Unit 4 Exam

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ajcksn613
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112626
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Unit 4 Exam
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2011-10-27 15:11:05
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Oxygenation
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Oxygenation
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  1. The client has a tracheostomy secondary to head
    and neck surgery. The nurse monitors the client for complications related to the absence of which important protective mechanism?
    • A. The ability to cough
    • B. * Filtration and humidification of
    • inspired air
    • C. The sneeze reflex initiated by irritants in the nasal passages
    • D. Decrease in oxygen-carrying capacity of the trachea

  2. Which client would the nurse closely observe for
    a decreased or absent cough reflex?
    • A. The client with a nasal fracture
    • B. * The client with impairment of vagus nerve conduction
    • C. The client with a sinus infection
    • D. The client with reduction in respiratory membrane conduction

  3. The client complains of difficulty breathing. Which of the following assessment findings would the nurse commonly associate with that complaint? (Select all
    that apply.)
    • A. * Use of accessory muscles
    • B. * Increased respiratory depth
    • C. * Increased respiratory rate
    • D. * Decreased respiratory depth
    • E. Decreased respiratory rate
  4. The client has been admitted with complaints of
    shortness of breath of 2 weeks duration and has received the nursing diagnosis Impaired Gas Exchange. Which admission laboratory result would support the choice of
    this diagnosis?
    • A. * Increased hematocrit
    • B. Decreased BUN
    • C. Increased blood sugar
    • D. Increased sedimentation rate
  5. The client with chronic obstructive lung disease
    has oxygen ordered at 1.5 liters per minute via nasal cannula. The client complains of shortness of breath. What action should be taken by the nurse?



    • A. Increase the oxygen to 3 liters per minute via nasal cannula.
    • B. Lower the head of the client's bed to semi-Fowler's position.
    • C. * Have the client breathe through pursed
    • lips.
    • D. Encourage the client to breathe more rapidly.

  6. The client has just been told that his medical
    condition is terminal and that he has less than 6 months to live. The client
    begins to hyperventilate and complains that he is light-headed and that his
    fingers, toes, and mouth are tingling. What action should be taken by the
    nurse?
    • A. Prepare
    • to resuscitate the client.

    • B. * Have the client concentrate on slowing
    • down respirations.
    • C. Place the client in Trendelenburg's position and ask him to cough forcefully.
    • D. Administer 25 mg of meperidine demerol) according to the prn pain order.

  7. The client is experiencing severe shortness of
    breath, but is not cyanotic. What lab value would the nurse review in an
    attempt to understand this phenomenon?
    • A. Blood sugar
    • B. * Hemoglobin and hematocrit
    • C. Cardiac enzymes
    • D. Serum electrolytes

  8. The client has a 20-year history of asthma with
    chronic hypoxia. Which change in the client's fingers would the nurse
    expect?
    • A. Clubbing


  9. The client has a medical condition that often
    results in the development of metabolic acidosis. The nurse should observe this
    client for the development of which breathing pattern as a result of this
    condition?
    • A. Cheyne-Stokes
    • B. Biot's
    • C. Cluster
    • D. * Kussmaul's



  10. Upon
    assessment, the nurse notes that the client is dyspneic, has bibasilar
    crackles, and tires easily upon exertion. Which nursing diagnosis is best
    supported by these assessment details?



    • A. Ineffective Breathing Pattern
    • B. Anxiety
    • C. * Ineffective Airway Clearance
    • D. Impaired Gas Exchange


  11. The client is hypoxic according to arterial
    blood gas measurement. What nursing diagnosis problem statement is most appropriate for this client? __________
    • Impaired Gas Exchange

  12. The nurse encourages the client to expectorate
    sputum rather than swallowing it. What is the rationale for this direction?



    • A. Sputum contains bacteria that should be expectorated.
    • B. Swallowing sputum is dangerous to the system.
    • C. * The nurse should view the sputum for
    • quality and quantity.
    • D. The client is likely to aspirate the sputum while
    • attempting to swallow it.

  13. The
    nurse is planning a time schedule for a client's twice-daily postural drainage.
    Which time schedule would be best?



