NUR 102: Chapter 33: Oxygenation

A nurse is discussing ventilation and perfusion with a newly licensed nurse. The nurse should include in the discussion that the exchange of O2 and CO2 occurs at which of the following locations? 1. trachea 2. alveoli 3. diaphragm 4. bronchial tubes

ANS 2 1. allows air to move in and out 3. contracts and releases to facilitate ventilation 4. allow air to move in and out of the lungs

A nurse is assessing a client who has COPD. The nurse should identify that which of the following is an expected finding? 1. jugular vein distention 2. clubbing of the fingers 3. heart murmur 4. paradoxial breahting

ANS 2 vein distension is for fluid overload heart murmur is for aortic stenosis paradoxial breathing in irregular breathing occurs in chest traumas

Which blood level normally provides the primary stimulus for breathing? 1) pH 2) Oxygen 3) Bicarbonate 4) Carbon dioxid

ANS 4 Blood pH does not provide the stimulus for breathing. 2 Oxygen level does not provide the stimulus for breathing. 3 Bicarbonate level does not provide the stimulus for breathing. 4 Carbon dioxide (CO2) level provides the primary stimulus to breathe. High CO2 levels stimulate breathing to eliminate the excess CO2. A secondary, although important, drive to breathe is hypoxemia. Low blood O2 levels stimulate breathing to bring more oxygen into the lungs.

A nurse is teaching a client how to perform the purse-lipped breathing technique. Place the steps for purse-lipped breathing in the correct order. 1. relax the neck and shoulders 2. take a deep breath 3. inhale slowly through the nostrils 4. exhale slowly through the mouth 5. purse the lips

1, 2, 3, 5, 4

A nurse is caring for a client with a chest tube and is assessing the drainage. Which of the following findings should the nurse document? Select all that apply 1. Amount 2. odor 3. color 4. consistency

1, 3, 4 the nurse should measure the amount, color, and consistency of drainage in the chamber during each shift. These items must be documented to determine if the clients lung is healing properly Odor would not be documented unless a sample is collected. The chest tube drainage system is closed unit that does not emit an odor.

A nurse is caring for a client with OSA. Which of the following are manifestations of OSA. (Select all that apply) 1. loud snoring 2. restlessness 3. nausea 4. extreme daytime drowsiness 5. headache in the evening.

1,2,4 In clients with OSA, a partial or complete closure of the upper airway occurs during sleep. As a result, the client has apneic episodes that can last for longer than 10 seconds. Manifestations include a morning headache, extreme daytime drowsiness, loud snoring, and restlessness.

A client is experiencing hypoxia. Which of the following manifestation can a nurse expect to find in this client? 1. bradycardia 2. restlessness 3. hypotension 4. bradypnea

2 Hypoxia is caused by low blood O2 levels and restlessness is a common symptom. The client may also experience tachycardia, hypertension and tacypnea with hypoxia.

A client reports experiencing stress about their new diagnosis of CAD. Which of the following are manifestations of prolonged stress? 1. decreased BP 2. decreased HR 3. increased cortisol level 4. increased fat metabolism

3 Prolonged or unmangaged stress can raise BP by triggering the fight-or-flight response, which causes cortisol to be released from the hypothalamus of the brain. The HR will increase, which causes the heart to pump faster so that O2 is supplied to muscles, giving them the strength to react to the perceived threat. Increased cortisol levels and decreased metabolism of fat during stressful periods increase weight gain

A nurse is caring for a client who requires 1L of O2. Which of the following O2 delivery devices should the nurse expect to use? 1. nasal canula 2. nonrebreather mask 3. partial rebreather maske 4. simple face mask

ANS 1

A nurse is assessing a client who is being discharged. The nurse notes that the client has regular and quiet breathing. The nurse should identify this breathing pattern as which of the following? 1. normal breathing 2. kussmaul breathing 3. cheyne stokes breathing 4. apnea

ANS 1 2. resp are rapid and deep 3. periods of apnea, then deep and rapid breathing followed by slower breathing 4. absence of resp

The nurse examines the site of a client's tuberculin skin test as being 5 mm induration and documents that the test is positive. Which information in the client's history did the nurse use to make this clinical determination? 1) HIV positive 2) Type 2 diabetes mellitus 3) Lives in a skilled nursing facility 4) Recent immigrant to the United States

ANS 1 An induration of 5 mm is considered positive for the tuberculin skin test for the client who is HIV positive. 2 An induration of 10 mm is considered positive for the tuberculin skin test for the client who has diabetes. 3 An induration of 10 mm is considered positive for the tuberculin skin test for the client who lives in a skilled nursing facility. 4 An induration of 10 mm is considered positive for the tuberculin skin test for the client who is from a country having a high incidence of TB.

