Chapter 39: Oxygenation and Perfusion (1)
The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier? pg. 1503
"Small water droplets come from this, thus preventing dry mucous membranes."
A client, 90 years of age, has been in a motor vehicle collision and sustained four fractured ribs on the left side of the thorax. The nurse recognizes the client is experiencing respiratory complications when which sign(s) is observed? Select all that apply. pg. 1490
- The client's capillary refill is assessed at 4 seconds. - The client demonstrates restlessness. - The client has uneven movements of the chest with respirations. - The client has flaring nostrils.
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? pg. 1524-1527
Document this expected assessment finding.
Which teaching about the humidifier is important for the nurse to provide to a client using oxygen? pg. 1490
It decreases dry mucous membranes via delivering small water droplets.
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? pg. 1483
Stay indoors as much as possible.
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? pg. 1494
Wheezing
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? pg. 1503
educating the client on the use of incentive spirometry
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? pg. 1509
nasal cannula
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: pg. 1491-1492
a bronchospasm.
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: pg. 1483-1503
"He is using his chest muscles to help him breathe."
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? pg. 1510-1511
Check the fit of the oxygen mask.
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? pg. 1497
Pleural effusion
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the mostappropriate intervention in this situation? pg. 1515
Remove the airway, turn the client to the side, and provide mouth suction, if necessary.
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? pg. 1496
Residual Volume (RV)
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? pg. 1494
They are low-pitched, soft sounds heard over peripheral lung fields.
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: pg. 1489-1494
crackles.
Oxygen and carbon dioxide move between the alveoli and the blood by: pg. 1484
diffusion.
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? pg. 1508
flow meter
A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered? pg. 1509
nasal cannula
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? pg. 1496
pulse oximetry