Taylor chapter-38 review questions. Oxygen and Perfusion

The nurse is caring for a client who is diagnosed with impaired gas exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis? A. low pulse rate B. high temperature C. high respiratory rate D. low blood pressure

high respiratory rate Explanation: A client diagnosed with impaired gas exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.

The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client? A. simple mask B. face tent C. nasal cannula D. tracheostomy collar

nasal cannula Explanation: A nasal cannula is ideal for administering low concentrations of oxygen to clients who are not extremely hypoxic or have chronic lung disease. The client does not have a tracheostomy. A simple mask is used to administer higher levels of oxygen than 2 L/min. A face tent is used without a mask.

The nurse is caring for a 2-year-old client who experienced smoke inhalation during a house file. When oxygen is ordered, what delivery device will the nurse gather? A. venturi mask B. non-rebreather mask C. oxygen tent D. nasal catheter

oxygen tent Explanation: An oxygen tent is often used when caring for active toddlers who require oxygen, since they are less likely to keep a mask on. Other devices are inappropriate for a child of this age.

While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique? A. pattern of thoracic expansion B. consolidated portions of the lung C. presence of pleural rub D. fluid-filled portions of the lung

pattern of thoracic expansion Explanation: The nurse can assess patterns of thoracic expansion through palpation. Fluid-filled and consolidated portions of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation.

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response? A. "I can assist you to the bathroom and back to bed." D. "The chest tube cannot be moved." B. "You will need to use a bedpan while the chest tube is in position." C. "Let me get the unlicensed assistive personnel (UAP) for you."

"I can assist you to the bathroom and back to bed." Explanation: The client can move in bed, and ambulate while carrying the drainage system as long as he or she has orders to do so. The nurse should supervise ambulation to the bathroom and back to bed while the client has the drain inserted, to make sure it stays intact and to monitor for safety. Other answers are incorrect.

A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving? A. 32% B. 47% C. 23% D. 28%

32% Explanation: A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44%

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? A. A 12-year-old with a respiratory rate of 20 bpm B. An infant with a respiratory rate of 20 bpm C. A 4-year-old with a respiratory rate of 40 bpm D. A 70-year-old with a respiratory rate of 18 bpm

An infant with a respiratory rate of 20 bpm Explanation: The infant's normal respiratory rate is 30 to 55 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 40 breaths per minute. For a child 6 to 12 years of age the normal respiratory rate is 18 to 26 breaths per minute. The normal respiratory rate for an adult 65 years and older is 16 to 24 breaths per minute.

The nurse is caring for an older adult client on home oxygen who has dentures, but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate? A. Check fit of oxygen mask. B. Contact the oxygen supplier to request an oxygen tent. C. Increase the flow of oxygen. D . Discontinue oxygen therapy until the client is reassessed by the healthcare provider.

Check fit of oxygen mask. Explanation: The fit of the oxygen mask can be affected by the discontinuation of wearing dentures. The nurse should check the fit to make sure the client is getting the prescribed amount of oxygen. Other answers are inappropriate actions that do not address the problem.

A nurse is percussing the thorax of a client with chronic emphysema. What percussion sound would most likely be assessed? A. Flat B. Hyperresonance C. Resonance D. Tympany

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

A physician has ordered an arterial blood gas test for a client with a respiratory disorder. What is the most common role of the nurse in performing the arterial blood gas test? A. Perform the arterial puncture to obtain the specimen. B. Implement measures to prevent complications after arterial puncture. C. Measure the partial pressure of oxygen dissolved in plasma. D. Measure the percentage of hemoglobin saturated with oxygen.

Implement measures to prevent complications after arterial puncture. Explanation: During the arterial blood gas test, the nurse should implement measures to prevent complications after the arterial puncture. The nurse would not be involved in measuring the partial pressure of oxygen dissolved in plasma or the percentage of hemoglobin saturated with oxygen. Intensive care nurses commonly obtain arterial blood gases.

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered? A. Simple oxygen mask B. Partial rebreather mask C. Nasal cannula D. Venturi mask

Nasal cannula Explanation: Nasal cannula and tubing administers oxygen concentrations at 22% to 44%.