A nurse is caring for a client who had left sided heart failure. Which of the following findings should the nurse expect? 1. crackles in the lungs 2. edema of the lower extremities 3. a rapid irregular HR 4. a systolic murmur

ANS 1 Causes blood to back up into the pulmonary circulation 2. right sided heart failure 3. A fib 4. valve problem

. The nurse notes that a client has a prescription for a peak expiratory flow meter. For which health problem should the nurse prepare teaching for this client? 1) Asthma 2) Pneumonia 3) Emphysema 4) Pulmonary edema

ANS 1 Peak expiratory flow rate (PEFR) measures the amount of air that can be exhaled with forcible effort. Patients with asthma use PEFR monitoring to detect subtle changes in their condition, often before symptoms occur. 2 PEFR is not used for clients with pneumonia. 3 PEFR is not used for clients with emphysema. 4 PEFR is not used for clients with pulmonary edema.

9. What is the rationale for wrapping petroleum gauze around a chest tube insertion site? 1) Prevents air from leaking around the site 2) Prevents infection at the insertion site 3) Absorbs drainage from the insertion site 4) Protects the tube from becoming dislodged

ANS 1 Petroleum gauze creates a seal around the insertion site. Collapse of the lung can occur if there is a leak around the insertion site that causes loss of negative pressure within the system. Air leaks are one common cause of loss of negative pressure. 2 Petroleum gauze is not used to reduce infection. 3 Petroleum gauze is not used to absorb drainage from the insertion site. 4 Petroleum gauze does not protect the tube from becoming dislodged.

A nurse is assissting with the care of a client who has a chest tube. Which of the following actions should the nurse take? 1. monitor the client for subq emphysema 2. expect contiunous bubbling in the water seal chamber 3. keep the drainage system about the level of the clients chest 4. clap the chest tubing when the client ambulates.

ANS 1 This indicated a leak or blockage of the system, if continuous bubbling indicates an air leak in the tube system, drainage system should be below the clients chest to reduce risk of drainage flowing back, do not clamp the chest tube or will cause tension pneumothorax.

A nurse is collecting data from a client. Which of the following findings should the nurse identify as risk factors for heart disease? Select all that apply 1. a diet high in saturated fats 2. a hx of an overactive bladder 3. a hx of smoking for 25 years 4. a sedentary lifestyle 5. a waist circumference of 84cm

ANS 1, 3, 4 diet high in fats increased BP and cholesterol smoking increases BP and risk for heart disease lifestyle increases risk for heart disease

A patient with COPD has a pulse oximetry reading of 97%. What other finding would indicate adequate tissue and organ oxygenation? Select all that apply. 1) Normal urine output 2) Strong peripheral pulses 3) Clear breath sounds bilaterally 4) Normal muscle strength 5) Orientation

ANS 1,2,4,5 1. Impaired tissue oxygenation to the kidneys would result in abnormal kidney function (e.g., poor urine output). 2. Good peripheral circulation is characterized by strong peripheral pulses. 3. Adequacy of tissue oxygenation cannot be determined by assessing pulmonary ventilation alone; circulation must also be assessed. 4. Hypoxic limb tissue would result in abnormal muscle functioning (e.g., muscle weakness and pain with exercise). 5. If a patient is oriented, adequate oxygen is reaching the cerebrum.

. The nurse is counseling a 17-year-old girl on smoking cessation. What should the nurse include when teaching this client? Select all that apply. 1) "Keep healthy snacks or gum available to chew instead of smoking a cigarette." 2) "Don't tell your friends and family you are trying to quit, until you feel confident that you'll be successful." 3) "Plan a time to quit when you will not have many other demands or stressors in your life." 4) "Reward yourself with an activity you enjoy when you quit smoking." 5) "Spend time with friends who do not smoke."

ANS 1,3,4,5 1. Having something to chew (e.g., carrot sticks, gum, nuts, or seeds) can distract from the desire to smoke a cigarette. 2. People who are trying to quit smoking often are more successful when they are accountable to other people who are encouraging and supportive. 3. Setting a date to stop smoking and choosing a time of low stress are two strategies that help people be more successful with smoking cessation. 4. Self-reward for meeting goals is a form of positive reinforcement. 5. Identify friends who do not smoke and plan to spend time with them.

