Chapter 39: Oxygenation Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 6th Edition

MULTIPLE CHOICE

1. The nurse has reviewed information about the cardiovascular system before caring for a client with heart disease. The nurse knows that which following statement is true concerning the physiology of the cardiovascular system?

a.

Stimulating the parasympathetic system would cause the heart rate to go up.

b.

When a person has heart muscle disease, the heart muscles stretch as far as is necessary to maintain function.

c.

The QRS interval on the electrocardiogram represents the electrical impulses passing through the ventricles.

d.

When stroke volume decreases, a resultant decrease in heart rate occurs.

ANS: c

c. The QRS complex indicates that the electrical impulse has traveled through the ventricles.

a. Stimulating the parasympathetic system would cause the heart rate to decrease, not increase.

b. In the diseased heart, the stretch of the myocardium is beyond the hearts physiological limits.

d. When stroke volume is decreased, an increase in heart rate occurs.

REF: Text Reference: p. 1070

2. The nurse is working on a respiratory care unit in the hospital. On entering the room of a client with emphysema, it is noted that the client is experiencing respiratory distress. The nurse should:

a.

Instruct the client to breathe rapidly

b.

Provide 20% oxygen at 2 L per minute via nasal cannula

c.

Place the client in the supine position

d.

Go to contact the physician

ANS: b

b. The client should be instructed to use pursed-lip breathing.

a. The nurse should provide a low concentration of oxygen to the client.

c. The most effective position for the client with cardiopulmonary disease is the 45-degree semi-Fowlers position, using gravity to assist in lung expansion and reduce pressure from the abdomen on the diaphragm.

d. The nurses first priority should be to attend to the client who is in respiratory distress, not to contact the physician.

REF: Text Reference: p. 1079

3. A 64-year-old client is seen in the emergency department for palpitations and mild shortness of breath. The ECG reveals a normal P wave, P-R interval, and QRS complex with a regular rhythm and rate of 108. The nurse should recognize this cardiac dysrhythmia as:

a.

Sinus dysrhythmia

b.

Sinus tachycardia

c.

Supraventricular tachycardia

d.

Ventricular tachycardia

ANS: b

b. The client is experiencing sinus tachycardia. The rhythm is regular with a normal P wave, normal QRS complex, and a rate of 100 to 180 beats per minute.

a. A sinus dysrhythmia has a rate of 60 to 100 beats per minute, slows during inspiration, and increases with expiration. The client is not experiencing a sinus dysrhythmia.

c. With supraventricular tachycardia, the heart rate is 150 to 250 beats/minute, the P wave may be buried in the preceding T wave, and the PR interval is variable. This client is not experiencing supraventricular tachycardia.

d. With ventricular tachycardia the rhythm is slightly irregular at a rate of 100 to 200 beats per minute, the P wave is absent, PR interval is absent, and the QRS complex is wide. This client is not experiencing ventricular tachycardia.

REF: Text Reference: p. 1075

4. A client recently fractured his spinal cord at the C-3 level and is at great risk for developing pneumonia, primarily because the:

a.

Resulting paralysis immobilizes him, and secretions will increase in his lungs

b.

Innervation to the phrenic nerve is absent, preventing chest expansion

c.

Resulting abnormal chest shape disallows efficient ventilatory movement

d.

Trauma decreases the ability of his red blood cells to carry oxygen

ANS: b

b. Cervical trauma at C3 to C5 can result in paralysis of the phrenic nerve, preventing chest expansion.

a. Although this is a risk factor, the clients greatest risk is related to the level of his fracture.

c. No mention of an abnormal chest shape is seen. This clients greatest risk for developing pneumonia is related to the level of his fracture.

d. If the client were anemic as a result of blood loss from trauma, his oxygen-carrying capacity of blood would be decreased. No mention of excessive blood loss is noted, nor would this place him at great risk for developing pneumonia.

REF: Text Reference: p. 1074

5. The client has experienced a myocardial infarction, resulting in damage to the left ventricle. A possible complication the client may experience that the nurse is alert to is:

a.

