Chapter 38 Oxygenation and Tissue Perfusion

Question 1

The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which oxygen delivery device will the nurse use for this patient?
a. Non-rebreather mask
b. Bag-valve-mask unit
c. Continuous positive airway pressure (CPAP)
d. High-flow nasal cannula

Answer 1

B. BVM - used in emergencies!

Question 2

The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient is breathing spontaneously but is minimally responsive and having difficulty maintaining a patent airway. Which intervention is the most appropriate for the patient to improve oxygenation?
a. Insert an oral airway.
b. Lower the head of the bed.
c. Turn the patient’s head to the side.
d. Monitor the patient’s pulse oximetry.

Answer 2

a. insert an oral airway
- prevents Pt’s tongue from falling back and occluding airway.

Question 3

The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient’s pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of the nurse?
a. Administer the ordered intravenous diuretic.
b. Prepare for insertion of a chest tube.
c. Suction secretions from the patient’s respiratory tract.
d. Have the patient use the ordered incentive spirometer.

Answer 3

a. administer the ordered intravenous diuretic

Question 4

The nurse is caring for a patient who has been intubated with an oral endotracheal tube for several weeks. The physicians predict that the patient will need to remain on a ventilator for at least several more weeks before he will be able to maintain his airway and breathe on his own. What procedure does the nurse anticipate will be planned for the patient to facilitate recovery?
a. Placement of a tracheostomy tube
b. Diagnostic thoracentesis
c. Pulmonary angiogram
d. Lung transplantation surgery

Answer 4

a. placement of a tracheostomy tube
- will secure Pt’s airway directly through trachea, eliminating need for endotracheal tube.

Question 5

The nurse is caring for a patient with a chest tube who was transported to radiology for testing. When the patient returns to the nursing unit, the transporter shows the nurse the patient’s chest tube collection device, which was badly damaged after being caught in the elevator door. What is the priority action of the nurse?
a. Clamp the chest tube until the collection device is replaced.
b. Cover the insertion site with a new occlusive dressing.
c. Ensure that there is gentle bubbling in the water seal chamber.
d. Check the patient’s lung sounds and pulse oximetry.

Answer 5

a. clamp the chest tube until the collection device is replaced
- broken collection device may no longer be used to collect chest tube drainage. clamping chest tube until collection decive is replaced will prevent air from entering lung space until new collection device is attached

Question 6

The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has the highest priority?
a. Activity intolerance r/t generalized weakness and hypoxemia
b. Impaired nutritional intake r/t poor appetite and increased metabolic needs
c. Impaired airway clearance r/t thick secretions in trachea and bronchi
d. Lack of knowledge r/t use of nebulizer and inhaled bronchodilators

Answer 6

c. impaired airway clearance r/t thick secretions in trachea and bronchi

Question 7

The nurse is caring for a patient who developed a pulmonary embolism after surgery. Which goal statement is the highest priority for the nurse to include in the patient’s care plan for the diagnosis impaired gas exchange r/t impaired pulmonary blood flow from embolus?
a. The patient will maintain pulse oximetry values of at least 95% on room air.
b. The patient will verbalize understanding of ordered anticoagulants.
c. The patient will report chest pain of no greater than 3 on a 1 to 10 scale.
d. The patient will ambulate 50 feet in hallway without shortness of breath.

Answer 7

a. Pt will maintain pule oximetry values of at least 95% on room air

Question 8

The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented. What is the priority action of the nurse?
a. Obtain an arterial blood gas to check for carbon dioxide retention.
b. Increase the patient’s oxygen until the pulse oximetry is greater than 98%.
c. Lower the head of the patient’s bed and insert a nasal airway.
d. Administer a mild sedative and reorient the patient as needed

Answer 8

a. Obtain an arterial blood gas to check for carbon dioxide retention.

Question 9

The nurse is caring for a patient who has been prescribed warfarin (Coumadin) therapy after being diagnosed with atrial fibrillation. The patient asks the nurse what could happen if the prescription doesn’t get filled. What is the nurse’s best response?
a. “You could have a stroke.”
b. “Your kidneys could fail.”
c. “You could develop heart failure.”
d. “You could go into respiratory failure.”

Answer 9

a. “You could have a stroke.”