Which factor influences normal lung volumes and capacities? Select all that apply. 1) Age 2) Race 3) Body size 4) Activity level 5) Gender

ANS 1,3,4,5 1. Normal lung volumes and capacities vary with age. 2. Normal lung volumes and capacities are not impacted by race. 3. Normal lung volumes and capacities vary with body size. 4. Normal lung volumes and capacities vary with exercise level. 5. Men have greater lung volume and capacity for ventilation

. A client has a chest drainage system. What should the nurse include when teaching the client about this system? Select all that apply. 1) Perform frequent coughing and deep-breathing exercises. 2) Sit up in a chair but do not walk while the drainage system is in place. 3) Get out of bed without assistance as much as possible. 4) Immediately notify the nurse if experiencing increased shortness of breath. 5) Make sure the collection device is above the level of the chest tube insertion site

ANS 1,4 1. Patients should regularly perform coughing and deep-breathing exercises to promote lung reexpansion. 2. To promote lung reexpansion, the nurse should encourage the patient to be as active as the condition permits, rather than telling the patient not to walk. 3. Chest drainage systems are bulky, but patients with disposable systems can still get out of bed and ambulate. However, the patient will need assistance from one or two staff members to protect and monitor the system and to monitor responses to activity; the patient should not get out of bed without assistance. 4. If a patient with a chest drainage system becomes acutely short of breath, the patient should immediately notify the nurse so the nurse can check for occlusion of the system, which can result in a tension pneumothorax. 5. The chest drainage collection device should always be below the level of the chest tube insertion site.

. Which statement is accurate about nasotracheal suctioning? Select all that apply. 1) Apply suction for no longer than 10 to 15 seconds during a single pass. 2) Apply suction while inserting and removing the catheter. 3) Reapply oxygen between suctioning passes for ventilator patients. 4) Gently rotate the suction catheter as you remove it. 5) Allow intervals of at least 30 seconds between suctioning.

ANS 1,4,5 1. Limiting suctioning to 10 seconds or less and reapplying oxygen between suctioning passes prevent hypoxia. 2. Suction should be applied only while withdrawing the catheter. 3. Endotracheal suctioning is used when the patient is being mechanically ventilated, and most ventilator patients have in-line suctioning, so there is no need to reapply oxygen. 4. Suction should be applied using a continuing rotating motion to prevent trauma to the airway. 5. Each pass of suctioning should be separated by 30 seconds.

A nurse is reinforcing teaching with a client who has a new prescription for a CPAP machine to treat obstructive sleep apnea. Which of the following statements should the nurse include. 1. use the CPAP mask during the daytime 2. cover your nose with CPAP mask 3. medication to assist with breathing can be administered through the CPA machine 4. You will need supplemental O2 to use the CPAP machine.

ANS 2

A client is coughing and has bilateral rhonchi throughout the lung fields. Which nursing diagnosis is most appropriate for these assessment findings? 1) Impaired Gas Exchange 2) Ineffective Airway Clearance 3) Ineffective Breathing Pattern 4) Impaired Spontaneous Ventilation

ANS 2 1 Impaired Gas Exchange is the appropriate diagnosis if the patient is ventilating adequately but diffusion of gases across the alveolar-capillary membrane is impaired. 2 Ineffective Airway Clearance is the diagnosis used for the inability to maintain a clear airway. 3 Ineffective Breathing Pattern is the diagnosis used to describe inadequate ventilation, such as hypoventilation, hyperventilation, tachypnea, or bradypnea. 4 Impaired Spontaneous Ventilation is the diagnosis used to describe a condition in which a patient, as a result of decreased energy reserves, is unable to maintain breathing adequate to support life.

When using sterile technique to perform tracheostomy care of a new tracheostomy, which action is correct? 1) Apply sterile gloves. 2) Place the patient in semi-Fowler's position, if possible. 3) Clean the stoma under the faceplate with hydrogen peroxide. 4) Cut a slit in sterile 4 ｴ 4 gauze halfway through to make a dressing.

ANS 2 1 Two pairs of sterile gloves are needed: one pair for dressing removal and a clean pair for the rest of the procedure. 2 Semi-Fowler's position promotes lung expansion and prevents back strain for the nurse. 3 The stoma should be cleaned under the faceplate with sterile saline. 4 Never cut a 4 ｴ 4 gauze for the dressing because lint and fibers from the cut edge could enter the trachea and cause respiratory distress.

