Oxygenation

ANS: A, B, D Hypertension, obesity, and excessive stress are all modifiable risk factors for coronary artery disease. Age is a nonmodifiable risk factor.

A nursing student learns about modifiable risk factors for coronary artery disease. Which factors does this include? (Select all that apply.) a. Hypertension b. Stress c. Age d. Obesity

ANS: D Hypoxia occurs because of decreased circulating blood volume, which leads to decreased oxygen to muscles, causing fatigue, decreased activity tolerance, and a feeling of shortness of breath.

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status?

ANS: A The incorrect options do not contain evidence of abnormal gas exchange values. Pallor, tachycardia, hypertension, and fever can occur with Impaired Gas Exchange but alone do not yield that nursing diagnosis. Bradycardia, lethargy, flushed, and hypothermia could be an option in unusual circumstances but are not the typical picture of Impaired Gas Exchange. Elevated bicarbonate, metabolic alkalosis, irritability, and pallor do not reflect gas exchange abnormalities.

A 12-year-old is being treated for acute respiratory distress syndrome. Which assessment finding would be indicative of the nursing diagnosis Impaired Gas Exchange? a. Oxygen saturation of 62% b. Heart rate of 100 bpm c. Respiratory rate of 30/minute d. Bicarbonate level of 38

ANS: A The medication in a metered-dose inhaler is sprayed into the spacer. The child can then inhale the medication without having to coordinate the spraying and breathing.

A 4-year-old child needing to use a metered-dose inhaler to treat asthma cannot coordinate her breathing to use it effectively. The appropriate intervention by nurse is to use which piece of respiratory equipment? a. A spacer b. A nebulizer c. A peak expiratory flow meter d. Chest physiotherapy

ANS: A All responses indicate conditions that are beneficial to the child. Respiratory distress and hypoxia cause anxiety as this vital life function is threatened. When anxiety improves, the nurse knows that the respiratory status must be improving as well even if signs and symptoms continue.

A 4-year-old child with croup is brought to the emergency department. The child is anxious and crying and has a high-pitched stridor, retractions, and a barky cough. After administration of cool mist therapy, which assessment finding would indicate significant improvement in the child's respiratory status? a. The child is less anxious. b. The respiratory rate is decreased. c. Wheezing is less loud. d. The child drinks 8 ounces of fluid.

ANS: A Aspirin causes an increase in carbon dioxide; the body compensates for this by increasing ventilations to blow off excess CO2. Hypoventilation would cause the body to retain even more carbon dioxide and therefore respiratory acidosis. Flail chest occurs with trauma to the chest wall. Shallow respirations would increase serum pH.

A 5-year-old who has strep throat was given aspirin for fever. The nurse knows to expect which change in the child's respiratory pattern? a. Hyperventilation to decrease serum levels of carbon dioxide b. Hypoventilation to compensate for metabolic alkalosis c. Flail chest to decrease the work of breathing d. Shallow respirations to decrease serum pH

ANS: A When the body cannot meet the increased oxygenation need, the increased metabolic rate causes breakdown of protein and wasting of respiratory muscles, increasing the work of breathing.

A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104°F (40°C). What physiological process explains why the child is at risk for developing dyspnea? a. Fever increases metabolic demands, requiring increased oxygen need. b. Blood glucose stores are depleted, and the cells do not have energy to use oxygen. c. Carbon dioxide production increases as result of hyperventilation. d. Carbon dioxide production decreases as a result of hypoventilation.

ANS: A Air trapping is not present in all cases of impaired gas exchange. Delayed development does not occur unless the condition is chronic or acutely damaging. The early phase of impaired gas exchange does not cause injury or dehydration, although fatigue can occur.

A child in the early stages of impaired gas exchange will often have which diagnosis as well? a. Anxiety related to hypoxia b. Fatigue related to air trapping c. Injury related to fatigue and dehydration d. Delayed Development related to hypoxia

ANS: D The forced expiratory volume measures the maximum amount of air that can be forcefully exhaled in the first second. This can provide an objective measure of pulmonary function compared with the child's baseline.

A child with asthma is having pulmonary function tests. Which phrase explains the purpose of the forced expiratory volume (FEV1)? a. It confirms the diagnosis of asthma. b. It determines the cause of asthma. c. It identifies the "triggers" of asthma. d. It assesses the severity of asthma.

ANS: D Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a. Obtain a new oximeter from central supply. b. Change the sensor on the pulse oximeter. c. Tell the client to take slow, deep breaths. d. Assess for other manifestations of hypoxia.

ANS: C A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best? a. "Maybe the client has respiratory distress syndrome." b. "Breathing so rapidly interferes with oxygenation." c. "The blood clot interferes with perfusion in the lungs." d. "The client needs immediate intubation and mechanical ventilation."

ANS: B The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs.

A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a. Assess the respiratory rate. b. Ensure a patent airway. c. Apply oxygen at 100%. d. Start two large-bore IV lines.

ANS: D Airway always is the priority. The other actions are important in this situation as well, but the nurse should stay with the client and ensure the airway remains patent (especially if vomiting occurs) while another person calls the provider (or Rapid Response Team) and facilitates getting an ECG done. Aspirin will probably be administered, depending on the provider's prescription and the client's current medications.

A client in the cardiac stepdown unit reports severe, crushing chest pain accompanied by nausea and vomiting. What action by the nurse takes priority? a. Notify the provider b. Call for an electrocardiogram (ECG) c. Administer an aspirin d. Maintain airway patency

ANS: B This client's physiologic parameters did not exceed normal during and after activity, so it is safe for the client to continue using the bathroom. There is no indication that the client needs oxygen, a commode, or a bedpan.

