Oxygenation

A nurse is auscultating a client's heart sounds and hears a low-pitched whooshing or blowing sound over the apex of the heart. The nurse should identify that this indicates which of the following? A) Tachycardia B) Murmur C) Gallop D) Stroke volume

B) Murmur A whooshing or blowing sound indicates a murmur and can be low-, medium-, or high-pitched.

The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance. Which action by the nurse is the most appropriate? A) Encourage strenuous activity. B) Consult a dietitian for low-calorie meals. C) Space periods of activity with periods of rest. D) Encourage dependence with activities of daily living.

C) Space periods of activity with periods of rest. The client with shortness of breath will experience activity intolerance due to a lack of oxygen and fatigue. It will often be appropriate to space periods of activity with periods of rest.

A client is scheduled for a BAL, or bronchoalveolar lavage. What is the best description of this procedure? A) Cleaning out the back of the throat B) Suctioning sputum from the nose C) Washing the skin over the chest D) Washing out of the airways of the lungs

D) Washing out of the airways of the lungs

The nurse is preparing to assist a client in obtaining a sputum specimen and should place the client in which position? A) Low Fowler's B) Side-lying C) Semi-Fowler's D) Trendelenburg

C) Semi-Fowler's Semi-Fowler's position allows for maximum lung ventilation and expansion. Other positions that would be effective would be high Fowler's, or sitting on the side of a bed or in a chair.

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? A: Increased breathlessness but increased activity tolerance B: Decreased breathlessness and decreased activity tolerance C: Increased activity tolerance and decreased breathlessness D: Decreased activity tolerance and increased breathlessness

D: Decreased activity tolerance and increased breathlessness

A nursing student is assessing a client with atelectasis. The client asks the student about the purpose of turning, coughing, and deep breathing. Which response is correct? A) To mobilize secretions and inflate the alveoli B) To prevent post-op fever due to surgical site infection C) To assist with skin integrity and circulation D) To expel pathogens from the lungs to prevent pneumonia

A) To mobilize secretions and inflate the alveoli When a client turns from one side to another, this mobilizes secretions in the lungs. Coughing and deep breathing assist to expel secretions and inflate the alveoli.

A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as risk factors for heart disease? (Select all that apply.) A) A diet high in saturated fats. B) A history of an overactive bladder C) A history of smoking for 25 years. D) A sedentary lifestyle. E) A waist circumference of 84cm (33in)

A, C, D A diet high in saturated fats, history of smoking, and a sedentary lifestyle can increase blood pressure and cholesterol. This increases the risk for heart disease.

A nurse is discussing ventilation and perfusion with a newly licensed nurse. The nurse should include in the discussion that the exchange of oxygen and carbon dioxide occurs at which of the following locations? A) Trachea B) Alveoli C) Diaphragm D) Bronchial tubes

B) Alveoli The alveoli are air-filled sacs where the exchange of oxygen and carbon dioxide occurs.

A client is in need of an emergency tracheostomy. Which of the following scenarios does this involve? A) A tube is passed into the mouth and through the larynx B) A tube is passed through the nose and into the trachea C) A puncture is made through the cricothyroid cartilage D) A surgical incision is made into the trachea

D) A surgical incision is made into the trachea

The nurse is assigned to care for a client admitted to the hospital with chronic obstructive pulmonary disease (COPD). Which medication does the nurse anticipate to decrease this client's risk for developing a respiratory infection? A) A broad-spectrum antibiotic B) A bronchodilator C) A corticosteroid D) An influenza vaccine

D) An influenza vaccine An influenza vaccine may be ordered to reduce the risk of respiratory infections.

Which clinical manifestation does the nurse correctly attribute to hypoxia in a client with acute respiratory distress syndrome (ARDS)? A) Fluid imbalance B) Hypertension C) Bradycardia D) Dyspnea

D) Dyspnea Dyspnea is a clinical manifestation of clients experiencing hypoxia secondary to ARDS.

The nurse is caring for a client with pneumonia and should be most concerned about which assessment? A) The client cannot remember which day it is. B) The client's heart rate has risen from 72 to 78 bpm. C) The client's pulse oximetry has decreased from 99% to 97%. D) The client respiratory rate has risen from 16 to 20 breaths per minute.

A) The client cannot remember which day it is. One of the early signs of hypoxia is confusion and should be reported immediately.

A nurse is caring for a client who is recovering from a chest injury. The provider orders arterial blood gases for the client. The results are pH 7.26, pCO2 52 mmHg, HCO3 25 mmHg, and oxygen saturation 92 percent. Which of the following best describes this client's condition? A) Respiratory alkalosis B) Respiratory acidosis C) Metabolic alkalosis D) Metabolic acidosis

B) Respiratory acidosis

A client with chest trauma has ABGs drawn. The nurse anticipates which scenario upon ABG analysis? A) Respiratory alkalosis B) Respiratory acidosis C) Metabolic acidosis D) Metabolic alkalosis

B) Respiratory acidosis Chest trauma usually correlates with breathing difficulties. The nurse would anticipate respiratory acidosis upon analysis of the client's ABG results.

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.) A) Apply petroleum jelly around and inside the nares. B) Remove the nasal cannula during mealtimes. C) Check the position of the cannula frequently. D) Report any nausea or difficulty breathing. E) Post "No Smoking" signs in prominent locations.

C) Check the position of the cannula frequently. D) Report any nausea or difficulty breathing. E) Post "No Smoking" signs in prominent locations.

The structure of the respiratory system that serves as the site of gas exchange is the A) macrophage. B) bronchi. C) alveoli. D) bronchiole.

C) alveoli. The alveoli comprise the terminal structures of the lower respiratory system. Alveoli serve as the sites of gas exchange, specifically, carbon dioxide and oxygen.

A nurse is caring for a client who requires 7L of oxygen to maintain oxygen saturation. Which of the following oxygen delivery devices should the nurse expect to use? A) Nasal cannula B) Nonrebreather mask C) Partial rebreather mask D) Simple face mask

D) Simple face mask The nurse should expect to use a simple face mask because it can deliver oxygen at medium concentrations of 5 to 8 L/min.

Which of the following is a common finding in an open pneumothorax? a) A flail chest b) Trachea deviated to the side of the injury c) Trachea deviated to the side opposite the injury d) A sucking sound on inspiration and expiration

d) A sucking sound on inspiration and expiration In an open pneumothorax, there is an open wound to the outside so a sucking sound is heard on inspiration and expiration.

A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take? A) Monitor the client for subcutaneous emphysema. B) Expect continuous bubbling in the water seal chamber. C) Keep the drainage system above the level of the client's chest. D) Clamp the chest tube tubing when the client ambulates.

A) Monitor the client for subcutaneous emphysema. The nurse should monitor the client for subcutaneous emphysema, which can indicate a leak or blockage of the system.

Vaccinations can help promote healthy oxygenation by A) reducing the transmission of preventable diseases. B) increasing the exchange of oxygen for carbon dioxide in the lungs. C) promoting adequate blood circulation to organs and tissues. D) preventing all respiratory infections.

A) reducing the transmission of preventable diseases. Vaccinations help decrease the transmission of preventable diseases, many of which are spread by respiratory secretions. Many of these diseases also affect the respiratory system and can alter oxygenation.

A client has just been intubated for placement on a mechanical ventilator. What is the first assessment of the tube placement? A) Chest X-Ray B) Auscultation of breath sounds C) Pulse oximetry reading of 95% D) End tidal CO2 monitoring

D) End tidal CO2 monitoring End tidal CO2 monitoring is the first intervention to determine if the endotracheal tube is in place, but a chest x-ray is still needed to confirm proper placement.

A nurse is caring for a client who has atelectasis. The nurse should identify that which of the following substances is required to keep the client's alveoli from collapsing and causing atelectasis? A) Lymphatic fluid B) Oxygenated blood C) Synovial fluid D) Surfactant

D) Surfactant The nurse should identify that surfactant is a lubricant required to keep alveoli in the lungs from collapsing during exhalation. A lack of surfactant can result in atelectasis.

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 midsternumC: Crackles only in apex of lungs D: Inspiratory crackles in lung bases

D: Inspiratory crackles in lung bases

Which action will the nurse plan to take for a patient who is scheduled for pulmonary function testing (PFT)? a. Explain reasons for NPO status. b. Administer sedative drug before PFT. c. Assess pulse and BP after the procedure. d. Teach deep inhalation and forceful exhalation.

d. Teach deep inhalation and forceful exhalation. For PFT, the patient should inhale deeply and exhale as long, hard, and fast as possible. The other actions are not needed with PFT.

