TB Ch: 41 - Oxygenation

Question 1

A nurse is teaching staff about the conduction of the heart. In which order will the nurse present the conduction cycle, starting with the first structure?

1. Bundle of His
2. Purkinje network
3. Intraatrial pathways
4. Sinoatrial (SA) node
5. Atrioventricular (AV) node
   a. 5, 4, 3, 2, 1
   b. 4, 3, 5, 1, 2
   c. 4, 5, 3, 1, 2
   d. 5, 3, 4, 2, 1

Answer 1

B

The conduction system originates with the SA node, the “pacemaker” of the heart. The electrical impulses are transmitted through the atria along intraatrial pathways to the AV node. It assists atrial emptying by delaying the impulse before transmitting it through the Bundle of His and the ventricular Purkinje network.

Question 2

A nurse is teaching the patient with mitral valve problems about the valves in the heart. Starting on the right side of the heart, describe the sequence of the blood flow through these valves.

1. Mitral
2. Aortic
3. Tricuspid
4. Pulmonic
   a. 1, 3, 2, 4
   b. 4, 3, 2, 1
   c. 3, 4, 1, 2
   d. 2, 4, 1, 3

Answer 2

ANS: C

The blood flows through the valves in the following direction: tricuspid, pulmonic, mitral, and aortic.

Question 3

A

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 3

ANS: A

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 4

A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close?

a.

Aortic and mitral

b.

Mitral and tricuspid

c.

Aortic and pulmonic

d.

Mitral and pulmonic

Answer 4

ANS: C

As the ventricles empty, the ventricular pressures decrease, allowing closure of the aortic and pulmonic valves, producing the second heart sound, S2. The mitral and tricuspid produce the first heart sound, S1. The aortic and mitral do not close at the same time. The mitral and pulmonic do not close at the same time.

Question 5

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 5

ANS: D

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 6

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 6

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.

Question 7

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

Answer 7

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.

Question 8

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 8

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.

Question 9

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

Answer 9

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.

Question 10

A patient has a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia?

a.

Superior vena cava

b.

Pulmonary artery

c.

Coronary artery

d.

Carotid artery

Answer 10

ANS: C

A myocardial infarction is the lack of blood flow due to obstruction to the coronary artery, which supplies the heart with blood. The superior vena cava returns blood back to the heart. The pulmonary artery supplies deoxygenated blood to the lungs. The carotid artery supplies blood to the brain.

Question 11

A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium?

a.

Right ventricle, left ventricle, left atrium

b.

Left atrium, right ventricle, left ventricle

c.

Right ventricle, left atrium, left ventricle

d.

Left atrium, left ventricle, right ventricle

Answer 11

ANS: C

Unoxygenated blood flows through the venae cavae into the right atrium, where it is pumped down to the right ventricle; the blood is then pumped out the pulmonary artery and is returned oxygenated via the pulmonary vein to the left atrium, where it flows to the left ventricle and is pumped out to the rest of the body via the aorta.

Question 12

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

Answer 12

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.

Question 13

A patient has heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output?

a.

Myocardial contractility × Myocardial blood flow

b.

Ventricular filling time/Diastolic filling time

c.

Stroke volume × Heart rate

d.

Preload/Afterload

Answer 13

ANS: C

Cardiac output can be calculated by multiplying the stroke volume and the heart rate. The other options are not measures of cardiac output.

Question 14

A patient’s heart rate increased from 94 to 164 beats/min. What will the nurse expect?

a.

Increase in diastolic filling time

b.

Decrease in hemoglobin level

c.

Decrease in cardiac output

d.

Increase in stroke volume

Answer 14

ANS: C

With a sustained heart rate greater than 160 beats/min, diastolic filling time decreases, decreasing stroke volume and cardiac output. The hemoglobin level would not be affected.

Question 15

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

Answer 15

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.

Question 16

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 16

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.

Question 17

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 17

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.

Question 18

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 18

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%.

Question 19

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

Answer 19

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.

Question 20

A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave?

a.

SA node

b.

AV node

c.

Bundle of His

d.

Purkinje fibers

Answer 20

ANS: A

The P wave represents the electrical conduction through both atria; the SA node initiates electrical conduction through the atria. The AV node conducts down through the bundle of His and the Purkinje fibers to cause ventricular contraction.

Question 21

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 21

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.

Question 22

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 22

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.

Question 23

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 23

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.

Question 24

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 24

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.

Question 25

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 25

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.

Question 26

A nurse is caring for a patient who is taking warfarin (Coumadin) and discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient?

a.

Increased cholesterol level

b.

Distended jugular vein

c.

Bleeding

d.

