1. The nurse is caring for a patient with respiratory problems. Which assessment
finding indicates a late sign of hypoxia?
a. Elevated blood pressure
b. Increased pulse rate
c. Restlessness
d. Cyanosis
ANS: D
Cyanosis, blue discoloration of the skin and mucous membranes caused by
the presence of desaturated hemoglobin in capillaries, is a late sign of
hypoxia. Elevated blood pressure, increased pulse rate, and restlessness are
early signs of hypoxia.
2. A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The
nurse expects this patient to hyperventilate. Which factor does the nurse
remember when planning care for this type of hyperventilation?
a. Anxiety over illness
b. Decreased drive to breathe
c. Increased metabolic demands
d. Infection destroying lung tissues
ANS: C
Increased body temperature (fever) increases the metabolic rate, thereby increasing
carbon dioxide production. The increased carbon dioxide level stimulates an
increase in the patient’s rate and depth of respiration, causing hyperventilation.
Anxiety can cause hyperventilation, but this is not the direct cause from a fever.
Sleep causes a decreased respiratory drive; hyperventilation speeds up breathing.
The cause of the fever in this question is unknown.
3. A nurse is preparing a patient for nasotracheal suctioning. In which order will
the nurse perform the steps, beginning with the first step?
1. Insert catheter.
2. Apply suction and remove.
,3. Have patient deep breathe.
4. Encourage patient to cough.
5. Attach catheter to suction system.
6. Rinse catheter and connecting tubing.
a. 1, 2, 3, 4, 5, 6
b. 4, 5, 1, 2, 3, 6
c. 5, 3, 1, 2, 4, 6
d. 3, 1, 2, 5, 4, 6
ANS: C
The steps for nasotracheal suctioning are as follows: Verify that catheter is
attached to suction; have patient deep breathe; insert catheter; apply intermittent
suction for no more than 10 seconds and remove; encourage patient to cough;
and rinse catheter and connecting tubing with normal saline.
25. A patient has carbon dioxide retention from lung problems. Which type of
diet will the nurse most likely suggest for this patient?
a. Low-carbohydrate
b. Low-caffeine
c. High-caffeine
d. High-carbohydrate
ANS: A
A low-carbohydrate diet is best. Diets high in carbohydrates play a role in
increasing the carbon dioxide load for patients with carbon dioxide retention. As
carbohydrates are metabolized, an increased load of carbon dioxide is created and
excreted via the lungs. A low- or high-caffeine diet is not as important as the
carbohydrate load.
, 26. A nurse is caring for a patient who is taking warfarin (Coumadin) and
discovers that the patient is taking garlic to help with hypertension. Which
condition will the nurse assess for in this patient?
a. Increased cholesterol level
b. Distended jugular vein
c. Bleeding
d. Angina
ANS: C
Patients taking warfarin (Coumadin) for anticoagulation prolong the
prothrombin time (PT)/international normalized ratio (INR) results if they are
taking gingko biloba, garlic, or ginseng with the anticoagulant. The drug
interaction can precipitate a life-threatening bleed. Increased cholesterol
levels are associated with saturated fat dietary intake. A distended jugular vein
and peripheral edema are associated with damage to the right side of the heart.
Angina is temporary ischemia of the heart muscle.
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