Oxygenation

What should the nurse include in the assessment of a client admitted with a diagnosis of community-acquired pneumonia? Select all that apply. 1. Presence of cough 2. Amount and color sputum 3. Occurrence of fever 4. Chest x-rays 5. Neubuifizer treatments

1, 2, 3. 1. Presence of cough: The nurse should assess if the client has a cough, as this is a frequent finding in pneumonia 2. The nurse should assess the amount, color, and consistency of any sputum the client produces. Sputum occurs due to fluid and debris caught in the airways from causative microorganisms. 3. Pneumonia frequently causes fevers, and the nurse should monitor for its occurrence and treat with antipyretic. Option 4: The nurse would make sure that x-rays are obtained as prescribed; however, this is not included in an assessment. It is an intervention. Option 5: Nebulizer treatments are an intervention and would not be included in the assessment.

The nurse is educating a client with chronic obstructive pulmonary disease (COPD) about deep breathing exercises. Which aspect should the nurse include particularly for this client? 1. Have the client forcefully cough 2. Exhale slowly through pursed lips 3. Take in slow deep breaths 4. Sit in a semi-Fowler's position

2. Exhale slowly through pursed lips: a client with COPD should exhale slowest through pursed lips to avoid high expiratory pressures. This can collapse diseased airways. Option 1: While coughing promotes deep breathing and expulsion of secretions, the nurse would not instruct the client with COPD to forcefully cough. Option 3: All clients, not just those with COPD, need to take in slow deep breaths when doing deep breathing exercises. Option 4: The nurse would ask the client with COPD to sit in a high-Fowler's position or a tripod position. This promotes maximum expansion.

The nurse receives the arterial blood gas values for a client with pneumonia. Which finding by the nurse requires health-care provider intervention? 1. FIO2 at 21% 2. pH level 7.4 3. Pco2 level 65 mm Hg 4. Po2 level 90 mm Hg

3. A Pco2 level of 65 mm Hg indicates hypercarbia, which, if elevated, can suppress the respiratory drive. This value requires immediate health-care provider intervention. Option 1: an FIO2 of 21% is normal on room air and does not require notifying the health-care provider. Option 2: A client with a pH of 7.4 indicates a normal finding. The nurse does not need to notify the health-are provider. Option 4: a Po2 level of 90 mm Hg is a normal finding and does not require intervention.

In which position would the nurse place a client to perform percussion and postural drainage for the middle lung lobes? 1. Supine 2. Semi-Fowler's 3. High Fowler's 4. Trendelenburg

4. Trendelenburg: The nurse places the clinet in the Trendelenburg position to facilitate secretion removal. Option 1: The nurse does NOT place the client in the supine position, as the client would be lying on his or her lung fields. Option 2: The Semi-Fowler's position does not facilitate secretion of mucus. Option 3: The nurse places the client in the High-Fowler's position to promote lung expansion or performing percussion and postural drainage in the apical lung areas.

The nurse is developing a plan of care for a client who just had a chest tube inserted. Which emergency supplies should the nurse keep at the client's bedside? Select all that apply. 1. Sterile gloves 2. Petroleum gauze 3. Roll of adhesive tape 4. Rubber-tipped clamps 5. Spare disposable drainage system

2, 4, 5 Option 1: Sterile gloves - It is not necessary to keep sterile gloves at the bedside, as they would not be needed in an emergency procedure. 2. The nurse should keep petroleum gauze at the bedside in case the chest tube becomes dislodged. Option 3: The nurse would not need to keep a roll of adhesive take nearby, as this would not be considered an emergency supply. 4. Rubber-tipped clamps should be placed at the client's bedside. This is to clamp the chest tube to determine the presence of an air leak. 5. In case the drainage system become upended or full, the nurse would keep a spare disposable drainage system at the bedside.

Which instructions are most important to for the nurse to provide a client when using portable oxygen in the home setting? Select all that apply. 1. Refrain from any smoking in the home. 2. Store oxygen tanks in an upright position. 3. Increase oxygen delivery levels as needed. 4. Insert the nasal cannula with prongs facing up. 6. Wash the nasal cannula and tubing with hydrogen peroxide.

