Oxygenation and Perfusion

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client? a. nasal cannula b. flow meter c. oxygen analyzer d. nasal strip

b. flow meter

A nurse must take a client's pulse oximetry reading. The nurse is explaining the technique to the client. Which statements about pulse oximetry are true? Select all that apply. a. The pulse oximetry sensor can produce accurate results even if circulation to the sensor site is impaired. b. A range of 88% to 95% is considered normal oxygen saturation for infants. c. Pulse oximetry measurement requires insertion of an arterial line. d. Pulse oximeters display oxygen saturation and respiratory rate. e. Sensors are available for use on the finger, toe, foot, earlobe, forehead, and bridge of the nose. f. Once the oximetry probe is correctly placed, a beam of red and infrared light travels through the tissue and blood vessels.

e, f

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing a. Congestive heart failure b. Poor tissue perfusion c. Malnutrition d. Anemia

a. Congestive heart failure

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client? a. nasal cannula b. nonrebreather mask c. face tent d. simple mask

a. nasal cannula

The nurse is caring for a client with respiratory alkalosis. Which arterial blood gas data does the nurse anticipate finding? a. pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation b. pH less than 7.35; HCO3 low; PaCO2 low c. pH greater than 7.45; HCO3 high; PaCO2 high d. pH less than 7.35; HCO3 high; PaCO2 high

a. pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? a. Contact the health care provider for nutrition shake. b. Eat smaller meals that are high in protein. c. Snack on high-carbohydrate foods frequently. d. Eat one large meal at noon.

b. Eat smaller meals that are high in protein.

A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of: a. pneumonia. b. croup. c. alcohol use. d. asthma.

a. pneumonia.

The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client? a. "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." b. "Breathing through your nose first will warm, filter, and humidify the air you are breathing." c. "If you breathe through the mouth first, you will swallow germs into your stomach." d. "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation."

b. "Breathing through your nose first will warm, filter, and humidify the air you are breathing."

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which instruction will the nurse include in the teaching? a. Inhale through the nose instead of the mouth. b. Be sure to shake the canister before using it. c. Inhale two sprays with one breath for faster action. d. Inhale the medication rapidly.

b. Be sure to shake the canister before using it.

The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier? a. mineral oil b. distilled water c. normal saline d. tap water

b. distilled water

A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs? a.Simple mask b. Nonrebreather mask c. Nasal cannula d. Partial rebreather mask

c. Nasal cannula

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? a. They are low-pitched, soft sounds heard over peripheral lung fields. b. They are medium-pitched blowing sounds heard over the major bronchi. c. They are loud, high-pitched sounds heard primarily over the trachea and larynx. d. They are soft, high-pitched discontinuous (intermittent) popping lung sounds.

a. They are low-pitched, soft sounds heard over peripheral lung fields.

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing: a. bronchospasm. b. bronchiectasis. c. bronchitis. d. bronchiolitis.

a. bronchospasm.

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? a. Suction the client's mouth through the oropharyngeal airway to prevent aspiration. b. Leave the airway in place and promptly notify the health care provider for further instructions. c. Remove the airway, turn the client to the side, and provide mouth suction, if necessary. d. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider.

c. Remove the airway, turn the client to the side, and provide mouth suction, if necessary.

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: a. crackles. b. bronchovesicular. c. wheezes. d. vesicular.

a. crackles.

An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize? a. "Did someone loosen the straps on your mask?" b. "Did someone take your mask off?" c. "Did you remove your dentures?" d. "Is your mask causing discomfort?"

d. "Is your mask causing discomfort?"

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen a. Instruct the client to inhale deeply and then cough. b. Place the client in the dorsal recumbent position to collect the specimen. c. Discard the first sputum produced by the client. d. Have the client clear the nose and throat and gargle with salt water before beginning the procedure.

a. Instruct the client to inhale deeply and then cough.

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? a. It regulates the amount of oxygen received. b. It determines whether the client is getting enough oxygen. c. It decreases dry mucous membranes via delivering small water droplets. d. It prescribes oxygen concentration.

b. It determines whether the client is getting enough oxygen.

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? a. Leave the airway in place and promptly notify the health care provider for further instructions. b. Remove the airway, turn the client to the side, and provide mouth suction, if necessary. c. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. d. Suction the client's mouth through the oropharyngeal airway to prevent aspiration.

b. Remove the airway, turn the client to the side, and provide mouth suction, if necessary.

The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document? a. Absent breath sounds in lower lobes b. Crackles c. Stridor d. Wheezing

b. wheezing

The nurse is caring for a client with emphysema who has been prescribed portable oxygen, 2 L/min. Which action(s) does the nurse take to administer low concentrations of oxygen to the client? Select all that apply. a. Place the finger at the nasal cannula outlet to feel for the flow of oxygen b. Place the outlet of nasal cannula into a glass of water to ensure the flow of oxygen c. Confirm that the nasal cannula is worn properly by the client d. Ensure that the oxygen concentrator is turned on e. Verify the oxygen concentrator is set on the prescribed flow rate

c. Confirm that the nasal cannula is worn properly by the client d. Ensure that the oxygen concentrator is turned on e. Verify the oxygen concentrator is set on the prescribed flow rate

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations? a. Atelectasis b. Perfusion c. Hypoxia d. Hyperventilation

c. Hypoxia

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is: A. "He will require additional testing to determine the cause." b. "His infection is causing him to breathe harder." c. "His lung muscles are swollen so he is using abdominal muscles." d. "He is using his chest muscles to help him breathe."

d. "He is using his chest muscles to help him breathe."

A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client? a. peak expiratory flow rate b. thoracentesis c. pulse oximetry d. spirometry

c. pulse oximetry

The nurse is admitting a new client who has had a chest tube inserted on the right side. Which action should the nurse prioritize for this client? a.provide bedside commode for client b.limit movement of the right arm while tube is in place c.coughing and deep breathing at least q2h while awake d. maintain bed in at least semi-Fowler position at all times

c.coughing and deep breathing at least q2h while awake

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? a. "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." b. "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling." c. "Take in a small amount of air very quickly and then exhale as quickly as possible." d. "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly

d. "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? a. "I understand; I used to be a smoker also." b. "Oxygen is a flammable gas." c. "An occasional cigarette will not hurt you." d. "You should never smoke when oxygen is in use."

d. "You should never smoke when oxygen is in use."

The nurse is caring for a client who is wearing oxygen via nasal cannula. The client asks about the bubbling water attached to the oxygen. Which response by the nurse is appropriate? a. It regulates the amount of oxygen received. b. It prescribes oxygen concentration. c. It determines whether you are getting enough oxygen. d. It decreases dry mucous membranes by delivering small water droplets.

d. It decreases dry mucous membranes by delivering small water droplets.