Therapeutics: Course Point (CH. 38)

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/min O2 nasal cannula

A nurse is using a pulse oximeter to measure the arterial oxyhemoglobin saturation (SaO2 or SpO2) of a client's arterial blood. What range is considered a normal value for SpO2?

95-100%

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 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.

A client's spouse reports that the client snores loudly and incessantly every night. What is the appropriate nursing response when the client's spouse asks about nasal breathing strips?

Nasal strips may reduce or eliminate snoring

The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach?

Take in as much air as possible, hold your breath briefly, and exhale slowly

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse, if noted by the charge nurse, would cause the charge nurse to intervene?

The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). (Care of a tracheostomy tube in a stable situation, such as long-term care and other community-based care settings, may be delegated to licensed practical/vocational nurses (LPN/LVN); not in an acute instance.)

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

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

True or False: After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

True

The nurse is caring for a client with a nonhealing wound who has been prescribed hyperbaric oxygen therapy (HBOT). When the client asks, "How will this help me?" what is the appropriate nursing response?

Wounds heal because HBOT helps to regenerate new tissue quickly

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

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?

ask the client what factors contribute to nonadherence

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 (Anemia, a decrease in the amount of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen.)

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?

contract the abdominal muscles

A client with closed-angle glaucoma and a cough has a prescription for a cough medicine. The nurse would question which cough medicine if prescribed for this client?

cough medicine with an antihistamine (The client with closed-angle glaucoma should avoid cough medicine because of its anticholinergic action)

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

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

A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?

educating the client on the use of incentive spirometry

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

The nurse is delegating hygiene care to the UAP for a client with hypoxia. What position will the nurse tell the UAP to place the client in?

high Fowler's

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

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 ( inadequate amount of oxygen is available to cells)

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

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?

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)

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

The nurse caring for a client with pulmonary disease who is acutely ill demonstrates a good understanding of positioning when frequently repositioning this client in which position?

prone (Research has demonstrated the prone position allows the lungs' posterior dependent sections to be better perfused and ventilated)

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 (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 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

What is the action of codeine when used to treat a cough?

suppressant

The nurse is caring for a client who was 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

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