A nurse is caring for a client who is recieving supplemental oxygen for hypoxia. The nurse hsould identify that which of the following can cause hypoxia? 1. diabetic ketoacidosis 2. smoke inhalation 3. administration of a stimulant medication 4. right sided heart failure

ANS 2 1. this can cause hyperventilate 3. adminsitration of narcotics and benzodiazpines will cause this 4. this will cause peripheral edema

A nurse is auscultating a clients heart sounds and hears a low pitched whooshing or blowing sound over the apex of the heart. The nurse should identify that this indicates which of the following? 1. tacycardia 2. murmur 3. gallop 4. stroke volume

ANS 2 1. this is increase HR 3. additionals heart sounds of S3 or S4 4. amount of blood ejected from the ventricles.

. A client with pulmonary hypertension and right-sided heart failure has conversational dyspnea and shortness of breath. What is the first action the nurse should take? 1) Review and implement the primary care provider's prescriptions for treatments. 2) Perform a quick physical examination of breathing, circulation, and oxygenation. 3) Gather a thorough medical history, including current symptoms, from the family. 4) Administer oxygen to the patient through a nasal cannula.

ANS 2 Following a quick assessment, the nurse should then review and implement physician's orders. 2 The first action the nurse should take is to make a quick assessment of the adequacy of breathing, circulation, and oxygenation in order to determine the type of immediate intervention required. The nurse's assessment should include simple questions about current symptoms. 3 A more thorough medical history can be gathered once the patient's oxygenation needs are addressed. 4 Administering oxygen is not appropriate without knowing what treatments the primary care provider has prescribed.

A nurse is assessing a client who is recieving O2 therapy. The nurse should identify that which of the following can indicated O2 toxicity? 1. hypertension 2. ringing in the ears 3. fever 4. dilated pupils

ANS 2 Headache, disorientation and muscle twitching occur in O2 toxicity too hyperventilation and dyspnea occur in O2 toxcity shivering occurs blurred vision and double vision occurs

The nurse is caring for a patient who is experiencing dyspnea. Which position would be most effective if incorporated into the patient's care? 1) Supine 2) Head of bed elevated 80° 3) Head of bed elevated 30° 4) Lying on left side

ANS 2 Most patients with dyspnea cannot tolerate lying down. 2 Position affects ventilation. An upright or elevated position pulls abdominal organs down, thus allowing maximum diaphragm excursion and lung expansion. 3 The head of the bed should be higher to facilitate breathing. 4 Lying on the left side will not help with this patient's dyspnea.

A nurse is reinforicng teaching with a client who has a new prescription for an incentive spirometer. Which of the following instructions should the nurse include? 1. exhale into the incentive spirometer 2. use the incentive spirometer qhour while awake 3. hold your breath for 10seconds when using the incentive spirometer 4. use the incentive spirometer two times each session

ANS 2 Promotes lung expansion and mobilizes secretions

22. A client recovering from a respiratory infection is concerned about a new onset of diarrhea. What should the nurse assess in this client? 1) Last use of steroids 2) Amount of vitamin C ingested 3) Frequency of decongestant use 4) Use of over-the-counter antitussives

ANS 2 Steroids are not known to cause diarrhea. 2 Vitamin C in daily doses of 200 mg or more has not been found to prevent colds, but it has been shown to reduce the length and severity of symptoms. In amounts of 2,000 mg, it may cause diarrhea and gas. 3 Decongestants are not identified as causing diarrhea. 4 Antitussives are not identified as causing diarrhea.

A client with a tracheostomy being mechanically ventilated has a pulse oximetry reading of 85%, heart rate of 113 beats/min, and respiratory rate of 30 breaths/min. The client is restless, and crackles and rhonchi are auscultated over both lungs. Which action should the nurse take? 1) Call the respiratory therapist to check the ventilator settings. 2) Provide endotracheal suctioning. 3) Provide tracheostomy care. 4) Notify the physician of the patient's signs of fluid overload.

ANS 2 There is nothing that indicates the ventilator settings need to be adjusted. 2 Increased pulse and respiratory rates, decreased oxygen saturation, gurgling sounds during respiration, auscultation of adventitious breath sounds, and restlessness are signs that indicate the need for suctioning. Airways are suctioned to remove secretions and maintain patency. The patient's symptoms should subside once the airway is cleared. 3 There is no reason to complete tracheostomy care at this time. 4 The vital signs do not indicate fluid overload.

