EAQ-Gas Exchange

Which client in the intensive care unit would the nurse assess first? 1. Client with increasingly labored respiratory effort after aspiration of gastric contents 2 days ago 2. Client who is receiving positive pressure mechanical ventilation after an accidental opioid overdose 3. Client who is being observed after successful anaphylaxis treatment and has a prednisone dose due 4. Client who has pneumocystis pneumonia and has intravenous antibiotic and antiretroviral medications due

Correct 1. Client with increasingly labored respiratory effort after aspiration of gastric contents 2 days ago Explanation: Increasingly labored respirations in a client with aspiration may indicate the development of acute respiratory distress syndrome and respiratory failure. The nurse will need to immediately assess the client's respiratory and hemodynamic status and anticipate changes to treatment such as high flow oxygen, intubation, and positive pressure mechanical ventilation. The client with an opioid overdose is already receiving mechanical ventilation and there is no indication of a need for an immediate change in therapy. The client who had successful treatment of anaphylaxis needs the prescribed prednisone, but there is no indication that the client is destabilizing. The client with pneumocystis pneumonia needs to receive the prescribed antibiotic and antiretroviral medications, but there is typically a "window" in which medications can be administered, and there is no indication that the client is becoming increasingly dyspneic or needs immediate care.

The nurse determines that a newborn is suffering from respiratory distress. Which visible signs confirm this assessment? Select all that apply. One, some, or all responses may be correct. 1. Crackles 2. Cyanosis 3. Wheezing 4. Tachypnea 5. Retractions

Correct 2. Cyanosis 4. Tachypnea 5. Retractions Explanations: Cyanosis occurs because of inadequate oxygenation. Tachypnea is a compensatory mechanism necessary to increase oxygenation. Retractions occur in an effort to increase lung capacity. Crackles occur in a healthy newborn. Wheezing in the newborn is benign. Test-

Which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema? 1. Prevents bronchial spasm 2. Decreases air trapping in lung 3. Improves alveolar surface area 4. Strengthens diaphragmatic contraction

Correct 2. Decreases air trapping in lung Explanation: Pursed-lip breathing provides positive pressure in the airways during expiration, prolonging expiration and decreasing the air trapping, which is characteristic of emphysema. Pursed-lip breathing will not decrease bronchospasm, which is characteristic of asthma. Alveolar surface area is not changed by pursed-lip expiration. Diaphragmatic contraction is not strengthened by pursed-lip breathing.

Which intervention would the nurse implement for a client admitted for an exacerbation of asthma? 1. Determine the client's emotional state. 2. Give prescribed medications to promote bronchiolar dilation. 3. Provide education about the effect of a family history. 4. Encourage the client to use an incentive spirometer routinely.

Correct 2. Give prescribed medications to promote bronchiolar dilation. Explanation: Asthma involves spasms of the bronchi and bronchioles as well as increased production of mucus; this decreases the size of the lumina, interfering with inhalation and exhalation. Bronchiolar dilation will reduce airway resistance and improve the client's breathing. Although identifying and addressing a client's emotional state is important, maintaining airway and breathing are the priority. In addition, emotional stress is only one of many precipitating factors, such as allergens, temperature changes, odors, and chemicals. Although recent studies indicate a genetic correlation along with other factors that may predispose a person to the development of asthma, exploring this issue is not the priority. The use of an incentive spirometer is not helpful because of mucosal edema, bronchoconstriction, and secretions, all of which cause airway obstruction.

A client reports a cold accompanied by a severe cough. The frequent coughing episodes last for several minutes and are followed by exhaustion. The nurse observes a "whooping" sound at the end of the cough. Which organism may be responsible for this client's condition? 1. Coronavirus 2. Bacillus anthracis 3. Bordetella pertussis 4. Group A beta-hemolytic Streptococcus

Correct 3. Bordetella pertussis Explanation: Pertussis is a respiratory infection caused by the Bordetella pertussis bacterium. In the paroxysmal stage of pertussis, the client may have a cold and severe cough that lasts for several minutes accompanied by frequent exhaustion. A distinct "whooping" sound is heard at the end of the cough. Coronaviruses cause severe acute respiratory syndrome. Bacillus anthracis causes inhalation anthrax. Group A beta-hemolytic Streptococcus causes peritonsillar abscess.

A client with an upper respiratory infection asks the nurse why the health care provider did not prescribe an antibiotic. Which response from the nurse would be the best? 1. "I don't know; however, I will ask your health care provider for a prescription as soon as possible." 2. "Antibiotics are used to treat viruses, and your cultures indicate the presence of a bacterial infection." 3. "Antibiotics are ineffective for treating the bacteria that caused your upper respiratory infections." 4. "Upper respiratory infections are generally caused by viruses and would not be treated with antibiotics."

Correct 4. "Upper respiratory infections are generally caused by viruses and would not be treated with antibiotics." Explanation: Generally, upper respiratory infections are viral; therefore antibiotics would not be used. Overuse of antibiotics results in antibiotic-resistant strains of bacteria. Antibiotics are used to treat bacteria, not viruses.

The nurse in the health clinic is counseling a college student who recently was diagnosed with asthma. Which aspect of counseling would the nurse focus on? 1. Teaching how to make a room allergy-free 2. Referring to a support group for individuals with asthma 3. Arranging with the college to ensure a speedy return to classes 4. Evaluating whether the necessary lifestyle changes are understood

Correct 4. Evaluating whether the necessary lifestyle changes are understood Explanation: Understanding the disorder and the details of care are essential for the client to be self-sufficient. Although teaching is important, a perceived understanding of the need for specific interventions must be expressed before there is a readiness for learning. Referring to a support group is premature; this may be done eventually. Although ensuring a speedy return to classes is important, involving the college should be the client's decision.

An infant with cardiopulmonary disease displays signs and symptoms of bronchiolitis and pneumonia. Which condition would the nurse anticipate when planning care? 1. Poliomyelitis 2. Pneumococcal infection 3. Meningococcal infection 4. Respiratory syncytial virus infection

Correct 4. Respiratory syncytial virus infection Explanation: Respiratory syncytial virus infections are the most common cause for hospitalization of infants younger than 1 year of age; this disease especially affects premature infants and infants with cardiopulmonary disease. Poliomyelitis is caused by the poliovirus. Streptococcus pneumonia infections cause meningitis, sepsis, pneumonia, and otitis media. Neisseria meningitidis causes meningitis.

A client is admitted to the hospital because of inhaling noxious chemicals. During an examination, the primary health care provider identifies damage to the upper airway. Which manifestations will the nurse observe related to upper airway damage? Select all that apply. One, some, or all responses may be correct. 1. Edema 2. Stridor 3. Blisters 4. Dyspnea 5. Wheezing

Correct: 1. Edema 2. Stridor 3. Blisters Explanation: The inhalation of hot air may cause upper airway and lower airway damage. The manifestations of upper airway damage include edema, stridor, and blisters. The manifestations of lower airway injury are dyspnea and wheezing.

Which finding is indicative of abnormal newborn breathing? Select all that apply. One, some, or all responses may be correct. 1. Stridor 2. Mottling 3. Bradypnea 4. Nasal flaring 5. Expiratory grunting

Correct: 1. Stridor 2. Mottling 3. Bradypnea 4. Nasal flaring 5. Expiratory grunting Explanation: Findings indicative of abnormal breathing in newborns include stridor, mottling, bradypnea, nasal flaring, and expiratory grunting.