Exam 2: Oxygenation (NCLEX)Questions and Answers 100% correct
A (DNR) client has a non-rebreather oxygen mask and breathing appears to be labored. What does the nurse
do first?
A. Ensures that the tubing is patent and that oxygen flow is high
B. Notifies the chaplain and the family member of record
C. Calls the Rapid Response Team and prepares to intubate
D. Comforts the client and confirms that signed DNR orders are in the chart - ansA
Labored breathing and ultimately suffocation can occur if the reservoir bag kinks, or if the oxygen source
disconnects or is not set to high flow levels.
A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104°F (40°C). What physiological
process explains why the child is at risk for developing dyspnea?
A: Fever increases metabolic demands, requiring increased oxygen need.
B: Blood glucose stores are depleted, and the cells do not have energy to use oxygen.
C: Carbon dioxide production increases as result of hyperventilation.
D: Carbon dioxide production decreases as a result of hypoventilation. - ansA
A black male client with asthma seeks emergency care for acute respiratory distress. Because of this client's
dark skin, the nurse should assess for cyanosis by inspecting the:
a. lips.
b. mucous membranes.
c. nail beds.
d. earlobes - ansB
A client has been brought in by the rescue squad to the emergency department. The client is having an acute
,exacerbation of chronic obstructive pulmonary disease (COPD) and is severely short of breath. On arrival, the
client is on 15 L/min of oxygen via rebreather mask. Which action by the nurse takes priority?
a. Immediately reduce the oxygen flow to 2 to 4 L/min via nasal cannula.
b. Perform a thorough respiratory assessment and attach pulse oximetry.
c. Call the laboratory to obtain arterial blood gases as soon as possible.
d. Obtain a stat chest x-ray, then slowly wean the client's oxygen down. - ansB
Oxygen-induced hypoventilation can occur in clients with chronically elevated PCO2 levels, such as those seen
in COPD. Giving oxygen can eliminate their hypoxic drive to breathe and can cause respiratory arrest. However,
hypoxemia is a greater threat to an acutely ill client than is the potential for oxygen-induced hypoventilation,
and clients should be given the amount of oxygen they require. The nurse should perform a thorough
respiratory assessment and should monitor the client for signs of this problem, rather than automatically
reducing oxygen delivery. Blood gases and a chest x-ray will also be obtained, but they do not take priority over
assessing and monitoring the client.
A client has been placed on 6 L of humidified oxygen via nasal cannula. Which action by the nurse is most
appropriate?
a. Drain condensation back into the humidifier, maintaining a closed system.
b. Keep the water sterile by draining it from the water trap back into the humidifier.
c. Turn down the humidity when condensation begins to collect in the tubing.
d. Remove condensation in the tubing by disconnecting and emptying it appropriately. - ansD
Condensation often forms in the tubing when a client receives humidified high-flow oxygen. Remove this
condensation as it collects by disconnecting the tubing and emptying the water. Some humidifiers and
nebulizers have a water trap that hangs from the tubing so the condensation can be drained without
disconnecting. To prevent bacterial contamination, never drain the fluid back into the humidifier or the
nebulizer. Do not turn down the humidity because the physician has ordered it and the client needs it.
Minimize how long the tubing is disconnected because the client does not receive oxygen during this period.
A client has just been admitted to the emergency department and requires high-flow oxygen therapy after
suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially?
,A. Face tent
B. Venturi mask
C. Nasal cannula
D. Non-rebreather mask - ansA
A client with smoke inhalation and facial burns who requires high-flow oxygen should initially be placed on a
face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating
contact with burned facial tissue.
A client is receiving oxygen via Venturi mask at 40%. On assessment the nurse finds the client cyanotic with
labored respirations. Which action does the nurse perform first?
a. Remove bedding from around the adaptor opening.
b. Listen to lung sounds and obtain a respiratory rate.
c. Call respiratory therapy to check oxygen saturation.
d. Notify the provider or Rapid Response Team immediately. - ansA
The Venturi mask works by drawing in a specific amount of air to mix with the oxygen through holes in an
adaptor fitted at the bottom of the mask. Holes of different sizes allow different amounts of room air to be
entrained, changing the amount of oxygen delivered. Bedding (or clothing) wrapped around those holes would
effectively change the FiO2. The nurse should ensure that the holes remain unobstructed. Other options are
appropriate but are not the first choice, because this simple step may be what solves the problem.
A client requires oxygen received via a face mask but wants to remain as mobile as possible once discharged
home. Which intervention by the home health nurse best provides the client with maximal mobility?
a. Arrange a consultation with pulmonary rehabilitation to decrease oxygen needs.
b. Encourage the client to remove the mask occasionally to assess tolerance.
c. Add extra connecting pieces of tubing to the client's existing oxygen setup.
d. Change the face mask to a nasal cannula occasionally, such as at mealtimes. - ansC
A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer
, nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose
of oral Valium 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4
L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress?
A. The client is not being treated for asthma
B. The client has a mental disorder
C. The client received a dose of Valium
D. The client is receiving oxygen at 4 L/min - ansD
A simple facemask must receive oxygen at a rate of at least 5 L/min to prevent inhalation of exhaled breath,
which has low levels of oxygen and can eventually suffocate the client.
A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related
to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the
nurse should implement which activities? Select all that apply.
1.Suctioning the client as needed
2.Encouraging coughing every 2 hours
3.Placing the bed in low Fowler's position
4.Supporting the neck incision when the client coughs
5.Monitoring the respiratory status frequently as prescribed - ans1245
A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is
becoming increasingly confused. What does the nurse do first?
a. Notify the health care provider.
b. Assess the client's pulse oximetry.
c. Document the observation.
d. Raise the head of the bed. - ansB
Cerebral hypoxia is a cause of confusion and is a sensitive indicator that the client needs more oxygen.
