ML8 CH39

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 OR FALSE

TRUE

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 OR FALSE

TRUE

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed: A) 6 L/minute. B) 4 L/minute. C) 10 L/minute. D) 1 L/minute.

A) 6 L/minute.

A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client? A) Ambu bag B) Oxygen tent C) Oxygen mask D) Nasal cannula

A) Ambu bag

A client who was prescribed CPAP reports nonadherence to treatment. What is the prioritynursing intervention? A) Ask the client what factors contribute to nonadherence. B) Contact the health care provider to report the client's current status. C) Document outcomes of modifications in care. D) Explain the use of a BiPAP mask instead of a CPAP mask.

A) Ask the client what factors contribute to nonadherence.

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is: A) "His infection is causing him to breathe harder." B) "He is using his chest muscles to help him breathe." C) "His lung muscles are swollen so he is using abdominal muscles." D) "He will require additional testing to determine the cause."

B) "He is using his chest muscles to help him breathe."

A client is taking albuterol via nebulizer. Which instruction will the nurse provide to teach the client how to use the nebulizer? A) Place the mouthpiece in your mouth. Intermittently breathe through your nose and mouth so that all of the medicine goes into your lungs B) Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs. C) Place the mouthpiece near your mouth. Inhale the medicine into your lungs. D) Place the mouthpiece in your mouth. Breath in the medication then remove the mouthpiece to breathe the medicine out.

B) Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs.

The nurse is preparing to provide hygiene care to a client with hypoxia. Into what position will the nurse place the client? A) Trendelenburg B) high Fowlers C) supine D) prone

B) high Fowlers

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) Bronchial B) Bronchovesicular C) Vesicular D) Adventitious

A) Bronchial

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia? A) Clubbing B) Hemoptysis C) Constipation D) Edema

A) Clubbing

Oxygen and carbon dioxide move between the alveoli and the blood by: A) diffusion. B) osmosis. C) negative pressure. D) hyperosmolar pressure.

A) Diffusion

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? A) Vesicular B) Crackles C) Bronchial D) Bronchovesicular

A) Vesicular

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client? A) simple mask B) nasal cannula C) nonrebreather mask D) face tent

B) nasal cannula

Which skin disorder is associated with asthma? A) Seborrhea B) Psoriasis C) Eczema D) Abrasions

C) Eczema

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 medium-pitched blowing sounds heard over the major bronchi. C) They are soft, high-pitched discontinuous (intermittent) popping lung sounds. D) They are low-pitched, soft sounds heard over peripheral lung fields.

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

A client's spouse reports that the client snores loudly and incessantly every night. What is the appropriate nursing response when the client's spouse asks about nasal breathing strips? A) "Those do not work for snoring." B) "The nasal diameter is decreased by nasal strips." C) "You will need a prescription for nasal strips." D) "Nasal strips may reduce or eliminate snoring."

D) "Nasal strips may reduce or eliminate snoring."

Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system? Select all that apply. 1) crackles heard on inspiration. 2) quiet and nonlabored respiration occurring at a rate of 18 to 30 bpm 3) anteroposterior diameter of the chest less than the transverse diameter 4) slightly contoured chest with no sternal depression 5) barrel chest appearance in older adults 6) bronchial, vesicular, and bronchovesicular breath sounds

3) anteroposterior diameter of the chest less than the transverse diameter 4) slightly contoured chest with no sternal depression 6) bronchial, vesicular, and bronchovesicular breath sounds

A nurse is performing CPR on a client who collapsed. Which guidelines should be used for this procedure? Select all that apply. 1) If trauma to the head or neck is present or suspected, do not attempt to open the airway. 2) If possible, place the client on a soft mattress to minimize injury. 3) Look, listen, and feel for air exchange for at least 10 seconds and no more than 20 seconds. 4) Use the head tilt-chin lift maneuver to open the airway. 5) Position the client supine on his or her back. 6) Rest elbows on the flat surface under the client, grasp the angle of the client's lower jaw, and lift with both hands.

4) Use the head tilt-chin lift maneuver to open the airway. 5) Position the client supine on his or her back. 6) Rest elbows on the flat surface under the client, grasp the angle of the client's lower jaw, and lift with both hands.

The client is experiencing respiratory distress and the nurse places the client in a high Fowler position. Which action does the nurse take next? A) Ensure airway patency B) Assess breathing pattern C) Evaluate oxygen delivery D) Monitor fluid management

A) Ensure airway patency

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) Hypoxia B) Atelectasis C) Hyperventilation D) Perfusion

A) Hypoxia

A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention? A) Inquire about factors that contribute to non-adherence. B) Document assessment and plan for intervention. C) Explain uses of BiPAP masks versus CPAP masks. D) Notify the healthcare provider of the client's current status.

A) Inquire about factors that contribute to non-adherence.

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen? A) Instruct the client to inhale deeply and then cough. B) Have the client clear the nose and throat and gargle with salt water before beginning the procedure. C) Place the client in the dorsal recumbent position to collect the specimen. D) Discard the first sputum produced by the client.

