Oxygenation/Gas Exchange

During the first 24 hours after a client is diagnosed with addisonian crisis, which intervention should the nurse perform frequently? Weigh the client. Test urine for ketones. Assess vital signs. Administer oral hydrocortisone.

Assess vital signs. Rationale: Because the client in addisonian crisis is unstable, vital signs and fluid and electrolyte balance should be assessed every 30 minutes until he's stable. Daily weights are sufficient when assessing the client's condition. The client shouldn't have ketones in his urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn't administered during the first 24 hours in severe adrenal insufficiency.

Which nursing intervention is the priority for a client in myasthenic crisis? Assessing respiratory effort Administering intravenous immunoglobin (IVIG) per orders Preparing for plasmapheresis Ensuring adequate nutritional support

Assessing respiratory effort Rationale: A client in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early. Administering IVIG, preparing for plasmapheresis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.

A patient is brought to the emergency department and diagnosed with decompression sickness. The nurse interprets this as indicating that the patient most likely has been involved with which of the following? Swimming in a lake Diving in an ocean Running a race in hot humid weather Working in a chemical plant

Diving in an ocean Rationale: Decompression sickness occurs when patients have engaged in diving in a lake or ocean or high-altitude flying or flying in a commercial aircraft within 24 hours of diving. Swimming in a lake could lead to a near-drowning episode. Running a race in hot humid weather would increase a person's risk for heat stroke. Working in a chemical plant would increase the risk for chemical burns.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Despite various medication regimes, the client's symptoms are gradually increasing. The nurse realizes that this client is which phase of the Trajectory Model of Chronic Illness? Unstable Acute Downward Dying

Downward Rationale: The downward phase occurs when symptoms worsen or the disability progresses despite attempts to control the course through proper management. The unstable phase is characterized by development of complications or reactivation of the illness. The acute phase is characterized by sudden onset of severe or unrelieved symptoms or complications that may necessitate hospitalization for their management. The dying phase is characterized by gradual or rapid shutting down of life-maintaining functions.

You are caring for a client who is 42-years-old and status post adenoidectomy. You find the client in respiratory distress when you enter their room. You ask another nurse to call the physician and bring an endotracheal tube into the room. What do you suspect? Infection Post operative bleeding Edema of the upper airway Plugged tracheostomy tube

Edema of the upper airway Rationale: An endotracheal tube is inserted through the mouth or nose into the trachea to provide a patent airway for clients who cannot maintain an adequate airway on their own. The scenario does not indicate infection, post operative bleeding, or a plugged tracheostomy tube.

A client is postoperative immediately following a total laryngectomy. The client's respirations are 32 breaths/minute, shallow, and noisy. The tracheostomy pad is moist with mucus. Pulse oximetry is 88%. The client's eyes are wide open, and the client appears apprehensive. What is a priority nursing concern? Ineffective airway clearance Anxiety Ineffective breathing pattern Impaired gas exchange

Ineffective airway clearance Rationale: All may be appropriate nursing diagnoses for this client. The nurse would follow Maslow's hierarchy of needs and ABCs (airway, breathing, circulation) to determine the highest priority. Ineffective airway clearance is the nursing diagnosis of highest priority.

Which respiratory volume is the maximum volume of air that can be inhaled after a normal exhalation? Tidal volume Expiratory reserve volume Residual volume Inspiratory reserve volume

Inspiratory reserve volume Rationale: Inspiratory reserve volume is normally 3000 mL. Tidal volume is the volume of air inhaled and exhaled with each breath. Expiratory reserve volume is the maximum volume of air that can be exhaled forcibly after a normal exhalation. Residual volume is the volume of air remaining in the lungs after a maximum exhalation.

A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia? Staphylococcus aureus Mycobacterium tuberculosis Pseudomonas aeruginosa Streptococcus pneumoniae

Streptococcus pneumoniae Rationale: Streptococcus pneumoniae (pneumococcus) is the most common cause of community-acquired pneumonia in people younger than 60 years without comorbidity and in those 60 years and older with comorbidity (Wunderink & Niederman, 2012). S. pneumoniae, a gram-positive organism that resides naturally in the upper respiratory tract, colonizes the upper respiratory tract and can cause disseminated invasive infections, pneumonia and other lower respiratory tract infections, and upper respiratory tract infections such as otitis media and rhinosinusitis. It may occur as a lobar or bronchopneumonic form in patients of any age and may follow a recent respiratory illness.