1, 2 1. Due to the combustibility of oxygen, the client should never allow anyone to smoke in the home. 2. Oxygen tanks should be stored. In an upright and secured position. If oxygen tanks fall, the compressed oxygen can shoot out from the tank, causing it to become a missile. Option 3: he nurse would instruct the client to maintain the oxygen level at the prescribed rate. Clients with chronic obstructive pulmonary disease can further damage alveoli by increasing oxygen delivery. Option 4: The nasal cannula prongs should be facing downward, not upward. Option 5: The nurse would instruct the client o wash the nasal cannula and tubing with soap and water, not hydrogen peroxide.

What should the nurse include when educating the parents of a toddler about safety hazards that can affect breathing? Select all that apply. 1. Water safety 2. Choking on objects 3. Environmental allergens 4. Exercise-induced asthma 5. Respiratory distress syndrome

1, 2 1. Water safety: it is important to instruct parents on water safety, as toddlers are at risk for drowning. 2. Choking on objects: Infants and toddlers put many things in their mouth that can lead to choking. The nurse should instruct the parents on keeping small objects out of the reach of children. Option 3: Environmental allergens: can be irritating but would not be a safety hazard that can affect breathing. Option 4: Exercise-induced asthma: tends to happen in school-age children and not toddlers. Option 5: Respiratory distress syndrome: affects premature infants and not usually toddlers.

The nurse enters the client's room who s receiving oxygen at 4 L/min via nasal cannula. What should the nurse do to prevent complications? Select all that apply. 1. Ensure the client keeps nasal prongs in the nares. 2. Assess the nares for excessive dryness. 3. Pad the oxygen tubing behind the ears. 4. Encourage taking slow deep mouth breaths. 5. Obtain arterial blood gas values.

1, 2, 3 1. Nasal prongs can easily become dislodged from the nasal cannula. Therefore, the nurse should ensure the nasal prongs are in the nares to provide adequate oxygenation. 2. With the high flow of oxygen flowing through the nasal cannula, the nares can become dry. 3. The pressure of the oxygen tubing constantly behind the ears can cause skin breakdown. Therefore, it is important to pad the oxygen tubing. Option 4: The client using a nasal cannula should breathe in through the nose because this is where the oxygen is being delivered. This can lead to hypoxia. Option 5: Arterial blood gas values would not be obtained unless the client was in respiratory distress. This would not be a necessary intervention.

The client asks the nurse about taking over-the-counter decongestants for a cold. Which questions should the nurse ask first? Select all that apply. 1. "Do you have a history of hypertension?" 2. "What medications do you take every day?" 3. "Have you ever been diagnosed with heart problems?" 4. "What medications have you taken for colds in the past?" 5. "Are you having difficulty breathing through your nose?"

1, 2, 3 Rationales: 1. Clients with hypertension should not take nasal decongestants because these can further increase the blood pressure. 2. Prior to verifying ability to take over-the-counter medications, the nurse would want to obtain a current medication list to prevent interactions between the medications. 3. The nurse should determine the presence of cardiovascular disease prior to administering nasal decongestants, as these medications can cause palpitations and tachycardia. Option 4: The nurse would NOT ask which medications the client has taken in the past for colds, as new diagnoses could have been diagnosed. Option 5: The nurse would not need to ask the client if he or she is having difficulty breathing through the nose. The client is asking about nasal decongestants, so it is obvious the client has nasal stuffiness.

