Deck 88: Oxygenation

Question 1

The nurse would expect to see increased ventilations if a patient exhibits

A) Increased oxygen saturation.
B) Decreased carbon dioxide levels.
C) Decreased pH.
D) Increased hemoglobin levels.

Answer 1

C
Retained CO₂ creates H⁺ byproducts that lower pH.This sends a chemical signal to increase respiratory rate and would result in increased ventilation.All other options would cause the ventilation rate to normalize or decrease to increase carbon dioxide retention or as the result of delivery of higher levels of oxygen to tissues.

Question 2

Normal cardiac output is 4 to 6 L/min in a healthy adult at rest.Which of the following is the correct formula to calculate cardiac output?

A) Stroke volume ´ Heart rate
B) Stroke volume/Body surface area
C) Body surface area ´ Cardiac index
D) Heart rate/Stroke volume

Answer 2

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

Question 3

The nurse would expect a patient with right-sided heart failure to have which of the following?

A) Peripheral edema
B) Basilar crackles
C) Chest pain
D) Cyanosis

Answer 3

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 and hepatojugular distention 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 4

A nurse caring for a patient who was in a motor vehicle accident that resulted in trauma to C4 would expect to find

A) Decreased tidal volumes.
B) Increased perfusion.
C) Increased use of accessory muscles.
D) Decreased hemoglobin.

Question 5

The structure that is responsible for returning oxygenated blood to the heart is the

A) Pulmonary artery.
B) Pulmonary vein.
C) Superior vena cava.
D) Inferior vena cava.

Question 6

The process of exchanging gases through the alveolar capillary membrane is known as

A) Disassociation.
B) Diffusion.
C) Perfusion.
D) Ventilation.

Question 7

A patient has inadequate stroke volume related to decreased preload.The nurse anticipates

A) Placing the patient on oxygen monitoring.
B) Administering vasodilators.
C) Verifying that the blood consent form has been signed.
D) Preparing the patient for dialysis.

Question 8

The nurse knows that anemia will result in

A) Hypoxemia.
B) Impaired ventilation.
C) Hypovolemia.
D) Decreased lung compliance.

Question 9

Chemical receptors that stimulate inspiration are located in the

A) Brain.
B) Lungs.
C) Aorta.
D) Heart.

Question 10

A patient's heart rate increased from 80 bpm to 160 bpm.The nurse knows that what will follow is a(n)

A) Increase in diastolic filling time.
B) Decrease in cardiac output.
C) Increase in stroke volume.
D) Increase in contractility.

Question 11

The nurse caring for a patient with ischemia to the left coronary artery would expect to find

A) Increased ventricular diastole.
B) Increased stroke volume.
C) Decreased preload.
D) Decreased afterload.

Question 12

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.What do these symptoms most likely indicate?

A) Left-sided heart failure
B) Right-sided heart failure
C) Atrial fibrillation
D) Myocardial ischemia

Question 13

The nurse recommends that a patient install a carbon monoxide detector in the home because

A) It is required by law.
B) Carbon monoxide tightly bonds 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.

Question 14

When caring for a patient with atrial fibrillation,the nurse is most concerned with which vital sign?

A) Heart rate
B) Pain
C) Oxygen saturation
D) Blood pressure

Question 15

The nurse knows that a myocardial infarction is an occlusion of what blood vessel?

A) Pulmonary artery
B) Ascending aorta
C) Coronary artery
D) Carotid artery

Question 16

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

Question 17

The P wave is represented by which portion of the conduction system?

A) SA node
B) AV node
C) Bundle of HIS
D) Purkinje network

Question 18

The nurse is careful to monitor a patient's cardiac output because this helps the nurse to determine

A) Peripheral extremity circulation.
B) Oxygenation requirements.
C) Cardiac arrhythmias.
D) Ventilation status.

Question 19

The nurse knows that the primary function of the alveoli is to

A) Carry out gas exchange.
B) Store oxygen.
C) Regulate tidal volume.
D) Produce hemoglobin.

Question 20

A nurse is assisting a patient with ambulation.The patient becomes short of breath and begins to complain of sharp chest pain.Which action by the nurse is the first priority?

