NUR 1018 - Gas exchange - adaptive Q's

Correct3 Restlessness and increase in pulse

A child had an emergency tracheotomy and is receiving humidified air through a tracheotomy collar. Which early clinical manifestations of hypoxia would alert the nurse to suction the tracheotomy? Dyspnea and cyanosis 2 Agitation and diaphoresis 3 Restlessness and increase in pulse 4 Severe substernal retractions and stridor

Correct4 Crackles at bases of the lungs

A client is admitted to the intensive care unit with pulmonary edema. Which clinical finding would the nurse expect when performing the admission assessment? 1 Weak, rapid pulse 2 Decreased blood pressure 3 Radiating anterior chest pain 4 Crackles at bases of the lungs

Correct3 Orthopneic

A client is experiencing dyspnea. In which position would the nurse place the client? 1 Sims 2 Supine 3 Orthopneic 4 Trendelenburg

Correct1 Assess the patency of airway.

A client is transferred to an acute care nursing unit after surgery. Which action of the nurse is most important and would be performed first? 1 Assess the patency of airway. 2 Ask if the client is comfortable. 3 Determine the level of consciousness. 4 Review the order for intravenous fluids

4 drain the fluid from the peritoneal cavity

A client receiving peritoneal dialysis develops symptoms of severe respiratory difficulty during the infusion of the dialysate solution. Which action would the nurse take? 1 Increase the rate of infusion. 2 Auscultate the lungs for breath sounds. 3 Place the client in a supine position. 4 Drain the fluid from the peritoneal cavity.

Correct4 It removes air from the pleural space

A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" Which information would the nurse provide about the purpose of the chest tube? 1 It checks for bleeding in the lung. 2 It monitors the function of the lung. 3 It drains fluid from the pleural space. 4 It removes air from the pleural space

Correct3 Teach the client to do pursed-lip breathing.

A client with an acute emphysema episode is dyspneic and anxious. To decrease the dyspnea, which action would the nurse take 1 Increase the client's oxygen intake. 2 Have the client breathe into a paper bag. 3 Teach the client to do pursed-lip breathing. 4 Check the client's vital signs

Correct3 High concentrations of oxygen eliminate the respiratory drive.

A client with emphysema reports increased shortness of breath and becoming increasingly anxious. The health care provider prescribes oxygen at 1 L/min via nasal cannula. The nurse recognizes that this prescription is appropriate for which reason? 1 The client does not need any more than 1 L/min. 2 High concentrations of oxygen cause alveoli to rupture. 3 High concentrations of oxygen eliminate the respiratory drive. 4 The oxygen at 1 L/min should be enough to diminish the anxiety

1 Oxygen Saturation 89%

An older client with shortness of breath is admitted to the hospital. The medical history reveals and a diagnosis of pneumonia 3 days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? 1 Oxygen saturation: 89% 2 Body temperature: 101°F 3 Blood pressure: 130/80 mm Hg 4 Respiratory rate: 26 beats/minute

1. Suction the nasopharynx so a patent airway can be maintained.

During the respiratory assessment of an 8-month-old infant, the nurse notes bronchial breath sounds over areas of consolidation, mild substernal retractions, profuse nasal mucus production, pallor, and a temperature of 102°F (38.9°C). Which action would the nurse take? 1.Suction the nasopharynx so a patent airway can be maintained. 2 Start an intravenous infusion to provide necessary fluids and electrolytes. Incorrect3 Call the respiratory therapist to start preparations for oxygen administration. 4 Administer an antipyretic for the fever

4 Assess the client's response to the mechanical ventilation

Endotracheal intubation and positive-pressure ventilation are instituted because of a client's deteriorating respiratory status. Which is an important nursing intervention? 1 Facilitate verbal communication. 2 Prepare the client for emergency surgery. 3 Maintain sterility of the ventilation system. 4 Assess the client's response to the mechanical ventilation.

1. Assess lung sounds and vital signs 2.Activate the ventilator hyper oxygenation setting 3. Insert catheter without applying suction 4. rotate catheter while suctioning is applied

In which order would the nurse take these actions when suctioning a client who is receiving mechanical ventilation through an endotracheal tube? 1. Activate the ventilator hyper oxygenation settings 2. Assess lung sounds and vital signs 3. rotate catheter while suctioning 4. insert catheter without suctioning

Correct4 Uncompensated respiratory acidosis

The arterial blood gases for a client with acute respiratory distress are pH 7.30, PaO 2 80 mm Hg (10.64 kPa), PaCO 2 55 mm Hg (7.32 kPa), and HCO 3 23 mEq/L (23 mmol/L). How would the nurse interpret these findings? 1 Hypoxemia 2 Hypocapnia 3 Compensated metabolic acidosis 4 Uncompensated respiratory acidosis

Correct4 Start a cool-mist humidifier close to the child

The nurse is providing discharge teaching for the parents of a child with acute laryngotracheobronchitis. Which would the nurse instruct the parents to do to control symptoms at home? 1 Mechanically induce vomiting. 2 Call a community emergency service. 3 Administer the prescribed antihistamine. 4 Start a cool-mist humidifier close to the child

3. Decreased sounds

When a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest? 1. Crackling 2. Wheezing 3. Decreased sounds 4. Vesicular sounds

Correct4 Continually assessing the respiratory status

Which action would be the priority for the nurse caring for a child with acute laryngotracheobronchitis? 1 Initiating measures to reduce fever 2 Ensuring delivery of humidified oxygen 3 Providing support to reduce apprehension 4 Continually assessing the respiratory status

Correct1 Pulse 104 beats/minute

Which assessment finding presents the highest risk for cardiac shock? Correct1 Pulse 104 beats/minute 2 Respirations 22 breaths/minute 3 Temperature 98.9°F (37.2°C) 4 Blood pressure 114/68 mm Hg

A. Severe respiratory distress

Which client would be triaged first based on condition? A. Severe respiratory distress B. Chest pain caused by trauma C. Hip fracture in older patient D. Cystitis

1 dyspnea

Which condition of the client with laryngeal trauma and hemoptysis stands first in the priority list? 1 Dyspnea 2 Aphonia 3 Hoarseness 4 Subcutaneous emphysema

4. nail thickening

Which factor may affect the accuracy of oxygen saturations obtained using pulse oximetry? 1 Fever 2 Obesity 3 Hypertension 4 Nail thickening

1 rest

Which nursing care plan is indicated for a child admitted to the hospital with pneumonia? 1 rest 2 exercise 3 nutrition 4 elimination

Correct4 Erythema

While assessing the client's skin, the nurse notices a skin condition. The nurse realizes the pathophysiology involves increased visibility of oxyhemoglobin caused by an increased blood flow due to capillary dilation. Which skin condition is associated with this client? Pallor 2 Vitiligo 3 Cyanosis 4 Erythema