Chapter 41 Fundamental – Flashcards
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Which condition is most likely induced by salicylate poisoning?
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Hyperventilation
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The nurse is teaching a group of patients about respiratory disease. Which factors can affect the oxygen-carrying capacity of the blood? Select all that apply. 1 Anemia 2 Dysuria 3 Inhalation of toxins 4 Severe dehydration 5 Fracture of radius bone
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1,3,4
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Arrange the steps in order for applying a nasal cannula to a patient. Incorrect 1. Attach the nasal cannula to a humidified oxygen source Incorrect 2. Insert nasal prongs slightly into the patient's nostrils Incorrect 3. Fit the attached tubing over the patient's ears Incorrect 4. Use the slide connector and secure it under the chin
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2,3,4,1
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The hemoglobin level of a patient who has pallor and looks weak is 8 g/dL. Upon assessment, the patient's heart rate is 110 bpm and respiratory rate is 30 breaths per minute. Which physiological factor is directly responsible for this condition? 1 Increased metabolic rate 2 Reduced circulating blood volume 3 Decreased oxygen-carrying capacity 4 Decreased inspired oxygen concentration
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3
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What is the reason for heart failure after myocardial infarction (MI)? 1 Increased myocardial workload 2 Increased oxygen demands of the myocardium 3 Inability of the heart chambers to fill adequately 4 Impairment of the contractile function of the ventricle
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4
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The nurse assesses that the infant's oxygenation is affected by teething. Which condition is associated with this development? 1 Nasal congestion 2 Enlargement of the trachea 3 Reduced functional cilia 4 Calcification of the heart valves
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1
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A nurse assesses a patient and determines there are color changes to the skin due to hypoxia. What may be the cause of this change? 1 Decreased metabolic rate 2 Decreased circulation of blood volume 3 Decreased inspired oxygen concentration 4 Decreased carbon dioxide-carrying capacity
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2
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Which diagnostic test is used in the daily measurement for early detection of asthma exacerbations? 1 Lung scan 2 Thoracentesis 3 Pulmonary function test 4 Peak expiratory flow rate
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4
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A patient is admitted to a hospital with a myocardial infarction. Which common signs or symptoms should the nurse expect in this patient? Select all that apply. 1 The patient has a crushing or squeezing chest pain. 2 The pain does not last more than 20 minutes. 3 The pain is not ameliorated by rest or nitroglycerine. 4 There are convulsions and spasms of the extremities. 5 There may be shortness of breath along with chest pain
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1,3,5
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The nurse is conducting a health awareness program on the ill effects of smoking. Which information should the nurse include? Select all that apply. 1 Smoking causes vasodilatation and hypotension. 2 Smoking can cause lung cancer as well as leukemia. 3 Nicotine causes vasoconstriction and hypertension. 4 Smoking during pregnancy contributes to a macrocosmic infant. 5 Smoking during pregnancy can cause low-birth-weight babies
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2,3,5
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A patient complains of chest pain and discomfort. Which diagnostic studies should the nurse anticipate? Select all that apply. 1 Serum cholesterol 2 Electrocardiogram 3 Electroencephalogram 4 Serum cardiac enzymes 5 Ultrasonography of pelvis
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1,2,4
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While caring for a patient who has hypoxia, the nurse finds that the patient's airway clearance is ineffective due to retention of thick pulmonary secretions. Which nursing interventions may be beneficial for the patient? Select all that apply. 1 Encouraging fluid intake 2 Teaching cascade cough 3 Administering antipyretic drugs 4 Administering intravenous antibiotics 5 Placing the patient in a low Fowler's position
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1,2
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A patient who has left-sided heart failure develops fatigue, breathlessness, dizziness, and confusion. Chronologically arrange the pathophysiologic events involved in the development of this condition. 1. Decreased cardiac output 2. Development of tissue hypoxia 3. Decreased functioning of the left ventricle 4. Development of symptoms such as fatigue and breathlessness 5. Decreased amount of blood ejected from the left ventricle
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3, 5, 1, 2, 4
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While caring for a patient with respiratory disease, the nurse observes that the oxygen saturation drops from 94% to 85% when the patient ambulates. Which is the most appropriate nursing action? 1 Administer supplemental oxygen. 2 Obtain arterial blood gas (ABG) values to verify the oxygen saturation reading. 3 Continue to monitor the patient as this finding is a normal response to activity. 4 Move the oximetry probe from the finger to the earlobe for an accurate oxygen saturation measurement during activity
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1
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A patient who has a history of chronic obstructive pulmonary disease (COPD) and diabetes mellitus develops hypoventilation. What does the nurse suspect is the cause of the hypoventilation? 1 Salicylate poisoning 2 Diabetic ketoacidosis 3 Amphetamine overdose 4 Overdose of oxygen therapy
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4
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Which condition may cause hypoxia due to decreased movement of the chest wall? 1 Microcytic anemia 2 Anaphylactic shock 3 Guillain-Barré syndrome 4 Carbon monoxide toxicity
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3
