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The nurse is caring for a patient with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what?
- A. Impaired gas exchange
- B. Collapsed bronchial structures
- C. Necrosis of the alveoli
- D. Closed bronchial tree
Correct Answer: A
Rationale: The lower respiratory tract consists of the lungs, which contain the bronchial and alveolar structures needed for gas exchange. A lower respiratory tract infection does not collapse bronchial structures or close the bronchial tree. An infection does not cause necrosis of lung tissues.
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While assessing an acutely ill patients respiratory rate, the nurse assesses four normal breaths followed by an episode of apnea lasting 20 seconds. How should the nurse document this finding?
- A. Eupnea
- B. Apnea
- C. Biots respiration
- D. Cheyne-Stokes
Correct Answer: C
Rationale: The nurse will document that the patient is demonstrating a Biots respiration pattern. Biots respiration is characterized by periods of normal breathing (three to four breaths) followed by varying periods of apnea (usually 10 seconds to 1 minute). Cheyne-Stokes is a similar respiratory pattern, but it involves a regular cycle where the rate and depth of breathing increase and then decrease until apnea occurs. Biots respiration is not characterized by the increase and decrease in the rate and depth, as characterized by Cheyne-Stokes. Eupnea is a normal breathing pattern of 12 to 18 breaths per minute. Bradypnea is a slower-than-normal rate (<10 breaths per minute), with normal depth and regular rhythm, and no apnea.
A nurse educator is reviewing the implications of the oxyhemoglobin dissociation curve with regard to the case of a current patient. The patient currently has normal hemoglobin levels, but significantly decreased SaO2 and PaO2 levels. What is an implication of this physiological state?
- A. The patients tissue demands may be met, but she will be unable to respond to physiological stressors.
- B. The patients short-term oxygen needs will be met, but she will be unable to expel sufficient CO2.
- C. The patient will experience tissue hypoxia with no sensation of shortness of breath or labored breathing.
- D. The patient will experience respiratory alkalosis with no ability to compensate.
Correct Answer: A
Rationale: With a normal hemoglobin level of 15 mg/dL and a PaO2 level of 40 mm Hg (SaO2 75%), there is adequate oxygen available for the tissues, but no reserve for physiological stresses that increase tissue oxygen demand. If a serious incident occurs (e.g., bronchospasm, aspiration, hypotension, or cardiac dysrhythmias) that reduces the intake of oxygen from the lungs, tissue hypoxia results.
The nurse is completing a patients health history with regard to potential risk factors for lung disease. What interview question addresses the most significant risk factor for respiratory diseases?
- A. Have you ever been employed in a factory, smelter, or mill?
- B. Does anyone in your family have any form of lung disease?
- C. Do you currently smoke, or have you ever smoked?
- D. Have you ever lived in an area that has high levels of air pollution?
Correct Answer: C
Rationale: Smoking is the single most important contributor to lung disease, exceeding the significance of environmental, occupational, and genetic factors.
A patient with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath?
- A. Total lung capacity
- B. Forced vital capacity
- C. Tidal volume
- D. Residual volume
Correct Answer: C
Rationale: Tidal volume refers to the volume of air inspired and expired with a normal breath. Total lung capacity is the maximal amount of air the lungs and respiratory passages can hold after a forced inspiration. Forced vital capacity is vital capacity performed with a maximally forced expiration. Residual volume is the maximal amount of air left in the lung after a maximal expiration.
The nurse is caring for a patient admitted with an acute exacerbation of chronic obstructive pulmonary disease. During assessment, the nurse finds that the patient is experiencing increased dyspnea. What is the most accurate measurement of the concentration of oxygen in the patients blood?
- A. A capillary blood sample
- B. Pulse oximetry
- C. An arterial blood gas (ABG) study
- D. A complete blood count (CBC)
Correct Answer: C
Rationale: The arterial oxygen tension (partial pressure or PaO2) indicates the degree of oxygenation of the blood, and the arterial carbon dioxide tension (partial pressure or PaCO2) indicates the adequacy of alveolar ventilation. ABG studies aid in assessing the ability of the lungs to provide adequate oxygen and remove carbon dioxide and the ability of the kidneys to reabsorb or excrete bicarbonate ions to maintain normal body pH. Capillary blood samples are venous blood, not arterial blood, so they are not as accurate as an ABG. Pulse oximetry is a useful clinical tool but does not replace ABG measurement, because it is not as accurate. A CBC does not indicate the concentration of oxygen.