Taylors Fundamentals PrepU Ch. 40 Oxygenation and Perfusion

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." "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." "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.

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

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

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? "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." "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." "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling."

"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.

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? "Did you remove your dentures?" "Is your mask causing discomfort?" "Did someone take your mask off?" "Did someone loosen the straps on your mask?"

"Is your mask causing discomfort?" Explanation: It is possible for anyone using a mask to try and readjust it if it is uncomfortable. Depending on the older adult's cognitive status, he or she may have tried to make it more comfortable and in the process caused it to no longer fit correctly. This could also occur if the client removed their dentures, as some individual's choose to let the dentures soak overnight. If the mask was fitted with the dentures in, the mask will likely be loose with the dentures removed. The other questions could possibly be asked to see if someone else may have tried to help the client feel more comfortable with the mask on.

A nurse assesses the vital signs of a healthy newborn. What respiratory rate could be expected based on the developmental level of this client? 15 to 25 breaths/min 16 to 20 breaths/min 20 to 40 breaths/min 30 to 60 breaths/min

30 to 60 breaths/min Explanation: The normal range for a newborn through 1 year is 30 to 60 breaths/min. Normal respiratory rate for adults is 14 to 20 breaths/min. Other normal age-related variations in respiratory rates are: Toddler/preschooler (1 to 5 years): 20 to 40 breaths/min; school-age child (6 to 12 years): 15 to 25 breaths/min; and older adult (65+ years): 16 to 24 breaths/min.

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? Oxygen mask Nasal cannula Ambu bag Oxygen tent

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.

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

Apply oxygen as prescribed Explanation: 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 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 lung sounds Reposition client Elevate head of the bed Assess oxygen tubing connection

Assess oxygen tubing connection Explanation: If the client suddenly becomes cyanotic, the nurse should assess the oxygen tubing to make sure it is still connected. Assessing lung sounds, repositioning the client, and elevating the head of the bed will not correct the problem if the tubing is disconnected.

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which instruction will the nurse include in the teaching? Inhale through the nose instead of the mouth. Be sure to shake the canister before using it. Inhale the medication rapidly. Inhale two sprays with one breath for faster action.

Be sure to shake the canister before using it. Explanation: A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly. MDIs are inhaled through the mouth and into the lungs. The medication should be inhaled slowly to ensure a sufficient dose enters the lungs. If the order is for two sprays, these sprays are administered with one spray for each breath. The inhaled breath should be held briefly after each spray in order to prevent the client from immediately exhaling the medication.

A nurse is providing care in an area which is plagued by high levels of air pollutants from industry and motor vehicles. The nurse will expect a high incidence and prevalence of what respiratory disease? Atelectasis Bronchitis Bronchiectasis Croup

Bronchitis Explanation: Bronchitis refers to a condition in which the airways become inflamed, commonly due to respiratory irritants such as air pollution and high humidity. Exposure to such irritants leads to the release of inflammatory mediators, which in turn, lead to inflammation and narrowing of the airways and increased mucus production. Atelectasis refers to the partial or complete collapse of the small air sacs in the lungs, common after surgery or with obstruction or compression of the airways or lungs. Bronchiectasis results from chronic inflammation or infection causing an excess accumulation of mucus. Croup is an infection of the airways, most commonly viral in origin.

The nurse is assessing a client with lung cancer who has been receiving treatment for many months. What manifestations may suggest that the client has chronic hypoxia? Edema Hemoptysis Yellow or green sputum Clubbing

Clubbing Explanation: 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 discolored sputum do not result from hypoxia.

The client demonstrates soft, high-pitched, discontinuous sounds in the left lower lobe of the lung. How will the nurse accurately document this finding? Crackles Vesicular Wheezes Bronchial

Crackles Explanation: Crackles are soft, high-pitched, discontinuous sounds. Wheezes are a whistling or rattling sound in the chest as a result of obstruction in the air passages. Vesicular breath sounds are heard across the lung surface. Bronchial sounds are loud, high-pitched sounds heard primarily over the trachea and larynx.

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

Document this expected assessment finding. Explanation: 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.

An older adult client visits a health care facility for a scheduled physical assessment. During the assessment, the client reports difficulty breathing. Which suggestion could the nurse make to improve the client's respiratory function? Avoid strenuous exercises. Use a nasal strip. Drink liberal amounts of fluids. Receive annual immunizations.