Jugular neck vein distention

b.

Pulmonary congestion

c.

Peripheral edema

d.

Liver enlargement

ANS: b

b. Pulmonary congestion may be experienced in left-sided heart failure.

a. Jugular neck vein distention is characteristic of right-sided heart failure.

c. Peripheral edema is characteristic of right-sided heart failure.

d. Hepatomegaly (liver enlargement) is characteristic of right-sided heart failure.

REF: Text Reference: p. 1078

6. On admitting a client, the nurse finds a history of myocardial ischemia. The most disconcerting dysrhythmia for electrocardiography to reveal is:

a.

Sinus bradycardia

b.

Sinus dysrhythmia

c.

Ventricular tachycardia

d.

Atrial fibrillation

ANS: c

c. Ventricular tachycardia would be the most disconcerting dysrhythmia of the four options. Ventricular tachycardia results in a decreased cardiac output; it may lead to severe hypotension, loss of pulse, and consciousness.

a. Sinus bradycardia would not be of concern for this client. It is of no clinical significance unless it is associated with signs and symptoms of a decreased cardiac output.

b. Sinus dysrhythmia is of no clinical significance unless dizziness occurs with a decreased rate.

d. Atrial fibrillation is not as detrimental as ventricular tachycardia.

REF: Text Reference: p. 1077

7. Acute renal failure and a resulting metabolic acidosis develop in a client. The nurse recognizes that the respiratory system compensates through:

a.

Hypoventilation and increase of bicarbonate in the bloodstream

b.

Alternating periods of deep versus shallow breaths to maintain homeostasis of the serum pH

c.

Hyperventilation to decrease the serum CO2 and thereby increase the pH

d.

Expansion of the lung tissues to their fullest, which increases the inspiratory reserve volumes to provide more oxygen to the tissues

ANS: c

c. The respiratory system tries to correct metabolic acidosis by increasing ventilation to reduce the amount of carbon dioxide and thereby raise the pH.

a. The respiratory system would compensate for metabolic acidosis with increased respirations, not hypoventilation. Bicarbonate is the renal component of acid-base balance, not the respiratory component.

b. The pH measures hydrogen ion concentration. Alternating deep versus shallow breaths is not a compensating mechanism of the respiratory system for metabolic acidosis.

d. The respiratory system does not compensate by expanding the lung tissues to their fullest. In metabolic acidosis, the respiratory system compensates by exhaling a greater amount of carbon dioxide.

REF: Text Reference: p. 1079, Text Reference: p. 1140

8. A client is brought to the emergency department with a suspected narcotic (heroin) overdose. The nurse anticipates that assessment findings will reveal:

a.

Agitation

b.

Hyperpnea

c.

Restlessness

d.

Decreased level of consciousness

ANS: d

d. With a narcotic overdose, the respiratory center is depressed, reducing the rate and depth of respiration and the amount of inhaled oxygen. The client may display signs of hypoventilation, such as a decreased level of consciousness.

a. A narcotic (heroin) overdose would cause sedation and respiratory depression, not agitation.

b. The client would experience bradypnea, not hyperpnea.

c. A narcotic (heroin) overdose would cause sedation and respiratory depression, not restlessness.

REF: Text Reference: p. 1080

9. The nurse identifies that the client is unable to cough to produce a sputum specimen and must be suctioned. Which suctioning route is preferred for obtaining this specimen?

a.

Nasopharyngeal

b.

Nasotracheal

c.

Oropharyngeal

d.

Orotracheal

ANS: b

b. Nasotracheal suctioning is the preferred route for obtaining a sputum specimen when the client is unable to cough to produce a sputum specimen on his or her own.

a. The nasopharyngeal route for suctioning is used when the client is able to cough, but is unable to clear secretions by expectorating or swallowing. It is not the preferred route for obtaining a sputum specimen.

c. The oropharyngeal route is used when the client is able to cough, but is unable to clear secretions by expectorating or swallowing. It is not the preferred route for obtaining a sputum specimen.

d. The orotracheal route is used when the client is unable to manage secretions by coughing. The nasotracheal route is preferred over the orotracheal route because stimulation of the gag reflex is minimal.

