Oxygenation Flashcards
A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority?
a. Pulse
b. Respirations
c. Temperature
d. Blood pressure
ANS: B
Respirations and oxygen saturation are the priorities. Cervical trauma at C3 to C5 usually results in paralysis of the phrenic nerve. When the phrenic nerve is damaged, the diaphragm does not descend properly, thus reducing inspiratory lung volumes and causing hypoxemia. While pulse and blood pressure are important, respirations are the priority. Temperature is not a high priority in this situation.
The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires?
a. Stimulation of chemical receptors in the aorta
b. Reduction of arterial oxygen saturation levels
c. Requirement of elastic recoil lung properties
d. Enhancement of accessory muscle usage
ANS: A
Inspiration is an active process, stimulated by chemical receptors in the aorta. Reduced arterial oxygen saturation levels indicate hypoxemia, an abnormal finding. Expiration is a passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work. Prolonged use of the accessory muscles does not promote effective ventilation and causes fatigue.
The home health nurse recommends that a patient with respiratory problems install a carbon monoxide detector in the home. What is the rationale for the nurse’s action?
a. Carbon monoxide detectors are required by law in the home.
b. Carbon monoxide tightly binds to hemoglobin, causing hypoxia.
c. Carbon monoxide signals the cerebral cortex to cease ventilations.
d. Carbon monoxide combines with oxygen in the body and produces a deadly toxin.
ANS: B
Carbon monoxide binds tightly to hemoglobin; therefore, oxygen is not able to bind to hemoglobin and be transported to tissues, causing hypoxia. A carbon monoxide detector is not required by law, does not signal the cerebral cortex to cease ventilations, and does not combine with oxygen but with hemoglobin to produce a toxin.
. While performing an assessment, the nurse hears crackles in the patient’s lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient’s medical record?
a. Atrial fibrillation
b. Myocardial ischemia
c. Left-sided heart failure
d. Right-sided heart failure
ANS: C
Left-sided heart failure results in pulmonary congestion, the signs and symptoms of which include shortness of breath, cough, crackles, and paroxysmal nocturnal dyspnea (difficulty breathing when lying flat). Right-sided heart failure is systemic and results in peripheral edema, weight gain, and distended neck veins. Atrial fibrillation is often described as an irregularly irregular rhythm; rhythm is irregular because of the multiple pacemaker sites. Myocardial ischemia results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet myocardial oxygen demands, producing angina or myocardial infarction.
The nurse suspects the patient has increased afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition?
a. Pulse oximeter
b. Oxygen cannula
c. Blood pressure cuff
d. Yankauer suction tip catheter
ANS: C
A blood pressure cuff is needed. The diastolic aortic pressure is a good clinical measure of afterload. Afterload is the resistance to left ventricular ejection. In hypertension the afterload increases, making cardiac workload also increase. A pulse oximeter is used to monitor the level of arterial oxygen saturation; it will not help determine increased afterload. While an oxygen cannula may be needed to help decrease the effects of increased afterload, it will not help determine the presence of afterload. A Yankauer suction tip catheter is used to suction the oral cavity.
The nurse is careful to monitor a patient’s cardiac output. Which goal is the nurse trying to achieve?
a. To determine peripheral extremity circulation
b. To determine oxygenation requirements
c. To determine cardiac dysrhythmias
d. To determine ventilation status
ANS: A
Cardiac output indicates how much blood is being circulated systemically throughout the body to the periphery. The amount of blood ejected from the left ventricle each minute is the cardiac output. Oxygen status would be determined by pulse oximetry and the presence of cyanosis. Cardiac dysrhythmias are an electrical impulse monitored through ECG results. Ventilation status is measured by respiratory rate, pulse oximetry, and capnography. Capnography provides instant information about the patient’s ventilation. Ventilation status does not depend solely on cardiac output.