The nurse observes that the client's pulse oximetry is 89%. What is the priority nursing action? You Selected:Report pulse oximetry to the healthcare provider.

Perform respiratory assessment. Explanation: As the nurse enters the room the respiratory assessment immediately begins by visualizing client skin color, observing chest symmetry, vocalization, and auditory adventitious lung sounds. The nurse can then proceed to check the placement of the pulse oximeter, report findings to the healthcare provider and document.

While auscultating a client's chest, the nurse auscultates crackles in the lower lung bases. What condition does the nurse identify the client is experiencing? A. Inflammation of pleural surfaces B. Presence of fluid in the lungs C. Air passing through narrowed airways D. Presence of sputum in the trachea

Presence of sputum in the trachea Explanation: Coarse crackles heard on auscultation indicate the presence of sputum in the airways. Rales indicate presence of fluids in the lungs. Air passing through narrowed airways produces a wheezing sound, whereas inflammation of pleural surfaces gives rise to pleural rub.

A client with Type II diabetes has come for an annual wellness check-up with the healthcare provider. Which vaccine will the nurse discuss with the client?

Prevnar 13 ® Explanation: Clients over the age of 65 years old or those who have a compromising chronic health condition should be offered Prevnar 13 ®, which reduces strains of streptococcal pnuemoniae. Other options are not appropriate for the scenario.

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. Thoracentesis B. Pulse oximetry C. Peak expiratory flow rate D. Spirometry

Pulse oximetry Explanation: 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.

A nurse is preparing to use a wall unit to suction an endotracheal tube. At what pressure should the suction be set?

You Selected: 60 to 80 mm Hg Correct response: 80 to 150 mm Hg Explanation: When utilizing a wall unit to suction an endotracheal tube, the pressure should be set at 80 to 150 mm Hg. This level will provide enough pressure to suction out secretions from the endotracheal

The nurse assessing a client with chronic obstructive pulmonary disease (COPD) suspects chronic hypoxia based on which assessment finding?

You Selected: Cyanosis Clubbing fingers Correct response: Clubbing fingers Explanation: The effects of chronic hypoxia can be detected in all body systems and are manifested as altered thought processes, headaches, chest pain, enlarged heart, clubbing of the fingers and toes, anorexia, constipation, decreased urinary output, decreased libido, weakness of extremity muscles, and muscle pain. Cyanosis is a symptom of acute hypoxia.

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of: A. bronchospasm. B. croup. C. epiglottitis. D. atelectasis.

atelectasis. Explanation: Stiffer lungs tend to collapse and also cause their alveoli to collapse. This condition is called atelectasis.

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: A. rales. B. wheezes. C. vesicular. D. crackles.

crackles. Explanation: A coarse crackle is a low-pitched, rumbling sound in airways. When they are coarse and loud and occur with severe dyspnea, crackles may be a telling sign of pulmonary fibrosis, congestive heart failure, and pulmonary edema.

Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways? A. increases carbon dioxide, B. which stimulates breathing teaches him to prolong inspiration and shorten expiration C. decreases the amount of air trapping and resistance D. helps liquefy his secretions

decreases the amount of air trapping and resistance Explanation: Exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration, which prevents air from being trapped in the alveoli and decreases resistance to exhalation. Increasing carbon dioxide levels to stimulate breathing is the natural stimulus for a person without COPD to breathe. Prolonging inspiration and shortening expiration does not assist the client because exhalation is difficult for the COPD client. Humidification and fluid intake help to liquefy secretions.

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client? A. Simple mask B. Nasal cannula C. Face tent D. Non-rebreather mask

Nasal cannula Explanation: The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Non-rebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? A. "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." B. "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling." C. "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." D. "Take in a small amount of air very quickly and then exhale as quickly as possible."

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Explanation: Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.