An individual has recently moved from the coast of Florida to the Rocky Mountains in Colorado. What can be expected to physiologically occur over time to help facilitate oxygenation? Select all that apply. 1. Increased RBC production 2. Increased lung volume and pulmonary vascular urge 3. Increased ventilation 4. Arterial chemoreceptors stimulate ventilation 5. Irritation of the membranous lining of the lungs

1, 2, 3, 4 1. Increases RBC Production: increases to aid in transporting oxygen to tissues and organs. 2. Increased lung volume and pulmonary vasculature: results in an increase in the surface area enabling alveolar-capillary gas exchange. 3. Increases ventilation: brings more oxygen into the lungs 4. Arterial chemoreceptors stimulate ventilation: as fewer oxygen molecules are inhales, the depletion in oxygen levels triggers arterial chemoreceptors that stimulate ventilation. Option 5: Chemicals and fumes cause irritation in the lungs and are typically due to occupational exposure

Wha should be evaluated when assessing for type of cough? Select all that apply. 1. Dry, productive, or hacking 2. When does it occur 3. How long has the client had cough 4. What makes it worse or better 5. Fever 6. Irritant exposure

1, 2, 3, 4 1. The nurse should ask if the cough is dry, productive, or hacking 2. The nurse should ask when the cough occurs 3. The nurse should ask how long the client has had the cough 4. The nurse should ask about anything that helps or worsens the cough Option 5: Assessing for fever is important, but is not particular to a type of cough Option 6: Irritant exposure such as environmental factors and occupational debris are contributing factors to a type of cough

A client with a nagging cough had no other symptoms other than shortness of breath. Upon assessment, the client mentions having a spouse who is a heavy smoker and smokes approximately two packs per day. When educating the client on the increased risk of cancer, the client quickly states, "I don't breathe in that much smoke." What information should be given to the client? Select all that apply. 1. Even small amounts of smoke cause damage to the vessels and abnormal heart rate. 2. Secondhand smoke leads to increased risk for stroke and increased death from cancer. 3. There is no safe level of exposure to second hand smoke. 4. Once a person stops smoking, the body begins to repair itself. 5. Smoke inhalation can lead to emphysema and COPD.

1, 2, 3, 5 1. Secondhand smoke causes platelets to become sticky, thus resulting in damage to the vessels, which disturbs the heart rate. 2. Secondhand smoke exposure increases the risk for death from cancer and other health related diseases as well as stroke. 3 The EPA classifies secondhand smoke as aGroup-A carcinogen, there is no safe level of exposure. Option 4: Smokers who smoke can reduce damage once they have ceased smoking. 5. Smoke inhalation can lead to various lung disorders including chronic bronchitis, emphysema, and COPD.

The nurse is educating a group of teenagers about the physical damage that occurs from tobacco smoke. What should the nurse include in the teaching session? Select all that apply. 1. Paralyzes cilia 2. Dilates bronchioles 3. Leads to lung cancer 4. Produces pneumothoraces 5. Increases mucus production 6. Causes bronchial inflammation

1, 3, 5, 6 1. Cilia are the little hairs that line the air passages and remove pathogens from the airway. Tobacco smoke can paralyze the cilia. Option 2: Tobacco smoke constrict bronchioles, which can decrease oxygenation. 3. Cigarette smoking causes more than 80% of the cases of lung cancer. Option 4: Tobacco smoke does NOT cause a pneumothorax to form. Pneumothoraces form from injuries but not directly from tobacco smoke. 5. Mucus production increases from tobacco smoke exposure. 6. Tobacco smoke causes inflammation of the bronchial tree due to cilia damage.

A nurse is preparing to perform a focused assessment of a client's respiratory system. Which aspects should the nurse include in the assessment? Select all that apply. 1. Rate 2. Edema 3. Body position 4. Capillary refill 5. Breath sounds 6. Use of accessory muscles

1, 3, 5, 6 1. The nurse assesses the client's respiratory rate as part of the assessment. Option 2: The nurse assessed for edema in a client with cardiovascular problems, not as part of a focused pulmonary assessment. 3. It is important for the nurse to assess the client's body position. The tripod position is frequently used by clients with chronic obstructive pulmonary disease to improve breathing. Option 4: Capillary refill is included in a cardiovascular focused assessment, not a respiratory system assessment. 5. The nurse auscultated both lungs side by side to compare the left to the right. 6. The nurse assesses if the client is using accessory abdominal muscles for breathing. This breathing pattern is seen in clients with system fibrosis and chronic obstructive pulmonary disease.

