Chapter 30: Oxygenation

1.Which term should the nurse use to best describe the movement of air in and out of the patient’s lungs?

a.
Ventilation
b.
Diffusion
c.
Respiration
d.
Perfusion

ANS: A

The primary functions of the lungs include ventilation, the movement of air in and out of the lungs, and diffusion, the movement of gases between air spaces and the bloodstream. Respiration is the exchange of oxygen and carbon dioxide during cellular metabolism. The heart supports perfusion, the movement of blood into and out of the lungs to the organs and tissues of the body.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:800

OBJ: Describe the structure and function of the cardiopulmonary system.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

2.The nurse is educating a patient who has recently been diagnosed with chronic obstructive pulmonary disease (COPD). The nurse explains how the gasses in the lungs move between the air spaces and the bloodstream. Which process is the nurse describing?

a.
Ventilation
b.
Diffusion
c.
Respiration
d.
Perfusion

ANS: B

Diffusion is the movement of gases between air spaces and the bloodstream. One of the primary functions of the lungs includes ventilation, the movement of air in and out of the lungs. Respiration is the exchange of oxygen and carbon dioxide during cellular metabolism. The heart supports perfusion, the movement of blood into and out of the lungs to the organs and tissues of the body.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:800

OBJ: Describe the structure and function of the cardiopulmonary system.

TOP: Nursing Process: Implementation MSC: Client Needs: Physiological Integrity

3.The exchange of oxygen and carbon dioxide during cellular metabolism is best described as which of the following?

a.
Ventilation
b.
Diffusion
c.
Respiration
d.
Perfusion

ANS: C

Respiration is the exchange of oxygen and carbon dioxide during cellular metabolism. The primary functions of the lungs include ventilation, the movement of air in and out of the lungs, and diffusion, the movement of gases between air spaces and the bloodstream. The heart supports perfusion, the movement of blood into and out of the lungs to the organs and tissues of the body.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:800

OBJ:Identify the physiological processes involved in ventilation, perfusion, and exchange of respiratory gases.TOP:Nursing Process: Assessment

MSC:Client Needs: Physiological Integrity

4.When giving CPR, compressions are causing the heart to pump blood into and out of the lungs to the body’s organs. This movement of oxygenated blood is best described as which of the following?

a.
Ventilation
b.
Diffusion
c.
Respiration
d.
Perfusion

ANS: D

The heart supports perfusion, the movement of blood into and out of the lungs to the organs and tissues of the body. The primary functions of the lungs include ventilation, the movement of air in and out of the lungs, and diffusion, the movement of gases between air spaces and the bloodstream. Respiration is the exchange of oxygen and carbon dioxide during cellular metabolism.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:800

OBJ:Identify the physiological processes involved in ventilation, perfusion, and exchange of respiratory gases.TOP:Nursing Process: Assessment

MSC:Client Needs: Physiological Integrity

5.The patient is experiencing shortness of breath. Which of the following lab tests indirectly indicates the oxygen level in the blood system?

a.
Hemoglobin
b.
White blood cell count
c.
Electrolytes
d.
Creatinine

ANS: A

Hemoglobin transports most oxygen and serves as a carrier for both oxygen and carbon dioxide. White blood cell count is a lab test to measure infection. Electrolytes do not indicate oxygen levels but do indicate electrolytes like sodium and potassium. Creatinine levels measure kidney function.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:801

OBJ:Identify the physiological processes involved in ventilation, perfusion, and exchange of respiratory gases.TOP:Nursing Process: Assessment

MSC:Client Needs: Physiological Integrity

6.The nurse is admitting a patient with chronic obstructive pulmonary disease (COPD). During the initial head-to-toe assessment the patient’s pulse oximetry reading is 89% on room air. What is the nurse’s first priority?

a.
Administer oxygen immediately @ 4L/NC.
b.
Call the primary health care provider for an order for oxygen.
c.
Assist the patient into a recumbent position.
d.
Determine the patient’s normal pulse oximetry reading.

