Chapter 21 prep u

The nurse is using an oxygen analyzer to determine whether a client is receiving the amount prescribed by the health care provider. The nurse first checks the room air. What finding indicates a normal mixture of oxygen and other gases in the environment?

21%

A nurse is caring for a critically ill client who has been admitted to the intensive care unit at the health care facility. The client is unable to breathe on his own and requires a very high concentration of oxygen. Which oxygen delivery device is most appropriate for this client?

Non-rebreather mask

A 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 use?

Nonrebreather mask

The nurse is assessing a client's chest tube which was inserted 48 hours earlier. The nurse notes crackling in the skin around the insertion site. Which action should the nurse prioritize?

Notify the health care provider.

The nurse is caring for a 2-year-old client who experienced smoke inhalation during a house fire. When oxygen is prescribed, what delivery device will the nurse gather?

Oxygen tent

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 55 mmHg

A 72 year-old client has come for an annual wellness check-up with the health care provider. Which vaccine will the nurse discuss with the client?

Pneumococcal 13-valent conjugate

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 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

What structural changes to the respiratory system should a nurse observe when caring for older adults?

respiratory muscles become weaker

A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from?

sleep apnea

The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?

"An electric stove may be a safer choice for you."

The home health nurse is visiting a new client who has recently started using an oxygen concentrator. After assessing the home environment, which comment should the nurse prioritize?

"Have you discussed a back-up system with your health care provider in case your electricity goes out?"

Which is a sign of dyspnea specific to infants?

Nasal flaring

A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response?

"Have you tried nasal strips?"

Which response(s) will the nurse provide to a client concerned about developing chronic bronchitis due to smoking cigarettes, working with printing chemicals, and living near a paper mill? Select all that apply.

"Have you tried to stop smoking? This can reduce your risk?" "We can refer you to a smoking cessation program to help reduce developing any future pulmonary issues." "How long have you lived near the paper mill? This can increase you risk for chronic bronchitis and asthma." "Exposure to printing chemicals increases the risk for allergies which can trigger chronic bronchitis, so wearing a breathing mask may be needed."

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 is using his chest muscles to help him breathe."

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?

"I can assist you to the bathroom and back to bed."

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."

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?

"Is your mask causing discomfort?"

A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them?

"It is inserted into the space between the lining of the lungs and the ribs."

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the oxygen analyzer?

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

A nurse is educating a preoperative client on how to effectively deep breathe. Which instruction would be included?

"Make each breath deep enough to move the bottom ribs."

A client's spouse reports that the client snores loudly and incessantly every night. What is the appropriate nursing response when the client's spouse asks about nasal breathing strips?

"Nasal strips may reduce or eliminate snoring."

A client has been admitted to the post-surgical unit after a metatarsal (foot) amputation and has been provided with an incentive spirometer in order to prevent respiratory complications after surgery. What client education should the nurse provide about the correct use of incentive spirometry?

"Sit up as straight as you can when you're performing incentive spirometry."

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?

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

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 client reports rarely leaving the house since starting use of home oxygen. What education should the nurse provide to the client? Select all that apply.

-A portable oxygen device may be helpful. -The client likely only needs time to adjust. -Friends and family can be invited to visit the client at home.

The nurse is caring for an older adult client who has been admitted for an asthma exacerbation. While assessing the client's vital signs, the nurse observes the client's oxygen saturation is 88% on room air. Which additional assessment(s) related to this finding will the nurse undertake? Select all that apply.

-Count capillary refill time. -Obtain level of consciousness. -Observe movement of the chest.

Prior to performing an arterial puncture, the nurse is completing an Allen test. Place the steps of performing the Allen test done before the puncture in the correct sequence. Use all options.

-Flex the client's elbow and elevate the forearm where the arterial puncture will be made. -Compress the radial and ulnar arteries simultaneously. -Instruct the client to open and close the fist until the palm of the hand appears blanched. -Release pressure from the ulnar artery while maintaining pressure on the radial artery. -Observe whether the skin flushes or remains blanched. -Release pressure on the radial artery,

The nurse is administering oxygen to an older adult client who has been assessed to have increased work of breathing. If the intervention has been effective, what finding(s) will the nurse expect on the evaluation of the client? Select all that apply.