A client is in the hospital after suffering a myocardial infarction and has bathroom privileges. The nurse assists the client to the bathroom and notes the client's O2 saturation to be 95%, pulse 88 beats/min, and respiratory rate 16 breaths/min after returning to bed. What action by the nurse is best? a. Administer oxygen at 2 L/min b. Allow continued bathroom privileges c. Obtain a bedside commode d. Suggest the client use a bedpan

ANS: B Cholinergic antagonist drugs cause bronchodilation by inhibiting the parasympathetic nervous system. This allows the sympathetic nervous system to dominate and release norepinephrine that actives beta2 receptors. Bronchodilators relax bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors. Corticosteroids disrupt the production of pathways of inflammatory mediators. Cromones stabilize the membranes of mast cells and prevent the release of inflammatory mediators.

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic response to the medication? a. Bronchodilator - Stabilizes the membranes of mast cells and prevents the release of inflammatory mediators b. Cholinergic antagonist - Causes bronchodilation by inhibiting the parasympathetic nervous system c. Corticosteroid - Relaxes bronchiolar smooth muscles by binding to and activating pulmonary beta2 receptors d. Cromone - Disrupts the production of pathways of inflammatory mediators

ANS: A The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The nurse should document the finding, but the best action to take is to have the client start rinsing his or her mouth after using fluticasone. An oral specimen for culture and sensitivity will not provide information necessary to care for this client.

A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take? a. Encourage oral rinsing after fluticasone administration. b. Obtain an oral specimen for culture and sensitivity. c. Start the client on a broad-spectrum antibiotic. d. Document the finding as a known side effect.

ANS: C, E Suprasternal retraction caused by inhalation usually indicates that the client is using accessory muscles and is having difficulty moving air into the respiratory passages because of airway narrowing. Wheezing indicates a narrowed airway; a decreased pulse oxygen saturation also supports this finding. The asthma is not responding to the medication, and intervention is needed. Administration of a rescue inhaler is indicated, probably along with administration of oxygen. The nurse would not do a peak flow reading at this time, nor would a code be called. Midline trachea is a normal and expected finding.

A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.) a. Administer prescribed salmeterol (Serevent) inhaler. b. Assess the client for a tracheal deviation. c. Administer oxygen to keep saturations greater than 94%. d. Perform peak expiratory flow readings. e. Administer prescribed albuterol (Proventil) inhaler.

ANS: B, C, E Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat. The color of the client's sputum would not assist in determining activity tolerance. Asking whether the client walks upstairs every day is not as pertinent as determining if the client becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously.

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the client's activity tolerance? (Select all that apply.) a. "What color is your sputum?" b. "Do you have any difficulty sleeping?" c. "How long does it take to perform your morning routine?" d. "Do you walk upstairs every day?" e. "Have you lost any weight lately?"

ANS: D Tachycardia can indicate hypoxemia as the body tries to circulate the oxygen that is available. A barrel chest is not an emergency finding. Likewise, a pulse oximetry level of 92% is not considered an acute finding. The expiratory phase is expected to be longer than the inspiratory phase in someone with airflow limitation.

A nurse assesses several clients who have a history of asthma. Which client should the nurse assess first? a. A 66-year-old client with a barrel chest and clubbed fingernails b. A 48-year-old client with an oxygen saturation level of 92% at rest c. A 35-year-old client who has a longer expiratory phase than inspiratory phase d. A 27-year-old client with a heart rate of 120 beats/min

ANS: C The gene for AAT is a recessive gene. Clients with only one allele produce enough AAT to prevent chronic obstructive pulmonary disease (COPD) unless the client smokes. A client with two alleles is at high risk for COPD even if not exposed to smoke or other irritants. The client is a carrier, and children may or may not be at high risk depending on the partner's AAT levels. Contacting a genetic counselor may be helpful but does not address the client's current question.

A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, "What does this mean?" How should the nurse respond? a. "Your children will be at high risk for the development of chronic obstructive pulmonary disease." b. "I will contact a genetic counselor to discuss your condition." c. "Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke." d. "This is a recessive gene and should have no impact on your health."

ANS: A Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema. Inflammation in bronchi and bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is associated with left heart failure and is not caused by a 40-year smoking history.

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this client's history and clinical manifestations? a. Increased pulmonary pressure creating a higher workload on the right side of the heart b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c. Increased number and size of mucus glands producing large amounts of thick mucus d. Left ventricular hypertrophy creating a decrease in cardiac output

ANS: B Aspirin and other nonsteroidal anti-inflammatory drugs (NSAIDs) can trigger asthma in some people. This results from increased production of leukotriene when aspirin or NSAIDs suppress other inflammatory pathways and is a high priority given the client's history. Reviewing pulmonary function test results will not address the immediate problem of frequent asthma attacks. This is a good intervention for reviewing response to bronchodilators. Questioning the client about the use of bronchodilators will address interventions for the attacks but not their cause. Reviewing arterial blood gas results would not be of use in a client between attacks because many clients are asymptomatic when not having attacks

A nurse cares for a client with arthritis who reports frequent asthma attacks. Which action should the nurse take first? a. Review the client's pulmonary function test results. b. Ask about medications the client is currently taking. c. Assess how frequently the client uses a bronchodilator. d. Consult the provider and request arterial blood gases.

ANS: C Clients with severe COPD may not be able to perform daily activities, including bathing and eating, because of excessive shortness of breath. The nurse should ask the client if shortness of breath is interfering with basic activities. Although the nurse should know about the client's support systems, current knowledge, and medications, these questions do not address the client's appearance.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first? a. "Do you have a strong support system?" b. "What do you understand about your disease?" c. "Do you experience shortness of breath with basic activities?" d. "What medications are you prescribed to take each day?"

