Test 3 Quizlet

Martin is a 58-year-old smoker who was admitted to the hospital with worsening shortness of breath over the last 2 days. He states that he is having some chest discomfort. The nurse asks him further about this in order to characterize whether this may be cardiac related, musculoskeletal related, or respiratory related. Martin states that when he breathes in, he feels as if the air passing into his lungs is burning him. It is also very painful to swallow. Based on what Martin is stating, which illness does the nurse suspect is causing Martin's chest discomfort?

Acute bronchitis Explanation: Acute bronchitis is caused by inflammation. Inflammatory mediators such as histamine may directly stimulate nerve endings made hypersensitive by the disease process. This process causes a sensation of pain as air travels over those nerve endings. Clients with pneumonia often experience pain with deep breathing because each breath increases pressure on pain receptors that are already compressed and irritated by swollen, inflamed lung tissue. Coronary artery disease should be ruled out in anyone reporting chest pain, but Martin's sensation of burning in his airway with each breath is more suspicious for a respiratory issue. Emphysema is a more chronic illness that causes a slow progression of increasing shortness of breath. Martin is definitely at risk for emphysema but it would not explain his worsening shortness of breath over the last 2 days.

(see full question) 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 Explanation: The nurse should teach deep breathing techniques to the client who tends to breathe shallowly in order to help the client breathe more efficiently. Deep breathing is a technique for maximizing ventilation. Taking in a large volume of air fills alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing is a form of controlled ventilation in which the client consciously prolongs the expiration phase of breathing, which helps clients to eliminate more than the usual carbon dioxide from the lungs. It is used to increase the volume of air exchanged during inspiration and expiration. Incentive spirometry, a technique for deep breathing using a calibrated device, encourages clients to reach a goal-directed volume of inspired air. Diaphragmatic breathing is breathing that promotes the use of the diaphragm rather than the upper chest muscles. It is used to increase the volume of air exchanged during inspiration and expiration.

A nurse is caring for older adults in a nursing home. Which age-related changes may affect the respiratory functioning of the clients living there? Select all that apply.

Less air exchange, more secretions in lungs. • Greater risk for aspiration due to slower gastric motility. Explanation: Age-related changes include: decreased elastic recoil of the lungs; expiration requiring use of accessory muscles; fewer functional capillaries and more fibrous tissue in alveoli; decreased skeletal muscle strength in thorax; reduction in vital capacity and increase in residual volume; less air exchange; more secretions remaining in lungs; greater risk for aspiration due to slower gastric motility, impaired mobility and inactivity, effects of medication.

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 Explanation: Normal cardiac output averages from 3.5 L/minute to 8.0 L/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.

(see full question) 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. Explanation: Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.

(see full question) A patient with a diagnosis of advanced Alzheimer disease who is unable to follow directions requires an inhaled bronchodilator. Which of the following medication delivery systems is most appropriate for this patient?

nebulizer Explanation: Inhalers differ in the amount of dexterity that is 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 patient. For a patient with decreased cognition, a nebulizer may be more appropriate on account of the fact that the patient passively inhales the entire dose

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 Explanation: 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, whereas bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

bronchial

(loud, high-pitched sounds heard primarily over the trachea and larynx)

(see full question) 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 Explanation: 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.

(see full question) A nurse is performing CPR on a client who is in cardiac arrest. What action would the nurse perform second?

Activate the emergency response system. Explanation: The victim is first checked for unresponsiveness. Once this is established, the emergency response system is activated. An AED is secured next, followed by initiating CPR with the CAB sequence.

Which structures are primarily responsible for voluntary movement? Select all that apply.

Cerebral cortex • Pyramidal tract • Cerebellum Explanation: The cerebral cortex initiates voluntary motor activity. The pyramidal tract (the direct corticospinal pathway) initiates transmission of impulses to the spinal cord for voluntary movements. The cerebellum has a special role in controlling movement: it controls muscles used to maintain steady posture and coordinated, detailed movements. The hypothalamus is primarily responsible for regulating temperature, controlling hunger and thirst, and regulating circadian rhythms.

