NURS 3682-Chapter 38, Oxygenation and Perfusion

NURS 3682-Chapter 38, Oxygenation and Perfusion 1.The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the client's care plan? A) Provide six small meals daily. B) Provide three large meals daily. C) Encourage the client to eat immediately before breathing treatments. D) Encourage the client to alternate eating and using a nebulizer during meal time. Ans: A Feedback: The nurse should consider providing six small meals distributed over the course of the day instead of three large meals. Meals should be eaten one to two hours after breathing treatments and exercises. 2.The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is "Ineffective Airway Clearance related to copious and tenacious secretions." Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan? A) Encouraging the client to consume two to three quarts of clear fluids daily B) Creating an environment that is likely to reduce anxiety C) Positioning the client supine D) Encouraging the client to decrease the number of cigarettes smoked daily Ans: A Feedback: Clients can help keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of clear fluids daily. Although it is important to create an environment that is likely to reduce a client's anxiety, doing so will not assist in promoting airway clearance. The nurse should not encourage the client to decrease the number of cigarettes smoked daily, but should encourage the client to stop smoking. Proper positioning to ease respirations includes placing the client in a high-Fowler's position. 3.While the nurse is providing morning hygiene for a client who has a chest tube, the client has rolled over quickly and the chest tube has become disconnected from the drainage unit. How should the nurse first respond to this event? A) Submerge the end of the tube in sterile water. B) Clamp the tube near the end and also near the insertion point. C) Place the end of the tube on a sterile surface and seek help promptly. D) Clean the end of the tube with an alcohol swab and reconnect it to the drainage unit. Ans: A Feedback: If a chest tube becomes disconnected from the drainage unit, the nurse should submerge the end of the tube in a bottle of sterile water, thus preventing a pneumothorax but still Page 1 allowing air to escape. 4.A client has had a head injury affecting the brain stem. What is located in the brain stem that may affect respiratory function? A) Chemoreceptors B) Stretch receptors C) Respiratory center D) Oxygen center Ans: C Feedback: The medulla in the brain stem, immediately above the spinal cord, is the respiratory center. Stretch receptors are located in muscles. Chemoreceptors that affect respirations are located in the aortic arch and the carotid bodies. 5.Which of the following diseases may result in decreased lung compliance? A) Emphysema B) Appendicitis C) Acne D) Chronic diarrhea Ans: A Feedback: Lung compliance refers to the stretchability of the lungs, or the ease with which lungs can be inflated. Emphysema, a chronic lung disease, and the normal changes associated with aging are examples of conditions that result in decreased elasticity of lung tissue, which in turn decreases lung compliance. 6.A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate? A) changes in the alveolar-capillary membrane and diffusion B) alterations in the structures of the ribs and diaphragm C) rapid decreases in atmospheric and intrapulmonic pressures D) lower-than-normal concentrations of environmental oxygen Ans: A Feedback: Any change in the surface area of the lungs hinders diffusion of gas exchange. Any disease or condition that results in changes in the alveolar-capillary membrane, such as pneumonia or pulmonary edema, makes diffusion more difficult, assessed by decreased oxygen saturation measurement. 7.In what age group would a nurse expect to assess the most rapid respiratory rate? A) Older adults Page 2 B) Middle adults C) Adolescents D) Infants Ans: D Feedback: The normal infant's chest is small and the airways are short. There are fewer and smaller alveoli in infants. As a result, the respiratory rate is more rapid in infants than any other age group. 8.A father of a preschool-age child tells the nurse that his child "has had a constant cold since going to daycare." How would the nurse respond? A) "Your child must have a health problem that needs medical care." B) "Children in daycare have more exposure to colds." C) "Are you washing your hands before you touch the child?" D) "Be sure and have your child wear a protective mask at school." Ans: B Feedback: The preschool-age child's eustachian tubes, bronchi, and bronchioles are elongated and less angular. Thus, the average number of routine colds and infections increases when the child enters daycare or school and is exposed more frequently to pathogens. 9.A woman 90 years of age has been in an automobile