A healthcare provider has ordered oxygen to be delivered at 8 L/minute for a client who does not have a tracheostomy. Which oxygen delivery device will the nurse consider using? Select all that apply. A. non-rebreather mask B. partial rebreather mask C. nasal cannula D. t-piece E. simple mask F. venturi mask

-partial rebreather mask -non-rebreather mask Explanation: A partial rebreather mask and a non-rebreather mask will accommodate administration of 6-10 L/minute of oxygen delivery. The nasal cannula, simple mask, and venture do not accommodate administration of 8 L/minute. The client does not have a tracheostomy so a T-piece is inappropriate.

A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client? A. Nasal cannula B. Ambu bag C. Oxygen tent D. Oxygen mask

Ambu bag Explanation: If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Oxygen masks may cover only the nose and mouth and can vary in the amount of oxygen delivered. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostril. An oxygen tent is a tentlike enclosure within which the air supply can be enriched with oxygen to aid a client's breathing. Oxygen masks, nasal cannula, and oxygen tents are used for clients who have a respiratory drive.

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? A. Hematocrit values B. Arterial blood gas C. Hemoglobin levels D. Pulmonary function

Arterial blood gas Explanation: Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.

Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound? A. Vesicular B. Bronchial C. Bronchovesicular D. Adventitious

Bronchial Explanation: Bronchial breath sounds are loud, high-pitched sounds heard primarily over the trachea and larynx. Vesicular breath sounds are low-pitched, soft sounds heard over the peripheral lung fields. Bronchovesicular breath sounds are medium-pitched blowing sounds heard over the major bronchi. Vesicular, bronchial, and bronchovesicular breath sounds are normal breath sounds. Adventitious breath sounds are abnormal lung sounds.

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe? A. Wheezing in the upper lobes B. Expiratory stridor C. Crackles in the lower lobes D. Inspiratory stridor

Crackles in the lower lobes Explanation: People with chronic congestive heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels. Stridor is associated with respiratory infections such as croup. Wheezing may be heard in individuals who use tobacco products.

A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determines that the education was successful when the students identify which activity as occurring during inspiration? A. Chest pressure increases. B. Thorax size reduces. C. Air flows out of the lungs. D. Intercostal muscles contract.

Intercostal muscles contract. Explanation: During inspiration, the diaphragm and external intercostal muscles contract. Their contraction enlarges the thorax volume and decreases intrathoracic pressure. The expanding chest wall pulls the lungs outward. As the lungs expand, pressure drops within the airways. During exhalation, the diaphragm and intercostal muscles relax, causing the thorax to return to its smaller resting size. During exhalation, the pressure in the chest increases, allowing air to flow out of the lungs.

The nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FIO2 of 100%. Which oxygen delivery system should the nurse utilize? A. Simple mask B. Non-rebreather mask C. Venturi mask D. Nasal cannula

Non-rebreather mask Explanation: A non-rebreather mask is the only device that can deliver FIO2 of 100% to a client without a controlled airway. A Venturi mask delivers a maximum FIO2 of 55%. A nasal cannula delivers a maximum FIO2 of 44%. A simple mask delivers a maximum FIO2 of 60%.

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? A. Pneumonia B. Tachypnea C. Wheezes D. Pleural effusion

Pleural effusion Explanation: 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.

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 A. Anemia B. Congestive heart failure C. Malnutrition D. Poor tissue perfusion

Poor tissue perfusion Explanation: Chronically poor perfusion may result in hair loss in the affected area, discolored skin, thickened nails, and shiny, dry skin indicative of inadequate tissue nutrition.

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? A. They are soft, high-pitched discontinuous (intermittent) popping lung sounds. B. They are low-pitched, soft sounds heard over peripheral lung fields. C. They are loud, high-pitched sounds heard primarily over the trachea and larynx. D. They are medium-pitched blowing sounds heard over the major bronchi.

They are low-pitched, soft sounds heard over peripheral lung fields. Explanation: Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds. Reference:

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. mineral oil B. tap water C. distilled water D. normal saline

distilled water Explanation: Distilled water is used when humidification is desired. Other answers are incorrect.

The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal? A. vesicular breath sounds audible over peripheral lung fields B. resonance on percussion of lung fields C. fine crackles to the bases of the lungs bilaterally D. respiratory rate of 18 breaths per minute

fine crackles to the bases of the lungs bilaterally Explanation: Except in the case of infants, fine crackles always constitute an abnormal assessment finding. A respiratory rate of 18 is within acceptable range. Vesicular sounds over peripheral lung fields and resonance on percussion are expected assessment findings.

