CH 20, 21, 23 Respiratory (Oxygenation- CC3)

The nurse is caring for a patient with a pulmonary disorder. What observation by the nurse is indicative of a very late symptom of hypoxia? a. Cyanosis b. Dyspnea c. Confusion d. Restlessness

a. Cyanosis

The client has just had an invasive procedure to assess the respiratory system. What does the nurse know should be assessed on this client? a. Respiratory distress b. Loss of consciousness c. Masses in pleural space d. Watery sputum

a. Respiratory distress

The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should be assessed first? a. Pulmonary function test b. Arterial blood gases c. Pulse oximetry d. Chest x-ray

c. Pulse oximetry

What assessment method would the nurse use to determine the areas of the lungs that need draining? a. Auscultation b. Arterial blood gas (ABG) levels c. Chest X-ray d. Inspection

a. Auscultation

A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder? a. pH 7.35, PaCO2 48 mm Hg b. pH 7.28, PaO2 50 mm Hg c. pH 7.46, PaO2 80 mm Hg d. pH 7.36, PaCO2 32 mm Hg

b. pH 7.28, PaO2 50 mm Hg

Why is it important for a nurse to provide required information and appropriate explanations of diagnostic procedures to patients with respiratory disorders? a. Manage respiratory distress b. Ensure adequate rest periods c. Aid the caregivers of the client d. Manage decreased energy levels

d. Manage decreased energy levels

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema? a. Crackles in the lung bases b. Pleural friction rub c. Low-pitched rhonchi during expiration d. Sibilant wheezes

a. Crackles in the lung bases

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium? a. Difficulty in breathing b. Absent distal pulses c. Hematoma d. Urge to cough

a. Difficulty in breathing

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? a. Impaired gas exchange b. Decreased cardiac output c. Anxiety d. Ineffective tissue perfusion (cardiopulmonary)

a. Impaired gas exchange

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique? a. Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. b. Use aerosol sprays to deodorize the client's environment after postural drainage. c. Perform this measure with the client once a day. d. Administer bronchodilators and mucolytic agents following the sequence.

a. Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.

Which action by the nurse is most appropriate when the client demonstrates subcutaneous emphysema along the suture line or chest dressing 2 hours after chest surgery? a. Record the observation b. Measure the patient's pulse oximetry c. Apply a compression dressing to the area d. Report the finding to the physician immediately

a. Record the observation

The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes? a. They can be heard during inspiration and expiration. b. They occur when the pleural surfaces are inflamed. c. They are heard in clients with decreased secretions. d. They result from air passing through widened air passages.

a. They can be heard during inspiration and expiration.

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? a. 0.7 b. 0.21 c. 0.35 d. 0.5

b. 0.5

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? a. pH b. PaO2 c. HCO3 d. PCO2

b. PaO2

A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth? a. Central sulcus b. The pons c. The frontal lobe d. Wernicke's area

b. The pons

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

c. Few early symptoms

The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases? a. Lung contusion b. Hemorrhage c. Fibrotic changes in lungs d. Damage to surrounding tissues

c. Fibrotic changes in lungs

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily? a. Administer a large dose of furosemide (Lasix) IVP stat b. Schedule the client for pulmonary surgery c. Increase oxygen administration d. Intubate the client and control breathing with mechanical ventilation

d. Intubate the client and control breathing with mechanical ventilation

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a. pH b. Partial pressure of arterial carbon dioxide (PaCO2) c. Bicarbonate (HCO3-) d. Partial pressure of arterial oxygen (PaO2)

d. Partial pressure of arterial oxygen (PaO2)

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient? a. The patient is having a myocardial infarction. b. The patient is having a stress reaction. c. The patient is in a hypermetabolic state. d. The patient is hypoxic from suctioning.

d. The patient is hypoxic from suctioning.