Gas Exchange
Which medication would the nurse instruct a client to avoid while taking alprazolam? Select all that apply. One, some, or all responses may be correct. 1Opioids 2Alcohol 3Barbiturates 4 Antidepressants 5 First-generation antipsychotics
1Opioids 2Alcohol 3Barbiturates Respiratory depression can occur if a client combines benzodiazepines with opioids, alcohol, or barbiturates. Antidepressants and first-generation antipsychotics are safe to take with benzodiazepines.
Which amount is the normal value of a client's inspiratory reserve volume? 1 0.5 L 2 1.0 L 3 1.5 L 4 3.0 L
3.0 L The normal value of inspiratory reserve volume is 3.0 L. The normal value of tidal volume is 0.5 L. The normal value of expiratory reserve volume is 1.0 L. The normal value of residual volume is 1.5 L.
Soft swishing sounds of breathing are heard when the nurse auscultates a client's chest. Which term would be used when documenting this assessment finding? 1 Fine crackles 2 Adventitious sounds 3 Vesicular breath sounds 4 Diminished breath sounds
Vesicular breath sounds Vesicular breath sounds are expected respiratory sounds heard on auscultation as inspired air enters and leaves alveoli. Fine crackles are faint crackling sounds heard at the end of inspiration; they are associated with pulmonary edema. "Adventitious sounds" is a general term for all abnormal breath sounds. Diminished breath sounds are evidence of a decreased amount of air entering the alveoli; this usually is caused by obstruction or consolidation.
The nurse is assessing a newborn in the well-baby nursery. Which type of respirations would the nurse expect to identify in a healthy newborn? 1Deep and retracting 2Shallow and thoracic 3Stertorous and regular 4Abdominal and irregular
Abdominal and irregular A newborn's respirations are abdominal, diaphragmatic, and irregular; the rate varies from 30 to 60 breaths/min. Retractions are a sign of respiratory distress. A newborn's respirations are abdominal, not thoracic. Stertorous breathing may indicate respiratory distress. View Topics
A client reports left-sided chest pain after playing racquetball. The client is hospitalized and diagnosed with left pneumothorax. When assessing the client's left chest area, the nurse expects to identify which finding? 1 Dull sound on percussion 2 Vocal fremitus on palpation 3 Rales with rhonchi on auscultation 4 Absence of breath sounds on auscultation
Absence of breath sounds on auscultation The left lung is collapsed; therefore there are no breath sounds. A tympanic, not a dull, sound will be heard with a pneumothorax. There is no vocal fremitus because there is no airflow into the left lung as a result of the pneumothorax. Rales with rhonchi will not be heard because there is no airflow into the left lung as a result of the pneumothorax.
The nurse is preparing to administer an intravenous piggyback antibiotic that has been newly prescribed. Shortly after initiation, the client becomes restless and flushed and begins to wheeze. After stopping the infusion, which priority action will the nurse take? 1 Notify the primary health care provider immediately about the client's condition. 2 Take the client's blood pressure. 3 Obtain the client's pulse oximetry. 4 Assess the client's respiratory status.
Assess the client's respiratory status. The client is experiencing an allergic reaction. Severe allergic reactions commonly cause respiratory distress as a result of laryngeal edema or severe bronchospasm. Assessing and maintaining the client's airway is the priority. The nurse must determine the client's status before notifying the primary health care provider. Vital signs, including blood pressure and pulse oximetry, are obtained after airway patency is ensured and maintained.
To which part of the respiratory system would the client's radiology report refer when identifying the angle of Louis? 1Hilum 2Carina 3Alveoli 4Epiglottis
Carina Located at the level of the manubriosternal junction, the carina is also referred to as the angle of Louis. The mainstream bronchi, pulmonary vessels, and nerves enter the lungs through a slit called the hilum. Alveoli are small sacs that are the primary site of gas exchange in the lungs. The epiglottis is a small flap located behind the tongue that closes over the larynx during swallowing.
