ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 19 : Introduction to the Respiratory System Questions
Question 1 of 5
A client arrived in the emergency department with a sharp object penetrating the diaphragm. When planning nursing care, which client need would the nurse identify as a priority?
Correct Answer: C
Rationale: The diaphragm separates the thoracic and abdominal cavities. On inspiration, the diaphragm contracts and moves downward, creating a partial vacuum. Without this vacuum, air is not as efficiently drawn into the thoracic cavity. Hypoxia or hypoxemia may occur from the poor availability of oxygen. Although the nursing diagnosis of acute pain is probable, gas exchange is a higher priority. Ineffective airway clearance is not the greatest concern because the problem is with ventilation. Infection risk is present but is not the highest-priority client need.
Question 2 of 5
The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation?
Correct Answer: A
Rationale: Blood gases report the partial pressure of oxygen, which is dissolved in the blood. Normal readings are 80 to 100 mm Hg. By documenting oxygen levels in the blood, the nurse recognizes the current ventilation. The complete blood count provides information regarding number of blood cells, which can relate to the disease processes such as anemia and infection. The blood chemistry provides information on liver/renal function and electrolytes within the system. Serum alkaline phosphate is a laboratory test used to help detect liver disease and bone disorders.
Question 3 of 5
The nurse is analyzing a client's blood pH of 7.1. Which symptom would indicate that the client's body is working to stabilize?
Correct Answer: A
Rationale: Increased CO2 mechanism, which is present in body fluids primarily as carbonic acid, causes the pH to decrease below 7.4. As a homeostatic mechanism to normalize pH, the lungs eliminate carbonic acid by blowing off more CO2. Respirations increase to normalize pH. None of the other symptoms note a reflection of stabilizing blood pH.
Question 4 of 5
The nurse is providing health education on the body's ability to exchange oxygen and carbon dioxide through the alveolar capillary membrane. Which statement, provided by the nurse, is most correct when asked about diffusion during inspiration?
Correct Answer: D
Rationale: During inspiration, oxygen-rich air from the environment enters the pulmonary system. During inspiration, the concentration of inspired oxygen is higher in the alveoli than in the capillaries, causing diffusion from the alveoli to the capillaries. Thus, the concentration of oxygen is not equal in the alveoli and capillaries. There is no diffusion from the arterial system after the oxygen diffuses from the alveoli to the capillaries. Carbon dioxide does not provide the basis for all diffusion gradients.
Question 5 of 5
The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control?
Correct Answer: D
Rationale: Several mechanisms control ventilation. The respiratory center in the medulla oblongata and pons control rate and depth of respirations. The central chemoreceptors in the medulla and peripheral chemoreceptors in the aortic arch also provide a mechanism for detecting abnormalities and signal changes to alter the pH and levels of oxygen in the blood. The other options have an incorrect piece of the triad.