Drink liberal amounts of fluids. Explanation: The nurse could suggest liberal fluid intake for the client in order to improve respiratory function. Older adults need encouragement to maintain liberal fluid intake, which keeps the mucous membranes moist. Unless contraindicated, the nurse should encourage the client to engage in regular exercise to maintain optimal respiratory function. A nasal strip reduces airflow resistance by widening the nasal breathing passageway, thus promoting easier breathing. An older adult may or may not use a nasal strip to improve respiratory function. The nurse should advise older adults to receive annual influenza immunizations and a pneumonia immunization after 65 years of age or earlier if there is a history of chronic illness.

The nurse is caring for a client with emphysema who has been prescribed portable oxygen, 2 L/min. Which action(s) does the nurse take to administer low concentrations of oxygen to the client? Select all that apply. Ensure that the oxygen concentrator is turned on Confirm that the nasal cannula is worn properly by the client Verify the oxygen concentrator is set on the prescribed flow rate Place the finger at the nasal cannula outlet to feel for the flow of oxygen Place the outlet of nasal cannula into a glass of water to ensure the flow of oxygen

Ensure that the oxygen concentrator is turned on Confirm that the nasal cannula is worn properly by the client Verify the oxygen concentrator is set on the prescribed flow rate Explanation: The actions the nurse takes to deliver low concentrations of oxygen to the client include ensuring that the oxygen concentrator is turned on, confirming that the nasal cannula is worn properly by the client, and verifying that the oxygen concentrator is set on the prescribed flow rate. The nurse cannot rely on verifying that the flow of oxygen is felt with the finger from the nasal cannula outlet because, at 2 L/minute, it may be challenging to feel the flow of oxygen. Placing the cannula outlet in a glass of water to verify the flow by observing the water bubbling is not a standard of practice.

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? Hyperventilation Hypoxia Perfusion 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.

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

Instruct the client to inhale deeply and then cough. Explanation: 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 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 regulates the amount of oxygen received. It determines whether you are getting enough oxygen. It decreases dry mucous membranes by delivering small water droplets.

It decreases dry mucous membranes by delivering small water droplets. Explanation: The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flow meter is a gauge used to regulate the amount of oxygen that a client receives. The health care provider prescribes concentration.

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. Watch for increased wheezing or signs of a flare-up. Take advantage of pulmonary rehabilitation programs. Follow health care provider's prescription for oxygen administration. Create a long-term caregiving plan.

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

The nurse is monitoring a client who is receiving oxygen via a nonrebreather mask at 12 L/min. What actions by the nurse will promote the best outcomes for this client? Select all that apply. Maintain flow rate so that the reservoir bag collapses only slightly during inspiration. Use petroleum jelly around the nose and mouth to prevent the drying effects from the oxygen. Take the mask off frequently to allow the client to have rest periods. Check that the valves and rubber flaps are functioning properly. Monitor SaO2 with pulse oximeter.

Maintain flow rate so that the reservoir bag collapses only slightly during inspiration. Check that the valves and rubber flaps are functioning properly. Monitor SaO2 with pulse oximeter. Explanation: The use of a nonrebreather mask will deliver a low-flow administration of oxygen between 10 to 15 L/min. The flow rate should be maintained so that the reservoir bag only collapses slightly during inspiration. Petroleum jelly products should never be used around oxygen as they may be an accelerant during a spark or fire. The client should wear the mask at all times unless prescribed by the health care provider. Be sure that all valves and rubber flaps are functioning properly so that oxygen delivery will not be interrupted. The oxygen saturation should be monitored with pulse oximetry to be sure that the present therapy is having the desired effect and adjustments may be required in the flow rate or delivery system.

A nurse is overseeing the care of a client who is receiving oxygen via nasal cannula. Which aspects of the client's care can the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply. Auscultating the client's lungs to determine the effectiveness of treatment Measuring the client's respiratory rate Inserting the client's nasal cannula after it has become dislodged Increasing the flow rate of the client's oxygen when the client is short of breath Reapplying the client's nasal cannula after a bath

Measuring the client's respiratory rate Inserting the client's nasal cannula after it has become dislodged Reapplying the client's nasal cannula after a bath Explanation: Reapplication of the nasal cannula during nursing care activities, such as during bathing, may be performed by UAP. UAP may measure a client's respiratory rate in the context of measuring the client's vital signs. Chest auscultation and changes to oxygen delivery are beyond the scope of UAP.

