Oxygenation and Perfusion
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 client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?
Arterial blood gas
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?
Assess oxygen tubing connection
An older adult client comes to the clinic with SOB and yellow mucus. What factors of the clients history may have contributed to this situation?
BMI more than 30 Smoker
A nurse is auscultating a clients breath sounds. What actions should the nurse employ to receive the most accurate results?
Bases first Auscultate by mimicking both sides Assess long enough to hear sounds
A nurse is caring for a client with COPD. Which is the most important when administering oxygen?
Do not exceed 2 lpm
Which independent nursing actions are associated with a client who experiences hypoxemia?
Elevate HOB Attach pulse ox Remain calm Encourage client to cough
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 nurse is monitoring a client with requiring continuous pulse oximetry. What should the nurse do?
Monitor radial pulse also Cleanse the site Site should be changed every 2 hours
How do nurses reduce the risk of aspiration in toddlers?
No marshmallows Toys larger than fist No plastic bags or wrap
100% oxygen is prescribed to a client with breathing difficulty. What type of mask should the nurse use?
Nonrebreather
A client who has COPD who is receiving 2 lpm of O2 via nasal cannula has dyspnea, is using accessory muscles to breathe, and is responsive. O2 sat is 89%. Place the following actions in order.
Place in high fowlers Obtain VS Teach pursed lip breathing Notify PCP Monitor O2 sats Call rapid response if needed
A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence?
Remove the catheter.
A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident?
Remove the tape, adjust the depth to ordered depth and reapply the tape.
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?
The nurse encourages the patient to breathe through the nose with the mouth closed.
A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter?
The size of the endotracheal tube
60% O2 is prescribed for a client. Which oxygen delivery system should the nurse use?
Venturi mask
A nurse must obtain a sputum specimen from a client with an endotracheal tube. Place the steps in order.
Wash hands Sterile gloves/eye shield Lubricate tip of catheter Pt can cough Catheter advances where sputum is obtained Catheter should be removed slowly
Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway?
When holding the airway on the side of the client's face, it should reach from the tragus of the ear to the tip of the nostril.
A client arrives in the ED with with portable oxygen at 3 lpm via nasal cannula. The nurse in the Ed obtains a health hx and VS and performs a physical assessment. What should the nurse do based on this information?
call PCP
What auscultating breath sounds, the nurse identifies presence of stridor. What should the nurse do?
client needs medical attention
The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?
confusion
To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?
high-Fowler's position
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
A nurse identifies a client with exertional dyspnea. Difficulty breathing in relation to what behavior?
Exercise
A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient?
Group personal care activities into smaller steps, allowing rest periods between activities.
A nurse must perform nasopharyngeal suctioning. Place the actions in order.
High fowlers suction kit sterile gloves Distance between ear and nose Lubricate insert
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?
Hold the mask tightly over the patient's nose and mouth.
An older adult client asks, "Why am I experiencing more respiratory tract infections now that I'm older?" How should the nurse respond?
Muscles are weaker as one ages. The ribcage becomes more rigid. A sedentary lifestyle decreases gas exchange.
A nurse receives a prescription for an oropharyngeal tube for a client who is unconscious. Which nursing actions are associated with this tube?
Administer mouth care every 4 hrs
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 nurse is caring for a client with a bacterial infection of the lungs. Why type of sputum should the nurse expect?
Yellow-green
What structural changes to the respiratory system should a nurse observe when caring for older adults?
respiratory muscles become weaker
A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?
trauma to the tracheal mucosa
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 documents a client that is having Kussmaul respirations. What observations did the nurse make to come to this conclusion?
Hydrogen ions are increased. The body is attempting to blow off carbon dioxide.
What signs of dyspnea should the nurse assess the client?
Supraclavicular retractions Grunting Pursed lips
A nurse is teaching a client how to use a vibratory positive expiratory pressure device to facilitate expectorations of respiratory secretions. What should the nurse teach the client?
Take two deep breaths inhaling fully and exhaling forcefully.
A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended?
A teenager with cystic fibrosis
Oxygen 4 lpm via nasal cannula is prescribed for a client who is cachectic. What nursing actions should be implemented?
Pad zygomatic bones Humidify oxygen
A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply.
"I will continue to inhale when the cold propellant is in my throat.", "I will only inhale one spray with one breath.", "I will activate the device while continuing to inhale."
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."
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 nosebleed is noted with continued suctioning.
A nurse is caring for a client with excessive respiratory secretions. What should the nurse do when suctioning?
Assess breath sounds Pulse ox PPE
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?
Bronchitis
What action does the nurse perform to follow safe technique when using a portable oxygen cylinder?
Checking the amount of oxygen in the cylinder before using it
A nurse is to perform a PPD test. What are essential nursing interventions?
Circle the injection site with pen Immunosuppressants can cause a fake positive A severe reaction can occur The intradermal route is used
Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply.
Closely assess the patient before, during, and after the procedure., Hyperoxygenate the patient before and after suctioning., Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve., Use an appropriate suction pressure (80 to 150 mm Hg).
A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient?
Dyspnea
The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is:
Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter.
A nurse is monitoring a clients respiratory status. What should the nurse include in her teaching of the device? (PEFR)
Monitors peak expiratory flow rates. Exhale fully after deep breath.
A client is admitted to the ED after sustaining injuries in a MVC. The client is semiconscious and the nurse is concerned about maintaining the airway while diagnostic tests are being performed. Which should the nurse anticipate being prescribed by the provider?
Nasopharyngeal tube
A client with a diagnosis of advanced Alzheimer disease is unable to follow directions required to use an inhaled bronchodilator. Which medication delivery system is most appropriate for this client?
Nebulizer
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
An unconscious client has excessive oral secretions. In which position should the nurse place the client?
Sims'
A client is scheduled to have a PFT. What should the nurse instruct the client to do during the test?
Smoking should be avoided for 6 hrs before test
The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective?
SpO2 92%
A nurse is caring for a client who has a laryngeal spasm. For which clinical indicator should the nurse assess?
Stridor
When caring for a client with a tracheostomy, the nurse would perform which recommended action?
Suction the tracheostomy tube using sterile technique.
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.
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?
Put on gloves and insert the chest tube in a bottle of sterile saline.
A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply.
Reduce anxiety, Eat a high-protein/high-calorie diet, Maintain a high-Fowler's position when possible.
A client who had been in a house fire is experiencing a productive cough. What color sputum should the nurse expect?
Black
A nurse is caring for a client who is receiving intermittent enteral feedings. What should the nurse do to prevent aspiration?
Raise HOB 45 degrees during and after for at least an hour
A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation?
Pulse oximetry
