Taylor, Chapter 39: Oxygenation & Perfusion

Venturi mask delivers oxygen

at higher levels

The nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FIO2 of 100%. Which oxygen delivery system should the nurse utilize? -Non-rebreather mask -Venturi mask -Nasal cannula -Simple mask

-Non-rebreather mask

The nurse observes that the client's pulse oximetry is 89%. What is the priority nursing action? -Document hypoxemia. -Report pulse oximetry to the healthcare provider. -Perform respiratory assessment. -Check the placement of the pulse oximeter

-Perform respiratory assessment. As the nurse enters the room the respiratory assessment immediately begins by visualizing client skin color, observing chest symmetry, vocalization, and auditory adventitious lung sounds. The nurse can then proceed to check the placement of the pulse oximeter, report findings to the healthcare provider and document.

The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly? -small amount of subcutaneous air is detected at the sit of tube insertion -dressing is moist and intact -respirations are at 20 breaths per minute -drainage system is positioned slightly above chest level

-respirations are at 20 breaths per minute

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is: -"He will require additional testing to determine the cause." -"He is using his chest muscles to help him breathe." -"His infection is causing him to breathe harder." -"His lung muscles are swollen so he is using abdominal muscles."

-"He is using his chest muscles to help him breathe." The client will use accessory muscles to ease dyspnea and improve breathing.

A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level? -Clear sounds -Crackles -Bruits -Wheezes

-Crackles Normal breath sounds of an infant are harsh crackles at the end of deep inspiration. Wheezing is a whistling sound made while breathing. Clear sounds are usually not heard in an infant. A bruit is an audible vascular sound and not a pulmonary sound associated with turbulent blood flow.

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the oxygen analyzer? -"This is a gauge used to regulate the amount of oxygen that a client receives." -"The oxygen analyzer prescribes the concentration of oxygen." -"It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." -"Small water droplets come from this, thus preventing dry mucous membranes."

-"It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen. The humidifier produces small water droplets, which are delivered during oxygen administration to prevent or decrease dry mucous membranes.

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed: -6 L/minute -1 L/minute -4 L/minute -10 L/minute

-6 L/minute In general, if a flow rate of 6 L/minute fails to raise a client's oxygen saturation level satisfactorily, a mask should be used. 1-4 L/minute flow rates per nasal cannula are standard flow rates. Greater than 6 L/minute flow rate per nasal cannula is very uncomfortable for the client. A flow rate of 10 L /minute per nasal cannula is not acceptable.

The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner? -10 L/min oxygen via Venturi mask -8 L/min oxygen via partial rebreather mask -8 L/min oxygen via nasal cannula -12 L/min oxygen via nonrebreather mask

-8 L/min oxygen via nasal cannula The correct amount delivered FiO2 for a nonrebreather mask is 12 L/min; 8-11 L/min for partial rebreather mask; 4-10 L/min for Venturi mask; and 1-6 L/min for nasal cannula. However, per nasal cannula it may be no more than 2-3 L/min to for a client with chronic lung disease.

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? -Hematocrit values -Hemoglobin levels -Pulmonary function -Arterial blood gas

-Arterial blood gas Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.

The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take? -Assess lung sounds -Reposition client -Elevate head of the bed -Assess oxygen tubing connection

-Assess oxygen tubing connection If the client suddenly becomes cyanotic, the nurse should assess the oxygen tubing to make sure it is still connected. Assessing lung sounds, repositioning the client, and elevating the head of the bed will not correct the problem if the tubing is disconnected.

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia? -Edema -Hemoptysis -Constipation -Clubbing

-Clubbing Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many clients with chronic hypoxia due to respiratory or cardiac disease. Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD. Hemoptysis does not result from hypoxia.

A nurse is conducting a physical assessment of a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the client's oxygenation. What instruction should the nurse give the client? -Expand the thoracic cavity. -Relax the respiratory muscles. -Contract the abdominal muscles. -Elevate the ribs and sternum.

-Contract the abdominal muscles. The nurse should instruct the client to contract the abdominal muscles to exhale additional air. A person can forcibly exhale additional air by contracting abdominal muscles such as the rectus abdominis, transverse abdominis, and external and internal obliques. The client elevates the ribs and sternum and expands the thoracic cavity during inspiration. The client relaxes the respiratory muscles during normal expiration.

