Question 1

The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient?
A) Inform the patient of the importance of finishing the entire dose of antibiotics.
B) Encourage the patient to stay up-to-date on all vaccinations.
C) Schedule patient to get annual tuberculosis skin testing.
D) Create an exercise routine to run 45 minutes every day.

Accepted Answer

A nursing care plan for preventative health measures should be reasonable and feasible. Keeping up-to-date on vaccinations is important because vaccine reduces the severity of illnesses and serious complications. Determine if and when the patient has had a pneumococcal or influenza (flu) vaccine. This is especially important when assessing older adults because of their increased risk for respiratory disease. Although it is important to finish the full course of antibiotics, it is not a preventative health measure. Scheduling annual tuberculosis skin tests does not address prevention and is an unreliable indictor of tuberculosis in older patients. The exercise routine should be reasonable to increase compliance; exercise is recommended only 3 to 4 times a week for 30 to 60 minutes, and walking, rather than running, is an efficient method.

Question 2

A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step?
1) Insert catheter.
2) Apply suction and remove.
3) Have patient deep breathe.
4) Encourage patient to cough.
5) Attach catheter to suction system.
6) Rinse catheter and connecting tubing.
A) 1, 2, 3, 4, 5, 6
B) 4, 5, 1, 2, 3, 6
C) 5, 3, 1, 2, 4, 6
D) 3, 1, 2, 5, 4, 6

Accepted Answer

The steps for nasotracheal suctioning are as follows: Verify that catheter is attached to suction; have patient deep breathe; insert catheter; apply intermittent suction for no more than 10 seconds and remove; encourage patient to cough; and rinse catheter and connecting tubing with normal saline.

Question 3

A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest?
A) A cup of nonfat yogurt with granola and a handful of dried apricots
B) Whole wheat toast with butter and a side of bacon
C) A bowl of cereal with whole milk and a banana
D) Omelet with sausage, cheese, and onions

Accepted Answer

A 2000-calorie diet of fruits, vegetables, and low-fat dairy foods that are high in fiber, potassium, calcium, and magnesium and low in saturated and total fat helps prevent and reduce the effects of hypertension. Nonfat yogurt with granola is a good source of calcium, fiber, and potassium; dried apricots add a second source of potassium. Although cereal and a banana provide fiber and potassium, skim milk should be substituted for whole milk to decrease fat. An omelet with sausage and cheese is high in fat. Butter and bacon are high in fat.

Question 4

The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination?
A) Experiences chest pain after eating a heavy meal
B) Experiences adequate oxygen saturation during exercise
C) Experiences crushing chest pain for more than 20 minutes
D) Experiences tingling in the left arm that lasts throughout the morning

Accepted Answer

Angina pectoris is chest pain that results from limited oxygen supply. Often pain is precipitated by activities such as exercise, stress, and eating a heavy meal and lasts 3 to 5 minutes. Symptoms of angina pectoris are relieved by rest and/or nitroglycerin. Adequate oxygen saturation occurs with rest; inadequate oxygen saturation occurs during exercise. Pain lasting longer than 20 minutes or arm tingling that persists could be a sign of myocardial infarction.

Question 5

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient?
A) Discontinue the humidification delivery device to keep excess fluid from lungs.
B) Monitor oxygen saturation, and frequently auscultate lung bases.
C) Assist the patient to cough, turn, and deep breathe every 2 hours.
D) Decrease fluid intake to 300 mL a shift.

Accepted Answer

The goal of the nursing action should be the prevention of pneumonia; the action that best addresses this is to cough, turn, and deep breathe to keep secretions from pooling at the base of the lungs. Humidification thins respiratory secretions, making them easier to expel and should be used. Monitoring oxygen status is important but is not a method of prevention. Hydration assists in preventing hospital-acquired pneumonia. The best way to maintain thin secretions is to provide a fluid intake of 1500 to 2500 mL/day unless contraindicated by cardiac or renal status. Restricting fluids is contraindicated in this situation since there is no data indicating cardiac or renal disease.

Question 6

A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately?
A) Ventricular tachycardia
B) Atrial fibrillation
C) Sinus rhythm
D) Paroxysmal supraventricular tachycardia

Accepted Answer

Ventricular tachycardia and ventricular fibrillation are life-threatening rhythms that require immediate intervention. Ventricular tachycardia is a life-threatening dysrhythmia because of the decreased cardiac output and the potential to deteriorate into ventricular fibrillation or sudden cardiac death. Atrial fibrillation is a common dysrhythmia in older adults and is not as serious as ventricular tachycardia. Sinus rhythm is normal. Paroxysmal supraventricular tachycardia is a sudden, rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously.