REF: Text Reference: p. 1101

10. The nurse is checking the clients overall oxygenation. In assessment of the presence of central cyanosis, the nurse will inspect the clients:

a.

Palms and soles of the feet

b.

Nail beds

c.

Earlobes

d.

Tongue

ANS: d

d. Central cyanosis is observed in the tongue, soft palate, and conjunctiva of the eye, where blood flow is high. Central cyanosis indicates hypoxemia.

a. Peripheral cyanosis seen in the palms and soles of the feet is often a result of vasoconstriction and stagnant blood flow.

b. Peripheral cyanosis seen in the nail beds is often a result of vasoconstriction and stagnant blood flow.

c. Peripheral cyanosis seen in the earlobes is often a result of vasoconstriction and stagnant blood flow.

REF: Text Reference: p. 1080

11. A client has recently had a mitral valve replacement. To prevent excess serosanguineous fluid build-up, the nurse anticipates that care will include:

a.

Increased oxygen therapy

b.

Frequent chest physiotherapy

c.

Incentive spirometry on a regularly scheduled basis

d.

Chest tube placement in the thoracic cavity

ANS: d

d. Chest tubes are inserted to remove air and fluids from the pleural space, to prevent air or fluid from reentering the pleural space, and to re-establish normal intrapleural and intrapulmonic pressures. The client who had mitral valve replacement surgery would be expected to have a chest tube postoperatively to prevent excess fluid build-up in the pleural space.

a. Increased oxygen will not prevent excess fluid build-up.

b. Frequent chest physiotherapy may help facilitate removal of secretions, but will not prevent excess fluid build-up.

c. Incentive spirometry is used to promote deep breathing and to prevent or treat atelectasis in the postoperative client. It will not prevent excess fluid build-up.

REF: Text Reference: p. 1117

12. The client is admitted to the emergency department with a pneumothorax. The nurse anticipates that the client will be experiencing:

a.

Dyspnea

b.

Eupnea

c.

Fremitus

d.

Orthopnea

ANS: a

a. The client with a pneumothorax (collapsed lung) will exhibit dyspnea and pain.

b. Eupnea is normal, easy breathing. It would not be expected in the case of a pneumothorax.

c. Fremitus is the vibration felt when the hand is placed on the clients chest and the client speaks (vocal fremitus). Fremitus would be decreased with a pneumothorax.

d. Orthopnea is a condition in which the person must use multiple pillows when lying down or must sit with the arms elevated and leaning forward to breathe. The client with a pneumothorax would be exhibiting dyspnea.

REF: Text Reference: p. 1117

13. The client with a chronic obstructive respiratory disease is receiving oxygen via a nasal cannula. The nurse plans to include the following intervention in the clients care:

a.

Assess nares for skin breakdown every 6 hours

b.

Check patency of the cannula every 2 hours

c.

Inspect the mouth every 6 hours

d.

Check oxygen flow every 24 hours

ANS: a

a. The nurse caring for the client with a nasal cannula should plan to assess the clients nares and superior surface of both ears for skin breakdown every 6 hours.

b. The nurse should check patency of the cannula every 8 hours.

c. The nurse does not need to check the clients mouth in relation to the clients use of a nasal cannula. The nurse should continue providing oral hygiene and may assess the mouth (i.e., tongue) for cyanosis, along with other assessment measures.

d. Oxygen flow should be checked every 8 hours, not every 24 hours.

REF: Text Reference: p. 1124

14. All of the following clients are experiencing increased respiratory secretions and require intervention to assist in their removal. Chest percussion is indicated and appropriate for the client experiencing:

a.

Thrombocytopenia

b.

Cystic fibrosis

c.

Osteoporosis

d.

