chapter 40 Prep U

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?

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

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is:

"He is using his chest muscles to help him breathe."

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?

"You should never smoke when oxygen is in use."

A nurse assesses the vital signs of a healthy newborn. What respiratory rate could be expected based on the developmental level of this client?

30 to 60 breaths/min

A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving?

32%

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:

6 L/minute.

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?

Ambu bag

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?

An infant with a respiratory rate of 16 bpm

The nurse is caring for a postoperative adult client who has undergone abdominal surgery. The nurse will provide interventions aimed at preventing what respiratory complication?

Atelectasis

A nurse is volunteering at a day camp where a child is stung by a bee and develops wheezing in the upper airways. The nurse will provide interventions to address what health problem?

Bronchospasm

The nurse is assessing a client with lung cancer who has been receiving treatment for many months. What manifestations may suggest that the client has chronic hypoxia?

Clubbing

The nurse assessing a client with chronic obstructive pulmonary disease (COPD) suspects chronic hypoxia based on which assessment finding?

Clubbing fingers

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The nursing care plan will address implications of what medical diagnosis?

Congestive heart failure

The nurse is monitoring a client with continuous pulse oximetry. What action(s) by the nurse are important to obtain accurate results? Select all that apply.

Correlate the pulse oximetry reading with the client's heart rate. Use the forehead sensor if cardiac output is low. Determine if the client has a pre-existing condition affecting the oxygen saturation.

A client has been diagnosed with asthma and has been prescribed inhaled medications to relieve inflammation in the lung tissue. What medication will the nurse administer?

Corticosteroids

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse will document what breath sounds?

Crackles

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe?

Crackles in the lower lobes

The nurse is assessing a neonate whose breathing ceased for 4 to 5 seconds on three different occasions. What is the nurse's best action?

Document these expected apneic episodes

A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action?

Document this expected assessment finding.

The nurse is caring for a client with emphysema who has been prescribed portable oxygen, 2 L/min. Which action(s) does the nurse take to administer low concentrations of oxygen to the client? Select all that apply.

Ensure that the oxygen concentrator is turned on Confirm that the nasal cannula is worn properly by the client Verify the oxygen concentrator is set on the prescribed flow rate

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is:

He is using his chest muscles to help him breathe."

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?

Instruct the client to inhale deeply and then cough.

A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determines that the education was successful when the students identify which activity as occurring during inspiration?

Intercostal muscles contract.

An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize?

Is your mask causing discomfort?"

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?

It determines whether the client is getting enough oxygen.

The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response?

Maintain the client's oxygenation and alert the health care provider immediately.

A client is prescribed a corticosteroid for the treatment of asthma after having an asthma attack. What education should the nurse provide to the client regarding the administration of this medication?

Monitor blood pressure and blood sugar.

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?

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

A nurse conducts a health history for a client with chronic bronchitis. Which action does the nurse take first when the client begins to experience respiratory distress?

Place the client in a comfortable position, ensure an open airway and if oxygen is prescribed start administration

A client is taking albuterol via nebulizer. Which instruction will the nurse provide to teach the client how to use the nebulizer?

Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs.

A parents brings their 2-year-old to the emergency department in respiratory distress. SThe child's oxygen saturation is 81% and there is audible stridor. What intervention will the nurse anticipate?

Placement in an oxygen tent

The nurse provides care for the client with asthma reporting shortness of breath. Which action(s) does the nurse take to promote client comfort and decrease anxiety? Select all that apply.

Plan for periods of rest between activities Instruct on effective breathing as needed Assess the relationship of inspiration to expiration Assess the client's level of anxiety and possible causes Encourage relaxation activities such as music and reading

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?

Pleural effusion

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

Poor tissue perfusion

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). In what position does the nurse place the client in order to promote adequate oxygenation?

Prone

The nurse provides care for a client with pneumonia and acute respiratory distress syndrome whose oxygen saturation fluctuated between 86% and 90% over the past few days. The oxygenation saturation is consistently at 91%. Which step would the nurse take next?

Provide oxygen for consistent hypoxia

The nurse is caring for an older adult homebound client with advanced respiratory disease whose has inadequate nutrition. What recommendation will the nurse provide?

Provide suggestions of high-protein, high-calorie meals

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?

Pulmonary function tests

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?

Remove the airway, turn the client to the side, and provide mouth suction, if necessary.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

Residual Volume (RV)

The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care?

Stay indoors as much as possible.

When caring for a client with a tracheostomy, the nurse would perform which recommended action?

Suction the tracheostomy tube using sterile technique.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression.

A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate?

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

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

True

A nurse has received an order to suction an adult client's endotracheal tube. Which action is most appropriate when performing this intervention?

Use sterile saline to moisten the end of the suction catheter.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm.

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

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?

Warm the client's hands and try again.

The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?

Wheezing

The nurse is caring for the following clients. Which client is at highest risk for a depressed respiratory system?

a client taking an opioid for cancer pain

A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:

adequate tissue perfusion.

What assessments would a nurse make when auscultating the lungs?

air flow through the respiratory passages

The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier?

distilled water

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?

flow meter

The home health nurse arrives at a client's home and immediately notes the client is experiencing increased dyspnea. The client has a 7-year history of chronic obstructive pulmonary disease (COPD). Which assessment finding should the nurse prioritize?

flow meter set at 5 liters of oxygen

The nurse has received the arterial blood gas (ABG) results. The ABG was drawn on a client who has been receiving oxygen via partial rebreather mask. Which assessment findings should the nurse act upon after reviewing the ABG? Select all that apply.

headache sore throat fatigue

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's:

hemoglobin level.

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?

nasal cannula

The nurse is assessing a client's chest tube which was inserted 48 hours earlier. The nurse notes crackling in the skin around the insertion site. Which action should the nurse prioritize?

notify the health care provider

Which is a major organ of the upper respiratory tract?

pharynx

While auscultating a client's chest, the nurse auscultates crackles in the lower lung bases. What condition does the nurse identify the client is experiencing?

presence of fluid in the lungs

A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?

pulse oximetry

The nurse is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly?

reads 0.21 when checking oxygen in room air

The nurse is caring for a client who is experiencing an acute exacerbation of asthma. The nurse will explain to the client that after receiving the nebulized albuterol, the client can expect to experience which potential side effect(s) of this medication? Select all that apply.

tachycardia nausea lightheadedness sore throat nervousness

A nurse is teaching a home care client and the family about using prescribed oxygen. What is a critical factor that must be included in teaching?

the safety measures necessary to prevent a fire