Exam 2: Oxygenation (NCLEX)

The nurse is caring for a postoperative client who has a prescription for meperidine (Demerol) 7 5mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering Demerol, the nurse would assess which most important sign? a) Respiratory rate and depth b) Urinary intake and output c) Orthostatic blood pressure d) Apical pulse

A

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? a) Confusion b) Decreased blood pressure c) Decreased respiratory rate d) Hyperactivity

A

The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient? A: Nasal cannula B: Venturi mask C: Simple face mask without inflated reservoir bag D: Plastic face mask with inflated reservoir bag

A

The nurse will monitor for clinical manifestations of hypercapnia when a patient in the emergency department has a. chest trauma and multiple rib fractures. b. carbon monoxide poisoning after a house fire. c. left-sided ventricular failure and acute pulmonary edema. d. tachypnea and acute respiratory distress syndrome (ARDS).

A

The unlicensed assistive personnel (UAP) is assisting with feeding for a patient with severe end-stage chronic obstructive pulmonary disease (COPD). Which instruction will the nurse provide the UAP? A.) Encourage the patient to eat foods that are high in calories and protein. B.) Feed the patient as quickly as possible to prevent early satiety. C.) Offer lots of fluids between bites of food. D.) Try to get the patient to eat everything on the tray

A

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? a) Checking the amount of oxygen in the cylinder before using it b) Using a cylinder for a patient transfer that indicates available oxygen is 500 psi c) Placing the oxygen cylinder on the stretcher next to the patient d) Discontinuing oxygen flow by turning cylinder key counterclockwise until tight

A

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? a) Pulmonary function tests b) Chest x-ray c) Skin tests d) Bronchoscopy

A

Which of the following statements is true regarding oxygen toxicity? A) It can occur in patients who inhale greater than 50% oxygen for more than 24 hours. B) It causes destruction of oxygen-free radicals. C) The most common presenting symptom is respiratory depression. D) Chest radiography is a useful tool for early diagnosis.

A

At 11 p.m., a male client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86% and he's still wheezing. The nurse should plan to administer: a. alprazolam (Xanax). b. propranolol (Inderal) c. morphine. d. albuterol (Proventil).

D

An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? a) Tilt the patient's head forward. b) Hold the mask tightly over the patient's nose and mouth. c) Pull the patient's jaw backward. d) Compress the bag twice the normal respiratory rate for the patient.

B

The nurse is caring for a 22-year-old patient who came to the emergency department with acute respiratory distress. Which information about the patient requires the most rapid action by the nurse? a. Respiratory rate is 32 breaths/min. b. Pattern of breathing is shallow. c. The patient's PaO2 is 45 mm Hg. d. The patient's PaCO2 is 34 mm Hg.

C

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? a. Dry cough b. Hematuria c. Bronchospasm d. Blood-streaked sputum

C

After receiving change-of-shift report, which patient will the nurse assess first? a. A patient with cystic fibrosis who has thick, green-colored sputum b. A patient with pneumonia who has coarse crackles in both lung bases c. A patient with emphysema who has an oxygen saturation of 91% to 92% d. A patient with septicemia who has intercostal and suprasternal retractions

D

After the respiratory therapist performs suctioning on a patient who is intubated, the unlicensed assistive personnel (UAP) measures vital signs for the patient. Which vital sign value should the UAP be instructed to report to the RN immediately? a. Heart rate of 98 beats/min b. Respiratory rate of 24 breaths/min c. Blood pressure of 168/90 mm Hg d. Tympanic temperature of 101.4°F (38.6°C)

D

An experienced LPN/LVN, under the supervision of the team leader RN, is assigned to provide nursing care for a patient with a respiratory problem. Which actions are appropriate to the scope of practice of an experienced LPN/LVN? Select all that apply. 1.) Auscultating breath sounds 2.) Administering medications via metered-dose inhaler (MDI) 3.) Completing in-depth admission assessment 4.) Checking oxygen saturation using pulse oximetry 5.)Developing the nursing care plan 6.) Evaluating the patient's technique for using MDIs

124 The experienced LPN/LVN is capable of gathering data and making observations, including noting breath sounds and performing pulse oximetry. Administering medications, such as those delivered via MDIs, is within the scope of practice of the LPN/LVN. Independently completing the admission assessment, developing the nursing care plan, and evaluating a patient's abilities require additional education and skills within the scope of practice of the professional RN.

