Prep U | Oxygenation and Perfusion

A nurse is preparing to use a wall unit to suction the endotracheal tube of a 9-year-old child. At what pressure should the suction be set?

80 to 125 mm Hg For a wall unit for an adult: 100 to 150 mm Hg; neonates: 60 to 80 mm Hg; infants: 80 to 125 mm Hg; children: 80 to 125 mm Hg; adolescents: 80 to 150 mm Hg.

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings? 58 mm Hg 45 mm Hg 120 mm Hg 84 mm Hg

84 mm Hg

A nurse understands that a safe but low level of oxygen saturation provides for adequate tissue saturation while allowing no reserve for situations that threaten ventilation. What is a safe but low oxygen saturation level for a patient? 95% 75% 80% 40%

95%

A nurse is volunteering at a daycamp. A child is stung by a bee in develops wheezing in the upper airways. The child is experiencing

A bronchospasm

The nurse that's up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system

A child with pneumonia

In which client should the nurse prioritize assessments for respiratory depression?

A client taking opioids for cancer pain

Of all factors, what is the most important risk factor in pulmonary disease?

Active and passive cigarette smoke

The nurse is caring for a 70-year-old client with COPD. Which vaccine will the nurse offer the client?

All clients over 65 years old or anyone with a compromising chronic health condition should be offered Prevnar 13 ®. This vaccine is effective in reducing 13 strains of streptococcal pnuemoniae.

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?

Although HBOT treats a multitude of conditions, the reason for using HBOT for a nonhealing wound is to help regenerate new tissue quickly.

The nurse is caring for a 3-year-old client who experienced smoke inhalation during a house fire, and now requires oxygen. What delivery device will the nurse select that is most appropriate for this client?

An oxygen tent is often used when caring for active toddlers who require oxygen, since they are less likely to keep a mask on.

A client is experiencing hypoxia. Which of the following nursing diagnoses would be appropriate?

Anxiety

A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first?

Apply oxygen

What does pulse oximetry measure?

Arterial oxygen saturation

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?

Ask the client what factors contribute to nonadherence.

Which of the following is a potential complication of a low pressure in the endotracheal tube (ET) cuff?

Aspiration pneumonia

The nurse is caring for a client receiving oxygen therapy via nasal canal. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take

Assess oxygen tubing connection

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

Be sure to shake the canister before using it.

The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation? Blood gases Serum alkaline phosphate Blood chemistry Complete blood count

Blood gases

What category of medications may be administered by nebulizer or metered-dose inhaler to open narrowed airways?

Bronchodilators

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?

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.

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?

Check fit of 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?

Check the fit of the oxygen mask

The nurse is caring for a patient following a thoracotomy. Which of the following findings requires immediate intervention by the nurse? Heart rate: 112 bpm Moderate amounts of colorless sputum Pain of 5 on a 1 to 10 pain scale Chest tube drainage of 190 mL/hr

Chest tube drainage of 190 mL/hr

It is a red air-quality day in the city. This means the air is stagnant, with high pollution levels and high humidity. Which client is most likely to experience shortness of breath?

Child with asthma

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

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 assessment finding is consistent with hypoxia?

Confusion

Mr. Parks has chronic obstructive pulmonary disease. 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

The nurse enters the room of a client who is being monitored with pulse oximetry. Which of the following factors may alter the oximetry results? Reduced lighting in the room Increased temperature of the room Diagnosis of peripheral vascular disease Placement of the probe on an earlobe

Diagnosis of peripheral vascular disease

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?

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?

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. 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 skin disorder is associated with asthma?

Eczema

which skin disorder is associated with asthma

Eczema

Which of the following diseases may result in decreased lung compliance?

Emphysema

Question 5 of 10 A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply. Fatigue Dyspnea Substernal pain Mood swings Bradycardia SUBMIT ANSWER Exit quiz

Fatigue Dyspnea Substernal pain

The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment findings should the nurse interpret as abnormal?

Fine crackles to the base of the lungs bilaterally

A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion? Chest x-ray Fluoroscopy Magnetic resonance imaging (MRI) Computed tomography (CT) scan

Fluoroscopy

Forced expiratory volume

Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea?

High Fowler's position

Which type of oxygen therapy includes the administration of oxygen at pressure greater than 1 atmosphere? High-flow systems Transtracheal Hyperbaric Low-flow systems

Hyperbaric

The nurse is caring for a client receiving oxygen therapy via nasal cannula who suddenly becomes cyanotic with a pulse oximetry reading of 91%. Which is the next most appropriate action the nurse should take?

If the client suddenly becomes cyanotic, the nurse should assess the oxygen tubing to make sure it is still connected.

Incentive spirometry

Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions.

Which of the following would indicate a decrease in pressure with mechanical ventilation? Plugged airway tube Kinked tubing Increase in compliance Decrease in lung compliance

Increase in compliance

A nurse is conducting a health promotion program for adolescents to educate them about the hazards of smoking. When describing the effects on the respiratory system, which of the following would the nurse most likely include?

Inhibition of mucus removal

Which teaching about the humidifier is important for the nurse to provide to a client using oxygen?

It decreases dry mucous membranes via delivering small water droplets.

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?

It determines whether the client is getting enough oxygen

Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen?

It regulates the amount of oxygen received.

client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following? Respiratory rate is 12 to 18 breaths per minute. Client reports no chest pain. Lungs are clear on auscultation . Client can perform incentive spirometry.

Lungs are clear on auscultation

What supplies are needed for chest tube removal?

Mask, sterile gloves, suture removal kit, petroleum gauze, dry gauze, tape, hazardous waste bag, and disposable pad

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?

Nasal cannula

Which is a sign of dyspnea specific to infants?

Nasal flaring

What structural changes to the respiratory system should a nurse observe when caring for older adults?

One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker.

Perfusion

Perfusion refers to the process by which oxygenated capillary blood passes through body tissues.

A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse? Lung infarction Pleurisy Bronchogenic carcinoma Bacterial pneumonia

Pleurisy

When a nurse observes that an older client skin is dry and shiny and his nails are thickened, the nurses terms of the client is most likely experiencing

Poor tissue perfusion

While auscultating a client's chest, the nurse auscultates crackles in the lower lung bases. What condition does the nurse identify the client is experiencing?

Presence of sputum in the trachea

A 53-year-old client sees the physician because he has had laryngitis for 2 weeks. After a thorough examination, the doctor orders medications and instructs the client to follow-up in 1 week if his voice has not improved. What is the primary function of the larynx? Producing sound Facilitating coughing Preventing infection Protecting the lower airway from foreign objects

Producing sound

A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?

Prolonging expiration to reduce airway resistance

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). In what position does the nurse place the client in order to promote adequate oxygenation?

Prone

Which diagnostic procedure measures long size in airway patency, producing graphic representations of lung volumes and flows

Pulmonary function tests

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?

Pulmonary function tests

The nurse working on the intensive care unit is preparing to admit a client injured in a car accident. The client has damage to the medulla. The nurse would include which most important equipment when preparing to care for this client? Select all that apply.

Pulse oximeter Endotracheal tube

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:

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 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?

Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients.

Pulse oximetry

Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients.

Pursed-lip breathing primarily

Pursed-lip breathing primarily addresses dyspnea and anxiety

The nurse is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly?

Reads 0.21 when checking oxygen in room air

97% oxygen is carried by

Red blood cells (hemoglobin)

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the mostappropriate intervention in this situation?

Remove the airway, turn the client to the side, and provide mouth suction, if necessary.

A nurse is delivering oxygen to a client via an oxygen mask. Which of the following is a recommended guideline for this procedure?

Remove the mask and dry the skin every two to three hours if the oxygen is running continuously.

The nurse schedules a pulmonary function test to measure the amount of air left in a clients lungs at maximal expiration. What test does the nurse order?

Residual volume (RV)

The nurse is caring for a client with a chest to. Which assessment finding indicates that she was functioning correctly?

Respirations are at 20 breaths per minute

In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to which of the following acid-base imbalances?

Respiratory acidosis

What structural changes to the respiratory system should a nurse observe when caring for older adults?

Respiratory muscles become weaker

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?

Respiratory rate and depth

In which position should the client be placed for a thoracentesis?

Sitting on the edge of the bed

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?

SpO2 92%

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? clubbing of fingers respirations 26 breaths/minute heart rate 110 beats/minute SpO2 92%

SpO2 92%

A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first? Suction the client, withdraw residual air from the cuff, and reinflate it. Remove the malfunctioning cuff. Add more air to the cuff. Call the physician.

Suction the client, withdraw residual air from the cuff, and reinflate it.

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for: Symmetry of the client's chest expansion A scheduled time for deflation of the tracheal cuff Tracheal cuff pressure set at 30 mm Hg Cool air humidified through the tube

Symmetry of the client's chest expansion

The nurse provides care for a client with chronic bronchitis and a decrease in oxygen saturation. Which factors, if assess, indicate a deteriorating condition? Select all that apply.

Tachypnea Tachycardia Shortness of breath Wheezing and crackles in lungs

A physician prescribes the use of water-seal chest tube drainage for a client at a health care facility. What should the nurse ensure when using the water-seal chest tube drainage?

The chest tube should not be separated from the drainage system unless clamped.

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?

The client with chronic lung disease, such as emphysema, becomes insensitive to carbon dioxide and responds to hypoxia to stimulate breathing. If given excessive oxygen (4 L/minute), the stimulus to breathe is removed.

A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate?

The client's available hemoglobin is adequately saturated with oxygen.

A nurse takes a clients pulse oximetry reading and find that is normal. What does this finding indicate

The clients available hemoglobin is adequately saturated with oxygen

The nurse is demonstrating oxygen administration to a client. What teaching will the nurse include about the flowmeter?

The flowmeter is a gauge used to regulate the amount of oxygen that a client receives.

The nurse is assessing the respiratory rates of clients in a community health care facility. Which client exhibits an abnormal value?

The infant's normal respiratory rate is 30 to 55 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 40 breaths per minute. For a child 6 to 12 years of age the normal respiratory rate is 18 to 26 breaths per minute. The normal respiratory rate for an adult 65 years and older is 16 to 24 breaths per minute.

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? The newly hired nurse adjusts the bed to a comfortable working position. 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 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 delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN).

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

The nurse can assess patterns of thoracic expansion through palpation.

The nurse educator would intervene with client teaching if which action by the staff nurse occurs when teaching voluntary coughing?

The nurse has the client lying in bed in semi Fowler's position

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?

The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment.

The pharynx, mouth, and nose are major organs of the upper respiratory tract.

