NURS 270 Unit 5 UPDATED ACTUAL Questions
and CORRECT Answers
What is the most significant modifiable risk factor for the development of impaired gas exchange?
A. Age.
B. Tobacco use.
C. Drug overdose.
D. Prolonged immobility. - CORRECT ANSWER B. Tobacco use.
Tobacco use is the most preventable cause of death and disease and is the most important risk factor in the development
of impaired gas exchange. Age is not a modifiable risk factor. Drug overdose and immobility both contribute to impaired
gas exchange but are not as significant as tobacco use.
When evaluating the concept of gas exchange, how would the nurse best describe the movement of oxygen and carbon
dioxide?
A. Oxygen and carbon dioxide are exchanged across the capillary membrane to provide oxygen to hemoglobin.
B. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane.
C. The level of inspired oxygen must be sufficient to displace the carbon dioxide molecules in the alveoli.
D. Gases are exchanged between the atmosphere and the blood based on the oxygen-carrying capacity of the hemoglobin.
- CORRECT ANSWER B. Gas moves from an area of high pressure to an area of low pressure across the alveolar
membrane.
Oxygen and carbon dioxide move across the alveolar membrane based on the partial pressure of each gas. Molecules of
oxygen are not exchanged for molecules of carbon dioxide. The pressure gradient of each gas (carbon dioxide and
oxygen) in the alveoli is responsible for the movement of each gas.
A patient is having the arterial blood gas (ABG) measured. What would the nurse identify as the parameters to be
evaluated by this test?
A. Ratio of hemoglobin and hematocrit.
B. Status of acid-base balance in arterial blood.
C. Adequacy of oxygen transport.
D. Presence of a pulmonary embolus. - CORRECT ANSWER B. Status of acid-base balance in arterial blood.
The ABG results will indicate the acid-base balance of the arterial blood and the partial pressure of oxygen and carbon
dioxide. The ABG does not reveal the ratio of hemoglobin and hematocrit, the adequacy of oxygen transport to the cells,
or the presence of a pulmonary embolus.
The nurse is administering oral glucocorticoids to a patient with asthma. What assessment finding would the nurse
identify as a therapeutic response to this medication?
A. No observable respiratory difficulty or shortness of breath over the last 24 hours.
B. A decrease in the amount of nasal drainage and sneezing.
C. No sputum production, and a decrease in coughing episodes.
D. Relief of an acute asthmatic attack. - CORRECT ANSWER A. No observable respiratory difficulty or shortness
of breath over the last 24 hours.
Glucocorticoids (corticosteroids) decrease inflammation and prevent bronchospasm in the patient with asthma. The
glucocorticoids are used to prevent problems. Anticholinergics decrease the allergic response and decrease sneezing and
rhinorrhea. Antitussives are used to decrease cough, and mucolytics assist in the removal of mucus. Sympathomimetic
agents (beta2 agonist) are used to relieve bronchospasm in an acute episode.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient tells the nurse he is
having a "hard time breathing." His respiratory rate is 32 breaths per minute, his pulse is 120 beats per minute, and the
oxygen saturation is 90%. What would be the best nursing intervention for this patient?
A. Begin oxygen via a face mask at 60% FiO2 (fraction of inspired oxygen).
B. Administer a PRN (as necessary) dose of an intranasal glucocorticoid.
,C. Encourage coughing and deep breathing to clear the airway.
D. Initiate oxygen via a nasal cannula, and begin at a flow rate of 3 L/min. - CORRECT ANSWER D. Initiate
oxygen via a nasal cannula, and begin at a flow rate of 3 L/min.
The normal respiratory drive is a person's level of carbon dioxide (CO2) in the arterial blood. The COPD patient had
compensated for his chronic high levels of CO2, and his respiratory drive is dependent on his oxygen levels, not his CO2
levels. If the COPD patient's oxygen level is rapidly increased to what would be considered a normal level, it would
compensate for his respiratory drive. The patient with COPD who has difficulty breathing should be given low levels of
oxygen and closely observed for the quality and rate of ventilation. A dose of glucocorticoids will not address his
immediate needs, but it may provide decreased inflammation and better ventilation over an extended period of time.
