Coursepoint Chapter
The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis? A. low blood pressure B. high respiratory rate C. high temperature D. low pulse rate
B.
The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system? A. an adolescent who has asthma B. an older adult client who has COPD C. a child who has pneumonia D. an adult who is receiving oxygen at home
C.
The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier? A. "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." B. "Small water droplets come from this, thus preventing dry mucous membranes." C. "The humidifier prescribes the concentration of oxygen." D. "This is a gauge used to regulate the amount of oxygen that a client receives."
B.
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? A. nasal cannula B. oxygen analyzer C. flow meter D. nasal strip
C.
Oxygen and carbon dioxide move between the alveoli and the blood by: A. hyperosmolar pressure. B. negative pressure. C. diffusion. D. osmosis.
C.
The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take? A. Elevate head of the bed B. Assess lung sounds C. Assess oxygen tubing connection D. Reposition client
C.
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? A. normal saline B. mineral oil C. tap water D. distilled water
D.
To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test? A. Monitor the pressure of oxygen dissolved in plasma. B. Calculate the pressure of carbon dioxide dissolved in plasma. C. Measure the volume of air exhaled or inhaled over time. D. Monitor the amount of oxygen saturation in the blood.
D.
Which skin disorder is associated with asthma? A. Abrasions B. Seborrhea C. Psoriasis D. Eczema
D.
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: A. adequate tissue perfusion. B. heart failure. C. diminished stroke volume. D. high cardiac output.
A.
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? A. Vesicular B. Bronchial C. Bronchovesicular D. Crackles
A.
When caring for a client with a tracheostomy, the nurse would perform which recommended action? A. Clean the wound around the tube and inner cannula at least every 24 hours. B. Suction the tracheostomy tube using sterile technique. C. Use gauze dressings over the tracheostomy that are filled with cotton. D. Assess a newly inserted tracheostomy every 3 to 4 hours.
B.
The nurse is caring for a client with a 35% Venturi mask. Which administration considerations should the nurse use? Select all that apply. A. Assess the mask is tight against the face so oxygen does not leak. B. Ensure that air intake valves are not blocked. C. Examine the needed flow rate on the mask matches the rate on the oxygen flow meter. D. Use gauze pads under elastic strap to relieve irritation to scalp or ears. E. Inflate the reservoir bag with oxygen before placing mask.
B. C. D.
A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs? A. Nasal cannula B. Nonrebreather mask C. Simple mask D. Partial rebreather mask
A.
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. Ambu bag B. Nasal cannula C. Oxygen tent D. Oxygen mask
A.
A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of: A. pneumonia. B. asthma. C. croup. D. alcohol use.
A.
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A. True B. False
A.
The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? A. tracheostomy collar B. face tent C. nasal cannula D. simple mask
A.
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. Respiratory rate and depth B. Apical pulse C. Orthostatic blood pressure D. Urinary intake and output
A.
The nurse is listening to the client's lungs and hears them fill with air and then return to a resting position. How will the nurse document this assessment data? A. inspiration and expiration B. expiration and ventilation C. ventilation and respiration D. respiration and inspiration
A.
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? A. Residual Volume (RV) B. Tidal volume (TV) C. Forced Expiratory Volume (FEV) D. Total lung capacity (TLC)
A.
A nurse assesses the vital signs of a healthy newborn infant. What respiratory rates suggest a need for further assessment and possible interventions? Select all that apply. 80 breaths/min 20 breaths/min 35 breaths/min 65 breaths/min 50 breaths/min
A. B. D.
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? "Take in a small amount of air very quickly and then exhale as quickly as possible." "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling."
B.
The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse would cause the charge nurse to intervene? A. The newly hired nurse adjusts the bed to a comfortable working position. B. The newly hired nurse explains what she is doing and the reason to the client, even though the client does not appear to be alert. C. The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). D. The newly hired nurse assesses the client's pain and administers pain medication.
C.
A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from: A. myocardial infarction. B. lung cancer. C. pulmonary embolism. D. congestive heart failure.
D.
A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response? A. "Call your oxygen supplier immediately." B. "That will help the oxygen flow more freely." C. "That will make it easier to carry with you." D. "The caregiver will need to place the oxygen tank back into the secure carrier."
D.
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? A. "I understand; I used to be a smoker also." B. "Oxygen is a flammable gas." C. "An occasional cigarette will not hurt you." D. "You should never smoke when oxygen is in use."
D.
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.
A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment? A. 6,000 mL (6,000 × 109/L) B. 5,000 mL (5,000 × 109/L) C. 5,550 mL (5,500 × 109/L) D. 5,850 mL (5,850 × 109/L)
D.
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? A. Review the medications that the client has taken in the past 90 minutes. B. Raise the head of the client's bed slightly, if tolerated. C. Encourage the client to do deep-breathing exercises. D. Document this expected assessment finding.
D.