NU271 Week 12 EAQ Evolve Elsevier Oxygenation
Questions And Answers Latest Updates
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which
laboratory test would the nurse monitor for hypoxia?
o Red blood cell count
o Sputum culture
o Arterial blood gas
o Total hemoglobin
o Arterial blood gas
· Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with
respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the
lungs. This provides accurate information about the client’s oxygenation status.
A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. Which is/are the
best site(s) to assess this condition? Select all that apply. One, some, or all responses may be correct.
o Lips
o Sclera
o Mouth
o Sacrum
o Nail beds
o Shoulders
o Lips
o Mouth
o Nail beds
· Prolonged hypoxia resulting in increased amounts of deoxygenated blood causes cyanosis, which can be best
evaluated in lips, mouth, nail beds, and skin (in extreme conditions). Sclera is the site of assessment for
jaundice, whereas shoulders are assessed to confirm the condition of erythema.
A child had an emergency tracheotomy and is receiving humidified air through a tracheotomy collar. Which
early clinical manifestations of hypoxia would alert the nurse to suction the tracheotomy?
,o Dyspnea and cyanosis
o Agitation and diaphoresis
o Restlessness and increase in pulse
o Severe substernal retractions and stridor
o Restlessness and increase in pulse
· Restlessness and increase in pulse are some of the first signs of hypoxia; the airway must be kept patent to
promote oxygenation. The other options are late signs of respiratory difficulty; suctioning and other measures
should have been implemented before this time.
The nurse is suctioning a client’s airway. Which nursing action will limit hypoxia?
o Limit suctioning with catheter to 30 seconds.
o Apply suction only after the catheter is inserted.
o Lubricate the catheter with saline before insertion.
o Use a sterile suction catheter for each suctioning episode.
o Apply suction only after the catheter is inserted.
· The negative pressure from suctioning removes oxygen and secretions; suction should be applied only after
the catheter is inserted and is being withdrawn. Limiting suctioning with the catheter to half a minute is too
long; suctioning should be limited to 10 seconds. Lubrication will facilitate insertion and minimize trauma; it
will not prevent hypoxia. The use of a sterile catheter helps prevent infection, not hypoxia.
Which type of breathing pattern is manifested with hypercarbia?
o Eupnea
o Tachypnea
o Hypoventilation
o Kussmaul respiration
o Hypoventilation
· Hypercarbia may occur during hypoventilation. The respiratory rate is abnormally low and the depth of
ventilation is depressed in hypoventilation. In eupnea, the normal rate and depth of respiration are interrupted
while singing. The rate of breathing is regular, but abnormally rapid in tachypnea. Respirations are
abnormally deep, regular, and the rate is increased in Kussmaul respiration.
Which actions will the nurse include in the plan of care for a client with a left pneumothorax who has a chest
tube in place? Select all that apply. One, some, or all responses may be correct.
o Immobilize the left arm in a sling.
, o Check the water-seal chamber for air bubbling.
o Avoid use of nonsteroidal anti-inflammatory drugs.
o Keep the client on bed rest in semi-Fowler position.
o Observe frequently for drainage in the collection chamber.
o Assist the client to cough and deep breathe every hour while awake.
o Check the water-seal chamber for air bubbling.
o Assist the client to cough and deep breathe every hour while awake.
· The nurse would assess for air bubbling in the water-seal chamber to determine whether the client’s
pneumothorax is resolved. Hourly coughing and deep breathing helps re-expand the lung and prevents
atelectasis. Immobilization of the left arm is not needed and may lead to decreased shoulder and arm function.
Nonsteroidal anti-inflammatory drugs are helpful in decreasing pain from the chest tube. Bed rest is not
needed and would increase risk for complications such as deep vein thrombosis. With a pneumothorax, there
will be minimal drainage in the collection chamber.
Which finding best indicates that the chest tube for a client with a pneumothorax may be discontinued?
o Clear breath sounds heard in both lungs
o Oxygen saturation reading is higher than 90%
o Absence of bubbling in the water-seal chamber
o Full re-expansion of the lungs seen on chest x-ray
o Full re-expansion of the lungs seen on chest x-ray
· Chest x-ray films reveal the degree to which the lung fills the pleural cavity and also the presence or absence
of pneumothorax. Clear breath sounds heard bilaterally do help indicate that the lung has re-expanded, but a
chest x-ray is needed to confirm lung re-expansion. Oxygen saturations improve with resolution of
pneumothorax, but a chest x-ray is needed for confirmation. Because intrapleural air is expelled into the
water-seal chamber, lack of bubbling in the water-seal chamber indicates possible resolution of the
pneumothorax, but a chest x-ray is needed for confirmation.
A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage
system. If the chest tube and closed chest drainage system are effective, which type of pressure will be
reestablished?
o Neutral pressure in the pleural space
o Negative pressure in the pleural space
o Atmospheric pressure in the thoracic cavity
o Intrapulmonic pressure in the thoracic cavity
o Negative pressure in the pleural space
· Removal of air and fluid from the pleural space reestablishes negative pressure, resulting in lung expansion.