Encouraging coughing and deep breathing in a patient with COPD does not meet his needs as effectively as
administration of low-level oxygen does.
The nurse would anticipate that which of the following patients will need to be treated with insertion of a chest tube?
A. A patient with asthma and severe shortness of breath.
B. A patient undergoing a bronchoscopy for a biopsy.
C. A patient with a pleural effusion requiring fluid removal.
D. A patient experiencing a problem with a pneumothorax. - CORRECT ANSWER D. A patient experiencing a
problem with a pneumothorax.
When air is allowed to enter the pleural space, the lung will collapse and a chest tube will be inserted to remove the air
and reestablish negative pressure in the pleural space. Patients with asthma do not require a chest tube. A bronchoscopy is
done to evaluate the bronchi and lungs and to obtain a biopsy. A thoracentesis may be done to remove fluid from the
pleural space. A chest tube may be inserted if there are complications from the thoracentesis or for the bronchoscopy.
expected respiratory outcomes for hospitalized patient - CORRECT ANSWER -Have improved lung expansion
-Be able to mobilize secretions
-Maintain a patent airway
-Have improved activity tolerance
-Maintain oxygenation saturations >90%, respirations between 12-20
-Cough and deep breathe q 2 hours
nursing diagnoses related to oxygenation - CORRECT ANSWER -Ineffective Airway Clearance
-Impaired Gas Exchange
-Ineffective Breathing pattern
-Activity Intolerance
-Risk for Infection
care management interventions used in the treatment of impaired gas exchange - CORRECT ANSWER 1. assess
for lung sounds, vital signs, oximetry, and ABGs
2. administer oxygen (titrate to keep O2 saturation above 90% unless COPD patient)
3. collaborate with respiratory therapy if different O2 delivery system needed
4. increase HOB, CDB, incentive spirometry, suction PRN, rhonchi
5. early ambulation, adequate hydration to liquefy sections 2-4 liters/day
6. postural drainage to prevent infection
health promotion strategies for those at risk for oxygenation problems - CORRECT ANSWER influenza vaccine
(annually)
pneumonia vaccine (indicated for those at risk, including the elderly, chronic illness, nursing home residents, children
under 23 months, revaccination after age 65)
-adequate nutrition
-fluids
-avoid crowds and ill persons
-environmental protection (furnaces, smoke, wood stoves, pets, automobile exhaust, CO)
-humidity
interpretation of ABGs - CORRECT ANSWER 1. classify pH (acidic or basic)
2. assess PaCO2
3. assess HCO3
4. determine if compensation is occurring
, 5. If pH is abnormal, identify what is the primary disorder
6. determine if oxygenation problem by looking at PaCO2
normal parameters for ABG values - CORRECT ANSWER pH = 7.35-7.45
PaCO2 = 35-45 mm Hg
bicarbonate (HCO3) = 22-26 mEq/L
PaO2 = 80-100 mm Hg
SaO2 = greater than 95%
nasal cannula - CORRECT ANSWER An oxygen-delivery device in which oxygen flows through two small,
tubelike prongs that fit into the patient's nostrils; delivers 24% to 44% supplemental oxygen, depending on the flow rate.
simple face mask - CORRECT ANSWER used for short-term oxygen therapy. It fits loosely and delivers oxygen
concentrations from 35% to 50% FIO2. This is contraindicated for patients with carbon dioxide retention because
retention can be worsened. Flow rates should be 5 L or more to avoid rebreathing exhaled carbon dioxide retained in the
mask.
