Brunner Nursing Concept - Oxygenation

In which position should the client be placed for a thoracentesis? Supine Prone Lateral recumbent Sitting on the edge of the bed

Sitting on the edge of the bed Explanation: If possible, place the client upright or sitting on the edge of the bed with the feet supported and arms and head on a padded over-the-bed table. Other positions in which the client could be placed include straddling a chair with the arms and head resting on the back of the chair, or lying on the unaffected side with the head of the bed elevated 30 to 45 degrees (if the client is unable to assume a sitting position).

A nurse is discussing asthma complications with a client and family. What complications should the nurse include in the teaching? Select all that apply. Status asthmaticus Atelectasis Respiratory failure Pertussis Thoracentesis

Status asthmaticus Respiratory failure Atelectasis Explanation: Complications of asthma may include status asthmaticus, respiratory failure, and atelectasis. Pertussis is not an asthma complication. Thoracentesis is a diagnostic procedure, not a complication.

The nurse is teaching a client the proper technique for diaphragmatic breathing. Place the steps for this procedure in the correct sequence. 1 Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. 2 Press firmly inward and upward on the abdomen while breathing out. 3 Breathe out through pursed lips while tightening the abdominal muscles. 4 Repeat for 1 minute; follow with a 2-minute rest period. 5 Place one hand on the abdomen and the other hand on the middle of the chest to increase awareness of the position of the diaphragm and its function in breathing.

1 Place one hand on the abdomen and the other hand on the middle of the chest to increase awareness of the position of the diaphragm and its function in breathing. 2 Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. 3 Breathe out through pursed lips while tightening the abdominal muscles. 4 Press firmly inward and upward on the abdomen while breathing out. 5 Repeat for 1 minute; follow with a 2-minute rest period.

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. The client is placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. What setting would be the best maximum FIO2 setting? 0.21 0.7 0.35 0.5

0.5 Explanation: An FIO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. Clients with respiratory disorders are given oxygen therapy only to increase the partial pressure of oxygen (PaO2) back to the patient's normal baseline, which may vary from 60 to 95 mm Hg. In terms of the oxyhemoglobin dissociation curve, arterial hemoglobin at these levels is 80% to 98% saturated with oxygen; higher FiO2 flow values add no further significant amounts of oxygen to the red blood cells or plasma. Instead of helping, increased amounts of oxygen may produce toxic effects on the lungs and central nervous system or may depress ventilation. The ideal oxygen source is room air FIO2 0.21.

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for Malfunction of the alarm button A cut or slice in the tubing from the ventilator A kink in the ventilator tubing Higher than normal endotracheal cuff pressure

A kink in the ventilator tubing Explanation: One event that could cause the ventilator's peak-airway-pressure alarm to sound is a kink in the ventilator tubing. After making this and other assessments without correction, then it could be a malfunction of the alarm button. Higher than normal endotracheal cuff pressure could cause client tissue damage but would not make the ventilator alarms sound. A cut or slice in the tubing from the ventilator would result in decreased pressure.

A client is admitted to the hospital with reports of chest pain. The nurse is monitoring the client and notifies the physician when the client exhibits Adventitious breath sounds Decreased frequency of premature ventricular contractions (PVCs) to 4 per minute A change in apical pulse rate from 102 to 88 beats/min Troponin levels less than 0.35 ng/mL

Adventitious breath sounds Explanation: The nurse monitors the client's hemodynamic and cardiac status to prevent cardiogenic shock. He or she promptly reports adverse changes in the client's status, such as adventitious breath sounds. The other options are positive changes or indicative that the client did not experience myocardial infarction.

What are the primary causes for an acute exacerbation of COPD? Select all that apply. Air pollution Gastrointestinal viruses Tracheobronchial infection Change in season from spring to summer Hypertension

Air pollution Tracheobronchial infection Explanation: Common causes of an acute exacerbation include tracheobronchial infection and air pollution. However, the cause of approximately one third of severe exacerbations cannot be identified. Change in season from spring to summer, hypertension, and GI viruses are not causes of exacerbation of COPD. Winter is worse for COPD when viral and bacterial infections are more prevalent.

A patient visited a health care clinic for treatment of upper respiratory tract congestion, fatigue, and sputum production that was rust-colored. Which of the following diagnoses is likely based on this history and inspection of the sputum? An infection with pneumococcal pneumonia Bronchitis A lung abscess Bronchiectasis

An infection with pneumococcal pneumonia Explanation: Sputum that is rust colored suggests infection with pneumococcal pneumonia. Bronchiectasis and a lung abscess usually are associated with purulent thick and yellow-green sputum. Bronchitis usually yields a small amount of purulent sputum.

Which nursing intervention is the priority for a client in myasthenic crisis? Administering intravenous immunoglobin (IVIG) per orders Ensuring adequate nutritional support Assessing respiratory effort Preparing for plasmapheresis

Assessing respiratory effort Explanation: A client in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early. Administering IVIG, preparing for plasmapheresis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction that leads to the collapse of alveoli. This complication is known as Pleurisy Atelectasis Emphysema Pneumonia

Atelectasis Explanation: Retention of secretions and subsequent obstruction ultimately cause the alveoli distal to the obstruction to collapse (atelectasis).

Which is the most important risk factor for development of chronic obstructive pulmonary disease (COPD)? Genetic abnormalities Air pollution Cigarette smoking Occupational exposure

Cigarette smoking Explanation: Pipe, cigar, and other types of tobacco smoking are also risk factors for COPD. Although risk factors, neither occupational exposure nor air pollution is the most important risk factor for development of COPD. Genetic abnormalities are also a risk factor, but again, not the most important one.

Which nursing assessment finding indicates the client with renal dysfunction has not met expected outcomes? Client denies frequency and urgency. Client rates pain at a 3 on a scale of 0 to 10. Urine output is 100 ml/hr. Client reports increasing fatigue.

