Chapter 38: Oxygenation and Tissue Perfusion
Yoost & Crawford: Fundamentals of Nursing: Active Learning for Collaborative
Practice, 2nd Edition
MULTIPLE CHOICE
1. The nurse finds the patient in cardiopulmonary arrest with no pulse or respirations. Which
oxygen delivery device will the nurse use for this patient?
a. Non-rebreather mask
b. Bag-valve-mask unit
c. Continuous positive airway pressure
(CPAP)
d. High-flow nasal cannula
ANS: B
The priority of the nurse is to ventilate the patient manually using a bag-valve-mask unit (also
called by the proprietary name Ambu bag). This allows air to be forced into the patient’s lungs
when there are no spontaneous respirations. The non-rebreather mask and nasal cannula require
the patient to breathe on his or her own. CPAP is used for patients who are awake, oriented, and
in respiratory failure.
DIF: Understanding OBJ: 38.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Adaptation: Physiological Adaptation
NOT: Concepts: Gas Exchange
2. The nurse is caring for a patient who is slow to awaken following general anesthesia. The patient
is breathing spontaneously but is minimally responsive and having difficulty maintaining a
patent airway. Which intervention is the most appropriate for the patient to improve
oxygenation?
a. Insert an oral airway.
b. Lower the head of the bed.
c. Turn the patient’s head to the side.
d. Monitor the patient’s pulse oximetry.
ANS: A
An oral airway will prevent the patient’s tongue from falling back and occluding the airway.
Lowering the head of the bed will only increase airway occlusion and risk of aspiration. Turning
the patient’s head to the side will not clear the back of the patient’s tongue from the airway.
Monitoring the patient’s pulse oximetry will not improve oxygenation or clear the airway.
DIF: Applying OBJ: 38.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Gas Exchange
3. The nurse is caring for a patient with a history of left-sided congestive heart failure who is
acutely short of breath. The nurse hears fine crackles throughout both lung fields and notes that
the patient’s pulse oximetry is only 88% on 4 L of oxygen. What is the priority intervention of
the nurse?
a. Administer the ordered intravenous
diuretic.
b. Prepare for insertion of a chest tube.
c. Suction secretions from the patient’s
respiratory tract.
d. Have the patient use the ordered incentive
spirometer.
ANS: A
The patient’s respiratory distress is due to pulmonary edema and fluid overload from left-sided
congestive heart failure. A diuretic will pull the excess fluid out of the body through the urine
and relieve the patient’s distress. A chest tube is not needed as the fluid is within the alveoli
rather than between the lung and chest wall. Suctioning and use of an incentive spirometer will
not address fluid overload or improve the patient’s symptoms.
DIF: Understanding OBJ: 38.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Fluid and Electrolyte Balance
4. The nurse is caring for a patient who has been intubated with an oral endotracheal tube for
several weeks. The physicians predict that the patient will need to remain on a ventilator for at
least several more weeks before he will be able to maintain his airway and breathe on his own.
What procedure does the nurse anticipate will be planned for the patient to facilitate recovery?
a. Placement of a tracheostomy tube
b. Diagnostic thoracentesis
c. Pulmonary angiogram
d. Lung transplantation surgery
ANS: A
Placement of a tracheostomy tube will secure the patient’s airway directly through the trachea,
eliminating the need for the endotracheal tube. This will make the patient more comfortable and
may allow eating while minimizing damage to the oropharynx from the endotracheal tube.
DIF: Understanding OBJ: 38.6 TOP: Planning
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Gas Exchange
5. The nurse is caring for a patient with a chest tube who was transported to radiology for testing.
When the patient returns to the nursing unit, the transporter shows the nurse the patient’s chest
tube collection device, which was badly damaged after being caught in the elevator door. What is
the priority action of the nurse?
a. Clamp the chest tube until the collection
device is replaced.
b. Cover the insertion site with a new
occlusive dressing.
c. Ensure that there is gentle bubbling in the
water seal chamber.
d. Check the patient’s lung sounds and pulse
oximetry.
