PVN 132: Final

A child with a history of asthma is brought to the emergency department experiencing an acute exacerbation of asthma. Which nursing assessment findings support this conclusion? Select all that apply.

Wheezing Tachycardia Bronchial constriction with mucus production causes wheezing. With the decrease in arterial oxygenation associated with asthma, the heart rate will increase.

A client reports frequent awakening at night, insomnia, and excessive daytime sleepiness. The client adds that his bed partner also complains about his loud snoring. What does the nurse anticipate including in the patient's teaching plan?

"Get fitted for an oral appliance that will bring the lower jaw and tongue forward." Frequent awakening at night, insomnia, excessive daytime sleepiness, and loud snoring indicate obstructive sleep apnea. To help the client manage obstructive sleep apnea, the nurse may suggest that he get fitted for an oral appliance that will bring the mandible and tongue forward to enlarge the airway space.

A licensed practical nurse (LPN) is providing palliative care to a client who has undergone surgery as a measure to treat lung cancer. A registered nurse teaches the LPN the interventions that need to be performed if ineffective airway clearance related to the surgery develops in the client. Which statement by the nurse indicates a need for further teaching?

"I'll facilitate optimal breathing by placing the client in supine position." Clients who have undergone surgery as a measure to treat lung cancer may experience ineffective airway clearance. To manage this condition, the nurse should facilitate optimal breathing by placing the client in a sitting position, not supine.

A client with an upper respiratory infection asks the nurse why the health care provider did not prescribe an antibiotic. What would be the best response from the nurse?

"Upper respiratory infections generally are caused by viruses and therefore should not be treated with antibiotics." Generally, upper respiratory infections are viral; therefore, antibiotics should not be used.

Arrange the events that occur in respiratory acidosis.

1. The level of carbonic acid in the blood is increased. 2. The blood pH falls and ratio of bicarbonate-to-carbonic acid ratio is upset. 3. The partial pressure of carbon dioxide increases. 4.Respiration must increase to eliminate carbon dioxide Any condition that impairs normal ventilation and prevents the respiratory system from eliminating the appropriate amount of carbon dioxide causes respiratory acidosis. Carbon dioxide is retained and blood levels of carbonic acid increase. This reduces the pH level of the blood, and the normal ratio of bicarbonate to carbonic acid (20:1) is disturbed. This results in an increase in the partial pressure of the carbon dioxide. Finally, the respiratory rate must increase to eliminate carbon dioxide.

Which value is within the normal range of values for arterial blood gas?

7.44 The normal value range for arterial blood gas is between 7.35 and 7.45. Therefore, 7.44 is the normal value.

When providing care for a client with a nasogastric (NG) tube, the nurse should take measures to prevent what serious complication?

Aspiration pneumonia Of the choices provided, the potential complication of highest risk for a client with an NG tube is aspiration pneumonia. Care should be taken to prevent dislodging of the tube or vomiting. Proper positioning of the client with an NG tube would include supine or side-lying, semi-Fowler or higher.

Which client is most likely to report experiencing fatigue?

A client with increased oxygen demand A client with increased oxygen demand is at risk for fatigue.

Which laboratory finding indicates metabolic alkalosis?

A pH value of more than 7.45 pH values of more than 7.45 may indicate metabolic alkalosis.

A registered nurse supervises a licensed practical nurse (LPN) who is caring for a client with hyperthermia. Which action by the LPN may indicate a need for further supervision? Select all that apply.

Advising the client to increase physical activities Keeping bed linens wet to reduce the client's temperature Removing the client's external coverings if temperature is subnormal A client with a fever should increase rest periods and not physical activity. Keeping the bed linens wet may cause chills; therefore, bed linens should be kept dry. If the client's temperature is subnormal, the client should be covered with more blankets.

Which parameter does the nurse assess first while assessing a client with severe trauma?

Airway Airway is first assessed in a client with severe trauma because inadequate oxygen supply can lead to brain injury that can progress to anoxic brain death.

The nurse is caring for a client with bomb blast injuries. Which are priority emergency assessments that need to be performed? Select all that apply.

Airway, breathing, circulation, exposure or environmental control. The primary survey focuses on airway, breathing, circulation (ABC), and environmental control. These are surveyed during emergency assessments in a primary survey to identify life-threatening conditions and to analyze the appropriate interventions.

Which action should be the nurse's first priority for a client with major burns?

Assessing airway patency The first action of the nurse for a client with major burns should be assessing airway patency because airway obstruction will lead to the death of the client.

Which condition may cause respiratory alkalosis?

Asthma

A client with a history of heart failure is admitted to the hospital with the diagnosis of pulmonary edema. For which signs and symptoms specific to pulmonary edema should the nurse assess the client? Select all that apply.

Crackles, coughing, orthopnea Fluid moves into the pulmonary interstitial space and then into the alveoli; this results in crackles, severe dyspnea, and coughing. Fluid in the pulmonary interstitial space and alveoli interferes with gas exchange. Sitting upright while leaning forward with the arms supported (orthopnea) is an attempt to maximize thoracic expansion and limit the pressure of abdominal organs against the diaphragm.