A client who has undergone radical neck dissection for a tumor has a potential problem of obstruction related to postoperative edema, drainage, and secretions. To promote adequate respiratory function in this client, the nurse should implement which activities? Select all that apply. 1.Suctioning the client as needed 2.Encouraging coughing every 2 hours 3.Placing the bed in low Fowler's position 4.Supporting the neck incision when the client coughs 5.Monitoring the respiratory status frequently as prescribed

1245

A patient admits to the E.D. with fractures of 3 lower ribs. Which of the following is the priority concern of the nurse caring for this patient? 1) infection risk 2) pain 3) hemorrhage risk 4) airway maintenance

3

The nurse enters the patient's room at the beginning of her shift. The patient is 3 days post-op right-sided pneumonectomy. Which of the following findings requires most immediate intervention by the nurse? 1) The patient is slowly sipping iced water. 2) The CNA reports that urinary output for the last 6 hours is 200 mL. 3) The patient is positioned on her left side with SCDs in place. 4) The patient reports pain at 9/10.

3 The post-op pneumonectomy patient should be positioned on the OPERATIVE (bad) side OR on the back. Sipping iced water in itself isn't harmful to this patient. Urinary output is sufficient. Pain is expected, although this would be the nurse's second concern.

A nurse is caring for a 29 year-old patient on a med-surg unit with 3 lower rib fractures. Which of the following findings, if noted by the nurse, is most concerning? 1) Patient rates pain 8/10. 2) Patient reports feeling muscle spasms over the fracture area when he coughs. 3) Patient's temperature is 99.8F. 4) The nurse feels a crackling, grating sensation over the lower ribs.

3 This patient has spiked a fever which, even though it is slight, could be indicative of pneumonia or atelectasis. This needs to be further investigated. Crepitus and muscle spasms over the area are expected. Extreme pain is also expected, and would be the nurse's immediate concern after addressing the patient's elevated temperature.

The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the LPN? 1. The client with pneumonia who has a pulse oximeter reading of 91%. 2. The client with a hemothorax who has Hgb of 9 mg/dL and Hct of 20%. 3. The client with chest tubes who has jugular vein distention and BP of 96/60. 4. The client who is two (2) hours post-bronchoscopy procedure.

4

A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104°F (40°C). What physiological process explains why the child is at risk for developing dyspnea? A: Fever increases metabolic demands, requiring increased oxygen need. B: Blood glucose stores are depleted, and the cells do not have energy to use oxygen. C: Carbon dioxide production increases as result of hyperventilation. D: Carbon dioxide production decreases as a result of hypoventilation.

A

A patient has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the patient discouraged and saddened. The client states, I am recovering so slowly. I really thought I would be better by now. What nursing action should the nurse prioritize? A) Provide emotional support to the patient and family. B) Schedule a visit to the patients primary physician within 24 hours. C) Notify the physician that the patient needs a referral to a psychiatrist. D) Place a referral for a social worker to visit the patient.

A

A patient is brought to the emergency department unconscious following a barbiturate overdose. Which potential complication will the nurse include when developing the plan of care? a. Hypercapnic respiratory failure related to decreased ventilatory effort b. Hypoxemic respiratory failure related to diffusion limitations c. Hypoxemic respiratory failure related to shunting of blood d. Hypercapnic respiratory failure related to inc

A

A physician has ordered an arterial blood gas test for a client with a respiratory disorder. What is the most common role of the nurse in performing the arterial blood gas test? a) Implement measures to prevent complications after arterial puncture. b) Measure the partial pressure of oxygen dissolved in plasma. c) Measure the percentage of hemoglobin saturated with oxygen. d) Perform the arterial puncture to obtain the specimen.

A

Gina, a home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? a. Hypoxia b. Delirium c. Hyperventilation d. Semiconsciousness

A

The amount of air inspired and expired with each breath is called: a. tidal volume. b. residual volume. c. vital capacity. d. dead-space volume.

A

The critical care charge nurse is responsible for the care of four patients receiving mechanical ventilation. Which patient is most at risk for failure to wean and ventilator dependence? a. A 68-year-old patient with a history of smoking and emphysema b. A 57-year-old patient who experienced a cardiac arrest c. A 49-year-old postoperative patient who had a colectomy d. A 29-year-old patient who is recovering from flail chest

A

The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first? A: Raise the head of the bed to 45 degrees. B: Take his oxygen saturation with a pulse oximeter. C: Take his blood pressure and respiratory rate. D: Notify the health care provider of his shortness of breath

A

The nurse is caring for a client who is diagnosed with impaired gas exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis? a) high respiratory rate b) low pulse rate c) high temperature d) low blood pressure

A

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation? a) Arterial blood gas b) Hemoglobin levels c) Hematocrit values d) Pulmonary function

A Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.

A client has just been admitted to the emergency department and requires high-flow oxygen therapy after suffering facial burns and smoke inhalation. Which oxygen delivery device should the nurse use initially? A. Face tent B. Venturi mask C. Nasal cannula D. Non-rebreather mask

A A client with smoke inhalation and facial burns who requires high-flow oxygen should initially be placed on a face tent because this is the only noninvasive high-flow device that will minimize painful and contaminating contact with burned facial tissue.

