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Exam 2: Oxygenation (NCLEX)
An RN from the orthopedic unit has been floated to the medical unit. Which client assignment for the floated RN is best?
A. The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula
B. The client with chronic lung disease who is being evaluated for possible home oxygen use
C. The client with a newly placed tracheostomy who is receiving oxygen through a tracheostomy collar
D. The client with chronic bronchitis who is receiving oxygen at 60% through a Venturi mask
A
Orthopedic nurses are familiar with pulmonary emboli and with administration of oxygen through nasal cannulas.
Which value indicates clinical hypoxemia and the need to increase oxygen delivery?
A. Hemoglobin of 22 g/dL
B. PaCO2 of 30 mm Hg
C. PaO2 of 65 mm Hg
D. Oxygen saturation of 88%
C
PaO2 of 65 mm Hg indicates low levels of oxygen in the arterial blood; this is termed hypoxemia.
A client with COPD has a physician's prescription stating, "Adjust oxygen to SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN?
A. Adjust the position of the oxygen tubing
B. Assess for signs and symptoms of hypoventilation
C. Change the O2 flow rate to keep SpO2 as prescribed
D. Choose which O2 delivery device should be used for the client
A
The scope of a nursing assistant's work includes positioning of oxygen tubing for client comfort.
A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response?
A. "You can quit when you are ready."
B. "It's never too late to quit."
C. "Just turn off your oxygen when you smoke."
D. "You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous."
D
This is a great opening for the nurse to educate the client about the dangers of smoking in the presence of oxygen, as well as the benefits of quitting.
Which client has the most urgent need for frequent nursing assessment?
A. An older client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year 2- pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask
B. A young client who has had a tracheostomy for 1 week, who is on room air with SpO2 in the upper 90's, who has been receiving antibiotic therapy for 16 hours, and who has foul-smelling drainage on the tracheostomy ties
C. An older adult client who is anxious to go home with her new tank of oxygen and supply of nasal cannulas and is being discharged with a new prescription for home oxygen therapy
D. A middle-aged client who was admitted yesterday with pneumonia and is receiving oxygen at 2 L/min through a nasal cannula
A
An older adult client with a long history of smoking and chronic lung disease who is receiving high-flow oxygen delivery is at elevated risk for respiratory depression owing to the hypoxic drive of respirations
The client is admitted to the hospital for COPD, and the physician requests a nasal cannula at 2 L/min. Within 30 minutes, the client's color improves. What does the nurse continue to monitor that may require immediate attention?
A. Increasing carbon dioxide levels
B. Decreasing respiratory rate
C. Increasing adventitious breath sounds
D. Increased coughing
B
Respiratory rate and depth should be monitored closely while the client receives oxygen, because hypoventilation is seen during the first 30 minutes of oxygen therapy in clients with hypoxic drive for respiration. The client's color will improve (from ashen or gray to pink) because of an increase in PaO level before apnea or respiratory arrest occurs from loss of the hypoxic drive.
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
D
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 patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status?
A: Increased breathlessness but increased activity tolerance
B: Decreased breathlessness and decreased activity tolerance
C: Increased activity tolerance and decreased breathlessness
D: Decreased activity tolerance and increased breathlessness
D
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.
A
The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost- effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?
A: Antibiotics
B: Frequent change of position
C: Oxygen humidification
D: Chest physiotherapy
B
A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning?
The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? (Select all that apply.)
A: SpO2 levels
B: Amount of sputum production
C: Change in respiratory rate and pattern
D: Pain in lower calf area
ABC
Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient?
A: Postural drainage
B: Chest percussion
C: Incentive spirometer
D: Suctioning
C
The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient?
A: Nasal cannula
B: Venturi mask
C: Simple face mask without inflated reservoir bag
D: Plastic face mask with inflated reservoir bag
A
For a male client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?
A. Restricting fluid intake to 1,000 ml/day
B. Enforcing absolute bed rest
C. Teaching the client how to perform controlled coughing
D. Administering prescribed sedatives regularly and in large amounts
C
For a client who is having respiratory symptoms of unknown etiology, the diagnostic test that is most invasive is:
A. Pulse oximetry to determine oxygen saturation levels
B. Throat cultures with sterile swabs
C. Bronchoscopy of the bronchial trees
D. Computed tomography of the lung fields
C
The nurse identifies that the client is unable to cough to produce a sputum specimen and must be suctioned. Which suctioning route is preferred?