The pharynx, mouth, and nose are major organs of the upper respiratory tract.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? The system is functioning normally. The system has an air leak. The chest tube is obstructed. The client has a pneumothorax.

The system has an air leak.

vesicular breath sounds

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

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?

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.

Toddlers and preschoolers have a respiratory rate

Toddlers and preschoolers have a respiratory rate of 20 to 30 per minute.

Which of the following alveolar cells secrete surfactant? Type I Type IV Type III Type II

Type II

What is the difference between respiration and ventilation? Ventilation is the process of getting oxygen to the cells. Ventilation is the exchange of gases in the lung. Ventilation is the movement of air in and out of the respiratory tract. Ventilation is the process of gas exchange.

Ventilation is the movement of air in and out of the respiratory tract.

The nursing instructor is teaching a pre-nursing pathophysiology class. The class is covering the respiratory system. The instructor explains that the respiratory system is comprised of both the upper and lower respiratory system. The nose is part of the upper respiratory system. The instructor continues to explain that the nasal cavities have a vascular and ciliated mucous lining. What is the purpose of the vascular and ciliated mucous lining of the nasal cavities? Warm and humidify inspired air Move mucus to the back of the throat Cool and dry expired air Moisten and filter expired air

Warm and humidify inspired air

While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following? Pleural friction rub Crackles Rhonchi Wheezes

Wheezes

The nurse auscultates The Longs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding says the nurse expect to document?

Wheezing

Which scenario describes how carbon dioxide levels determine the frequency and depth of ventilation?

When carbon dioxide levels in the blood increase, chemoreceptors are stimulated, causing deeper and more rapid breathing.

Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway?

When holding the airway on the side of the client's face, it should reach from the tragus of the ear to the tip of the nostril.

Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway?

When holding the airway on the side of the clients face, it should reach from the tragus of the ear to the tip of the nostril

With decreased cardiac output,

With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion

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 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:

a bronchospasm.

In which client would the nurse assess for a depressed respiratory system?

a client taking opioids for cancer pain

Funnel chest occurs when

a depression occurs in the lower portion of the sternum, which may result in murmurs.

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: adequate tissue perfusion. diminished stroke volume. high cardiac output. heart failure.

adequate tissue perfusion

A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:

adequate tissue perfusion.

What respiratory organ is the site of gas exchange?

alveoli

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

atelectasis

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

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

atelectasis.

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.

are loud, high-pitched sounds heard over the trachea and larynx.

bronchial

What assessments would a nurse make when auscultating the lungs?

cardiovascular function

pulmonary embolism

clot or other material lodges in vessels of the lung

atelectasis

collapsed lung

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

confusion

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:

congestive heart failure.

What is a symptom of poor perfusion?

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?

decreases the amount of air trapping and resistance

During the physical assessment of a client who has been inactive due to a leg injury, the nurse notes that the client tends to breathe very shallowly. What technique should the nurse teach the client in order to breathe more efficiently?

deep breathing

cellulitis

diffuse, acute infection of the skin marked by local heat, redness, pain, and swelling

Oxygen and carbon dioxide move between the alveoli and the blood by: osmosis. hyperosmolar pressure. diffusion. negative pressure.

diffusion

Oxygen and carbon dioxide move between the alveoli and the blood by:

diffusion.

Kyphoscoliosis is characterized by

elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax.

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

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:

hemoglobin level

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?

high respiratory rate

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?

high-Fowler's position

The nurse is delegating hygiene care to the UAP for a client with hypoxia. What position will the nurse tell the UAP to place the client in?

high-flowers

The nurse is listening to the client's lungs and hears them fill with air and then return to a resting position. How will the nurse document this assessment data?

inspiration and expiration

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 and the diaphragm is moving downward, and ribs are moving upward

Biot's respiration

is characterized by periods of normal breathing (3 to 4 breaths) followed by a varying period of apnea (usually 10 to 60 seconds).

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?

nasal cannula

If the chest tube falls out, what supplies will you need to use?

petroleum gauze and a sterile 4x4

orthopena

placed in a high Fowler's position to facilitate breathing

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing

poor tissue perfusion

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?

pulse oximetry

The nurse is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly?

reads 0.21 when checking oxygen in room air

Total volume

refers to the total amount of air inhaled and exhaled with one breath.

what allows the administration of higher levels of oxygen than a cannula for a short period of time

simple mask

MRI can visualize .

soft tissues, characterize nodules, and help stage carcinomas.

Crackles

soft, high-pitched, discontinuous popping sounds that occur during inspiration.

If the chest tube is disconnected, what do you need?

sterile water

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

suppressant

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.

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?

tracheostomy collar

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?

tracheostomy collar

Wheezes are continuous, musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions or tumors

true

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?

vesicular

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?

wheezing

What is atelectasis?

when the alveoli shut down

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?

" I can assist you to the bathroom and back to bed"

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output?

" if the clients stroke volume is 50 ML in the heart rate is 50 bpm, when the cardiac output is 2.5 L/minute."

The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?

"An electric stove may be a safer choice for you."

The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?

"And electric stove may be a safer choice for you"

A father of a preschool-age child tells the nurse that his child "has had a constant cold since going to daycare." How would the nurse respond?

"Children in daycare have more exposure to colds."

An older adult client was recently placed on home oxygen. The client's caregiver reports that the client now refuses to leave the house. What teaching will the nurse provide the caregiver? Select all that apply.

"Continued socialization with others is important." "Discuss with the client switching to a portable oxygen device." "Invite friends and family to the client's house."

A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response?

"Have you tried nasal strips?"

The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated. "I have been coughing all morning and am barely bringing anything up." "I just changed into my running suit; we can do my CPT now." "I just finished eating my lunch, I'm ready for my CPT now." "I received my pain medication 10 minutes ago, let's do my CPT now."

"I just finished eating my lunch, I'm ready for my CPT now."

The nurse is instructing the client on the normal sensations, which can occur when contrast medium is infused during pulmonary angiography. Which statement, made by the client, demonstrates an understanding? "I will feel warm and an urge to cough." "I will feel a dull pain when the catheter is introduced." "I will feel waves of nausea throughout the procedure." "I will feel light-headed when the contrast medium is introduced."

"I will feel warm and an urge to cough."

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output?

"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute." (Cardiac Output = Stroke Volume x Heart Rate).

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 55 breaths/minute

A nurse is delivering 3 L a minute oxygen to a client via nasal canal. What percentage of delivered oxygen is the client receiving?

32%

A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving?

32%

The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner?

8 L/min oxygen via nasal cannula

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?

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

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

"Nasal strips may reduce or eliminate snoring."

A client with chronic obstructive pulmonary disease (COPD) reports severe shortness of breath when it is raining. The nurse says to the client:

"The air is thicker or more viscous with humidity, thus it is harder for you to breathe."

What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home?

"You will be asked to forcefully exhale into a mouthpiece."

The nurse is reviewing the results of a client's arterial blood gas and pH analysis. Which findings indicate to the nurse that intervention is not required? Select all that apply.

* pH 7.45 * PCO2 40 mm Hg * Base excess or deficit +2 mmol/L

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:

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

A nurse assesses the vital signs of a healthy newborn infant. What respiratory rate suggest a need for further assessment and possible interventions? Select all that apply.

20 breaths per minute 65 breaths per minute 80 breaths per minute

Normal cardiac output averages from

3.5 L/minute to 8.0 L/minute.

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

32%

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment?

5,850 mL (5,850 × 109/L)

The nurse is providing an educational demonstration to an older, postsurgical client. The intervention is intended to minimize the effect of what age-related change specifically relevant to such a client?

A decrease in ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs

Which individual is at greater risk for respiratory illnesses from environmental causes?

A factory worker in a large city

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?

Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH

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

Ask the client what factors contribute to nonadherence.

A client 57 years of age is recovering in the hospital following a bilateral mastectomy in breast reconstruction two days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurses education on the benefits of early mobilization following surgery. The nurse would recognize that the clients prolonged immobility creates a risk for

Atelectasis

Upon ask elation of the clients lungs, the nurse hears loud, high-pitched sounds over the larynx. Which term will the nurse use in documentation to describe his breath sound?

Bronchial

What finding by the nurse may indicate that the patient has chronic hypoxia? Peripheral edema Clubbing of the fingers Crackles Cyanosis

Clubbing of the fingers

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

Congestive heart failure

Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system? Select all that apply.

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

The nurse is applying a pulse oximeter to a client with bronchitis. Which factor does the nurse communicate to the client that could interfere with accurate pulse oximetry? Select all that apply.

-peripheral vascular disease -acrylic nails -thickness of nails -nail polish

School-age children and adolescents have a respiratory rate

. School-age children and adolescents have a respiratory rate of 12 to 20 breaths per minute

Erin is a 35-year-old woman being cared for in the emergency department for a cough and hemoptysis for 3 days. Erin states that she has smoked one-and-a-half packs of cigarettes per day for the last 5 years. In trying to identify risk factors for Erin, the nurse calculates her pack-year history to write on the intake form. What is Erin's pack-year of smoking? 5 7.5 5.5 7

7.5 1.5 X 5

What prevents air from re-entering the pleural space when chest tubes are inserted?

A closed water-seal drainage system

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines?

A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly.

Constant bubbling in the water seal of a chest drainage system indicates which of the following problems? Tidaling Increased drainage Air leak Tension pneumothorax

Air leak

The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what did you or the nurse provide?

An electric stove may be a safer choice for you

Upon evaluation of clients medical history, the nurse recognizes that which condition may lead to an in adequate supply of oxygen to the tissues of the body

Chronic anemia

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?

Clubbing

The pediatric nurse is instructing parents on safety when caring for toddlers and preschoolers. Which of the following teaching interventions is appropriate for this age group?

Cut a hotdog in half, then pieces

Oxygen and carbon dioxide move between the alveoli and the blood by

Diffusion

The nurse is assessing a client with a chest tube that has been inserted after experiencing blunt trauma that resulted in a pneumothorax. What nursing action is appropriate when constant bubbling is noted in the suction control chamber?

Document the finding.

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

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

Eat smaller meals that are high in protein

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather?

Face tent

The nurse is delegating hygiene care to the UAP for a client with hypoxia. What position will the nurse tell the UAP to place the client in?

High Fowlers position allows the client with hypoxia to breathe easier by promoting lung expansion, as the abdominal organs descend away from the diaphragm.

A nurse is caring for a client who suddenly begins to have respiratory difficulty. In what position would the nurse place the client to facilitate respirations?

High-Fowler's

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea?