ANS: A
The broken collection device may no longer be used to collect chest tube drainage. Clamping the
chest tube until the collection device is replaced will prevent air from entering the lung space
until the new collection device is attached.
DIF: Applying OBJ: 38.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Gas Exchange
6. The nurse is caring for a patient who is hospitalized for pneumonia. Which Nursing diagnosis
has the highest priority?
a. Activity intolerance r/t generalized
weakness and hypoxemia
b. Impaired nutritional intake r/t poor
appetite and increased metabolic needs
c. Impaired airway clearance r/t thick
secretions in trachea and bronchi
d. Lack of knowledge r/t use of nebulizer
and inhaled bronchodilators
ANS: C
Airway maintenance and patency is the highest priority for all patients, especially patients with
respiratory disorders. Oxygenation is the most important human need. The other diagnoses can
apply once the patient’s airway is kept patent.
DIF: Applying OBJ: 38.4 TOP: Diagnosis
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Gas Exchange
7. The nurse is caring for a patient who developed a pulmonary embolism after surgery. Which goal
statement is the highest priority for the nurse to include in the patient’s care plan for the
diagnosis impaired gas exchange r/t impaired pulmonary blood flow from embolus?
a. The patient will maintain pulse oximetry
values of at least 95% on room air.
b. The patient will verbalize understanding
of ordered anticoagulants.
c. The patient will report chest pain of no
greater than 3 on a 1 to 10 scale.
d. The patient will ambulate 50 feet in
hallway without shortness of breath.
ANS: A
Oxygenation is the most important human need, so adequate oxygenation of tissues as evidenced
by pulse oximetry values of at least 95% on room air is the highest priority goal. The other goals
may be addressed once the oxygenation goal has been met.
DIF: Applying OBJ: 38.5 TOP: Planning
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Gas Exchange
8. The nurse is caring for a patient with severe COPD who is becoming increasingly confused and
disoriented. What is the priority action of the nurse?
a. Obtain an arterial blood gas to check for
carbon dioxide retention.
b. Increase the patient’s oxygen until the
pulse oximetry is greater than 98%.
c. Lower the head of the patient’s bed and
insert a nasal airway.
d. Administer a mild sedative and reorient
the patient as needed.
ANS: A
Confusion and disorientation in a patient with severe COPD may likely be due to carbon dioxide
retention. An arterial blood gas should be drawn to determine if this is the case. COPD patients
should be kept on low oxygen flow rates whenever possible to avoid impeding the drive to
breathe. Lowering the head of the bed will increase the difficulty of breathing as the abdominal
contents press on the diaphragm. A sedative will cause respiratory depression and should be
avoided.
DIF: Applying OBJ: 38.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Gas Exchange
9. The nurse is caring for a patient who has been prescribed warfarin (Coumadin) therapy after
being diagnosed with atrial fibrillation. The patient asks the nurse what could happen if the
prescription doesn’t get filled. What is the nurse’s best response?
a. “You could have a stroke.”
b. “Your kidneys could fail.”
c. “You could develop heart failure.”
d. “You could go into respiratory failure.”
ANS: A
A major complication of chronic atrial fibrillation is formation of blood clots within the atria due
to sluggish blood flow. Anticoagulation therapy is common to prevent blood clot formation that
could travel to the brain, causing a stroke.
DIF: Understanding OBJ: 38.6 TOP: Teaching/Learning
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Patient Education
10. The preceptor is working with a new nurse to provide care for a patient with a chest tub to
relieve a pneumothorax. Which action by the new nurse indicates need for additional teaching
about chest tube care?
a. The suction is discontinued when the
patient is ambulated to the bathroom.
b. The collection device is emptied at the end
of the shift and output recorded in the
chart.
c. The patient’s bed is placed in the semi-
Fowler’s position to facilitate lung
reexpansion.
d. The patient is encouraged to use his
incentive spirometer at least 10 times
every hour.
ANS: B
The chest tube collection device is not emptied at the end of the shift. Instead, the amount of
drainage present at the end of the shift (or specified time) is marked on the collection device and
the amount of drainage is documented in the patient’s chart.
