Craven ch 30- Respiratory function
A nurse needs to use a wall suction machine on an adult client with breathing difficulties due to chest congestion, as per the order from the client's health care provider. What amount of negative pressure should the nurse apply for this client?
100 to 140 mmHg
The nurse is preparing to perform nasopharyngeal suctioning on an adult using a wall unit. What is the appropriate suction pressure setting for an adult?
100-120 mm Hg
A client with a diagnosis of stage II Alzheimer's disease also has a history of chronic obstructive pulmonary disease (COPD). Which medication delivery system is most appropriate for this client?
Neubuliser
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?
Non-rebreather mask
An infant with a small toy lodged in the trachea is crying. What is the nurse's priority action?
Observe the infants respiratory effort
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 55 mmHg
The nurse is reviewing the results of a client's arterial blood gas and pH analysis. Which findings indicate to the nurse that intervention is not required? Select all that apply.
Ph 7.5, PCO2 40 mm Hg, base excess or deficit +2 mmol/L
A nurse conducts a health history for a client with chronic bronchitis. Which action does the nurse take first when the client begins to experience respiratory distress?
Place the client in a comfortable position, ensure an open airway and if oxygen is prescribed start administration
A 72 year-old client 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 nurse is preparing to insert an oral airway on an unconscious client. How should the nurse proceed?
Position the client with the neck hyperextended.
The health care provider has prescribed a short acting beta 2 agonist for a client with a history of bronchospasm. What teaching about this drug will the nurse include?
This drug is to be used as a rescue inhalant
The health care provider has prescribed a short-acting beta-2 agonist (SABA) for a client with a history of bronchospasm. What teaching about this drug will the nurse include?
This drug is to be used as a rescue inhalant.
The health care provider directs the nurse to use oropharyngeal suctioning to remove liquid secretions for a client with a respiratory problem. What is oropharyngeal suctioning?
removing secretions from the throat through an orally inserted catheter
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)
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
The home health nurse is visiting a new client who has recently started using an oxygen concentrator. After assessing the home environment, which comment should the nurse prioritize?
"Have you discussed a back-up system with your health care provider in case your electricity goes out?"
A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?
"I can assist you to the bathroom and back to bed."
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."
A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them?
"It is inserted into the space between the lining of the lungs and the ribs."
The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach?
"Take in as much air as possible, hold your breath briefly, and exhale slowly."
The nurse is preparing to discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach?
"Take in as much air as possible, hold your breath briefly, and exhale slowly."
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 caring for a client at risk for pneumonia after having major abdominal surgery. Which nursing instructions is essential for use of an incentive spirometer? Select all that apply.
-Splint the abdomen with a pillow to decrease discomfort prior to use. -Instruct the client to exhale normally and then place lips securely around the mouthpiece. -Encourage the client to complete breathing exercises about 5 to 10 times every 1 to 2 hours, if possible. -Assist the client to an upright or semi-Fowler position.
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."
Oxygen Tent
- best tolerated technique for infants and small pediatric patients -tent like device used to deliver high levels of oxygen to a bedridden pt -used for humidification/oxygen
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 min
The nurse is caring for four clients. Which client does the nurse identify who would best benefit from chest physiotherapy?
21-year-old client with cystic fibrosis
A client is receiving oxygen therapy via a nasal cannula at 3 L/min. The nurse estimates that the client is receiving which concentration of oxygen?
30%
A nurse assesses the vital signs of a healthy newborn infant. What respiratory rate could be expected based on the developmental level of this client?
30-60 breaths/minute
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
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?
80-100 mm Hg
A client is receiving supplemental oxygen and the nurse is monitoring the client's oxygen saturation level using pulse oximetry. The nurse notifies the health care provider if the client reaches which oxygen saturation level?
92%
What prevents air from reentering the pleural space when chest tubes are inserted?
