Oxygenation midterm

Question 1

A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds?
A) Sonorous wheezes in the left lower lung
B) Rhonchi midsternum
C) Crackles only in apex of lungs
D) Inspiratory crackles in lung bases

Answer 1

D) Inspiratory crackles in lung bases

Question 2

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?
A) Antibiotics
B) Frequent change of position
C) Oxygen humidification
D) Chest physiotherapy

Answer 2

B) Frequent change of position

Question 3

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning?
A) Coughing up thick sputum only occasionally
B) Coughing up thin, watery sputum easily after nebulization
C) Decreased independent ability to cough
D) Lung sounds clear only after coughing

Answer 3

C) Decreased independent ability to cough

Question 4

A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education?
A) “I’ll make sure that I rest between activities so I don’t get so short of breath.”
B) “I’ll rest for 30 minutes before I eat my meal.”
C) “If I have trouble breathing at night, I’ll use two to three pillows to prop up.”
D) “If I get short of breath, I’ll turn up my oxygen level to 6 L/min.”

Answer 4

D) “If I get short of breath, I’ll turn up my oxygen level to 6 L/min.”

Question 5

The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first?
A) Raise the head of the bed to 45 degrees.
B) Take his oxygen saturation with a pulse oximeter.
C) Take his blood pressure and respiratory rate.
D) Notify the health care provider of his shortness of breath.

Answer 5

A) Raise the head of the bed to 45 degrees.

Question 6

The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? (Select all that apply.)
A) SpO2 levels
B) Amount of sputum production
C) Change in respiratory rate and pattern
D) Pain in lower calf area

Answer 6

A) SpO2 levels
B) Amount of sputum production
C) Change in respiratory rate and pattern

Question 7

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient?
A) Postural drainage
B) Chest percussion
C) Incentive spirometer
D) Suctioning

Answer 7

C) Incentive spirometer

Question 8

A client with COPD has a physician’s prescription stating, “Adjust oxygen to SpO2 at 90% to 92%.” Which nursing action can be delegated to a nursing assistant working under the supervision of an RN?

A. Adjust the position of the oxygen tubing
B. Assess for signs and symptoms of hypoventilation
C. Change the O2 flow rate to keep SpO2 as prescribed
D. Choose which O2 delivery device should be used for the client

Answer 8

A. Adjust the position of the oxygen tubing

Question 9

A client who smokes is being discharged home on oxygen. The client states, “My lungs are already damaged, so I’m not going to quit smoking.” What is the discharge nurse’s best response?

A. “You can quit when you are ready.”
B. “It’s never too late to quit.”
C. “Just turn off your oxygen when you smoke.”
D. “You are right, the damage has been done. But let’s talk about why smoking around oxygen is dangerous.”

Answer 9

D. “You are right, the damage has been done. But let’s talk about why smoking around oxygen is dangerous.”

Question 10

Which client has the most urgent need for frequent nursing assessment?

A. An older client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year 2-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask
B. A young client who has had a tracheostomy for 1 week, who is on room air with SpO2 in the upper 90’s, who has been receiving antibiotic therapy for 16 hours, and who has foul-smelling drainage on the tracheostomy ties
C. An older adult client who is anxious to go home with her new tank of oxygen and supply of nasal cannulas and is being discharged with a new prescription for home oxygen therapy
D. A middle-aged client who was admitted yesterday with pneumonia and is receiving oxygen at 2 L/min through a nasal cannula

Answer 10

A. An older client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year 2-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask

Question 11

The client is admitted to the hospital for COPD, and the physician requests a nasal cannula at 2 L/min. Within 30 minutes, the client’s color improves. What does the nurse continue to monitor that may require immediate attention?

A. Increasing carbon dioxide levels
B. Decreasing respiratory rate
C. Increasing adventitious breath sounds
D. Increased coughing

Answer 11

B. Decreasing respiratory rate

Question 12

A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose of oral Valium 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress?

A. The client is not being treated for asthma
B. The client has a mental disorder
C. The client received a dose of Valium
D. The client is receiving oxygen at 4 L/min

Answer 12

D. The client is receiving oxygen at 4 L/min

Question 13

For a male client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?

