Chapter 40: Oxygenation Nursing School Test Banks

Potter & Perry: Fundamentals of Nursing, 7th Edition

Test Bank

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 of the following statements is true concerning the physiology of the cardiovascular system?

1.

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

2.

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

3.

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

4.

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

ANS: 3

The QRS complex indicates that the electrical impulse has traveled through the ventricles. Stimulating the parasympathetic system would cause the heart rate to decrease, not increase. In the diseased heart, the stretch of the myocardium is beyond the hearts physiological limits. When stroke volume is decreased, there is an increase in heart rate.

DIF: A REF: 910 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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

1.

Instruct the client to breathe rapidly

2.

Provide 20% oxygen at 2 L/min via nasal cannula

3.

Place the client in the supine position

4.

Go to contact the health care provider

ANS: 2

The nurse should provide a low concentration of oxygen to the client. The client should be instructed to use pursed-lip breathing. 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. The nurses first priority should be to attend to the client who is in respiratory distress, not to contact the health care provider.

DIF: B REF: 960 OBJ: Application

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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

1.

Sinus dysrhythmia

2.

Sinus tachycardia

3.

Supraventricular tachycardia

4.

Ventricular tachycardia

ANS: 2

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 sinus dysrhythmia has a rate of 60 to 100 beats per minute and slows during inspiration and increases with expiration. The client is not experiencing a sinus dysrhythmia. With supraventricular tachycardia, the heart rate is 150 to 250 beats per minute, the P wave may be buried in the preceding T wave, and the P-R interval is variable. This client is not experiencing supraventricular tachycardia. With ventricular tachycardia the rhythm is slightly irregular at a rate of 100 to 200 beats per minute, the P wave is absent, the P-R interval is absent, and the QRS complex is wide. This client is not experiencing ventricular tachycardia.

DIF: C REF: 914 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

4. A client recently fractured his spinal cord at the C3 level and is at great risk for developing pneumonia primarily because the:

1.

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

2.

Innervation to the phrenic nerve is absent, preventing chest expansion

3.

Resulting abnormal chest shape disallows efficient ventilatory movement

4.

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

ANS: 2

Cervical trauma at C3 to C5 can result in paralysis of the phrenic nerve, preventing chest expansion. Although the increase in lung secretions as a result of immobility is a risk factor, the clients greatest risk is related to the level of his fracture. There is no mention of an abnormal chest shape. This clients greatest risk for developing pneumonia is related to the level of his fracture. If the client were anemic as a result of blood loss from trauma, his oxygen-carrying capacity of blood would be decreased. There is no mention of excessive blood loss, nor would this place him at great risk for developing pneumonia.

DIF: C REF: 910 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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:

1.

Jugular neck vein distention

2.

Pulmonary congestion

3.

Peripheral edema

4.

Liver enlargement

ANS: 2

Pulmonary congestion may be experienced in left-sided heart failure. Jugular neck vein distention is characteristic of right-sided heart failure. Peripheral edema is characteristic of right-sided heart failure. Hepatomegaly (liver enlargement) is characteristic of right-sided heart failure.

DIF: A REF: 913 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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

1.

Sinus bradycardia

2.

Sinus dysrhythmia

3.

Ventricular tachycardia

4.

Atrial fibrillation

ANS: 3

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 and loss of pulse rate and consciousness. 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. Sinus dysrhythmia is of no clinical significance unless dizziness occurs with a decreased rate. Atrial fibrillation is not as detrimental as ventricular tachycardia.

DIF: C REF: 915 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

7. A client develops acute renal failure and a resulting metabolic acidosis. The nurse recognizes that the respiratory system compensates through:

1.

Hypoventilation and increase of bicarbonate levels in the bloodstream

2.

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

3.

Hyperventilation to decrease the serum CO2 level and thereby raise the pH

4.

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

ANS: 3

The respiratory system tries to correct metabolic acidosis by increasing ventilation to reduce the amount of carbon dioxide and thereby raise the pH. 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. The pH measures hydrogen ion concentration. Alternating deep versus shallow breaths is not a compensating mechanism of the respiratory system for metabolic acidosis. 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.

DIF: A REF: 916 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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

1.

Agitation

2.

Hyperpnea

3.

Restlessness

4.

Decreased level of consciousness

ANS: 4

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 narcotic (heroin) overdose would cause sedation and respiratory depression, not agitation. The client would experience bradypnea, not hyperpnea. A narcotic (heroin) overdose would cause sedation and respiratory depression, not restlessness.

DIF: A REF: 916 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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

1.

Nasopharyngeal

2.

Nasotracheal

3.

Oropharyngeal

4.