Spinal fracture

ANS: b

b. Chest percussion is indicated and appropriate for the client experiencing cystic fibrosis to assist in mobilizing the thick pulmonary secretions.

a. Percussion is contraindicated in clients with bleeding disorders, such as the client with thrombocytopenia.

c. Percussion is contraindicated in the client with osteoporosis.

d. Percussion is contraindicated in the client with a spinal fracture or with fractured ribs.

REF: Text Reference: p. 1098

15. The nurse is working on a pulmonary unit at the local hospital. The nurse is alert to one of the early signs of hypoxia in the clients which is:

a.

Cyanosis

b.

Restlessness

c.

A decreased respiratory rate

d.

A decreased blood pressure

ANS: b

b. Mental status changes are often the first signs of respiratory problems and may include restlessness and irritability.

a. Cyanosis is a late sign of hypoxia.

c. A decreased respiratory rate is not an early sign of hypoxia. The respiratory rate will increase as the body attempts to compensate for the decreased level of oxygen. As the hypoxia worsens, the respiratory rate may decline.

d. During early stages of hypoxia, the blood pressure is elevated unless the condition is caused by shock.

REF: Text Reference: p. 1080

16. It is suspected that the clients oxygenation status is deteriorating. The nurse is aware that the abnormal assessment finding that represents the most serious indication of the clients decreased oxygenation is:

a.

Poor skin turgor

b.

Clubbing of the nails

c.

Central cyanosis

d.

Pursed-lip breathing

ANS: c

c. Central cyanosis is the most serious finding because it indicates hypoxemia.

a. Poor skin turgor indicates dehydration. It is not an indication of the clients decreased oxygenation.

b. Clubbing of the nails is found in clients with prolonged oxygen deficiency, endocarditis, and congenital heart defects. It is a change that occurs over time, and not an indication of the clients current deterioration in oxygenation status.

d. Pursed-lip breathing is used to slow expiratory flow. It is not the most serious indication of a clients decreased oxygenation.

REF: Text Reference: p. 1086

17. In teaching a client about an upcoming diagnostic test, the nurse identifies that which one of the following uses an injection of contrast material?

a.

Holter monitor

b.

Echocardiography

c.

Cardiac catheterization

d.

Exercise stress test

ANS: c

c. A cardiac catheterization involves the injection of contrast material to visualize the cardiac chambers, valves, the great vessels, and coronary arteries. It also is used to measure the pressures and volumes within the chambers of the heart.

a. A Holter monitor is a portable ECG worn by the client. It does not require contrast media.

b. Echocardiography is a noninvasive measure that graphically depicts overall cardiac performance.

d. An exercise stress test evaluates the cardiac response to the physical stress of the client on a treadmill. Contrast material is not used for this test.

REF: Text Reference: p. 1089

18. At a community health fair, the nurse informs the residents that the influenza vaccine is recommended for clients:

a.

Only older than 65 years

b.

Aged 40 to 60 years

c.

In any age group who have a chronic disease

d.

In any age group who are currently experiencing flu-like symptoms

ANS: c

c. Annual influenza vaccine is recommended for clients of any age with a chronic disease.

a. Annual influenza vaccine is recommended for clients older than 65 years, but this is not the only group.

b. Annual influenza vaccine is recommended for any age group, including those age 40 to 60 years, who have a chronic disease of the heart, lung, or kidneys; clients with diabetes; clients with immunosuppression or severe forms of anemia; or those in close or frequent contact with anyone in a high-risk group.

d. Clients with an acute febrile illness should not be vaccinated.

REF: Text Reference: p. 1095

19. The unit manager is orienting a new staff nurse and evaluates which of the following as an appropriate technique for nasotracheal suctioning?

a.

Placing the client in a supine position

b.

Preparing for a clean or nonsterile technique

c.

Suctioning the oropharyngeal area first, and then the nasotracheal area

d.

