NUR FUND + PREP U-Chapter 38: Oxygenation and Perfusion

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

"Breathing through your nose first will warm, filter, and humidify the air you are breathing." Explanation: Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring.

A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response? "Let me teach you about incentive spirometry." "There is very little that can be done for snoring." "Pursed-lip breathing can reduce your amount of snoring." "Have you tried nasal strips?"

"Have you tried nasal strips?" Explanation: Nasal strips are available over the counter and are used to widen the nasal passageways. A common use for nasal strips is to reduce or eliminate snoring.

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? "You will need a prescription for nasal strips." "The nasal diameter is decreased by nasal strips." "Nasal strips may reduce or eliminate snoring." "Those do not work for snoring."

"Nasal strips may reduce or eliminate snoring." Explanation: Nasal strips are available over the counter and are used to widen the nasal passageways. A common use for nasal strips is to reduce or eliminate snoring.

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? "Oxygen is a flammable gas." "You should never smoke when oxygen is in use." "An occasional cigarette will not hurt you." "I understand; I used to be a smoker also."

"You should never smoke when oxygen is in use." Explanation: The nurse will educate the client about the dangers of smoking when oxygen is in use. Oxygen is not flammable, but it oxidizes other materials.

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: "His infection is causing him to breathe harder." "His lung muscles are swollen so he is using abdominal muscles." "He is using his chest muscles to help him breathe." "He will require additional testing to determine the cause."

He is using his chest muscles to help him breathe." Explanation: The client will use accessory muscles to ease dyspnea and improve breathing.

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. False True

True Explanation: This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis.

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 which of the following?

Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol abuse do not lead to atelectasis. Croup is a common condition in young children that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol abuse depresses the central respiratory center.

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? Discontinue oxygen therapy until the client is reassessed by the healthcare provider. Check fit of oxygen mask. Increase the flow of oxygen. Contact the oxygen supplier to request an oxygen tent.

Check fit of oxygen mask. Explanation: The fit of the oxygen mask can be affected by the discontinuation of wearing dentures. The nurse should check the fit to make sure the client is getting the prescribed amount of oxygen. Other answers are inappropriate actions that do not address the problem.

In which client would the nurse assess for a depressed respiratory system? a client taking amlodipine for hypertension a client taking antibiotics for a urinary tract infection a client taking opioids for cancer pain a client taking insulin for diabetes

a client taking opioids for cancer pain Explanation: Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations.

A client with no prior history of respiratory illness has been admitted to a postsurgical 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?

b) Educating the client on the use of incentive spirometry Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.

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: bronchiolitis. bronchitis. bronchiectasis. a bronchospasm.

bronchospasm. Explanation: When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm.

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the 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: blood pH. sodium and potassium levels. age. hemoglobin level.

hemoglobin level. Explanation: Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.

What is the action of codeine when used to treat a cough?

suppressant Explanation: Codeine, which is an ingredient in many cough preparations, is generally considered to be the preferred cough suppressant ingredient.

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which of the following assessment findings is consistent with hypoxia?

Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

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?

Bronchial breath sounds are loud, high-pitched sounds heard primarily over the trachea and larynx. Vesicular breath sounds are low-pitched, soft sounds heard over the peripheral lung fields. Bronchovesicular breath sounds are medium-pitched blowing sounds heard over the major bronchi. Vesicular, bronchial, and bronchovesicular breath sounds are normal breath sounds. Adventitious breath sounds are abnormal lung sounds.

A 55-year-old client visits a health care facility for a scheduled physical assessment. During the assessment, the client complains of difficulty breathing. What suggestion could the nurse make to improve the client's respiratory function in this case? Use a nasal strip. Receive annual immunizations. Drink liberal amounts of fluids. Avoid strenuous exercises.

Drink liberal amounts of fluids. Explanation: The nurse could suggest liberal fluid intake for the client in order to improve respiratory function. Older adults need encouragement to maintain liberal fluid intake, which keeps the mucous membranes moist. Unless contraindicated, the nurse should encourage the client to engage in regular exercise to maintain optimal respiratory function. A nasal strip reduces airflow resistance by widening the nasal breathing passageway, thus promoting easier breathing. An older adult may or may not use a nasal strip to improve respiratory function. The nurse should advise older adults to receive annual influenza immunizations and a pneumonia immunization after 65 years of age or earlier if there is a history of chronic illness.

