of bed without assistance as much as possible.

4)

Immediately notify the nurse if she experiences increased shortness of breath.

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:1DIF:ModerateREF:pp. 1313, 1358

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

____ 4. 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

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 and airway obstruction. 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:1DIF:ModerateREF:p. 1297

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

____ 5. 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

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: p. 1299

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

____ 6. Which of the following is/are accurate about nasotracheal suctioning? Choose all that apply.

1)

Apply suction for no longer than 10-15 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.

ANS: 1, 4

Limiting suctioning to 10 seconds 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: p. 1347

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

____ 7. 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

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:1DIF:EasyREF:p. 1305

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

____ 8. 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.

ANS: 3, 4

Pain alters the rate and depth of respirations. Often, patients in pain breathe shallowly, which puts them 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. This will help to open air sacs and mobilize secretions in the airways.

PTS: 1 DIF: Moderate REF: pp. 1303, 1313 ; critical-thinking item that requires synthesis of information

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

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.

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 exchangethat 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:1DIF:EasyREF:p. 1295

KEY: Nursing process: N/A | Client need: HPM | Cognitive level: Comprehension

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

ANS: surfactant

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

PTS:1DIF:ModerateREF:p. 1314

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

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.

ANS: tidal volume; 500

PTS:1DIF:EasyREF:p. 1306

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

True or False

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

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:1DIF:EasyREF:p. 1305

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

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