Ch. 39 PREPU

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 7-year old with nasal cannula 10-year old with simple mask 13-year old with nonrebreather mask

3-year old in croup tent An oxygen analyzer is used most commonly when caring for newborns in isolettes, children in croup tents, and clients who are mechanically ventilated. Other answers are incorrect.

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? Assist with intubation Apply oxygen Raise the head of the bed Educate client on incentive spirometry

Apply oxygen The nurse should first apply oxygen, which will help to improve oxygen saturation and health status. The client may not require intubation, once oxygen is provided. Although the client may require education on incentive spirometry, the immediate priority intervention is to stabilize the client's oxygen saturation. Similarly, raising the head of the bed may help with the client's comfort but may not have sufficient effect on oxygen saturation.

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

High Fowlers position allows the client with hypoxia to breathe easier. This promotes lung expansion because the abdominal organs descend away from the diaphragm. Other answers are incorrect.

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. orthopnea. dyspnea. hypercapnia.

apnea The newborn's breathing pattern is characterized by occasional pauses of several seconds between breaths. This periodic breathing is normal during the first 3 months of life, but frequent or prolonged periods of apnea (cessation of breathing 20 seconds or longer) are abnormal. Dyspnea refers to shortness of breath. Orthopnea refers to difficulty breathing when lying flat. An elevation of carbon dioxide levels in the blood is termed hypercapnia.

The obstetric nurse is assisting the birth of a preterm neonate. In preparing for the respiratory needs of the neonate, the nurse is aware that surfactant is formed in utero around: 30 to 32 weeks. 32 to 34 weeks. 34 to 36 weeks. 36 to 38 weeks.

34 to 36 weeks. Rational: 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.

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

Ask the client what factors contribute to nonadherence. The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment. Then, the nurse can work with the health care provider to find alternate treatment options if necessary, and then document the care.

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

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.

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? Assess the client's respiratory status and check vital signs every 1 minute for the next hour. Page the respiratory therapist STAT. Cover the tracheostomy stoma and apply oxygen by nasal cannula Maintain the client's oxygenation and alert the health care provider immediately.

Maintain the client's oxygenation and alert the health care provider immediately. If the tracheostomy becomes dislodged and is not easily replaced, the nurse should notify the primary care provider immediately, cover the tracheostomy stoma, and assess client's respiratory status.

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

crackles. A coarse crackle is a low-pitched, rumbling sound in airways. When they are coarse and loud and occur with severe dyspnea, crackles may be a telling sign of pulmonary fibrosis, congestive heart failure, and pulmonary edema.

The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select? nasal cannula tracheostomy collar face tent simple mask

tracheostomy collar A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. Other devices are not appropriate for this client.

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 Increase fluid intake to 3 L/day (3000 mL/day) Pulse oximetry High-Fowler's position

4 L/minute O2 (66 mL/second) nasal cannula 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 or 66 mL/second), the stimulus to breathe is removed. Clients with emphysema are most comfortable in high Fowler's position because it aids in the use of the accessory muscles to promote respirations. Increasing fluid intake helps keep the client's secretions thin. Pulse oximetry monitors the client's arterial oxyhemoglobin saturation while receiving oxygen therapy.

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 Oxygen tent Nasal cannula Oxygen mask

Ambu bag If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Oxygen masks may cover only the nose and mouth and can vary in the amount of oxygen delivered. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostril. An oxygen tent is a tentlike enclosure within which the air supply can be enriched with oxygen to aid a client's breathing. Oxygen masks, nasal cannula, and oxygen tents are used for clients who have a respiratory drive.

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

Ask the client what factors contribute to nonadherence. The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment. Then, the nurse can work with the health care provider to find alternate treatment options if necessary, and then document the care.

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? Atelectasis Bronchiectasis Bronchitis Croup

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

The nurse is caring for 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? Increase the flow of oxygen. Contact the oxygen supplier to request an oxygen tent. Check the fit of the oxygen mask. Discontinue oxygen therapy until the client is reassessed by the healthcare provider.

Check the fit of the oxygen mask. The fit of the oxygen mask can be affected by the discontinuation of wearing dentures. The nurse should check the fit to make sure the client is getting the prescribed amount of oxygen. Other answers are inappropriate actions that do not address the problem.