The nurse is preparing to provide hygiene care to a client with hypoxia. Into what position will the nurse place the client? A. Trendelenburg B. prone C. high Fowlers D. supine

high Fowlers Explanation: High Fowlers position allows the client with hypoxia to breathe easier. This promotes lung expansion because the abdominal organs descend away from the diaphragm. Other answers are incorrect.

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position? A. high-Fowler's position left side with a pillow under the chest wall B. Trendelenburg position C. side-lying position, D. half on the abdomen and half on the side

high-Fowler's position Explanation: Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. High-Fowler's position is used to drain the apical sections of the upper lobes of the lungs. Placing the client lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.

The nurse is caring for a client who will be wearing a simple mask for oxygen delivery. What planning regarding the mask will the nurse include in the plan of care?

may cause anxiety in client with claustrophobia Explanation: A simple mask may cause anxiety in clients with claustrophobia. The simple mask provides 5-8 L/min of oxygen administration. It does not create a risk for oxygen toxicity, nor will it be used for a client with a tracheostomy.

A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of: A. asthma. B. pneumonia. C. alcohol abuse. D. croup.

pneumonia. Explanation: Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol abuse do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol abuse depresses the central respiratory center.

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 sit of tube insertion B. respirations are at 20 breaths per minute C. drainage system is positioned slightly above chest level D. dressing is moist and intact

respirations are at 20 breaths per minute Explanation: Respirations of 20 breaths per minute indicate that the tube is functioning correctly. Other findings require nursing intervention.

The nurse is caring for a client with a nonhealing wound who has been prescribed hyperbaric oxygen therapy (HBOT). When the client asks, "How will this help me?" what is the appropriate nursing response? A. "HBOT treats aerobic infections." B. "Wounds heal because HBOT helps to regenerate new tissue quickly." C. "It will help you breathe much easier, and feel better." D. "You will be treated for decompression sickness."

"Wounds heal because HBOT helps to regenerate new tissue quickly." Explanation: Although HBOT treats a multitude of conditions, the reason for using HBOT for a nonhealing wound is to help regenerate new tissue quickly. HBOT is used to treat anaerobic infections. The other responses are inappropriate. Reference:

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? A. 12 L/min oxygen via nonrebreather mask B. 8 L/min oxygen via nasal cannula 1 C. 0 L/min oxygen via Venturi mask D. 8 L/min oxygen via partial rebreather mask

8 L/min oxygen via nasal cannula Explanation: 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. However, per nasal cannula it may be no more than 2-3 L/min to for a client with chronic lung disease.

Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body? A. Pancreatitis B. Parkinson's disease C. Chronic anemia D. Graves' disease

Chronic anemia Explanation: The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the amount of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissues of the body. Graves' disease, Parkinson's disease, and pancreatitis do not directly lead to a decrease in the number of red blood cells. Graves' disease is an immune system disorder that results in the overproduction of thyroid hormones (hyperthyroidism). Parkinson's disease (PD) is a neurodegenerative disorder that affects predominately dopamine-producing ("dopaminergic") neurons in a specific area of the brain called substantia nigra that causes a movement disorder. Pancreatitis is inflammation in the pancreas.

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? A. Nasal strip B. Flow meter C. Nasal cannula D. Oxygen analyzer

Flow meter Explanation: The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.

The nurse is preparing to educate a client on how to perform incentive spirometry. Which concepts should the nurse include? A. The client should forcefully exhale into the incentive spirometer and continue to exhale until unable to continue. B. Decrease of oxygen saturation is expected during the first few minutes of incentive spirometry. C. Proper, frequent use of incentive spirometry can improve pulmonary circulation. D. Incentive spirometry provides visual reinforcement of deep breathing.

Incentive spirometry provides visual reinforcement of deep breathing. Explanation: Incentive spirometry is used to enhance inspiratory effort. The client inhales slowly and deeply from the incentive spirometer which increases the lung capacity. There is an initial increase in the oxygen saturation during incentive spirometry. Incentive spirometer increases the exchange of oxygen and carbon dioxide but does not influence pulmonary circulation.