ANS: D

The nurse must determine what is normal for this patient. The patient has COPD and the breathing stimulus is low oxygen, not increased carbon dioxide. When caring for patients with COPD and chronically elevated PaCO2 levels, remember that inappropriate administration of excessive oxygen will result in hypoventilation. Patients with COPD and hypercapnia (high carbon dioxide levels) have adapted to the higher carbon dioxide level. The carbon dioxide–sensitive chemoreceptors are no longer sensitive to increased carbon dioxide as a stimulus to breathe. Their stimulus to breathe is a decreased PaO2. The most effective position for patients with cardiopulmonary diseases is the 45-degree semi-Fowler’s position, using gravity to assist in lung expansion and reduce pressure from the abdomen on the diaphragm. Administering excessive oxygen to patients with COPD satisfies the oxygen requirement of the body and negates the stimulus to breathe. High concentrations of oxygen (e.g., greater than 24% to 28% [1 to 3 L/min]) prevent the PaO2 from falling. As a result, this suppresses the stimulus to breathe, resulting in hypoventilation.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:802

OBJ:Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Planning

MSC:Client Needs: Physiological Integrity

7.A 36-year-old patient diagnosed with meningitis has a fever of 102.3° F. A family member verbalizes a concern that the patient is “breathing fast.” Upon assessment, the nurse notes a respiratory rate of 20 breaths/min, pulse oximetry is 92% on 2L/O2, and lungs clear to auscultation. What is the best explanation for the rapid respiratory rate that the nurse can give the family member?

a.
“He is most likely anxious because he is in the hospital.”
b.
“His fever has increased his metabolic rate and is causing him to breathe faster.”
c.
“He is hyperventilating because he needs more oxygen.”
d.
“He has an acid-base imbalance, which is causing him to hyperventilate.”

ANS: B

An increase of 1° F in body temperature causes a 7% increase in the metabolic rate, thereby increasing carbon dioxide production. The clinical response is increased rate and depth of respiration. Anxiety is not the reason for increased respirations in this scenario. The fever (102.3° F) is the cause of the increased respirations. The patient may have increased breathing but the patient is not hyperventilating. Hyperventilation occurs when the respiratory rate is greater than 20 breaths per minute in an adult, causing an increase in carbon dioxide elimination.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:802

OBJ:Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Implementation

MSC:Client Needs: Physiological Integrity

8.What is the best indicator the nurse can use to determine the adequacy of a patient’s cardiac output?

a.
Stroke volume
b.
Myocardial contractility
c.
Afterload
d.
Cardiac index

ANS: D

Cardiac index is a measure of adequacy of the cardiac output. It equals the cardiac output divided by the patient’s body surface area. This calculation provides the caregiver with a more accurate calculation of blood flow by considering the patient’s body surface area. Stroke volume (SV) is the amount of blood ejected from the ventricle with each contraction. The normal range for a healthy adult is 50 to 75 mL per contraction. Myocardial contractility is the ability of the heart to squeeze blood from the ventricles and prepare for the next contraction. This is difficult to measure because preload, afterload, and heart rate must remain constant. Afterload is the resistance to the ejection of blood from the left ventricle. The left ventricular pressure must be greater than the aortic pressure to eject blood from the heart.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:803

OBJ:Describe the relationship of cardiac output, preload, afterload, contractility, and heart rate.TOP:Nursing Process: Assessment

MSC:Client Needs: Physiological Integrity

9.A patient has been admitted to the cardiac unit with the diagnosis of bradycardia. The patient states “I am confused about what the doctor said is wrong with me, he said my pacemaker is not working. I don’t have a pacemaker.” What is the nurse’s best response?

a.
“The sinoatrial node is the ‘pacemaker’ of your heart.”
b.
“Myocardial contractility determines your heart rate.”
c.
“The atrioventricular node is the ‘pacemaker’ of your heart.”
d.
“The ventricular Purkinje network determines your heart rate.”

ANS: A

The conduction system originates with the sinoatrial node, the “pacemaker” of the heart. Electrical impulses are then transmitted along intraatrial pathways to the atrioventricular (AV) node. The AV node mediates impulse transmission between the atria and the ventricles. Delaying the impulse at the AV node before transmitting it through the bundle of His and ventricular Purkinje network. The heart rate is regulated by the sympathetic and parasympathetic systems, not by myocardial contractility and ventricular Purkinje network. Myocardial contractility is the ability of the heart to squeeze blood from the ventricles and prepare for the next contraction. This is difficult to measure because preload, afterload, and heart rate must remain constant.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:803 | 804

OBJ:Describe the relationship of cardiac output, preload, afterload, contractility, and heart rate.TOP:Nursing Process: Implementation

MSC:Client Needs: Physiological Integrity

10.A 45-year-old patient was diagnosed with an anterior myocardial infarction. The patient asks the nurse why his chest hurt when he had his heart attack. What is the best response from the nurse?

a.
“One of your heart valves wasn’t working properly and caused an obstructed blood flow.”
b.
“One of your coronary arteries had a spasm, and your heart muscle wasn’t able to get enough blood.”
c.
“Your heart muscle was deprived of oxygen, which caused chest pain.”
d.
“The heart muscle is sensitive to changes in electrical conduction.”