A nurse is delivering 3 L/min oxygen to a patient via nasal cannula. What percentage of delivered oxygen is the patient receiving? a) 32% b) 28% c) 47% d) 23%

A 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%

Which client has the most urgent need for frequent nursing assessment? A. An older client who was admitted 2 hours ago with emphysema and dyspnea and has a 45-year 2-pack-per-day smoking history, and is receiving 50% oxygen through a Venturi mask B. A young client who has had a tracheostomy for 1 week, who is on room air with SpO2 in the upper 90's, who has been receiving antibiotic therapy for 16 hours, and who has foul-smelling drainage on the tracheostomy ties C. An older adult client who is anxious to go home with her new tank of oxygen and supply of nasal cannulas and is being discharged with a new prescription for home oxygen therapy D. A middle-aged client who was admitted yesterday with pneumonia and is receiving oxygen at 2 L/min through a nasal cannula

A An older adult client with a long history of smoking and chronic lung disease who is receiving high-flow oxygen delivery is at elevated risk for respiratory depression owing to the hypoxic drive of respirations countered by high levels of oxygen. This client must be assessed frequently while receiving high-flow oxygen.

Which of the following nursing diagnoses would be the most important yet relevant nursing diagnosis for the patient diagnosed with having a pulmonary contusion? A) Fluid Volume Overload B) Imbalanced Nutrition: Less than body requirements C) Acute Pain D) Risk for Infection

A Fluid volume overload would be appropriate for this client because of the fluid build-up occurring in the lungs (AEB: Crackles, decreased breath sounds, etc.). This build-up is caused by the bruising and edema pulling fluid from the vascular spaces.

A (DNR) client has a non-rebreather oxygen mask and breathing appears to be labored. What does the nurse do first? A. Ensures that the tubing is patent and that oxygen flow is high B. Notifies the chaplain and the family member of record C. Calls the Rapid Response Team and prepares to intubate D. Comforts the client and confirms that signed DNR orders are in the chart

A Labored breathing and ultimately suffocation can occur if the reservoir bag kinks, or if the oxygen source disconnects or is not set to high flow levels.

An RN from the orthopedic unit has been floated to the medical unit. Which client assignment for the floated RN is best? A. The client with a resolving pulmonary embolus who is receiving oxygen at 6 L/min through a nasal cannula B. The client with chronic lung disease who is being evaluated for possible home oxygen use C. The client with a newly placed tracheostomy who is receiving oxygen through a tracheostomy collar D. The client with chronic bronchitis who is receiving oxygen at 60% through a Venturi mask

A Orthopedic nurses are familiar with pulmonary emboli and with administration of oxygen through nasal cannulas.

A patient has been on a non-rebreathing mask at 10 L/min for 4 days and is complaining of a dry cough, a stuffy nose, and substernal chest pain (pain score, 6 of 10) that increases with deep breathing. The chest radiograph shows no changes, and the 12-lead electrocardiography (ECG) findings are normal. The nurse suspects the patient is experiencing: A) hypercapnia. B) oxygen toxicity. C) unstable angina. D) absorption atelectasis.

B

A client is receiving oxygen via Venturi mask at 40%. On assessment the nurse finds the client cyanotic with labored respirations. Which action does the nurse perform first? a. Remove bedding from around the adaptor opening. b. Listen to lung sounds and obtain a respiratory rate. c. Call respiratory therapy to check oxygen saturation. d. Notify the provider or Rapid Response Team immediately.

A The Venturi mask works by drawing in a specific amount of air to mix with the oxygen through holes in an adaptor fitted at the bottom of the mask. Holes of different sizes allow different amounts of room air to be entrained, changing the amount of oxygen delivered. Bedding (or clothing) wrapped around those holes would effectively change the FiO2. The nurse should ensure that the holes remain unobstructed. Other options are appropriate but are not the first choice, because this simple step may be what solves the problem.

A client with COPD has a physician's prescription stating, "Adjust oxygen to SpO2 at 90% to 92%." Which nursing action can be delegated to a nursing assistant working under the supervision of an RN? A. Adjust the position of the oxygen tubing B. Assess for signs and symptoms of hypoventilation C. Change the O2 flow rate to keep SpO2 as prescribed D. Choose which O2 delivery device should be used for the client

A The scope of a nursing assistant's work includes positioning of oxygen tubing for client comfort.

Which of the following would be most appropriate for a male client with an arterial blood gas (ABG) of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3 24 mEq/L, and PaO2 94 mm Hg? a. Administer a prescribed decongestant. b. Instruct the client to breathe into a paper bag. c. Offer the client fluids frequently. d. Administer prescribed supplemental oxygen.

B

The unlicensed assistive personnel (UAP) tells the nurse that a patient who is receiving oxygen at a flow rate of 6 L/min by nasal cannula is reporting nasal passage discomfort. What intervention should the nurse suggest to the UAP to improve the patient's comfort for this problem? A.) Humidify the patient's oxygen. B.) Use a simple face mask instead of a nasal cannula. C.) Provide the patient with an extra pillow. D.) Have the patient sit up in a chair at the bedside.