The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is: A. Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter. B. Hypoxia related to pneumonia and ineffective airway clearance related to dyspnea edema. C. Impaired Gas Exchange related to increased carbon dioxide and irritability. D. Risk for Ineffective Airway Clearance related to infection as evidenced by dyspnea and yellow- green sputum.

Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter. Explanation: Ineffective breathing pattern is the state in which a person's inspiration and/or expiration pattern does not provide adequate ventilation.

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? A. Metered-dose inhaler with spacer B. Metered-dose inhaler without spacer C. Nebulizer D. Dry powder inhaler

Metered-dose inhaler with spacer Correct response: Nebulizer Explanation: Inhalers differ in the amount of dexterity required in order to deliver an accurate dose, but each requires some degree of coordinated activity and the ability to follow directions on the part of the client. For a client with decreased cognition, a nebulizer may be more appropriate because the client passively inhales the entire dose. A dry powder inhaler is initiated by inhalation and requires an ability to follow directions and keep the mouth around the port. If the client cannot follow directions then only the nebulizer is appropriate.

The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign? A. Urinary intake and output B. Apical pulse C. Respiratory rate and depth D. Orthostatic blood pressure

Respiratory rate and depth Explanation: The client receiving narcotics/opioids needs monitoring of the respiratory rate and depth to ensure that respiratory depression does not result in progressive respiratory issues, physiologic damage from respiratory depression, or loss of consciousness. The pulse, blood pressure, and urinary intake and output are not as important as respiratory status when administering narcotics.

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? A. clubbing of fingers B. SpO2 92% C. respirations 26 breaths/minute D. heart rate 110 beats/minute

SpO2 92% Explanation: An SpO2 at or above 90% is normal, reflecting that oxygen therapy is being effective. Clubbing, respirations greater than 26 breaths/minute, and a heart rate greater than 100 beat per minute may indicate that more oxygen is needed.

A new graduate nurse is performing a focused respiratory assessment. The nurse preceptor will intervene if which action by the graduate nurse is noted? A. The graduate nurse palpates the point of maximal impulse (PMI). B. The graduate nurse explains the assessment procedure before performing it. C. The graduate nurse attaches a pulse oximeter to the client's index finger. D. The graduate nurse auscultates breath sounds as the client breathes through the nose.

The graduate nurse auscultates breath sounds as the client breathes through the nose. Explanation: Breath sounds should be auscultated while the client breathes slowly through an open mouth; nose breathing may produce false breath sounds. Explanation before procedures helps reduce a client's anxiety. Palpation of the PMI and attaching the pulse oximeter are included in the respiratory assessment.

The nurse is performing an arterial blood gas sampling on a client at 10:45. The nurse educator intervenes if which action is taken by the nurse? A. The nurse immediately places the arterial specimen on ice. B. The nurse performs the Allen test after blood sample is taken. C. The nurse selects the radial artery as choice of site. D. The nurse stops holding pressure at 10:55.

The nurse performs the Allen test after blood sample is taken. Explanation: The Allen test is done before puncture to ensure adequate ulnar blood flow when using the radial artery. The arterial specimen is immediately placed on ice and taken to the laboratory. The radial, brachial, or femoral arteries are usually the sites of choice for an arterial blood sampling. The nurse should apply pressure for 5 to 10 minutes, longer if the client is on anticoagulant therapy.

A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determines that the education was successful when the students identify which activity as occurring during inspiration?

You Selected: Chest pressure increases. Correct response: Intercostal muscles contract. Explanation: During inspiration, the diaphragm and external intercostal muscles contract. Their contraction enlarges the thorax volume and decreases intrathoracic pressure. The expanding chest wall pulls the lungs outward. As the lungs expand, pressure drops within the airways. During exhalation, the diaphragm and intercostal muscles relax, causing the thorax to return to its smaller resting size. During exhalation, the pressure in the chest increases, allowing air to flow out of the lungs.

