Respiratory Prep-U

A client is discussing advance directives with the nurse. Which statement made by the client indicates a need for further teaching?

"If I sign a DNR, then I may not receive continued care."

A client is experiencing hypoxia. Which nursing diagnosis would be appropriate?

Anxiety

A nurse is assisting a very obese client with a partial airway obstruction caused by a large piece of food. Which action should the nurse take to relieve the client's obstruction?

Give chest thrusts.

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?

RV

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

Suction the tracheostomy tube using sterile technique. Sterile technique is required when suctioning a tracheostomy in order to prevent introduction of microorganisms into the respiratory tract. The area around a new tracheostomy may need to be assessed and cleaned every 1 to 2 hours. Gauze dressings that are not filled with cotton must be used to prevent aspiration of lint or cotton fibers into the trachea.

What can a nurse ask a client to do before suctioning to prevent hypoxemia?

Take several deep breaths.

A physician orders an oropharyngeal airway to be inserted into a client. What accurately describes the use of this device?

The nurse can insert this device at the bedside with little to no trauma to the unconscious client. Rationale: It can help protect the airway of an unconscious client by preventing the tongue from falling back against the posterior pharynx and blocking it. Tape is not used to hold the airway in place because the client should be able to expel the airway once he becomes alert. They are not normally well-tolerated by conscious clients.

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

The nurse would expect to recommend an oxygen tent for which client?

a child who will not leave a facemask or cannula in place a comatose client who has a head injury an adult client who has COPD an older adult client who is unable to get out of bed

Which physiologic change does the nurse anticipate will be found in the older adult client with an ongoing nonproductive cough?

laryngeal atrophy The older adult client experiences laryngeal atrophy as the body ages, drier mucous membranes, diminished lung capacity, and increased rigidity of the chest wall.

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

pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation

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

respiratory muscles become weaker

A client with type 2 diabetes has come for an annual wellness check-up with the health care provider. Which vaccine will the nurse discuss with the client?

Pneumococcal 13-valent conjugate

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

A client has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy tube is removed for cleaning?

inner cannula obturator outer cannula cuff Rationale: The obturator guides the tube into place and is removed. The outer cannula remains in place in the trachea while the inner cannula is removed for cleaning or replacement.

During what part of respirations do wheezes occur?

inspiration and expiration

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

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?

sleep apnea pneumonia chronic obstructive pulmonary disease (COPD) chronic bronchitis

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 (A tracheostomy collar delivers oxygen near an artificial opening in the neck.)

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

It regulates the amount of oxygen received. It prescribes oxygen concentration. It determines whether the client is getting enough oxygen. It decreases dry mucous membranes via delivering small water droplets. Rationale: The provider prescribes concentration. The O2 analyzer measures the percentage of delivered O2. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.

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

A client with a 26-year history of cigarette smoking is recovering from pneumonia. Which information will be most important for the nurse to include in the discharge teaching?

options for smoking cessation reasons for annual sputum cytology testing how to perform chest physiotherapy needing to have a CT screening for lung cancer

The nurse is preparing to suction a client's airway. How long will the nurse preoxygenate the client to achieve a maintenance Sp02 of 95-100%?

1-2 minutes 5-6 minutes 3-4 minutes 7-8 minutes

Which technique would the nurse employ to maximize the effectiveness of postural drainage?

Combine it with percussion and vibration. Maximize how long the client holds each position to 60 minutes. Encourage the client to increase the frequency to eight times a day. Conduct it before administering inhalant medications. Rationale: Combining postural drainage with percussion and vibration enhances overall effectiveness. The technique should be done after inhalant medications are administered. The nurse should not encourage the client to do postural drainage more than four times a day and should advise the client to hold each position for no more than 45 minutes.

A nurse walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action?

Start chest compressions. (After 2 minutes of compressions, the rescuer opens the victim's airway.)

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 pancreatitis Graves' disease Parkinson's disease Rationale: The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the amount of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissues of the body.

The nurse receives a change-of-shift report on the following clients with chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first?

client with a respiratory rate of 36 breaths/minute A respiratory rate of 36 breaths/minute indicates severe respiratory distress (tachypneic) the client needs immediate assessment and intervention to prevent possible respiratory arrest. Lack of oxygen for more than 4 to 6 minutes can result in death or permanent brain damage. Therefore, it is essential to identify respiratory problems and to plan care accordingly for clients at risk.

The nurse is caring for an older adult client with pathologic pulmonary changes. The nurse should be aware that which conditions cause pathologic pulmonary change? Select all that apply.

clients with a history of smoking occupations where clients have inhaled pollutants clients residing in an area with toxic emission clients with reduced air exchanges clients with reduced efficiency in ventilation

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?