A When the oxygen flow rate is higher than 4 L/min, the mucous membranes can be dried out. The best treatment is to add humidification to the oxygen delivery system. Applying water-soluble jelly to the nares can also help decrease mucosal irritation. None of the other options will treat the problem.

A patient is admitted to the emergency department with an open stab wound to the left chest. What is the first action that the nurse should take? a. Position the patient so that the left chest is dependent. b. Tape a nonporous dressing on three sides over the chest wound. c. Cover the sucking chest wound firmly with an occlusive dressing. d. Keep the head of the patient's bed at no more than 30 degrees elevation.

B

The nurse is caring for a patient who exhibits labored breathing and uses accessory muscles. The patient has crackles in both lung bases and diminished breath sounds. Which would be priority assessments for the nurse to perform? (Select all that apply.) A: SpO2 levels B: Amount of sputum production C: Change in respiratory rate and pattern D: Pain in lower calf area

ABC

Which of the following would the nurse anticipate being ordered for the patient with pulmonary contusion? SATA: A) IV fluids B) Intubation/mechanical ventilation C) Opioids D) Antibiotics E) Albumin

ABCD IV fluids would be necessary to prevent hypovolemia because of the fluid that is leaving the vascular spaces into the lungs/pleural spaces. This must be administered judiciously to prevent fluid volume overload or worsening lung function. Intubation or mechanical ventilation may be ordered, if pulmonary contusion is severe. Opioids are often used for pain relief. Antibiotics would be administered prophylactically to prevent infection from arising. Albumin would not be given in this disorder.

A patient with a diagnosis of advanced Alzheimer disease who is unable to follow directions requires an inhaled bronchodilator. Which of the following medication delivery systems is most appropriate for this patient? a) metered-dose inhaler with spacer b) nebulizer c) metered-dose inhaler without spacer d) dry powder inhaler

B

A patient with hypercapnic respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. Which collaborative intervention will the nurse anticipate? a. Administration of 100% oxygen by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of bilevel positive pressure ventilation (BiPAP)

B

A black male client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the: a. lips. b. mucous membranes. c. nail beds. d. earlobes

B

A female client with interstitial lung disease is prescribed prednisone (Deltasone) to control inflammation. During client teaching, the nurse stresses the importance of taking prednisone exactly as prescribed and cautions against discontinuing the drug abruptly. A client who discontinues prednisone abruptly may experience: a. hyperglycemia and glycosuria. b. acute adrenocortical insufficiency. c. GI bleeding. d. restlessness and seizures.

B

A male adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? a. Immediately before a meal b. At least 2 hours after a meal c. When bronchospasms occur d. When secretions have mobilized

B

A newly hired nurse is performing a focused respiratory assessment. The nurse mentor will intervene if which action by the newly hired nurse is noted? a) The newly hired nurse palpates the point of maximal impulse (PMI). b) The newly hired nurse auscultates breath sounds as the client breathes through the nose. c) The newly hired nurse attaches a pulse oximetry to the client's index finger. d) The newly hired nurse explains the assessment procedure before performing it.

B

A nurse is providing postural drainage for a patient with cystic fibrosis. In which position should the nurse place the patient to drain the right lobe of the lung? a) High Fowler's position b) Left side with pillow under chest wall c) Lying position/half on abdomen and half on side d) Trendelenberg position

B

Mr. J, a 26-year-old patient with diabetes, is admitted to the unit in severe diabetic ketoacidosis. His pH is 7.29. Understanding the principles of the oxyhemoglobin dissociation curve, you would expect which finding when you measure his SaO2? A) The SaO2 may be higher than normal. B) The SaO2 may be lower than normal. C) The SaO2 is not affected because he does not have pulmonary disease. D) You must know the HCO3- before you can predict changes in the SaO2.

B

The RN is teaching an unlicensed assistive personnel (UAP) to check oxygen saturation by pulse oximetry. What will the nurse be sure to tell the UAP about patients with darker skin? A.) "Be aware that patients with darker skin usually show a 3% to 5% higher oxygen saturation compared with light-skinned patients." B.) "Usually dark-skinned patients show a 3% to 5% lower oxygen saturation by pulse oximetry than light-skinned patients." C.) "With a dark-skinned patient, you may get more accurate results by measuring pulse oximetry on the patient's toes." D.) "More accurate results may result from continuous pulse oximetry monitoring than spot checking when a patient has darker skin."