DIF: Understanding OBJ: 38.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Safety
11. The nurse is caring for a postoperative patient who has just been diagnosed with a deep vein
thrombosis (DVT) in the right leg. Which focused assessment question has the highest priority
for this patient?
a. “Do you have a headache or any
dizziness?”
b. “Do you have any chest pain or shortness
of breath?”
c. “When did you first notice the swelling
and redness in your leg?”
d. “Do you have any cramping or muscle
spasms in your leg?”
ANS: B
The highest risk of a DVT is the potential for the clot to break free and travel through the
bloodstream to cause a pulmonary embolus (PE). The nurse should ask the patient about chest
pain or shortness of breath to assess if a PE may have occurred.
DIF: Applying OBJ: 38.3 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Clotting
12. The nurse identifies which patient who would benefit from postural drainage?
a. A patient with a heart murmur and jugular
venous distention
b. A patient with asthma and audible
wheezing
c. A patient with right-sided heart failure and
pitting edema
d. A patient with chronic bronchitis and
congested cough
ANS: D
Postural drainage is used for patients who have difficulty removing thick secretions from the
airway. A patient with chronic bronchitis and a congested, productive cough would benefit from
postural drainage because it would help clear the airway.
DIF: Understanding OBJ: 38.6 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Gas Exchange
13. The nurse is caring for a patient who has a history of congestive heart failure with generalized
pitting edema. Which laboratory results will the nurse expect to find in the patient’s chart?
a. Glycosylated hemoglobin 12%
b. Platelet count 450,000/mm3
c. Hematocrit 32%
d. Prothrombin time 8.8 seconds
ANS: C
Hemodilution is a common finding when patients are in fluid overload caused by congestive
heart failure. A normal hematocrit result is 42% to 52% for a male and 37% to 47% for a female,
so the patient’s 32% hematocrit level is markedly low. The other laboratory results are not
expected due to congestive heart failure or fluid overload.
DIF: Applying OBJ: 38.6 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Fluid and Electrolyte Balance
14. The nurse is caring for a patient with high cholesterol who has been prescribed atorvastatin
(Lipitor). Which laboratory result indicates that the patient has been taking the medication as
ordered and following the physician’s dietary recommendations?
a. Serum triglyceride level 325 mg/dL
b. High-density lipoproteins (HDL) 56
mg/dL
c. Low-density lipoproteins (LDL) 155
mg/dL
d. Total cholesterol level 185 mg/dL
ANS: D
Total cholesterol levels should be less than 200 mg/dL, so a cholesterol level of 185 mg/dL
indicates that the patient has been compliant with the prescribed therapy. The other laboratory
results are abnormal and would not indicate compliance.
DIF: Applying OBJ: 38.6 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Nutrition
15. The nurse is caring for a patient who has presented to the ER with chest pain. Which diagnostic
test will best indicate if there is significant blockage of important blood vessels that provide
oxygen to the heart muscle?
a. Cardiac catheterization
b. Chest x-ray
c. Echocardiogram
d. Electrocardiogram
ANS: A
Cardiac catheterization includes the use of contrast dye to visualize the coronary arteries and
determine blood flow to cardiac muscle. The other tests will not allow the physician to determine
which (if any) coronary arteries are occluded.
DIF: Understanding OBJ: 38.6 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Perfusion
16. The nurse hears a loud murmur when listening to the patient’s heart. Which diagnostic test will
best display the condition of the valves and structures within the patient’s heart that could be
causing the murmur?
a. Chest x-ray
b. Cardiac catheterization
c. Echocardiogram
d. Electrocardiogram
ANS: C
Echocardiograms allow for ultrasound visualization of the structures of the heart along with
function of the heart valves and cardiac musculature.