Orotracheal

ANS: 2

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. 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. 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. 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.

DIF: A REF: 931 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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

1.

Palms and soles of the feet

2.

Nail beds

3.

Earlobes

4.

Tongue

ANS: 4

Central cyanosis is observed in the tongue, soft palate, and conjunctiva of the eye, where blood flow is high. Central cyanosis indicates hypoxemia. Peripheral cyanosis seen in the palms and soles of the feet, nail beds, or earlobes is often a result of vasoconstriction and stagnant blood flow.

DIF: A REF: 917 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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

1.

Increased oxygen therapy

2.

Frequent chest physiotherapy

3.

Incentive spirometry on a regularly scheduled basis

4.

Chest tube placement in the thoracic cavity

ANS: 4

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 reestablish 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 buildup in the pleural space. Increased oxygen will not prevent excess fluid buildup. Frequent chest physiotherapy may help facilitate removal of secretions but will not prevent excess fluid buildup. Incentive spirometry is used to promote deep breathing and to prevent or treat atelectasis in the postoperative client. It will not prevent excess fluid buildup.

DIF: A REF: 950 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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

1.

Dyspnea

2.

Eupnea

3.

Fremitus

4.

Orthopnea

ANS: 1

The client with a pneumothorax (collapsed lung) will exhibit dyspnea and pain. Eupnea is normal, easy breathing. It would not be expected in the case of a pneumothorax. 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. 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.

DIF: A REF: 951 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

13. The client with a chronic obstructive respiratory disease is receiving oxygen via a nasal cannula. Which of the following interventions does the nurse plan to include in the clients care?

1.

Assess nares for skin breakdown every 6 hours.

2.

Check patency of the cannula every 2 hours.

3.

Inspect the mouth every 6 hours.

4.

Check oxygen flow every 24 hours.

ANS: 1

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. The nurse should check patency of the cannula every 8 hours. 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. Oxygen flow should be checked every 8 hours, not every 24 hours.

DIF: A REF: 957 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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:

1.

Thrombocytopenia

2.

Cystic fibrosis

3.

Osteoporosis

4.

Spinal fracture

ANS: 2

Chest percussion is indicated and appropriate for the client with cystic fibrosis to assist in mobilizing the thick pulmonary secretions. Percussion is contraindicated in clients with bleeding disorders, such as the client with thrombocytopenia. Percussion is also contraindicated in the client with osteoporosis and the client with a spinal fracture or with fractured ribs.

DIF: A REF: 931 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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:

1.

Cyanosis

2.

Restlessness

3.

A decreased respiratory rate

4.

A decreased blood pressure

ANS: 2

Mental status changes are often the first signs of respiratory problems and may include restlessness and irritability. Cyanosis is a late sign of hypoxia. 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. During early stages of hypoxia the blood pressure is elevated unless the condition is caused by shock.

DIF: A REF: 916 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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:

1.

Poor skin turgor

2.

Clubbing of the nails

3.

Central cyanosis

4.

Pursed-lip breathing

ANS: 3

Central cyanosis is the most serious finding because it indicates hypoxemia. Poor skin turgor indicates dehydration. It is not an indication of the clients decreased oxygenation. 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 is not an indication of the clients current deterioration in oxygenation status. Pursed-lip breathing is used to slow expiratory flow. It is not the most serious indication of a clients decreased oxygenation.

DIF: C REF: 917 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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?

1.

Holter monitor

2.

Echocardiography

3.

Cardiac catheterization

4.

Exercise stress test

ANS: 3

A cardiac catheterization involves the injection of contrast material in order 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 Holter monitor is a portable ECG worn by the client. It does not require contrast media. An echocardiography is a noninvasive measure that graphically depicts overall cardiac performance. 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.

DIF: A REF: 925 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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

1.

Only older than age 65

2.

40 to 60 years of age

3.

In any age-group who have a chronic disease

4.

Who have an acute febrile illness

ANS: 3

Annual influenza vaccine is recommended for clients of any age with a chronic disease. Annual influenza vaccine is recommended for clients older than age 65, but this is not the only group. Annual influenza vaccine is recommended for any age-group, including those age 40 to 60, 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. Clients with an acute febrile illness should not be vaccinated.

DIF: A REF: 927 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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

1.

Placing the client in a supine position

2.

Preparing for a clean or nonsterile technique

3.

Suctioning the oropharyngeal area first, then the nasotracheal area

4.

Applying intermittent suction for 10 seconds during catheter removal

ANS: 4

Intermittent suction for up to 10 to 15 seconds should be applied during catheter removal to prevent injury to the mucosa. 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 mainstem bronchus. Nasotracheal suctioning is a sterile procedure. The nasotracheal area should be suctioned first, then the oropharyngeal area. The mouth and pharynx contain more bacteria than the trachea.

