Question 1

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?

Accepted Answer

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 B

Question 2

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

Accepted Answer

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

Question 3

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

Accepted Answer

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

Question 4

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

Accepted Answer

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

Question 5

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?

Accepted Answer

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 6

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

Accepted Answer

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 7

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

Accepted Answer

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 8

Myocardial blood flow is unidirectional; the nurse knows that the correct pathway is which of the following?

Accepted Answer

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 9

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

Accepted Answer

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 10

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

Accepted Answer

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 11

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?

Accepted Answer

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

Question 12

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?

Accepted Answer

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 13

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

Accepted Answer

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 14

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

Accepted Answer

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

Question 15

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

Accepted Answer

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

Question 16

Which statement by the patient indicates an understanding of atelectasis?

Accepted Answer

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 17

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?

Accepted Answer

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 18

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

Accepted Answer

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

Question 19

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?

Accepted Answer

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

Question 20

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

Accepted Answer

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.

Exam 88: Oxygenation