Ch 40 prepu oxygenation and perfusion

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: a. he is using his chest muscles to help him breathe b. he will require additional testing to determine the cause c. his infection is causing him to breathe harder d. his lung muscles are swollen so he is using abdominal muscles

a

What assessments would a nurse make when auscultating the lungs? a. air flow through respiratory passages b. volume of air exhaled or inhaled c. abnormal chest structures d. presence of edema

a

Which should the nurse teach the family about caring for a client with emphysema at home? Select all that apply. a. create long term caregiving plan b. maintain smoke-free environment c. watch for increased wheezing of signs of a flare up d. follow tcp's prescription for oxygen administration e. take advantage of pulmonary rehabilitation programs

a, b, c, d, e

A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply. a. nasal cannula b. venturi mask c. humidified venturi mask d. simple oxygen mask e. partial rebreather mask

a, d, e

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? a. flow meter b. nasal cannula c. oxygen analyzer d. nasal strip

a. flow meter

The nurse is assessing a neonate whose breathing ceased for 4 to 5 seconds on three different occasions. What is the nurse's best action? a. obtain an order for airway suctioning as needed b. reposition infant to promote adequate oxygenation c. document these expected apnea episodes d. arrange for immediate assessment by pcp

a. suction

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? a. tracheostomy collar b. simple mask c. nasal cannula d. face tent

a. t collar

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention? a. contact hcp to report pt current status b. ask pt what factors contribute to nonadherence c. explain use of bipap instead of cpap d. document outcomes of modifications in care

b

The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis? a. low bp b. high rr c. low pulse rate d. high temp

b

An older adult client was recently placed on home oxygen. The client's caregiver reports that the client now refuses to leave the house. What teaching will the nurse provide the caregiver? Select all that apply. a. remove oxygen for times when pt wants to leave house b. discuss w pt switching to a portable oxygen device c. invite friends and fam to pt house d. give pt time to adjust e. continued socialization w others is important

b, c, e

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: a. diminished stroke volume b. adequate tissue perfusion c. high cardiac output d. heart failure

b. adequate tissue perfusion

A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client? a. thoracentesis b. spirometry c. pulse ox d. peak expiratory flow rate

c

A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action? a. raise head of bed slightly, if tolerated b. review meds that pt has taken in past 90 minutes c. document this expected assessment finding d. encourage pt to do deep breathing exercises

c

A parents brings their 2-year-old to the emergency department in respiratory distress. SThe child's oxygen saturation is 81% and there is audible stridor. What intervention will the nurse anticipate? a. chest physiotherapy b. corticosteroids by metered-dose inhaler c. placement in an oxygen tent d. deep breathing and coughing exercises

c oxygen tent

A parents brings their 2-year-old to the emergency department in respiratory distress. SThe child's oxygen saturation is 81% and there is audible stridor. What intervention will the nurse anticipate? a. we are concerned about you developing a snoring habit, so we encourage nasal breathing first b. breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation c. breathing through your nose first will warm, filter, and humidify the air y

c warm, filter, humidify

The nurse is caring for a client who is wearing oxygen via nasal cannula. The client asks about the bubbling water attached to the oxygen. Which response by the nurse is appropriate? a. it determines whether you are getting enough oxygen b. it prescribes oxygen concentration c. it regulates the amount of oxygen received d. it decreases dry mucous membranes by delivering small water droplets

d

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? a. nonrebreather b. face tent c. simple mask d. nasal cannula

d nasal cannula

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? a. page the RT STAT b. assess pt respiratory status and check VS q1 minute for next hr c. cover tracheostomy stoma and apply oxygen by nasal cannula d. maintain pt's oxygenation and alert hcp immediately

d. maintain oxygenation and immediately alert hcp

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. a. true b. false

true