Fundamentals of Success Oxygenation
A nurse teaching a preoperative client how to use an incentive spirometer. Place the following steps of the use of an incentive spirometer in the order in which they should be performed. 1. Inhale slowly. 2. Hold the incentive spirometer level. 3. Remove the mouthpiece and exhale normally. 4. Keep the visual indicator at the inspiratory goal for several seconds. 5. Maintain a firm seal, with the lips around the mouthpiece during inhalation.
Answer: 2, 5, 1, 4, 3 1. Inspiration should be accomplished through a slow, deep breath. A rapid, forceful inhalation can collapse the airway and is contraindicated. 2. Holding the incentive spirometer level prevents factors, such as friction and gravity, from altering the correct function of the device. 3. Each exhalation should be an unforced, normal exhalation. A seal does not need to be maintained around the mouthpiece. 4. When the visual indicator reaches the present goal during inhalation, the inhalation should be maintained for 2 to 6 seconds to ensure ventilation of the alveoli. 5. A firm seal around the mouthpiece is necessary during inhalation, but the mouthpiece should be removed during exhalation.
A primary health-care provider prescribes oxygen via a simple face mask at a flow rate of six liters for a client. The nurse explains the procedure to the client and maintains standard precautions. Place the following steps in the order in which they should be implemented 1. Place the mask on the client's face from the bridge of the nose to under the chin. 2. Secure the elastic bands around the back of the client's head. 3. Attach the prefilled humidifier to the flowmeter. 4. Attach the flowmeter to the wall oxygen source. 5. Attach the face mask tubing to the humidifier. 6. Turn the oxygen flowmeter on to six liters.
Answer: 4, 3, 5, 6, 1, 2 1. The fifth step is placing the mask on the client's face. Applying it from the bridge of the client's nose to under the chin limits oxygen from leaking around the edges of the mask. 2. The sixth step is securing the elastic bands around the back of the client's head. This helps to hold the mask in position. 3. The second step is to attach the prefilled humidifier to the flowmeter. Humidification reduces drying of the respiratory system mucous membranes and is essential when oxygen delivery is 4 L or higher. 4. The first step is to attach the flowmeter to the wall oxygen source. The flowmeter controls the amount of oxygen delivered. 5. The third step is attaching the mask's tubing to the humidifier. This prepares the equipment for use. 6. The fourth step is turning on the oxygen flow rate to 6 L. This primes the tubing and mask with oxygen so that there is no delay once the mask is applied to the client's face.
Which outcome best reflects achievement of the goal, "The client will expectorate lung secretions with no signs of respiratory complications"? A. Absence of adventitious breaths sounds B. Deep breathing and coughing nonproductively C. Drinking 3,000 mL of fluid in the last 24 hours D. Expectorating sputum three times between 3 p.m. and 11 p.m.
Answer: A A. Adventitious breath sounds are abnormal breath sounds that occur when pleural linings are inflamed or when air passes through narrowed airways or through airways filled with fluid. The absence of abnormal sounds is desirable. B. To expectorate secretions, coughing must be productive, not nonproductive. A nonproductive cough is dry, which means that no respiratory secretions are raised and spat out (expectorated) because of coughing. C. Drinking fluid is an intervention that will liquefy respiratory secretions, thus facilitating their expectoration. However, just drinking fluid will not ensure that the secretions will be expectorated. D. Although spitting out sputum reflects achievement of the goal in relation to expectorating lung secretions, it does not address the absence of respiratory complications, which is the ultimate goal of decreasing stasis of respiratory secretions.
A nurse is teaching a client how to use an incentive spirometer. Which position should the nurse assist the client to assume during this procedure? A. Sitting B. Side-lying C. Orthopneic D. Low-Fowler
Answer: A A. An upright sitting position in a bed or a chair facilitates maximum thoracic excursion because it permits the diaphragm to contract without pressure being exerted against it by abdominal viscera. B. The side-lying position is not ideal for the use of an incentive spirometer because it limits thoracic expansion. The side-lying position allows abdominal viscera to exert pressure against the diaphragm during inspiration, and the lung on the lower side of the body is compressed by the weight of the body. C. Although the orthopneic position allows for thoracic expansion, leaning forward with the arms on an over-bed table does not free the hands for holding the spirometer. D. The low-Fowler position does not maximize the effects of gravity. In the high-Fowler position, gravity moves abdominal viscera away from the diaphragm and thus facilitates the contraction of the diaphragm, both of which promote thoracic expansion.
A primary health-care provider prescribes bedrest for a client. Which should the nurse explain to the client is the primary purpose of bedrest? A. Conserve energy. B. Maintain strength. C. Enhance protein synthesis. D. Reduce intestinal peristalsis.
Answer: A A. Bedrest reduces cardiopulmonary demands, muscle contraction, and other bodily functions. All of this reduces the basal metabolic rate, which conserves energy. B. Activity, not bedrest, maintains strength. C. Protein synthesis is enhanced by the intake of amino acids, not bedrest. D. Although bedrest may limit peristalsis, it is not the most common reason bedrest is prescribed.
