Unit 7 Oxygenation and Perfusion Chapter 38 Practice Questions Flashcards
The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which oxygen delivery device will the nurse use for this patient?
a. Non-rebreather mask
b. Bag-valve-mask unit
c. Continuous positive airway pressure (CPAP)
d. High-flow nasal cannula
ANS: B
The priority of the nurse is to ventilate the patient manually using a bag-valve-mask (BVM) unit. This allows air to be forced into the patient’s lungs when there are no spontaneous respirations. The non-rebreather mask and nasal cannula require the patient to breathe on his or her own. CPAP is used for patients who are awake, oriented, and in respiratory failure.
The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient is breathing spontaneously but is minimally responsive and having difficulty maintaining a patent airway. Which intervention is the most appropriate for the patient to improve oxygenation?
a. Insert an oral airway.
b. Lower the head of the bed.
c. Turn the patient’s head to the side.
d. Monitor the patient’s pulse oximetry.
ANS: A
An oral (oropharyngeal) airway will prevent the patient’s tongue from falling back and occluding the airway. Lowering the head of the bed will only increase airway occlusion and risk of aspiration. Turning the patient’s head to the side will not clear the back of the patient’s tongue from the airway. Monitoring the patient’s pulse oximetry will not improve oxygenation or clear the airway.
- The nurse is caring for a patient who has been intubated with an oral endotracheal tube for several weeks. The physicians predict that the patient will need to remain on a ventilator for at least several more weeks before he will be able to maintain his airway and breathe on his own. What procedure does the nurse anticipate will be planned for the patient to facilitate recovery?
a. Placement of a tracheostomy tube
b. Diagnostic thoracentesis
c. Pulmonary angiogram
d. Lung transplantation surgery
ANS: A
Placement of a tracheostomy tube will secure the patient’s airway directly through the trachea, eliminating the need for the endotracheal tube. This will make the patient more comfortable and may allow eating while minimizing damage to the oropharynx from the endotracheal tube.
- The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has the highest priority?
a. Activity intolerance r/t generalized weakness and hypoxemia
b. Impaired nutritional intake r/t poor appetite and increased metabolic needs
c. Impaired airway clearance r/t thick secretions in trachea and bronchi
d. Lack of knowledge r/t use of nebulizer and inhaled bronchodilators
c. Impaired airway clearance r/t thick secretions in trachea and bronchi
ANS: C
Airway maintenance and patency is the highest priority for all patients, especially patients with respiratory disorders. Oxygenation is the most important human need. The other diagnoses can apply once the patient’s airway is kept patent.
NURSING PRIORITIES A,B,C’S
A-AIRWAY
B-BREATHING
C-CIRCULATION
- The nurse is caring for a patient who developed a pulmonary embolism after surgery. Which goal statement is the highest priority for the nurse to include in the patient’s care plan for the diagnosis impaired gas exchange r/t impaired pulmonary blood flow from embolus?
a. The patient will maintain pulse oximetry values of at least 95% on room air.
b. The patient will verbalize understanding of ordered anticoagulants.
c. The patient will report chest pain of no greater than 3 on a 1 to 10 scale.
d. The patient will ambulate 50 feet in hallway without shortness of breath.
ANS: A
Oxygenation is the most important human need, so adequate oxygenation of tissues as evidenced by pulse oximetry values of at least 95% on room air is the highest priority goal. The other goals may be addressed once the oxygenation goal has been met.
What is the desired outcome related to the nursing diagnosis of Impaired Airway
Clearance?
a. Patient’s respiratory secretions will become thicker so they are not moved when
coughing.
b. Patient’s respiratory secretions will have a thinner consistency after being given a
mucolytic agent.
c. Patient will have improved range of motion while in bed.
d. Patient’s respiratory rate will increase from 16 to 28 breaths/min during
hospitalization.
Answer: b
The use of mucolytic agents may thin the secretions and allow easier removal. Thickened secretions in the airways can make it more difficult to cough effectively. The goal is to decrease the thickness of secretions. Improved range of motion is related to musculoskeletal problems. The normal respiratory rate is 12 to 20 breaths/min, and 28 breaths/min is considered tachypnea and is not desired.