DIF: A REF: 931 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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

1.

Clamp the tubes except during client assessments

2.

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

3.

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

4.

Coil and secure excess tubing next to the client

ANS: 4

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 the tubing remains secure. Clamping the tubes except during client assessments is an inaccurate statement. Clamping a chest tube is contraindicated when the client is ambulating or being transported. In a water-sealed system, gentle bubbling in the suction-control chamber indicates it is functioning. The suction source may be checked to verify 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. The chest tube should be stripped or milked only if indicated (e.g., there is clotted drainage 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 less of a pressure change.

DIF: A REF: 950 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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

1.

Suction continuously for 30-second intervals

2.

Replace the oxygen and allow rest in between suctioning passes

3.

Increase the amount of suction pressure to 200 mm Hg

4.

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

ANS: 2

To promote maximum oxygenation, the nurse should replace the oxygen and allow rest in between suctioning passes. Suctioning should be intermittent for up to 10 to 15 seconds. Wall suction is set at 80 to 120 mm Hg; portable suction is set at 7 to 15 mm Hg for adults. Elevated pressure settings, such as 200 mm Hg, increase the risk for trauma to mucosa and can induce greater hypoxia. 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.

DIF: A REF: 936 OBJ: Comprehension

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

22. A client with a chest tube in place is being transported via 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:

1.

Clamps the tube

2.

Tells the client to hyperventilate

3.

Raises the tubing above the clients chest level

4.

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

ANS: 4

If the drainage unit is broken, the end of the chest tube can be quickly submerged in a container of sterile water to reestablish the seal. Clamping the chest tube may result in a tension pneumothorax. If the tubing becomes disconnected, the client should be instructed to exhale as much as possible and to cough. The client should not hyperventilate. Raising the tubing above the clients chest level will not help the situation.

DIF: C REF: 950 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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

1.

Extremely fatigued

2.

Complaining of chest pain

3.

Experiencing a fluttering sensation in the chest

4.

Having no clinical signs based on the assessment

ANS: 4

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. The client with atrial fibrillation may complain of fatigue. The client experiencing a sinus dysrhythmia would not be expected to complain of chest pain. The client with atrial fibrillation may complain of a fluttering sensation in the chest.

DIF: A REF: 913 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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

1.

Administer atropine

2.

Prepare for cardiopulmonary resuscitation (CPR)

3.

Prepare the client for surgical placement of a pacemaker

4.

Instruct the client to perform the Valsalva maneuver

ANS: 2

The nurse should prepare for CPR for the client experiencing ventricular fibrillation. Atropine is used for sinus bradycardia with hypotension and decreased cardiac output. In this case, the nurse should prepare to administer CPR, not atropine. A pacemaker may be required for the client with sinus bradycardia. It is not the treatment for ventricular fibrillation. The Valsalva maneuver is used to treat supraventricular tachycardia, not ventricular fibrillation.

DIF: B REF: 913 OBJ: Application

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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:

1.

Dyspnea

2.

Confusion

3.

Dizziness

4.

Peripheral edema

ANS: 4

Peripheral edema is an expected assessment finding in the client diagnosed with right-sided heart failure. Dyspnea is an expected assessment finding in the client diagnosed with left-sided heart failure. Confusion is a symptom of hypoventilation. Dizziness is an expected assessment finding in the client experiencing hypoxia.

DIF: A REF: 913 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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:

1.

Visual difficulties

2.

Epigastric pain

3.

Loss of motor function unilaterally

4.

Right scapular discomfort and stiffness

ANS: 2

Epigastric pain is a symptom of a myocardial infarction in women. Visual disturbances, loss of motor function unilaterally, and right scapular discomfort and stiffness are not symptoms of a myocardial infarction in women.

DIF: A REF: 916 OBJ: Comprehension

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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

1.

Palpable, elevated hardened area around a tuberculosis skin testing site.

2.

Sputum for culture and sensitivity identifies Mycobacterium tuberculosis

3.

Presence of acid fast bacilli in sputum

4.

Arterial oxygen tension (PaO2) of 95 mm Hg

ANS: 4

A palpable, elevated, hardened area surrounding a tuberculosis skin testing site is indicative of an antigen-antibody reaction and is considered a positive skin test. Sputum for culture and sensitivity noted the presence of an organism and acid fast bacilli. Normal arterial oxygen tension (PaO2) ranges between 95-100 mmHg.

DIF: A REF: 916 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

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:

1.

Xanthelasma

2.