ANS: C Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. Encouraging a client to participate in activities without verbalizing concerns also would not be an effective strategy for decreasing social isolation.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond? a. "There are a variety of support groups for people who have COPD." b. "I will ask your provider to prescribe you with an antianxiety agent." c. "Share any thoughts and feelings that cause you to limit social activities." d. "Friends can be a good support system for clients with chronic disorders."

ANS: C Cystic fibrosis is an autosomal recessive disorder in which both gene alleles must be mutated for the disorder to be expressed. The nurse should encourage both the client and partner to be tested for the abnormal gene. The other statements are not true.

A nurse cares for a female client who has a family history of cystic fibrosis. The client asks, "Will my children have cystic fibrosis?" How should the nurse respond? a. "Since many of your family members are carriers, your children will also be carriers of the gene." b. "Cystic fibrosis is an autosomal recessive disorder. If you are a carrier, your children will have the disorder." c. "Since you have a family history of cystic fibrosis, I would encourage you and your partner to be tested." d. "Cystic fibrosis is caused by a protein that controls the movement of chloride. Adjusting your diet will decrease the spread of this disorder."

ANS: D Oxygen should be administered to a client who is hypoxic even if the client has COPD and is a carbon dioxide retainer. The other interventions do not address the client's hypoxia, which is the priority.

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results Vital Signs pH = 7.32 PaCO2 = 62 mm Hg PaO2 = 46 mm Hg HCO3- = 28 mEq/L Heart rate = 110 beats/min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Oxygen saturation = 76% Which action should the nurse take first? a. Administer a short-acting beta2 agonist inhaler. b. Document the findings as normal for a client with COPD. c. Teach the client diaphragmatic breathing techniques. d. Initiate oxygenation therapy to increase saturation to 92%.

ANS: C Up to the age of 6 years, children breathe primarily with their diaphragm. The intercostal muscles assist by increasing the chest diameter. When distress occurs, the intercostal muscles between the rib cage work with extra effort to move air through narrow airways. This causes retractions.

A nurse explains why a 4-year-old presenting with respiratory distress has retractions. Which statement by the parent indicates that the teaching was understood? a. "When distress occurs, children swallow air, leading to expansion of the rib cage and retractions." b. "Retractions occur in all children, because their ribs are soft and pliable. They are not related to respiratory distress." c. "Children breathe primarily with their diaphragm, but when distress occurs, the muscles between the rib cage work with extra effort to move air through narrow airways." d. "Children breathe primarily with the muscles between the ribs, so when distress occurs, the extra work of breathing causes retractions."

ANS: B The patient is experiencing cardiac distress for reasons unknown. The nurse should first secure the safety of the patient and decrease the workload on the patient's heart by putting him in a resting position; this will increase cardiac output by decreasing after load. Once the patient is stable, the nurse can obtain oxygen to put on the patient. Next, the nurse can begin to monitor the patient's oxygen and cardiac status. If necessary, the emergency team may be activated to defibrillate.

A nurse is assisting a patient with ambulation. The patient becomes short of breath and begins to complain of sharp chest pain. Which action by the nurse is the first priority? a. Call for the emergency response team to bring the defibrillator. b. Have the patient sit down in the nearest chair. c. Return the patient to the room and apply 100% oxygen. d. Ask a coworker to get the ECG machine STAT.

ANS: A, B, D The nurse can delegate assisting the client to get up in the chair or ambulate to the bathroom, applying TEDs or sequential compression devices, and taking/recording vital signs. The spirometer should be used every hour the day after surgery. Assessing pain using a 0-to-10 scale is a nursing assessment, although if the client reports pain, the UAP should inform the nurse so a more detailed assessment is done.

A nurse is caring for a client who had coronary artery bypass grafting yesterday. What actions does the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) a. Take and record a full set of vitals per hospital protocol. b. Assist the client to the chair for meals and to the bathroom c. Have the client rate pain on a 0-10 scale and report to the nurse d. Ensure the client wears TED hose or sequential compression devices

ANS: A Fever increases the metabolic demands of the body, increasing production of carbon dioxide. The body hyperventilates to get rid of excess carbon dioxide. Anxiety can cause hyperventilation, but this is not the direct cause from a fever. Hyperventilation decreases the drive to breathe. The cause of the fever in this question is unknown.

A nurse is caring for a patient whose temperature is 100.2° F. The nurse expects this patient to hyperventilate owing to a. Increased metabolic demands. b. Anxiety over illness. c. Decreased drive to breathe. d. Infection destroying lung tissues.

ANS: C Clients with CF often are malnourished due to vitamin deficiency and pancreatic malfunction. Maintaining nutrition is essential. Daily antibiotics and daily exercise are not essential actions. Genetic screening would not help the client manage CF better.

A nurse is teaching a client who has cystic fibrosis (CF). Which statement should the nurse include in this client's teaching? a. "Take an antibiotic each day." b. "Contact your provider to obtain genetic screening." c. "Eat a well-balanced, nutritious diet." d. "Plan to exercise for 30 minutes every day."

ANS: A, B, D Interventions to decrease thick tenacious secretions include maintaining adequate hydration and providing humidified oxygen. These actions will help to thin secretions, making them easier to remove by coughing. The use of a vibrating positive expiratory pressure device can also help clients remove thick secretions. Although suctioning may assist with the removal of secretions, frequent suctioning can cause airway trauma and does not support the client's ability to successfully remove secretions through normal coughing. Diaphragmatic breathing is not used to improve the removal of thick secretions.

