Deck 50: Oxygenation

Question 1

A client with a nasotracheal tube in place has been restless and pulling at the tube.How should the nurse assess if the tube is still in place?

A)Count the client's respirations.
B)Assess the depth of the client's respirations.
C)Auscultate for bilateral breath sounds.
D)Deflate the cuff and listen for minimal leak.

Answer 1

Auscultate for bilateral breath sounds.

Question 2

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

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

Answer 2

0700 and 2000

Question 3

The nurse who is performing care for a client with a new tracheostomy needs to change the ties.What is the best method for changing these ties?

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

Answer 3

Have an assistant hold the tracheostomy tube in place,remove the soiled ties,and replace the ties.

Question 4

The client has been admitted with complaints of shortness of breath of 2 weeks duration and has received the nursing diagnosis Impaired Gas Exchange.Which admission laboratory result would support the choice of this diagnosis?

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

Question 5

The nurse is caring for a client with a tracheostomy.For what protective mechanism will the nurse monitor in the client?

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

Question 6

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)Pad the tubing where it contacts the client's ears.
C)Set the oxygen delivery to 5 liters.
D)Secure the cannula with ties around the client's head.

Question 7

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

Question 8

A client has a newly created tracheostomy for mechanical ventilation after a surgical procedure.What action should the nurse plan for this client?

A)Deflate the cuff of the tracheostomy tube every 2 hours for 5 minutes.
B)Remove the tracheostomy ties and replace them with an elastic bandage.
C)Remove the tracheostomy inner cannula.
D)Tape the tracheostomy obturator to the head of the bed.

Question 9

When planning care,for which client should the nurse include close observation for a decreased or absent cough reflex?

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

Question 10

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

A)Blood sugar
B)Hemoglobin and hematocrit
C)Cardiac enzymes
D)Serum electrolytes

Question 11

The nurse is planning the care of a client who has need for frequent suctioning.What should the nurse delegate to the UAP?

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

Question 12

Upon assessment,the nurse notes that a client has dyspnea,crackles in both lung bases,and tires easily upon exertion.Which nursing diagnosis is best supported by these assessment details?

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

Question 13

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

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

Question 14

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)Swallowing sputum is dangerous to the system.
C)The nurse should view the sputum for quality and quantity.
D)The client is likely to aspirate the sputum while attempting to swallow it.

Question 15

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

Question 16

A client is receiving oxygen by nonrebreather mask,but the bag is deflating on inspiration.What action should be taken by the nurse?

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

Question 17

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

Question 18

The client complains of difficulty breathing.Which assessment findings should the nurse associate with that complaint?

A)Use of accessory muscles
B)Increased respiratory depth
C)Increased respiratory rate
D)Decreased respiratory depth
E)Decreased respiratory rate

Question 19

After learning of a terminal illness and life expectancy,the client begins to hyperventilate and complains of being light-headed with the fingers,toes,and mouth tingling.What action should be taken by the nurse?

A)Prepare to resuscitate the client.
B)Have the client concentrate on slowing down respirations.
C)Place the client in Trendelenburg's position and ask him to cough forcefully.
D)Administer 25 mg of meperidine (Demerol)according to the prn pain order.

Question 20

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

Question 21

The nurse has completed nasopharyngeal suctioning of a client.What should the nurse document about this procedure?
Standard Text: Select all that apply.

A)Amount,consistency,color,and odor of sputum
B)Amount of sterile solution used to flush the catheter
C)Lung sounds before the procedure
D)Lung sounds after the procedure
E)Oxygen saturation after the procedure

Question 22

A client is diagnosed with congestive heart failure.The nurse should assess the client for which conditions that can alter this client's respiratory function?

A)Conditions that affect the airway.
B)Conditions that affect transport.
C)Conditions that affect the movement of air.
D)Conditions that affect diffusion.

Question 23

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

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

Question 24

A client is concerned about maintaining a healthy respiratory system.What should the nurse instruct the client to do to promote a healthy respiratory status?
Standard Text: Select all that apply.

A)Use pursed-lip breathing.
B)Exercise regularly.
C)Do not smoke.
D)Breathe through the nose.
E)Breathe through the mouth.

Question 25

The nurse wants to delegate the Yankauer suctioning of a client to UAP.What will the nurse ensure that UAP know before delegating this activity?

A)How to apply suction during the insertion of the catheter
B)Not to apply suction during the insertion of the catheter
C)How to maintain sterile technique
D)How to listen for lung sounds

Question 26

The nurse is conducting a health history for a client with a respiratory disorder.What should the nurse include in this assessment?
Standard Text: Select all that apply.

A)Lifestyle
B)Presence of cough
C)Sputum production
D)Pain
E)Diet

Question 27

A client is demonstrating signs of hypoxia.What laboratory value will help the nurse determine the client's degree of effective gas exchange?