    • A. 0800and 1100
    • B. 1200 and 1800
    • C. * 0700 and 2000
    • D. 0900 and 2100

  14. The client is receiving oxygen by nonrebreather
    mask, but the bag is not deflating on inspiration. What action should be taken
    by the nurse?



    • A. Turn the client to the left side.
    • B. Increase the percentage of oxygen being delivered.
    • C. Check for an airtight seal between the client's face and the mask.
    • D. * Increase the liter flow of oxygen being
    • delivered.

  15. The nurse has placed an oropharyngeal airway in
    a client. What action should the nurse take at this time?
    • A. Tape the airway in place.
    • B. Suction the client.
    • C. * Turn the client's head to the side.
    • D. Insert a nasal trumpet.


  16. The nurse has received a client immediately
    after surgery for head and neck cancer. The client has a tracheostomy that was created during the surgery and is being mechanically ventilated. What nursing
    action should be planned for this client?



    • A. Deflate the cuff of the tracheostomy tube every 2 hours for 5 minutes.
    • B. Remove the tracheostomy ties and replace them with an elastic bandage.
    • C. Remove the tracheostomy inner cannula.
    • D. * Tape the tracheostomy obturator to the
    • head of the bed.

  17. The hospital policy and procedure for suctioning
    requires hyperinflation of the client prior to suctioning. How should the nurse
    proceed with this requirement?



    • A. Turn the suction level up to 60 cm prior to inserting the catheter.
    • B. Increase the oxygen flow to the client by 20% prior to suctioning.
    • C. * Provide 2 to 3 breaths at 1.5 times the
    • tidal volume prior to suction.
    • D. Instruct the client to cough forcefully from the abdomen prior to suction.



  18. The nurse who is assessing a client's chest tube
    insertion site notices a fine crackling sound and feeling upon palpating the
    area. What action should the nurse take?
    • A. Discontinue the chest tube suction.
    • B. * Collaborate with the client's physician.
    • C. Mark the area involved and remove the tube.
    • D. Reinforce the chest tube dressing.


  19. The nurse is preparing to assist with the
    removal of a chest tube that is a simple insertion without a purse-string suture.
    What materials should the nurse gather for this procedure?



    • A. * An occlusive dressing
    • B. A 4 × 4 gauze
    • C. An adhesive gauze pad dressing
    • D. A nonadherent gauze dressing
  20. The
    nurse has completed discharge teaching for a client who will be going home on
    oxygen therapy. What statement, made by the client, would indicate that this
    client needs further instruction?



    • A. * "I will replace my cotton blankets with polyester ones."
    • B. "My son will not be able to smoke when I am around."
    • C. "I will have my electrical appliance checked for grounding."
    • D. "I will buy a fire extinguisher for my
    • bedroom."

  21. The
    client who has a nasotracheal tube in place has been restless and pulling at
    the tube. How would the nurse assess if the tube is still in place?



    A. Count the client's respirations.

    B. Assess the depth of the client's respirations.

    C. * Auscultate for bilateral breath sounds.

    D. Deflate the cuff and listen for minimal leak.
  22. The nurse has just initiated oxygen by nasal
    cannula for a client with the medical diagnosis of chronic obstructive
    pulmonary disease. What is the nurse's next action?



    A. Fill the humidifier with normal saline.

    • B. * Pad the tubing where it contacts the
    • client's ears.

    C. Set the oxygen delivery to 5 liters.

    • D. Secure the cannula with ties around the client's
    • head.

  23. The nurse who is performing care for a client
    with a new tracheostomy determines the ties are very soiled and must be
    changed. What is the best method for changing these ties?



    A. Remove the old ties, clean the area well, and then put on new ties.

    B. Attach the new tape and tie with a square knot behind the client's neck.

    • C. * Have an assistant hold the tracheostomy
    • tube in place, remove the soiled ties, and replace the ties.

    • D. Remove the outer cannula, replace the soiled ties, and reinsert.