A nurse is caring for a group of patients. Which patient should the nurse see first?
a. A patient with hypercapnia wearing an oxygen mask
b. A patient with a chest tube ambulating with the chest tube unclamped
c. A patient with thick secretions being tracheal suctioned first and then orally
d. A patient with a new tracheostomy and tracheostomy obturator at bedside
ANS: A
The mask is contraindicated for patients with carbon dioxide retention (hypercapnia) because retention can be worsened; the nurse must see this patient first to correct the problem. All the rest are using correct procedures and do not need to be seen first. A chest tube should not be clamped when ambulating. Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a tension pneumothorax. Use nasotracheal suctioning before pharyngeal suctioning whenever possible. The mouth and pharynx contain more bacteria than the trachea. Keep tracheostomy obturator at bedside with a fresh (new) tracheostomy to facilitate reinsertion of the outer cannula if dislodged.
. A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer?
a. Diuretics
b. Vasodilators
c. Chest physiotherapy
d. Intravenous (IV) fluids
ANS: D
Preload is affected by the circulating volume; if the patient has decreased fluid volume, it will need to be replaced with fluid or blood therapy. Preload is the amount of blood in the left ventricle at the end of diastole, often referred to as end-diastolic volume. Giving diuretics and vasodilators will make the situation worse. Diuretics causes fluid loss; the patient is already low on fluids or the preload would not be decreased. Vasodilators reduced blood return to the heart, making the situation worse; the patient does not have enough blood and fluid to the heart or the preload would not be decreased. Chest physiotherapy is a group of therapies for mobilizing pulmonary secretions. Chest physiotherapy will not help this cardiovascular problem.
A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning?
a. Pulse 75
b. Pulse 80
c. Oxygen saturation 91%
d. Oxygen saturation 88%
ANS: D
Stop when oxygen saturation is 88%. Monitor patient’s vital signs and oxygen saturation during procedure; note whether there is a change of 20 beats/min (either increase or decrease) or if pulse oximetry falls below 90% or 5% from baseline. If this occurs, stop suctioning. A pulse rate of 75 is only 10 beats different from the start of the procedure. A pulse rate of 80 is 15 beats different from the start of suctioning. Oxygen saturation of 91% is not 5% from baseline or below 90%.
The patient has right-sided heart failure. Which finding will the nurse expect when performing an assessment?
a. Peripheral edema
b. Basilar crackles
c. Chest pain
d. Cyanosis
ANS: A
Right-sided heart failure results from inability of the right side of the heart to pump effectively, leading to a systemic backup. Peripheral edema, distended neck veins, and weight gain are signs of right-sided failure. Basilar crackles can indicate pulmonary congestion from left-sided heart failure. Cyanosis and chest pain result from inadequate tissue perfusion.
A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis?
a. “Atelectasis affects only those with chronic conditions such as emphysema.”
b. “It is important to do breathing exercises every hour to prevent atelectasis.”
c. “If I develop atelectasis, I will need a chest tube to drain excess fluid.”
d. “Hyperventilation will open up my alveoli, preventing atelectasis.”
ANS: B
Atelectasis develops when alveoli do not expand. Breathing exercises, especially deep breathing and incentive spirometry, increase lung volume and open the airways, preventing atelectasis. Deep breathing also opens the pores of Kohn between alveoli to allow sharing of oxygen between alveoli. Atelectasis can affect anyone who does not deep breathe. A chest tube is for pneumothorax or hemothorax. It is deep breathing, not hyperventilation, that prevents atelectasis.
The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia?
a. Elevated blood pressure
b. Increased pulse rate
c. Restlessness
d. Cyanosis
ANS: D
Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. Elevated blood pressure, increased pulse rate, and restlessness are early signs of hypoxia.
A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation?
a. Anxiety over illness
b. Decreased drive to breathe
c. Increased metabolic demands
d. Infection destroying lung tissues
ANS: C
Increased body temperature (fever) increases the metabolic rate, thereby increasing carbon dioxide production. The increased carbon dioxide level stimulates an increase in the patient’s rate and depth of respiration, causing hyperventilation. Anxiety can cause hyperventilation, but this is not the direct cause from a fever. Sleep causes a decreased respiratory drive; hyperventilation speeds up breathing. The cause of the fever in this question is unknown.