Client reports increasing fatigue. Explanation: Fatigue, shortness of breath, and exercise intolerance are consistent with unexplained anemia, which can be secondary to gradual renal dysfunction.

High or increased compliance occurs in which condition? Emphysema Pneumothorax ARDS Pleural effusion

Emphysema Explanation: High or increased compliance occurs if the lungs have lost their elasticity and the thorax is overdistended, as in emphysema. Conditions associated with decreased compliance include pneumothorax, pleural effusion, and acute respiratory distress syndrome (ARDS).

You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis? Provide meticulous mouth care every 4 hours. Caution against frequent coughing. Encourage deep breathing every 2 hours. Monitor for signs of dysphagia.

Encourage deep breathing every 2 hours. Explanation: The nurse should encourage a client undergoing laryngeal surgery to practice deep breathing and coughing every 2 hours while the client is awake. These measures prevent atelectasis and promote effective gas exchange. Monitoring for signs of dysphagia and providing meticulous mouth care every 4 hours are the interventions related to the client's caloric intake.

Which finding would indicate a decrease in pressure with mechanical ventilation? Increase in compliance Decrease in lung compliance Plugged airway tube Kinked tubing

Increase in compliance Explanation: A decrease in pressure in the mechanical ventilator may be caused by an increase in compliance. Kinked tubing, decreased lung compliance, and a plugged airway tube cause an increase in peak airway pressure.

The client with cardiac failure is taught to report which symptom to the health care provider or clinic immediately? Weight loss Ability to sleep through the night Increased appetite Persistent cough

Persistent cough Explanation: Persistent cough may indicate an onset of left-sided heart failure. Loss of appetite, weight gain, interrupted sleep, unusual shortness of breath, and increased swelling should also be reported immediately.

A client who was diagnosed with type 1 diabetes 14 years ago is admitted to the medical-surgical unit with abdominal pain. On admission, the client's blood glucose level is 470 mg/dl. Which finding is most likely to accompany this blood glucose level? Slow, shallow respirations Cool, moist skin Arm and leg trembling Rapid, thready pulse

Rapid, thready pulse Explanation: This client's abnormally high blood glucose level indicates hyperglycemia, which typically causes polyuria, polyphagia, and polydipsia. Because polyuria leads to fluid loss, the nurse should expect to assess signs of deficient fluid volume, such as a rapid, thready pulse; decreased blood pressure; and rapid respirations. Cool, moist skin and arm and leg trembling are associated with hypoglycemia. Rapid respirations — not slow, shallow ones — are associated with hyperglycemia.

A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first? Remove the malfunctioning cuff. Suction the client, withdraw residual air from the cuff, and reinflate it. Add more air to the cuff. Call the physician.

Suction the client, withdraw residual air from the cuff, and reinflate it. Explanation: After discovering an air leak, the nurse first should check for insufficient air in the cuff — the most common cause of a cuff air leak. To do this, the nurse should suction the client, withdraw all residual air from the cuff, and then reinflate the cuff to prevent overinflation and possible cuff rupture. The nurse should notify the physician only after determining that the air leak can't be corrected by nursing interventions, or if the client develops acute respiratory distress. The tracheostomy tube cuff can't be removed and replaced with a new one without changing the tracheostomy tube; also, removing the cuff would create a total air leak, which isn't correctable. Adding more air to the cuff without first removing residual air may cause cuff rupture.

A nurse is caring for an older adult with emphysema. Which nursing action demonstrates primary prevention? Teaching the client safety precautions on the use of supplemental oxygen Encouraging the client to have periodic chest x-rays for early detection of cancer Comparing the client's peak expiratory flow rate with the baseline measurement Teaching the client various methods to help prevent pneumonia

Teaching the client various methods to help prevent pneumonia Explanation: The only action that is considered primary prevention is teaching the client methods to prevent pneumonia. Primary prevention focuses on health promotion and the prevention of illness. Teaching the client on current medications or oxygen, as well as comparing peaks flows are part of treating established disease states and would not be considered primary prevention. Early detection for cancer is considered secondary prevention, not primary.

Which term refers to the volume of air inhaled or exhaled during each respiratory cycle? Tidal volume Vital capacity Functional residual capacity Maximal voluntary ventilation

Tidal volume Explanation: Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.

A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath and fatigue for 1 hour after awakening in the morning. Which of the following statements by the nurse would best help with the client's shortness of breath and fatigue? "Raise your arms over your head." "Delay self-care activities for 1 hour." "Sit in a chair whenever doing an activity." "Drink fluids upon arising from bed."

"Delay self-care activities for 1 hour." Explanation: Some clients with COPD have shortness of breath and fatigue in the morning on arising as a result of bronchial secretions. Planning self-care activities around this time may be better tolerated by the client, such as delaying activities until the client is less short of breath or fatigued. The client raising the arms over the head may increase dyspnea and fatigue. Sitting in a chair when bathing or dressing will aid in dyspnea and fatigue but does not address the situation upon arising. Drinking fluids will assist in liquifying secretions which, thus, will aid in breathing, but again does not address the situation in the morning.

The nurse is caring for a client who has diminished lung function due to emphysema. The terminally ill client is short of breath on exertion and reports difficulty sleeping in bed. The client states, "I am so afraid of getting any worse." Which statement, by the nurse, assists the client in sustaining hope? "I will talk with the health care provider to determine the next step in your care." "I hear you say that you are not sleeping well." "Your grandchild is almost here, and you will enjoy seeing him." "Do not worry, I will be here for you to help you with your needs."

"I will talk with the health care provider to determine the next step in your care." Explanation: The client is assisted in hopefulness by believing that the healthcare team will make his remaining days meaningful. By conveying a sense that the nurse will discuss the client's condition with the health care provider, the client recognizes that the healthcare team will use whatever treatment and comfort measures are available. Telling a client not to worry is not therapeutic and is condescending. Waiting for a grandchild does not address the client's thought. Reflecting what the client said for clarification opens communication but does not instill hopefulness.