High-Fowler's position

bronchovesicular

Medium-pitched blowing sounds heard over the major bronchi

What needs to be by the bedside of the patient at all times when they have a chest tube?

Sterile water, petroleum gauze, sterile 4x4, and a clamp

When caring for a client with a tracheotomy , the nurse would perform which recommended action?

Suction the tracheostomy tube using the sterile technique

Suctioning

Suctioning is only indicated when clients are unable to independently mobilize secretions.

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority? Medication allergies Ability to deep breathe Swallow reflex Presence of carotid pulse

Swallow reflex The physician sprays a local anesthetic into the client's throat before performing a bronchoscopy. The nurse must assess the swallow reflex when the client returns to the unit and before giving him anything by mouth. The nurse should also assess for medication allergies, carotid pulse, and deep breathing, but they aren't the priority at this time.

The trachea, bronchi, and lungs are major organs of the lower respiratory tract.

The trachea, bronchi, and lungs are major organs of the lower respiratory tract.

Tidal volume

Tidal volume refers to the total amount of air inhaled and exhaled with one breath

What can be done to prevent air leaks from happening?

Use zip ties to prevent accidental disconnection

purpose of the vascular and ciliated mucous lining of the nasal cavities?

Warm and humidify inspired air

what is used for clients with facial trauma and burns when administrating oxygen

a face tent

Fine crackles

are associated with pulmonary fibrosis.

Crackles

are secondary to fluid in the airways or alveoli or to delayed opening of collapsed alveoli.

barrel chest occurs .

as a result of over inflation of the lungs

pulmonary edema

crackles in the lung base

The nurse is preparing to provide hygiene care to a client with hypoxia. Into what position will the nurse place the client?

high Fowlers

what should be used for clients when administarting oxygen requiring a high concentration of oxygen and who are critically ill.

non-rebreather mask

How can a nurse reduce pain during chest tube placement or removal?

premedicate the patient and allow for adequate time for the drug to take effect

Wheezes

usually heard on expiration, are continuous, musical, high pitched, and whistle-like sounds caused by air passing through narrowed airways. Often, wheezes are associated with asthma

The nurse working in the intensive care unit is preparing to admit a client from the emergency department that had a stroke located in the medulla. What equipment should the nurse have present in the room upon the client's arrival into the unit related to the client's condition? Select all that apply.

*Pulse oximeter *Ventilator

How many liters of oxygen can a nurse administer before getting an order

2

A client who was prescribed CPAP reports nonadherence to treatment. What is the prioritynursing intervention?

Ask the client what factors contribute to nonadherence.

Where is the most common point for air leaks?

At the point where the distal end of the tube connects to the drainage device tubing

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?

Check the fit of the oxygen mask.

The nurse assessing a client with chronic obstructive pulmonary disease suspects chronic hypoxia based on which assessment finding

Clubbing fingers

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium? Urge to cough Difficulty in breathing Absent distal pulses Hematoma

Difficulty in breathing

An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur?

Inspiration and expiration

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use?

Nonrebreather mask

When assessing a client, which adaptation indicates the presence of respiratory distress? Orthopnea Respiratory rate of 14 breaths per minute Productive cough Sore throat

Orthopnea

Which is a major organ of the upper respiratory tract?

Pharynx

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?

Rapid respirations

The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:

Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.

sibilant wheezes

They can be heard during inspiration and expiration

Total lung capacity

Total lung capacity is the amount of air contained within the lungs at maximum inspiration.

pleural effusion

accumulation of fluid in this space

MRI

uses magnetic fields and radiofrequency signals to produce a detailed diagnostic image. MRI can visualize soft tissues, characterize nodules, and help stage carcinomas. The other options describe different studies.

Which mask is the most accurate?

venturi mask

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." "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."

"Small water droplets come from this, thus preventing dry mucous membranes."

what finding is a late indicator of hypoxia?

Cyanosis

An older adult client visits a health care facility for a scheduled physical assessment. During the assessment, the client reports difficulty breathing. What suggestion could the nurse make to improve the client's respiratory function in this case?

Drink liberal amounts of fluids

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is "Ineffective Airway Clearance related to copious and tenacious secretions." Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan?

Encouraging the client to consume two to three quarts of clear fluids daily

Hyperventilation

Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements.

The nurse assesses a client and detects the following findings, difficulty breathing, increase respiratory and pulse rates, and pale skin with regions of cyanosis. What condition with the nurse suspect as causing these respiratory alterations?

Hypoxia

In what age group would a nurse expect to assess the most rapid respiratory rate?

Infants

A nurse is educating a postoperative client on how to use an incentive spirometer. Which of the following is an accurate step that should be included in the teaching plan?

Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose.

The nurse is caring for a client with a chest tube. Stationary clots are noted in the tubing. What is the appropriate nursing action?

Milk the tubing to strip it of clots.

The patient is having pulmonary function studies performed. The patient has a spirometry test and has a FEV1/FVC ratio of 60%. This finding suggests:

Obstructive lung disease. Explanation: Spirometry is used to evaluate airflow obstruction, which is determined by the ratio of forced expiration volume in 1 second to forced vital capacity. Obstructive lung disease is a FEV1/FVC ratio less than 70%.

While examining a client, the nurse palpates the clients chest and back. What would the nurse expect to identify with this technique

Pattern of thoracic expansion

A client returns to a 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?

Pulse oximetry

Spirometry

Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy.

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?

Stay indoors as much as possible.

Which is NOT true regarding the structure of the respiratory system?

The lungs move actively. The lungs move only passively. They stretch and recoil in response to neuromuscular activity.

Thoracentesis

Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.

The nurse is caring for a client who has a PCT following a skydiving accident. Which oxygen delivery device will the nurse select?

Tracheostomy collar

A nurse is assessing a clients respiratory effort notes that the client is breathing is 8 shallow breaths per minute. Which action best meets the clients immediate oxygenation needs?

Use a bag and mask

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: dyspnea apnea orthopnea hypercapnea

apnea

Sibilant wheezes

are associated with asthma and bronchospasm.

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:

breathing becomes increasingly difficult as the diaphragm is displaced.

What post removal tests needs to be ordered by the provider?

chest x-ray

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as:

crackles.

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

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

high fowlers

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?

nasal cannula

What structural changes to the respiratory system should a nurse observe when caring for older adults?

respiratory muscles become weaker

The amount of air inspired and expired with each breath is called: vital capacity. tidal volume. residual volume. dead-space volume.

tidal volume.

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?

trauma to the tracheal mucosa

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?

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

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?

"You should never smoke when oxygen is in use."

The nurse must obtain a blood specimen for blood gas analysis. What is the most important thing for the nurse to do immediately after the needle has been removed?

Apply study, firm pressure on the puncture site for 5 to 15 minutes.

The nurse is caring for a client who has a compromise cardio pulmonary system and needs to assess the clients tissue oxygenation. The nurse would use which appropriate message to assess the clients oxygenation?

Arterial blood gas

The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take?

Assess oxygen tubing connection

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

Atelectasis

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?

Breath sounds should be auscultated while the client breathes slowly through an open mouth; nose breathing may produce false breath sounds.

The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? Hypoxic hypoxia Histotoxic hypoxia Anemic hypoxia Circulatory hypoxia

Circulatory hypoxia Given this patient's vital signs, he appears to be in shock. Circulatory hypoxia is hypoxia resulting from inadequate capillary circulation. It may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause.

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?

Corticosteroids

Crackles

Crackles are soft, high-pitched discontinuous (intermittent) popping sounds

A physician has ordered an arterial blood gas test for a client with a respiratory disorder. What is the most common role of the nurse in performing the arterial blood gas test?

Implement measures to prevent complications after arterial puncture.

A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention?

Inquire about factors that contribute to non-adherence.

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? An ET cuff leak Kinking of the ventilator tubing A disconnected ventilator tube A change in the oxygen concentration without resetting the oxygen level alarm

Kinking of the ventilator tubing

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? Simple mask Nasal cannula Face tent Non-rebreather mask

Nasal cannula

Upon palpation of the sinus area, what would the nurse identify as a normal finding? Tenderness during palpation Pain sensation behind the eyes No sensation during palpation Light not going through the sinus cavity

No sensation during palpation

Normal cardiac output averages

Normal cardiac output averages from 3.5 L/minute to 8.0 L/minute.

A nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant?

Oxygen hood

The nurse is caring for a client currently on a mechanical ventilator. What should the nurse determine when comparing today's arterial blood gas (ABG) results with the results obtained 24 hours earlier?

Oxygenation is improving.

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?

Pleural effusion

A nurse is assigned to care for a client admitted to the healthcare facility with the diagnosis of ATELECTASIS. When interviewing the client, the nurse would anticipate a history of

Pneumonia

When reviewing data collection on a client with a cardiac output of 2.5 L per minute, the nurse inspects the client for which symptom?

Rapid respirations

While the nurse is providing morning hygiene for a client who has a chest tube, the client has rolled over quickly and the chest tube has become disconnected from the drainage unit. How should the nurse first respond to this event?

Submerge the end of the tube in sterile water.

When inspecting a clients chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test?

The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood.

And insertion of a chest tube, fluctuations in the water seal chamber that correspond with inspiration and expiration are an expected a normal finding

True

Breath sounds should be auscultated while the client breathes slowly through

an open mouth

bronchial

bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx)

pulmonary function studies

one of a number of tests used to access volume and airflow rate of the lungs

bronchoscopy

procedure which sends a scope down the throat, the gag reflex is anesthetized to reduce discomfort

A client using home oxygen asks the nurse about changing to an oxygen concentrator. What is the appropriate nursing response? (Select all that apply.)

* "It collects and concentrates oxygen from room air." * "It eliminates the need for a central reservoir of piped oxygen." * "You may notice an increase in your electric bill." * "It costs less than oxygen supplied in portable tanks."

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?

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

A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them?

"It is inserted into the space between the lining of the lungs and the ribs."

A nurse is performing CPR on a client who collapsed. Which guidelines should be used for this procedure? Select all that apply.

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

high respiratory rate

A client diagnosed with impaired gas exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase

What are characteristics of a normal breathing pattern? Select all that apply.

-The average adult moves about a quarter of a liter of air per breath. -Normal breathing occurs at a rate of 12 to 20 breaths per minute in the adult. -Usually a person breathes slightly faster when awake than when asleep. -Exhaling normally takes twice as long as inhaling. -The athlete normally breathes more slowly and deeply while at rest than someone who is less fit. -Normally, each breath is the same size.

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 nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action?