The nurse 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. Remove the chest tube. Remind the client to remain stationary in bed to stop the bubbling. Contact the Rapid Response Team.

Document the finding Constant bubbling in the suction control chamber is normal and should be documented. Other actions are inappropriate.

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? Wheezes Pleural effusion Pneumonia Tachypnea

Pleural effusion Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis. Pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.

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 Malnutrition Anemia Congestive heart failure Poor tissue perfusion

Poor tissue perfusion Chronically poor perfusion may result in hair loss in the affected area, discolored skin, thickened nails, and shiny, dry skin indicative of inadequate tissue nutrition.

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom? Weight loss Mental alertness Rapid respirations Increased urine output

Rapid respirations 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. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.

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. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. Leave the airway in place and promptly notify the health care provider for further instructions. Suction the client's mouth through the oropharyngeal airway to prevent aspiration.

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

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. Practice good hand hygiene. Avoid exposure to large crowds. Cut down on smoking.

Stay indoors as much as possible. Using the air quality index, a red color designation signifies that the air quality is unhealthy for all people, not just sensitive groups. Air pollution and high humidity are respiratory irritants. Pollutants cause increased mucus production and contribute to bronchitis and asthma. Reducing contact with irritants by staying indoors during times of increased air pollution will decrease their effect on the respiratory system. Clients should be encouraged to quit smoking, not just cut down. Avoiding large crowds and practicing good hand hygiene will prevent respiratory infections but not cut down on the effect of air pollution.

The client is reporting to the nurse that the continuous positive airway pressure (CPAP) mask is torture. What is the best response from the nurse? Would you like to talk to your health care provider concerning this? Perhaps we need to change you to a different type of mask. Can you explain to me what settings you are using? Tell me more about why it bothers you.

Tell me more about why it bothers you. First, the nurse should find out what is bothering or most concerning to the client. Then, the nurse will have a better idea of the best next step, which can include the other responses. It is possible this client will do better with a bilevel positive airway pressure (BiPAP) machine instead of a CPAP machine.

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. The nurse reminds the client to combine coughing and deep breathing. The nurse develops a specific schedule for coughing. The nurse encourages the client to cough before meals.

The nurse has the client lying in bed in semi-Fowler's position. The client should be sitting upright with feet flat on the floor to be most effective. As part of the client's plan of care, the nurse should develop a specific schedule for coughing. Coughing before meals improves the taste of food and oxygenation. When combined with deep breathing, coughing is most effective.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. 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. Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.

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. Guidelines to determine suction catheter depth include the following: 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 past the length of the endotracheal tube. Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Using a spare endotracheal or tracheostomy tube of the same size as being used for the client, insert the suction catheter to the end of the tube and note the length of catheter used to reach the end of the tube. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm.

A nurse is preparing to use a wall unit to suction an endotracheal tube. At what pressure should the suction be set? 60 to 80 mm Hg 100 to 160 mm Hg 80 to 150 mm Hg 120 to 170 mm Hg

When utilizing a wall unit to suction an endotracheal tube, the pressure should be set at 80 to 150 mm Hg. This level will provide enough pressure to suction out secretions from the endotracheal tube.

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? low pulse rate low blood pressure high temperature high respiratory rate

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.

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 peak expiratory flow rate spirometry thoracentesis

pulse oximetry Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. 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. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.

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

"He is using his chest muscles to help him breathe." The client will use accessory muscles to ease dyspnea and improve breathing.

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." "If the client's stroke volume is 60 mL and heart rate is 60 beats per minute, then the cardiac output is 3.2 L/minute." "If the client's stroke volume is 80 mL and heart rate is 80 beats per minute, then the cardiac output is 6.0 L/minute." "If the client's stroke volume is 70 mL and heart rate is 70 beats per minute, then the cardiac output is 4.7 L/minute."

"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 following formula is used to determine cardiac output: Cardiac Output = Stroke Volume x Heart Rate. A client with a stroke volume of 50 mL and heart rate of 50 beats per minute has a cardiac output of 2.5 L/minute. If stroke volume is 70 and heart rate is 70 beats per minute, then the cardiac output is 4.9 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 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? "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling." "Take in a small amount of air very quickly and then exhale as quickly as possible." "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier? "The humidifier prescribes the concentration of oxygen." "This is a gauge used to regulate the amount of oxygen that a client receives." "Small water droplets come from this, thus preventing dry mucous membranes." "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." The humidifier produces small water droplets which are delivered during oxygen administration to prevent or decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen.

