Fundamentals Chapter 26 (Respiratory)

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 Explanation: Normal breathing rate (breaths per minute) for an infant is 30 to 60; for a 6- to 12-year-old the rate is 15 to 25 breaths/min; for an older adult the rate is 16 to 20 breaths/min; and for a 1- to 5-year-old the rate is 20 to 40 breaths/min.

A nurse uses a simple mask to administer oxygen to a client with nasal trauma who breathes through the mouth. What is the minimum amount of oxygen delivered to the client using a simple mask?

5 L/min Rational: When a simple mask is used for a client with nasal trauma who breathes through the mouth, oxygen is delivered at no less than 5 L/min. A simple mask, like other types of masks, allows the administration of higher levels of oxygen than are possible with a cannula. A simple mask is sometimes substituted for a cannula when a client has nasal trauma or breathes through the mouth.

A nurse caring for a client with chronic bronchitis has orders to perform postural drainage with percussion and vibration and to administer inhalation therapy with a bronchodilator. What is the most appropriate nursing action?

Administer the bronchodilator, and then complete the postural drainage with percussion and vibration. Rationale:Bronchodilators are administered before chest physiotherapy. Clients remain in each postural drainage position for 5 minutes. Percussion is done while the client is in the postural drainage position. The other choices are incorrect and could risk putting the client at harm.

While in the dining room at the hospital, the nurse notes a visitor has forceful coughs. Which actions would the nurse take to assist this visitor? Select all that apply.

Allow the visitor to cough. Assess for a weak, ineffective cough. Explanation: The client is exhibiting a partial airway obstruction by coughing forcefully during the meal. The nurse would allow the client to cough as the client may remove the obstruction without any intervention from the nurse. The nurse would assess for a worsening in the client's condition, such as a weak, ineffective cough. The nurse would leave the client alone rather than assist to the floor. The nurse would not perform the Heimlich maneuver at this time, nor start CPR.

A client in cardiac arrest is being resuscitated when the family arrives. What is the appropriate nursing action?

Ask the family members if they wish to remain in the room during the resuscitation. Explanation: Family presence during resuscitation has positive psychological value, regardless of the outcome. It is also important that a staff member supports the observers throughout the experience as well as afterward. The other options may be appropriate if the family decides not to remain with the client.

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 Rational: Aerosol therapy encourages spontaneous coughing. It also improves breathing and helps to raise sputum for diagnostic purposes by loosening secretions. Postural drainage is a positioning technique that promotes gravity drainage of secretions from various lobes or segments of the lungs. Aerosol therapy does not prevent lung infections. Aerosol therapy also does not produce mucus; the body continuously produces mucus.

The physician at the health care facility directs the nurse to perform vibration along with percussion on a frail client with a respiratory diagnosis. What is a possible outcome of performing vibration on the client?

helps shake underlying tissue and loosen the retained secretion Rational:The nurse should be aware that vibration helps shake the underlying tissue and loosen the retained secretion. Secretions do not normally adhere to the trachea. Vibration is used with (or as an alternative to) percussion, especially for frail clients. Percussion helps dislodge respiratory secretion that adheres to the bronchial wall. Postural drainage promotes gravity drainage of secretion from the various lobes or segments of the lungs. Aerosol therapy helps the client raise sputum for diagnostic purposes.

The nurse is caring for a client with metabolic acidosis whose breathing rate is 28 breaths per minute. Which arterial blood gas data does the nurse anticipate finding?

pH less than 7.35; HCO3 low; PaCO2 low Explanation: In metabolic acidosis, anticipated arterial blood gas results are anticipated to reflect pH less than 7.35; HCO3 low; and PaCO2 low. Other answers are incorrect.

While auscultating a client's chest, a nurse hears coarse crackles that are low-pitched and rumbling. The nurse interprets this finding as indicating:

presence of sputum in the airways. Explanation: Coarse crackles heard on auscultation indicate the presence of sputum in the airways. Rales indicate presence of fluids in the lungs. Air passing through narrowed airways produces a wheezing sound, whereas inflammation of pleural surfaces gives rise to pleural rub. It is atypical for fluid to be present in the upper airways.

Which breathing technique(s) will the nurse teach to the client who has hypoxemia and hypercarbia? (Select all that apply.)

pursed-lip breathing diaphragmatic breathing Rational: Pursed-lip breathing and diaphragmatic breathing are helpful for clients who have excessive levels of carbon dioxide in the blood. Deep breathing, incentive spirometry, and use of nasal strips does not eliminate as much carbon dioxide from the blood.

The health care provider has prescribed a long-acting bronchodilator for a client with a history of bronchospasm. What teaching about this drug will the nurse include?

"Use drug daily to prevent bronchospasm." Long-acting bronchodilators are used daily for preventing asthma attacks or exercise-induced bronchospam. SABAs are used for quick relief and in rescue situations. They are not to be used only when exercising.

A nurse is teaching a cardiopulmonary resuscitation (CPR) class for health care providers. Which information is appropriate to include in the teaching plan? Select all that apply.

