N3280: Exam 3

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 determines whether you are getting enough oxygen. It regulates the amount of oxygen received. It decreases dry mucous membranes by delivering small water droplets.

It decreases dry mucous membranes by delivering small water droplets.

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 Pneumonia Tachypnea Wheezes

Pleural effusion Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis. Pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.

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

Pulmonary function tests Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.

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 False

True 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 nurse caring for a client with a chest tube should monitor the client's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

a bronchospasm When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm.

non-rebreather mask

low flow 10-15L/min 80-95% FiO2 allows release of CO2, used in emergent situations

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 encourages you to sit up straighter to increase expansion of the lungs during inhalation." "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." "Breathing through your nose first will warm, filter, and humidify the air you are breathing." "If you breathe through the mouth first, you will swallow germs into your stomach."

"Breathing through your nose first will warm, filter, and humidify the air you are breathing." Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring.

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." "I understand; I used to be a smoker also." "You should never smoke when oxygen is in use." "Oxygen is a flammable gas."

"You should never smoke when oxygen is in use." The nurse will educate the client about the dangers of smoking when oxygen is in use. Oxygen is not flammable, but it oxidizes other materials. Other answers are inappropriate.

In which client should the nurse prioritize assessments for respiratory depression?

A client taking opioids for cancer pain Many medications affect the function of the respiratory system and depress the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Beta-adrenergic blockers, antibiotics, and insulin do not appreciably affect the respiratory system.

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: A. "He is using his chest muscles to help him breathe." B. "His lung muscles are swollen so he is using abdominal muscles." C. "He will require additional testing to determine the cause." D. "His infection is causing him to breathe harder."

A. "He is using his chest muscles to help him breathe." The client will use accessory muscles to ease dyspnea and improve breathing.

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? Educate client on incentive spirometry Assist with intubation Apply oxygen as prescribed Raise the head of the bed

Apply oxygen as prescribed The nurse should first apply oxygen, which will help to improve oxygen saturation and health status. The client may not require intubation, once oxygen is provided. Although the client may require education on incentive spirometry, the immediate priority intervention is to stabilize the client's oxygen saturation. Similarly, raising the head of the bed may help with the client's comfort but may not have sufficient effect on oxygen saturation.

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. face tent B. tracheostomy collar C. simple mask D. nasal cannula

B. tracheostomy collar A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. All other devices are less appropriate for this client.

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? Croup Bronchitis Bronchiectasis Atelectasis

Bronchitis

A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? A. The nurse assures that the oxygen is flowing into the prongs. B. The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. C. The nurse encourages the patient to breathe through the nose with the mouth closed. D. The nurse adjusts the flow rate to 6 L/min or more.

C. The nurse encourages the patient to breathe through the nose with the mouth closed. The nurse should encourage the patient to breathe through the nose with the mouth closed. The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should adjust the fit of the cannula so it is snug but not tight against the skin. The nurse should adjust the flow rate as ordered.

nasal cannula

(low flow) 1-6L/min, 24-44% FiO2 apply if SpO2 lower than 90%, increased resp rate *patient is stable*

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?

Clubbing Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many clients with chronic hypoxia due to respiratory or cardiac disease. Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD. Hemoptysis, edema, and diarrhea do not result from hypoxia.

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather? face tent tracheostomy collar nasal cannula simple mask

face tent A face tent is used without a mask; it is open and loose around the face and is often used for clients with facial trauma or burns. A simple mask or nasal cannula would irritate the facial skin. The client does not have a tracheostomy.

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. A. Closely assess the patient before, during, and after the procedure. B. Hyperoxygenate the patient before and after suctioning. C. Limit the application of suction to 20 to 30 seconds. D. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. E. Use an appropriate suction pressure (80 to 150 mm Hg). F. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.

A. Closely assess the patient before, during, and after the procedure. B. Hyperoxygenate the patient before and after suctioning. D. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. E. Use an appropriate suction pressure (80 to 150 mm Hg). Close assessment of the patient before, during, and after the procedure is necessary to limit negative effects. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. The nurse should also take the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis related to the use of high negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis.

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 respiratory rate is in the normal range. C. The client's red blood cell (RBC) count 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. Pulse oximetry is a noninvasive technique that measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial blood. This test measures only the percentage of oxygen carried by the available hemoglobin. Thus, even a client with a low hemoglobin level could appear to have a normal SpO2 because most of that hemoglobin is saturated. However, the client may not have enough oxygen to meet body needs. A normal pulse oximetry reading does not necessarily indicate a normal RBC count or heart rate.

