Chapter 26 Respiratory Function - PrepU questions
A nurse is educating a preoperative client on how to effectively deep breathe. Which instruction would be included? - "Breathe through the mouth when you inhale and exhale." - "Breathe in through the mouth and out through the nose." - "Make each breath deep enough to move the bottom ribs." - "Practice deep breathing at least once each week."
"Make each breath deep enough to move the bottom ribs." Explanation: The nurse should instruct the client to make each breath deep enough to move the bottom ribs. The client should start each deep breath by inhaling through the nose and exhaling through the mouth. Deep breathing should be done hourly when awake, or 4 times a day.
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. - insufficient chewing - compromised swallowing - aspiration of vomitus - excess intake of high-fiber food - continuous laughing or talking
- compromised swallowing - aspiration of vomitus - insufficient chewing Explanation: The common causes of airway obstruction are compromised swallowing, aspiration of vomitus, insufficient chewing, and eating when intoxicated, as well as other causes. Eating high-fiber food items or laughing and talking continuously do not cause airway obstruction.
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 - 10 to 60 mm Hg - 50 to 100 mm Hg - 150 to 200 mm Hg
100 to 120 mm Hg Explanation: The appropriate suction pressure for a wall unit for an adult is 100 to 120 mm Hg. Higher pressures can cause excessive trauma, hypoxemia, and atelectasis.
The nurse is caring for four clients. Which client does the nurse identify who would best benefit from chest physiotherapy? - 51-year-old client with diabetic ketoacidosis - 45-year-old client with influenza - 34-year-old client with appendicitis - 21-year-old client with cystic fibrosis
21-year-old client with cystic fibrosis Explanation: Clients with chronic respiratory diseases who have difficulty coughing or raising thick mucus, such as those with cystic fibrosis, will benefit best from chest physiotherapy. Chest physiotherapy is not as beneficial to those with appendicitis, influenza, or diabetic ketoacidosis.
A nurse assesses the vital signs of a healthy newborn infant. What respiratory rate could be expected based on the developmental level of this client? - 20 to 40 breaths/minute - 15 to 25 breaths/minute - 16 to 20 breaths/minute - 30 to 60 breaths/minute
30 to 60 breaths/minute Explanation: Normal breathing rate (breaths per minute) for an infant is 30 to 60; for a 6- to 12-year-old the rate is 15 to 25 breaths/min; for an older adult the rate is 16 to 20 breaths/min; and for a 1- to 5-year-old the rate is 20 to 40 breaths/min.
A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving? - 28% - 23% - 36% - 32%
32% Explanation: A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44%. ** note the a prior question gave the answer as 34%
A nurse is caring for a client who is unable to breathe efficiently by himself. The physician has directed the nurse to put the client on oxygen therapy. The client is receiving a high concentration of oxygen. At what level should a nurse use a humidifier for the client? - 4 L/min - 1 L/min - 3 L/min - 2 L/min
4 L/min Explanation: The nurse should use a humidifier when the client has been receiving more than 4 L/min of oxygen over an extended period. A humidifier is a device that produces small water droplets and may be used during oxygen administration because oxygen dries the mucous membranes. In most cases, oxygen is humidified only when more than 4 L/min is administered for an extended period. When humidification is desired, a bottle is filled with distilled water and attached to the flow meter.
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: - 10 L/minute. - 1 L/minute. - 6 L/minute. - 4 L/minute.
6 L/minute. Explanation: In general, if a flow rate of 6 L/minute fails to raise a client's oxygen saturation level satisfactorily, a mask should be used. 1-4 L/minute flow rates per nasal cannula are standard flow rates. Greater than 6 L/minute flow rate per nasal cannula is very uncomfortable for the client. A flow rate of 10 L /minute per nasal cannula is not acceptable.
A client is receiving supplemental oxygen and the nurse is monitoring the client's oxygen saturation level using pulse oximetry. The nurse notifies the physician if the client reaches which oxygen saturation level? - 98% - 94% - 96% - 92%
92% Explanation: An oxygen saturation level less than 93% usually indicates the need for increased supplemental oxygen.
A person is found on the floor and not breathing. A syringe is in the arm, and signs of frequent intravenous drug use are present. What is the priority response? - Begin chest compressions. - Administer naloxone. - Open the airway. - Provide rescue breaths.
Administer naloxone. Explanation: Opioid overdose can cause a person to stop breathing. In situations where naloxone, a single-dose auto injector opioid antagonist, is available, it should be used. If the client does not respond to the naloxone, then chest compressions would begin following the normal sequence of circulation, airway, and breathing.
The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider? - A 70-year-old with a respiratory rate of 18 bpm - A 4-year-old with a respiratory rate of 40 bpm - An infant with a respiratory rate of 20 bpm - A 12-year-old with a respiratory rate of 20 bpm
An infant with a respiratory rate of 20 bpm Explanation: The infant's normal respiratory rate is 30 to 55 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 40 breaths per minute. For a child 6 to 12 years of age the normal respiratory rate is 18 to 26 breaths per minute. The normal respiratory rate for an adult 65 years and older is 16 to 24 breaths per minute.
A client is experiencing hypoxia. Which nursing diagnosis would be appropriate? - Pain - Anxiety - Hypothermia - Nausea
Anxiety Explanation: Clients who are hypoxic commonly experience anxiety and restlessness related to feelings of suffocation. Pain, nausea, and hypothermia is not associated with a client experiencing hypoxia.
