Oxygenation - Chapter 40

Question 1

The structure that is responsible for returning oxygenated blood to the heart is the

1. Pulmonary artery.
2. Pulmonary vein.
3. Superior vena cava.
4. Inferior vena cava.

Answer 1

2. Pulmonary vein.

Rationale:

The pulmonary vein carries oxygenated blood to the heart. The pulmonary artery carries deoxygenated blood from the heart to the lungs. Both venae cavae return blood to the right atrium of the heart.

Question 2

Chemical receptors that stimulate inspiration are located in the

1. Brain.
2. Lungs.
3. Aorta.
4. Heart.

Answer 2

3. Aorta.

Rationale:

Chemical receptors in the aorta send signals to begin the inspiration process. The brain, lungs, and heart all are affected by this chemical reaction.

Question 3

The nurse knows that the primary function of the alveoli is to

1. Carry out gas exchange.
2. Store oxygen.
3. Regulate tidal volume.
4. Produce hemoglobin.

Answer 3

1. Carry out gas exchange.

Rationale:

The alveolus is a capillary membrane that allows gas exchange of oxygen and carbon dioxide during respiration. The alveoli do not store oxygen, regulate tidal volume, or produce hemoglobin.

Question 4

The nurse knows that anemia will result in

1. Hypoxemia.
2. Impaired ventilation.
3. Hypovolemia.
4. Decreased lung compliance.

Answer 4

1. Hypoxemia.

Rationale:

Patients who are anemic do not have the same level of oxygen-carrying capacity. As a result, oxygen is unable to properly perfuse the tissues, resulting in hypoxemia. Impaired ventilation occurs when oxygen/carbon dioxide exchange occurs at the alveolar level. Hypovolemia is related to decreased circulating blood volume. Lung compliance is related to the elasticity of the lung tissue.

Question 5

The process of exchanging gases through the alveolar capillary membrane is known as

1. Disassociation.
2. Diffusion.
3. Perfusion.
4. Ventilation.

Answer 5

2. Diffusion.

Rationale:

Diffusion is the process of gases exchanging across the alveoli and capillaries of body tissues. Disassociation is not related to oxygenation. Perfusion is the ability of the cardiovascular system to carry oxygenated blood to tissues and return deoxygenated blood to the heart. Ventilation is the process of moving gases into and out of the lungs.

Question 6

A nurse caring for a patient who was in a motor vehicle accident that resulted in trauma to C4 would expect to find

1. Decreased tidal volumes.
2. Increased perfusion.
3. Increased use of accessory muscles.
4. Decreased hemoglobin.

Answer 6

1. Decreased tidal volumes.

Rationale:

A C4 injury would result in damage to the phrenic nerve and would cause a decrease in inspiratory lung expansion. Accessory muscles will also be damaged by a C4 injury. The patient may exhibit decreased perfusion and increased hemoglobin to compensate for hypoxemia.

Question 7

The nurse would expect to see increased ventilations if a patient exhibits

1. Increased oxygen saturation.
2. Decreased carbon dioxide levels.
3. Decreased pH.
4. Increased hemoglobin levels.

Answer 7

3. Decreased pH.

Rationale:

Retained CO2 creates H+ byproducts that lower pH. This sends a chemical signal to increase respiratory rate and would result in increased ventilation. All other options would cause the ventilation rate to normalize or decrease to increase carbon dioxide retention or as the result of delivery of higher levels of oxygen to tissues.

Question 8

The nurse recommends that a patient install a carbon monoxide detector in the home because

1. It is required by law.
2. Carbon monoxide tightly bonds to hemoglobin, causing hypoxia.
3. Carbon monoxide signals the cerebral cortex to cease ventilations.
4. Carbon monoxide combines with oxygen in the body and produces a deadly toxin.

Answer 8

2. Carbon monoxide tightly bonds to hemoglobin, causing hypoxia.

Rationale:

Carbon monoxide has a higher affinity for hemoglobin; therefore, oxygen is not able to bond to hemoglobin and be transported to tissues. A carbon monoxide detector is not required by law, does not signal the cerebral cortex to cease ventilations, and does not combine with oxygen but with hemoglobin to produce a toxin.

Question 9

While performing an assessment, the nurse hears crackles in the patient’s lung fields. The nurse also learns that the patient is sleeping on three pillows. What do these symptoms most likely indicate?

