NURS 3111 Exam ? Ch 39
a) Fine crackles to the bases of the lungs bilaterally Pg. 1499 Except in the case of infants, fine crackles always constitute an abnormal assessment finding. A respiratory rate of 18 is within acceptable range. Vesicular sounds over peripheral lung fields and resonance on percussion are expected assessment findings.
1. The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal? a) Fine crackles to the bases of the lungs bilaterally b) Respiratory rate of 18 breaths per minute c) Vesicular breath sounds audible over peripheral lung fields d) Resonance on percussion of lung fields
c) Nasal cannula Pg. 1509 A nasal cannula is ideal for administering low concentrations of oxygen to clients who are not extremely hypoxic or have chronic lung disease. The client does not have a tracheostomy. A simple mask is used to administer higher levels of oxygen than 2 L/min. A face tent is used without a mask.
10. The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client? a) Tracheostomy collar b) Simple mask c) Nasal cannula d) Face tent
a) True Pg. 1513-1514 After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A nurse caring for a client with a chest tube should monitor the patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.
11. After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. a) True b) False
a) Crackles Pg. 1489-1494 Crackles are soft, high-pitched, discontinuous sounds. Wheezes are a whistling or rattling sound in the chest as a result of obstruction in the air passages. Rales are small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person breathes in (inhales). Vesicular breath sounds are heard across the lung surface.
12. The client demonstrates soft, high-pitched, discontinuous sounds in the left lower lobe of the lung. How will the nurse accurately document this finding? a) Crackles b) Rales c) Vesicular d) Wheezes
c) Respiratory rate and depth Pg. 1492 The client receiving opioids needs monitoring of the respiratory rate and depth to ensure that respiratory depression does not result in progressive respiratory issues, physiologic damage from respiratory depression, or loss of consciousness. The pulse, blood pressure, and urinary intake and output are not as important as respiratory status when administering opioids.
13. The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign? a) Apical pulse b) Orthostatic blood pressure c) Respiratory rate and depth d) Urinary intake and output
b) They are low-pitched, soft sounds heard over peripheral lung fields Pg. 1494 Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.
14. The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? a) They are soft, high-pitched discontinuous (intermittent) popping lung sounds b) They are low-pitched, soft sounds heard over peripheral lung fields c) They are loud, high-pitched sounds heard primarily over the trachea and larynx d) They are medium-pitched blowing sounds heard over the major bronchi
c) Check the fit of the oxygen mask Pg. 1510-1511 The fit of the oxygen mask can be affected by the discontinuation of wearing dentures. The nurse should check the fit to make sure the client is getting the prescribed amount of oxygen. Other answers are inappropriate actions that do not address the problem.
15. The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate? a) Contact the oxygen supplier to request an oxygen tent b) Increase the flow of oxygen c) Check the fit of the oxygen mask d) Discontinue oxygen therapy until the client is reassessed by the healthcare provider
c) Distilled water Pg. 1503 Distilled water is used when humidification is desired. Other answers are incorrect.
16. The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier? a) Mineral oil b) Tap water c) Distilled water d) Normal saline
b) "An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist" Pg. 1503 The best way to explain caregiving is to describe the specific position and type of chair to use as well as teach the caregiver why it is the best position and device. Teaching the caregiver to place the parent at the sink and then stand outside the shower does not provide the best position nor the device to obtain, plus it does not address the facts that the parent standing in the shower may not be possible due to hypoxia and is not safe. Teaching the caregiver to use whichever position is most comfortable for the parent does not address the safest position for the client nor the position that provides easiest breathing and energy conservation. Standing for the period of time it may take to complete daily hygiene is not feasible or safe for the client and should not be recommended by the nurse.
17. A client is diagnosed with hypoxia related to emphysema. The client's adult child will be assisting the client with daily hygiene. How will the nurse explain positioning of the client to the caregiver? a) "A standing position works best to allow your parent to move around in the bathroom and to allow you to help your parent in and out of the shower" b) "An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist" c) "Place your parent at the sink to allow teeth brushing and stand outside of the shower to help if needed" d) "Whichever position helps your parent feel most comfortable and will allow you to help with hygiene is fine"
d) Crackles Pg. 1489-1494 Crackles, frequently heard on inspiration, are soft, high-pitched discontinuous (intermittent) popping sounds. Wheezes are continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors. Vesicular sounds are low-pitched, soft sounds heard over peripheral lung fields. Bronchovesicular sounds are medium-pitched blowing sounds heard over the major bronchi.
18. The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: a) Bronchovesicular b) Wheezes c) Vesicular d) Crackles
c) Chronic anemia Pg. 1487 The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the number of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissues of the body. Graves' disease, Parkinson's disease, and pancreatitis do not directly lead to a decrease in the number of red blood cells. Graves' disease is an immune system disorder that results in the overproduction of thyroid hormones (hyperthyroidism). Parkinson's disease (PD) is a neurodegenerative disorder that affects predominately dopamine-producing ("dopaminergic") neurons in a specific area of the brain called substantia nigra that causes a movement disorder. Pancreatitis is inflammation in the pancreas.
19. Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body? a) Parkinson's disease b) Pancreatitis c) Chronic anemia d) Graves' disease
b) Deep breathing Pg. 1502-1504 The nurse should teach deep breathing techniques to the client who is recovering from an injury and tends to breathe shallowly in order to help the client breathe more efficiently. Deep breathing is a technique for maximizing ventilation. Taking in a large volume of air fills alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing is a form of controlled ventilation in which the client consciously prolongs the expiration phase of breathing, which helps clients, especially with COPD, to eliminate more than the usual carbon dioxide from the lungs. It is used to increase the volume of air exchanged during inspiration and expiration. Incentive spirometry, a technique for deep breathing using a calibrated device, encourages clients to reach a goal-directed volume of inspired air; however, it is not always recommended for routine prophylactic use in postoperative adult and pediatric clients. Diaphragmatic breathing is breathing that promotes the use of the diaphragm rather than the upper chest muscles. It is used to increase the volume of air exchanged during inspiration and expiration in client with COPD.
2. During the physical assessment of a client who has been inactive due to a leg injury, the nurse notes that the client tends to breathe very shallowly. What technique should the nurse teach the client in order to breathe more efficiently? a) Incentive spirometry b) Deep breathing c) Pursed-lip breathing d) Diaphragmatic breathing
a) Atelectasis Pg. 1485-1529-1544 Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize atelectasis. Immobility is not commonly implicated in cases of pneumothorax or hemothorax. A pneumothorax is a collapsed lung. Hemothorax is a collection of blood in the space between the chest wall and the lung. Tachypnea, if present, would likely be a sign of atelectasis rather than an independent finding.
20. A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for: a) Atelectasis b) Pneumothorax c) Tachypnea d) Hemothorax
d) Educating the client on the use of incentive spirometry Pg. 1503 Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.
21. A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery? a) Oropharyngeal suctioning twice daily b) Administration of inhaled corticosteroids c) Educating the client on pursed-lip breathing techniques d) Educating the client on the use of incentive spirometry
d) "Small water droplets come from this, thus preventing dry mucous membranes" Pg. 1503 The humidifier produces small water droplets which are delivered during oxygen administration to prevent or decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen.
22. The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier? a) "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed" b) "This is a gauge used to regulate the amount of oxygen that a client receives" c) "The humidifier prescribes the concentration of oxygen" d) "Small water droplets come from this, thus preventing dry mucous membranes"
a) Tracheostomy collar Pg. 1517 A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. Other devices are not appropriate for this client.
23. The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select? a) Tracheostomy collar b) Face tent c) Simple mask d) Nasal cannula
a) Flow meter Pg. 1496 In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. A humidifier is a device that produces small water droplets and may be used during oxygen administration because oxygen dries the mucous membranes. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen.
24. During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? a) Flow meter b) Oxygen analyzer c) Nasal cannula d) Humidifier
c) Croup Pg. 1489-1490 Croup and epiglottitis are common in young children. The child has an obstruction of the upper airways, with swelling of the throat tissue. Atelectasis results when the lungs collapse as a result of the alveoli being unable to expand. Symptoms include difficulty breathing and discomfort. Pulmonary fibrosis is a condition in which the lung tissue becomes stiff and unable to expand appropriately. Asthma is a condition associated with bronchoconstriction. The symptoms include nonproductive cough, dyspnea, and wheezing.
25. A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from: a) Asthma b) Atelectasis c) Croup d) Pulmonary fibrosis
d) Tracheostomy collar Pg. 1517 A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. All other devices are less appropriate for this client.
26. The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? a) Nasal cannula b) Simple mask c) Face tent d) Tracheostomy collar
c) Nasal cannula Pg. 1532-1534 A nasal cannula is used to deliver from 1 L/min to 6 L/min of oxygen. Masks are used with higher flow rates of oxygen.
27. A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs? a) Partial rebreather mask b) Nonrebreather mask c) Nasal cannula d) Simple mask
b) "Is your mask causing discomfort?" Pg. 1535 It is possible for anyone using a mask to try and readjust it if it is uncomfortable. Depending on the older adult's cognitive status, he or she may have tried to make it more comfortable and in the process caused it to no longer fit correctly. This could also occur if the client removed their dentures, as some individual's choose to let the dentures soak overnight. If the mask was fitted with the dentures in, the mask will likely be loose with the dentures removed. The other questions could possibly be asked to see if someone else may have tried to help the client feel more comfortable with the mask on.
28. An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize? a) "Did someone take your mask off?" b) "Is your mask causing discomfort?" c) "Did you remove your dentures?" d) "Did someone loosen the straps on your mask?"
a) Pulse oximetry Pg. 1496 Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.
29. A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client? a) Pulse oximetry b) Peak expiratory flow rate c) Thoracentesis d) Spirometry
c) Nasal cannula Pg. 1509 The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Nonrebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.
