Fundamentals of Nursing: Oxygenation - Questions and Answers, Exams of Nursing

Download Fundamentals of Nursing: Oxygenation - Questions and Answers and more Exams Nursing in PDF only on Docsity!

Fundamentals of Nursing__

Oxygenation (QUESTIONS)

2024-2025. Questions &

Correct Answers. Graded A

A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104°F (40°C). What physiological process explains why the child is at risk for developing dyspnea? A) Fever increases metabolic demands, requiring increased oxygen need. B) Blood glucose stores are depleted, and the cells do not have energy to use oxygen. C) Carbon dioxide production increases as result of hyperventilation. D) Carbon dioxide production decreases as a result of hypoventilation. – ANS Fever increases metabolic demands, requiring increased oxygen need.

A patient complains of chest pain. When assessing the pain, you decide that its origin is cardiac - rather than respiratory or gastrointestinal - when it? A) Does not occur with respiratory variations. B) Is peripheral and may radiate to the scapular region. C) Is aggravated by inspiratory movements. D) Is non radiating and occurs during inspiration. – ANS Does not occur with respiratory variations A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status? A) Increased breathlessness but increased activity tolerance B) Decreased breathlessness and decreased activity tolerance C) Increased activity tolerance and decreased breathlessness

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy, not cyanotic, the nurse understands that the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following: A) Stimulates hyperventilation, causing respiratory alkalosis B) Forms a strong bond with hemoglobin, creating a functional anemia. C) Stimulates hypoventilation, causing respiratory acidosis D) Causes alveoli to overinflate, leading to atelectasis – ANS Forms a strong bond with hemoglobin, creating a functional anemia. A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning?

A) Coughing up thick sputum only occasionally B) Coughing up thin, watery sputum easily after nebulization C) Decreased independent ability to cough D) Lung sounds clear only after coughing – ANS Decreased independent ability to cough A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds? A) Sonorous wheezes in the left lower lung B) Rhonchi midsternum C) Crackles only in apex of lungs D) Inspiratory crackles in lung bases - ANSInspiratory crackles in lung bases

Airway resistance - ANSthe increase in pressure that occurs as the diameter of the airways decreases from mouth/nose to alveoli. Atelectasis - ANScollapse of the alveoli that prevents normal exchange of oxygen and carbon dioxide. Cascade cough - ANSpatient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then he or she 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. Chest percussion - ANSinvolves rhythmically clapping on the chest wall over the area being drained to force secretions into

larger airways for expectoration. Cannot perform on patients with broken ribs, osterporiuos, and bleeding disorders. Compliance - ANSthe ability of the lungs to distend or expand in response to increased intraalveolar pressure Diaphragmatic breathing - ANSuseful for patients with pulmonary disease, postoperative patients, and women in labor to promote relaxation and provide pain control. The exercise improves efficiency of breathing by decreasing air trapping and reducing the WOB. Diffusion - ANSresponsible for moving the respiratory gases from one area to another by concentration gradients Directed coughing - ANSa deliberate maneuver that is effective when spontaneous coughing is not adequate

inhaling slowly and deep through the mouth for 3- 5 seconds Hold breathe for 10 seconds. Exhale through pursed-lips Huff cough - ANSstimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the word huff. With practice he or she inhales more air and is able to progress to the cascade cough. Indications for home oxygen therapy - ANSan arterial partial pressure (PaO2) of 55 mm Hg or less or an arterial oxygen saturation (SaO2) of 88% or less on room air at rest, on exertion, or with exercise. Nasal Cannula - ANSsimple, comfortable device used for precise oxygen delivery. Attach it to a humidified oxygen source with a flow rate up to 6 L/min (24% to 40% oxygen). Flow rates equal to or greater than 4 L/min have a drying effect on the mucosa and thus need to be humidified.

Non rebreather mask - ANSIt has a one-way valve that prevent exhaled air from returning to the reservoir bag. The flow rate should be a minimum of 10 L/min and deliver FIO2 of 60% to 80%. Frequently inspect the reservoir bag to make sure that it is inflated. If it is deflated, the patient is breathing large amounts of exhaled carbon dioxide. High-flow oxygen systems should be humidified. Normal pulse oximetry - ANS95%-100% Oxygen saturation - ANSthe percentage of hemoglobin that is bound with oxygen Partial rebreather mask - ANSsimple mask with a reservoir bag that should be at least one third to one-half full-on inspiration and delivers from 40% to 70% FIO2 with a flow rate of 6 to 10 L/min. The flow rate should be a minimum of 10 L/min and deliver FIO2 of 60% to 80%. Frequently inspect the reservoir bag to make sure that it is inflated. If it is deflated, the patient

Postural drainage position for adult left upper lobe - anterior lung segment - ANSSupine with head elevated Postural drainage position for adult left upper lobe - posterior lung segment - ANSSide-lying with left side of chest elevated on pillows Postural drainage position for adult right lower lobe - posterior lung segment - ANSProne with right side of chest elevated in Trendelenburg's position Postural drainage position for adult right lower lobe lung segment - ANSLeft side-lying in Trendelenburg's position Postural drainage position for adult right middle lobe - anterior lung segment - ANSThree-fourths supine position with dependent lung in Trendelenburg's position Postural drainage position for adult right middle lobe- posterior lung segment - ANSProne with thorax and abdomen elevated

Postural drainage position for adult right upper lobe - anterior lung segment - ANSSupine with head elevated Postural drainage position for adult right upper lobe - posterior lung segment - ANSSide-lying with right side of chest elevated on pillows Postural drainage position for child bilateral apical lung segment - ANSSitting on nurse's lap, leaning slightly forward flexed over pillow Postural drainage position for child bilateral lobes - anterior lung segments - ANSLying supine on nurse's lap, back supported with pillow Postural drainage position for child bilateral middle lobes - anterior lung segments - ANSSitting on nurse's lap, leaning against nurse Pulmonary circulation - ANSmoves blood to and from the alveolar capillary membranes gas exchange

oximeter. C) Take his blood pressure and respiratory rate. D) Notify the health care provider of his shortness of breath. - ANSRaise the head of the bed to 45 degrees. The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? (Select all that apply.) A) SpO2 levels B) Amount of sputum production C) Change in respiratory rate and pattern D) Pain in lower calf area

• ANSSpO2 levels Amount of sputum production Change in respiratory rate and pattern The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion? A) Antibiotics B) Frequent change of position C) Oxygen humidification D) Chest physiotherapy - ANSFrequent change of position The nurse

needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient? A) Nasal cannula B) Venturi mask C) Simple face mask without inflated reservoir bag D) Plastic face mask with inflated reservoir bag - ANSNasal cannula Tidal volume - ANSthe amount of air exhaled after normal inspiration. Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? A) Record the amount and continue to monitor drainage B) Notify the health care provider C) Strip the chest tube starting at the chest D) Increase the suction by 10 mm Hg - ANSRecord the amount and continue to monitor drainage

requires sterile technique." B) "I'll apply suction while rotating and withdrawing the suction catheter." C) "I'll suction the mouth after I suction the endotracheal tube." D) "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient." - ANS"I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient." Work of breathing - ANSThe effort required to expand and contract the lungs