Oxygenation

The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal?

30-55 breaths per minute

A nurse is delivering 3 L/min oxygen to a patient via nasal cannula. What percentage of delivered oxygen is the patient receiving?

32%

The nurse sets up an oxygen tent for a patient. Which patient is the best candidate for this oxygen delivery system?

A child who has pneumonia

In which of the following clients would the nurse assess for a depressed respiratory system?

A client taking opioids for cancer pain

The nurse is assessing the respiratory rates of patients in a community health care facility. Which patient exhibits an abnormal value?

An infant with a respiratory rate of 20 bpm

A nurse measuring the arterial oxyhemoglobin saturation (SaO2 or SpO2) of a patient's arterial blood gets a weak signal from the pulse oximeter. What would be the appropriate intervention in this situation?

Check vital signs and patient condition.

Upon evaluation of a client's medical history, the nurse recognizes that which of the following conditions may lead to an inadequate supply of oxygen to the tissues of the body?

Chronic anemia

Oxygen and carbon dioxide move between the alveoli and the blood by

Diffusion

Which of the following dietary guidelines would be appropriate for the elderly homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

Eat smaller meals that are high in protein

A client with no prior history of respiratory illness has been admitted to a postsurgical unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?

Educating the client on the use of incentive spirometry

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?

Flowmeter

To drain the apical sections of the upper lobes of the lungs, the nurse should place the patient in which of the following positions?

High Fowler's position

pulse oximetry. What is the purpose of the pulse oximetry technique?

Monitor the amount of oxygen saturation in the blood

A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function?

Pleural effusion

The nurse schedules a pulmonary function test to measure the amount of air left in a patient's lungs at maximal expiration. What test does the nurse order?

Residual Volume (RV)

The nurse is caring for a postoperative client who has a prescription for meperidine (Demerol) 7 5mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering Demerol, the nurse would assess which most important sign?

Respiratory rate and depth

What is the action of codeine when used to treat a cough?

Suppressant

A nurse auscultates the lungs of a patient with asthma. Which lung sound is characteristic of this condition?

Wheezes

The nurse educator is presenting a lecture on emphysema with the aid of balloons. Which responses, if given by the nursing staff, would indicate to the educator that further teaching is needed? Select all that apply.

• "Respirations of the client with emphysema can be compared to a balloon that has been blown up before." • "Emphysema, like a new balloon, takes less effort to empty air out of the alveoli." The lungs in a client with emphysema are stiff and noncompliant. The lungs (alveoli) are compared to a new balloon that takes more effort to blow up and release air out. As in emphysema, a new balloon takes extra effort to blow up; the client with emphysema has to exert more effort to breathe in and out, leading to shortness of breath. The new balloon is difficult to expand, representing decreased elasticity leading to decreased compliance.

A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient?

Ambu bag

The nurse is teaching an adolescent with asthma how to use a meter-dosed inhaler. Which teaching point follows recommended guidelines?

Be sure to shake the canister before using it.

During oxygen administration to the client, which of the following pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

Flow meter

When inspecting a patient's chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression.

The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner?

8 L/min oxygen via nasal cannula; The correct amount delivered FiO2 for a nonrebreather mask is 12 L/min; 8-11 L/min for partial rebreather mask; 4-10 L/min for Venturi mask; and 1-6 L/min for nasal cannula.

The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which of the following assessment findings should the nurse interpret as abnormal?

Fine crackles to the bases of the lungs bilaterally

The nurse is caring for a client who is diagnosed with an impair exchange. While performing a physical assessment of the client, which of the following data is the nurse likely to find, keeping in mind the client's diagnosis?

High respiratory rate

The nurse assesses a patient 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?

Hypoxia

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client?

Nasal cannula

A patient with a diagnosis of advanced Alzheimer disease who is unable to follow directions requires an inhaled bronchodilator. Which of the following medication delivery systems is most appropriate for this patient?

Nebulizer

A patient returns to the telemetry unit after an operative procedure. Which of the following diagnostic tests will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the patient?

Pulse oximetry

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?

Rapid respirations

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse, if noted by the charge nurse, would cause the charge nurse to intervene?

The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN).

The nurse is performing an arterial blood gas sampling on a client at 1045. The nurse educator intervenes if which action is taken by the nurse?

The nurse performs the Allen's test after blood sample is taken. The Allen's test is done before puncture to ensure adequate ulnar blood flow when using radial artery.

The nurse is auscultating the lungs of a patient and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

They are low-pitched, soft sounds heard over peripheral lung fields.

When preparing a patient for a cardiac catheterization, what are the responsibilities of the nurse? (Select all that apply.)

Verify that an informed consent was obtained. • Make sure the patient is NPO after midnight before the procedure. • Inform the patient that when dye is given, a feeling of warmth or flushing, or a metallic taste may occur.

A nurse is percussing the thorax of a patient with chronic emphysema. What percussion sound would most likely be assessed?

hyperresonance; Hyperresonance is a loud, low, booming sound typically heard with percussion over emphysematous (excessively air-filled) lungs.

The nurse caring for a client who will have a chest tube removed within the next hour includes which of the following nursing interventions on the client's plan of care? (Select all that apply)

• Administer prescribed pain medication 15 to 30 minutes before chest tube removal • Teach the client about relaxation exercises to be used during chest tube removal

The nurse is planning a diet for a patient with COPD. Which recommended nutritional guidelines would the nurse consider? (Select all that apply.)

• The diet should consist of 40% to 55% carbohydrates. • The diet should be rich in antioxidants and vitamin A, C, and B. • The diet should contain 12% to 20% protein.

The nurse performs assessments of cardiopulmonary functioning and oxygenation during regular physical assessments. Based on developmental variations, which findings would the nurse consider normal? (Select all that apply.)

• The power of the respiratory and abdominal muscles is reduced in the elderly, and therefore the diaphragm moves less efficiently. • The normal infant's chest is small and the airways are short, making aspiration a potential problem. • Alterations in respiratory function due to aging in the elderly increase the risk for disease, especially pneumonia and other chest infections. • The respiratory rate is more rapid in infants until the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates.

The nurse is reviewing the results of a patient's arterial blood gas and pH analysis. Normal findings include: (Select all that apply.)

• pH 7.45 • PCO2 40 mm Hg • Base excess or deficit +2 mmol/L