Exam (elaborations)
Chapter 38 Oxygenation and Tissue Perfusion
- Course
- Fundamentals of Nursing
- Institution
- Oxford College Of Emory University
Chapter 38 Oxygenation and Tissue Perfusion
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DAWITChapter 38: Oxygenation and Tissue Perfusion
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative
Practice, 3RD Edition
MULTIPLE CHOICE
1. The nurse finds the 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
ANS: B
The priority of the nurse is to ventilate the patient manually using a bag-valve-mask unit (also
called by the proprietary name Ambu bag). This allows air to be forced into the patient‘s lungs
when there are no spontaneous respirations. The non-rebreather mask and nasal cannula
require the patient to breathe on his or her own. CPAP is used for patients who are awake,
oriented, and in respiratory failure.
DIF: Understanding OBJ: 38.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Adaptation: Physiological Adaptation
NOT: Concepts: Gas Exchange
2. 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. N
WUhR hI
icS teGrvT
inN eB
nt.
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s the most appropriate for the patient 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 the patient‘s pulse oximetry.
ANS: A
An oral airway will prevent the patient‘s tongue from falling back and occluding the airway.
Lowering the head of the bed will only increase airway occlusion and risk of aspiration.
Turning the patient‘s head to the side will not clear the back of the patient‘s tongue from the
airway. Monitoring the patient‘s pulse oximetry will not improve oxygenation or clear the
airway.
DIF: Applying OBJ: 38.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Gas Exchange
3. 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?
a. Administer the ordered intravenous diuretic.
b. Prepare for insertion of a chest tube.
, DAWIT
c. Suction secretions from the patient‘s respiratory tract.
d. Have the patient use the ordered incentive spirometer.
ANS: A
The patient‘s respiratory distress is due to pulmonary edema and fluid overload from
left-sided congestive heart failure. A diuretic will pull the excess fluid out of the body through
the urine and relieve the patient‘s distress. A chest tube is not needed as the fluid is within the
alveoli rather than between the lung and chest wall. Suctioning and use of an incentive
spirometer will not address fluid overload or improve the patient‘s symptoms.
DIF: Understanding OBJ: 38.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Fluid and Electrolyte Balance
4. 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?
a. Placement of a tracheostomy tube
b. Diagnostic thoracentesis
c. Pulmonary angiogram
d. Lung transplantation surgery
ANS: A
Placement of a tracheostomy tube will secure the patient‘s airway directly through the trachea,
eliminating the need for the endotracheal tube. This will make the patient more comfortable
and may allow eating while minimizing damage to the oropharynx from the endotracheal
tube. NURSINGTB.COM
DIF: Understanding OBJ: 38.6 TOP: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Gas Exchange
5. 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?
a. Clamp the chest tube until the collection device is replaced.
b. Cover the insertion site with a new occlusive dressing.
c. Ensure that there is gentle bubbling in the water seal chamber.
d. Check the patient‘s lung sounds and pulse oximetry.
ANS: A
The broken collection device may no longer be used to collect chest tube drainage. Clamping
the chest tube until the collection device is replaced will prevent air from entering the lung
space until the new collection device is attached.
DIF: Applying OBJ: 38.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Gas Exchange
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