A nurse is assisting with planning care for a group of clients on cardiopulmonary unit. Which of the following clients should the nurse plan to see first? 1. a client who requires teaching about a new cholesterol lowering medication 2. a client who reports dyspnea when walking to the BR 3. a client who has a new diagnosis of aortic valve stenosis and needs a referral to a he cardiologist 4. a client who has asthma and is being discharged to home

ANS 2 Urgent vs non urgent approach, the client experiencing hypoxia due to inadequate O2, teaching is non urgent, a newly diagnosis is non urgent and client with asthma is non urgent

A nurse is reviewing the medical hx of a client who has heart disease and a narrowed valve. Which of the following findings should the nurse expect? 1. regurgitation 2. stenosis 3. muscle atrophy 4. hypotension

ANS 2 a client who has a heart disease and a narrowed valve to have stenosis. Stenosis will cause an enlarged or hypertrophied heart muscles and hypertension

A nurse is teaching a newly licensed nurse about pulmonary function tests. The nurse should include that which of the following is the vital capacity? 1. the volume of air inspired and expired with a regular breath 2. the maximum volume of air that is expired after a maximum inspiration 3. the amount of additional air that can be inspired after a regular inspiration 4. the amount of air in the lung after maximal inspiration

ANS 2 amount of air that is forcibly expelled after maximal inspiration. Tidal volume is 1 inspiratory reserve volume is 3 total lung capacity is 4

A nurse is teaching a client who has an abdominal incision about coughing and deep breathing. In which order should the nurse instruct the client to perform the following steps? 1. Exhale Slowly 2. Take a deep breath 3. Hold your breath for several seconds 4. Brace the incision with a pillow and try to cough deeply

ANS 2, 3, 1, 4 2.this promotes lung expansion 3. promotes lung expansion 1. promotes alveolar inflation 4. brace the incision for comfort and support and to cough clear secretions

. The nurse instructs the mother of a toddler on safety. What information about the toddler's developmental stage and factors that influence oxygenation should the nurse include? Select all that apply. 1) Frequent, serious respiratory infections 2) Airway obstruction from aspiration of small objects 3) Drowning in small amounts of water around the home 4) Development of asthma 5) Develop shortness of breath with extreme activity

ANS 2,3 1. As a toddler's respiratory and immune systems mature, the risk for frequent and serious infections is less than in infanthood. Most children recover from upper respiratory infections without difficulty. 2. Toddlers' airways are relatively short and small and may be easily obstructed, and they often put objects in their mouth as part of exploring their environment, thus increasing their risk for aspiration and airway obstruction. 3. Toddlers are at high risk for drowning in very small amounts of water around the home (e.g., in a bucket of water or toilet bowl). 4. The risk for developing asthma is not significantly influenced by the child's developmental stage. 5. Toddlers do not develop shortness of breath with extreme activity as a developmental issue.

For which condition is obesity associated with a higher risk of conditions that affect the pulmonary and cardiovascular systems? Select all that apply. 1) Reduced alveolar-capillary gas exchange 2) Lower respiratory tract infections 3) Sleep apnea 4) Hypertension 5) Dyspnea on exertion

ANS 2,3,4,5 1. Obesity does not cause reduced alveolar-capillary gas exchange. 2. The risk for respiratory infection increases because lower lung segments are poorly ventilated, and secretions are not removed effectively. 3. Excess neck girth and fat stores in the upper airway often lead to obstructive sleep apnea. 4. Obesity also increases the risk of developing atherosclerosis and hypertension. 5. Large abdominal fat stores press upward on the diaphragm, preventing full chest expansion and leading to hypoventilation and dyspnea on exertion.

A nurse is discussing atrial fib with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicated an understanding of atrial fib? 1. Atrial fib is caused by electrical signals that come from the ventricles 2. Afib caused a lower than expected HR 3. Afib is caused by electrical signals outside of the SA node 4. Afib causes diaphoresis is most clients

ANS 3 1. is this ventricular dysrthymias 2. causes a higher than expected HR 4. angina and myocardial infarction can cause diaphoresis

A client in labor after 32 weeks' gestation is eager to deliver. Which client statement indicates that teaching provided about fetal development was effective? 1) "The baby's lungs are well developed now, but he will be at increased risk for SIDS if I deliver early." 2) "We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early." 3) "If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening." 4) "Thanks for reassuring me; I was pretty sure there isn't much risk to the baby this far along in my pregnancy."