A) Call for the emergency response team to bring the defibrillator.
B) Have the patient sit down in the nearest chair.
C) Return the patient to the room and apply 100% oxygen.
D) Ask a coworker to get the ECG machine STAT.

Question 21

Which statement by the patient indicates an understanding of atelectasis?

A) "It is important to do breathing exercises every hour to prevent atelectasis."
B) "If I develop atelectasis, I will need a chest tube to drain excess fluid."
C) "Atelectasis affects only those with chronic conditions such as emphysema."
D) "Hyperventilation will open up my alveoli, preventing atelectasis."

Question 22

A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension.When the patient asks what he should eat for breakfast,what should the nurse recommend?

A) A bowl of cereal with whole milk and a banana
B) A cup of nonfat yogurt with granola, and a handful of dried apricots
C) Whole wheat toast with butter, a side of cottage cheese
D) Omelet with sausage, cheese, and onions

Question 23

The nurse would expect which change in cardiac output for a patient with fluid volume overload?

A) Increased preload
B) Decreased afterload
C) Decreased tissue perfusion
D) Increased heart rate

Question 24

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 that the patient could achieve?

A) Running 30 minutes every morning
B) Stopping smoking immediately
C) Sleeping on two to three pillows at night
D) Limiting the diet to 1500 calories a day

Question 25

The nurse is assessing a patient with emphysema.Which assessment finding requires further follow-up with the physician?

A) Clubbing of the fingers
B) Increased anterior-posterior diameter of the chest
C) Hemoptysis
D) Tachypnea

Question 26

A nurse is caring for a patient whose temperature is 100.2° F.The nurse expects this patient to hyperventilate owing to

A) Increased metabolic demands.
B) Anxiety over illness.
C) Decreased drive to breathe.
D) Infection destroying lung tissues.

Question 27

The nurse needs to closely monitor the oxygen status of an elderly patient undergoing anesthesia because of which age-related change?

A) Decreased lung defense mechanisms may cause ineffective airway clearance.
B) Thickening of the heart muscle wall decreases cardiac output.
C) Decreased lung capacity makes proper anesthesia induction more difficult.
D) Alterations in mental status prevent patients' awareness of ineffective breathing.

Question 28

The nurse determines that an elderly patient is at risk for infection due to decreased immunity.Which plan of care best addresses the prevention of infection for the patient?

A) Encourage the patient to stay up to date on all vaccinations.
B) Inform the patient of the importance of finishing the entire dose of antibiotics.
C) Schedule patient to get annual tuberculosis skin testing.
D) Create an exercise routine to run 30 minutes every day.

Question 29

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an elderly patient?

A) Assist patient to cough, turn, and deep breathe every 2 hours.
B) Encourage patient to drink through a straw to prevent aspiration.
C) Discontinue humidification delivery device to keep excess fluid from lungs.
D) Monitor oxygen saturation, and frequently assess lung bases.

Question 30

A 5-year-old who has strep throat was given aspirin for fever.The nurse knows to expect which change in the child's respiratory pattern?

A) Hyperventilation to decrease serum levels of carbon dioxide
B) Hypoventilation to compensate for metabolic alkalosis
C) Flail chest to decrease the work of breathing
D) Shallow respirations to decrease serum pH

Question 31

A nonmodifiable risk factor for lung disease is

A) Allergies.
B) Smoking.
C) Stress.
D) Asbestos exposure.

Question 32

A patient with COPD asks the nurse why he is having increased difficulty with his fine motor skills,such as buttoning his shirt.Which response by the nurse is most therapeutic?

A) "Your body isn't receiving enough oxygen to send down to your fingers; this causes them to club and makes dexterity difficult."
B) "Your disease process makes even the smallest tasks seem exhausting. Try taking a nap before getting dressed."
C) "Often patients with your disease lose mental status and forget how to perform daily tasks."
D) "Your disease affects both your lungs and your heart, and not enough blood is being pumped. So you are losing sensory feedback in your extremities."

