Ch 25: Respiratory Function

A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them?

"It is inserted into the space between the lining of the lungs and the ribs."

The nurse is preparing to perform nasopharyngeal suctioning on an adult using a wall unit. What is the appropriate suction pressure setting for an adult?

100 to 120 mm Hg

The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal?

30 to 60 breaths per minute

A nurse assesses the vital signs of a healthy newborn infant. What respiratory rate could be expected based on the developmental level of this client?

30 to 60 breaths/minute

A client is receiving oxygen therapy via a nasal cannula at 3 L/min. The nurse estimates that the client is receiving which concentration of oxygen?

30%

A nurse is caring for a client who is unable to breathe efficiently by himself. The physician has directed the nurse to put the client on oxygen therapy. The client is receiving a high concentration of oxygen. At what level should a nurse use a humidifier for the client?

4 L/min

Erin is a 35-year-old woman being cared for in the emergency department for a cough and hemoptysis for 3 days. Erin states that she has smoked one-and-a-half packs of cigarettes per day for the last 5 years. In trying to identify risk factors for Erin, the nurse calculates her pack-year history to write on the intake form. What is Erin's pack-year of smoking?

7.5

A client is receiving supplemental oxygen and the nurse is monitoring the client's oxygen saturation level using pulse oximetry. The nurse notifies the physician if the client reaches which oxygen saturation level?

92%

Martin is a 58-year-old smoker who was admitted to the hospital with worsening shortness of breath over the last 2 days. He states that he is having some chest discomfort. The nurse asks him further about this in order to characterize whether this may be cardiac related, musculoskeletal related, or respiratory related. Martin states that when he breathes in, he feels as if the air passing into his lungs is burning him. It is also very painful to swallow. Based on what Martin is stating, which illness does the nurse suspect is causing Martin's chest discomfort?

Acute bronchitis

A client is experiencing hypoxia. Which nursing diagnosis would be appropriate?

Anxiety

What does pulse oximetry measure?

Arterial oxygen saturation

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines?

Be sure to shake the canister before using it.

Assessment of a client with a respiratory disorder reveals rounded and enlarged fingers. The nurse documents this finding as which of the following?

Clubbing

Which technique would the nurse employ to maximize the effectiveness of postural drainage?

Combine it with percussion and vibration.

A physician is choosing a chest drainage system for a client who is ambulating daily. Which system would be the best choice for this client?

Dry suction/one-way valve system

Which disease may result in decreased lung compliance?

Emphysema

A normal pulse oximetry reading indicates that the body's oxygen demands are being met.

False

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

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

Flow meter

The nurse is caring for a client who reports difficulty breathing. In what position would the nurse place this client?

Fowler's position

A nurse is assisting a very obese client with a partial airway obstruction caused by a large piece of food. Which action should the nurse take to relieve the client's obstruction?

Give chest thrusts.

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?

Hypoxia

Oxygen hoods are generally used to deliver oxygen at rates approaching 100% to which developmental group?

Infants

A nurse is beginning to conduct a health history for a client with respiratory problems. He notes that the client is having respiratory distress. What would the nurse do next?

Initiate interventions to help relieve the symptoms.

A nurse is caring for older adults in a nursing home. Which age-related changes may affect the respiratory functioning of the clients living there? Select all that apply.

Less air exchange, more secretions in lungs. • Greater risk for aspiration due to slower gastric motility.

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test?

Monitor the amount of oxygen saturation in the blood.

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?

Nasal cannula

Which is a sign of dyspnea specific to infants?

Nasal flaring

The nurse is reviewing the arterial blood gas results of a client with a respiratory disorder. What would alert the nurse to a problem?

PaCO2 of 55 mmHg

A client at a health care facility has been diagnosed with an upper respiratory disorder. The nurse understands that which of the following structures forms a part of the upper airway?

Pharynx

Which is a major organ of the upper respiratory tract?

Pharynx

The physician directs a nurse at the health care facility to perform vibration on a client with chest congestion. How should the nurse perform vibration on this client to relieve the congestion?

Position hands on the client's chest or back during inhalation.

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?

Pulmonary function tests

A client returns to the 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

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the appropriate intervention in this situation?

Remove the airway, turn the client to the side and provide mouth suction, if necessary.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

Residual Volume (RV)

A client has had a head injury affecting the brain stem. What is located in the brain stem that may affect respiratory function?

Respiratory center

A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from?

Sleep apnea

When caring for a client with a tracheostomy, the nurse would perform which recommended action?

Suction the tracheostomy tube using sterile technique.

What can a nurse ask a client to do before suctioning to prevent hypoxemia?

Take several deep breaths.

What is the rationale for placing a writing board in the room of a client who has had surgery to insert a tracheostomy tube?

The client is not able to speak.

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

They are low-pitched, soft sounds heard over peripheral lung fields.

A group of nursing students is reviewing information about artificial airways in preparation for a class discussion the next day. The students demonstrate understanding of the information when they identify which of the following as an artificial airway consisting of a plastic tube surgically implanted just below the larynx into the trachea?