An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? A. Tilt the patient's head forward. B. Hold the mask tightly over the patient's nose and mouth. C. Pull the patient's jaw backward. D. Compress the bag twice the normal respiratory rate for the patient.

B. Hold the mask tightly over the patient's nose and mouth. With the patient's head tilted back, jaw pulled forward, and airway cleared, the mask is held tightly over the patient's nose and mouth. The bag also fits easily over tracheostomy and endotracheal tubes. The operator's other hand compresses the bag at a rate that approximates normal respiratory rate (e.g., 16 to 20 breaths/min in adults).

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? A. Place the client in the dorsal recumbent position to collect the specimen. B. Discard the first sputum produced by the client. C. Instruct the client to inhale deeply and then cough. D. Have the client clear the nose and throat and gargle with salt water before beginning the procedure.

C. Instruct the client to inhale deeply and then cough. The client should be instructed to inhale deeply and cough; if this results in sputum, it should be collected in the container. The client should be placed in a semi-Fowler's position and instructed to clear the nose and throat and rinse the throat with water.

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? A. Page the respiratory therapist STAT. B. Cover the tracheostomy stoma and apply oxygen by nasal cannula C. Maintain the client's oxygenation and alert the health care provider immediately. D. Assess the client's respiratory status and check vital signs every 1 minute for the next hour.

C. Maintain the client's oxygenation and alert the health care provider immediately. If the tracheostomy becomes dislodged and is not easily replaced, the nurse should notify the primary care provider immediately, cover the tracheostomy stoma, and assess client's respiratory status.

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. Shine available light on the equipment to facilitate accurate reading. B. Use a blood pressure cuff to increase circulation to the site. C. Warm the client's hands and try again. D. Place the probe on the client's earlobe.

C. Warm the client's hands and try again.

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? A. The patient vomits during suctioning. B. The secretions appear to be stomach contents. C. The catheter touches an unsterile surface. D. A nosebleed is noted with continued suctioning.

D. A nosebleed is noted with continued suctioning. When nosebleed (epistaxis) is noted with continued suctioning, the nurse should notify the health care provider and anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning.

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? A. Hyperventilation B. Perfusion C. Atelectasis D. Hypoxia

D. Hypoxia Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia. Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements. Perfusion refers to the process by which oxygenated capillary blood passes through body tissues. Atelectasis refers to collapsed alveoli.

A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? A. Notify the health care provider. B. Apply an occlusive dressing on the site. C. Assess the patient for signs of respiratory distress. D. Put on gloves and insert the chest tube in a bottle of sterile saline.

D. Put on gloves and insert the chest tube in a bottle of sterile saline. When a chest tube becomes separated from the drainage device, the nurse should submerge the end in water, creating a water seal, but allowing air to escape, until a new drainage unit can be attached. This is done instead of clamping to prevent another pneumothorax. Then the nurse should assess vital signs and notify the health care provider.

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. Review the medications that the client has taken in the past 90 minutes. Raise the head of the client's bed slightly, if tolerated. Document this expected assessment finding.

Document this expected assessment finding. A range of 95% to 100% is considered normal oxygen saturation. As such, there is no need to change the client's position, encourage deep-breathing exercises and coughing, or to review the client's medication history.

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. congestive heart failure. lung cancer.

congestive heart failure A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.

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: age. hemoglobin level. blood pH. sodium and potassium levels.

hemoglobin level Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.

high flow nasal cannula

up to 60 L/min, 100% FiO2 humidified air

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 one large meal at noon. Eat smaller meals that are high in protein. Contact the physician for nutrition shake.

Eat smaller meals that are high in protein The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength

A client, 90 years of age, has been in a motor vehicle collision and sustained four fractured ribs on the left side of the thorax. The nurse recognizes the client is experiencing respiratory complications when which sign(s) is observed? Select all that apply. The client demonstrates restlessness. The client has uneven movements of the chest with respirations. The client has a respiratory rate of 16 breaths/min. The client's capillary refill is assessed at 4 seconds. The client has flaring nostrils.