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. - Administer pulmonary function tests. - Assess for allergies before treatment. - Assist the client to lie down to complete a full physical assessment.
Ask specific questions about the history of the cough and shortness of breath. Explanation: Inquiring about a current history of coughing, determining how long the cough has been present, and observing and describing any sputum are important when assessing older adults. The client may have difficulty lying down for the assessment. Allergies should be assessed, but are not the priority. Administration of pulmonary function tests would be completed after the initial assessment.
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? - Initiate rescue breathing. - Begin chest compressions. - Activate the emergency medical services. - Assess the victim for consciousness.
Assess the victim for consciousness. Explanation: The priority action is to check the victim for consciousness. With the victim in a supine position on a dry, firm surface, a quick assessment taking no more than 10 seconds is performed to determine unresponsiveness and the absence of normal breathing or a pulse. The other actions are not the priority.
A nurse working in a pediatric unit finds an infant unresponsive without respirations or a pulse. After calling for help, what is the nurse's most appropriate action? - Call the infant's parents. - Begin rescue breathing. - Bring the crash cart into the room. - Begin chest compressions.
Begin chest compressions. Explanation: Resuscitation must proceed with CAB (circulation, airway, breathing). Chest compressions would be the nurse's priority action.
Which technique would the nurse employ to maximize the effectiveness of postural drainage? - Combine it with percussion and vibration. - Encourage the client to increase the frequency to eight times a day. - Conduct it before administering inhalant medications. - Maximize how long the client holds each position to 60 minute
Combine it with percussion and vibration. Explanation: Combining postural drainage with percussion and vibration enhances overall effectiveness. The technique should be done after inhalant medications are administered. The nurse should not encourage the client to do postural drainage more than four times a day and should advise the client to hold each position for no more than 45 minutes.
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? - Measure the volume of air exhaled or inhaled over time. - Calculate the pressure of carbon dioxide dissolved in plasma. - Monitor the pressure of oxygen dissolved in plasma. - Monitor the amount of oxygen saturation in the blood.
Monitor the amount of oxygen saturation in the blood. Explanation: The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. The arterial blood gases test the client's blood for the partial pressure of oxygen dissolved in plasma, the percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma. Spirometry measures the volume of air in liters exhaled or inhaled by a client over time.
An infant with a small toy lodged in the trachea is crying. What is the nurse's priority action? - Palpate the brachial artery for a pulse. - Call a code. - Check the infant's level of consciousness. - Observe the infant's respiratory effort.
Observe the infant's respiratory effort. Explanation: Since the infant is crying, the airway is partially obstructed. Other than supporting the infant, a partial airway obstruction requires no additional resuscitation efforts. If the situation worsens, activating the emergency medical system by calling a code is appropriate. The remainder of the assessments would be completed after assessing breathing.
A client returns to the unit following an insertion of a tracheostomy tube. Where should the nurse place the obturator? - Keep the obturator in the nursing station. - Send the obturator home with the client's family. - Place the obturator in a plastic bag and put it at the bedside. - Attach the obturator to a string and tie it to the bed.
Place the obturator in a plastic bag and put it at the bedside. Explanation: The obturator is a curved guide with a bullet-shaped tip. The obturator is used at the time of tube insertion to prevent the edge of the cannula from traumatizing tracheal tissue. Once the tube is in place, the obturator is removed, placed in a plastic bag, and retained at the bedside in the event of an accidental extubation.
A nurse is preparing to insert an oral airway on an unconscious client. How should the nurse proceed? - Position the client with the neck hyperextended. - Elevate the head of the bed. - Hold the airway so the curved tip points downward. - Use a block wedge to hold the mouth open during insertion.
Position the client with the neck hyperextended. - Position the client supine with the neck hyperextended unless contraindicated. This position opens the airway and facilitates insertion. Open the client's mouth using a gloved finger and thumb or a tongue blade. Doing so prevents injury to the teeth during insertion. Hold the airway so that the curved tip points upward toward the roof of the mouth or the side of the cheek. Insert it about halfway. Such placement prevents pushing the tongue into the pharynx during insertion.
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? - Pulmonary function tests - Chest x-ray - Bronchoscopy - Skin tests
Pulmonary function tests - Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.
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) - Forced Expiratory Volume (FEV) - Tidal volume (TV) - Total lung capacity (TLC)
Residual Volume (RV) Explanation: During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds.
A client has had a head injury affecting the brain stem. What is located in the brain stem that may affect respiratory function? - Oxygen center - Stretch receptors - Chemoreceptors - Respiratory center
Respiratory center Explanation: The medulla in the brain stem, immediately above the spinal cord, is the respiratory center. Stretch receptors are located in muscles. Chemoreceptors that affect respirations are located in the aortic arch and the carotid bodies. There is not a oxygen center in the body.
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? - Give the client oxygen. - Start chest compressions. - Get the crash cart with automatic defibrillator. - Open the airway.
Start chest compressions. Explanation: Resuscitation must proceed with CAB (circulation, airway, breathing). Chest compressions are used to keep blood moving through the body and to the vital areas, such as the brain. After 2 minutes of compressions, the rescuer opens the victim's airway.
A nurse is at a baseball game and responds when a person collapses. The nurse begins CPR and requests an automated external defibrillator (AED). The family is angry when the nurse stops compressions to apply the AED. What is the appropriate action? - Stop compressions for less than 10 seconds to apply the AED. - Do not apply the AED. - Continue compressions without stopping. - Wait for the emergency response to use the AED.
