fundamentals chapter 40

A client has been diagnosed with asthma and has been prescribed inhaled medications to relieve inflammation in the lung tissue. What medication will the nurse administer? Antibiotics Bronchodilators Expectorants Corticosteroids

Corticosteroids Explanation: In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation but bronchodilators do not. Antibiotics address infection, not inflammation. Expectorants loosen secretions rather than relieving inflammation.

The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide? "It is important to eat at least five servings of vegetables daily." "Remove your oxygen before cooking near the gas stove." "An electric stove may be a safer choice for you." "Be careful not to trip over your oxygen tubing while cooking."

"An electric stove may be a safer choice for you." Explanation: For safety purposes, oxygen tanks should be kept at least 10 feet away from gas stoves, fires, and other flammable devices. If the client removes the oxygen while cooking at a gas stove, hypoxia may occur and the client may become confused and sustain burns.

A parents brings their 2-year-old to the emergency department in respiratory distress. The child's oxygen saturation is 81% and there is audible stridor. What intervention will the nurse anticipate? Corticosteroids by metered-dose inhaler Placement in an oxygen tent Chest physiotherapy Deep breating and coughing exercises

Placement in an oxygen tent Explanation: Stridor often accompanies croup in young children. Due to the child's age, an oxygen tent would be an appropriate oxygen delivery device. The child is too young for metered-dose inhalers or deep breathing and coughing exercises.

Which is a sign of dyspnea specific to infants? increased respiratory rate nasal flaring a forward-leaning position panting respirations

nasal flaring Explanation: In the infant, flaring of the nostrils and retractions of the ribs during inspiration are notable signs of air hunger and extraordinary work of breathing.

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use? Venturi mask nasal cannula nonrebreather mask simple mask

nonrebreather mask Explanation: A nonrebreather mask is the only device that can deliver an FiO2 of 100% to a client without a controlled airway. A Venturi mask delivers a maximum FiO2 of 55%. A nasal cannula delivers a maximum FiO2 of 44%. A simple mask delivers a maximum FiO2 of 60%.

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? "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." "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." "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." "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."

"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." Explanation: The following formula is used to determine cardiac output: Cardiac Output = Stroke Volume x Heart Rate. A client with a stroke volume of 50 mL and heart rate of 50 beats per minute has a cardiac output of 2.5 L/minute. If stroke volume is 70 and heart rate is 70 beats per minute, then the cardiac output is 4.9 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute. If stroke volume is 60 and heart rate is 60 beats per minute, then the cardiac output is 3.6 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute.

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

"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 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? Hemoglobin levels Hematocrit values Arterial blood gas Pulmonary function

Arterial blood gas Explanation: 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.

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? Assess lung sounds Assess oxygen tubing connection Elevate head of the bed Reposition client

Assess oxygen tubing connection Explanation: If the client suddenly becomes cyanotic, the nurse should assess the oxygen tubing to make sure it is still connected. Assessing lung sounds, repositioning the client, and elevating the head of the bed will not correct the problem if the tubing is disconnected.

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse will document what breath sounds? Vesicular Wheezes Bronchovesicular Crackles

Crackles Explanation: Crackles, frequently heard on inspiration, are soft, high-pitched discontinuous (intermittent) popping sounds. Wheezes are continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors. Vesicular sounds are low-pitched, soft sounds heard over peripheral lung fields. Bronchovesicular sounds are medium-pitched blowing sounds heard over the major bronchi.

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe? Wheezing in the upper lobes Inspiratory stridor Expiratory stridor Crackles in the lower lobes

Crackles in the lower lobes Explanation: People with chronic heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels. Stridor is associated with respiratory infections such as croup. Wheezing may be heard in individuals who use tobacco products.

The client is experiencing respiratory distress and the nurse places the client in a high Fowler position. Which action does the nurse take next? Evaluate oxygen delivery Monitor fluid management Ensure airway patency Assess breathing pattern

Ensure airway patency Explanation: After placing a client experiencing respiratory distress in a high Fowler position, the next action by the nurse is to follow the ABCs—airway, breathing, circulation. First, the nurse ensures airway patency by having the client cough or suctioning the client's airways. Then, the nurse will assess the client's breathing pattern and evaluate oxygen delivery by looking at the client's oxygen saturation. Lastly, the nurse will monitor fluid management to ensure hydration but prevent overload.

