Deck 38: Oxygenation and Perfusion

Question 1

A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate?

A) changes in the alveolar-capillary membrane and diffusion
B) alterations in the structures of the ribs and diaphragm
C) rapid decreases in atmospheric and intrapulmonic pressures
D) lower-than-normal concentrations of environmental oxygen

Answer 1

changes in the alveolar-capillary membrane and diffusion

Question 2

An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur?

A) Inspiration and expiration
B) Only on inspiration
C) Only on expiration
D) When coughing

Answer 2

Inspiration and expiration

Question 3

Which of the following diseases may result in decreased lung compliance?

A) Emphysema
B) Appendicitis
C) Acne
D) Chronic diarrhea

Answer 3

Emphysema

Question 4

Which individual is at greater risk for respiratory illnesses from environmental causes?

A) A farmer on a large farm
B) A factory worker in a large city
C) A woman living in a small town
D) A child living in a rural area

Question 5

What does pulse oximetry measure?

A) Cardiac output
B) Peripheral blood flow
C) Arterial oxygen saturation
D) Venous oxygen saturation

Question 6

A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?

A) Using upper chest muscles more effectively
B) Replacing the use of incentive spirometry
C) Reducing the need for p.r.n. pain medications
D) Prolonging expiration to reduce airway resistance

Question 7

A nurse is caring for a client who suddenly begins to have respiratory difficulty. In what position would the nurse place the client to facilitate respirations?

A) Supine
B) Prone
C) High-Fowler's
D) Dorsal recumbent

Question 8

A client is experiencing hypoxia. Which of the following nursing diagnoses would be appropriate?

A) Anxiety
B) Nausea
C) Pain
D) Hypothermia

Question 9

What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home?

A) "Although the test is uncomfortable, it is not painful."
B) "You will be asked to forcefully exhale into a mouthpiece."
C) "The test is used to determine how much air you inhale."
D) "You will do this each morning while still lying in bed."

Question 10

A nurse is beginning to conduct a health history for a client with respiratory problems. He notes that the client is having respiratory distress. What would the nurse do next?

A) Continue with the health history, but more slowly.
B) Ask questions of the family instead of the client.
C) Conduct the interview later and let the client rest.
D) Initiate interventions to help relieve the symptoms.

Question 11

While the nurse is providing morning hygiene for a client who has a chest tube, the client has rolled over quickly and the chest tube has become disconnected from the drainage unit. How should the nurse first respond to this event?

A) Submerge the end of the tube in sterile water.
B) Clamp the tube near the end and also near the insertion point.
C) Place the end of the tube on a sterile surface and seek help promptly.
D) Clean the end of the tube with an alcohol swab and reconnect it to the drainage unit.

Question 12

Of all factors, what is the most important risk factor in pulmonary disease?

A) Air pollution from vehicles
B) Dangerous chemicals in the workplace
C) Active and passive cigarette smoke
D) Loss of the ozone layer of the atmosphere

Question 13

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is "Ineffective Airway Clearance related to copious and tenacious secretions." Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan?

A) Encouraging the client to consume two to three quarts of clear fluids daily
B) Creating an environment that is likely to reduce anxiety
C) Positioning the client supine
D) Encouraging the client to decrease the number of cigarettes smoked daily

Question 14

The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the client's care plan?

A) Provide six small meals daily.
B) Provide three large meals daily.
C) Encourage the client to eat immediately before breathing treatments.
D) Encourage the client to alternate eating and using a nebulizer during meal time.

Question 15

A woman 90 years of age has been in an automobile crash and sustained four fractured ribs on the left side of her thorax. Based on her age and the injury, she is at risk for what complication?

A) Pneumonia
B) Altered thought processes
C) Urinary incontinence
D) Viral influenza

Question 16

In what age group would a nurse expect to assess the most rapid respiratory rate?

A) Older adults
B) Middle adults
C) Adolescents
D) Infants

Question 17

A nurse is educating a preoperative client on how to effectively deep breathe. Which of the following would be included?

A) "Make each breath deep enough to move the bottom ribs."
B) "Breathe through the mouth when you inhale and exhale."
C) "Breathe in through the mouth and out through the nose."
D) "Practice deep breathing at least once each week."

Question 18

A client has had a head injury affecting the brain stem. What is located in the brain stem that may affect respiratory function?

A) Chemoreceptors
B) Stretch receptors
C) Respiratory center
D) Oxygen center

Question 19

A father of a preschool-age child tells the nurse that his child "has had a constant cold since going to daycare." How would the nurse respond?

A) "Your child must have a health problem that needs medical care."
B) "Children in daycare have more exposure to colds."
C) "Are you washing your hands before you touch the child?"
D) "Be sure and have your child wear a protective mask at school."