A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step?
- Insert catheter.
- Apply suction and remove.
- Have patient deep breathe.
- Encourage patient to cough.
- Attach catheter to suction system.
- Rinse catheter and connecting tubing.
a. 1, 2, 3, 4, 5, 6
b. 4, 5, 1, 2, 3, 6
c. 5, 3, 1, 2, 4, 6
d. 3, 1, 2, 5, 4, 6
ANS: C
The steps for nasotracheal suctioning are as follows: Verify that catheter is attached to suction; have patient deep breathe; insert catheter; apply intermittent suction for no more than 10 seconds and remove; encourage patient to cough; and rinse catheter and connecting tubing with normal saline.
. A patient has carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient?
a. Low-carbohydrate
b. Low-caffeine
c. High-caffeine
d. High-carbohydrate
ANS: A
A low-carbohydrate diet is best. Diets high in carbohydrates play a role in increasing the carbon dioxide load for patients with carbon dioxide retention. As carbohydrates are metabolized, an increased load of carbon dioxide is created and excreted via the lungs. A low- or high-caffeine diet is not as important as the carbohydrate load.
ANS: A
A low-carbohydrate diet is best. Diets high in carbohydrates play a role in increasing the carbon dioxide load for patients with carbon dioxide retention. As carbohydrates are metabolized, an increased load of carbon dioxide is created and excreted via the lungs. A low- or high-caffeine diet is not as important as the carbohydrate load.
ANS: A
A 2000-calorie diet of fruits, vegetables, and low-fat dairy foods that are high in fiber, potassium, calcium, and magnesium and low in saturated and total fat helps prevent and reduce the effects of hypertension. Nonfat yogurt with granola is a good source of calcium, fiber, and potassium; dried apricots add a second source of potassium. Although cereal and a banana provide fiber and potassium, skim milk should be substituted for whole milk to decrease fat. An omelet with sausage and cheese is high in fat. Butter and bacon are high in fat.
A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen?
a. Nasal cannula
b. Simple face mask
c. Non-rebreather mask
d. Partial non-rebreather mask
ANS: A
Nasal cannulas deliver oxygen from 1 to 6 L/min. All other devices (simple face mask, non-rebreather mask, and partial non-rebreather mask) are intended for flow rates greater than 6 L/min.
The nurse needs to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change?
a. Thinner heart valves cause lipid accumulation and fibrosis.
b. Diminished respiratory muscle strength may cause poor chest expansion.
c. Alterations in mental status prevent patients’ awareness of ineffective breathing.
d. An increased number of pacemaker cells make proper anesthesia induction more difficult.
ANS: B
Age-related changes in the thorax that occur from ossification of costal cartilage, decreased space between vertebrae, and diminished respiratory muscle strength lead to problems with chest expansion and oxygenation,whereby the patient will have difficulty excreting anesthesia gas. The nurse needs to monitor the patient’s oxygen status carefully to make sure the patient does not retain too much of the drug. Older adults experience alterations in cardiac function as a result of calcification of the conduction pathways, thicker and stiffer heart valves caused by lipid accumulation and fibrosis, and a decrease in the number of pacemaker cells in the SA node. Altered mental status is not a normal age-related change; it indicates possible cardiac and/or respiratory problems.
ANS: B
Age-related changes in the thorax that occur from ossification of costal cartilage, decreased space between vertebrae, and diminished respiratory muscle strength lead to problems with chest expansion and oxygenation,whereby the patient will have difficulty excreting anesthesia gas. The nurse needs to monitor the patient’s oxygen status carefully to make sure the patient does not retain too much of the drug. Older adults experience alterations in cardiac function as a result of calcification of the conduction pathways, thicker and stiffer heart valves caused by lipid accumulation and fibrosis, and a decrease in the number of pacemaker cells in the SA node. Altered mental status is not a normal age-related change; it indicates possible cardiac and/or respiratory problems.