Petechiae

3.

Corneal arcus

4.

Pale conjunctiva

ANS: 4

Pale conjunctiva is an assessment finding consistent with the diagnosis of anemia. Xanthelasma is caused by hyperlipidemia. Petechiae appear on the skin in clients with platelet deficiency (thrombocytopenia). Petechiae on the conjunctivae is consistent with a fat embolus or bacterial endocarditis. Corneal arcus is caused by hyperlipidemia in young to middle-age adults. It is a normal finding in older adults with arcus senilis.

DIF: A REF: 923 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

29. Several nursing students are discussing cardiac conduction with their clinical instructor. When asked where a heart rate of 56 beats per minute most likely originates, the most informed student replies:

1.

The atrioventricular (AV) node

2.

The sinoatrial (SA) node

3.

The Purkinje network

4.

The bundle of His

ANS: 1

The conduction system originates with the sinoatrial (SA) node, the pacemaker of the heart. The SA node is in the right atrium next to the entrance of the superior vena cava. Impulses are initiated at the SA node at an intrinsic rate between 60 and 100 beats per minute. The electrical impulses are transmitted through the atria along intraatrial pathways to the atrioventricular (AV) node. The AV node mediates impulses between the atria and the ventricles. The intrinsic rate of the normal AV node is between 40 and 60 beats per minute. The AV node assists atrial emptying by delaying the impulse before transmitting it through the bundle of His and the ventricular Purkinje network. The intrinsic rate of the bundle of His and the ventricular Purkinje network is between 20 and 40 beats per minute.

DIF: A REF: 913 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

30. A client asks the nurse, I was told that my heart is beating in normal sinus rhythm (NSR). What does that mean? The nurse replies most therapeutically when responding with which of the following?

1.

Are you worried about how your heart is working?

2.

It means your heart is working just the way it is supposed to work.

3.

A damaged heart doesnt beat in normal sinus rhythm like yours does.

4.

Each beat starts in the SA node and then causes the chambers to contract.

ANS: 4

NSR implies that the impulse originates at the SA node and follows the normal sequence through the conduction system.

DIF: C REF: 913 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

31. When the nurse is reviewing a clients laboratory results, a low calcium level is noted. When the nurse then reviews the clients electrocardiogram, the most likely change noted will be a(n):

1.

Increased Q-T interval

2.

Increased P-R interval

3.

Q-T interval less than 0.12 seconds

4.

QRS interval greater than 0.12 seconds

ANS: 1

The normal Q-T interval is 0.12 to 0.42 second. Changes in electrolyte values, such as hypocalcemia, or therapy with drugs such as disopyramide or amiodarone increase the Q-T interval. The remaining options do not reflect a low calcium level.

DIF: A REF: 910 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

32. The primary reason a client with chronic obstructive pulmonary disease (COPD) often experiences fatigue and activity intolerance is related to:

1.

The increased presence of surfactant that results in sticky alveoli

2.

The presence of chronic infections in the lungs and bronchial tree

3.

The extra energy that is needed to exhale the air from the damaged lungs

4.

The clients elevated anxiety level related to the air hunger being experienced

ANS: 3

Clients with advanced COPD lose the elastic recoil of the lungs and thorax. As a result, the clients work of breathing increases. Although the remaining options are not incorrect, they are not the primary source of the clients fatigue.

DIF: C REF: 911 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

33. The nurse is assessing a client with a history of chronic obstructive pulmonary disease. When assessing for the presence of air hunger, the nurse should:

1.

Monitor the clients pulse oximetry reading

2.

Measure the movement of air by counting respirations

3.

Auscultate breath sounds both anteriorly and posteriorly

4.

Observe for the elevation of the clients clavicles during inspiration

ANS: 4

During an assessment, observe for elevation of the clients clavicles during inspiration. Elevation of the clavicles during inspiration can indicate ventilatory fatigue, air hunger, or decreased lung expansion. Although the remaining options are assessment methods, they are not as effective for determining air hunger.

DIF: C REF: 911 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

34. Pregnancy affects a womans oxygenation needs primarily because of:

1.

The increased metabolic demands required to support the fetus

2.

The increased tendency to develop anemia as a result of low iron reserves

3.

The decreased ability to engage in the physical exercise required to promote circulation

4.

The decreased lung capacity resulting from the pressure of the uterus on the diaphragm

ANS: 1

Increased metabolic demands, such as pregnancy or fever and infection, affect a clients oxygen-carrying capacity (of the blood). The remaining options can affect respiratory function but are not the primary cause of increased oxygenation requirements.

DIF: C REF: 912 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

35. The primary effect of chronic fevers on the bodys respiratory functioning is seen in:

1.

