Oxygen and Tissue Perfusion Quiz

The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which oxygen delivery device will the nurse use for this patient?

• High-flow nasal cannula

• Bag-valve-mask unit

• Continuous positive airway pressure (CPAP)

• Non-rebreather mask

The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient is breathing spontaneously but is minimally responsive and having difficulty maintaining a patent airway. Which intervention is the most appropriate for the patient to improve oxygenation?

• Lower the head of the bed.

• Monitor the patient's pulse oximetry.

• Insert an oral airway.

• Turn the patient's head to the side.

The nurse is caring for a patient with a history of left-sided congestive heart failure who is acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that the patient's pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of the nurse?

• Have the patient use the ordered incentive spirometer.

• Administer the ordered intravenous diuretic.

• Prepare for insertion of a chest tube.

• Suction secretions from the patient's respiratory tract.

The nurse is caring for a patient who has been intubated with an oral endotracheal tube for several weeks. The physicians predict that the patient will need to remain on a ventilator for at least several more weeks before he will be able to maintain his airway and breathe on his own. What procedure does the nurse anticipate will be planned for the patient to facilitate recovery?

• Lung transplantation surgery

• Placement of a tracheostomy tube

• Diagnostic thoracentesis

• Pulmonary angiogram

The nurse is caring for a patient with a chest tube who was transported to radiology for testing. When the patient returns to the nursing unit, the transporter shows the nurse the patient's chest tube collection device, which was badly damaged after being caught in the elevator door. What is the priority action of the nurse?

• Clamp the chest tube until the collection device is replaced.

• Check the patient's lung sounds and pulse oximetry.

• Ensure that there is gentle bubbling in the water seal chamber.

• Cover the insertion site with a new occlusive dressing.

The nurse is caring for a patient who is hospitalized for pneumonia. Which nursing diagnosis has the highest priority?

• Impaired airway clearance r/t thick secretions in trachea and bronchi

• Impaired nutritional intake r/t poor appetite and increased metabolic needs

• Lack of knowledge r/t use of nebulizer and inhaled bronchodilators

• Activity intolerance r/t generalized weakness and hypoxemia

The nurse is caring for a patient who developed a pulmonary embolism after surgery. Which goal statement is the highest priority for the nurse to include in the patient's care plan for the diagnosis impaired gas exchange r/t impaired pulmonary blood flow from embolus?

• The patient will report chest pain of no greater than 3 on a 1 to 10 scale.

• The patient will verbalize understanding of ordered anticoagulants.

• The patient will ambulate 50 feet in hallway without shortness of breath.

• The patient will maintain pulse oximetry values of at least 95% on room air.

The nurse is caring for a patient with severe COPD who is becoming increasingly confused and disoriented. What is the priority action of the nurse?

• Administer a mild sedative and reorient the patient as needed.

• Increase the patient's oxygen until the pulse oximetry is greater than 98%.

• Obtain an arterial blood gas to check for carbon dioxide retention.

• Lower the head of the patient's bed and insert a nasal airway.

The nurse is caring for a patient who has been prescribed warfarin (Coumadin) therapy after being diagnosed with atrial fibrillation. The patient asks the nurse what could happen if the prescription doesn't get filled. What is the nurse's best response?

• You could go into respiratory failure.

• You could develop heart failure.

• You could have a stroke.

• Your kidneys could fail.

The preceptor is working with a new nurse to provide care for a patient with a chest tube to relieve a pneumothorax. Which action by the new nurse indicates need for additional teaching about chest tube care?

• The patient is encouraged to use his incentive spirometer at least 10 times every hour.

• The patient's bed is placed in the semi-Fowler's position to facilitate lung reexpansion.

• The suction is discontinued when the patient is ambulated to the bathroom.

• The collection device is emptied at the end of the shift and output recorded in the chart.