prep-u Chapter 21: Oxygenation

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

The nurse is using an oxygen analyzer to determine whether a client is receiving the amount prescribed by the health care provider. The nurse first checks the room air. What finding indicates a normal mixture of oxygen and other gases in the environment? a) 21% (0.21) b) 11% (0.11) c) 31% (0.31) d) 41% (0.41)

a) 21% (0.21)

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 will require additional testing to determine the cause." b) "He is using his chest muscles to help him breathe." c) "His infection is causing him to breathe harder." d) "His lung muscles are swollen so he is using abdominal muscles."

b) "He is using his chest muscles to help him breathe."

The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier? a) tap water b) normal saline c) distilled water d) mineral oil

c) distilled water

A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from? a) chronic obstructive pulmonary disease (COPD) b) chronic bronchitis c) sleep apnea d) pneumonia

c) sleep apnea

A client's spouse reports that the client snores loudly and incessantly every night. What is the appropriate nursing response when the client's spouse asks about nasal breathing strips? a) "Those do not work for snoring." b) "The nasal diameter is decreased by nasal strips." c) "You will need a prescription for nasal strips." d) "Nasal strips may reduce or eliminate snoring."

d) "Nasal strips may reduce or eliminate snoring."

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? a) pulse oximetry b) thoracentesis c) spirometry d) peak expiratory flow rate

a) pulse oximetry

During a physical assessment, a client reports a desire to reduce snoring because it interferes with the spouse's ability to sleep properly. What suggestion could the nurse make to improve the client's condition? a) Encourage the client to take deep breaths before going to bed. b) Teach the client to perform diaphragmatic breathing. c) Instruct the client on the use of the pursed-lip breathing technique. d) Tell the client to use nasal strips when sleeping.

d) Tell the client to use nasal strips when sleeping.

A client with a nonhealing pressure injury has been prescribed hyperbaric oxygen therapy (HBOT). The client tells the nurse, "This kind of treatment doesn't make any sense to me." What is the appropriate nursing response? a "It will help you breathe easier and feel better more quickly." b) "Wounds heal because HBOT helps to regenerate new tissue quickly." c) "In the chamber, you will be treated for decompression sickness." d) "When you become oxygen-toxic, the wound will heal faster."

b) "Wounds heal because HBOT helps to regenerate new tissue quickly."

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: a) adequate tissue perfusion. b) diminished stroke volume. c) high cardiac output. d) heart failure.

a) adequate tissue perfusion.

A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response? a)"Have you tried nasal strips?" b) "There is very little that can be done for snoring." c) "Pursed-lip breathing can reduce your amount of snoring." d) "Let me teach you about incentive spirometry."

a)"Have you tried nasal strips?"

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? a) "An occasional cigarette will not hurt you." b) "You should never smoke when oxygen is in use." c) "I understand; I used to be a smoker also." d) "Oxygen is a flammable gas."

b) "You should never smoke when oxygen is in use."

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the oxygen analyzer? a) "This is a gauge used to regulate the amount of oxygen that a client receives." b) "The oxygen analyzer prescribes the concentration of oxygen." c) "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." d) "Small water droplets come from this, thus preventing dry mucous membranes."

c) "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed."

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? a) It prescribes oxygen concentration. b) It regulates the amount of oxygen received. c) It determines whether you are getting enough oxygen. d) It decreases dry mucous membranes by delivering small water droplets.

d) It decreases dry mucous membranes by delivering small water droplets.

A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure? a) uses upper chest muscles more effectively b) replaces the use of incentive spirometry c) reduces the need for PRN pain medications d) prolongs expiration to reduce airway resistance

d) prolongs expiration to reduce airway resistance

A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention? a) Inquire about factors that contribute to non-adherence. b) Notify the healthcare provider of the client's current status. c) Explain uses of BiPAP masks versus CPAP masks. d) Document assessment and plan for intervention.

a) Inquire about factors that contribute to non-adherence.

The nurse is caring for a client with a chest tube in situ. When performing a focused respiratory assessment, which action is important to take before auscultating the lungs? a) Turn off the suction regulator attached to the tube. b) Inspect the insertion site for drainage. c) Palpate the skin around the chest tube. d) Check all tubing is unkinked and hanging freely.

a) Turn off the suction regulator attached to the tube.

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing concern for this client is altered airway clearance related to copious and tenacious secretions. What is an appropriate nursing intervention to include in the client's care plan? a) encouraging the client to consume at least 1.5 to 2 L of fluids daily of clear fluids daily b) creating an environment that is likely to reduce anxiety c) positioning the client supine encouraging the client to decrease the number of cigarettes smoked daily

a) encouraging the client to consume at least 1.5 to 2 L of fluids daily of clear fluids daily

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? a) "Did you remove your dentures?" b) "Is your mask causing discomfort?" c) "Did someone take your mask off?" d) "Did someone loosen the straps on your mask?"

b) "Is your mask causing discomfort?"

The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly? a) small amount of subcutaneous air is detected at the site of tube insertion b) dressing is moist and intact c) respirations are at 20 breaths per minute d) drainage system is positioned slightly above chest level

c) respirations are at 20 breaths per minute