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The nurse is teaching an adolescent with asthma how to use a meter-dosed inhaler. Which teaching point follows recommended guidelines?
Be sure to shake the canister before using it.
Upon auscultation of the patient'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?
Bronchial
What assessments would a nurse make when auscultating the lungs?
Cardiovascular function
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?
Flowmeter
You are caring for a patient who has spontaneous respirations and needs to have oxygen administer at a FIO2 of 100%. Which of the following oxygen deliver systems should the nurse utilize?
Nonrebreather mask
The nurse is assessing an elderly client brought to the emergency department by her spouse. The spouse states, ?She is confused and had trouble when trying to take a breath.? The nurse would next implement which priority nursing intervention for this client who is experiencing these symptoms?
Obtain baseline vital signs and oxygen saturation
When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?
Rapid respirations
A nurse uses an oxygen analyzer to measure the percentage of oxygen delivered to a client. When checking the percentage of oxygen in the room air, what should the reading of the analyzer be if there is a normal mixture of oxygen and other gases in the environment?
0.21
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 reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner?
8 L/min oxygen via nasal cannula
A nurse is performing CPR on a patient who is in cardiac arrest. What action would the nurse perform second?
Activate the emergency response system.
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?
Ambu bag
The nurse is assessing the respiratory rates of patients in a community health care facility. Which patient exhibits an abnormal value?
An infant with a respiratory rate of 20 bpm
The nurse is conducting a respiratory assessment of a 71-year-old patient who has been recently admitted to the hospital unit. Which of the following assessment findings should the nurse interpret as abnormal?
Fine crackles to the bases of the lungs bilaterally
A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function?
Pleural effusion
A nurse is assigned to care for a client admitted to the healthcare facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of which of the following?
Pneumonia
A patient vomits as a nurse is inserting his oropharyngeal airway. What would be the appropriate intervention in this situation?
Remove the airway, turn the patient 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 patient's lungs at maximal expiration. What test does the nurse order?
Residual Volume (RV)
What structural changes to the respiratory system should a nurse observe when caring for older adults?
Respiratory muscles becomes weaker
When caring for a patient with a tracheotomy, the nurse would perform which recommended action?
Suction the tracheostomy tube using sterile technique.
Which of the following describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway?
When holding the airway on the side of the patient's face, it should reach from the tragus of the ear to the nostril plus 1 inch.
A 57-year-old patient is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the patient has been unwilling to mobilize despite the nurse's teaching about the benefits of early mobilization following surgery. The nurse would recognize that the patient's prolonged immobility creates a risk for:
atelectasis.
What is the action of codeine when used to treat a cough?
suppressant
A patient is complaining of slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:
6 L/minute
Which of the following oxygen delivery systems is most commonly used because it does not impede eating or speaking?
Nasal cannula
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?
Arterial blood gas
A patient with no prior history of respiratory illness has been admitted to a postsurgical 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?
Teaching the patient to use incentive spirometry
During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?
Vesicular
The nurse is auscultating the lungs of a patient and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?
pitched
A nurse is teaching a home care patient and his family about using prescribed oxygen. What is a critical factor that must be included in teaching?
the safety measures necessary to prevent a fire
The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal?
30 to 55 breaths per minute
Which of the following dietary guidelines would be appropriate for the elderly homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?
Eat smaller meals that are high in protein
Which of the following is a recommended guideline for determining suction catheter depth when suctioning an endotracheal tube?
Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align and insert the suction catheter no further than an additional 1 cm.
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 technique?
Monitor the amount of oxygen saturation in the blood
While examining a client, the nurse palpates the client's chest and back. Which of the following would the nurse expect to identify with this technique?
Pattern of thoracic expansion
A nurse suctioning a patient 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
The nurse sets up an oxygen tent for a patient. Which patient is the best candidate for this oxygen delivery system?
A child who has pneumonia
The nurse is caring for a client receiving oxygen therapy via nasal cannula who suddenly becomes cyanotic with a pulse oximetry reading of 91%. Which is the next most appropriate action the nurse should take?
Assess oxygen tubing connection
During the physical assessment of a client who has been inactive due to a leg injury, the nurse notes that the client tends to breathe very shallowly. What technique should the nurse teach the client in order to breathe more efficiently?
Deep breathing
Oxygen and carbon dioxide move between the alveoli and the blood by
Diffusion
A physician has ordered an arterial blood gas test for a client with a respiratory disorder. What is the most common role of the nurse in performing the arterial blood gas test?
Implement measures to prevent complications after arterial puncture.
When inspecting a patient's chest to assess respiratory status, the nurse should be aware of which normal finding?
The chest should be slightly convex with no sternal depression.
T or F 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
The nurse assessing a patient with COPD suspects chronic hypoxia due to which of the following assessment findings?
clubbing of toes constipation
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?
?Breathing through your nose first will warm, filter, and humidify the air you are breathing.?
The nurse is caring for a client with a dysrhythmia with a prescription for oxygen therapy. The client is concerned and asks the nurse, ?Why am I getting oxygen when I came in with a heart problem?" What appropriate response would the nurse give this client?
?The dysrhythmia interferes with the heart?s circulation, leading to changes in oxygenation.?
The nurse caring for a client on the medical-surgical unit collects the following data during head-to-toe assessment; mid-sternal chest pain, nausea, and pulse oximetry (SpO2) of 86%. The nurse would next implement which priority nursing intervention for this client who is experiencing these symptoms?
Administer oxygen
The nurse is teaching a patient the proper use of inhaled medications. What are appropriate teaching points to include? (Select all that apply.)
Bronchodilators are used to liquefy or loosen thick secretions or reduce inflammation in airways. DPIs are actuated by the patient'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.
The nurse is caring for a client who is diagnosed with an impaired gas exchange. While performing a physical assessment of the client, which of the following data is the nurse likely to find, keeping in mind the client's diagnosis?
High respiratory rate
The nurse assesses a patient 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
A patient returns to the telemetry unit after an operative procedure. Which of the following diagnostic tests will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the patient?
Pulse oximetry
