Ch. 38 Prep U

The charge nurse is observing a new nurse care for a client who is receiving oxygen via a simple mask with an FIO2 of 40%. The client states, "This moisture on my face is bothersome. Can something be done about it?" Which response by the new nurse would require clarification by the charge nurse? a) "After I dry your face, I can apply powder to absorb the moisture and protect your skin." b) "The mask and its moisture can be bothersome, so let me demonstrate some distraction techniques to help you cope with them." c) "Your mask should remain on, but I will help you dry your face when it becomes too wet." d) "I will confer with your primary care provider to find out if a nasal cannula can be used."

a) "After I dry your face, I can apply powder to absorb the moisture and protect your skin."

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? a) Flow meter b) Nasal cannula c) Nasal strip d) Oxygen analyzer

a) Flow meter

The nurse is caring for a postoperative client who has a prescription for meperidine (Demerol) 7 5mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering Demerol, the nurse would assess which most important sign? a) Respiratory rate and depth b) Urinary intake and output c) Apical pulse d) Orthostatic blood pressure

a) Respiratory rate and depth

A nurse is delivering 3 L/min oxygen to a patient via nasal cannula. What percentage of delivered oxygen is the patient receiving? a) 23% b) 32% c) 47% d) 28%

b) 32% A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44%

A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient? a) Oxygen tent b) Ambu bag c) Nasal cannula d) Oxygen mask

b) Ambu bag

The 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 utilize? a) Venturi mask b) Non-rebreather mask c) Simple mask d) Nasal cannula

b) Non-rebreather mask

The nurse is caring for a client with a North America Diagnosis Association-International (NANDA-I) diagnosis of Imbalanced nutrition: Less than body requirements, related to difficulty breathing. The nurse would implement which measures to maintain an adequate nutritional status for this client? Select all that apply. a) Encourage client to eat 1 to 2 hours before breathing treatments and exercises. b) Provide frequent oral hygiene especially before meals. c) Encourage client to decrease protein, but increase calcium intake. d) Distribute six small meals over the course of the day. e) Encourage client to eat alone for privacy during mealtime.

b) Provide frequent oral hygiene especially before meals. d) Distribute six small meals over the course of the day.

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? a) They are loud, high-pitched sounds heard primarily over the trachea and larynx. b) They are low-pitched, soft sounds heard over peripheral lung fields. c) They are medium-pitched blowing sounds heard over the major bronchi. d) They are soft, high-pitched discontinuous (intermittent) popping lung sounds.

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

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? a) low blood pressure b) high respiratory rate c) high temperature d) low pulse rate

b) high respiratory rate

A nurse is percussing the thorax of a patient with chronic emphysema. What percussion sound would most likely be assessed? a) flat b) hyperresonance c) tympany d) resonance

b) hyperresonance

A patient with a diagnosis of advanced Alzheimer disease who is unable to follow directions requires an inhaled bronchodilator. Which of the following medication delivery systems is most appropriate for this patient? a) dry powder inhaler b) nebulizer c) metered-dose inhaler without spacer d) metered-dose inhaler with spacer

b) nebulizer

What structural changes to the respiratory system should a nurse observe when caring for older adults? a) increased use of accessory muscles for breathing b) respiratory muscles become weaker c) diminished coughing and gag reflexes d) increased mouth breathing and snoring

b) respiratory muscles become weaker

What is the action of codeine when used to treat a cough? a) antisuppressant b) suppressant c) antihistamine d) expectorant

b) suppressant

The nurse is instructing the client with a pulmonary disorder on deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client? a) "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." b) "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." c) "Breathing through your nose first will warm, filter, and humidify the air you are breathing." d) "If you breathe through the mouth first, you will swallow germs into your stomach."

c) "Breathing through your nose first will warm, filter, and humidify the air you are breathing."

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation? a) Pulmonary function b) Hemoglobin levels c) Arterial blood gas d) Hematocrit values

c) Arterial blood gas

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? a) Hyperventilation b) Perfusion c) Hypoxia d) Atelectasis

c) Hypoxia

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding? a) The skin at the thorax should be cool and moist. b) The anteroposterior diameter should be greater than the transverse diameter. c) The chest should be slightly convex with no sternal depression. d) The contour of the intercostal spaces should be rounded.

c) The chest should be slightly convex with no sternal depression.

Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound? a) Vesicular b) Bronchovesicular c) Adventitious d) Bronchial

d) Bronchial

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? a) Contact the physician for nutrition shake. b) Snack on high-carbohydrate foods frequently. c) Eat one large meal at noon. d) Eat smaller meals that are high in protein.

d) Eat smaller meals that are high in protein.

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position? a) side-lying position, half on the abdomen and half on the side b) Trendelenburg position c) left side with a pillow under the chest wall d) high-Fowler's position

d) high-Fowler's position