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe? -Crackles in the lower lobes -Inspiratory stridor -Expiratory stridor -Wheezing in the upper lobes

-Crackles in the lower lobes People with chronic congestive heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels. Stridor is associated with respiratory infections such as croup. Wheezing may be heard in individuals who use tobacco products.

The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is: -Hypoxia related to pneumonia and ineffective airway clearance related to dyspnea edema. -Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter. -Risk for Ineffective Airway Clearance related to infection as evidenced by dyspnea and yellow-green sputum. -Impaired Gas Exchange related to increased carbon dioxide and irritability.

-Ineffective Breathing Pattern related to

A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention? -Inquire about factors that contribute to non-adherence. -Notify the healthcare provider of the client's current status. -Explain uses of BiPAP masks versus CPAP masks. -Document assessment and plan for intervention.

-Inquire about factors that contribute to non-adherence. The nurse must first assess the reasons that contribute to non-adherence; interventions cannot be determined without a thorough assessment. Other interventions take place after assessment.

A client with a diagnosis of advanced Alzheimer disease is unable to follow directions required to use an inhaled bronchodilator. Which medication delivery system is most appropriate for this client? -Nebulizer -Dry powder inhaler -Metered-dose inhaler with spacer -Metered-dose inhaler without spacer

-Nebulizer Inhalers differ in the amount of dexterity required in order to deliver an accurate dose, but each requires some degree of coordinated activity and the ability to follow directions on the part of the client. For a client with decreased cognition, a nebulizer may be more appropriate because the client passively inhales the entire dose. A dry powder inhaler is initiated by inhalation and requires an ability to follow directions and keep the mouth around the port. If the client cannot follow directions then only the nebulizer is appropriate.

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing -Anemia -Malnutrition -Poor tissue perfusion -Congestive heart failure

-Poor tissue perfusion Chronically poor perfusion may result in hair loss in the affected area, discolored skin, thickened nails, and shiny, dry skin indicative of inadequate tissue nutrition.

A client with Type II diabetes has come for an annual wellness check-up with the healthcare provider. Which vaccine will the nurse discuss with the client? -DTAP -Hepatitis A -MMR -Prevnar 13 ®

-Prevnar 13 ® Clients over the age of 65 years old or those who have a compromising chronic health condition should be offered Prevnar 13 ®, which reduces strains of streptococcal pnuemoniae. Other options are not appropriate for the scenario.

When caring for a client with a tracheostomy, the nurse would perform which recommended action? -Clean the wound around the tube and inner cannula at least every 24 hours. -Assess a newly inserted tracheostomy every 3 to 4 hours. -Use gauze dressings over the tracheostomy that are filled with cotton. -Suction the tracheostomy tube using sterile technique.

-Suction the tracheostomy tube using sterile technique. Sterile technique is required when suctioning a tracheostomy in order to prevent introduction of microorganisms into the respiratory tract. The area around a new tracheostomy may need to be assessed and cleaned every 1 to 2 hours. Gauze dressings that are not filled with cotton must be used to prevent aspiration of lint or cotton fibers into the trachea.

The nurse is observing the unlicensed assistive personnel (UAP) perform oropharyngeal suctioning on a client. Which action, performed by the UAP, would indicate to the nurse that suctioning is being properly performed? -The UAP advances the catheter approximately 3 to 4 inches to reach the pharynx. -The UAP advances the catheter approximately 5 to 6 inches to reach the pharynx. -The UAP applies lubricant to the first 2 to 3 inches of the catheter. -The UAP allows 30-second to 1-minute intervals between suctioning passes.

-The UAP advances the catheter approximately 3 to 4 inches to reach the pharynx. When performing oropharyngeal suctioning, the catheter should be placed along the side of the mouth toward the trachea and advanced 3 to 4 inches to reach the pharynx. In nasopharyngeal suctioning, the catheter should be inserted through the naris and along the floor of the nostril toward the trachea; it should be advanced approximately 5 to 6 inches to reach the pharynx. Applying lubricant to the first 2 to 3 inches of the catheter facilitates passage of the catheter and reduces trauma to mucous membranes. Allowing 30-second to 1-minute intervals between suction passes allows for reventilation and reoxygenation of airways.

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? -Crackles -Bronchovesicular -Bronchial -Vesicular

-Vesicular Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: -crackles. -vesicular. -wheezes. -rales.