The nurse working in the radiology clinic is assisting with a pulmonary angiography. The nurse knows that when monitoring clients after a pulmonary angiography, what should the physician be notified about? Flushed feeling in the client Raised temperature in the affected limb Excessive capillary refill Absent distal pulses

Absent distal pulses When monitoring clients after a pulmonary angiography, nurses must notify the physician about diminished or absent distal pulses, cool skin temperature in the affected limb, and poor capillary refill. When the contrast medium is infused, the client will sense a warm, flushed feeling.

The nurse is caring for a patient diagnosed with pneumonia. The nurse will assess the patient for tactile fremitus by completing which of the following? Instructing the patient to take a deep breath and hold it while the diaphragm is percussed Placing the thumbs along the costal margin of the chest wall and instructing the patient to inhale deeply A sking the patient to say "one, two, three" while auscultating the lungs Asking the patient to repeat "ninety-nine" as the nurse's hands move down the patient's thorax

Asking the patient to repeat "ninety-nine" as the nurse's hands move down the patient's thorax

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."

Which vaccine should a nurse encourage a client with chronic obstructive pulmonary disease (COPD) to receive?

Clients with COPD are more susceptible to respiratory infections, so they should be encouraged to receive the influenza and pneumococcal vaccines. Clients with COPD aren't at high risk for varicella or hepatitis B. The HPV vaccine is to guard against cervical cancer and is recommended only for women ages 9 to 26.

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?

Crackles in the lower lobes

The nurse is providing discharge teaching to client going home with oxygen therapy. Which statements made by the client would indicate to the nurse at the teaching was effective?

I will not allow smoking within 10 feet of my oxygen I will keep the oxygen tank away from Director sunlight or heat

In general, if a flow rate of 6 L/minute fails to raise a client's oxygen saturation level satisfactorily, a mask should be used.

In general, if a flow rate of 6 L/minute fails to raise a client's oxygen saturation level satisfactorily, a mask should be used.

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test?

Monitor the amount of oxygen saturation in the blood.

The nurse is caring for a postoperative client who has a prescription for meperidine (Demerol) 7 5mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering Demerol, the nurse would assess which most important sign?

Respiratory rate and depth. 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, physiological damage from respiratory depression, or loss of consciousness.

Surfactant is formed in utero

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

The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner?

The correct amount delivered FiO2 for a nonrebreather mask is 12 L/min; 8-11 L/min for partial rebreather mask; 4-10 L/min for Venturi mask; and 1-6 L/min for nasal cannula. However, per nasal cannula it may be no more than 2-3 L/min to patient with chronic lung disease.

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?

Vesicular

A nurse assessing a client respiratory status is a weak signal from the pulse oximeter. The clients other vital signs are within reference ranges. What is the nurses best action?

Warm the clients hands and try again

Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body?

chronic anemia

The caregiver of an older adult client who was recently placed on home oxygen reports that the client now refuses to leave the house. What teaching will the nurse select? (Select all that apply.)

continued socialization with others is important consider a portable oxygen device invite friends and family to the client's house

Pigeon chest occurs as a result of .

displacement of the sternum, resulting in an increase in the anteroposterior diameter

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?

nasal cannula

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:

adequate tissue perfusion.

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:

apnea

bronchovesicular

bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. sounds

Pulse oximetry

is a noninvasive method of monitoring oxygen saturation of hemoglobin. A probe is placed on the fingertip, forehead, earlobe, or bridge of nose. Inaccuracy of results may be from anemia, bright lights, shivering, nail polish, or peripheral vascular disease.

A health care provider has prescribed oxygen to be delivered at 8 L/minute for a client who does not have a tracheostomy. Which oxygen delivery device(s) will the nurse consider using? Select all that apply.

nasal cannula simple mask partial rebreather mask

The nurse is teaching a client and caregiver how to properly use an incentive spirometer. Place the following steps in the correct order. Use all options.

note the goal for inhalation exhale normally seal the lips around the mouthpiece inhale slowly until reach desired volume hold breath for 4 seconds remove mouthpiece and breathe normally

thoracentesis

surgical puncture to remove fluid from the pleural space

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?

Arterial blood gas

Which of the following is a potential complication of a low pressure in the ET cuff? Pressure necrosis Tracheal ischemia Tracheal bleeding Aspiration pneumonia

Aspiration pneumonia Low pressure in the cuff can increase the risk for aspiration pneumonia. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis.

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? By providing a tracheostomy plug to use for verbal communication By suctioning the client frequently B y placing the call button under the client's pillow By supplying a magic slate or similar device

By supplying a magic slate or similar device

A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform? Inquire if there have been any stressful visitors. Assess the radial pulse. Assist the client to lie down. Count the rate of respirations.

Count the rate of respirations.

A physician is choosing a chest drainage system for a client who is ambulating daily. Which of the following systems would be the best choice for this client?

Dry suction/one-way valve system

Residual Volume (RV)

During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume

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?

Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia.

A nurse is caring for a toddler who is having an acute asthmatic attack with copious mucus and difficulty breathing. The child's skin is cyanotic, respirations are labored and rapid, and pulse is rapid. What nursing diagnosis would have priority for care of this child?

Ineffective Airway Clearance

The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is:

Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter.

The nurse is preparing discharge teaching for a client who has COPD. Which teaching about deep breathing well the nurse include

Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly

A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis. Between the eyes and behind the nose Above the eyebrows Behind the ethmoid sinuses On the cheeks below the eyes

On the cheeks below the eyes

Peak expiratory flow rate

Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control.

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing

Poor tissue perfusion

patient exhibited signs of an altered ventilation-perfusion ratio. The nurse is aware that adequate ventilation but impaired perfusion exists when the patient has which of the following conditions? Tumor Infective process Pulmonary embolism Atelectasis

Pulmonary embolism

When caring for a client with a tracheostomy, the nurse would perform which recommended action?

Sterile technique is required when suctioning a tracheostomy in order to prevent introduction of microorganisms into the respiratory tract.

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 auscultates breath sounds as the client breathes through the nose.

A nurse is suctioning a client through a tracheostomy tube should be careful not to occlude the y-port when inserting the suction catheter because it could cause what condition to occur?

Trauma to the Tracheal mucosa

Question 1 of 10 Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with: a malignant tumor. pneumonia. hyperthermia. a compromised skin graft.

a compromised skin graft. A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.

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 oropharyngeal suctioning twice daily administration of inhaled corticosteroids educating the client on pursed-lip breathing techniques

educating the client on the use of incentive spirometry

List the nursing assessments after chest tube removal

pulse ox (Sp02), breath sound auscultation, respiratory rate and effort, signs of cyanosis

The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly?

respirations are at 20 breaths per minute

With a significant air leak, what will the nurse be able to palpate?

subcutaneous emphysema or "crackling" under the skin

A client is diagnosed with hypoxia related to emphysema. The client's adult child will be assisting the client with daily hygiene. How will the nurse explain positioning of the client to the caregiver?

"An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist."

A nurse is reading a journal article about pollutants and their insights on an individual's respiratory function. What problem with the nurse most likely identify as an effective exposure to automobile pollutants.

Bronchitis

A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level?

Crackles

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. What additional assessment would the nurse expect to observe?

Crackles in the lower lobes

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume.

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs? Decreased cardiac output Ineffective airway clearance Impaired spontaneous ventilation Impaired gas exchange

Impaired gas exchange

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?

In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation.

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside? Water-seal chest drainage set-up Oxygen analyzer Tracheostomy cleaning kit Manual resuscitation bag

Manual resuscitation bag

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields)

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:

Pneumonia

A woman 90 years of age has been in an automobile crash and sustained four fractured ribs on the left side of her thorax. Based on her age and the injury, she is at risk for what complication?

Pneumonia

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?

Pulmonary function testing is used to measure lung size and airway patency.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

Residual Volume (RV)

The nurse is planning the care of a complex elderly patient who has been admitted to the medical ward for the treatment of cellulitis. The nurse notes that the patient has a longstanding history of chronic obstructive pulmonary disease (COPD). What assessment finding would most clearly indicate the need for oxygen therapy?

SaO2 of 86% on room air Explanation: Crackles, coughing, and increased RR are all consistent with COPD. However, the decision on whether to apply oxygen therapy is most commonly made on the basis of oxygen levels as determined by pulse oximetry.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The adult chest contour is slightly convex, with no sternal depression.

The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes? They are heard in clients with decreased secretions. They result from air passing through widened air passages. They occur when the pleural surfaces are inflamed. They can be heard during inspiration and expiration.

They can be heard during inspiration and expiration.

A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from?

This client has all the risk factors of sleep apnea, which consists of multiple periods of apnea during sleep. These periods of apnea cause the person to move into a lighter sleep more often than someone without this disease, thus causing the daytime sleepiness.

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?

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).

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply. To provide visual feedback to encourage the client to inhale slowly and deeply To provide adequate transport of oxygen in the blood To clear respiratory secretions To reduce stress on the myocardium To decrease the work of breathing

To provide adequate transport of oxygen in the blood To reduce stress on the myocardium To decrease the work of 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.

True

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

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

Hypoxia is a condition

Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia.

Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen? It prescribes oxygen concentration. It regulates the amount of oxygen received. 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

The nurse is suctioning a clients tracheostomy me when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse is most appropriate response?

Maintain the clients oxygenation and alert the healthcare provider immediately

A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply.

Monitor the client's respiratory rate. Check the symmetry of the client's chest. Observe the breathing pattern and effort.

A clients 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?

Pleural effusion

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:

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.

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 as much air as possible, hold your breath briefly, and exhale slowly." "Take in a large volume of air and hold your breath as long as you can." "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."

The nurse is caring for a client who will have a chest tube removed within the next hour. What action by the nurse will be included in the plan of care for this client for removal of the chest tube? Select all that apply

*Administer prescribed pain medication 15 to 30 minutes before chest tube removal *Teach the client about relaxation exercises to be used during chest tube removal *Apply a cold compress to the site prior to the removal

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? 20 to 25 seconds 0 to 5 seconds 10 to 15 seconds 30 to 35 seconds

10 to 15 seconds

The pediatric nurse is caring for four clients. Which client will receive the greatest benefit from the use of an oxygen analyzer to assure that the client is receiving the prescribed amount of oxygen?

3-year old in croup tent

Which oxygen delivery system is most commonly used because it does not impede eating or speaking?

A nasal cannula is commonly used because it does not impede eating or speaking and is easily used in the home.

A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44%

A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44%

The UAP reports to the nurse that the client's pulse oximetry is 89%. What is the priority nursing action?