Stop compressions for less than 10 seconds to apply the AED. Explanation: If there is no circulation, breathing, or movement after five cycles of cardiac compressions and rescue breathing, an automated external defibrillator (AED) is attached without exceeding a 10-second interruption in CPR. It will be difficult to apply the AED without stopping for a moment, and waiting to apply the AED is not in the best interest of the victim, as rapid defibrillation increases the odds of survival.
When caring for a client with a tracheostomy, the nurse would perform which recommended action? - Clean the wound around the tube and inner cannula at least every 24 hours. - Suction the tracheostomy tube using sterile technique. - Use gauze dressings over the tracheostomy that are filled with cotton. - Assess a newly inserted tracheostomy every 3 to 4 hours.
Suction the tracheostomy tube using sterile technique. Explanation: Sterile technique is required when suctioning a tracheostomy in order to prevent introduction of microorganisms into the respiratory tract. The area around a new tracheostomy may need to be assessed and cleaned every 1 to 2 hours. Gauze dressings that are not filled with cotton must be used to prevent aspiration of lint or cotton fibers into the trachea.
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 _ False
True Explanation: After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A nurse caring for a client with a chest tube should monitor the patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.
When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding? - The anteroposterior diameter should be greater than the transverse diameter. - The chest should be slightly convex with no sternal depression. - The skin at the thorax should be cool and moist. - The contour of the intercostal spaces should be rounded.
The chest should be slightly convex with no sternal depression. Explanation: The adult chest contour is slightly convex, with no sternal depression. The skin of the thorax should be warm and dry, and the anteroposterior diameter of the chest should be less than the transverse diameter. The contour of the intercostal spaces should be flat or depressed.
A client has just returned from getting a new tracheostomy inserted. When the nurse enters the room, the client is cyanotic, with the tracheostomy tube lying on the bed. What is the nurse's priority action? - Call a code. - Auscultate the client's breath sounds. - Ventilate the client with a resuscitation bag with mask. - Insert the obturator into the neck.
Ventilate the client with a resuscitation bag with mask. Explanation: Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult. Oxygenation of the client is the nurse's priority. First, ventilate the client using a manual resuscitation bag and face mask while another nurse calls for help. Reinsertion of a fresh tracheostomy tube will require the physician's intervention.
A nurse is preparing to orally suction a client with dysphagia following a stroke. Which suction device is appropriate? - bulb syringe - open suctioning - Yankauer catheter - closed suctioning
Yankauer catheter Explanation: Nurses perform oral suctioning (removing secretions from the mouth) with a suctioning device called a Yankauer-tip or tonsil-tip catheter. This is the appropriate device to use for a client with difficulty swallowing. The other types of suctioning (open and closed) are used for the lower airways. Bulb syringes are used with infants.
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. - pneumothorax. - hemothorax. - tachypnea.
atelectasis. Explanation: Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize atelectasis. Immobility is not commonly implicated in cases of pneumothorax or hemothorax. A pneumothorax is a collapsed lung. Hemothorax is a collection of blood in the space between the chest wall and the lung. Tachypnea, if present, would likely be a sign of atelectasis rather than an independent finding.
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? - normal saline - tap water - distilled water - mineral oil
distilled water Explanation: Distilled water is used when humidification is desired. Other answers are incorrect.
The nurse is caring for a client with facial burns who also is prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? - simple mask - tracheostomy collar - face tent - nasal cannula
face tent Explanation: A face tent is used without a mask; it is open and loose around the face and is often used for patients with facial trauma or burns. This device is most appropriate for a client with facial burns. All other methods of delivery would irritate the facial skin.
An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur? - only on inspiration - when coughing - inspiration and expiration - only on expiration
inspiration and expiration explanation: Wheezes are continuous sounds heard on expiration and sometimes on inspiration. They originate as air passes through airways constricted by swelling (as in asthma), secretions, or tumors. Coughing, by forcing air out of the lungs under high pressure, attempts to clear the throat of foreign particles.
Which physiologic change does the nurse anticipate will be found in the older adult client with an ongoing nonproductive cough? - moist mucous membranes - increased lung capacity - flexibility of the chest wall - laryngeal atrophy
laryngeal atrophy Explanation: The older adult client experiences laryngeal atrophy as the body ages, drier mucous membranes, diminished lung capacity, and increased rigidity of the chest wall.
A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure? - uses upper chest muscles more effectively - reduces the need for p.r.n. pain medications - prolongs expiration to reduce airway resistance - replaces the use of incentive spirometry
prolongs expiration to reduce airway resistance Explanation: Pursed-lip breathing can help clients with dyspnea and feelings of panic gain control of their respirations. This exercise trains the muscles to prolong expiration, increasing airway pressure during expiration, and reducing the amount of airway trapping and resistance. Pursed-lip breathing does not replace incentive spirometry but is a way to train a client to have more control of their dyspnea. This does not use upper thoracic muscles more effectively.
The physician 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 mouth using a Yankauer-tip or tonsil-tip catheter - removing secretions from the throat through a nasally inserted catheter - removing secretions from the throat through an orally inserted catheter - removing secretions from the upper portion of the lower airway through a nasally inserted catheter
removing secretions from the throat through an orally inserted catheter Explanation: Oropharyngeal suctioning is the removal of secretions from the lung through an orally inserted catheter. Nasotracheal suctioning is the removal of the secretion from the upper portion of the lower airway through a nasally inserted catheter. Oral suctioning is the removal of secretions from the mouth using a Yankauer-tip or tonsil-tip catheter. Nasopharyngeal suctioning means removing secretions from the throat through a nasally inserted catheter.
