Fundamentals PrepU: Chapter 39

Which response(s) will the nurse provide to a client concerned about developing chronic bronchitis due to smoking cigarettes, working with printing chemicals, and living near a paper mill? Select all that apply.

1) "Have you tried to stop smoking? This can reduce your risk?" 2) "We can refer you to a smoking cessation program to help reduce developing any future pulmonary issues." 3) "How long have you lived near the paper mill? This can increase you risk for chronic bronchitis and asthma." 4) "Exposure to printing chemicals increases the risk for allergies which can trigger chronic bronchitis, so wearing a breathing mask may be needed."

The nurse is caring for a client who is experiencing an acute exacerbation of asthma. The nurse will explain to the client that after receiving the nebulized albuterol, the client can expect to experience which potential side effect(s) of this medication? Select all that apply.

1) tachycardia 2) nausea 3) lightheadedness 4) sore throat 5) nervousness

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL and a pulse of 78 beats/min. What number would the nurse document for this assessment?

5,850 mL

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?

Apply oxygen

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.

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

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?

Document this expected assessment finding.

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 smaller meals that are high in protein.

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.

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?

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

Poor tissue perfusion

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)

The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign?

Respiratory rate and depth

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?

Tell me more about why it bothers you.

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: 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.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

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.

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?

Vesicular

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.

In which client would the nurse assess for a depressed respiratory system?

a client taking opioids for cancer pain

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.

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

crackles.

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 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

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?

high respiratory rate

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

An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize?

"Is your mask causing discomfort?"

The nurse determines that the student who has been instructed about lung function and smoking requires additional teaching when the student says

"Smoking only once in a while will not make a person addicted to smoking."

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."