NSG 1520 CHAPTER 39
A client taking opioids for cancer pain
In which client should the nurse prioritize the assessments for respiratory depression?
A client taking opioids for cancer pain.
In which client would the nurse assess for a depressed respiratory system?
Hypoxia
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 are causing these respiratory alterations?
Clubbing
The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?
High Respiratory Rate
The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment, which data is the nurse likely to find, keeping in mind the client's diagnosis?
Check the fit of the oxygen mask.
The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate?
"Breathing through your nose first will warm, filter, and humidify the air you are breathing."
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?
Remove nail polish and access circulation, assess mental status, auscultate lungs, and use alternate site: earlobe or bridge of nose
The nurse prepares to apply the pulse oximeter to the client's hand. The fingers are edematous, cool to touch, and have black nail polish. Which actions should the nurse take? Select all that apply.
Rapid respirations
When reviewing data collection on a client client it's a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom?
Corticosteroids
Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?
Pleural Effusion
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?
Dyspnea
A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient?
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. T of F.
Hold the mask tightly over the patient's nose and mouth.
An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure?
Pulse oximetry
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 l?
Remove the catheter
A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence?
A Bronchospasm
A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:
Put on gloves and insert the chest tube in a bottle of sterile saline
A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation?
1) Reduce anxiety, 2) Eat a high-protein/high-calorie diet, 3) Maintain a high-Fowler's position when possible.
A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply.
Stay indoors as much as possible.
The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care?
Checking the amount of oxygen in the cylinder before using it.
What action does the nurse perform to follow safe technique when using a portable oxygen in the cylinder?
"He is using his chest muscles to help him breathe."
A child is admitted to the pediatric division with an acute asthma attack. The nurse assessed the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach?" The nurses most accurate response is:
Flow meter
A client has been put on oxygen therapy because of low level oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?
Congestive heart failure
A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:
"You should never smoke when oxygen is in use."
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?
Ask the client what factors contribute to nonadherence.
A client who was prescribed CPAP reports nonadherence to treatment. Which is the priority nursing intervention?
Nasal Cannula
A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?
Educating the client on the use of incentive spirometry
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?
Ambu bag
A nurse assessing a clients respiratory effort notes that the clients breaths are shallow and 8 per minute. Shortly after, the clients respiration's cease. Which form of oxygen delivery should the nurse use for this client?
Vesicular
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?
Diffusion
Oxygen and carbon dioxide move between the alveoli and the blood by:
Flow meter set at 5 liters of oxygen
The home health nurse arrived at a clients home and immediately noted the client is experiencing increased dyspnea. The client has a 7-year history of COPD. Which assessment finding should the nurse prioritize?
Clubbing fingers
The nurse assessing a client with COPD suspects chronic hypoxia based on which assessment finding?
Crackles
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as:
Apnea
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 the his condition as:
They are low-pitched, soft sounds heard over peripheral lung fields.
The nurse is auscultation the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?
Poor tissue perfusion
When a nurse observes that an older clients skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing:
Eat smaller meals that are high in protein.
Which dietary guideline would be appropriate for the older adult home bound client with advanced respiratory disease who informs the nurse that she has no energy to eat?
Nasal Cannula
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?
Croup
A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from:
Nasal Cannula
The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2L/min. What delivery device will the nurse select to apply oxygen to the client?
Adequate tissue perfusion
A nurse admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the clients weight and places EKG leads on the chest and a pulse oximeter on the left finger. The clients heart rate reads 100bpm and the pulse oximeter reads 99%. These readings best indicate:
A teenager with cystic fibrosis
A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended?
Pulse oximetry
A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation?
The nurse encourages the patient to breathe through the nose with the mouth closed.
A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. Which nursing action is performed correctly?
The size of the endotracheal tube
A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter?
Remove the tape, adjust the depth to ordered depth and reapply the tape.
A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident?
A nosebleed is noted with continued suctioning.
A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for nasal trumpet?
1) "I will continue to inhale with the cold propellant is in my throat," 2) "I will only inhale one spray with one breath," 3) "I will activate the device while continuing to inhale."
A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply.
Group personal care activities into smaller steps, allowing rest periods between activities.
A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient?
Tracheostomy Collar
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?
Ensure that the oxygen concentrator is turned on, confirm that the nasal cannula is worn properly by the client, verify the oxygen concentrator is set on the prescribed flow rate.
The nurse is caring for a client with emphysema who has been prescribed portable oxygen, 2L/min. Which action(s) does the nurse take to administer low concentrations of oxygen to the client? Select all that apply.
Respiratory rate and depth
The nurse is caring for a postoperative client who has a prescription for meperidine 75mg IM every 4 hours as needed for pain. Before administering meperidine, the nurse would assess which most important sign?
1) closely assess the patient before, during, and after the procedure. 2) Hyperoxygenate the patient before and after suctioning. 3) Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. 4) Use an appropriate suction pressure.
Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply.
Using a suction catheter with cm increments on it, insert the suction catheter into the endotracheal tube until the cm markings on both align, and insert the suction catheter no further than an additional 1cm.
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?
Pattern of thoracic expansion.
While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique?
