Chapter 39 PrepU

A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs? Simple mask Nonrebreather mask Partial rebreather mask Nasal cannula

nasal cannula

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather? nasal cannula tracheostomy collar simple mask face tent

face tent

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

presence of fluid in the lungs

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

Document this expected assessment finding.

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? normal saline distilled water tap water mineral oil

distilled water

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: alcohol use. asthma. croup. pneumonia.

pneumonia

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? low pulse rate high respiratory rate high temperature low blood pressure

high respiratory rate

In which client should the nurse prioritize assessments for respiratory depression? A client taking insulin for type 1 diabetes A client taking a beta-adrenergic blocker for hypertension A client taking opioids for cancer pain A client taking antibiotics for a urinary tract infection

A client taking opioids for cancer pain

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? Increase the flow of oxygen. Check the fit of the oxygen mask. Discontinue oxygen therapy until the client is reassessed by the healthcare provider. Contact the oxygen supplier to request an oxygen tent.

Check the fit of the oxygen mask.

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

It determines whether the client is getting enough oxygen.

The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response? Maintain the client's oxygenation and alert the health care provider immediately. Cover the tracheostomy stoma and apply oxygen by nasal cannula Page the respiratory therapist STAT. Assess the client's respiratory status and check vital signs every 1 minute for the next hour.

Maintain the client's oxygenation and alert the health care provider immediately.

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. Practice good hand hygiene. Cut down on smoking. Avoid exposure to large crowds.

Stay indoors as much as possible.

A nurse has received an order to suction an adult client's endotracheal tube. Which action is most appropriate when performing this intervention? Put on sterile gloves in preparation for setting up the equipment field. Assist the client into a supine position in preparation for suctioning. Use sterile saline to moisten the end of the suction catheter. Set the wall suction to a maximum of 80 mm Hg.

Use sterile saline to moisten the end of the suction catheter.

The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document? Stridor Crackles Wheezing Absent breath sounds in lower lobes

Wheezing

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 bronchospasm. bronchitis. bronchiectasis. bronchiolitis.

bronchospasm

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 Anemia Malnutrition Poor tissue perfusion Congestive heart failure

poor tissue perfusion

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. Oxygen saturation reads 88% on 5L of oxygen. The client is able to state the date, time, and location. Mucous membranes are pink and moist. Respiratory rate is 33 breaths/min at rest.

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

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

Instruct the client to inhale deeply and then cough.

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

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

air flow through the respiratory passages