Angina

Answer 26

ANS: C

Patients taking warfarin (Coumadin) for anticoagulation prolong the prothrombin time (PT)/international normalized ratio (INR) results if they are taking gingko biloba, garlic, or ginseng with the anticoagulant. The drug interaction can precipitate a life-threatening bleed. Increased cholesterol levels are associated with saturated fat dietary intake. A distended jugular vein and peripheral edema are associated with damage to the right side of the heart. Angina is temporary ischemia of the heart muscle.

Question 27

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 27

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.

Question 28

Upon auscultation of the patient’s chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse?

a.

The beginning of the systolic phase

b.

Regurgitation of the mitral valve

c.

The opening of the aortic valve

d.

Presence of orthopnea

Answer 28

ANS: B

When regurgitation occurs, there is a backflow of blood into an adjacent chamber. For example, in mitral regurgitation the mitral leaflets do not close completely. When the ventricles contract, blood escapes back into the atria, causing a murmur, or “whooshing” sound. The systolic phase begins with ventricular filling and closing of the aortic valve, which is heard as the first heart sound, S1. Orthopnea is an abnormal condition in which a patient uses multiple pillows when reclining to breathe easier or sits leaning forward with arms elevated.

Question 29

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

Answer 29

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.

Question 30

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 30

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.

Question 31

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 31

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.

Question 32

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 32

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.

Question 33

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

Answer 33

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.

Question 34

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

Answer 34

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.

Question 35

A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the nurse describe as modifiable?

a.

Stress

b.

Allergies

c.

Family history

d.

Gender

Answer 35

ANS: A

Young and middle-age adults are exposed to multiple cardiopulmonary risk factors: an unhealthy diet, lack of exercise, stress, over-the-counter and prescription drugs not used as intended, illegal substances, and smoking. Reducing these modifiable factors decreases a patient’s risk for cardiac or pulmonary diseases. A nonmodifiable risk factor is family history; determine familial risk factors such as a family history of lung cancer or cardiovascular disease. Other nonmodifiable risk factors include allergies and gender.

Question 36

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 36

ANS: A

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 37

A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority?

a.

Risk for skin breakdown

b.

Impaired gas exchange

c.

Activity intolerance

d.

Risk for infection

Answer 37

ANS: B

The most important nursing intervention is to maintain airway and circulation for this patient; therefore, Impaired gas exchange is the first nursing priority. Activity intolerance is a concern but is not the priority in this case. Risk for skin breakdown and Risk for infection are also important but do not address an immediate impairment with physiologic integrity.

Question 38

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 38

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.

Question 39

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

Answer 39

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.

Question 40

A patient with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic?

a.

“Your disease doesn’t send enough oxygen to your fingers.”

b.

“Your disease affects both your lungs and your heart, and not enough blood is being pumped.”

c.

“Your disease will be helped if you pursed-lip breathe.”

d.

“Your disease often makes patients lose mental status.”

Answer 40

ANS: A

Clubbing of the nail bed can occur with COPD and other diseases that cause prolonged oxygen deficiency or chronic hypoxemia. Pursed-lipped breathing helps the alveoli stay open but is not the cause of clubbing. Loss of mental status is not a normal finding with COPD and will not result in clubbing. Low oxygen and not low circulating blood volume is the problem in COPD that results in clubbing.

Question 41

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 41

ANS: C

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 42

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 42

ANS: B

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 43

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 43

ANS: B

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 44

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

a.

Huff

b.

Quad

c.

Cascade

d.

Incentive spirometry

Answer 44

ANS: A

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 45

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 45

ANS: B

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 46

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 46

ANS: A

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 47

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 47

ANS: D

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 48

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 48

ANS: B

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 49

A nurse is following the Ventilator Bundle standards to prevent ventilator-associated pneumonia. Which strategies is the nurse using? (Select all that apply.)

a.

Head of bed elevation to 90 degrees at all times

b.

Daily oral care with chlorhexidine

c.

Cuff monitoring for adequate seal

d.

Clean technique when suctioning

e.

Daily “sedation vacations”

f.

Heart failure prophylaxis

Answer 49

ANS: B, C, E

The key components of the Institute for Healthcare Improvement (IHI) Ventilator Bundle are:

Elevation of the head of the bed (HOB)—elevation is 30 to 45 degrees

Daily “sedation vacations” and assessment of readiness to extubate

Peptic ulcer disease prophylaxis

Deep venous thrombosis prophylaxis

Daily oral care with chlorhexidine

Monitor cuff pressure frequently to ensure that there is an adequate seal to prevent aspiration of secretions is also included. Sterile technique is used for suctioning when on ventilators. Heart failure prophylaxis is not a component.

Question 50

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 50

ANS: A, F

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 51

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 51

ANS: C, D

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.