Question 10

The preceptor is working with a new nurse to provide care for a patient with a chest tube to relieve a pneumothorax. Which action by the new nurse indicates need for additional teaching about chest tube care?
a. The suction is discontinued when the patient is ambulated to the bathroom.
b. The collection device is emptied at the end of the shift and output recorded in the
chart.
c. The patient’s bed is placed in the semi-Fowler’s position to facilitate lung
reexpansion.
d. The patient is encouraged to use his incentive spirometer at least 10 times every
hour.

Answer 10

b. The collection device is emptied at the end of the shift and output recorded in the
chart.

Question 11

The nurse is caring for a postoperative patient who has just been diagnosed with a deep vein thrombosis (DVT) in the right leg. Which focused assessment question has the highest priority for this patient?
a. “Do you have a headache or any dizziness?”
b. “Do you have any chest pain or shortness of breath?”
c. “When did you first notice the swelling and redness in your leg?”
d. “Do you have any cramping or muscle spasms in your leg?”

Answer 11

b. “Do you have any chest pain or shortness of breath?”

Question 12

The nurse identifies which patient who would benefit from postural drainage?
a. A patient with a heart murmur and jugular venous distention.
b. A patient with asthma and audible wheezing.
c. A patient with right-sided heart failure and pitting edema.
d. A patient with chronic bronchitis and congested cough.

Answer 12

d. A patient with chronic bronchitis and congested cough.

Question 13

The nurse is caring for a patient who has a history of congestive heart failure with generalized pitting edema. Which laboratory results will the nurse expect to find in the patient’s chart?
a. Glycosylated hemoglobin 12%
b. Platelet count 450,000/mm3
c. Hematocrit 32%
d. Prothrombin time 8.8 seconds

Answer 13

c. Hematocrit 32%

Question 14

The nurse is caring for a patient with high cholesterol who has been prescribed atorvastatin (Lipitor). Which laboratory result indicates that the patient has been taking the medication as ordered and following the physician’s dietary recommendations?
a. Serum triglyceride level 325 mg/dL
b. High-density lipoproteins (HDL) 56 mg/dL
c. Low-density lipoproteins (LDL) 155 mg/dL
d. Total cholesterol level 185 mg/dL

Answer 14

d. Total cholesterol level 185 mg/dL

Question 15

The nurse is caring for a patient who has presented to the ER with chest pain. Which diagnostic test will best indicate if there is significant blockage of important blood vessels that provide oxygen to the heart muscle?
a. Cardiac catheterization
b. Chest x-ray
c. Echocardiogram
d. Electrocardiogram

Answer 15

a. Cardiac catheterization

Question 16

The nurse hears a loud murmur when listening to the patient’s heart. Which diagnostic test will best display the condition of the valves and structures within the patient’s heart that could be causing the murmur?
a. Chest x-ray
b. Cardiac catheterization
c. Echocardiogram
d. Electrocardiogram

Answer 16

c. Echocardiogram

Question 17

The nurse is caring for a patient who will be returning to the nursing unit following a cardiac catheterization via the right femoral artery. Which assessment is the highest priority for the nurse to perform when the patient arrives on the unit?
a. Checking the patient’s right pedal pulse and warmth of the right leg
b. Checking pulse oximetry and listening to the patient’s lung sounds
c. Checking bilateral radial pulses to check for a pulse deficit
d. Estimating the patient’s jugular venous pressure

Answer 17

a. Checking the patient’s right pedal pulse and warmth of the right leg

Question 18

The home care nurse is caring for a patient who has severe COPD and home oxygen therapy. The patient tells the nurse that she feels much better after increasing the oxygen flowmeter from 2 L to 5 L/min. The patient’s pulse oximetry is 98%. What is the priority action of the nurse?
a. Reduce the oxygen flow rate until the patient’s pulse oximetry value is more than
88%.
b. Inform the patient’s physician and obtain an order for oxygen at 5 L/min.
c. Document the intervention and findings in the patient’s medical record.
d. Listen to the patient’s lung fields and reinforce pursed-lip breathing techniques.

