Ch. 26: Respiratory PrepU
A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response?
"The caregiver will need to place the oxygen tank back into the secure carrier."
The health care provider has prescribed a long-acting bronchodilator for a client with a history of bronchospasm. What teaching about this drug will the nurse include?
"Use drug daily to prevent bronchospasm"
The nurse is teaching the family of a client with a tracheostomy about home care. Which family statement requires nursing intervention?
"We will remove the outer cannula for cleaning."
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?
"You should never smoke when oxygen is in use."
A nurse is administering a prescribed dose of IV medication to a client who is recovering from partial airway obstruction. What are common reasons for airway obstruction to occur? Select all that apply.
- compromised swallowing - aspiration of vomitus - insufficient chewing
The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal?
30 to 60 breaths per minute
A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?
Ask the client what factors contribute to nonadherence
A nurse working in a pediatric unit finds an infant unresponsive without respirations or a pulse. After calling for help, what is the nurse's most appropriate action?
Begin chest compressions
The nurse is caring for an older adult client who worked in a coal mine for 40 years. What assessment finding does the nurse anticipate?
Cough
The nurse is preparing to provide hygiene care to a client with hypoxia. Into what position will the nurse place the client?
High Fowlers
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 respiratory rate
A client has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy tube is removed for cleaning?
Inner cannula
A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention?
Inquire about factors that contribute to non-adherence
A nurse has an order to obtain a sputum specimen on a newly admitted client. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
Label the sputum specimen and take it to the lab
The nurse is preparing to suction a client's mouth to remove secretions. Which type of suctioning will the nurse perform?
Oral
Upon entering a client's room, the nurse notes the client's pulse oximetry to be 86%. What is the priority nursing action?
Perform a complete respiratory assessment
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:
Pneumonia
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?
Pulmonary function tests
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the appropriate intervention in this situation?
Remove the airway, turn the client to the side and provide mouth suction, if necessary
The physician directs the nurse to use oropharyngeal suctioning to remove liquid secretions for a client with a respiratory problem. What is oropharyngeal suctioning?
Removing secretions from the throat through an orally inserted catheter
The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly?
Respirations are at 20 breaths per minute
A client has had a head injury affecting the brain stem. What is located in the brain stem that may affect respiratory function?
Respiratory center
The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective?
SpO2 92%
A nurse is at a baseball game and responds when a person collapses. The nurse begins CPR and requests an automated external defibrillator (AED). The family is angry when the nurse stops compressions to apply the AED. What is the appropriate action?
Stop compressions for less than 10 seconds to apply the AED
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?
Tracheostomy collar
A nurse needs to perform the Heimlich maneuver on an 8-month-old infant with a partial airway obstruction. Which action should the nurse perform?
Use the heel of one hand to administer back blows
A nurse is preparing to orally suction a client with dysphagia following a stroke. Which suction device is appropriate?
Yankauer catheter
A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?
prolonging expiration to reduce airway resistance
A client is discussing advance directives with the nurse. Which statement made by the client indicates a need for further teaching?
"If I sign a DNR, then I may not receive continued care."
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?
"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."
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?
"Take in as much air as possible, hold your breath briefly, and exhale slowly."
The nurse is demonstrating oxygen administration to a client. What teaching will the nurse include about the flowmeter?
"This is a gauge used to regulate the amount of oxygen that a client receives."
The nurse is caring for four clients. Which client does the nurse identify that would best benefit from chest physiotherapy?
21-year-old with cystic fibrosis
A client is receiving oxygen therapy via a nasal cannula at 3 L/min. The nurse estimates that the client is receiving which concentration of oxygen?
30%
A nurse is caring for a client who is unable to breathe efficiently by himself. The physician has directed the nurse to put the client on oxygen therapy. The client is receiving a high concentration of oxygen. At what level should a nurse use a humidifier for the client?
4 L/min
Erin is a 35-year-old woman being cared for in the emergency department for a cough and hemoptysis for 3 days. Erin states that she has smoked one-and-a-half packs of cigarettes per day for the last 5 years. In trying to identify risk factors for Erin, the nurse calculates her pack-year history to write on the intake form. What is Erin's pack-year of smoking?
7.5
A client is receiving supplemental oxygen and the nurse is monitoring the client's oxygen saturation level using pulse oximetry. The nurse notifies the physician if the client reaches which oxygen saturation level?
92%
The nurse would expect to recommend an oxygen tent for which client?
A child who will not leave a facemask or cannula in place
An unconscious teenager is brought to the emergency department with a respiratory rate of 6/min following a suspected opioid drug overdose. What is the nurse's most appropriate action?
Administer naloxone
While jogging through the neighborhood, a nurse witnesses the collapse of a nearby jogger and suspects cardiac arrest. Which action should the nurse take first?
Assess the victim for consciousness
A nurse enters a client's room to find that the client is breathing 4 to 5 shallow breaths per minute. Which oxygen delivery system should the nurse use for this client?
Bag and mask
Which category of medications may be administered by nebulizer or metered-dose inhaler to open narrowed airways?
Bronchodilators
A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate?
Changes in the alveolar-capillary membrane and diffusion
Which technique would the nurse employ to maximize the effectiveness of postural drainage?
Combine it with percussion and vibration
A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario?
Cyanosis
A nurse is caring for a client with who has a long history of smoking, and states, "I cough for a long time every morning." The client has thick mucus secretions and is dyspneic with a respiratory rate of 28/min. The nurse uses which phase of the nursing process to apply the NANDA of Ineffective Airway Clearance?
Diagnosis
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?
Distilled water
The nurse is assessing a client with a chest tube that has been inserted after experiencing blunt trauma that resulted in a pneumothorax. What nursing action is appropriate when constant bubbling is noted in the suction control chamber?
Document the finding
The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is Ineffective Airway Clearance related to copious and tenacious secretions. Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan?
Encouraging the client to consume 2 to 3 quarts of clear fluids daily
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?
Fine crackles to the bases of the lungs bilaterally
During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?
Flow meter
A nurse is performing the Heimlich maneuver on a young client to relieve a mechanical airway obstruction. Which action should the nurse perform to increase intrathoracic pressure?
Give five quick abdominal thrusts above the navel
Which physiologic change does the nurse anticipate will be found in the older adult client with an ongoing nonproductive cough?
Laryngeal atrophy
A nurse is giving chest thrusts with two fingers to an infant with a partial obstruction. Which place is most suitable for giving chest thrusts to an infant?
Middle of the sternum
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?
Monitor the amount of oxygen saturation in the blood
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?
Nasal cannula
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?
Nasal cannula
An infant with a small toy lodged in the trachea is crying. What is the nurse's priority action?
Observe the infant's respiratory effort
The nurse is reviewing the arterial blood gas results of a client with a respiratory disorder. What would alert the nurse to a problem?
PaCO2 of 55 mmHg
A nurse is preparing to insert an oral airway on an unconscious client. How should the nurse proceed?
Position the client with the neck hyperextended
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?
Pulse oximetry
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?
Residual Volume (RV)
A nurse walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action?
Start chest compressions
When caring for a client with a tracheostomy, the nurse would perform which recommended action?
Suction the tracheostomy tube using sterile technique
What can a nurse ask a client to do before suctioning to prevent hypoxemia?
Take several deep breaths
Which is not true regarding the structure of the respiratory system?
The lungs move actively
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?
They are low-pitched, soft sounds heard over peripheral lung fields
True or False: 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
The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?
a child who has pneumonia
An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur?
inspiration and expiration
A client with a head injury will require long-term airway support. Which device will be required for this client?
tracheostomy tube
