Oxygenation and Gas Exchange- PrepU

The nurse identifies which finding to be most consistent prior to the onset of acute respiratory distress?

Normal lung function

Which item must the nurse consider when positioning a client for tracheal suctioning?

Position in a semi-Fowler's position.

A G3P2 woman at 39 weeks' gestation presents highly agitated, reporting something "came out" when her membranes just ruptured. Which action should the nurse prioritize after noting the umbilical cord is hanging out of the vagina?

Put her in bed immediately, call for help, and hold the presenting part of the cord.

As status asthmaticus worsens, the nurse would expect which acid-base imbalance?

Respiratory acidosis

A nurse is in the cafeteria at work. A fellow worker at another table suddenly stands up, leans forward with hands crossed at the neck, and makes gasping noises. The nurse first

Stands behind the worker, who has hands across the neck

Which client would a nurse monitor most closely for postoperative respiratory complications?

a 55-year-old client with a history of asthma who had a colon resection

The nurse is encouraging a client to cough frequently and complete deep breathing exercises. The nurse knows that many factors can cause a decrease of gas exchange for clients. Based on this information, what factors can cause a decrease in gas exchange? Select all that apply.

Immobility Thoracic/pulmonary surgery Pneumonia

The nurse is caring for a client with Guillain-Barré syndrome. Which assessment finding would indicate the need for oral suctioning?

Increased pulse rate, adventitious breath sounds

Which is the priority nursing diagnosis for a client undergoing a laryngectomy?

Ineffective airway clearance

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

Ineffective airway clearance related to edema of the respiratory passages

An elderly client exhibits blood pressure of 110/76 while prone, 100/72 sitting, and 92/64 standing. The nurse instructs the client to

Ingest five or six small meals each day.

The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique?

It prolongs exhalation.

An infant with poor feeding is suspected of having a congenital heart defect. The parents are asking why a chest x-ray is necessary in their infant. What is the best response from the nurse?

It will determine if the heart is enlarged.

Which cells release erythropoietin and renin in response a decrease in the pressure of the blood entering the glomerulus?

Juxtaglomerular cells

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Light-headedness or paresthesia

The most important nursing priority of treatment for a patient with an altered LOC is to:

Maintain a clear airway to ensure adequate ventilation.

The nurse is assessing the respiratory status and lungs of a 6-year-old child. What finding would the nurse report immediately?

Minimal air movement through the lungs

A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease (COPD). The first action of the nurse is to administer which of the following prescribed treatments?

Oxygen through nasal cannula at 2 L/minute

What is the most common cause of anaphylaxis?

PCN

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher.

An older adult client who was recently diagnosed with emphysema asks the nurse what caused the disease. Which statement is the best response?

"One of the causes of emphysema is a history of cigarette smoking that causes damage to the lungs. Have you ever smoked?"

Approximately what percentage of people who are initially infected with TB develop active disease?

10%

A mother asks the nurse how to swaddle her newborn because she heard that it helps infants calm down. Which statement will the nurse include in the teaching?

"Wrapping the infant too tightly can impaired breathing."

After instituting interventions to increase oxygenation, the client shows no signs of improvement. What is the nurse's priority action?

Communicate with the physician for additional orders.

What is the normal tidal volume for a person at rest?

500mL

The nurse is caring for four clients. Select the client at risk for the development of a pulmonary embolism.

A 62-year-old male who is postoperative for repair of a fractured femur

The infection control nurse at a large hospital has instituted a new education campaign aimed at reducing the incidence of hospital-acquired pneumonia (HAP). The nurse should identify which client as being particularly susceptible to hospital-acquired pneumonia?

An intubated client who is ventilator dependent following a traumatic head injury

A client arrives at the ED with an exacerbation of left-sided heart failure and reports shortness of breath. Which is the priority nursing intervention?

Assess oxygen saturation

The nurse is administering oxygen by face mask to a client. Which action will the nurse include?

Assist the client to the semi-Fowler's position if possible.

A client at 35 weeks' gestation is now in stable condition after being admitted for vaginal bleeding. Which assessment should the nurse prioritize?

Fetal heart tones

A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected?

Flail Chest; When a flail chest exists, during inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. On expiration, because the intrathoracic pressure exceed atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale.

