Oxygenation - Chapter 41 Streamlined

Question 1

A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli’s function will the nurse share with the patient?

a. Carries out gas exchange
b. Regulates tidal volume
c. Produces hemoglobin
d. Stores oxygen

Answer 1

a. Carries out gas exchange

Rationale:

The alveolus is a capillary membrane that allows gas exchange of oxygen and carbon dioxide during respiration. The alveoli do not store oxygen, regulate tidal volume, or produce hemoglobin.

Question 2

The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process?

a. Ventilation
b. Surfactant
c. Perfusion
d. Diffusion

Answer 2

d. Diffusion

Rationale:

Diffusion is the process of gases exchanging across the alveoli and capillaries of body tissues.Ventilation is the process of moving gases into and out of the lungs. Surfactant is a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing. Perfusion is the ability of the cardiovascular system to carry oxygenated blood to tissues and return deoxygenated blood to the heart.

Question 3

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

Answer 3

b. Respirations

Rationale:

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.

Question 4

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.

Answer 4

b. Carbon monoxide tightly binds to hemoglobin, causing hypoxia.

Rationale:

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.

Question 5

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

Answer 5

a. A patient with hypercapnia wearing an oxygen mask

Rationale:

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.

Question 6

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

Answer 6

d. Intravenous (IV) fluids

Rationale:

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.

Question 7

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%

Answer 7

d. Oxygen saturation 88%

Rationale:

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%.

Question 8

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.”

Answer 8

b. “It is important to do breathing exercises every hour to prevent atelectasis.”

Rationale:

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.

Question 9

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

Answer 9

d. Cyanosis

Rationale:

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.

Question 10

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

Answer 10

c. Increased metabolic demands

Rationale:

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.

Question 11

A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step?

1. Insert catheter.
2. Apply suction and remove.
3. Have patient deep breathe.
4. Encourage patient to cough.
5. Attach catheter to suction system.
6. 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

Answer 11

c. 5, 3, 1, 2, 4, 6

Rationale:

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.

Question 12

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

Answer 12

a. Low-carbohydrate

Rationale:

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.

Question 13

A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest?

a. A cup of nonfat yogurt with granola and a handful of dried apricots
b. Whole wheat toast with butter and a side of bacon
c. A bowl of cereal with whole milk and a banana
d. Omelet with sausage, cheese, and onions

Answer 13

a. A cup of nonfat yogurt with granola and a handful of dried apricots

Rationale:

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.

Question 14

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.

Answer 14

b. Diminished respiratory muscle strength may cause poor chest expansion.

Rationale:

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.

Question 15

The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient?

a. Inform the patient of the importance of finishing the entire dose of antibiotics.
b. Encourage the patient to stay up-to-date on all vaccinations.
c. Schedule patient to get annual tuberculosis skin testing.
d. Create an exercise routine to run 45 minutes every day.

Answer 15

b. Encourage the patient to stay up-to-date on all vaccinations.

Rationale:

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.

Question 16

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

Answer 16

a. Increased preload

Rationale:

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.

Question 17

The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal the patient could achieve?

a. Sleeping on two to three pillows at night
b. Limiting the diet to 1500 calories a day
c. Running 30 minutes every morning
d. Stopping smoking immediately

Answer 17

a. Sleeping on two to three pillows at night

Rationale:

To achieve a short-term goal, the nurse should plan a lifestyle change that the patient can make immediately that will have a quick effect. Sleeping on several pillows at night will immediately relieve orthopnea and open the patient’s airway, thereby reducing fatigue. Running 30 minutes a day will improve cardiopulmonary health, but a patient needs to build up exercise tolerance. Smoking cessation is another process that many people have difficulty doing immediately. A more realistic short-term goal would be to gradually reduce the number of cigarettes smoked. Limiting caloric intake can help a patient lose weight, but this is a gradual process and is not reasonable for a short-term goal.

Question 18

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.

Answer 18

c. Assist the patient to cough, turn, and deep breathe every 2 hours.

Rationale:

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.

Question 19

A patient with a pneumothorax has a chest tube inserted and is placed on low constant suction. Which finding requires immediate action by the nurse?

a. The patient reports pain at the chest tube insertion site that increases with movement.
b. Fifty milliliters of blood gushes into the drainage device after the patient coughs.
c. No bubbling is present in the suction control chamber of the drainage device.
d. Yellow purulent discharge is seen leaking out from around the dressing site.