As the nurse enters the room the respiratory assessment immediately begins by visualizing client skin color, observing chest symmetry, vocalization, and auditory adventitious lung sounds. The nurse can then proceed to check the placement of the pulse oximeter

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as:

Crackles

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 post operative pneumonia and atelectasis during this time of reduced mobility following surgery?

Educating the client on the use of incentives spirometry

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?

High Fowlers position

Which is a sign of dyspnea specific to infants?

In the infant, flaring of the nostrils and retractions of the ribs during inspiration are notable signs of air hunger and extraordinary work of breathing.

A healthcare provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?

Instruct the client to inhale deeply and then cough

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped? Respiratory rate of 16 breaths/minute Runs of ventricular tachycardia Oxygen saturation of 93% Blood pressure increase from 120/74 mm Hg to 134/80 mm Hg

Runs of ventricular tachycardia Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. Although the client's blood pressure has increased, it hasn't increased more than 20% over baseline, which would indicate that the client isn't tolerating the weaning process.

A nurse caring for a patient with a pulmonary embolism understands that a high ventilation-perfusion ratio may exist. What does this mean for the patient? Ventilation matches perfusion. Ventilation exceeds perfusion. There is an absence of perfusion and ventilation. Perfusion exceeds ventilation.

Ventilation exceeds perfusion. A high ventilation-perfusion rate means that ventilation exceeds perfusion, causing dead space. The alveoli do not have an adequate blood supply for gas exchange to occur. This is characteristic of a variety of disorders, including pulmonary emboli, pulmonary infarction, and cardiogenic shock.

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?

cyanosis

Pink frothy sputum may be an indication of an infection. pulmonary edema. bronchiectasis. a lung abscess.

pulmonary edema.

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? You Selected:

trauma to the tracheal mucosa

During data collection, the nurse osculates low pitched, soft sounds over the lungs peripheral fields. Which appropriate terminology with the nurse use to describe these long sounds when documenting?

Vesicular

Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system? Select all that apply.

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

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results with the nurse report to the healthcare provider?

An infant with a respiratory rate of 16 BPM

Mrs. Fawcett is a 70-year-old woman who has a diagnosis of emphysema and who receives long-term oxygen therapy. She has presented to the emergency department because she states that she is experiencing an exacerbation of her chronic obstructive pulmonary disease (COPD), and she is in visible respiratory distress. How can the nurse best assess Mrs. Fawcett's dyspnea?

Ask her to rate her shortness of breath on a scale of 0 to 10.

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?

Contract the abdominal muscles.

When the client demonstrates soft, high pitched discontinuous sounds, the nurse documents the breath sounds heard as which of the following?

Crackles are soft, high pitched discontinuous sounds.

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: atelectasis. pulmonary fibrosis. asthma. croup.

Croup

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?

Ambu bag

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?

Bronchitis

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation? Bronchial breath sounds Absent breath sounds Egophony Crackles at lung bases

Crackles at lung bases

A nurse is preparing a client for bronchoscopy. Which instruction should the nurse give to the client? Don't walk. Don't eat. Don't talk. Don't cough.

Don't eat.

Which type of ventilator has a present volume of air to be delivered with each inspiration? Volume-controlled Pressure-cycled Negative-pressure Time-cycled

Volume-controlled With volume-controlled ventilation, the volume of air to be delivered with each inspiration is present. Negative pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a present pressure, and then cycles off, and expiration occurs passively.

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?

Flow meter

The nurse is preparing to provide hygiene care to a client with hypoxia. Into what position will the nurse place the client?

High-Fowlers

A nurse is beginning to conduct a health history for a client with respiratory problems. He notes that the client is having respiratory distress. What would the nurse do next?

Initiate interventions to help relieve the symptoms.

A patient diagnosed with diabetic ketoacidosis would be expected to have which type of respiratory pattern? Kussmaul respirations Biot's respirations Apnea Cheyne-Stokes

Kussmaul respirations

pulmonary edema

Pink, frothy sputum may be an indication of

The nurse is caring for a client with a North America Diagnosis Association-International (NANDA-I) diagnosis of Imbalanced nutrition: Less than body requirements, related to difficulty breathing. The nurse would implement which measures to maintain an adequate nutritional status for this client? Select all that apply.

*Provide frequent oral hygiene especially before meals. *Distribute six small meals over the course of the day.

The nurse is planning a diet for a patient with Chronic Obstructive Pulmonary Disease (COPD). Which recommended nutritional guidelines would the nurse discuss with the client? Select all that apply

*The diet should consist of 40% to 55% carbohydrates. *The diet should be rich in antioxidants and vitamin A, C, and B. *The diet should contain 12% to 20% protein.

the newborn to have a respiratory

the newborn to have a respiratory rate of 30 to 55 breaths per minute.

A nurse is educating a preoperative client on how to effectively deep breathe. Which of the following would be included?

"Make each breath deep enough to move the bottom ribs."

A nurse is admitting a six-year-old after a tonsillectomy to 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 100 bpm in the pulse oximeter reads 99%. These readings best indicate

Adequate tissue perfusion

The client has an increased anterposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is

Ineffective breathing pattern related to a hyperventilation related to increased anteroposterior

A nurse on a cardiac care unit oversees the care of diverse clients' cardiac health problems. Which action can be most appropriately delegated to a licensed practical nurse (LPN)?

Initiation of CPR for a client who is found unresponsive

Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration? Expiratory reserve volume Tidal volume Inspiratory reserve volume Residual volume

Inspiratory reserve volume

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?

It can cause the nasal mucosa to dry in case of high flow.

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?

The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen

Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? Partial-rebreathing mask Venturi mask T-piece Nasal cannula

Venturi mask The Venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. Nasal cannula, T-piece, and partial-rebreathing masks are not the most reliable and accurate methods of oxygen administration.

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

"Have you tried nasal strips?"

Which response would the nurse provide to a client concerned about developing chronic bronchitis due to smoking cigarettes, working with printing chemicals, and living near a paper mill?

"Have you tried to stop smoking? This can reduce your risk?" "We can refer you to a smoking cessation program to help reduce developing any future pulmonary issues." "How long have you lived near the paper mill? This can increase you risk for chronic bronchitis and asthma." "Exposure to printing chemicals increases the risk for allergies which can trigger chronic bronchitis, so wearing a breathing mask may be needed."

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the oxygen analyzer?

"It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed."

A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient?

Ambu bag

The nurse is caring for an asthmatic patient hospitalized with an acute asthma exacerbation. What drugs would the nurse anticipate being ordered for this patient to gain underlying control of persistent asthma?

Anti-inflammatory drugs Explanation: Because the underlying pathology of asthma is inflammation, control of persistent asthma is accomplished primarily with regular use of anti-inflammatory medications. Rescue inhalers, antibiotics, and antitussives do not aid in the control of persistent asthma.

A client has a sucking stab wound to the chest. Which action should the nurse take first? Apply a dressing over the wound and tape it on three sides. Draw blood for a hematocrit and hemoglobin level. Prepare a chest tube insertion tray. Prepare to start an I.V. line.

Apply a dressing over the wound and tape it on three sides The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds in respiratory rate. The mother asked the nurse, why is his chest sucking and above his stomach? The nurse most accurate response is:

He is using his chest muscles to help him breathe

A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. What should the nurse use for this patient?

If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag)may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube.

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:

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

The nurse is caring for a 2-year-old client who experienced smoke inhalation during a house file. When oxygen is ordered, what delivery device will the nurse gather?

oxygen tent

The nurse is monitoring a client who is receiving oxygen via a nonrebreather mask at 12 L/min. What actions by the nurse will promote the best outcomes for this client? Select all that apply.

*Maintain flow rate so that the reservoir bag collapses only slightly during inspiration. *Check that the valves and rubber flaps are functioning properly. *Monitor SaO2 with pulse oximeter.

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider?

An infant with a respiratory rate of 16 bpm

The nurse is caring for a patient with a pulmonary disorder. What observation by the nurse is indicative of a very late symptom of hypoxia? Cyanosis Confusion Dyspnea Restlessness

Cyanosis

A nurse using a pulse oximeter to measure a clients SPO2 attend a reading of 95% what is the nurse is most appropriate action

Document as expected assessment finding

A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan? Encourage the client's communication attempts by allowing him time to select or write words. Make an effort to read the client's lips to foster communication. Avoid using a tracheostomy plug because it blocks the airway. Answer questions for the client to reduce his frustration.

Encourage the client's communication attempts by allowing him time to select or write words.

Question 8 of 10 The nurse has instructed a patient on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which of the following? Promote the patient's ability to intake oxygen Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing Promote the strengthening of the patient's diaphragm Promote a more efficient and controlled ventilation and to decrease the work of breathing

Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing

A resident of a long-term care facility has lived with chronic obstructive pulmonary disease (COPD) for many years but has experienced a gradual increase in dyspnea despite the use of long-term oxygen therapy. In recent weeks, dyspnea has interfered with the resident's ability to eat, and the nurse recognizes the potential nursing diagnosis of altered nutrition: less than body requirements. How can the nurse best foster this resident's nutritional status?

Order small, frequent meals and nutritional supplements for the resident.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

Suction the client's artificial airway. A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of oxygen from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.

The nurse educator is presenting a lecture on emphysema with the aid of balloons. Which responses, if given by the nursing staff, would indicate to the educator that further teaching is needed? Select all that apply.

"Emphysema, like a new balloon, takes less effort to empty air out of the alveoli." "Respirations of the client with emphysema can be compared to a balloon that has been blown up before." The lungs in a client with emphysema are stiff and noncompliant. The lungs (alveoli) are compared to a new balloon that takes more effort to blow up and release air out. As in emphysema, a new balloon takes extra effort to blow up; the client with emphysema has to exert more effort to breathe in and out, leading to shortness of breath. The new balloon is difficult to expand, representing decreased elasticity and leading to decreased compliance.

The nurse is providing discharge teaching to a client going home with oxygen therapy. Which statements made by the client would indicate to the nurse that the teaching was effective? Select all that apply.

"I will not allow smoking within 10 feet (3 m) of my oxygen." "I will keep the oxygen tank away from direct sunlight or heat." Oxygen is combustible, so keep it away from smoking or direct sunlight. It is important to allow adequate airflow around the oxygen concentrator, so it should not be placed flush against the wall. It's more important to follow the prescription than to adjust the oxygen flow rate because too much or too little oxygen may be detrimental to the client. The client must use caution with both gas and electric stoves.

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output?

"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute."

