NURS (FUNDAMENTAL): NCLEX Oxygenation and Perfusion with complete solutions

A nurse caring for a patient with chronic obstructive pulmonary disease (COPD) knows that hypoxia may occur in patients with respiratory problems. What are signs of this serious condition? Select all answers that apply. a) Dyspnea b) Hypotension c) Small pulse pressure d) Decreased respiratory rate e) Pallor f) Increased pulse rate a, c, e, f If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis. A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? a) The patient vomits during suctioning. b) The secretions appear to be stomach contents. c) The catheter touches an unsterile surface. d) Epistaxis is noted with continued suctioning. d) Epistaxis is noted with continued suctioning. When epistaxis is noted with continued suctioning, the nurse should notify the physician and anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning. 00:01 01:36 A nurse is inserting an oropharyngeal airway for a patient who vomits when it is inserted. Which action would be the first that should be taken by the nurse related to this occurrence? a) Quickly position the patient on his or her side. b) Put on disposable gloves and remove the oral airway. c) Check that the airway is the appropriate size for the patient. d) Put on sterile gloves and suction the airway. a) Quickly position the patient on his or her side. A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the catheter to use? a) The age of the patient b) The size of the endotracheal tube c) The type of secretions to be suctioned d) The height and weight of the patient b) The size of the endotracheal tube A nurse is caring for a 16-year-old male patient who has been hospitalized for an acute asthma exacerbation. Which testing methods might the nurse use to measure the patient's oxygen saturation? Select all that apply. a) Thoracentesis b) Spirometry c) Pulse oximetry d) Peak expiratory flow rate e) Diffusion capacity f) Maximal respiratory pressure b, c, d Spirometers are used to monitor the health status of patients with respiratory disorders, such as asthma. Pulse oximetry is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma, along with PEFR to monitor airflow. These three tests may be administered by the nurse. A patient with COPD is unable to perform activities of daily living (ADLs) without becoming exhausted. Which nursing diagnosis best describes this alteration in oxygenation as the etiology? a) Decreased Cardiac Output related to difficulty breathing b) Impaired Gas Exchange related to use of bronchodilators c) Fatigue related to impaired oxygen transport system d) Ineffective Airway Clearance related to fatigue c) Fatigue related to impaired oxygen transport system A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a) Refrain from exercise. b) Reduce anxiety. c) Eat meals 1 to 2 hours prior to breathing treatments. d) Eat a high-protein/high-calorie diet. e) Maintain a high-Fowler's position when possible. f) Drink 2 to 3 pints of clear fluids daily. b, d, e When caring for patients with COPD, it is important to create an environment that is likely to reduce anxiety and ensure that they eat a high-protein/high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high Fowler's position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises, and drinking 2 to 3 quarts (1.9-2.9 L) of clear fluids daily is recommended. A nurse is providing postural drainage for a patient with cystic fibrosis. In which position should the nurse place the patient to drain the right lobe of the lung? a) High Fowler's position b) Left side with pillow under chest wall c) Lying position/half on abdomen and half on side d) Trendelenberg position b) Left side with pillow under chest wall A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. a) "I will be careful not to shake up the canister before using it." b) "I will hold the canister upside-down when using it." c) "I will inhale the medication through my nose." d) "I will continue to inhale when the cold propellant is in my throat." e) "I will only inhale one spray with one breath." f) "I will activate the device while continuing to inhale." d, e, f When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal cannula, what does the nurse expect? a) The oxygen must be humidified. b) The rate will be no more than 2 to 3 L/min or less. c) Arterial blood gases will be drawn every 4 hours to assess flow rate. d) The rate will be 6 L/min or more. b) The rate will be no more than 2 to 3 L/min or less. A rate higher than 3 L/min may destroy the hypoxic drive that stimulates respirations in the medulla in a patient with chronic lung disease. Oxygen delivered at low rates does not necessarily have to be humidified, and arterial blood gases are not required at regular intervals to determine the flow rate.