A closed water-seal drainage system
Flowmeter
A device on oxygen cylinders used to control and measure the flow of oxygen
A nurse admitting a 6 year old child after a tonsillectomy to the surgical unit. The nurse obtains the clients weight and places ekg leads on the chest and a pulse ox on the left finger. The clients heart rate reads 100 bpm and the pulse ox reads 99%. These readings best indicate
Adequate tissue perfusion
A client with chronic obstructive pulmonary disease who uses supplemental oxygen via mask requires oral suctioning. Which action demonstrates the components of appropriate oral suctioning technique by the nurse? Select all that apply.
Allowing client to rest for 30-60 sec in between suctionings Removing the clients oxygen and inserting the yankauer catheter into clients mouth Replacing oxygen on client and clearing out suction Cather by placing yankauer in the basin of the water Running the catheter along the clients gum line to the pharynx on a cocer motion while keeping yankauer moving
Gas exchange in the lungs takes place between the walls of the
Alveoli
What is the name of tiny air sacs found in the lungs?
Alveoli
A nurse uses a simple mask to administer oxygen to a client with nasal trauma who breathes through the mouth. What is the minimum amount of oxygen delivered to the client using a simple mask? A) 5 L/min B) 4 L/min C) 3 L/min D) 2 L/min
Ans: A Feedback: When a simple mask is used for a client with nasal trauma who breathes through the mouth, oxygen is delivered at no less than 5 L/min. A simple mask, like other types of masks, allows the administration of higher levels of oxygen than are possible with a cannula. A simple mask is sometimes substituted for a cannula when a client has nasal trauma or breathes through the mouth. When a simple mask is used, oxygen is delivered at no less than 5 L/min.
A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply. A) Monitor the client's respiratory rate. B) Note the amount of oxygen administered. C) Check the symmetry of the client's chest. D) Observe the breathing pattern and effort. E) Check the devices used to deliver oxygen.
Ans: A, C, D
While jogging through the neighborhood, a nurse witnesses the collapse of a nearby jogger and suspects cardiac arrest. Which action should the nurse take first?
Assess the victim for consciousness.
Inspired air will pass directly from the trachea into which of the following structures?
Bronchi
What do you call the tiny hairs that keep mucus and dirt out of your lungs?
Cilia
The nurse is caring for a client with respiratory acidosis. Which arterial blood gas data does the nurse anticipate finding?
pH less than 7.35; HCO3 high; PaCO2 high
Which technique would the nurse employ to maximize the effectiveness of postural drainage?
Combine it with percussion and vibration.
The nurse provides care for the client with chronic obstructive pulmonary disease experiencing hypoxia. Which assessment prompts the nurse to immediately report findings to the health care provider?
Decreased level of consciousness
Which muscle allows for quiet inhalation?
Diaphragm
A client at a long-term care facility reports to the nurse that "stuff" feels like it gets stuck in the throat when the client tries to clear the throat first thing in the morning. Which action should the nurse recommend the client try?
Do deep breathing exercises several times per day
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
A chest drainage system is being chosen for a client who is ambulating daily. Which system would be the best choice for this client?
Dry suction/one-way valve system
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.
Which is the best response by the nurse to the client being prepared for a tracheostomy placement who verbalizes concern about not being able to speak after the procedure?
I hear you saying that not being able to speak is a concern so let's talk with your health care provider and speech therapist about the possibility of using a 'talking' tracheostomy tube."
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease. Which teaching about deep breathing will the nurse include?
Inhale slowly over three seconds purse your lips contract abd muscles and exhale slowly.
Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen?
It regulates the amount of oxygen received.
A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?
Prolonging expiration to reduce airway resistance
A nurse is caring for a client with a tracheostomy tube in place who has rhonchi bilaterally and a SaO2 of 94%. If the client is unsuccessful in coughing up secretions, what action should the nurse take?
Put on sterile gloves and use a sterile catheter to suction.
A nurse is delivering oxygen to a client via an oxygen mask. Which guideline is recommended for this procedure?
Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously.
Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system?