ANS 3 A premature infant's lungs are not well developed. 2 A premature infant is not at risk for developing sleep apnea. 3 Premature infants (younger than 33 weeks' gestation) are born before the alveolar surfactant system is fully developed. Therefore, they are at high risk for respiratory distress syndrome (RDS). RDS is characterized by widespread atelectasis (collapse of alveoli), usually related to a deficiency of surfactant that keeps air sacs open. 4 There is a risk that the infant's lungs will not be mature.

. The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which response indicates to the nurse that the medication is effective? 1) The amount of sputum decreases with each dose administered. 2) Cough is completely suppressed, and the patient is able to sleep through the night. 3) Dry, unproductive cough is reduced, but voluntary coughing is more productive. 4) Involuntary coughing produces large amounts of thick yellow sputum.

ANS 3 An antitussive does not reduce the amount of sputum produced. 2 An antitussive is not a cough suppressant. 3 Antitussives are cough suppressants that reduce the frequency of an involuntary, dry, nonproductive cough. Antitussives are useful for adults when coughing is unproductive and frequent, leading to throat irritation or interrupted sleep. 4 Expectorants help make coughing more productive.

Chest percussion and postural drainage would be an appropriate intervention for which condition? 1) Congestive heart failure 2) Pulmonary edema 3) Pneumonia 4) Pulmonary embolus

ANS 3 Chest physiotherapy is not effective for conditions that do not involve the development of airway secretions, including congestive heart failure. 2 Chest physiotherapy is not effective for conditions that do not involve the development of airway secretions, including pulmonary edema. 3 Chest physiotherapy moves secretions to the large central airways for expectoration or suctioning. 4 Chest physiotherapy is not effective for conditions that do not involve the development of airway secretions, including pulmonary embolus.

Which information provides the most reliable data about the effectiveness of airway suctioning? 1) The amount, color, consistency, and odor of secretions 2) The patient's tolerance for the procedure 3) Breath sounds, vital signs, and pulse oximetry before and after suctioning 4) The number of suctioning passes required to clear secretions

ANS 3 Information about the amount and appearance of secretions provides data about the likelihood of airway infection and/or inflammation. 2 Data about the patient's tolerance of suctioning provide information about the patient's overall condition. 3 Breath sounds, vital signs, and oxygen saturation levels before and after suctioning provide data about the effectiveness of suctioning. 4 The number of suctioning passes required to clear the secretions provides information about the amount of secretions present.

A patient has just had a chest tube inserted to dry-seal suction drainage. Which is a correct nursing intervention for maintenance? 1) Keep the head of the bed flat for 6 hours. 2) Immobilize the patient's arm on the affected side. 3) Keep the drainage system lower than the insertion site. 4) Drain condensation into the humidifier when it collects in the tubing

ANS 3 Maintain patient in semirecumbent position (head of bed elevated 30 to 45 degrees), not flat. This is extremely important to promote lung expansion, reduce gastric reflux, and prevent ventilator-associated pneumonia if the person is being mechanically ventilated. 2 Encourage the patient to move the arm on the affected side; if he cannot, perform passive range of motion. 3 The drainage system must be below the insertion site to prevent fluid flowing back into the pleural cavity and compromising the patient's respiratory status. 4 The fluid should not be drained into the humidifier because the patient's secretions may have contaminated it.

A nurse is caring for a client who has a hx of asthma and is wheezing. Which of the following actions should the nurse take first? 1. auscultate the lung sound 2. document the Resp rate 3. obtain O2 sat 4. check the capillary refill

ANS 3 Obtaining the O2 sat will determine the next intervention, the nurse can auscultate lung sounds after, document after and check the capillary refill after

A nurse is suctioning a clients tracheostomy using an open system. Which of the following actions should the nurse take? 1. use clean technique to perform the procedure 2. apply suction when inserting the catheter 3. administer 100% O2 before the procedure 4. suction the tracheotomy for 20 seconds each time.