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Ask the client to drink 2 liters of fluids daily. b. Add humidity to the prescribed oxygen. c. Suction the client every 2 to 3 hours. d. Use a vibrating positive expiratory pressure device. e. Encourage diaphragmatic breathing.

ANS: A, B, C Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. The client should increase calorie and protein intake to prevent malnourishment. The client should not increase carbohydrate intake as this will increase carbon dioxide production and increase the client's risk of for acidosis.

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this client's teaching? (Select all that apply.) a. "Avoid drinking fluids just before and during meals." b. "Rest before meals if you have dyspnea." c. "Have about six small meals a day." d. "Eat high-fiber foods to promote gastric emptying." e. "Increase carbohydrate intake for energy."

ANS: B Room air is 21% oxygen.

A nursing student caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air? a. 14% b. 21% c. 28% d. 31%

ANS: B Clients are often in denial after a coronary event. The client who seems to be in denial but is compliant with treatment may be using a healthy form of coping that allows time to process the event and start to use problem-focused coping. The student should not discourage this type of denial and coping, but rather continue providing education in a positive manner. Emphasizing complications may make the client defensive and more anxious. Telling the client that denial is normal is placing too much attention on the process. Forcing the client to verbalize understanding of the illness is also potentially threatening to the client.

A nursing student is caring for a client who had a myocardial infarction. The student is confused because the client states nothing is wrong and yet listens attentively while the student provides education on lifestyle changes and healthy menu choices. What response by the experienced nurse is best? a. "You need to make sure the client understands this illness." b. "Continue to educate the client on possible healthy changes." c. "Emphasize complications that can occur with noncompliance." d. "Tell the client that denial is normal and will soon go away."

ANS: D Hypoxia is the drive to breathe in a patient with chronic obstructive pulmonary disease who has become used to acidic pH and elevated CO2 levels. Turning up to 6 L/min increases the oxygen level, which turns off the drive to breathe.

A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education? a. "I'll make sure that I rest between activities so I don't get so short of breath." b. "I'll rest for 30 minutes before I eat my meal." c. "If I have trouble breathing at night, I'll use two to three pillows to prop up." d. "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

ANS: B Carbon monoxide strongly binds to hemoglobin, making it unavailable for oxygen binding and transport.

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy, not cyanotic, the nurse understands that the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following: a. Stimulates hyperventilation, causing respiratory alkalosis b. Forms a strong bond with hemoglobin, creating a functional anemia. c. Stimulates hypoventilation, causing respiratory acidosis d. Causes alveoli to overinflate, leading to atelectasis

ANS: C Impaired ability to cough up mucus caused by weakness or very thick secretions indicates a need for suctioning when you know the patient has pneumonia.

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? a. Coughing up thick sputum only occasionally b. Coughing up thin, watery sputum easily after nebulization c. Decreased independent ability to cough d. Lung sounds clear only after coughing

ANS: D Decreased effective contraction of left side of heart leads to back up of fluid in the lungs, increasing hydrostatic pressure and causing pulmonary edema, resulting in crackles in lung bases.

A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds? a. Sonorous wheezes in the left lower lung b. Rhonchi midsternum c. Crackles only in apex of lungs d. Inspiratory crackles in lung bases

ANS: B The ABG results will indicate the acid-base balance of the arterial blood and the partial pressure of oxygen and carbon dioxide. The ABG does not reveal the ratio of hemoglobin and hematocrit, the adequacy of oxygen transport to the cells, or the presence of a pulmonary embolus.

A patient is having the arterial blood gas (ABG) measured. What would the nurse identify as the parameters to be evaluated by this test? a. Ratio of hemoglobin and hematocrit b. Status of acid-base balance in arterial blood c. Adequacy of oxygen transport d. Presence of a pulmonary embolus

ANS: A When the lung collapses, the thoracic space fills with air on each inspiration, and the atmospheric air irritates the parietal pleura, causing pain.

A patient was admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax, which includes which of the following? a. Sharp pleuritic pain that worsens on inspiration b. Crackles over lung bases of affected lung c. Tracheal deviation toward the affected lung d. Increased diaphragmatic excursion on side of rib fractures

Effects of nicotine on blood vessels and lung tissue have been proven to increase pathological changes, leading to heart disease and lung cancer.

A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder:

ANS: A Clubbing of the nail bed is a frequent symptom of COPD and can make activities of daily living difficult. Taking a nap decreases fatigue but does not help the patient perform fine motor skills. Loss of mental status is not a normal finding with COPD. Low oxygen not low circulating blood volume is the problem in COPD.

A patient with COPD asks the nurse why he is having increased difficulty with his fine motor skills, such as buttoning his shirt. Which response by the nurse is most therapeutic? a. "Your body isn't receiving enough oxygen to send down to your fingers; this causes them to club and makes dexterity difficult." b. "Your disease process makes even the smallest tasks seem exhausting. Try taking a nap before getting dressed." c. "Often patients with your disease lose mental status and forget how to perform daily tasks." d. "Your disease affects both your lungs and your heart, and not enough blood is being pumped. So you are losing sensory feedback in your extremities."

ANS: B The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how well the client is breathing and provide interventions to minimize respiratory failure. The other clients are not in acute distress.

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? a. A 46-year-old with a 30-pack-year history of smoking b. A 52-year-old in a tripod position using accessory muscles to breathe c. A 68-year-old who has dependent edema and clubbed fingers d. A 74-year-old with a chronic cough and thick, tenacious secretions

ANS: C A, D, E, and K are the fat-soluble vitamins that need to be supplemented.