-Rescue breathing for infants is completed at the rate of two breaths for every 15 compressions when administered by two trained rescuers. -During cardiopulmonary resuscitation, each breath should be given over 1 second - After five cycles compressions and breathing an automated external defibrillator is attached. Explanation: Rescue breathing continues at the rate of two breaths for every 30 compressions for an adult for one or two rescuers; for children or infants, the rate is two breaths for every 30 compressions for a single trained rescuer or two breaths for every 15 compressions when administered by two trained rescuers. Each rescue breath should last 1 second and should cause the chest to rise visibly. If there is no circulation, breathing, or movement after five cycles of cardiac compressions and rescue breathing, an automated external defibrillator is attached without exceeding a 10-second interruption in CPR.

The obstetric nurse is assisting the birth of a preterm neonate. In preparing for the respiratory needs of the neonate, the nurse is aware that surfactant is formed in utero around:

34 to 36 weeks. Rational: Surfactant is formed in utero around 34 to 36 weeks. An infant born prior to 34 weeks may not have sufficient surfactant produced, leading to collapse of the alveoli and poor alveolar exchange. Synthetic surfactant can be given to the infant to help reopen the alveoli.

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 Explanation: Acute bronchitis is caused by inflammation. Inflammatory mediators such as histamine may directly stimulate nerve endings made hypersensitive by the disease process. This process causes a sensation of pain as air travels over those nerve endings. Clients with pneumonia often experience pain with deep breathing because each breath increases pressure on pain receptors that are already compressed and irritated by swollen, inflamed lung tissue. Coronary artery disease should be ruled out in anyone reporting chest pain, but Martin's sensation of burning in his airway with each breath is more suspicious for a respiratory issue. Emphysema is a more chronic illness that causes a slow progression of increasing shortness of breath. Martin is definitely at risk for emphysema but it would not explain his worsening shortness of breath over the last 2 days.

A nurse is caring for a client who breathes very shallowly and has been reporting severe back pain. What suggestion could the nurse make to help the client breathe efficiently?

Encourage the client to take deep breaths. Rational: To help the client breathe efficiently, the nurse could encourage the client to take deep breaths. Deep breathing maximizes the ventilation and fills the alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing and diaphragmatic breathing help to eliminate the extra carbon dioxide from the lungs. A nasal strip reduces airflow resistance by widening the nasal-breathing passageways, thus promoting easier breathing. It is used for reducing or eliminating snoring.

A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determines that the education was successful when the students identify which activity as occurring during inspiration?

Intercostal muscles contract. Rational: During inspiration, the diaphragm and external intercostal muscles contract. Their contraction enlarges the thorax volume and decreases intrathoracic pressure. The expanding chest wall pulls the lungs outward. As the lungs expand, pressure drops within the airways. During exhalation, the diaphragm and intercostal muscles relax, causing the thorax to return to its smaller resting size. During exhalation, the pressure in the chest increases, allowing air to flow out of the lungs.

A client is prescribed a corticosteroid for the treatment of asthma after having an asthma attack. What education should the nurse provide to the client regarding the administration of this medication?

Monitor blood pressure and blood sugar Explanation: Blood pressure and blood glucose levels may rise while taking corticosteroids and levels should be measured. The sodium intake should be decreased and not increased while taking corticosteroids. This medication will not cause drowsiness and may have the effect of sleeplessness. The best time to weigh is first thing in the morning when rising.

Upon entering a client's room, the nurse notes the client's pulse oximetry to be 86%. What is the priority nursing action?

Perform a respiratory assessment. Explanation: As the nurse enters the room, he or she will immediately begin assessment of respiratory efforts, vocalizations, chest symmetry or lack thereof, and auditory lung sounds. Other actions can take place subsequent to the assessment.

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. Explanation: The nurse performs vibration by positioning the hands on the client's chest or back during inhalation and then vibrates them as the client exhales to increase intensity of expiration. When performing percussion on a client, the nurse cups the hands, keeping the fingers and thumbs together and applies the cupped hands to the client's chest. This technique is performed for 3 to 5 minutes in each postural position.

A client with Type II diabetes has come for an annual wellness check-up with the healthcare provider. Which vaccine will the nurse discuss with the client?

Prevnar 13 ® Explanation: Clients over the age of 65 years old or those who have a compromising chronic health condition should be offered Prevnar 13 ®, which reduces strains of streptococcal pnuemoniae. Other options are not appropriate for the scenario.

A client has just returned from getting a new tracheostomy inserted. When the nurse enters the room, the client is cyanotic, with the tracheostomy tube lying on the bed. What is the nurse's priority action?

Ventilate the client with a resuscitation bag with mask. Rational: Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult. Oxygenation of the client is the nurse's priority. First, ventilate the client using a manual resuscitation bag and face mask while another nurse calls for help. Reinsertion of a fresh tracheostomy tube will require the physician's intervention.

Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways?

decreases the amount of air trapping and resistance Rational: Exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration, which prevents air from being trapped in the alveoli and decreases resistance to exhalation. Increasing carbon dioxide levels to stimulate breathing is the natural stimulus for a person without COPD to breathe. Prolonging inspiration and shortening expiration does not assist the client because exhalation is difficult for the COPD client. Humidification and fluid intake help to liquefy secretions.

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 Rational: Oropharyngeal suctioning is the removal of secretions from the lung through an orally inserted catheter. Nasotracheal suctioning is the removal of the secretion from the upper portion of the lower airway through a nasally inserted catheter. Oral suctioning is the removal of secretions from the mouth using a Yankauer-tip or tonsil-tip catheter. Nasopharyngeal suctioning means removing secretions from the throat through a nasally inserted catheter.