CH 30
The nurse is preparing to suction a client's airway. How long will the nurse preoxygenate the client to achieve a maintenance Sp02 of 95-100%?
1-2 min
The nurse is preparing to perform nasopharyngeal suctioning on an adult using a wall unit. What is the appropriate suction pressure setting for an adult?
100 to 120 mm Hg
A client is receiving oxygen therapy via a nasal cannula at 3 L/min. The nurse estimates that the client is receiving which concentration of oxygen?
30%
A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:
6 L/minute.
Erin is a 35-year-old woman being cared for in the emergency department for a cough and hemoptysis for 3 days. Erin states that she has smoked one-and-a-half packs of cigarettes per day for the last 5 years. In trying to identify risk factors for Erin, the nurse calculates her pack-year history to write on the intake form. What is Erin's pack-year of smoking?
7.5
A nurse is preparing to use a wall unit to suction the endotracheal tube of a 9-year-old child. At what pressure should the suction be set?
80 to 100 mm Hg
The nurse is providing an educational demonstration to an older, postsurgical client. The intervention is intended to minimize the effect of what age-related change specifically relevant to such a client?
A decrease in ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs
While in the dining room at the hospital, the nurse notes a visitor eating lunch. The visitor begins coughing forcefully. Which action(s) will the nurse take to assist this visitor? Select all that apply.
Allow the visitor to cough. Assess for a weak, ineffective cough.
An older adult client with a history of chronic obstructive pulmonary disease is admitted to the hospital with a cough and acute shortness of breath. Which priority action should the nurse take during the initial assessment of the client?
Ask specific questions about the history of the cough and shortness of breath.
A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?
Ask the client what factors contribute to nonadherence.
A client in cardiac arrest is being resuscitated when the family arrives. What is the appropriate nursing action?
Ask the family members if they wish to remain in the room during the resuscitation.
While jogging through the neighborhood, a nurse witnesses the collapse of a nearby jogger and suspects cardiac arrest. Which action should the nurse take first?
Assess the victim for consciousness.
The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which instruction will the nurse include in the teaching?
Be sure to shake the canister before using it.
Which technique would the nurse employ to maximize the effectiveness of postural drainage?
Combine it with percussion and vibration.
The nurse is monitoring a client with continuous pulse oximetry. What action(s) by the nurse are important to obtain accurate results? Select all that apply.
Correlate the pulse oximetry reading with the client's heart rate. Use the forehead sensor if cardiac output is low Determine if the client has a pre-existing condition affecting the oxygen saturation.
The nurse assisting a 7-year-old client at mealtime utilizes which essential strategy(ies) to facilitate safe eating for this child? Select all that apply.
Have a drink available while client eats Position client in an upright, sitting position Ensure that the food is cut into bite-sized pieces Instruct client to chew and swallow slowly Remind the client not to talk while food is in the mouth
The nurse is caring for a client with emphysema. When teaching the client pursed-lip breathing, the nurse will include which instruction(s)? Select all that apply.
Inhale slowly through the nose for a count of three. Shape the lips as if you were about to blow a whistle. Over time, begin to increase the length of the exhale. Exhale slowly through pursed lips. Ensure that the exhale lasts twice as long as the inhale.
A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention?
Inquire about factors that contribute to non-adherence.
A nurse is teaching a preoperative client how to use an incentive spirometer. Which instruction should be included in the teaching plan?
Insnhale slowly and as deeply as possible through the mouthpiece without using the nose.
A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determines that the education was successful when the students identify which activity as occurring during inspiration?
Intercostal muscles contract.
Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen?
It regulates the amount of oxygen received.
A nurse has an order to obtain a sputum specimen on a newly admitted client. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
Label the sputum specimen and take it to the lab.
Which should the nurse teach the family about caring for a client with emphysema at home? Select all that apply.
Maintain a smoke-free environment. Watch for increased wheezing or signs of a flare-up. Take advantage of pulmonary rehabilitation programs. Follow health care provider's prescription for oxygen administration. Create a long-term caregiving plan.
The nurse enters a client's room, observes the client coughing vigorously, and determines that the client is breathing but has a partially obstructed airway. Which action should the nurse take next?
Observe the client's respiratory effort.
A 72 year-old client has come for an annual wellness check-up with the health care provider. Which vaccine will the nurse discuss with the client?
PCV13 - Pneumococcal 13-valent conjugate
The nurse is reviewing the arterial blood gas results of a client with a respiratory disorder. What would alert the nurse to a problem?
