PrepU ch 39 oxygenation and perfusion
A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?
" I can assist you to the bathroom and back to bed"
The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output?
" if the clients stroke volume is 50 ML in the heart rate is 50 bpm, when the cardiac output is 2.5 L/minute."
A nurse assesses the vital signs of a healthy newborn infant. What respiratory rate suggest a need for further assessment and possible interventions? Select all that apply.
20 breaths per minute 65 breaths per minute 80 breaths per minute
A nurse is admitting a six-year-old after a tonsillectomy to surgical unit. The nurse obtains the clients weight and places EKG leads on the chest and a pulse oximeter on the left finger. The clients heart rate reads 100 bpm in the pulse oximeter reads 99%. These readings best indicate
Adequate tissue perfusion
Upon ask elation of the clients lungs, the nurse hears loud, high-pitched sounds over the larynx. Which term will the nurse use in documentation to describe his breath sound?
Bronchial
A nurse is reading a journal article about pollutants and their insights on an individual's respiratory function. What problem with the nurse most likely identify as an effective exposure to automobile pollutants.
Bronchitis
The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate?
Check the fit of the oxygen mask
Mr. Parks has chronic obstructive pulmonary disease. His nurse has taught him pursed lip breathing, which helps him in which of the following ways?
Decreases the amount of air trapping and resistance
Oxygen and carbon dioxide move between the alveoli and the blood by
Diffusion
which skin disorder is associated with asthma
Eczema
The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather?
Face tent
During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?
Flow meter
The client has an increased anterposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is
Ineffective breathing pattern related to a hyperventilation related to increased anteroposterior
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?
It determines whether the client is getting enough oxygen
Which is a sign of dyspnea specific to infants?
Nasal flaring
The nurse is obtaining a pulse oximetry reading for a client admitted with exacerbation of chronic obstructive pulmonary disease. When observing a reading of 89% what action should the nurse perform?
No action is required, because this may be normal for the client
When reviewing data collection on a client with a cardiac output of 2.5 L per minute, the nurse inspects the client for which symptom?
Rapid respirations
The nurse is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly?
Reads 0.21 when checking oxygen in room air
When caring for a client with a tracheotomy , the nurse would perform which recommended action?
Suction the tracheostomy tube using the sterile technique
The nurse is caring for a client who has a PCT following a skydiving accident. Which oxygen delivery device will the nurse select?
Tracheostomy collar
During data collection, the nurse osculates low pitched, soft sounds over the lungs peripheral fields. Which appropriate terminology with the nurse use to describe these long sounds when documenting?
Vesicular
A nurse assessing a client respiratory status is a weak signal from the pulse oximeter. The clients other vital signs are within reference ranges. What is the nurses best action?
Warm the clients hands and try again
The nurse auscultates The Longs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding says the nurse expect to document?
Wheezing
A nurse is conducting a physical assessment on a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the clients oxygenation. What instruction should the nurse give the client?
contract abdominal muscles
The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?
"And electric stove may be a safer choice for you"
A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 909% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:
6 L/minute.
A nurse is volunteering at a daycamp. A child is stung by a bee in develops wheezing in the upper airways. The child is experiencing
A bronchospasm
In which client should the nurse prioritize assessments for respiratory depression?
A client taking opioids for cancer pain
The nurse is providing an educational demonstration to an older, post surgical client. The intervention is intended to minimize the effect of what age related changes specifically relevant to such a client?
A decrease in ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs
Upon evaluation of clients medical history, the nurse recognizes that which condition may lead to an in adequate supply of oxygen to the tissues of the body
Chronic anemia
The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?
Clubbing
The nurse assessing a client with chronic obstructive pulmonary disease suspects chronic hypoxia based on which assessment finding
Clubbing fingers
A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level?
Crackles
A nurse using a pulse oximeter to measure a clients SPO2 attend a reading of 95% what is the nurse is most appropriate action
Document as expected assessment finding
A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent post operative pneumonia and atelectasis during this time of reduced mobility following surgery?
Educating the client on the use of incentives spirometry
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?
Flow meter
To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?
High Fowlers position
The nurse is preparing discharge teaching for a client who has COPD. Which teaching about deep breathing well the nurse include
Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly
A healthcare provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?
Instruct the client to inhale deeply and then cough
A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use?
Nonrebreather mask
A nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant?
Oxygen hood
While examining a client, the nurse palpates the clients chest and back. What would the nurse expect to identify with this technique
Pattern of thoracic expansion
Which is a major organ of the upper respiratory tract?
Pharynx
What structural changes to the respiratory system should a nurse observe when caring for older adults?
Respiratory muscles become weaker
A nurse is suctioning a client through a tracheostomy tube should be careful not to occlude the y-port when inserting the suction catheter because it could cause what condition to occur?
