Oxygenation Perfusion Practice Questions

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NURS (FUNDAMENTAL): NCLEX Oxy...

70 terms nurseathrtPreview Fundamentals Chapter 39- Oxygena...61 terms Casey_Baumberger Preview Fundamentals Exam 4 - Oxygenatio...47 terms Ahlam_Shaikh Preview Fluid a 33 terms Ale The nurse is assessing a patient with a respiratory problem. Which is most reflective of an early adaptation to hypoxia?

• Apnea
• Cyanosis
• Restlessness
• Dysrhythmias
• Restlessness
• Apnea, a complete absence of respirations, is

the cause of, not an adaptation to, hypoxia.

• Cyanosis, a bluish discoloration of the skin

and mucous membranes caused by reduced oxygen in the blood, is a late sign of hypoxia.

• Hypoxia is insuffi cient oxygen anywhere

in the body. An early sign of hypoxia is restlessness, which is caused by the lack of cerebral perfusion of oxygen.

• A dysrhythmia, a pulse with an irregular

rhythm, can occur with hypoxia but it is a late adaptation.

The nurse in the Post-Anesthesia Care Unit is monitoring several patients who received general anesthesia. Which patient adaptation causes the most concern?

• Pain
• Stridor
• Lethargy
• Diaphoresis
• Stridor
• Pain is an expected response to the trauma of

surgery and usually can be managed effectively.

• Stridor is an obvious audible shrill, harsh

sound caused by laryngeal obstruction.The larynx can become edematous because of the trauma of intubation associated with general anesthesia. Obstruction of the larynx is life-threatening because it prevents the exchange of gases between the lungs and atmospheric air.

• Lethargy, which is drowsiness or sluggishness,

is an expected response to anesthesia and narcotic medications because these medications depress the central nervous system.

• Although diaphoresis is a cause for concern,

it is not as immediately life-threatening as an adaptation in another option. Diaphoresis can be related to a warm environment, impaired thermoregulation, the General Adaptation Syndrome, or shock.

When administering oxygen via a wall-outlet system, the nursing action that is unnecessary for a low liter flow as opposed to a high liter flow is:

• Attaching a flowmeter to the wall outlet
• Providing oral hygiene whenever necessary
• Hanging an Oxygen in Use sign outside the patient's room
• Humidifying the oxygen before it is delivered to the patient
• Humidifying the oxygen before it is delivered to the patient
• All oxygen systems should have a flowmeter to

control and maintain the flow of oxygen gas.

• All oxygen is drying to the oral mucosa.

Therefore, oral hygiene should be provided frequently to moisten the mucous membranes.

• Oxygen in use signs should be displayed

prominently on the patient's door and bed to alert others that oxygen is in use and that safety precautions should be implemented.

• A low liter fl ow system administers a

volume of oxygen designed to supplement the inspired room air to provide airfl ow equal to the person's minute ventilation.A high liter fl ow system administers a volume of oxygen designed to exceed the volume of air required for the person's minute ventilation. The low liter fl ow system is less drying than the high liter fl ow system and humidifi cation is unnecessary. A humidifi er is a mechanical device that adds water vapor to air in a particle size that can carry moisture to the small airways.

The nurse is teaching a patient how to use an incentive spirometer. The nurse should assist the patient to assume which position?

• Sitting
• Side-lying
• Orthopneic
• Low-Fowler's
• Sitting
• An upright sitting position in a bed or chair

facilitates maximum thoracic excursion because it permits the diaphragm to contract without pressure being exerted against it by abdominal viscera.

• The side-lying position is not ideal for the use

of an incentive spirometer because it limits thoracic expansion. The side-lying position allows the abdominal viscera to exert pressure against the diaphragm during inspiration and the lung on the lower side of the body is compressed by the weight of the body.

• The orthopneic position raises intraabdominal

and intrathoracic pressures that can limit thoracic excursion.

• The low-Fowler's position does not maximize

the effects of gravity. Gravity moves abdominal viscera away from the diaphragm and thus facilitates the contraction of the diaphragm, both of which promote thoracic expansion.Which is the most important action by the nurse after a patient has a thoracotomy?

• Ensure the patient's intake is at least 3000 mL of fl uid per 24 hours
• Provide the patient with adequate medication for pain relief
• Maintain the integrity of the patient's chest tube
• Reposition the patient every 2 hours
• Maintain the integrity of the patient's chest tube
• This is unnecessary. A fluid intake of

approximately 2000 mL of fluid is adequate.

• Although this is extremely important, it is not

the priority.

• A tension pneumothorax may occur

if the integrity of the chest drainage system becomes compromised (e.g., open to atmospheric pressure, clogged drainage tube, or mechanical dysfunction).Maintaining respiratory functioning is the priority.

• Although repositioning is done to promote

drainage of secretions from lung segments and aeration of lung tissue, it is not the priority.