DIF: Understanding OBJ: 38.2 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Perfusion
17. The nurse is caring for a patient who will be returning to the nursing unit following a cardiac
catheterization via the right femoral artery. Which assessment is the highest priority for the nurse
to perform when the patient arrives on the unit?
a. Checking the patient’s right pedal pulse
and warmth of the right leg
b. Checking pulse oximetry and listening to
the patient’s lung sounds
c. Checking bilateral radial pulses to check
for a pulse deficit
d. Estimating the patient’s jugular venous
pressure
ANS: A
Cardiac catheterization includes the insertion of a large IV needle into the patient’s femoral
artery. Occlusion of the femoral artery may develop after the procedure leading to faint or absent
pedal pulses and loss of warmth to the right leg. The nurse should check the patient’s right pedal
pulses and leg warmth to ensure that the femoral artery has not become occluded. The other
assessments may be performed once the patient’s right leg is found to be warm with strong
pulses.
DIF: Applying OBJ: 38.3 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Perfusion
18. The home care nurse is caring for a patient who has severe COPD and home oxygen therapy.
The patent tells the nurse that she feels much better after increasing the oxygen flowmeter from 2
L to 5 L/min. The patient’s pulse oximetry is 98%. What is the priority action of the nurse?
a. Reduce the oxygen flow rate until the
patient’s pulse oximetry value is more
than 90%.
b. Inform the patient’s physician and obtain
an order for oxygen at 5 L/min.
c. Document the intervention and findings in
the patient’s medical record.
d. Listen to the patient’s lung fields and
reinforce pursed-lip breathing techniques.
ANS: A
The goal of long-term therapy for the patient with COPD is usually to have an oxygen saturation
level of more than 90%, which represents adequate delivery of oxygen to the tissues. Oxygen
saturation may decrease during exercise, sleep, or deterioration of the respiratory status. For the
patient with COPD, use low-flow oxygen delivery only
(≤ 2 L/min) unless a higher level of oxygen administration is indicated by low oxygen saturation
levels. High-flow oxygen may lead to respiratory suppression caused by loss of the patient’s
drive to breathe. The nurse should reduce the oxygen flow rate until the patient’s pulse oximetry
is more than 90% and educate the patient about oxygen therapy for COPD.
DIF: Analyzing OBJ: 38.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Gas Exchange
MULTIPLE RESPONSE
1. The nurse is caring for a patient with advanced COPD who reports feeling short of breath. The
nurse notes that the patient’s lung sounds are diminished bilaterally and the patient’s pulse
oximetry is 91% on 2 L/min oxygen via nasal cannula. What actions will the nurse take to make
the patient more comfortable? (Select all that apply.)
a. Increase the patient’s oxygen to 4 L/min
via nasal cannula.
b. Suction the patient’s airway using sterile
technique.
c. Maintain eye contact and provide calm
reassurance.
d. Turn the patient onto the side for postural
drainage.
e. Administer the ordered nebulized
bronchodilator.
f. Elevate the head of the patient’s bed to
fully upright.
ANS: C, E, F
Patients who are acutely short of breath due to advanced COPD will benefit from nebulized
bronchodilator medication to open the airways. Elevating the head of the bed will prevent
pressure on the diaphragm from the abdominal contents. A caring demeanor with eye contact
will help the patient remain calm until the medication begins to work and the shortness of breath
is eased. Patients with COPD should be kept on low-flow oxygen to maintain pulse oximetry of
more than 90%.
DIF: Applying OBJ: 38.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Physiological Adaptation
NOT: Concepts: Gas Exchange
2. The nurse is performing a respiratory assessment on a patient. Which assessment findings
indicate to the nurse that the patient has a history of long-standing chronic respiratory disease?
(Select all that apply.)
a. All the patient’s fingernails are noticeably
clubbed.
b. The patient needs to sleep on at least four
to five pillows at night.
c. The patient’s chest has equal antero-
posterior and transverse diameters.
d. The patient’s lower legs have large areas
of brownish spotted discoloration.
e. The patient reports puffiness of both feet
when standing for long periods.
f. The patient’s forced vital capacity test
result is 3.8 L of air.
ANS: A, B, C
Clubbing of fingernails, the need to sleep in an upright position, and a barrel chest are all
indicative of long-standing chronic respiratory disease like COPD. Brownish spotted
discoloration is indicative of venous insufficiency. Edema can be seen in renal and heart failure.
Forced vital capacity of almost 4 L is found in patients with good respiratory function.