A nurse is reviewing the laboratory results of a client with the preliminary diagnosis of anemia. An abnormal response of which diagnostic test would reflect iron-deficiency anemia? A. Hemoglobin B. Platelet count C. Serum albumin D. Blood urea nitrogen
Answer: A A. Iron is necessary for hemoglobin synthesis. Therefore, reduced intake of dietary iron results in iron-deficiency anemia. Hemoglobin is the main component of red blood cells and transports oxygen and carbon dioxide through the bloodstream. B. Platelets are unrelated to iron-deficiency anemia. Platelets (thrombocytes) are non-nucleated, round or oval, flattened, disk-shaped, formed elements in the blood that are necessary for blood clotting. C. Albumin is unrelated to iron-deficiency anemia. Albumin is a protein in the blood that helps to maintain blood volume and blood pressure. D. Blood urea nitrogen (BUN) is unrelated to iron-deficiency anemia. BUN is a test that measures the nitrogen portion of urea present in the blood. It is an index of glomerular function in the production and excretion of urea.
A nurse is assessing a postoperative client. Which complication has occurred when the client experiences purulent sputum, dyspnea, and chest pain? A. Hypostatic pneumonia B. Hypovolemic shock C. Thrombophlebitis D. Pneumothorax
Answer: A A. Postoperative clients often experience hypoventilation, immobility, and ineffective coughing that may lead to stasis of respiratory secretions and the multiplication of microorganisms, causing hypostatic pneumonia. Dyspnea results from decreased lung compliance, chest pain results from coughing and the increased work of breathing, and purulent sputum results from the presence of pathogens. B. Hypovolemic shock is characterized by tachycardia, tachypnea, and hypotension. C. Thrombophlebitis is characterized by localized pain, swelling, warmth, and erythema. If a thrombus breaks loose and travels through the venous circulation to the lung (pulmonary embolus), it will cause dyspnea and chest pain, not purulent sputum. D. Pneumothorax is characterized by a sudden onset of sharp pain on inspiration, dyspnea, tachycardia, and hypotension.
A nurse raises the head of the bed for a client who has difficulty breathing. Which science includes the principle that explains how this intervention facilitates respiration? A. Physics B. Biology C. Anatomy D. Chemistry
Answer: A A. Raising the head of the bed drops the abdominal organs away from the diaphragm via the principle of gravity, facilitating breathing. Gravity, the tendency of weight to be pulled toward the center of the earth, is a physics principle. B. Raising the head of the bed is not related to biology. Biology is the study of living organisms. C. Raising the head of the bed is not related to anatomy. Anatomy is the study of the form and structure of living organisms. D. Raising the head of the bed is not related to chemistry. Chemistry is the study of elements, compounds, and atomic relations of matter.
Which nursing assessment best indicates a client's ability to tolerate activity? A. Vital signs that take three minutes to return to preactivity level B. Absence of adventitious breath sounds on auscultation C. Flexibility of both muscles and joints D. Reports of weakness after activity
Answer: A A. Vital signs reflect cardiopulmonary functioning of the body. Vital signs obtained before and after activity provide data that can be compared to determine the body's response to the energy demands of ambulation. When the vital signs return to the preactivity level within 3 minutes, it indicates that the client has tolerated the activity. B. The absence of abnormal breath sounds (adventitious sounds) indicates the nonexistence of a respiratory problem. Adventitious breath sounds (e.g., wheezes, rhonchi, rales, pleural friction rub, and stridor) indicate narrowed airways, presence of excessive respiratory secretions, pleural inflammation, or diminished ventilation and are not the best signs to use when assessing a person's tolerance to activity. C. Flexibility relates to mobility, not one's physiological capacity to endure activities that require energy. D. A report of weakness indicates that the client has not tolerated the activity.
A nurse is caring for a client receiving oxygen via a nasal cannula. Which of the following should the nurse implement? Select all that apply. A. Apply a water-based lubricant to the client's nares. B. Adjust the flowmeter to the prescribed oxygen flow rate. C. Reassess nares, cheeks, and ears for signs of pressure every 2 hours. D. Place the nasal prongs so that they curve downward when in the nares. E. Loop the tubing over the client's ears and adjust it gently under the chin.
Answer: A, B, C, D, E A. A water-based lubricant will keep the nares supple. An oil-based lubricant should not be used because volatile, flammable substances can ignite in the presence of oxygen. B. Adjusting the flowmeter to the prescribed oxygen flow rate ensures that the client is receiving the accurate dose of oxygen. C. Reassessing the client's skin for signs of pressure every 2 hours ensures that tissue irritation or capillary compression does not occur from the nasal prongs or tubing. The tubing should be snug enough to keep the nasal prongs from becoming displaced but loose enough not to compress or irritate tissue. D. Placing the nasal prongs curving downward in the nares follows the natural curve of the nasal passages, preventing injury. E. Looping the tubing over the client's ears and adjusting it gently under the chin is the correct placement of the tubing. A firm adjustment can cause pressure ulcers around the ears.