ANS: C

When decreased myocardial blood perfusion is extensive or perfusion is completely blocked, the tissue becomes necrotic and a myocardial infarction occurs. Angina or angina pectoris is the result of decreased blood flow to the myocardium as a result of coronary artery spasms or temporary constriction. When stenosis occurs in the aortic and pulmonic valves, the adjacent ventricles work harder to move the ventricular volume beyond the stenotic valve. When regurgitation occurs, there is a backflow of blood into an adjacent chamber, which causes either pulmonary or systemic congestion. A dysrhythmia is a disturbance in the electrical impulse of the heart rhythm. Any rhythm not generated at the sinoatrial node is classified as such. Dysrhythmias are primary conduction disturbances that occur as a response to ischemia, valvular abnormalities, anxiety, and drug toxicity (e.g., digoxin toxicity).

PTS:1DIF:Cognitive Level: Applying (Application)

REF:804 | 805

OBJ:Describe the relationship of cardiac output, preload, afterload, contractility, and heart rate.TOP:Nursing Process: Implementation

MSC:Client Needs: Physiological Integrity

11.A patient was admitted to the surgical unit after surgical removal of an abdominal tumor. As the nurse performs a postsurgical assessment, the patient’s blood pressure is 90/54, heart rate is 94, and respiratory rate is 22. Based on these values, the nurse should be most concerned with which of the following conditions?

a.
Hypovolemia
b.
Left-sided heart failure
c.
Right-sided heart failure
d.
Hypervolemia

ANS: A

Hypovolemia is a reduced circulating blood volume resulting from extracellular fluid losses that occurs in conditions such as shock and severe dehydration. If the fluid loss is significant, the body tries to adapt by increasing the heart rate and constricting peripheral vessels to increase the volume of blood returned to the heart and increase the cardiac output. The patient is experiencing shock (low blood pressure, increased pulse and respirations). Left-sided heart failure is characterized by impaired functioning of the left ventricle. This is usually caused by increased preload (fluid volume overload) or afterload (increased systemic vascular resistance such as hypertension). Right-sided heart failure results from impaired functioning of the right ventricle, which is typically caused by pulmonary disease or pulmonary hypertension. Fluid volume overload or hypervolemia may lead to vascular congestion in patients with heart, kidney, or lung diseases. The patient has lost fluid, not gained fluid.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:805

OBJ:Identify and describe clinical outcomes as a result of disturbances in conduction, altered cardiac output, impaired valvular function, myocardial ischemia, and impaired tissue perfusion.TOP:Nursing Process: Assessment

MSC:Client Needs: Physiological Integrity

12.The guardians of a premature infant who was delivered at 31-weeks’ gestation is expected to be discharged from the hospital within the next few days. The guardians have voiced concern regarding how to prevent respiratory syncytial virus (RSV) exposure to the baby. What is the best response from the nurse?

a.
“You will need to limit the baby’s exposure to crowds of people.”
b.
“You need to make sure that the car seat is facing backward in the back seat of your car.”
c.
“You do not need to be concerned; the baby has a natural protection against this disease.”
d.
“You must sterilize all the bottles for the first 6 months.”

ANS: A

Premature infants are at risk for development of respiratory illnesses such as respiratory syncytial virus (RSV) as a result of the underdevelopment of the lung. Limiting exposure to crowds of people will limit the exposure to respiratory viruses. Premature infants do not have protection against this virus. The virus is respiratory, so the car seat and bottles will not affect this illness.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:808

OBJ:Identify nursing interventions for promotion, maintenance, and restoration of cardiopulmonary function in the primary care, acute care, and restorative and continuing care settings.TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

13.A 3-month-old infant is being seen for a well-child check at the pediatric clinic. The nurse is assessing the guardian’s knowledge level about the infant’s growth and development. One of the topics that the nurse has chosen to address in this session is the risk for airway obstruction. What is the main reason that the nurse has chosen this topic?

a.
Infants can have severe allergic reactions to food based on exposure to secondhand smoke.
b.
Infants are prone to lower airway infections that can become obstructive.
c.
Infants have a tendency to place foreign objects in their mouths.
d.
Infants can have airway obstruction from excessive drooling associated with teething.

