Chapter 39 Oxygenation and Perfusion

remove the airway, turn the client to the side, and provide mouth suction, if necessary

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?

- the client is demonstrates restlessness - the client's capillary refill is assessed at 4 seconds - the client has uneven movements of the chest with respirations - the client has flaring nostrils

A client, 90 years of age, has been in a motor vehicle collision and sustained four fractured ribs on the left side of the thorax. The nurse recognizes the client is experiencing respiratory complications when which signs are observed? Select all that apply.

crackles

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as:

wheezing

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?

they are low-pitched, soft sounds heard over peripheral lung fields

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

respiratory rate and depth

The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign?

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

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?

cardiovascular function

What assessments would a nurse make when auscultating the lungs?

rapid respirations

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?

eat smaller meals that are high in protein

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

congestive heart failure

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:

monitor blood pressure and blood sugar

A client is prescribed a corticosteroid for the treatment of asthma after having an asthma attack. What education should the nurse provide to the client regarding the administration of this medication?

ask the client what factors contribute to non adherence

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

pleural effusion

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?

instruct the client to inhale deeply and then cough

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?

bronchitis

A nurse is reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would the nurse most likely identify as an effect of exposure to automobile pollutants?

a bronchospasm

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

- tachypnea - tachycardia - shortness of breath - wheezing and crackles in lungs

The nurse provides care for a client with chronic bronchitis and a decreasing oxygen saturation. Which factor(s), if assessed, indicate a deteriorating condition? Select all that apply.

- tachypnea - hydration status - coughing effectiveness - asymmetric chest movements - sputum color, viscosity, and odor

The nurse provides care for the client admitted to the emergency department with pneumonia that was unresponsive to single antibiotic therapy. The nurse administers multiple antibiotics, mucolytics, expectorants, and bronchodilators. For which factor(s) does the nurse monitor the client? Select all that apply.

residual volume (RV)

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?

- pulse oximeter - ventilator

The nurse working in the intensive care unit is preparing to admit a client from the emergency department who had a stroke located in the medulla. What equipment should the nurse have present in the room upon the client's arrival into the unit? Select all that apply.