Applying intermittent suction for 10 seconds during catheter removal

ANS: d

d. Intermittent suction for up to 10 to 15 seconds should be applied during catheter removal to prevent injury to the mucosa.

a. The client is not placed in a supine position. The client is usually placed in a semi-Fowlers position. The clients head is turned to the right to help the nurse suction the left mainstem bronchus and the clients head is then turned to the left to help the nurse suction the right main-stem bronchus.

b. Nasotracheal suctioning is a sterile procedure.

c. The nasotracheal area should be suctioned first, and then the oropharyngeal area. The mouth and pharynx contain more bacteria than the trachea does.

REF: Text Reference: p. 1105

20. The client has chest tubes in place after thoracic surgery. In working with a client who has a chest tube, the nurse should:

a.

Clamp off the tubes except during client assessments

b.

Remove the tubing from the connection to check for adequate suction power

c.

Milk or strip the tubes every 15 to 30 minutes to maintain drainage

d.

Coil and secure excess tubing next to the client

ANS: d

d. If the client is in a chair and the tubing is coiled, the tubing should be lifted every 15 minutes to promote drainage. Care should be taken to ensure that the tubing remains secure.

a. This is inaccurate. Clamping a chest tube is contraindicated when the client is ambulating or being transported.

b. In a water-sealed system, gentle bubbling in the suction-control chamber indicates it is functioning. The suction source may be checked to verify that it is on the appropriate setting. In a waterless system, the suction control (float ball) indicates the amount of suction the clients intrapleural space is receiving. The tubing should not be disconnected.

c. The chest tube should be stripped or milked only if indicated (i.e., clotted drainage appears in the tube; check institutional policy). It is believed that stripping the tube greatly increases intrapleural pressure, which could damage the pleural tissue and cause or worsen an existing pneumothorax. Milking causes a smaller pressure change.

REF: Text Reference: p. 1119

21. The client has supplemental oxygen in place and requires suctioning to remove excess secretions from the airway. To promote maximal oxygenation, an appropriate action by the nurse is to:

a.

Suction continuously for 30 second intervals

b.

Replace the oxygen and allow rest between suctioning passes

c.

Increase the amount of suction pressure to 200 mm Hg

d.

Complete a number of suctioning passes until the catheter comes back clear

ANS: b

b. To promote maximal oxygenation, the nurse should replace the oxygen and allow rest between suctioning passes.

a. Suctioning should be intermittent for up to 10 to 15 seconds.

c. Wall suction is set at 80 to 120 mm Hg; portable suction 7 to 15 mm Hg for adults. Elevated pressure settings, such as 200 mm Hg, increase the risk of trauma to mucosa and can induce greater hypoxia.

d. The number of suctioning passes is determined by client assessment and need. Repeated passes can remove oxygen and may induce laryngospasm. The client is not suctioned until the catheter comes back clear.

REF: Text Reference: p. 1103, Text Reference: p. 1106

22. A client with a chest tube in place is being transported by stretcher to another room closer to the nurses station. During the transport, the collection unit bangs against the wall and breaks open. The nurse immediately:

a.

Clamps the tube

b.

Tells the client to hyperventilate

c.

Raises the tubing above the clients chest level

d.

Places the end of the tube in a container of sterile water

ANS: d

d. If the drainage unit is broken, the end of the chest tube can be quickly submerged in a container of sterile water to re-establish the seal.

a. Clamping the chest tube may result in a tension pneumothorax.

b. In the case of the tubing becoming disconnected, the client should be instructed to exhale as much as possible and to cough. The client should not hyperventilate.

c. Raising the tubing above the clients chest level will not help the situation.

REF: Text Reference: p. 1121

23. The client is experiencing a sinus dysrhythmia with a pulse rate of 82 beats per minute. On entering the room, the nurse expects to find the client:

a.

Extremely fatigued

b.

Complaining of chest pain

c.

Experiencing a fluttering sensation in the chest

d.

