Gas Exchange

A nurse is performing chest physiotherapy on a client who has a respiratory infection. To increase the velocity and turbulence of the air the client exhales, which of the following techniques should the nurse use?

Vibration

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first?

Auscultate lung fields.

A nurse is caring for a client 1 day postoperative who has developed atelectasis. Which of the following manifestations is an expected finding for this condition?

Hypoxemia

A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect?

Intercostal retractions

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider?

Movement of the trachea toward the unaffected side

A nurse in the intensive care unit is providing teaching for a client prior to removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching?

"Avoid speaking for long periods."

A nurse is providing teaching to the parents of a 1 week old infant who has a prescription for home oxygen and pulse oximetry monitoring. Which of the following statements by the parents indicates a need for further teaching?

"We will rotate the probe of the pulse oximeter every 24 hours."

A nurse is caring for a client who is receiving heparin 3,800 units subcutaneous daily. Available is heparin 5,000 units/mL. How many mL should the nurse administer? (Round the answer to the nearest tenth.)

0.8 mL

A nurse is completing the admission assessment of a newborn. Which of the following anatomical landmarks should the nurse use when measuring the newborn's chest circumference?

Nipple line

A nurse is preparing to administer a continuous heparin infusion at 1600 units/hr. Available is heparin 25,000 units in dextrose 5% in water (D5W) 500 mL. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

32 mL/hr

A nurse is assessing a newborn 1 hr after birth. Which of the following respiratory rates is within the expected reference range for a newborn?

48/min

A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which of the following?

480 mL

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having an increased risk of aspiration while eating? (Select all that apply.)

A client who has had a cerebrovascular accident A client who is 4 hr postoperative following a leg amputation with general anesthesia A client who has had radiation therapy for head and neck cancer

A nurse is planning care for a child who has cystic fibrosis and a prescription to receive chest physiotherapy (CPT). Which of the following actions should the nurse plan to take?

Administer albuterol prior to CPT.

A nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first?

Administer oxygen therapy.

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take?

Administer oxygen via nasal cannula.

A nurse is preparing to admit a client to the PACU who received a competitive neuromuscular blocking agent. Which of the following items should the nurse place at the client's bedside?

Bag valve mask device

A nurse is caring for a client who reports that he has a headache and vertigo after turning on his furnace for the first time this season. The nurse should suspect which of the following conditions?

Carbon monoxide poisoning

A nurse is caring for a client who is receiving a continuous IV infusion of heparin. Which of the following actions should the nurse take?

Check the activated partial thromboplastin time (aPTT) every 4 hr.

A nurse is caring for a client who is postoperative and has a prescription for antiembolic stockings. Which of the following actions should the nurse take?

Check the stockings for wrinkles.

A nurse is preparing to provide tracheostomy care for a client who has a nondisposable tracheostomy tube. Which of the following equipment should the nurse plan to use? (Select all that apply.)

Clean gloves Sterile cotton-tipped applicators Sterile basin

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration?

Continue to monitor the client.

A nurse is caring for an older adult client who had a femoral head fracture 24 hr ago and is in skin traction. The client reports shortness of breath and dyspnea. The nurse should suspect that the client has developed which of the following complications?

Fat embolism

A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect?

Decreased serum calcium level

A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention?

Development of subcutaneous emphysema

A nurse is caring for a client who has a closed suction drain. Which of the following actions should the nurse take? (Select all that apply.)

Empty the collection chamber using sterile technique.

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions?

Encourage the client to increase fluid intake.

A nurse is caring for a client who has multiple long bone fractures caused by a motor-vehicle crash that happened 24 hr ago. The client tells the nurse he is short of breath and experiencing chest pain. The nurse should assess the client further for which of the following potential complications?

Fat embolism syndrome

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following?

Flail chest

A nurse is caring for a client who has a newly inserted chest drainage system with a water seal. Which of the following actions should the nurse take?

Keep the collection device below the level of the client's chest.

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take?

Perform pre-oxygenation prior to suctioning.

A nurse is preparing to administer an intramuscular (IM) injection of meperidine to a client. Which of the following is the priority assessment the nurse should complete?

Respiratory rate

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse take to reduce the risk for ventilator-associated pneumonia?

Rinse the client's mouth with an antimicrobial solution every 4 hr.

A nurse is caring for a client who has a tracheostomy. Which of the following interventions should the nurse implement when performing tracheostomy care?

Secure new tracheostomy ties before removing old ones.

A nurse in a critical care unit is caring for a client who is postoperative following a right pneumonectomy. After extubation from the ventilator, in which of the following positions should the client be placed?