Increased oxygen requirements that exceed the bodys ability to satisfy its needs

2.

Increased respiratory rates that tax the bodys reserves of stored energy

3.

Breakdown of muscle mass, causing ineffective intercostal muscle function

4.

The presence of a sense of general malaise that stresses the immune system

ANS: 3

When fever persists, the metabolic rate remains high and the body begins to break down protein stores, resulting in muscle wasting and decreased muscle mass. Respiratory muscles such as the diaphragm and intercostal muscles are also wasted. Although the remaining options are not incorrect, they do not represent the primary effect.

DIF: C REF: 912 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

36. The nurse is caring for a client who experienced a flailed chest injury (multiple rib fractures) as a result of a motorcycle accident. The nurse realizes that pain management for this client will directly impact the effectiveness of his respiratory functioning primarily because:

1.

Pain increases metabolic needs, thus increasing oxygen consumption

2.

Pain increases emotional distress, which can lead to hyperventilation

3.

Pain will decrease the clients motivation to deep breathe, contributing to shallow, diminished inspirations

4.

Pain will decrease the clients ability to both relax and recuperate, thus extending the period of recovery

ANS: 3

Chest wall trauma and upper abdominal incisions decrease chest wall movement as the client uses shallow respirations to minimize chest wall movement to avoid pain.

DIF: C REF: 913 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

37. The nurse observes that a clients pulse rate is 58 beats per minute and regular in rhythm. Which of the following statements made by the nurse shows the appropriate understanding of the clients further need for assessment?

1.

Ill wait 15 minutes and reevaluate the clients pulse rate.

2.

Her pulse rate is usually in the mid 60s, so there isnt a problem.

3.

Ill need to assess her for the presence of chest pain and/or dizziness.

4.

You run an electrocardiogram, and Ill notify her health care provider.

ANS: 3

A low but regular heart rate has no clinical significance unless associated with signs and symptoms of reduced cardiac output such as dizziness or syncope or the presence of chest pain.

DIF: C REF: 914 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

38. The nurse suspects that a 59-year-old client has experienced angina pectoris. Which of the following assessment questions will most likely produce information that will assist in the diagnosis?

1.

How long did the pain last?

2.

Can you describe the pain for me?

3.

Did the pain radiate into your left arm?

4.

What were you doing when the pain started?

ANS: 1

Unlike the pain resulting from a myocardial infarction, anginal pain usually lasts from 1 to 15 minutes. The remaining questions could also relate to cardiac pain from other origins.

DIF: C REF: 916 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

39. The nurse is preparing to discuss myocardial infarctions (MIs) with a womens group. Which of the following assessment findings should be included when discussing the typically observed signs and symptoms in females experiencing an MI?

1.

Originates both at rest and upon exertion

2.

Pain lasting longer than 30 minutes

3.

Pain radiating up into left jaw

4.

Significant gastric indigestion

ANS: 4

There is a significant difference between men and women in relation to coronary artery disease. Womens symptoms differ from those seen in men. The most common initial symptom in women is angina, but atypical symptoms of fatigue, indigestion, vasospasm, shortness of breath, or back or jaw pain are also present. The remaining options are reflective of symptoms experienced by both men and women.

DIF: A REF: 916 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

40. When assisting with PM care for an 82-year-old client recuperating from pneumonia, the nurse observes that the client appears to be uncharacteristically confused, asking Where am I? Which of the following interventions is the most therapeutic for this particular client?

1.

Listen for lung sounds.

2.

Reorient the client to place.

3.

Ask some simple questions to confirm the confusion.

4.

Assess the clients pulse oximetry reading on room air.

ANS: 4

Because mental status changes are often the first signs of respiratory problems and often include forgetfulness and irritability, assessing the clients blood oxygen is the most therapeutic intervention.

DIF: B REF: 916-917 OBJ: Application

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

41. When interviewing a newly admitted client, the nurse learns that the client is a cigarette smoker. It is determined that the client has a 50 pack-year history. This means that the client has smoked:

1.

2 packs of cigarettes a day for 25 years

2.

50 cigarettes a week for the last year

3.

1 pack a week for the last year

4.

50 packs within the last year

ANS: 2

If a client smoked 2 packs a day for 20 years, the client has a 40 pack-year history (packages per day x years smoked).

DIF: A REF: 920 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

42. A client diagnosed with chronic bronchitis is awakened from sleep experiencing shortness of breath. The nurse suspects that he is experiencing orthopnea and suggests positioning him to minimize the dyspnea so he can sleep more peacefully. The nurse best describes this position to the client as:

1.