An older adult asks, "What can I do to prevent getting a chest cold during the winter?" Which suggestion(s) will the nurse make to this client? Select all that apply. "Stop smoking." "Make sure you drink enough fluid every day." "Get the annual flu shot." "Suppress the urge to cough." "Engage in regular exercise."

"Stop smoking." "Get the annual flu shot." "Engage in regular exercise." "Make sure you drink enough fluid every day." Explanation: The respiratory system compensates well for the functional changes of aging. In general there is very little decline in respiratory functioning in a healthy nonsmoking older adult. Suggestions that the nurse should recommend to the client to maximize respiratory functioning and prevent the development of a respiratory illness include not smoking and getting the annual influenza vaccination. The client should also be encouraged to engage in regular exercise and ensure adequate fluid intake every day. Older adults should be encouraged to cough more frequently to maintain lung capacity and cough efficiency.

A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration? An oropharyngeal catheter A partial rebreathing mask A nasal cannula A Venturi mask

A partial rebreathing mask Explanation: Partial rebreathing masks have a reservoir bag that must remain inflated during both inspiration and expiration. The nurse adjusts the oxygen flow to ensure that the bag does not collapse during inhalation. A high concentration of oxygen (50% to 75%) can be delivered because both the mask and the bag serve as reservoirs for oxygen. The other devices listed cannot deliver oxygen at such a high concentration.

A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. The client also reports nausea, diaphoresis, and shortness of breath. What is the nurse's priority action? Gain I.V. access, give sublingual nitroglycerin, and alert the cardiac catheterization team. Administer oxygen, attach a cardiac monitor, and notify the health care provider. Complete the client's registration information, perform an electrocardiogram, gain I.V. access, and take vital signs. Administer oxygen, attach a cardiac monitor, take vital signs, and alert the cardiac catheterization team.

Administer oxygen, attach a cardiac monitor, take vital signs, and alert the cardiac catheterization team. Explanation: Cardiac chest pain is caused by myocardial ischemia. Therefore the nurse should administer supplemental oxygen to increase the myocardial oxygen supply, attach a cardiac monitor to help detect life-threatening arrhythmias, and take vital signs to ensure that the client isn't hypotensive before giving sublingual nitroglycerin for chest pain. Registration information may be delayed until the client is stabilized. Alerting the cardiac catheterization team or the health care provider before completing the initial assessment is premature.

The nurse is caring for a patient with GBS in the intensive care unit and is assessing the patient for autonomic dysfunction. What interventions should be provided in order to determine the presence of autonomic dysfunction? Assess the blood pressure and heart rate. Assess the peripheral pulses. Assess the respiratory rate and oxygen saturation. Listen to the bowel sounds.

Assess the blood pressure and heart rate. Explanation: The nurse assesses the blood pressure and heart rate frequently to identify autonomic dysfunction so that interventions can be initiated quickly if needed.

During the first 24 hours after a client is diagnosed with addisonian crisis, which intervention should the nurse perform frequently? Assess vital signs. Test urine for ketones. Administer oral hydrocortisone. Weigh the client.

Assess vital signs. Explanation: Because the client in addisonian crisis is unstable, vital signs and fluid and electrolyte balance should be assessed every 30 minutes until he's stable. Daily weights are sufficient when assessing the client's condition. The client shouldn't have ketones in his urine, so there is no need to assess the urine for their presence. Oral hydrocortisone isn't administered during the first 24 hours in severe adrenal insufficiency.

A client has recently undergone a coronary artery bypass graft (CABG). The nurse should be alert to which respiratory complication? Atelectasis Urinary tract infection (UTI) Elevated blood glucose level Hyperkalemia

Atelectasis Explanation: Respiratory complications that may occur include atelectasis. An incentive spirometer and the use of deep breathing exercises are necessary to prevent atelectasis and pneumonia. Elevated blood sugar levels, hyperkalemia, UTI, and are complications that can occur but are unrelated to the respiratory system.

Which symptom of thyroid disease is seen in older adults? Weight gain Atrial fibrillation Hyperactivity Restlessness

Atrial fibrillation Explanation: Symptoms seen in older adults include weight loss and atrial fibrillation. Older adults may not experience restlessness or hyperactivity.

Upon assessment, the nurse suspects that a client with COPD may have bronchospasm. What manifestations validate the nurse's concern? Select all that apply. Jugular vein distention Ascites Wheezes Decreased airflow Compromised gas exchange

Compromised gas exchange Decreased airflow Wheezes Explanation: Bronchospasm, which occurs in many pulmonary diseases, reduces the caliber of the small bronchi and may cause dyspnea, static secretions, and infection. Bronchospasm can sometimes be detected on auscultation with a stethoscope when wheezing or diminished breath sounds are heard. Increased mucus production, along with decreased mucociliary action, contributes to further reduction in the caliber of the bronchi and results in decreased airflow and decreased gas exchange. This is further aggravated by the loss of lung elasticity that occurs with COPD (GOLD, 2015).

An elderly client reports fatigue without shortness of breath with walking 30 minutes five times each week. The nurse assesses the resting heart rate as 72 beats per minute; 10 minutes after walking, the client's heart rate is 92 beats per minute. What should the nurse instruct the client to do next? Decrease walking frequency to three times each week. Continue to walk at his current level. Refrain from any form of exercise. Increase walking at a faster pace.

Continue to walk at his current level. Explanation: Elderly clients may report fatigue with increased activity as a result of a slower heart rate recovery, which may be a physiological response to aging. An appropriate nursing intervention is to educate the client to exercise regularly but also to pace activities. The nurse does not want to tell the client not to exercise, to walk faster, or to decrease frequency.

A client with Alzheimer disease becomes agitated while the nurse is attempting to take vital signs. What action by the nurse is most appropriate? Place the client in a secluded room until calm. Continue taking the vital signs. Distract the client with a familiar object or music. Document the inability to assess vital signs due to client's agitation.