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? "That will make it easier to carry with you." "That will help the oxygen flow more freely." "Call your oxygen supplier immediately." "The caregiver will need to place the oxygen tank back into the secure carrier."

"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.

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

"You should never smoke when oxygen is in use." The nurse will educate the client about the dangers of smoking when oxygen is in use. Oxygen is not flammable, but it oxidizes other materials. Other answers are inappropriate.

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? 5,550 mL (5,500 × 109/L) 5,000 mL (5,000 × 109/L) 5,850 mL (5,850 × 109/L) 6,000 mL (6,000 × 109/L)

5,850 mL (5,850 × 109/L) Cardiac output is determined by multiplying the stroke volume by the heart rate/min, which equals 5,850 mL (5,850 × 109/L). Cardiac output and peripheral resistance determine both systolic and diastolic pressures.

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 60 to 80 mm Hg 100 to 150 mm Hg 100 to 130 mm Hg

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.

In which client should the nurse prioritize assessments for respiratory depression? A client taking a beta-adrenergic blocker for hypertension A client taking opioids for cancer pain A client taking antibiotics for a urinary tract infection A client taking insulin for type 1 diabetes

A client taking opioids for cancer pain Many medications affect the function of the respiratory system and depress the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Beta-adrenergic blockers, antibiotics, and insulin do not appreciably affect the respiratory system.

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? pancreatitis chronic anemia Parkinson's disease Graves' disease

Chronic anemia The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the number 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. Graves' disease, Parkinson's disease, and pancreatitis do not directly lead to a decrease in the number of red blood cells. Graves' disease is an immune system disorder that results in the overproduction of thyroid hormones (hyperthyroidism). Parkinson's disease (PD) is a neurodegenerative disorder that affects predominately dopamine-producing ("dopaminergic") neurons in a specific area of the brain called substantia nigra that causes a movement disorder. Pancreatitis is inflammation in the pancreas.

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

Clubbing 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. Hemoptysis does not result from hypoxia.

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. atelectasis. asthma. pulmonary fibrosis.

Croup Croup and epiglottitis are common in young children. The child has an obstruction of the upper airways, with swelling of the throat tissue. Atelectasis results when the lungs collapse as a result of the alveoli being unable to expand. Symptoms include difficulty breathing and discomfort. Pulmonary fibrosis is a condition in which the lung tissue becomes stiff and unable to expand appropriately. Asthma is a condition associated with bronchoconstriction. The symptoms include nonproductive cough, dyspnea, and wheezing.

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? Encourage the client to do deep-breathing exercises. Review the medications that the client has taken in the past 90 minutes. Document this expected assessment finding. Raise the head of the client's bed slightly, if tolerated.

Document this expected assessment finding. A range of 95% to 100% is considered normal oxygen saturation. As such, there is no need to change the client's position, encourage deep-breathing exercises and coughing, or to review the client's medication history.

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

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.

The nurse is administering oxygen to an older adult client who has been assessed to have increased work of breathing. If the intervention has been effective, what finding(s) will the nurse expect on evaluation of the client? Select all that apply. Mucous membranes are pink and moist. Client is able to state the date, time and location. Respiratory rate is 33 breaths/min at rest. Oxygen saturation reads 88% on 5L of oxygen. Heart rate is 64 beats/min.

Heart rate is 64 beats/min. Mucous membranes are pink and moist. Client is able to state the date, time and location. A normal resting heart rate indicates a tolerable work of breathing. When in respiratory distress, clients will also experience tachycardia or a heart rate higher than 100 beats/min. Skin color and mucous membranes are another indicator of the client's oxygenation status. When hypoxic, a client will present as pale skinned, sometimes with bluish-ness around the mouth called cyanosis. Mucous membranes can also appear pale or blanched due to poor circulation. A client with normal work of breathing will have pink and moist mucous membranes. Level of consciousness is another indicators or normal oxygenation. If the client is oriented to day, time and place, the client has an intact level of consciousness, a sign of normal oxygenation. A respiratory rate of 33 breaths/min indicates tachypnea related to increased work of breathing. This is a sign of hypoxia. The nurse will oxygenate the client with an aim to bring the client's oxygen saturation above 90%, to ease the work of breathing. An oxygen saturation of 88% with oxygen supplementation is too low and the nurse will need to re-evaluate the effectiveness of the intervention.