A nurse is caring for a client who has a chest tube after thoracic surgery. Which of the following should the nurse implement when caring for this client? Select all that apply. A. Encourage the client to cough and deep breathe at regular intervals. B. Clamp the tube when providing for activities of daily. C. Position the collection device below the level of the chest. D. Maintain an airtight dressing over the puncture wound. E. Empty drainage from the device every shift. F. Avoid using pins to secure tubing.
Answer: A, C, D, F A. Coughing and deep breathing should be encouraged because this helps to expand the lungs. B. Clamping the tube when providing for activities of daily living is contraindicated because clamping a chest tube may cause a tension pneumothorax. C. The chest drainage system should be kept below the level of the insertion site to promote the flow of drainage from the pleural space and prevent the flow of drainage back into the pleural space. D. An airtight dressing seals the pleural space from the environment. If the pleural space is left open to the environment, atmospheric pressure causes air to enter the pleural space, which results in a tension pneumothorax. E. Emptying chest tube drainage every shift is unnecessary. Chest drainage systems are closed, self-contained systems that have a chamber for drainage. At routine intervals (as per hospital policy), the date, time, and nurse's initials mark the level of drainage on the drainage collection chamber. F. Avoiding using pins to secure tubing averts the risk of puncturing the tubing, which will cause an air leak.
A nurse is caring for a male client who had several laboratory tests performed. Which of the following increase the client's risk for an impaired ability to tolerate activity? Select all that apply. A. Hct of 45% B. Hb of 10 g/dL C. O2 saturation of 97% D. WBC count of 7,500 cells/mcL E. RBC count of 4.8 million cells/mcL
Answer: B A. A hematocrit of 45% is within the expected range for hematocrit for men (42% to 52%). The expected hematocrit range for women is 36% to 48%. B. A hemoglobin of 10 g/dL is less than the expected range for hemoglobin for men (14.0 to 17.4 g/dL). the expected hemoglobin range for women is 12.0 to 16.0 g/dL. C. Adequate oxygen levels of more than 95% are necessary to meet the metabolic demands of activity that requires muscle contraction. D. A white blood cells (WBC) count of 7,500 cells/mcL is within the expected range of 3,500 to 10,500 cells/mcL for WBCs. WBCs are not related to a client's oxygenation status; they are related to protecting the client from infection. E. A red blood cell count of 4.8 million cells/mcL is within the expected range of 4.2 to 5.4 million cells/mcL for red blood cells for men.
Which should the nurse do first when an adult who is choking on food become unconscious? A. Apply upward thrusts over the client's xiphoid process. B. Initiate a cardiopulmonary resuscitation protocol. C. Strike the middle of the client's back firmly. D. Perform a blind finger sweep of the mouth.
Answer: B A. Abdominal thrusts should not be performed on people who are unconscious because of a foreign body airway obstruction. Another intervention is more effective. B. Chest compressions are more effective than abdominal thrusts when attempting to eject a foreign body obstructing the airway of an unconscious adult. Chest compressions more effectively raise intrathoracic pressure. C. Hitting the middle of the client's back firmly should never be done for an unconscious adult who is choking. The American Red Cross advocates alternating 5 back blows and 5 abdominal thrusts for a conscious adult who is choking. D. A blind finger sweep should never be performed because it may push the foreign body deeper into the airway.
An obese client has limited mobility after an open reduction and internal fixation of a fractured hip. For which human response related to increased blood coagulability should the nurse monitor this client? A. Muscle deterioration B. Pain in the calf C. Hypotension D. Bradypnea
Answer: B A. Although muscle deterioration (atrophy) can occur with immobility, it is unrelated to hypercoagulability, Muscle atrophy is the decrease in the size of a muscle resulting from disease. B. Immobility promotes venous vasodilation, venous stasis, and hypercoagulability of the blood, which can precipitate the formation of a clot in a vein of the leg (venous thrombus) and inflammation of the vein (phlebitis). This results in pain. C. Hypotension, an abnormally low systolic blood pressure (less than 100 mm Hg), is not related to hypercoagulability precipitated by immobility. D. Bradypnea, abnormally slow breathing (less than 10 breaths per minute), is unrelated to hypercoagulability caused by immobility.
Which action is effective in meeting the needs of a client experiencing laryngospasm after extubation? A. Ensuring hyperextension of the head B. Providing positive-pressure ventilation C. Instituting cardiopulmonary resuscitation D. Administering oxygen by using a face mask
Answer: B A. Although tilting the head backward (hyperextension of the head) elongates the pharynx, reducing airway resistance, it will do nothing to correct the obstruction at the glottis (opening through the vocal cords). Also ,the tongue will block the airway unless there is forward pressure applied on the lower angle of the jaw (jaw thrust maneuver). B. Positive pressure will push the vocal cords backward toward the wall of the larynx, opening the glottis (space between the vocal cords), which allows ventilation of the lung. C. Instituting cardiopulmonary resuscitation is unnecessary. The client is having a respiratory, not a cardiac, problem. D. Administering oxygen by using a face mask is useless because the glottis is obstructed and the oxygenated air will not enter the lung.