partial rebreather mask - CORRECT ANSWER a device used in medicine to assist in the delivery of oxygen
therapy. An NRB requires that the patient can breathe unassisted, but unlike low flow nasal cannula, the NRB allows for
the delivery of higher concentrations of oxygen; FiO2 60-80% oxygen; deliver 10-15 L oxygen
venturi mask - CORRECT ANSWER FiO2 24-55%; 4-12 L of oxygen; can be helpful in the treatment of COPD
because specific amount of oxygen can be delivered; a medical device to deliver a known oxygen concentration to
patients on controlled oxygen therapy
HCO3 - CORRECT ANSWER Bicarbonate 22-25 carried in the blood mainly by c02
above 25 = acidosis more acid
below 22= basic alkalosis
postural drainage positions - CORRECT ANSWER Postural drainage makes use of gravity to drain secretions from
the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing.
*High Fowler's position is used to drain the apical sections of the upper lobes of the lungs.
*Placing the patient lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung.
Placing the patient in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the
posterior sections of the upper lobes of the lungs. Trendelenburg position, on a table flipped almost upside down. assists
in draining the lower lobes of the lungs
normal breath sounds - CORRECT ANSWER Normal breath sounds include vesicular (low-pitched, soft sounds
heard over peripheral lung fields), the lung shape, up and down the ribs
bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and
bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds, close to core of the sternum
abnormal (adventitious) breath sounds - CORRECT ANSWER crackles range from soft to fine, to coarse.
CRACKLES=RALES
discontinuous heard on inspiration, indicate fluid in the lungs
obstructive diseases/pneumonia, sign of pulmonary fibrosis, CHF, and pulmonary edema.
FINE RALES/CRACKLES high pitched popping alveoli
COARSE CRACKLES= RHONCHI
low pitch rumbling, sputum in the airwarys, can clear with strong cough, patients have chronic bronchitis and cystic
fibrosis. excess mucus, bubbling moist sounds.
WHEEZE
continuous sounds air thru narrow airway.
HIGH PITCH WHEEZE=
musical air through bronchospastic or edematous airways.
Expiratory wheeze with asthma and COPD. Typically heard in upper airways
need bronchodilaters, steroids.
and CORRECT Answers
What is the most significant modifiable risk factor for the development of impaired gas exchange?
A. Age.
B. Tobacco use.
C. Drug overdose.
D. Prolonged immobility. - CORRECT ANSWER B. Tobacco use.
Tobacco use is the most preventable cause of death and disease and is the most important risk factor in the development
of impaired gas exchange. Age is not a modifiable risk factor. Drug overdose and immobility both contribute to impaired
gas exchange but are not as significant as tobacco use.
When evaluating the concept of gas exchange, how would the nurse best describe the movement of oxygen and carbon
dioxide?
A. Oxygen and carbon dioxide are exchanged across the capillary membrane to provide oxygen to hemoglobin.
B. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane.
C. The level of inspired oxygen must be sufficient to displace the carbon dioxide molecules in the alveoli.
D. Gases are exchanged between the atmosphere and the blood based on the oxygen-carrying capacity of the hemoglobin.
- CORRECT ANSWER B. Gas moves from an area of high pressure to an area of low pressure across the alveolar
membrane.
Oxygen and carbon dioxide move across the alveolar membrane based on the partial pressure of each gas. Molecules of
oxygen are not exchanged for molecules of carbon dioxide. The pressure gradient of each gas (carbon dioxide and
oxygen) in the alveoli is responsible for the movement of each gas.
A patient is having the arterial blood gas (ABG) measured. What would the nurse identify as the parameters to be
evaluated by this test?
A. Ratio of hemoglobin and hematocrit.
B. Status of acid-base balance in arterial blood.
C. Adequacy of oxygen transport.
D. Presence of a pulmonary embolus. - CORRECT ANSWER B. Status of acid-base balance in arterial blood.
The ABG results will indicate the acid-base balance of the arterial blood and the partial pressure of oxygen and carbon
dioxide. The ABG does not reveal the ratio of hemoglobin and hematocrit, the adequacy of oxygen transport to the cells,
or the presence of a pulmonary embolus.