Answer 19

c. No bubbling is present in the suction control chamber of the drainage device.

Rationale:

No bubbling in the suction control chamber indicates an obstruction of the drainage system. An obstruction causes increased pressure, which can cause a tension pneumothorax, which can be life threatening. The nurse needs to determine whether the leak is inside the thorax or in the tubing and act from there. Occasional blood gushes from the lung owing to lung expansion, as during a cough; this is reserve drainage. Drainage over 100 mL/hr after 3 hours of chest tube placement is cause for concern. Yellow purulent drainage indicates an infection that should be reported to the health care provider but is not as immediately life threatening as the lack of bubbling in the suction control chamber.

Question 20

The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance?

a. Suctioning respiratory secretions several times every hour
b. Administering humidified oxygen through a tracheostomy collar
c. Instilling normal saline into the tracheostomy to thin secretions before suctioning
d. Deflating the tracheostomy cuff before allowing the patient to cough up secretions

Answer 20

b. Administering humidified oxygen through a tracheostomy collar

Rationale:

Humidification from air humidifiers or humidified oxygen tracheostomy collars can help prevent drying of secretions that cause occlusion. Suctioning should be done only as needed; too frequent suctioning can damage the mucosal lining, resulting in thicker secretions. Normal saline should not be instilled into a tracheostomy; research showed no benefit with this technique. The purpose of the tracheostomy cuff is to keep secretions from entering the lungs; the nurse should not deflate the tracheostomy cuff unless instructed to do so by the health care provider.

Question 21

The nurse is educating a student nurse on caring for a patient with a chest tube. Which statement from the student nurse indicates successful learning?

a. “I should clamp the chest tube when giving the patient a bed bath.”
b. “I should report if I see continuous bubbling in the water-seal chamber.”
c. “I should strip the drains on the chest tube every hour to promote drainage.”
d. “I should notify the health care provider first, if the chest tube becomes dislodged.”

Answer 21

b. “I should report if I see continuous bubbling in the water-seal chamber.”

Rationale:

Correct care of a chest tube involves knowing normal and abnormal functioning of the tube. A constant or intermittent bubbling in the water-seal chamber indicates a leak in the drainage system, and the health care provider must be notified immediately. Stripping the tube is not routinely performed as it increases pressure. If the tubing disconnects from the drainage unit, instruct the patient to exhale as much as possible and to cough. This maneuver rids the pleural space of as much air as possible. Temporarily reestablish a water seal by immersing the open end of the chest tube into a container of sterile water. The chest tube should not be clamped unless necessary; if so, the length of time clamped would be minimal to reduce the risk of pneumothorax.

Question 22

Which coughing technique will the nurse use to help a patient clear central airways?

a. Huff
b. Quad
c. Cascade
d. Incentive spirometry

Answer 22

a. Huff

Rationale:

The huff cough stimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the word huff. The quad cough technique is for patients without abdominal muscle control such as those with spinal cord injuries. While the patient breathes out with a maximal expiratory effort, the patient or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough. With the cascade cough the patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then he or she opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in patients with large volumes of sputum. Incentive spirometry encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It promotes deep breathing and prevents or treats atelectasis in the postoperative patient.

Question 23

The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take?

a. Set suction regulator at 150 to 200 mm Hg.
b. Limit the length of suctioning to 10 seconds.
c. Apply suction while gently rotating and inserting the catheter.
d. Liberally lubricate the end of the suction catheter with a water-soluble solution.

Answer 23

b. Limit the length of suctioning to 10 seconds.

Rationale:

Suctioning passes should be limited to 10 seconds to avoid hypoxemia. Suction for a tracheostomy should be set at 100 to 150 mm Hg. Excessive lubrication can clog the catheter or occlude the airway; lubricant is not necessary for oropharyngeal or artificial airway (tracheostomy) suctioning. Suction should never be applied on insertion.

Question 24

The nurse is caring for a patient who needs oxygen via a nasal cannula. Which task can the nurse delegate to the nursing assistive personnel?

a. Applying the nasal cannula
b. Adjusting the oxygen flow
c. Assessing lung sounds
d. Setting up the oxygen

Answer 24

a. Applying the nasal cannula

Rationale:

The skill of applying (not adjusting oxygen flow) a nasal cannula or oxygen mask can be delegated to nursing assistive personnel (NAP). The nurse is responsible for assessing the patient’s respiratory system, response to oxygen therapy, and setup of oxygen therapy, including adjustment of oxygen flow rate.