1. Left-sided heart failure
2. Right-sided heart failure
3. Atrial fibrillation
4. Myocardial ischemia

Answer 9

1. Left-sided heart failure

Rationale:

Left-sided heart failure results in pulmonary congestion, the signs and symptoms of which include shortness of breath, crackles, and discomfort when lying supine. Right-sided heart failure is systemic and results in peripheral edema and hepatojugular distention. Atrial fibrillation results in an irregular heart rate. Myocardial ischemia most often results in chest pain, along with shortness of breath, nausea, and fatigue.

Question 10

The nurse knows that a myocardial infarction is an occlusion of what blood vessel?

1. Pulmonary artery
2. Ascending aorta
3. Coronary artery
4. Carotid artery

Answer 10

3. Coronary artery

Rationale:

A myocardial infarction is the lack of blood flow due to obstruction to the coronary artery, which supplies the heart with blood. The ascending aorta is a vessel that leads from the heart to perfuse the brain. The pulmonary artery supplies blood to the lungs. The carotid artery supplies blood to the brain.

Question 11

The nurse caring for a patient with ischemia to the left coronary artery would expect to find

1. Increased ventricular diastole.
2. Increased stroke volume.
3. Decreased preload.
4. Decreased afterload.

Answer 11

4. Decreased afterload.

Rationale:

The left coronary artery supplies the muscles of the left ventricle; the strength of the muscle affects the contractility of the heart. The other options are not impacted by the muscles of the left ventricle.

Question 12

Normal cardiac output is 4 to 6 L/min in a healthy adult at rest. Which of the following is the correct formula to calculate cardiac output?

1. Stroke volume  Heart rate
2. Stroke volume/Body surface area
3. Body surface area  Cardiac index
4. Heart rate/Stroke volume

Answer 12

1. Stroke volume  Heart rate

Rationale:

Cardiac output can be calculated by multiplying the stroke volume and the heart rate. The other options are not measures of cardiac functioning.

Question 13

A patient’s heart rate increased from 80 bpm to 160 bpm. The nurse knows that what will follow is a(n)

1. Increase in diastolic filling time.
2. Decrease in cardiac output.
3. Increase in stroke volume.
4. Increase in contractility.

Answer 13

2. Decrease in cardiac output.

Rationale:

An increased heart rate would decrease the diastolic filling time and stroke volume, thus decreasing overall cardiac output. A decrease in cardiac output results from decreased stroke volume and/or decreased heart rate. An increase in stroke volume and contractility would cause a decrease in heart rate to maintain cardiac output.

Question 14

The nurse is careful to monitor a patient’s cardiac output because this helps the nurse to determine

1. Peripheral extremity circulation.
2. Oxygenation requirements.
3. Cardiac arrhythmias.
4. Ventilation status.

Answer 14

1. Peripheral extremity circulation.

Rationale:

Cardiac output indicates how much blood is being circulated systemically. Oxygen status would be determined by pulse oximetry and the presence of cyanosis. Cardiac arrhythmias are an electrical impulse monitored through 5-lead ECG. Ventilation status is not solely dependent on cardiac output.

Question 15

A nurse is assisting a patient with ambulation. The patient becomes short of breath and begins to complain of sharp chest pain. Which action by the nurse is the first priority?

1. Call for the emergency response team to bring the defibrillator.
2. Have the patient sit down in the nearest chair.
3. Return the patient to the room and apply 100% oxygen.
4. Ask a coworker to get the ECG machine STAT.

Answer 15

2. Have the patient sit down in the nearest chair.

Rationale:

The patient is experiencing cardiac distress for reasons unknown. The nurse should first secure the safety of the patient and decrease the workload on the patient’s heart by putting him in a resting position; this will increase cardiac output by decreasing after load. Once the patient is stable, the nurse can obtain oxygen to put on the patient. Next, the nurse can begin to monitor the patient’s oxygen and cardiac status. If necessary, the emergency team may be activated to defibrillate.

Question 16

A patient has inadequate stroke volume related to decreased preload. The nurse anticipates

1. Placing the patient on oxygen monitoring.
2. Administering vasodilators.
3. Verifying that the blood consent form has been signed.
4. Preparing the patient for dialysis.

Answer 16

3. Verifying that the blood consent form has been signed.

Rationale:

Preload is affected by the circulating volume; if the patient has decreased fluid, it will need to be replaced with fluid or blood therapy. Before administering blood products, a type and match should be preformed. Monitoring the patient’s oxygenation status will not affect preload. Administering vasodilators affects afterload. Dialysis would further remove fluid from the patient, thus decreasing preload.