A nurse hears a client explain the purpose of pursed-lip breathing to a relative. Which information would indicate to the nurse that the client correctly understood the nurse's teaching about pursed-lip breathing? A. Precipitates coughing B. Helps maintain open airways C. Decreases intrathoracic pressure D. Facilitates expectoration of mucus
Answer: B A. Deep breathing and huff coughing, not pursed-lip breathing, stimulate effective coughing. B. Pursed-lip breathing involves deep inspiration and prolonged expiration against slightly closed lips. The pursed lips create a resistance to the air flowing out of the lungs, which prolongs exhalation and maintains positive airway pressure, thereby maintaining an open airway and preventing airway collapse. C. Pursed-lip breathing increases, not decreases, intrathoracic pressure. D. The huff cough stimulates the natural cough reflex and is effective for clearing the central airways of sputum. Saying the word huff with short, forceful exhalations keeps the glottis open, mobilizes sputum, and stimulates a cough.
A meal tray arrives for a client who is receiving 24% oxygen via a Venturi mask. Which should the nurse do to meet this client's needs? A. Discontinue the oxygen when the client is eating meals. B. Request a prescription to use a nasal cannula during meals. C. Obtain a prescription to change the mask to a nonrebreather mask during meals. D. Arrange for liquid supplements that can be administered via a straw through a valve in the mask.
Answer: B A. Discontinuing oxygen when the client is eating is unsafe because it can compromise the client's respiratory status while the oxygen is disconnected. B. A Venturi mask interferes with eating because it covers the nose and mouth. Using a nasal cannula during meals will help meet both the nutritional and oxygen needs of the client. A nasal cannula delivers oxygen via prongs placed in the client's nares, leaving the mouth unobstructed, which promotes talking and eating. Specific oxygen delivery systems require a prescription, and their use is a dependent function of the nurse, except in emergency situations. C. A Venturi mask and a nonrebreather mask are both masks that cover the mouth, which interferes with eating. D. Liquid supplements are unnecessary. The client should eat the diet prescribed by the primary health-care provider.
A nurse in the postanesthesia care unit is monitoring several clients who received general anesthesia. Which client response causes the most concern? A. Pain B. Stridor C. Lethargy D. Diaphoresis
Answer: B A. Pain is an expected response to the trauma of surgery and usually can be managed effectively. B. Stridor is an obvious audible, shrill, harsh sound caused by laryngeal obstruction. The larynx can become edematous because of the trauma of intubation associated with general anesthesia. Obstruction of the larynx is life-threatening because it prevents the exchange of gases between the lungs and the atmosphere. C. Lethargy, which is drowsiness or sluggishness, is an expected response to anesthesia and opioid medications because these medications depress the central nervous system. D. Although diaphoresis is a cause for concern, it is not as immediately life-threatening as an adaptation in another option. Diaphoresis can be related to a warm environment, impaired thermoregulation, the general adaptation syndrome, or shock.
A nurse teaches a client how to use an incentive spirometer. Which projected client outcome supports the conclusion that the use of the incentive spirometer was effective? A. Expiratory volume will be decreased. B. Inspiratory volume will be increased. C. Sputum will be expectorated. D. Coughing will be stimulated.
Answer: B A. The expiratory volume should increase, not decrease, with the use of an incentive spirometer. B. An incentive spirometer provides a visual goal for and measurement of inspiration. It encourages the client to execute and maintain a sustained inspiration. A sustained inspiration opens airways, increases the inspiratory volume, and reduces the risk of atelectasis. C. Although sputum may be expectorated after the use of an incentive spirometer, this is not the primary reason for its use. D. Although the deep breathing associated with the use of an incentive spirometer may stimulate coughing, this is not the primary reason for its use.
A nurse, working in the emergency department, identifies that a client's hands are edematous when attempting to apply a pulse oximetry probe for a short-term use. Which action should the nurse implement? A. Attach the probe to one of the client's toes. B. Connect the probe to one of the client's earlobes. C. Wash the client's hand before attaching the probe to the finger. D. Encourage the client to perform active range-of-motion exercises of the hand with the probe.
Answer: B A. The use of a toe for pulse oximetry can result in inaccurate results because of concurrent problems, such as vasoconstriction, hypothermia, impaired peripheral circulation, and movement of the foot. B. An earlobe is an excellent site to monitor pulse oximetry. It is least affected by decreased blood flow, has greater accuracy at lower saturations, and rarely is edematous. This site is used for intermittent, not continuous, monitoring. C. Soap and water will not resolve edema. In addition, attaching a pulse oximeter clip sensor to an edematous finger is contraindicated because interstitial fluid interferes with obtaining an accurate oxygen saturation level. D. The cause of the edema must be identified first because range-of-motion exercises may be contraindicated.