Question 7

The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia?
A) Elevated blood pressure
B) Increased pulse rate
C) Restlessness
D) Cyanosis

Accepted Answer

Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. Elevated blood pressure, increased pulse rate, and restlessness are early signs of hypoxia.

Question 8

Upon auscultation of the patient's chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse?
A) The beginning of the systolic phase
B) Regurgitation of the mitral valve
C) The opening of the aortic valve
D) Presence of orthopnea

Accepted Answer

When regurgitation occurs, there is a backflow of blood into an adjacent chamber. For example, in mitral regurgitation the mitral leaflets do not close completely. When the ventricles contract, blood escapes back into the atria, causing a murmur, or "whooshing" sound. The systolic phase begins with ventricular filling and closing of the aortic valve, which is heard as the first heart sound, S?. Orthopnea is an abnormal condition in which a patient uses multiple pillows when reclining to breathe easier or sits leaning forward with arms elevated.

Question 9

A patient has carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient?
A) Low-carbohydrate
B) Low-caffeine
C) High-caffeine
D) High-carbohydrate

Accepted Answer

A low-carbohydrate diet is best. Diets high in carbohydrates play a role in increasing the carbon dioxide load for patients with carbon dioxide retention. As carbohydrates are metabolized, an increased load of carbon dioxide is created and excreted via the lungs. A low- or high-caffeine diet is not as important as the carbohydrate load.

Question 10

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

Accepted Answer

To achieve a short-term goal, the nurse should plan a lifestyle change that the patient can make immediately that will have a quick effect. Sleeping on several pillows at night will immediately relieve orthopnea and open the patient's airway, thereby reducing fatigue. Running 30 minutes a day will improve cardiopulmonary health, but a patient needs to build up exercise tolerance. Smoking cessation is another process that many people have difficulty doing immediately. A more realistic short-term goal would be to gradually reduce the number of cigarettes smoked. Limiting caloric intake can help a patient lose weight, but this is a gradual process and is not reasonable for a short-term goal.

Question 11

A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the nurse describe as modifiable?
A) Stress
B) Allergies
C) Family history
D) Gender

Accepted Answer

Young and middle-age adults are exposed to multiple cardiopulmonary risk factors: an unhealthy diet, lack of exercise, stress, over-the-counter and prescription drugs not used as intended, illegal substances, and smoking. Reducing these modifiable factors decreases a patient's risk for cardiac or pulmonary diseases. A nonmodifiable risk factor is family history; determine familial risk factors such as a family history of lung cancer or cardiovascular disease. Other nonmodifiable risk factors include allergies and gender.

Question 12

A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation?
A) Anxiety over illness
B) Decreased drive to breathe
C) Increased metabolic demands
D) Infection destroying lung tissues

Accepted Answer

Increased body temperature (fever) increases the metabolic rate, thereby increasing carbon dioxide production. The increased carbon dioxide level stimulates an increase in the patient's rate and depth of respiration, causing hyperventilation. Anxiety can cause hyperventilation, but this is not the direct cause from a fever. Sleep causes a decreased respiratory drive; hyperventilation speeds up breathing. The cause of the fever in this question is unknown.

Question 13

The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse $\bold{most}$ likely expect?
A) Increased preload
B) Increased heart rate
C) Decreased afterload
D) Decreased tissue perfusion

Accepted Answer

Preload refers to the amount of blood in the left ventricle at the end of diastole; an increase in circulating volume would increase the preload of the heart. Afterload refers to resistance; increased pressure would lead to increased resistance, and afterload would increase. A decrease in tissue perfusion would be seen with hypovolemia. A decrease in fluid volume would cause an increase in heart rate as the body is attempting to increase cardiac output.

Question 14

The nurse needs to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change?
A) Thinner heart valves cause lipid accumulation and fibrosis.
B) Diminished respiratory muscle strength may cause poor chest expansion.
C) Alterations in mental status prevent patients' awareness of ineffective breathing.
D) An increased number of pacemaker cells make proper anesthesia induction more difficult.