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:

6 L/minute.

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for A kink in the ventilator tubing A cut or slice in the tubing from the ventilator Malfunction of the alarm button Higher than normal endotracheal cuff pressure

A kink in the ventilator tubing

The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated? Deflating the cuff routinely Deflating the cuff prior to tube removal E nsuring that humidified oxygen is always introduced through the tube Checking the cuff pressure every 6 to 8 hours

Deflating the cuff routinely Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

In general, if a flow rate of 6 L/minute fails to raise a client's oxygen saturation level satisfactorily, a mask should be used.

A nurse is educating a client who has congested lungs how to keep secretions thin, and more easily coughed up and expectorated. What would be one self-care measure to teach?

Increase oral intake of fluids to two to three quarts per day.

The nurse provides care for a client with pneumonia and acute respiratory distress syndrome whose oxygen saturation fluctuated between 86% and 90% over the past few days. The oxygenation saturation is consistently at 91%. Which step would the nurse take next?

Provide oxygen for consistent hypoxia

In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in tension iincreased carbon dioxiden arterial blood, leading to which of the following acid-base imbalances?

Respiratory acidosis Explanation: Increased carbon dioxide tension in arterial blood leads to respiratory acidosis and chronic respiratory failure. In acute illness, worsening hypercapnia can lead to acute respiratory failure.

Which of the following results in decreased gas exchange in older adults? The number of alveoli decreases with age. The alveolar walls become thicker. The alveolar walls contain fewer capillaries. The elasticity of the lungs increases with age.

The alveolar walls contain fewer capillaries

The nurse caring for a client with cystic fibrosis is performing chest physiotherapy. The nurse educator would INTERVENE if which actions performed by the nurse are noted? Select all that apply.

To prevent tissue damage, percussion should NOT be performed on bare skin or under the ribs. When vibrating, the nurse should use rhythmic contraction and relaxation of shoulder and arm muscles during client's exhalation. To drain the posterior section of the client's upper lobes, the client should be placed in a lying position, half on the side. The nurse's hands should be held in a rigid, dome-shaped position when percussing. Postural drainage should be performed for 20 to 30 minutes up to four times a day.

pulmonary angiography

a contrast medium is injected into the femoral artery. When the medium is infused, the client will feel a sense of warm and flushed with an urge to cough. The client will feel a pressure when the catheter is inserted.

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

A nurse is assessing a clients respiratory effort notes that the clients breaths are shallow and eight per minute. Shortly after, the clients respirations seas. Which form of oxygen delivery should the nurse use for this client?

Ambu bag

A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority? Assessing the client's respiratory status, orientation, and skin color Applying an oil-based lubricant to the client's mouth and nose Posting a "No smoking" sign over the client's bed Changing the mask and tubing daily

Assessing the client's respiratory status, orientation, and skin color

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?

Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many clients with chronic hypoxia due to respiratory or cardiac disease. Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD.

Question 4 of 5 A client receiving a unit of packed red blood cells (PRBCs) has been prescribed morphine 1 mg intravenously now for pain. What is the best method for the nurse to administer the morphine? Inject the morphine into a distal port on the blood tubing. Administer the morphine into the closest tubing port to the client for fast delivery. Disconnect the blood tubing, flush with normal saline, and administer morphine. Add the morphine to the blood to be slowly administered.

Disconnect the blood tubing, flush with normal saline, and administer morphine. Never add medications to blood or blood products. The transfusion must be temporarily stopped in order to administer the morphine.

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

Flow meter

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:

Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize atelectasis

The nurse is caring for a client with respiratory acidosis. Which arterial blood gas data does the nurse anticipate finding?

pH less than 7.35; HCO3 high; PaCO2 high

The nurse is providing discharge teaching to a client going home with oxygen therapy. Which statements made by the client would indicate to the nurse that the teaching was effective? Select all that apply.

"I will keep the oxygen tank away from direct sunlight or heat." "I will not allow smoking within 10 feet (3 m) of my oxygen."

The nurse is providing discharge teaching to a client going home with oxygen therapy. Which statements made by the client would indicate to the nurse that the teaching was effective? Select all that apply.

"I will not allow smoking within 10 feet (3 m) of my oxygen." "I will keep the oxygen tank away from direct sunlight or heat."

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?

"The caregiver will need to place the oxygen tank back into the secure carrier." 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 calculating the patient's smoking history in pack-years. The patient has recently been diagnosed with malignant lung cancer. The patient states he has been smoking two packs of cigarettes a day for the past 11 years. The nurse correctly documents the patient's pack-years as which of the following? 10 11 5 22

22

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 909% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

6 L/minute.

The nurse is providing an educational demonstration to an older, post surgical client. The intervention is intended to minimize the effect of what age related changes specifically relevant to such a client?

A decrease in ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs

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 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.

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?

An oxygen tent is commonly used with children who need a cool and highly humidified airflow. It is also more effective for children because they often do not like to keep oxygen administration devices in place. Since the tent does not allow the maintenance of a satisfactory or precise oxygen concentration, is difficult to maintain a consistent level of oxygen. The oxygen tent does not adequately deliver oxygen at a rate higher than 30% to 50%; thus, it is rarely used with other clients.

A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for? Stagnant hypoxia Anemic hypoxia Histotoxic hypoxia Hypoxic hypoxia

Anemic hypoxia Anemic hypoxia is a result of decreased effective hemoglobin concentration, which causes a decrease in the oxygen-carrying capacity of the blood. It is rarely accompanied by hypoxemia. Carbon monoxide poisoning, because it reduces the oxygen-carrying capacity of hemoglobin, produces similar effects but is not strictly anemic hypoxia, because hemoglobin levels may be normal.

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? Fluid intake for the past 24 hours Electrocardiogram (ECG) results Prior outcomes of weaning Baseline arterial blood gas (ABG) levels

Baseline arterial blood gas (ABG) levels Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.

A client presents to the emergency department with fluid overload. The nurse is concerned about fluid accumulation in the lungs. On which of the following areas would the nurse focus the lung assessment? Posterior bronchioles Anterior bronchial tree Right lower lobe Bilateral lower lobes

Bilateral lower lobes Assessment of the anterior and posterior lungs is part of the nurse's routine evaluation. Fluid overload should be monitored for accumluation in the lungs. Dependent areas must be assessed for breath sounds. The bases of the lungs are considered dependent areas. Fluid in the lungs will usually produce the adventitious sounds of crackles, most frequently auscultated in the bilateral bases of the lungs

What treatment modality will be the most effective for this patient? Continuous positive airway pressure Surgery to remove the tonsils and adenoids Bi-level positive airway pressure Medications to assist the patient with sleep at night

Continuous positive airway pressure Continuous positive airway pressure (CPAP) provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. To use CPAP, the patient must be breathing independently.

The client demonstrates soft, high-pitched, discontinuous sounds in the left lower lobe of the lung. How will the nurse accurately document this finding?

Crackles Crackles are soft, high-pitched, discontinuous sounds. Wheezes are a whistling or rattling sound in the chest as a result of obstruction in the air passages. Vesicular breath sounds are heard across the lung surface. Bronchial sounds are loud, high-pitched sounds heard primarily over the trachea and larynx.

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?

Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions.

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?

Instruct the client to inhale deeply and then cough.

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique? Administer bronchodilators and mucolytic agents following the sequence. Use aerosol sprays to deodorize the client's environment after postural drainage. Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. Perform this measure with the client once a day.

Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes.

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?

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 with a diagnosis of advanced Alzheimer's disease is unable to follow directions required to use an inhaled bronchodilator. Which medication delivery system is most appropriate for this client?

Nebulizer

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

Residual Volume

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which of the following describes these sounds? Rhonchi Crackles Bronchial Pleural friction rub

Rhonchi Rhonchi are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? Suction the client's artificial airway. Increase the oxygen percentage. Check for an apical pulse. Ventilate the client with a handheld mechanical ventilator.

Suction the client's artificial airway. A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of oxygen from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.

client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth? The pons The frontal lobe Central sulcus Wernicke's area

The pons

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? Air-leak chamber Suction control chamber Water-seal chamber Collection chamber

Water-seal chamber Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.

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?

Wheezing The nurse expects to document wheezing in the lungs of a client with asthma, which would be more pronounced when the client has a respiratory infection. Wheezing is a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration. Wheezing is caused by air passing through constricted passages caused by swelling or secretions. Stridor and crackles are other abnormal breath sounds caused by fluid, infection, or inflammation in the lungs. Absent breath sounds are not normally found in asthmatic clients; they are characteristic of pneumonia.

Which of the following is an adverse reaction that would require termination of the weaning process from the ventilator? PaOgreater than 60 mmHg with a FiO less than 40% Heart rate less than 100 B blood pressure increase of 20 mm Hg Vital capacity of 12 mL/kg

blood pressure increase of 20 mm Hg Criteria for termination of the weaning process includes: heart rate increase of 20 beats per minute, and systolic blood pressure increase of 20 mm Hg. A normal vital capacity is 10 to 15 mL/kg.

A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by: suctioning the tracheostomy tube frequently. keeping the tracheostomy tube plugged. u sing a cuffed tracheostomy tube. using the minimal-leak technique with cuff pressure less than 25 cm H2O.

using the minimal-leak technique with cuff pressure less than 25 cm H2O.

On arrival at the intensive care unit, a critically ill client suffers respiratory arrest and is placed on mechanical ventilation. The physician orders pulse oximetry to monitor the client's arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values? Tachypnea Fever Tachycardia Hypotension

Hypotension

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test? Monitor the pressure of oxygen dissolved in plasma. Monitor the amount of oxygen saturation in the blood. Calculate the pressure of carbon dioxide dissolved in plasma. Measure the volume of air exhaled or inhaled over time.

Monitor the amount of oxygen saturation in the blood.

The client is returning from the operating room following a broncho scopy. Which action, performed by the nursing assistant, would the nurse stop if began prior to nursing assessment? The nursing assistant is asking a question requiring a verbal response. The nursing assistant is assisting the client to the side of the bed to use a urinal. The nursing assistant is assisting the client to a semi-Fowler's position. The nursing assistant is pouring a glass of water to wet the client's mouth.

The nursing assistant is pouring a glass of water to wet the client's mouth.

An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize?

"Is your mask causing discomfort?" It is possible for anyone using a mask to try and readjust it if it is uncomfortable. Depending on the older adult's cognitive status, he or she may have tried to make it more comfortable and in the process caused it to no longer fit correctly. This could also occur if the client removed their dentures, as some individual's choose to let the dentures soak overnight. If the mask was fitted with the dentures in, the mask will likely be loose with the dentures removed. The other questions could possibly be asked to see if someone else may have tried to help the client feel more comfortable with the mask on.

