Fundamentals Chapter 39- Oxygenation and Perfusion

c. Vesicular

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting? a. Crackles b. Bronchovesicular c. Vesicular d. Bronchial

d. a client taking opioids for cancer pain

In which client would the nurse assess for a depressed respiratory system? a. a client taking amlodipine for hypertension b. a client taking antibiotics for a urinary tract infection c. a client taking insulin for diabetes d. a client taking opioids for cancer pain

c. The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN).

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse would cause the charge nurse to intervene? a. The newly hired nurse adjusts the bed to a comfortable working position. b. The newly hired nurse explains what she is doing and the reason to the client, even though the client does not appear to be alert. c. The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). d. The newly hired nurse assesses the client's pain and administers pain medication.

b. "Breathing through your nose first will warm, filter, and humidify the air you are breathing."

The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client? a. "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." b. "Breathing through your nose first will warm, filter, and humidify the air you are breathing." c. "If you breathe through the mouth first, you will swallow germs into your stomach." d. "We are concerned about you developing a snoring habit, so we encourage nasal breathing first."

d. 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? a. Tidal volume (TV) b. Total lung capacity (TLC) c. Forced Expiratory Volume (FEV) d. Residual Volume (RV)

a. chronic anemia

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? a. chronic anemia b. Graves' disease c. Parkinson's disease d. pancreatitis

d. The chest should be slightly convex with no sternal depression.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding? a. The contour of the intercostal spaces should be rounded. b. The skin at the thorax should be cool and moist. c. The anteroposterior diameter should be greater than the transverse diameter. d. The chest should be slightly convex with no sternal depression.

a. True 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. Reference:

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. True b. False

d. flow meter

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? a. oxygen analyzer b. nasal strip c. nasal cannula d. flow meter

a. Ask the client what factors contribute to nonadherence.

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention? a. Ask the client what factors contribute to nonadherence. b. Contact the health care provider to report the client's current status. c. Explain the use of a BiPAP mask instead of a CPAP mask. d. Document outcomes of modifications in care.

a. hemoglobin level.

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: a. hemoglobin level. b. age. c. blood pH. d. sodium and potassium levels.

a. flow meter

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? a. flow meter b. oxygen analyzer c. humidifier d. nasal cannula

d. Clubbing

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia? a. Edema b. Hemoptysis c. Diarrhea d. Clubbing

b. Hypoxia

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? a. Hyperventilation b. Hypoxia c. Perfusion d. Atelectasis

a. Tell me more about why it bothers you.

The client is reporting to the nurse that the continuous positive airway pressure (CPAP) mask is torture. What is the best response from the nurse? a. Tell me more about why it bothers you. b. Would you like to talk to your health care provider concerning this? c. Can you explain to me what settings you are using? d. Perhaps we need to change you to a different type of mask.

c. high-Fowler's position 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.

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position? a. left side with a pillow under the chest wall b. side-lying position, half on the abdomen and half on the side c. high-Fowler's position d. Trendelenburg position

a. crackles.

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: a. crackles. b. vesicular. c. wheezes. d. bronchovesicular.

d. Assess oxygen tubing connection

The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take? a. Assess lung sounds b. Reposition client c. Elevate head of the bed d. Assess oxygen tubing connection

c. "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD.

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? a. "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." b. "Take in a small amount of air very quickly and then exhale as quickly as possible." c. "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." d. "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling."

b. presence of fluid in the lungs

While auscultating a client's chest, the nurse auscultates crackles in the lower lung bases. What condition does the nurse identify the client is experiencing? a. presence of sputum in the trachea b. presence of fluid in the lungs c. air passing through narrowed airways d. inflammation of pleural surfaces

c. Ambu bag

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

a. nasal cannula

An adult client is discharged to home with a prescription for oxygen at 2 L/min. Which method of oxygen delivery should the nurse use in this situation? a. nasal cannula b. oxygen mask c. oxygen hood d. oxygen tent

c. Stay indoors as much as possible.

The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care? a. Cut down on smoking. b. Avoid exposure to large crowds. c. Stay indoors as much as possible. d. Practice good hand hygiene.

c. 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? a. Stridor b. Crackles c. Wheezing d. Absent breath sounds in lower lobes

a. headache b. sore throat c. fatigue

The nurse has received the arterial blood gas (ABG) results. The ABG was drawn on a client who has been receiving oxygen via partial rebreather mask. Which assessment findings should the nurse act upon after reviewing the ABG? Select all that apply. a. headache b. sore throat c. fatigue d. nasal flaring e. tachycardia

a. No action is required, because this may be normal for the client

The nurse is obtaining a pulse oximetry reading for a client admitted with exacerbation of chronic obstructive pulmonary disease (COPD). When observing a reading of 89%, what action should the nurse perform? a. No action is required, because this may be normal for the client b. The nurse should prepare intubation equipment for the health care provider c. Administer oxygen at 6 L/m by nasal cannula d. Have the client breath into a paper bag

a. reads 0.21 when checking oxygen in room air An oxygen analyzer should read 0.21 when checking oxygen in room air if there is a normal mixture of oxygen and other gases in the environment. When the analyzer is positioned near or within the device used to prescribe oxygen, it should register at the prescribed amount (>0.21).