While performing nasotracheal suctioning, the nurse notes the older adult client with an alteration in oxygenation is moving the head around and pulling at the nurse's hand to remove the suction catheter. Which actions by the nurse are appropriate? Select all that apply. A) Remove the suction catheter B) Lower the head of the bed C) Decrease the suction pressure D) Apply restraints to the client's arms and legs E) Hyperoxygenate the client

A) Remove the suction catheter C) Decrease the suction pressure E) Hyperoxygenate the client The older adult client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, decrease the suction pressure, and hyperoxygenate the client.

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which factors in the client's history support the current diagnosis? Select all that apply. A) Working in an industrial environment B) Working in an office setting with air conditioning C) History of asthma D) Current cigarette smoking E) Playing golf several times a week

A) Working in an industrial environment C) History of asthma D) Current cigarette smoking Risk factors associated with the development of COPD include working in an industrial environment, a history of asthma, and cigarette smoking.

A nurse is providing teaching for a client who has a new prescription for an incentive spirometer. Which of the following instructions should the nurse include? A) "Exhale into the incentive spirometer." B) "Use the incentive spirometer every hour while awake." C) "Hold your breath for 10 seconds when using the incentive spirometer." D) "Use the incentive spirometer two times each session."

B) "Use the incentive spirometer every hour while awake." The nurse should instruct the client to use the incentive spirometer every hour while awake to promote lung expansion and mobilize secretions.

A nurse is planning care for a group of clients on a cardiopulmonary unit. Which of the following clients should the nurse plan to see first? A) A client who requires teaching about a new cholesterol-lowering medication B) A client who reports dyspnea when walking to the bathroom C) A client who has a new diagnosis of aortic valve stenosis and needs a referral to a cardiologist D) A client who has asthma and is being discharged to home

B) A client who reports dyspnea when walking to the bathroom When using the urgent vs. nonurgent approach to client care, the nurse determines that the first client the nurse should see is the client who reports dyspnea. The client might be experiencing hypoxia due to inadequate oxygenation, which requires further intervention by the nurse.

The nurse is assessing a client who presented to the emergency room for shortness of breath. The client states, "I just cannot breath deeply, it feels like there is someone holding my ribs tight." What is the priority for this client? A) Check the client's airway B) Get an EKG (ECG) C) Tell the client to take a deep breath D) Call a rapid response

B) Get an EKG (ECG) Chest pressure can indicate a myocardial infarction. This client is able to speak a complete sentence, so the client has an airway and is breathing. The nurse will need to contact the provider for an EKG (ECG) right away.

The nurse is caring for a client with tuberculosis and is giving report to the oncoming nurse. Which of the following statements is most appropriate? A) "The client is positive for TB and will require enteric precautions" B) "The client screened positive for TB so I have stocked surgical masks outside the room" C) "The client is positive for TB and will require airborne precautions" D) "Since the client has started TB treatment, there are only 24 hours left for isolation precautions"

C) "The client is positive for TB and will require airborne precautions"

The nurse is caring for a Spanish-speaking client admitted for exacerbation of chronic obstructive pulmonary disease (COPD). The client speaks very little English and is a smoker. Which action would be the most beneficial for this client? A) Have the adult child of the client translate during the assessment process B) Encourage aerobic activity C) Encourage the client to write down questions prior to seeing the healthcare provider D) Obtain educational materials about smoking cessation written in Spanish.

D) Obtain educational materials about smoking cessation written in Spanish. A Spanish-speaking client who smokes and is diagnosed with COPD requires information regarding smoking cessation. For clients who do not speak English, it is appropriate for the nurse to obtain written education material for the client in the client's native language, Spanish.

A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? A. Notify the health care provider. B. Apply an occlusive dressing on the site. C. Assess the patient for signs of respiratory distress. D. Put on gloves and insert the chest tube in a bottle of sterile saline.

D. Put on gloves and insert the chest tube in a bottle of sterile saline. When a chest tube becomes separated from the drainage device, the nurse should submerge the end in water, creating a water seal, but allowing air to escape, until a new drainage unit can be attached. This is done instead of clamping to prevent another pneumothorax. Then the nurse should assess vital signs and notify the health care provider.

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."

D: "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."

When auscultating a patients chest while the patient takes a deep breath, the nurse hears loud, high-pitched, blowing sounds at both lung bases. The nurse will document these as a. normal sounds. b. vesicular sounds. c. abnormal sounds. d. adventitious sounds.

c. abnormal sounds. The description indicates that the nurse hears bronchial breath sounds that are abnormal when heard at the lung base. Adventitious sounds are extra breath sounds such as crackles, wheezes, rhonchi, and friction rubs. Vesicular sounds are low-pitched, soft sounds heard over all lung areas except the major bronchi.

When preparing the patient with a right-sided pleural effusion for a thoracentesis, how will the nurse position the patient? a. Supine with the head of the bed elevated 45 degrees b. In the Trendelenburg position with both arms extended c. On the left side with the right arm extended above the head d. Sitting upright with the arms supported on an over bed table

d. Sitting upright with the arms supported on an over bed table The upright position with the arms supported increases lung expansion, allows fluid to collect at the lung bases, and expands the intercostal space so that access to the pleural space is easier. The other positions would increase the work of breathing for the patient and make it more difficult for the health care provider performing the thoracentesis.

Of the following instructions, which is most important for the nurse to teach the client to help loosen secretions and increase comfort during medical treatment for sinusitis? a. blow the nose frequently b. elevate the head of the bed by 45 degrees c. engage in normal activity d. increase fluid intake

d. increase fluid intake the nurse needs to inform the client receiving medical treatment for sinusitis that use of mouthwashes and humidification as well as increased fluid intake may loosen secretions and increase comfort; the nurse should also instruct the client to take nasal decongestants and antihistamines as ordered.

A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation? A. Thoracentesis B. Pulse oximetry C. Diffusion capacity D. Maximal respiratory pressure

B. Pulse oximetry Pulse oximetry is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma. Diffusion capacity estimates the patient's ability to absorb alveolar gases and determines if a gas exchange problem exists. Maximal respiratory pressures help evaluate neuromuscular causes of respiratory dysfunction. Both tests are usually performed by a respiratory therapist. The physician or other advanced practice professional can perform a thoracentesis at the bedside with the nurse assisting, or in the radiology department.

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

B: Frequent change of position

A nurse is caring for a client with a diagnosis of respiratory alkalosis. Which pH finding would be consistent with this diagnosis? A) 7.45 B) 7.35 C) 7.49 D) 7.29

C) 7.49

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: A: Alcoholism and hypertension B: Obesity and diabetes C: Stress-related illnesses D: Cardiopulmonary disease and lung cancer

D: Cardiopulmonary disease and lung cancer

The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? (Select all that apply.) A: SpO2 levels B: Amount of sputum production C: Change in respiratory rate and pattern D: Pain in lower calf area

A: SpO2 levels B: Amount of sputum production C: Change in respiratory rate and pattern

The nurse obtains this information when assessing a patient with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea over the last 3 days. Which finding is most important to report to the health care provider? a. Respirations are 36 breaths/minute. b. Anterior-posterior chest ratio is 1:1. c. Lung expansion is decreased bilaterally. d. Hyperresonance to percussion is present.

a. Respirations are 36 breaths/minute. The increase in respiratory rate indicates respiratory distress and a need for rapid interventions such as administration of oxygen or medications. The other findings are common chronic changes occurring in patients with COPD.

A patient with acute shortness of breath is admitted to the hospital. Which action should the nurse take during the initial assessment of the patient? a. Complete a full physical examination to determine the systemic effect of the respiratory distress. b. Obtain a comprehensive health history to determine the extent of any prior respiratory problems. c. Delay the physical assessment and ask family members about any history of respiratory problems. d. Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress.

d. Perform a respiratory system assessment and ask specific questions about this episode of respiratory distress.When a patient has severe respiratory distress, only information pertinent to the current episode is obtained, and a more thorough assessment is deferred until later. Obtaining a comprehensive health history or full physical examination is unnecessary until the acute distress has resolved. A focused physical assessment should be done rapidly to help determine the cause of the distress and suggest treatment. Although family members may know about the patients history of medical problems, the patient is the best informant for these data.