What is a nurse's responsibility when administering prescribed opioid analgesics? Select all that apply.

Count the clients respirations Document the intensity of the client's pain Verify the number of doses in the locked cabinet before administering the prescribed dose. Opioid analgesics can cause respiratory depression; the nurse must monitor respirations. The intensity of pain must be documented before and after administering an analgesic to evaluate its effectiveness. Because of the potential for abuse, the nurse is legally required to verify an accurate count of doses before taking a dose from the locked source and at the change of the shift.

Which central nervous system manifestation observed in a client with a respiratory disorder indicates inadequate oxygenation?

Early unexplained restlessness Early unexplained restlessness is a central nervous system sign of inadequate oxygenation that may be observed in the client with a respiratory disorder.

When caring for a client with pneumonia, which nursing intervention is the highest priority?

Employ breathing exercises and controlled coughing. For most clients, the most effective means of preventing fluid consolidation in the lungs with a diagnosis of pneumonia is to keep active by deep breathing and controlled coughing exercises.

A client with respiratory disorder complains of fatigue. Which nursing intervention will be beneficial for this client?

Encouraging adequate periods of rest A client with fatigue should be encouraged to get adequate rest to conserve energy and reduce fatigue.

A client with asthma is pregnant. Which nursing intervention is advisable to ensure the safe delivery of the baby?

Have the client continue the asthma treatment Untreated maternal asthma poses a high risk to the fetus. Therefore the client should continue the medication.

Which older client is likely at an increased risk for developing pneumonia due to not having been vaccinated?

Hispanic Older Hispanic clients have a lower immunization rate for both pneumonia and flu which increases the risk for developing pneumonia.

A client with diabetic ketoacidosis who is receiving intravenous fluids and insulin reports tingling and numbness of the fingers and toes, and shortness of breath. The nurse identifies a U wave on the cardiac monitor. What should the nurse suspect is causing these clinical findings?

Hypokalemia These are classic signs of hypokalemia that occur when potassium levels are reduced as potassium reenters cells with glucose.

Metabolic Acidosis (pH 7.30 Bicarbonate ion: 20 mEq/L Potassium ion: 6 mEq/L)

In metabolic acidosis, the blood pH value less is than 7.35, the bicarbonate ion level is less than 22 mEq/L, and the potassium ion level is greater than 5 mEq/L

Respiratory alkalosis (pH: 7.48 PaCO2: 32mm HG)

In respiratory alkalosis, the blood pH value is more than 7.45, and the partial pressure of carbon dioxide (PaCO2) is below 35 mm Hg.

A client with a coronary occlusion is experiencing chest pain and distress. What is the primary reason that the nurse should administer oxygen to this client?

Increase oxygen concentration to heart cells

The nurse finds that a client has an increased temperature. What other sign can be noticed on further assessment?

Increased respiratory rate. An increase in body temperature is associated with increased respiratory rate.

A nurse is assisting a health-care provider in providing palliative care to a client with lung cancer who has just undergone surgery. The provider instructs the nurse to assist the client with frequent position changes. Which complication is this intervention intended to prevent?

Ineffective airway clearance. Clients who undergo lung surgery for the management of lung cancer may have ineffective airway clearance. This problem can be addressed with frequent position changes.

When providing nursing care to children the nurse remembers that in the child, as in the adult, respiratory patterns are controlled by what?

Medulla

Which acid-base imbalance results in excretion of carbon dioxide by the lungs in a compensatory attempt to raise pH levels?

Metabolic acidosis In metabolic acidosis, the lungs excrete carbon dioxide to raise pH levels.

As a result of pulmonary tuberculosis, a client has a decreased surface area for gas exchange in the lungs. Which physiologic process does the nurse consider will be affected as a result?

Molecular diffusion Decreased surface area affects diffusion. The respiratory membrane, consisting of alveolar and capillary walls, is extremely thin. Thinness facilitates exchange of respiratory gases by diffusion without the need for additional energy; molecules move from an area of higher concentration to an area with lower concentration.

Which medication does the nurse anticipate will be prescribed to relieve anxiety and apprehension in a client with pulmonary edema?

Morphine Morphine binds with the same receptors as natural opioids. However, it has a rapid onset, lowers the blood pressure, decreases pulmonary reflexes, and produces sedation.

When is the most appropriate time for the nurse to plan for chest percussion and postural drainage for a toddler with cystic fibrosis?

One hour before meals Performing chest percussion and postural drainage 1 hour before meals will give the child an opportunity to rest before eating.

What should a nurse do immediately when a client returns from the postanesthesia care unit following a subtotal thyroidectomy?

Place a tracheostomy set at the bedside. Thyroid surgery sometimes results in accidental removal of the parathyroid glands. A resultant hypocalcemia may lead to contraction of the glottis, causing airway obstruction; edema around the operative site also may cause an airway obstruction. A patent airway takes priority over incision inspection.

Which technique is not used to manage mild sleep apnea?

