ADN 202 Respiratory Exam 1 with Questions and Answers

ADN 202 Respiratory Exam 1 with Questions and Answers The nurse includes which nursing diagnosis in the plan of care for the patient admitted with pneumonia? A. Anxiety related to hypoxia B. Deficient knowledge related to cause of disorder C. Fear related to the threat of pain D. Ineffective breathing pattern related to decreased surfactant ANSWER Answer: A Rationale: Patients experiencing hypoxia usually have signs of irritability, restlessness, anxiety and confusion. As the brain cells receive less oxygen the patient becomes more confused. The nurse is reviewing orders on the patient who is to receive supplemental oxygen. It is a priority for the nurse to follow up with the provider about which order? A. Nasal cannula at 2 L/min B. Venturi mask at 24% concentration C. Nasal cannula at 8 L/min D. Venturi mask at 50% concentration ANSWER Answer: C Rationale: Nasal cannula oxygen should not be ordered at a level greater than 6L/NC. Rates greater than 6L/NC do not increase oxygenation due to the anatomic dead space is full. Greater levels of oxygen causes irritation to mucous membranes. What is the most important information for the nurse to include in the teaching plan about management of home oxygen therapy? (Select all that apply.) A. Do not change the settings of the oxygen without the health-care provider's permission. B. Place "No smoking" signs within the home. C. Oxygen is a fire hazard. D. Others may smoke around you as long as you do not smoke. E. Keep a fire extinguisher near the oxygen source ANSWER Answer: A, B, C, and E Rationale: Changing oxygen levels without the permission of the health-care provider could lead to oxygen toxicity. No smoking signs will indicate that oxygen is in the home. Oxygen is a fire hazard. A fire extinguisher is required due to the severity complications if there is a fire related to the oxygen delivery system.