Prep-U Chapter 39: Oxygenation and Perfusion

A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action? A.) Encourage the client to do deep-breathing exercises. B.) Raise the head of the client's bed slightly, if tolerated. C.) Review the medications that the client has taken in the past 90 minutes. D.) Document this expected assessment finding.

Answer: D.) Document this expected assessment finding.

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

Answer: D.) Pulmonary function tests

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? A.) Cut down on smoking. B.) Avoid exposure to large crowds. C.) Practice good hand hygiene. D.) Stay indoors as much as possible.

Answer: D.) Stay indoors as much as possible.

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: A.) atelectasis. B.) pulmonary fibrosis. C.) asthma. D.) croup.

Answer: D.) croup.

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: A.) a bronchospasm. B.) bronchitis. C.) bronchiectasis. D.) bronchiolitis.

Answer: A.) a bronchospasm.

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered? A.) nasal cannula B.) simple oxygen mask C.) Venturi mask D.) partial rebreather mask

Answer: A.) nasal cannula

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? A.) Snack on high-carbohydrate foods frequently. B.) Eat smaller meals that are high in protein. C.) Contact the physician for nutrition shake. D.) Eat one large meal at noon.

Answer: B.) Eat smaller meals that are high in protein. Rationale: 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.

The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier? A.) tap water B.) normal saline C.) distilled water D.) mineral oil

Answer: C.) distilled water

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 antibiotics for a urinary tract infection C.) A client taking insulin for type 1 diabetes D.) A client taking opioids for cancer pain

Answer: D.) A client taking opioids for cancer pain

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

Answer: D.) Check the fit of the oxygen mask. Rationale: 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.

The nurse prepares the client for a 12-lead electrocardiogram (ECG). Which actions should the nurse provide? Select all that apply. - Instruct the client to relax arms away from waist and legs not touching the footboard. - Prepare skin, removing excess oil and clip areas of excessive hair. - Lead cables should be taut to improve the quality and accuracy of the ECG. - Place self-stick electrodes and place according to anatomical locations. - Explain that the client needs to lie still and not talk during the ECG recording.

Answer: - Instruct the client to relax arms away from waist and legs not touching the footboard. - Prepare skin, removing excess oil and clip areas of excessive hair. - Place self-stick electrodes and place according to anatomical locations. - Explain that the client needs to lie still and not talk during the ECG recording.

A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs? A.) Nasal cannula B.) Simple mask C.) Partial rebreather mask D.) Nonrebreather mask

Answer: A.) Nasal cannula

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.) Pleural effusion B.) Tachypnea C.) Wheezes D.) Pneumonia

Answer: A.) Pleural effusion Rationale: 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.

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? A.) Remove the airway, turn the client to the side, and provide mouth suction, if necessary. B.) Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. C.) Leave the airway in place and promptly notify the health care provider for further instructions. D.) Suction the client's mouth through the oropharyngeal airway to prevent aspiration.

Answer: A.) Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Rationale: If the client vomits as the oropharyngeal airway is inserted, quickly position the client onto his or her side to prevent aspiration, remove the oral airway, and suction the mouth, if needed. It would be inappropriate and unsafe to leave the airway in place. Rinsing the client's mouth with water is not a priority.

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.) educating the client on the use of incentive spirometry B.) educating the client on pursed-lip breathing techniques C.) oropharyngeal suctioning twice daily D.) administration of inhaled corticosteroids

Answer: A.) educating the client on the use of incentive spirometry

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? A.) fine crackles to the bases of the lungs bilaterally B.) respiratory rate of 18 breaths per minute C.) resonance on percussion of lung fields D.) vesicular breath sounds audible over peripheral lung fields

Answer: A.) fine crackles to the bases of the lungs bilaterally

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.) hemoglobin level. B.) age. C.) blood pH. D.) sodium and potassium levels.

Answer: A.) hemoglobin level.

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.) thoracentesis C.) spirometry D.) peak expiratory flow rate

Answer: A.) pulse oximetry

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

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

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

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

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

Answer: B.) "You should never smoke when oxygen is in use."

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.) "Your chest diameter has increased as the musculature has matured in an effort to obtain increased amounts of oxygen." B.) "Your lung condition limits the ability of the lungs to fully exhale, causing this change in shape." C.) "Chronic lung conditions such as this are associated with fluid retention in the lower lung fields, causing the change in the chest shape." D.) "The corticosteroids prescribed to manage the condition have caused a change in the shape of the chest wall."

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

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? A.) Inhale through the nose instead of the mouth. B.) Be sure to shake the canister before using it. C.) Inhale the medication rapidly. D.) Inhale two sprays with one breath for faster action.

Answer: B.) Be sure to shake the canister before using it.

A nurse is reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would the nurse most likely identify as an effect of exposure to automobile pollutants? A.) Atelectasis B.) Bronchitis C.) Bronchiectasis D.) Croup

Answer: B.) Bronchitis Rationale: Bronchitis refers to a condition in which the airways become inflamed, commonly due to respiratory irritants such as air pollution and high humidity. Exposure to such irritants leads to the release of inflammatory mediators, which in turn, lead to inflammation and narrowing of the airways and increased mucus production. Atelectasis refers to the partial or complete collapse of the small air sacs in the lungs, common after surgery or with obstruction or compression of the airways or lungs. Bronchiectasis results from chronic inflammation or infection causing an excess accumulation of mucus. Croup is an infection of the airways, most commonly viral in origin.

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

Answer: B.) 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.) simple mask B.) tracheostomy collar C.) nasal cannula D.) face tent

Answer: B.) tracheostomy collar

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.) Oxygen mask B.) Nasal cannula C.) Ambu bag D.) Oxygen tent

Answer: C.) Ambu bag

A nurse is conducting a physical assessment of a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the client's oxygenation. What instruction should the nurse give the client? A.) Expand the thoracic cavity. B.) Relax the respiratory muscles. C.) Contract the abdominal muscles. D.) Elevate the ribs and sternum.

Answer: C.) Contract the abdominal muscles.

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? A.) This medication may cause drowsiness and should be used with caution while driving. B.) Increase sodium intake while taking this medication. C.) Monitor blood pressure and blood sugar. D.) Weigh yourself each night prior to going to bed.

Answer: C.) Monitor blood pressure and blood sugar.

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.) Apical pulse B.) Orthostatic blood pressure C.) Respiratory rate and depth D.) Urinary intake and output

Answer: C.) Respiratory rate and depth rationale: The client receiving narcotics/opioids needs monitoring of the respiratory rate and depth to ensure that respiratory depression does not result in progressive respiratory issues, physiologic damage from respiratory depression, or loss of consciousness. The pulse, blood pressure, and urinary intake and output are not as important as respiratory status when administering narcotics.

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 low-pitched, soft sounds heard over peripheral lung fields. D.) They are soft, high-pitched discontinuous (intermittent) popping lung sounds.

Answer: C.) They are low-pitched, soft sounds heard over peripheral lung fields.