An older adult client had been admitted with a diagnosis of emphysema and COPD, and the client had been experiencing shortness of breath and low SaO2 levels evidenced by pallor and SaO2 reading of 88%. What would be an appropriate nursing diagnosis for this client? 1. Altered oxygen levels related to impaired gas exchange AEB cyanosis and low SaO2 levels 2. Impaired gas exchange related to altered oxygen levels, AMB cyanosis, and low SaO2 levels 3. Impaired oxygen-carrying capacity of lungs related to emphysema and COPD 4. Alveolar-capillary membrane changes related to emphysema and COPD AMB cyanosis and SaO2 levels

1. A client who has a low SaO2 level of 88% obviously had altered oxygen levels caused by the COPD and emphysema, manifested as cyanosis and low SaO2 levels. Option 2: Impaired gas exchange is an issue when such a low SaO2 level is seen, but altered oxygen levels are caused by impaired gas exchange. Option 3: Impaired oxygen-carrying capacity might be a nursing diagnosis when pulmonary function studies have determined the capacity of the lungs. Option 4: Alveolar-capillary changes may be related to lung disorders, but this would be "evidenced by", not manifested.

The nursing instructor notices a client who is in pain does not have a pulse oximeter in use and suggests to the student that one should be attached. Why? 1. Clients in pain tend to breathe shallowly, which increases the risk for ateletasis. 2. Oxygen levels should always be monitored in client's experiencing high levels of pain. 3. Kussmaul's respirations are typical of clients experiencing increased levels of pain. 4. Pain triggers Biot's respirations, which cause apnea.

1. Clients should be assessed regularly for pain, as this can cause altered oxygen levels and increase the right for atelctasis. Option 2: Oxygen levels should be monitored when pain is involved, but this statement does not explain why. Option 3: Kussmaul's respirations are seen in those clients experiencing metabolic disorders and in hyperventilation. Option 4: Biot's respirations are typically seen in clients with damage to the medullary respiratory center.

An individual begins grasping for air and makes an unusual high-pitched, harsh, crowing sound. What could be occurring? 1. Airway obstruction 2. Asthma attack 3. Pneumonia 4. Croup

1. Airway obstruction: Partial airway obstruction such as that seen in anaphylaxis can quickly become a complete obstruction and should be addressed immediately. Option 2: clients with asthma will tend to have more of a wheezing sound Option 3: Lung congestion issues such as pneumothorax and pneumonia will cause a wheezing sound Option 4: Croup typically manifests as a rough, braking sound that is not high-pitched

The nurse is caring for a postoperative client with an oxygen saturation of 90% who has fine crackles in both lung bases. Which intervention would be most effective in improving this client's respiratory status? 1. Use an incentive spirometer 2. Administer bronchodilators 3. Provide oxygen at 2L/minute via nasal cannula 4. Elevate the head of the bed

1. An incentive spirometer can increase oxygen saturation levels and promote lung expansion in postoperative clients. Option 2: Bronchodilators can open up airways in clients with COPD, but is not as effective in postoperative clients. Option 3: The may increase the oxygen level in the client; however, it will not help with the fine crackles noted in both bases. Option 4: while elevating the head of the bed can facilitate better gas exchange, it will not eliminate the fine crackles.

Which medication would the nurse expect to find on the medication administration record for a client with seasonal allergies? 1. Cetirizine 2. Corticosteroids 3. Methylxanthine 4. Alprozolam

1. Cetirizine is an antihistamine used in the treatment of seasonal allergies. Option 2: Corticosteroids are anti-inflammatory drugs used to decrease inflamed airways in clients with COPD or asthma. Option 3: Methylxanthine is a bronchodilator used to open airways. It is not effective in the treatment of seasonal allergies. Option 4: Alprazolam is a drug that is typically prescribed for alleviation of symptoms of anxiety disorders. It will not be prescribed to alleviate symptoms of seasonal allergies.