Which skin disorder is associated with asthma? Psoriasis Seborrhea Abrasions Eczema

Eczema Explanation: The client with asthma often recalls childhood allergies and eczema.

A client with no prior history of respiratory illness has been admitted to a postsurgical 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?

Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.

What structural changes to the respiratory system should a nurse observe when caring for older adults? a) Increased mouth breathing and snoring b) Diminished coughing and gag reflexes c) Increased use of accessory muscles for breathing d) Respiratory muscles becomes weaker

One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker. The nurse should also observe other structural changes: the chest wall becomes stiffer as a result of calcification of the intercostals cartilage, kyphoscoliosis, and arthritic changes to costovertebral joints; the ribs and vertebrae lose calcium; the lungs become smaller and less elastic; alveoli enlarge; and alveolar walls become thinner. Diminished coughing and gag reflexes, increased use of accessory muscles for breathing, and increased mouth breathing and snoring are functional changes to the respiratory system in older adults.

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

Small water droplets come from this, thus preventing dry mucous membranes." Explanation: The humidifier produces small water droplets which are delivered during oxygen administration to prevent or decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen.

The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective? heart rate 110 beats/minute SpO2 92% respirations 26 breaths/minute clubbing of fingers

SpO2 92% Explanation: An SpO2 at or above 90% is normal, reflecting that oxygen therapy is being effective. Clubbing, respirations greater than 26 breaths/minute, and a heart rate greater than 100 beat per minute may indicate that more oxygen is needed.

Upon evaluation of a client's medical history, the nurse recognizes that which of the following conditions may lead to an inadequate supply of oxygen to the tissues of the body? Pancreatitis Chronic anemia Parkinson's disease Graves' disease

The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the amount of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissues of the body. Graves' disease, Parkinson's disease, and pancreatitis do not directly lead to a decrease in the number of red blood cells.

A newly hired nurse is performing a focused respiratory assessment. The nurse mentor will intervene if which action by the newly hired nurse is noted? The newly hired nurse palpates the point of maximal impulse (PMI). The newly hired nurse explains the assessment procedure before performing it. The newly hired nurse attaches a pulse oximetry to the client's index finger. The newly hired nurse auscultates breath sounds as the client breathes through the nose.

The newly hired nurse auscultates breath sounds as the client breathes through the nose. Explanation: Breath sounds should be auscultated while the client breathes slowly through an open mouth; nose breathing may produce false breath sounds. Explanation before procedures helps reduce a client's anxiety. Palpation of the PMI and attaching the pulse oximetry are included in the respiratory assessment.

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client?

The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Non-rebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.

Which actions should a nurse perform when inserting an oropharyngeal airway? Select all that apply. Wash hands and put on PPE, as indicated. Insert the airway with the curved tip pointing down toward the base of the mouth. Rotate the airway 180 degrees as it passes the uvula. Remove airway for a brief period every 4 hours or according to facility policy. Position client flat on his or her back with the head turned to one side. Use an airway that reaches from the nose to the back angle of the jaw.

Wash hands and put on PPE, as indicated. Rotate the airway 180 degrees as it passes the uvula. Remove airway for a brief period every 4 hours or according to facility policy. Explanation: The nurse will come into contact with respiratory secretions during the insertion of the oral airway, making it necessary to wear appropriate PPE. The airway will need to be rotated 180 degrees as it passes the uvula because the airway is more easily inserted with the curved tip pointing up towards the roof of the mouth. The airway should be removed for brief periods every 4 hours (or according to facility policy) to prevent constant pressure on the surrounding structures. The airway should reach from the opening of the mouth to the back angle of the jaw. The client should be positioned in a semi-Fowler's position to ease insertion of the airway.

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula?

a) It can cause the nasal mucosa to dry in case of high flow. When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss.

A nurse is admitting a 6-year-old child status post tonsillectomy to the surgical unit. The nurse obtains his weight and places EKG and a pulse oximeter on the client's left finger. His heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate: diminished stroke volume. high cardiac output. heart failure. adequate tissue perfusion.

adequate tissue perfusion. Explanation: Pulse oximetry is often used as a measure of tissue perfusion. An oxygen saturation of greater than 94% is typically indicative of good tissue perfusion.