Question 17

When caring for a patient with atrial fibrillation, the nurse is most concerned with which vital sign?

1. Heart rate
2. Pain
3. Oxygen saturation
4. Blood pressure

Answer 17

3. Oxygen saturation

Rationale:

Atrial fibrillation results in pooling of blood in the atria, forming emboli that can be pumped out to the rest of the body. The most common manifestations are stroke, myocardial infarction, and pulmonary embolus. A sudden and drastic drop in oxygenation and blood pressure can indicate both pulmonary embolus and myocardial infarction.

Question 18

The nurse would expect a patient with right-sided heart failure to have which of the following?

1. Peripheral edema
2. Basilar crackles
3. Chest pain
4. Cyanosis

Answer 18

1. Peripheral edema

Rationale:

Right-sided heart failure results from inability of the right side of the heart to pump effectively, leading to a systemic backup. Peripheral edema and hepatojugular distention are signs of right-sided failure. Basilar crackles can indicate pulmonary congestion from left-sided heart failure. Cyanosis and chest pain result from inadequate tissue perfusion.

Question 19

The P wave is represented by which portion of the conduction system?

1. SA node
2. AV node
3. Bundle of HIS
4. Purkinje network

Answer 19

1. SA node

Rationale:

The SA node initiates electrical conduction through the atria. The AV node conducts down through the bundle of HIS and the Purkinje network to cause ventricular contraction.

Question 20

Which statement by the patient indicates an understanding of atelectasis?

1. “It is important to do breathing exercises every hour to prevent atelectasis.”
2. “If I develop atelectasis, I will need a chest tube to drain excess fluid.”
3. “Atelectasis affects only those with chronic conditions such as emphysema.”
4. “Hyperventilation will open up my alveoli, preventing atelectasis.”

Answer 20

1. “It is important to do breathing exercises every hour to prevent atelectasis.”

Rationale:

Atelectasis develops when alveoli do not expand. Breathing exercises increase lung volume and open the airways. Deep breathing opens the pores of Kohn between the alveoli to allow sharing of oxygen between alveoli. This prevents atelectasis from developing.

Question 21

The nurse is caring for an African American patient with COPD. The nurse knows that the best location to assess for hypoxia is the

1. Nailbeds.
2. Oral mucosa.
3. Earlobe.
4. Lower extremities.

Answer 21

2. Oral mucosa.

Rationale:

Because of skin pigmentation, translucent areas of high blood flow such as mucous membranes are best to check for cyanosis, which is a sign of hypoxia. It is important to remember that cyanosis is a late sign of hypoxia.

Question 22

A nurse is caring for a patient whose temperature is 100.2° F. The nurse expects this patient to hyperventilate owing to

1. Increased metabolic demands.
2. Anxiety over illness.
3. Decreased drive to breathe.
4. Infection destroying lung tissues.

Answer 22

1. Increased metabolic demands.

Rationale:

Fever increases the metabolic demands of the body, increasing production of carbon dioxide. The body hyperventilates to get rid of excess carbon dioxide. Anxiety can cause hyperventilation, but this is not the direct cause from a fever. Hyperventilation decreases the drive to breathe. The cause of the fever in this question is unknown.

Question 23

What assessment finding is the earliest sign of hypoxia?

1. Restlessness
2. Decreased blood pressure
3. Cardiac dysrhythmias
4. Cyanosis

Answer 23

1. Restlessness

Rationale:

Hypoxia is due to inadequate tissue oxygen at the cellular level. The earliest sign of hypoxia is restlessness; as it progresses, mental status changes, cardiac changes, and cyanosis can occur. Early hypoxia results in an elevated blood pressure. In later hypoxia, vital sign changes such as increased heart and respiratory rate occur. Cyanosis is a late sign of hypoxia.

Question 24

A 5-year-old who has strep throat was given aspirin for fever. The nurse knows to expect which change in the child’s respiratory pattern?

1. Hyperventilation to decrease serum levels of carbon dioxide
2. Hypoventilation to compensate for metabolic alkalosis
3. Flail chest to decrease the work of breathing
4. Shallow respirations to decrease serum pH

Answer 24

1. Hyperventilation to decrease serum levels of carbon dioxide

Rationale:

Aspirin causes an increase in carbon dioxide; the body compensates for this by increasing ventilations to blow off excess CO2. Hypoventilation would cause the body to retain even more carbon dioxide and therefore respiratory acidosis. Flail chest occurs with trauma to the chest wall. Shallow respirations would increase serum pH.