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

A nurse is caring for a critically ill client who has been admitted to the intensive care unit at the health care facility. The client is unable to breathe on his own and requires a very high concentration of oxygen. Which oxygen delivery device is most appropriate for this client?

nonrebreather mask The nurse should use a nonrebreather mask for a client who is critically ill and requires a high concentration of oxygen. A nonrebreather mask contains one-way valves that allow inhalation of only oxygen from the source and the reservoir bag; no atmospheric air is inhaled, and all exhaled air is vented from the mask. A simple mask, partial breather mask, and Venturi mask cannot be used for this client. A simple mask delivers a higher level of oxygen than a nasal cannula and is used for clients with nasal trauma and mouth breathing. A partial rebreather mask delivers a mixture of atmospheric air, oxygen from its source, and oxygen from the reservoir bag. A Venturi mask mixes a precise amount of oxygen and atmospheric air and delivers the prescribed amount.

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

prolongs expiration to reduce airway resistance Rationale: This exercise trains the muscles to prolong expiration, increasing airway pressure during expiration, and reducing the amount of airway trapping and resistance. Pursed-lip breathing does not replace incentive spirometry but is a way to train a client to have more control of their dyspnea.

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." "It is important to eat at least five servings of vegetables daily." "Remove your oxygen before cooking near the gas stove." "Be careful not to trip over your oxygen tubing while cooking." Rationale: For safety purposes, oxygen tanks should be kept at least 10 feet away from gas stoves, fires, and other flammable devices. If the client removes the oxygen while cooking at a gas stove, hypoxia may occur and the client may become confused and sustain burns.

The nurse is preparing a client for a tracheostomy insertion with a fenestrated tracheostomy tube. Which statement made by the client indicates an accurate understanding of the fenestrated tube?

"I'm glad I will still be able to talk once I get this tube inserted." Rationale: A fenestrated tube has a hole in it and allows air to flow over the vocal chords, so the client will be able to speak. The tube still needs to be cleaned and suctioned. The tube may still become dislodged, and the client is able to swallow.

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

"This is a gauge used to regulate the amount of oxygen that a client receives."

The nurse is teaching the family of a client with a tracheostomy about home care. Which family statement requires nursing intervention?

"We will remove the outer cannula for cleaning."

A client is receiving supplemental oxygen and the nurse is monitoring the client's oxygen saturation level using pulse oximetry. The nurse notifies the physician if the client reaches which oxygen saturation level?

92% Rationale: An O2 sat <93% indicates need for increased O2

An older adult client with a history of chronic obstructive pulmonary disease is admitted to the hospital with a cough and acute shortness of breath. Which priority action should the nurse take during the initial assessment of the client?

Ask specific questions about the history of the cough and shortness of breath. Rationale: Administration of pulmonary function tests would be completed after the initial assessment.

The nurse is planning care for a client who is prescribed a simple mask for oxygen delivery. What intervention will the nurse include in the plan of care?

Assess the client for anxiety due to claustrophobia

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

A nurse is teaching a client and family about postural drainage. What should be included in the teaching plan? SATA

Complete postural drainage four times a day. Cough out any expectorated sputum in a tissue and dispose of properly. Return to a comfortable position when tired, lightheaded, or short of breath. Rationale: The nurse should teach the family to plan to perform postural drainage two to four times daily; administer the prescribed inhalant medications before performing postural drainage; cough out expectorate secretions that drain into the upper airway; and have paper tissues and waterproof container nearby for collecting expectorated sputum. The client should use positions that drain the appropriate lung areas, and should remain in each prescribed position for 15 to 30 minutes. The client should resume a comfortable position after expectorating the usual volume of sputum or if tired, feel lightheaded, or have a rapid pulse rate, difficulty breathing, or chest pain.

A nurse is performing the Heimlich maneuver on a young client to relieve a mechanical airway obstruction. Which action should the nurse perform to increase intrathoracic pressure?

Give five quick abdominal thrusts above the navel. Assist the client onto the floor and into a prone position. Avoid opening the client's airway with the head-tilt maneuver. Activate the emergency response system.

A nurse has an order to obtain a sputum specimen on a newly admitted client. Which action is appropriate for the nurse to delegate to a UAP?

Label the sputum specimen and take it to the lab.

A nurse has an order to obtain a sputum specimen on a newly admitted client. Which action is appropriate for the nurse to delegate to UAP?

Label the sputum specimen and take it to the lab. Perform chest physiotherapy. Instruct the client on how to use a nebulizer. Auscultate the client's lung sounds before the sputum specimen is collected.

The nurse is reviewing the arterial blood gas results of a client with a respiratory disorder. What would alert the nurse to a problem?