Trauma to the Tracheal mucosa
And insertion of a chest tube, fluctuations in the water seal chamber that correspond with inspiration and expiration are an expected a normal finding
True
A nurse is assessing a clients respiratory effort notes that the client is breathing is 8 shallow breaths per minute. Which action best meets the clients immediate oxygenation needs?
Use a bag and mask
A client who uses portable home oxygen states, " I still like to smoke cigarettes every now and then." What is the appropriate nursing response?
You should never smoke when oxygen is in use
A nurse is delivering 3 L a minute oxygen to a client via nasal canal. What percentage of delivered oxygen is the client receiving?
32%
The nurse that's up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system
A child with pneumonia
A nurse is assessing a clients respiratory effort notes that the clients breaths are shallow and eight per minute. Shortly after, the clients respirations seas. Which form of oxygen delivery should the nurse use for this client?
Ambu bag
The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what did you or the nurse provide?
An electric stove may be a safer choice for you
The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results with the nurse report to the healthcare provider?
An infant with a respiratory rate of 16 BPM
The nurse must obtain a blood specimen for blood gas analysis. What is the most important thing for the nurse to do immediately after the needle has been removed?
Apply study, firm pressure on the puncture site for 5 to 15 minutes.
The nurse is caring for a client who has a compromise cardio pulmonary system and needs to assess the clients tissue oxygenation. The nurse would use which appropriate message to assess the clients oxygenation?
Arterial blood gas
The nurse is caring for a client receiving oxygen therapy via nasal canal. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take
Assess oxygen tubing connection
A client 57 years of age is recovering in the hospital following a bilateral mastectomy in breast reconstruction two days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurses education on the benefits of early mobilization following surgery. The nurse would recognize that the clients prolonged immobility creates a risk for
Atelectasis
The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?
Confusion
A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from
Congestive heart failure
Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?
Corticosteroids
The pediatric nurse is instructing parents on safety when caring for toddlers and preschoolers. Which of the following teaching interventions is appropriate for this age group?
Cut a hotdog in half, then pieces
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?
Eat smaller meals that are high in protein
The nurse is caring for a client with emphysema who has been prescribed portable oxygen, 2 L a minute. Which actions does the nurse take to administer low concentrations of oxygen to the client? Select all that apply
Ensure that the oxygen concentrator is turned on Confirm that the nasal canal is worn properly by the client Verify the oxygen concentrator is set up on the prescribed flow rate
The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment findings should the nurse interpret as abnormal?
Fine crackles to the base of the lungs bilaterally
A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds in respiratory rate. The mother asked the nurse, why is his chest sucking and above his stomach? The nurse most accurate response is:
He is using his chest muscles to help him breathe
The nurse assesses a client and detects the following findings, difficulty breathing, increase respiratory and pulse rates, and pale skin with regions of cyanosis. What condition with the nurse suspect as causing these respiratory alterations?
Hypoxia
The nurse is providing discharge teaching to client going home with oxygen therapy. Which statements made by the client would indicate to the nurse at the teaching was effective?
I will not allow smoking within 10 feet of my oxygen I will keep the oxygen tank away from Director sunlight or heat
The nurse is suctioning a clients tracheostomy me when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse is most appropriate response?
Maintain the clients oxygenation and alert the healthcare provider immediately
A client with a diagnosis of advanced Alzheimer's disease is unable to follow directions required to use an inhaled bronchodilator. Which medication delivery system is most appropriate for this client?
Nebulizer
A clients primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?
Pleural effusion
A nurse is assigned to care for a client admitted to the healthcare facility with the diagnosis of ATELECTASIS. When interviewing the client, the nurse would anticipate a history of
Pneumonia
When a nurse observes that an older client skin is dry and shiny and his nails are thickened, the nurses terms of the client is most likely experiencing
Poor tissue perfusion
Which diagnostic procedure measures long size in airway patency, producing graphic representations of lung volumes and flows
Pulmonary function tests
A client returns to a 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?
Pulse oximetry
The nurse schedules a pulmonary function test to measure the amount of air left in a clients lungs at maximal expiration. What test does the nurse order?
Residual volume (RV)
The nurse is caring for a client with a chest to. Which assessment finding indicates that she was functioning correctly?
Respirations are at 20 breaths per minute
The nurse provides care for a client with chronic bronchitis and a decrease in oxygen saturation. Which factors, if assess, indicate a deteriorating condition? Select all that apply.
Tachypnea Tachycardia Shortness of breath Wheezing and crackles in lungs
When inspecting a clients chest to assess respiratory status, the nurse should be aware of which normal finding?
The chest should be slightly convex with no sternal depression
A nurse takes a clients pulse oximetry reading and find that is normal. What does this finding indicate
The clients available hemoglobin is adequately saturated with oxygen
The nurse educator would intervene with client teaching if which action by the staff nurse occurs when teaching voluntary coughing?
The nurse has the client lying in bed in semi Fowler's position
Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway?
When holding the airway on the side of the clients face, it should reach from the tragus of the ear to the tip of the nostril