PaCO2 of 55 mmHg
A nurse is caring for a client who sustained head trauma. The client is in a medically induced coma and on mechanical ventilation. The client's parent is at the bedside in tears. The parent states, "I just want my child to know I am here." To address the needs of the parent and the client, what would be the nurse's most appropriate response?
Place a chair next to the bed and encourage the parent to hold the client's hand.
A nurse conducts a health history for a client with chronic bronchitis. Which action does the nurse take first when the client begins to experience respiratory distress?
Place the client in a comfortable position, ensure an open airway and if oxygen is prescribed start administration
A client is taking albuterol via nebulizer. Which instruction will the nurse provide to teach the client how to use the nebulizer?
Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs.
A client returns to the unit following an insertion of a tracheostomy tube. Where should the nurse place the obturator?
Place the obturator in a plastic bag and put it at the bedside.
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?
Pulmonary function tests
A nurse is delivering oxygen to a client via an oxygen mask. Which guideline is recommended for this procedure?
Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously.
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)
A nurse walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action?
Start chest compressions.
The nurse performs assessments of cardiopulmonary functioning and oxygenation during regular physical assessments. Based on developmental variations, which findings would the nurse consider normal? Select all that apply.
The power of the respiratory and abdominal muscles is reduced in older adults, and therefore the diaphragm moves less efficiently. The normal infant's chest is small and the airways are short, making aspiration a potential problem. Alterations in respiratory function due to aging in older adults increase the risk for disease, especially pneumonia and other chest infections. The respiratory rate is more rapid in infants until the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates.
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.
A nurse needs to perform the Heimlich maneuver on an 8-month-old infant with a partial airway obstruction. Which action should the nurse perform?
Use the heel of one hand to administer back blows.
The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?
Wheezing
A nurse is preparing to orally suction a client with dysphagia following a stroke. Which suction device is appropriate?
Yankauer catheter
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
What prevents air from reentering the pleural space when chest tubes are inserted?
a closed water-seal drainage system
A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:
adequate tissue perfusion.
A client is experiencing hypoxia. Which nursing concern is appropriate to address when planning care?
anxiety
What does pulse oximetry measure?
arterial oxygen saturation
A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for:
atelectasis.
A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate?
changes in the alveolar-capillary membrane and diffusion
The nurse receives a change-of-shift report on the following clients with chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first?
client with a respiratory rate of 36 breaths/minute
A nurse is administering a prescribed dose of IV medication to a client who is recovering from partial airway obstruction. What are common reasons for airway obstruction to occur? Select all that apply.
compromised swallowing aspiration of vomitus insufficient chewing
The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?
confusion
The school nurse is reviewing the record of a new fourth grade student with a history of asthma. Which action should the nurse take when the student drops off an inhaler with salmeterol to be used in case of an asthma attack?
contact the parents for clarification
The nurse assesses that a client's Sp02 is 88%. What other assessment findings does the nurse anticipate?
cool extremities
Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways?
decreases the amount of air trapping and resistance
A nurse is caring for a client who has a long history of smoking, and states, "I cough for a long time every morning." The client has thick mucus secretions and is dyspneic with a respiratory rate of 28/min. The nurse uses which phase of the nursing process to apply the NANDA of Ineffective Airway Clearance?
diagnosis
The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier?
distilled water
The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing concern for this client is altered airway clearance related to copious and tenacious secretions. What is an appropriate nursing intervention to include in the client's care plan?
encouraging the client to consume at least 1.5 to 2 L of fluids daily of clear fluids daily
The nurse has received a prescription to obtain an arterial blood gas (ABG) on a client who has a history of chronic obstructive pulmonary disease (COPD) and is receiving oxygen via nasal cannula. Which step is the most important for the nurse to fulfill?
ensure client is at rest at least 30 minutes before obtaining the specimen
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 home health nurse arrives at a client's home and immediately notes the client is experiencing increased dyspnea. The client has a 7-year history of chronic obstructive pulmonary disease (COPD). Which assessment finding should the nurse prioritize?
flow meter set at 5 liters of oxygen
An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to 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.