A client with chronic obstructive pulmonary disease requires low-flow oxygen. How will the oxygen be administered? Select all that apply.

b) Nasal cannula c) Simple oxygen mask e) Partial rebreather mask Nasal cannula with tubing administers oxygen at low-flow rates and concentrations at 22-44%. Simple masks and partial rebreathers both deliver a low-flow rate at concentrations of 40-60%. Venturi masks mix oxygen with room air and create a high flow of oxygen.

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the 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 ...

b) hemoglobin level Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.

During a routine prenatal care visit, a pregnant woman in her last trimester of pregnancy reports that she has occasional shortness of breath. The nurse instructs her that: a prompt referral for follow up care will be made. breathing becomes increasingly difficult as the diaphragm is displaced. the nurse will assess her lung sounds and determine whether she has pneumonia. a chest x-ray is likely indicated.

breathing becomes increasingly difficult as the diaphragm is displaced. Explanation: During the last weeks of pregnancy, breathing may become increasingly difficult in a supine position because the fetus displaces the diaphragm upward.

During a routine prenatal care visit, a pregnant woman in her last trimester of pregnancy reports that she has occasional shortness of breath. The nurse instructs her that: the nurse will assess her lung sounds and determine whether she has pneumonia. breathing becomes increasingly difficult as the diaphragm is displaced. a chest x-ray is likely indicated. a prompt referral for follow up care will be made.

breathing becomes increasingly difficult as the diaphragm is displaced. Explanation: During the last weeks of pregnancy, breathing may become increasingly difficult in a supine position because the fetus displaces the diaphragm upward.

A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction two 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 what?

c) Atelectasis Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize atelectasis. Immobility is not commonly implicated in cases of pneumothorax or hemothorax. Tachypnea, if present, would likely be a sign of atelectasis rather than an independent finding.

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?

educating the client on the use of incentive spirometry Explanation: Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.

Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate to observe in a client with these arterial blood gas results? increase in the rate of respirations and decrease in the depth increase in rate and depth of respirations decrease in the rate of respirations and increase in depth decrease in rate and depth of respirations

increase in rate and depth of respirations Explanation: The medulla in the brainstem is the respiratory center. The medulla is stimulated by an increased concentration of carbon dioxide and hydrogen ions and, to a lesser degree, by the decreased amount of oxygen in the arterial blood. Stimulation of the medulla increases the rate and depth of ventilation to blow off carbon dioxide and hydrogen and increase oxygen levels. This compensatory mechanism causes the client to breathe faster and more deeply.

The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select? simple mask face tent tracheostomy collar nasal cannula

tracheostomy collar Explanation: A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. Other devices are not appropriate for this client.

The nurse is caring for a client who was 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? face tent nasal cannula tracheostomy collar simple mask

tracheostomy collar Explanation: A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. All other devices are less appropriate for this client.

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? "Take in a small amount of air very quickly and then exhale as quickly as possible." "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling." "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Explanation: Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.

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

"Small water droplets come from this, thus preventing dry mucous membranes." Explanation: The humidifier produces small water droplets which are delivered during oxygen administration to prevent or decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen.

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? They are soft, high-pitched discontinuous (intermittent) popping lung sounds. They are loud, high-pitched sounds heard primarily over the trachea and larynx. They are low-pitched, soft sounds heard over peripheral lung fields. They are medium-pitched blowing sounds heard over the major bronchi.

They are low-pitched, soft sounds heard over peripheral lung fields. Explanation: Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields) bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx) bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response? "That will help the oxygen flow more freely." "That will make it easier to carry with you." "The caregiver will need to place the oxygen tank back into the secure carrier." "Call your oxygen supplier immediately."

"The caregiver will need to place the oxygen tank back into the secure carrier." Explanation: Oxygen tanks are transported on a wheeled carrier to avoid accidental force. Accidental force could cause the tank to explode. The tank should not be carried, and taking it out of the carrier does not affect the flow of oxygen.

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? "Take in a little air, hold your breath 15 seconds, and exhale slowly." "Take in a small amount of air and exhale quickly." "Take in a large volume of air and hold your breath as long as you can." "Take in as much air as possible, hold your breath briefly, and exhale slowly."

"Take in as much air as possible, hold your breath briefly, and exhale slowly." Explanation: This technique maximizes ventilation taking in a large volume of air fills alveoli to a greater capacity, which improves gas exchange. Deep breathing is useful for client's who has been inactive or in pain as associated with pneumonia. The other techniques do not promote improved gas exchange.