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A patient reports having chronic dry cough in the mornings, with occasional production of thick, yellow-green sputum in small quantities. The nurse finds that the patient has dry skin and the mucous membranes are dry. On auscultation, crackles are heard in lower lobes bilaterally. Which intervention will relieve dryness of the mucous membranes? 1 Giving a nebulizer treatment 2 Giving plenty of oral fluids 3 Administering 2 L/min of oxygen 4 Instilling normal saline into airways
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2
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The nurse is caring for a patient who has been diagnosed with pneumonia. The blood gases report that was taken during admission indicates respiratory acidosis with mild hypoxemia. Repeated arterial blood gas (ABG) analysis reveals that hypoxemia is worsening. Presently, the PaO2 is 50 mm Hg and SpO2 is 70%. Which signs or symptoms consistent with decreased oxygen levels may the nurse find in the patient? Select all that apply. 1 Tachypnea 2 Cough 3 Fever 4 Cyanosis 5 Tachycardia
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1,4,5
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The nurse is caring for a patient who has been diagnosed with pneumonia. The patient reports intermittent episodes of cough accompanied with thick yellow sputum. On auscultation, the nurse finds abnormal lung sounds (crackles) in the left base and both upper lobes. A chest x-ray reveals infiltrations in both upper lobes and the left lower lobe. Which instructions given by the nurse are appropriate for this patient? Select all that apply. 1 "Drink good quantities of warm water." 2 "Walk around as much as you can." 3 "Place a hot-water bag on your chest." 4 "Try to spend most of your time in prone position." 5 "Perform deep-breathing exercises once every 2 hours.
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1,2,5
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A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds? 1 Sonorous wheezes in the left lower lung 2 Rhonchi midsternum 3 Crackles only in apex of lungs 4 Inspiratory crackles in lung bases
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4
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Which age-related changes in the older adult may result in decreased tissue oxygenation due to impaired chest expansion? Select all that apply. 1 Change in cough mechanism 2 Impairment of the immune system 3 Ossification of costal cartilage 4 Decreased intervertebral space 5 Diminished respiratory muscle strength
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3,4,5
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During assessment, which finding indicates the presence of pneumothorax? 1 Absence of lung sounds on the affected side 2 Inability to auscultate tracheal breath sounds 3 Pleuritic pain that worsens on inspiration
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3
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The nurse asks a patient to say "ahh" while performing suctioning. What is the rationale behind this intervention? 1 To facilitate breathing 2 To elevate the bronchial passage 3 To assist in opening the glottis 4 To permit the flow of secretions into the mouth
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3
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Which nursing action is most appropriate during suctioning? 1 Picking up the connecting tubing with the dominant hand 2 Applying a clean glove to the dominant hand for oropharyngeal suctioning 3 Applying a sterile glove to the nondominant hand for artificial airway suctioning 4 Picking up a suction catheter with the nondominant hand and not letting the catheter touch nonsterile surfaces
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2
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What is the most serious complication of a tracheostomy? 1 Hypoxemia 2 Arrhythmia 3 Hypotension 4 Airway obstruction
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4
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Which type of suctioning should be performed before pharyngeal suctioning? 1 Orotracheal suctioning 2 Nasotracheal suctioning 3 Oropharyngeal suctioning 4 Nasopharyngeal suctioning
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2
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Which risk is associated with suctioning when performed in an appropriate time interval on a patient who has a head injury? 1 Irregular heartbeat 2 Decreased blood pressure 3 Increased intracranial pressure 4 Abnormal decrease in oxygen concentration
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3
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While caring for a patient undergoing suctioning, the nurse suddenly insists on stopping the process of suctioning. Which parameter observed by the nurse supports this intervention? 1 Pulse oximetry of 90% 2 Body temperature of 99° F 3 Heart rate of 40 bpm 4 Respiratory rate of 20 breaths per minute
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3
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A registered nurse evaluates the actions of a nursing student who is performing tracheal suctioning in a patient who has a history of respiratory distress. Which of the student's nursing actions indicates effective learning? 1 Applying the suction before the patient has coughed 2 Applying suction pressure while inserting the catheter 3 Continuing the press without allowing rests in between passes of the catheter 4 Maintaining the suction pressure between 120 and 150 mm Hg while withdrawing the catheter
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4
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While performing airway suctioning, the nurse detects that the patient's blood pressure is low and finds that the patient has hypoxemia and arrhythmias. Which nursing action is most likely responsible for the patient's condition? 1 Rotating the catheter 2 Performing too frequent suctioning 3 Applying negative pressure during the withdrawal of the catheter 4 Maintaining pressure at 125 mm Hg while withdrawing the catheter
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2
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What is the rationale for hyperventilating the patient who has a head injury prior to suctioning? 1 To decrease the stimulus to breathe 2 To reduce the possibility of hypocarbia 3 To reduce the potential increase in intracranial pressure (ICP) 4 To reduce the risk of spreading microorganisms into the lower respiratory tract
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3
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The nurse is performing inner cannula care for a patient with a tracheostomy. Which intervention provided by the nurse is incorrect? 1 Dropping the inner cannula into normal saline solution 2 Removing the inner cannula with the nondominant hand 3 Holding the inner cannula over a basin and rinsing it with water 4 Using a small brush to remove secretions inside the cannula