A primary health-care provider prescribes chest physiotherapy with percussion and vibration for a newly admitted client. Which information obtained by the nurse during the health history should alert the nurse to question the provider's prescription? A. Emphysema B. Osteoporosis C. Cystic fibrosis D. Chronic bronchitis
Answer: B A. These are appropriate interventions for a client with emphysema. Emphysema is a chronic obstructive pulmonary disease characterized by an abnormal increase in the size of air spaces distal to the terminal bronchioles with destructive changes in their walls. B. Implementing the primary health-care provider's prescription may compromise client safety because percussion and vibration in the presence of osteoporosis may cause fractures. Osteoporosis is an abnormal loss of bone mass and strength. C. These are appropriate interventions for a client with cystic fibrosis. Cystic fibrosis causes widespread dysfunction of the exocrine glands. It is characterized by thick, tenacious secretions in the respiratory system that block the bronchioles, creating breathing difficulties. D. These are appropriate interventions for a client with chronic bronchitis. Bronchitis is an inflammation of the mucous membranes of the bronchial airways.
A nurse is assessing a client with a respiratory problem. Which clinical manifestation is reflective of an early response to hypoxia that requires a nursing intervention? Select all that apply. A. Dysrhythmias B. Restlessness C. Irritability D. Cyanosis E. Apnea
Answer: B, C A. A dysrhythmia, a heart rate with an irregular rhythm, can occur with hypoxia but it is a late response. B. Hypoxia is insufficient oxygen anywhere in the body. An early sign of hypoxia is restlessness, which is caused by impaired cerebral perfusion of oxygen. C. Irritability is an early sign of hypoxia caused by impaired cerebral perfusion of oxygen. D. Cyanosis, a bluish discoloration of the skin and mucous membranes caused by reduced oxygen in the blood, is a late sign of hypoxia. E. Apnea, a complete absence of respirations, is the cause of, not a response to, hypoxia.
A nurse is caring for a client with thrombophlebitis. For which of the following clinical manifestations of a complication associated with thrombophlebitis should the nurse monitor the client? Select all that apply. A. Postural hypotension B. Difficulty breathing C. Blanchable erythema D. Dependent edema E. Acute chest pain
Answer: B, E A. Postural hypotension is unrelated to thrombophlebitis. Postural hypotension (orthostatic hypotension) is a decrease in blood pressure related to positional or postural changes from the lying down to sitting or standing positions. B. Dyspnea is a clinical manifestation of a pulmonary embolus, a life-threatening condition. A thrombus that breaks loose from a vein wall and travels through the circulation (embolus) eventually will obstruct a pulmonary artery or one of its branches (pulmonary embolus). C. Blanchable erythema is unrelated to thrombophlebitis. Blanchable erythema (reactive hyperemia) is a reddened area caused by localized vasodilation in response to lack of blood flow to the underlying tissue. The reddened area will turn pale with fingertip pressure. D. Dependent edema is unrelated to thrombophlebitis. Although fluid will collect in the interstitial compartment (edema) around a thrombophlebitis, it is localized, not dependent, edema. Dependent edema is the collection of fluid in the interstitial tissues below the level of the heart; it occurs bilaterally and usually is caused by cardiopulmonary problems. E. Immobility promotes venous stasis, which, in conjunction with hypercoagulability and injury to vessel walls, predisposes clients to thrombophlebitis. These three factors are known as Virchow's triad. A thrombus can break loose from the vein wall and travel through the circulation (embolus), where eventually it obstructs a pulmonary artery or one of its branches and causes sudden, acute chest pain, dyspnea, coughing, and frothy sputum.
For which clinical manifestation should the nurse monitor the client when concerned about a potential for respiratory distress? A. Productive cough B. Sore throat C. Orthopnea D. Eupnea
Answer: C A. A productive cough indicates that the person is managing respiratory secretions adequately and keeping the airway patent. B. A sore throat indicates posterior oropharyngeal irritation or inflammation. This may or may not progress to respiratory distress. C. Orthopnea, the ability to breathe easily only in an upright (standing or sitting) position, is a classic sign of respiratory distress. The upright position permits maximum thoracic expansion because the abdominal organs do not press against the diaphragm and inspiration is aided by the principle of gravity. D. Eupnea is respirations that are quiet, rhythmic, and effortless within the expected rate per minute for age.
A client has thick, tenacious respiratory secretions. Which should the nurse do to liquefy the client's respiratory secretions? A. Change the client's position every two hours. B. Get a prescription for an antitussive agent. C. Encourage the client to drink more fluid. D. Teach effective deep breathing.
Answer: C A. Changing positions will mobilize, not liquefy, respiratory secretions. B. Mucolytics, not antitussives, liquefy respiratory secretions. Antitussives prevent or relieve coughing. C. A fluid intake of 2,500 to 3,000 mL is recommended to maintain the moisture of the respiratory mucous membranes. Adequate fluid keeps respiratory secretions thin so that they can be moved by ciliary action or be coughed up and spat out (expectorated). D. Deep breathing mobilizes, not liquefies, respiratory secretions.