The nurse is administering oral glucocorticoids to a patient with asthma. What assessment finding would the nurse
identify as a therapeutic response to this medication?
A. No observable respiratory difficulty or shortness of breath over the last 24 hours.
B. A decrease in the amount of nasal drainage and sneezing.
C. No sputum production, and a decrease in coughing episodes.
D. Relief of an acute asthmatic attack. - CORRECT ANSWER A. No observable respiratory difficulty or shortness
of breath over the last 24 hours.
Glucocorticoids (corticosteroids) decrease inflammation and prevent bronchospasm in the patient with asthma. The
glucocorticoids are used to prevent problems. Anticholinergics decrease the allergic response and decrease sneezing and
rhinorrhea. Antitussives are used to decrease cough, and mucolytics assist in the removal of mucus. Sympathomimetic
agents (beta2 agonist) are used to relieve bronchospasm in an acute episode.
The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient tells the nurse he is
having a "hard time breathing." His respiratory rate is 32 breaths per minute, his pulse is 120 beats per minute, and the
oxygen saturation is 90%. What would be the best nursing intervention for this patient?
A. Begin oxygen via a face mask at 60% FiO2 (fraction of inspired oxygen).
B. Administer a PRN (as necessary) dose of an intranasal glucocorticoid.
,C. Encourage coughing and deep breathing to clear the airway.
D. Initiate oxygen via a nasal cannula, and begin at a flow rate of 3 L/min. - CORRECT ANSWER D. Initiate
oxygen via a nasal cannula, and begin at a flow rate of 3 L/min.
The normal respiratory drive is a person's level of carbon dioxide (CO2) in the arterial blood. The COPD patient had
compensated for his chronic high levels of CO2, and his respiratory drive is dependent on his oxygen levels, not his CO2
levels. If the COPD patient's oxygen level is rapidly increased to what would be considered a normal level, it would
compensate for his respiratory drive. The patient with COPD who has difficulty breathing should be given low levels of
oxygen and closely observed for the quality and rate of ventilation. A dose of glucocorticoids will not address his
immediate needs, but it may provide decreased inflammation and better ventilation over an extended period of time.
Encouraging coughing and deep breathing in a patient with COPD does not meet his needs as effectively as
administration of low-level oxygen does.
The nurse would anticipate that which of the following patients will need to be treated with insertion of a chest tube?
A. A patient with asthma and severe shortness of breath.
B. A patient undergoing a bronchoscopy for a biopsy.
C. A patient with a pleural effusion requiring fluid removal.
D. A patient experiencing a problem with a pneumothorax. - CORRECT ANSWER D. A patient experiencing a
problem with a pneumothorax.
When air is allowed to enter the pleural space, the lung will collapse and a chest tube will be inserted to remove the air
and reestablish negative pressure in the pleural space. Patients with asthma do not require a chest tube. A bronchoscopy is
done to evaluate the bronchi and lungs and to obtain a biopsy. A thoracentesis may be done to remove fluid from the
pleural space. A chest tube may be inserted if there are complications from the thoracentesis or for the bronchoscopy.