-crackles. A coarse crackle is a low-pitched, rumbling sound in airways. When they are coarse and loud and occur with severe dyspnea, crackles may be a telling sign of pulmonary fibrosis, congestive heart failure, and pulmonary edema.

The nurse is caring for a client who will be wearing a simple mask for oxygen delivery. What planning regarding the mask will the nurse include in the plan of care? -will accommodate up to 10 L/min of oxygen administration -will create a risk for oxygen toxicity -may cause anxiety in client with claustrophobia -may pull on tracheostomy tubing

-may cause anxiety in client with claustrophobia

The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client? -nasal cannula -tracheostomy collar -simple mask -face tent

-nasal cannula A nasal cannula is ideal for administering low concentrations of oxygen to clients who are not extremely hypoxic or have chronic lung disease. The client does not have a tracheostomy. A simple mask is used to administer higher levels of oxygen than 2 L/min. A face tent is used without a mask.

The nurse is caring for a 3-year-old client who experienced smoke inhalation during a house fire, and now requires oxygen. What delivery device will the nurse select that is most appropriate for this client? -nasal catheter -oxygen tent -venturi mask -non-rebreather mask

-oxygen tent An oxygen tent is often used when caring for active toddlers who require oxygen, since they are less likely to keep a mask on. Nasal catheters and masks are inappropriate, as the child will attempt to remove them and not receive the benefit of oxygen therapy.

While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique? -fluid-filled portions of the lung -pattern of thoracic expansion -consolidated portions of the lung -presence of pleural rub

-pattern of thoracic expansion The nurse can assess patterns of thoracic expansion through palpation. Fluid-filled and consolidated portions of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation.

What structural changes to the respiratory system should a nurse observe when caring for older adults? -respiratory muscles become weaker -diminished coughing and gag reflexes -increased use of accessory muscles for breathing -increased mouth breathing and snoring

-respiratory muscles become weaker One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker. The nurse should also observe other structural changes: the chest wall becomes stiffer as a result of calcification of the intercostals cartilage, kyphoscoliosis, and arthritic changes to costovertebral joints; the ribs and vertebrae lose calcium; the lungs become smaller and less elastic; alveoli enlarge; and alveolar walls become thinner. Diminished coughing and gag reflexes, increased use of accessory muscles for breathing, and increased mouth breathing and snoring are functional changes to the respiratory system in older adults.

Which nursing skill requires the nurse to use sterile technique? -suctioning a tracheostomy -administering nebulizers -providing oxygen by nasal cannula -administering oxygen by face mask

-suctioning a tracheostomy Suctioning is always a sterile procedure, whereas the administration of oxygen by face mask or by nasal cannula and nebulized medications require clean technique.

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response? -"The chest tube cannot be moved." -"You will need to use a bedpan while the chest tube is in position." -"Let me get the unlicensed assistive personnel (UAP) for you." -"I can assist you to the bathroom and back to bed."

-"I can assist you to the bathroom and back to bed." The client can move in bed, and ambulate while carrying the drainage system as long as he or she has orders to do so. The nurse should supervise ambulation to the bathroom and back to bed while the client has the drain inserted, to make sure it stays intact and to monitor for safety. Other answers are incorrect.

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's: -hemoglobin level. -age. -blood pH. -sodium and potassium levels.

-hemoglobin level.

Nasal cannulas and simple face masks are typically used to deliver

low levels of oxygen

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output? -"If the client's stroke volume is 70 mL and heart rate is 70 beats per minute, then the cardiac output is 4.7 L/minute." -"If the client's stroke volume is 80 mL and heart rate is 80 beats per minute, then the cardiac output is 6.0 L/minute." -"If the client's stroke volume is 60 mL and heart rate is 60 beats per minute, then the cardiac output is 3.2 L/minute." -"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute."

-"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute." The following formula is used to determine cardiac output: Cardiac Output = Stroke Volume x Heart Rate. A client with a stroke volume of 50 mL and heart rate of 50 beats per minute has a cardiac output of 2.5 L/minute. If stroke volume is 70 and heart rate is 70 beats per minute, then the cardiac output is 4.9 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute.

A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response? -"That will help the oxygen flow more freely." -"The caregiver will need to place the oxygen tank back into the secure carrier." -"That will make it easier to carry with you." -"Call your oxygen supplier immediately."