ANS: C

Infants and toddlers are at risk for airway obstruction because of their tendency to place a foreign object in their mouth. Infants and toddlers are at risk for upper respiratory tract infections, not allergic food reactions, as a result of frequent exposure to other children and exposure to secondhand smoke. During the teething process some infants develop nasal congestion, which encourages bacterial growth and increases the risk for respiratory tract infection, but not for airway obstruction. Infants are prone to upper respiratory tract infections, not lower airway infections, which usually are not dangerous, and infants and toddlers recover with little difficulty.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:808

MSC: Client Needs: Health Promotion and Maintenance

14.A patient who is 7 months pregnant with her first child is visiting the health care provider for her scheduled prenatal checkup. She tells the nurse that she is short of breath and fatigued. What is the best response from the nurse?

a.
“You should have let us know immediately instead of waiting until your appointment.”
b.
“I’ll make a note of it on your chart.”
c.
“That is normal; your uterus is causing pressure on your diaphragm, making it more difficult to breathe.”
d.
“Oxygen is needed for you and the baby. I will give you some oxygen to help you.”

ANS: C

Pregnancy causes changes in ventilation. As the fetus grows during pregnancy, the greater size of the uterus pushes abdominal contents up against the diaphragm. During the last trimester of pregnancy the inspiratory capacity declines, resulting in dyspnea on exertion and increased fatigue. Letting the nurse know immediately and applying oxygen are not needed because this is a normal finding. Making a note of it on the chart does not address the patient’s need.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:808

OBJ:Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

15.A 58-year-old Caucasian woman is at the clinic for her annual check-up. She tells the nurse that she noticed her blood pressure is higher than it was when she was younger. She asks the nurse why this would happen. What is the nurse’s best response?

a.
“Your race and gender are predisposing factors for heart disease.”
b.
“Well, if you stop smoking your blood pressure would go down.”
c.
“As we age, our blood vessels become less elastic, which causes higher blood pressure.”
d.
“I don’t think it’s anything to worry about.”

ANS: C

Arterial vessels in the older adult become calcified and lose elastin. This may lead to hypertension and a rise in systolic blood pressure. Both of these normal changes of aging place the older adult at risk for heart failure. Do not be judgmental about smoking and the question does not indicate the female is a smoker. Males, not females, are more prone to heart disease. African-Americans, American Indians, and Mexican-Americans are at greater risk than Caucasians for developing heart disease. Telling the patient to not worry is not therapeutic.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:809 | 810

OBJ:Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

16.A healthy 33-year-old mother of three children reports “having no energy.” She asks the nurse, how she could increase her energy level. What is the best response for the nurse to give?

a.
“You should decrease iron intake.”
b.
“Daily exercise has been shown to increase a person’s energy level.”
c.
“Energy caffeinated drinks are a good substitute for exercise.”
d.
“Try to exercise 90 minutes every other day.”

ANS: B

A physical exercise program has many benefits. People who exercise daily for 30 to 60 minutes, not 90, have a lower heart rate, lower blood pressure, decreased cholesterol, increased blood flow, and greater oxygen extraction by working muscles. Fully conditioned people are able to increase oxygen consumption by 10% to 20% because of increased cardiac output and efficiency of the myocardium. If the diet does not supply iron needed for hemoglobin synthesis, RBC synthesis is reduced, and oxygen-carrying capacity decreases. A risk factor for cardiopulmonary disease is excessive use of caffeinated energy drinks.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:808 | 809

OBJ:Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

17.The family member of a 73-year-old patient with chronic obstructive pulmonary disease (COPD) is concerned about the patient’s recent weight loss. When questioned by the nurse, the patient denies any change in diet or activity, but admits to losing 10 lb in the past 6 weeks. What is the nurse’s best response to the family member’s concern?

a.
“Maybe the patient has a higher metabolic rate than you.”
b.
“It doesn’t seem fair that some people can lose weight so easily.”
c.
“This disease affects the respiratory system and causes the body to burn more calories to supply the energy to breathe.”
d.
“You need to discuss this with the health care provider so testing can be ordered for tuberculosis.”

ANS: C

A patient with chronic lung disease usually requires a diet higher in calories because of the increased work of breathing. Inadequate nutrition occurs when nutritional intake does not meet nutritional needs. Without essential nutrients, a patient may experience respiratory muscle wasting, resulting in decreased muscle strength and respiratory excursion. One symptom of tuberculosis is rapid weight loss, which is not appropriate based on the question. The effort of breathing, not metabolic rate, is the reason for the weight loss. Saying that it doesn’t seem fair does not address the family member’s concern.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:808

OBJ:Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

18.A college student who smokes asks a healthcare professional if there really is a connection between smoking and lung cancer. What is the healthcare worker’s best response?

a.
The risk for lung cancer for smokers than for nonsmokers is 5 times greater.
b.
The risk for lung cancer for smokers than for nonsmokers is 10 times greater.
c.
The risk for lung cancer for smokers than for nonsmokers is 50 times greater.
d.
Lung cancer affects smokers and non-smokers equally due to occupational hazards.