The nurse is caring for a client currently on a mechanical ventilator. What should the nurse determine when comparing arterial blood gas (ABG) results from the current day (4/27) with the results obtained 24 hours earlier (4/26)? Oxygenation is improving. Both results indicate within normal limits. The client can be weaned from the ventilator. The oxygen will be adjusted.

Oxygenation is improving. Explanation: This client is showing improvement over the 24-hour period. The first day showed slight hypoxemia while the second set is closer to being within normal limits. Only the PaCO2 is only slightly elevated. The most likely current treatment will continue as is. The decision to wean the client off the ventilator will be determined based on more factors in the client's overall condition. The health care provider may decide to adjust the flow rate depending on the client's overall condition. ABG normal results are pH 7.35-7.45, PaO2 80 to 100 mm Hg (10.64 to 13.30 kPa), PaCO2 35 to 45 mm Hg (4.66 to 5.99 kPa), SaO2 95% to 100% (0.95 to 1.0), and HCO3 22 to 26 mEq/l (22 to 36 mmol/l).

A client is taking albuterol via nebulizer. Which instruction will the nurse provide to teach the client how to use the nebulizer? Place the mouthpiece in your mouth. Breath in the medication then remove the mouthpiece to breathe the medicine out. Place the mouthpiece in your mouth. Intermittently breathe through your nose and mouth so that all of the medicine goes into your lungs Place the mouthpiece near your mouth. Inhale the medicine into your lungs. Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs.

Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs. Explanation: A nebulizer is used to administer medications in the form of an inhaled mist. The nurse will instruct the client to place the mouthpiece in the mouth, keep the lips firm around the mouthpiece so that all of the medicine goes into the lungs, and continue until the mist stops. Any other option allows for the medication to be lost, rather than inhaled into the lungs.

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

Pulmonary function tests Explanation: 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.

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

Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Explanation: 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.

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

Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Explanation: 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 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? clubbing of fingers respirations 26 breaths/minute heart rate 110 beats/minute SpO2 96%

SpO2 96% Explanation: An SpO2 at or above between 95% and 100% is normal, reflecting that oxygen therapy is being effective. Clubbing, respirations greater than 26 breaths/min, and a heart rate greater than 100 beats/min may indicate that more oxygen is needed.

The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care? Stay indoors as much as possible. Cut down on smoking. Avoid exposure to large crowds. Practice good hand hygiene.

Stay indoors as much as possible. Explanation: Using the air quality index, a red color designation signifies that the air quality is unhealthy for all people, not just sensitive groups. Air pollution and high humidity are respiratory irritants. Pollutants cause increased mucus production and contribute to bronchitis and asthma. Reducing contact with irritants by staying indoors during times of increased air pollution will decrease their effect on the respiratory system. Clients should be encouraged to quit smoking, not just cut down. Avoiding large crowds and practicing good hand hygiene will prevent respiratory infections but not cut down on the effect of air pollution.

What is the action of codeine when used to treat a cough? Antisuppressant Suppressant Antihistamine Expectorant

Suppressant Explanation: Codeine, which is an ingredient in many cough preparations, is generally considered to be the preferred cough suppressant ingredient.

A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate? The client's available hemoglobin is adequately saturated with oxygen. The client's oxygen demands are being met. The client's red blood cell (RBC) count is in the normal range. The client's respiratory rate is in the normal range.

The client's available hemoglobin is adequately saturated with oxygen. Explanation: 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.

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 Explanation: 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.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm. Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.

Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm. Explanation: Guidelines to determine suction catheter depth include the following: Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm past the length of the endotracheal tube. Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Using a spare endotracheal or tracheostomy tube of the same size as being used for the client, insert the suction catheter to the end of the tube and note the length of catheter used to reach the end of the tube. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm.

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? Crackles Bronchovesicular Bronchial Vesicular

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 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. Place the probe on the client's earlobe. Shine available light on the equipment to facilitate accurate reading. Use a blood pressure cuff to increase circulation to the site.

