Gas Exchange Exam 4
3) Respiratory rate: 14 4) Blood pressure: 110/70 5) Oxygen saturation: 92%
A 50 y.o. client with a 30-yr history of smoking reports a chronic cough and a shortness of breath r/t COPD. The clinical data on admission are as follows: HR: 100, BP of 138/82, a RR: 32, tympanic membrane temp of 99F, and an oxygen saturation of 880%. Which VS obtained by the nurse during the therapy indicates a positive outcome? SATA. 1) radial pulse: 70 2) temp 99F 3) RR: 14 4) BP 110/70 5) O2 92%
3) Schedule nursing activities to allow for rest
A client complaining of fatigue is admitted to the hospital with a diagnosis of COPD. What should the nurse do to prevent fatigue? 1)Provide small, frequent meals 2) Encourage pursed-lip breathing 3)Schedule nursing activities to allow for rest 4) Encourage bed rest until energy level improves
1) Course crackles
A client has been admitted for COPD exacerbation secondary to an upper respiratory tract infection. The nurse should expect which findings when auscltating the client's breath sounds? 1) course crackes 2) prolonged inspiration 3) short, rapid inspiration 4) normal breath sounds
3) orthopenic
A client is admitted to the hospital with a dx of emphysema and dyspnea. The nurse should encourage the client to assume what position? 1) supine 2) contour 3) orthopenic 4) semi-fowlers
2) Expected course of pneumonia
A client is admitted with a tentative diagnosis of pnuemonia. On admission, the client is not in respirator distress, but later develops chest pain, and a fever of 103F. A productive cough produces rust-colored sputum. How should the nurse interpret these findings? 1) Onset of pulmonary edema 2) Expected course of pneumonia 3) Precense of a pulmonary embolus 4) Insidious onset of tuberculosis
3) Obstructive sleep apnea
An obese smoker complains of feeling sleepy during the daytime, waking up tired in the morning, and snoring heavy while sleeping. The client is found to have enlarged tonsils. Which condition may the patient have? 1) Laryngeal trauma 2) Vocal cord paralysis 3) Obstructive sleep apnea 4) Subcutaneous Emphysema
1) oxygen saturation 89%
An older client with SOB is admitted to the hospital. The medical history reveals hypertension in the last year and a diagnosis of pneumonia three days ago. which vs assessment would be seen as a sign that the client needs immediate medical attention? 1) o2 sat 89% 2) body temp 101F 3) BP: 130/80 4) RR: 26
3) Mental Confusion
The arterial blood gases of a client with COPD deteriorate, and respiratory failure is impending. Which clinical indicator should the nurse assess first? 1) cyanosis 2) bradycardia 3) mental confusion 4) distended neck veins
4) Diaphragmatic excercises to improve contraction of the diaphragm
What breathing excercises should the nurse teach a client with a diagnosis of emphysema? 1)An inhalation that is prolonged to promote gas exchange 2) abdominal excercises to limit the use of accessory muscles 3) Sit-ups to help strengthen the accessory muscles of respiration 4) diaphragmatic excercises to improve contraction of the diaphragm
3) Monitoring breathing status
What is a nursing priority to prevent complications in clients with respiratory acidosis? 1) Assessing the nail beds 2) Listening to breath sounds 3) Monitoring breathing status 4) Checking muscle contractions
2) Employ breathing exercises ad controlled coughing
When caring for a client with pneumonia, which nursing intervention is the highest priority? 1) Increase fluid intake 2) Employ breathing exercises and controlled coughing 3) Ambulate as much as possible 4) Maintain a NPO status
4) Pleural friction rub
When performing a respiratory assessment of a client with pneumonia, what sound should the nurse expect to hear? 1) rhonchi 2) fine crackles 3) coarse crackles 4) pleeural friction rub
1) headache 2) irritability 3) restlessness
Which of the following are associated with respiratory acidosis? SATA 1) headahce 2) irritability 3) restlessness 4) hypertension 5)lightheadedness
2) ceftriaxone Streptococcus pneumoniae causes pneumococcal pneumonia. The drug preferred for the disease caused by this bacterium is ceftriaxone.