B

The nurse identifies that the client is unable to cough to produce a sputum specimen and must be suctioned. Which suctioning route is preferred? A. Nasopharyngeal B. Nasotracheal C. Oropharyngeal D. Orotracheal

B

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion? A: Antibiotics B: Frequent change of position C: Oxygen humidification D: Chest physiotherapy

B

The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient? A) How to milk the chest tubing B) How to splint the incision when coughing C) How to take prophylactic antibiotics correctly D) How to manage the need for fluid restriction

B

The nurse is caring for a patient with chronic obstructive pulmonary disease (COPD). The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity? A) Bradycardia and frontal headache B) Dyspnea and substernal pain C) Peripheral cyanosis and restlessness D) Hypotension and tachycardia

B

The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is positioned for postural drainage the nurse will perform which action to help loosen secretions? a. Palpation and clubbing b. Percussion and vibration c. Hyperoxygenation and suctioning d. Administer a bronchodilator and monitor peak flow

B

The nurse is evaluating and assessing a patient with a diagnosis of chronic emphysema. The patient is receiving oxygen at a flow rate of 5 L/min by nasal cannula. Which finding concerns the nurse immediately? A.) Fine bibasilar crackles B.) Respiratory rate of 8 breaths/min C.) The patient sitting up and leaning over the nightstand D.) A large barrel chest

B

The nurse receives change-of-shift report on the following four patients. Which patient should the nurse assess first? a. A 23-year-old patient with cystic fibrosis who has pulmonary function testing scheduled b. A 46-year-old patient on bed rest who is complaining of sudden onset of shortness of breath c. A 77-year-old patient with tuberculosis (TB) who has four antitubercular medications due in 15 minutes d. A 35-year-old patient who was admitted the previous day with pneumonia and has a temperature of 100.2° F (37.8° C)

B

When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal cannula, what does the nurse expect? a) The oxygen must be humidified. b) The rate will be no more than 2 to 3 L/min or less. c) Arterial blood gases will be drawn every 4 hours to assess flow rate. d) The rate will be 6 L/min or more.

B A rate higher than 3 L/min may destroy the hypoxic drive that stimulates respirations in the medulla in a patient with chronic lung disease. Oxygen delivered at low rates does not necessarily have to be humidified, and arterial blood gases are not required at regular intervals to determine the flow rate.

A client who is receiving continuous oxygen therapy by nasal cannula for an acute respiratory problem is becoming increasingly confused. What does the nurse do first? a. Notify the health care provider. b. Assess the client's pulse oximetry. c. Document the observation. d. Raise the head of the bed.

B Cerebral hypoxia is a cause of confusion and is a sensitive indicator that the client needs more oxygen. Although you would want to notify the provider of the change in the client's condition, the best action is first to assess pulse oximetry and then to increase the oxygen. You would not just document the assessment finding without intervening. Raising the head of the bed would not help the client oxygenate better.

What structural changes to the respiratory system should a nurse observe when caring for older adults? a) increased use of accessory muscles for breathing b) respiratory muscles become weaker c) increased mouth breathing and snoring d) diminished coughing and gag reflexes

B 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 client has been brought in by the rescue squad to the emergency department. The client is having an acute exacerbation of chronic obstructive pulmonary disease (COPD) and is severely short of breath. On arrival, the client is on 15 L/min of oxygen via rebreather mask. Which action by the nurse takes priority? a. Immediately reduce the oxygen flow to 2 to 4 L/min via nasal cannula. b. Perform a thorough respiratory assessment and attach pulse oximetry. c. Call the laboratory to obtain arterial blood gases as soon as possible. d. Obtain a stat chest x-ray, then slowly wean the client's oxygen down.

B Oxygen-induced hypoventilation can occur in clients with chronically elevated PCO2 levels, such as those seen in COPD. Giving oxygen can eliminate their hypoxic drive to breathe and can cause respiratory arrest. However, hypoxemia is a greater threat to an acutely ill client than is the potential for oxygen-induced hypoventilation, and clients should be given the amount of oxygen they require. The nurse should perform a thorough respiratory assessment and should monitor the client for signs of this problem, rather than automatically reducing oxygen delivery. Blood gases and a chest x-ray will also be obtained, but they do not take priority over assessing and monitoring the client.

A male client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breathe sounds in right upper lobe of the lung. The nurse immediately assesses for other signs of: A. Pulmonary Embolism B. Right pneumothorax C. Displaced endotracheal tube D. Acute respiratory distress syndrome

B Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left main stem bronchi.

The client is admitted to the hospital for COPD, and the physician requests a nasal cannula at 2 L/min. Within 30 minutes, the client's color improves. What does the nurse continue to monitor that may require immediate attention? A. Increasing carbon dioxide levels B. Decreasing respiratory rate C. Increasing adventitious breath sounds D. Increased coughing

B Respiratory rate and depth should be monitored closely while the client receives oxygen, because hypoventilation is seen during the first 30 minutes of oxygen therapy in clients with hypoxic drive for respiration. The client's color will improve (from ashen or gray to pink) because of an increase in PaO2 level before apnea or respiratory arrest occurs from loss of the hypoxic drive.