- When administering oxygen to a patient, the nurse recognizes that using which oxygen delivery system places a patient in danger of receiving inadequate oxygen?
a. Nasal cannula at a flow rate of 2 L/min
b. Nasal cannula at a flow rate of 5 L/min
c. Simple mask at a flow rate of 6 L/min
d. Nonrebreather mask at a flow rate of 5 L/min
Answer: d
A nonrebreather mask with a flow rate of 5 L/min does not give the patient adequate levels of oxygen in the reservoir bag and may result in the person developing hypoxemia. The accepted range of oxygen delivery with a nonrebreather mask is 10 to 15 L/min. The amount that can be delivered by nasal cannula is 1 to 6 L/min, and oxygen delivered at 2 or 5 L/min by nasal cannula is within the safe range. Oxygen delivered at 5 L/min by a simple face mask delivers adequate oxygen because the range for a face mask is 5 to 10
The nurse understands that which of the following is most likely occurring when caring for a pulmonary patient who has bluish discoloration around the lips?
a. Increased PaCO2 levels
b. Hemoglobin that is not saturated with oxygen
c. Elevated white blood cell count
d. Decreased PaCO2 levels
Answer: b
Cyanosis occurs due to hypoxemia, which is a low level of oxygen in the blood. Hemoglobin that is not saturated with oxygen causes a bluish discoloration of the skin. Increased or decreased levels of carbon dioxide (CO2) may indicate an acid-base imbalance. An elevated white blood cell count may indicate an infection.
- A patient with chronic obstructive pulmonary disease (COPD) uses which drive to breathe?
a. Increased PaCO2
b. Decreased hemoglobin
c. Decreased PaO2 levels
d. Increased PaO2 levels
Answer: c
Chronically elevated level of carbon dioxide in the chemoreceptors become tolerant of high levels. The carbon dioxide ceases to be the patient’s trigger to breathe; therefore, what drives the patient to breathe is the hypoxic (low oxygen) drive. A person normally uses increased PaCO2 levels as the drive to breathe. A patient with COPD has chronic elevation of PaCO2 and has lost sensitivity to it as a drive to breathe. Instead, a decreased PaO2 level becomes the drive to breathe.
- The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented. What is the priority action of the nurse?
a. Obtain an arterial blood gas to check for carbon dioxide retention.
b. Increase the patient’s oxygen until the pulse oximetry is greater than 98%.
c. Lower the head of the patient’s bed and insert a nasal airway.
d. Administer a mild sedative and reorient the patient as needed.
ANS: A
Alteration of lung tissue may decrease delivery of oxygen to the alveoli, impede transfer of oxygen from alveoli to the bloodstream, and hinder expulsion of carbon dioxide. COPD causes impaired gas exchange, leading to decreased oxygen levels and higher circulating levels of carbon dioxide (i.e., respiratory acidosis). Confusion and disorientation in a patient with severe COPD may likely be due to carbon dioxide retention. An arterial blood gas should be drawn to determine if this is the case. COPD patients should be kept on low oxygen flow rates whenever possible to avoid impeding the drive to breathe. Lowering the head of the bed will increase the difficulty of breathing as the abdominal contents press on the diaphragm. A sedative will cause respiratory depression and should be avoided.
The nurse identifies which patient who would benefit from postural drainage?
a. A patient with a heart murmur and jugular venous distention.
b. A patient with asthma and audible wheezing.
c. A patient with right-sided heart failure and pitting edema.
d. A patient with chronic bronchitis and congested cough.
ANS: D
Patients who benefit from postural drainage therapy include those who are unable or reluctant to change body positions and patients with unilateral lung diseases that are related to poor oxygenation due to position. Patients who have diseases such as cystic fibrosis or bronchiectasis, COPD, abscesses, or difficulty removing secretions may benefit from postural drainage therapy. A patient with chronic bronchitis and a congested, productive cough would benefit from postural drainage because it would help clear the airway.
What is the normal range for hematocrit for a male and female?
Adult male: 42- 52
Adult female: 37-47
What does an elevated (HIGH) hematocrit level indicate
Major burns
Cardiovascular disease
Chronic lung disease
Congenital heart defect
Polycythemia vera
Dehydration
What does a decreased hematocrit level indicate
Anemia
Bone marrow suppression
Chronic infection Hemorrhage
Renal disease
Vitamin B6, B12, or folic acid
deficiency Overhydration
what is the normal range for hemoglobin for woman and men
Adult male: 14- 18
Adult female: 12-16
The nurse is caring for a patient who has a history of congestive heart failure with generalized pitting edema. Which laboratory results will the nurse expect to find in the patient’s chart?
a. Glycosylated hemoglobin 12%
b. Platelet count 450,000/mm3
c. Hematocrit 32%
d. Prothrombin time 8.8 seconds
c. Hematocrit 32%
Hemodilution may be found when patients are in fluid overload caused by congestive heart failure. A normal hematocrit result is 42% to 52% for a male and 37% to 47% for a female, so the patient’s 32% hematocrit level is markedly low. The other laboratory results are not expected due to congestive heart failure or fluid overload.
