EAQ Gas Exchange

Which assessment finding of a client being treated in the emergency department after a motor vehicle collision indicates the need for immediate health care provider intervention? Select all that apply. One, some, or all responses may be correct.

-Facial edema -Septal deviation -Clear nasal drainage -Oxygen saturation 89% -Bilateral periorbital bruising

Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? Select all that apply. One, some, or all responses may be correct.

-mold -cold air -pet dander -air pollution -cigarette smoke

In which order would the nurse teach the client the steps to follow while performing expansion breathing?

1. Sit in an upright position with knees slightly bent. 2. Place hands on each side of lower ribcage, just above the waist. 3.Take a deep breath through your nose, using shoulder muscles to expand your lower ribcage outward during inhalation. 4.Exhale, first moving the chest and then lower ribs inward while gently squeezing the ribcage, forcing air out of the base of lungs.

A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen?

Increase oxygen concentration to heart cells

Which explanation would the nurse provide to the parents of a child with spasmodic croup who ask why their child is receiving humidified oxygen?

It helps prevent drying of membranes.

A client with cystic fibrosis asks why the percussion procedure is being performed. Which rationale would the nurse give to the client?

It loosens pulmonary secretions

Which nursing intervention would the nurse consider the highest priority for a client who was in a motor bike accident and has a severe neck injury?

Maintaining a patent airway

For a client admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung, which action would the nurse take when caring for the chest tube drainage system?

Mark the time and fluid level on the side of the drainage chamber

Which statement supports the need for the nurse to pursue the daughter's condition as a potential case finding when caring for a chronically ill older client living with a daughter who has three small children, seems run-down, coughs a lot, and sleeps all the time?

Older adults with chronic illness are more susceptible to tuberculosis

A client has a closed chest drainage system in place. How would the nurse determine the amount of chest tube drainage?

Refer to the date and time markings on the outside of the collection chamber.

A child with cystic fibrosis (CF) has recurrent episodes of bronchitis, and the parents ask why this happens. Which reason would the nurse include in the reply?

Tenacious secretions that obstruct the respiratory tract provide a favorable medium for growth of bacteria

Which statement describes a client's tidal volume?

Tidal volume is the volume of air inhaled and exhaled with each breath.

Which parameter describes the maximum volume of air a client's lungs may contain?

Total Lung Capacity

Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the emergency department to a neurological trauma unit?

Validating availability of a bag-valve mask during the transfer

A client is hospitalized with a left pneumothorax, and when assessing the left chest area, the nurse would expect to identify which finding?

absence of breath sounds on auscultation

After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client experiences a sudden onset of cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. Which is the priority nursing action?

administer oxygen

Which condition would the nurse give the highestpriority for a client admitted in the emergency department who has airway obstruction, chest wall trauma, external hemorrhage, and hypoglycemia?

airway obstruction

Which color tag would the triage nurse working at a train accident use to label a client experiencing respiratory distress?

red

Before beginning administration of morphine via patient-controlled analgesia (PCA), which assessment would the nurse perform first?

respirations

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO ) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing?

respiratory acidosis

Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety?

respiratory alkalosis

Which adverse effect will the nurse assess for when caring for a client taking morphine sulfate for severe metastatic bone pain?

respiratory depression

When a preterm newborn requires oxygen, the nurse in the neonatal intensive care unit monitors and adjusts the oxygen concentration. Which complication do these adjustments attempt to prevent?

retinopathy of prematurity

In which position will the nurse place a client who has been transferred from the postanesthesia care unit to the intensive care unit after a radical neck dissection?

semi-fowler

Which client would the triage nurse provide care to first based on condition? A. severe respiratory distress B. chest pain resulting from trauma C. hip fracture in older client D. cystitis

severe respiratory distress

The nurse provides teaching to a client who is being discharged after treatment for a pneumothorax. The nurse instructs the client to notify the health care provider immediately if experiencing which symptom of a recurring pneumothorax?

severe shortness of breath

Which sign in the newborn infant would reflect an Apgar score of 1 in the category of respiration?

slow, weak cry

The nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. Which is the most important intervention for the nurse to include in this plan?

taking medications as prescribed

Soft swishing sounds of breathing are heard when the nurse auscultates a client' s chest. Which term would the nurse use to document this assessment finding?

vesicular breath sounds

When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding?

vesicular breath sounds

Which statement by the nurse regarding anesthetic drugs in pediatric clients requires correction?