Accepted Answer

Age-related changes in the thorax that occur from ossification of costal cartilage, decreased space between vertebrae, and diminished respiratory muscle strength lead to problems with chest expansion and oxygenation,whereby the patient will have difficulty excreting anesthesia gas. The nurse needs to monitor the patient's oxygen status carefully to make sure the patient does not retain too much of the drug. Older adults experience alterations in cardiac function as a result of calcification of the conduction pathways, thicker and stiffer heart valves caused by lipid accumulation and fibrosis, and a decrease in the number of pacemaker cells in the SA node. Altered mental status is not a normal age-related change; it indicates possible cardiac and/or respiratory problems.

Question 15

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen?
A) Nasal cannula
B) Simple face mask
C) Non-rebreather mask
D) Partial non-rebreather mask

Accepted Answer

Nasal cannulas deliver oxygen from 1 to 6 L/min. All other devices (simple face mask, non-rebreather mask, and partial non-rebreather mask) are intended for flow rates greater than 6 L/min.

Question 16

A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is a priority?
A) Risk for skin breakdown
B) Impaired gas exchange
C) Activity intolerance
D) Risk for infection

Accepted Answer

The most important nursing intervention is to maintain airway and circulation for this patient; therefore, Impaired gas exchange is the first nursing priority. Activity intolerance is a concern but is not the priority in this case. Risk for skin breakdown and Risk for infection are also important but do not address an immediate impairment with physiologic integrity.

Question 17

A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis?
A) "Atelectasis affects only those with chronic conditions such as emphysema."
B) "It is important to do breathing exercises every hour to prevent atelectasis."
C) "If I develop atelectasis, I will need a chest tube to drain excess fluid."
D) "Hyperventilation will open up my alveoli, preventing atelectasis."

Accepted Answer

Atelectasis develops when alveoli do not expand. Breathing exercises, especially deep breathing and incentive spirometry, increase lung volume and open the airways, preventing atelectasis. Deep breathing also opens the pores of Kohn between alveoli to allow sharing of oxygen between alveoli. Atelectasis can affect anyone who does not deep breathe. A chest tube is for pneumothorax or hemothorax. It is deep breathing, not hyperventilation, that prevents atelectasis.

Question 18

The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider?
A) Increased anterior-posterior diameter of the chest
B) Accessory muscle used for breathing
C) Clubbing of the fingers
D) Hemoptysis

Accepted Answer

Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies are needed to determine the cause of blood in the sputum. Clubbing of the fingers, barrel chest (increased anterior-posterior chest diameter), and accessory muscle use are all normal findings in a patient with emphysema.

Question 19

A patient with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic?
A) "Your disease doesn't send enough oxygen to your fingers."
B) "Your disease affects both your lungs and your heart, and not enough blood is being pumped."
C) "Your disease will be helped if you pursed-lip breathe."
D) "Your disease often makes patients lose mental status."

Accepted Answer

Clubbing of the nail bed can occur with COPD and other diseases that cause prolonged oxygen deficiency or chronic hypoxemia. Pursed-lipped breathing helps the alveoli stay open but is not the cause of clubbing. Loss of mental status is not a normal finding with COPD and will not result in clubbing. Low oxygen and not low circulating blood volume is the problem in COPD that results in clubbing.

Question 20

A nurse is caring for a patient who is taking warfarin (Coumadin) and discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient?
A) Increased cholesterol level
B) Distended jugular vein
C) Bleeding
D) Angina

Accepted Answer

Patients taking warfarin (Coumadin) for anticoagulation prolong the prothrombin time (PT)/international normalized ratio (INR) results if they are taking gingko biloba, garlic, or ginseng with the anticoagulant. The drug interaction can precipitate a life-threatening bleed. Increased cholesterol levels are associated with saturated fat dietary intake. A distended jugular vein and peripheral edema are associated with damage to the right side of the heart. Angina is temporary ischemia of the heart muscle.

Quiz 41: Oxygenation

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

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

The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination?

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

A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately?

The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia?

Upon auscultation of the patient's chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse?

A patient has carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient?

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 the patient could achieve?

A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the nurse describe as modifiable?

A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation?

The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most\bold{most}most likely expect?

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

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen?

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

A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis?

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

A patient with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic?

A nurse is caring for a patient who is taking warfarin (Coumadin) and discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient?

The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse $\bold{most}$ likely expect?