A)Blood glucose
B)Serum potassium
C)Serum sodium
D)Arterial blood gas

Question 28

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

Question 29

A client is experiencing atelectasis.The nurse anticipates that this client will have an alteration in

A)Ventilation.
B)Alveolar gas exchange.
C)Transportation of oxygen and carbon dioxide.
D)Systemic diffusion.

Question 30

The nurse is assessing an older client.What effects of aging should the nurse keep in mind during this assessment?
Standard Text: Select all that apply.

A)Decreased cough reflex
B)Stiffening of blood vessels
C)Alteration in protein synthesis
D)Dry mucous membranes
E)Increased risk of aspiration

Question 31

A client complains of difficulty breathing.What will the nurse most likely assess in this client?
Standard Text: Select all that apply.

A)Use of accessory muscles
B)Increased respiratory depth
C)Increased respiratory rate
D)Decreased respiratory depth
E)Decreased respiratory rate

Question 32

The nurse documents that a prescribed expectorant has been effective for a client.What did the nurse evaluate in this client?

A)Respiratory rate 24 and labored
B)Audible wheeze upon auscultation
C)High-pitched cough present
D)Presence of a productive cough

Question 33

A client's blood gas results reveal a low oxygen level.The nurse realizes that which area of the body will respond to this level and influence respirations?

A)Alveoli
B)Trachea
C)Bronchioles
D)Carotid bodies

Question 34

The nurse is determining a client's ability to transport oxygen from the lungs to body tissues.What factors will influence this ability?
Standard Text: Select all that apply.

A)Cardiac output
B)Exercise
C)Diet
D)Erythrocyte count
E)Hematocrit

Question 35

The nurse is performing nasotracheal suctioning of a client.What should the nurse do when suctioning this client?

A)Apply suction for 5-10 seconds.
B)Plan to suction for 10 minutes.
C)Apply suction while inserting the catheter.
D)Apply suction for 20-30 seconds.

Question 36

A client who is being mechanically ventilated has copious amounts of secretions ranging from thick and tenacious to frothy.In preparing to suction this client,the nurse should take which action?

A)Hyperventilate the client using the settings on the mechanical ventilator.
B)Hyperventilate the client using a manual resuscitator.
C)Avoid hyperventilation,but instill normal saline into the endotracheal tube.
D)Avoid hyperventilation and increase the oxygen to 100% for several breaths.

Question 37

A client's blood gas analysis results show an increase in carbon dioxide level.What will the nurse most likely assess in this client?

A)Decreased respiration rate
B)Increased respiration rate
C)Increased blood pressure
D)Decreased bowel sounds

Question 38

Which client statement indicates to the nurse that instruction about the use of a humidifier has been effective?

A)"A humidifier takes moisture out of the air."
B)"A humidifier tightens secretions."
C)"A humidifier prevents my lungs from getting too dry."
D)"A humidifier replaces the use of oxygen."

Question 39

An older client is prescribed diazepam (Valium).What should the nurse monitor in this client?

A)Respirations
B)Urine output
C)Muscle tone
D)Appetite

Question 40

A client who was a victim of a house fire is coughing.The nurse realizes that the purpose of the cough is to

A)improve oxygenation.
B)remove irritants from the nasal passages.
C)remove irritants from the trachea or bronchi.
D)close the glottis.

Question 41

The nurse is planning care for a client who was admitted after having a myocardial infarction.Based upon this history,the nurse's greatest concern is that this client might develop which health problem?

A)Chronic renal failure
B)A gastric ulcer
C)Hypoxemia
D)A cerebral vascular accident

Question 42

Before administering the prescribed medication propranolol (Inderal)to a client,the nurse contacts the health care provider to the order.What health problems did the client have that caused the nurse to the medication order?
Standard Text: Select all that apply.

A)COPD
B)Asthma
C)Arthritis
D)Gastritis
E)Heart failure

Question 43

The nurse is planning care for a client with an oral endotracheal tube.Which interventions should be included in this client's plan of care?
Standard Text: Select all that apply.

A)Insert an oropharyngeal airway.
B)Provide nasal care every 2 to 4 hours.
C)Provide oral hygiene every 2 to 4 hours.
D)Adjust non-humidified airflow as prescribed.
E)Move the tube to opposite sides of the mouth every 8 hours.

Question 44

The nurse is documenting the completion of tracheostomy suctioning and tracheostomy care in a client's medical record.What should this documentation include?
Standard Text: Select all that apply.

A)Lung sounds before and after suctioning
B)Characteristics of suctioned sputum
C)Integrity of the skin around the stoma
D)Side on which the tracheostomy tie knot is located
E)Flow rate of oxygen