A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped? Respiratory rate of 16 breaths/minute Oxygen saturation of 93% Runs of ventricular tachycardia Blood pressure remains stable

Runs of ventricular tachycardia Rationale: Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. The client's blood pressure remains stable, so the weaning can continue.

A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure? Insidious onset of lung impairment in a client who had normal lung function Sudden onset of lung impairment in a client who had normal lung function Insidious onset of lung impairment in a client who had compromised lung function Sudden onset of lung impairment in a client who had compromised lung function

Sudden onset of lung impairment in a client who had normal lung function Rationale: In acute respiratory failure, the ventilation or perfusion mechanisms in the lung are impaired. Acute respiratory failure occurs suddenly in a client who previously had normal lung function.

The nurse is caring for a client with coronary artery disease. What is the nurse's priority goal for the client? decrease anxiety enhance myocardial oxygenation administer sublingual nitroglycerin educate the client about his symptoms

enhance myocardial oxygenation Rationale: Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration isn't the first priority. Although educating the client and decreasing anxiety are important in care, neither is a priority when a client is compromised.

A nurse is caring for a client who was admitted for an asthma exacerbation. In the past year, the client has been admitted for three asthma events. What will the nurse include in the client teaching about preventing repeat hospitalizations? Complete the following sentence(s) by choosing from the lists of options. The nurse should teach about _____________ followed by ___________

triggers to avoid, medication knowledge Rationale: In teaching a client to prevent hospitalization, the nurse should implement an asthma action plan. This plan includes use of a peak flow meter, identification of triggers to avoid and ways to avoid them, and medication knowledge. Counting respirations and breathing deeply are not included in the plan. Hand hygiene is not indicated with asthma. Teach back would be included after the nurse teaches the client about the medication. The cleaning of the peak flow would occur after the nurse taught about how to use the peak flow meter. A sputum culture is not indicated with asthma exacerbations. Swish and spit would be taught with medications such as with inhaled corticosteroids and leukotriene modifiers.

During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure? wheezes with wet lung sounds stridor high-pitched sounds laborious breathing

wheezes with wet lung sounds Rationale: If the left side of the heart fails to pump efficiently, blood backs up into the pulmonary veins and lung tissue. For abnormal and normal breath sounds, the nurse auscultates the lungs. With left-sided congestive heart failure, auscultation reveals a crackling sound, wheezes, and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe. With left-sided congestive heart failure, auscultation does not reveal a high pitched sound.

A client reports recent onset of chest pain that occurs sporadically with exertion. The client also has fatigue and mild ankle swelling, which is most pronounced at the end of the day. The nurse suspects a cardiovascular disorder. What other client report increases the likelihood of a cardiovascular disorder? Shortness of breath Insomnia Irritability Lower substernal abdominal pain

SOB Rationale: Common signs and symptoms of cardiovascular dysfunction include shortness of breath, chest pain, palpitations, fainting, fatigue, and peripheral edema. Insomnia seldom indicates a cardiovascular problem. Although irritability may occur if cardiovascular dysfunction leads to cerebral oxygen deprivation, this symptom more commonly reflects a respiratory or neurologic dysfunction. Lower substernal abdominal pain occurs with some GI disorders.

The nurse is gathering data from a client recently admitted to the hospital. The nurse asks the client about experiencing orthopnea. What question would the nurse ask to obtain this information? "Are you only able to breathe when you are sitting upright?" "How far can you walk without becoming short of breath?" "Are you coughing up blood at night?" "Are you urinating excessively at night?"

"Are you only able to breathe when you are sitting upright?" Rationale: To determine if a client is having orthopnea, the nurse needs to ask about the inability to breathe unless sitting upright. Determining how far the client can walk without becoming short of breath would indicate exertional dyspnea. Coughing up blood would indicate hemoptysis. Urinating excessively at night can be indicative of different factors such as taking a diuretic late in the evening causing the client to urinate often at night. This question would be vague.