(see full question) A 90-year-old widower lives alone in her home. The nurse knows that older clients are at increased risk for falls. What other factors contribute to increased risk for falls in clients? Select all that apply.

Correct response: • ataxic gait • history of a fall 5 years ago • diuretics Explanation: Gait disturbances, history of falls, certain medications, and weakness are highly predictive of a fall. Well-tacked carpeting can help prevent a fall in a home, while hardwood floors or loose rugs present a fall risk.

(see full question) 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. Explanation: The nurse could suggest liberal fluid intake for the client in order to improve respiratory function. Older adults need encouragement to maintain liberal fluid intake, which keeps the mucous membranes moist. Unless contraindicated, the nurse should encourage the client to engage in regular exercise to maintain optimal respiratory function. A nasal strip reduces airflow resistance by widening the nasal breathing passageway, thus promoting easier breathing. An older adult may or may not use a nasal strip to improve respiratory function. The nurse should advise older adults to receive annual influenza immunizations and a pneumonia immunization after 65 years of age or earlier if there is a history of chronic illness.

(see full question) A nurse is caring for a client who breathes very shallowly and has been reporting severe back pain. What suggestion could the nurse make to help the client breathe efficiently?

Encourage the client to take deep breaths. Explanation: To help the client breathe efficiently, the nurse could encourage the client to take deep breaths. Deep breathing maximizes the ventilation and fills the alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing and diaphragmatic breathing help to eliminate the extra carbon dioxide from the lungs. A nasal strip reduces airflow resistance by widening the nasal-breathing passageways, thus promoting easier breathing. It is used for reducing or eliminating snoring

(see full question) After positioning a client to move from the bed into a wheelchair, how would the nurse stand when helping the client to sit up on the side of the bed?

Near the client's hip, with legs shoulder-width apart and one foot near the head of the bed Explanation: When assisting the client from the bed into a wheelchair, the nurse would take position near the client's hip, with legs shoulder-width apart and one foot near the head of the bed. This ensures that the nurse's center of gravity is placed near the client's greatest weight, to assist the client to a sitting position safely.

(see full question) A nurse is performing range-of-motion exercises on a patient who is on bedrest. What would be the nurse's best action when the patient complains: "I'm just too tired to do these exercises today.

Stop the exercises and reevaluate the nursing plan of care. Explanation: While you are performing range-of-motion exercises, and the client complains of feeling tired, stop the activity for that time and re-evaluate the nursing plan of care. Consider spacing the exercises out at different times of the day. Schedule exercise times for the parts of the day the client is typically feeling more rested. The nurse would not encourage the client to finish the exercises and then reevaluate the nursing plan. The nurse would not finish the exercises and report the incident to the primary care provider. The nurse would not modify the number of repetitions for each exercise and then modify the plan.

When caring for a client with a tracheostomy, the nurse would perform which recommended action?

Suction the tracheostomy tube using sterile technique. Explanation: 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.

(see full question) When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression. Explanation: 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. (l

A newly hired nurse is performing a focused respiratory assessment. The nurse mentor will intervene if which action by the newly hired nurse is noted?

The newly hired nurse auscultates breath sounds as the client breathes through the nose. Explanation: Breath sounds should be auscultated while the client breathes slowly through an open mouth; nose breathing may produce false breath sounds. Explanation before procedures helps reduce a client's anxiety. Palpation of the PMI and attaching the pulse oximetry are included in the respiratory assessment

(see full question) The nurse educator would intervene with client teaching if which action by the staff nurse occurs when teaching voluntary coughing?

The nurse has the client lying in bed in semi-Fowler's position. Explanation: The client should be sitting upright with feet flat on the floor to be most effective. As part of the client's plan of care, the nurse should develop a specific schedule for coughing. Coughing before meals improves the taste of food and oxygenation. When combined with deep breathing, coughing is most effective.

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. Explanation: Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds. (less)

(see full question) 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. Explanation: Peripheral and central chemoreceptors in the aortic arch and carotid arteries and the medulla are sensitive to circulating blood levels of carbon dioxide and hydrogen ions. Increased carbon dioxide levels lead to more rapid and shallow breathing, whereas decreased carbon dioxide levels lead to slower and deeper respirations.

