Oxygenation

OXYGENATION
1. Which of the following action should the nurse take when during assessment, he/she finds the client
who is 2 days post liver transplant has a temperature of 38.8, pulse 95, respiratory rate of 18?
A. Reposition the client

B. Administer oxygen
C. Administer pain medication
D. Call the physician
2. A nurse is assessing the vital signs of a client and notices that the oxygen level is 91% on room air.
The client complains of headache and wheezing is noted upon auscultation. Which nursing intervention
would be best?
A. Ask the client to sit in high fowlers position

B. Ask the client to cough and reassess
C. Apply 2Liters of Oxygen per nasal cannula
D. Offer a pain medication for the headache
3. The nurse obtains the following vital signs on a client who has been admitted to the unit: BP 160/80,
pulse 100 and irregular, respirations 16, and pulse oximetry 85. Which would be the immediate nursing
intervention?
A. Place the client on cardiac telemetry

B. Call the physician to report the vital signs
C. Start a saline lock for IV medication access
D. Start Oxygen at 2-4 Liters per minute as per nasal cannula per protocol
4. The client has pulse oximetry ordered to monitor oxygen saturation. The nurse applies the
monitoring probe to the right index finger and receives a reading of 91%. The nurse should:
A. Notify the physician

B. Encourage the client to take a deep breath
C. Check oxygen level on each of the other fingers
D. Check the monitor site for skin breakdown form the probe
5. The most appropriate nursing order for a patient who develops dyspnea and shortness of breath
would be…
A. Maintain the patient on strict bed rest at all times
B. Maintain the patient in an orthopneic position as needed
C. Administer oxygen by Venturi mask at 24%, as needed
D. Allow a 1 hour rest period between activities
6. The nurse observes that Mr. Adams begins to have increased difficulty breathing. She elevates the
head of the bed to the high Fowler position, which decreases his respiratory distress. The nurse
documents this breathing as:
A. Tachypnea
B. Eupnea
C. Orthopnea
D. Hyperventilation
7. Which of the following parameters should be checked when assessing respirations?

A. Rate
B. Rhythm
C. Symmetry
D. All of the above
8. A 38-year old patient’s vital signs at 8 a.m. are axillary temperature of 37.6 C; pulse rate, 88;
respiratory rate, 30. Which findings should be reported?
A. Respiratory rate only

B. Temperature only
C. Pulse rate and temperature
D. Temperature and respiratory rate
9. The physician orders the administration of high-humidity oxygen by face mask and placement of the
patient in a high Fowler’s position. After assessing Mrs. Paul, the nurse writes the following nursing
diagnosis: Impaired gas exchange related to increased secretions. Which of the following nursing
interventions has the greatest potential for improving this situation?
A. Encourage the patient to increase her fluid intake to 200 ml every 2 hours
B. Place a humidifier in the patient’s room.
C. Continue administering oxygen by high humidity face mask
D. Perform chest physiotherapy on a regular schedule
10. A patient has exacerbation of chronic obstructive pulmonary disease (COPD) manifested by
shortness of breath; orthopnea: thick, tenacious secretions; and a dry hacking cough. An appropriate
nursing diagnosis would be:
A. Ineffective airway clearance related to thick, tenacious secretions.
B. Ineffective airway clearance related to dry, hacking cough.
C. Ineffective individual coping to COPD.
D. Pain related to immobilization of affected leg.
11. The most appropriate time for the nurse to obtain a sputum specimen for culture is:
A. Early in the morning
B. After the patient eats a light breakfast
C. After aerosol therapy
D. After chest physiotherapy
12. The nurse explains to a patient that a cough:
A. Is a protective response to clear the respiratory tract of irritants
B. Is primarily a voluntary action
C. Is induced by the administration of an antitussive drug
D. Can be inhibited by “splinting” the abdomen
13. An appropriate nursing diagnosis for a patient with pneumonia ho is expectorating copious amounts
of sputum is:
A. Altered tissue perfusion related to congested lungs
B. Altered tissue perfusion related to copious amount of sputum
C. Potential for ineffective airway clearance related to pneumonia
D. Potential for ineffective airway clearance related to excessive accumulation of lung secretions
14. The client is admitted to the Emergency Room with Pneumothorax . The nurse anticipates that the
client will be experiencing:
A. Dyspnea
B. Eupnea
C. Fremitus
D. Orthopnea
15. As a nurse working in a pulmonary unit at the Community General Hospital ,you should be alert on
one of the early signs of hypoxia which is:
A. Cyanosis
B. Restlessness
C. Decrease in respiratory rate
D. Decreased in BP

Oxygenation

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OXYGENATION

A. Reposition the client

A. Ask the client to sit in high fowlers position

A. Place the client on cardiac telemetry

A. Notify the physician

7. Which of the following parameters should be checked when assessing respirations?

A. Respiratory rate only

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