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?

Hypercapnia, hypoventilation, and hypoxemia

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation.

A student nurse is working with a client who is diagnosed with head trauma. The nurse has documented Cheyne-Stokes respirations. The student would expect to see which of the following?

Regular breathing where the rate and depth increase, then decrease; Observing the rate and depth of respiration is an important aspect of the nursing assessment. Certain patterns of breathing are characteristic of specific disease states or conditions. Head trauma can cause damage to the respiratory center in the brain, thereby altering the rate and depth of respirations. Cheyne-Stokes breathing is characterized by a regular cycle in which the rate and depth of breathing increase, then decrease until apnea occurs.

A child is brought to the emergency department with an asthma attack. Assessment revealed the use of accessory muscles, a weak cough, audible wheezing sound, moist skin, and tachycardia. Which drug will the nurse anticipate administering first?

Short-acting beta 2-adrenergic agonists such as albuterol (SABA); The quick-relief medications such as SABA (e.g., albuterol, levalbuterol, pirbuterol) relax bronchial smooth muscle and provide prompt relief of symptoms, usually within 30 minutes. They are administered by inhalation (i.e., metered-dose inhaler or nebulizer), and their recommended use is in alleviating acute attacks of asthma.

Following a nephrectomy, which assessment finding is most important in determining nursing care for the client?

SpO2 at 90% with fine crackles in the lung bases

Pancrelipase would most likely be used to treat a patient with cystic fibrosis.

TRUE

A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth?

The Pons

The nurse is reviewing the circulatory system. Which statements are correct about the functional organization of the circulatory system? Select all that apply.

The arterial system distributes oxygenated blood to the tissues. The venous system collects deoxygenated blood from the tissues.

What is the nurse's expectation about a client's ability to compensate for a metabolic blood gas disorder?

The client will compensate with the respiratory system.

A client with hypertension comes to the outpatient department for a routine checkup. Because hypertension is a risk factor for cerebral hemorrhage, the nurse questions the client closely about warning signs and symptoms of hemorrhage. Which complaint is a possible indicator of cerebral hemorrhage in this client?

Tinnitus

As the first priority of care, a patient with a burn injury will initially need:

a patent airway established

A client has just received combined spinal epidural. Which nursing assessment should be performed first?

assess vital signs

What is the best way for the nurse to assess the newborn's heartbeat?

auscultating the apical pulse for 60 seconds

A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:

cough as the cuff is being deflated.

A group of students are reviewing the mechanics of oxygen and carbon dioxide exchange in the alveoli. The students demonstrate understanding when they identify which mechanism as being responsible?

diffusion

Frequently, what is the earliest symptom of left-sided heart failure?

dyspnea on exertion

The nurse is assessing a pregnant client with a known history of congestive heart failure who is in her third trimester. Which assessment findings should the nurse prioritize?

dyspnea, crackles, and irregular weak pulse

A common symptom that would alert the nurse that a preterm infant is developing respiratory distress syndrome is:

expiratory grunting; Expiratory grunting is a physiologic measure to ensure alveoli do not fully close on expiration (so they require less energy expenditure to reopen).

The nurse knows the mortality rate is high in lung cancer clients due to which factor?

few early symptoms

A novice nurse asks to be assigned to the least complex antepartum client. Which condition would necessitate the least complex care requirements?

gestational hypertension

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention?

oxygen saturation (SaO2) of 89%

Arterial blood gas analysis would reveal which value related to acute respiratory failure?

pH 7.28

All the options are signs of respiratory distress in the newborn except:

respiratory rate >50 breaths/minute; Coughing and sneezing are normal reflexes present in newborns. The expected respiratory rate of newborn is 30 to 60 breaths per minute.

A nurse working in the newborn observational unit is assigned four newborns closely being monitored. Which newborn is at greatest risk of developing respiratory distress syndrome?

the male preterm infant born by cesarean birth with cold stress

The volume of air inhaled and exhaled with each breath is termed

tidal volume

A nurse assesses a client's respiratory status. Which observation indicates that the client is having difficulty breathing?

use of accessory muscles

While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following?

wheezes

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?

wheezing

A client with chest pain doesn't respond to nitroglycerin. When the client is admitted to the emergency department, the healthcare team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?

within 6 hours