chapter 39- oxygenation and perfusion

The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide? a. "An electric stove may be a safer choice for you." b. "Be careful not to trip over your oxygen tubing while cooking." c. "Remove your oxygen before cooking near the gas stove." d. "It is important to eat at least five servings of vegetables daily."

a. "An electric stove may be a safer choice for you."

The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective? a. SpO2 92% b. clubbing of fingers c. heart rate 110 beats/minute d. respirations 26 breaths/minute

a. SpO2 92%

When caring for a client with a tracheostomy, the nurse would perform which recommended action? a. Suction the tracheostomy tube using sterile technique. b. Assess a newly inserted tracheostomy every 3 to 4 hours. c. Use gauze dressings over the tracheostomy that are filled with cotton. d. Clean the wound around the tube and inner cannula at least every 24 hours.

a. Suction the tracheostomy tube using sterile technique.

A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate? a. The client's available hemoglobin is adequately saturated with oxygen. b. The client's red blood cell (RBC) count is in the normal range. c. The client's respiratory rate is in the normal range. d. The client's oxygen demands are being met.

a. The client's available hemoglobin is adequately saturated with oxygen.

A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first? a. Apply oxygen b. Educate client on incentive spirometry c. Assist with intubation d. Raise the head of the bed

a. apply oxygen

A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for: a. atelectasis. b. hemothorax. c. pneumothorax. d. tachypnea.

a. atelectasis

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue? a. Corticosteroids b. Bronchodilators c. Antibiotics d. Expectorants

a. corticosteroids

Which skin disorder is associated with asthma? a. Eczema b. Abrasions c. Seborrhea d. Psoriasis

a. eczema

A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur? a. trauma to the tracheal mucosa b. suctioning of carbon dioxide c. loss of sterile field d. prevention of suctioning

a. trauma to the tracheal mucosa

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed: a. 4 L/minute. b. 6 L/minute. c. 10 L/minute. d. 1 L/minute.

b. 6 L/minute

The nurse is obtaining a pulse oximetry reading for a client admitted with exacerbation of chronic obstructive pulmonary disease (COPD). When observing a reading of 89%, what action should the nurse perform? a. Administer oxygen at 6 L/m by nasal cannula b. No action is required, because this may be normal for the client c. Have the client breath into a paper bag d. The nurse should prepare intubation equipment for the health care provider

b. No action is required, because this may be normal for the client

The nurse is caring for a client with a NANDA-I diagnosis of Imbalanced nutrition: Less than body requirements, related to difficulty breathing. The nurse would implement which measures to maintain an adequate nutritional status for this client? Select all that apply. a. Encourage client to eat 1 to 2 hours before breathing treatments and exercises. b. Encourage client to decrease protein, but increase calcium intake. c. Distribute six small meals over the course of the day. d. Provide frequent oral hygiene, especially before meals. e. Encourage client to eat alone for privacy during mealtime.

b. Provide frequent oral hygiene especially before meals. d. Distribute six small meals over the course of the day.

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider? a. A 12-year-old with a respiratory rate of 20 bpm b. An infant with a respiratory rate of 20 bpm c. A 4-year-old with a respiratory rate of 40 bpm d. A 70-year-old with a respiratory rate of 18 bpm

b. an infant with a respiratory rate of 20 bpm

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia? a. decreased blood pressure b. confusion c. hyperactivity d. decreased respiratory rate

b. confusion

A client with closed-angle glaucoma and a cough has a prescription for a cough medicine. The nurse would question which cough medicine if prescribed for this client? a. Cough medicine with iodine b. Cough medicine with an antihistamine c. Cough medicine with a high sugar content d. Cough medicine with a decongestant

b. cough medicine with an antihistamine

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing a. Anemia b. Poor tissue perfusion c. Congestive heart failure d. Malnutrition

b. poor tissue perfusion

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output? a. "If the client's stroke volume is 80 mL and heart rate is 80 beats per minute, then the cardiac output is 6.0 L/minute." b. "If the client's stroke volume is 70 mL and heart rate is 70 beats per minute, then the cardiac output is 4.7 L/minute." c. "If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute." d. "If the client's stroke volume is 60 mL and heart rate is 60 beats per minute, then the cardiac output is 3.2 L/minute."

c. "If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute."

The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client? a. "If you breathe through the mouth first, you will swallow germs into your stomach." b. "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." c. "Breathing through your nose first will warm, filter, and humidify the air you are breathing." d. "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation."

c. "breathing through you nose first will warm, filter, and humidify the air you are breathing"

A nurse is conducting a physical assessment of a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the client's oxygenation. What instruction should the nurse give the client? a. Elevate the ribs and sternum. b. Expand the thoracic cavity. c. Contract the abdominal muscles. d. Relax the respiratory muscles.

c. Contract the abdominal muscles.

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system? a. an older adult client who has COPD b. an adult who is receiving oxygen at home c. a child who has pneumonia d. an adolescent who has asthma

c. a child who has pneumonia

A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client? a. Oxygen mask b. Nasal cannula c. Ambu bag d. Oxygen tent

c. ambu bag

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position? a. side-lying position, half on the abdomen and half on the side b. left side with a pillow under the chest wall c. high-Fowler's position d. Trendelenburg position

c. high-fowler's position

Which is a sign of dyspnea specific to infants? a. panting respirations b. a forward-leaning position c. nasal flaring d. increased respiratory rate

c. nasal flaring

What structural changes to the respiratory system should a nurse observe when caring for older adults? a. diminished coughing and gag reflexes b. increased use of accessory muscles for breathing c. respiratory muscles become weaker d. increased mouth breathing and snoring

c. respiratory muscles become weaker

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? a. It regulates the amount of oxygen received. b. It prescribes oxygen concentration. c. It decreases dry mucous membranes via delivering small water droplets. d. It determines whether the client is getting enough oxygen.

d. It determines whether the client is getting enough oxygen.

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia? a. Edema b. Hemoptysis c. Constipation d. Clubbing

d. clubbing

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? a. Bronchoscopy b. Chest x-ray c. Skin tests d. Pulmonary function tests

d. pulmonary function tests

The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign? a. Orthostatic blood pressure b. Apical pulse c. Urinary intake and output d. Respiratory rate and depth

d. respiratory rate and depth

A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action? a. Use a blood pressure cuff to increase circulation to the site. b. Shine available light on the equipment to facilitate accurate reading. c. Place the probe on the client's earlobe. d. Warm the client's hands and try again.

d. warm the client's hands and try again

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?

vesicular