A client with Guillain-Barré syndrome has paralysis affecting the respiratory muscles and requires mechanical ventilation. When the client asks the nurse about the paralysis, how should the nurse respond? "The paralysis caused by this disease is temporary." "You'll be permanently paralyzed; however, you won't have any sensory loss." "It must be hard to accept the permanency of your paralysis." "You'll first regain use of your legs and then your arms."

"The paralysis caused by this disease is temporary." Rationale: The nurse should inform the client that the paralysis that accompanies Guillain-Barré syndrome is only temporary. Return of motor function begins proximally and extends distally in the legs.

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. The client is placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. What setting would be the best maximum FIO2 setting? 0.21 0.35 0.5 0.7

0.5 Rationale: An FIO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. Clients with respiratory disorders are given oxygen therapy only to increase the partial pressure of oxygen (PaO2) back to the patient's normal baseline, which may vary from 60 to 95 mm Hg. In terms of the oxyhemoglobin dissociation curve, arterial hemoglobin at these levels is 80% to 98% saturated with oxygen; higher FiO2 flow values add no further significant amounts of oxygen to the red blood cells or plasma. Instead of helping, increased amounts of oxygen may produce toxic effects on the lungs and central nervous system or may depress ventilation. The ideal oxygen source is room air FIO2 0.21.

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient? 40% 50% 60% 70%

70% Rationale: Continuous central venous oximetry (ScvO2) monitoring may be used to evaluate mixed venous blood oxygen saturation and severity of tissue hypoperfusion states. A central catheter is introduced into the superior vena cava (SVC), and a sensor on the catheter measures the oxygen saturation of the blood in the SVC as blood returns to the heart and pulmonary system for re-oxygenation. A normal ScvO2 value is 70%.

Which long-term care facility resident most likely faces the greatest risk for aspiration? A resident who suffered a severe stroke several weeks ago A resident with mid-stage Alzheimer disease A 92-year-old resident who needs extensive help with activities of daily living (ADLs) A resident with severe and deforming rheumatoid arthritis

A resident who suffered a severe stroke several weeks ago Rationale: Aspiration may occur if the client cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. These reflexes are often affected by stroke. A client with mid-stage Alzheimer disease does not likely have the voluntary muscle problems that occur later in the disease. Clients that need help with ADLs or have arthritis should not have difficulty swallowing unless it exists secondary to another problem.

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following? Acute respiratory distress syndrome Lung cancer Bronchitis Tracheobronchitis

Acute respiratory distress syndrome Rationale: Factors associated with the development of ARDS include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. Smoke inhalation does not increase the risk for lung cancer, bronchitis, and tracheobronchitis.

The nurse caring for a 2-year-old near-drowning victim monitors for what possible complication? Atelectasis Acute respiratory distress syndrome Metabolic alkalosis Respiratory acidosis

Acute respiratory distress syndrome Rationale: Factors associated with the development of acute respiratory distress syndrome include aspiration related to near drowning or vomiting; drug ingestion/overdose; hematologic disorders such as disseminated intravascular coagulation or massive transfusions; direct damage to the lungs through prolonged smoke inhalation or other corrosive substances; localized lung infection; metabolic disorders such as pancreatitis or uremia; shock; trauma such as chest contusions, multiple fractures, or head injury; any major surgery; embolism; and septicemia. The nurse would not monitor for atelectasis, metabolic alkalosis, or respiratory acidosis in this scenario.

A patient was brought into the ED after sustaining injuries due to an explosion while welding. The patient is breathing but has an oxygen saturation of 90%, a respiratory rate of 32, and is coughing. What is the priority action by the nurse? Administer oxygen at 2 L/min via nasal cannula. Administer oxygen with a nonrebreather mask. Start an IV of normal saline solution at 125 mL/h. Obtain a chest x-ray.

Administer oxygen with a nonrebreather mask. Rationale: Blast lung results from the blast wave as it passes through air-filled lungs. The result is hemorrhage and tearing of the lung, ventilation-perfusion mismatch, and possible air emboli. Typical signs and symptoms include dyspnea, hypoxia, tachypnea or apnea (depending on severity), cough, chest pain, and hemodynamic instability. Management involves providing respiratory support that includes administration of supplemental oxygen with a nonrebreathing mask but may also require endotracheal intubation and mechanical ventilation.

Which action should the nurse take first when providing care for a client during an acute asthma attack? Obtain arterial blood gases. Send for STAT chest x-ray. Administer prescribed short-acting bronchodilator. Initiate oxygen therapy and reassess pulse oximetry in 10 minutes.