A nurse must take a client's pulse oximetry reading. The nurse is explaining the technique to the client. Which statements about pulse oximetry are true? Select all that apply. The pulse oximetry sensor can produce accurate results even if circulation to the sensor site is impaired. Once the oximetry probe is correctly placed, a beam of red and infrared light travels through the tissue and blood vessels. Pulse oximeters display oxygen saturation and respiratory rate. Pulse oximetry measurement requires insertion of an arterial line. A range of 88% to 95% is considered normal oxygen saturation for infants. Sensors are available for use on the finger, toe, foot, earlobe, forehead, and bridge of the nose.

Once the oximetry probe is correctly placed, a beam of red and infrared light travels through the tissue and blood vessels. Sensors are available for use on the finger, toe, foot, earlobe, forehead, and bridge of the nose.

A client is admitted to the emergency department with shortness of breath and oxygen saturation of 88%. The client has a barrel chest and clubbed fingers. What is the nurse's priority intervention? Ambulate the client Assist the client with incentive spirometer Place client in the tripod position Teach the client deep-breathing exercises

Place client in the tripod position Explanation: Placing the client in the tripod position would relieve shortness of breath and increase the client's oxygen saturation level. Ambulating the client would exacerbate the symptoms, and assisting the client with the incentive spirometer is not appropriate at this time. The client will be unable to perform deep breathing exercises if hypoxic.

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? Pneumonia Tachypnea Wheezes Pleural effusion

Pleural effusion Explanation: Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis. Pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.

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 Congestive heart failure Malnutrition Poor tissue perfusion Anemia

Poor tissue perfusion Explanation: Chronically poor perfusion may result in hair loss in the affected area, discolored skin, thickened nails, and shiny, dry skin indicative of inadequate tissue nutrition.

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? nasal strip oxygen analyzer nasal cannula flow meter

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 health care provider. 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. sodium and potassium levels. age. hemoglobin level.

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.

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? high temperature high respiratory rate low pulse rate low blood pressure

high respiratory rate Explanation: A client diagnosed with Impaired Gas Exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.

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

pattern of thoracic expansion Explanation: The nurse can assess patterns of thoracic expansion through palpation. Fluid-filled and consolidated portions of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation.

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. croup. alcohol use. 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 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: 1 L/minute. 6 L/minute. 10 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 health care provider has prescribed oxygen to be delivered at 8 L/minute for a client who does not have a tracheostomy. Which oxygen delivery device(s) will the nurse consider using? Select all that apply. Venturi mask nonrebreather mask simple mask partial rebreather mask T-piece

simple mask partial rebreather mask A simple mask, and partial rebreather mask accommodate a flow of 8 L/min. A venturi mask accommodates 4-6 L/min, and a nonrebreather mask accommodates 10-15 L/min. The client does not have a tracheostomy so a T-piece is inappropriate.

The nurse is caring for a postoperative adult client who has undergone abdominal surgery. The nurse will provide interventions aimed at preventing what respiratory complication? Croup Bronchospasm Epiglottitis Atelectasis

Atelectasis Explanation: For the patient with an abdominal incision, the discomfort of breathing deeply often forces shallow breathing; this is why atelectasis is common in patients after surgery. None of the other listed respiratory conditions are common in the post-operative period or are considered complications of surgery.

The nurse is caring for a client with emphysema. When teaching the client pursed-lip breathing, the nurse will include which instruction(s)? Select all that apply. Ensure that the exhale lasts twice as long as the inhale. Exhale slowly through pursed lips. Inhale slowly through the nose for a count of three. Keep abdominal muscles in a relaxed state. Over time, begin to increase the length of the exhale. Shape the lips as if you were about to blow a whistle.

Inhale slowly through the nose for a count of three. Shape the lips as if you were about to blow a whistle. Over time, begin to increase the length of the exhale. Exhale slowly through pursed lips. Ensure that the exhale lasts twice as long as the inhale.

The nurse is caring for a client who is wearing oxygen via nasal cannula. The client asks about the bubbling water attached to the oxygen. Which response by the nurse is appropriate? It prescribes oxygen concentration. It decreases dry mucous membranes by delivering small water droplets. It determines whether you are getting enough oxygen. It regulates the amount of oxygen received.