Slightly contoured chest w no sternal depression Anteroposterior diameter of the chest less than the transverse diameter Bronchial, vesicular, and bronchovesicular breath sounds
The nurse is caring for an older adult client who worked in a coal mine for 40 years. Which finding(s) does the nurse anticipate upon assessment of the client's respiratory system? Select all that apply
Sob, chest tightness/discomfort, winded at rest and w activity, cough w or w out Black sputum
The 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
What can a nurse ask a client to do before suctioning to prevent hypoxemia?
Take several deep breaths
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
accessory muscles
The secondary muscles of respiration. They include the neck muscles (sternocleidomastoids), the chest pectoralis major muscles, and the abdominal muscles.
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic or vesicular breath sounds?
They are low pitched soft sounds heard over peripheral lung fields.
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 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 nurse caring for a client with a chest tube should monitor the patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.
The nurse is assessing a client with a history of asthma. Which assessment finding indicates that the nurse should take immediate action?
Use of accessory muscles in breathing
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 the drug daily to prevent bronchospasm
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 the heel of one hand to administer back blows.
A client has just returned from getting a new tracheostomy inserted. When the nurse enters the room, the client is cyanotic, with the tracheostomy tube lying on the bed. What is the nurse's priority action?
Ventilate the client with a resuscitation bag with mask.
The nurse auscultates the lungs of a client with asthma who reports sob sore throat and congestion. Which finding does the nurse expect to document?
Wheezing
Which scenario describes how carbon dioxide levels determine the frequency and depth of ventilation?
When carbon dioxide levels in the blood increase, chemoreceptors are stimulated, causing deeper and more rapid breathing.
A nurse is preparing to orally suction a client with dysphagia following a stroke. Which suction device is appropriate?
Yankauer catheter
A client is experiencing hypoxia. Which nursing concern is appropriate to address when planning care?
anxiety
What does a pulse oximeter 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
A client has just arrived to the postanesthesia care unit (PACU) after surgery with an oral airway in place. What action should the nurse prioritize if noting mild cyanosis around the lips, respiratory rate of 22 breaths/min, and shallow and diminished breath sounds in both lower lobes?
check oral airway device
The nurse is creating a plan of care for a client with ineffective airway clearance related to a weak, persistent cough. What expected outcome will the nurse identify for the client?
clear airway as evidenced by clear lung sounds by Friday
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
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
The nurse is caring for a 2-year-old client who experienced smoke inhalation during a house fire. When oxygen is prescribed, what delivery device will the nurse gather?
oxygen tent
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
The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing concern for this client is altered airway clearance related to copious and tenacious secretions. What is an appropriate nursing intervention to include in the client's care plan?
encouraging the client to consume at least 1.5 to 2 L of fluids daily of clear fluids daily
What prevents food or water from entering in the trachea?
epiglottis
The health care provider at the health care facility directs the nurse to perform vibration along with percussion on a frail client with a respiratory diagnosis. What is a possible outcome of performing vibration on the client?
helps shake underlying tissue and loosen the retained secretion
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
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
Oxygen hoods are generally used to deliver oxygen at rates approaching 100% to which developmental group?
infants
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
Which physiologic change does the nurse anticipate will be found in the older adult client with an ongoing nonproductive cough?
laryngeal atrophy
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
A nurse at a health care facility uses a tonsil-tip catheter to remove the secretions from the mouth of a client with chest congestion. Which suctioning technique is the nurse using in this case?
oral suctioning
A nurse is completing tracheostomy care on a client with an inner cannula. Which supply will the nurse use to clean and dry the inner cannula?
pipe cleaners
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
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?
pulmonary function tests
The nurse is caring for a client who has excess levels of carbon dioxide in the blood, and chronic hypoxemia. Which intervention will the nurse recommend?
pursed lip breathing
The pharynx is also known as the
throat
A client with a head injury will require long-term airway support. Which device will be required for this client?
tracheostomy tube
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
Trachea is also called
windpipe
Which actions should a nurse perform when inserting an oropharyngeal airway?
• Wash hands and put on PPE, as indicated. • Rotate the airway 180 degrees as it passes the uvula. • Remove airway for a brief period every 4 hours or according to facility policy.
