Nurs1020 Important Oxygenation Questions EAQ (Exam 2)

Which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema? Prevents bronchial spasm Decreases air trapping in lung Improves alveolar surface area Strengthens diaphragmatic contraction

Decreases air trapping in lung Pursed-lip breathing provides positive pressure in the airways during expiration, prolonging expiration and decreasing the air trapping, which is characteristic of emphysema.

For a client with a chest tube, which action would the nurse take to check for the presence of subcutaneous emphysema ?

Palpate around the tube insertion sites for crepitus. Subcutaneous emphysema occurs when air leaks from the intrapleural space through the thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sound heard when tissues containing gas are palpated.

The nurse provides immediate postoperative care to a client. The client reports a sudden onset of shortness of breath and chest pain. Which action would the nurse take? Provide supplemental oxygen Administer intravenous morphine Prepare for endotracheal intubation Administer sublingual nitroglycerin

Provide supplemental oxygen

After the nurse has finished teaching a postoperative client about prevention of pulmonary embolism, which client statement indicates that the teaching has been effective? 'I will avoid crossing my legs.' 'Pillows placed under my knees will help avoid clots.' 'Three times every day I will massage my lower legs to get blood moving.'

'I will avoid crossing my legs.' Clients should avoid crossing the legs to prevent the constriction of blood flow in the lower leg, which can lead to deep vein thrombosis (DVT). When dislodged, DVT can become a pulmonary embolus. Pillows should not be placed under the knees because this constricts blood flow to and from the lower leg and increases risk for DVT. Activity, rather than staying immobile in bed, helps encourage blood flow. The lower legs should not be massaged because this action could dislodge a DVT that has formed.

Which antihypertensive medication class would the nurse identify as the likely cause of the cough in a client taking multiple medications for hypertension who develops a persistent, hacking cough? Thiazide diuretics Calcium channel blockers Direct renin inhibitors Angiotensin-converting enzyme (ACE) inhibitors

(ACE) inhibitors The ACE breaks down kinins. When ACE is inhibited, the increase of kinins in the lung can cause bronchial irritation, leading to the common adverse effect sometimes referred to as an ACE cough.

After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client experiences a sudden onset of cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. Which is the priority nursing action? Obtain vital signs. Administer oxygen. Notify the health care provider. Auscultate the client's lung sounds.

Administer oxygen. It is likely that the client is experiencing a fat embolus which is a known complication after a long bone fracture; oxygen reduces the surface tension of fat globules, reducing hypoxia. Vital signs should be taken after oxygen administration. Obtaining vital signs will delay an intervention that may help reduce the client's distress. Interventions should be initiated to help the client before taking the time to notify the health care provider. Auscultating the lungs is important, but the priority is to provide oxygenation.

Nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complication? Pleural effusion Pneumothorax Atelectasis

Atelectasis Atelectasis occurs after general anesthesia because of decreased respiratory depth and resulting collapse of alveoli. Its the complete or partial collapse of a lung or a section (lobe) of a lung.

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

Decreased sounds Because the right lung is collapsed with a right pneumothorax, the nurse would expect very decreased or absent breath sounds on the right. Crackles occur with movement of air through fluid, such as with pulmonary edema, and would not be expected with pneumothorax. Wheezes occur with air movement through narrowed airways and would not be heard when there is no air movement because of lung collapse. Vesicular sounds are the normal sounds heard with inspiration and expiration and would not be heard on the right side.

Which intervention would the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma? Apply a thoracic binder for support. Encourage coughing and deep breathing. Defer pain medication the first day after injury. Position the client face-down on a soft mattress.

Encourage coughing and deep breathing Atelectasis with impaired gas exchange is a major complication when clients use shallow breathing to avoid pain; coughing and deep breathing help mobilize secretions. Analgesics are essential to diminish pain caused by breathing and to help motivate the client to cough and to breathe deeply. The prone position may diminish breathing for both lungs and is contraindicated.

When a client who has had a thoracotomy develops respiratory acidosis, which action would the nurse take? Administer oral fluids. Encourage deep breathing. Increase the flow rate. Increase oxygen Perform nosatracheal suctioning.

Encourage deep breathing. Increase the flow rate. Hypoventilation because of pain is the usual cause of respiratory acidosis after chest surgery and the nurse would encourage deep breathing to help eliminate excess carbon dioxide. Increasing oxygen flow rate would be used to treat hypoxemia, but will not decrease carbon dioxide levels in the blood. Suctioning would help eliminate excessive secretions if the client was unable to cough effectively, but would not decrease carbon dioxide levels.

Which priority nursing intervention would the nurse implement when caring for a client with pneumonia? Increase fluid intake. Instruct client on breathing exercises and controlled coughing. Encourage client to ambulate as much as possible. Maintain a nothing-by-mouth (NPO) status.

Instruct client on breathing exercises and controlled coughing. For most clients, the most effective means of preventing fluid consolidation in the lungs with a diagnosis of pneumonia is to keep active by deep breathing and controlled coughing exercises. Increased fluid intake and ambulation are important aspects of care if not contraindicated, but they are secondary to deep breathing and coughing. Keeping the client NPO is not necessary; unless contraindicated, the client with pneumonia is usually offered the regular diet as tolerated.

