Gas Exchange

A nurse is caring for a client who is receiving oxygen at 2 L/min via nasal cannula. The nurse recognizes the client is receiving which of the following inspired oxygen concentration? a. 28% b. 36% c. 50% d. 70%

a. 28% The nurse should recognize that a flow rate of 2 L/min via nasal cannula delivers an oxygen concentration of about 28%.

A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and postural drainage. Prior to the procedure, which of the following nursing actions should the nurse complete first? a. Auscultate lung fields. b. Assess pulse and respirations. c. Assess characteristics of her sputum. d. Instruct to slowly exhale with pursed lips.

a. Auscultate lung fields. The first action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is to auscultate lung fields to provide knowledge of which lung areas are most affected and would be the focus of the procedure.

A nurse is caring for a client who's has emphysema. Which of the following findings should the nurse expect to assess in the client? (Select all that apply.) a. Dyspnea b. Bradycardia c. Barrel chest d. Clubbing of the fingers e. Deep respirations

a. Dyspnea is correct. Emphysema is a lung disease involving damage to the alveoli in which they become weakened and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount of oxygen available to the tissues. c. Barrel chest is correct. Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward. This produces the barrel chest typical of emphysema clients. d. Clubbing of the fingers is correct. Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the nails become extremely curved from front to back.

A nurse is auscultating a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take? a. Repeat auscultation after asking the client to breathe deeply and cough. b. Instruct the client to limit fluid intake to less than 2000 mL/day. c. Prepare to administer antibiotic. d. Place the client on bed rest in semi-Fowler's position.

a. Repeat auscultation after asking the client to breathe deeply and cough. Although crackles often indicate fluid in the alveoli, they can also be the result of positioning or decreased ventilation. They sometimes clear after a deep breath or a cough.

A nurse is reviewing the ABG values for a client. The pH is 7.32, PaCO2 48mm Hg and thew HCO3 is 213mEq/L. The nurse should recognize that these findings indicate of which of the following acid base balances? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

a. Respiratory acidosis A number of conditions can lead to respiratory acidosis, including COPD and pneumonia. In the presence of respiratory acidosis, the client's blood gas values meet the following criteria: a pH less than 7.35, a PaCO2 greater than greater 45 mg/Hg, and a HCO3 that is normal or slightly elevated (22 to 26 mEq/mL).

A nurse is caring for a child who ingested kerosene. Which of the following assessment is the nurse's priority? a. Respiratory rate b. Burns of the mouth c. Bowel sounds d. Visual acuity

a. Respiratory rate Using the airway, breathing, circulation approach to client care, the nurse should prioritize assessing the client's respiratory rate. Small amounts of kerosene can enter the lungs and damage them directly, causing a severe aspiration pneumonia. Because the pneumonia is caused by chemical irritation rather than bacteria, antibiotics aren't useful for prevention or treatment. Breathing becomes rapid and gasping, and vomiting and persistent coughing can follow. In severe cases, brain damage can occur.

A nurse is teaching a client who has asthma about how to use how not use an albuterol inhaler. Which of the following actions by the client idiots an understanding of the teaching? a. The client holds his breath for 10 seconds after inhaling the medication. b. The client takes a quick inhalation while releasing the medication from the inhaler. c. The client exhales as the medication is released from the inhaler. d. The client waits 10 min between inhalations.

a. The client holds his breath for 10 seconds after inhaling the medication. The medication should be retained in the lungs for a minimum of 10 seconds so the maximum amount of the dosage can be delivered properly to the airways. To use the inhaler, the client exhales normally just prior to releasing the medication, inhales deeply as the medication is released, then holds the medication in the lungs for approximately 10 seconds prior to exhaling.

A college health nurse interprets the peak expiratory flow rate for a student who has asthma and finds that the student is in the yellow zone of his asthma action plan. The nurse should base her actions on which of the following information? (Select all the apply.) a. The student should use his quick-relief inhaler. b. The student's asthma is not well controlled. c. The student's peak flow is 50% to 80% of his best peak flow. d. The student needs to go to the hospital. e. The nurse should obtain a second expiratory flow rate.

a. The student should use his quick-relief inhaler is correct. The student should use his quick-relief inhaler is correct. A student in the yellow zone should use a quick-relief inhaler such as albuterol to reverse airway obstruction. b. The student's asthma is not well controlled is correct. The student's asthma is not well controlled is correct. The yellow zone indicates that the student's asthma is not well controlled. The desired range is the green zone which is represents 80 % of the client's personal best. c. The student's peak flow is 50% to 80% of his best peak flow is correct. The student's peak flow is 50% to 80 % of his best peak flow is correct. This is the range for a client who is in the yellow zone. e. The nurse should obtain a second expiratory flow rate is correct. The nurse should obtain a second expiratory flow rate is correct. The second peak flow rate should be obtained after the student uses his quick-relief inhaler.