A) Instruct the client to inhale deeply and then cough.

The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document? A) Wheezing B) Absent breath sounds in lower lobes C) Stridor D) Crackles

A) Wheezing

A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for: A) atelectasis. B) tachypnea. C) hemothorax. D) pneumothorax.

A) atelectasis.

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) high respiratory rate B) low blood pressure C) low pulse rate D) high temperature

A) high respiratory rate

A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of: A) pneumonia. B) asthma. C) alcohol use. D) croup.

A) pneumonia.

A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client? A) pulse oximetry B) spirometry C) thoracentesis D) peak expiratory flow rate

A) pulse oximetry

The nurse is caring for a client who has excess levels of carbon dioxide in the blood, and chronic hypoxemia. Which intervention will the nurse recommend? A) pursed-lip breathing B) incentive spirometry C) deep breathing D) diaphragmatic breathing

A) pursed-lip breathing

The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach? A) "Take in a small amount of air and exhale quickly." B) "Take in as much air as possible, hold your breath briefly, and exhale slowly." C) "Take in a large volume of air and hold your breath as long as you can." D) "Take in a little air, hold your breath 15 seconds, and exhale slowly."

B) "Take in as much air as possible, hold your breath briefly, and exhale slowly."

The nurse is demonstrating oxygen administration to a client. What teaching will the nurse include about the flowmeter? A) "Small water droplets come from this, thus preventing dry mucous membranes." B) "This is a gauge used to regulate the amount of oxygen that a client receives." C) "The flowmeter prescribes the concentration of oxygen." D) "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed."

B) "This is a gauge used to regulate the amount of oxygen that a client receives."

A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving? A) 23% B) 32% C) 28% D) 47%

B) 32%

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) Hemoglobin levels B) Arterial blood gas C) Hematocrit values D) Pulmonary function

B) Arterial blood gas

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? A) Bronchoscopy B) Pulmonary function tests C) Skin tests D) Chest x-ray

B) Pulmonary function tests

When caring for a client with a tracheostomy, the nurse would perform which recommended action? A) Assess a newly inserted tracheostomy every 3 to 4 hours. B) Suction the tracheostomy tube using sterile technique. C) Clean the wound around the tube and inner cannula at least every 24 hours. D) Use gauze dressings over the tracheostomy that are filled with cotton.

B) Suction the tracheostomy tube using sterile technique.

A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario? A) hypercapnia B) cyanosis C) eupnea D) hypoxemia

B) cyanosis

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? A) increases carbon dioxide, which stimulates breathing B) decreases the amount of air trapping and resistance C) helps liquefy his secretions D) teaches him to prolong inspiration and shorten expiration

B) decreases the amount of air trapping and resistance

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's: A) blood pH. B) hemoglobin level. C) sodium and potassium levels. D) age.

B) hemoglobin level.

The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client? A) simple mask B) nasal cannula C) face tent D) tracheostomy collar

B) nasal cannula

A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client? A) thoracentesis B) pulse oximetry C) spirometry D) peak expiratory flow rate

B) pulse oximetry

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? A) "Take in a small amount of air very quickly and then exhale as quickly as possible." B) "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling." C) "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." D) "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly."

C) "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

The nurse is talking with a client who has chronic obstructive pulmonary disease (COPD). The client reports chest shape seems to have changed over the past year. What information should be provided by the nurse? A) "The corticosteroids prescribed to manage the condition have caused a change in the shape of the chest wall." B) "Your chest diameter has increased as the musculature has matured in an effort to obtain increased amounts of oxygen." C) "Your lung condition limits the ability of the lungs to fully exhale, causing this change in shape." D) "Chronic lung conditions such as this are associated with fluid retention in the lower lung fields, causing the change in the chest shape."

C) "Your lung condition limits the ability of the lungs to fully exhale, causing this change in shape."

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? A) It decreases dry mucous membranes via delivering small water droplets. B) It prescribes oxygen concentration. C) It determines whether the client is getting enough oxygen. D) It regulates the amount of oxygen received.

C) It determines whether the client is getting enough oxygen.

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function? A) Wheezes B) Pneumonia C) Pleural effusion D) Tachypnea

C) Pleural effusion

The nurse is caring for a 70-year-old client with COPD. Which vaccine will the nurse offer the client? A) meningococcal conjugate B) DTAP C) Prevnar 13 ® D) hepatitis B

C) Prevnar 13 ®

A nurse assessing a client's respiratory effort notes that the client is breathing 8 shallow breaths/min. Which action best meets this client's immediate oxygenation needs? A) Suction the client's upper airway. B) Establish an oxygen hood. C) Use a bag and mask. D) Apply nasal cannula at 6 L/min

C) Use a bag and mask.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? A) Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. B) Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. C) 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. D) For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.

C) 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.