Semi-Fowler's

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.)

Severe dyspnea Decreased level of consciousness Headache Hypotension

A nurse is assessing a client who has hypoxia. Which of the following findings should the nurse expect?

Tachycardia

A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take?

Verify that the suction regulator is on and check the tubing for leaks.

A home health nurse is teaching a child's parents about endotracheal suctioning. Which of the following information should the nurse include in the teaching?

Apply suction for less than 10 seconds.

A nurse is planning care for a client who has quadriplegia. Which of the following actions should the nurse take to prevent a pulmonary embolism (PE)? (Select all that apply.)

Assess legs for redness. Apply elastic compression stockings. Perform passive range of motion exercises.

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first?

Assess the client's airway.

A nurse is assessing a client who is 2 days postoperative and auscultates bilateral breath sounds, but absent breath sounds in the bases. The nurse should suspect which of the following postoperative complications?

Atelectasis

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions?

Atelectasis

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?

Clear breath sounds

A nurse is assessing a client who has chronic respiratory insufficiency. Which of the following findings should the nurse expect as result of the long-term inadequate oxygenation?

Clubbing of the fingers

A nurse in a provider's office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment findings is a manifestation of pneumonia in the older adult client?

Confusion

A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication?

Continuous bubbling in the water-seal chamber

A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations?

Continuous bubbling in the water-seal chamber

The nurse is caring for a postoperative client who has a chest tube connected to suction and a water seal drainage system. Which of the following indicates to the nurse that the chest tube is functioning properly?

Fluctuation of the fluid level within the water seal chamber

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering?

Heparin

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication?

Increased respiratory rate from 18 to 44/min.

A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect?

Increasing dyspnea

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take?

Keep the drainage system below the level of the client's chest at all times.

A nurse is performing pulmonary hygiene for a client who has pneumonia and positions the client on his left side in Trendelenburg position. From which of the following lung segments should the nurse expect secretions to be mobilized with the client in this position?

Lateral segment of the right lower lobe

A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect?

Movement of the ET tube into the right main bronchus

A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded?

No fluctuations in the water seal chamber

A nurse is caring for a client with a tracheostomy. The client's partner has been taught to perform suctioning. Which of the following actions by the partner should indicate to the nurse a readiness for the client's discharge?

Performing the procedure independently

A nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first?

Provide high-flow oxygen.

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first?

Raise the head of the bed.

As part of an annual physical examination, a nurse is preparing a client to undergo a chest x-ray. Which of the following instructions should the nurse give the client prior to the procedure?

Remove all metal necklaces.

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take?

Repeat auscultation after asking the client to breathe deeply and cough.

A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take?

Reposition the client.

A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider?

Stridor

A nurse is performing tracheostomy care for a client and suctioning to remove copious secretions. Which of the following actions should the nurse take?

Suction two to three times with a 60-second pause between passes.

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes?

Suppress respiratory effort

A nurse is preparing to suction a client who has a tracheostomy. Identify the sequence of actions the nurse should take. (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)

First, the nurse should adjust the suction, then don sterile gloves. Next, the nurse should check the function of the suction catheter by suctioning a small amount of solution into the tubing, then ask a peer to hyperoxygenate the client using a manual resuscitation bag valve mask connected to oxygen. The nurse should insert the suction catheter without suction and then apply suction for no more than 10 seconds while rotating the catheter. Finally, the nurse should assess for clearance of secretions.

A nurse is assisting a provider with a sterile procedure and prepares to pour solution onto a piece of sterile gauze. In what order should the nurse perform the following steps when pouring sterile solution? (Move the steps on the left into the box on the right, placing them in the selected order of performance. Use all the steps.) Remove the bottle cap. Pick up the bottle with the label facing toward the palm. Perform hand hygiene. Pour 1 to 2 mL into a receptacle. Pour the solution onto the gauze. Place the bottle cap face-up on a clean surface.

Perform hand hygiene. Remove bottle cap. Place the bottle cap face-up on a clean surface. Pick up the bottle with the label facing toward the palm. Pour 1 to 2 mL into a receptacle. Pour the solution onto the gauze.

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan?

Place in a prone position.

A nurse is caring for a client who has a central venous catheter and suddenly develops chest pain, dyspnea, dizziness, and tachycardia. The nurse suspects air embolism and clamps the catheter immediately. What other action should the nurse take at this time?

Place the client on his left side in Trendelenburg position.

A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take?

Preoxygenate the client with 100% oxygen for up to 3 min.