ANS: B

The risk for lung cancer is 10 times greater for a person who smokes than for a nonsmoker. Exposure to secondhand smoke increases the risk for lung cancer in the nonsmoker and worsens other pulmonary problems such as asthma or COPD: 5 times is too small; 50 times is too great. Lung cancer does not affect smokers and nonsmokers equally

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:809

OBJ:Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

19.A patient on the surgical unit is 1 day postoperative for surgery to remove stomach cancer. In addition to the physiological stress this patient has undergone, the nurse recognizes that this patient will have to deal with the psychological stress of finding out that the cancer has metastasized to the liver. Which physiological change would the nurse expect to see as a response to stress?

a.
Decreased heart rate
b.
Increased hemoptysis output
c.
Increased respiratory rate
d.
Decreased cardiac output

ANS: C

A continuous state of stress increases the body’s metabolic rate and the oxygen demand. The body responds to stress by an increased rate and depth of respiration and increased cardiac output. Hemoptysis, bloody sputum, does not occur in stress.

PTS: 1 DIF: Cognitive Level: Remembering (Knowledge)

REF:809

OBJ:Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Assessment

MSC:Client Needs: Physiological Integrity

20.A 47-year-old woman with a history of diabetes and hypertension calls the clinic complaining of epigastric pain and shortness of breath with activity. She has taken antacids with no relief. What type of pain is the patient experiencing?

a.
Pericardial pain
b.
Pleuritic chest pain
c.
Musculoskeletal pain
d.
Cardiac pain

ANS: D

Some women have epigastric pain, complaints of indigestion, or a choking feeling and dyspnea when experiencing cardiac pain. Cardiac pain does not occur with respiratory variations. Cardiac pain is most often substernal and typically radiates to the left arm and jaw in men. Pericardial pain resulting from an inflammation of the pericardial sac is usually nonradiating and often occurs with inspiration or when leaning forward. Pleuritic chest pain is peripheral and usually radiates to the scapular regions. Inspiratory maneuvers such as coughing, yawning, and sighing aggravate pleuritic chest pain. An inflammation or infection in the pleural space usually causes pleuritic chest pain. Musculoskeletal pain is often present following exercise, rib trauma, and prolonged coughing episodes. Inspiratory movements aggravate the pain and are easily confused with pleuritic chest pain.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:812

MSC:Client Needs: Physiological Integrity

21.A patient has been admitted to the pulmonary unit of the hospital with right lower lobe pneumonia and history of chronic obstructive pulmonary disease (COPD). During the initial assessment the nurse notes that the patient has a respiration rate of 18 with retractions, tachycardia, and complains of dyspnea and dizziness. The nurse identifies that these are clinical signs of which condition?

a.
Paroxysmal nocturnal dyspnea
b.
Orthopnea
c.
Hemoptysis
d.
Hypoxia

ANS: D

Dyspnea is a clinical sign of hypoxia. Dyspnea is the subjective sensation of breathlessness as perceived by the patient. Hypoxia is inadequate tissue oxygenation with a deficiency in oxygen delivery or oxygen utilization at the cellular level. Signs and symptoms of hypoxia include tachycardia, peripheral vasoconstriction, dizziness, and mental confusion. Dyspnea that occurs when a patient is sleeping is called paroxysmal nocturnal dyspnea. The patient awakens in a panic, feels as if he or she is suffocating, and has a strong need to sit up to relieve the breathlessness. Orthopnea is an abnormal condition in which a patient has difficulty breathing when lying down and has to use multiple pillows or sit to breathe. Hemoptysis is bloody sputum. It is associated with coughing and bleeding from the upper respiratory tract, from sinus drainage, or from the gastrointestinal tract.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:802 | 812

OBJ:Identify and describe clinical outcomes for hyperventilation, hypoventilation, and hypoxemia.TOP:Nursing Process: Assessment

MSC:Client Needs: Physiological Integrity

22.A health care worker received an annual tuberculosis test administered 56 hours ago. The injection site is very red and flat. The certified nurse who is reading the test should take which action?

a.
Advise the health care worker another test must be done because the test was not read within the proper time.
b.
Tell the health care worker the results are positive and cannot return to work.
c.
Document the results as a negative reaction.
d.
Measure the area in millimeters.

ANS: C

A reddened flat area is not a positive reaction, and you do not need to measure it.

Tuberculosis skin testing positive results is a palpable, elevated, hardened area around the injection site, caused by edema and inflammation from the antigen-antibody reaction, measured in millimeters. Tuberculin skin tests are read between 48 and 72 hours so the health care worker came at the right time (56 hours).