The nurse is caring for a client with respiratory alkalosis. Which arterial blood gas data does the nurse anticipate finding? A. pH less than 7.35; HCO3 low; PaCO2 low B. pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation C. pH greater than 7.45; HCO3 high; PaCO2 high D. pH less than 7.35; HCO3 high; PaCO2 high

You Selected: pH less than 7.35; HCO3 low; PaCO2 low Correct response: pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation Explanation: In respiratory alkalosis, anticipated arterial blood gas results are anticipated to reflect pH greater than 7.45; HCO3 low; and PaCO2 low. Other answers are incorrect.

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system? A. an older adult client who has COPD B. a child who has pneumonia C. an adult who is receiving oxygen at home D. an adolescent who has asthma

a child who has pneumonia Explanation: An oxygen tent is commonly used with children who need a cool and highly humidified airflow. It is also more effective for children because they often do not like to keep oxygen administration devices in place. Since the tent does not allow the maintenance of a satisfactory or precise oxygen concentration, is difficult to maintain a consistent level of oxygen. The oxygen tent does not adequately deliver oxygen at a rate higher than 30% to 50%; thus, it is rarely used with other clients.

The nurse is caring for a client with respiratory acidosis. Which arterial blood gas data does the nurse anticipate finding? A. pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation B. pH greater than 7.45; HCO3 high; PaCO2 high C. pH less than 7.35; HCO3 low; PaCO2 low D. pH less than 7.35; HCO3 high; PaCO2 high

pH less than 7.35; HCO3 high; PaCO2 high Explanation: In respiratory acidosis, anticipated arterial blood gas results are anticipated to reflect pH less than 7.35; HCO3 high; and PaCO2 high. Other answers are incorrect.

The nurse is caring for a client who was 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. nasal cannula B. simple mask C. face tent D. tracheostomy collar

tracheostomy collar Explanation: 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.

The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach? A. "Take in as much air as possible, hold your breath briefly, and exhale slowly." B. "Take in a little air, hold your breath 15 seconds, and exhale slowly." C. "Take in a large volume of air and hold your breath as long as you can." D. "Take in a small amount of air and exhale quickly."

"Take in as much air as possible, hold your breath briefly, and exhale slowly." Explanation: This technique maximizes ventilation taking in a large volume of air fills alveoli to a greater capacity, which improves gas exchange. Deep breathing is useful for client's who has been inactive or in pain as associated with pneumonia. The other techniques do not promote improved gas exchange.

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom? A. Mental alertness B. Weight loss C. Rapid respirations D. Increased urine output

Rapid respirations Explanation: Normal cardiac output averages from 3.5 L/minute to 8.0 L/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 respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order? A. Tidal volume (TV) B. Total lung capacity (TLC) C. Forced Expiratory Volume (FEV) D. Residual Volume (RV)

Residual Volume (RV) Explanation: During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding? A. The skin at the thorax should be cool and moist. B. The chest should be slightly convex with no sternal depression. C. The anteroposterior diameter should be greater than the transverse diameter. D. The contour of the intercostal spaces should be rounded.

The chest should be slightly convex with no sternal depression. Explanation: The adult chest contour is slightly convex, with no sternal depression. The skin of the thorax should be warm and dry, and the anteroposterior diameter of the chest should be less than the transverse diameter. The contour of the intercostal spaces should be flat or depressed.

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. Bronchovesicular C. Crackles D. Bronchial

Vesicular Explanation: 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.

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. bronchiectasis. B. a bronchospasm. C. bronchitis. D. bronchiolitis.

a bronchospasm. Explanation: 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.

A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for: A. atelectasis. B. hemothorax. C. pneumothorax. D. tachypnea.

atelectasis. Explanation: Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize atelectasis. Immobility is not commonly implicated in cases of pneumothorax or hemothorax. A pneumothorax is a collapsed lung. Hemothorax is a collection of blood in the space between the chest wall and the lung. Tachypnea, if present, would likely be a sign of atelectasis rather than an independent finding.