Warm the client's hands and try again. Explanation: Finding an absent or weak signal, the nurse should check vital signs and client condition. If satisfactory, warming the extremity may facilitate a stronger reading. This should be attempted prior to resorting to using the client's earlobe. Bright light can interfere with the operation of light sensors and cause an unreliable report. A blood pressure cuff will compromise venous blood flow to the site leading to inaccurate readings.

The nurse is caring for the following clients. Which client is at highest risk for a depressed respiratory system? a client taking amlodipine for hypertension a client taking methocarbamol for low back spasms a client taking methimazole for hyperthyroidism a client taking an opioid for cancer pain

a client taking an opioid for cancer pain Explanation: Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Amlodipine is a calcium channel blocker and the medication decreases blood pressure, so the nurse would need to assess blood pressure. Muscle relaxants such as methocarbamol could depress respiratory status, but this occurs less often than with opioids. Methimazole is used to treat hyperthyroidism, thus lowering the body's metabolic functions, which can depress respirations; however, this is a very rare occurrence with this medication. The client at highest risk is the one taking an opioid.

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: adequate tissue perfusion. diminished stroke volume. high cardiac output. heart failure.

adequate tissue perfusion. Explanation: Pulse oximetry is often used as a measure of tissue perfusion. An oxygen saturation of greater than 94% is typically indicative of good tissue perfusion.

What assessments would a nurse make when auscultating the lungs? air flow through the respiratory passages abnormal chest structures presence of edema volume of air exhaled or inhaled

air flow through the respiratory passages Explanation: Auscultation of the lungs assesses air flow through the respiratory passages and lungs. The nurse listens for normal, as well as abnormal, breath sounds. 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.

The nurse has received a prescription to obtain an arterial blood gas (ABG) on a client who has a history of chronic obstructive pulmonary disease (COPD) and is receiving oxygen via nasal cannula. Which step is the most important for the nurse to fulfill? ensure client is at rest at least 30 minutes before obtaining the specimen notify laboratory personnel of the prescription place the specimen in cold water after filling the tube apply pressure to the puncture site for at least 15 minutes after the puncture

ensure client is at rest at least 30 minutes before obtaining the specimen Explanation: Unless the procedure is an emergency, it is advisable for the client to be at rest at least 30 minutes prior to obtaining the specimen. The ABG represents the client status at the moment of sampling and activity can lower oxygen levels in the blood, which can lead to an incorrect interpretation of the results. Some facilities require laboratory personnel to obtain this sample which would require the nurse to notify the lab; however, with the current use of computers, they may already know and not need to be contacted. The specimen tube should be placed on ice for transport to the laboratory to help preserve the specimen as it slows metabolism and helps ensure accurate results. Manual pressure should be applied for 5 to 10 minutes after the puncture and followed with a pressure dressing to reduce the potential of arterial bleeding.

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? oxygen analyzer nasal strip nasal cannula flow meter

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 health care provider. 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.

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

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.

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? high temperature high respiratory rate low pulse rate 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.

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

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 applying a pulse oximeter to a client with bronchitis. Which factor(s) does the nurse communicate to the client that could interfere with accurate pulse oximetry? Select all that apply. nail polish thickness of nails acrylic nails respiratory rate peripheral vascular disease

nail polish thickness of nails acrylic nails peripheral vascular disease Explanation: If the client is wearing nail polish, has thick nails or is wearing acrylic nails, this will interfere with the probe detecting an accurate oxygen saturation. Peripheral vascular disease reduces or diminishes blood flow to fingers and toes. For these reasons, the nurse will need to determine a site to ensure monitor readings are accurate. Where circulation may be reduced or diminished, the pulse oximeter will not read well. The pulse oximeter reading will vary with the rate and depth that the respirations but should not be deemed inaccurate because of them. Instead, the nurse will be aware to note changes in the oxygen saturation based on changes in the respiratory rate. Brief, transient changes are not remarkable and do not require intervention.

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

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.

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? presence of sputum in the trachea presence of fluid in the lungs air passing through narrowed airways inflammation of pleural surfaces

presence of fluid in the lungs Explanation: Coarse crackles heard on auscultation indicate the presence of fluid in the lungs. Air passing through narrowed airways produces a wheezing sound, whereas inflammation of pleural surfaces gives rise to pleural rub. Sputum in the trachea produces stridor, a harsh, noisy squeak when something is blocking the airway.

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

rapid respirations Explanation: 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.

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? simple mask tracheostomy collar nasal cannula face tent

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.