Distract the client with a familiar object or music. Explanation: The nurse should try to calm the patient by using distraction with a familiar object or music. Continuing to take the vital signs will cause further agitation and possible harm to the client or nurse. Placing the client in a secluded room may increase agitation and should not be used in this situation. The nurse should document the inability to assess vital signs and the reason why this should be done after the client's basic needs have been met.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Despite various medication regimes, the client's symptoms are gradually increasing. The nurse realizes that this client is which phase of the Trajectory Model of Chronic Illness? Downward Unstable Dying Acute

Downward Explanation: The downward phase occurs when symptoms worsen or the disability progresses despite attempts to control the course through proper management. The unstable phase is characterized by development of complications or reactivation of the illness. The acute phase is characterized by sudden onset of severe or unrelieved symptoms or complications that may necessitate hospitalization for their management. The dying phase is characterized by gradual or rapid shutting down of life-maintaining functions.

A client has chronic obstructive pulmonary disease (COPD) and is exhibiting shallow respirations of 32 breaths per minute and a pulse oximetry of 93% despite receiving nasal oxygen at 2 L/minute. What action should the nurse take? Teach the client to perform upper chest breaths. Encourage the client to exhale slowly against pursed lips. Increase the flow of oxygen. Encourage the client to take deep breaths.

Encourage the client to exhale slowly against pursed lips. Explanation: When a client with COPD exhibits shallow, rapid, and inefficient respirations, the nurse encourages the client to perform pursed-lip breathing, which includes exhaling slowly against pursed lips. Pursed-lip breathing helps slow expiration, prevents collapse of small airways, and helps the client control the rate and depth of respiration. It also promotes relaxation, enabling the client to gain control of dyspnea and reduce feelings of panic. Taking deep breaths and upper chest breathing are inefficient breathing techniques; the client with COPD should be encouraged to practice diaphragmatic breathing. Increasing oxygen flow is not necessary because the pulse oximetry is 93%.

A nurse identifies a nursing diagnosis of risk for ineffective breathing pattern related to incisional pain and restricted positioning for a client who has had a nephrectomy. Which of the following would be most appropriate for the nurse to include in the client's plan of care? Administer isotonic fluid therapy as ordered. Encourage use of incentive spirometer every 2 hours. Monitor temperature every 4 hours. Keep the drainage catheter below the level of insertion.

Encourage use of incentive spirometer every 2 hours. Explanation: To address the issue of ineffective breathing pattern, encouraging the use of incentive spirometer would be most appropriate to help increase alveolar ventilation. Administering isotonic fluid therapy would be appropriate for issues involving fluid loss such as bleeding or hemorrhage. Keeping the drainage catheter below the level of insertion would be appropriate to reduce the risk of obstruction leading to acute pain. Monitoring the temperature every 4 hours would be appropriate to reduce the client's risk for infection.

A nurse evaluates the results of a spirometry test to help confirm a diagnosis of obstructive lung disease. Which one of the following results indicates an initial early stage of COPD? (FEV1 refers to forced expired volume in 1 second.) FEV1 = 70% FEV1 = 30% FEV1 = 50% FEV1 > 80%

FEV1 > 80% Explanation: The FEV1 decreases as the severity of obstruction increases. Therefore, an FEV1 of more than 80% indicates an initial stage, and an FEV1 of 30% indicates a very severe stage.

A nurse has established a nursing diagnosis of ineffective airway clearance. The datum that best supports this diagnosis is that the client Reports shortness of breath Cannot perform activities of daily living Has a respiratory rate of 28 breaths/minute Has wheezes in the right lung lobes

Has wheezes in the right lung lobes Explanation: Of the data listed, wheezing, an adventitious lung sound, is the best datum that supports the diagnosis of ineffective airway clearance. An increased respiratory rate and a report of dyspnea are also defining characteristics of this nursing diagnosis. They could support other nursing diagnoses, as would inability to perform activities of daily living.

A patient has been diagnosed with a deficiency of the major neurotransmitter acetylcholine. Based on this information, the nurse knows to assess the patient for complications associated with: Fine movements. Heart rate and rhythm. Emotional balance. Sleep patterns.

Heart rate and rhythm. Explanation: Acetylcholine is a major transmitter of the parasympathetic nervous system and stimulates the vagal nerve to slow the heart rate.

You are assessing the respiratory system of a client just admitted to your unit. What do you know to assess in addition to the physical and functional issues related to breathing? How these issues affect the client's quality of life How these issues affect the relationships in the client's life How these issues affect the client's effort to breathe How these issues affect the client's ability to function

How these issues affect the client's quality of life Explanation: Assessment of the respiratory system includes obtaining information about physical and functional issues related to breathing. It also means clarifying how these issues may affect the client's quality of life. Therefore, options B, C, and D are incorrect.

A patient with diabetes is being treated for a wound on the lower extremity that has been present for 30 days. What option for treatment is available to increase diffusion of oxygen to the hypoxic wound? Vacuum-assisted closure device Hyperbaric oxygen Enzymatic debridement Surgical debridement

Hyperbaric oxygen Explanation: Hyperbaric oxygenation (HBO) may be beneficial as an adjunct treatment in patients with diabetes with no signs of wound healing after 30 days of standard wound treatment. HBO is accomplished by placing the patient into a chamber that increases barometric pressure while the patient is breathing 100% oxygen. Treatment regimens vary from 90 to 120 minutes once daily for 30 to 90 sessions. The process by which HBO is thought to work involves several factors. The edema in the wound area is decreased because high oxygen tension facilitates vasoconstriction and enhances the ability of leukocytes to phagocytize and kill bacteria. In addition, HBO is thought to increase diffusion of oxygen to the hypoxic wound, thereby enhancing epithelial migration and improving collagen production.