Having no clinical signs based on the assessment

ANS: d

d. The nurse would expect to find the client experiencing a sinus dysrhythmia at a rate of 82 beats per minute to have no clinical symptoms.

a. The client with atrial fibrillation may complain of fatigue.

b. The client experiencing a sinus dysrhythmia would not be expected to complain of chest pain.

c. The client with atrial fibrillation may complain of a fluttering sensation in the chest.

REF: Text Reference: p. 1075

24. The electrical activity of the clients heart is being continuously monitored while he is on the coronary care unit. Suddenly, the nurse finds that the client is experiencing ventricular fibrillation. The nurse will prepare to:

a.

Administer atropine

b.

Prepare for CPR

c.

Prepare the client for surgical placement of a pacemaker

d.

Instruct the client to perform the Valsalva maneuver

ANS: b

b. The nurse should prepare for CPR for the client experiencing ventricular fibrillation.

a. Atropine is used for sinus bradycardia with hypotension and decreased cardiac output. In this case, the nurse should prepare to administer CPR, not atropine.

c. A pacemaker may be required for the client with sinus bradycardia. It is not the treatment for ventricular fibrillation.

d. The Valsalva maneuver is used to treat supraventricular tachycardia, not ventricular fibrillation.

REF: Text Reference: p. 1077

25. The client is admitted to the medical center with a diagnosis of right sided heart failure. In assessment of this client, the nurse expects to find:

a.

Dyspnea

b.

Confusion

c.

Dizziness

d.

Peripheral edema

ANS: d

d. Peripheral edema is an expected assessment finding in the client diagnosed with right- sided heart failure.

a. Dyspnea is an expected assessment finding in the client diagnosed with left-sided heart failure.

b. Confusion is a symptom of hypoventilation.

c. Dizziness is an expected assessment finding in the client experiencing hypoxia.

REF: Text Reference: p. 1078

26. The nurse is preparing to teach a group of adult women about the signs and symptoms of a myocardial infarction (heart attack). The nurse will include in the teaching plan the results of research that demonstrate women may experience specific symptoms, such as:

a.

Visual difficulties

b.

Epigastric pain

c.

Loss of motor function unilaterally

d.

Right scapular discomfort and stiffness

ANS: b

b. Epigastric pain is a symptom of a myocardial infarction in women.

a. Visual disturbances are not a symptom of a myocardial infarction in women.

c. Loss of motor function unilaterally is not a symptom of myocardial infarction in women.

d. Right scapular discomfort and stiffness is not a symptom of myocardial infarction in women.

REF: Text Reference: p. 1079

27. The nurse is reviewing the results of the clients diagnostic testing for pulmonary function. Of the following results, the finding that falls within expected or normal limits is:

a.

SpO2 88%

b.

pH 7.52

c.

paCO2 40 mm Hg

d.

Decreased PEFR from prior assessment

ANS: c

c. The normal paCO2 is 35 to 45 mm Hg; the clients paCO2 is elevated at 55 mm Hg.

a. The normal SpO2 is 98% to 100%; the clients is low at 88%

b. The normal pH is 7.35 to 7.45; the clients is high at 7.5b.

d. The normal PEFR should increase or remain the same when compared with the prior assessment. A decreased PEFR would indicate airway obstruction. Predicted values are based on age, sex, and height.

REF: Text Reference: p. 1090

28. The nurse is completing a physical examination for a client who is anemic. In assessing the clients eyes, a sign assessed by the nurse that is consistent with the diagnosis is:

a.

Xanthelasma

b.

Petechiae

c.

Corneal arcus

d.

Pale conjunctiva

ANS: d

d. Pale conjunctiva is an assessment finding consistent with the diagnosis of anemia.

a. Xanthelasma is caused by hyperlipidemia.

b. Petechiae appear on the skin in patients with platelet deficiency (thrombocytopenia). Petechiae on the conjunctivae are consistent with a fat embolus or bacterial endocarditis.

c. Corneal arcus is caused by hyperlipidemia in young to middle adults. It is a normal finding in older adults with arcus senilis.

REF: Text Reference: p. 1087

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