Deck 52: Oxygenation

Question 1

The nurse encourages the client to expectorate sputum rather than swallowing it. What is the rationale for this direction?

A) Sputum contains bacteria that should be expectorated.
B) The client is likely to aspirate the sputum while attempting to swallow it.
C) Swallowing sputum is dangerous to the system.
D) The nurse should view the sputum for quality and quantity.

Answer 1

The nurse should view the sputum for quality and quantity.

Question 2

What are the three components of respiration?

Answer 2

pulmonary ventilation, gas exchange, transport

Question 3

The client is receiving oxygen by non-rebreather mask, but the bag is not deflating on inspiration. What action should be taken by the nurse?

A) Turn the client to the left side.
B) Check for an airtight seal between the client's face and the mask.
C) Increase the percentage of oxygen being delivered.
D) Increase the litre flow of oxygen being delivered.

Answer 3

Increase the litre flow of oxygen being delivered.

Question 4

Upon assessment, the nurse notes that the client is dyspnoeic, has bibasilar crackles, and tires easily upon exertion. Which nursing diagnosis is best supported by these assessment details?

A) Anxiety.
B) Impaired Gas Exchange.
C) Ineffective Airway Clearance.
D) Ineffective Breathing Pattern.

Question 5

The client has a 20-year history of asthma with chronic hypoxia. Which change in the client's fingers would the nurse expect?

Question 6

The client with chronic obstructive lung disease has oxygen ordered at 1.5 litres per minute via nasal cannula. The client complains of shortness of breath. What action should be taken by the nurse?

A) Have the client breathe through pursed lips.
B) Encourage the client to breathe more rapidly.
C) Increase the oxygen to three litres per minute via nasal cannula.
D) Lower the head of the client's bed to semi-Fowler's position.

Question 7

The client has a tracheostomy secondary to head and neck surgery. The nurse monitors the client for complications related to the absence of which important protective mechanism?

A) Decrease in oxygen-carrying capacity of the trachea.
B) The sneeze reflex initiated by irritants in the nasal passages.
C) Filtration and humidification of inspired air.
D) The ability to cough.

Question 8

Which client would the nurse closely observe for a decreased or absent cough reflex?

A) The client with reduction in respiratory membrane conduction.
B) The client with impairment of vagus nerve conduction.
C) The client with a nasal fracture.
D) The client with a sinus infection.

Question 9

Clients with severe head injuries are at particular risk for respiratory problems because of:

A) unconsciousness depresses the positive inspiratory pressures.
B) the intrapleural pressure is positive.
C) depression of the drive to breathe.
D) chest expansion is more difficult.

Question 10

The client has been admitted with complaints of shortness of breath of two weeks duration and has received the nursing diagnosis Impaired Gas Exchange. Which admission laboratory result would support the choice of this diagnosis?

A) Increased sedimentation rate.
B) Increased blood sugar.
C) Decreased BUN.
D) Increased haematocrit.

Question 11

The client has just been told that his medical condition is terminal and that he has less than six months to live. The client begins to hyperventilate and complains that he is light-headed and that his fingers, toes, and mouth are tingling. What action should be taken by the nurse?

A) Prepare to resuscitate the client.
B) Administer 75 mg pethidine hydrochloride (Pethidine) IM according to the prn pain order.
C) Have the client concentrate on slowing down respirations.
D) Place the client in Trendelenburg's position and ask him to cough forcefully.

Question 12

The nurse has received a client immediately after surgery for head and neck cancer. The client has a tracheostomy that was created during the surgery and is being mechanically ventilated. What nursing action should be planned for this client?

A) Remove the tracheostomy ties and replace them with an elastic bandage.
B) Tape the tracheostomy obturator to the head of the bed.
C) Deflate the cuff of the tracheostomy tube every two hours for five minutes.
D) Remove the tracheostomy inner cannula.

Question 13

A premature infant is especially at risk of respiratory distress syndrome because of a lack of:

A) cilia.
B) haemoglobin.
C) surfactant.
D) tidal volume.

Question 14

The efficient transport of oxygen throughout the body is dependent on:

A) plasma levels of the blood.
B) haemoglobin level.
C) alveoli pressure.
D) intrapleural pressure.

Question 15

The nurse has placed an oropharyngeal airway in a client. What action should the nurse take at this time?

A) Suction the client.
B) Turn the client's head to the side.
C) Tape the airway in place.
D) Insert a nasal trumpet.

Question 16

The nurse is planning a time schedule for a client's twice-daily postural drainage. Which time schedule would be best?

A) 1200 and 1800.
B) 0700 and 2000.
C) 0900 and 2100.
D) 0800 and 1100.