PTS:1DIF:Cognitive Level: Applying (Application)

REF:815

OBJ:Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Implementation

MSC: Client Needs: Health Promotion and Maintenance

23.The nursing student is formulating a nursing care plan for a patient with pneumonia. The care plan is directed toward meeting the potential oxygenation needs of the patient. Which of the following examples would be the best way for the nursing student to write an expected outcome for the care plan?

a.
“The patient will have less pain.”
b.
“The patient will be able to breathe better.”
c.
“The patient’s pulse oximetry reading will remain greater than 92%.”
d.
“The patient’s interactions will be normal.”

ANS: C

All goals need to have measurable outcomes for you to be able to determine whether they have been met. These include objective data, such as oxygen saturation levels, arterial blood gas levels, laboratory findings, chest radiographs, electrocardiogram patterns, blood pressure, and pulse. Quantify subjective findings, such as the reported degree of breathlessness or pain on visual analog scales. Less pain, breathe better, and normal interactions do not include objective data, making them hard to measure.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:815 | 816

MSC:Client Needs: Physiological Integrity

24.The RN and nursing assistive personnel (NAP) are caring for six patients on the pulmonary unit. Which of the following tasks would be most appropriate for the nurse to delegate to the NAP?

a.
Taking vital signs on a 56-year-old man with severe dyspnea
b.
Suctioning a patient with hemoptysis
c.
Encouraging a postoperative patient to use the incentive spirometer
d.
Performing chest percussion on a patient with atelectasis

ANS: C

Base your decision to delegate responsibility to nursing assistive personnel (NAP) on your assessment of the patient and the type of care the patient will receive. Consider which tasks are safe to delegate within the skill set of the NAP and how the patient will feel about the care that you have delegated. Incentive spirometry is a method of encouraging voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It is an effective method for promoting deep breathing to prevent or treat atelectasis in the postoperative patient. Incentive spirometry encourages patients to breathe to their normal inspiratory capacities and can be delegated to a NAP. The priority is to maintain or improve the patient’s oxygenation and meet the patient’s needs. You are ultimately responsible for all the total patient care. In all the other responses the patient is experiencing difficulties that require the nurse’s attention: severe dyspnea (difficulty breathing), hemoptysis (bloody sputum), and chest percussion (done by nurses or respiratory therapists).

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:812 | 815 | 825 | 827

MSC: Client Needs: Safe and Effective Care Environment

25.A student nurse caring for a patient with a chest tube has been asked what equipment should be at the bedside to assess for an air leak. Which information indicates the student nurse has a correct understanding of the equipment needed?

a.
Suction equipment wrapped in plastic to keep instrument clean
b.
Hemostat covered with gauze to prevent penetration of the chest tube
c.
Cup of water to place the end of the chest tube
d.
Petroleum gauze to use as a dressing

ANS: B

Covered hemostats are used to assess for air leaks, not a cup of water, suction equipment, or petroleum gauze. Hemostats have a covering to prevent hemostat from penetrating the chest tube. The use of these hemostats or other clamp prevents air from re-entering the pleural space. Suctioning does not determine an air leak; it is used to clear secretions. If there is a break in the chest drainage device, place the end of the chest tube in a bottle of sterile saline, not water. If a chest tube becomes dislodged apply pressure to chest tube site wound using petroleum gauze, a dry gauze dressing, and adhesive tape.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:839

MSC: Client Needs: Safe and Effective Care Environment

26.A nurse is being oriented to work for an intensive care unit. The hemodynamic data indicate that the patient has a decreased preload. Which information indicates the nurse has a correct understanding of the concept of preload?

a.
It is the amount of blood ejected from the left ventricle each minute.
b.
It is the amount of blood in the heart at the end of ventricular diastole.
c.
It is the resistance to the ejection of blood from the left ventricle.
d.
It is the rhythmic relaxation and contraction of the heart chambers.

ANS: B

Preload is the amount of blood at the end of ventricular diastole. Cardiac output is the amount of blood ejected from the left ventricle each minute. Cardiac conduction is the rhythmic relaxation and contraction of the atria and ventricles dependent on transmission of electrical impulses. Afterload is the resistance of the ejection of blood from the left ventricle.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:803

OBJ:Identify the physiological processes of cardiac output, myocardial blood flow, coronary artery circulation, and respiratory gas exchange.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

27.A patient with pulmonary congestion needs to cough to clear secretions. The nurse instructs the patient to inhale and perform a series of coughs during exhalation. What type of cough did the nurse teach the patient?

a.
Quad
b.
Huff
c.
Cascade
d.
Splinting

ANS: C

With the cascade cough a patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. He or she then opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in patients with large volumes of sputum. A quad cough is used for patients who have a spinal cord injury and no use of their abdominal muscles. While the patient breathes out with a maximal expiratory effort, the patient or you push inward and upward on the abdominal muscles toward the diaphragm, causing the cough. A huff cough stimulates a natural cough reflex. While exhaling, a patient opens the glottis by saying the word huff. Splinting occurs when the patient supports the abdomen when coughing; it is not a type of cough.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:823

MSC:Client Needs: Physiological Integrity

28.The nurse is evaluating a patient who has a chest tube. To properly maintain chest tube function, what is the nurse’s best action?

a.
Strip the tube every hour to maintain drainage.
b.
Place the device below the patient’s chest.
c.
Double clamp the tubes except during assessments.
d.
Remove the tubing from the drainage device to check for proper suctioning.

