PrepU Chapter 30: Respiratory
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 to 120 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 physician if the client reaches which oxygen saturation level?
92%
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.
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
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 has an order to obtain a sputum specimen on a newly admitted client. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
Label the sputum specimen and take it to the lab.
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?
Pulmonary function tests
A 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.
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.
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 nurse is administering a prescribed dose of IV medication to a client who is recovering from partial airway obstruction. What are common reasons for airway obstruction to occur? Select all that apply.
compromised swallowing aspiration of vomitus insufficient chewing
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
A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?
flow meter
A home care nurse finds an adult client slumped in a chair. The client is not breathing. Which method should the nurse use to open and maintain the client's airway?
head tilt-chin lift method
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 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
A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?
prolongs expiration to reduce airway resistance
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
A nurse has to perform nasotracheal suctioning for a client with difficulty breathing due to congestion. Which statement describes the purpose of nasotracheal suctioning?
removes secretions from the upper portion of the lower airway through a nasally inserted catheter
The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?
tracheostomy collar
A client with a head injury will require long-term airway support. Which device will be required for this client?
tracheostomy tube
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?
"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."
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 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."