Premature babies are at night risk for what respiratory problem? 1. Respiratory distress syndrome 2. Upper respiratory infection 3. Asthma 4. Airway obstruction

1. Due to an undeveloped alveolar surfactant system, premature babies are at higher risk for developing respiratory distress syndrome (RDS) Option 2: Due to enlarged tonsils and adenoids, toddlers are more prone to upper respiratory infections, not premature infants. Option 3: While premature infants may develop asthma over a period of time as lungs develop, this is not an issue directly related to premature birth. Option 4: Airway obstruction is typically seen in toddlers due to ingestion of large pieces of food, candy, and items placed in the mouth.

What should the nurse document in the medical record for a client who has 14 respiration's per minute that were unlabored? 1. Eupneic 2. Dyspnea can 3. Bradypneic 4. Tachypneic

1. Eupneic: The nurse documents in the medical record that a client with a respiratory rate of 12 - 20 breaths per minute is eupneic. Option 2: Dyspnea is difficulty breathing. The client has unlabored breathing, so the nurse does not chart that the client is dyspnea. Option 3: A client with a respiratory rate of less than 10 breaths per minute is bradypneic. Option 4: A client with a respiratory rate higher than 24 breaths per minute is tachypneic.

How often should the nurse provide tracheostomy care? 1. Every 8 hours 2. Every 24 hours 3. Every other day 4. Every week

1. Every 8 hours: The nurse should preform tracheostomy care every 8 hours. This cleans the area around the cannula from excessive secretions and helps prevent infection. Option 2: The nurse may change the ties to the tracheostomy collar once a day, but this is not applicable for tracheostomy care. Option 3: The nurse does not perform tracheostomy care every other day. This would not be beneficial to the client. Option 4: The nurse needs to perform tracheostomy care more often than once a week, as the area needs to be cleaned more often.

Gas exchange that occurs in the alveoli-capillary membrane is referred to as what type of respiration? 1. External 2. Internal 3. Hyperventilation 4. Hypoventilation

1. External: External respiration occurs between the alveoli and capillaries where oxygen and carbon dioxide exchange occurs. Option 2: Internal respiration occurs between the body organs and tissues where oxygen and carbon dioxide are exchanged between capillary-cellular membranes. Option 3: Hyperventilation occurs when the body breathes rapidly causing too much carbon dioxide to be removed from the alveoli. Option 4: Hypoventilation occurs when the body breathes too slowly or shallow breathing does not allow enough oxygen to reach the alveoli.

A postoperative cardiac surgery client is experiencing phrenic nerve palsy causing inability to breathe on his or her own. What intervention should be taken with the client? 1. Negative pressure ventilation 2. Positive pressure ventilation 3. Insertion of drainage tube 4. Suction of airway

1. Negative pressure ventilation: Used on clients with neuromuscular disease and paralysis, negative pressure ventilators pull the chest outward and force the client to inhale air, mimicking normal breathing. Option 2: Positive pressure ventilators are the most frequently used mechanical ventilators but come with risks including decreased cardiac output, which is contraindicated in post-cardiac surgical clients. Option 3: Chest drainage is used to make room for lung expansion and involves one-way flow from the client to the container. Option 4: With phrenic nerve palsy, the client is unable to breathe without assistance, so suctioning of the airway may or may not be needed.

What nursing intervention should be applied for a client with pneumonia of the right lower lobe? 1. Place on left side and elevate the foot of the bed 2. Place on right side and elevate the head of the bed 3. Place in Trendelenburg position 4. Place in Fowler's position

1. Placing the client on the left side and elevating the foot of the bed will allow the lung to drain. Option 2: Placing the client in the proper position is important for draining the lung, but the right side is not the correct position. Option 3: The Trendelenburg position can be used for a drastic drop in blood pressure, not for draining lungs. Option 4: Fowler's position may help with ventilation, not with draining the lung

A nurse is concerned that a client is in need of increased suctioning. With whom should the nurse collaborate to work out a plan for optimal effect? 1. Respiratory therapist 2. Nursing assistive professional (NAP) 3. Licensed practical nurse (LPN) 4. Physician

1. Respiratory therapist: The respiratory therapist and nurse are both responsible for suctioning the client and should keep each other informed on any changes. Option 2: NAP's are not responsible for suctioning and only use a Yankauer tube for oral suctioning in personal hygiene. Option 3: LPN's can suction clients, but the RN is responsible for the direct care and collaboration with other health professionals caring for the client. Option 4: While physicians are ultimately responsible for any change in medical orders for a client, the nurse is responsible for immediate needs and collaboration with other health-care providers.