A nurse is giving chest thrusts with two fingers to an infant with a partial obstruction. Which place is most suitable for giving chest thrusts to an infant? - below the rib cage - the middle of the sternum - over the heart - above the nipple line
the middle of the sternum Explanation: Nurses turn the infant supine and use two fingers to give five chest thrusts at approximately one per second to the middle of the breastbone just below the nipple line, not above the nipple line. They do not give thrusts below the rib cage or close to the heart. They should repeatedly alternate five back blows and chest thrusts until the object is dislodged or the infant fails to respond.
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 - 5 - 7 - 5.5
7.5 Explanation: One "pack-year" is equal to smoking one pack of cigarettes for a day for 1 year. Based on Erin's information, Erin's has a 7.5 pack-year smoking history. 20 cig/pk x 1.5 pk/day = 30 30 cig/day x 5 yrs smoked = 150 150/20 (cigs in pack) = 7.5
What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home? - "Although the test is uncomfortable, it is not painful." - "You will do this each morning while still lying in bed." - "You will be asked to forcefully exhale into a mouthpiece." - "The test is used to determine how much air you inhale."
You will be asked to forcefully exhale into a mouthpiece." Explanation: Peak expiratory flow rate (PEFR) refers to the volume of air that can be forcibly exhaled. While sitting or standing, the client takes a deep breath and forcibly exhales through a mouthpiece. The client does this three times, and the highest number is recorded. Clients commonly measure PEFR at home to monitor airflow when they have conditions such as asthma. The PEFR can be performed at any time of the day but not while lying in the bed. This test is not uncomfortable or painful.
The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system? - an adolescent who has asthma - an older adult client who has COPD - a child who has pneumonia - an adult who is receiving oxygen at home
a child who has pneumonia Explanation: An oxygen tent is commonly used with children who need a cool and highly humidified airflow. It is also more effective for children because they often do not like to keep oxygen administration devices in place. Since the tent does not allow the maintenance of a satisfactory or precise oxygen concentration, is difficult to maintain a consistent level of oxygen. The oxygen tent does not adequately deliver oxygen at a rate higher than 30% to 50%; thus, it is rarely used with other clients.
A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate? - lower-than-normal concentrations of environmental oxygen - rapid decreases in atmospheric and intrapulmonic pressures - changes in the alveolar-capillary membrane and diffusion - alterations in the structures of the ribs and diaphragm
changes in the alveolar-capillary membrane and diffusion Explanation: - Any change in the surface area of the lungs hinders diffusion of gas exchange. Any disease or condition that results in changes in the alveolar-capillary membrane, such as pneumonia or pulmonary edema, makes diffusion more difficult. Diffusion is assessed by a decreased oxygen saturation measurement. The environmental oxygen which comprises the atmospheric pressure, ribs, and diaphragm do not influence the diffusion of gas exchange inside the lungs.
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? - Graves' disease - chronic anemia - pancreatitis - Parkinson's disease
chronic anemia Explanation: The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the number of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissues of the body. Graves' disease, Parkinson's disease, and pancreatitis do not directly lead to a decrease in the number of red blood cells. Graves' disease is an immune system disorder that results in the overproduction of thyroid hormones (hyperthyroidism). Parkinson's disease (PD) is a neurodegenerative disorder that affects predominately dopamine-producing ("dopaminergic") neurons in a specific area of the brain called substantia nigra that causes a movement disorder. Pancreatitis is inflammation in the pancreas.
The nurse is preparing a client for a tracheostomy insertion with a fenestrated tracheostomy tube. Which statement made by the client indicates an accurate understanding of the fenestrated tube? - "This tube will never become dislodged." - "I'm glad I will still be able to talk once I get this tube inserted." - "Since this tube has holes, I won't be able to swallow." - "This type of tube does not have to be cleaned."
"I'm glad I will still be able to talk once I get this tube inserted." Explanation: A fenestrated tube has a hole in it and allows air to flow over the vocal chords, so the client will be able to speak. The tube still needs to be cleaned and suctioned. The tube may still become dislodged, and the client is able to swallow.
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? - "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." - "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." - "Take in a small amount of air very quickly and then exhale as quickly as possible." - "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling."
"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Explanation: Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.
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? - "Always keep this drug at home where you can reach it quickly." - "This drug is to be used as a rescue inhalant." - "You only need this drug if you are exercising." - "Use this drug daily to prevent bronchospasm."
"This drug is to be used as a rescue inhalant." Explanation: SABAs are used for quick relief and in rescue situations. They are not drugs to be used daily, or just when exercising. The client should be taught to keep the drug handy at all times, not just at home
The health care provider has prescribed a long-acting bronchodilator for a client with a history of bronchospasm. What teaching about this drug will the nurse include? - "You only need this drug if you are exercising." - "Use this drug daily to prevent bronchospasm." - "Take this drug when you need quick relief." - "This drug is to be used as a rescue inhalant."
"Use this drug daily to prevent bronchospasm." Explanation: Long-acting bronchodilators are used daily for preventing asthma attacks or exercise-induced bronchospasm. SABAs are used for quick relief and in rescue situations. They are not to be used only when exercising.
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." - "We will check on our loved one often." - "Our loved one may require frequent suctioning." - "Our loved one will not be able to speak."
