Chapter 38: Oxygenation and Perfusion Questions

1. A nurse caring for a patient with chronic obstructive pulmonary disease (COPD) knows that hypoxia may occur in patients with respiratory problems. What are signs of this serious condition? Select all answers that apply. Dyspnea Hypotension Small pulse pressure Decreased respiratory rate Pallor Increased pulse rate 2. A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? The patient vomits during suctioning. The secretions appear to be stomach contents. The catheter touches an unsterile surface. Epistaxis is noted with continued suctioning. p. 1465p. 14663. A nurse is inserting an oropharyngeal airway for a patient who vomits when it is inserted. Which action would be the first that should be taken by the nurse related to this occurrence? Quickly position the patient on his or her side. Put on disposable gloves and remove the oral airway. Check that the airway is the appropriate size for the patient. Put on sterile gloves and suction the airway. 4. A nurse is choosing a catheter to use to suction a patient’s endotracheal tube via an open system. On which variable would the nurse base the size of the catheter to use? The age of the patient The size of the endotracheal tube The type of secretions to be suctioned The height and weight of the patient 5. A nurse is caring for a 16-year-old male patient who has been hospitalized for an acute asthma exacerbation. Which testing methods might the nurse use to measure the patient’s oxygen saturation? Select all that apply. Thoracentesis Spirometry Pulse oximetry Peak expiratory flow rate Diffusion capacity Maximal respiratory pressure 6. A patient with COPD is unable to perform activities of daily living (ADLs) without becoming exhausted. Which nursing diagnosis best describes this alteration in oxygenation as the etiology? Decreased Cardiac Output related to difficulty breathing Impaired Gas Exchange related to use of bronchodilators Fatigue related to impaired oxygen transport system Ineffective Airway Clearance related to fatigue 7. A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. Refrain from exercise. Reduce anxiety. Eat meals 1 to 2 hours prior to breathing treatments. Eat a high-protein/high-calorie diet. Maintain a high-Fowler’s position when possible. Drink 2 to 3 pints of clear fluids daily. 8. A nurse is providing postural drainage for a patient with cystic fibrosis. In which position should the nurse place the patient to drain the right lobe of the lung? High Fowler’s position Left side with pillow under chest wall Lying position/half on abdomen and half on side Trendelenberg position 9. A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. “I will be careful not to shake up the canister before using it.” “I will hold the canister upside-down when using it.” “I will inhale the medication through my nose.” “I will continue to inhale when the cold propellant is in my throat.” “I will only inhale one spray with one breath.” “I will activate the device while continuing to inhale.” 10. When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal cannula, what does the nurse expect? The oxygen must be humidified. The rate will be no more than 2 to 3 L/min or less. Arterial blood gases will be drawn every 4 hours to assess flow rate. The rate will be 6 L/min or more. 11. A nurse is securing a patient’s endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? Instruct assistant to notify the primary care provider. Assess the patient’s vital signs. Remove the tape, adjust the depth to ordered depth and reapply the tape. No action is required as depth will adjust automatically. 12. What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? Checking the amount of oxygen in the cylinder before using it Using a cylinder for a patient transfer that indicates available oxygen is 500 psi Placing the oxygen cylinder on the stretcher next to the patient Discontinuing oxygen flow by turning cylinder key counterclockwise until tight 13. A nurse providing care of a patient’s chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? Notify the physician. Apply an occlusive dressing on the site. Assess the patient for signs of respiratory distress. Put on gloves and insert the chest tube in a bottle of sterile saline. 14. An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? Tilt the patient’s head forward. Hold the mask tightly over the patient’s nose and mouth. Pull the patient’s jaw backward. Compress the bag twice the normal respiratory rate for the patient. 15. Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. Closely assess the patient before, during, and after the procedure. Hyperoxygenate the patient before and after suctioning. Limit the application of suction to 20 to 30 seconds. Monitor the patient’s pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Use an appropriate suction pressure (80–150 mm Hg). Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.