PaCO2 of 55 mmHg

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

Pulmonary function tests Rationale: Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.

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) Total lung capacity (TLC) Forced Expiratory Volume (FEV) Tidal volume (TV) Rationale: TV refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. 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.

A nurse is at a baseball game and responds when a person collapses. The nurse begins CPR and requests an automated external defibrillator (AED). The family is angry when the nurse stops compressions to apply the AED. What is the appropriate action?

Stop compressions for less than 10 seconds to apply the AED. Continue compressions without stopping. Do not apply the AED. Wait for the emergency response to use the AED. Rationale: If there is no circulation, breathing, or movement after five cycles of cardiac compressions and rescue breathing, an automated external defibrillator (AED) is attached without exceeding a 10-second interruption in CPR.

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.

The nurse performs assessments of cardiopulmonary functioning and oxygenation during regular physical assessments. Based on developmental variations, which findings would the nurse consider normal? SATA

The power of the respiratory and abdominal muscles is reduced in older adults, and therefore the diaphragm moves less efficiently. The normal infant's chest is small and the airways are short, making aspiration a potential problem. Alterations in respiratory function due to aging in older adults increase the risk for disease, especially pneumonia and other chest infections. The respiratory rate is more rapid in infants until the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates.

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

a factory worker in a large city a farmer on a large farm a woman living in a small town a child living in a rural area

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

active and passive cigarette smoke

What assessments would a nurse make when auscultating the lungs?

cardiac

A nurse is administering a prescribed dose of IV medication to a client who is recovering from partial airway obstruction. What are common reasons for airway obstruction to occur? SATA

compromised swallowing aspiration of vomitus insufficient chewing

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 tap water normal saline mineral oil

When performing a physical assessment of an adult client reporting dyspnea, the nurse is aware that which of the following is an abnormal finding?

dullness over the lung fields with percussion symmetrical movement of the chest auscultation of low-pitched, soft sounds over the peripheral lung fields the chest contour is slightly convex, with no sternal depression Rationale: Percussion that produces dullness over the lung fields occurs when fluid or solid tissue replaces normal lung tissue.

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

pattern of thoracic expansion Rationale: Fluid-filled and consolidated portions of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation.

A client with a head injury will require long-term airway support. Which device will be required for this client?

tracheostomy tube oropharyngeal airway endotracheal tube home oxygen Rationale: Clients who require prolonged airway support via mechanical ventilation and oxygenation are more likely to be candidates for a tracheostomy to maintain the airway and provide a new route for ventilation. Therefore, the tracheostomy tube is the device required for this client. The other devices are not required for the client with a head injury and long-term airway support needs.

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 loss of sterile field suctioning of carbon dioxide prevention of suctioning Rationale: 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. Suctioning during insertion of the catheter would not compromise sterility.

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." Rationale: Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.

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."

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

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

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." "That will make it easier to carry with you." "That will help the oxygen flow more freely." "Call your oxygen supplier immediately." Rationale: 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.

A client who is scheduled for a tracheostomy placement tells the nurse, "I am afraid of not being able to speak after I have this procedure done." What is the appropriate nursing response?

"This must be very scary for you. Would you like to talk about it?" Only clients who have a fenestrated tracheostomy tube or speaking valve can talk after having a tracheostomy placed.

The health care provider has prescribed a long-acting bronchodilator for a client with a history of bronchospasm. What teaching about this drug will the nurse include?

"Use this drug daily to prevent bronchospasm." Long-acting bronchodilators are used daily for preventing asthma attacks or exercise-induced bronchospasm. SABAs are used for quick relief and in rescue situations. They are not to be used only when exercising.

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."

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." "Although the test is uncomfortable, it is not painful." "The test is used to determine how much air you inhale." "You will do this each morning while still lying in bed." Rationale: Peak expiratory flow rate (PEFR) refers to the volume of air that can be forcibly exhaled. While sitting or standing, the client takes a deep breath and forcibly exhales through a mouthpiece. The client does this three times, and the highest number is recorded. Clients commonly measure PEFR at home to monitor airflow when they have conditions such as asthma. The PEFR can be performed at any time of the day but not while lying in the bed. This test is not uncomfortable or painful.

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. 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. 1-4 L/minute flow rates per nasal cannula are standard flow rates. Greater than 6 L/minute flow rate per nasal cannula is very uncomfortable for the client. A flow rate of 10 L /minute per nasal cannula is not acceptable.

A nurse is caring for a client who breathes very shallowly and has been reporting severe back pain. What suggestion could the nurse make to help the client breathe efficiently?

Encourage the client to take deep breaths.