3. A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client? a) Face tent b) Simple mask c) Nasal cannula d) Nonrebreather mask
b) Rotate the airway 180 degrees as it passes the uvula d) Wash hands and put on PPE, as indicated f) Remove airway for a brief period every 4 hours or according to facility policy Pg. 1515 The nurse will come into contact with respiratory secretions during the insertion of the oral airway, making it necessary to wear appropriate PPE. The airway will need to be rotated 180 degrees as it passes the uvula because the airway is more easily inserted with the curved tip pointing up towards the roof of the mouth. The airway should be removed for brief periods every 4 hours (or according to facility policy) to prevent constant pressure on the surrounding structures. The airway should reach from the opening of the mouth to the back angle of the jaw. The client should be positioned in a semi-Fowler's position to ease insertion of the airway.
30. Which actions should a nurse perform when inserting an oropharyngeal airway? Select all that apply. a) Insert the airway with the curved tip pointing down toward the base of the mouth b) Rotate the airway 180 degrees as it passes the uvula c) Use an airway that reaches from the nose to the back angle of the jaw d) Wash hands and put on PPE, as indicated e) Position client flat on his or her back with the head turned to one side f) Remove airway for a brief period every 4 hours or according to facility policy
a) Maintain the client's oxygenation and alert the health care provider immediately Pg. 1542-1547 If the tracheostomy becomes dislodged and is not easily replaced, the nurse should notify the primary care provider immediately, cover the tracheostomy stoma, and assess client's respiratory status.
31. The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response? a) Maintain the client's oxygenation and alert the health care provider immediately b) Cover the tracheostomy stoma and apply oxygen by nasal cannula c) Assess the client's respiratory status and check vital signs every 1 minute for the next hour d) Page the respiratory therapist STAT
b) Clubbing Pg. 1485 Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many clients with chronic hypoxia due to respiratory or cardiac disease. Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD. Hemoptysis, edema, and diarrhea do not result from hypoxia.
32. The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia? a) Hemoptysis b) Clubbing c) Edema d) Diarrhea
a) Pattern of thoracic expansion Pg. 1494 The nurse can assess patterns of thoracic expansion through palpation. Fluid-filled and consolidated portions of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation.
33. While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique? a) Pattern of thoracic expansion b) Presence of pleural rub c) Consolidated portions of the lung d) Fluid-filled portions of the lung
a) Bronchospasm Pg. 1491-1492 When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm.
34. A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing: a) Bronchospasm b) Bronchiolitis c) Bronchitis d) Bronchiectasis
a) Ask the client what factors contribute to nonadherence Pg. 1512 The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment. Then, the nurse can work with the health care provider to find alternate treatment options if necessary, and then document the care.
35. A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention? a) Ask the client what factors contribute to nonadherence b) Contact the health care provider to report the client's current status c) Explain the use of a BiPAP mask instead of a CPAP mask d) Document outcomes of modifications in care
a) Nasal cannula Pg. 1509 Nasal cannula and tubing administer oxygen concentrations at 22% to 44%.
4. A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered? a) Nasal cannula b) Venturi mask c) Simple oxygen mask d) Partial rebreather mask
d) A client taking opioids for cancer pain Pg. 1492 Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Amlodipine is a calcium channel blocker and the medication decreased blood pressure, so the nurse would need to assess blood pressure. Antibiotics are used for urinary tract infections as well as other infections and the infections do not affect the respiratory system. Insulin decreases blood sugar which a person with diabetes may need to take every day. Insulin does not affect the respiratory system.
5. In which client would the nurse assess for a depressed respiratory system? a) A client taking insulin for diabetes b) A client taking amlodipine for hypertension c) A client taking antibiotics for a urinary tract infection d) A client taking opioids for cancer pain
d) Cyanosis Pg. 1492 Cyanosis around the lips indicates serious hypoxemia. Cyanosis is caused by a desaturation of oxygen on the hemoglobin in the blood. Hypercapnia is caused by an abnormally high carbon dioxide level in the blood. Hypoxemia is caused by low oxygen levels in the blood. Eupnea is easy, free respiration.
6. A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario? a) Eupnea b) Hypoxemia c) Hypercapnia d) Cyanosis
c) Monitor blood pressure and blood sugar Pg. 1507 Blood pressure and blood glucose levels may rise while taking corticosteroids and levels should be measured. The sodium intake should be decreased and not increased while taking corticosteroids. This medication will not cause drowsiness and may have the effect of sleeplessness. The best time to weigh yourself is first thing in the morning when rising.
7. A client is prescribed a corticosteroid for the treatment of asthma after having an asthma attack. What education should the nurse provide to the client regarding the administration of this medication? a) This medication may cause drowsiness and should be used with caution while driving b) Increase sodium intake while taking this medication c) Monitor blood pressure and blood sugar d) Weigh yourself each night prior to going to bed
c) "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly" Pg. 1503 Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.
8. The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? a) "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling" b) "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly" c) "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly" d) "Take in a small amount of air very quickly and then exhale as quickly as possible"
c) It decreases dry mucous membranes via delivering small water droplets Pg. 1490 The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration.
9. Which teaching about the humidifier is important for the nurse to provide to a client using oxygen? a) It prescribes oxygen concentration b) It determines whether the client is getting enough oxygen c) It decreases dry mucous membranes via delivering small water droplets d) It regulates the amount of oxygen received