A primary health-care provider prescribes chest physiotherapy with percussion and vibration for a client. After the primary health-care provider leaves, the client says, "I still don't understand the purpose of this therapy." Which statement should be included in the nurse's response? A. "It eliminates the need to cough." B. "It limits the production of bronchial mucus." C. "It helps clear the airways of excessive secretions." D. "It promotes the flow of secretions to the base of the lungs."
Answer: C A. Chest physiotherapy promotes, not eliminates, the need for coughing. B. Chest physiotherapy promotes the expectoration of, not limits the production of, bronchial mucus. C. The striking of the skin over the lung (percussion, clapping) and fine, vigorous, shaking pressure with the hands on the chest wall during exhalation (vibration) mobilize secretions so that they can be coughed up and expectorated. D. Chest physiotherapy mobilizes secretions, thus facilitating expectoration and interfering with the flow of secretions to the base of the lungs.
Which is the most important action by the nurse after a client has a chest tube inserted to treat a pneumothorax? A. ensure the client's intake is at least 3,000 mL of fluid per 24 hours. B. Provide the client with adequate medication for pain relief. C. Maintain the integrity of the client's chest tube. D. Reposition the client every 2 hours.
Answer: C A. Ensuring a fluid intake of at least 3,000 mL is unnecessary. A fluid intake of approximately 2,000 mL is adequate. B. Although providing for adequate pain relief is extremely important, it is not the priority. C. A tension pneumothorax may occur if the integrity of the chest drainage system because compromised (e.g., open to atmospheric pressure, clogged drainage tube, or mechanical dysfunction). Maintaining respiratory functioning is the priority. D. Although repositioning is done to promote drainage of secretions from lung segments and aeration of lung tissue, it is not the priority.
When are effective leg exercises the nurse should encourage a client to perform to prevent circulatory complications during the postoperative period? A. Knee flexion B. Isometric exercises C. Dorsiflexion exercises D. Passive range of motion
Answer: C A. Flexing the knees exerts pressure on the veins in the popliteal space; this reduces venous return, which increases, not decreases, the risk of postoperative circulatory complications. B. Isometric exercises strengthen muscles; they do not prevent postoperative circulatory complications. Isometric exercises change the muscle tension but do not change the muscle length of move joints. C. Alternating dorsiflexion and plantar flexion (calf pumping) contracts and relaxes the calf muscles. This muscle contraction promotes venous return, preventing venous stasis that contributes to the development of postoperative thrombophlebitis. D. Passive range-of-motion exercises are done by another person moving a client's joints through their complete range of movement. This does not prevent postoperative circulatory complications because the power is supplied by a person other than the client. To facilitate circulation, a client should contract and relax muscles actively.
A client's hemoglobin saturation via pulse oximetry indicates inadequate oxygenation. Which should the nurse do first? A. Notify the primary health-care provider. B. Encourage breathing deeply. C. Raise the head of the bed. D. Administer oxygen.
Answer: C A. Notifying the primary health-care provider is premature. The client's needs must be met first. B. Although encouraging deep breathing might be done eventually, it is not the priority at this time. It may or may not help. Inadequate oxygenation can be caused by a variety of problems other than shallow breathing. C. A nurse can implement this immediate, independent action. Nurses are permitted to treat human responses. Raising the head of the bed facilitates the dropping of the abdominal organs by gravity away from the diaphragm, which permits the greatest lung expansion. D. Obtaining and setting up the equipment take time that can be used for other more appropriate interventions first.
A client sucking on a hard candy inhales while laughing and develops a total airway obstruction. Which is the nurse attempting to do when implementing an abdominal thrust? A. Produce a burp. B. Pump the heart. C. Push air out of the lungs. D. Put pressure on the stomach.
Answer: C A. Producing a burp originating from the stomach in this situation is ineffective. B. Pressing on the heart (compression) is used in cardiopulmonary resuscitation (CPR). C. When trapped air behind an obstruction is forced out in response to an abdominal thrust, the forced air may push out what is causing the obstruction. D. Applying pressure against the stomach is ineffective in this situation. Whatever is causing the obstruction is not lodged in the esophagus, which leads to the stomach, but in the respiratory system.
A client is admitted with the diagnosis of lower extremity arterial disease. Which is a specific desirable outcome for a client with this diagnosis? A. Respirations within the expected range B. Oriented to the environment C. Palpable peripheral pulses D. Prolonged capillary refill
Answer: C A. Respirations within the expected range are unrelated to lower extremity arterial disease (LEAD). B. LEAD does not involve inadequate circulation to the brain. C. Palpable peripheral pulses are an appropriate expected outcome for a client with LEAD, which is a decrease in nutrition and respiration at the peripheral cellular level because of a decrease in capillary blood supply. A physiological response associated with LEAD is diminished or absent arterial pulses. D. A prolonged capillary refill indicates a continued problem with peripheral tissue perfusion. After compression, blanched tissue should return to its original color within 2 seconds (blanch test).