. The nurse is caring for a patient who has presented to the ER with chest pain. Which diagnostic test will best indicate if there is significant blockage of important blood vessels that provide oxygen to the heart muscle?
a. Cardiac catheterization
b. Chest x-ray
c. Echocardiogram
d. Electrocardiogram
ANS: A
Cardiac catheterization includes the use of contrast dye to visualize the coronary arteries and determine blood flow to cardiac muscle. The other tests will not allow the physician to determine which (if any) coronary arteries are occluded.
What is the function of a Cardiac Catheter?
Cardiac catheterization uses contrast and a long, flexible catheter to visualize the heart chambers, coronary arteries, and great vessels. It is used to evaluate chest pain, locate the region of coronary artery occlusion, and determine the effects of valvular heart disease
What is the function of a Chest X-ray ?
A chest x-ray is performed to examine the lungs, heart, and bones of the chest (Fig. 38.7). A chest x-ray shows areas of increased density in the lungs, the proximity of organs to each other, and the size of the heart. Abnormal findings include rib fractures, tumors, pneumothorax (air in the pleural cavity), pneumonia (inflammation of the lungs due to infection), pleural effusion (excess fluid accumulation in the pleural cavity), pericardial effusion (fluid around the heart), an enlarged heart,
What is the function of an echocardiogram?
An echocardiogram is a noninvasive ultrasound of the heart (Fig. 38.9). The examination uses sound waves to visualize the heart structure and evaluate the function of the heart.
example, echocardiograms can determine if heart murmurs are present
What is the function of a electrocardiogram?
An electrocardiogram (ECG; also called EKG) is a graphic representation of the electrical activity that occurs in the heart.
PG 2609
The nurse hears a loud murmur when listening to the patient’s heart. Which diagnostic test will best display the condition of the valves and structures within the patient’s heart that could be causing the murmur?
a. Chest x-ray
b. Cardiac catheterization
c. Echocardiogram
d. Electrocardiogram
ANS: C
Echocardiograms allow for ultrasound visualization of the structures of the heart along with function of the heart valves and cardiac musculature.
The nurse is caring for a patient who will be returning to the nursing unit following a cardiac catheterization via the right femoral artery. Which assessment is the highest priority for the nurse to perform when the patient arrives on the unit?
a. Checking the patient’s right pedal pulse and warmth of the right leg
b. Checking pulse oximetry and listening to the patient’s lung sounds
c. Checking bilateral radial pulses to check for a pulse deficit
d. Estimating the patient’s jugular venous pressure
ANS: A
Cardiac catheterization includes the insertion of a large IV needle into the patient’s right femoral or brachial artery to view the left side of the heart and inserted into the antecubital or femoral vein to view structures on the right side of the heart. In this case, occlusion of the femoral artery may develop after the procedure leading to faint or absent pedal pulses and loss of warmth to the right leg. The nurse should check the patient’s right pedal pulses and leg warmth to ensure that the femoral artery has not become occluded. The other assessments may be performed once the patient’s right leg is found to be warm with strong pulses.
What is Cardiac output?
Cardiac output is calculated by multiplying the heart rate in beats per minute (beats/min or bpm) times stroke volume in liters per beat
What is eupnea
normal breathing
What is apnea
Absent breathing
What is the normal range of Hemoglobin
Adult male: 14- 18
Adult female: 12-16
FOUND IN CHAPTER 34
What is the normal range for Leukocytes (White blood cells)
Adult: 5000-
10,000
FOUND IN CHAPTER 34
What is Afterload
Afterload is the resistance that has to be exceeded for the ventricle to eject the blood during systole.
What is Preload
Preload is the amount of blood and pressure in the ventricle at the end of diastole.
What is an Antiembolism Hose?
-TIGHTLY FITTED STOCKINGS ,
-USED TO PROMOTE VENOUS BLOOD RETURN
-PREVENT EDEMA
-PREVENT DVT
-PREVENT VENOUS STASIS
-PREVENT PULMONARY EMBOLISM
What is a sequential Compression Device?
-ARE USED FOR IMMOBILE PATIENTS
-INFLATABLE SLEEVES THAT WRAP AROUND A PATIENTS LEGS
-LOWERS RISK FOR VENOUS STASIS, DVT, AND PULMONARY EMBOLISM
Would you remove the SCD if a pt complains of pain but a DVT is still present?
A.Yes
B. No
B. No
SAFE PRACTICE ALERT
-Remove SCD if a pt complains of calf pain UNTIL deep vein thrombosis is ruled out.