Absorption of fat-soluble vitamins is decreased in children with cystic fibrosis; therefore supplementation of which vitamins is necessary? A. C, D B. A, E, K C. A, D, E, K D. C, folic acid

ANS: B To perform diaphragmatic breathing correctly, the client should place his or her hands on his or her abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.

After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client's understanding. Which action demonstrates that the client correctly understands the teaching? a. The client lays on his or her side with his or her knees bent. b. The client places his or her hands on his or her abdomen. c. The client lays in a prone position with his or her legs straight. d. The client places his or her hands above his or her head.

ANS: C Long-acting beta2 agonist medications will help prevent an acute asthma attack because they are long acting. The client will take this medication every day for best effect. The client does not have to always keep this medication with him or her because it is not used as a rescue medication. This is not the medication the client will use during an acute asthma attack because it does not have an immediate onset of action. The client will not be weaned off this medication because this is likely to be one of his or her daily medications.

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates the client comprehends the teaching? a. "I will carry this medication with me at all times in case I need it." b. "I will take this medication when I start to experience an asthma attack." c. "I will take this medication every morning to help prevent an acute attack." d. "I will be weaned off this medication when I no longer need it."

ANS: C Salmeterol is designed to prevent an asthma attack; it does not relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it should not be used as a rescue drug. The drug must be shaken well because it has a tendency to separate easily. Poor technique on the client's part allows the drug to escape through the nose and mouth.

After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching? a. "I will be certain to shake the inhaler well before I use it." b. "It may take a while before I notice a change in my asthma." c. "I will use the drug when I have an asthma attack." d. "I will be careful not to let the drug escape out of my nose and mouth."

ANS: B The nurse responds with the most informative, accurate response. The decision not to use antibiotics for viral pneumonia was based on sound rationale about the etiology of the illness, not cost.

An 8-year-old child is diagnosed with viral pneumonia and sent home from the clinic with no antibiotic prescription. The symptoms worsen, and the child returns to the clinic a week later with signs of a higher fever, listlessness, and a harsh, productive cough. The child's mother states, "I knew a prescription for antibiotics was needed." Which response by the nurse is the most appropriate? a. "It is better to wait to make sure so we don't use antibiotics unnecessarily. This approach also saves healthcare dollars." b. "Antibiotics are not effective for viral pneumonia. Bacteria can grow later in the course of the illness, requiring the need for antibiotics at that time." c. "You do not want to expose your child to medication unnecessarily. Now it is necessary, because it is bacterial pneumonia." d. "Sometimes we just do not know. I'm glad you came back in."

ANS: A Children with cystic fibrosis have thick mucus gland secretions. The viscous secretions obstruct small passages in organs such as the pancreas.

Cystic fibrosis may affect single or multiple systems of the body. What is the primary factor responsible for possible multiple clinical manifestations? a. Mechanical obstruction caused by increased viscosity of mucous gland secretions. b. Atrophic changes in mucosal wall of intestines. c. Hypoactivity of the autonomic nervous system. d. Hyperactivity of sweat glands.

ANS: C All of the children are acutely ill. A child with asthma who was wheezing and now has decreased breath sounds is acutely ill. This child's ability to move air is decreasing and is approaching respiratory arrest. Intubation protects the airway from closing in epiglottitis and a chest tube is the treatment for tension pneumothorax in a different room; therefore these children are stable. The infant with RSV is sleeping with a normal respiratory rate so there is no immediate danger here.

Following assessment, the nurse anticipates potential respiratory arrest for which child? a. A 5-month-old infant with RSV who is sleeping and has a respiratory rate of 24. b. A 2-year-old with epiglottitis who was intubated in the emergency department. c. A 6-year-old with asthma who was previously wheezing and now has decreased breath sounds. d. A 4-year-old, status post-tension pneumothorax from a motor vehicle accident with a chest tube in place, who complains of pain.

ANS: D Respiratory infections can trigger an asthmatic attack. Annual influenza vaccine is recommended. All respiratory equipment should be kept clean.

One of the goals for children with asthma is to prevent respiratory infections. Why is this goal so important? a. Respiratory infections encourage exercise-induced asthma. b. Allergen sensitivity is increased in the presence of infection. c. Asthma medication becomes less effective when a respiratory infection is present. d. Respiratory infections can trigger an episode or aggravate the asthmatic state.

ANS: B To prevent a sternal wound infection, the nurse washes hands or performs hand hygiene as a priority. Vital signs do not necessarily need to be assessed beforehand. A mask and gown are not needed. The nurse should gather needed supplies, but this is not the priority.

The nurse is preparing to change a client's sternal dressing. What action by the nurse is most important? a. Assess vital signs b. Perform hand hygiene c. Don (put on) a mask and gown d. Gather needed supplies

ANS: B Because the child is not having difficulty breathing, the nurse should teach the parents the signs of respiratory distress and tell them to come to the emergency department if they develop. Cool mist is recommended to provide relief.

The mother of a 20-month-old child tells the nurse that the child has a barking cough at night. The child's temperature is 37 °C (98.6 °F). Based on the nurse's knowledge of upper respiratory infections, this is a symptom of croup. What should the nurse instruct the mother to do? a. Control the fever with acetaminophen and call if the cough gets worse tonight. b. Try a cool-mist vaporizer at night and watch for signs of difficulty breathing. c. Try over-the-counter cough medicine and come to the clinic tomorrow if there is no improvement. d. Take the child to the hospital in case epiglottitis occurs.

ANS: A Raising the head of the bed brings the diaphragm down and allows for better chest expansion, thus improving ventilation.