Which piece of information documented in the clinical record of a male adult should the nurse consider problematic? Client's Clinical Record Laboratory Results - WBC 8,000 cells/mcL - Hb 17 g/dL - Hct 50% Physical Assessment - BP: 132/70 mm Hg - Pulse: 100 beats per minute - Respirations: 22 breaths per minute - Temperature: 99F, oral - Oxygen saturation: 85% Medication Reconciliation Form - Levothyroxine 100 mcg, PO, daily - Simvastatin 20 mg, PO, hs - Montelukast 10 mg, PO, hs A. Simvastatin 20 mg, PO, in the evening B. Pulse 100 beats per minute C. Oxygen saturation 85% D. WBC 8,000 cells/mcL
Answer: C A. Simvastatin 20 mg once a day is within the expected dose range of 5 to 40 mg daily and is not a cause for concern. Simvastatin, a lipid-lowering agent, should be taken in the evening because the body produces the most cholesterol overnight. B. A pulse rate of 100 beats per minute is within the expected range of 60 to 100 beats per minute and is not a cause for concern. C. An oxygen saturation level of 85% is a cause for concern. An oxygen saturation level of 95% to 100% is considered expected. An oxygen saturation level of less than 90% is considered low and is associated with hypoxemia. D. A WBC count of 8,000 cells/mcL is within the expected range of 3,500 to 10,500 cells/mcL and is not a cause for concern.
Which action should the nurse implement to increase both the respiratory and the circulatory functions of a client in a coma? A. Encourage the client to cough. B. Massage the client's bony areas. C. Assist the client with breathing exercises. D. Change the client's position every two hours.
Answer: D A. A client in a coma is unable to respond to an instruction to cough. B. Massage increases circulation only in the localized area being massaged. In addition, massage should be performed around, not over, bony prominences. C. A client in a coma is unable to respond to an instruction to perform breathing exercises. D. Changing the client's position every 2 hours helps respirations by promoting drainage of secretions from lung segments and aerating lung tissue, which helps prevent airway obstruction and respiratory infections. Changing position helps circulation because activity increases blood flow and relieves local pressure.
Which should the nurse do first when caring for a nonverbal client who is restless, agitated, and irritable? A. Administer oxygen. B. Suction the oropharynx. C. Reduce environmental stimuli. D. Determine patency of the airway.
Answer: D A. Administering oxygen may or may not be necessary. The need for oxygen administration will depend on the results of other interventions that should be done first. B. Suctioning the oropharynx is premature. Mucus or sputum may not be the cause of the problem. C. Reducing environmental stimuli will serve no purpose at this time and is not the priority. D. Early signs of hypoxia are restlessness, agitation, and irritability resulting from reduced oxygen to brain cells. A partial or completely obstructed airway prevents the passage of gases into and out of the lungs. The ABCs (Airway, Breathing, Circulation) of emergency care identify airway as the priority.
A primary health-care provider prescribes oxygen for a client to be delivered at a high flow rate. Which additional nursing action is necessary when implementing a high-liter flow as opposed to a low-liter flow? A. Attaching a flowmeter to the wall outlet B. Providing oral hygiene whenever necessary C. Using an oil-based lubricant when caring for the nares D. Humidifying oxygen before it is delivered to the client
Answer: D A. All oxygen systems should have a flowmeter to control and maintain the flow of oxygen. B. All oxygen is drying to the oral mucosa. Therefore, oral hygiene should be provided frequently to moisten the mucous membranes. C. The use of an oil-based lubricant is unsafe because it is a volatile, flammable material in the presence of oxygen. A water-based lubricant should be used. D. A low-liter flow system administers a volume of oxygen designed to supplement the inspired room air to provide airflow equal to the person's minute ventilation (total volume of gas in liters exhaled from the lung per minute). A high-liter flow system administers a volume of oxygen designed to exceed the volume of air required for the person's minute ventilation. The low-liter flow system is less drying that the high-liter flow system, and humidification is unnecessary. A humidifier is a mechanical device that adds water vapor to air in a particle size that can carry moisture to the small airways.
Which clinical manifestation is of most concern when the nurse assesses a client who has impaired mobility? A. Shallow respirations B. Increased oxygen saturation C. Decreased chest wall expansion D. Gurgling sounds when breathing
Answer: D A. Although shallow respirations are a concern, they are not as serious as a clinical manifestation in another option. B. Oxygen saturation may be decreased, not increased, with immobility. C. Although decreased chest wall expansion is a concern, it is not as serious as a clinical manifestation in another option. D. Impaired activity contributes to accumulation of respiratory secretions in lung segments. Activity promotes drainage of secretions from lung segments and aerates lung tissue, thereby reducing the risk of airway obstruction and infection. respirations that sound gurgling (gurgles, rhonchi) indicate air passing through narrowed air passages because of secretions, swelling, or a tumor. A partial or total obstruction of the airway can occur, which is life-threatening.