Question 25

A nurse is caring for a patient who suffered a myocardial infarction to the left coronary artery. Upon assessment, the nurse expects to find 1. Blood in the sputum. 2. Distended jugular vein. 3. Peripheral edema. 4. Crackles in the lungs.

Answer 25

4. Crackles in the lungs. Rationale: The left coronary artery supplies the left ventricle of the heart; damage to the muscle in the left ventricle leads to pulmonary congestion and frothy sputum, and crackles may be heard. A distended jugular vein and peripheral edema are associated with damage to the right side of the heart. Blood in the sputum is indicative of an infection such as tuberculosis.

Question 26

A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what he should eat for breakfast, what should the nurse recommend? 1. A bowl of cereal with whole milk and a banana 2. A cup of nonfat yogurt with granola, and a handful of dried apricots 3. Whole wheat toast with butter, a side of cottage cheese 4. Omelet with sausage, cheese, and onions

Answer 26

2. A cup of nonfat yogurt with granola, and a handful of dried apricots Rationale: Diets high in potassium, fiber, and calcium and low in fat are best for someone who is managing hypertension. Nonfat yogurt with granola is a good source of calcium, fiber, and potassium; dried apricots add a second source of potassium. Although cereal and a banana provide fiber and potassium, skim milk should be substituted for whole milk to decrease fat. An omelet with sausage and cheese is high in fat. Butter is high in fat.

Question 27

Upon auscultation, the nurse hears a whooshing sound at the fifth intercostal space. The nurse recognizes that this sound is 1. The beginning of the systolic phase. 2. The opening of the aortic valve. 3. S3, the third heart sound. 4. Regurgitation of the mitral valve.

Answer 27

4. Regurgitation of the mitral valve. Rationale: A whooshing sound at the fifth intercostal space is a murmur; a prolapsed valve allows regurgitation that is heard as a whooshing sound. The systolic phase begins with ventricular filling and closing of the aortic valve, which is heard as the first heart sound, S1. The third heart sound, S3, is heard with heart failure.

Question 28

A nurse caring for a patient with COPD knows that which oxygen delivery device is most appropriate? 1. Nasal cannula 2. Simple face mask 3. Partial non-rebreather mask 4. Non-rebreather mask

Answer 28

1. Nasal cannula Rationale: Nasal cannulas deliver oxygen from 1 to 6 L/min. A patient with COPD should never receive more than 3 L/min because this decreases the drive to breathe, resulting in hypoventilation. All other devices are intended for flow rates greater than 6 L/min.

Question 29

The nurse needs to closely monitor the oxygen status of an elderly patient undergoing anesthesia because of which age-related change? 1. Decreased lung defense mechanisms may cause ineffective airway clearance. 2. Thickening of the heart muscle wall decreases cardiac output. 3. Decreased lung capacity makes proper anesthesia induction more difficult. 4. Alterations in mental status prevent patients’ awareness of ineffective breathing.

Answer 29

1. Decreased lung defense mechanisms may cause ineffective airway clearance. Rationale: The age-related change that would affect airway clearance is decreased defense mechanisms, whereby the patient will have difficulty excreting anesthesia gas. The nurse needs to monitor the patient’s oxygen status carefully to make sure the patient does not retain too much of the drug. Heart muscle thickening and mental status do not affect oxygenation in patients undergoing anesthesia. Lung capacity is not related to anesthesia induction.

Question 30

The nurse determines that an elderly patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient? 1. Encourage the patient to stay up to date on all vaccinations. 2. Inform the patient of the importance of finishing the entire dose of antibiotics. 3. Schedule patient to get annual tuberculosis skin testing. 4. Create an exercise routine to run 30 minutes every day.

Answer 30

1. Encourage the patient to stay up to date on all vaccinations. Rationale: A nursing care plan for preventative health measures should be reasonable and feasible. Keeping up to date on vaccinations is important because vaccine reduces the severity of illnesses and serious complications. Although it is important to finish the full course of antibiotics, it is not a preventative health measure. Scheduling annual tuberculosis skin tests does not address prevention. The exercise routine should be reasonable to increase compliance.