It decreases dry mucous membranes by delivering small water droplets. Explanation: The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flow meter is a gauge used to regulate the amount of oxygen that a client receives. The health care provider prescribes concentration.

The nurse has received a prescription to obtain an arterial blood gas (ABG) on a client who has a history of chronic obstructive pulmonary disease (COPD) and is receiving oxygen via nasal cannula. Which step is the most important for the nurse to fulfill? apply pressure to the puncture site for at least 15 minutes after the puncture place the specimen in cold water after filling the tube ensure client is at rest at least 30 minutes before obtaining the specimen notify laboratory personnel of the prescription

ensure client is at rest at least 30 minutes before obtaining the specimen Explanation: Unless the procedure is an emergency, it is advisable for the client to be at rest at least 30 minutes prior to obtaining the specimen. The ABG represents the client status at the moment of sampling and activity can lower oxygen levels in the blood, which can lead to an incorrect interpretation of the results. Some facilities require laboratory personnel to obtain this sample which would require the nurse to notify the lab; however, with the current use of computers, they may already know and not need to be contacted. The specimen tube should be placed on ice for transport to the laboratory to help preserve the specimen as it slows metabolism and helps ensure accurate results. Manual pressure should be applied for 5 to 10 minutes after the puncture and followed with a pressure dressing to reduce the potential of arterial bleedin

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

reads 0.21 when checking oxygen in room air Explanation: 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).

What structural changes to the respiratory system should a nurse observe when caring for older adults? respiratory muscles become weaker diminished coughing and gag reflexes increased mouth breathing and snoring 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.

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? air passing through narrowed airways inflammation of pleural surfaces presence of fluid in the lungs presence of sputum in the trachea

presence of fluid in the lungs Explanation: Coarse crackles heard on auscultation indicate the presence of fluid in the lungs. Air passing through narrowed airways produces a wheezing sound, whereas inflammation of pleural surfaces gives rise to pleural rub. Sputum in the trachea produces stridor, a harsh, noisy squeak when something is blocking the airway.

A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client? spirometry thoracentesis pulse oximetry peak expiratory flow rate

pulse oximetry Explanation: Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the health care provider to aspirate pleural fluid for diagnostic or therapeutic purposes.

Which breathing technique(s) will the nurse teach to the client who has hypoxemia and hypercarbia? Select all that apply. pursed-lip breathing diaphragmatic breathing apply nasal strips incentive spirometry deep breathing

pursed lip breathing diaphragmatic breathing Pursed-lip breathing and diaphragmatic breathing are helpful for clients who have excessive levels of carbon dioxide in the blood. Deep breathing, incentive spirometry, and use of nasal strips does not eliminate as much carbon dioxide from the blood.

Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways? teaches him to prolong inspiration and shorten expiration increases carbon dioxide, which stimulates breathing helps liquefy his secretions decreases the amount of air trapping and resistance

decreases the amount of air trapping and resistance Explanation: Exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration, which prevents air from being trapped in the alveoli and decreases resistance to exhalation. Increasing carbon dioxide levels to stimulate breathing is the natural stimulus for a person without COPD to breathe. Prolonging inspiration and shortening expiration does not assist the client because exhalation is difficult for the COPD client. Humidification and fluid intake help to liquefy secretions.

The client has an increased anterior-posterior chest diameter, dyspnea, and nasal flaring. Which nursing concern is most appropriate for this client's care plan? Altered gas exchange due to carbon monoxide toxicity Altered airway clearance risk due to infection Hypoxia due to pneumonia and unproductive airway clearance Decreased oxygenation due to inability to fully exhale

Decreased oxygenation due to inability to fully exhale Explanation: In COPD, the patient's chest becomes overinflated over time because of an inability to exhale fully. This increases the anterior-posterior chest diameter, resulting in a barrel-shaped appearance and ultimately in decreaed oxygenation. This is unrelated to carbon monoxide exposure or acute lung infections.

A client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and the secretions are thick and sticky. Which intervention will the nurse use to promote respiratory hygiene in this situation? Assisted ambulation four times daily Increased oral fluid intake Coughing and deep-breathing exercises Range-of-motion exercises as tolerated

Increased oral fluid intake Explanation: When a cough is productive, it is important to establish the source of the sputum and assess its color, volume, consistency, and other noteworthy characteristics. The nurse should instruct the client to increase fluid intake to help thin secretions. Encouraging coughing and deep breathing should be done; however, the problem is thick secretions and increasing oral fluids will address the problem directly. Range-of-motion exercises and assisted ambulation help with mobility concerns but will not help to thin out the secretions.

A nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant? Venturi mask Oxygen hood Simple mask Nasal cannula

Oxygen hood Explanation: An oxygen hood is a delivery device for infants that can deliver oxygen concentrations up to 80% to 90%. None of the other devices listed can deliver oxygen at the concentration needed.

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

The client's available hemoglobin is adequately saturated with oxygen. Explanation: Pulse oximetry is a noninvasive technique that measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial blood. This test measures only the percentage of oxygen carried by the available hemoglobin. Thus, even a client with a low hemoglobin level could appear to have a normal SpO2 because most of that hemoglobin is saturated. However, the client may not have enough oxygen to meet body needs. A normal pulse oximetry reading does not necessarily indicate a normal RBC count or heart rate.

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 soft, high-pitched discontinuous (intermittent) popping lung 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 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 has received a prescription to obtain an arterial blood gas (ABG) on a client who has a history of chronic obstructive pulmonary disease (COPD) and is receiving oxygen via nasal cannula. Which step is the most important for the nurse to fulfill? apply pressure to the puncture site for at least 15 minutes after the puncture ensure client is at rest at least 30 minutes before obtaining the specimen place the specimen in cold water after filling the tube notify laboratory personnel of the prescription

ensure client is at rest at least 30 minutes before obtaining the specimen Explanation: Unless the procedure is an emergency, it is advisable for the client to be at rest at least 30 minutes prior to obtaining the specimen. The ABG represents the client status at the moment of sampling and activity can lower oxygen levels in the blood, which can lead to an incorrect interpretation of the results. Some facilities require laboratory personnel to obtain this sample which would require the nurse to notify the lab; however, with the current use of computers, they may already know and not need to be contacted. The specimen tube should be placed on ice for transport to the laboratory to help preserve the specimen as it slows metabolism and helps ensure accurate results. Manual pressure should be applied for 5 to 10 minutes after the puncture and followed with a pressure dressing to reduce the potential of arterial bleeding

When reviewing data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom? weight loss rapid respirations increased urine output strong, rapid pulse

rapid respirations Explanation: Normal cardiac output averages from 3.5 to 8.0 liter/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing the respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display a thready pulse.

The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? tracheostomy collar simple mask face tent nasal cannula

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.

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? "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." "Breathing through your nose first will warm, filter, and humidify the air you are breathing." "If you breathe through the mouth first, you will swallow germs into your stomach."

"Breathing through your nose first will warm, filter, and humidify the air you are breathing." Explanation: Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring.

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is: "His infection is causing him to breathe harder." "His lung muscles are swollen so he is using abdominal muscles." "He is using his chest muscles to help him breathe." "He will require additional testing to determine the cause."

"He is using his chest muscles to help him breathe." Explanation: The client will use accessory muscles to ease dyspnea and improve breathing.

The nurse is providing discharge teaching to a client going home with oxygen therapy. Which statements made by the client would indicate to the nurse that the teaching was effective? Select all that apply. "I will secure my tank by placing it flush against the wall." "I will adjust the oxygen flow according to my needs." "I will keep the oxygen tank away from direct sunlight or heat." "I will only use an electrical instead of gas stove." "I will not allow smoking within 10 feet (3 m) of my oxygen."

"I will keep the oxygen tank away from direct sunlight or heat." "I will not allow smoking within 10 feet (3 m) of my oxygen."

The pediatric nurse is caring for four clients. Which client will receive the greatest benefit from the use of an oxygen analyzer to assure that the client is receiving the prescribed amount of oxygen? 10-year old with simple mask 7-year old with nasal cannula 13-year old with nonrebreather mask 3-year old in croup tent

3-year old in croup tent Explanation: An oxygen analyzer is used most commonly when caring for newborns in isolettes, children in croup tents, and clients who are mechanically ventilated. Other answers are incorrect.

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

32%

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? Increase fluid intake to 3 L/day (3000 mL/day) 4 L/minute O2 (66 mL/second) nasal cannula High-Fowler's position Pulse oximetry

4 L/minute O2 (66 mL/second) nasal cannula Explanation: 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 or 66 mL/second), 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.