"We will remove the outer cannula for cleaning." Explanation: The inner cannula is removed periodically for cleaning. The outer cannula stays in place until the entire tube is replaced. All other family statements are appropriate and demonstrate understanding.
Which category of medications may be administered by nebulizer or metered-dose inhaler to open narrowed airways? - Narcotics - Antihistamines - Bronchodilators - Bronchoconstrictors
Bronchodilators Explanation: A nebulizer is used to administer medications in the form of an inhaled mist. Bronchodilators are medications that may be administered by nebulizer or metered-dose inhaler to open narrowed airways. Antihistamines are not administered via nebulizer; they are prescribed to manage allergy-related symptoms. Narcotics are not administered via nebulizer; they are used to manage reports of pain. Bronchoconstrictors agents are not used to open the airways but constrict them.
A nurse is performing the Heimlich maneuver on a young client to relieve a mechanical airway obstruction. Which action should the nurse perform to increase intrathoracic pressure? - Give five quick abdominal thrusts above the navel. - Activate the emergency response system. - Avoid opening the client's airway with the head-tilt maneuver. - Assist the client onto the floor and into a prone position.
Give five quick abdominal thrusts above the navel. Explanation: For all people older than 1 year of age, the rescuer gives a series of five quick abdominal upward thrusts slightly above the navel to increase intrathoracic pressure. The rescuer opens the client's airway with the head-tilt or chin-lift maneuver and continues administering upward thrusts if initial efforts are not successful. Only if the client becomes unconscious should nurses assist clients to the floor, activate the emergency response system, and begin performing cardiopulmonary resuscitation (CPR).
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? - Hyperventilation - Atelectasis - Perfusion - Hypoxia
Hypoxia Explanation: Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia. Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements. Perfusion refers to the process by which oxygenated capillary blood passes through body tissues. Atelectasis refers to collapsed alveoli.
A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention? - Explain uses of BiPAP masks versus CPAP masks. - Notify the healthcare provider of the client's current status. - Inquire about factors that contribute to non-adherence. - Document assessment and plan for intervention.
Inquire about factors that contribute to non-adherence. Explanation: The nurse must first assess the reasons that contribute to non-adherence; interventions cannot be determined without a thorough assessment. Other interventions take place after assessment.
The nurse is reviewing the arterial blood gas results of a client with a respiratory disorder. What would alert the nurse to a problem? - HCO3 of 25 mEq/L - PaCO2 of 55 mmHg - pH of 7.35 - PaO2 of 92 mmHg
PaCO2 of 55 mmHg Explanation: A PaCO2 below 35 or above 45 mmHg is considered abnormal and indicates a problem. The PaO2and HCO3 levels are within normal parameters (80-100 mmHg and 22-26 mEq/L, respectively), as is the pH (7.35-7.45).
What can a nurse ask a client to do before suctioning to prevent hypoxemia? - Take several deep breaths. - Breathe normally for at least 5 minutes. - Lie flat in bed and practice relaxation. - Sit in an upright position and cough.
Take several deep breaths. Explanation: Suctioning removes oxygen from the respiratory tract, possibly causing hypoxemia (insufficient oxygen in the blood). The client should be hyperoxygenated before suctioning, so the nurse should ask him to take several deep breaths before the nurse inserts the suction catheter.
A physician orders an oropharyngeal airway to be inserted into a client. What accurately describes the use of this device? - The nurse can insert this device at the bedside with little to no trauma to the unconscious client. - Tape is used to hold the airway in place because the client should not be able to expel the airway once he becomes alert. - The oropharyngeal airway can help protect the airway of an unconscious client by pushing the tongue back against the posterior pharynx to prevent blockage. - The oropharyngeal airway is a semicircular tube of plastic or rubber inserted into the back of the pharynx through the mouth in a conscious client in respiratory distress.
The nurse can insert this device at the bedside with little to no trauma to the unconscious client Explanation: A nurse can insert an oropharyngeal airway without trauma in an unconscious client. It can help protect the airway of an unconscious client by preventing the tongue from falling back against the posterior pharynx and blocking it. Tape is not used to hold the airway in place because the client should be able to expel the airway once he becomes alert. They are not normally well-tolerated by conscious clients.
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 loud, high-pitched sounds heard primarily over the trachea and larynx. - They are low-pitched, soft sounds heard over peripheral lung fields. - They are soft, high-pitched discontinuous (intermittent) popping lung sounds. -They are medium-pitched blowing sounds heard over the major bronchi.
They are low-pitched, soft sounds heard over peripheral lung fields. Explanation: Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.
The nurse is caring for a client with ineffective airway clearance. Which beverage will the nurse remove from the client's dietary tray? - coffee - water - milk - orange juice
milk Explanation: The nurse will remove milk from the client's dietary tray, as this contributes to mucus formation. Other beverages listed do not contribute to mucus formation in the same way that milk does.
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 who has a productive cough of thick, green mucus - client with a day-old tracheostomy - client with a respiratory rate of 36 breaths/minute - client with loud expiratory wheezing
client with a respiratory rate of 36 breaths/minute - A respiratory rate of 36 breaths/minute indicates severe respiratory distress, and the client needs immediate assessment and intervention to prevent possible respiratory arrest. Lack of oxygen for more than 4 to 6 minutes can result in death or permanent brain damage. Therefore, it is essential to identify respiratory problems and to plan care accordingly for clients at risk. The other clients also need assessment as soon as possible, but they do not need to be assessed as urgently as the tachypneic client.