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 Hyperventilation Perfusion Atelectasis Rationale: 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. Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements. Perfusion refers to the process by which oxygenated capillary blood passes through body tissues. Atelectasis refers to collapsed alveoli.

The nurse is preparing to teach a client how to perform incentive spirometry. Which concept should the nurse include?

Incentive spirometry provides visual reinforcement of deep breathing. Proper, frequent use of incentive spirometry can improve pulmonary circulation. Oxygen saturation is expected to decrease during the first few minutes of incentive spirometry. The client should forcefully exhale into the incentive spirometer and continue to exhale until unable to continue. Rationale: Incentive spirometry assists the client to perform adequate deep breathing. Incentive spirometry affects ventilation rather than perfusion. Oxygen saturation should increase with the use of incentive spirometry, not decrease. Incentive spirometry is used to enhance inspiratory effort; thus, the client should inhale through the incentive spirometer, not exhale through it.

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. Notify the healthcare provider of the client's current status. Document assessment and plan for intervention. Explain uses of BiPAP masks versus CPAP masks.

A nurse needs to perform the Heimlich maneuver on an 8-month-old infant with a partial airway obstruction. Which action should the nurse perform?

Use finger sweeps to locate the obstruction. Give a series of subdiaphragmatic thrusts. Support the client with a safety belt on a table. Use the heel of one hand to administer back blows.

What prevents air from reentering the pleural space when chest tubes are inserted?

a closed water-seal drainage system the location of the tube insertion the sutures that hold in the tube respiratory inspiration and expiration Rationale: After insertion, the chest tube is secured with a suture and tape, covered with an airtight dressing, and is usually attached to a closed water-seal drainage system that prevents air from reentering the pleural space. The sutures hold the tube next to the skin to keep it in place. The tube is placed in the pleural space. The respiratory phase includes the inspiratory and expiratory components.

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. diminished stroke volume. high cardiac output. heart failure.

What does pulse oximetry measure?

arterial oxygen saturation

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

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 Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia.

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

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 vesicular breath sounds audible over peripheral lung fields resonance on percussion of lung fields respiratory rate of 18 breaths per minute

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 nasal strip nasal cannula oxygen analyzer Rationale: 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. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.

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

flowmeter oxygen analyzer humidifier nasal cannula Rationale: A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen.

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 Ratiionale: Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.

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 face tent simple mask tracheostomy collar Rationale: A nasal cannula is ideal for administering low concentrations of oxygen to clients who are not extremely hypoxic or have chronic lung disease. The client does not have a tracheostomy. A simple mask is used to administer higher levels of oxygen than 2 L/min. A face tent is used without a mask.

The nurse is preparing to suction a client's mouth to remove secretions. Which type of suctioning will the nurse perform?

oral Oropharyngeal suctioning removes secretions from the throat through a nasally inserted catheter. Nasopharyngeal suctioning removes secretions from the throat through a nasally inserted catheter. Nasotracheal suctioning removes secretions from the upper portion of the lower airway through a nasally inserted catheter.

A nurse is caring for a critically ill client who is receiving oxygen through a nonrebreather mask. The nurse should remember that which situation could lead to oxygen toxicity in the client?

oxygen concentration of more than 50% given for longer than 48 hours Rationale: When administering oxygen to a critically ill client using a nonrebreather mask, the nurse should remember that an oxygen concentration of more than 50% given for longer than 48 hours can cause oxygen toxicity in the client. Oxygen toxicity refers to lung damage that develops when oxygen concentrations of more than 50% are administered for longer than 48 to 72 hours. The best way to prevent oxygen toxicity is to administer the lowest FiO2 possible for the shortest amount of time.

A client at a health care facility who requires prolonged mechanical ventilation has a tracheostomy tube inserted through a surgically created opening into the trachea. The tracheostomy tube also has a balloon cuff. How does the inflated balloon cuff aid the client?

prevents the aspiration of oral fluids A tracheostomy tube may have a balloon cuff; when inflated, the cuff seals the upper airway to prevent aspiration of oral fluids and provide more efficient ventilation. An oral airway is a curved device that keeps a relaxed tongue positioned forward within the mouth, preventing the tongue from obstructing the upper airway. During insertion of a tracheostomy tube, an obturator, a curved guide, is used. Most clients with tracheostomy tubes require frequent suctioning.

A nurse is caring for a client with influenza who requires an external source of oxygen in order to breathe efficiently. In which situation is oxygen humidified?

when more than 4 L/min of oxygen is administered for an extended period When administering oxygen to a client using an external source of oxygen, the nurse should remember that oxygen is humidified when more than 4 L/min of oxygen is administered for an extended period. Oxygen need not be humidified if less than 4 L/min of oxygen has been administered to the client. Oxygen administered over an extended period of time, not intermittently, is humidified.