ATI LPN
Fundamentals of Nursing: The Art and Science of Person-Centered Care Tenth, North American Edition
Chapter 40 : Oxygenation and Perfusion Questions
Question 1 of 5
A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient?
Correct Answer: D
Rationale:
To prevent fatigue during activities including hygiene, the nurse should group (personal care) activities into smaller steps and encourage rest periods between activities. The nurse promotes and maintains dignity, independence, and strength by assisting with activities when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits and teach the patient to coordinate pursed-lip or diaphragmatic breathing with the activity.
Question 2 of 5
A nurse working in the pulmonary clinic is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend?
Correct Answer: B,D,E
Rationale: When caring for patients with COPD, it is important to help create an environment that is likely to reduce anxiety, which increases oxygen demand. A high-protein/high-calorie diet is recommended to meet increased energy needs due to the work of breathing. People with dyspnea and orthopnea are most comfortable in a high-Fowler (upright) position because accessory muscles can easily be used to facilitate respiration and lung expansion. Meals should be eaten 1 to 2 hours after breathing treatments; exercise and drinking 2 to 3 quarts (1.9 to 2.9 L) of clear fluids daily is recommended, rather than 2 to 3 pints.
Question 3 of 5
A student with a history of asthma visits the school nurse reporting difficulty breathing and wheezing. Which tool would the nurse use to assess the severity of airway resistance?
Correct Answer: A
Rationale: A peak flow meter is used to assess the point of highest flow during forced expiration. It is routinely used by and for patients with moderate or severe asthma to measure the severity of the disease and degree of disease management. Capnography or end-tidal CO2 monitoring is used for assessing and monitoring ventilation and placement of artificial airways, predicting patients who are at risk for respiratory compromise, are experiencing partial or complete airway obstruction, or are experiencing hypoventilation. A chest tube is used to remove air or fluid from the pleural space. The arterial blood gas (ABG) is used to assess oxygenation, ventilation, and acid-base status; it is invasive and not performed in the school setting.
Question 4 of 5
A nurse is teaching a patient how to use a metered-dose inhaler for asthma. Which comments from the patient assure the nurse that the teaching has been effective?
Correct Answer: D,E,F
Rationale: Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, inhaling two sprays with one breath, and not activating the device while inhaling.
Question 5 of 5
A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly?
Correct Answer: A,C,E
Rationale: The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should encourage the patient to breathe through their nose with the mouth closed. The nurse should adjust the flow rate and maintain the patient's oxygen saturation as prescribed. The nurse should implement pressure injury prevention strategies; pressure from the tubing could result in medical device-related alterations in skin integrity.