ANS: B

Observe the chest drainage system to be sure it is upright and below the level of tube insertion. Most institution have stopped stripping the chest tube because this greatly increases intrapleural pressure unless the patient is fresh from postoperative thoracic surgery or has chest trauma. Chest tubes are only clamped under specific circumstances per health care provider’s order or nursing policy to assess for an air leak, to quickly empty or change disposable drainage systems, or to assess if the chest tube is ready to be removed. Clamping the chest tube is not recommended because it may result in a tension pneumothorax, a life-threatening event. Removing the tubing would cause a disruption in the suctioning of the chest tube and should not be done.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:829 | 842

MSC:Client Needs: Physiological Integrity

29.A patient presents with an acute myocardial infarction that resulted in right ventricular damage. The nurse needs to assess the patient for right-sided heart failure, which includes which of the following?

a.
Crackles on auscultation
b.
Jugular neck vein distention
c.
Increased myocardial perfusion
d.
Orthopnea

ANS: B

Right-sided heart failure causes distended jugular veins and peripheral edema. Right-sided heart failure results from impaired functioning of the right ventricle, which is typically caused by pulmonary disease or pulmonary hypertension. An increase in pressure in the pulmonary system causes increased resistance in the right ventricle. The right ventricle fails as a result of this pressure. Left-sided heart failure results in crackles on auscultation and patient complaints of fatigue, dyspnea, and orthopnea. Increased myocardial perfusion does not occur.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:805

MSC:Client Needs: Physiological Integrity

30.A patient reports chest pain. The nurse is attempting to assess the pain to differentiate the pain as cardiac, respiratory, or gastrointestinal. The nurse can properly identify the pain as cardiac in origin when the patient states that the cardiac pain:

a.
does not occur with respiratory variations.
b.
is peripheral and may radiate to the scapular areas.
c.
is aggravated by inspiratory movements.
d.
is nonradiating and occurs during inspiration.

ANS: A

Cardiac pain does not occur with respiratory variations. Cardiac chest pain is most often substernal and radiates to the left arm and jaw in men, but some women have epigastric pain, complaints of indigestion, or a choking feeling and dyspnea. Pericardial pain results from an inflammation of the pericardial sac and is usually nonradiating and often occurs with inspiration. Pleuritic chest pain is peripheral and usually radiates to the scapular region. Inspiratory maneuvers aggravate pleuritic chest pain.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:812

OBJ:Identify the physiological processes of cardiac output, myocardial blood flow, coronary artery circulation, and respiratory gas exchange.

TOP: Nursing Process: Evaluation MSC: Client Needs: Physiological Integrity

31.A patient with a tracheostomy is experiencing thick and tenacious secretions. To maintain this patient’s airway, what is the most appropriate action for the nurse?

a.
Tracheal suctioning
b.
Oropharyngeal suctioning
c.
Nasotracheal suctioning
d.
Orotracheal suctioning

ANS: A

Tracheal suctioning is performed through an artificial airway such as a tracheostomy. Oropharyngeal suctioning clears secretions from the mouth and upper airway. Nasotracheal suctioning introduces the catheter through the naris into the trachea. Orotracheal suctioning introduces the catheter through the mouth into the trachea.

PTS:1DIF:Cognitive Level: Applying (Application)

REF:824

MSC:Client Needs: Physiological Integrity

32.The assistive personnel reports that an older patient is complaining of shortness of breath and palpitations. The nurse connects the patient to an electrocardiogram monitor and analyzes the rhythm with normal P wave and normal QRS and T waves. The rate is 116 beats per minute and regular. The nurse identifies this rhythm as which of the following?

a.
Sinus bradycardia
b.
Ventricular tachycardia
c.
Sinus tachycardia
d.
Normal sinus rhythm

