Exam 38: Oxygenation and Tissue Perfusion

The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient's pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of the nurse?

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 certain important blood vessels that provide oxygen to the heart muscle?

The nurse is caring for a patient with advanced COPD who reports feeling short of breath. The nurse notes that the patient's lung sounds are diminished bilaterally and the patient's pulse oximetry is 91% on 2 L/min oxygen via nasal cannula. What actions will the nurse take to make the patient more comfortable? (Select all that apply.)

The nurse is caring for a patient who has been prescribed warfarin (Coumadin) therapy after being diagnosed with atrial fibrillation. The patient tells the nurse that he doesn't want to take any more pills and asks what could happen if he doesn't fill the prescription. What is the nurse's best response?

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 his recovery?

The nurse is caring for a patient who has a history of congestive heart failure with generalized pitting edema. Which of the following laboratory results will the nurse expect to find in the patient's chart?

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?

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?

The home care nurse is caring for a patient who has severe COPD and home oxygen therapy. The patient tells the nurse that she feels much better after increasing the oxygen flowmeter from 2 L to 5 L/min. The patient's pulse oximetry is 98%. What is the priority action of the nurse?

The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has the highest priority?

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?

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?

The preceptor is working with a new nurse to suction a patient through his new tracheostomy. Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.)

The nurse is caring for a postoperative patient who has just been diagnosed with a deep vein thrombosis (DVT) in the right leg. Which focused assessment question has the highest priority for this patient?

The nurse notes the following findings when assessing a patient with COPD. Which require prompt nursing intervention? (Select all that apply.)

The nurse is caring for a patient with a chest tube who was transported to radiology for testing. When the patient returns to the nursing unit, the transporter shows the nurse the patient's chest tube collection device, which was badly damaged after being caught in the elevator door. What is the priority action of the nurse?

The preceptor is working with a new nurse to provide care for a patient with a new tracheostomy. Which actions by the new nurse indicate need for additional teaching about the procedure? (Select all that apply.)

The nurse is working with a nursing assistant to care for a patient with a new tracheostomy. Which tasks may the nurse delegate to the assistant? (Select all that apply.)

The preceptor is working with a new nurse to provide care for a patient with a chest tube to relieve a pneumothorax. Which action by the new nurse indicates need for additional teaching about chest tube care?

The nurse is caring for a patient who has just had a massive myocardial infarction. Which is the priority nursing diagnosis for this patient?