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 Atelectasis Perfusion

Hypoxia 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.

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? Discard the first sputum produced by the client. Instruct the client to inhale deeply and then cough. Place the client in the dorsal recumbent position to collect the specimen. Have the client clear the nose and throat and gargle with salt water before beginning the procedure.

Instruct the client to inhale deeply and then cough. The client should be instructed to inhale deeply and cough; if this results in sputum, it should be collected in the container. The client should be placed in a semi-Fowler's position and instructed to clear the nose and throat and rinse the throat with water.

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. Page the respiratory therapist STAT. Assess the client's respiratory status and check vital signs every 1 minute for the next hour. Cover the tracheostomy stoma and apply oxygen by nasal cannula

Maintain the client's oxygenation and alert the health care provider immediately. If the tracheostomy becomes dislodged and is not easily replaced, the nurse should notify the primary care provider immediately, cover the tracheostomy stoma, and assess client's respiratory status.

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? Nonrebreather mask Partial rebreather mask Nasal cannula Simple mask

Nasal cannula A nasal cannula is used to deliver from 1 L/min to 6 L/min of oxygen. Masks are used with higher flow rates of oxygen.

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

Pulmonary function tests Pulmonary function testing is used to measure lung size and airway patency. 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? Total lung capacity (TLC) Residual Volume (RV) Forced Expiratory Volume (FEV) Tidal volume (TV)

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. Tidal volume 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.

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 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 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 adjusts the bed to a comfortable working position.

The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). 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), but not in an acute instance. Adjusting the bed to a comfortable working position prevents back and muscle strain. Explanation alleviates fears; even if the client appears unconscious, the nurse should explain what is happening. When tracheostomy is new, pain medication may be needed before performing tracheostomy care.

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 loud, high-pitched sounds heard primarily over the trachea and larynx. They are soft, high-pitched discontinuous (intermittent) popping lung sounds. They are medium-pitched blowing sounds heard over the major bronchi. They are low-pitched, soft sounds heard over peripheral lung fields.

They are low-pitched, soft sounds heard over peripheral lung fields. Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

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 medium-pitched blowing sounds heard over the major bronchi. They are low-pitched, soft sounds heard over peripheral lung fields. They are soft, high-pitched discontinuous (intermittent) popping lung sounds. They are loud, high-pitched sounds heard primarily over the trachea and larynx.

They are low-pitched, soft sounds heard over peripheral lung fields. Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

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? Crackles Stridor Absent breath sounds in lower lobes Wheezing

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.

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. bronchiectasis. bronchiolitis. bronchitis.

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 volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing: bronchiectasis. bronchitis. a bronchospasm. bronchiolitis.

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.

In which client would the nurse assess for a depressed respiratory system? a client taking opioids for cancer pain a client taking insulin for diabetes a client taking antibiotics for a urinary tract infection a client taking amlodipine for hypertension

a client taking opioids for cancer pain Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Amlodipine is a calcium channel blocker and the medication decreased blood pressure, so the nurse would need to assess blood pressure. Antibiotics are used for urinary tract infections as well as other infections and the infections do not affect the respiratory system. Insulin decreases blood sugar which a person with diabetes may need to take every day. Insulin does not affect the respiratory system.

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

adequate tissue perfusion. 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 has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from: lung cancer. congestive heart failure. pulmonary embolism. myocardial infarction.

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

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 normal saline mineral oil tap water

distilled water Distilled water is used when humidification is desired. Other answers are incorrect.

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 oxygen analyzer nasal strip nasal cannula

flow meter 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.

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 face tent nonrebreather mask simple mask

nasal cannula 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. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Nonrebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.

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: asthma. alcohol use. croup. pneumonia.

pneumonia. 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. Croup, asthma, and alcohol use do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol use depresses the central respiratory center.

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? loss of sterile field trauma to the tracheal mucosa prevention of suctioning suctioning of carbon dioxide

trauma to the tracheal mucosa 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.