Administer prescribed short-acting bronchodilator Rationale: Administering a short-acting bronchodilator will dilate the airway and enable oxygen to reach the lungs. Although ABGs and a chest x-ray are valid diagnostic tests for lung disorders, immediate action to restore gas exchange is a priority in an acute asthma attack. The administration of oxygen is indicated, but without open bronchioles, the action will not be effective in an acute attack.

A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits A change in apical pulse rate from 102 to 88 beats/min Adventitious breath sounds Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute Troponin levels less than 0.35 ng/mL

Adventitious breath sounds Rationale: The nurse monitors the client's hemodynamic and cardiac status to prevent cardiogenic shock. He or she promptly reports adverse changes in the client's status, such as adventitious breath sounds. The other options are positive changes or indicative that the client did not experience myocardial infarction.

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply. Bradycardia Hypertension Bradypnea Hypotension Tachycardia

Bradycardia Hypertension Bradypnea Rationale: The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated immediately.

A client with asthma is prescribed an inhaled corticosteroid. For which reason will the nurse recommend that a small volume nebulizer (SVN) be used to provide the medication to the client? Medication requires rapid inhalation Client has rheumatoid arthritis Client needs to exhale through the device Client needs to hold breath after inhalation

Client has rheumatoid arthritis Rationale: A small volume nebulizer (SVN) is used to administer corticosteroids in addition to other medications. It requires slow tidal breathing with occasional deep breaths and administers the medication through a tight fitting facemask which is ideal for clients unable to use a mouthpiece. This delivery system is less dependent on the client's coordination and cooperation. A client with rheumatoid arthritis has swelling of the hands and would have difficulty using another delivery system for the medication. The SVN does not require rapid inhalation. Exhalation is not done through the device. The client does not need to hold the breath after inhalation.

An elderly client reports fatigue without shortness of breath with walking 30 minutes five times each week. The nurse assesses the resting heart rate as 72 beats per minute; 10 minutes after walking, the client's heart rate is 92 beats per minute. What should the nurse instruct the client to do next? Continue to walk at his current level. Refrain from any form of exercise. Increase walking at a faster pace. Decrease walking frequency to three times each week.

Continue to walk at his current level. Rationale: Elderly clients may report fatigue with increased activity as a result of a slower heart rate recovery, which may be a physiological response to aging. An appropriate nursing intervention is to educate the client to exercise regularly but also to pace activities. The nurse does not want to tell the client not to exercise, to walk faster, or to decrease frequency.

The nurse is assessing a patient who has been admitted with possible ARDS. Which finding would be evidence for a diagnosis of cardiogenic pulmonary edema rather than ARDS? Elevated white blood count Elevated troponin levels Elevated myoglobin levels Elevated B-type natriuretic peptide (BNP) levels

Elevated B-type natriuretic peptide (BNP) levels Rationale: Common diagnostic tests performed in patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. Cardiogenic pulmonary edema is an acute event that results from heart failure, in which the cardiac chambers release atrial natriuretic peptide (ANP) and BNP to promote vasodilation and diuresis. BNP levels are not similarly elevated with ARDS.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? Endotracheal suctioning Encouragement of coughing Use of a cooling blanket Incentive spirometry

Endotracheal suctioning Rationale: Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

Which exposure accounts for most cases of COPD? Exposure to tobacco smoke Occupational exposure Passive smoking Ambient air pollution

Exposure to tobacco smoke Rationale: Exposure to tobacco smoke accounts for an estimated 80% to 90% of COPD cases. Occupational exposure, passive smoking, and ambient air pollution are risk factors, but they do not account for most cases.

The nurse knows the mortality rate is high in lung cancer clients due to which factor? Increase in women smokers Increased incidence among the elderly Increased exposure to industrial pollutants Few early symptoms

Few early symptoms Rationale: Because lung cancer produces few early symptoms, its mortality rate is high. Lung cancer has increased in incidence due to an increase in the number of women smokers, a growing aging population, and exposure to pollutants but these are not directly related to the incidence of mortality rates.

A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following? Client can perform incentive spirometry. Lungs are clear on auscultation. Respiratory rate is 12 to 18 breaths per minute. Client reports no chest pain.