ANS 3 Reduce risk for hypoxia, use a sterile technique, apply intermittent suction when withdrawing and apply suction for 10-15 seconds to reduce hypoxia.

because lung problems already exist. Which would be the best response to his statement? 1) "You should quit so your family does not get sick from exposure to secondhand smoke." 2) "You will need to use oxygen, but remember it is a fire hazard to smoke with oxygen in your home." 3) "Once you stop smoking, your body will begin to repair some of the damage to your lungs." 4) "You should ask your primary care provider for a prescription for a nicotine patch to help you quit."

ANS 3 The suggestion that the patient's family will become ill appears to be a scare tactic, which can be seen as coercive and would not be effective in motivating the patient to stop smoking. 2 The suggestion that oxygen is a fire hazard appears to be a scare tactic, which can be seen as coercive and would not be effective in motivating the patient to stop smoking. 3 The nurse's response should focus on correcting the patient's misinformation rather than on convincing him to stop smoking. Once a person stops smoking, the body begins to repair the damage. During the first few days, the person will cough more as the cilia begin to clear the airways. The coughing then subsides, and breathing becomes easier. Even long-time smokers can benefit from smoking cessation. 4 Although asking the primary care provider for a prescription may help the patient to stop smoking, it does not address the fact that he does not understand why he needs to stop smoking even though lung problems already exist.

A nurse is planning to measure the cardiac output of a client who had a myocardial infarction. Which of the following data should the nurse use to calculate the clients cardiac output? 1. resp rate 2. BP 3. stroke volume 4. vital capacity

ANS 3 cardiac output is a measurement of the volume of blood pumped by the left ventricle in 1 min.

Which intervention is likely to reduce the risk of postoperative atelectasis? Select all that apply. 1) Administer bronchodilators. 2) Apply low-flow oxygen. 3) Encourage coughing and deep breathing and coughing. 4) Administer pain medication. 5) Assist to move and reposition in bed.

ANS 3,4,5 1. Bronchodilators are not routinely prescribed as postoperative medication to prevent atelectasis. 2. Low-flow oxygen will not prevent atelectasis. 3. Once pain is controlled, encouraging patients to deep-breathe and cough will help mobilize secretions and prevent atelectasis. 4. Pain alters the rate and depth of respirations. Often, patients in pain breathe shallowly, which puts them at risk for atelectasis. Regularly assess all patients for pain. 5. Movement and repositioning helps prevent postoperative atelectasis.

. A client with a closed head injury has a respiratory pattern that progressively increases and then decreases in depth, followed by a period of apnea. What is this client's breathing pattern? 1) Biot's breathing 2) Kussmaul's respirations 3) Sleep apnea 4) Cheyne-Stokes respirations

ANS 4 1 Biot's respirations are irregular respirations of variable depth (usually shallow), alternating with periods of apnea. 2 Kussmaul's respirations are regular but increased in rate and abnormally deep respirations. 3 Sleep apnea is not a type of breathing pattern. 4 This respiratory pattern is known as Cheyne-Stokes respirations. It is often associated with damage to the medullary respiratory center or high intracranial pressure due to brain injury.

A patient with chronic obstructive pulmonary disease (COPD) is prescribed O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient? 1) Nonrebreather mask 2) Nasal cannula 3) Partial rebreather mask 4) Venturi mask

ANS 4 1 Rebreather masks are used when high concentrations of oxygen are required. 2 A nasal cannula administers oxygen in liters per minute and does not allow administration of a precise FIO2. 3 Rebreather masks are used when high concentrations of oxygen are required. 4 The Venturi mask is capable of delivering 24% to 50% FIO2. The cone-shaped adapter at the base of the mask allows a precise FIO2 to be delivered. This is very useful for patients with chronic lung disease.

A nurse is caring for a client who requires 7L of O2 to maintain O2 Sat. WHich of the following O2 delivery system should the nurse expect to use? 1. nasal cannula 2. nonrebreather mask 3. partial rebreather mask 4. simple face mask

ANS 4 5-8L on simple 1-4L on nasal 10-15L on nonrebreather and partial

A client has a nursing diagnosis of Ineffective Breathing Pattern identified on the care plan. What should the nurse expect when assessing this client? 1) Coughing 2) Cold extremities 3) Adventitious breath sounds 4) Respiratory rate of 8 breaths/min

ANS 4 Coughing would be the finding for the diagnosis of Ineffective Airway Clearance. 2 A variety of diagnoses would be appropriate for the finding of cold extremities. 3 Adventitious breath sounds would be the finding for the diagnosis of Ineffective Airway Clearance. 4 An Ineffective Breathing Pattern is used to describe inadequate ventilation, such as hypoventilation, hyperventilation, tachypnea, or bradypnea. A breathing rate of 8 breaths/min is what the nurse should expect to assess in this client.

