Chemical receptors that stimulate inspiration are located in the
- Brain.
- Lungs.
- Aorta.
- Heart.
- 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.
The nurse knows that the primary function of the alveoli is to
- Carry out gas exchange.
- Store oxygen.
- Regulate tidal volume.
- Produce hemoglobin.
- 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.
The nurse knows that anemia will result in
- Hypoxemia.
- Impaired ventilation.
- Hypovolemia.
- Decreased lung compliance.
- 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.
The process of exchanging gases through the alveolar capillary membrane is known as
- Disassociation.
- Diffusion.
- Perfusion.
- Ventilation.
- 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.
A nurse caring for a patient who was in a motor vehicle accident that resulted in trauma to C4 would expect to find
- Decreased tidal volumes.
- Increased perfusion.
- Increased use of accessory muscles.
- Decreased hemoglobin.
- 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.
The nurse would expect to see increased ventilations if a patient exhibits
- Increased oxygen saturation.
- Decreased carbon dioxide levels.
- Decreased pH.
- Increased hemoglobin levels.
- 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.
The nurse recommends that a patient install a carbon monoxide detector in the home because
- It is required by law.
- Carbon monoxide tightly bonds to hemoglobin, causing hypoxia.
- Carbon monoxide signals the cerebral cortex to cease ventilations.
- Carbon monoxide combines with oxygen in the body and produces a deadly toxin.
- 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.
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?
- Call for the emergency response team to bring the defibrillator.
- Have the patient sit down in the nearest chair.
- Return the patient to the room and apply 100% oxygen.
- Ask a coworker to get the ECG machine STAT.
- 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.
A patient has inadequate stroke volume related to decreased preload. The nurse anticipates
- Placing the patient on oxygen monitoring.
- Administering vasodilators.
- Verifying that the blood consent form has been signed.
- Preparing the patient for dialysis.
- 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.
Which statement by the patient indicates an understanding of atelectasis?
- “It is important to do breathing exercises every hour to prevent atelectasis.”
- “If I develop atelectasis, I will need a chest tube to drain excess fluid.”
- “Atelectasis affects only those with chronic conditions such as emphysema.”
- “Hyperventilation will open up my alveoli, preventing atelectasis.”
- “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.
A nurse is caring for a patient whose temperature is 100.2° F. The nurse expects this patient to hyperventilate owing to
- Increased metabolic demands.
- Anxiety over illness.
- Decreased drive to breathe.
- Infection destroying lung tissues.
- 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.
What assessment finding is the earliest sign of hypoxia?
- Restlessness
- Decreased blood pressure
- Cardiac dysrhythmias
- Cyanosis
- 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.
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?
- Hyperventilation to decrease serum levels of carbon dioxide
- Hypoventilation to compensate for metabolic alkalosis
- Flail chest to decrease the work of breathing
- Shallow respirations to decrease serum pH
- 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.
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?
- A bowl of cereal with whole milk and a banana
- A cup of nonfat yogurt with granola, and a handful of dried apricots
- Whole wheat toast with butter, a side of cottage cheese
- Omelet with sausage, cheese, and onions
- 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.
The nurse needs to closely monitor the oxygen status of an elderly patient undergoing anesthesia because of which age-related change?
- Decreased lung defense mechanisms may cause ineffective airway clearance.
- Thickening of the heart muscle wall decreases cardiac output.
- Decreased lung capacity makes proper anesthesia induction more difficult.
- Alterations in mental status prevent patients’ awareness of ineffective breathing.
- 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.
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?
- Encourage the patient to stay up to date on all vaccinations.
- Inform the patient of the importance of finishing the entire dose of antibiotics.
- Schedule patient to get annual tuberculosis skin testing.
- Create an exercise routine to run 30 minutes every day.
- 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.
A nonmodifiable risk factor for lung disease is
- Allergies.
- Smoking.
- Stress.
- Asbestos exposure.
- 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.
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?
- Running 30 minutes every morning
- Stopping smoking immediately
- Sleeping on two to three pillows at night
- Limiting the diet to 1500 calories a day
- 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.
Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an elderly patient?
- Assist patient to cough, turn, and deep breathe every 2 hours.
- Encourage patient to drink through a straw to prevent aspiration.
- Discontinue humidification delivery device to keep excess fluid from lungs.
- Monitor oxygen saturation, and frequently assess lung bases.
- 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.
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?
- Fifty milliliters of blood gushes into the drainage device after the patient coughs.
- The patient complains of pain at the chest tube insertion site that increases with movement.
- No bubbling is present in the suction control chamber of the drainage device.
- Yellow purulent discharge is seen leaking out from around the dressing site.
- 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.
The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance?
- Suctioning respiratory secretions several times every hour
- Administering humidified oxygen through a tracheostomy collar
- Instilling normal saline into the tracheostomy to thin secretions before suctioning
- Deflating the tracheostomy cuff before allowing the patient to cough up secretions
- 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.
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
- “I should strip the drains on the chest tube every hour to promote drainage.”
- “If the chest tube becomes dislodged, the first thing I should do is notify the physician.”
- “I should clamp the chest tube when giving the patient a bed bath.”
- “I should report if I see continuous bubbling in the water-seal chamber.”
- “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.
Which nursing diagnosis is the priority when caring for a patient with a traumatic brain injury who had a tracheostomy placed?
- Risk for skin breakdown
- Impaired gas exchange
- Ineffective airway clearance
- Risk for infection
- 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.
The nurse knows that the most effective method for suctioning a patient with a tracheostomy tube is to
- Set suction regulator at 150 to 200 mm Hg.
- Liberally lubricate the end of the suction catheter with a water-soluble solution.
- Limit the length of suctioning to 10 to 15 seconds.
- Apply suction while gently rotating and inserting the catheter.
- 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.