In which grade of COPD is the forced expiratory volume in 1 second (FEV1) less than 30% predicted? I II III IV

IV Explanation: COPD is classified into four grades depending on the severity measured by pulmonary function tests. However, pulmonary function is not the only way to assess or classify COPD; pulmonary function is evaluated in conjunction with symptoms, health status impairment, and the potential for exacerbations. Grade I (mild): FEV1 ≥80% predicted. Grade II (moderate): FEV1 50% to 80% predicted. Grade III (severe): FEV1 <30% to 50% predicted. Grade IV (very severe): FEV1 <30% predicted.

A client diagnosed with asthma is preparing for discharge. The nurse is educating the client on the proper use of a peak flow meter. The nurse instructs the client to complete which action? Sit down while completing a peak flow reading. If coughing occurs during the procedure, repeat it. Take and record peak flow readings three times daily. Move the indicator to the top of the numbered scale.

If coughing occurs during the procedure, repeat it. Explanation: Steps for using the peak flow meter correctly include; (1) moving the indicator to the bottom of the numbered scale; (2) standing up; (3) taking a deep breath and filling the lungs completely; (4) placing the mouthpiece in the mouth and closing the lips around it; (5) blowing out hard and fast with a single blow; (6) recording the number achieved on the indicator. If the client coughs or a mistake is made in the process, repeat the procedure. Peak flow readings should be taken during an asthma attack.

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority? Ineffective tissue perfusion (cardiopulmonary) Anxiety Impaired gas exchange Decreased cardiac output

Impaired gas exchange Explanation: For a client with chest trauma, a diagnosis of Impaired gas exchange takes priority because adequate gas exchange is essential for survival. Although the other nursing diagnoses — Anxiety, Decreased cardiac output, and Ineffective tissue perfusion (cardiopulmonary) — are possible for this client, they are lower priorities than Impaired gas exchange.

A client is admitted to the hospital with pneumonia. He has a history of Parkinson disease, which his family says is worsening. Which assessment should the nurse expect? Tremors in the fingers that increase with purposeful movement Impaired speech Muscle flaccidity Pleasant and smiling demeanor

Impaired speech Explanation: In Parkinson's disease, dysarthria, or impaired speech, results from a disturbance in muscle control. Muscle rigidity, not flaccidity, causes resistance to passive muscle stretching. The client may exhibit a masklike appearance rather than a pleasant and smiling demeanor. Tremors should decrease, not increase, with purposeful movement and sleep.

Which of the following would the nurse identify as indicating that a client is experiencing a complete airway obstruction? Select all that apply. Clutching of the neck Spontaneous coughing Inability to speak Cyanosis Stridor

Inability to speak Clutching of the neck Stridor Cyanosis Explanation: Manifestations of a complete airway obstruction include the inability to speak, breathe, or cough; clutching the neck; inspiratory and expiratory stridor; and cyanosis (a late sign). If the client can cough spontaneously, then a partial airway obstruction is most likely.

A client reports nasal congestion, sneezing, sore throat, and coughing up of yellow mucus. The nurse assesses the client's temperature as 100.2°F. The client states this is the third episode this season. The highest priority nursing diagnosis is Acute pain related to upper airway irritation Ineffective airway clearance related to excess mucus production Deficient fluid volume related to increased fluid needs Deficient knowledge related to prevention of upper respiratory infections

Ineffective airway clearance related to excess mucus production Explanation: All the listed nursing diagnoses are appropriate for this client. Following Maslow's hierarchy of needs, physiological needs are addressed first and, within physiological needs, airway, breathing, and circulation are the most immediate. Thus, ineffective airway clearance is the priority nursing diagnosis.

Which of the following is the key underlying feature of asthma? Chest tightness Inflammation Shortness of breath Productive cough

Inflammation Explanation: Inflammation is the key underlying feature and leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheeze, and dyspnea.

A nurse is inserting a nasogastric tube in an alert client. During the procedure, the client begins to cough constantly and has difficulty breathing. The nurse suspects the nasogastric tube is Irritating the epiglottis Inserted into the lungs Passing into the esophagus Coiling in the client's mouth

Inserted into the lungs Explanation: The alert client may cough constantly and have difficulty with respirations when the nasogastric tube enters the lungs. The client may cough but will not have difficulty with respirations with the nasogastric tube coiling in the mouth or irritating the epiglottis. Usually if the nasogastric tube is entering the esophagus, the client will not exhibit coughing or dyspnea.

An elderly female client has been taking prednisone for breathing problems for many years. The nurse notes that the client's current height is 64 inches. Two years ago, her height was 66 inches. The nurse assesses this loss in height is most likely the result of Loss of bone density Degeneration in the efficiency of bone joints Decreased muscle mass and joint cartilage The client's failure to exercise

Loss of bone density Explanation: Elderly clients experience decreased bone density; they also may experience a loss of bone density from insufficient exercise. For this client, however, additional information indicates that she is taking prednisone, which may induce osteoporosis (loss of bone density). No information indicates that the client is not exercising or has experienced degeneration of bone joints. Degeneration in the efficiency of the bone joints and decreased muscle mass and joint cartilage would have more of an effect on increased pain than on decreased height.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client? Lung auscultation and measurement of vital capacity and tidal volume Evaluation for signs and symptoms of increased intracranial pressure (ICP) Evaluation of pain and discomfort Evaluation of nutritional status and metabolic state

Lung auscultation and measurement of vital capacity and tidal volume Explanation: In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.

A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following? Client reports no chest pain. Lungs are clear on auscultation. Respiratory rate is 12 to 18 breaths per minute. Client can perform incentive spirometry.

Lungs are clear on auscultation. Explanation: Assessment of lung sounds includes auscultation for airflow through the bronchial tree. The nurse evaluates for fluid or solid obstruction in the lung. When airflow is decreased, as with fluid or secretions, adventitious sounds may be auscultated. Often crackles are heard with fluid in the airways.

A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply. Request order for patient-controlled analgesia pump Monitor and record hourly intake and output. Encourage deep breathing exercises. Regularly assess the client's vital signs every 2 to 4 hours. Monitor pulmonary status as directed and needed.