expected respiratory outcomes for hospitalized patient - CORRECT ANSWER -Have improved lung expansion
-Be able to mobilize secretions
-Maintain a patent airway
-Have improved activity tolerance
-Maintain oxygenation saturations >90%, respirations between 12-20
-Cough and deep breathe q 2 hours
nursing diagnoses related to oxygenation - CORRECT ANSWER -Ineffective Airway Clearance
-Impaired Gas Exchange
-Ineffective Breathing pattern
-Activity Intolerance
-Risk for Infection
care management interventions used in the treatment of impaired gas exchange - CORRECT ANSWER 1. assess
for lung sounds, vital signs, oximetry, and ABGs
2. administer oxygen (titrate to keep O2 saturation above 90% unless COPD patient)
3. collaborate with respiratory therapy if different O2 delivery system needed
4. increase HOB, CDB, incentive spirometry, suction PRN, rhonchi
5. early ambulation, adequate hydration to liquefy sections 2-4 liters/day
6. postural drainage to prevent infection
health promotion strategies for those at risk for oxygenation problems - CORRECT ANSWER influenza vaccine
(annually)
pneumonia vaccine (indicated for those at risk, including the elderly, chronic illness, nursing home residents, children
under 23 months, revaccination after age 65)
-adequate nutrition
-fluids
-avoid crowds and ill persons
-environmental protection (furnaces, smoke, wood stoves, pets, automobile exhaust, CO)
-humidity
interpretation of ABGs - CORRECT ANSWER 1. classify pH (acidic or basic)
2. assess PaCO2
3. assess HCO3
4. determine if compensation is occurring
, 5. If pH is abnormal, identify what is the primary disorder
6. determine if oxygenation problem by looking at PaCO2
normal parameters for ABG values - CORRECT ANSWER pH = 7.35-7.45
PaCO2 = 35-45 mm Hg
bicarbonate (HCO3) = 22-26 mEq/L
PaO2 = 80-100 mm Hg
SaO2 = greater than 95%
nasal cannula - CORRECT ANSWER An oxygen-delivery device in which oxygen flows through two small,
tubelike prongs that fit into the patient's nostrils; delivers 24% to 44% supplemental oxygen, depending on the flow rate.
simple face mask - CORRECT ANSWER used for short-term oxygen therapy. It fits loosely and delivers oxygen
concentrations from 35% to 50% FIO2. This is contraindicated for patients with carbon dioxide retention because
retention can be worsened. Flow rates should be 5 L or more to avoid rebreathing exhaled carbon dioxide retained in the
mask.
partial rebreather mask - CORRECT ANSWER a device used in medicine to assist in the delivery of oxygen
therapy. An NRB requires that the patient can breathe unassisted, but unlike low flow nasal cannula, the NRB allows for
the delivery of higher concentrations of oxygen; FiO2 60-80% oxygen; deliver 10-15 L oxygen
venturi mask - CORRECT ANSWER FiO2 24-55%; 4-12 L of oxygen; can be helpful in the treatment of COPD
because specific amount of oxygen can be delivered; a medical device to deliver a known oxygen concentration to
patients on controlled oxygen therapy
HCO3 - CORRECT ANSWER Bicarbonate 22-25 carried in the blood mainly by c02
above 25 = acidosis more acid
below 22= basic alkalosis
postural drainage positions - CORRECT ANSWER Postural drainage makes use of gravity to drain secretions from
the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing.
*High Fowler's position is used to drain the apical sections of the upper lobes of the lungs.
*Placing the patient lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung.
Placing the patient in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the
posterior sections of the upper lobes of the lungs. Trendelenburg position, on a table flipped almost upside down. assists
in draining the lower lobes of the lungs
normal breath sounds - CORRECT ANSWER Normal breath sounds include vesicular (low-pitched, soft sounds
heard over peripheral lung fields), the lung shape, up and down the ribs
bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and
bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds, close to core of the sternum
abnormal (adventitious) breath sounds - CORRECT ANSWER crackles range from soft to fine, to coarse.
CRACKLES=RALES
discontinuous heard on inspiration, indicate fluid in the lungs
obstructive diseases/pneumonia, sign of pulmonary fibrosis, CHF, and pulmonary edema.
FINE RALES/CRACKLES high pitched popping alveoli
COARSE CRACKLES= RHONCHI
low pitch rumbling, sputum in the airwarys, can clear with strong cough, patients have chronic bronchitis and cystic
fibrosis. excess mucus, bubbling moist sounds.
WHEEZE
continuous sounds air thru narrow airway.
HIGH PITCH WHEEZE=
musical air through bronchospastic or edematous airways.
Expiratory wheeze with asthma and COPD. Typically heard in upper airways
need bronchodilaters, steroids.