A hypothermic patient is admitted to the emergency department, and pulse oximetry (SpO2) indicates that the O2 saturation is 94%. Which action should the nurse take next? a. Initiate rewarming of the patient. b. Complete a head-to-toe assessment. c. Obtain arterial blood gases (ABGs). d. Place the patient on high-flow oxygen.

d. Place the patient on high-flow oxygen. Although the O2 saturation is adequate, the left shift in the oxyhemoglobin dissociation curve will decrease the amount of oxygen delivered to tissues, so high oxygen concentrations should be given until the patient is normothermic. The other actions also are appropriate, but the initial action should be to administer oxygen.

The nurse has just received arterial blood gas (ABG) results on four patients. Which result is most important to report rapidly to the health care provider? a. pH 7.34, PaO2 82 mm Hg, PaCO2 40 mm Hg, and O2 sat 97% b. pH 7.35, PaO2 85 mm Hg, PaCO2 45 mm Hg, and O2 sat 95% c. pH 7.46, PaO2 90 mm Hg, PaCO2 32 mm Hg, and O2 sat 98% d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96%

d. pH 7.31, PaO2 91 mm Hg, PaCO2 50 mm Hg, and O2 sat 96% These ABGs indicate uncompensated respiratory acidosis and should be reported to the health care provider. The other values are normal or close to normal.

A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (Select all that apply.) A) Apply suction while withdrawing the catheter. B) Perform suctioning on a routine basis every 2 to 3 hr. C) Maintain medical asepsis during suctioning. D) Use a new catheter for each suctioning attempt. E) Apply suction for 10 to 15 seconds.

A) Apply suction while withdrawing the catheter. D) Use a new catheter for each suctioning attempt. E) Apply suction for 10 to 15 seconds.

A nurse is providing a teaching for a client who has a prescription for home oxygen. Which of the following instructions should the nurse include? (Select all that apply.) A) Post a "No Smoking" sign inside the home. B) Attach oxygen containers to a fixed object. C) Store spare oxygen containers in a closet. D) Notify the fire department that oxygen is used in the home. E) Ensure oxygen tubing is no longer than 60 feet in length.

A) A "No Smoking" sign should be posted inside and outside a home where oxygen is in use to reduce the risk of fire. B) Attach oxygen containers to a fixed object. D) Notify the fire department that oxygen is used in the home.

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply.) A) Apply the oxygen source loosely if the SpO2 decreases during the procedure. B) Use surgical asepsis to remove and clean the inner cannula. C) Clean the outer cannula surfaces in a circular motion from the stoma site outward. D) Replace the tracheostomy ties with new ties. E) Cut a slit in gauze squares to place beneath the tube holder.

A) Apply the oxygen source loosely if the SpO2 decreases during the procedure. B) Use surgical asepsis to remove and clean the inner cannula. C) Clean the outer cannula surfaces in a circular motion from the stoma site outward.

The nurse is assisting a client in obtaining a sputum specimen. After a deep cough, the client produces approximately 1/2 tsp of sputum. Which is the nurse's next action? A) Assist the client to cough again and produce more sputum. B) Send the specimen to the lab. C) Allow the client to rest for one hour and then ask the client to cough again. D) Ask the client to walk around for 30 minutes and try again to produce sputum.

A) Assist the client to cough again and produce more sputum. A sputum specimen requires 1-2 tsp of sputum, so the nurse should assist the client to repeat the coughing to produce additional sputum.

A client being treated for asthma needs to take the next dose of bronchodilator medication. After administering the drug, the nurse notes that the nursing assistant is passing out breakfast trays. Which of the following items on the breakfast tray should the nurse discuss with the client before the client consumes breakfast? A) Coffee B) Waffles C) Grapefruit juice D) Eggs

A) Coffee

A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect? A) Crackles in the lungs B) Edema of the lower extremities C) A rapid, irregular heart rate D) A systolic murmur

A) Crackles in the lungs The nurse should expect the client who has left-sided heart failure to have crackles in the lungs. Left-sided heart failure causes the blood to back up into the pulmonary circulation, causing crackles in the lungs.

The nurse is providing care to an adult client with a long history of chronic obstructive pulmonary disease (COPD). The client is admitted to the intensive care unit with a pneumothorax. Which interventions are appropriate for this client? Select all that apply. A) Elevate head of the bed B) Administer a high rate of oxygen by nasal cannula C) Prepare for a chest tube insertion D) Administer prescribed antihypertensive medications E) Administer intravenous caffeine per order

A) Elevate head of the bed C) Prepare for a chest tube insertion The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed because of the client's dyspnea and orthopnea and prepare for a chest tube insertion.

12) Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation? Select all that apply. A) Encouraging deep breathing exercises B) Assisting with positioning C) Providing suctioning D) Prescribing bronchodilators E) Monitoring activity intolerance

A) Encouraging deep breathing exercises B) Assisting with positioning C) Providing suctioning D) Prescribing bronchodilators Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs).

The nurse is conducting an assessment for a client on a medical-surgical unit. Which findings are indicative of a client who is experiencing tachypnea? Select all that apply. A) Excessive rapid breathing B) Chest pain C) Rapid breathing at rest D) Shallow breathing E) Cyanosis

A) Excessive rapid breathing C) Rapid breathing at rest D) Shallow breathing Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations of tachypnea.

The nurse is caring for a client with asthma who must receive regular breathing treatments. Which of the following are adverse drug reactions for bronchodilators? Select all that apply. A) Headache B) Sneezing C) Tachycardia D) Palpitations E) Back pain

A) Headache C) Tachycardia D) Palpitations Common adverse reactions for bronchodilators include allergic reactions such as a rash, hives or itching, headache, tachycardia, restlessness, and palpitations.

The nurse is caring for a client with a respiratory disorder and should alert the healthcare provider if the client displays which signs or symptoms that indicate early hypoxia? Select all that apply. A) Headache B) Nausea C) Heart rate of 52 D) Respiratory rate of 30 E) Blurred vision F) Hemoglobin of 17.3 mg/dl

A) Headache D) Respiratory rate of 30 E) Blurred vision Headache, tachypnea and visual disturbances are all early signs of hypoxia.

The nurse recognizes that which pathophysiologic changes are occurring when caring for the client with respiratory acidosis? Select all that apply. A) Increased CO2 B) Vasoconstriction C) Decreased O2 D) Decreased intracranial pressure (ICP) E) Increased pulse rate

A) Increased CO2 C) Decreased O2 E) Increased pulse rate Respiratory acidosis is an alteration of acid-base imbalance that is caused by decreased oxygen intake, resulting in an excess of dissolved carbon dioxide (increased CO2). The pulse rate increases in an attempt to compensate for oxygen deprivation.

The nurse is providing care for a client admitted during an acute exacerbation of asthma. Which medication does the nurse anticipate to relieve the acute symptoms exhibited by the client? A) Inhaled short-acting beta-agonists B) Oral corticosteroids C) Inhaled long-acting beta-agonists D) Oral anticholinergics

A) Inhaled short-acting beta-agonists The client admitted with an acute exacerbation of asthma will require a rescue medication, such as an inhaled short-acting beta-agonist.

The nurse is planning care for a client diagnosed with chronic obstructive pulmonary disease (COPD). Which interventions should the nurse select to address the client's ineffective breathing pattern? Select all that apply. A) Instruct in pursed-lip breathing B) Teach visualization and meditation C) Deep breathing and coughing every hour D) Instruct in abdominal breathing E) Provide oxygen 2 liters nasal cannula.

A) Instruct in pursed-lip breathing B) Teach visualization and meditation D) Instruct in abdominal breathing Techniques used to instruct a client to control the breathing pattern include pursed-lip breathing, abdominal breathing, and relaxation such as visualization and meditation.

A nurse is caring for a client who is receiving chest physiotherapy (CPT). Which of the following is the desired outcome of this treatment? A) Loosen secretions and re-inflate alveoli B) Reduce intrapulmonary pressure C) Reduce alveolar pressure D) Drain fluid from the pleural space

A) Loosen secretions and re-inflate alveoli CPT involves using vibrations to loosen secretions. It may be in the form of cupping, using a vest that vibrates, or activating the bed setting (on certain beds) to vibrate. Once mobilized, the client can expel the secretions and inhale deeply to re-inflate the alveoli.