Polysomnography Polysomnography is used to diagnose sleep apnea, not manage it.

A client suffering severe metabolic acidosis is comatose. Which nursing action would be appropriate? Select all that apply.

Providing mechanical ventilation Administering sodium bicarbonate The use of mechanical ventilation is necessary if the metabolic acidosis is severe and the client is in comatose stage. The administration of sodium bicarbonate can also be used to treat metabolic acidosis.

After reviewing a client's medical records, a nurse suspects that the client has sleep apnea. Which medical diagnosis is related to sleep apnea?

Pulmonary edema Clients with sleep apnea may have acute pulmonary edema; it can be the initial condition leading to a diagnosis of sleep apnea.

The laboratory reports of a client with a history of congestive heart failure show a blood pH value more than 7.45. Which type of acid-base imbalance may most likely be found in the client?

Respiratory alkalosis Congestive heart failure can cause respiratory alkalosis, in which the blood pH is equal to or more than 7.45

An emergency tracheotomy is performed on a toddler in acute respiratory distress from laryngotracheobronchitis (viral croup). What early signs of respiratory distress indicate that it is necessary for the nurse to suction the tracheotomy? Select all that apply.

Restlessness Increased pulse rate Restlessness and increased pulse rate are early signs of hypoxia; suctioning is required to keep the airway patent.

The nurse is caring for a client with a pneumothorax and chest tube. To evaluate the effectiveness of a chest tube, the nurse assesses for which finding?

Return of breath sounds The return of breath sounds indicates that the lung has reinflated.

Which nursing action would be appropriate for treating a client with respiratory alkalosis caused by hyperventilation secondary to anxiety? Select all that apply.

Sedating the client. Helping the client breath into a paper bag. Instructing the client to breathe slowly to retain and accumulate carbon dioxide in the body. Sedating the client can be beneficial to slow the client's breathing. Asking the client to breathe into a paper bag and/or breathe slowly will help retain and accumulate carbon dioxide in the body.

In what position should the nurse place a client recovering from general anesthesia?

Side-lying Turning the client to the side promotes drainage of secretions and prevents aspiration, especially when the gag reflex is not intact. This position also brings the tongue forward, preventing it from occluding the airway when it is in the relaxed state.

What is the first thing that must occur in the respiratory system to compensate for increased alkalinity in the system?

Slowing down the respiratory rate When there is increased alkaline in the system, the respiratory system should be slowed down, in order to increase the carbon dioxide in the blood. This then raises the level of carbonic acid, resulting in lowering the pH level.

While preforming nasotracheal suctioning, the nurse notices that the client has blood pressure of 90/70 and a heart rate of 50 beats per minute. What is the priority nursing intervention in this situation?

Stopping the suctioning procedure immediately Nasotracheal suctioning can result in vagal stimulation and bronchospasm. Vagal stimulation can result in hypotension, bradycardia, heart block, ventricular tachycardia, or other dysrhythmias and require immediate intervention. Blood pressure of 90/70 and heart rate of 50 breaths per minute indicate hypotension and bradycardia so the nurse should immediately stop the suctioning procedure.

A client with asthma was taught about self-management with long-acting medication. Which action performed by the client indicates a need for correction?

Taking the medication when an attack is triggered. The client should take the prescribed long-acting medication correctly and on time to prevent the risk of attack

An adolescent is admitted to the hospital in respiratory distress, and the health care provider orders oxygen at 40% by way of a Venturi mask. The instructions for the Venturi mask indicate that delivery of 4 L/min equals 24% to 28% oxygen, delivery of 8 L/min equals 35% to 40% oxygen, and 12 L/min equals 50% to 60% oxygen. Mark where the ball of the flow meter should be raised to deliver the percentage of oxygen ordered by the health care provider.

The ball of the oxygen flowmeter should be set at 8 L/min to deliver 40% oxygen through the Venturi mask.

How does the body compensate for metabolic alkalosis?

The lungs retain carbon dioxide to lower pH levels. In metabolic alkalosis, the body must lower pH levels. The lungs do this by retaining carbon dioxide.

A nurse tells a 71-year-old client with dyspnea, orthopnea, pulmonary crackles, wheezing, and frothy, pink sputum upon coughing to avoid isometric exercise. What is the rationale behind this suggestion?

To prevent fatigue A 71-year-old client with dyspnea, orthopnea, pulmonary crackles, wheezing, and frothy, pink sputum upon coughing most likely has left ventricular cardiac insufficiency. A client with cardiac insufficiency may have decreased cardiac output, which can lead to fatigue. Therefore, when the nurse instructs the client to avoid isometric exercise, the rationale is to prevent fatigue.

Which is a clinical manifestation of respiratory acidosis?

Tremors Tremors are a clinical manifestation of respiratory acidosis.

Which nursing action would be appropriate to decrease carbon dioxide for a client with respiratory acidosis?

Using continuous positive airway pressure (CPAP) The aim of treating respiratory acidosis is to improve ventilation and to decrease carbon dioxide levels in the body. Continuous positive airway pressure (CPAP) helps achieve these goals.