-Heart rate is 64 beats/min. -Mucous membranes are pink and moist. -The client is able to state the date, time, and location.

The nurse is caring for a client at risk for pneumonia after having major abdominal surgery. Which nursing instruction(s) is essential for the use of an incentive spirometer? Select all that apply.

-Splint the abdomen with a pillow to decrease discomfort prior to use. -Instruct the client to exhale normally and then place lips securely around the mouthpiece. -Encourage the client to complete breathing exercises about 5 to 10 times every 1 to 2 hours, if possible. -Assist the client to an upright or semi-Fowler position.

The pediatric nurse is caring for four clients. Which client will receive the greatest benefit from the use of an oxygen analyzer to assure that the client is receiving the prescribed amount of oxygen?

3-year old in croup tent

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's Sa02 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:

6L/min

What prevents air from reentering the pleural space when chest tubes are inserted?

A closed water-seal drainage system

The nurse has received the arterial blood gas (ABG) results. The ABG was drawn on a client who has been receiving oxygen via partial rebreather mask. Which assessment findings should the nurse act upon after reviewing the ABG? Select all that apply.

Headache, sore throat, fatigue

The nurse provides care for the client with chronic obstructive pulmonary disease and a low oxygen saturation level despite oxygen therapy. Which intervention(s) does the nurse utilize to help increase the client's oxygenation? Select all that apply.

Advise client to increase water intake Teach the client to do pursed lip breathing Assist the client to do diaphragmatic breathing Ensure that the client is actually using the prescribed oxygen correctly

The nurse is planning care for a client who is prescribed a simple mask for oxygen delivery. What intervention will the nurse include in the plan of care?

Assess the client for anxiety due to claustrophobia

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD). The client has returned to bed after ambulating down the hallway and the nurse observes the client's oxygen saturation is 86% on room air. What action will the nurse take first?

Give oxygen by nasal prongs at a rate of 1 to 2 liters/minute.

The dient is experiencing respiratory distress and the nurse places the client in a high Fowler position. Which action does the nurse take next?

Ensure airway patency

A client with a history of emphysema has been admitted to the hospital with an exacerbation of her symptoms. The nurse is teaching the client to perform pursed-lip breathing in an effort to alleviate hypercarbia and shortness of breath. When performing pursed-lip breathing correctly, the client will do which of the following?

Exhale more slowly than she normally does.

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

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 client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply.

Monitor the client's respiratory rate. Check the symmetry of the client's chest. Observe the breathing pattern and effort.

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 decreases dry mucous membranes by delivering small water droplets.

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?

It determines whether the client is getting enough oxygen.

Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen?

It regulates the amount of oxygen received.

A nurse is teaching the client the steps of diaphragmatic breathing. Place the steps in the correct sequence from first to last. Use all options.

Lie down with knees slightly bent. Place one hand on the abdomen and the other on the chest. Inhale slowly and deeply through the nose while letting the abdomen rise more than the chest. • Purse the lips. • Contract the abdominal muscles and begin to exhale. Press inward and upward with the hand on the abdomen while continuing to exhale.

To determine the quality of oxygenation, the nurse performs the physical assessment, the arter 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 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

The nurse provides care for a client with pneumonia and acute respiratory distress syndrome whose oxygen saturation fluctuated between 86% and 90% over the past few days. The oxygenation saturation is consistently at 91%. Which step would the nurse take next?

Provide oxygen for consistent hypoxia

A nurse is delivering oxygen to a client via an oxygen mask. Which guideline is recommended for this procedure?

Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously.

The nurse has completed a focused respiratory assessment of a client and is documenting the assessment findings in the client's medical record. How should the nurse document the results of pulse oximetry testing?

Sp02 = 96%

The nurse provides care for a client with chronic bronchitis and a decreasing oxygen saturation. Which factor(s), if assessed, indicate a deteriorating condition? Select all that apply.

