NCLEX Review Questions (Wagner) - Chapter (33)

Chapter 33: Determinants and Assessment of Oxygen Delivery and Oxygen Consumption NCLEX® Review This activity contains 10 questions. A nurse is working to improve a patient's oxygen delivery. Nursing interventions should be focused on improving which processes? Select all that apply. Oxygen consumption Partial pressure of oxygen in arterial blood Anticoagulant status Cardiac output Saturation of hemoglobin The nurse must assess which components to ensure the patient is being well oxygenated? Oxygen delivery Adequacy of return mechanisms Oxygen consumption Purity of external sources of oxygen Pulmonary gas exchange A patient has thick, tenacious sputum secondary to a lung infection. The nurse intervenes to protect which physiologic process of pulmonary gas exchange? Diffusion Affinity Ventilation Perfusion A nurse uses auscultation to assess a patient's lungs. What is the primary physiological disturbance the nurse would detect? Presence of cough Change in airflow Depth of respirations Rhythm of respirations A patient's arterial blood oxygen concentration is very low. Which interventions would the nurse expect to increase this patient's oxygenation? Select all that apply. Administering a vasodilator Administering oxyhemoglobin Administration of packed red blood cells Ambulating the patient Giving supplemental oxygen A nurse is called to assess a neighbor who may be having a myocardial infarction. While waiting for the paramedics, the nurse could be fairly well assured that the neighbor's cardiac output is adequate by which assessments? Select all that apply. The neighbor's capillary refill is within normal limits. The neighbor has circumoral cyanosis. The neighbor's skin is cool and damp. The neighbor's pulse is 72/min., regular, and strong. The neighbor is conscious and alert. A nurse new to the acute care unit says, "I think I will do my nursing assessment during the patient's bath. We can change the bed linens while we have the patient up on the bed scale sling. Then he can rest for a while." What advice would the manager provide this nurse? "Just ask his visitors to leave the room." "He will have to rest between procedures." "Sounds like a good way to save time for the staff." "You could change his dressing at the same time." A patient has liver cancer resulting from years of alcohol abuse. Serum lactate levels this morning are less 2.6 mm/L. How should the nurse interpret this finding? The patient's lactate level is normal. The patient has inadequate oxygenation. The patient's metabolism is anaerobic. Serum lactate level may be altered due to the patient's disease process. A patient's physiologic status is deteriorating. What are the nurse's obligations to this patient? Select all that apply. To evaluate effectiveness of interventions To implement nursing interventions to reverse deterioration To carry out all medical orders received To identify that deterioration is occurring To communicate assessment findings to the provider Which assessment findings would the nurse interpret as possible indicators of fluid volume overload resulting in high preload? Select all that apply. Peripheral edema Jugular venous distention Decreased red blood cell count Increased blood pressure Wet lung sounds