A. Restricting fluid intake to 1,000 ml/day
B. Enforcing absolute bed rest
C. Teaching the client how to perform controlled coughing
D. Administering prescribed sedatives regularly and in large amounts

Answer 13

C. Teaching the client how to perform controlled coughing

Question 14

For a client who is having respiratory symptoms of unknown etiology, the diagnostic test that is most invasive is:

A. Pulse oximetry to determine oxygen saturation levels
B. Throat cultures with sterile swabs
C. Bronchoscopy of the bronchial trees
D. Computed tomography of the lung fields

Answer 14

C. Bronchoscopy of the bronchial trees

Question 15

The nurse identifies that the client is unable to cough to produce a sputum specimen and must be suctioned. Which suctioning route is preferred?

A. Nasopharyngeal
B. Nasotracheal
C. Oropharyngeal
D. Orotracheal

Answer 15

B. Nasotracheal

Question 16

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply.

a) Refrain from exercise.
b) Reduce anxiety.
c) Eat meals 1 to 2 hours prior to breathing treatments.
d) Eat a high-protein/high-calorie diet.
e) Maintain a high-Fowler’s position when possible.
f) Drink 2 to 3 pints of clear fluids daily.

Answer 16

b) Reduce anxiety.
d) Eat a high-protein/high-calorie diet.
e) Maintain a high-Fowler’s position when possible.

Question 17

A nurse is providing postural drainage for a patient with cystic fibrosis. In which position should the nurse place the patient to drain the right lobe of the lung?

a) High Fowler’s position
b) Left side with pillow under chest wall
c) Lying position/half on abdomen and half on side
d) Trendelenberg position

Answer 17

b) Left side with pillow under chest wall

Question 18

When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal cannula, what does the nurse expect?

a) The oxygen must be humidified.
b) The rate will be no more than 2 to 3 L/min or less.
c) Arterial blood gases will be drawn every 4 hours to assess flow rate.
d) The rate will be 6 L/min or more.

Answer 18

b) The rate will be no more than 2 to 3 L/min or less.

Question 19

The nurse is caring for a client who is diagnosed with impaired gas exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client’s diagnosis?

a) high respiratory rate
b) low pulse rate
c) high temperature
d) low blood pressure

Answer 19

a) high respiratory rate

Question 20

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

a) Eat one large meal at noon.
b) Snack on high-carbohydrate foods frequently.
c) Eat smaller meals that are high in protein.
d) Contact the physician for nutrition shake.

Answer 20

c) Eat smaller meals that are high in protein.

Question 21

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?

a) Confusion
b) Decreased blood pressure
c) Decreased respiratory rate
d) Hyperactivity

Answer 21

a) Confusion

Question 22

A physician has ordered an arterial blood gas test for a client with a respiratory disorder. What is the most common role of the nurse in performing the arterial blood gas test?

a) Implement measures to prevent complications after arterial puncture.
b) Measure the partial pressure of oxygen dissolved in plasma.
c) Measure the percentage of hemoglobin saturated with oxygen.
d) Perform the arterial puncture to obtain the specimen.

Answer 22

a) Implement measures to prevent complications after arterial puncture.

Question 23

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?

a) Pulmonary function tests
b) Chest x-ray
c) Skin tests
d) Bronchoscopy

Answer 23

a) Pulmonary function tests

Question 24

The nurse is caring for a client with emphysema. A review of the client’s chart reveals pH 7.36, paO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription, if prescribed by the health care practitioner?

a) Pulse oximetry
b) 4 L/minute O2 nasal cannula
c) High-Fowler’s position
d) Increase fluid intake to 3 L/day

Answer 24

b) 4 L/minute O2 nasal cannula

Question 25

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client’s tissue oxygenation. The nurse would use which appropriate method to assess this client’s oxygenation?

a) Arterial blood gas
b) Hemoglobin levels
c) Hematocrit values
d) Pulmonary function

Answer 25

a) Arterial blood gas

Question 26

A nurse is delivering 3 L/min oxygen to a patient via nasal cannula. What percentage of delivered oxygen is the patient receiving?

a) 32%
b) 28%
c) 47%
d) 23%

Answer 26

a) 32%

Question 27

What structural changes to the respiratory system should a nurse observe when caring for older adults?

a) increased use of accessory muscles for breathing
b) respiratory muscles become weaker
c) increased mouth breathing and snoring
d) diminished coughing and gag reflexes

Answer 27

b) respiratory muscles become weaker

Question 28

A client has been brought in by the rescue squad to the emergency department. The client is having an acute exacerbation of chronic obstructive pulmonary disease (COPD) and is severely short of breath. On arrival, the client is on 15 L/min of oxygen via rebreather mask. Which action by the nurse takes priority?

a. Immediately reduce the oxygen flow to 2 to 4 L/min via nasal cannula.
b. Perform a thorough respiratory assessment and attach pulse oximetry.
c. Call the laboratory to obtain arterial blood gases as soon as possible.
d. Obtain a stat chest x-ray, then slowly wean the client’s oxygen down.