The nurse is demonstrating oxygen administration to a client. What teaching will the nurse include about the flowmeter? A. "This is a gauge used to regulate the amount of oxygen that a client receives." B. "The flowmeter prescribes the concentration of oxygen." C. "Small water droplets come from this, thus preventing dry mucous membranes." D. "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed."

"This is a gauge used to regulate the amount of oxygen that a client receives." Explanation: The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The humidifier produces small water droplets, which are delivered during oxygen administration to prevent or decrease dry mucous membranes.

The charge nurse is observing a new nurse care for a client who is receiving oxygen via a simple mask with an FIO2 of 40%. The client states, "This moisture on my face is bothersome. Can something be done about it?" Which response by the new nurse would require clarification by the charge nurse? A. "Your mask should remain on, but I will help you dry your face when it becomes too wet." B. "After I dry your face, I can apply powder to absorb the moisture and protect your skin." C. "I will confer with your primary care provider to find out if a nasal cannula can be used." D. "The mask and its moisture can be bothersome, so let me demonstrate some distraction techniques to help you cope with them."

"After I dry your face, I can apply powder to absorb the moisture and protect your skin." Explanation: The new nurse should be corrected by the charge nurse to not apply powder to the face to absorb the moisture. Applying powder can accidentally be inhaled and cause a inhalation issue. Drying the face when the moisture becomes too wet is an appropriate response. The new nurse should attempt to change the simple mask to a nasal cannula if allowed. Teaching the client about distraction techniques is also appropriate.

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? A. "Breathing through your nose first will warm, filter, and humidify the air you are breathing." B. "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." C. "If you breathe through the mouth first, you will swallow germs into your stomach." D. "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." Explanation: 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.

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

"It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." Explanation: 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 healthcare provider prescribed the concentration of oxygen. The humidifier produces small water droplets, which are delivered during oxygen administration to prevent or decrease dry mucous membranes. Reference:

The obstetric nurse is assisting the birth of a preterm neonate. In preparing for the respiratory needs of the neonate, the nurse is aware that surfactant is formed in utero around: A. 30 to 32 weeks. B. 36 to 38 weeks. C. 32 to 34 weeks. D. 34 to 36 weeks.

34 to 36 weeks. Explanation: Surfactant is formed in utero around 34 to 36 weeks. An infant born prior to 34 weeks may not have sufficient surfactant produced, leading to collapse of the alveoli and poor alveolar exchange. Synthetic surfactant can be given to the infant to help reopen the alveoli.

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client 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 Explanation: In general, if a flow rate of 6 L/minute fails to raise a client's oxygen saturation level satisfactorily, a mask should be used. 1-4 L/minute flow rates per nasal cannula are standard flow rates. Greater than 6 L/minute flow rate per nasal cannula is very uncomfortable for the client. A flow rate of 10 L /minute per nasal cannula is not acceptable.

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? A. Hyperactivity B. Confusion C. Decreased blood pressure D. Decreased respiratory rate

Confusion Explanation: Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue? A. Corticosteroids B. Bronchodilators C. Antibiotics D. Expectorants

Corticosteroids Explanation: In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation.

The nurse educator would intervene with client teaching if which action by the staff nurse occurs when teaching voluntary coughing? A. The nurse has the client lying in bed in semi-Fowler's position. B. The nurse encourages the client to cough before meals. C. The nurse develops a specific schedule for coughing. D. The nurse reminds the client to combine coughing and deep breathing.

The nurse has the client lying in bed in semi-Fowler's position. Explanation: The client should be sitting upright with feet flat on the floor to be most effective. As part of the client's plan of care, the nurse should develop a specific schedule for coughing. Coughing before meals improves the taste of food and oxygenation. When combined with deep breathing, coughing is most effective.

What assessments would a nurse make when auscultating the lungs?

You Selected: presence of edema Correct response: cardiovascular function Explanation: If cardiovascular function is not adequate, the results will lead to impaired oxygenation; therefore, it is important to assess cardiovascular function when assessing respiratory function. Both systems work in conjunction with each other, and the proximity of lung auscultation lends itself to assessment of cardiovascular function. Abnormal chest structures would be assessed when inspecting the chest and thoracic region. Presence of edema would be assessed as part of the cardiovascular status of the client. Volume of air exhaled and inhaled would be performed during a pulmonary function test.