Neutral pressure in the pleural space will cause collapse of the lung. Atmospheric pressure in the thoracic
Questions And Answers Latest Updates
The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which
laboratory test would the nurse monitor for hypoxia?
o Red blood cell count
o Sputum culture
o Arterial blood gas
o Total hemoglobin
o Arterial blood gas
· Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with
respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the
lungs. This provides accurate information about the client’s oxygenation status.
A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. Which is/are the
best site(s) to assess this condition? Select all that apply. One, some, or all responses may be correct.
o Lips
o Sclera
o Mouth
o Sacrum
o Nail beds
o Shoulders
o Lips
o Mouth
o Nail beds
· Prolonged hypoxia resulting in increased amounts of deoxygenated blood causes cyanosis, which can be best
evaluated in lips, mouth, nail beds, and skin (in extreme conditions). Sclera is the site of assessment for
jaundice, whereas shoulders are assessed to confirm the condition of erythema.
A child had an emergency tracheotomy and is receiving humidified air through a tracheotomy collar. Which
early clinical manifestations of hypoxia would alert the nurse to suction the tracheotomy?
,o Dyspnea and cyanosis
o Agitation and diaphoresis
o Restlessness and increase in pulse
o Severe substernal retractions and stridor
o Restlessness and increase in pulse
· Restlessness and increase in pulse are some of the first signs of hypoxia; the airway must be kept patent to
promote oxygenation. The other options are late signs of respiratory difficulty; suctioning and other measures
should have been implemented before this time.
The nurse is suctioning a client’s airway. Which nursing action will limit hypoxia?
o Limit suctioning with catheter to 30 seconds.
o Apply suction only after the catheter is inserted.
o Lubricate the catheter with saline before insertion.
o Use a sterile suction catheter for each suctioning episode.
o Apply suction only after the catheter is inserted.
· The negative pressure from suctioning removes oxygen and secretions; suction should be applied only after
the catheter is inserted and is being withdrawn. Limiting suctioning with the catheter to half a minute is too
long; suctioning should be limited to 10 seconds. Lubrication will facilitate insertion and minimize trauma; it
will not prevent hypoxia. The use of a sterile catheter helps prevent infection, not hypoxia.
Which type of breathing pattern is manifested with hypercarbia?
o Eupnea
o Tachypnea
o Hypoventilation
o Kussmaul respiration
o Hypoventilation
· Hypercarbia may occur during hypoventilation. The respiratory rate is abnormally low and the depth of
ventilation is depressed in hypoventilation. In eupnea, the normal rate and depth of respiration are interrupted
while singing. The rate of breathing is regular, but abnormally rapid in tachypnea. Respirations are
abnormally deep, regular, and the rate is increased in Kussmaul respiration.
Which actions will the nurse include in the plan of care for a client with a left pneumothorax who has a chest
tube in place? Select all that apply. One, some, or all responses may be correct.
o Immobilize the left arm in a sling.
, o Check the water-seal chamber for air bubbling.
o Avoid use of nonsteroidal anti-inflammatory drugs.
o Keep the client on bed rest in semi-Fowler position.
o Observe frequently for drainage in the collection chamber.
o Assist the client to cough and deep breathe every hour while awake.
o Check the water-seal chamber for air bubbling.
o Assist the client to cough and deep breathe every hour while awake.
· The nurse would assess for air bubbling in the water-seal chamber to determine whether the client’s
pneumothorax is resolved. Hourly coughing and deep breathing helps re-expand the lung and prevents
atelectasis. Immobilization of the left arm is not needed and may lead to decreased shoulder and arm function.
Nonsteroidal anti-inflammatory drugs are helpful in decreasing pain from the chest tube. Bed rest is not
needed and would increase risk for complications such as deep vein thrombosis. With a pneumothorax, there
will be minimal drainage in the collection chamber.
Which finding best indicates that the chest tube for a client with a pneumothorax may be discontinued?
o Clear breath sounds heard in both lungs
o Oxygen saturation reading is higher than 90%
o Absence of bubbling in the water-seal chamber
o Full re-expansion of the lungs seen on chest x-ray
o Full re-expansion of the lungs seen on chest x-ray
· Chest x-ray films reveal the degree to which the lung fills the pleural cavity and also the presence or absence
of pneumothorax. Clear breath sounds heard bilaterally do help indicate that the lung has re-expanded, but a
chest x-ray is needed to confirm lung re-expansion. Oxygen saturations improve with resolution of
pneumothorax, but a chest x-ray is needed for confirmation. Because intrapleural air is expelled into the
water-seal chamber, lack of bubbling in the water-seal chamber indicates possible resolution of the
pneumothorax, but a chest x-ray is needed for confirmation.
A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage
system. If the chest tube and closed chest drainage system are effective, which type of pressure will be
reestablished?
o Neutral pressure in the pleural space
o Negative pressure in the pleural space
o Atmospheric pressure in the thoracic cavity
o Intrapulmonic pressure in the thoracic cavity
o Negative pressure in the pleural space
· Removal of air and fluid from the pleural space reestablishes negative pressure, resulting in lung expansion.
Neutral pressure in the pleural space will cause collapse of the lung. Atmospheric pressure in the thoracic