Tracheostomy

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

True

A nurse needs to perform the Heimlich maneuver on an 8-month-old infant with a partial airway obstruction. Which action should the nurse perform?

Use the heel of one hand to administer back blows.

Which scenario describes how carbon dioxide levels determine the frequency and depth of ventilation?

When carbon dioxide levels in the blood increase, chemoreceptors are stimulated, causing deeper and more rapid breathing.

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?

a child who has pneumonia

The nurse would expect to recommend an oxygen tent for which client?

a child who will not leave a facemask or cannula in place

In which client would the nurse assess for a depressed respiratory system?

a client taking opioids for cancer pain

What prevents air from reentering the pleural space when chest tubes are inserted?

a closed water-seal drainage system

Which individual is at greater risk for respiratory illnesses from environmental causes?

a factory worker in a large city

A nurse is admitting a 6-year-old child status post tonsillectomy to the surgical unit. The nurse obtains his weight and places EKG and a pulse oximeter on the client's left finger. His heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:

adequate tissue perfusion.

A home care nurse finds a client lying on the floor. The client is not breathing. Her response is based on the ABCs of basic life support. What does the B stand for in these initials?

breathing

What assessments would a nurse make when auscultating the lungs?

cardiovascular function

A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate?

changes in the alveolar-capillary membrane and diffusion

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 postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?

educating the client on the use of incentive spirometry

A nurse is caring for a client with a sinus infection at a health care facility. The physician has prescribed aerosol therapy to keep the mucous membranes moist and the mucus thin. What is a benefit of using aerosol therapy?

encourages spontaneous coughing

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is Ineffective Airway Clearance related to copious and tenacious secretions. Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan?

encouraging the client to consume 2 to 3 quarts of clear fluids daily

A nurse is assessing a client with partial airway obstruction. Which signs should the nurse observe if a client has partial airway obstruction? Select all that apply.

exhibits cyanosis • coughs when eating • makes wheezing sounds

The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal?

fine crackles to the bases of the lungs bilaterally

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's:

hemoglobin level.

The nurse is caring for a client who is diagnosed with impaired gas exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis?

high respiratory rate

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?

high-Fowler's position

Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate to observe in a client with these arterial blood gas results?

increase in rate and depth of respirations

A client has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy tube is removed for cleaning?

inner cannula

A nurse is giving chest thrusts with two fingers to an infant with a partial obstruction. Which place is most suitable for giving chest thrusts to an infant?

middle of the sternum

A nurse is caring for a critically ill client who is receiving oxygen through a non-rebreather mask. The nurse should remember that which situation could lead to oxygen toxicity in the client?

oxygen concentration of more than 50% given for longer than 48 hours

While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique?

pattern of thoracic expansion

A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of:

pneumonia

A client at a health care facility who requires prolonged mechanical ventilation has a tracheostomy tube inserted through a surgically created opening into the trachea. The tracheostomy tube also has a balloon cuff. How does the inflated balloon cuff aid the client?

prevents the aspiration of oral fluids

A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?

prolonging expiration to reduce airway resistance

The physician directs the nurse to use oropharyngeal suctioning to remove liquid secretions for a client with a respiratory problem. What is oropharyngeal suctioning?

removing secretions from the throat through an orally inserted catheter

Which nursing skill requires the nurse to use sterile technique?

suctioning a tracheostomy

A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?

trauma to the tracheal mucosa

A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply.

• Monitor the client's respiratory rate. • Check the symmetry of the client's chest. • Observe the breathing pattern and effort.

Which statements about pulse oximetry are true? Select all that apply.

• Once the oximetry probe is correctly placed, a beam of red and infrared light travels through the tissue and blood vessels. • Sensors are available for use on the finger, toe, foot, earlobe, forehead, and bridge of the nose.

The nurse performs assessments of cardiopulmonary functioning and oxygenation during regular physical assessments. Based on developmental variations, which findings would the nurse consider normal? Select all that apply.

• The power of the respiratory and abdominal muscles is reduced in older adults, and therefore the diaphragm moves less efficiently. • The normal infant's chest is small and the airways are short, making aspiration a potential problem. • Alterations in respiratory function due to aging in older adults increase the risk for disease, especially pneumonia and other chest infections. • The respiratory rate is more rapid in infants until the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates.

The nurse is educating a client on the proper use of inhaled medications. What are appropriate education points to include? Select all that apply.

• When using an MDI, the client must activate the device before and after inhaling. • DPIs are actuated by the client's inspiration, so there is no need to coordinate the delivery of puffs with inhalation. • Metered-dose inhalers deliver a controlled dose of medications with each compression of the canister.

A nurse is administering a prescribed dose of IV medication to a client who is recovering from partial airway obstruction. What are common reasons for airway obstruction to occur? Select all that apply.

• aspiration of vomitus • compromised swallowing • insufficient chewing