Question 20

A nurse is caring for a toddler who is having an acute asthmatic attack with copious mucus and difficulty breathing. The child's skin is cyanotic, respirations are labored and rapid, and pulse is rapid. What nursing diagnosis would have priority for care of this child?

A) Anxiety
B) Ineffective Airway Clearance
C) Excess Fluid Volume
D) Disturbed Sensory Perception

Question 21

A nurse is caring for an older adult client who is to be discharged from the health care facility. The client has been prescribed the use of a liquid oxygen unit at home to continue with oxygen therapy. What should the nurse tell the client regarding the potential problems of using a liquid oxygen unit? Select all that apply.

A) Liquid oxygen may leak during warm weather.
B) The unit may give off a bad smell if not cleaned regularly.
C) The unit's outlet may become occluded because of frozen moisture.
D) Portable liquid oxygen is more expensive.
E) The unit may require a secondary source of oxygen.

Question 22

What prevents air from re-entering the pleural space when chest tubes are inserted?

A) The location of the tube insertion
B) The sutures that hold in the tube
C) A closed water-seal drainage system
D) Respiratory inspiration and expiration

Question 23

A nurse is conducting a health promotion program for adolescents to educate them about the hazards of smoking. When describing the effects on the respiratory system, which of the following would the nurse most likely include?

A) Decreased production of mucus
B) Inhibition of mucus removal
C) Increase in the mucous escalator
D) Inhibition of bacterial colonization

Question 24

A nurse is delivering oxygen to a client via an oxygen mask. Which of the following is a recommended guideline for this procedure?

A) Adjust the mask so it fits tightly around the face.
B) For a mask with a reservoir, fill the reservoir half-full of oxygen.
C) Remove the mask and dry the skin every two to three hours if the oxygen is running continuously.
D) If the client is experiencing redness around the mask, remove and apply powder to the mask.

Question 25

A nurse assesses the vital signs of a healthy newborn infant. What respiratory rate could be expected based on the developmental level of this client?

A) 15 to 25 breaths/minute
B) 16 to 20 breaths/minute
C) 20 to 44 breaths/minute
D) 30 to 55 breaths/minute

Question 26

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. What additional assessment would the nurse expect to observe?

A) Crackles in the lower lobes
B) Inspiratory stridor
C) Expiratory stridor
D) Wheezing in the upper lobes

Question 27

A physician prescribes the use of water-seal chest tube drainage for a client at a health care facility. What should the nurse ensure when using the water-seal chest tube drainage?

A) Filters need to be cleaned regularly to avoid unpleasant taste or smell.
B) The chest tube should not be separated from the drainage system unless clamped.
C) A nasal cannula should be used to administer oxygen when cleaning the opening.
D) A secondary source of oxygen should be available in case of power failure.

Question 28

A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply.

A) Monitor the client's respiratory rate.
B) Note the amount of oxygen administered.
C) Check the symmetry of the client's chest.
D) Observe the breathing pattern and effort.
E) Check the devices used to deliver oxygen.

Question 29

A nurse is educating a postoperative client on how to use an incentive spirometer. Which of the following is an accurate step that should be included in the teaching plan?

A) Instruct the client to inhale normally and then place the lips securely around the mouthpiece.
B) Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose.
C) When the client cannot inhale anymore, the patient should hold his or her breath and count to 10.
D) Encourage the client to perform incentive spirometry two to three times every one to two hours, if possible.

Question 30

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula?

A) It can cause the nasal mucosa to dry in case of high flow.
B) It can cause anxiety in clients who are claustrophobic.
C) It can create a risk of suffocation.
D) It can result in an inconsistent amount of oxygen.

Question 31

What category of medications may be administered by nebulizer or metered-dose inhaler to open narrowed airways?

A) Bronchoconstrictors
B) Antihistamines
C) Narcotics
D) Bronchodilators

Question 32

A nurse is educating a client who has congested lungs how to keep secretions thin, and more easily coughed up and expectorated. What would be one self-care measure to teach?

A) Limit oral intake of fluids to less than 500 mL per day.
B) Increase oral intake of fluids to two to three quarts per day.
C) Maintain bed rest for at least three days.
D) Take warm baths every night for a week.

Question 33

A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them?

A) "It is inserted into the space between the lining of the lungs and the ribs."
B) "I don't exactly know, but I will make sure the doctor comes to explain."
C) "It is inserted directly into the lung itself, connecting to a lung airway."
D) "It is inserted into the peritoneal space and drains into the lungs."

Question 34

A physician is choosing a chest drainage system for a client who is ambulating daily. Which of the following systems would be the best choice for this client?

A) Traditional water seal
B) Wet suction
C) Dry suction water seal
D) Dry suction/one-way valve system

Question 35

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of

A) Atelectasis
B) Bronchospasm
C) Croup
D) Epiglottitis