A client with no prior history of respiratory illness has been admitted to a postoperative 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? A) administration of inhaled corticosteroids B) oropharyngeal suctioning twice daily C) educating the client on the use of incentive spirometry D) educating the client on pursed-lip breathing techniques

C) educating the client on the use of incentive spirometry

An adult client is discharged to home with a prescription for oxygen at 2 L/min. Which method of oxygen delivery should the nurse use in this situation? A) oxygen tent B) oxygen mask C) nasal cannula D) oxygen hood

C) nasal cannula

The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? A) face tent B) simple mask C) tracheostomy collar D) nasal cannula

C) tracheostomy collar

The nurse is teaching the client with a pulmonary disorder about 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) "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." B) "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." C) "If you breathe through the mouth first, you will swallow germs into your stomach." D) "Breathing through your nose first will warm, filter, and humidify the air you are breathing."

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

The nurse performs a respiratory assessment on a healthy client. While listening to the client's lungs, the nurse hears them fill with air and then return to a resting position. The nurse deems the findings normal. Which is the best way to document this respiratory assessment and lung sounds? A) "Client breathing without difficulty; respiratory rate 22 and regular on 2 liters of oxygen per nasal cannula; dry, hacky, intermittent cough; reports slight shortness of breath with exertion." B) "Client sitting upright in bed, respirations 24 and shallow, lungs clear bilaterally, oxygen at 2 liters per nasal cannula, productive cough." C) "Respiratory rate 22, regular; lungs sounds clear bilaterally; spontaneous, nonproductive cough, yellow drainage from nostrils." D) "Respiratory rate 14, even, regular, and easy; depth with acceptable parameters; lung sounds clear all lobes bilaterally; absence of adventitious lung sounds; absence of spontaneous cough; oxygen saturation 98%."

D) "Respiratory rate 14, even, regular, and easy; depth with acceptable parameters; lung sounds clear all lobes bilaterally; absence of adventitious lung sounds; absence of spontaneous cough; oxygen saturation 98%."

A client with a nonhealing pressure injury has been prescribed hyperbaric oxygen therapy (HBOT). The client tells the nurse, "This kind of treatment doesn't make any sense to me." What is the appropriate nursing response? A) "In the chamber, you will be treated for decompression sickness." B) "When you become oxygen-toxic, the wound will heal faster." C) "It will help you breathe easier and feel better more quickly." D) "Wounds heal because HBOT helps to regenerate new tissue quickly."

D) "Wounds heal because HBOT helps to regenerate new tissue quickly."

The nurse is caring for a client with emphysema. A review of the client's chart reveals pH 7.36, PaO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription if prescribed by the health care practitioner? A) Increase fluid intake to 3 L/day (3000 mL/day) B) High-Fowler's position C) Pulse oximetry D) 4 L/minute O2 (66 mL/second) nasal cannula

D) 4 L/minute O2 (66 mL/second) nasal cannula

In which client should the nurse prioritize assessments for respiratory depression? A) A client taking a beta-adrenergic blocker for hypertension B) A client taking insulin for type 1 diabetes C) A client taking antibiotics for a urinary tract infection D) A client taking opioids for cancer pain

D) A client taking opioids for cancer pain

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe? A) Inspiratory stridor B) Wheezing in the upper lobes C) Expiratory stridor D) Crackles in the lower lobes

D) Crackles in the lower lobes

Which teaching about the humidifier is important for the nurse to provide to a client using oxygen? A) It determines whether the client is getting enough oxygen. B) It regulates the amount of oxygen received. C) It prescribes oxygen concentration. D) It decreases dry mucous membranes via delivering small water droplets.

D) It decreases dry mucous membranes via delivering small water droplets.

The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign? A) Orthostatic blood pressure B) Urinary intake and output C) Apical pulse D) Respiratory rate and depth

D) Respiratory rate and depth

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 contour of the intercostal spaces should be rounded. C) The anteroposterior diameter should be greater than the transverse diameter. D) The chest should be slightly convex with no sternal depression.

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

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse would cause the charge nurse to intervene? A) The newly hired nurse adjusts the bed to a comfortable working position. B) The newly hired nurse assesses the client's pain and administers pain medication. C) The newly hired nurse explains what she is doing and the reason to the client, even though the client does not appear to be alert. D) The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN).

D) The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN).

A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action? A) Place the probe on the client's earlobe. B) Shine available light on the equipment to facilitate accurate reading. C) Use a blood pressure cuff to increase circulation to the site. D) Warm the client's hands and try again.

D) Warm the client's hands and try again.

The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as: A) hypercapnia. B) orthopnea. C) dyspnea. D) apnea.

D) apnea.

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of: A) croup. B) epiglottitis. C) bronchospasm. D) atelectasis.

D) atelectasis.

The nurse is caring for a client with facial burns who also is prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? A) simple mask B) tracheostomy collar C) nasal cannula D) face tent

D) face tent

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) low pulse rate C) high temperature D) high respiratory rate

D) high respiratory rate

The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? A) face tent B) simple mask C) nasal cannula D) tracheostomy collar

D) tracheostomy collar

A nurse suctioning a client 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? A) suctioning of carbon dioxide B) prevention of suctioning C) loss of sterile field D) trauma to the tracheal mucosa

D) trauma to the tracheal mucosa