The nurse is caring for a client with respiratory acidosis due to a benzodiazepine overdose. Which of the following nursing interventions are appropriate for this client? Select all that apply. A) Monitor respiratory status B) Provide supplemental oxygen C) Insert a nasogastric tube D) Administer alprazolam as ordered E) Administer flumazenil as ordered

A) Monitor respiratory status B) Provide supplemental oxygen E) Administer flumazenil as ordered

A nurse is caring for a client who requires 1 L of oxygen. Which of the following oxygen delivery devices should the nurse expect to use? A) Nasal cannula B) Nonrebreather mask C) Partial rebreather mask D) Simple face mask

A) Nasal cannula The nurse should plan to use a nasal cannula because oxygen via nasal cannula can be delivered at low concentrations of 1 to 4 L/min.

A nurse is assessing a client who is being discharged. The nurse notes the client has regular and quiet breathing. The nurse should identify this breathing pattern as which of the following? A) Normal breathing B) Kussmaul breathing C) Cheyne-Stokes breathing D) Apnea

A) Normal breathing A normal breathing pattern is regular, quiet, and shows no manifestations of discomfort.

What is the best way nurses can help clients reduce the risk of COPD? A) Providing smoking cessation resources B) Encouraging clients to receive vaccinations C) Referring clients to a nutritionist D) Providing references to local fitness facilities

A) Providing smoking cessation resources The primary cause of COPD is smoking, so nurses can reduce the risk of clients developing COPD by providing smoking cessation resources and encouraging clients to follow through with plans to stop smoking.

The nurse is providing care to a client with arterial blood gas analysis as follows: PaO2 of 82, PaCO2 of 49, HCO3 of 26, and pH of 7.31. Which assessment by the nurse is correct? A) Respiratory acidosis B) Respiratory alkalosis C) Metabolic alkalosis D) Metabolic acidosis

A) Respiratory acidosis Both the pH and the carbon dioxide levels represent acidosis.

The nurse is caring for a client who was just placed on supplemental oxygen per nasal cannula and should contact the healthcare provider if which assessment data are noted at the next assessment? Select all that apply. A) The client complains of feeling anxious and restless. B) Skin color is pink and warm to touch. C) The heart rate is 82. D) The respiratory rate is 36. E) The client is using accessory muscles to breathe.

A) The client complains of feeling anxious and restless. D) The respiratory rate is 36. E) The client is using accessory muscles to breathe. Feelings of anxiety and restlessness are signs of hypoxia and should be reported. A respiratory rate of 36 indicates the client is breathing abnormally fast and it should be reported.

The nurse is observing a new mother use a bulb syringe to suction her newborn's nose and mouth and should provide further instruction if the mother performs which action? A) The mother begins the procedure by suctioning the infant's nose. B) The mother deflates the bulb before placing the tip of the bulb syringe in the infant's nose. C) The mother releases the bulb and removes the bulb syringe from the infant's nose. D) The mother washes the bulb syringe with soap and water and then allows it to air dry.

A) The mother begins the procedure by suctioning the infant's nose. The mother should be taught to suction the infant's mouth before suctioning the infant's nose to prevent aspiration of secretions in the throat.

The nurse should know that which takes priority in assisting the client to effectively use a volume-oriented incentive spirometer? A) The spirometer must be held in an upright position. B) A nose clip must be used for effective inhalation. C) The procedure must be repeated every 15 minutes to be effective. D) Clean the spirometer in the dishwasher when used at home.

A) The spirometer must be held in an upright position. A volume-oriented incentive spirometer must be used in an upright position to function correctly.

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. A. Closely assess the patient before, during, and after the procedure. B. Hyperoxygenate the patient before and after suctioning. C. Limit the application of suction to 20 to 30 seconds. D. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. E. Use an appropriate suction pressure (80 to 150 mm Hg). F. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube

A, B, D, E Close assessment of the patient before, during, and after the procedure is necessary to limit negative effects. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. The nurse should also take the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis related to the use of high negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? A. Checking the amount of oxygen in the cylinder before using it B. Using a cylinder for a patient transfer that indicates available oxygen is 500 psi C. Placing the oxygen cylinder on the stretcher next to the patient D. Discontinuing oxygen flow by turning the cylinder key counterclockwise until tight

A. Checking the amount of oxygen in the cylinder before using it The cylinder must always be checked before use to ensure that enough oxygen is available for the patient. It is unsafe to use a cylinder that reads 500 psi or less because not enough oxygen remains for a patient transfer. A cylinder that is not secured properly may result in injury to the patient. Oxygen flow is discontinued by turning the valve clockwise until it is tight.

A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? A. Dyspnea B. Hypotension C. Decreased respiratory rate D. Decreased pulse rate

A. Dyspnea If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

What are strategies to prevent Ventilator-associated Pneumonia? (select all that apply) A. Oral care every 4 hours, B. HOB elevated 30-45 degrees unless contraindicated by the patient's condition C. HOB elevated 10-15 degrees, unless contraindicated by the patient's condition D. Allow family to suction patient as needed to remove secretions

A. Oral care Q4h B. HOB elevated 30-45 degrees unless contraindicated by patients condition

A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? A. Remove the catheter. B. Notify the primary care provider. C. Check that the airway is the appropriate size for the patient. D. Place the patient on his or her back.

A. Remove the catheter. When a patient vomits upon suctioning of an oropharyngeal airway, the nurse should remove the catheter; it has probably entered the esophagus inadvertently. If the patient needs to be suctioned again, the nurse should change the catheter, because it is probably contaminated. The nurse should also turn the patient to the side and elevate the head of the bed to prevent aspiration.

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.

A: Fever increases metabolic demands, requiring increased oxygen need.

The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient? A: Nasal cannula B: Venturi mask C: Simple face mask without inflated reservoir bag D: Plastic face mask with inflated reservoir bag

A: Nasal cannula

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

A: Raise the head of the bed to 45 degrees.

Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? A: Record the amount and continue to monitor drainage B: Notify the health care provider C: Strip the chest tube starting at the chest D: Increase the suction by 10 mm Hg

A: Record the amount and continue to monitor drainage

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

A: Sharp pleuritic pain that worsens on inspiration

A nurse is providing teaching for a client who has a new prescription for a continuous positive airway pressure (CPAP) machine to treat obstructive sleep apnea. Which of the following statements should the nurse include? A) "Use the CPAP mask during the daytime." B) "Cover your nose with the CPAP mask." C) "Medications to assist with breathing can be administered through the CPAP machine." D) "You will need supplemental oxygen to use the CPAP machine."

B) "Cover your nose with the CPAP mask." The nurse should instruct the client to cover their nose with the CPAP mask to create a seal to treat obstructive sleep apnea. CPAP is used for obstructive sleep apnea to keep the upper airway open and increase a client's oxygenation.

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A) Increase the oxygen flow. B) Assist the client to Fowler's position. C) Promote removal of pulmonary secretions. D) Obtain a specimen for arterial blood gases.

B) Assist the client to Fowler's position.

The nurse is preparing to insert an oropharyngeal airway in an unresponsive client and should do which to ensure the airway is inserted correctly? A) Using a tongue depressor, push the tongue to the side of the mouth when inserting the airway. B) Begin the procedure by inserting the airway upside down and then rotating it to the correct position. C) Position the airway in a downward position and then rotate it upward as it passes by the back of the throat. D) Refrain from taping the bottom of the airway to prevent esophageal injury when the client swallows.

B) Begin the procedure by inserting the airway upside down and then rotating it to the correct position. The procedure is begun with the airway curved upward (upside down) and then rotated 180 degrees.

A nurse is assessing a client who has COPD. The nurse should identify that which of the following is an expected finding? A) Jugular vein distension B) Clubbing of the fingers C) Heart murmur D) Paradoxical breathing

B) Clubbing of the fingers The nurse should identify that clubbing of the fingers is an expected finding for a client who has a chronic pulmonary disease, such as COPD.

While checking vital signs on an adult client admitted to the hospital from home, the nurse notes that the client's oxygen saturation level is 95% on room air. Which action of the nurse is most appropriate? A) Place the client in the Trendelenburg position B) Continue to monitor and assess for changes C) Provide heated and humidified oxygen via nasal cannula D) Administer 100 percent oxygen by facemask

B) Continue to monitor and assess for changes A desirable oxygen saturation level is between 95 and 100 percent for an adult. If the client has an oxygen saturation of 95 percent on room air, the nurse should continue to monitor for changes in respiratory status.

The nurse is preparing to provide tracheostomy care to a 6-month-old infant and should know that which takes priority when performing this procedure? A) Teaching the parents how to perform the procedure B) Ensuring that a second person is available to assist with the procedure C) Completing the procedure while the infant is asleep to minimize traumatizing the infant D) Use clean rather than sterile procedure because the infant will be going home with the tracheostomy

B) Ensuring that a second person is available to assist with the procedure An assistant should always be present while trach care is performed in an infant or child.