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3
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What is the consequence of using an artificial airway that is too large? 1 Hypotension 2 Thick secretions 3 Airway obstruction 4 Aspiration of gastric contents
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3
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What should the nurse do when a patient with a tracheostomy tube experiences the signs and symptoms of respiratory distress? 1 Perform manual ventilation 2 Remove the outer cannula of the endotracheal tube 3 Remove secretions around the stoma 4 Seek the assistance of the nursing assistive personnel
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1
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he nurse is observing a patient's respiratory rate and depth. During which stage of the nursing process does this take place? 1 Planning 2 Evaluation 3 Assessment 4 Implementation
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3
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Which statement about a simple face mask is true? 1 It is more expensive than other cannulas 2 It is used while transporting the patient 3 It does not impede eating or talking 4 It is used to treat carbon dioxide retention
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2
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While preparing a patient for an endotracheal tube, the nurse uses a Yankauer suction tip. What is the rationale for this nursing action? 1 To reduce anxiety and encourage cooperation 2 To reduce the risk of accidental extubation of the artificial airway 3 To facilitate procedure completion without causing discomfort 4 To reduce the transmission of microorganisms to linens and bedclothes
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4
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The nurse is caring for a patient with an endotracheal tube. Which of the nurse's actions requires correction? 1 Holding the endotracheal tube firmly 2 Cleaning the oral airway with plain water 3 Keeping the endotracheal tube cuff inflated 4 Cleaning the face and neck with a soapy washcloth
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2
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What are the disadvantages of using an oxygen-conserving cannula? Select all that apply. 1 Increases risk of aspiration 2 Cannula cannot be cleaned 3 May induce feelings of claustrophobia 4 More expensive than standard cannula 5 Contraindicated in patients who retain carbon dioxide
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2,4
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Which patient finding indicates the need for home oxygen therapy? 1 Heart rate 72 bpm 2 Respiratory rate 24 bpm 3 Arterial partial pressure 50 mm Hg 4 Serum carbon dioxide level 24 mEq/L
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3
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Which type of oxygen mask is contraindicated for patients who have carbon dioxide retention? 1 Venturi mask 2 Nasal cannula 3 Simple face mask 4 Partial rebreather
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3
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Which oxygen delivery system is indicated for long-term oxygen use at home? 1 Oxyimer 2 Partial mask 3 Nasal cannula 4 Nonbreather mask
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1 Indicated for long-term oxygen use at home. Partial masks, nasal cannulas, and nonrebreather masks are used for short periods.
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While caring for a patient who has a chest tube, the nurse finds continuous bubbling in a water-seal chamber. Which intervention would be beneficial for the patient? 1 Unclamping the chest tube 2 Obtaining a large-gauge needle 3 Obtaining a flutter (Heimlich) valve 4 Determining that the chest tube is not occluded
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1
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Which action by the nurse involves squeezing, twisting, and kneading the chest tube to create a burst of suction to move clots? 1 Milking 2 Tidaling 3 Stripping 4 Suctioning
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1
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Which statement is true regarding chest tubes? 1 Chest tubes are routinely stripped to move clots. 2 Chest tubes are used in the treatment of pneumothorax. 3 Chest tube removal can be done without any patient preparation. 4 Chest tubes are catheters inserted through lungs to remove air from the pleural space
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2
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While caring for a patient who has a nasal cannula, the nurse loosens the elastic strap. Which unexpected patient outcome is responsible for the nurse's action? 1 Epistaxis 2 Skin irritation 3 Continuous hypoxia 4 Dry upper airway mucosa
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2
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Which position is appropriate in a patient who has a chest tube drainage system, in order to drain fluid from the chest? 1 Supine 2 High-Fowler's 3 Semi-Fowler's 4 Trendelenburg's
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2
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Why would the nurse request a humidification device while delivering oxygen to a patient in the home care setting? 1 Oxygen delivery greater than 4 L/minute 2 Storing oxygen delivery devices upright 3 Symptoms of hypoxia are noticed in the patient 4 Equipment is placed at least 8 ft from heat source
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1
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A patient who has atelectasis has a tracheostomy. While providing care, the nurse elevates the head of the patient's bed to 30 degrees and also changes the patient's body position frequently. What is the rationale behind the nurse's actions? 1 To prevent pulmonary aspiration 2 To maintain prolonged oral hygiene 3 To ensure an adequate sealing of the tube 4 To prevent the draining of the secretions from the tube
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1
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The registered nurse instructs the nursing assistive person (NAP) to frequently reposition the elastic strap on the patient's oxygen mask. What is the rationale behind this? 1 To prevent epistaxis 2 To prevent skin breakdown 3 To prevent continued hypoxia 4 To prevent nasal mucosal dryness
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2