A nurse is providing discharge teaching to a client who has asthma and new prescriptions for cromolyn and albuterol, both by nebulizer. Which of the following statements by the client indicates an understanding of the teaching? a. "If my breathing begins to feel tight, I will use the cromolyn immediately." b. "I will be sure to take the albuterol before taking the cromolyn." c. "I will use both medications immediately after exercising." d. "I will administer the medication 10 minutes apart."

b. "I will be sure to take the albuterol before taking the cromolyn." The client should always use the bronchodilator (albuterol) prior to using the leukotriene modifier (cromolyn). Using the bronchodilator first allows the airways to be opened, ensuring that the maximum dose of medication will get to the client's lungs.

A nurse is teaching a client who's has COPD about ways to facilitate eating. Which of the following statements indicates a need for further teaching? a. "I will rest for at least 30 minutes before eating." b. "I will take my bronchodilators after meal." c. "I will eat five or six each day." d. "I will choose foods are not gas-forming."

b. "I will take my bronchodilators after meal." Bronchodilators should be taken before meals, not after, in order to reduce shortness of breath. This statement by the client indicates a need for further teaching.

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and sever pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify the finding as which of the following? a. Atelectasis b. Flail chest c. Hemothorax d. Pneumothorax

b. Flail chest Flail chest is the result of multiple rib fractures that cause instability. During inspiration, the thorax moves inward and during expiration it bulges out.

A nurse is caring for a client who's experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? a. An upper respiratory infection b. Pulmonary edema c. Atelectasis d. Delayed gastric emptying

c. Atelectasis Atelectasis is the collapse of part or all of a lung by blockage of the air passages (bronchus or bronchioles) or by hypoventilation. Prolonged bedrest with few changes in position, ineffective coughing, and underlying lung disease are risk factors for the development of atelectasis.

A nurse in a provider's office is assessing an older adult client whose son reports that the client has been sick with a respiratory illness for the past 6 days. Which of the following assessment finding s is a manifestation of pneumonia in the older adult client? a. Bradycardia b. Night sweats c. Confusion d. Narrowed pulse pressure

c. Confusion Confusion, weakness and anorexia are manifestations of pneumonia in an older adult client.

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? a. Encourage the client to ambulate frequently. b. Encourage coughing and deep breathing. c. Encourage the client to increase fluid intake. d. Encourage regular use of the incentive spirometer.

c. Encourage the client to increase fluid intake. Increasing fluid intake to1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.

A client is planning to perform nasotracheal suction for a client who has COPD and an artificial airway. Which of the following actions should the nurse take? a. Perform suctioning for up to four passes. b. Apply suction to the catheter when advancing it into the trachea. c. Preoxygenate the client with 100% oxygen for up to 3 min. d. Limit each suction pass to 25 seconds.

c. Preoxygenate the client with 100% oxygen for up to 3 min. To prevent hypoxemia, the nurse should preoxygenate the client with 100% oxygen for 30 seconds to 3 min prior to suctioning.

A nurse is caring for a client who is taking montelukast. Which of the following outcomes indicates a therapeutic effect of the medication? a. The client experiences less muscle pain. b. The client's seizure threshold is reduced. c. The client experiences an increased ease of breathing. d. The client's platelet count is increased.

c. The client experiences an increased ease of breathing. Montelukast is a bronchodilator that is prescribed for clients who have chronic asthma or seasonal rhinitis. Therapeutic effects of the medication are an increased ease of breathing.

A nurse is caring for a client who has COPD. The client tells the nurse, "I can the congestion in my lints, and I certainly cough a lot, but I can't seem to bring anything up." Which of the following actions should the nurse take to help this client with tenacious bronchial secretions? a. Maintaining a semi-Fowler's position as often as possible. b. Administering oxygen via nasal cannula at 2L/min. c. Help the client select a low-salt diet. d. Encourage the client to drink 2 to 3 L of water daily.

d. Encourage the client to drink 2 to 3 L of water daily. COPD is a term for two diseases of the respiratory system: chronic bronchitis and emphysema. Maintaining hydration through the consumption of adequate fluids will help liquefy thick secretions and facilitate their expectoration.

A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? a. Bradycardia b. Bradypnea c. Lethargy d. Intercostal retractions

d. Intercostal retractions. Hypoxia is a condition in which the tissues of the body are oxygen-starved. It follows hypoxemia (low oxygen in the blood) and is manifested as substernal or intercostal retractions as the body works harder to draw more oxygen into the lungs.

A nurse is implementing a plan of care for a client who has AIDs with recurring pneumonia. Which of the following actions should the nurse take? a. Encourage fluid intake of 1500 mL/day. b. Position head of bed at 10 degrees. c. Cough and deep breathe every 8 hrs. d. Obtain a sputum culture.

d. Obtain a sputum culture. The nurse should obtain a sputum culture to determine which antibiotic is needed for the organism that is causing the pneumonia.

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's O2 sat is 85%. Which of the following actions should the nurse take first? a. Administer oxygen at 2L/min. b. Administer prescribed analgesic medication. c. Encourage coughing and deep breathing. d. Raise the head of the bed.

d. Raise the head of the bed. Elevating the head of the bed uses gravity to reduce pressure on the diaphragm from the abdominal organs and allows for increased expansion of the lungs. The head and neck can be extended, which promotes a patent airway. This is the first action the nurse should take and is the least invasive.