The nurse is caring for a client with emphysema. A review of the client's chart reveals pH 7.36, paO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription, if prescribed by the health care practitioner? a) Pulse oximetry b) 4 L/minute O2 nasal cannula c) High-Fowler's position d) Increase fluid intake to 3 L/day

B The client with chronic lung disease, such as emphysema, becomes insensitive to carbon dioxide and responds to hypoxia to stimulate breathing. If given excessive oxygen (4 L/minute), the stimulus to breathe is removed. Clients with emphysema are most comfortable in high-Fowler's position because it aids in the use of the accessory muscles to promote respirations. Increasing fluid intake helps keep the client's secretions thin. Pulse oximetry monitors the client's arterial oxyhemoglobin saturation while receiving oxygen therapy.

When the nurse is caring for an obese patient with left lower lobe pneumonia, gas exchange will be best when the patient is positioned a. on the left side. b. on the right side. c. in the tripod position. d. in the high-Fowler's position.

B The patient should be positioned with the "good" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions.

Which of the following skills can be delegated to the LPN? (Select all that apply.) A. Nasotracheal suctioning B. Oropharyngeal suctioning of a stable patient C. Suctioning a new artificial airway D. Permanent tracheostomy tube suctioning E. Care of an endotracheal tube (ETT)

BDE

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a) Refrain from exercise. b) Reduce anxiety. c) Eat meals 1 to 2 hours prior to breathing treatments. d) Eat a high-protein/high-calorie diet. e) Maintain a high-Fowler's position when possible. f) Drink 2 to 3 pints of clear fluids daily.

BDE When caring for patients with COPD, it is important to create an environment that is likely to reduce anxiety and ensure that they eat a high-protein/high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high Fowler's position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises, and drinking 2 to 3 quarts (1.9-2.9 L) of clear fluids daily is recommended.

Mr. D, a 28-year-old man, has been admitted to the intensive care unit for monitoring after a motor vehicle accident (MVA). Your physical assessment reveals multiple abrasions and bruising across the chest but an otherwise healthy young man. Suddenly, Mr. D complains of difficulty breathing. You quickly perform an assessment of his respiratory status and observe that his O2 saturation has dropped dramatically, there are decreased breath sounds on the left, and it appears that there is some tracheal deviation. What would be your next logical action? A) Notify Mr. D's physician and prepare for a stat V/Q scan. B) Start Mr. D on O2 at 4 L/min nasal cannula and prepare an aminophylline drip. C) Call the rapid response team and prepare for emergency insertion of a chest tube. D) Notify Mr. D's physician of these changes.

C

A client requires oxygen received via a face mask but wants to remain as mobile as possible once discharged home. Which intervention by the home health nurse best provides the client with maximal mobility? a. Arrange a consultation with pulmonary rehabilitation to decrease oxygen needs. b. Encourage the client to remove the mask occasionally to assess tolerance. c. Add extra connecting pieces of tubing to the client's existing oxygen setup. d. Change the face mask to a nasal cannula occasionally, such as at mealtimes.

C

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? A: Coughing up thick sputum only occasionally B: Coughing up thin, watery sputum easily after nebulization C: Decreased independent ability to cough D: Lung sounds clear only after coughing

C

Before seeing a newly assigned female client with respiratory alkalosis, the nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis? a. Myasthenia gravis b. Type 1 diabetes mellitus c. Extreme anxiety d. Narcotic overdose

C

For a client who is having respiratory symptoms of unknown etiology, the diagnostic test that is most invasive is: A. Pulse oximetry to determine oxygen saturation levels B. Throat cultures with sterile swabs C. Bronchoscopy of the bronchial trees D. Computed tomography of the lung fields

C

For a male client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? A. Restricting fluid intake to 1,000 ml/day B. Enforcing absolute bed rest C. Teaching the client how to perform controlled coughing D. Administering prescribed sedatives regularly and in large amounts

C

The nurse is performing nasotracheal suctioning on a medical patient and obtains copious amounts of secretions from the patients airway, even after inserting and withdrawing the catheter several times. How should the nurse proceed? A) Continue suctioning the patient until no more secretions are obtained. B) Perform chest physiotherapy rather than nasotracheal suctioning. C) Wait several minutes and then repeat suctioning. D) Perform postural drainage and then repeat suctioning.

C

The nurse notes that a patient has incisional pain, a poor cough effort, and scattered rhonchi after a thoracotomy. Which action should the nurse take first? a. Assist the patient to sit upright in a chair. b. Splint the patient's chest during coughing. c. Medicate the patient with prescribed morphine. d. Observe the patient use the incentive spirometer.