Question 33

The nurse is caring for an African American patient with COPD.The nurse knows that the best location to assess for hypoxia is the

A) Nailbeds.
B) Oral mucosa.
C) Earlobe.
D) Lower extremities.

Question 34

What assessment finding is the earliest sign of hypoxia?

A) Restlessness
B) Decreased blood pressure
C) Cardiac dysrhythmias
D) Cyanosis

Question 35

A nurse caring for a patient with COPD knows that which oxygen delivery device is most appropriate?

A) Nasal cannula
B) Simple face mask
C) Partial non-rebreather mask
D) Non-rebreather mask

Question 36

The nurse expects a patient with angina pectoris to

A) Experience feelings of indigestion after eating a heavy meal.
B) Have decreased oxygen saturation during rest.
C) Hypoventilate during periods of acute stress.
D) Complain of tingling in the left arm that lasts throughout the morning.

Question 37

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

A) Activity intolerance
B) Risk for skin breakdown
C) Impaired gas exchange
D) Risk for infection

Question 38

A nurse is caring for a patient with COPD who is in recovery for a myocardial infarction.Which of the following nursing actions is the priority?

A) Place the patient on continuous cardiac monitoring.
B) Put the patient on 6 L/min of oxygen via nasal cannula.
C) Deep suction the patient every 2 hours.
D) Assess bilateral lung sounds every hour.

Question 39

Upon auscultation,the nurse hears a whooshing sound at the fifth intercostal space.The nurse recognizes that this sound is

A) The beginning of the systolic phase.
B) The opening of the aortic valve.
C) S₃, the third heart sound.
D) Regurgitation of the mitral valve.

Question 40

A nurse is caring for a patient who suffered a myocardial infarction to the left coronary artery.Upon assessment,the nurse expects to find

A) Blood in the sputum.
B) Distended jugular vein.
C) Peripheral edema.
D) Crackles in the lungs.

Question 41

The nurse is educating a student nurse on caring for a patient with a chest tube.The nurse knows that teaching has been effective when the student states

A) "I should strip the drains on the chest tube every hour to promote drainage."
B) "If the chest tube becomes dislodged, the first thing I should do is notify the physician."
C) "I should clamp the chest tube when giving the patient a bed bath."
D) "I should report if I see continuous bubbling in the water-seal chamber."

Question 42

The nurse knows that the most effective method for suctioning a patient with a tracheostomy tube is to

A) Set suction regulator at 150 to 200 mm Hg.
B) Liberally lubricate the end of the suction catheter with a water-soluble solution.
C) Limit the length of suctioning to 10 to 15 seconds.
D) Apply suction while gently rotating and inserting the catheter.

Question 43

The nurse is assessing a patient with a right pneumothorax.Which finding would the nurse expect?

A) Bilateral expiratory crackles
B) Absence of breath sounds on the right side
C) Right-sided wheezes on inspiration
D) Trachea deviated to the right

Question 44

A patient with a pneumothorax had a chest tube inserted and was placed on low constant suction.Which finding requires immediate action by the nurse?

A) Fifty milliliters of blood gushes into the drainage device after the patient coughs.
B) The patient complains of pain at the chest tube insertion site that increases with movement.
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.

Question 45

While the nurse is changing the ties on a tracheostomy collar,the patient coughs,dislodging the tracheostomy tube.What is the nurse's first nursing action?

A) Press the emergency response button.
B) Place the patient on a face mask delivering 100% oxygen.
C) Insert a spare tracheostomy without the obturator.
D) Manually occlude the tracheostomy with sterile gauze.

Question 46

The nurse knows that a closed suction device would be most appropriate for which patient?

A) A 5-year-old with an asthma attack following severe allergies
B) A 24-year-old with a right pneumothorax following a motor vehicle accident
C) A 50-year-old with pulmonary edema following a myocardial infarction
D) A 75-year-old with aspiration pneumonia following a stroke

Question 47

Which nursing diagnosis is the priority when caring for a patient with a traumatic brain injury who had a tracheostomy placed?

A) Risk for skin breakdown
B) Impaired gas exchange
C) Ineffective airway clearance
D) Risk for infection

Question 48

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