The nurse has been asked to obtain a sputum specimen from a client who is in the first postoperative day after a surgical gastric resection for stomach cancer. The nurse will ensure that which item is provided to the client to ensure an effective sputum collection? A) Supplemental oxygen B) Folded bath blanket C) Peak expiratory flow meter D) Sterile applicator stick

B) Folded bath blanket A folded bath blanket will be used by the client to hold against the abdomen to allow for effective coughing.

The nurse is caring for a client who had a chest tube inserted 48 hours ago. During the first AM assessment, the nurse noted there was intermittent bubbling of the water in the water-seal chamber. When assessing the client 2 hours later, the nurse notes that the water is now continuously bubbling. Which is the nurse's priority action at this time? A) Document the presence of the bubbling. B) Immediately contact the healthcare provider. C) Instruct the client to perform deep-breathing exercises. D) Disconnect the chest tube from the drainage system and place the chest tube in a new chest tube drainage system.

B) Immediately contact the healthcare provider. Because continuous bubbling in the water-seal chamber indicates a possible break in the system, the nurse should immediately notify the healthcare provider and follow any orders received.

A nurse is performing chest percussion therapy on a client. Which of the following actions should the nurse take? A) Perform chest percussion therapy six times per day. B) Listen for a hollow sound when performing chest percussion therapy. C) Use flat hands to perform chest percussion therapy. D) Apply chest percussion therapy over the client's ribs.

B) Listen for a hollow sound when performing chest percussion therapy. The nurse should hear a hollow sound when performing chest percussion therapy. This indicates proper technique is being used to loosen the secretions.

A client with chronic obstructive pulmonary disease (COPD) is prescribed oxygen 24% 2 L/min. Which is the best method to administer oxygen to this client? A) Face mask B) Nasal cannula C) Nonrebreather mask D) Venturi mask

B) Nasal cannula The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2 liters per minute is through nasal cannula.

A female client presents to the ER reporting difficulty breathing. Upon assessment, the client reports "it feels like it's squeezing all around my ribs when I try to take a deep breath and it's making me nauseous." What is the priority nursing intervention for this patient? A) Auscultate lung sounds B) Obtain a 12-lead EKG C) Check a blood pressure D) Apply oxygen

B) Obtain a 12-lead EKG The priority will be to obtain a 12-lead EKG. Because female clients tend to report atypical cardiac symptoms when having a myocardial infarction, it is imperative to rule out MI in this client.

The nurse is preparing to do tracheostomy care for a client and should know that which must be present at the bedside before beginning this procedure? A) One pair of sterile gloves B) Obturator C) Full-strength hydrogen peroxide D) Sterile water

B) Obturator The nurse must have an obturator at the bedside in case the trach tube is inadvertently dislodged. The obturator will allow the tube to be reinserted immediately.

A 23-year-old client requires chest physiotherapy while in the hospital for treatment for cystic fibrosis. The nurse assists the respiratory therapist by helping the client with postural drainage. Which of the following actions best describes this process? A) Encourage the client to cough and deep breathe B) Place the client in Trendelenburg position C) Teach the client how to clap or percuss the affected area D) Assist the client to sit up in bed at a 90-degree angle

B) Place the client in Trendelenburg position Chest physiotherapy involves working with the client to loosen and expectorate secretions in the respiratory system. Postural drainage involves placing the client into a position in which the trachea is lower than the affected area of the lung so the secretions will drain. The client remains in this position for a period of time to allow secretions to drain into the main bronchus and the trachea and then the secretions are removed through suctioning or expectoration.

A nurse is assessing a client who is receiving oxygen therapy. The nurse should identify that which of the following findings can indicate oxygen toxicity? A) Hypertension B) Ringing in the ears C) Fever D) Dilated pupils

B) Ringing in the ears The nurse should identify that ringing in the ears, as well as headache, disorientation, and muscle twitching, can indicate oxygen toxicity.

A nurse is caring for a client who is receiving supplemental oxygen for hypoxia. The nurse should identify that which of the following can cause hypoxia? A) Diabetic ketoacidosis B) Smoke inhalation C) Administration of a stimulant medication D) Right-sided heart failure

B) Smoke inhalation The nurse should identify that smoke inhalation can cause hypoxia. Smoke inhalation can cause a client to become hypoxic due to a lack of oxygen and ventilation.

A nurse is reviewing the medical history of a client who has a heart disease and a narrowed valve. Which of the following findings should the nurse expect? A) Regurgitation B) Stenosis C) Muscle atrophy D) Hypotension

B) Stenosis The nurse should expect a client who has heart disease and a narrowed valve to have stenosis. Stenosis is a narrowing or stiffening of the heart valve that causes backflow of the blood.

The nurse is caring for a 4-year-old postoperative client who has been unable to understand the use of the incentive spirometer. The nurse should choose which activity that will assist the child to perform the same action as the spirometer? A) Blowing out candles B) Sucking on a straw C) Filling up a balloon D) Using bubbles

B) Sucking on a straw Incentive spirometry focuses on inhalation, which is the action that sucking on a straw will imitate.

The nurse is caring for a group of clients with respiratory disorders and should know that which client should not be placed on continuous positive airway pressure (CPAP) to assist with respiratory distress? A) The client with chronic obstructive pulmonary disease (COPD) who is complaining of shortness of breath B) The client whose respirations have fallen to 8/minute after receiving morphine sulfate C) The client who experiences apnea during sleep D) The client who is experiencing wheezing and is having difficulty moving air adequately

B) The client whose respirations have fallen to 8/minute after receiving morphine sulfate CPAP should never be used on clients receiving opioids because it causes the pharynx to relax and contributes to further airway obstruction.

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

B) The maximum volume of air that is expired after a maximum inspiration. The vital capacity is the amount of air that is forcibly expelled after a maximal inspiration.

The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client with asthma. Which action by the newly licensed nurse requires immediate intervention? A) The newly licensed nurse is observed obtaining the pulse oximetry reading 10 minutes after the client used an albuterol inhaler. B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment. C) The newly licensed nurse is observed assessing the client's thoracic wall, skin, and nail beds. D) The newly licensed nurse is observed auscultating breath sounds with a stethoscope.

B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment. The charge nurse should intervene immediately if the nurse observes the client is demonstrating impairment at or near respiratory failure; the client will not be able to respond to questions. Assessment questions should be tailored and asked of any family member or friend accompanying the client.

An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? A. Tilt the patient's head forward. B. Hold the mask tightly over the patient's nose and mouth. C. Pull the patient's jaw backward. D. Compress the bag twice the normal respiratory rate for the patient

B. Hold the mask tightly over the patient's nose and mouth. With the patient's head tilted back, jaw pulled forward, and airway cleared, the mask is held tightly over the patient's nose and mouth. The bag also fits easily over tracheostomy and endotracheal tubes. The operator's other hand compresses the bag at a rate that approximates normal respiratory rate (e.g., 16 to 20 breaths/min in adults

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. A. Refrain from exercise. B. Reduce anxiety. C. Eat meals 1 to 2 hours prior to breathing treatments. D. Eat a high-protein/high-calorie diet. E. Maintain a high-Fowler's position when possible. F. Drink 2 to 3 pints of clear fluids daily.

B. Reduce anxiety. D. Eat a high-protein/high-calorie diet. E. Maintain a high-Fowler's position when possible. When caring for patients with COPD, it is important to create an environment that is likely to reduce anxiety and ensure that they eat a high-protein/high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high-Fowler's position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises, and drinking 2 to 3 quarts (1.9 to 2.9 L) of clear fluids daily is recommended

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter? A. The age of the patient B. The size of the endotracheal tube C. The type of secretions to be suctioned D. The height and weight of the patient

B. The size of the endotracheal tube The nurse would base the size of the suctioning catheter on the size of the endotracheal tube. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. Larger catheters can contribute to trauma and hypoxemia.

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

B: Forms a strong bond with hemoglobin, creating a functional anemia.

A nurse is discussing atrial fibrilation with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of atrial fibrilation? A) "Atrial fibrillation is caused by electrical signals that come from the ventricles." B) "Atrial fibrillation causes a lower-than-expected heart rate." C) "Atrial fibrillation is caused by electrical signals outside of the SA node." D) "Atrial fibrillation causes diaphoresis in most clients."