Question 31

The nurse would expect which change in cardiac output for a patient with fluid volume overload? 1. Increased preload 2. Decreased afterload 3. Decreased tissue perfusion 4. Increased heart rate

Answer 31

1. Increased preload Rationale: Preload refers to the stretch of the ventricle related to the volume of blood; an increase in circulating volume would increase the preload of the heart. Afterload refers to resistance; increased pressure would lead to increased resistance, and afterload would increase. A decrease in tissue perfusion would be seen with hypovolemia. A decrease in fluid volume would cause an increase in heart rate as the body is attempting to increase cardiac output.

Question 32

A nurse is caring for a patient with COPD who is in recovery for a myocardial infarction. Which of the following nursing actions is the priority? 1. Place the patient on continuous cardiac monitoring. 2. Put the patient on 6 L/min of oxygen via nasal cannula. 3. Deep suction the patient every 2 hours. 4. Assess bilateral lung sounds every hour.

Answer 32

1. Place the patient on continuous cardiac monitoring. Rationale: A patient who has a recent myocardial infarction can convert back to a deadly rhythm and needs to be placed on continuous cardiac monitoring. The patient has COPD and should not be placed on oxygen over 4 L/min. Proper cardiac functioning will allow oxygenated blood to be distributed to tissues. Patients with recent myocardial infarction should not be suctioned. This patient does not have any indicators to warrant hourly assessment of lung fields.

Question 33

The nurse expects a patient with angina pectoris to 1. Experience feelings of indigestion after eating a heavy meal. 2. Have decreased oxygen saturation during rest. 3. Hypoventilate during periods of acute stress. 4. Complain of tingling in the left arm that lasts throughout the morning.

Answer 33

1. Experience feelings of indigestion after eating a heavy meal. Rationale: Angina pectoris is chest pain that results from limited oxygen supply. Often pain is precipitated by activities such as exercise, stress, and eating a heavy meal and lasts from 1 to 15 minutes. Hyperventilation may occur to compensate for decreased oxygen perfusion. Symptoms of angina pectoris are relieved by rest and/or nitroglycerin. Oxygen saturation, pain, and tingling in the arm should be relieved by rest. Pain or arm tingling that persists could be a sign of myocardial infarction.

Question 34

A nonmodifiable risk factor for lung disease is 1. Allergies. 2. Smoking. 3. Stress. 4. Asbestos exposure.

Answer 34

1. Allergies. Rationale: A nonmodifiable risk factor is one the patient has no control over. The patient can manage her allergies but cannot control her immune-mediated responses. Smoking, stress, and asbestos exposure are all modifiable risk factors.

Question 35

The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal that the patient could achieve? 1. Running 30 minutes every morning 2. Stopping smoking immediately 3. Sleeping on two to three pillows at night 4. Limiting the diet to 1500 calories a day

Answer 35

3. Sleeping on two to three pillows at night Rationale: To achieve a short-term goal, the nurse should plan a lifestyle change that the patient can make immediately that will have a quick effect. Sleeping on several pillows at night will immediately relieve orthopnea and open the patient’s airway, thereby reducing sleep apnea and reducing fatigue. Running 30 minutes a day will improve cardiopulmonary health, but a patient needs to build up exercise tolerance. Smoking cessation is another process that many people have difficulty doing immediately. It often occurs as a slow progression, beginning with reduction of frequency. A more realistic short-term goal would be to gradually reduce the number of cigarettes smoked. Limiting caloric intake can help a patient lose weight, but this is a gradual process and is not reasonable for a short-term goal.

Question 36

A nurse is caring for a patient with left sided hemiparesis who has developed bronchitis and has a heart rate of 105, blood pressure of 156/90, and a respiration rate of 30. Which nursing diagnosis is the priority for this patient? 1. Activity intolerance 2. Risk for skin breakdown 3. Impaired gas exchange 4. Risk for infection

Answer 36

3. Impaired gas exchange Rationale: The most important nursing intervention is to maintain airway and circulation for this patient; therefore, Impaired gas exchange is the first nursing priority. Activity intolerance is a concern but is not the priority in this case. Risk for skin breakdown and Risk for infection are also important but do not address an immediate impairment with physiologic integrity.

Question 37

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an elderly patient? 1. Assist patient to cough, turn, and deep breathe every 2 hours. 2. Encourage patient to drink through a straw to prevent aspiration. 3. Discontinue humidification delivery device to keep excess fluid from lungs. 4. Monitor oxygen saturation, and frequently assess lung bases.