Tachypnea Tachycardia Shortness of breath Wheezing and crackles in lungs

During a physical assessment, a client reports a desire to reduce snoring because it interferes with the spouse's ability to sleep properly. What suggestion could the nurse make to improve the client's condition?

Tell the client to use nasal strips when sleeping

The nurse is instructing a client with the use of an incentive spirometer for the first time. Which instruction will the nurse provide to the client to ensure effective use of the device?

Use the device hourly to gain maximum benefit.

A nurse is preparing to suction a client through a previously inserted oral airway. What are the most appropriate actions of the nurse before beginning the procedure? Select all that apply.

Wash hands. Pre-oxygenate the client. Open the suction kit.

Which scenario describes how carbon dioxide levels determine the frequency and depth of ventilation?

When carbon dioxide levels in the blood increase, chemoreceptors are stimulated, causing deeper and more rapid breathing.

The nurse would expect to recommend an oxygen tent for which client?

a child who will not leave a facemask or cannula in place

The nurse is caring for a client with respiratory acidosis. Which arterial blood gas data does the nurse anticipate finding?

pH less than 7.35; HCO3 high; PaCO2 high

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

The nurse is caring for a client admitted with chronic obstructive pulmonary disease. During shift assessment, the nurse finds that the client is experiencing a change in respiratory and mental status. The most accurate measurement of the concentration of oxygen in the client's blood is:

an arterial blood gas study.

A client is experiencing hypoxia. Which nursing concern is appropriate to address when planning care?

anxiety

The client has a nursing diagnosis of Ineffective Airway Clearance related to retained secretions as evidenced by moist lung sounds, respiratory rate of 28 to 30 breaths per minute, and ineffective cough. The nurse evaluates client outcome and determines the outcome is met when the client demonstrates:

clear lung sounds

A client has been receiving treatment with a nonrebreather mask for the past 96 hours. How should the nurse respond if the unlicensed assistive personnel (UAP) suddenly reports the client has vomited?

conduct a focused assessment

The nurse is admitting a new client who has had a chest tube inserted on the right side. Which action should the nurse prioritize for this client?

coughing and deep breathing at least q2h while awake

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

The nurse is providing care for a client who has a diagnosis of chronic obstructive pulmonary disease (COPD). When providing supplementary oxygen by nasal cannula for this client, the nurse must use caution in order to avoid what problem?

decreased respiratory drive

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 developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing concern for this client is altered airway clearance related to copious and tenacious secretions. What is an appropriate nursing intervention to include in the client's care plan?

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

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

The nurse observes a client practice pursed-lip breathing in preparation for discharge. Which action should the nurse point out needs correcting?

exhales to a count of 4

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?

flow meter

The home health nurse arrives at a client's home and immediately notes the client is experiencing increased dyspnea. The client has a 7-year history of chronic obstructive pulmonary disease (COPD). Which assessment finding should the nurse prioritize?

flow meter set at 5 liters of oxygen

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

Upon analysis of a client's arterial blood gas results, the nurse determines that the concentratipn of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate to observe in a client with these arterial blood gas results?

increase in rate and depth of respirations

Oxygen hoods are generally used to deliver oxygen at rates approaching 100% to which developmental group

infants

An adult client is discharged to home with a prescription for oxygen at 2 L/min. Which method of oxygen delivery should the nurse use in this situation?

nasal cannula

Which is a major organ of the upper respiratory tract?

pharynx

A nurse is completing tracheostomy care on a client with an inner cannula. Which supply will the nurse use to clean and dry the inner cannula?

pipe cleaners

The nurse has completed a respiratory assessment of an older adult client with numerous health problems. The results of the assessment include a respiratory rate of 24 breaths per minute and pulse oximetry of 90%. The nurse's next action should be to:

position the client in a high Fowler position.

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 is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly?

reads 0.21 when checking oxygen in room air

A nurse is teaching a home care client and the family about using prescribed oxygen. What is a critical factor that must be included in teaching?

the safety measures necessary to prevent a fire