While a patient is receiving hygiene care, the chest tube becomes disconnected from the water-seal chest drainage system (CDU). Which action should the nurse take immediately? 1) Clamp the chest tube close to the insertion site. 2) Set up a new drainage system and connect it to the chest tube. 3) Have the patient take and hold a deep breath while the nurse reconnects the tube to the CDU. 4) Place the disconnected end nearest the patient into a bottle of sterile water.

ANS 4 Do not clamp the chest tube because this can rapidly lead to a tension pneumothorax. 2 A new drainage system should be set up to decrease the risk of infection, but the immediate action is to place the disconnected end into a bottle of sterile water. 3 The new drainage system needs to be in place before asking the patient to take and hold a deep breath. 4 Recollapse of the lung can occur because of loss of negative pressure within the system. This is commonly caused by air leaks, disconnections, or cracks in the bottles or chambers. If any of these occur, the nurse should immediately place the disconnected end nearest the patient into a bottle of sterile water or saline to a depth of 2 cm to serve as an emergency water seal until a new system can be connected.

The nurse administers intravenous morphine sulfate to a patient for pain control. For which adverse effect should the nurse monitor this patient? 1) Decreased heart rate 2) Muscle weakness 3) Decreased urine output 4) Respiratory depression

ANS 4 Opioids do not have a major effect on heart rate. 2 Opioids do not impact muscle function. 3 Opioids do not influence urine output. 4 Opioids are potent respiratory depressants. Patients receiving opioids should be monitored for decreased rate and depth of respirations.

A client's pulse oximetry reading is 90%. What action should the nurse take first? 1) Raise the head of the bed. 2) Prepare to administer oxygen. 3) Notify the healthcare provider. 4) Move the sensor to another area

ANS 4 Raising the head of the bed is appropriate if the client is short of breath. There is no evidence that this client is experiencing dyspnea. 2 The client might need oxygen; however, more assessment is required. 3 The healthcare provider does not need to be notified yet. 4 The nurse should relocate the sensor to another body area. The hands may be cold or the elbow might be bent. The earlobe should be attempted before implementing any other actions.

A nurse is caring for a client who has atelectasis. The nurse should identify that which of the following substances is required to keep the clients alveoli from collapsing and causing atelectasis? 1. lymphatic fluid 2. oxygenated blood 3. synovial fluid 4. surfactant

ANS 4 is a lubricant to keep aveoli in the lungs from collapsing during exhalation, this can result in atelectaisis. Lymph fluid is required to remove toxins and wastes from the body, deoxygenated blood flows into the alveolar capillaries and synovial fluid requires to cushion movements in joints

A nurse is providing teaching for a client who has a prescription for home O2. Which of the following instructions should the nurse include? Select all that apply 1. post a No Smoking sign inside the home 2. attach oxygen containers to a fixed object 3. store spare O2 containers in a closet 4. notify the fire department that O2 is in the home 5. ensure O2 tubing is no longer than 60 feet in length.

ANS, 1,2,4

A nurse is performing chest percussion therapy on a client? Which of the following actions should the nurse take? 1. perform chest percussion therapy 6x/day 2. listen for a hollow sound when performing chest percussion therapy 3. use flat hands to perform chest percussion therapy 4. apply chest percussion therapy over the clients ribs.

ANS. 2 this indicated proper technique is being used to loosen the secretions

What is left sided heart failure and what are manifestations of this disease?

Left sided heart failure affects the left ventricle of the heart. The heart is unable to pump blood to the rest of the body. During physical activity a client may experience hypoxia, crackles, SOB, or coughing

Define the two types of valvular dysfunctions.

Regurgitation occurs when the heart valves leak and do not close. Stenosis is the narrowing of a heart valve.

What are expected respiration for an adult while resting?

Resp are between 12 and 20 breaths per minute for an adult at rest.

What is ride sided heart failure and what are manifestations of this disease?

Right sided heart failure affects the right ventricle of the heart. The heart is unable to pump blood to the lungs. Manifestations include edema in the genitals, organs or abdomen.

What is the importance of using an incentive spirometer?

To promote deep breathing. The nurse should teach the client to do 10 repetitions per hour and hold the breath for 3-5 seconds during each repetition