The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first? a. Raise the head of the bed to 45 degrees. b. Take his oxygen saturation with a pulse oximeter. c. Take his blood pressure and respiratory rate. d. Notify the health care provider of his shortness of breath.

ANS: C The proper order for correctly using an inhaler with a spacer is as follows. Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer. Shake the whole unit vigorously three or four times. Place the mouthpiece into the mouth, over the tongue, and seal the lips tightly around it. Press down firmly on the canister of the inhaler to release one dose of medication into the spacer. Breathe in slowly and deeply. Remove the mouthpiece from the mouth, and, keeping the lips closed, hold the breath for at least 10 seconds. Then breathe out slowly. Wait at least 1 minute between puffs.

The nurse instructs a client on how to correctly use an inhaler with a spacer. In which order should these steps occur? 1. "Press down firmly on the canister to release one dose of medication." 2. "Breathe in slowly and deeply." 3. "Shake the whole unit vigorously three or four times." 4. "Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer." 5. "Place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece." 6. "Remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds." a. 2, 3, 4, 5, 6, 1 b. 3, 4, 5, 1, 6, 2 c. 4, 3, 5, 1, 2, 6 d. 5, 3, 6, 1, 2, 4

ANS: A The proper order for obtaining a peak expiratory flow rate is as follows. Make sure the device reads zero or is at base level. The client should stand up (unless he or she has a physical disability). The client should take as deep a breath as possible, place the meter in the mouth, and close the lips around the mouthpiece. The client should blow out as hard and as fast as possible for 1 to 2 seconds. The value obtained should be written down. The process should be repeated two more times, and the highest of the three numbers should be recorded in the client's chart.

The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur? 1. "Take as deep a breath as possible." 2. "Stand up (unless you have a physical disability)." 3. "Place the meter in your mouth, and close your lips around the mouthpiece." 4. "Make sure the device reads zero or is at base level." 5. "Blow out as hard and as fast as possible for 1 to 2 seconds." 6. "Write down the value obtained." 7. "Repeat the process two additional times, and record the highest number in your chart." a. 4, 2, 1, 3, 5, 6, 7 b. 3, 4, 1, 2, 5, 7, 6 c. 2, 1, 3, 4, 5, 6, 7 d. 1, 3, 2, 5, 6, 7, 4

ANS: A Glucocorticoids (corticosteroids) decrease inflammation and prevent bronchospasm in the patient with asthma. The glucocorticoids are used to prevent problems. Anticholinergics decrease the allergic response and decrease sneezing and rhinorrhea. Antitussives are used to decrease cough, and mucolytics assist in the removal of mucus. Sympathomimetic agents (beta2 agonist) are used to relieve bronchospasm in an acute episode.

The nurse is administering oral glucocorticoids to a patient with asthma. What assessment finding would the nurse identify as a therapeutic response to this medication? a. No observable respiratory difficulty or shortness of breath over the last 24 hours. b. A decrease in the amount of nasal drainage and sneezing. c. No sputum production, and a decrease in coughing episodes. d. Relief of an acute asthmatic attack.

ANS: C Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies are needed to determine the cause of blood in the sputum. Clubbing of the fingers, barrel chest, and tachypnea are all normal findings in a patient with emphysema.

The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the physician? a. Clubbing of the fingers b. Increased anterior-posterior diameter of the chest c. Hemoptysis d. Tachypnea

ANS: D Long-acting beta2 agonists should be used every day to prevent asthma attacks. This medication should not be taken when an attack starts. Asthma medications can be expensive. Telling the client that he or she is using the inhaler incorrectly does not address the client's financial situation, which is the main issue here. Clients with limited incomes should be provided with community resources. Asking the client about fears related to breathlessness does not address the client's immediate concerns.

The nurse is caring for a client who is prescribed a long-acting beta2 agonist. The client states, "The medication is too expensive to use every day. I only use my inhaler when I have an attack." How should the nurse respond? a. "You are using the inhaler incorrectly. This medication should be taken daily." b. "If you decrease environmental stimuli, it will be okay for you to use the inhaler only for asthma attacks." c. "Tell me more about your fears related to feelings of breathlessness." d. "It is important to use this type of inhaler every day. Let's identify potential community services to help you."

ANS: B Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting the effectiveness of gas exchange processes.

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion? a. Antibiotics b. Frequent change of position c. Oxygen humidification d. Chest physiotherapy

ANS: D The normal respiratory drive is a person's level of carbon dioxide (CO2) in the arterial blood. The COPD patient had compensated for his chronic high levels of CO2, and his respiratory drive is dependent on his oxygen levels, not his CO2 levels. If the COPD patient's oxygen level is rapidly increased to what would be considered a normal level, it would compensate for his respiratory drive. The patient with COPD who has difficulty breathing should be given low levels of oxygen and closely observed for the quality and rate of ventilation. A dose of glucocorticoids will not address his immediate needs, but it may provide decreased inflammation and better ventilation over an extended period of time. Encouraging coughing and deep breathing in a patient with COPD does not meet his needs as effectively as administration of low-level oxygen does.

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient tells the nurse he is having a "hard time breathing." His respiratory rate is 32 breaths per minute, his pulse is 120 beats per minute, and the oxygen saturation is 90%. What would be the best nursing intervention for this patient? a. Begin oxygen via a face mask at 60% FiO2 (fraction of inspired oxygen). b. Administer a PRN (as necessary) dose of an intranasal glucocorticoid. c. Encourage coughing and deep breathing to clear the airway. d. Initiate oxygen via a nasal cannula, and begin at a flow rate of 3 L/min.

