JSRCC NSG 170 - PrepU 1. Gas Exchange

The nurse observes that a client who has received midazolam for conscious sedation is having shallow respirations. The nurse should do all except: A. encourage the client to deep-breathe. B. have respiratory resuscitation equipment in the room. C. administer oxygen as prescribed. D. administer naloxone.

D. administer naloxone. The nurse does not administer naloxone because naloxone is the antidote for morphine, not midazolam. The benzodiazepine-receptor antagonist for midazolam is flumazenil. The nurse can promote oxygenation by encouraging deep breathing and administering oxygen. Resuscitation equipment should be accessible if needed.

A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because with increased lung tension, the: A. ductus arteriosus remains open. B. foramen ovale closes prematurely. C. aorta or aortic valve strictures. D. pulmonary artery closes.

A. ductus arteriosus remains open. Excess pressure in the alveoli stimulates the ductus arteriosus to remain open, compromising efficient cardiovascular function.

The nurse is caring for a motor vehicle accident client who is unresponsive on arrival to the emergency department. The client has numerous fractures, internal abdominal injuries, and large lacerations on the head and torso. The family arrives and seeks update on the client's condition. A family member asks, "What causes the body to go into shock?"Given the client's condition, which statement is most correct? A. "The client is in shock because the blood volume has decreased in the system." B. "The client is in shock because your loved one is not responding and brain dead." C. "The client is in shock because the heart is unable to circulate the body fluids." D. "The client is in shock because all peripheral blood vessels have massively dilated."

A. "The client is in shock because the blood volume has decreased in the system." Shock is a life-threatening condition that occurs when arterial blood flow and oxygen delivery to tissues and cells are inadequate. Hypovolemic shock, where the volume of extracellular fluid is significantly diminished due to the loss of or reduced blood or plasma, frequently occurs with accidents.

The nurse is caring for a 10-year-old boy following a cardiac catheterization. Four hours after the procedure, the nurse notes some minor bleeding at the site. Which action would be most appropriate? A. Apply pressure 1 inch above the site. B. Change the dressing. C. Contact the physician. D. Ensure that the child's leg is kept straight.

A. Apply pressure 1 inch above the site. If bleeding occurs after a cardiac catheterization, apply pressure 1 inch above the site to create pressure over the vessel, thereby reducing the blood flow to the area. The nurse should first apply pressure and then notify the physician if this measure is ineffective or the bleeding increases. The child should maintain the leg in a straight position for about 4 to 8 hours. However, this would not address the bleeding assessed at the site. Changing the dressing would not be effective.

The nurse is assessing an infant for peripheral edema. Based on the nurse's knowledge, the nurse would expect edema to occur in which area first? A. Face B. Lower extremities C. Upper extremities D. Presacral region

A. Face In infants, peripheral edema occurs first in the face, then the presacral region, and then the extremities. Edema of the lower extremities is characteristic of right ventricular heart failure in older children.

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. Flow meter B. Nasal cannula C. Nasal strip D. Oxygen analyzer

A. Flow meter 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 physician. 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.

The nurse is developing a plan of care for a client with toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome. Which action should the nurse include? A. Frequently inspect the oral cavity. B. Use friction when repositioning the client. C. Limit fluids. D. Apply a continuous current of warm air.

A. Frequently inspect the oral cavity. The nurse should frequently inspect the oral cavity of a client with TEN or Stevens-Johnson syndrome. Additionally, care should be taken to reduce friction and shear when turning or repositioning the client. Fluids should not be limited because these clients are susceptible to dehydration. A continuous current of warm air on denuded skin can worsen dehydration.

The nurse is caring for a client with chronic obstructive pulmonary disease. The client reports that he is having difficulty breathing and is feeling fatigued. The nurse realizes that this client is at high risk for which condition? A. Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis

A. Respiratory acidosis Respiratory acidosis occurs when the body is unable to blow off CO2 due to the hypoventilation of disease processes such as COPD. An increase in blood carbon dioxide concentration occurs and a decreased pH causing acidosis. Respiratory alkalosis is a decrease in acidity of the blood and often caused by hyperventilation. Metabolic acidosis and alkalosis are not directly caused by respiratory disorders.

Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means? A. Venturi mask B. Partial-rebreathing mask C. Nasal cannula D. T-piece

A. Venturi mask The Venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. Nasal cannula, T-piece, and partial-rebreathing masks are not the most reliable and accurate methods of oxygen administration.

An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first? A. a middle-aged man with no injuries who has rapid respirations and coughs B. a 20-year-old with first-degree burns on her hands and forearms C. a woman who is 5 months pregnant with no apparent injuries D. a 10-year-old with a simple fracture of the humerus who is in severe pain

A. a middle-aged man with no injuries who has rapid respirations and coughs The man with respiratory distress and coughing should be transported first because he is probably experiencing smoke inhalation. The pregnant woman is not in imminent danger or likely to have a precipitous childbirth. The 10-year-old is not at risk for infection and could be treated in an outpatient facility. First-degree burns are considered less urgent.