An overweight client is complaining of being excessively sleepy during the day and wakes up many times during the night due to snoring. What would the nurse expect the physician to order for this client? 1. Sleep study 2. Arterial blood gases 3. Oxygen therapy 4. CPAP machine

1. Sleep study: A sleep study will record the sleep patterns and breathing dysfunction associated with sleep apnea. Option 2: The need for arterial blood gases are not indicated in this situation. Option 3: Oxygen therapy is not indicated in a situation such as this unless there are obvious signs of distress. Option 4: Continuous positive airway pressure machines are ordered once sleep apnea has been diagnosed, not before.

The nurse is discussing the need for annual influenza vaccinations with an elderly client. The client refuses the vaccination and states, "It didn't work last year. I got the vaccine and still got the flu!" What is the nurse's best response? 1. "Flu shots can diminish the severity of the symptoms." 2. "Maybe that dose of vaccine was not the most effective." 3. "It is mandatory and required prior to discharge." 4. "Do you have any other reasons that you do not want the vaccine?"

1. The nurse should explain to the client that even though he or she had the flu last year with the shot, receiving the shot lessens the severity of the flu. Option 2: The nurse would not inform the client that he or shy may have received a weaker dose. This is inaccurate and unknown information. Option 3: The client has the right to refuse the vaccine. The nurse should not inform the client it is mandatory. Option 4: The client has stated his or her beliefs and this response does not provide the client information to make a decision.

When teaching a client how to use a peak flow meter at home, what should be done if the reading falls within the yellow marker of the meter? 1. Use a fast-acting bronchodilator 2. Immediately seek medical care 3. Take an antihistamine 4. Wait 10 minutes and complete the test again

1. Use a fast-acting brochodilator. To prevent any exacerbation of symptoms, use of a rescue inhaler such as a fast-acting bronchodilator is the first priority when a client reaches the yellow marker. Option 2: The client does not need to seek immediate medical care unless the reading falls within the red marker. Option 3: Histamine production is no a factor in an asthma attack, so an antihistamine will not be affective. Option 4: Waiting and repeating the test is not suggested with a peak flow in the yellow parameters.

Which of the following assessment finding would help confirm a diagnosis of asthma in a client? 1. Wheezing on inspiration and expiration 2. Strider upon inspiration 3. Increased forced expiratory volume 4. Normal breath sounds but with retraction

1. Wheezing on inspiration and expiration: Inspiratory and expiratory wheezes are typical findings in asthma. Option 2: Stridor can be heard when there is a partial airway obstruction. Option 3: Decreased forces expiratory volume would be found due to inability to move air out of the lungs. Option 4: Breath sounds will be markedly decreased and obstructed, not normal.

What is the most common cause of infectious pharyngitis? 1. Streptococcal progenies 2. Staphylococcus aureus 3. Influenza virus 4. Respiratory syncytial virus

2. Streptococcal progenies is the most common cause of infectious pharyngitis, otherwise known as "strep" throat. Option 2: Staph aureus is the cause of many infections such as MRSA, but not infections pharyngitis. Option 3: Influenza typically affects the lower airways and is more severe than the common cold. Option 4: Respiratory syncytial virus (RSV) is a common viral infection infecting the upper respiratory system and lower airways.

Which concept involves the movement of air in and out of the lungs through the act of breathing? 1. Inhalation 2. Ventilation 3. Respiration 4. Oxygenation

2. Ventilation: Ventilation is the movement of air in and out of the lungs by the process of breathing. Option 1: Inhalation is the expansion of the chest cavity and lungs to negative pressure inside the lungs. It forces air to be drawn into the lungs. Option 3: Respiration is the exchange of the gases oxygen and carbon dioxide in the lungs. Option 4: Oxygenation refers to how well the cells, tissues, and organs of the body are supplied with oxygen.