A. Nasopharyngeal
B. Nasotracheal
C. Oropharyngeal
D. Orotracheal
B
A. Nasotracheal suctioning
B. Oropharyngeal suctioning of a stable patient
C. Suctioning a new artificial airway
D. Permanent tracheostomy tube suctioning
E. Care of an endotracheal tube (ETT)
BDE
The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider?
a. Dry cough
b. Hematuria
c. Bronchospasm
d. Blood-streaked sputum
C
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding?
a. Slow, deep respirations
b. Rapid, deep respirations
c. Paradoxical respirations
d. Pain, especially with inspiration
D
The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions?
a. Palpation and clubbing
b. Percussion and vibration
c. Hyperoxygenation and suctioning
d. Administer a bronchodilator and monitor peak flow
B
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
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.
What action does the nurse perform to follow safe technique when using a portable oxygen cylinder?
a) Checking the amount of oxygen in the cylinder before using it
b) Using a cylinder for a patient transfer that indicates available oxygen is 500 psi
c) Placing the oxygen cylinder on the stretcher next to the patient
d) Discontinuing oxygen flow by turning cylinder key counterclockwise until tight
A
An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure?
a) Tilt the patient's head forward.
b) Hold the mask tightly over the patient's nose and mouth.
c) Pull the patient's jaw backward.
d) Compress the bag twice the normal respiratory rate for the patient.
B
A patient with a diagnosis of advanced Alzheimer disease who is unable to follow directions requires an inhaled bronchodilator. Which of the following medication delivery systems is most appropriate for this patient?
a) metered-dose inhaler with spacer
b) nebulizer
c) metered-dose inhaler without spacer
d) dry powder inhaler
B
The nurse is caring for a client who is diagnosed with impaired gas exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis?
a) high respiratory rate
b) low pulse rate
c) high temperature
d) low blood pressure
A
A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient?
a) Oxygen tent
b) Oxygen mask
c) Nasal cannula
d) Ambu bag
D
If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag)may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube.
Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?
a) Eat one large meal at noon.
a) Respiratory rate and depth
b) Urinary intake and output
c) Orthostatic blood pressure
d) Apical pulse
A
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?
a) Pulmonary function tests
b) Chest x-ray
c) Skin tests
d) Bronchoscopy
A
A newly hired nurse is performing a focused respiratory assessment. The nurse mentor will intervene if which action by the newly hired nurse is noted?
a) The newly hired nurse palpates the point of maximal impulse (PMI).
b) The newly hired nurse auscultates breath sounds as the client breathes through the nose.
c) The newly hired nurse attaches a pulse oximetry to the client's index finger.
d) The newly hired nurse explains the assessment procedure before performing it.
B
The nurse is caring for a client with emphysema. A review of the client's chart reveals pH 7.36, paO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription, if prescribed by the health care practitioner?
a) Pulse oximetry
b) 4 L/minute O2 nasal cannula
c) High-Fowler's position
d) Increase fluid intake to 3 L/day
B
The client with chronic lung disease, such as emphysema, becomes insensitive to carbon dioxide and responds to hypoxia to stimulate breathing. If given excessive oxygen (4 L/minute), the stimulus to breathe is removed. Clients with emphysema are most comfortable in high-Fowler's position because it aids in the use of the accessory muscles to promote respirations. Increasing fluid intake helps keep the client's secretions thin. Pulse oximetry monitors the client's arterial oxyhemoglobin saturation while receiving oxygen therapy.
The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?
a) Arterial blood gas
b) Hemoglobin levels
c) Hematocrit values
d) Pulmonary function
A
Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.
A nurse is delivering 3 L/min oxygen to a patient via nasal cannula. What percentage of delivered oxygen is the patient receiving?
a) 32%
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 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.
A
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.
C
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.
B
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.
The nurse is caring for a client with orders for oxygen at 5 L/min. Approximately how much FiO2 is the client receiving?
a. 24%
b. 28%
c. 36%
d. 40%
D
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?