"During general anesthesia, the upper airway obstruction risk is less in pediatrics."

After the nurse has finished teaching a postoperative client about prevention of pulmonary embolism, which client statement indicates that the teaching has been effective?

"I will avoid crossing my legs"

Which response will the nurse provide when a family member asks why a client who is intubated and receiving mechanical ventilation has restraints in place?

"Restraints are a last resort to prevent accidental extubation"

Which amount would the nurse recognize as the normal value of a client's inspiratory reserve volume?

3.0 L

Which response would the nurse implement when the spouse of a client with pulmonary tuberculosis (TB) receives a tuberculin skin test and is found to have an area of induration greater than 10 mm?

Additional tests are necessary to determine infection status

When the nurse educator is observing a student performing tracheal suctioning of a client with thick secretions, which student action requires intervention?

Applies suction during insertion of the catheter

A client with chronic obstructive pulmonary disease is admitted to the hospital with a tentative diagnosis of pleuritis. It is important for the nurse to perform which intervention?

Assess for signs of pneumonia

Which condition would the nurse associate with a client' s regular and slow respiratory rate?

Bradypnea

To which part of the respiratory system would the client's radiology report refer when identifying the angle of Louis?

Carina

Which goal is the priority for a client with asthma who has a prescription for an inhaled bronchodilator?

Demonstrates use of a metered-dose inhaler

Which explanation would the nurse give to a client with a diagnosis of myocardial infarction who asks the nurse, "What is causing the pain I am having?"?

Inadequate oxygenation of the myocardium

Which priority nursing intervention would the nurse implement when caring for a client with pneumonia?

Instruct client on breathing exercises and controlled coughing

The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning?

Preoxygenate the client before suctioning.

A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and would begin with which aspect of care?

The disease process and breathing exercises.

Which action will the nurse take after stopping the antibiotic infusion of a client who becomes restless and flushed, and begins to wheeze during the administration of an antibiotic?

Assess the client's respiratory status

A client is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). Which action would the nurse take to prevent client fatigue?

Schedule nursing activities to allow for rest

Which action would be the nurse's first priority when receiving a client with major burns?

assess airway patency

Which action would the nurse plan to take to prevent respiratory complications after abdominal surgery?

assist client to use the incentive spirometer

Nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complication?

atelectasis

When a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest?

decreased sounds

Which pathophysiological abnormality is present in cystic fibrosis?

dysfunction of the mucus-secreting glands

Which intervention would the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma?

encourage coughing and deep breathing

Which is the priority nursing intervention to prevent thrombus formation in a child with sickle cell anemia?

encouraging fluids

Which nursing intervention would be the priority for a client with multiple injuries from an accident?

establishing a patent airway in the client

Which instruction would the nurse include when teaching a client how to perform diaphragmatic breathing?

expand the abdomen on inhilation

The nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. The nurse would include which information in the education?

importance of meticulous oral hygiene

A client presenting with an acute asthma attack is being assessed in the emergency department. The client' s spouse reports that the client currently is undergoing treatment for an upper respiratory infection. The nurse would understand that the client most likely has which type of asthma?

intrinsic

Upon noticing a client with heart disease has digital cyanosis, which site would the nurse assess to confirm cyanosis?

lips

Which is the purpose of an occlusive dressing over a client's sucking chest wound?

maintains negative pressure within the chest cavity

Which statement must the nurse emphasize to the family when preparing a school-aged child with persistent asthma for discharge?

medications must be continued even when the child is asymptomatic

Which substance will the home care nurse instruct a client to use after laryngectomy to cleanse the stoma site?

mild soap and water

The nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange?

orthopneic

Which action will the nurse take to support safe oral intake after tracheostomy?

position client as upright as possible

Which is the function of the water-seal chamber on a closed chest drainage system for a client with hemothorax?

prevents reflux of air back into the pleural space

The nurse provides immediate postoperative care to a client. The client reports a sudden onset of shortness of breath and chest pain. Which action would the nurse take?

provide supplemental oxygen

Which inference would the nurse draw when crackles are heard while auscultating the lungs of a client admitted with severe preeclampsia?

pulmonary edema may have developed