The client demonstrates restlessness The client has uneven movements of the chest with respirations. The client's capillary refill is assessed at 4 seconds. The client has flaring nostrils. Careful assessment of older adults who demonstrate restlessness or confusion is imperative for accurately differentiating signs of inadequate oxygenation from signs of delirium or dementia. While the nurse may be observing signs of cognitive impairment, restlessness commonly accompanies respiratory distress. The nurse will not dismiss this sign and will consider it as part of the respiratory assessment. A prolonged capillary refill time (any time longer than 3 seconds) is indicative of poor perfusion secondary to poor oxygenation. This is a sign that the client may be experiencing respiratory complications. The nurse observes for paradoxical (uneven) chest movement that would indicate a possible flail chest. These complications may require insertion of a chest tube or other surgery, blood transfusion or artificial ventilation. Flaring nostrils indicate increased work of breathing related to poor gas exchange. A respiratory rate that ranges from 12 to 16 breaths/min is normal for adults and older adults.

Which should the nurse teach the family about caring for a client with emphysema at home? Select all that apply. Maintain a smoke-free environment. Follow health care provider's prescription for oxygen administration. Watch for increased wheezing or signs of a flare-up. Take advantage of pulmonary rehabilitation programs. Create a long-term caregiving plan. Even if the person with emphysema is not smoking anymore, the person may be living in a home where family members still smoke. Family must understand why it is important to keep tobacco smoke out of the house. Caregivers need to be ready and know the signs of a flare-up. For instance, the client may wheeze more, get increasingly short of breath, cough more than usual, or have more or a change in color of mucus. If there is a flare-up, the sooner the client can get treatment, the less likely the client will require hospitalization. It is worthwhile for clients with emphysema to look into pulmonary rehabilitation programs. These programs combine exercise, support, and education that will improve one's breathing and health. People with emphysema can live a really long time. Therefore, the family will require a clear plan to address caregiving long term. Oxygen therapy in a client with emphysema is often necessary but too much oxygen may result in knocking out the hypoxic drive, causing further depression of the respiratory drive.

(all the above) Maintain a smoke-free environment. Follow health care provider's prescription for oxygen administration. Watch for increased wheezing or signs of a flare-up. Take advantage of pulmonary rehabilitation programs. Create a long-term caregiving plan.

A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? A. Dyspnea B. Hypotension C. Decreased respiratory rate D. Decreased pulse rate

A. Dyspnea If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

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

A. It determines whether the client is getting enough oxygen. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.

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. Crackles C. Bronchial D. Bronchovesicular

A. Vesicular Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

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? A. Wheezing B. Crackles C. Absent breath sounds in lower lobes D. Stridor

A. Wheezing The nurse expects to document wheezing in the lungs of a client with asthma, which would be more pronounced when the client has a respiratory infection. Wheezing is a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration. Wheezing is caused by air passing through constricted passages caused by swelling or secretions. Stridor and crackles are other abnormal breath sounds caused by fluid, infection, or inflammation in the lungs. Absent breath sounds are not normally found in asthmatic clients; they are characteristic of pneumonia.

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? A. Suction the client's mouth through the oropharyngeal airway to prevent aspiration. B. Leave the airway in place and promptly notify the health care provider for further instructions. C. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. D. Remove the airway, turn the client to the side, and provide mouth suction, if necessary.

D. Remove the airway, turn the client to the side, and provide mouth suction, if necessary. If the client vomits as the oropharyngeal airway is inserted, quickly position the client onto his or her side to prevent aspiration, remove the oral airway, and suction the mouth, if needed. It would be inappropriate and unsafe to leave the airway in place. Rinsing the client's mouth with water is not a priority.

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? redness behind both ears nasal cannula placed upside down flow meter set at 5 liters of oxygen nasal mucosa appears crusty

flow meter set at 5 liters of oxygen High percentages of oxygen are contraindicated for a client with COPD, because the client has adapted to excessive levels of retained carbon dioxide and low blood oxygen levels to stimulate the drive to breathe. If a client with COPD receives more than 2 to 3 liters of oxygen over a sustained period, the respiratory rate slows or even stops. Adjusting the flow meter and performing necessary emergent care would be the priority. The other findings are also concerns which can occur when receiving oxygen and would be addressed after dealing with the dyspnea.

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 Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.

When reviewing data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom? strong, rapid pulse rapid respirations increased urine output weight loss

rapid respirations Normal cardiac output averages from 3.5 to 8.0 liter/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing the respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display a thready pulse.