Lungs are clear on auscultation. Rationale: Assessment of lung sounds includes auscultation for airflow through the bronchial tree. The nurse evaluates for fluid or solid obstruction in the lung. When airflow is decreased, as with fluid or secretions, adventitious sounds may be auscultated. Often crackles are heard with fluid in the airways.

To detect cyanosis in clients with dark skin, it is most important that the nurse assess which area? Oral mucosa Fingernails Sclera Nose

Oral mucosa Rationale: In a client with dark skin, the skin usually assumes a grayish cast. To detect cyanosis, observe conjunctivae, oral mucosa, and nail beds.

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia? PaO2 pH PCO2 HCO3

PaO2 Rationale: Hypoxemic hypoxia, or hypoxemia, is a decreased oxygen level in the blood (PaO2) resulting in decreased oxygen diffusion into the tissues.

A client presents to the ED experiencing symptoms of COPD exacerbation. The nurse understands that goals of therapy should be achieved to improve the client's condition. Which statements reflect therapy goals? Select all that apply. Provide medical support for the current exacerbation. Treat the underlying cause of the event. Return the client to their original functioning abilities. Provide long-term support for medical management. Teach the client to suspend activity.

Provide medical support for the current exacerbation. Treat the underlying cause of the event. Return the client to their original functioning abilities. Provide long-term support for medical management. Rationale: The goal is to have a stable client with COPD leading the most productive life possible. COPD cannot necessarily be cured, but it can be managed so that the client can live a reasonably normal life. With adequate management, clients should not have to give up their usual activities.

The nurse is caring for a client who is intubated for mechanical ventilation. Which intervention(s) will the nurse implement to reduce the client's risk of injury? Select all that apply. Provide oral hygiene. Assess for a cuff leak. Reduce pulling on ventilator tubing. Monitor cuff pressure every 8 hours. Position with head above the stomach level.

Provide oral hygiene. Assess for a cuff leak. Reduce pulling on ventilator tubing. Monitor cuff pressure every 8 hours. Position with head above the stomach level. Rationale: Maintaining the endotracheal or tracheostomy tube is an essential part of airway management. Oral hygiene is provided frequently because the oral cavity is a primary source of lung contamination in the client who is intubated. Assessing for a leak from the cuff of the endotracheal tube needs to be done at the same time as providing other respiratory care. Ventilator tubing should be positioned so that there is minimal pulling or distortion of the tube in the trachea which reduces the risk of trauma to the trachea. Cuff pressure is monitored every 8 hours to maintain the pressure at 20 to 25 mm Hg. The head of the bed should be higher than the stomach to reduce the risk of aspiration.

Following a burn injury, the nurse determines which area is the priority for nursing assessment? Pulmonary system Cardiovascular system Pain Nutrition

Pulmonary System Rationale: Airway patency and breathing must be assessed during the initial minutes of emergency care. Immediate therapy is directed toward establishing an airway and administering humidified 100% oxygen. Pulmonary problems may be caused by the inhalation of heat and/or smoke or edema of the airway. Assessing a patent airway is always a priority after a burn injury followed by breathing. Remember the ABCs.

When assessing an older adult, the nurse anticipates an increase in which component of respiratory status? Vital capacity Gas exchange and diffusing capacity Cough efficiency Residual lung volume

Residual lung volume Rationale: With an increase in residual lung volume the client experiences fatigue and breathlessness with sustained activity. The nurse anticipates decreased vital capacity. The nurse anticipates decreased gas exchange and diffusing capacity resulting in impaired healing of tissues due to decreased oxygenation. The nurse anticipates difficulty coughing up secretions due to decreased cough efficiency.

A client who has sustained burns to the anterior chest and upper extremities is brought to the burn center. During the initial stage of assessment, which nursing diagnosis is primary? Risk for Impaired Gas Exchange Acute Pain Infection Risk Altered Tissue Perfusion

Risk for Impaired Gas Exchange Rationale: During the initial assessment of a burn victim, the nurse must look for evidence of inhalation injury. Once oxygen saturation and respirations are determined, pain intensity is evaluated. The assessment of damage to the tissues and prevention of infection are secondary to airway issues.

The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample? Tickle the back of the throat to produce the gag reflex. Drink 8 oz of water to thin the secretions for expectoration. Use the secretions present in the oral cavity. Take deep breaths and cough forcefully.