Answer 37

1. Assist patient to cough, turn, and deep breathe every 2 hours. Rationale: The goal of the nursing action should be the prevention of pneumonia; the action that best addresses this is to cough, turn, and deep breathe to keep secretions from pooling at the base of the lungs. Drinking through a straw increases the risk of aspiration. Humidification thins respiratory secretions, making them easier to expel. Monitoring oxygen status is important but is not a method of prevention.

Question 38

The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the physician? 1. Clubbing of the fingers 2. Increased anterior-posterior diameter of the chest 3. Hemoptysis 4. Tachypnea

Answer 38

3. Hemoptysis Rationale: Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies are needed to determine the cause of blood in the sputum. Clubbing of the fingers, barrel chest, and tachypnea are all normal findings in a patient with emphysema.

Question 39

A patient with COPD asks the nurse why he is having increased difficulty with his fine motor skills, such as buttoning his shirt. Which response by the nurse is most therapeutic? 1. “Your body isn’t receiving enough oxygen to send down to your fingers; this causes them to club and makes dexterity difficult.” 2. “Your disease process makes even the smallest tasks seem exhausting. Try taking a nap before getting dressed.” 3. “Often patients with your disease lose mental status and forget how to perform daily tasks.” 4. “Your disease affects both your lungs and your heart, and not enough blood is being pumped. So you are losing sensory feedback in your extremities.”

Answer 39

1. “Your body isn’t receiving enough oxygen to send down to your fingers; this causes them to club and makes dexterity difficult.” Rationale: Clubbing of the nail bed is a frequent symptom of COPD and can make activities of daily living difficult. Taking a nap decreases fatigue but does not help the patient perform fine motor skills. Loss of mental status is not a normal finding with COPD. Low oxygen not low circulating blood volume is the problem in COPD.

Question 40

A patient with a pneumothorax had a chest tube inserted and was placed on low constant suction. Which finding requires immediate action by the nurse? 1. Fifty milliliters of blood gushes into the drainage device after the patient coughs. 2. The patient complains of pain at the chest tube insertion site that increases with movement. 3. No bubbling is present in the suction control chamber of the drainage device. 4. Yellow purulent discharge is seen leaking out from around the dressing site.

Answer 40

3. No bubbling is present in the suction control chamber of the drainage device. Rationale: No bubbling in the suction control chamber indicates an obstruction of the drainage system. An obstruction causes increased pressure, which can cause a tension pneumothorax, which can be life threatening. The nurse needs to determine whether the leak is inside the thorax or in the tubing and act from there. Occasional blood gushes from the lung owing to lung expansion, as during a cough; this is reserve drainage. Drainage over 100 mL/hr after 24 hours of chest tube placement is cause for concern. Yellow purulent drainage indicates an infection that should be reported to the physician but is not immediately life threatening.

Question 41

The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance? 1. Suctioning respiratory secretions several times every hour 2. Administering humidified oxygen through a tracheostomy collar 3. Instilling normal saline into the tracheostomy to thin secretions before suctioning 4. Deflating the tracheostomy cuff before allowing the patient to cough up secretions

Answer 41

2. Administering humidified oxygen through a tracheostomy collar Rationale: Humidification of air will help keep the mucous membranes moist and will make secretions easier to expel. Suctioning should be done only as needed; too frequent suctioning can damage the mucosal lining, resulting in thicker secretions. Normal saline should never be instilled into a tracheostomy because this could lead to infection. The purpose of the tracheostomy cuff is to keep secretions from entering the lungs; the nurse should not deflate the tracheostomy cuff unless instructed to do so by the physician.

Question 42

The nurse is educating a student nurse on caring for a patient with a chest tube. The nurse knows that teaching has been effective when the student states 1. “I should strip the drains on the chest tube every hour to promote drainage.” 2. “If the chest tube becomes dislodged, the first thing I should do is notify the physician.” 3. “I should clamp the chest tube when giving the patient a bed bath.” 4. “I should report if I see continuous bubbling in the water-seal chamber.”

Answer 42

4. “I should report if I see continuous bubbling in the water-seal chamber.” Rationale: Correct care of a chest tube involves knowing normal and abnormal functioning of the tube. Bubbling in the water-seal chamber is expected. Stripping the drain requires a physician order. If the chest tube becomes dislodged, immediately apply occlusive pressure over the insertion site. The chest tube should not be clamped unless necessary; if so, the length of time clamped would be minimal to reduce the risk of pneumothorax.