The nurse is developing a plan of care for a client with a chest tube. Which intervention should the nurse do first if the chest tube becomes dislodged from the drainage container? 1. Clamp the chest tube 2. Cover the site with a dry dressing 3. Insert the tube into sterile water 4. Notify the primary health-care provider

3 Option 1: Clamping the chest tube can cause a tension pneumothorax. Option 2: The nurse would only cover the site with a dry sterile dressing if the tube comes out from the insertion site. This is not the first intervention for the chest tube becoming dislodged. 3. The nurse should insert the loose end of the chest tube into a container of sterile water to prevent complications. Option 4: The nurse would notify the primary health-care provider, but this would not be the first intervention.

The nurse is caring for an elderly client admitted to the hospital for abdominal surgery and develops a plan of care to prevent respiratory complication. Which factors would lead the nurse to develop this plan of care? Select all that apply. 1. Increased lung expansion 2. Increased immune response 3. Difficulty coughing up secretions 4. Diminished diaphragmatic function 5. Increased immune response 6. Amplified chemoreceptors response

3, 4 Option 1: Anesthesia can affect respiratory function. Elderly clients have decreased lung expansion due to calcification of costal cartilage and loss of recoil ability. Therefore, this can lead to atelectasis and pneumonia. Option 2: The elderly client will present with a decreased immune response. 3. Elderly clients have a less effective cough reflex and less mucus, which increases the risk for respiratory complications. 4. The diaphragm is unable to expand and contract as efficiently with age, which decreased tidal volume. This leads to air trapping. Option 5: Elderly clients have a decreased immune response, which places them at higher risk for respiratory infections. Option 6: Chemoreceptors that control breathing respond slower to changes in oxygen demands or elevated CO2 levels. This leads to hypoxia and hypercapnia and can affect respiratory function.

The nurse is providing tuberculin testing at a campus health program. Which factors should the nurse assess for when developing a prevaccination screening tool? Select all that apply. 1. History of diabetes mellitus 2. Current and past tobacco use 3. Prior exposure to tuberculosis 4. County of birth and recent travel 5. Employment in a health-care setting

3, 4, 5 Option 1: Having a history of diabetes mellitus does not increase a client's risk for tuberculosis. However, I a client does test positive, the degree of induration changes for a client with diabetes mellitus. Option 2: A client's smoking history does not affect the risk for tuberculosis. Therefore, the nurse does not need to ask this in a pre-vaccination questionnaire. 3. The nurse asks participants about exposure to tuberculosis prior to administering the vaccine. 4. The nurse asks clients if they have traveled out of the country recently, as those who are foreign-born are at a higher risk for tuberculosis. 5. Heath-care workers are at a higher risk for tuberculosis due to client exposure.

The nurse is assessing the chest tube insertion site of a client with a hemothorax of the right lower lobe. Which assessment finding would most concern the nurse? 1. Diminished breath sounds in the right base 2. Pulse oximetry reading of 95% on room air 3. Crepitus around the chest tube insertion site 4. Serosanguinous drainage in the collection device

3. Crepitus is an indication of air leaking into the subcutaneous tissues. This indicates the chest tube may be compromised. Option 1: The nurse would expect to find diminished breath sounds at the location of the hemothorax. This would not cause concern. Option 2: A pulse oximetry reading of 95% on room air is a normal finding as oxygen saturation levels should be 95% - 100%. Option 4: Serosanguinous drainage in the collection device is a normal finding and does not cause concern.

Place the steps for performing a tracheostomy or endotracheal suctioning in order. 1. Remove and discard gloves; then open the suction catheter kit. 2. Don sterile gloves. Attach the suction catheter to the connection tubing. 3. Done face shield/goggles and turn on suction using the lowest pressure. 4. Assess the client's respiratory status, position in semi-Fowler's, and place linen-saver padding on the clients chest. 5. Pre-measure the catheter insertion distance. 6. Place the tip of the catheter in the sterile saline, suction a small amount of solution through the catheter. 7. Lubricate the suction catheter tip with normal saline solution. 8. Don gloves. Pour sterile saline into the sterile container. 9. Gently and quickly insert the suction catheter into the tubing and apply suctioning. 10. Perform hand hygiene, then perform mouth care for the client. 11. Don non-sterile glove and test the suction.