The nurse assesses the lungs of a client and auscultates soft, crackling, bubbling breath sounds that are more obvious on inspiration. Which would the nurse document these sounds as? 1Vesicular 2 Bronchial 3 Crackles 4 Rhonchi
Crackles Crackles are abnormal breath sounds described as soft, crackling, bubbling sounds produced by air moving across fluid in the alveoli. Vesicular breath sounds are normal. They are quiet, soft, and inspiration sounds that are short and almost silent on expiration. They are heard over the lung periphery. Bronchial breath sounds are normal and consist of a full inspiration and expiratory phase with the expiratory phase being louder. They are heard over the trachea and large bronchi of the lungs. Rhonchi are abnormal breath sounds heard over the large airways of the lungs. They consist of a low pitch and are caused by the movement of secretions in the larger airways; they usually clear with coughing.
A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline is started at 125 mL/h. One hour later, the client begins screaming, "I can't breathe!" How would the nurse respond? 1 Discontinue the IV and notify the health care provider. 2 Elevate the head of the client's bed and obtain vital signs. 3 Assess the client for allergies and change the IV to an intermittent lock. 4 Contact the health care provider to request a prescription for a sedative.
Elevate the head of the client's bed and obtain vital signs. Verbalization indicates that the client is breathing; elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Vital signs reflect the current status of the client. Discontinuing the IV access line is unsafe because IV medications may need to be administered and restarting the IV will cause unnecessary discomfort and expense; more information is needed before calling the health care provider. No information is available to support changing the IV to an intermittent lock. Not enough information is available to support requesting a prescription for a sedative; further assessment is required.
A client with a diagnosis of myocardial infarction asks the nurse, "What is causing the pain I am having?" Which explanation would the nurse give? 1 Compression of the heart muscle 2 Release of myocardial isoenzymes 3 Rapid vasodilation of the coronary arteries 4 Inadequate oxygenation of the myocardium
Inadequate oxygenation of the myocardium Cessation of the blood flow that normally carries oxygen to the myocardium results in pain because of ischemia of myocardial tissue. Myocardial infarction does not involve compression of the heart. The release of myocardial isoenzymes is an indication of myocardial damage; this does not cause myocardial pain. Vasodilation will increase perfusion and contribute to pain relief, not cause myocardial pain.
While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse? 1 Initiate oxygen via a nasal cannula 2 Administer the prescribed morphine 3 Prepare the client for endotracheal intubation 4 Place a nitroglycerin tablet under the client's tongue
Initiate oxygen via a nasal cannula Supplemental oxygen supports the body while the cause of the problem is identified; supplemental oxygen can be instituted without a prescription in an emergency. Morphine is used in the treatment of chest pain, but it is not the priority intervention. Endotracheal intubation is not the priority intervention. If the client's condition deteriorates and the client becomes unconscious or experiences respiratory failure or obstruction, endotracheal intubation is warranted. Nitroglycerin is available in most client acute care areas and does lessen chest pain if the pain is cardiac in origin, but it is not the priority intervention and requires a prescription.
Which explanation would the nurse provide to the parents of a child with spasmodic croup who ask why their child is receiving humidified oxygen? 1 It helps prevent drying of membranes. 2 It provides a mode of giving inhalant medications. 3 It increases the surface tension of the respiratory tract. 4 It provides an environment free of pathogenic organisms.
It helps prevent drying of membranes. Humidified oxygen helps reduce inflammation and edema of the upper respiratory tract. Inhalant medications are administered with the use of a nebulizer. The mist has no effect on surface tension in the respiratory tract. Eliminating pathogenic organisms is not the purpose of humidified oxygen.
A client with cystic fibrosis asks why the percussion procedure is being performed. Which rationale would the nurse give to the client? 1 It relieves bronchial spasms. 2 It increases the depth of respirations. 3 It loosens pulmonary secretions. 4 It expels carbon dioxide from the lungs.
It loosens pulmonary Secretions Postural drainage and percussion, also known as chest physical therapy (CPT), is a way to help clients with cystic fibrosis (CF) breathe with less difficulty and stay healthy. This intervention uses gravity and clapping the chest to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate removal of carbon dioxide from the lungs.
Which is the priority assessment for the client who has Guillain-Barré syndrome with rapidly ascending paralysis? 1 Monitoring urinary output 2 Assessing nutritional status 3 Monitoring respiratory status 4 Assessing communication needs
Monitoring respiratory status The most serious complication of Guillain-Barré syndrome is respiratory failure caused by respiratory muscle paralysis. Urinary retention is common in Guillain-Barré, but monitoring urinary output is of lower priority than monitoring respiratory status. If ascending paralysis impairs the gag reflex, clients may require tube feedings or parenteral nutrition. Assessing nutritional status, however, is of lower priority than monitoring respiratory status. If ascending paralysis impairs cranial nerve functioning or if the client is intubated, verbal communication abilities are lost.