Question 25

The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method?

a. A 5-year-old with excessive drooling from epiglottitis
b. A 5-year-old with an asthma attack following severe allergies
c. A 24-year-old with a right pneumothorax following a motor vehicle accident
d. A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation

Answer 25

d. A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation

Rationale:

Closed suctioning is most often used on patients who require invasive mechanical ventilation to support their respiratory efforts because it permits continuous delivery of oxygen while suction is performed and reduces the risk of oxygen desaturation. In this case, the acute respiratory distress syndrome requires mechanical ventilation. In the presence of epiglottitis, croup, laryngospasm, or irritable airway, the entrance of a suction catheter via the nasal route causes intractable coughing, hypoxemia, and severe bronchospasm, necessitating emergency intubation or tracheostomy. The 5-year-old child with asthma would benefit from an inhaler. A chest tube is needed for the pneumothorax.

Question 26

While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first?

a. Press the emergency response button.
b. Insert a spare tracheostomy with the obturator.
c. Manually occlude the tracheostomy with sterile gauze.
d. Place a face mask delivering 100% oxygen over the nose and mouth.

Answer 26

b. Insert a spare tracheostomy with the obturator.

Rationale:

The nurse’s first priority is to establish a stable airway by inserting a spare trach into the patient’s airway; ideally an obturator should be used. The nurse could activate the emergency response team if the patient is still unstable after the tracheostomy is placed. A patient with a tracheostomy breathes through the tube, not the nose or mouth; a face mask would not be an effective method of getting air into the lungs. Manually occluding pressure over the tracheostomy site is not appropriate and would block the patient’s only airway.

Question 27

A nurse is teaching a community health promotion class and discusses the flu vaccine. Which information will the nurse include in the teaching session? (Select all that apply.)

a. It is given yearly.
b. It is given in a series of four doses.
c. It is safe for children allergic to eggs.
d. It is safe for adults with acute febrile illnesses.
e. The nasal spray is given to people over 50.
f. The inactivated flu vaccine is given to people over 50.

Answer 27

a. It is given yearly.
f. The inactivated flu vaccine is given to people over 50.

Rationale:

Annual (yearly) flu vaccines are recommended for all people 6 months and older. The inactivated flu vaccine should be given to these individuals with chronic health problems and those 50 and older. People with a known hypersensitivity to eggs or other components of the vaccine should consult their health care provider before being vaccinated. There is a flu vaccine made without egg proteins that is approved for adults 18 years of age and older. Adults with an acute febrile illness should schedule the vaccination after they have recovered. The live, attenuated nasal spray vaccine is given to people from 2 through 49 years of age if they are not pregnant or do not have certain long-term health problems such as asthma; heart, lung, or kidney disease; diabetes; or anemia.

Question 28

A nurse is caring for a patient with sleep apnea. Which types of ventilator support should the nurse be prepared to administer for this patient? (Select all that apply.)

a. Assist-control (AC)
b. Pressure support ventilation (PSV)
c. Bilevel positive airway pressure (BiPAP)
d. Continuous positive airway pressure (CPAP)
e. Synchronized intermittent mandatory ventilation (SIMV)

Answer 28

c. Bilevel positive airway pressure (BiPAP)
d. Continuous positive airway pressure (CPAP)

Rationale:

Ventilatory support is achieved using a variety of modes, including continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BiPAP). The purpose of CPAP and BiPAP is to maintain a positive airway pressure and improve alveolar ventilation. This prevents or treats atelectasis by inflating the alveoli, reducing pulmonary edema by forcing fluid out of the lungs back into circulation, and improving oxygenation in those with sleep apnea. AC, PSV, and SIMV are invasive mechanical ventilation and are not routinely used on patients with sleep apnea. AC delivers a set tidal volume (VT) with each breath, regardless of whether the breath was triggered by the patient or the ventilator. Synchronized intermittent mandatory ventilation like AC delivers a minimum number of fully assisted breaths per minute that are synchronized with the patient’s respiratory effort. Any breaths taken between volume-cycled breaths are not assisted; the volume of these breaths is determined by the patient’s strength, effort, and lung mechanics. PSV mode is often combined with SIMV mode: inspiratory pressure is added to spontaneous breaths to overcome the resistance of the endotracheal tube or to help increase the volume of the patient’s spontaneous breaths.