Intro HCC Exam 4

Which documentation would indicate nursing actions were effective in reducing breathing problems for a client? Select all that apply.

-Anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min -Lung sounds clear bilaterally with non-labored respirations noted

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?

84 mm Hg

The nurse is caring for a patient with COPD. The patient is receiving oxygen therapy via nasal cannula. The nurse understands that the goal of oxygen therapy is to maintain the patient's SaO2 level at or above what percent?

90%

The nurse is conducting the physical assessment of a client at the health care facility. The nurse uses the pulse oximetry technique to monitor the oxygen saturation in the client's blood. Which of the following pulse oximeter ranges indicates that the client is adequately oxygenated?

95% to 100%

A nurse uses observation to examine a patient's skin. Which patient would the nurse document as having cyanosis?

A patient whose skin is a dusky, bluish color

You are caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?

A puncture at the radial artery

What is the pH of gastric aspirate?

Acidic

A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; Pco2 48 mm Hg (6.4 kPa); Po2 58 mm Hg (7.7 kPa); HCO3 26 mEq/L (26 mmol/L). Which prescription should the nurse implement first?

Albuterol Nebulizer

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The decrease in pH exists because the client's lungs:

Are not able to blow off carbon dioxide.

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?

Arterial Blood Gases (ABGs)

If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment?

Bilateral lower lobes

Which of the following is a true statement regarding pharmacologic aspects of aging?

Change in gastric pH may affect absorption of medications

When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. How should the nurse should record the breathing pattern?

Cheyne-Stokes respiration.

A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform?

Count the rate of respirations.

The nurse is providing care for a 69-year-old male patient who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the patient's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. Which of the following should the nurse document the presence of?

Crackles

Which of the following is a late sign of hypoxia?

Cyanosis

After suctioning a client's tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent:

Depriving the client of sufficient oxygen supply.

A client has smoked most of his life and has labored respirations. He is experiencing:

Dyspnea

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

Flow meter

A child is admitted to the emergency department with dyspnea related to bronchospasms. The nurse should place the client in which position?

High Fowler's

Which of the following would be a potential cause of respiratory acidosis?

Hypoventilation

A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following?

Hypoxia

The nurse assesses a patient and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?

Hypoxia

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Light-headedness or paresthesia

The nurse is caring for a client with multiple organ failure who is in metabolic acidosis. Which pair of organs is responsible for regulatory processes and compensation?

Lungs and kidneys

A client in the emergency department reports that they have been vomiting excessively for the past 2 days. The client's arterial blood gas analysis shows a pH of 7.50, partial pressure of arterial carbon dioxide (PaCO2) of 43 mm Hg, partial pressure of arterial oxygen (PaO2) of 75 mm Hg, and bicarbonate (HCO3-) of 42 mEq/L. Based on these findings, the nurse documents that the client is experiencing which type of acid-base imbalance?

Metabolic alkalosis

The nurse is assessing an elderly client brought to the emergency department by her spouse. The spouse states, ?She is confused and had trouble when trying to take a breath.? The nurse would next implement which priority nursing intervention for this client who is experiencing these symptoms?

Obtain baseline vital signs and oxygen saturation

Which of the following terms is used to describe the inability to breathe easily except in an upright position?

Orthopnea

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

Partial pressure of arterial oxygen (PaO2)

The nurse is caring for a client with acute respiratory distress syndrome. What portion of arterial blood gas results does the nurse find most concerning, requiring intervention?

Partial pressure of arterial oxygen (PaO2) of 69 mm Hg

A nurse is providing end-of-life care to a terminally ill client. Which of the following actions should the nurse take to remove mucus and saliva from the client's mouth?

Perform suction in the client's mouth.

A physician stated to the nurse that the patient has fluid noted in the pleural space and will need a thoracentesis. The nurse would expect that the physician will document this fluid as which of the following?

Pleural effusion

A patient returns to the telemetry unit after an operative procedure. Which of the following diagnostic tests will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the patient?

Pulse oximetry

A patient vomits as a nurse is inserting his oropharyngeal airway. What would be the appropriate intervention in this situation?

Remove the airway, turn the client to the side and provide mouth suction, if necessary.

A client appears flushed and has shallow respirations. The arterial blood gas report shows the following: pH, 7.24; partial pressure of arterial carbon dioxide (PaCO2), 49 mm Hg (6.5 kPa); bicarbonate (HCO3-), 24 mEq/L (24 mmol/L). These findings are indicative of which acid-base imbalance?

Respiratory acidosis

A client who is being treated for pneumonia reports sudden shortness of breath. An arterial blood gas (ABG) is drawn, yielding the following values: pH 7.21, PaCO2 64 mm Hg, HCO3 = 24 mm Hg. What does the ABG reflect?

Respiratory acidosis

In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to what acid-base imbalance?

Respiratory acidosis

Which sign is an early indicator of hypoxia in the unconscious client?

Restlessness

A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance?

Returning bicarbonate to the body's circulation

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which of the following describes these sounds?

Rhonchi

A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3- 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which nursing clinical judgment should the nurse make?

The client is severely hypoxic.

The term for the volume of air inhaled and exhaled with each breath is:

Tidal volume

Knowing respiratory physiology is important to understand how the disease process can work within that system. Which hollow tube transports air from the laryngeal pharynx to the bronchi?

Trachea

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?

Use of accessory muscles

Upon auscultation of a patient's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?

Wheezes

The nurse is assessing a client with chronic obstructive pulmonary disease. The client weighs 200 lb (90.7 kg) and is 6 feet (183 cm) tall. Using the diagram shown here, how should the nurse describe the client's chest in the record in the health history?

barrel-shaped

The nurse is conducting a respiratory assessment of a 71-year-old patient who has been recently admitted to the hospital unit. Which of the following assessment findings should the nurse interpret as abnormal?

fine crackles to the bases of the lungs bilaterally

Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention?

oxygen saturation of 85%

When evaluating a client's arterial blood gases (ABGs), which value is consistent with metabolic alkalosis?

pH 7.48

A client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis?

pH, 7.25; PaCO2 50 mm Hg.

The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as

pleural friction rub

A neonate weighing 1,870 g with a respiratory rate of 46 breaths/minute, a pulse rate of 175 bpm, and a serum pH of 7.11 has received sodium bicarbonate intravenously. The drug has been effective if the neonate exhibits which finding?

resolves the metabolic acidosis

A client has these arterial blood gas values: pH, 7.30; PaO2, 89 mm Hg; PaCO2, 50 mm Hg; and HCO3-, 26 mEq/L. Based on these values, the nurse should suspect which condition?

respiratory acidosis

The physician has prescribed sodium chloride for a hospitalized 51-year-old client in metabolic alkalosis. Which nursing actions are required to manage this client? Select all that apply.

• Maintain intake and output records. • Document presenting signs and symptoms. • Compare ABG findings with previous results.