C HAPTER 41: O XYGENATION
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. The nurse is completing a physical examination for a client who is
anemic. In assessing the clients eyes, a sign assessed by the nurse that is
consistent with the diagnosis is:
A. Xanthelasma
B. Petechiae
C. Corneal arcus
D. Pale conjunctiva
ANS: D
Pale conjunctiva is an assessment finding consisten t 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: NC LEX test plan designation:
Physiological Integrity/Physiological Adaptation/ Alterations in
Body S ystems
,2. Several nursing students are discussing cardiac conduction with their
clinical instructor. When asked where a heart rate of 56 beats per minute
most likel y originates, the most informed student replies:
A. The atrioventricular (AV) node
B. The sinoatrial (SA) node
C. The Purkinje network
D. The bundle of His
ANS: A
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 th e 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 mediat es
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 empt ying by delaying the impulse before transmitting it
through the bundle of His and the ventricul ar 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: NC LEX test plan designation:
Physiological Integrity/Physiological Adaptation/ Alterations in
Body S ystems
3. 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
therapeuticall y when responding with which of the follow ing?
, A. Are you worried about how your heart is working?
B. It means your heart is working just the way it is supposed to work.
C. A damaged heart doesn ’t beat in normal sinus rhythm like yours
does.
D. Each beat starts in the SA node and then causes the chambers to
contract.
ANS: D
NSR implies that the impulse originates at the SA node and follows the
normal sequence through the conduction system.
DIF: C REF: 913 OBJ: Anal ysis TOP: Nursing Process:
Planning MSC: NC LEX test plan designation: Physiological
Integrit y/Physiological Adaptation/ Alterations in Body S ystems
4. 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 likel y change noted will be a(n):
A. Increased Q-T interval
B. Increased P -R interval
C. Q-T interval less than 0.12 seconds
D. QRS interval greater than 0.12 seconds
ANS: A
The normal Q -T interval is 0.12 to 0.42 second. Changes in electrol yte
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: NC LEX test plan designation:
Physiological Integrity/Physiological Adapt ation/ Alterations in
Body S ystems
5. The primary reason a client with chronic obstructive pulmonary disease
(COPD) often experiences fatigue and activit y intolerance is related to:
A. The increased presence of surfactant that results in sticky alveoli
B. The presence of chronic infections in the lungs and bronchial tree
C. The extra energy that is needed to exhale the air from the damaged
lungs
D. The clients elevated anxiet y level related to the air hunger being
experienced
ANS: C
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: Anal ysis TOP: Nursing Process:
Assessment MSC: NC LEX test plan designation: Physiological
Integrit y/Physiological Adaptation/ Alterations in Body S ystems
6. The nurse is assessing a client with a history of chronic obstructive
pulmonary disease. When assessing for the presence of air hunge r, the
nurse should:
A. Monitor the clients pulse oximetry reading
Fundamentals of Nursing 10th Edition; Potter Perry
MULTIPLE CHOICE
1. The nurse is completing a physical examination for a client who is
anemic. In assessing the clients eyes, a sign assessed by the nurse that is
consistent with the diagnosis is:
A. Xanthelasma
B. Petechiae
C. Corneal arcus
D. Pale conjunctiva
ANS: D
Pale conjunctiva is an assessment finding consisten t 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: NC LEX test plan designation:
Physiological Integrity/Physiological Adaptation/ Alterations in
Body S ystems
,2. Several nursing students are discussing cardiac conduction with their
clinical instructor. When asked where a heart rate of 56 beats per minute
most likel y originates, the most informed student replies:
A. The atrioventricular (AV) node
B. The sinoatrial (SA) node
C. The Purkinje network
D. The bundle of His
ANS: A
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 th e 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 mediat es
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 empt ying by delaying the impulse before transmitting it
through the bundle of His and the ventricul ar 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: NC LEX test plan designation:
Physiological Integrity/Physiological Adaptation/ Alterations in
Body S ystems
3. 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
therapeuticall y when responding with which of the follow ing?
, A. Are you worried about how your heart is working?
B. It means your heart is working just the way it is supposed to work.
C. A damaged heart doesn ’t beat in normal sinus rhythm like yours
does.
D. Each beat starts in the SA node and then causes the chambers to
contract.
ANS: D
NSR implies that the impulse originates at the SA node and follows the
normal sequence through the conduction system.
DIF: C REF: 913 OBJ: Anal ysis TOP: Nursing Process:
Planning MSC: NC LEX test plan designation: Physiological
Integrit y/Physiological Adaptation/ Alterations in Body S ystems
4. 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 likel y change noted will be a(n):
A. Increased Q-T interval
B. Increased P -R interval
C. Q-T interval less than 0.12 seconds
D. QRS interval greater than 0.12 seconds
ANS: A
The normal Q -T interval is 0.12 to 0.42 second. Changes in electrol yte
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: NC LEX test plan designation:
Physiological Integrity/Physiological Adapt ation/ Alterations in
Body S ystems
5. The primary reason a client with chronic obstructive pulmonary disease
(COPD) often experiences fatigue and activit y intolerance is related to:
A. The increased presence of surfactant that results in sticky alveoli
B. The presence of chronic infections in the lungs and bronchial tree
C. The extra energy that is needed to exhale the air from the damaged
lungs
D. The clients elevated anxiet y level related to the air hunger being
experienced
ANS: C
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: Anal ysis TOP: Nursing Process:
Assessment MSC: NC LEX test plan designation: Physiological
Integrit y/Physiological Adaptation/ Alterations in Body S ystems
6. The nurse is assessing a client with a history of chronic obstructive
pulmonary disease. When assessing for the presence of air hunge r, the
nurse should:
A. Monitor the clients pulse oximetry reading