Answer 28

b. Perform a thorough respiratory assessment and attach pulse oximetry.

Question 29

A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. What does the nurse do first?

a. Notify the health care provider.
b. Assess the client’s pulse oximetry.
c. Document the observation.
d. Raise the head of the bed.

Answer 29

b. Assess the client’s pulse oximetry.

Question 30

The nurse assesses a client who is receiving oxygen via a partial rebreather mask. Which assessment finding does the nurse intervene to correct?

a. The bag is two thirds inflated during inhalation.
b. The client’s pulse oximetry reading is 93%.
c. The oxygen flow rate is 2 L/min.
d. The arterial oxygen level is 90%.

Answer 30

c. The oxygen flow rate is 2 L/min.

Question 31

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity?

A) Bradycardia and frontal headache
B) Dyspnea and substernal pain
C) Peripheral cyanosis and restlessness
D) Hypotension and tachycardia

Answer 31

B) Dyspnea and substernal pain

Question 32

The nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns the nurse immediately?

A.) Fine bibasilar crackles
B.) Respiratory rate of 8 breaths/min
C.) The patient sitting up and leaning over the nightstand
D.) A large barrel chest

Answer 32

B.) Respiratory rate of 8 breaths/min

Question 33

The unlicensed assistive personnel (UAP) tells the nurse that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should the nurse suggest to the UAP to improve the patient’s comfort for this problem?

A.) Humidify the patient’s oxygen.
B.) Use a simple face mask instead of a nasal cannula.
C.) Provide the patient with an extra pillow.
D.) Have the patient sit up in a chair at the bedside.

Answer 33

A.) Humidify the patient’s oxygen.

Question 34

The RN is teaching an unlicensed assistive personnel (UAP) to check oxygen saturation by pulse oximetry. What will the nurse be sure to tell the UAP about patients with darker skin?

A.) “Be aware that patients with darker skin usually show a 3% to 5% higher oxygen saturation compared with light-skinned patients.”
B.) “Usually dark-skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients.”
C.) “With a dark-skinned patient, you may get more accurate results by measuring pulse oximetry on the patient’s toes.”
D.) “More accurate results may result from continuous pulse oximetry monitoring than spot checking when a patient has darker skin.”

Answer 34

B.) “Usually dark-skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients.”

Question 35

After the respiratory therapist performs suctioning on a patient who is intubated, the unlicensed assistive personnel (UAP) measures vital signs for the patient. Which vital sign value should the UAP be instructed to report to the RN immediately?

a. Heart rate of 98 beats/min
b. Respiratory rate of 24 breaths/min
c. Blood pressure of 168/90 mm Hg
d. Tympanic temperature of 101.4°F (38.6°C)

Answer 35

d. Tympanic temperature of 101.4°F (38.6°C)

Question 36

The critical care charge nurse is responsible for the care of four patients receiving mechanical ventilation. Which patient is most at risk for failure to wean and ventilator dependence?

a. A 68-year-old patient with a history of smoking and emphysema
b. A 57-year-old patient who experienced a cardiac arrest
c. A 49-year-old postoperative patient who had a colectomy
d. A 29-year-old patient who is recovering from flail chest

Answer 36

a. A 68-year-old patient with a history of smoking and emphysema

Question 37

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first?

a. Administer anticoagulant drug therapy.
b. Notify the patient’s health care provider.
c. Prepare patient for a spiral computed tomography (CT).
d. Elevate the head of the bed to a semi-Fowler’s position.

Answer 37

d. Elevate the head of the bed to a semi-Fowler’s position.

Question 38

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first?

a. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled
b. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath
c. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes
d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)

Answer 38

b. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath

Question 39

A male adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure?

a. Immediately before a meal
b. At least 2 hours after a meal
c. When bronchospasms occur
d. When secretions have mobilized

Answer 39

b. At least 2 hours after a meal

Question 40

The amount of air inspired and expired with each breath is called:

a. tidal volume.
b. residual volume.
c. vital capacity.
d. dead-space volume.

Answer 40

a. tidal volume.

Question 41

Which of the following would be most appropriate for a male client with an arterial blood gas (ABG) of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3 24 mEq/L, and PaO2 94 mm Hg?

a. Administer a prescribed decongestant.
b. Instruct the client to breathe into a paper bag.
c. Offer the client fluids frequently.
d. Administer prescribed supplemental oxygen.