-"The caregiver will need to place the oxygen tank back into the secure carrier." Oxygen tanks are transported on a wheeled carrier to avoid accidental force. Accidental force could cause the tank to explode. The tank should not be carried, and taking it out of the carrier does not affect the flow of oxygen.

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." -"The flowmeter prescribes the concentration of oxygen." -"It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." -"Small water droplets come from this, thus preventing dry mucous membranes."

-"This is a gauge used to regulate the amount of oxygen that a client receives." The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The humidifier produces small water droplets, which are delivered during oxygen administration to prevent or decrease dry mucous membranes.

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." -"The flowmeter prescribes the concentration of oxygen." -"It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." -"Small water droplets come from this, thus preventing dry mucous membranes."

-"This is a gauge used to regulate the amount of oxygen that a client receives." The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The humidifier produces small water droplets, which are delivered during oxygen administration to prevent or decrease dry mucous membranes.

A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving? -23% -28% -32% -47%

-32% A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44%

A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving? -23% -28% -32% -47%

-32% A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44%

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? -Pulse oximetry -High-Fowler's position -4 L/minute O2 (66 mL/second) nasal cannula -Increase fluid intake to 3 L/day (3000 mL/day)

-4 L/minute O2 (66 mL/second) nasal cannula The client with chronic lung disease, such as emphysema, becomes insensitive to carbon dioxide and responds to hypoxia to stimulate breathing. If given excessive oxygen (4 L/minute or 66 mL/second), the stimulus to breathe is removed. Clients with emphysema are most comfortable in high Fowler's position because it aids in the use of the accessory muscles to promote respirations. Increasing fluid intake helps keep the client's secretions thin. Pulse oximetry monitors the client's arterial oxyhemoglobin saturation while receiving oxygen therapy.

A nurse is preparing to use a wall unit to suction an endotracheal tube. At what pressure should the suction be set? -60 to 80 mm Hg -80 to 150 mm Hg -100 to 160 mm Hg -120 to 170 mm Hg

-80 to 150 mm Hg When utilizing a wall unit to suction an endotracheal tube, the pressure should be set at 80 to 150 mm Hg. This level will provide enough pressure to suction out secretions from the endotracheal tube.

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider? -An infant with a respiratory rate of 20 bpm -A 4-year-old with a respiratory rate of 40 bpm -A 12-year-old with a respiratory rate of 20 bpm -A 70-year-old with a respiratory rate of 18 bpm

-An infant with a respiratory rate of 20 bpm The infant's normal respiratory rate is 30 to 55 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 40 breaths per minute. For a child 6 to 12 years of age the normal respiratory rate is 18 to 26 breaths per minute. The normal respiratory rate for an adult 65 years and older is 16 to 24 breaths per minute.

The nurse is caring for a client who has a chest tube in place that is draining blood from a hemothorax. Which item will the nurse obtain to respond appropriately to accidental disconnection of the chest tube from the drainage device? -An unopened bottle of sterile water -A Heimlich valve -Two rubber-tipped clamps -A spare chest tube insertion kit

-An unopened bottle of sterile water Keep a bottle of sterile saline or water at bedside. If chest tube disconnects from drainage unit, submerge end in water to create a water seal so as not to have the client "breath" through the tube and cause a pneumothorax. The chest tube should not be clamped. A spare chest tube insertion kit is not warranted. A Heimlich valve is used instead of a collection container device but should not be used if the chest tube becomes dislodged.

It is a red air-quality day in the city. This means the air is stagnant, with high pollution levels and high humidity. Which client is most likely to experience shortness of breath? -Child with asthma -Middle-age adult with hypertension -Teenager with contact dermatitis -Young adult without disease

-Child with asthma Air pollution and high humidity are respiratory irritants. Pollutants cause increased mucus production and contribute to bronchitis and asthma. While pollution is not good for any group of individuals it would be less of an impact on the person with hypertension or dermatitis.

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia? -Confusion -Decreased blood pressure -Decreased respiratory rate -Hyperactivity

-Confusion

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue? -Antibiotics -Bronchodilators -Expectorants -Corticosteroids

-Corticosteroids In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation.

A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determines that the education was successful when the students identify which activity as occurring during inspiration? -Intercostal muscles contract. -Chest pressure increases. -Thorax size reduces. -Air flows out of the lungs.