ANS: B Because of skin pigmentation, translucent areas of high blood flow such as mucous membranes are best to check for cyanosis, which is a sign of hypoxia. It is important to remember that cyanosis is a late sign of hypoxia.

The nurse is caring for an African American patient with COPD. The nurse knows that the best location to assess for hypoxia is the a. Nailbeds. b. Oral mucosa. c. Earlobe. d. Lower extremities.

ANS: C Cotton balls can decrease pressure ulcers from the oxygen tubing. Continuous oxygen orders mean the client should wear the oxygen at all times. Oxygen fuels a fire. Wearing oxygen while grilling and smoking increases the risk for fire.

The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching? a. "I plan to wear my oxygen when I exercise and feel short of breath." b. "I will use my portable oxygen when grilling burgers in the backyard." c. "I plan to use cotton balls to cushion the oxygen tubing on my ears." d. "I will only smoke while I am wearing my oxygen via nasal cannula."

ANS: A The alveolus is a capillary membrane that allows gas exchange of oxygen and carbon dioxide during respiration. The alveoli do not store oxygen, regulate tidal volume, or produce hemoglobin.

The nurse knows that the primary function of the alveoli is to a. Carry out gas exchange. b. Store oxygen. c. Regulate tidal volume. d. Produce hemoglobin.

ANS: A The age-related change that would affect airway clearance is decreased defense mechanisms, whereby the patient will have difficulty excreting anesthesia gas. The nurse needs to monitor the patient's oxygen status carefully to make sure the patient does not retain too much of the drug. Heart muscle thickening and mental status do not affect oxygenation in patients undergoing anesthesia. Lung capacity is not related to anesthesia induction.

The nurse needs to closely monitor the oxygen status of an elderly patient undergoing anesthesia because of which age-related change? a. Decreased lung defense mechanisms may cause ineffective airway clearance. b. Thickening of the heart muscle wall decreases cardiac output. c. Decreased lung capacity makes proper anesthesia induction more difficult. d. Alterations in mental status prevent patients' awareness of ineffective breathing.

ANS: D When air is allowed to enter the pleural space, the lung will collapse and a chest tube will be inserted to remove the air and reestablish negative pressure in the pleural space. Patients with asthma do not require a chest tube. A bronchoscopy is done to evaluate the bronchi and lungs and to obtain a biopsy. A thoracentesis may be done to remove fluid from the pleural space. A chest tube may be inserted if there are complications from the thoracentesis or for the bronchoscopy.

The nurse would anticipate that which of the following patients will need to be treated with insertion of a chest tube? a. A patient with asthma and severe shortness of breath. b A patient undergoing a bronchoscopy for a biopsy. c. A patient with a pleural effusion requiring fluid removal. d. A patient experiencing a problem with a pneumothorax.

ANS: C Retained CO2 creates H+ byproducts that lower pH. This sends a chemical signal to increase respiratory rate and would result in increased ventilation. All other options would cause the ventilation rate to normalize or decrease to increase carbon dioxide retention or as the result of delivery of higher levels of oxygen to tissues.

The nurse would expect to see increased ventilations if a patient exhibits a. Increased oxygen saturation. b. Decreased carbon dioxide levels. c. Decreased pH. d. Increased hemoglobin levels.

ANS: D The neurologic system controls respiratory drive; the respiratory system controls delivery of oxygen to the lung capillaries; and the cardiac system is responsible for the perfusion of vital organs. These systems are primarily responsible for the adequacy of gas exchange in the body. The endocrine and hepatic systems are not directly involved with gas exchange. The immune system primarily protects the body against infection.

The nurse would identify which body systems as directly involved in the process of normal gas exchange? a. Hepatic system b. Endocrine system, Cardiovascular system c. Immune system, Hepatic system, Cardiovascular system d. Pulmonary system, Cardiovascular system, Neurological system

ANS: A The child is exhibiting signs of increasing respiratory distress suggestive of a pneumothorax. The child needs to be seen as soon as possible.

The parent of a child with cystic fibrosis calls the clinic nurse and describes signs and symptoms of tachypnea, tachycardia, dyspnea, pallor, and cyanosis. What does the nurse suspect the child is experiencing? a. A pneumothorax b. Bronchodilation c. Carbon dioxide retention d. Extremely thick sputum

ANS: B Diffusion is the process of gases exchanging across the alveoli and capillaries of body tissues. Disassociation is not related to oxygenation. Perfusion is the ability of the cardiovascular system to carry oxygenated blood to tissues and return deoxygenated blood to the heart. Ventilation is the process of moving gases into and out of the lungs.

The process of exchanging gases through the alveolar capillary membrane is known as a. Disassociation. b. Diffusion. c. Perfusion. d. Ventilation.

ANS: A A positive inotrope is a medication that increases the strength of the heart's contractions. The other options are not correct.

The provider requests the nurse start an infusion of an inotropic agent on a client. How does the nurse explain the action of these drugs to the client and spouse? a. "It increases the force of the heart's contractions." b. "It dilates vessels, which lessens the work of the heart." c. "It slows the heart rate down for better filling." d. "It constricts vessels, improving blood flow."

ANS: A Hypoxia is due to inadequate tissue oxygen at the cellular level. The earliest sign of hypoxia is restlessness; as it progresses, mental status changes, cardiac changes, and cyanosis can occur. Early hypoxia results in an elevated blood pressure. In later hypoxia, vital sign changes such as increased heart and respiratory rate occur. Cyanosis is a late sign of hypoxia.