The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client? - nasal cannula - face tent - simple mask - tracheostomy collar
nasal cannula Explanation: A nasal cannula is ideal for administering low concentrations of oxygen to clients who are not extremely hypoxic or have chronic lung disease. The client does not have a tracheostomy. A simple mask is used to administer higher levels of oxygen than 2 L/min. A face tent is used without a mask.
The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia? - hyperactivity - confusion - decreased blood pressure - decreased respiratory rate
confusion Explanation: Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, elevated blood pressure with small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.
When performing a physical assessment of an adult client reporting dyspnea, the nurse is aware that which of the following is an abnormal finding? - symmetrical movement of the chest - dullness over the lung fields with percussion - auscultation of low-pitched, soft sounds over the peripheral lung fields - the chest contour is slightly convex, with no sternal depression
dullness over the lung fields with percussion Explanation: Percussion that produces dullness over the lung fields occurs when fluid or solid tissue replaces normal lung tissue. Normal assessment findings include a slightly convex chest contour with no sternal depression and symmetrical chest movement. Vesicular breath sounds described as low-pitched, soft sounds over the peripheral lung fields are also a normal respiratory assessment finding.
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 - administration of inhaled corticosteroids - educating the client on pursed-lip breathing techniques - oropharyngeal suctioning twice daily
educating the client on the use of incentive spirometry Explanation: Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.
The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is Ineffective Airway Clearance related to copious and tenacious secretions. Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan? - encouraging the client to decrease the number of cigarettes smoked daily - creating an environment that is likely to reduce anxiety - encouraging the client to consume 2 to 3 qt (1.9 L to 2.9 L) of clear fluids daily - positioning the client supine
encouraging the client to consume 2 to 3 qt (1.9 L to 2.9 L) of clear fluids daily Explanation: Clients can help keep their secretions thin by drinking 2 to 3 quarts (1.9 L to 2.9 L) of clear fluids daily. Although it is important to create an environment that is likely to reduce a client's anxiety, doing so will not assist in promoting airway clearance. The nurse should not encourage the client to decrease the number of cigarettes smoked daily, but should encourage the client to stop smoking. Proper positioning to ease respirations includes placing the client in a high-Fowler's position.
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? - nasal cannula - face tent - simple mask - tracheostomy collar
tracheostomy collar Explanation: A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. All other devices are less appropriate for this client
A client is discussing advance directives with the nurse. Which statement made by the client indicates a need for further teaching? - "If I sign a DNR, then I may not receive continued care." - "I don't want to be on a ventilator, but I am willing to receive medication." - "Without a signed DNR, I will receive all resuscitation efforts." -"My daughter is my power of attorney, and she knows my wishes."
"If I sign a DNR, then I may not receive continued care." Explanation: Some older adults fear if they specify that they do not wish to be resuscitated, they will receive less-than-appropriate care and treatment of their illness. The client's record must contain his or her resuscitation status. If no information is documented, CPR is administered in any life-threatening situation, regardless of the client's age.
A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them? - "I don't exactly know, but I will make sure the doctor comes to explain." - "It is inserted into the space between the lining of the lungs and the ribs." - "It is inserted into the peritoneal space and drains into the lungs." - "It is inserted directly into the lung itself, connecting to a lung airway."
"It is inserted into the space between the lining of the lungs and the ribs." Explanation: A nurse can teach the client that a chest tube is a firm plastic tube with drainage holes in the proximal end that is inserted into the pleural space, thus allowing compressed lung tissue to re-expand. The nurse does not need to contact the physician for information.
The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier? - "The humidifier prescribes the concentration of oxygen." - "This is a gauge used to regulate the amount of oxygen that a client receives." - "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." - "Small water droplets come from this, thus preventing dry mucous membranes."
"Small water droplets come from this, thus preventing dry mucous membranes." Explanation: The humidifier produces small water droplets which are delivered during oxygen administration to prevent or decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen.
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? - 34% - 22% - 26% - 30%
30% Explanation: Using the 'rule of four" for each L/min, the oxygen concentration increases by 4%. Therefore, 1 L/min provides 22% oxygen and 2 L/min provides 26%. The nurse would estimate that 3 L/min would provide 30% oxygen. A flow rate of 4 L/min would provide an oxygen concentration of 34%. **note this is inconsistent with answer to a prior question
Which technique would the nurse employ to maximize the effectiveness of postural drainage? - Encourage the client to increase the frequency to eight times a day. - Maximize how long the client holds each position to 60 minutes. - Combine it with percussion and vibration. - Conduct it before administering inhalant medications.
Combine it with percussion and vibration. Explanation: Combining postural drainage with percussion and vibration enhances overall effectiveness. The technique should be done after inhalant medications are administered. The nurse should not encourage the client to do postural drainage more than four times a day and should advise the client to hold each position for no more than 45 minutes.
A nurse is teaching a preoperative client how to use an incentive spirometer. Which instruction should be included in the teaching plan? - Instruct the client to inhale normally and then place the lips securely around the mouthpiece. - Instruct the client to inhale slowly and as deeply as possible through the mouthpiece without using the nose. - When the client cannot inhale anymore, the client should hold his or her breath and count to 10. - Encourage the client to perform incentive spirometry hourly, if possible.