-Intercostal muscles contract. During inspiration, the diaphragm and external intercostal muscles contract. Their contraction enlarges the thorax volume and decreases intrathoracic pressure. The expanding chest wall pulls the lungs outward. As the lungs expand, pressure drops within the airways. During exhalation, the diaphragm and intercostal muscles relax, causing the thorax to return to its smaller resting size. During exhalation, the pressure in the chest increases, allowing air to flow out of the lungs.

A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply. -Nasal cannula -Simple oxygen mask -Venturi mask -Partial rebreather mask -Humidified venturi mask

-Nasal cannula -Simple oxygen mask -Partial rebreather mask Nasal cannula with tubing administers oxygen at low-flow rates and concentrations at 22%-44%. Simple masks and partial rebreathers both deliver a low-flow rate at concentrations of 40%-60%. Venturi masks mix oxygen with room air and create a high flow of oxygen.

The nurse is caring for a client with a NANDA-I diagnosis of Imbalanced nutrition: Less than body requirements, related to difficulty breathing. The nurse would implement which measures to maintain an adequate nutritional status for this client? Select all that apply. -Encourage client to eat 1 to 2 hours before breathing treatments and exercises. -Provide frequent oral hygiene, especially before meals. -Distribute six small meals over the course of the day. Encourage client to eat alone for privacy during mealtime. -Encourage client to decrease protein, but increase calcium intake.

-Provide frequent oral hygiene, especially before meals. -Distribute six small meals over the course of the day. Frequent oral hygiene, especially before meals, removes unpleasant tastes and aids in enjoyment of the meals. Six small meals instead of three large ones reduce the tension in the client's stomach to increase client's comfort. Clients should eat after treatments and exercises to prevent fatigue. Clients should eat in the company of others, if possible, to make mealtime more pleasant. Clients should have adequate protein, minerals, and calcium intake.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding? -The contour of the intercostal spaces should be rounded. -The skin at the thorax should be cool and moist. -The anteroposterior diameter should be greater than the transverse diameter. -The chest should be slightly convex with no sternal depression.

-The chest should be slightly convex with no sternal depression. The adult chest contour is slightly convex, with no sternal depression. The skin of the thorax should be warm and dry, and the anteroposterior diameter of the chest should be less than the transverse diameter. The contour of the intercostal spaces should be flat or depressed.

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system? -an older adult client who has COPD -a child who has pneumonia -an adult who is receiving oxygen at home -an adolescent who has asthma

-a child who has pneumonia An oxygen tent is commonly used with children who need a cool and highly humidified airflow. It is also more effective for children because they often do not like to keep oxygen administration devices in place. Since the tent does not allow the maintenance of a satisfactory or precise oxygen concentration, is difficult to maintain a consistent level of oxygen. The oxygen tent does not adequately deliver oxygen at a rate higher than 30% to 50%; thus, it is rarely used with other clients.

While reading a physician's progress notes, a student notes that an assigned client is having hypoxia. What abnormal assessments would the student expect to find? -abdominal pain, hyperthermia, dry skin -diarrhea, flatulence, decreased skin turgor -hypotension, reddened skin, edema -dyspnea, tachycardia, cyanosis

-dyspnea, tachycardia, cyanosis

The nurse is caring for a client with facial burns who also is prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? -simple mask -tracheostomy collar -nasal cannula -face tent

-face tent A face tent is used without a mask; it is open and loose around the face and is often used for patients with facial trauma or burns. This device is most appropriate for a client with facial burns. All other methods of delivery would irritate the facial skin.

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position? -left side with a pillow under the chest wall -side-lying position, half on the abdomen and half on the side -high-Fowler's position -Trendelenburg position

-high-Fowler's position Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. High-Fowler's position is used to drain the apical sections of the upper lobes of the lungs. Placing the client lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.

The nurse is caring for a 2-year-old client who experienced smoke inhalation during a house file. When oxygen is ordered, what delivery device will the nurse gather? -venturi mask -oxygen tent -nasal catheter -non-rebreather mask

-oxygen tent An oxygen tent is often used when caring for active toddlers who require oxygen, since they are less likely to keep a mask on. Other devices are inappropriate for a child of this age.

A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of: -croup. -asthma. -alcohol use. -pneumonia.

-pneumonia.

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 -prevention of suctioning -loss of sterile field -suctioning of carbon dioxide

-trauma to the tracheal mucosa