Ill use pillows to take the pressure off your lungs so that they can expand more effectively.

2.

By leaning forward and resting on these pillows, you will be least likely to be short of breath.

3.

This is an upright position that you will be comfortable in and able to breathe more effectively.

4.

Well place two pillows behind your back so you are sitting more upright; that will let you rest better.

ANS: 4

Orthopnea is an abnormal condition in which the client uses multiple pillows when lying down or must sit with the arms elevated and leaning forward to breathe. The number of pillows used, such as two or three pillows, usually helps to quantify the orthopnea (e.g., two- or three-pillow orthopnea).

DIF: C REF: 920 OBJ: Analysis

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

43. The nurse is preparing an educational handout for older adults with chronic respiratory diseases. To best minimize the risk for infection, the nurse should include which of the following guidelines in the material?

1.

Remember to take your respiratory medication on schedule.

2.

If you are prescribed breathing treatments, take them as ordered.

3.

Avoid large, crowded places, especially during the winter months.

4.

Remember to talk with your health care provider about a flu vaccination.

ANS: 3

Clients with cardiopulmonary alterations need to minimize their risk for infection, especially during the winter months. Teach clients to avoid large, crowded places; keep their mouth and nose covered; and be sure to dress warmly, including a scarf, hat, and gloves. This is especially important during the peak of the influenza season. A flu shot may be recommended, but it does not protect against the various other infections commonly encountered. The remaining options are not directly related to infection but are more relevant to general management

DIF: C REF: 921 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

44. The nurse working on the cardiac unit notes that the client has an S2 murmur, which the nurse understands is caused by:

1.

Pulmonic or aortic valve backflow or regurgitation

2.

Mitral valve backflow or regurgitation

3.

Tricuspid valve backflow or regurgitation

4.

Poor coronary arterial circulation

ANS: 1

Closure of aortic and pulmonic valves represents S2, or the second heart sound. Some clients with valvular disease have backflow or regurgitation of blood through the incompetent valve, causing a murmur that you can hear on auscultation. During ventricular diastole the atrioventricular (mitral and tricuspid) valves open and blood flows from the higher-pressure atria into the relaxed ventricles. This represents S1, or the first heart sound. A murmur is caused by blood turbulence, not coronary artery disease

DIF: A REF: 912-913 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

45. A client with coronary artery disease is being prepared for a coronary arterial bypass graft surgery. The nurse knows that the coronary artery that carries the most blood and can cause the most harm when blocked is the:

1.

Left coronary artery

2.

Posterior interventricular artery

3.

Circumflex artery

4.

Anterior interventricular artery

ANS: 1

The left coronary artery, the most abundant blood supply, feeds the left ventricular myocardium, which is more muscular and does most of the hearts work. The posterior and anterior interventricular arteries supply blood to the walls of both ventricles. The circumflex artery supplies blood to the walls of the left atrium and left ventricle.

DIF: A REF: 912 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

46. A client who has a history of a major myocardial infarction is taking digoxin. The nurse explains this medication helps increase cardiac output by:

1.

Increasing the heart rate

2.

Reducing the resistance of pulmonary circulation

3.

Increasing the force of the myocardial contraction

4.

Increasing cardiac conduction

ANS: 3

Myocardial contractility affects stroke volume and cardiac output. Increased contraction increases the amount of blood ejected by the ventricles. Digoxin increases cardiac output by inhibiting the sodium-potassium ATPase, which makes more calcium available for contractile proteins, which results in a positive inotropic effect. One of the adverse reactions of digoxin is bradycardia. Digoxin does not reduce the resistance of pulmonary circulation or affect the electrical conduction of the heart.

DIF: A REF: 912 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

47. When obtaining vital signs, a nursing assistive personnel is concerned that the heart rate of 56 is too low for a 23-year-old client who has been training for a marathon. The nurse explains that:

1.

A low heart rate is normal in well-conditioned athletes

2.

The health care provider needs to be notified immediately

3.

The heart rate needs to be rechecked before taking any action

4.

The heart rate could be caused by hyperthyroidism

ANS: 1

A heart rate lower then 60 is a normal response to sleep or in a well-conditioned athlete; diminished blood flow to SA node, vagal stimulation, hypothyroidism, increased intracranial pressure, or pharmacological agents (e.g., digoxin, propranolol, quinidine, procainamide) sometimes cause abnormal drops in rate. Any action that the nurse is considering taking should occur only after verifying an abnormal vital sign.

DIF: A REF: 913 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

48. During pretesting for an elective surgery, it is discovered that the older adult client has atrial fibrillation. The nurse knows that this is a common dysrhythmia in older people and can cause:

1.