C) "Atrial fibrillation is caused by electrical signals outside of the SA node." This statement by the newly licensed nurse indicates an understanding of atrial fibrillation. Atrial fibrillation is caused when electrical impulses start outside of the SA node, causing an irregular heart rate.

A nurse is suctioning a client's tracheostomy using an open system. Which of the following actions should the nurse take? A) Use clean technique to perform the procedure. B) Apply suction when inserting the catheter. C) Administer 100% oxygen before the procedure. D) Suction the tracheostomy for 20 seconds each time.

C) Administer 100% oxygen before the procedure. The nurse should administer 100% oxygen to the client before the procedure to reduce the risk for hypoxia.

A nurse checks a client's oxygen saturation by using a bedside sensory probe. The client has pneumonia that is currently being treated with antibiotics. When the nurse places the pulse oximeter probe on the client, the first reading she notes is 89 percent. Which of the following actions should the nurse perform first? A) Raise the head of the bed and ask the client to take a deep breath B) Administer 100 percent oxygen and monitor the pulse oximetry until it reaches 95 percent C) Assess the probe site to ensure an accurate reading D) Contact the provider for a chest x-ray

C) Assess the probe site to ensure an accurate reading

The nurse is caring for a client who has a chest tube. Upon assessment, the nurse notes that there is continuous bubbling of water in the suction container of the chest tube but very little if any bubbling in the water seal chamber. Which is the nurse's best action at this time? A) Contact respiratory therapy for immediate assistance. B) Reposition the client to the affected side. C) Auscultate the client's lungs, paying close attention to the area near the chest tube. D) Wait 15 minutes and reassess the client.

C) Auscultate the client's lungs, paying close attention to the area near the chest tube. Auscultation of the client's lungs should be the nurse's first action because the nurse needs to know if there continues to be lack of air movement (tube is blocked) or possible healing of air leak before contacting the healthcare provider.

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD) after years of experiencing emphysema. Which clinical manifestation does the nurse anticipate when assessing this client? A) Tachycardia B) Cough C) Barrel chest D) Wheezing

C) Barrel chest Barrel chest occurs because the lungs are chronically overinflated with air, so the rib cage stays partially expanded.

When auscultating the lungs of a client experiencing dyspnea, the nurse hears a low-pitched sound that is continuous throughout inspiration. What does this lung sound indicate to the nurse? A) Narrow bronchi B) Narrow trachea passages C) Blocked large airway passages D) Inflamed pleural surfaces

C) Blocked large airway passages The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout inspiration. Rhonchi suggests blockage of large airway passages, which may be cleared with coughing.

The low tidal volume alarm on a client's ventilator keeps sounding. What is the nurse's first action? A) Manually ventilate the client. B) Put air into the endotracheal tube cuff. C) Check ventilator connections. D) Call the physician.

C) Check ventilator connections Ventilator connections should be check initially and loose connections or disconnections should be fixed. If there is no immediate problem found, the client should be manually ventilated and another person should check the ventilator connections. Test Plan: Management of care

A nurse walks into a client's room and discovers that the client is in respiratory distress. The client has tracheal deviation to the right side. The nurse knows to prepare for which of the following emergent procedures? A) Chest tube insertion on the right side B) Tracheostomy C) Chest tube insertion on the left side D) Intubation

C) Chest tube insertion on the left side

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical manifestations are the direct result of altered perfusion? Select all that apply. A) Bounding pulse B) Pink nail beds C) Cyanosis D) Confusion E) Wheezing

C) Cyanosis D) Confusion A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include cyanosis and confusion.

The nurse is caring for an older adult client who had a tracheostomy placed 3 days ago and should know that which issue will take priority when caring for this client? A) Reducing the client's anxiety concerning self-care of the tracheostomy B) Reassuring the client that the tracheostomy is a temporary measure C) Ensuring that the skin around the client's tracheostomy stoma is assessed frequently D) Referring the client to a support group for individuals with tracheostomies

C) Ensuring that the skin around the client's tracheostomy stoma is assessed frequently The nurse should place priority on caring for the skin around the client's stoma because older adults are more prone to skin breakdown.

The nurse is caring for a client who is exhibiting severe respiratory distress and is receiving supplemental oxygen through a nonrebreather mask. While assessing the client, the nurse notes that the bag attached to the mask is deflated. Which is the nurse's best action? A) Document it as functioning normally. B) Decrease the flow of oxygen to the mask. C) Increase the flow of oxygen to the mask. D) Prepare for endotracheal intubation.

C) Increase the flow of oxygen to the mask. If the bag is completely deflated, the nurse should increase the flow of oxygen to the mask and then contact the healthcare provider.

The nurse observes a client using the incentive spirometer and s that further instruction is required when the client performs which action? A) Exhales before placing the incentive spirometer to the lips B) Seals the lips tightly around the mouthpiece of the incentive spirometer C) Inhales quickly, causing the spirometer balls to snap to the top of the incentive spirometer D) Attempts to cough productively after using the incentive spirometer

C) Inhales quickly, causing the spirometer balls to snap to the top of the incentive spirometer The client should inhale slowly, not quickly, and deeply to ensure maximal lung expansion.

During shift report, the oncoming nurse is told that an assigned client has atelectasis. The nurse knows this could be caused by which of the following? Select all that apply. A) Brain aneurysm B) Ventricular tachycardia C) Intubation during general anesthesia D) Deep vein thrombosis E) Collapsed lung

C) Intubation during general anesthesia E) Collapsed lung When a client is intubated, a machine breathes for the client. Normally a person's diaphragm contracts, which increases the space in the chest cavity and causes air to enter the lungs. When intubated, a machine forces air into the lungs, which is the opposite mechanism for lung inflation than normal, and can cause a certain measure of obstruction. Clients who are intubated nearly always have some amount of atelectasis afterward. A person with a collapsed lung will have atelectasis in the affected area.

A nurse is caring for a client who has a history of asthma and is wheezing. Which of the following actions should the nurse take first? A) Auscultate the lung sounds. B) Document the respiratory rate. C) Obtain the oxygen saturation. D) Check the capillary refill.

C) Obtain the oxygen saturation. The greatest risk to this client is injury from hypoxia; therefore, the first action the nurse should take is to obtain the client's oxygen saturation. Obtaining the client's oxygen saturation will assist the nurse in determining the next intervention.

After completing instructions for collecting a sputum specimen to the client, the nurse observes the client remove the lid of the specimen container and spit into the cup. Which is the nurse's next best action? A) Ask the client if the specimen obtained was sputum or saliva. B) Explain to the client that the specimen will have to be obtained by suctioning. C) Provide the client with a new specimen container and explain again how to obtain the specimen. D) Send the specimen to the lab as obtained but label it as saliva.

C) Provide the client with a new specimen container and explain again how to obtain the specimen. The nurse should explain again how to obtain the specimen and give the client a new specimen container.

A nurse is planning to measure the cardiac output of a client who had a myocardial infarction. Which of the following data should the nurse use to calculate the client's cardiac output? A) Respiratory rate B) Blood pressure C) Stroke volume D) Vital capacity

C) Stroke volume The nurse should use stroke volume to calculate the client's cardiac output. Cardiac output is a measurement of the volume of blood pumped by the left ventricle in 1 min. Cardiac output is calculated by multiplying the client's heart rate by the client's stroke volume.

A preceptor asks a student nurse where carbon dioxide and oxygen exchange occurs in the lungs. Which response is correct? A) The atrium B) The pulmonary veins C) The alveoli D) The alveolar ducts

C) The alveoli Gas exchange occurs in the alveoli. The alveoli are the functional unit of the lungs.

A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? A. A postoperative adult B. An adult with COPD C. A teenager with cystic fibrosis D. A child with pneumonia

C. A teenager with cystic fibrosis hest physiotherapy may help loosen and mobilize secretions, increasing mucus clearance. This is especially helpful for patients with large amounts of secretions or an ineffective cough, such as patients with cystic fibrosis. Chest physiotherapy has limited evidence for its effectiveness and is not recommended for use in numerous patient populations, including children with pneumonia, adults with COPD, and postoperative adults

A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? A. Instruct the assistant to notify the primary care provider. B. Assess the patient's vital signs. C. Remove the tape, adjust the depth to ordered depth and reapply the tape. D. No action is required as depth will adjust automatically.

C. Remove the tape, adjust the depth to ordered depth and reapply the tape. The tube depth should be maintained at the same level unless otherwise ordered by the health care provider. If the depth changes, the nurse should remove the tape, adjust the tube to ordered depth, and reapply the tape.