The nurse is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly? a. reads 0.21 when checking oxygen in room air b. reads 0.25 when checking oxygen in room air c. reads 0.19 when positioned near oxygen device d. reads 0.20 when positioned near oxygen device

c. Poor tissue perfusion

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing a. Anemia b. Malnutrition c. Poor tissue perfusion d. Congestive heart failure

d. Suction the tracheostomy tube using sterile technique.

When caring for a client with a tracheostomy, the nurse would perform which recommended action? a. Clean the wound around the tube and inner cannula at least every 24 hours. b. Assess a newly inserted tracheostomy every 3 to 4 hours. c. Use gauze dressings over the tracheostomy that are filled with cotton. d. Suction the tracheostomy tube using sterile technique.

d. Pulmonary function tests

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

d. Corticosteroids

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue? a. Antibiotics b. Bronchodilators c. Expectorants d. Corticosteroids

b. cyanosis

A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario? a. eupnea b. cyanosis c. hypercapnia d. hypoxemia

c. croup.

A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from: a. atelectasis. b. pulmonary fibrosis. c. croup. d. asthma.

b. apnea.

The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as: a. dyspnea. b. apnea. c. orthopnea. d. hypercapnia.

c. Document the finding. Small stationary clots are a normal finding. The chest tubing should never be stripped of clots because this can create intrathoracic negative pressure. Clamping chest tubes is not recommended as it can create a tension pneumothorax. The rapid response team should be called if the chest tube becomes dislodged, an air leak occurs, or the client experiences dyspnea.

The nurse is caring for a client with a chest tube. Stationary clots are noted in the tubing. What is the appropriate nursing action? a. Clamp the tube. b. Strip the chest tubing of clots. c. Document the finding. d. Contact the rapid response team.

d. It decreases dry mucous membranes via delivering small water droplets.

Which teaching about the humidifier is important for the nurse to provide to a client using oxygen? a. It prescribes oxygen concentration. b. It regulates the amount of oxygen received. c. It determines whether the client is getting enough oxygen. d. It decreases dry mucous membranes via delivering small water droplets.

a. Wheezing b. Chronic cough c. Shortness of breath e. Loss of appetite Emphysema is a chronic obstructive pulmonary disease (COPD) which is most frequently related to a history of cigarette smoking and occupational exposure to fumes or dust from chemicals, both of which this client has. The symptoms that the nurse expects to find include wheezing, chronic cough, shortness of breath, loss of appetite, and weight loss, not weight gain.

A 55-year-old male client with emphysema worked with photography chemicals and smoked cigarettes for 30 years. Which symptom(s) will the nurse expects to find? Select all that apply. a. Wheezing b. Chronic cough c. Shortness of breath d. Weight gain e. Loss of appetite

a. atelectasis. 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.

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: a. atelectasis. b. pneumothorax. c. hemothorax. d. tachypnea.

a. 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? a. Remove the airway, turn the client to the side, and provide mouth suction, if necessary. b. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. c. Leave the airway in place and promptly notify the health care provider for further instructions. d. Suction the client's mouth through the oropharyngeal airway to prevent aspiration.

d. "I can assist you to the bathroom and back to bed."

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response? a. "The chest tube cannot be moved." b. "You will need to use a bedpan while the chest tube is in position." c. "Let me get the unlicensed assistive personnel (UAP) for you." d. "I can assist you to the bathroom and back to bed."

a. nasal cannula

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered? a. nasal cannula b. simple oxygen mask c. Venturi mask d. partial rebreather mask

a. 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? a. Pleural effusion b. Tachypnea c. Wheezes d. Pneumonia

b. Warm the client's hands and try again.

A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action? a. Place the probe on the client's earlobe. b. Warm the client's hands and try again. c. Shine available light on the equipment to facilitate accurate reading. d. Use a blood pressure cuff to increase circulation to the site.

d. pneumonia.