Fatigue, a fluttering in the chest, or shortness of breath if the ventricular response is rapid

2.

Acute loss of pulse and respiration

3.

Severe hypotension and loss of pulse and consciousness

4.

Dizziness, syncope, or chest pain

ANS: 1

There is a loss of the atrial kick (portion of the cardiac output squeezed in the ventricles with a coordinated atrial contraction), pooling of blood in the atria, and development of microemboli. The client often complains of fatigue, a fluttering in the chest, or shortness of breath if the ventricular response is rapid. It is a commonly occurring dysrhythmia in the aging and older adult. Acute loss of pulse and respiration is indicative of ventricular fibrillation. Immediate defibrillation is needed after assessment of ABCs of CPR. Ventricular tachycardia results in decreased cardiac output due to decreased ventricular filling time and often leads to severe hypotension and loss of pulse and consciousness. Sinus bradycardia may present signs and symptoms of reduced cardiac output such as dizziness, syncope, or presence of chest pain.

DIF: A REF: 908 OBJ: Knowledge

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

49. A 47-year-old female client tells the nurse that her heart feels as though it is racing. The clients pulse is 160 beats per minute. The nurse knows that a vagal response will stimulate the parasympathetic nervous system to slow the heart rate and instructs the client to:

1.

Bear down as though she is having a bowel movement

2.

Take a hot shower

3.

Take a cold bath

4.

Hold her breath

ANS: 1

Paroxysmal supraventricular tachycardia is a sudden rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously. Sometimes excitement, fatigue, caffeine, smoking, or alcohol use precipitates paroxysmal supraventricular tachycardia. When needed, treatment includes vagal stimulation such as carotid sinus massage or Valsalva maneuver to decrease the ventricular response. A hot shower would cause the heart to beat faster in order to cool down the body. A cold bath could cause additional stress and would not be appropriate. Holding the breath will increase the heart rate as it compensates for the lack of oxygen intake and buildup of carbon dioxide.

DIF: B REF: 908 OBJ: Application

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

50. A client has been admitted to the emergency department with an aspirin overdose. The nurse anticipates that the client will be experiencing respiratory complications because the nurse knows that aspirin (salicylate) poisoning causes excessive stimulation of the respiratory system as the body attempts to compensate for:

1.

Decreased hemoglobin

2.

Excess carbon monoxide

3.

Decreased oxygen

4.

Excess carbon dioxide

ANS: 4

The body is attempting to correct the acid-base balance, so the respiratory system causes the body to breathe faster in order to try to blow off the excessive carbon dioxide. The hemoglobin is not decreased but does not release oxygen to tissues as readily, and tissue hypoxia results. The body does not produce carbon monoxide. Oxygen levels are not decreased, but the body is attempting to compensate for metabolic acidosis by producing a respiratory alkalosis.

DIF: A REF: 909 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

51. The nurse knows that the client who smokes is how much more likely to develop lung cancer than a nonsmoker?

1.

Twice

2.

Three times

3.

Five times

4.

Ten times

ANS: 4

According to the American Cancer Society, the risk for lung cancer is 10 times greater for a person who smokes than for a nonsmoker. Exposure to secondhand smoke increases the risk for lung cancer and cardiovascular disease.

DIF: A REF: 909 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

52. A 45-year-old male client shares with the nurse that he has noticed that when he is anxious he feels short of breath. The nurse shares with the client that dyspnea can be caused by many conditions and that the client can make an objective assessment of the severity of the dyspnea by using which of the following?

1.

Peak expiratory flow rate meter (PEFR)

2.

Chest x-ray examination

3.

Pulmonary function test

4.

Visual analog scale from 1 to 10

ANS: 4

The use of a visual analog scale (VAS) helps clients to make an objective assessment of their dyspnea. The visual analog scale is a 100-mm vertical line; 0 is equated with no dyspnea, and 100 is equated with the worst breathlessness the client has experienced. The use of the VAS to evaluate the level of a clients dyspnea is useful in evaluating nursing interventions designed to reduce dyspnea. The PEFR reflects changes in large airway sizes and is an excellent predictor of overall airway resistance in the client with asthma. Daily measurement is for early detection of asthma exacerbations. Chest x-ray examination is used to observe the lung fields for fluid, masses, fractures, pneumothorax, and other abnormal processes. The pulmonary function test determines the ability of the lungs to efficiently exchange oxygen and carbon dioxide. It is used to differentiate pulmonary obstructive from restrictive disease.

DIF: C REF: 915 OBJ: Analysis

TOP: Nursing Process: Planning

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

53. The nurse working on the pulmonary unit is asked to obtain an acid-fast bacillus (AFB) sputum specimen from a client. The nurse knows that this test is used to screen for:

1.