Answer 41

b. Instruct the client to breathe into a paper bag.

Question 42

A black male client with asthma seeks emergency care for acute respiratory distress. Because of this client’s dark skin, the nurse should assess for cyanosis by inspecting the:

a. lips.
b. mucous membranes.
c. nail beds.
d. earlobes

Answer 42

b. mucous membranes.

Question 43

A female client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client’s serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range?

a. 1 to 2 mcg/ml
b. 2 to 5 mcg/ml
c. 5 to 10 mcg/ml
d. 10 to 20 mcg/ml

Answer 43

d. 10 to 20 mcg/ml

Question 44

At 11 p.m., a male client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He’s anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client’s arterial blood oxygen saturation is 86% and he’s still wheezing. The nurse should plan to administer:

a. alprazolam (Xanax).
b. propranolol (Inderal)
c. morphine.
d. albuterol (Proventil).

Answer 44

d. albuterol (Proventil).

Question 45

When the nurse is caring for an obese patient with left lower lobe pneumonia, gas exchange will be best when the patient is positioned

a. on the left side.
b. on the right side.
c. in the tripod position.
d. in the high-Fowler’s position.

Answer 45

b. on the right side.

Question 46

When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first?

a. Check pupil reaction to light.
b. Notify the health care provider.
c. Attempt to calm and reassure the patient.
d. Assess oxygenation using pulse oximetry.

Answer 46

d. Assess oxygenation using pulse oximetry.

Question 47

During oxygen administration to the client, which of the following pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

a) Nasal cannula
b) Flow meter
c) Oxygen analyzer
d) Humidifier

Answer 47

b) Flow meter

Question 48

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is “Ineffective Airway Clearance related to copious and tenacious secretions.” Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client’s care plan?

a) Encouraging the client to consume two to three quarts of clear fluids daily
b) Creating an environment that is likely to reduce anxiety
c) Positioning the client supine
d) Encouraging the client to decrease the number of cigarettes smoked daily

Answer 48

a) Encouraging the client to consume two to three quarts of clear fluids daily

Question 49

A client with no prior history of respiratory illness has been admitted to a postsurgical unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?

a) Educating the client on pursed-lip breathing techniques
b) Oropharyngeal suctioning twice daily
c) Administration of inhaled corticosteroids
d) Educating the client on the use of incentive spirometry

Answer 49

a) Educating the client on pursed-lip breathing techniques

Question 50

While auscultating a client’s chest, a nurse hears coarse crackles that are low-pitched and rumbling. The nurse interprets this finding as indicating which of the following?

a) Air passing through narrowed airways
b) Inflammation of pleural surfaces
c) Presence of fluid in the lungs
d) Presence of sputum in the airways

Answer 50

d) Presence of sputum in the airways

Question 51

The nurse is teaching a patient how to use an incentive spirometer. The nurse should assist the patient to assume which position?
1. Sitting
2. Side-lying
3. Orthopneic
4. Low-Fowler’s

Answer 51

1. Sitting

Question 52

The nurse is assessing a postoperative patient. Which complication has most likely occurred when the patient experiences purulent sputum, dyspnea, and chest pain?
1. Hypostatic pneumonia
2. Hypovolemic shock
3. Thrombophlebitis
4. Pneumothorax

Answer 52

1. Hypostatic pneumonia

Question 53

When assessing a patient, which adaptation indicates the presence of respiratory distress?
1. Rate of fourteen breaths per minute
2. Productive cough
3. Sore throat
4. Orthopnea

Answer 53

4. Orthopnea

Question 54

When attempting to apply a pulse oximetry probe, the nurse identifies that a patient’s hands are edematous. The priority action should be to:
1. Attach the probe to one of the patient’s toes
2. Connect the probe to one of the patient’s earlobes
3. Wash the patient’s hand before attaching the probe to the finger
4. Encourage the patient to perform active range-of-motion exercises of the hand

Answer 54

2. Connect the probe to one of the patient’s earlobes

Question 55

The nurse teaches a patient how to use an incentive spirometer. The nurse understands that the most appropriate expected outcome associated with the use of an incentive spirometer is:
1. Coughing will be stimulated
2. Sputum will be expectorated
3. Inspiratory volume will be increased
4. Supplemental oxygen use will be reduced

Answer 55

3. Inspiratory volume will be increased

Question 56

A patient has thick tenacious respiratory secretions. To best help liquefy the patient’s respiratory secretions, the nurse should:
1. Change the patient’s position every two hours
2. Encourage the patient to drink more fluid
3. Obtain an order for an antitussive agent
4. Teach effective deep breathing