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 client diagnosed with impaired gas exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.

The nurse caring for a client who will have a chest tube removed within the next hour includes which of the following nursing interventions on the client's plan of care? (Select all that apply)

After the chest tube is removed, the plan of care should include the following nursing interventions: administration of prescribed pain medication 15 to 30 minutes before chest tube removal and teaching the client relaxation exercises to utilize during the procedure.

The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to: Administer prescribed pain medication. Notify the physician. Lay the client's head to a flat position. Assess pulse and blood pressure.

Assess pulse and blood pressure. The client has bled 120 mL of bloody drainage in the chest drainage system within 15 minutes. It is most important for the nurse to assess for signs and symptoms of hemorrhage, which may be indicated by a rapid pulse and decreasing blood pressure. The nurse may then lay the client in a flat position and notify the physician.

The nurse is caring for a patient with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which of the following? Instruct the patient that bed rest must be maintained for 2 hours. Offer the patient ice chips. Ensure the patient remains moderately sedated to decrease anxiety. Assess the patient for a cough reflex.

Assess the patient for a cough reflex. After the procedure, the patient must take nothing by mouth until the cough reflex returns, because the preoperative sedation and local anesthesia impair the protective laryngeal reflex and swallowing. Once the patient demonstrates a cough reflex, the nurse may offer ice chips and eventually fluids. The patient is sedated during the procedure, not afterward. The patient is not required to maintain bed rest following the procedure.

The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely? Asthma Pneumothorax Acute respiratory obstruction Adult respiratory distress syndrome

Asthma The presence of both inspiratory and expiratory wheezing usually signifies asthma if the individual does not have heart failure. Sudden dyspnea is an indicator of the other choices.

For a client with an endotracheal (ET) tube, which nursing action is the most important? Auscultating the lungs for bilateral breath sounds Monitoring serial blood gas values every 4 hours Providing frequent oral hygiene Turning the client from side to side every 2 hours

Auscultating the lungs for bilateral breath sounds For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.

A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs? Chest X-ray Arterial blood gas (ABG) levels Inspection Auscultation

Auscultation The nurse should assess breath sounds before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function but aren't necessary to determine lung areas requiring postural drainage.

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse Contacts the respiratory therapy department to report the ventilator is malfunctioning Consults with the physician about removing the client from the ventilator Continues assessing the client's respiratory status frequently Changes the setting on the ventilator to increase breaths to 14 per minute

Continues assessing the client's respiratory status frequently The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client. There are not sufficient data to suggest the client could be removed from the ventilator. There is no reason to increase the ventilator's setting to 14 breaths per minute or to contact respiratory therapy to report the machine is not working properly.

For a client with chronic obstructive pulmonary disease, which nursing intervention helps maintain a patent airway?

Correct response: Teaching the client how to perform controlled coughing Explanation: Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the client's ability to maintain a patent airway, causing a high risk of infection from pooled secretions.

A son brings his father into the clinic, stating that his father's color has changed to bluish around the mouth. The father is confused, with a respiratory rate of 28 breaths per minute and scattered crackles throughout. The son states this condition just occurred within the last hour. Which of the following factors indicates that the client's condition has lasted for more than 1 hour? Respiratory rate Crackles Cyanosis Son's statement

Cyanosis The client's appearance may give clues to respiratory status. Cyanosis, a bluish coloring of the skin, is a very late indicator of hypoxia. The presence of cyanosis is from decreased unoxygenated hemoglobin. In the presence of a pulmonary condition, cyanosis is assessed by observing the color of the tongue and lips.

A client arrives at the physician's office stating dyspnea; a productive cough for thick, green sputum; respirations of 28 breaths/minute, and a temperature of 102.8° F. The nurse auscultates the lung fields, which reveal poor air exchange in the right middle lobe. The nurse suspects a right middle lobe pneumonia. To be consistent with this anticipated diagnosis, which sound, heard over the chest wall when percussing, is anticipated? Tympanic Resonant Hyperresonant Dull

Dull A dull percussed sound, heard over the chest wall, is indicative of little or no air movement in that area of the lung. Lung consolidation such as in pneumonia or fluid accumulation produces the dull sound. A tympanic sound is a high-pitched sound commonly heard over the stomach or bowel. A resonant sound is noted over normal lung tissue. A hyper resonant sound is an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax.

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath and fatigue for 1 hour after awakening in the morning. Which of the following statements by the nurse would best help with the client's shortness of breath and fatigue?

Dyspnea and fatigue disproportionate to pulmonary function abnormalities Right ventricular enlargement Elevated plasma brain natriuretic peptide (BNP) Enlargement of central pulmonary arteries Explanation: The diagnosis of pulmonary hypertension associated with COPD is suspected in patients complaining of dyspnea and fatigue that appear to be disproportionate to pulmonary function abnormalities. Enlargement of the central pulmonary arteries on the chest X-ray, echocardiogram suggestive of right ventricular enlargement, and elevated plasma BNP may be present.

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education? Have the patient lie in a supine position during the use of the spirometer. Encourage the patient to try to stop coughing during and after using the spirometer. Encourage the patient to take approximately 10 breaths per hour, while awake. Inform the patient that using the spirometer is not necessary if the patient is experiencing pain.

Encourage the patient to take approximately 10 breaths per hour, while awake

Question 5 of 10 A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? Encouragement of coughing Use of a cooling blanket Incentive spirometry Endotracheal suctioning

Endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

The nurse is caring for a client with emphysema who has been prescribed portable oxygen, 2 L a minute. Which actions does the nurse take to administer low concentrations of oxygen to the client? Select all that apply

Ensure that the oxygen concentrator is turned on Confirm that the nasal canal is worn properly by the client Verify the oxygen concentrator is set up on the prescribed flow rate

A 6-month-old male client and his elder brother, a 3-year-old male, are being seen in the pediatric clinic for their third middle ear infection of the winter. The mother reports they develop an upper respiratory infection and an ear infection seems quick to follow. What contributes to this event? Oropharynx Genetics Epiglottis Eustachian tubes

Eustachian tubes

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? Delirium Hyperventilation Semiconsciousness Hypoxia

Hypoxia As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.

he nursing instructor is talking with senior nursing students about diagnostic procedures used in respiratory diseases. The instructor discusses thoracentesis, defining it as a procedure performed for diagnostic purposes or to aspirate accumulated excess fluid or air from the pleural space. What would the instructor tell the students purulent fluid indicates? Heart failure Infection Cancer Inflammation

Infection A small amount of fluid lies between the visceral and parietal pleurae. When excess fluid or air accumulates, the physician aspirates it from the pleural space by inserting a needle into the chest wall. This procedure, called thoracentesis, is performed with local anesthesia. Thoracentesis also may be used to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes such as a culture, sensitivity, or microscopic examination. Purulent fluid is the recommended diagnosis for infection. Serous fluid may be associated with cancer, inflammatory conditions, or heart failure.

A nurse is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide?

It helps prevent early airway collapse. Explanation: Pursed-lip breathing helps prevent early airway collapse. Learning this technique helps the client control respiration during periods of excitement, anxiety, exercise, and respiratory distress. To increase inspiratory muscle strength and endurance, the client may need to learn inspiratory resistive breathing. To decrease accessory muscle use and thus reduce the work of breathing, the client may need to learn diaphragmatic (abdominal) breathing. In pursed-lip breathing, the client mimics a normal inspiratory-expiratory (I:E) ratio of 1:2. (A client with emphysema may have an I:E ratio as high as 1:4.)

Question 5 of 5 The nurse should notify the healthcare provider before administering fresh frozen plasma (FFP) based on which assessment finding? Strong pedal pulses Jugular venous distention White sclera Absence of tenting skin turgor

Jugular venous distention During the pre-transfusion assessment, the nurse should carefully inspect for any signs of cardiac failure, such as jugular venous distention. The sclera should be examined for icterus; white is an expected finding. Weak pedal pulses would be a sign of cardiac failure. Tenting skin turgor is a sign of dehydration; low vascular volume would be a cause for transfusion, not a contraindication.

A nurse is caring for an older adult client who is to be discharged from the health care facility. The client has been prescribed the use of a liquid oxygen unit at home to continue with oxygen therapy. What should the nurse tell the client regarding the potential problems of using a liquid oxygen unit? Select all that apply.

Liquid oxygen may leak during warm weather. The unit's outlet may become occluded because of frozen moisture. Portable liquid oxygen is more expensive.

A physician has ordered that a client with suspected lung cancer undergo magnetic resonance imaging (MRI). The nurse explains the benefits of this study to the client. Included in teaching would be which of the following regarding the MRI? Tumor densities can be seen with radiolucent images. Narrow-beam x-ray can scan successive lung layers. Lung blood flow can be viewed after a radiopaque agent is injected. MRI can view soft tissues and can help stage cancers.

MRI can view soft tissues and can help stage cancers.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? Keeping the collection chamber at chest level Stripping the chest tube every hour Maintaining continuous bubbling in the water-seal chamber Measuring and documenting the drainage in the collection chamber

Measuring and documenting the drainage in the collection chamber The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

The nurse is obtaining a pulse oximetry reading for a client admitted with exacerbation of chronic obstructive pulmonary disease. When observing a reading of 89% what action should the nurse perform?

No action is required, because this may be normal for the client

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?

Normal cardiac output averages from 3.5 L/minute to 8.0 L/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing respiratory rate to increase oxygen delivery to the tissues.

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?

Occluding the Y-port on the suction tubing is what creates the suction. While suctioning would be difficult but possible, suctioning while advancing the tube would damage the tracheal mucosa and remove excessive amounts of oxygen, not carbon dioxide, from the respiratory tract

Erin is a 35-year-old woman being cared for in the emergency department for a cough and hemoptysis for 3 days. Erin states that she has smoked one-and-a-half packs of cigarettes per day for the last 5 years. In trying to identify risk factors for Erin, the nurse calculates her pack-year history to write on the intake form. What is Erin's pack-year of smoking?

One "pack-year" is equal to smoking one pack of cigarettes for a day for 1 year. Based on Erin's information, Erin has a 7.5 pack-year smoking history.

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia? pH PaO2 HCO3 PCO2

PaO2

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? Partial pressure of arterial carbon dioxide (PaCO2) Bicarbonate (HCO3-) pH Partial pressure of arterial oxygen (PaO2)

Partial pressure of arterial oxygen (PaO2)

A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mm Hg. The nurse is aware of what complications that can be caused by this pressure? (Select all that apply.) Tracheal ischemia Pressure necrosis Hypoxia Tracheal bleeding Tracheal aspiration

Pressure necrosis Tracheal bleeding Tracheal aspiration Complications can occur from pressure exerted by the cuff on the tracheal wall. Cuff pressures should be maintained between 15 and 20 mm Hg (Morton, Fontaine, Hudak, et al., 2009). High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can increase the risk of aspiration pneumonia. Routine deflation of the cuff is not recommended because of the increased risk of aspiration and hypoxia.