An unconscious client who had oral surgery is admitted to the postanesthesia care unit. In which position should the nurse place the client? A. Prone B. Supine C. Fowler D. Lateral
Answer: D A. Although the prone position allows for drainage from the mouth, it is contraindicated because lying on the side of the face compresses oral tissues, impedes assessment, complicates oral suctioning, and may compromise the airway. B. The supine position is unsafe. In an unconscious client, the gag and swallowing reflexes may be impaired, increasing the risk for aspiration as well as letting the tongue fall to the back of the oropharynx, occluding the airway. C. The Fowler position is unsafe. An unconscious client is unable to maintain an upright position. D. The lateral position facilitates the flow of secretions out of the mouth by gravity, keeps the tongue to the side of the mouth, maintaining the airway, and permits effective assessment of the oropharynx and respiratory status.
A nurse is planning to teach one client pursed-lip breathing and another client diaphragmatic breathing. Which technique associated with diaphragmatic breathing is different from pursed-lip breathing and should be included by the nurse in the teaching plan? A. Inhale through the mouth. B. Exhale through pursed lip. C. Raise both shoulders while inhaling deeply. D. Tighten the abdominal muscles while exhaing.
Answer: D A. Inhalation is through the nose for both diaphragmatic and pursed-lip breathing. B. Exhalation through pursed lips is performed only with pursed-lip breathing. C. Raising both shoulders while breathing deeply is not part of diaphragmatic or pursed-lip breathing. The use of these accessory muscles of respiration is a compensatory mechanism that helps to increase thoracic excursion when inhaling. D. With diaphragmatic breathing, the contraction of abdominal muscles at the end of expiration helps to reduce the amount of air left in the lungs (residual volume).
A nurse teaches a client to make a series of short, forceful exhalations (huffing) just before actually coughing. Which information should the nurse include when explaining the purpose of this action? A. Conserves energy when coughing B. Limits pain precipitated when coughing C. Liquefies respiratory secretions when coughing D. Raises sputum to a level where it can be expectorated when coughing
Answer: D A. Regardless of the type of cough, coughing uses, not conserves, energy. However, after the airway is cleared of sputum, the client's oxygen demands will be met more effectively. B. Limiting pain precipitated by coughing is not the purpose of huff coughing. Coughing usually is not painful unless the thoracic muscles are strained or the client has had abdominal or pelvic surgery. C. An increased fluid intake, not coughing, liquefies respiratory secretions. D. The huff cough stimulates the natural cough reflex and is effective for clearing the central airways of sputum. Saying the word "huff" with short, forceful exhalations keeps the glottis open and raises sputum to a level where it can be coughed up and expectorated.
A primary health-care provider's prescription reads, "6 L oxygen via face mask." The client, who has been extremely confused since being in the unfamiliar environment of the hospital, becomes agitated and repeatedly pulls off the mask. Which should the nurse do? A. Tighten the strap around the head. B. Reapply the mask every time the client pulls it off. C. Provide an explanation of why the oxygen is necessary. D. Request that the prescription for oxygen be changed to a nasal cannula.
Answer: D A. Tightening the strap around the head is unsafe because it can compress the capillaries under the strap, which may interfere with tissue perfusion and result in pressure ulcers. B. Reapplying the mask every time the client pulls it off may increase the client's agitation and it is impractical. C. Providing an explanation of why the oxygen is necessary will probably be ineffective because an agitated client often does not understand cause and effect. D. Agitated, confused clients generally tolerate a nasal cannula better than a face mask. A nasal cannula (nasal prongs) is less intrusive than a mask. Masks are oppressive and may cause a client to feel claustrophobic.
A nurse in the operative suite is preparing an older adult for surgery. Which of the following physiological factors place the older adult at greater risk of life-threatening complications associated with surgery? Select all that apply. A. Skin elasticity B. Bladder emptying C. Tolerance for pain D. Respiratory excursion E. Cardiovascular capacity
Answer: D, E A. In older adults, atrophy and thinning of both the epithelial and subcutaneous layers of tissue occur, collagenous attachments become less effective, sebaceous gland activity decreases, and interstitial fluid decreases. These changes lead to decreased skin elasticity and the potential to take longer for an incision to heal. However, these are not life-threatening complications associated with surgery and the aging process. B. In older adults, bladder muscles weaken, bladder capacity decreases, the micturition reflex is delayed, emptying of the bladder becomes more difficulty, and residual volume increases. However, these are not life-threatening complications associated with surgery and age-related changes. C. In older adults, there is an increased threshold for sensations of pain, touch, and temperature because of age-related changes in the nerves and nerve conduction. This is not a life-threatening complication associated with surgery and the aging process. D. Age-related changes in older adults include calcification of costal cartilage (making the trachea and rib cage more rigid), an increase in the anteroposterior chest diameter, and weakening of thoracic muscles. These changes decrease respiratory excursion, which can result in multiple life-threatening postoperative complications such as atelectasis and hypostatic pneumonia. E. In older adults, there is a decrease in functioning capacity of the heart and vascular system. Atherosclerosis of the aorta, coronary arteries, and carotid arteries could decrease cardiac output, impair circulation to vital organs and distal extremities, and increase the workload of the heart at times of stress. These age-related changes are associated with life-threatening dysrhythmias, thrombophlebitis, and pulmonary emboli.