Monitor pulmonary status as directed and needed. Regularly assess the client's vital signs every 2 to 4 hours. Encourage deep breathing exercises. Explanation: Interventions to improve the client's gas exchange include monitoring pulmonary status as directed and needed, assessing vital signs every 2 to 4 hours, and encouraging deep breathing exercises. The nurse would request an order for patient-controlled analgesia if appropriate for the client, but that would be an intervention related to post-surgical pain, not impaired gas exchange. Monitoring and recording hourly intake and output are essential interventions for ensuring appropriate fluid balance but not directly related to impaired gas exchange.

A priority nursing intervention for a client with hypervolemia involves which of the following? Drawing a blood sample for typing and crossmatching. Establishing I.V. access with a large-bore catheter. Encouraging the client to consume sodium-free fluids. Monitoring respiratory status for signs and symptoms of pulmonary complications.

Monitoring respiratory status for signs and symptoms of pulmonary complications. Explanation: Hypervolemia, or fluid volume excess (FVE), refers to an isotonic expansion of the extracellular fluid. Nursing interventions for FVE include measuring intake and output, monitoring weight, assessing breath sounds, monitoring edema, and promoting rest. The most important intervention in the list involves monitoring the respiratory status for any signs of pulmonary congestion. Breath sounds are assessed at regular intervals.

The nurse identifies which finding to be most consistent prior to the onset of acute respiratory failure? Chronic lung disease Loss of lung function Normal lung function Slow onset of symptoms

Normal lung function Explanation: Acute respiratory failure occurs suddenly in clients who previously had normal lung function.

A client experiences an acute myocardial infarction. Current blood pressure is 90/58, pulse is 118 beats/minute, and respirations are 30 breaths/minute. The nurse intervenes first by administering the following prescribed treatment: Morphine 2 mg intravenously Dopamine (Intropin) intravenous solution Oxygen at 2 L/min by nasal cannula NS at 60 mL/hr via an intravenous line

Oxygen at 2 L/min by nasal cannula Explanation: In the early stages of cardiogenic shock, the nurse first administers supplemental oxygen to achieve an oxygen saturation exceeding 90%. The nurse may then administer morphine to relieve chest pain and/or to reduce the workload of the heart and decrease client anxiety. Intravenous fluids are given carefully to prevent fluid overload. Vasoactive medications, such as dopamine, are then administered to restore and maintain cardiac output.

A patient describes his chest pain as knife-like on inspiration. Which of the following is the most likely diagnosis? A lung infection Bacterial pneumonia Pleurisy Bronchogenic carcinoma

Pleurisy Explanation: Pleuritic pain from irritation of the parietal pleura is sharp and seems to "catch" on inspiration. Some patients describe the pain as being "stabbed by a knife." Chest pain associated with the other conditions may be dull, aching, and persistent.

The nurse is reviewing the electronic health record of a client with an empyema. What health problem in the client's history is most likely to have caused the empyema? Pneumonia Smoking Asbestosis Lung cancer

Pneumonia Explanation: Most empyema's occur as complications of bacterial pneumonia or lung abscess. Cancer, smoking, and asbestosis are not noted to be common causes.

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients? Pleurisy Pneumonia Hypoxemia Pulmonary edema

Pneumonia Explanation: Older clients recover more slowly, have longer hospital stays, and are at greater risk for development of postoperative complications. Delirium, pneumonia, decline in functional ability, exacerbation of comorbid conditions, pressure ulcers, decreased oral intake, GI disturbance, and falls are all threats to recovery in the older adult.

A nurse is caring for a client with COPD. While reviewing breathing exercises, the nurse instructs the client to breathe in slowly through the nose, taking in a normal breath. Then the nurse asks the client to pucker his lips as if preparing to whistle. Finally, the client is told to exhale slowly and gently through the puckered lips. The nurse teaches the client this breathing exercise to accomplish which goals? Select all that apply. Release air trapped in the lungs Control the rate and depth of respirations Condition the inspiratory muscles Prevent airway collapse Strengthen the diaphragm

Prevent airway collapse Control the rate and depth of respirations Release air trapped in the lungs Explanation: The nurse is teaching the client the technique of pursed-lip breathing. It helps slow expiration, prevents collapse of the airways, releases air trapped in the lungs, and helps the client control the rate and depth of respirations. This helps clients relax and get control of dyspnea and reduces the feelings of panic they may experience. Diaphragmatic breathing strengthens the diaphragm during breathing. In inspiratory muscle training, the client will be instructed to inhale against a set resistance for a prescribed amount of time every day in order to condition the inspiratory muscles.

A student nurse is working with a client who is diagnosed with head trauma. The nurse has documented Cheyne-Stokes respirations. The student would expect to see which of the following? Irregular breathing at 14 to 18 breaths per minute Regular breathing where the rate and depth increase, then decrease Periods of normal breathing followed by periods of apnea Period of cessation of breathing

Regular breathing where the rate and depth increase, then decrease Explanation: Observing the rate and depth of respiration is an important aspect of the nursing assessment. Certain patterns of breathing are characteristic of specific disease states or conditions. Head trauma can cause damage to the respiratory center in the brain, thereby altering the rate and depth of respirations. Cheyne-Stokes breathing is characterized by a regular cycle in which the rate and depth of breathing increase, then decrease until apnea occurs.

The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis? Dyspnea and coughing Stabbing pain during respiratory movement Fever and chills Dullness or flatness on percussion over areas of collected fluid

Stabbing pain during respiratory movement Explanation: When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is severe, sharp, knifelike pain. The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases.

The nurse is caring for a client who has been diagnosed with chronic obstructive pulmonary disease (COPD) and is experiencing respiratory acidosis. The client asks what is making the acidotic state. What does the nurse identify as the result of the disease process that causes the fall in pH? The lungs have ineffective cilia from years of smoking. The lungs are unable to exchange oxygen and carbon dioxide. The lungs are unable to breathe in sufficient oxygen. The lungs are not able to regulate carbonic acid levels.