The nurse is taking a respiratory history for a patient who has come into the clinic with a chronic cough. What information should the nurse obtain from this patient? (Select all that apply.) Previous history of smoking Social support Previous history of lung disease in the patient or family Financial ability to pay the bill Occupational and environmental influences

Previous history of smoking Previous history of lung disease in the patient or family Occupational and environmental influences

A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding? Metabolic acidosis Respiratory alkalosis Metabolic alkalosis Respiratory acidosis

Respiratory acidosis Respiratory acidosis would be reported to the physician citing the lab values. Analysis of the blood gases reveals that the client is acidotic with a pH under 7.35. Also noted is the PCO2above the normal range of 30 to 40 mm Hg. The HCO3− is slightly elevated because the normal level is 22 to 26 mEq/L

The nurse is caring for a client with chronic obstructive pulmonary disease. The client calls the doctor and states having difficulty breathing and overall feeling fatigued. The nurse realizes that this client is at high risk for which condition? Respiratory alkalosis Respiratory acidosis Metabolic acidosis Metabolic alkalosis

Respiratory acidosis Respiratory acidosis occurs when the body is unable to blow off CO2 due to the hypoventilation of disease processes such as COPD. An increase in blood carbon dioxide concentration occurs and a decreased pH causing acidosis. Respiratory alkalosis is a decrease in acidity of the blood and often caused by hyperventilation. Metabolic acidosis/alkalosis are disorders that affect the bicarbonate.

A nurse is reviewing arterial blood gas results on an assigned client. The pH is 7.32 with PCO2 of 49 mm Hg and a HCO3−of 28 mEq/L. The nurse reports to the physician which finding? Respiratory acidosis Metabolic alkalosis Metabolic acidosis Respiratory alkalosis

Respiratory acidosis Respiratory acidosis would be reported to the physician citing the lab values. Analysis of the blood gases reveals that the client is acidotic with a pH under 7.35. Also noted is the PCO2above the normal range of 30 to 40 mm Hg. The HCO3− is slightly elevated because the normal level is 22 to 26 mEq/L.

nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.) Sustains positive end expiratory pressure (PEEP) Decreases hypoxemia Increases oxygen consumption Decreases patient anxiety Prevents aspiration

Sustains positive end expiratory pressure (PEEP) Decreases hypoxemia Decreases patient anxiety An in-line suction device allows the patient to be suctioned without being disconnected from the ventilator circuit. In-line suctioning (also called closed suctioning) decreases hypoxemia, sustains PEEP, and can decrease patient anxiety associated with suctioning (Sole et al., 2013).

A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to: Lay in bed with the head on a pillow. Take prescribed albuterol (Ventolin) before performing postural drainage. Perform drainage 1 hour after meals. Hold each position for 5 minutes.

Take prescribed albuterol (Ventolin) before performing postural drainage. When a client is to perform postural drainage, the nurse should instruct the client to use the prescribed bronchodilator (eg, albuterol) first. This will open airways and promote drainage. The client is to perform postural drainage before meals, not after. This will aid in preventing nausea, vomiting, and aspiration. For secretions accumulated in the upper lobes, the client will sit up or even lean forward while sitting. Head on a pillow is not a sufficient increase in height. The client is also to lay in each position for 10 to 15 minutes.

The nurse answers the call light of a male patient. The patient is complaining of an irritating tickling sensation in the throat, a salty taste, and a burning sensation in the chest. Upon further assessment, the nurse notes a tissue with bright red, frothy blood at the bedside. The nurse can assume the source of the blood is likely from which of the following? The rectum The stomach The lungs The nose

The lungs Blood from the lung is usually bright red, frothy, and mixed with sputum. Initial symptoms include a tickling sensation in the throat, a salty taste, a burning or bubbling sensation in the chest, and perhaps chest pain, in which case the patient tends to splint the bleeding side. This blood has an alkaline pH (>7.0). Blood from the stomach is vomited rather than expectorated, may be mixed with food, and is usually much darker; often referred to as "coffee ground emesis." This blood has an acid pH (<<7.0). Bloody sputum from the nose or the nasopharynx is usually preceded by considerable sniffing, with blood possibly appearing in the nose.

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?

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.

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient? The patient is in a hypermetabolic state. The patient is having a myocardial infarction. The patient is having a stress reaction. The patient is hypoxic from suctioning.

The patient is hypoxic from suctioning. Apply suction while withdrawing and gently rotating the catheter 360 degrees (no longer than 10-15 seconds). Prolonged suctioning may result in hypoxia and dysrhythmias, leading to cardiac arrest.

The nurse is preparing to assist the health care provider with the removal of a patient's chest tube. Which of the following instructions will the nurse correctly give the patient? "Exhale forcefully while the chest tube is being removed." "When the tube is being removed, take a deep breath, exhale, and bear down." " While the chest tube is being removed, raise your arms above your head." " During the removal of the chest tube, do not move because it will make the removal more painful."

When the tube is being removed, take a deep breath, exhale, and bear down."

The nurse is educating a client on the proper use of inhaled medications. What are appropriate education points to include? Select all that apply.

When using a metered-dose inhaler (MDI) , the client must activate the device before and after inhaling. MDIs deliver a controlled dose of medications with each compression of the canister. Dry powder inhalers (DPIs) are actuated by the client's inspiration, so there is no need to coordinate the delivery of puffs with inhalation.

A client who uses portable home oxygen states, " I still like to smoke cigarettes every now and then." What is the appropriate nursing response?

You should never smoke when oxygen is in use

A nurse is preparing a client with a pleural effusion for a thoracentesis. The nurse should: raise the arm on the side of the client's body on which the physician will perform the thoracentesis. place the client supine in the bed, which is flat. raise the head of the bed to a high Fowler's position. assist the client to a sitting position on the edge of the bed, leaning over the bedside table.

assist the client to a sitting position on the edge of the bed, leaning over the bedside table. A physician usually performs a thoracentesis when the client is sitting in a chair or on the edge of the bed, with the legs supported and the arms folded and resting on a pillow or on the bedside table. Raising an arm, lying supine, or raising the head of the bed won't allow the physician to easily access the thoracic cavity.

When the nurse observes a newborn infant demonstrating an irregular abdominal breathing pattern, with a respiratory rate of 50 breaths/minute with occasional pauses in breathing of 5-second durations. What is the most appropriate action by the nurse?

continue to assess the infant

A nurse is conducting a physical assessment on 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 clients oxygenation. What instruction should the nurse give the client?

contract abdominal muscles

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

decreases the amount of air trapping and resistance 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.

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:

hemoglobin level.

A nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant?

oxygen hood

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:

pneumonia.

A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as: continuous positive airway pressure (CPAP). assist-control (AC) ventilation. synchronized intermittent mandatory ventilation (SIMV). pressure support ventilation (PSV).

synchronized intermittent mandatory ventilation (SIMV).

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?

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

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?

High Fowler's position

A client with a diagnosis of advanced Alzheimer disease is unable to follow directions required to use an inhaled bronchodilator. Which medication delivery system is most appropriate for this client?

Nebulizer

The nurse is obtaining a pulse oximetry reading for a client admitted with exacerbation of chronic obstructive pulmonary disease (COPD). When observing a reading of 89%, what action should the nurse perform?

No action is required, because this may be normal for the client

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?

Pleural effusion

A client has had a head injury affecting the brain stem. What is located in the brain stem that may affect respiratory function?

Respiratory center

When caring for a client with a tracheostomy, the nurse would perform which recommended action?

Suction the tracheostomy tube using sterile technique.

The nurse is performing an arterial blood gas sampling on a client at 1045. The nurse educator intervenes if which action is taken by the nurse?

The nurse performs the Allen's test after blood sample is taken.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

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 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 bronchospasm.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.

A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level?

crackles

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

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:

6 L/minute

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider?

An infant with a respiratory rate of 20 bpm (normal infant bpm approx. 40)

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines?

Be sure to shake the canister before using it.

The nurse is assessing a client with a chest tube that has been inserted after experiencing blunt trauma that resulted in a pneumothorax. What nursing action is appropriate when constant bubbling is noted in the suction control chamber?

Document the finding

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?

Document this expected assessment finding.

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.

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output?

If the client's stroke volume is 50 ml and heart rate is 50 beats per minute, then the cardiac output is 2.5L/ minute.

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?

It determines whether the client is getting enough oxygen.

Which statement accurately describes a general consideration when performing CPR on a client?

Perform CPR on an obese client the same as on a non-obese client.

The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the client's care plan?

Provide six small meals daily.

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?

Remove the airway, turn the client to the side, and provide mouth suction, if necessary.

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 low-pitched, soft sounds heard over peripheral lung fields.

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?

Vesicular Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

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?

Warm the client's hands and try again.

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?

a child who has pneumonia

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:

atelectasis.

A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate?

changes in the alveolar-capillary membrane and diffusion

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:

congestive heart failure. A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.

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:

croup

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?

distilled water

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather?

face tent

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:

hemoglobin level.

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?

high respiratory rate

The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response?

Maintain the client's oxygenation and alert the health care provider immediately.

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?

flow meter

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

flow meter

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier?

"Small water droplets come from this, thus preventing dry mucous membranes."

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?

"The caregiver will need to place the oxygen tank back into the secure carrier."

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?

Hypoxia

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression.

A nurse is providing home care instructions for a client who is being discharged to his home with a tracheostomy in place. Which statement accurately describes a guideline for care that should be included in the teaching plan?

Clean, rather than sterile, technique can be used in the home setting.

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?

fine crackles to the bases of the lungs bilaterally

The health care provider has prescribed an oropharyngeal airway for a client with a decreased level of consciousness. The health care provider has noted gurgling respirations and the client's tongue is in the posterior pharynx. The client vomits as the airway is inserted. Which actions should the nurse take? Select all that apply.

- Position client onto the side immediately. - Remove oropharyngeal airway. - Provide oral suctioning and mouth care.

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.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea?

High Fowler's position Clients with COPD are most comfortable in high Fowler's position because it aids in the use of the accessory muscles to promote respirations. The supine position with one pillow, side-lying with head slightly elevated, or lying with the head slightly lowered does not promote easier respirations.

Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system? Select all that apply.

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