  24. The
    nurse is planning the care of a client who has need for frequent suctioning.
    Which of the following should the nurse delegate to the UAP?



    A. Both oral and tracheal suctioning

    B. * Only oral suctioning

    C. Only tracheal suctioning

    • D. Neither oral nor tracheal suctioning

  25. During tracheal suctioning, the nurse notes that
    the client' heart rate has increased from 80 to 100 bpm. Based upon this
    assessment, what action should the nurse take?



    A. Immediately discontinue suctioning.

    B. Prepare to resuscitate the client.

    C. Continue to suction until the airway is clear.

    • D. * Complete the suction episode as quickly
    • as possible.

  26. The client who is being mechanically ventilated
    has copious amounts of secretions ranging from thick and tenacious to frothy.
    In preparing to suction this client the nurse should:



    • A. Hyperventilate the client using settings on the mechanical ventilator.
    • B. Hyperventilate the client using a manual resuscitator.
    • C. Avoid hyperventilation, but instill normal saline into the endotracheal tube.
    • D. * Avoid hyperventilation and increase the
    • oxygen to 100% for several breaths.



  27. As a part of preoperative teaching, the nurse is
    instructing the client on the use of a volume-oriented incentive spirometer.
    Which instruction should be included in this teaching? (Select all that apply.)
    • A. Blow out into the canister
    • until the enclosed cylinder rises.
    • B. * Close your lips tightly around the mouthpiece.
    • C. Inhale sharply to elevate the enclosed cylinder.
    • D. * Use a nose clip to occlude nasal passages if necessary.
    • E. * Cough after using the device.
  28. The client has been prescribed both a
    bronchodilator and a steroid medication that is delivered by inhaler. What information is essential to teach this client in regard to these medications?
    • A. The medications cannot be used on the same day.
    • B. The steroid inhaler should be used when immediate effects are necessary.
    • C. The bronchodilator should be used only when absolutely necessary and only after the steroid inhaler.
    • D. * Both medications have the possible side
    • effect of increased heart rate.



  29. hypoxia
  30. hyperventilation
  31. hypocapnia
  32. hypercapnia
  33. physiological processes involved in ventilation
  34. physiological processes involved exchange of respiratory gases.