Which statement must the nurse emphasize to the family when preparing a school-aged child with persistent asthma for discharge? A cold, dry environment is desirable. Limits should not be placed on the child's behavior. The health problem is gone when symptoms subside. Medications must be continued even when the child is asymptomatic.

Medications must be continued even when the child is asymptomatic. Rationale Children with persistent asthma must continue taking medications to keep them asymptomatic. Inhaled corticosteroids, long-acting β 2-agonists, and leukotriene modifiers are used as controller medications. Some environmental moisture is necessary for these children. Consistent limits should be placed on any child's behavior, regardless of the disease; a chronic illness does not remove the need for setting limits.

The nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange? Supine Orthopneic Low-Fowler Semi-Fowler

Orthopneic The orthopneic position is a sitting position that permits maximum lung expansion for gaseous exchange; it also enables the client to press the lower chest or abdomen against the overbed table, which increases pressure on the diaphragm to help with exhalation, reducing residual volume. Low-Fowler and semi-Fowler positions do not maximize lung expansion to the same degree as the orthopneic position.

The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning? Preoxygenate the client before suctioning. Employ gentle suctioning as the catheter is being inserted. Loosen the client's secretions before suctioning by instilling saline. Ensure that the cuff of the tracheostomy is inflated during suctioning.

Preoxygenate the client before suctioning. Administration of 100% oxygen for a few minutes before suctioning reduces the risk of hypoxia, the major complication of suctioning. Suction is applied as the catheter is withdrawn, not during insertion, to prevent hypoxia.

The nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise? Decreases chest pain Conserves energy Increases oxygen saturation Promotes elimination of CO 2

Promotes elimination of CO 2 Pursed-lip breathing increases positive pressure within the alveoli and makes it easier for clients to expel air from the lungs. This in turn promotes elimination of CO 2. It also helps clients slow their breathing pattern and depth with respirations. It does not decrease chest pain, conserve energy, or increase oxygen saturation.

Which inference would the nurse draw when crackles are heard while auscultating the lungs of a client admitted with severe preeclampsia?

Pulmonary edema may have developed. Pulmonary edema is associated with severe preeclampsia; as vasospasms worsen, capillary endothelial damage results in capillary leakage into the alveoli.

A client is admitted to the emergency department with a stab wound of the chest. Which is a priority nursing assessment? Level of pain Quality and depth of respirations Amount of serosanguinous drainage Blood pressure and pupillary response

Quality and depth of respirations The Airway, Breathing, Circulation, Disability, Exposure (ABCDE) approach is applicable in all clinical emergencies for immediate assessment and treatment. The approach likely improves outcomes by helping health care providers focus on the most life-threatening clinical problems. The concern is to identify a pneumothorax caused by the injury, which can be life threatening. Although important, pain is not a life-threatening symptom. Bleeding may accumulate in the pleural space, but it is inaccessible to direct observation. Excessive blood loss will cause a decreased blood pressure, but bleeding is indicated first by respiratory changes because the blood will accumulate in the pleural space; pupillary response is unaffected.

After percussing a client's posterior chest and hearing low-pitched hollow sounds over the whole chest, which term would the nurse use to document the finding? Dull Flat Tympanic Resonance

Resonance Resonance is a low-pitched hollow sound normally heard over the air-filled lungs during percussion in healthy individuals. Dullness is a medium-pitched "thud-like" sound that might be heard with problems like lung consolidation due to pneumonia. Flatness is a high-pitched and short duration sound that might be heard over a pleural effusion. Tympanic sounds are high-pitched and musical; tympany might be heard over a pneumothorax.

Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety? Respiratory acidosis Respiratory alkalosis Respiratory compensation Respiratory decompensation

Respiratory alkalosis Hyperventilation causes excess amounts of carbon dioxide (CO2) to be eliminated, causing respiratory alkalosis. Respiratory acidosis is caused by excess CO2 retained in the lungs from conditions such as hypoventilation or chronic obstructive pulmonary disease (COPD)

A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What would this behavior indicate to the nurse? The client's gag reflex has returned. The client is confused due to anesthesia. The client is nauseated and wants to vomit. The client's airway is becoming obstructed.

The client's gag reflex has returned. The ability to spit out the oral airway indicates that the normal gag reflex has returned, and the client can protect his or her airway

A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin reports tingling and numbness of the fingers and toes, and shortness of breath. The nurse identifies a U wave on the cardiac monitor. Which electrolyte imbalance is causing these clinical findings? Hypokalemia Hyponatremia Hyperglycemia Hypercalcemia

These are classic signs of hypokalemia that occur when potassium levels are reduced as potassium reenters cells with glucose.

Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the emergency department to a neurological trauma unit? Notifying the receiving unit of the transfer Having the client's records ready for the transfer Verifying that the family has been notified of the transfer Validating availability of a bag-valve-mask during the transfer

Validating availability of a BVM during transfer is vital in case respiratory distress, increased ICP compressed the brainstem, which contains the medulla, the respiratory center (Respiratory status is priority)