exam 4
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?
"An occasional cigarette will not hurt you." "You should never smoke when oxygen is in use." * "I understand; I used to be a smoker also." "Oxygen is a flammable gas."
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?
"Did you remove your dentures?" "Is your mask causing discomfort?" * "Did someone take your mask off?" "Did someone loosen the straps on your mask?"
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?
"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 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 little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." "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 large volume of air over 5 seconds and hold your breath as long as you can before exhaling."
In which client should the nurse prioritize assessments for respiratory depression?
A client taking a beta-adrenergic blocker for hypertension A client taking antibiotics for a urinary tract infection A client taking insulin for type 1 diabetes A client taking opioids for cancer pain *
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
Anemia Malnutrition Poor tissue perfusion# Congestive heart failure
A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?
Ask the client what factors contribute to nonadherence. * Contact the health care provider to report the client's current status. Explain the use of a BiPAP mask instead of a CPAP mask. Document outcomes of modifications in care.
A nurse is reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would the nurse most likely identify as an effect of exposure to automobile pollutants?
Atelectasis Bronchitis# Bronchiectasis Croup
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?
Chest x-ray Bronchoscopy Skin tests Pulmonary function tests#
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?
Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. 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.# Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.
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?
Encourage the client to do deep-breathing exercises. Raise the head of the client's bed slightly, if tolerated. Review the medications that the client has taken in the past 90 minutes. Document this expected assessment finding.*
The nurse is caring for a client who is wearing oxygen via nasal cannula. The client asks about the bubbling water attached to the oxygen. Which response by the nurse is appropriate?
It prescribes oxygen concentration. It regulates the amount of oxygen received. It determines whether you are getting enough oxygen. It decreases dry mucous membranes by delivering small water droplets.*
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?
It prescribes oxygen concentration. It regulates the amount of oxygen received. It determines whether the client is getting enough oxygen. * It decreases dry mucous membranes via delivering small water droplets.
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?
Oxygen mask Nasal cannula Ambu bag * Oxygen tent
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?
Page the respiratory therapist STAT. Maintain the client's oxygenation and alert the health care provider immediately. * Cover the tracheostomy stoma and apply oxygen by nasal cannula Assess the client's respiratory status and check vital signs every 1 minute for the next hour.
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?
Place the client in the dorsal recumbent position to collect the specimen. Have the client clear the nose and throat and gargle with salt water before beginning the procedure. Instruct the client to inhale deeply and then cough.# Discard the first sputum produced by the client.
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.# Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. Leave the airway in place and promptly notify the health care provider for further instructions. Suction the client's mouth through the oropharyngeal airway to prevent aspiration.
Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?
Snack on high-carbohydrate foods frequently. Eat smaller meals that are high in protein. * Contact the physician for nutrition shake. Eat one large meal at noon.
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?
Stridor Crackles Wheezing* Absent breath sounds in lower lobes
When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?
The contour of the intercostal spaces should be rounded. The skin at the thorax should be cool and moist. The anteroposterior diameter should be greater than the transverse diameter. The chest should be slightly convex with no sternal depression.#
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?
They are loud, high-pitched sounds heard primarily over the trachea and larynx. They are medium-pitched blowing sounds heard over the major bronchi. They are low-pitched, soft sounds heard over peripheral lung fields. * They are soft, high-pitched discontinuous (intermittent) popping lung sounds.
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?
Tidal volume (TV) Total lung capacity (TLC) Forced Expiratory Volume (FEV) Residual Volume (RV) *
The nurse is caring for the following clients. Which client is at highest risk for a depressed respiratory system?
a client taking amlodipine for hypertension a client taking methocarbamol for low back spasms a client taking methimazole for hyperthyroidism 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. * diminished stroke volume. high cardiac output. heart failure.
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as:
crackles. * vesicular. wheezes. bronchovesicular.
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:
croup. asthma. alcohol use. pneumonia.*
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* nasal flaring tachycardia
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?
high temperature high respiratory rate * low pulse rate low blood pressure
A nurse is performing CPR on a client who collapsed. Which guidelines should be used for this procedure? Select all that apply.
if possible, place the client on a soft mattress to minimize injury. Position the client supine on his or her back. Use the head tilt-chin lift maneuver to open the airway. If trauma to the head or neck is present or suspected, do not attempt to open the airway. Rest elbows on the flat surface under the client, grasp the angle of the client's lower jaw, and lift with both hands. Look, listen, and feel for air exchange for at least 10 seconds and no more than 20 seconds.
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?
oxygen analyzer nasal strip nasal cannula flow meter *
The nurse is caring for a client with metabolic acidosis whose breathing rate is 28 breaths per minute. Which arterial blood gas data does the nurse anticipate finding?
pH less than 7.35; HCO3 low; PaCO2 low * pH greater than 7.45; HCO3 high; PaCO2 high pH less than 7.35; HCO3 high; PaCO2 high pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation
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 sputum in the trachea presence of fluid in the lungs * air passing through narrowed airways inflammation of pleural surfaces
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:
pulmonary embolism. myocardial infarction. lung cancer. congestive heart failure.#
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 * thoracentesis spirometry peak expiratory flow rate
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?
simple mask nasal cannula * face tent nonrebreather mask
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?
simple mask tracheostomy collar * nasal cannula face tent
