Fundamental Ch 39

A client with no prior history of respiratory illness has been admitted to a post operative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent post operative pneumonia and Atelectasis during this time of reduced immobility following surgery.

Educating the client on how on the use of an incentive spirometer

A nurse is caring for a client who breaths very shallowly and has been reporting severe back pain. What suggestions could the nurse make to help the client breathe effectively

Encourage your client to take deep breaths

Nasal Cannula

F10/2 of 44%

Ventri Mask

F10/2 of 55%

Simple Mask

F10/2 of 60%

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

Flow Meter

The nurse caring for a client who was 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

The nurse is caring for a client with COPD who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea?

High-Fowler's Position

The nurse is preparing to educate a client on how to use an incentive spirometry. Which concepts should the nurse include?

Incentive spirometry provides visual reinforcement of deep breathing

A nurse is caring for an asthmatic patient who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?

Nasal Cannula

Which oxygen delivery system is most commonly used because it does not impede eating or speaking?

Nasal Cannula

The nurse should assess for respiratory depression before and after administration of which drugs?

Opioid Analgesics

A nurse is assigned to care for a client admitted with a diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of:

Pneumonia

What structural changes to the respiratory system should the nurse observe when caring for older people

Respiratory muscles become weaker

Which nursing skill requires the nurse to use sterile technique?

Suctioning a tracheotomy

Vesicular Breath Sounds

low-pitched, soft sound during expiration heard over most of the lungs

While examining a client, the nurse palpates a client's chest and back. What would the nurse expect to identify with this technique?

pattern of thoracic expansion

The charge nurse is observing a new nurse for a client who is receiving oxygen simple mask with an F10/2 of 40%. The client states, "The moisture on my face is bothersome. Can something be done about it?" Which response by the new nurse requires clarification by the charge nurse?

"After I dry your face, I can apply powder to absorb the moisture to protect your skin."

A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply:

1) Nasal cannula, 2) Simple oxygen mask, 3) Partial rebreather mask

A nurse is using a pulse ox to measure the arterial oxyhemoglobin saturation of a client's arterial blood. What range is considered a normal value for SpO2?

95% to 100%

In which client would the nurse assess for a depressed respiratory system?

A client taking opioids for cancer pain

A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction two 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 what?

Atelectasis (incomplete lung expansion due to bed rest)

Upon auscultation of a patient's lungs, the nurse hears loud, high pitched sounds over the larynx. Which term will the nurse use in documentation to describe this breath sound?

Bronchial

Upon evaluation of a client's medical history, the nurse recognizes that which of the following conditions may lead to an inadequate supply of oxygen to the tissues of the body?

Chronic Anemia

The nurse is informed while receiving nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?

Confusion

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with a lung disease. What is the most important thing to remember when using the nasal cannula.

It can cause the nasal mucosa to dry in case of high flow

The nurse is caring for a client who has spontaneous respiration and needs oxygen administration at F10/2 of 100% Which oxygen delivery system should the nurse utilize.

Non-Rebreather Mask

The nurse is conducting a respiratory assessment on 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 base of the lungs bilaterally

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 re-positioning the client and measuring the clients oxygen saturation using a pulse ox yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's

hemoglobin level

bronchovesicular breath sounds

medium-pitched and quieter sounds normally heard over the major bronchi