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1. A nurse assessing a client's respirato- C. Warm the client's hands and try again.
ry status gets a weak signal from the
pulse oximeter. The client's other vi-
tal signs are within reference ranges.
What is the nurse's best action?
A. Shine available light on the equip-
ment to facilitate accurate reading.
B. Use a blood pressure cuff to in-
crease circulation to the site.
C. Warm the client's hands and try
again.
D. Place the probe on the client's ear-
lobe.
2. The nurse is caring for a client who B. tracheostomy collar
has had a percutaneous tracheostomy
(PCT) following a motor vehicle acci- A tracheostomy collar delivers oxygen near an arti-
dent and has been prescribed oxygen. ficial opening in the neck. This is appropriate for a
What delivery device will the nurse se- client who has had a PCT. All other devices are less
lect that is most appropriate for this appropriate for this client.
client?
A. face tent
B. tracheostomy collar
C. simple mask
D. nasal cannula
3. A nurse takes a client's pulse oxime- A.The client's available hemoglobin is adequately
try reading and finds that it is normal. saturated with oxygen.
What does this finding indicate?
Pulse oximetry is a noninvasive technique that mea-
, N3280: Exam 3
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A.The client's available hemoglobin is sures the arterial oxyhemoglobin saturation (SaO2
adequately saturated with oxygen. or SpO2) of arterial blood. This test measures only
B. The client's respiratory rate is in the the percentage of oxygen carried by the available
normal range. hemoglobin. Thus, even a client with a low hemo-
C. The client's red blood cell (RBC) globin level could appear to have a normal SpO2
count is in the normal range. because most of that hemoglobin is saturated.
D. The client's oxygen demands are However, the client may not have enough oxygen to
being met. meet body needs. A normal pulse oximetry reading
does not necessarily indicate a normal RBC count
or heart rate.
4. Which should the nurse teach the fam- (all the above)
ily about caring for a client with em- Maintain a smoke-free environment.
physema at home? Select all that ap- Follow health care provider's prescription for oxy-
ply. gen administration.
Watch for increased wheezing or signs of a
Maintain a smoke-free environment. flare-up.
Follow health care provider's prescrip- Take advantage of pulmonary rehabilitation pro-
tion for oxygen administration. grams.
Watch for increased wheezing or signs Create a long-term caregiving plan.
of a flare-up.
Take advantage of pulmonary rehabil-
itation programs.
Create a long-term caregiving plan.
Even if the person with emphyse-
ma is not smoking anymore, the per-
son may be living in a home where
family members still smoke. Family
must understand why it is important
to keep tobacco smoke out of the
house. Caregivers need to be ready
, N3280: Exam 3
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and know the signs of a flare-up.
For instance, the client may wheeze
more, get increasingly short of breath,
cough more than usual, or have more
or a change in color of mucus. If there
is a flare-up, the sooner the client
can get treatment, the less likely the
client will require hospitalization. It is
worthwhile for clients with emphyse-
ma to look into pulmonary rehabilita-
tion programs. These programs com-
bine exercise, support, and education
that will improve one's breathing and
health. People with emphysema can
live a really long time. Therefore, the
family will require a clear plan to ad-
dress caregiving long term. Oxygen
therapy in a client with emphysema is
often necessary but too much oxygen
may result in knocking out the hypox-
ic drive, causing further depression of
the respiratory drive.
5. Which teaching about the oxygen an- A. It determines whether the client is getting
alyzer is important for the nurse to enough oxygen.
provide to a client using oxygen?
The oxygen analyzer measures the percentage of
A. It determines whether the client is delivered oxygen to determine whether the client
getting enough oxygen. is receiving the prescribed amount. The flowmeter
B. It prescribes oxygen concentration. is a gauge used to regulate the amount of oxy-
C. It regulates the amount of oxygen gen that a client receives. The provider prescribes
received. concentration. The humidifier produces small water