PrepU: oxygenation and perfusion

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

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

crackles

Which is a major organ of the upper respiratory tract?

pharynx

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 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

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 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 client is learning how to do diaphragmatic breathing. For which length of time will the nurse advise the client to rest between repetitions of the exercise?

2 minutes

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

Ask the client what factors contribute to nonadherence.

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

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.

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 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 is caring for the following clients. Which client is at highest risk for a depressed respiratory system?

a client taking an opioid for cancer pain

What is the most important risk factor in pulmonary disease?

active and passive cigarette smoke

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

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 home setting

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

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

crackles

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

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 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 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

The nursing assessment reveals reduced fremitus. This manifestation is consistent with which conditions? Select all that apply.

left sided heart failure pneumothorax pulmonary edema bronchial obstruction

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

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which instruction will the nurse include in the teaching?

Be sure to shake the canister before using it

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."

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 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.

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.

The nurse determines that the student who has been instructed about lung function and smoking requires additional teaching when the student says

Smoking only once in a while will not make a person addicted to smoking."

What assessments would a nurse make when auscultating the lungs

air flow through the respiratory passages

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

clubbing

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

high fowlers

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?

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 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

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

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 fowlers position

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