To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?
high-Fowler's position
Oxygen hoods are generally used to deliver oxygen at rates approaching 100% to which developmental group?
infants
Which physiologic change does the nurse anticipate will be found in the older adult client with an ongoing nonproductive cough?
laryngeal atrophy
A nurse is assessing a client with partial airway obstruction. Which signs should the nurse observe if a client has partial airway obstruction? Select all that apply.
makes wheezing sounds coughs when eating exhibits cyanosis
A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use?
nonrebreather mask
A nurse is caring for a critically ill client who has been admitted to the intensive care unit at the health care facility. The client is unable to breathe on his own and requires a very high concentration of oxygen. Which oxygen delivery device is most appropriate for this client?
nonrebreather mask
A client with a 26-year history of cigarette smoking is recovering from pneumonia. Which information will be most important for the nurse to include in the discharge teaching?
options for smoking cessation
The nurse is preparing to suction a client's mouth to remove secretions. Which type of suctioning will the nurse perform?
oral
A nurse at a health care facility uses a tonsil-tip catheter to remove the secretions from the mouth of a client with chest congestion. Which suctioning technique is the nurse using in this case?
oral suctioning
A nurse is caring for a critically ill client who is receiving oxygen through a nonrebreather mask. The nurse should remember that which situation could lead to oxygen toxicity in the client?
oxygen concentration of more than 50% given for longer than 48 hours
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
A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of:
pneumonia.
A client at a health care facility who requires prolonged mechanical ventilation has a tracheostomy tube inserted through a surgically created opening into the trachea. The tracheostomy tube also has a balloon cuff. How does the inflated balloon cuff aid the client?
prevents the aspiration of oral fluids
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
Which breathing technique(s) will the nurse teach to the client who has hypoxemia and hypercarbia? Select all that apply.
pursed-lip breathing diaphragmatic breathing
The health care provider directs the nurse to use oropharyngeal suctioning to remove liquid secretions for a client with a respiratory problem. What is oropharyngeal suctioning?
removing secretions from the throat through an orally inserted catheter
A client has had a head injury affecting the brain stem. What is located in the brain stem that may affect respiratory function?
respiratory center
What structural changes to the respiratory system should a nurse observe when caring for older adults?
respiratory muscles become weaker
A group of nursing students is reviewing information about artificial airways in preparation for a class discussion the next day. The students demonstrate understanding of the information when they identify what as an artificial airway consisting of a plastic tube surgically implanted just below the larynx into the trachea?
tracheostomy
The nurse is caring for a client who has 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
The nurse is assessing a client with a history of asthma. Which assessment finding indicates that the nurse should take immediate action?
use of accessory muscles in breathing
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 health care provider has prescribed a short-acting beta-2 agonist (SABA) for a client with a history of bronchospasm. What teaching about this drug will the nurse include?
"This drug is to be used as a rescue inhalant."
The nurse is caring for four clients. Which client does the nurse identify who would best benefit from chest physiotherapy?
21-year-old client with cystic fibrosis
Which is a sign of dyspnea specific to infants?
Nasal flaring
An infant with a small toy lodged in the trachea is crying. What is the nurse's priority action?
Observe the infant's respiratory effort.
The health care provider directs a nurse at the health care facility to perform vibration on a client with chest congestion. How should the nurse perform vibration on this client to relieve the congestion?
Position hands on the client's chest or back during inhalation.
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.
When performing a physical assessment of an adult client reporting dyspnea, the nurse is aware that which of the following is an abnormal finding?
dullness over the lung fields with percussion
A home care nurse finds an adult client slumped in a chair. The client is not breathing. Which method should the nurse use to open and maintain the client's airway?
head tilt-chin lift method
The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly?
respirations are at 20 breaths per minute
A client with a head injury will require long-term airway support. Which device will be required for this client?
tracheostomy tube
A client is diagnosed with hypoxia related to emphysema. The client's adult child will be assisting the client with daily hygiene. How will the nurse explain positioning of the client to the caregiver?
"An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist."
An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize?
"Is your mask causing discomfort?"
A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them?
"It is inserted into the space between the lining of the lungs and the ribs."
A nurse is educating a preoperative client on how to effectively deep breathe. Which instruction would be included?
"Make each breath deep enough to move the bottom ribs."
The nurse is demonstrating oxygen administration to a client. What teaching will the nurse include about the flowmeter?
"This is a gauge used to regulate the amount of oxygen that a client receives."
The nurse is teaching the family of a client with a tracheostomy about home care. Which family statement requires nursing intervention?
"We will remove the outer cannula for cleaning."
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?
"You should never smoke when oxygen is in use."
What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home?
"You will be asked to forcefully exhale into a mouthpiece."