The lungs are not able to regulate carbonic acid levels. Explanation: In clients with chronic respiratory acidosis, the client's lungs are not able to regulate carbonic acid levels. The increase in carbonic acid leads to acidosis. In COPD, the client is able to breathe in oxygen, and gas exchange can occur, but the lungs' ability to remove the carbon dioxide from the system is limited. Although individuals with COPD frequently have a history of smoking, ineffective cilia is not the cause of the acidosis.

The nurse develops outcome criteria for a patient with chronic obstructive pulmonary disease. Which outcome criteria are appropriate for this patient? The patient will have the ability to climb a flight of stairs without experiencing difficulty in breathing. The patient will not experience an alteration in skin integrity. The nurse will obtain a pulse oximetry reading twice a day. The patient will perform passive range-of-motion exercises once daily.

The patient will have the ability to climb a flight of stairs without experiencing difficulty in breathing. Explanation: Outcomes of teaching strategies can be stated in terms of expected behaviors of patients, families, or both. Outcomes should be realistic and measurable, and the critical time periods for attaining them should be identified. The desired outcomes and the critical time periods serve as a basis for evaluating the effectiveness of the teaching strategies.

The nurse is caring for a client diagnosed with asthma. While performing the shift assessment, the nurse auscultates breath sounds including sibilant wheezes, which are continuous musical sounds. What characteristics describe sibilant wheezes? They result from air passing through widened air passages. They are heard in clients with decreased secretions. They occur when the pleural surfaces are inflamed. They can be heard during inspiration and expiration.

They can be heard during inspiration and expiration. Explanation: Sibilant or hissing or whistling wheezes are continuous musical sounds that can be heard during inspiration and expiration. They result from air passing through narrowed or partially obstructed air passages and are heard in clients with increased secretions. The crackling or grating sounds heard during inspiration or expiration are friction rubs. They occur when the pleural surfaces are inflamed.

The nurse is providing education to a 65-year-old female client with pneumococcal pneumonia being discharged from the health clinic on oral antibiotics. The client is a nonsmoker, takes levothyroxine for Hashimoto disease, and is otherwise in good health. For each client statement, click to specify if the finding indicates understanding or the need for reinforcement of the teaching. "Sleeping with a humidifier can help loosen secretions." "I will rest and avoid overexertion." "I will drink 1 liter of fluid each day." "I will perform deep-breathing exercises once per day." "I will take the antibiotics until the secretions clear up." "I should get the PPSV23 this year because I got the PCV13 last year." "A persistent or recurring fever is normal after starting antibiotics." "I will seek medical attention if my cough worsens."

Understanding: "Sleeping with a humidifier can help loosen secretions." "I will seek medical attention if my cough worsens." "I will rest and avoid overexertion." "I will take the antibiotics until the secretions clear up." Reinforcement: "A persistent or recurring fever is normal after starting antibiotics." "I will perform deep-breathing exercises once per day." "I should get the PPSV23 this year because I got the PCV13 last year." Explanation: The nurse needs to educate the client with pneumonia about the medical regimen, signs and symptoms to report, measures to prevent pneumonia, and supportive care. Because the client is 65 years old and has previously been vaccinated with PCV13, the client should receive the PPSV23 vaccination. The client is also correct that breathing humidified air helps to liquefy secretions and relieve tracheobronchial irritation. Additionally, the client understands that a worsening cough can signal a lack of response to the antibiotics and a deterioration in the client's condition. The client with pneumonia should also obtain adequate rest and avoid overexertion. The nurse needs to reinforce to the client that, to successfully treat pneumonia, antibiotics need to be taken for the fully prescribed course and should not be stopped when symptoms subside. The nurse should also reinforce that the client should drink 2 to 3 liters of fluid each day because hydration thins and loosens pulmonary secretions. Additionally, a persistent and recurrent fever after starting antibiotics is not an expected therapeutic response to antibiotics and requires medical attention. Performing deep-breathing exercises once a day is not sufficient to inflate alveoli and prevent atelectasis. These exercises should be performed at least every 2 hours.

The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS? Unresponsive arterial hypoxemia Diminished alveolar dilation Tachypnea Increased PaO2

Unresponsive arterial hypoxemia Explanation: Acute respiratory distress syndrome (ARDS) can be thought of as a spectrum of disease, from its milder form (acute lung injury) to its most severe form of fulminate, life-threatening ARDS. This clinical syndrome is characterized by a severe inflammatory process causing diffuse alveolar damage that results in sudden and progressive pulmonary edema, increasing bilateral infiltrates on chest x-ray, hypoxemia unresponsive to oxygen supplementation regardless of the amount of PEEP, and the absence of an elevated left atrial pressure.

A client being treated for pancreatitis faces the risk of atelectasis. Which of the following interventions would be important to implement to minimize this risk? Instruct the client to cough only when necessary. Use incentive spirometry every hour. Monitor pulse oximetry every hour. Withhold analgesics unless necessary.

Use incentive spirometry every hour. Explanation: The nurse instructs the client in techniques of coughing and deep breathing and in the use of incentive spirometry to improve respiratory function. The nurse assists the client to perform these activities every hour. Repositioning the client every 2 hours minimizes the risk of atelectasis. The client should be instructed to cough every 2 hours to reduce atelectasis. Monitoring pulse oximetry helps show changes in respiratory status and promotes early intervention, but it would do little to minimize the risk of atelectasis. Withholding analgesics is not an appropriate intervention due to the severe pain associated with pancreatitis.

The nurse documents breath sounds that are soft, with inspiratory sounds longer than expiratory and found over the periphery of the lungs. Which of the following will the nurse chart? Vesicular Bronchial Adventitious Tracheal

Vesicular Explanation: Vesicular breath sounds are heard over the entire lung field except the upper sternum and between the scapulae. Their pitch and intensity are low. Inspiration sounds are longer than expiratory sounds. These are considered normal breath sounds.