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? "Take in a small amount of air and exhale quickly." "Take in a large volume of air and hold your breath as long as you can." "Take in as much air as possible, hold your breath briefly, and exhale slowly." "Take in a little air, hold your breath 15 seconds, and exhale slowly."

"Take in as much air as possible, hold your breath briefly, and exhale slowly." Explanation: This technique maximizes ventilation taking in a large volume of air fills alveoli to a greater capacity, which improves gas exchange. Deep breathing is useful for client's who has been inactive or in pain as associated with pneumonia. The other techniques do not promote improved gas exchange.

The nurse is caring for a client with a nonhealing wound who has been prescribed hyperbaric oxygen therapy (HBOT). When the client asks, "How will this help me?" What is the appropriate nursing response? "Wounds heal because HBOT helps to regenerate new tissue quickly." "You will be treated for decompression sickness." "It will help you breathe much easier, and feel better." "HBOT treats aerobic infections."

"Wounds heal because HBOT helps to regenerate new tissue quickly." Explanation: Although HBOT treats a multitude of conditions, the reason for using HBOT for a nonhealing wound is to help regenerate new tissue quickly. HBOT is used to treat anaerobic infections.

The nurse is caring for a client who is diagnosed with an impaired gas exchange. While performing a physical assessment of the client, which of the following data is the nurse likely to find, keeping in mind the client's diagnosis?

Chronic anemia Explanation: The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the amount of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissues of the body. Graves' disease, Parkinson's disease, and pancreatitis do not directly lead to a decrease in the number of red blood cells. A client diagnosed with an impaired gas exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. The options of high temperature, low pulse rate, and low blood pressure are incorrect; this is because, as a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? Eat smaller meals that are high in protein. Snack on high-carbohydrate foods frequently. Contact the physician for nutrition shake. Eat one large meal at noon.

Eat smaller meals that are high in protein. Explanation: The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength.

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

It regulates the amount of oxygen received. Explanation: The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The oxygen analyzer measures the percentage of delivered oxygen. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.

A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function? Tachypnea Wheezes Pneumonia Pleural effusion

Pleural effusion Explanation: Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis and pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.

A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function? Tachypnea Pleural effusion Wheezes Pneumonia

Pleural effusion Explanation: Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse, if noted by the charge nurse, would cause the charge nurse to intervene? The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). The newly hired nurse assesses the client's pain and administers pain medication. 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. The newly hired nurse adjusts the bed to a comfortable working position.

The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). Explanation: Care of a tracheostomy tube in a stable situation, such as long-term care and other community-based care settings, may be delegated to licensed practical/vocational nurses (LPN/LVN); not in an acute instance. Adjusting the bed to a comfortable working position prevents back and muscle strain. Explanation alleviates fears; even if the client appears unconscious, the nurse should explain what is happening. When tracheostomy is new, pain medication may be needed before performing tracheostomy care.

While examining a client, the nurse palpates the client's chest and back. Which of the following would the nurse expect to identify with this technique?

The nurse can assess patterns of thoracic expansion through palpation. Fluid-filled and consolidated portions of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation.

A nurse is admitting a 6-year-old child status post tonsillectomy to the surgical unit. The nurse obtains his weight and places EKG and a pulse oximeter on the client's left finger. His heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate: heart failure. diminished stroke volume. high cardiac output. adequate tissue perfusion.

adequate tissue perfusion. Explanation: Pulse oximetry is often used as a measure of tissue perfusion. An oxygen saturation of greater than 94% is typically indicative of good tissue perfusion.

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

atelectasis. Explanation: Stiffer lungs tend to collapse and also cause their alveoli to collapse. This condition is called atelectasis.

During oxygen administration to the client, which of the following pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

b) Flow meter In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. A humidifier is a device that produces small water droplets and may be used during oxygen administration, since oxygen dries the mucous membranes. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen.

The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal? vesicular breath sounds audible over peripheral lung fields fine crackles to the bases of the lungs bilaterally resonance on percussion of lung fields respiratory rate of 18 breaths per minute

fine crackles to the bases of the lungs bilaterally Explanation: Except in the case of infants, fine crackles always constitute an abnormal assessment finding. A respiratory rate of 18 is within acceptable range. Vesicular sounds over peripheral lung fields and resonance on percussion are expected assessment findings.