V-Sim Christopher Parrish

The nurse is preparing to continuously monitor a patient's arterial oxygen saturation levels using a pulse oximetry ear probe. Which conditions will the nurse monitor for their effects on the accuracy of the reading?

- A drop in systolic blood pressure - Excessive movement by the patient - proper contact between the probe and the patient's ear lobe

Which nursing actions pertain to the objective portion of a respiratory assessment?

- Encourage the patient to ask questions - Gather equipment - Be attentive to the patient's verbal and nonverbal responses related to the need for privacy

Which interview questions will best help the nurse identify issues related to diet adherence that need to be discussed with Chris and his parents as a part of discharge instructions?

- How would you describe your appetiite? - Do you enjoy cooking for yourself - Do you often eat out with friends?

The nurse has concluded discharge education for a patient diagnosed with cystic fibrosis. Which patient statement(s) indicate that the education has been effective?

- I know it's very important to avoid beinf around tobacco smoke - We have the furnace filters changed regularly to help manage dust - Staying hydrated is important so i drink water throughout the day - Everyone in the family knows how to help me with my chest percussion treatments

A patient is experiencing hypoxia related to an ineffective airway. Which assessment findings support the presence of hypoxia?

- Nasal Flaring - Cyanotic nail beds

The nurse's patient, Christopher Parrish, is being monitored for the effects of cystic fibrosis on his respiratory function related to the nursing diagnosis of ineffective airway clearance. The following data have been recorded in his medical record by the nursing staff. Which data directly reflect his impaired ability to get oxygen into his lungs?

- Pulse oxietry: 95% on 2L/min. Nasal cannula - Incentive spirometry every hour while awake has been tolerated well - Arterial blood gas (ABG): pH 7.3 - PaO2 50mm - PaCO2 50 mmHg

The nurse's patient, Christopher Parrish, is being prepared for discharge. Which responses by the patient or his mother indicare an understanfing of how chest physiotheraphy should be performed?

- We never do chest physiotherapy right before or within 2 hours of chris eating - I use my nebulizer before the percussion to prevent bronchospasms - Inhaling deeply through my nose and then exhaling in puffs really helps me cough up the sputum

Which interventuon will the nurse implement to best ensure a patient's oxygen saturation level remains above 94%?

Administering 2-4 L of supplemental oxygen

During a respiratory assessment the nurse auscultates what may be an adventitious lung sound. What is the nurse's initial response?

Ask the patient to cough

A nurse is performing a respiratory assessment on a patient when the patient reports occasional chest pain. Which initial response by the nurse demonstraes effective management of the patient's report?

Asking, "Are you experiencing chest pain now?"

A patient is reporting symptoms and demonstrating signs associated with dyspnea. What is the nurse's initial action?

Begin administering supplemental oxygen

A dark-skinned patient is being assessed after reporting dyspnea. Which documentation best reflects the nurse's understanding of the effects of cyanosis on this specific patient?

Bluish, dull skin is noted in the perioral area.

A nurse is assessing the respiratory function of a patient demonstrating signs and symptoms of dyspnea. Which intervention is most appropriate for effective assessment of this particular patient's respiratory status?

Counting respirations for a full 60 seconds

Which finding by the nurse best supports the presence of obstructive secretions int he patient's lungs?

Cracles occuring early in the inspiration phase

The nurse is assessing the lung sounds of a patient diagnosed with cystic fibrosis who is experiencing dyspnea. Which finding would the nurse associate with the pathophysiology associated with this diagnosis?

Diminished breath sounds in lung bases bilaterally

A patient diagnosed with cystic fibrosis suggests asking the provider to order chest physiotherapy because "it has always helped me get up the secretions in the past." which action will the jurse take when the patient's medical hsitory reports a recent myocardial infraction (MI)?

Explain that chest physiotherapy is contraindicated by the patient's recent MI

A patient with a hisotry of cystic fibrosis is being discharged after receiving treatment for a respiratory infection. Which nursing diagnosis will the nurse focus on when developing discharge teacing to best minimize the buildup of respiratory secretions?

Ineffective Airway Clearance related to knowledge deficit regarding effective coughing and deep breathing techniques

The nurse is assessing a patient for crepitus. Which hand placement technique will the nurse use to perform this assessment effectively?

Use fingertips to palpate the anterior and posterior chest