What assessment finding is the earliest sign of hypoxia? a. Restlessness b. Decreased blood pressure c. Cardiac dysrhythmias d. Cyanosis

ANS: B Tobacco use is the most preventable cause of death and disease and is the most important risk factor in the development of impaired gas exchange. Age is not a modifiable risk factor. Drug overdose and immobility both contribute to impaired gas exchange but are not as significant as tobacco use.

What is the most significant modifiable risk factor for the development of impaired gas exchange? a. Age. b. Tobacco use. c. Drug overdose. d. Prolonged immobility.

ANS: B Oxygen and carbon dioxide move across the alveolar membrane based on the partial pressure of each gas. Molecules of oxygen are not exchanged for molecules of carbon dioxide. The pressure gradient of each gas (carbon dioxide and oxygen) in the alveoli is responsible for the movement of each gas.

When evaluating the concept of gas exchange, how would the nurse best describe the movement of oxygen and carbon dioxide? a. Oxygen and carbon dioxide are exchanged across the capillary membrane to provide oxygen to hemoglobin. b. Gas moves from an area of high pressure to an area of low pressure across the alveolar membrane. c. The level of inspired oxygen must be sufficient to displace the carbon dioxide molecules in the alveoli. d. Gases are exchanged between the atmosphere and the blood based on the oxygen-carrying capacity of the hemoglobin.

ANS: C The low pH, the elevated carbon dioxide level, and the low oxygen concentration all indicate that the client is experiencing poor gas exchange and has acidosis. The low pH and the low oxygen concentration could occur without hypercarbia. Only the elevated carbon dioxide concentration confirms hypercarbia.

Which blood gas value indicates that the client is experiencing hypercarbia? a. pH = 7.33 b. Bicarbonate = 20 mEq/L c. PaCO2 = 60 mm Hg d. PaO2 = 80 mm Hg

ANS: B As the client's PaO2 rises, the client's color and pulse oximetry improve and cannot be used to determine hypoventilation. As the client's PaO2 rises, respirations decrease in depth and rate, indicating hypoventilation.

Which clinical manifestation alerts you to the presence of hypoventilation when you are monitoring a client with chronic lung disease and hypercarbia who is receiving oxygen therapy? a. Coarse crackles and wheezes on auscultation b. Slow, shallow respirations c. Pulse oximetry of 90% d. Clubbing of the fingers

ANS: C A 7-year-old is at an age when medication administration responsibility ought to be initiated. The spacer whistle is significant, although its significance varies with each type of spacer. Children may use dry powder inhalers when they are old enough to have a rapid inhalation.

Which comments by the parents of a 7-year-old child with asthma indicate comprehension of instructions regarding medication use for control of the illness? a. The medications are too complicated for a 7-year-old to understand. b. If a spacer is used, a whistling sound indicates that the medication is being inhaled correctly. c. A spacer used on an inhaler helps trap the medication so it is inhaled more readily. d. Dry powder inhalers are for adult use only.

c.Incentive spirometer is used to encourage deep breathing to inflate alveoli and open pores of Kohn. The rest are used to treat atelectasis and increased mucus production.

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient? a. Postural drainage b. Chest percussion c. Incentive spirometer d. Suctioning

ANS: A The goal of the nursing action should be the prevention of pneumonia; the action that best addresses this is to cough, turn, and deep breathe to keep secretions from pooling at the base of the lungs. Drinking through a straw increases the risk of aspiration. Humidification thins respiratory secretions, making them easier to expel. Monitoring oxygen status is important but is not a method of prevention

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an elderly patient? a. Assist patient to cough, turn, and deep breathe every 2 hours. b. Encourage patient to drink through a straw to prevent aspiration. c. Discontinue humidification delivery device to keep excess fluid from lungs. d. Monitor oxygen saturation, and frequently assess lung bases.

ANS: D Saline has been found to cause more side effects when suctioning and does not increase the amount of secretions removed.

Which of the following statements made by a student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube? a. "Suctioning the patient requires sterile technique." b. "I'll apply suction while rotating and withdrawing the suction catheter." c. "I'll suction the mouth after I suction the endotracheal tube." d. "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."

ANS: A, D, E Respirations of 68 for an 8-month-old infant are high. The nurse needs to assess for retractions and wheezing. A 2-year-old who becomes quiet following respiratory distress could be experiencing decompensation and requires an evaluation. Suctioning is a sterile procedure that only the nurse should perform.

Which tasks should the nurse perform rather than delegate to an assistant? (Select all that apply.) a. Suctioning a 2-year-old with a tracheostomy. b. Changing the diaper of the 3-month-old infant recovering from RSV. c. Walking with a 2-year-old who has an IV receiving antibiotics for pneumonia. d. Relieving the nurse who is watching a 2-year-old with croup, because he now sounds quiet. e. Taking the temperature of an 8-month-old infant with bronchiolitis whose respirations are 68 and who is irritable.

ANS: A Left-sided heart failure results in pulmonary congestion, the signs and symptoms of which include shortness of breath, crackles, and discomfort when lying supine. Right-sided heart failure is systemic and results in peripheral edema and hepatojugular distention. Atrial fibrillation results in an irregular heart rate. Myocardial ischemia most often results in chest pain, along with shortness of breath, nausea, and fatigue.

While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows. What do these symptoms most likely indicate? a. Left-sided heart failure b. Right-sided heart failure c. Atrial fibrillation d. Myocardial ischemia

ANS: D. By humidifying the inspired air, the membranes inflamed by the infection and dry air are soothed.

Why is a humidified atmosphere recommended for a young child with an upper respiratory tract infection? a. It liquefies secretions. b. It improves oxygenation. c. It promotes ventilation. d. It is soothing to inflamed mucous membrane.