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? A. prevention of suctioning B. loss of sterile field C. trauma to the tracheal mucosa D. suctioning of carbon dioxide

trauma to the tracheal mucosa Explanation: Occluding the Y-port on the suction tubing is what creates the suction. While suctioning would be difficult but possible, suctioning while advancing the tube would damage the tracheal mucosa and remove excessive amounts of oxygen, not carbon dioxide, from the respiratory tract. Suctioning during insertion of the catheter would not compromise sterility.

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? A. "If the client's stroke volume is 80 mL and heart rate is 80 beats per minute, then the cardiac output is 6.0 L/minute." B. "If the client's stroke volume is 60 mL and heart rate is 60 beats per minute, then the cardiac output is 3.2 L/minute." C. "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." D. "If the client's stroke volume is 70 mL and heart rate is 70 beats per minute, then the cardiac output is 4.7 L/minute."

"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." Explanation: The following formula is used to determine cardiac output: Cardiac Output = Stroke Volume x Heart Rate. A client with a stroke volume of 50 mL and heart rate of 50 beats per minute has a cardiac output of 2.5 L/minute. If stroke volume is 70 and heart rate is 70 beats per minute, then the cardiac output is 4.9 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute.

The nurse is caring for a client with emphysema. A review of the client's chart reveals pH 7.36, PaO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription if prescribed by the health care practitioner? A. 4 L/minute O2 (66 mL/second) nasal cannula B. Pulse oximetry C. High-Fowler's position D. Increase fluid intake to 3 L/day (3000 mL/day)

4 L/minute O2 (66 mL/second) nasal cannula Explanation: The client with chronic lung disease, such as emphysema, becomes insensitive to carbon dioxide and responds to hypoxia to stimulate breathing. If given excessive oxygen (4 L/minute or 66 mL/second), the stimulus to breathe is removed. Clients with emphysema are most comfortable in high Fowler's position because it aids in the use of the accessory muscles to promote respirations. Increasing fluid intake helps keep the client's secretions thin. Pulse oximetry monitors the client's arterial oxyhemoglobin saturation while receiving oxygen therapy.

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. Perfusion B. Hypoxia C. Hyperventilation D. Atelectasis

Hypoxia Explanation: 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.

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

It regulates the amount of oxygen received. Explanation: The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The oxygen analyzer measures the percentage of delivered oxygen. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test? A. Monitor the pressure of oxygen dissolved in plasma. B. Calculate the pressure of carbon dioxide dissolved in plasma. C. Monitor the amount of oxygen saturation in the blood. D. Measure the volume of air exhaled or inhaled over time.

Monitor the amount of oxygen saturation in the blood. Explanation: The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. The arterial blood gases test the client's blood for the partial pressure of oxygen dissolved in plasma, the percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma. Spirometry measures the volume of air in liters exhaled or inhaled by a client over time.

A client with no prior history of respiratory illness has been admitted to a postoperative 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? A. educating the client on pursed-lip breathing techniques B. oropharyngeal suctioning twice daily C. administration of inhaled corticosteroids D. educating the client on the use of incentive spirometry

educating the client on the use of incentive spirometry Explanation: Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the 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: A. age. B. blood pH. C. sodium and potassium levels. D. hemoglobin level.

hemoglobin level. Explanation: 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.

What structural changes to the respiratory system should a nurse observe when caring for older adults? A. increased mouth breathing and snoring B. diminished coughing and gag reflexes C. increased use of accessory muscles for breathing D. respiratory muscles become weaker

respiratory muscles become weaker Explanation: One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker. The nurse should also observe other structural changes: the chest wall becomes stiffer as a result of calcification of the intercostals cartilage, kyphoscoliosis, and arthritic changes to costovertebral joints; the ribs and vertebrae lose calcium; the lungs become smaller and less elastic; alveoli enlarge; and alveolar walls become thinner. Diminished coughing and gag reflexes, increased use of accessory muscles for breathing, and increased mouth breathing and snoring are functional changes to the respiratory system in older