gas exchange
During oxygen administration to the client, which of the following pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?
Flowmeter
A client has smoked most of his life and has labored respirations. He is experiencing
Dyspnea
A patient returns to the telemetry unit after an operative procedure. Which of the following diagnostic tests will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the patient?
Pulse oximetry
The nurse is assessing a client with chronic obstructive pulmonary disease. The client weighs 200 lb (90.7 kg) and is 6 feet (183 cm) tall. Using the diagram shown here, how should the nurse describe the client's chest in the record in the health history?
barrel-shaped
The nurse is providing care for a 69-year-old male patient who has been admitted to the hospital for the treatment of pneumonia. Auscultation of the patient's lungs reveals the presence of discontinuous, popping sounds during inspiration over the lower lung fields. Which of the following should the nurse document the presence of?
crackles
Which documentation would indicate nursing actions were effective in reducing breathing problems for a client? Select all that apply.
-anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min -lung sounds clear bilaterally with non-labored respirations noted
The nurse is caring for a patient with COPD. The patient is receiving oxygen therapy via nasal cannula. The nurse understands that the goal of oxygen therapy is to maintain the patient's SaO2level at or above what percent?
90%
The nurse is conducting the physical assessment of a client at the health care facility. The nurse uses the pulse oximetry technique to monitor the oxygen saturation in the client's blood. Which of the following pulse oximeter ranges indicates that the client is adequately oxygenated?
95%-100%
A nurse uses observation to examine a patient's skin. Which patient would the nurse document as having cyanosis?
A patient whose skin is a dusky, bluish color
If concern exists about fluid accumulation in a client's lungs, what area of the lungs will the nurse focus on during assessment?
Bilateral lower lobes
When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. How should the nurse should record the breathing pattern?
Cheyne-Stokes respiration
A client appears to be breathing faster than during the last assessment. Which of the following interventions should the nurse perform?
Count the rate of respirations.
Which of the following is a late sign of hypoxia?
Cyanosis
The nurse is conducting a respiratory assessment of a 71-year-old patient who has been recently admitted to the hospital unit. Which of the following assessment findings should the nurse interpret as abnormal?
Fine crackles to the bases of the lungs bilaterally
A patient with a history of chronic respiratory illness exhibits nail clubbing. The nurse interprets this finding as indicating which of the following?
Hypoxia
The nurse assesses a patient 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
The nurse is assessing an elderly client brought to the emergency department by her spouse. The spouse states, ?She is confused and had trouble when trying to take a breath.? The nurse would next implement which priority nursing intervention for this client who is experiencing these symptoms?
Obtain baseline vital signs and oxygen saturation
Following admission of the postoperative client to the clinical unit, which of the following assessment data requires the most immediate attention?
Oxygen saturation of 82%
A nurse is providing end-of-life care to a terminally ill client. Which of the following actions should the nurse take to remove mucus and saliva from the client's mouth?
Perform suction in the client's mouth.
A physician stated to the nurse that the patient has fluid noted in the pleural space and will need a thoracentesis. The nurse would expect that the physician will document this fluid as which of the following?
Pleural effusion
A patient vomits as a nurse is inserting his oropharyngeal airway. What would be the appropriate intervention in this situation?
Remove the airway, turn the patient to the side and provide mouth suction, if necessary.
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which of the following describes these sounds?
Rhonchi
Upon auscultation of a patient's lung fields, the nurse hears a continuous high-pitched sound on expiration. These are characteristics of which adventitious breath sound?
Wheezes
After suctioning a client's tracheostomy tube, the nurse waits a few minutes before suctioning again. The nurse should use intermittent suction primarily to help prevent:
depriving the client of sufficient oxygen supply.
A child is admitted to the emergency department with dyspnea related to bronchospasms. The nurse should place the client in which position?
high Fowler's
Which of the following terms is used to describe the inability to breathe easily except in an upright position?
orthopnea
The nurse auscultates lung sounds that are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as
pleural friction rub.
The term for the volume of air inhaled and exhaled with each breath is
tidal volume
Knowing respiratory physiology is important to understand how the disease process can work within that system. Which hollow tube transports air from the laryngeal pharynx to the bronchi?
trachea
A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?
use of accessory muscles