DIF: Applying OBJ: 38.3 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Gas Exchange
3. The nurse notes the following findings when assessing a patient with COPD. Which require
prompt nursing intervention? (Select all that apply.)
a. The patient is unable to speak without
gasping.
b. The patient’s fingernails are noticeably
clubbed.
c. The patient’s sputum has turned from
yellow to greenish-brown.
d. The patient has stridor with wheezes heard
in all lung fields.
e. The patient’s forced vital capacity has
increased from 2.8 to 3.4 L.
f. The patient has become confused and
mildly disoriented.
ANS: A, C, D, F
A patient who is unable to speak without gasping is indicative of poor airflow through the
airways, which must be addressed promptly. Greenish-brown sputum may indicate pneumonia
requiring antibiotic treatment. Stridor and wheezes are indicative of an acute asthma attack.
Confusion and disorientation in a patient with COPD may indicate retention of carbon dioxide.
Clubbed fingernails are indicative of a chronic respiratory condition. Increased forced vital
capacity is a positive sign.
DIF: Applying OBJ: 38.3 TOP: Assessment
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Gas Exchange
4. The nurse is working with a nursing assistant to care for a patient with a new tracheostomy.
Which tasks may the nurse delegate to the assistant? (Select all that apply.)
a. Obtaining masks, gloves, and suction
supplies from the utility room
b. Helping to reassure the patient before,
during, and after suctioning
c. Changing the Velcro or twill ties used to
secure the tracheostomy
d. Transporting sputum specimens to the lab
for culture and sensitivity testing
e. Assessing need for suctioning of the
oropharynx or tracheostomy
f. Teaching the patient how to remove and
clean the inner cannula
ANS: A, B, D
Care of a new tracheostomy may not be delegated to a nursing assistant. Obtaining supplies
needed for care, helping to reassure the patient, and bringing specimens to the lab are tasks that
may be assigned to the assistant.
DIF: Applying OBJ: 38.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Safe and Effective Care Environment: Management of Care
NOT: Concepts: Care Coordination
5. The preceptor is working with a new nurse to provide care for a patient with a new tracheostomy.
Which actions by the new nurse indicate need for additional teaching about the procedure?
(Select all that apply.)
a. The outer cannula is cleaned with the
brush and half-strength H2O2.
b. The new tracheostomy holder is secured
before the old soiled one is removed.
c. A Yankauer suction catheter is used to
remove secretions from the patient’s
mouth.
d. Sterile gloves are applied before the soiled
dressing is removed from the
tracheostomy.
e. Half-strength H2O2 is used to remove
crusted secretions around the
tracheostomy site.
f. Pain medication is administered to the
patient prior to suctioning.
ANS: A, D, E
Only the inner cannula of the tracheostomy is removed for cleaning. The outer cannula stays in
the trachea to maintain airway patency. Clean gloves are applied before the soiled dressing is
removed. Normal sterile saline is used to remove secretions that have built up on the inner
cannula and also is used to clean the patient’s skin as needed.
DIF: Applying OBJ: 38.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Gas Exchange
6. The preceptor is working with a new nurse to suction a patient through a new tracheostomy.
Which actions by the new nurse indicate need for additional teaching about the procedure?
(Select all that apply.)
a. The suction is not applied to the catheter
until it is being withdrawn.
b. The patient is placed in the supine position
prior to suctioning.
c. The suction catheter is twirled side to side
as it is being withdrawn.
d. Suction is applied continuously as the
catheter is withdrawn.
e. The patient’s oxygen is reapplied between
suction attempts.
f. Water-soluble lubricant is applied to the
suction catheter before insertion.
ANS: B, D, F
The head of the patient’s bed should be elevated prior to suctioning to facilitate coughing out
secretions. Suction is always applied intermittently as the catheter is withdrawn. Water-soluble
lubricant is used when suctioning the naris but not a tracheostomy because the secretions negate
the need for additional lubrication.
DIF: Understanding OBJ: 38.6 TOP: Implementation
MSC: NCLEX Client Needs Category: Physiological Integrity: Reduction of Risk Potential
NOT: Concepts: Gas Exchange