Take deep breaths and cough forcefully. Rationale: Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated into a specimen container. Producing a gag reflex elicits stomach contents and not respiratory sputum. Dilute and thinned secretions are not helpful in aiding expectoration. A sputum culture is not a component of oral secretions.

A nurse is teaching a client about diaphragmatic breathing. What client action indicates that further teaching is needed? The client places the hands on the lower chest to feel the rise and fall with breathing. The client performs diaphragmatic breathing in a semi-Fowler's position. The client exhales forcefully with a short expiration. The client breathes in deeply through the nose and mouth.

The client exhales forcefully with a short expiration. Rationale: Diaphragmatic breathing should be performed gently and fully. Placing the hands on the lower chest to feel the rise and fall with breathing, performing diaphragmatic breathing in a semi-Fowler's position, and breathing deeply through the nose and mouth are all aspects of diaphragmatic breathing.

A client with a pulmonary embolism is being treated with a heparin infusion. What diagnostic finding suggests to the nurse that treatment is effective? The client's PT is within reference ranges. Arterial blood sampling tests positive for the presence of factor XIII. The client's platelet level is below 100,000/mm3. The client's activated partial thromboplastin time (aPTT) is 1.5 to 2.5 times the control value.

The client's activated partial thromboplastin time (aPTT) is 1.5 to 2.5 times the control value. Rationale: The therapeutic effect of heparin is monitored by serial measurements of the aPTT; the dose is adjusted to maintain the range at 1.5 to 2.5 times the laboratory control. Heparin dosing is not determined on the basis of platelet levels, the presence or absence of clotting factors, or PT levels.

A client has a myocardial infarction in the left ventricle and develops crackles bilaterally; 3-pillow orthopnea; an S3 heart sound; and a cough with pink, frothy sputum. The nurse obtains a pulse oximetry reading of 88%. What do these signs and symptoms indicate for this client? The development of chronic obstructive pulmonary disease (COPD) The development of left-sided heart failure The development of right-sided heart failure

The development of left-sided heart failure Rationale: When the left ventricle fails, the heart muscle cannot contract forcefully enough to expel blood into the systemic circulation. Blood subsequently becomes congested in the left ventricle, left atrium, and finally the pulmonary vasculature. Symptoms of left-sided failure include fatigue; paroxysmal nocturnal dyspnea; orthopnea; hypoxia; crackles; cyanosis; S3 heart sound; cough with pink, frothy sputum; and elevated pulmonary capillary wedge pressure. COPD develops over many years and does not develop after a myocardial infarction. The development of right-sided heart failure would generally occur after a right ventricle myocardial infarction or after the development of left-sided heart failure. Cor pulmonale is a condition in which the heart is affected secondarily by lung damage.

A nurse is discussing squamous epithelial cells lining each alveolus, which consist of different types of cells. Which type of alveolar cells produce surfactant? Type I cells Type II cells Type III cells Type IV cells

Type II cells Rationale: There are three types of alveolar cells. Type I and type II cells make up the alveolar epithelium. Type I cells account for 95% of the alveolar surface area and serve as a barrier between the air and the alveolar surface; type II cells account for only 5% of this area, but are responsible for producing type I cells and surfactant. Surfactant reduces surface tension, thereby improving overall lung function. Alveolar macrophages, the third type of alveolar cells, are phagocytic cells that ingest foreign matter and, as a result, provide an important defense mechanism. The epithelium of the alveoli does not contain Type IV cells.

A nurse is assessing a client who is experiencing significant stress due to septicemia. Drag words from the choices below to fill in each blank in the following sentence. The nurse should ________________ , _____________ and ____________________. Interventions obtain the lactate level administer oxygen therapy increase oral (PO) fluid intake maintain prone position monitor temperature

administer oxygen therapy, monitor temperature, and obtain the lactate level Rationale: The nurse should expect to administer oxygen therapy to support perfusion, monitor temperature to assess metabolic response, and obtain lactate levels, which serve as a critical predictor of the client's metabolic stress response. The nurse should not place a client with septicemia in a prone position because this would lead to further respiratory compromise. The nurse should not increase PO fluid intake because this would also lead to respiratory compromise and fluid volume overload.