A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first? Apply oxygen as prescribed Assist with intubation Educate client on incentive spirometry Raise the head of the bed

Apply oxygen as prescribed Explanation: The nurse should first apply oxygen, which will help to improve oxygen saturation and health status. The client may not require intubation, once oxygen is provided. Although the client may require education on incentive spirometry, the immediate priority intervention is to stabilize the client's oxygen saturation. Similarly, raising the head of the bed may help with the client's comfort but may not have sufficient effect on oxygen saturation.

A nurse is providing care in an area which is plagued by high levels of air pollutants from industry and motor vehicles. The nurse will expect a high incidence and prevalence of what respiratory disease? Atelectasis Bronchitis Croup Bronchiectasis

Bronchitis Explanation: Bronchitis refers to a condition in which the airways become inflamed, commonly due to respiratory irritants such as air pollution and high humidity. Exposure to such irritants leads to the release of inflammatory mediators, which in turn, lead to inflammation and narrowing of the airways and increased mucus production. Atelectasis refers to the partial or complete collapse of the small air sacs in the lungs, common after surgery or with obstruction or compression of the airways or lungs. Bronchiectasis results from chronic inflammation or infection causing an excess accumulation of mucus. Croup is an infection of the airways, most commonly viral in origin.

A nurse is volunteering at a day camp where a child is stung by a bee and develops wheezing in the upper airways. The nurse will provide interventions to address what health problem? Bronchiectasis Bronchospasm Bronchitis Bronchiolitis

Bronchospasm Explanation: When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm. Bronchitis and bronchiectasis are chronic respiratory effects and bronchiolitis is infectious.

The nurse is assessing a client with lung cancer who has been receiving treatment for many months. What manifestations may suggest that the client has chronic hypoxia? Clubbing Yellow or green sputum Edema Hemoptysis

Clubbing Explanation: Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many clients with chronic hypoxia due to respiratory or cardiac disease. Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD. Hemoptysis, edema, and discolored sputum do not result from hypoxia.

A nurse is conducting a physical assessment of a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the client's oxygenation. What instruction should the nurse give the client? Elevate the ribs and sternum. Relax the respiratory muscles. Expand the thoracic cavity. Contract the abdominal muscles.

Contract the abdominal muscles. Explanation: The nurse should instruct the client to contract the abdominal muscles to exhale additional air. A person can forcibly exhale additional air by contracting abdominal muscles such as the rectus abdominis, transverse abdominis, and external and internal obliques. The client elevates the ribs and sternum and expands the thoracic cavity during inspiration. The client relaxes the respiratory muscles during normal expiration.

The nurse provides care for the client with chronic obstructive pulmonary disease experiencing hypoxia. Which assessment prompts the nurse to immediately report findings to the health care provider? Frequent coughing Decreased level of consciousness Wheezing Cyanosis

Decreased level of consciousness Explanation: If a problem exists in ventilation, respiration, or perfusion, hypoxia (a condition in which an inadequate amount of oxygen is available to cells) may occur. The nurse providing care for the client with chronic obstructive pulmonary disease experiencing hypoxia will immediately report the client's decreased level of consciousness to the health care provider because it may indicate severe respiratory distress including respiratory failure. The findings of cyanosis, wheezing, and frequent coughing may not be a change from the client's usual condition.

The nurse is assessing a neonate whose breathing ceased for 4 to 5 seconds on three different occasions. What is the nurse's best action? Obtain an order for airway suctioning as needed Document these expected apneic episodes Arrange for immediate assessment by the primary care provider Reposition the infant to promote adequate oxygenation

Document these expected apneic episodes Explanation: The newborn's breathing pattern is characterized by occasional pauses of several seconds between breaths. This periodic breathing is normal during the first 3 months of life, but frequent or prolonged periods of apnea (cessation of breathing 20 seconds or longer) are abnormal. In the absence of symptoms of hypoxia, referrals and further interventions such as suctioning are unnecessary.

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? Hypoxia Atelectasis Hyperventilation Perfusion

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.

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

It determines whether the client is getting enough oxygen.

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? Monitor the pressure of oxygen dissolved in plasma. Calculate the pressure of carbon dioxide dissolved in plasma. Measure the volume of air exhaled or inhaled over time. 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.