  35. physiological processes involved perfusion,
  36. Examine factors that affect respiratory function.
  37. Describe conditions that contribute to alterations
    in breathing patterns.
  38. Explain defenses of the respiratory ystem.
  39. Apply the nursing process to the care of patients
    with respiratory problems
  40. Vesicular breath sounds are heard over most of the peripheral lung fields, and are
    described as soft, low pitched, and with a gentle rustling quality.
    These are normal breath sounds -ormal breath sound production is directly related to air flow velocity and airway lumen architecture. Air flow velocity is primarily determined by pulmonary ventilation (­minute volume ® ­ velocity) and TOTAL cross sectional airway area (¯ area ® ­ velocity) at any given level in the lungs.
  41. Vesicular breath sounds are heard over most of the peripheral lung fields, and are
    described as soft, low pitched, and with a gentle rustling quality.
    These are normal breath sounds -ormal breath sound production is directly related to air flow velocity and airway lumen architecture. Air flow velocity is primarily determined by pulmonary ventilation (­minute volume ® ­ velocity) and TOTAL cross sectional airway area (¯ area ® ­ velocity) at any given level in the lungs.
  42. Vesicular breath sounds are heard over most of the peripheral lung fields, and are
    described as soft, low pitched, and with a gentle rustling quality.
    These are normal breath sounds -ormal breath sound production is directly related to air flow velocity and airway lumen architecture. Air flow velocity is primarily determined by pulmonary ventilation (­minute volume ® ­ velocity) and TOTAL cross sectional airway area (¯ area ® ­ velocity) at any given level in the lungs.
  43. Vesicular breath sounds are heard over most of the peripheral lung fields, and are
    described as soft, low pitched, and with a gentle rustling quality.
    These are normal breath sounds -ormal breath sound production is directly related to air flow velocity and airway lumen architecture. Air flow velocity is primarily determined by pulmonary ventilation (­minute volume ® ­ velocity) and TOTAL cross sectional airway area (¯ area ® ­ velocity) at any given level in the lungs.
  44. Vesicular breath sounds are heard over most of the peripheral lung fields, and are
    described as soft, low pitched, and with a gentle rustling quality.
    These are normal breath sounds -ormal breath sound production is directly related to air flow velocity and airway lumen architecture. Air flow velocity is primarily determined by pulmonary ventilation (­minute volume ® ­ velocity) and TOTAL cross sectional airway area (¯ area ® ­ velocity) at any given level in the lungs.
  45. Vesicular breath sounds are heard over most of the peripheral lung fields, and are
    described as soft, low pitched, and with a gentle rustling quality.
    These are normal breath sounds -ormal breath sound production is directly related to air flow velocity and airway lumen architecture. Air flow velocity is primarily determined by pulmonary ventilation (­minute volume ® ­ velocity) and TOTAL cross sectional airway area (¯ area ® ­ velocity) at any given level in the lungs.
  46. Vesicular breath sounds are heard over most of the peripheral lung fields, and are
    described as soft, low pitched, and with a gentle rustling quality.
    These are normal breath sounds -ormal breath sound production is directly related to air flow velocity and airway lumen architecture. Air flow velocity is primarily determined by pulmonary ventilation (­minute volume ® ­ velocity) and TOTAL cross sectional airway area (¯ area ® ­ velocity) at any given level in the lungs.
  47. Vesicular breath sounds are heard over most of the peripheral lung fields, and are
    described as soft, low pitched, and with a gentle rustling quality.
    These are normal breath sounds -ormal breath sound production is directly related to air flow velocity and airway lumen architecture. Air flow velocity is primarily determined by pulmonary ventilation (­minute volume ® ­ velocity) and TOTAL cross sectional airway area (¯ area ® ­ velocity) at any given level in the lungs.
  48. Vesicular breath sounds are heard over most of the peripheral lung fields, and are
    described as soft, low pitched, and with a gentle rustling quality.
    These are normal breath sounds -ormal breath sound production is directly related to air flow velocity and airway lumen architecture. Air flow velocity is primarily determined by pulmonary ventilation (­minute volume ® ­ velocity) and TOTAL cross sectional airway area (¯ area ® ­ velocity) at any given level in the lungs.
  49. Vesicular breath sounds are heard over most of the peripheral lung fields, and are
    described as soft, low pitched, and with a gentle rustling quality.
    These are normal breath sounds -ormal breath sound production is directly related to air flow velocity and airway lumen architecture. Air flow velocity is primarily determined by pulmonary ventilation (­minute volume ® ­ velocity) and TOTAL cross sectional airway area (¯ area ® ­ velocity) at any given level in the lungs.
  50. Vesicular breath sounds are heard over most of the peripheral lung fields, and are
    described as soft, low pitched, and with a gentle rustling quality.
    These are normal breath sounds -ormal breath sound production is directly related to air flow velocity and airway lumen architecture. Air flow velocity is primarily determined by pulmonary ventilation (­minute volume ® ­ velocity) and TOTAL cross sectional airway area (¯ area ® ­ velocity) at any given level in the lungs.
  51. Vesicular breath sounds are heard over most of the peripheral lung fields, and are
    described as soft, low pitched, and with a gentle rustling quality.
    These are normal breath sounds -ormal breath sound production is directly related to air flow velocity and airway lumen architecture. Air flow velocity is primarily determined by pulmonary ventilation (­minute volume ® ­ velocity) and TOTAL cross sectional airway area (¯ area ® ­ velocity) at any given level in the lungs.
  52. Vesicular breath sounds are heard over most of the peripheral lung fields, and are
    described as soft, low pitched, and with a gentle rustling quality.
    These are normal breath sounds -ormal breath sound production is directly related to air flow velocity and airway lumen architecture. Air flow velocity is primarily determined by pulmonary ventilation (­minute volume ® ­ velocity) and TOTAL cross sectional airway area (¯ area ® ­ velocity) at any given level in the lungs.

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