Question 17

The client is hypoxic according to arterial blood gas measurement. What nursing diagnosis problem statement is most appropriate for this client?

Question 18

The client is experiencing severe shortness of breath, but is not cyanotic. What lab value would the nurse review in an attempt to understand this phenomenon?

A) Blood sugar.
B) Cardiac enzymes.
C) Haemoglobin and haematocrit.
D) Serum electrolytes.

Question 19

The client has a medical condition that often results in the development of metabolic acidosis. The nurse should observe this client for the development of which breathing pattern as a result of this condition?

A) Biot's.
B) Kussmaul's.
C) Cluster.
D) Cheyne-Stokes.

Question 20

Respiratory regulation includes both ________ and ________ controls to maintain the correct oxygen, carbon dioxide and hydrogen ions in body fluids.

Question 21

The nurse is planning the care of a client who has need for frequent suctioning. Which of the following should the nurse delegate to the Assistant in Nursing (AIN)?

A) Only tracheal suctioning.
B) Only oral suctioning.
C) Both oral and tracheal suctioning.
D) Neither oral nor tracheal suctioning.

Question 22

The client who has a tracheostomy tube in place has been restless and pulling at the tube. How would the nurse assess if the tube is still in place?

A) Assess the depth of the client's respirations.
B) Deflate the cuff and listen for minimal leak.
C) Count the client's respirations.
D) Check position of tube placement.

Question 23

The nurse has completed discharge teaching for a client who will be going home on oxygen therapy. What statement, made by the client, would indicate that this client needs further instruction?

A) "I will buy a fire extinguisher for my bedroom."
B) "My son will not be able to smoke when I am around."
C) "I will replace my cotton blankets with polyester ones."
D) "I will have my electrical appliance checked for grounding."

Question 24

The nurse who is assessing a client's chest tube insertion site notices a fine crackling sound and feeling upon palpating the area. What action should the nurse take?

A) Collaborate with the client's medical practitioner.
B) Mark the area involved and remove the tube.
C) Discontinue the chest tube suction.
D) Reinforce the chest tube dressing.

Question 25

The hospital policy and procedure for suctioning requires hyperoxygenation of the client prior to suctioning. How should the nurse proceed with this requirement?

A) Increase the oxygen flow to the client by 100% prior to suctioning.
B) Provide two to three breaths at 1.5 times the tidal volume prior to suction.
C) Turn the suction level up to 60 cm prior to inserting the catheter.
D) Instruct the client to cough forcefully from the abdomen prior to suction.

Question 26

As a part of preoperative teaching, the nurse is instructing the client on the use of a volume-oriented incentive spirometer. Which instruction should be included in this teaching?

A) Blow out into the canister until the enclosed cylinder rises.
B) Close your lips tightly around the mouthpiece.
C) Inhale sharply to elevate the enclosed cylinder.
D) Use a nose clip to occlude nasal passages if necessary.
E) Cough after using the device.
F) Tilt the device slightly toward yourself while using.

Question 27

The nurse is preparing to assist with the removal of a chest tube that is a simple insertion without a purse-string suture. What materials should the nurse gather for this procedure?

A) A non-adherent gauze dressing.
B) An adhesive gauze pad dressing.
C) A 4 × 4 gauze.
D) An occlusive dressing.

Question 28

The client has been prescribed both a bronchodilator and a steroid medication that is delivered by inhaler. What information is essential to teach this client in regard to these medications?

A) The steroid inhaler should be used when immediate effects are necessary.
B) Both medications have the possible side effect of increased heart rate.
C) The medications cannot be used on the same day.
D) The bronchodilator should be used only when absolutely necessary and only after the steroid inhaler.

Question 29

The nurse who is performing care for a client with a new tracheostomy determines the ties are very soiled and must be changed. What is the best method for changing these ties?

A) Have an assistant hold the tracheostomy tube in place, remove the soiled ties, and replace the ties.
B) Remove the old ties, clean the area well, and then put on new ties.
C) Remove the outer cannula, replace the soiled ties, and reinsert.
D) Attach the new tape and tie with a square knot behind the client's neck.

Question 30

During tracheal suctioning, the nurse notes that the client's heart rate has increased from 80 to 100 BPM. Based upon this assessment, what action should the nurse take?

A) Immediately discontinue suctioning.
B) Continue to suction until the airway is clear.
C) Prepare to resuscitate the client.
D) Complete the suction episode as quickly as possible.

Question 31

The nurse has just initiated oxygen by nasal cannula for a client with the medical diagnosis of chronic obstructive pulmonary disease. What is the nurse's next action?

A) Fill the humidifier with normal saline.
B) Set the oxygen delivery to five litres.
C) Pad the tubing where it contacts the client's ears.
D) Secure the cannula with ties around the client's head.