Question 43

Which nursing diagnosis is the priority when caring for a patient with a traumatic brain injury who had a tracheostomy placed? 1. Risk for skin breakdown 2. Impaired gas exchange 3. Ineffective airway clearance 4. Risk for infection

Answer 43

3. Ineffective airway clearance Rationale: Patients with tracheotomies rely on the tracheostomy to provide a stable open airway. The nurse is most concerned about a dementia patient who is extubating himself unknowingly. The nurse is also concerned that the patient would not be able to cough up his own secretions and could occlude the tracheostomy, putting him at risk for Ineffective airway clearance. Nursing priorities are airway, breathing, and circulation. Frequently occurring nursing diagnoses should be addressed before “Risk” diagnoses. Skin breakdown and infection are not immediately life threatening.

Question 44

The nurse knows that the most effective method for suctioning a patient with a tracheostomy tube is to 1. Set suction regulator at 150 to 200 mm Hg. 2. Liberally lubricate the end of the suction catheter with a water-soluble solution. 3. Limit the length of suctioning to 10 to 15 seconds. 4. Apply suction while gently rotating and inserting the catheter.

Answer 44

3. Limit the length of suctioning to 10 to 15 seconds. Rationale: Suctioning passes should be limited to 10 to 15 seconds to avoid oxygen desaturation. Suction for a tracheostomy should be set at 100 to 150 mm Hg. Excessive lubrication can clog the catheter or occlude the airway. Suction should not be applied until after the catheter has been inserted.

Question 45

The nurse is assessing a patient with a right pneumothorax. Which finding would the nurse expect? 1. Bilateral expiratory crackles 2. Absence of breath sounds on the right side 3. Right-sided wheezes on inspiration 4. Trachea deviated to the right

Answer 45

2. Absence of breath sounds on the right side Rationale: A right pneumothorax is a collapsed lung; therefore, no breath sounds should be heard on that side. Crackles indicate pneumonia. Wheezes are asthma related. A collapsed right lung would cause the trachea to deviate to the left.

Question 46

The nurse knows that a closed suction device would be most appropriate for which patient? 1. A 5-year-old with an asthma attack following severe allergies 2. A 24-year-old with a right pneumothorax following a motor vehicle accident 3. A 50-year-old with pulmonary edema following a myocardial infarction 4. A 75-year-old with aspiration pneumonia following a stroke

Answer 46

4. A 75-year-old with aspiration pneumonia following a stroke Rationale: Suctioning is most appropriate for someone with increased lung secretions who may have difficulty getting them up on their own. In this case, the stroke patient would have decreased coughing abilities and already has a diagnosis of pneumonia. The 5-year-old child would benefit from an inhaler. A chest tube is needed for the pneumothorax. Suctioning is contraindicated in patients with a myocardial infarction.

Question 47

While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. What is the nurse’s first nursing action? 1. Press the emergency response button. 2. Place the patient on a face mask delivering 100% oxygen. 3. Insert a spare tracheostomy without the obturator. 4. Manually occlude the tracheostomy with sterile gauze.

Answer 47

3. Insert a spare tracheostomy without the obturator. Rationale: The nurse’s first priority is to establish a stable airway by inserting a spare trach into the patient’s airway; ideally an obturator should be used, but it is not life threatening to omit this. The nurse could activate the emergency response team if the patient is still unstable after the tracheostomy is placed. A patient with a tracheostomy has an impairment that causes him not to be able to breathe normally; a face mask would not be an effective method of getting air into the lungs. Manually occluding pressure over the tracheostomy site is not appropriate.

Question 48

While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. What is the nurse’s first nursing action? 1. Press the emergency response button. 2. Place the patient on a face mask delivering 100% oxygen. 3. Insert a spare tracheostomy without the obturator. 4. Manually occlude the tracheostomy with sterile gauze.

Answer 48

3. Insert a spare tracheostomy without the obturator. Rationale: The nurse’s first priority is to establish a stable airway by inserting a spare trach into the patient’s airway; ideally an obturator should be used, but it is not life threatening to omit this. The nurse could activate the emergency response team if the patient is still unstable after the tracheostomy is placed. A patient with a tracheostomy has an impairment that causes him not to be able to breathe normally; a face mask would not be an effective method of getting air into the lungs. Manually occluding pressure over the tracheostomy site is not appropriate;