Answer 56

2. Encourage the patient to drink more fluid

Question 57

A patient’s hemoglobin saturation via pulse oximetry indicates inadequate oxygenation. What should the nurse do first?
1. Administer oxygen at three liters per minute
2. Encourage deep breathing
3. Raise the head of the bed
4. Call the physician

Answer 57

3. Raise the head of the bed

Question 58

The major difference between pursed-lip breathing and diaphragmatic breathing is with diaphragmatic breathing the patient:
1. Inhales through the mouth
2. Exhales through pursed lips
3. Raises both shoulders while breathing deeply
4. Tightens the abdominal muscles while exhaling

Answer 58

4. Tightens the abdominal muscles while exhaling

Question 59

The client has emphysema from smoking. During a respiratory system assessment the nurse anticipates finding:

A. Abnormal palpation signs in the upper thorax
B. Dull sounds on percussion
C. A depressed sternum on inspection
D. Moist breath sounds on auscultation

Answer 59

B. Dull sounds on percussion

Question 60

Myocardial blood flow is unidirectional; the nurse knows that the correct pathway is which of the following?
a. Right atrium, right ventricle, left ventricle, left atrium
b. Right atrium, left atrium, right ventricle, left ventricle
c. Right atrium, right ventricle, left atrium, left ventricle
d. Right atrium, left atrium, left ventricle, right ventricle
carotid artery supplies blood to the brain.

Answer 60

c. Right atrium, right ventricle, left atrium, left ventricle

Question 61

For which of the following health problems is a patient who has a 40 year history of smoking at risk?
A. Alcoholism and hypertension
B. Obesity and diabetes
C. Stress-related illnesses
D. Cardiopulmonary disease and lung cancer

Answer 61

D. Cardiopulmonary disease and lung cancer

Question 62

A patient is admitted with the diagnosis left-sided heart failure. What adventitious lung sounds are expected on auscultation?
A. Sonorous wheezes in left lower lung
B. Rhonchi mid sternum
C. Crackles only in apex of lungs
D. Inspiratory crackles in lung bases

Answer 62

D. Inspiratory crackles in lung bases

Question 63

A nurse teaches a patient how to use an incentive spirometer. Which projected patient outcome will support the conclusion that use of the incentive spirometer was effective?

A) Supplemental oxygen use will be reduced
B) Inspiratory volume will be increased
C) Sputum will be expectorated
D) Coughing will be stimulated

Answer 63

A) Supplemental oxygen use will be reduced

Question 64

Which nursing assessment best indicates a patient’s ability to tolerate activity?

A) Vital signs that take three minutes to return to pre-activity level
B) Absence of adventitious breath sounds on auscultation
C) Flexibility of muscles and joints
D) Reports of weakness

Answer 64

A) Vital signs that take three minutes to return to pre-activity level

Question 65

What are the primary functions of the pulmonary system?

A) Gas exchange and the movement of air in and out of the lungs
B) Gas exchange and the transfer of oxygen to the tissues
C) The movement of blood in and out of the lungs and the removal of waste products
D) Gas exchange and the prevention of infections

Answer 65

A) Gas exchange and the movement of air in and out of the lungs

Question 66

Which part of the pulmonary anatomy does most of the work of breathing?

A) Pleura
B) Intercostal muscles
C) Diaphragm
D) Sternocleidomastoid

Answer 66

C) Diaphragm

Question 67

A nurse is assessing a patient with a respiratory problem. Which clinical manifestations are most reflective of an early response to hypoxia? Select all that apply.

A) Dysrhythmias
B) Restlessness
C) Irritability
D) Cyanosis
E) Apnea

Answer 67

B) Restlessness
C) Irritability

Question 68

A client was given morphine for pain at 9 am at 9:45 am, the nurse assesses the client and notes a respiratory rate of 4 breaths per minute. The nurse recognizes that the client is at high risk:

A) An asthma attack
B) Respiratory arrest
C) Myoclonic seizures
D) Spontaneous arousal

Answer 68

B) Respiratory arrest

Question 69

A client has a respiratory rate of 4 breaths per minute. What are this nurse’s priority assessments?

A) Arterial blood gas and breath sounds
B) Level of consciousness and a pulse oximetry value
C) Breath sounds and reflexes
D) Pulse oximetry value and heart sounds

Answer 69

B) Level of consciousness and a pulse oximetry value