ANS: C

Sinus tachycardia is a rate between 100 and 180 beats per minute with normal P, QRS, and T waves. Ventricular Tachycardia has a rhythm slightly irregular, rate 100 to 200 beats/min, P wave absent, QRS complex wide and bizarre, greater than 0.12 sec. Sinus bradycardia is a rate less than 60 beats per minute with normal P, QRS, and T waves. Normal sinus rhythm is a rate between 60 and 100 beats per minute with normal P, QRS, and T waves.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:805 | 806

MSC:Client Needs: Physiological Integrity

MULTIPLE RESPONSE

1.On entering the room, a nurse finds the patient sitting upright in bed with the upper torso resting on the over-bed table. The nurse assesses that this patient is experiencing acute hypoxemia. Which of the following are symptoms of acute hypoxemia? (Select all that apply.)

a.
Cyanosis
b.
Arrhythmias
c.
Eupnea
d.
Restlessness
e.
Diaphoresis

ANS: A, B, D, E

Symptoms of acute hypoxemia include changes in respiration (tachypnea, dyspnea); blood pressure (hypertension, hypotension); color (pallor, cyanosis); mental status (headache, anxiety, impaired judgment, confusion, euphoria, lethargy); motor function (loss of coordination, weakness, tremors, hyperactive reflexes, restlessness, stupor, coma [around 30 mm Hg], death); arrhythmias (tachycardia, bradycardia), diaphoresis, blurred or tunnel vision, and nausea/vomiting. Eupnea is a normal breathing rate.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:802

OBJ:Identify and describe clinical outcomes for hyperventilation, hypoventilation, and hypoxemia.TOP:Nursing Process: Assessment

MSC:Client Needs: Physiological Integrity

2.The home care nurse is admitting a patient with COPD. The primary healthcare provider has ordered O2 /nasal cannula at 3 L/min. To promote safety, the nurse would instruct the patient on which of the following safety measures? (Select all that apply.)

a.
Place “No smoking” signs in all areas where oxygen will be used.
b.
Instruct family and visitors who smoke that they must smoke a minimum of 10 feet from the patient.
c.
Store tanks in a small closet, trunk of a car, or near the hot water heater.
d.
Oxygen tanks should stay a minimum of 6 feet from space heaters, fireplaces, and appliances with an electric motor.
e.
Know the exit routes and where the fire extinguisher are located in the home.

ANS: A, D, E

Promote safety by using the following measures:

• Place “No smoking” signs on the patient’s room door, over the bed, and in every room of the home where oxygen is used. Inform the patient, visitors, roommates, and all personnel that smoking is not permitted in areas where oxygen is in use.

• Determine that all electrical equipment in a health facility room or patient’s home is functioning correctly and is properly grounded.

• Know the fire procedures and the location of the closest fire extinguisher.

• Check the oxygen level of portable tanks before transporting to ensure that there is enough oxygen in the tank.

• Store oxygen tanks in secure holders to prevent them from being knocked over.

• Store oxygen tanks 6 feet away from toys with electric motors, electric space heaters, fireplaces, electric blankets, hair dryers, or other appliances. Do not store in a trunk box or small closet.

PTS:1DIF:Cognitive Level: Analyzing (Analysis)

REF:820

OBJ:Describe the effects of a patient’s health status, age, lifestyle, and environment on tissue oxygenation.TOP:Nursing Process: Implementation

MSC: Client Needs: Safe and Effective Care Environment

3.An adult collapsed at the grocery store. Before being transported to the emergency department, an automated external defibrillator (AED) was used. The nurse remembers learning that the AED is effective in saving a life because of which factors? (Select all that apply.)

a.
Use of an AED strengthens the chain of survival.
b.
The AED can be used by nonmedical personnel.
c.
The AED sends heart rhythm to the closest emergency room (ER) for the physician to analyze and give orders.
d.
Every minute without defibrillation decreases the survival rate by 7% to 10%.
e.
The AED will automatically deliver a shock to the victim after announcing, “Everyone stand back.”

ANS: A, B, D

The following is information on the use of an automated external defibrillator (AED):

• The automated external defibrillator (AED) is a device used to administer an electrical shock through the chest wall to the heart.

• The AED has a built-in computer that assesses the victim’s heart rhythm and determines if defibrillation is needed.

• The rescuer delivers a shock to the victim after announcing, “Everyone stand back.”

• The AED can be used by nonmedical personnel.

• Use of an AED strengthens the chain of survival. Every minute of a sudden cardiac death without defibrillation decreases the survival rate by 7% to 10% (American Heart Association, 2005).

PTS:1DIF:Cognitive Level: Applying (Application)

REF:830

OBJ:Identify the physiological processes of cardiac output, myocardial blood flow, coronary artery circulation, and respiratory gas exchange.

TOP: Nursing Process: Planning MSC: Client Needs: Physiological Integrity