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: a. croup. b. asthma. c. alcohol use. d. pneumonia.

c. 5,850 mL

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL and a pulse of 78 beats/min. What number would the nurse document for this assessment? a. 5,450 mL b. 5,650 mL c. 5,850 mL d. 6,050 mL

c. 32% 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%

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

b. Measuring the client's respiratory rate c. Inserting the client's nasal cannula after it has become dislodged e. Reapplying the client's nasal cannula after a bath

A nurse is overseeing the care of a client who is receiving oxygen via nasal cannula. Which aspects of the client's care can the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply. a. Auscultating the client's lungs to determine the effectiveness of treatment b. Measuring the client's respiratory rate c. Inserting the client's nasal cannula after it has become dislodged d. Increasing the flow rate of the client's oxygen when the client is short of breath e. Reapplying the client's nasal cannula after a bath

b. 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. Atelectasis b. Bronchitis c. Bronchiectasis d. Croup

a. trauma to the tracheal mucosa 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.

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? a. trauma to the tracheal mucosa b. prevention of suctioning c. loss of sterile field d. suctioning of carbon dioxide

a. The client's available hemoglobin is adequately saturated with oxygen.

A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate? a. The client's available hemoglobin is adequately saturated with oxygen. b. The client's oxygen demands are being met. c. The client's red blood cell (RBC) count is in the normal range. d. The client's respiratory rate is in the normal range.

d. Document this expected assessment finding.

A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action? a. Encourage the client to do deep-breathing exercises. b. Raise the head of the client's bed slightly, if tolerated. c. Review the medications that the client has taken in the past 90 minutes. d. Document this expected assessment finding.

d. "If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute."

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output? a. "If the client's stroke volume is 70 mL and heart rate is 70 beats per minute, then the cardiac output is 4.7 L/minute." b. "If the client's stroke volume is 80 mL and heart rate is 80 beats per minute, then the cardiac output is 6.0 L/minute." c. "If the client's stroke volume is 60 mL and heart rate is 60 beats per minute, then the cardiac output is 3.2 L/minute." d. "If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute."

b. tracheostomy collar

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? a. simple mask b. tracheostomy collar c. nasal cannula d. face tent

d. SpO2 96%

The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective? a. clubbing of fingers b. respirations 26 breaths/minute c. heart rate 110 beats/minute d. SpO2 96%

c. Check the fit of the oxygen mask. The fit of the oxygen mask can be affected by the discontinuation of wearing dentures. The nurse should check the fit to make sure the client is getting the prescribed amount of oxygen.

The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate? a. Increase the flow of oxygen. b. Contact the oxygen supplier to request an oxygen tent. c. Check the fit of the oxygen mask. d. Discontinue oxygen therapy until the client is reassessed by the healthcare provider.

c. When using a metered-dose inhaler (MDI) , the client must activate the device before and after inhaling. d. Dry powder inhalers (DPIs) are actuated by the client's inspiration, so there is no need to coordinate the delivery of puffs with inhalation. e. MDIs deliver a controlled dose of medications with each compression of the canister.

The nurse is educating a client on the proper use of inhaled medications. What are appropriate education points to include? Select all that apply. a. Bronchodilators are used to liquefy or loosen thick secretions or reduce inflammation in airways. b. Nebulizers are used to deliver a controlled dose of medication with each compression of the canister. c. When using a metered-dose inhaler (MDI) , the client must activate the device before and after inhaling. d. Dry powder inhalers (DPIs) are actuated by the client's inspiration, so there is no need to coordinate the delivery of puffs with inhalation. e. MDIs deliver a controlled dose of medications with each compression of the canister.

b. Be sure to shake the canister before using it.

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? a. Inhale through the nose instead of the mouth. b. Be sure to shake the canister before using it. c. Inhale the medication rapidly. d. Inhale two sprays with one breath for faster action.

b. A decrease in ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs While all these changes are possible because of age, ineffective cough is most important after surgery. The intervention provided by the nurse is directed toward minimizing pain and maximizing expulsion of secretions, thus minimizing the risk for the development of postsurgical pneumonia.

The nurse is providing an educational demonstration to an older, postsurgical client (holding a pillow to your chest). The intervention is intended to minimize the effect of what age-related change specifically relevant to such a client? a. A decrease in gas exchange and an increase in the work of beathing related to decreased elastic recoil of the lungs b. A decrease in ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs c. A decrease in the ability to respond to stress related to ineffective cardiac muscle function d. A decrease in cardiac output related to progressive atherosclerosis

b. Maintain the client's oxygenation and alert the health care provider immediately.

The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response? a. Page the respiratory therapist STAT. b. Maintain the client's oxygenation and alert the health care provider immediately. c. Cover the tracheostomy stoma and apply oxygen by nasal cannula d. Assess the client's respiratory status and check vital signs every 1 minute for the next hour.

c. It determines whether the client is getting enough oxygen.

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? a. It prescribes oxygen concentration. b. It regulates the amount of oxygen received. c. It determines whether the client is getting enough oxygen. d. It decreases dry mucous membranes via delivering small water droplets.

b. pattern of thoracic expansion

While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique? a. fluid-filled portions of the lung b. pattern of thoracic expansion c. consolidated portions of the lung d. presence of pleural rub