A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? A. The nurse assures that the oxygen is flowing into the prongs. B. The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. C. The nurse encourages the patient to breathe through the nose with the mouth closed. D. The nurse adjusts the flow rate to 6 L/min or more.

C. The nurse encourages the patient to breathe through the nose with the mouth closed. The nurse should encourage the patient to breathe through the nose with the mouth closed. The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should adjust the fit of the cannula so it is snug but not tight against the skin. The nurse should adjust the flow rate as ordered.

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

C: Decreased independent ability to cough

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient? A: Postural drainage B: Chest percussion C: Incentive spirometer D: Suctioning

C: Incentive spirometer

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."

D: "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

The nurse is reviewing the results of laboratory tests conducted on a client admitted with an alteration in respiratory function. Which laboratory finding would be most significant for this client? A) Hemoglobin level 14 g/dL B) Oxygen saturation 96% C) Serum sodium 140 mg/dL D) Blood pH 7.32

D) Blood pH 7.32 Normal blood pH is 7.35-7.45. A decreased pH indicates that the client is experiencing acidosis, which indicates an alteration in oxygenation.

The nurse assigned to the newborn nursery is conducting shift assessments. While assessing one newborn, the nurse notes the respiratory rate is 52 breaths per minute. Which action by the nurse is appropriate? A) Notify the healthcare provider of this assessment finding. B) Obtain an arterial blood gas for further respiratory assessment. C) Begin monitoring the respiratory rate every 5 minutes. D) Continue to monitor the newborn per facility policy.

D) Continue to monitor the newborn per facility policy. A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates are highest and most variable in newborns.

Which assessment finding by the nurse supports the diagnosis that a client is in the early stages of chronic obstructive pulmonary disease (COPD)? A) Dysrhythmias B) Cyanotic nail beds C) Clubbing of the fingers D) Cough in the morning producing clear sputum

D) Cough in the morning producing clear sputum The earliest-presenting symptom of COPD is coughing in the morning with clear sputum unless the client develops an infection, in which case the sputum would become yellow or green in color.

The nurse should encourage the client to use incentive spirometry prior to which procedure? A) Ambulating the client B) Preparing the client for a rest period C) Removing the client's meal tray D) Obtaining a sputum specimen

D) Obtaining a sputum specimen The deep breathing that is completed with incentive spirometry may help a client prepare for obtaining a sputum specimen.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is experiencing increasing respiratory difficulty. The client has refused being placed on a mechanical ventilator and the nurse is aware that which would provide possible respiratory assistance to this client? A) Place an endotracheal tube without the use of a mechanical ventilator. B) Provide supplemental oxygen using a Venturi face mask. C) Put a nonrebreather mask on the client to help him breathe. D) Place the client on a bilevel positive airway pressure (BiPAP) machine.

D) Place the client on a bilevel positive airway pressure (BiPAP) machine. The use of a CPAP or BiPAP machine may provide an appropriate alternative to intubation.

The nurse has just completed insertion of a nasal trumpet to assist in protecting a responsive client's airway and should place the client in which position to maintain the airway? A) Supine with the head to the side B) Side-lying with chin positioned closest to the chest C) Prone with head to the side D) Side-lying with head slightly tilted up and centered on the pillow

D) Side-lying with head slightly tilted up and centered on the pillow The client should be positioned in a side-lying position with the head slightly tilted up to maintain and open airway and to allow for adequate drainage of secretions.

The nurse is preparing to perform tracheostomy care on an alert, cooperative adult client and should request an assistant prior to which step? A) An assistant is not required when performing tracheostomy care in a cooperative, alert adult client. B) The assistant is required prior to pouring liquids into the sterile container. C) The assistant is required prior to removing the inner cannula. D) The assistant is required prior to removing and placing new tracheostomy ties.

D) The assistant is required prior to removing and placing new tracheostomy ties. The nurse requires assistance prior to changing the ties of the trach tube because it is at this time that the entire trach could be dislodged.

Which best describes the purpose of pursed-lip breathing in the client with COPD? A) To exercise the muscles of the diaphragm B) To balance the effects of carbon dioxide and oxygen in the bloodstream C) To strengthen the muscles of the rib cage D) To reduce the overall work of breathing

D) To reduce the overall work of breathing

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who is receiving supplemental oxygen and should intervene if which delivery device is being used by the client? A) Nasal cannula B) Continuous positive airway pressure (CPAP) C) Bilevel positive airway pressure (BiPAP) D) Venturi face mask

D) Venturi face mask A Venturi face mask provides oxygen concentrations from 24% to 50% with flow rates from 4-10 L/min, which would be too high for a client with COPD and may cause the client's breathing stimuli to be suppressed.

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. A. "I will be careful not to shake up the canister before using it." B. "I will hold the canister upside down when using it." C. "I will inhale the medication through my nose." D. "I will continue to inhale when the cold propellant is in my throat." E. "I will only inhale one spray with one breath." F. "I will activate the device while continuing to inhale."

D. "I will continue to inhale when the cold propellant is in my throat." E. "I will only inhale one spray with one breath." F. "I will activate the device while continuing to inhale." Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, and inhaling two sprays with one breath.

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? A. The patient vomits during suctioning. B. The secretions appear to be stomach contents. C. The catheter touches an unsterile surface. D. A nosebleed is noted with continued suctioning.

D. A nosebleed is noted with continued suctioning. When nosebleed (epistaxis) is noted with continued suctioning, the nurse should notify the health care provider and anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning.

A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient? A. Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone. B. Teach the patient not to talk about the procedure, just to perform it at the best of his or her ability. C. Teach the patient to take short shallow breaths when performing hygiene measures. D. Group personal care activities into smaller steps, allowing rest periods between activities.

D. Group personal care activities into smaller steps, allowing rest periods between activities. For a patient who is too fatigued to complete daily hygiene on his or her own, the nurse should group personal care activities into smaller steps and allow rest periods between the activities. The nurse should assist with bathing and hygiene tasks as needed and only when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits, and teach the patient to coordinate diaphragmatic breathing with the activity.

A nurse is caring for a client after having a tracheostomy placed. Which of the following are appropriate nursing interventions for the client with a tracheostomy? a) Hyperoxygenate the client prior to suctioning b) Ensure that the cuff is deflated during meals c) Monitor arterial blood gases rather than pulse oximetry d)Insert the plug into the tracheostomy tube prior to removing the inner cannula

a) Hyperoxygenate the client prior to suctioning When a client has a tracheostomy tube, it will need to be suctioned regularly to prevent airflow occlusion. Each time the tracheostomy is suctioned, the client's oxygen level will drop because they are unable to take a breath. It is important to hyperoxygenate the client prior to suctioning the tracheostomy tube.

A client comes to the doctor's office describing shortness of breath and strange breath sounds when inhaling deeply. Upon auscultation of the lung fields, sibilant wheezes are noted. Which of the following statements by the nurse most correct? a. "Wheezes result from air passing through narrowed passages." b. "Wheezes result from air escaping through a pneumothorax." c. "Wheezes result from air collecting in the pleural cavity." d. "Wheezes result from air between visceral and parietal pleurae."

a. "Wheezes result from air passing through narrowed passages." wheezes may be sibilant (hissing/whistling) or sonorous (full and deep). Sibilant wheezes (formerly called wheezes) are continuous musical sounds that can be heard during inspiration and expiration; and result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions.

A patient with chronic hypoxemia (SaO2 levels of 89% to 90%) caused by chronic obstructive pulmonary disease (COPD) has been hospitalized with increasing shortness of breath. In planning for discharge, which of these actions by the nurse will be most effective in improving compliance with discharge teaching? a. Arrange for the patients spouse to be present during the teaching. b. Start giving the patient discharge teaching on the day of admission. c. Accomplish the patient teaching just before the scheduled discharge. d. Have the patient repeat the instructions immediately after the teaching.

a. Arrange for the patients spouse to be present during the teaching. Hypoxemia interferes with the patients ability to learn and retain information, so having the patients spouse present will increase the likelihood that discharge instructions will be followed. Having the patient repeat the instructions will indicate that the information is understood at the time, but it does not guarantee retention of the information. Because the patient is likely to be distracted just before discharge, giving discharge instructions just before discharge is not ideal. The patient is likely to be anxious and even more hypoxemic than usual on the day of admission, so teaching about discharge should be postponed.