After reviewing information about oxygenation for 4 clients with chronic obstruction pulmonary disease, which client will the nurse plan to teach about use of home long-term continuous oxygen therapy? 1 Partial pressure of oxygen (PaO 2) of 72; peripheral capillary oxygen saturation (SpO 2) of 96 2 PaO 2 of 60; SpO 2 of 90 3 PaO 2 of 55; SpO 2 of 88 4 PaO 2 of 70; SpO 2 of 92
PaO 2 of 55; SpO 2 of 88 A PaO 2 of 55 and SpO 2 of 88 indicate hypoxemia and that long-term oxygen therapy is needed. The values PaO 2 72 and SpO 2 96 indicate adequate oxygenation. The values PaO 2 60 and SpO 2 90 are adequate and the client would not require oxygen therapy. The values PaO 2 70 and SpO 2 92 are adequate and do not indicate a need for oxygen therapy.
The nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise? 1 Decreases chest pain 2 Conserves energy 3 Increases oxygen saturation 4 Promotes elimination of CO 2
Promotes elimination of CO 2 Pursed-lip breathing increases positive pressure within the alveoli and makes it easier for clients to expel air from the lungs. This in turn promotes elimination of CO 2. It also helps clients slow their breathing pattern and depth with respirations. It does not decrease chest pain, conserve energy, or increase oxygen saturation. View Topics
Which actions would the nurse take to obtain subjective data about a client's respiratory status? Select all that apply. One, some, or all responses may be correct. 1 Palpate the chest and back for masses. 2 Question the client about shortness of breath. 3 Check the hematocrit and hemoglobin values. 4 Inspect the skin and nails for integrity and color. 5 Ask the client about color and quantity of sputum.
Question the client about shortness of breath. Ask the client about color and quantity of sputum. Subjective data is collected directly from the client. During the respiratory assessment, the nurse would ask the client about any shortness of breath and about the color and quantity of any sputum produced. Objective data is collected by the nurse through physical examination and laboratory reports. The nurse would palpate the chest and back for masses while collecting objective data during the physical examination. The nurse checks the hematocrit and hemoglobin values while collecting objective diagnostic data. The nurse inspects the client's skin and nails for integrity and color to determine oxygenation of tissues.
A client has delivered her infant by cesarean birth. The nurse monitors the newborn's respiration closely, because infants born via the cesarean method are prone to atelectasis. Why does this occur? 1 The ribcage is not compressed and released during birth. 2 The sudden temperature change at birth causes aspiration. 3 There is usually oxygen deprivation after a cesarean birth. 4 There is no gravity during the birth to promote drainage from the lungs.
The ribcage is not compressed and released during birth. The release after compression of the chest during a vaginal birth is the mechanism for expansion of the newborn's lungs; because this does not occur during a cesarean birth, lung expansion may be incomplete, and atelectasis may result. Temperature change is not implicated in aspiration. The infant is monitored closely to prevent oxygen deprivation. The newborn's head may be held lower than the chest to allow gravity to promote drainage from the lungs after a cesarean birth.
A client who wakes up after a surgery spits out the oral airway placed during the recovery from anesthesia. What would this behavior indicate to the nurse? 1 Their gag reflex has returned. 2 They are confused due to anesthesia. 3 They are nauseated and want to vomit. 4 Their airway is becoming obstructed.
Their gag reflex has returned. The ability to spit out the oral airway indicates that the normal gag reflex has returned and the client can protect her or his airway. Confusion due to anesthesia may be manifested as disorientation. The ability to spit out the airway does not mean that the client is nauseated. An oral airway is meant to keep the airway patent; it may not obstruct the airway.
Which parameter describes the maximum volume of air a client's lungs may contain? 1 Vital capacity 2 Total lung capacity 3 Inspiratory capacity 4 Functional residual capacity
Total lung capacity Total lung capacity is the maximum volume of air that the lungs can contain. Vital capacity is the maximum volume of air that can be exhaled after maximum inspiration. Inspiratory capacity is the maximum volume of air that can be inhaled after maximum expiration. Functional residual capacity is the volume of air remaining in the lungs at the end of normal exhalation.
