An elderly woman is hospitalized with pneumonia and anemia. She is weak and has a
poor cough effort. She has a history of cardiomyopathy. Her current vital signs are
temperature 100.2 °F, pulse 114, respiration 26, blood pressure 106/58. She has
oxygen ordered at 2 liters by nasal cannula. Her ...
NURS 3105 FPCC - Ch 40 (Oxygenation)
Review Questions
An elderly woman is hospitalized with pneumonia and anemia. She is weak and has a
poor cough effort. She has a history of cardiomyopathy. Her current vital signs are
temperature 100.2 °F, pulse 114, respiration 26, blood pressure 106/58. She has
oxygen ordered at 2 liters by nasal cannula. Her oxygen saturation measures 88%
when on room air, 93% with supplemental oxygen. She develops shortness of breath on
any activity and eats little because it is difficult for her to eat and breathe at the same
time. Which of the following are risk factors for this patient developing hypoxia? (Select
all that apply.)
A.) Anemia
B.) Tachycardia
C.) Increased secretions with weak cough
D.) Cardiomyopathy
E.) Shortness of breath
F.) Pneumonia - ✔️✔️A, C, D, F
REASON: Hypoxia results when there is inadequate tissue oxygenation at the cellular
level. Lowered oxygen-carrying capacity from anemia can lead to hypoxia. A diminished
concentration of inspired oxygen, such as with an obstructed airway from secretions,
results in lowered oxygen saturation. Cardiomyopathy results in poor tissue perfusion
with oxygenated blood. With pneumonia there is decreased diffusion of oxygen from the
alveoli to the blood, leading to inadequate tissue oxygenation. An increase in pulse rate
is an adaptive response to meet the body's oxygen demand. Shortness of breath
(dyspnea) is a symptom of decreased oxygenation.
Which of the following patients would have the greatest potential for an alteration in
respiration?
A.) 15 year-old male with a migraine headache.
B.) 44 year-old female with anemia.
C.) 19 year-old female with diarrhea.
D.) 32 year-old male with an ear ache. - ✔️✔️B
REASON: Hemoglobin carries about 97% of oxygen to the tissues. Anemia lowers the
oxygen-carrying capacity of the blood and potentially leads to hypoxia.
Which of the following, if exhibited by the patient, would indicate late hypoxia?
A.) Restlessness
B.) Anxiety
C.) Eupnea
D.) Cyanosis - ✔️✔️D
, REASON: Restlessness and anxiety are early indicators of hypoxia. Cyanosis is a late
indicator of hypoxia. Eupnea is normal respiration.
Which of the following would lead to an increase in oxygen demand?
A.) A fever
B.) Sleep
C.) Taking a narcotic
D.) Postural drainage - ✔️✔️A
REASON: Increased metabolic activity associated with a fever increases tissue oxygen
demand. Postural drainage is an intervention used to mobilize secretions and maintain
an open airway.
What nursing intervention is appropriate for the patient with a large amount of sputum?
A.) Perform nasotracheal suctioning every hour
B.) Encourage the patient to cough every hour while awake
C.) Place the patient on fluid restriction
D.) Avoid all milk products - ✔️✔️B
REASON: A patient with a large amount of sputum should be encouraged to cough
every hour while awake. Suctioning should be performed on an as-needed basis.
Adequate fluids should be maintained to help keep secretions thin and easy to
expectorate. Although milk has a protein structure similar to sputum, it does not
increase sputum production and plays an important role in nutrition.
You are busy performing routine assessments of the patients on the unit. You note
audible gurgling on inspiration and expiration of the stable postoperative patient. Which
of the following tasks can you delegate to competent NAP?
A.) Performing oral suctioning
B.) Assessing the adequacy of respiratory functioning
C.) Evaluating the outcome of oral suctioning
D.) Performing nasotracheal suctioning - ✔️✔️A
REASON: Since the patient is stable, the task may be delegated to NAP. However, the
responsibility for assessing the adequacy of respiratory functioning and evaluating the
patient outcome of oral suctioning remains with you. Nasotracheal suctioning requires
sterile technique and cannot be delegated to NAP.
You are preparing to perform oropharyngeal suctioning. Which of the following steps in
the sequence is incorrect?
A.) Assist the patient into a supine position. Prepare supplies. Turn the suction unit on
and set the suction control gauge to high. Connect the suction tubing to the suction
machine and to the Yankauer suction catheter.
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