A client is hospitalized with pneumococcal pneumonia. Which drug will the nurse most likely administer? 1) penicillin g 2) ceftriaxone 3) vancomycin 4) meropenem
1) tremors 3) palpitations
A client is prescribed albuterol to relieve sever asthma. What adverse effect will the nurse instruct the client to anticipate? SATA 1) tremors 2) lethargy 3) palpitations 4) visual disturbances 5) decreased pulse rate
3) Respiratory acidosis
A client with COPD has a ph of 7.25 and pCO2 of 60mmHg. These blood gases require nursing attention because they indicate which condition? 1) Metabolic acidosis 2) Metabolic alkalosis 3) Respiratory acidosis 4) Respiratory alkalosis
2) Imbalanced nutrition: less than body requirements, related to fatigue
A client with COPD states, " I have had steady weight loss, and I am often too tired to eat." Which nursing diagnosis would be most appropriate for this patient? 1) Fatigue related to weight loss secondary to COPD 2) Imbalanced nutrition: less than body requirements, related to fatigue 3) Imbalanced nutrition: less than body requirements, related to COPD 4) Ineffective breathing pattern, related to alveolar hypoventilation
2) increase fluid intake to at least 2L
A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained secretions. To decrease the amount of secretions retained, what should the nurse do? 1) administer continous o2 2) increase fluid intake to at least 2L 3)Place the client in high-fowlers 4) instruct the client to gargle deep in the throat, using warm sterile water
1) "Tell me about your typical day before the excercises were prescribed".
A client with chronic bronchitis smokes one or 2 cigarettes a day and has not been performing the prescribed pulmonary physiotherapy excercises because they are too long. Which is the best response by the nurse? 1)" Tell me about your typical day before the excercises were prescribed" 2)"Smoking is probably the cause of the severity of your diseasae at this time" 3)I can't make you stop doing what you are doing, and it's your chouse to be sick or well." 4) "Your being so sick is probably because of your smoking and you choosing not to excercise."
4) Difficulty in expelling the air trapped in the alveoli
A client with emphysema experienced SOB and uses pursed-lip breathing and acessory muscles od respiration. The nurse determines that the cause of the dyspnea is for which reason? 1) Spasm of brochi that traps the air 2) Increase in the vital capacity of the lungs 3) Too rapid expulsion of air from the bronchioles 4) Difficulty in expelling the air trapped in the alveoli
4) suggest that the client limit smoking to one pack of cigarretes a day
A client with emphysema has a history of smoking 2 packs a day. What is the best approach for the nurses to help the client stop smoking? 1)Teach pursed-lip breathing 2) encourage the client to reduce emotional stress 3) Obtain a referral to a smoking-cessation program in the community 4) suggest that the client limit smoking to one pack of cigarettes a day
3) Decreased sounds
A client with emphysema is admitted to the hospital with pneumonia On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is mostt likely to be present when the nurse assesses the client's right side? 1)Crackling 2) Wheezing 3) Decreased Sounds 4) Adventitious Sounds
2) "Ill cut back to half a pack a day."
A nurse provides smoking-cessatoin education to a client with COPD. The nurse concludes that the client is ready to quit smoking when the client makes which statement? 1) "I'll just finish the carton that I have at home" 2) " I'll cut back to half a pack a day" 3) I'll find that smoking is the only way I can relax." 4) "I should find this easy because I don't smoke when I drink".
4) Watch for white patches in the mouth and report them to the primary HCP
The nurse is caring for a 6-y.o. child admitted to the ED after an acute asthma attack. The child has a new prescription of fluticasone. What instructions must the family be given about this drug before the discharge? 1) Fluticasone needs to be taken with food or milk 2) Fluticasone is primarily used to treat acute asthma attacks 3) The child should suck on hard candy to help relieve dry mouth 4) Watch for white patches in the mouth and report them to the primary HCP
