Taylor Ch. 38
The charge nurse is observing a new nurse care for a client who is receiving oxygen via a simple mask with an FIO2 of 40%. The client states, "This moisture on my face is bothersome. Can something be done about it?" Which response by the new nurse would require clarification by the charge nurse?
"After I dry your face, I can apply powder to absorb the moisture and protect your skin."
The nurse is instructing the client with a pulmonary disorder on deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client?
"Breathing through your nose first will warm, filter, and humidify the air you are breathing."
The nurse is planning a diet for a patient with COPD. Which recommended nutritional guidelines would the nurse consider? (Select all that apply.)
-The diet should consist of 40% to 55% carbohydrates. -The diet should be rich in antioxidants and vitamin A, C, and B. -The diet should contain 12% to 20% protein.
The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal?
30 to 55 breaths per minute
The nurse is caring for a client with emphysema. A review of the client's chart reveals pH 7.36, paO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription, if prescribed by the health care practitioner?
4 L/minute O2 nasal cannula
A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:
6 L/minute
A nurse is preparing to use a wall unit to suction an endotracheal tube. At what pressure should the suction be set?
80 to 150mm/hg
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 pulse oximeter range indicates that the client is adequately oxygenated?
95% to 100%
A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient?
Ambu bag
The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?
Arterial blood gas
Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body?
Chronic anemia
Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?
Corticosteroids
When the client demonstrates soft, high pitched discontinuous sounds, the nurse documents the breath sounds heard as which of the following?
Crackles
A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario?
Cyanosis
Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways?
Decreases the amount of air trapping and resistance
During the physical assessment of a client who has been inactive due to a leg injury, the nurse notes that the client tends to breathe very shallowly. What technique should the nurse teach the client in order to breathe more efficiently?
Deep breathing
A 55-year-old client visits a health care facility for a scheduled physical assessment. During the assessment, the client complains of difficulty breathing. What suggestion could the nurse make to improve the client's respiratory function in this case?
Drink liberal amounts of fluids.
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 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
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
During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?
Flow meter
The nurse assesses a client 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
Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate to observe in a client with these arterial blood gas results?
Increase in rate and depth of respirations
To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test?
Monitor the amount of oxygen saturation in the blood.
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 patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function?
Pleural effusion
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
When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?
Rapid respirations
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 (Demerol) 7 5mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering Demerol, the nurse would assess which most important sign?
Respiratory rate and depth
A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from?
Sleep apnea
When caring for a client with a tracheostomy, the nurse would perform which recommended action?
Suction the tracheostomy tube using sterile technique
What is the action of codeine when used to treat a cough?
Suppressant
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?
They are low-pitched, soft sounds heard over peripheral lung fields
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. T or F?
True
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 auscultates the lungs of a client with asthma. Which lung sound is characteristic of this condition?
Wheezes
Which scenario describes how carbon dioxide levels determine the frequency and depth of ventilation?
When carbon dioxide levels in the blood increase, chemoreceptors are stimulated, causing deeper and more rapid breathing.
In which client would the nurse assess for a depressed respiratory system?
a client taking opioids for cancer pain
A nurse is admitting a 6-year-old child status post tonsillectomy to the surgical unit. The nurse obtains his weight and places EKG and a pulse oximeter on the client's left finger. His heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:
adequate tissue perfusion.
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
While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique?
pattern of thoracic expansion
A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?
trauma to the tracheal mucosa