Chapter 36 Oxygenation

Chapter 36  Oxygenation

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. The nurse is providing care to a pregnant woman in preterm labor. The patient is 32 weeks pregnant. Initially, the patient states, “I’ve gained 30 pounds. That should be enough for the baby. Everything will be okay if I deliver now.” After teaching the patient about fetal development, the nurse will know her teaching is effective if the patient makes which of the following statements?
a)
“The baby’s lungs are well developed now, but he will be at increased risk for SIDS if I deliver early.”
b)
“We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early.”
c)
“If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening.”
d)
“Thanks for reassuring me; I was pretty sure there isn’t much risk to the baby this far along in my pregnancy.”

ANS: C
Premature infants (younger than 33 weeks’ gestation) are born before the alveolar surfactant system is fully developed. Therefore, they are at high risk for respiratory distress syndrome (RDS). RDS is characterized by widespread atelectasis (collapse of alveoli), usually related to a deficiency of surfactant that keeps air sacs open.

Difficulty: Moderate
Nursing Process: Evaluation
Client Need: PHSI
Cognitive Level: Application

PTS: 1

2. While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal chest drainage unit (CDU). Which action should the nurse take immediately?
a)
Clamp the chest tube close to the insertion site.
b)
Set up a new drainage system, and connect it to the chest tube.
c)
Have the patient take and then hold a deep breath while the nurse reconnects the tube to the CDU.
d)
Place the disconnected end nearest the patient into a bottle of sterile water.

ANS: D
Recollapse of the lung can occur because of loss of negative pressure within the system. This is commonly caused by air leaks, disconnections, or cracks in the bottles or chambers. If any of these occur, the nurse should immediately place the disconnected end nearest the patient into a bottle of sterile water or saline to a depth of 2 cm to serve as an emergency water seal until a new system can be connected. Do not clamp the chest tube because this can rapidly lead to a tension pneumothorax. A new drainage system should be set up to decrease the risk of infection, but the immediate action is to place the disconnected end into a bottle of sterile water.

Difficulty: Moderate
Nursing Process: Interventions
Client Need: PHSI
Cognitive Level: Analysis

PTS: 1

3. The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which of the following responses indicates to the nurse that the medication is effective?
a)
The amount of sputum the patient expectorates decreases with each dose administered.
b)
Cough is completely suppressed, and she is able to sleep through the night.
c)
Dry, unproductive cough is reduced, but her voluntary coughing is more productive.
d)
Involuntary coughing produces large amounts of thick yellow sputum.

ANS: C
Antitussives are cough suppressants that reduce the frequency of an involuntary, dry, nonproductive cough. Antitussives are useful for adults when coughing is unproductive and frequent, leading to throat irritation or interrupted sleep. Expectorants help make coughing more productive. The goal of an antitussive/expectorant combination is to reduce the frequency of dry, unproductive coughing while making voluntary coughing more productive.

Difficulty: Difficult
Nursing Process: Evaluation
Client Need: PHSI
Cognitive Level: Application

PTS: 1

4. The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure. The patient is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take?
a)
Review and implement the primary care provider’s prescriptions for treatments.
b)
Perform a quick physical examination of breathing, circulation, and oxygenation.
c)
Gather a thorough medical history, including current symptoms, from the family.
d)
Administer oxygen to the patient through a nasal cannula.

ANS: B
The first action the nurse should take is to make a quick assessment of the adequacy of breathing, circulation, and oxygenation to determine the type of immediate intervention required. The nurse’s assessment should include simple questions about current symptoms. A more thorough medical history can be gathered once the patient’s oxygenation needs are addressed. Following a quick assessment, the nurse should then review and implement physician’s orders. Administering oxygen is not appropriate without knowing what treatments the primary care provider has prescribed.

Difficulty: Moderate
Nursing Process: Interventions
Client Need: PHSI
Cognitive Level: Application

PTS: 1

5. You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patient’s respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern?
a)
Biot’s breathing
b)
Kussmaul’s respirations
c)
Sleep apnea
d)
Cheyne-Stokes respirations

ANS: D
This respiratory pattern is known as Cheyne-Stokes respirations. It is often associated with damage to the medullary respiratory center or high intracranial pressure due to brain injury.

Difficulty: Easy
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Comprehension

PTS: 1