C

What is the correct sequence for suctioning a patient? 1. Open kit and basin. 2. Apply gloves. 3. Lubricate catheter. 4. Verify functioning of suction device and pressure. 5. Connect suctioning tubing to suction catheter. 6. Increase supplemental oxygen. 7. Reapply oxygen. 8. Suction airway. A. 6, 4, 3, 1, 2, 5, 8, 7 B. 4, 6, 1, 2, 3, 8, 5, 7 C. 4, 6, 1, 3, 2, 5, 8, 7 D. 6, 4, 1, 3, 2, 5, 7, 8

C

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? a) Eat one large meal at noon. b) Snack on high-carbohydrate foods frequently. c) Eat smaller meals that are high in protein. d) Contact the physician for nutrition shake.

C

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient? A: Postural drainage B: Chest percussion C: Incentive spirometer D: Suctioning

C

The nurse assesses a client who is receiving oxygen via a partial rebreather mask. Which assessment finding does the nurse intervene to correct? a. The bag is two thirds inflated during inhalation. b. The client's pulse oximetry reading is 93%. c. The oxygen flow rate is 2 L/min. d. The arterial oxygen level is 90%.

C Flow rate should be 6 to 11 L/min. A flow rate of 2 L/min will not adequately inflate the bag. A bag that is two thirds inflated is desired. A pulse oximetry reading of 93% and higher is adequate, as is an arterial oxygenation of 90%.

The patient arrives to the ED and you are told by the reporting nurse that the patient is suspected of having flail chest. Which of the following would the nurse assess for first? A) Palpate the thorax for a crackling, grating sound B) Ask pt. pain level and location C) Monitor respirations D) Assess blood pressure and heart rate

C In order to look for s/s of flail chest, the most important assessment sign to watch for is paradoxical chest movement, which could be found by monitoring respirations. Palpating the thorax could cause further damage to the ribs. It would be very important to assess pain and bp and hr (bleeding) but these will not help confirm the suspected diagnosis.

The charge nurse is making assignments for the next shift. Which patient should be assigned to the fairly new nurse (6 months of experience) floated from the surgical unit to the medical unit? A.) A 58-year-old patient on airborne precautions for tuberculosis (TB) B.) A 65-year-old patient who just returned from bronchoscopy and biopsy C.) A 72-year-old patient who needs teaching about the use of incentive spirometry D.)A 69-year-old patient with chronic obstructive pulmonary disease (COPD) who is ventilator dependent

C Many surgical patients are taught about coughing, deep breathing, and the use of incentive spirometry preoperatively. Also, a fairly new nurse should be assigned more stable and less complicated patients. To care for the patient with TB in isolation, the nurse must be fitted for a high-efficiency particulate air (HEPA) respirator mask. The bronchoscopy patient needs specialized and careful assessment and monitoring after the procedure, and the ventilator-dependent patient needs a nurse who is familiar with ventilator care. Both of these patients need experienced nurses.

Which value indicates clinical hypoxemia and the need to increase oxygen delivery? A. Hemoglobin of 22 g/dL B. PaCO2 of 30 mm Hg C. PaO2 of 65 mm Hg D. Oxygen saturation of 88%

C PaO2 of 65 mm Hg indicates low levels of oxygen in the arterial blood; this is termed hypoxemia.

The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? a. Administer the scheduled IV antibiotic. b. Give the PRN acetaminophen (Tylenol) 650 mg. c. Obtain oxygen saturation using pulse oximetry. d. Notify the health care provider of the patient's vital signs.

C The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Administration of the scheduled antibiotic and administration of Tylenol also will be done, but they are not the highest priority for a patient who may be developing ARDS.

After change-of-shift report, which patient should the nurse assess first? a. 72-year-old with cor pulmonale who has 4+ bilateral edema in his legs and feet b. 28-year-old with a history of a lung transplant and a temperature of 101° F (38.3° C) c. 40-year-old with a pleural effusion who is complaining of severe stabbing chest pain d. 64-year-old with lung cancer and tracheal deviation after subclavian catheter insertion

D

A female client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range? a. 1 to 2 mcg/ml b. 2 to 5 mcg/ml c. 5 to 10 mcg/ml d. 10 to 20 mcg/ml

D

A male client with Guillain-Barré syndrome develops respiratory acidosis as a result of reduced alveolar ventilation. Which combination of arterial blood gas (ABG) values confirms respiratory acidosis? a. pH, 5.0; PaCO2 30 mm Hg b. pH, 7.40; PaCO2 35 mm Hg c. pH, 7.35; PaCO2 40 mm Hg d. pH, 7.25; PaCO2 50 mm Hg

D

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? a) The patient vomits during suctioning. b) The secretions appear to be stomach contents. c) The catheter touches an unsterile surface. d) Epistaxis is noted with continued suctioning.