ANS: B
A nursing care plan for preventative health measures should be reasonable and feasible. Keeping up-to-date on vaccinations is important because vaccine reduces the severity of illnesses and serious complications. Determine if and when the patient has had a pneumococcal or influenza (flu) vaccine. This is especially important when assessing older adults because of their increased risk for respiratory disease. Although it is important to finish the full course of antibiotics, it is not a preventative health measure. Scheduling annual tuberculosis skin tests does not address prevention and is an unreliable indictor of tuberculosis in older patients. The exercise routine should be reasonable to increase compliance; exercise is recommended only 3 to 4 times a week for 30 to 60 minutes, and walking, rather than running, is an efficient method.
. The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most likely expect?
a. Increased preload
b. Increased heart rate
c. Decreased afterload
d. Decreased tissue perfusion
ANS: A
Preload refers to the amount of blood in the left ventricle at the end of diastole; an increase in circulating volume would increase the preload of the heart. Afterload refers to resistance; increased pressure would lead to increased resistance, and afterload would increase. A decrease in tissue perfusion would be seen with hypovolemia. A decrease in fluid volume would cause an increase in heart rate as the body is attempting to increase cardiac output.
A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately?
a. Ventricular tachycardia
b. Atrial fibrillation
c. Sinus rhythm
d. Paroxysmal supraventricular tachycardia
ANS: A
Ventricular tachycardia and ventricular fibrillation are life-threatening rhythms that require immediate intervention. Ventricular tachycardia is a life-threatening dysrhythmia because of the decreased cardiac output and the potential to deteriorate into ventricular fibrillation or sudden cardiac death. Atrial fibrillation is a common dysrhythmia in older adults and is not as serious as ventricular tachycardia. Sinus rhythm is normal. Paroxysmal supraventricular tachycardia is a sudden, rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously.
The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination?
a. Experiences chest pain after eating a heavy meal
b. Experiences adequate oxygen saturation during exercise
c. Experiences crushing chest pain for more than 20 minutes
d. Experiences tingling in the left arm that lasts throughout the morning
ANS: A
Angina pectoris is chest pain that results from limited oxygen supply. Often pain is precipitated by activities such as exercise, stress, and eating a heavy meal and lasts 3 to 5 minutes. Symptoms of angina pectoris are relieved by rest and/or nitroglycerin. Adequate oxygen saturation occurs with rest; inadequate oxygen saturation occurs during exercise. Pain lasting longer than 20 minutes or arm tingling that persists could be a sign of myocardial infarction.
Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient?
a. Discontinue the humidification delivery device to keep excess fluid from lungs.
b. Monitor oxygen saturation, and frequently auscultate lung bases.
c. Assist the patient to cough, turn, and deep breathe every 2 hours.
d. Decrease fluid intake to 300 mL a shift.
ANS: C
The goal of the nursing action should be the prevention of pneumonia; the action that best addresses this is to cough, turn, and deep breathe to keep secretions from pooling at the base of the lungs. Humidification thins respiratory secretions, making them easier to expel and should be used. Monitoring oxygen status is important but is not a method of prevention. Hydration assists in preventing hospital-acquired pneumonia. The best way to maintain thin secretions is to provide a fluid intake of 1500 to 2500 mL/day unless contraindicated by cardiac or renal status. Restricting fluids is contraindicated in this situation since there is no data indicating cardiac or renal disease.
The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider?
a. Increased anterior-posterior diameter of the chest
b. Accessory muscle used for breathing
c. Clubbing of the fingers
d. Hemoptysis
ANS: D
Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies are needed to determine the cause of blood in the sputum. Clubbing of the fingers, barrel chest (increased anterior-posterior chest diameter), and accessory muscle use are all normal findings in a patient with emphysema.