A nurse is assessing a client who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? (Select all that apply.)
Restlessness
Tachypnea
Bradycardia
Confusion
Pallor
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse’s priority?
Increase the oxygen flow.
Assist the client to Fowler’s position.
Promote removal of pulmonary secretions.
Obtain a specimen for arterial blood gases.
A nurse is preparing to perform endotracheal suctioning for a client. Which of the following are appropriate guidelines for the nurse to follow? (Select all that apply.)
Apply suction while withdrawing the catheter.
Perform suctioning on a routine basis, every 2 to 3 hr.
Maintain medical asepsis during suctioning.
Use a new catheter for each suctioning attempt.
Limit suctioning to two to three attempts.
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take each time he provides tracheostomy care? (Select all that apply.)
Apply the oxygen source loosely if the SpO2 decreases during the procedure.
Use surgical asepsis to remove and clean the inner cannula.
Clean the outer surfaces in a circular motion from the stoma site outward.
Replace the tracheostomy ties with new ties.
Cut a slit in gauze squares to place beneath the tube holder.
A provider is discharging a client with a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.)
Apply petroleum jelly around and inside the nares.
Remove the nasal cannula during mealtimes.
Check the position of the cannula frequently.
Report any nasal stuffiness, nausea, or fatigue.
Post “no smoking” signs in a prominent location.
You are an ER nurse treating a 3-year-old trauma patient. When assessing the patient's respirations, you note that the rate is 28 per minute. According to this finding, you should
move on to your next area of assessment. The patient's respirations are normal.
call the respiratory therapist. The patient is hyperventilating.
call the physician to see if he would like to order a bronchodilator.
try to distract the patient and make them relax. They are tachypneic.
What does a pulmonary toilet do?
Prevents atelectasis and removes respiratory secretions
Prevents bronchospasm
Thins and cleans blood to help prevent pulmonary emoblism.
Dilates bronchioles and improves gas exchange.
Which of the following is NOT a technique to thin respiratory secretions?
Drinking fluid
Dosing mucolytic medication
Controlled coughing
Moderate activity
Blowing nose regularly
Which of the following is a high-flow oxygen delivery system?
Non-rebreather mask
Nasal cannula
Venturi mask
Simple face mask.
How would you instruct patients to use an incentive spirometer and peak flow meter?
Incentive= inhale; Peak flow= exhale
Incentive= exhale, Peak flow= inhale
Both require inhalation
Both require exhalation.
Pursed lip breathing works well with what types of patients?
COPD
Pneumonia
Lung cancer
Cystic fibrosis
Which of the following is NOT a sign of anemia?
Skin pallor
Tachypnea and/or dyspnea
Decreased hemoglobin
Decreased hematocrit
Which of the following reflects the normal ranges for RBC count, hemoglobin, and hematocrit (respectively)?
4.2-5.14 x 10(6) cells/ mm(3); 11.7-17.4 g/dL; 38- 44%
3.1- 5.14 x 10(6) cells/ mm(3); 11.0- 17.0 g/dL; 38- 54%
5.6- 7.9 x 10(6) cells/ mm(3); 12.3- 19.7 g/dL; 42- 51%
3.6- 5.14 x 10(6) cells/mm(3); 11.7- 17.4 g/dL; 40- 48%
The amount of blood circulating and entering the right atrium is the
Preload
Afterload
Stroke volume
Cardiac output
Heart rate X Stroke volume=
Rate of perfusion
Cardiac ouput
The pressure the heart must pump against is the
Which of the following symptoms can indicate decreased cardiac output?
Low hematocrit
Low hemoglobin
Low urine output
Dyspnea
The SA node is found
At the top of the right atrium
At the top of the left atrium
At the bottom of the right ventricle.
Next to the tricuspid valve.
Which of the following correctly identifies the path of an electrical impulse through the heart?
SA node --> AV junction --> HIS bundle --> bundle branches --> purkinjie fibers --> ventricular muscle
AV junction --> SA node --> bundle branches --> HIS bundle --> purkinjie fibers --> ventricular muscle
SA node --> HIS bundle --> AV junction --> purkinjie fibers --> bundle branches --> ventricular muscle
SA node --> AV junction --> bundle branches --> HIS bundle --> purkinjie fibers --> ventricular muscle
The stroke volume of the heart increases in response to an increase in the volume of blood filling the heart (the end diastolic volume) when all other factors remain constant is also know as
Frank Starling Law of the Heart
Which of the following is NOT a sign or symptom of heart failure?
Weakness, fatigue
Decreased exercise tolerance
Dizziness, syncope
Weight gain