A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is mostappropriate to this client's needs? Partial rebreather mask Nasal cannula Simple mask Nonrebreather mask

Nasal cannula Explanation: A nasal cannula is used to deliver from 1 L/min to 6 L/min of oxygen. Masks are used with higher flow rates of oxygen.

The nurse educator would intervene with client teaching if which action by the staff nurse occurs when teaching voluntary coughing? The nurse encourages the client to cough before meals. The nurse develops a specific schedule for coughing. The nurse reminds the client to combine coughing and deep breathing. The nurse has the client lying in bed in semi-Fowler's position.

The nurse has the client lying in bed in semi-Fowler's position. Explanation: The client should be sitting upright with feet flat on the floor to be most effective. As part of the client's plan of care, the nurse should develop a specific schedule for coughing. Coughing before meals improves the taste of food and oxygenation. When combined with deep breathing, coughing is most effective.

The nurse provides care for a client with pneumonia and acute respiratory distress syndrome whose oxygen saturation fluctuated between 86% and 90% over the past few days. The oxygenation saturation is consistently at 91%. Which step would the nurse take next? Continue to monitor oxygen to ensure the level does not fall below 90% Encourage use of spirometry to improve oxygenation through the lungs Obtain blood for hemoglobin testing to determine oxygen transport level Provide oxygen for consistent hypoxia

Provide oxygen for consistent hypoxia Explanation: In practice, the oxygen saturation range of 92% to 100% is generally acceptable for most clients, so an oxygen saturation level of 91% is not within a normal, acceptable range and the client is experiencing hypoxia. When an abnormal finding is identified, the next step is to act to correct the issue, in this case, provide oxygen for the client's hypoxia. While monitoring levels and promoting spirometry may be needed in certain postoperative and nonambulatory clients, this is a preventative measure and will not immediately address the need for oxygen. The oxygen level is not low enough to warrant testing for hemoglobin.

The nurse is caring for an older adult homebound client with advanced respiratory disease whose has inadequate nutrition. What recommendation will the nurse provide? Replace meals with protein shakes Practice intermittent fasting to promote appetite Increase use of dietary supplements Provide suggestions of high-protein, high-calorie meals

Provide suggestions of high-protein, high-calorie meals Explanation: TThe client should have sufficient caloric and protein intake for respiratory muscle strength, so promotion of a high-calorie, high-protein diet is appropriate. Protein shakes and dietary supplements may be appropriate but should complement, rather than replace, meals. Intermittent fasting promotes weight loss, not increased calorie intake.

Which diagnostic procedure measures lung size and airway latency, producing graphic representations of lung volumes and flows? Chest x-ray Bronchoscopy Skin tests Pulmonary function tests

Pulmonary function tests

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? Practice good hand hygiene. Cut down on smoking. Avoid exposure to large crowds. Stay indoors as much as possible.

Stay indoors as much as possible. Explanation: Using the air quality index, a red color designation signifies that the air quality is unhealthy for all people, not just sensitive groups. Air pollution and high humidity are respiratory irritants. Pollutants cause increased mucus production and contribute to bronchitis and asthma. Reducing contact with irritants by staying indoors during times of increased air pollution will decrease their effect on the respiratory system. Clients should be encouraged to quit smoking, not just cut down. Avoiding large crowds and practicing good hand hygiene will prevent respiratory infections but not cut down on the effect of air pollution.

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

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.

What assessments would a nurse make when auscultating the lungs? air flow through the respiratory passages volume of air exhaled or inhaled abnormal chest structures presence of edema

air flow through the respiratory passages Explanation: Auscultation of the lungs assesses air flow through the respiratory passages and lungs. The nurse listens for normal, as well as abnormal, breath sounds. Abnormal chest structures would be assessed when inspecting the chest and thoracic region. Presence of edema would be assessed as part of the cardiovascular status of the client. Volume of air exhaled and inhaled would be performed during a pulmonary function test.

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia? confusion decreased respiratory rate hyperactivity decreased blood pressure

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.

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? cyanosis pallor eupnea hypercapnia

cyanosis Explanation: Cyanosis around the lips indicates serious hypoxemia. Cyanosis is caused by a desaturation of oxygen on the hemoglobin in the blood. Hypercapnia is caused by an abnormally high carbon dioxide level in the blood. Hypoxemia is caused by low oxygen levels in the blood. Eupnea is easy, free respiration.