A (DNR) client has a non-rebreather oxygen mask and breathing appears to be labored. What does the nurse
do first?
A. Ensures that the tubing is patent and that oxygen flow is high
B. Notifies the chaplain and the family member of record
C. Calls the Rapid Response Team and prepares to intubate
D. Comforts the client and confirms that signed DNR orders are in the chart - ansA
Labored breathing and ultimately suffocation can occur if the reservoir bag kinks, or if the oxygen source
disconnects or is not set to high flow levels.
A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104°F (40°C). What physiological
process explains why the child is at risk for developing dyspnea?
A: Fever increases metabolic demands, requiring increased oxygen need.
B: Blood glucose stores are depleted, and the cells do not have energy to use oxygen.
C: Carbon dioxide production increases as result of hyperventilation.
D: Carbon dioxide production decreases as a result of hypoventilation. - ansA
A black male client with asthma seeks emergency care for acute respiratory distress. Because of this client's
dark skin, the nurse should assess for cyanosis by inspecting the:
a. lips.
b. mucous membranes.
c. nail beds.
d. earlobes - ansB
A client has been brought in by the rescue squad to the emergency department. The client is having an acute
,exacerbation of chronic obstructive pulmonary disease (COPD) and is severely short of breath. On arrival, the
client is on 15 L/min of oxygen via rebreather mask. Which action by the nurse takes priority?
a. Immediately reduce the oxygen flow to 2 to 4 L/min via nasal cannula.
b. Perform a thorough respiratory assessment and attach pulse oximetry.
c. Call the laboratory to obtain arterial blood gases as soon as possible.
d. Obtain a stat chest x-ray, then slowly wean the client's oxygen down. - ansB
Oxygen-induced hypoventilation can occur in clients with chronically elevated PCO2 levels, such as those seen
in COPD. Giving oxygen can eliminate their hypoxic drive to breathe and can cause respiratory arrest. However,
hypoxemia is a greater threat to an acutely ill client than is the potential for oxygen-induced hypoventilation,
and clients should be given the amount of oxygen they require. The nurse should perform a thorough
respiratory assessment and should monitor the client for signs of this problem, rather than automatically
reducing oxygen delivery. Blood gases and a chest x-ray will also be obtained, but they do not take priority over
assessing and monitoring the client.
A client has been placed on 6 L of humidified oxygen via nasal cannula. Which action by the nurse is most
appropriate?
a. Drain condensation back into the humidifier, maintaining a closed system.
b. Keep the water sterile by draining it from the water trap back into the humidifier.
c. Turn down the humidity when condensation begins to collect in the tubing.
d. Remove condensation in the tubing by disconnecting and emptying it appropriately. - ansD
Condensation often forms in the tubing when a client receives humidified high-flow oxygen. Remove this
condensation as it collects by disconnecting the tubing and emptying the water. Some humidifiers and
nebulizers have a water trap that hangs from the tubing so the condensation can be drained without
disconnecting. To prevent bacterial contamination, never drain the fluid back into the humidifier or the
nebulizer. Do not turn down the humidity because the physician has ordered it and the client needs it.
Minimize how long the tubing is disconnected because the client does not receive oxygen during this period.
A client has just been admitted to the emergency department and requires high-flow oxygen therapy after
suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially?
,A. Face tent
B. Venturi mask
C. Nasal cannula
D. Non-rebreather mask - ansA
A client with smoke inhalation and facial burns who requires high-flow oxygen should initially be placed on a
face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating
contact with burned facial tissue.
A client is receiving oxygen via Venturi mask at 40%. On assessment the nurse finds the client cyanotic with
labored respirations. Which action does the nurse perform first?
a. Remove bedding from around the adaptor opening.
b. Listen to lung sounds and obtain a respiratory rate.
c. Call respiratory therapy to check oxygen saturation.
d. Notify the provider or Rapid Response Team immediately. - ansA
The Venturi mask works by drawing in a specific amount of air to mix with the oxygen through holes in an
adaptor fitted at the bottom of the mask. Holes of different sizes allow different amounts of room air to be
entrained, changing the amount of oxygen delivered. Bedding (or clothing) wrapped around those holes would
effectively change the FiO2. The nurse should ensure that the holes remain unobstructed. Other options are
appropriate but are not the first choice, because this simple step may be what solves the problem.
A client requires oxygen received via a face mask but wants to remain as mobile as possible once discharged
home. Which intervention by the home health nurse best provides the client with maximal mobility?
a. Arrange a consultation with pulmonary rehabilitation to decrease oxygen needs.
b. Encourage the client to remove the mask occasionally to assess tolerance.
c. Add extra connecting pieces of tubing to the client's existing oxygen setup.
d. Change the face mask to a nasal cannula occasionally, such as at mealtimes. - ansC
A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer
, nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose
of oral Valium 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4
L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress?
A. The client is not being treated for asthma
B. The client has a mental disorder
C. The client received a dose of Valium
D. The client is receiving oxygen at 4 L/min - ansD
A simple facemask must receive oxygen at a rate of at least 5 L/min to prevent inhalation of exhaled breath,
which has low levels of oxygen and can eventually suffocate the client.
A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related
to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the
nurse should implement which activities? Select all that apply.
1.Suctioning the client as needed
2.Encouraging coughing every 2 hours
3.Placing the bed in low Fowler's position
4.Supporting the neck incision when the client coughs
5.Monitoring the respiratory status frequently as prescribed - ans1245
A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is
becoming increasingly confused. What does the nurse do first?
a. Notify the health care provider.
b. Assess the client's pulse oximetry.
c. Document the observation.
d. Raise the head of the bed. - ansB
Cerebral hypoxia is a cause of confusion and is a sensitive indicator that the client needs more oxygen.
