CHAPTER 38: Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford

Fundamentals of Nursing, 2nd Edition – Active Learning for Collaborative Practice by Yoost & Crawford Chapter 38: Oxygenation and Tissue Perfusion Multiple Choice Questions 1. The nurse finds a patient in cardiopulmonary arrest with no pulse or respirations. Which oxygen delivery device will the nurse use for this patient? A. Non-rebreather mask B. Bag-valve-mask unit C. Continuous positive airway pressure (CPAP) D. High-flow nasal cannula Answer: B Explanation: A bag-valve-mask unit is essential for manual ventilation during cardiopulmonary arrest, as it delivers oxygen without requiring spontaneous breathing. Other devices (A, C, D) rely on patient effort. Why Other Options Are Wrong: A and D require patient-initiated breathing. CPAP is for conscious patients in respiratory failure. 2. The nurse is caring for a postoperative patient slow to awaken from anesthesia with minimal responsiveness and airway difficulty. Which intervention is most appropriate to improve oxygenation? A. Insert an oral airway B. Lower the head of the bed C. Turn the patient's head to the side D. Monitor pulse oximetry Answer: A Explanation: An oral airway prevents tongue occlusion, addressing the immediate airway obstruction. Lowering the bed (B) worsens obstruction, and turning the head (C) doesn’t resolve posterior tongue occlusion. Why Other Options Are Wrong: B increases aspiration risk. C is ineffective for tongue occlusion. D doesn’t address the airway issue. 3. The nurse is caring for a patient with left-sided congestive heart failure, fine crackles bilaterally, and SpO₂ of 88% on 4 L oxygen. What is the priority intervention? A. Administer IV diuretic B. Prepare for chest tube insertion C. Suction respiratory secretions D. Use incentive spirometer Answer: A Explanation: Diuretics reduce pulmonary edema from fluid overload, directly addressing the cause of hypoxemia in heart failure. Chest tubes (B) treat pleural effusions, not alveolar fluid. Why Other Options Are Wrong: B is unnecessary for alveolar edema. C and D don’t treat fluid overload. 4. The nurse anticipates which procedure for a patient requiring prolonged mechanical ventilation after weeks of intubation? A. Tracheostomy tube placement B. Diagnostic thoracentesis C. Pulmonary angiogram D. Lung transplantation Answer: A Explanation: Tracheostomy secures the airway long-term, improves comfort, and reduces oropharyngeal damage compared to endotracheal tubes. Why Other Options Are Wrong: B drains pleural fluid. C assesses pulmonary vasculature. D is for end-stage disease. 5. A patient’s chest tube collection device is damaged during transport. What is the nurse’s priority action? A. Clamp the chest tube B. Apply an occlusive dressing C. Check water seal chamber bubbling D. Assess lung sounds and SpO₂ Answer: A Explanation: Clamping prevents pneumothorax until the device is replaced. B is for open pneumothorax. C and D are secondary after securing the tube. Why Other Options Are Wrong: B doesn’t address air entry. C/D are assessments, not interventions. 6. Which nursing diagnosis is highest priority for a hospitalized pneumonia patient? A. Activity intolerance B. Impaired nutrition C. Impaired airway clearance D. Lack of knowledge Answer: C Explanation: Airway patency is always the priority to ensure oxygenation. Other diagnoses are important but secondary. Why Other Options Are Wrong: A, B, and D are relevant but don’t address immediate oxygenation needs. 7. For a patient with a pulmonary embolism, which goal is highest priority for impaired gas exchange? A. SpO₂ ≥95% on room air B. Understanding anticoagulants C. Pain ≤3/10 D. Ambulating 50 feet Answer: A Explanation: Adequate oxygenation is critical. Other goals are important but follow stabilization. Why Other Options Are Wrong: B, C, and D are secondary to resolving hypoxemia. 8. A COPD patient becomes confused and disoriented. What is the nurse’s priority action? A. Obtain ABG for CO₂ retention B. Increase oxygen to SpO₂ 98% C. Lower HOB and insert nasal airway D. Administer sedative Answer: A Explanation: Confusion in COPD may signal CO₂ narcosis; ABG confirms this. High oxygen (B) can suppress respiratory drive. Why Other Options Are Wrong: B risks respiratory depression. C worsens dyspnea. D exacerbates hypoventilation. 9. A patient with atrial fibrillation asks about the risk of not taking warfarin. What is the nurse’s best response? A. "You could have a stroke." B. "Your kidneys could fail." C. "You could develop heart failure." D. "You could go into respiratory failure." Answer: A Explanation: Atrial fibrillation increases stroke risk due to atrial clot formation; anticoagulants prevent this. Why Other Options Are Wrong: B, C, and D are unrelated to atrial fibrillation’s thromboembolic risks. 10. A new nurse incorrectly documents emptying a chest tube collection device at shift end. What teaching is needed? A. Mark drainage levels hourly B. Record output without emptying C. Document suction pressure D. Replace the device daily Answer: B Explanation: Chest tube output is marked on the device and recorded; emptying is unnecessary and disrupts the closed system. Why Other Options Are Wrong: A is excessive. C/D are not standard practices. Multiple Response Questions 1. Which actions help a COPD patient with dyspnea and SpO₂ 91% on 2 L oxygen? A. Increase oxygen to 4 L B. Suction airway C. Provide calm reassurance D. Administer nebulized bronchodilator E. Elevate HOB Answer: C, D, E Explanation: Reassurance, bronchodilators, and upright positioning improve comfort without risking oxygen-induced respiratory depression. Why Other Options Are Wrong: A may suppress respiratory drive. B is unnecessary without secretions. 2. Which findings suggest chronic respiratory disease? A. Clubbed nails B. Barrel chest C. Sleeping on 4–5 pillows D. Brown leg discoloration Answer: A, B, C Explanation: Clubbing, barrel chest, and orthopnea are classic signs of chronic hypoxia (e.g., COPD). Why Other Options Are Wrong: D indicates venous stasis, not respiratory disease. 3. Which COPD assessment findings require immediate intervention? A. Gasping speech B. Greenish-brown sputum C. Stridor and wheezing D. Confusion Answer: A, B, C, D Explanation: Gasping indicates severe distress; colored sputum suggests infection; stridor signals obstruction; confusion may reflect CO₂ retention. Why Other Options Are Wrong: All options are urgent in COPD. 4. Which tasks can a nursing assistant perform for a tracheostomy patient? A. Fetch supplies B. Reassure the patient C. Transport specimens D. Assess suction need Answer: A, B, C Explanation: Assistants can gather supplies, provide comfort, and handle specimens but cannot assess or perform sterile procedures. Why Other Options Are Wrong: D and E require nursing judgment/sterile technique. 5. Which new nurse actions indicate incorrect tracheostomy care? A. Cleaning outer cannula with H₂O₂ B. Securing new ties before removing old C. Using Yankauer for oral suctioning D. Applying sterile gloves for dressing removal Answer: A, D Explanation: Only the inner cannula is cleaned; clean gloves suffice for dressing removal. Why Other Options Are Wrong: B and C are correct practices. 6. Which suctioning actions require correction? A. Applying suction during insertion B. Supine positioning C. Twirling catheter D. Using lubricant for tracheostomy Answer: A, B, D Explanation: Suction is applied only during withdrawal; HOB should be elevated; lubricant isn’t needed for tracheostomies. Why Other Options Are Wrong: C is correct technique.