4, 3, 11, 1, 8, 5, 2, 6, 7, 9, 10 4. Assess the client's respiratory status, position in semi-Fowler's, and place linen-saver padding on the clients chest. 3. Done face shield/goggles and turn on suction using the lowest pressure. 11. Don non-sterile glove and test the suction. 1. Remove and discard gloves; then open the suction catheter kit. 8. Don gloves. Pour sterile saline into the sterile container. 5. Pre-measure the catheter insertion distance. 2. Don sterile gloves. Attach the suction catheter to the connection tubing. 6. Place he tip of the catheter in the sterile saline, suction a small amount of solution through the catheter. 7. Lubricate the suction catheter tip with normal saline solution. 9. Gently and quickly insert the suction catheter into the tubing and apply suctioning. 10. Perform hand hygiene, then perform mouth care for the client.

The parents of a 10-mont-old infant with a cold ask the nurse about the use of honey to alleviate a cough. What is the nurse's best response? 1. "Only give half a teaspoon of honey three times per day." 2. "Let me talk with the health-care provider about the dose." 3. "It is safer to use over-the-counter cold medication for children." 4. "Honey should not be given to children under the age of 1 year."

4. Hone should not be given to infants under the age of 1 year because it can contain Clostridium botulinum spores and the child can develop botulism. Option 1: The nurse should not instruct the family to give half a teaspoon of honey three times per day. This is contraindicated for infants. Option 2: The nurse would not need to talk to the health-care provider for over-the-counter homeopathic remedies. Option 3: It is NOT safer to use over-the-counter medication for infants, as doses are very specific and it is easy to overmedicate small children.

Which finding would the nurse expect when assessing a client with pulmonary edema? 1. Black sputum 2. Green sputum 3. Foul-smelling sputum 4. Pink and frothy sputum

4. Pink and frothy sputum is noted in pulmonary edema Option 1: Black sputum indicates exposure to coal dust or soot. It would not be expected in a client with pulmonary edema. Option 2: Green or yellow sputum is a sign of infection, not pulmonary edema. Option 3: Foul-smelling sputum indicates a bacterial infection. This would not be found in a client with pulmonary edema.

A client presents with cyanosis, tachypnea, grunting, and reports that he or she cannot breathe. What is the immediate response the nurse should take? 1. Ask questions about symptoms while performing a quick examination. 2. Ask extensive questions about occupation factors, smoking habits, and living environment. 3. Complete a full assessment including demographic data, health history, respiratory-cardiovascular history, environmental history, and lifestyle. 4. Inspect to observe respiratory patterns and signs of respiratory distress.

4. The nurse's priority intervention in this scenario is to inspect respiratory patterns for signs of distress, including chest structures and movement, skin and mucous membrane color, edema, sputum characteristics, and overall general appearance. Option 1: If the client appears to be in obvious respiratory distress, the nurse should immediately assess the client to determine adequate oxygen levels, breathing, and circulation, and then ask questions about current symptoms. Option 2: Asking extensive questions would be appropriate for a client that is not in apparent distress. Option 3: The immediate need should be to address the client, then complete assessment can be conducted.

A client reports to the emergency room with shortness of breath and chest pain. The health—care provider suspects a pulmonary embolism. For which test should the nurse prepare the client? 1. Thoracentesis 2. Bronchoscope 3. Pulmonary function 4. Ventilation-perfusion scan

4. Ventilation-perfusion scan: A ventilation-perfusion scan involved the injection of radioactive substance used to diagnose pulmonary emboli. Option 1: A thoracentesis removes extra fluid from the pleural space when a client has a pleural effusion. This does not diagnose a pulmonary embolism. Option 2: A bronchoscope is a test used to examine the larynx, trachea, and bronchial tree. It can be used to obtain tissue samples for biopsies. Option 3: A pulmonary function test is used to detect lung function and capacity. it will not detect pulmonary embolism.