(see full question) The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?

a child who has pneumonia Explanation: 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.

Crackles

are soft, high-pitched discontinuous (intermittent) popping sounds. (less)

(see full question) A nurse is percussing the thorax of a patient with chronic emphysema. What percussion sound would most likely be assessed?

hyperresonance Explanation: Hyperresonance is a loud, low, booming sound typically heard with percussion over emphysematous (excessively air-filled) lungs.

(see full question) The nurse is assessing a client who is bedridden. For which condition would the nurse consider this client to be at risk?

predisposition to renal calculi Explanation: In a bedridden client, the kidneys and ureters are level, and urine remains in the renal pelvis for a longer period of time before gravity causes it to move into the ureters and bladder. Urinary stasis favors the growth of bacteria that, when present in sufficient quantities, may cause urinary tract infections. Poor perineal hygiene, incontinence, decreased fluid intake, or an indwelling urinary catheter can increase the risk for urinary tract infection in an immobile client. Immobility also predisposes the client to renal calculi, or kidney stones, which are a consequence of high levels of urinary calcium; urinary retention and incontinence resulting from decreased bladder muscle tone; the formation of alkaline urine, which facilitates growth of urinary bacteria; and decreased urine volume. The client would be at risk for decreased movement of secretion in the respiratory tract, due to lack of lung expansion. The client would suffer from decreased metabolic rate due to being bedridden. The client would not have an increase in circulating fibrinolysin.

(see full question) What structural changes to the respiratory system should a nurse observe when caring for older adults?

respiratory muscles become weaker Explanation: 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.

The nurse is planning care for a client with a nursing diagnosis of Activity Intolerance. What assessment finding would cause the nurse the most concern?

shortness of breath after walking up five stairs Explanation: Activity Intolerance may result from any condition that interferes with the transport of oxygenated blood to tissue. The altered response to activity includes exertional dyspnea, shortness of breath. Shortness of breath after walking up five stairs would be included in this nursing diagnosis. Another altered response would be excessive increase in pulse rate. After walking up 20 stairs, a change in pulse of 4 points is not excessive. Joint stiffness is a defining characteristic of the nursing diagnosis Impaired Physical Mobility. Walking with a slow and uncoordinated movement is another defining characteristic of Impaired Physical Mobility.

The nurse is providing discharge teaching to a client going home with oxygen therapy. Which statements made by the client would indicate to the nurse that the teaching was effective? Select all that apply.

• "I will not allow smoking within 10 feet of my oxygen." • "I will keep the oxygen tank away from direct sunlight or heat." Explanation: Oxygen is combustible, so keep it away from smoking or direct sunlight. It is important to allow adequate airflow around the oxygen concentrator, so it should not be placed flush against the wall. It's more important to follow the prescription, than to adjust the oxygen flow rate because too much or too little oxygen may be detrimental to the client. The client must use caution with both gas and electrical stoves.

A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply.

• Nasal cannula • Simple oxygen mask • Partial rebreather mask Explanation: 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.

(see full question) The nurse assessing a patient with COPD suspects chronic hypoxia due to which of the following assessment findings?

• clubbing of toes • constipation Explanation: The effects of chronic hypoxia can be detected in all body systems and are manifested as altered thought processes, headaches, chest pain, enlarged heart, clubbing of the fingers and toes, anorexia, constipation, decreased urinary output, decreased libido, weakness of extremity muscles, and muscle pain. Cyanosis is a symptom of acute hypoxia.

(see full question) Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system? Select all that apply.

• slightly contoured chest with no sternal depression • anteroposterior diameter of the chest less than the transverse diameter • bronchial, vesicular, and bronchovesicular breath sounds Explanation: The adult chest contour is slightly convex, with no sternal depression. The anteroposterior diameter should be less than the transverse diameter for normal respirations. Bronchial, vesicular, and bronchovesicular are normal breath sounds, depending on the lung fields being assessed. Respirations should be nonlabored with a normal rate of 12 to 20 breaths per minute. Crackles should not be heard on inspiration as this is a sign of mucus or fluid in the lung tissue.