The nurse is explaining the cause of angina pain to a client. What will the nurse say most directly caused the pain? a lack of oxygen in the heart muscle cells complete closure of an artery a destroyed part of the heart muscle incomplete blockage of a major coronary artery

a lack of oxygen in the heart muscle cells Explanation: Angina pectoris refers to chest pain that is brought about by myocardial ischemia. It is the result of cardiac muscle cells being deprived of oxygen due to the progressive symptoms of coronary artery disease. Artery blockage or closure leads to myocardial death. The destroyed part of the heart (death of heart tissue) is a myocardial infarction.

A client with emphysema is at a greater risk for developing which acid-base imbalance? respiratory alkalosis metabolic acidosis chronic respiratory acidosis metabolic alkalosis

chronic respiratory acidosis Explanation: Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis.

A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to: cough as the cuff is being deflated. take a deep breath as the nurse deflates the cuff. hold the breath as the cuff is being reinflated. exhale deeply as the nurse reinflates the cuff.

cough as the cuff is being deflated. Explanation: The nurse should instruct the client to cough during cuff deflation. If the client can't cough, the nurse should perform suctioning to prevent aspiration of secretions. Because the cuff should be deflated during expiration, the client shouldn't take a deep breath as the nurse deflates the cuff. Likewise, because the cuff is reinflated during inspiration, the client shouldn't hold the breath or exhale deeply during reinflation.

The nurse is caring for a client with coronary artery disease. What is the nurse's priority goal for the client? educate the client about his symptoms decrease anxiety administer sublingual nitroglycerin enhance myocardial oxygenation

enhance myocardial oxygenation Explanation: Enhancing myocardial oxygenation is always the first priority when a client exhibits signs or symptoms of cardiac compromise. Without adequate oxygen, the myocardium suffers damage. A nurse administers sublingual nitroglycerin to treat acute angina pectoris, but its administration isn't the first priority. Although educating the client and decreasing anxiety are important in care, neither is a priority when a client is compromised.

A client with chronic obstructive pulmonary disease (COPD) is admitted to the medical-surgical unit. To help this client maintain a patent airway and achieve maximal gas exchange, the nurse should: maintain the client on bed rest. administer pain medication as ordered. administer anxiolytics, as ordered, to control anxiety. instruct the client to drink at least 2 L of fluid daily.

instruct the client to drink at least 2 L of fluid daily. Explanation: Mobilizing secretions is crucial to maintaining a patent airway and maximizing gas exchange in the client with COPD. Measures that help mobilize secretions include drinking 2 L of fluid daily, practicing controlled pursed-lip breathing, and engaging in moderate activity. Anxiolytics rarely are recommended for the client with COPD because they may cause sedation and subsequent infection from inadequate mobilization of secretions. Because COPD rarely causes pain, pain medication isn't indicated.

A client has been treated for shock and is now at risk for which secondary but life-threatening complications? Select all that apply. GERD disseminated intravascular coagulation kidney failure hypoglycemia acute respiratory distress syndrome

kidney failure disseminated intravascular coagulation acute respiratory distress syndrome Explanation: When shock is treated adequately and promptly, the client usually recovers but may be at risk for secondary complications that result directly from tissue hypoxia and organ ischemia due to reduced oxygenation. Life-threatening complications include kidney failure, neurologic deficits, bleeding disorders such as disseminated intravascular coagulation, acute respiratory distress syndrome, stress ulcers, and sepsis that can lead to multiple organ dysfunction.

Each chamber of the heart has a particular role in maintaining cellular oxygenation. Which chamber is responsible for pumping blood to all the cells and tissues of the body? left atrium left ventricle right ventricle right atrium

left ventricle Explanation: The left ventricle pumps blood to all the cells and tissues of the body. The left atrium receives oxygenated blood from the lungs. The right ventricle pumps blood to the lungs to be oxygenated. The right atrium receives deoxygenated blood from the venous system.

The primary objective in the immediate postoperative period is relieving pain. maintaining pulmonary ventilation. monitoring for hypotension. controlling nausea and vomiting.

maintaining pulmonary ventilation. Explanation: The primary objective in the immediate postoperative period is to maintain pulmonary ventilation, which prevents hypoxemia. Controlling nausea and vomiting, relieving pain, and monitoring for hypotension are important, but they are not primary objectives in the immediate postoperative period.

The nurse is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's: hemoglobin, hematocrit, and red blood cell levels. extremities for signs of cyanosis. oxygen saturation level. level of consciousness (LOC).

oxygen saturation level. Explanation: The effectiveness of the client's oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The client's LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.

A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as hemothorax. pleural effusion. consolidation. pneumothorax.

pleural effusion. Explanation: Fluid accumulating within the pleural space is called a pleural effusion. A pneumothorax is air in the pleural space. A hemothorax is blood within the pleural space. Consolidation is lung tissue that has become more solid in nature as a result of the collapse of alveoli or an infectious process.

What does decreased pulse pressure reflect? elevated stroke volume reduced distensibility of the arteries reduced stroke volume tachycardia

reduced stroke volume Explanation: Decreased pulse pressure reflects reduced stroke volume and ejection velocity or obstruction to blood flow during systole. Increased pulse pressure would indicate reduced distensibility of the arteries, along with bradycardia.

During auscultation of the lungs, what would a nurse note when assessing a client with left-sided heart failure? wheezes with wet lung sounds high-pitched sounds laborious breathing stridor

wheezes with wet lung sounds Explanation: If the left side of the heart fails to pump efficiently, blood backs up into the pulmonary veins and lung tissue. For abnormal and normal breath sounds, the nurse auscultates the lungs. With left-sided congestive heart failure, auscultation reveals a crackling sound, wheezes, and gurgles. Wet lung sounds are accompanied by dyspnea and an effort to sit up to breathe. With left-sided congestive heart failure, auscultation does not reveal a high pitched sound.