D

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient's oxygen status? A: Increased breathlessness but increased activity tolerance B: Decreased breathlessness and decreased activity tolerance C: Increased activity tolerance and decreased breathlessness D: Decreased activity tolerance and increased breathlessness

D

A patient has been newly diagnosed with emphysema. In discussing his condition with the nurse, which of his statements would indicate a need for further education? A: "I'll make sure that I rest between activities so I don't get so short of breath." B: "I'll rest for 30 minutes before I eat my meal." C: "If I have trouble breathing at night, I'll use two to three pillows to prop up." D: "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

D

A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats/minute, blood pressure of 100/60 mmHg, and respirations of 42 breaths/minute. Which action should the nurse take first? a. Administer anticoagulant drug therapy. b. Notify the patient's health care provider. c. Prepare patient for a spiral computed tomography (CT). d. Elevate the head of the bed to a semi-Fowler's position.

D

The home care nurse is visiting a patient newly discharged home after a lobectomy. What would be most important for the home care nurse to assess? A) Resumption of the patients ADLs B) The familys willingness to care for the patient C) Nutritional status and fluid balance D) Signs and symptoms of respiratory complications

D

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? a. Slow, deep respirations b. Rapid, deep respirations c. Paradoxical respirations d. Pain, especially with inspiration

D

The nurse is caring for a client with orders for oxygen at 5 L/min. Approximately how much FiO2 is the client receiving? a. 24% b. 28% c. 36% d. 40%

D

The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge? A) Walk 1 mile 3 to 4 times a week. B) Use weights daily to increase arm strength. C) Walk on a treadmill 30 minutes daily. D) Perform shoulder exercises five times daily.

D

The nurse is reviewing the results of the patient's diagnostic testing. Of the following results, the finding that falls within expected or normal limits is: A. Palpable, elevated hardened area around a tuberculosis skin testing site. B. Sputum for culture and sensitivity identifies mycobacterium tuberculosis C. Presence of acid fast bacilli in sputum D. Arterial oxygen tension (PaO2) of 95 mmHg

D

The nurse provides discharge teaching for a patient who has two fractured ribs from an automobile accident. Which statement, if made by the patient, would indicate that teaching has been effective? a. "I am going to buy a rib binder to wear during the day." b. "I can take shallow breaths to prevent my chest from hurting." c. "I should plan on taking the pain pills only at bedtime so I can sleep." d. "I will use the incentive spirometer every hour or two during the day."

D

When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first? a. Check pupil reaction to light. b. Notify the health care provider. c. Attempt to calm and reassure the patient. d. Assess oxygenation using pulse oximetry.

D

Which of the following statements is true about intrapleural (the space between the parietal and visceral or pulmonary pleurae) pressure under normal conditions? A. It is always positive B. It is negative during inhalation; positive during exhalation C. It is positive during inhalation; negative during exhalation D. It is always negative

D

A client who has experienced a panic attack is being transferred to the medical-surgical ward. The transfer nurse reports that the client is doing much better after receiving bronchodilators via nebulizer and a small dose of oral Valium 4 hours ago in the emergency department. Vital signs are stable with oxygen delivered at 4 L/min via simple facemask. Why is this client at high risk for subsequent respiratory distress? A. The client is not being treated for asthma B. The client has a mental disorder C. The client received a dose of Valium D. The client is receiving oxygen at 4 L/min

D A simple facemask must receive oxygen at a rate of at least 5 L/min to prevent inhalation of exhaled breath, which has low levels of oxygen and can eventually suffocate the client.

A client has been placed on 6 L of humidified oxygen via nasal cannula. Which action by the nurse is most appropriate? a. Drain condensation back into the humidifier, maintaining a closed system. b. Keep the water sterile by draining it from the water trap back into the humidifier. c. Turn down the humidity when condensation begins to collect in the tubing. d. Remove condensation in the tubing by disconnecting and emptying it appropriately.

D Condensation often forms in the tubing when a client receives humidified high-flow oxygen. Remove this condensation as it collects by disconnecting the tubing and emptying the water. Some humidifiers and nebulizers have a water trap that hangs from the tubing so the condensation can be drained without disconnecting. To prevent bacterial contamination, never drain the fluid back into the humidifier or the nebulizer. Do not turn down the humidity because the physician has ordered it and the client needs it. Minimize how long the tubing is disconnected because the client does not receive oxygen during this period.

A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient? a) Oxygen tent b) Oxygen mask c) Nasal cannula d) Ambu bag

D If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag)may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube.

A client who smokes is being discharged home on oxygen. The client states, "My lungs are already damaged, so I'm not going to quit smoking." What is the discharge nurse's best response? A. "You can quit when you are ready." B. "It's never too late to quit." C. "Just turn off your oxygen when you smoke." D. "You are right, the damage has been done. But let's talk about why smoking around oxygen is dangerous."

D This is a great opening for the nurse to educate the client about the dangers of smoking in the presence of oxygen, as well as the benefits of quitting.