The nurse is caring for a client who has been brought to the ED for an asthma exacerbation. Which of the following would NOT be an expected finding when completing a comprehensive respiratory assessment of this client? a) Tachypnea b) Cheyne-Stokes respirations c) Wheezes d) Diminished breath sounds

b) Cheyne-Stokes respirations This is an abnormal respiratory pattern with periods of apnea. It is not an expected clinical finding in a client experiencing an acute asthma exacerbation. All other assessment findings would be expected with this clinical picture.

A nurse is working in the ED and has just received a client with an asthma exacerbation. Which of the following positions would be the MOST conducive to effective gas exchange for this client? a) Trendelenburg b) High-Fowler's c) Prone d) Dorsal Recumbant

b) High-Fowler's High-Fowler's - client sitting straight upright which would best facilitate breathing and gas exchange in a client with an asthma exacerbation.

A patient with a chronic cough has a bronchoscopy. Which action will be included in the nursing care plan after the procedure? a. Elevate the head of the bed to 80 to 90 degrees. b. Keep the patient NPO until the gag reflex returns. c. Place on bed rest for at least 4 hours postbronchoscopy. d. Notify the health care provider about blood-tinged mucus.

b. Keep the patient NPO until the gag reflex returns. Because a local anesthetic is used to suppress the gag/cough reflexes during bronchoscopy, the nurse should monitor for the return of these reflexes before allowing the patient to take oral fluids or food. Blood-tinged mucus is not uncommon after bronchoscopy. The patient does not need to be on bed rest, and the head of the bed does not need to be in the high-Fowlers position.

A patient is admitted with a metabolic acidosis of unknown origin. Based on this diagnosis, the nurse would expect the patient to have a. intercostal retractions. b. Kussmaul respirations. c. a low oxygen saturation (SpO2). d. a decrease in venous O2 pressure.

b. Kussmaul respirations. Kussmaul (deep and rapid) respirations are a compensatory mechanism for metabolic acidosis. Intercostal retractions, a low oxygen saturation rate, and a decrease in PvO2 would not be caused by acidosis.

When the nurse is analyzing the results of a patients arterial blood gases (ABGs), which finding indicates the need for most immediate action? a. The arterial oxygen saturation (SaO2) is 92%. b. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg. c. The partial pressure of CO2 in arterial blood (PaCO2) is 31 mm Hg. d. The bicarbonate level (HCO3) is 29 mEq/L.

b. The partial pressure of oxygen in arterial blood (PaO2) is 59 mm Hg. All the values are abnormal, but the low PaO2 indicates that the patient is at the point on the oxyhemoglobin dissociation curve where a small change in the PaO2 will cause a large drop in the O2 saturation and a decrease in tissue oxygenation. The nurse should intervene immediately to improve the patients oxygenation.

On auscultation of a patients lungs, the nurse hears short, high-pitched sounds during exhalation in the lower 1/3 of both lungs. The nurse records this finding as a. expiratory crackles at the bases. b. expiratory wheezes in both lungs. c. abnormal lung sounds in the bases of both lungs. d. pleural friction rub in the right and left lower lobes.

b. expiratory wheezes in both lungs. Wheezes are high-pitched sounds. In this case they are heard during the expiratory phase of the respiratory cycle. Abnormal breath sounds are either bronchial or bronchovesicular sounds heard in the peripheral lung fields. Crackles are low-pitched, bubbling sounds. Pleural friction rubs are grating sounds that are usually heard during both inspiration and expiration.

A nurse needs to obtain a sputum specimen from an adult client. Which nursing action will best facilitate obtaining the specimen? a. ask the client to spit into the collection container b. have the client take deep breaths c. restrict the client's fluids d. wait until after the client has eaten to get the specimen.

b. have the client take deep breaths collecting a sputum specimen have the client rinse their mouth with tap water; instruct the client to take several deep breaths, cough forcefully, and expectorate into the container.

Movement of air into and out of the lungs sufficient to maintain normal arterial oxygen and carbon dioxide tensions is termed what? a. perfusion b. ventilation c. diffusion d. inspiration

b. ventilation ventilation is the actual movement of air in and out of the respiratory tract. This process requires a patent airway and intact and functioning respiratory muscles.

After the nurse has received change-of-shift report, which of these patients should be assessed first? a. A patient with pneumonia who has crackles in the right lung base b. A patient with chronic obstructive pulmonary disease (COPD) and pulmonary function testing (PFT) that indicates low forced vital capacity c. A patient with possible lung cancer who has just returned after bronchoscopy d. A patient with hemoptysis and a 16-mm induration with tuberculin skin testing

c. A patient with possible lung cancer who has just returned after bronchoscopy Since the cough and gag are decreased after bronchoscopy, this patient should be assessed for airway maintenance. The other patients do not have clinical manifestations or procedures that require immediate assessment by the nurse.

The nurse palpates the posterior chest while the patient says 99 and notes that no vibration is felt. How should this be charted? a. Diminished expansion b. Dullness to percussion c. Absent tactile fremitus d. Decreased breath sounds

c. Absent tactile fremitus To assess for tactile fremitus, the nurse should use the palms of the hands to assess for vibration when the patient repeats a word or phrase such as 99. Different techniques are used to assess for dullness to percussion, decreased breath sounds, and diminished expansion.

While caring for a patient with respiratory disease, the nurse observes that the patients SpO2 drops from 92% to 88% while the patient is ambulating in the hallway. Which action should the nurse take next? a. Notify the health care provider. b. Document the response to exercise. c. Administer the PRN supplemental O2. d. Encourage the patient to pace activity.

c. Administer the PRN supplemental O2. The drop in SpO2 to 85% indicates that the patient is hypoxemic and needs supplemental oxygen when exercising. The other actions also are appropriate, but the first action should be to correct the hypoxemia.

When assessing the respiratory system of a 78-year-old patient, which finding indicates that the nurse should take immediate action? a. The chest appears barrel shaped. b. The patient has a weak cough effort. c. Crackles are heard from the lung bases to the midline. d. Hyperresonance is present across both sides of the chest.

c. Crackles are heard from the lung bases to the midline. Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated.

The nurse completes a shift assessment on a patient admitted in the early phase of heart failure. When auscultating the patients lungs, which finding would the nurse most likely hear? a. Continuous rumbling, snoring, or rattling sounds mainly on expiration b. Continuous high-pitched musical sounds on inspiration and expiration c. Discontinuous, high-pitched sounds of short duration heard on inspiration d. A series of long-duration, discontinuous, low-pitched sounds during inspiration

c. Discontinuous, high-pitched sounds of short duration heard on inspiration Fine crackles are likely to be heard in the early phase of heart failure. Fine crackles are discontinuous, high- pitched sounds of short duration heard on inspiration. Rhonchi are continuous rumbling, snoring, or rattling sounds mainly on expiration. Course crackles are a series of long-duration, discontinuous, low-pitched sounds during inspiration. Wheezes are continuous high-pitched musical sounds on inspiration and expiration.

The nurse is observing a student who is listening to a patients lungs. Which action by the student indicates a need to review respiratory assessment skills? a. The student compares breath sounds from side to side. b. The student listens only over the posterior part of the chest. c. The student places the stethoscope over the scapulae and then auscultates. d. The student starts at the base of the posterior lung and moves to the apices.

c. The student places the stethoscope over the scapulae and then auscultates. The stethoscope should be placed over lung tissue, not over bony structures. Breath sounds should be compared from side to side. The techniques of starting at the lung base and then moving toward the apices and listening only over the posterior chest are acceptable.

A nurse is auscultating the lung sounds of a client who came to the clinic for a physical exam. There is not any history of lung disease. What should the nurse expect to hear? a. adventitious breath sounds b. bronchial breath sounds c. bronchovesicular breath sounds d. vesicular breath sounds

c. bronchovesicular breath sounds the nurse auscultates breath sounds from side to side, moving from the upper to the lower chest. They listen anteriorly, laterally, and posteriorly. Normal breath sounds include bronchovesicular sounds.

When assessing the respiratory system of an older patient, which finding indicates that the nurse should take immediate action? a. Weak cough effort b. Barrel-shaped chest c. Dry mucous membranes d. Bilateral crackles at lung bases

d. Bilateral crackles at lung bases Crackles in the lower half of the lungs indicate that the patient may have an acute problem such as heart failure. The nurse should immediately accomplish further assessments, such as oxygen saturation, and notify the health care provider. A barrel-shaped chest, hyperresonance to percussion, and a weak cough effort are associated with aging. Further evaluation may be needed, but immediate action is not indicated. An older patient has a less forceful cough and fewer and less functional cilia. Mucous membranes tend to be drier