Cancer

2.

Tuberculosis (TB)

3.

Cystic fibrosis

4.

Histoplasmosis

ANS: 2

The test is used to screen for the presence of AFB for detection of TB by early morning specimens on 3 consecutive days. Cancer would be tested by a sputum specimen for cytologic examination. Cystic fibrosis and histoplasmosis are not screened for through sputum tests.

DIF: A REF: 913 OBJ: Knowledge

TOP: Nursing Process: Implementation

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

54. A humidity tent is frequently used for infants and young children to liquefy secretions and help reduce a fever. The nurse knows that humidified air puts the client at risk for:

1.

Respiratory distress

2.

Infection

3.

Skin breakdown

4.

Hypothermia

ANS: 4

Air in the humidity tent sometimes becomes cool and falls below 20 C (68 F), causing the child to become chilled. Children in humidity tents require frequent changes of clothing and bed linen to remain warm and dry. Humidified air helps in keeping the airway open by providing hydration to liquefy secretions, and the cool environment helps reduce bronchospasms. Humidified air liquefies secretions, allowing the child to cough them up, which reduces the risk for an infection. Humidified air should not lead to skin breakdown as long as the linens and clothing are not allowed to remain wet.

DIF: A REF: 916 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

MULTIPLE RESPONSE

1. Which of the following situations would cause the nurse to expect an increase in cardiac output in a client who is experiencing no health issues? (Select all that apply.)

1.

After playing a set of doubles tennis

2.

Being 31 weeks pregnant with twins

3.

Upon rising from a 45-minute afternoon nap

4.

During a panic attack resulting from an unknown trigger

5.

Experiencing a 100 F temperature resulting from a bacterial infection

6.

Following a 60-minute session that included aerobic exercise

ANS: 1, 2, 4, 5, 6

Exercise, pregnancy, and fever increase cardiac output, but during sleep it decreases.

DIF: A REF: 918 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

2. Which of the following are factors that affect the bloods capacity to carry sufficient oxygen to the various body organs? (Select all that apply.)

1.

The size of the individual

2.

The age of the individual

3.

The gender of the individual

4.

The amount of oxygen present in the blood

5.

The amount of hemoglobin present in the blood

6.

The amount of oxyhemoglobin present in the blood

ANS: 4, 5, 6

Three things influence the capacity of the blood to carry oxygen: the amount of dissolved oxygen in the plasma, the amount of hemoglobin, and the tendency of hemoglobin to bind with oxygen. The remaining options are not directly involved.

DIF: A REF: 920 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

3. The nurse caring for a morbidly obese client who is recovering from abdominal surgery recognizes that this client is at risk for respiratory complications specifically caused by: (Select all that apply.)

1.

Poor muscle tone, resulting in decreased respiratory muscle function

2.

Increased risk for infection, resulting in increased oxygen requirements

3.

Deceased lung volume resulting from compression of abdominal organs

4.

Increased presence of pulmonary secretions in the lower lobes bilaterally

5.

Obesity-hypoventilation syndrome resulting from chronic carbon dioxide retention

6.

Pain resulting in reluctance to deep breathe and facilitate exchange of oxygen and carbon dioxide

ANS: 1, 2, 3, 4, 5

Morbidly obese clients have a reduction in compliance as a result of encroachment of the abdomen into the chest, increased work of breathing, and decreased lung volumes. In some clients an obesity-hypoventilation syndrome develops in which oxygenation is decreased and carbon dioxide is retained. The obese client is also susceptible to pneumonia after surgery or an upper respiratory tract infection because the lungs do not fully expand and the lower lobes retain pulmonary secretions. Pain is a universal barrier to effective breathing; it is not unique to the obese client.

DIF: C REF: 924 OBJ: Analysis

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

4. The nurse expects to observe which of the following assessment findings in a client diagnosed with left-sided heart failure? (Select all that apply.)

1.

Ankle edema

2.

Bilateral crackles

3.

Mental confusion

4.

Distended neck veins

5.

Activity-induced dyspnea

6.

Being awakened by shortness of breath

ANS: 2, 3, 5, 6

Clinical findings of left-sided heart failure include crackles on auscultation, hypoxia, shortness of breath on exertion and often at rest, cough, and paroxysmal nocturnal dyspnea. The remaining options are more reflective of right-sided failure.

DIF: A REF: 930 OBJ: Comprehension

TOP: Nursing Process: Assessment

MSC: NCLEX test plan designation: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems

Mosby items and derived items 2009, 2005 by Mosby, Inc., an affiliate of Elsevier Inc.

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