Answer 18

a. Reduce the oxygen flow rate until the patient’s pulse oximetry value is more than

Question 19

The nurse is caring for a patient with advanced COPD who reports feeling short of breath. The nurse notes that the patient’s lung sounds are diminished bilaterally and the patient’s pulse oximetry is 91% on 2 L/min oxygen via nasal cannula. What actions will the nurse take to make the patient more comfortable? (Select all that apply.)
a. Increase the patient’s oxygen to 4 L/min via nasal cannula.
b. Suction the patient’s airway using sterile technique.
c. Maintain eye contact and provide calm reassurance.
d. Turn the patient onto the side for postural drainage.
e. Administer the ordered nebulized bronchodilator.
f. Elevate the head of the patient’s bed to fully upright.

Answer 19

c. Maintain eye contact and provide calm reassurance.
e. Administer the ordered nebulized bronchodilator.
f. Elevate the head of the patient’s bed to fully upright.

Question 20

The nurse is performing a respiratory assessment on a patient. Which assessment findings indicate to the nurse that the patient has a history of long-standing chronic respiratory disease? (Select all that apply.)
a. All the patient’s fingernails are noticeably clubbed.
b. The patient needs to sleep on at least four to five pillows at night.
c. The patient’s chest has equal antero-posterior and transverse diameters.
d. The patient’s lower legs have large areas of brownish spotted discoloration.
e. The patient reports puffiness of both feet when standing for long periods.
f. The patient’s forced vital capacity test result is 3.8 L of air.

Answer 20

a. All the patient’s fingernails are noticeably clubbed.
b. The patient needs to sleep on at least four to five pillows at night.
c. The patient’s chest has equal antero-posterior and transverse diameters.

Question 21

The nurse notes the following findings when assessing a patient with COPD. Which require prompt nursing intervention? (Select all that apply.)
a. The patient is unable to speak without gasping.
b. The patient’s sputum has turned from yellow to greenish-brown.
c. The patient has dyspnea and wheezes heard in all lung fields.
d. The patient’s forced vital capacity has increased from 2.8 to 3.4 L.
e. The patient has become confused and mildly disoriented.

Answer 21

a. The patient is unable to speak without gasping.
b. The patient’s sputum has turned from yellow to greenish-brown.
c. The patient has dyspnea and wheezes heard in all lung fields.
e. The patient has become confused and mildly disoriented.

Question 22

The nurse is working with a nursing assistant to care for a patient with a new tracheostomy. Which tasks may the nurse delegate to the assistant? (Select all that apply.)
a. Obtaining masks, gloves, and suction supplies from the utility room
b. Helping to reassure the patient before, during, and after suctioning
c. Changing the Velcro or twill ties used to secure the tracheostomy
d. Transporting sputum specimens to the lab for culture and sensitivity testing
e. Assessing need for suctioning of the oropharynx or tracheostomy
f. Teaching the patient how to remove and clean the inner cannula

Answer 22

a. Obtaining masks, gloves, and suction supplies from the utility room
b. Helping to reassure the patient before, during, and after suctioning
d. Transporting sputum specimens to the lab for culture and sensitivity testing

Question 23

The preceptor is working with a new nurse to provide care for a patient with a new tracheostomy. Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.)
a. The outer cannula is cleaned with the brush and half-strength H2O2.
b. The new tracheostomy holder is secured before the old soiled one is removed.
c. A Yankauer suction catheter is used to remove secretions from the patient’s mouth.
d. Sterile gloves are applied before the soiled dressing is removed from the tracheostomy.
e. Half-strength H2O2 is used to remove crusted secretions around the tracheostomy site.
f. Pain medication is administered to the patient prior to suctioning.

Answer 23

a. The outer cannula is cleaned with the brush and half-strength H2O2.
d. Sterile gloves are applied before the soiled dressing is removed from the tracheostomy.
e. Half-strength H2O2 is used to remove crusted secretions around the tracheostomy site.

Question 24

The preceptor is working with a new nurse to suction a patient through a new tracheostomy. Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.)
a. The suction is not applied to the catheter until it is being withdrawn.
b. The patient is placed in the supine position prior to suctioning.
c. The suction catheter is twirled side to side as it is being withdrawn.
d. Suction is applied continuously as the catheter is withdrawn.
e. The patient’s oxygen is reapplied between suction attempts.
f. Water-soluble lubricant is applied to the suction catheter before insertion.

Answer 24

b. The patient is placed in the supine position prior to suctioning.
d. Suction is applied continuously as the catheter is withdrawn.
f. Water-soluble lubricant is applied to the suction catheter before insertion.