Respiratory: Ch. 21

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? 45 mm Hg 84 mm Hg 58 mm Hg 120 mm Hg

84 mm Hg

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

A kink in the ventilator tubing

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? A. Kinking of the ventilator tubing B. A disconnected ventilator circuit C. An ET cuff leak D. A change in the oxygen concentration without resetting the oxygen level alarm

A. Kinking of the ventilator tubing

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

A. The system has an air leak

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned? Assess the CO2 level to determine if the patient requires suctioning. Have the patient inform the nurse of the need to be suctioned. Auscultate the lung for adventitious sounds. Have the patient cough.

Auscultate the lung for adventitious sounds.

What assessment method would the nurse use to determine the areas of the lungs that need draining? Arterial blood gas (ABG) levels Inspection Chest X-ray Auscultation

Auscultation

A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to: A. take a deep breath as the nurse deflates the cuff. B. hold the breath as the cuff is being reinflated. C. cough as the cuff is being deflated. D. exhale deeply as the nurse reinflates the cuff.

C. cough as the cuff is being deflated.

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 Anemic hypoxia Histotoxic hypoxia Circulatory hypoxia

Circulatory hypoxia

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

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

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

Hyperbaric

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 Tracheostomy cleaning kit Manual resuscitation bag Oxygen analyzer

Manual resuscitation bag

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?

PaO2

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? HCO3 pH PaO2 PCO2

PaO2

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

Partial pressure of arterial oxygen (PaO2)

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. Hold each position for 5 minutes. Perform drainage 1 hour after meals.

Take prescribed albuterol (Ventolin) before performing postural drainage.

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 client has a pneumothorax. The chest tube is obstructed. The system has an air leak.

The system has an air leak.