Instruct the client to inhale slowly and as deeply as possible through the mouthpiece without using the nose. Explanation: The client using an incentive spirometer should exhale normally and place the lips around the mouthpiece; inhale slowly and deeply without using the nose; and, when unable to inhale anymore, hold his or her breath and count to 3 before exhaling normally. This should be performed 5 to 10 times every 1 to 2 hours, if possible.
Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen? - It determines whether the client is getting enough oxygen. - It decreases dry mucous membranes via delivering small water droplets. - It prescribes oxygen concentration. - It regulates the amount of oxygen received.
It regulates the amount of oxygen received. Explanation: The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The oxygen analyzer measures the percentage of delivered oxygen. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.
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)? - Instruct the client on how to use a nebulizer. - Auscultate the client's lung sounds before the sputum specimen is collected. - Label the sputum specimen and take it to the lab. - Perform chest physiotherapy.
Label the sputum specimen and take it to the lab. Explanation: Labeling of specimens and transporting them to the lab is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel.
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? - Check the patient's level of consciousness. - Palpate extremities for bilateral pulses. - Observe the patient's respiratory effort. - Call a code.
Observe the patient's respiratory effort. Explanation: additional resuscitation efforts. If the client's independent efforts to relieve a partial obstruction are unsuccessful or if the situation worsens, activating the emergency medical system by calling a code is appropriate.
What prevents air from reentering the pleural space when chest tubes are inserted? - a closed water-seal drainage system - the sutures that hold in the tube - the location of the tube insertion - respiratory inspiration and expiration
a closed water-seal drainage system Explanation: After insertion, the chest tube is secured with a suture and tape, covered with an airtight dressing, and is usually attached to a closed water-seal drainage system that prevents air from reentering the pleural space. The pleural space is the tiny area between the two layers of the pleura (the thin covering that protects and cushions the lungs) between the lungs and chest cavity. The sutures hold the tube next to the skin to keep it in place. The tube is placed in the pleural space. The respiratory phase includes the inspiratory and expiratory components.
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? - vesicular breath sounds audible over peripheral lung fields - resonance on percussion of lung fields - respiratory rate of 18 breaths per minute - fine crackles to the bases of the lungs bilaterally
fine crackles to the bases of the lungs bilaterally Explanation: Except in the case of infants, fine crackles always constitute an abnormal assessment finding. A respiratory rate of 18 is within acceptable range. Vesicular sounds over peripheral lung fields and resonance on percussion are expected assessment findings.
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? - oxygen analyzer - flow meter - nasal cannula - nasal strip
flow meter Explanation: The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client
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: - blood pH. - hemoglobin level. - sodium and potassium levels. - age.
hemoglobin level. Explanation: Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.
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 - Trendelenburg position - left side with a pillow under the chest wall - side-lying position, half on the abdomen and half on the side
high-Fowler's position Explanation: Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. High-Fowler's position is used to drain the apical sections of the upper lobes of the lungs. Placing the client lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.
Oxygen hoods are generally used to deliver oxygen at rates approaching 100% to which developmental group? - infants - adults - older Adults - children
infants Explanation: Oxygen hoods are generally used to deliver oxygen to infants. They can supply an oxygen concentration up to 80% to 90%. Oxygen hoods enable the oxygen percentage to be measured more accurately and make appropriate humidification possible (Pease, 2006). The oxygen hood is placed over the infant's head and shoulders and allows easy access to the chest and lower body.
A nurse is conducting a health promotion program for adolescents to educate them about the hazards of smoking. When describing the effects on the respiratory system, what would the nurse most likely include? - increase in the mucous escalator - decreased production of mucus - inhibition of mucus removal - inhibition of bacterial colonization
inhibition of mucus removal Explanation: Smoking inhibits mucus removal. By producing more mucus and by slowing the mucous escalator, smoking inhibits mucus removal and can cause airway blockage, promoting bacterial colonization and infection.
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? - simple mask - nonrebreather mask - face tent - nasal cannula
nasal cannula Explanation: The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Nonrebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.
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 - partial rebreather mask - simple mask - Venturi mask
nonrebreather mask Explanation: The nurse should use a nonrebreather mask for a client who is critically ill and requires a high concentration of oxygen. A nonrebreather mask contains one-way valves that allow inhalation of only oxygen from the source and the reservoir bag; no atmospheric air is inhaled, and all exhaled air is vented from the mask. A simple mask, partial breather mask, and Venturi mask cannot be used for this client. A simple mask delivers a higher level of oxygen than a nasal cannula and is used for clients with nasal trauma and mouth breathing. A partial rebreather mask delivers a mixture of atmospheric air, oxygen from its source, and oxygen from the reservoir bag. A Venturi mask mixes a precise amount of oxygen and atmospheric air and delivers the prescribed amount.
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 - reasons for annual sputum cytology testing - needing to have a CT screening for lung cancer - how to perform chest physiotherapy
options for smoking cessation Explanation: Because smoking is the major cause of lung cancer, the most important role for the nurse is to advocate for smoking cessation following recovery from acute illness. The nurse should provide teaching about the benefits of and means of smoking cessation. CT scanning is currently being investigated as a screening test for high-risk patients. However, if there is a positive finding, the person already has lung cancer. Performance of chest physiotherapy is usually completed by health care providers.
The nurse is preparing to suction a client's mouth to remove secretions. Which type of suctioning will the nurse perform? - oropharyngeal - oral - nasotracheal - nasopharyngeal
oral Explanation: Oral suctioning removes secretions from the mouth. Oropharyngeal suctioning removes secretions from the throat through a nasally inserted catheter. Nasopharyngeal suctioning removes secretions from the throat through a nasally inserted catheter. Nasotracheal suctioning removes secretions from the upper portion of the lower airway through a nasally inserted catheter.
