Gas Exchange
Which diagnosis places a child at the greatest risk for airway obstruction? Epiglottitis Bronchiolitis Syncytial virus (RSV) Croup
Epiglottitis
After a client receives morphine sulfate for pain in the postanesthesia care unit (PACU), which assessment finding would the nurse obtain as a priority? Auscultate bowel sounds. Obtain temperature. Measure respiratory rate. Check the neurologic status.
Measure respiratory rate.
A client has undergone surgery for a spinal cord tumor that was located in the cervical area. The nurse would be especially alert for which of the following? Hemorrhage Bowel incontinence Respiratory dysfunction Skin breakdown
Respiratory dysfunction
The nurse is calculating the minute volume of a client. Select the correct categories of measurement. Tidal volume × respiratory rate Inspiratory reserve × tidal volume Respiratory rate × heart rate Total lung capacity × reserve volume
Tidal volume × respiratory rate
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
Wheezing
A nurse is discussing the use of naso-oral continuous positive airway pressure (NCPAP) with a client. What is the nurse's most appropriate response when the client asks what the purpose of this equipment is? "This device will generate a positive pressure that will promote your taking a breath." "This device will allow your nurse to suction your airway more easily." "This device will provide white noise to promote your sleeping." "This device will provide better alignment of your trachea."
"This device will generate a positive pressure that will promote your taking a breath."
The client is having difficulty breathing. The respiratory rate is 44 and the oxygen saturation is 89% (0.89 L). The nurse raises the head of the bed and applies oxygen at 3 L/min per nasal cannula. How does the nurse determine the effectiveness of the interventions? Select all that apply. The client's respiratory rate decreases. The client states, "I can breathe easier now." The client's oxygen saturation level increases. The client is watching television. The client's family asks if the client is going to be okay.
- The client's respiratory rate decreases. - The client states, "I can breathe easier now." - The client's oxygen saturation level increases.
A nurse is caring for a client diagnosed with Guillain-Barré syndrome. The client states, "It's getting harder to take a deep breath." Which action by the nurse is most appropriate? Call the physician and prepare for intubation. Explain the progression of the syndrome. Assess lung sounds. Encourage the client to cough.
Call the physician and prepare for intubation.
The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations? Hyperventilation Hypoxia Perfusion Atelectasis
Hypoxia
A client is admitted to a healthcare facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client? Activity intolerance related to shortness of breath Anxiety related to difficulty breathing Risk for infection related to retained secretions Impaired gas exchange related to airflow obstruction
Impaired gas exchange related to airflow obstruction
The nurse is caring for a patient who has been in a motor vehicle accident. The patient has been diagnosed with pleurisy. What is the preferred treatment for pain caused by pleurisy? Morphine sulfate Meperidine sulfate Acetaminophen Indomethacin
Indomethacin
A patient is in the progressive stage of shock with lung decompensation. What treatment does the nurse anticipate assisting with? Pericardiocentesis Thoracotomy with chest tube insertion Administration of oxygen via venture mask Intubation and mechanical ventilation
Intubation and mechanical ventilation
Which respiratory structure contains the vocal cords? Esophagus Pharynx Larynx Trachea
Larynx
A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal? Controlling bleeding Maintaining the airway Maintaining fluid volume Relieving the client's anxiety
Maintaining the airway
At 2300, a client is admitted to the emergency department with a respiratory rate of 44 breaths/minute and audible wheezes. Oxygen and methylprednisolone IV are administered. At 2330, the client's oxygen saturation is 86%, with wheezing present. Which medication will the nurse plan to administer next? fluticasone nebulizer beclomethasone inhaler ipratropium inhaler albuterol (salbutamol) nebulizer
albuterol (salbutamol) nebulizer
Which allergic reaction is potentially life threatening? angioedema urticaria contact dermatitis None of the listed allergic reactions is potentially life threatening.
angioedema
Specific potential complications are common to specific types of burns. Which burns can impair ventilation? face, neck, chest perineal hands, major joints All options are correct.
face, neck, chest
Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to all the cells and tissues of the body? left ventricle left atrium right ventricle right atrium
left ventricle
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? nausea or vomiting abdominal pain or diarrhea hallucinations or tinnitus light-headedness or paresthesia
light-headedness or paresthesia
During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure? wheezes with wet lung sounds stridor high-pitched sounds laborious breathing
wheezes with wet lung sounds