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 25% given for longer than 24 hours - oxygen concentration of more than 25% given for longer than 36 hours - oxygen concentration of more than 30% given for longer than 48 hours - oxygen concentration of more than 50% given for longer than 48 hours
oxygen concentration of more than 50% given for longer than 48 hours Explanation: When administering oxygen to a critically ill client using a nonrebreather mask, the nurse should remember that an oxygen concentration of more than 50% given for longer than 48 hours can cause oxygen toxicity in the client. Oxygen toxicity refers to lung damage that develops when oxygen concentrations of more than 50% are administered for longer than 48 to 72 hours. The best way to prevent oxygen toxicity is to administer the lowest FiO2 possible for the shortest amount of time.
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 mother is at the bedside in tears. The mother states, "I just want him to know I am here with him." To address the needs of the mother and the client, the nurse should: - place his hand on the mother's shoulder and reassure the mother that things will be fine. - place a chair next to the bed and encourage the mother to hold the son's hand. - leave the room and allow the mother to grieve. - encourage the mother to bring in pictures of the family that can be displayed in the room.
place a chair next to the bed and encourage the mother to hold the son's hand. Explanation: Despite its individuality, touch is viewed as one of the most effective nonverbal ways to express feelings of comfort, love, affection, security, anger, frustration, aggression, excitement, and many others. The nurse may feel it is appropriate to place his hand on the mother's shoulder; however, the nurse should not provide false hope. The nurse should not leave the mother alone to grieve; the nurse should show the mother how to use comforting communication. The client is in a chemically induced coma and will not be able to see pictures that are displayed in the room.
A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of: - croup. - asthma. - alcohol use. - pneumonia.
pneumonia. Explanation: Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol use do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol use depresses the central respiratory center.
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. - alcohol use. - croup. - asthma.
pneumonia. Explanation: Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol use do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol use depresses the central respiratory center.
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? - keeps the tongue in a relaxed position - prevents the aspiration of oral fluids - eliminates the need for frequent suctioning - facilitates insertion of the tracheostomy tube
prevents the aspiration of oral fluids Explanation: A tracheostomy tube may have a balloon cuff; when inflated, the cuff seals the upper airway to prevent aspiration of oral fluids and provide more efficient ventilation. An oral airway is a curved device that keeps a relaxed tongue positioned forward within the mouth, preventing the tongue from obstructing the upper airway. During insertion of a tracheostomy tube, an obturator, a curved guide, is used. Most clients with tracheostomy tubes require frequent suctioning.
What structural changes to the respiratory system should a nurse observe when caring for older adults? - increased mouth breathing and snoring - diminished coughing and gag reflexes - respiratory muscles become weaker - increased use of accessory muscles for breathing
respiratory muscles become weaker Explanation: One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker. The nurse should also observe other structural changes: the chest wall becomes stiffer as a result of calcification of the intercostals cartilage, kyphoscoliosis, and arthritic changes to costovertebral joints; the ribs and vertebrae lose calcium; the lungs become smaller and less elastic; alveoli enlarge; and alveolar walls become thinner. Diminished coughing and gag reflexes, increased use of accessory muscles for breathing, and increased mouth breathing and snoring are functional changes to the respiratory system in older adults.
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? - oropharyngeal airway - nasal trumpet - endotracheal tube - tracheostomy
tracheostomy Explanation: A tracheostomy is an artificial airway consisting of a plastic tube surgically implanted just below the larynx into the trachea. An endotracheal tube is a plastic tube inserted through the nose or mouth into the trachea. An oropharyngeal airway is inserted through the mouth to bypass upper airway obstructions. A nasal trumpet is inserted through the nose to bypass upper airway obstructions.
A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur? - prevention of suctioning - loss of sterile field - suctioning of carbon dioxide - trauma to the tracheal mucosa
trauma to the tracheal mucosa Explanation: Occluding the Y-port on the suction tubing is what creates the suction. While suctioning would be difficult but possible, suctioning while advancing the tube would damage the tracheal mucosa and remove excessive amounts of oxygen, not carbon dioxide, from the respiratory tract. Suctioning during insertion of the catheter would not compromise sterility.
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 - pulse oximetry reading of 92% - heart rate of 98 beats/min - respiratory rate of 20 breaths/minute
use of accessory muscles in breathing Explanation: Ineffective airway clearance related to retained secretions are manifested by weak and persistent cough without raising sputum, rapid and shallow respirations, and use of accessory muscles. Use of accessory muscle indicates that the client is experiencing respiratory distress and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment, but do not suggest that immediate treatment is required.
A nurse is caring for a client with influenza who requires an external source of oxygen in order to breathe efficiently. In which situation is oxygen humidified? - when more than 2 L/min but less than 3 L/min oxygen is administered - when more than 5 L/min of oxygen is administered intermittently - when more than 4 L/min of oxygen is administered for an extended period - when more than 2 L/min of oxygen is administered for an extended period
when more than 4 L/min of oxygen is administered for an extended period Explanation: When administering oxygen to a client using an external source of oxygen, the nurse should remember that oxygen is humidified when more than 4 L/min of oxygen is administered for an extended period. Oxygen need not be humidified if less than 4 L/min of oxygen has been administered to the client. Oxygen administered over an extended period of time, not intermittently, is humidified.