A client who has been prescribed an inhaler points to the spacer and asks, "What is this for?" What is the appropriate nursing response? A. "It makes the inhaler easier to hold in case you have arthritis." B. "Medication stays in the chamber so you can continue to inhale it." C. "You will receive the medication faster as it goes through this device." D. "This is to decrease the amount of drug that you receive."

B. "Medication stays in the chamber so you can continue to inhale it." A spacer provides a reservoir for aerosol medication. The client can take additional breaths (after the initial breath) to continue inhaling the medication held in the reservoir. The spacer does not decrease the amount of medication received, make the medication move faster, nor serve as a holding device.

Which nursing intervention is the priority for a client in myasthenic crisis? A. Ensuring adequate nutritional support B. Assessing respiratory effort C. Preparing for plasmapheresis D. Administering intravenous immunoglobin (IVIG) per orders

B. Assessing respiratory effort A client in myasthenic crisis has severe muscle weakness, including the muscles needed to support respiratory effort. Myasthenic crisis can lead to respiratory failure and death if not recognized early. Administering IVIG, preparing for plasmaphersis, and ensuring adequate nutritional support are important and appropriate interventions, but maintaining adequate respiratory status or support is the priority during the crisis.

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain? A. Fluid intake for the past 24 hours B. Baseline arterial blood gas (ABG) levels C. Prior outcomes of weaning D. Electrocardiogram (ECG) results

B. Baseline arterial blood gas (ABG) levels Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.

What information would be included in the care plan of an infant in heart failure? A. Administer digoxin even if the infant is vomiting. B. Begin formulas with increased calories. C. Maintain child in the supine position. D. Encourage larger, less frequent feedings.

B. Begin formulas with increased calories. Infants with heart failure need increased calories for growth. The infants are typically given smaller, more frequent feedings to decrease the amount given and to help conserve energy for feeding. They often times are given a higher-calorie formula. The infant should be placed in an upright position or in a car seat to increase oxygenation. The infant should not have any pressure on the diaphragm while in this position. Vomiting is a sign of digoxin toxicity and this should be considered before administering.

Fetal circulation differs from the circulatory path of the newborn infant. In utero the fetus has a hole connecting the right and left atria of the heart. This allows oxygenated blood to quickly pass to the major organs of the body. What is this hole called? A. Foramen magnum B. Foramen ovale C. Foramen arteriosus D. Foramen venosus

B. Foramen ovale The foramen ovale is a hole that connects the right and left atria so the majority of oxygenated blood can quickly pass into the left side of the fetal heart, go to the brain and move to the rest of the fetal body.

A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client? A. Risk for trauma related to endotracheal intubation and cuff pressure B. Impaired gas exchange related to ventilator setting adjustments C. Impaired physical mobility related to being on a ventilator D. Risk for infection related to endotracheal intubation and suctioning

B. Impaired gas exchange related to ventilator setting adjustments All the nursing diagnoses are appropriate for this client. Per Maslow's hierarchy of needs, airway, breathing, and circulation are the highest priorities within physiological needs. The client has an oxygen saturation of 91%, which is below normal. This places impaired gas exchange as the highest prioritized nursing diagnosis.

Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? A. Administer an ordered decongestant. B. Instruct the client to breathe into a paper bag. C. Offer the client fluids frequently. D. Administer ordered supplemental oxygen.

B. Instruct the client to breathe into a paper bag. The ABG results reveal respiratory alkalosis. The best intervention to raise the PaCO2 level would be to have the client breathe into a paper bag. Administering a decongestant, offering fluids frequently, and administering supplemental oxygen wouldn't raise the lowered PaCO2 level.

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? A. Partial pressure of arterial carbon dioxide (PaCO2) B. Partial pressure of arterial oxygen (PaO2) C. Bicarbonate (HCO3-) D. pH

B. Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2

The registered nurse is working with an unlicensed assistive personnel. Which client should the nurse not delegate to the unlicensed assistive personnel? A. The client who is pleasantly confused and requires assistance to the bathroom. B. The client with continuous pulse oximetry who requires pharyngeal suctioning. C. The client who requires assistance dressing in preparation for discharge. D. The client who needs vital signs taken following infusion of packed red blood cells.

B. The client with continuous pulse oximetry who requires pharyngeal suctioning. The nurse needs to perform the pharyngeal suctioning of the client with continuous pulse oximetry. This client requires the nurse to evaluate the client's response in pulse oximetry to the suctioning. The nurse can delegate the other clients to the unlicensed assistive personnel.

Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration? A. The oxygen will be lost at the client's nostrils if given at a higher level with a nasal cannula. B. The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing. C. The cells in the alveoli are so damaged by the client's long history of respiratory problems that increased oxygen levels and reduced carbon dioxide levels likely will cause the cells to burst. D. The client's long history of respiratory problems indicates that he would be unable to absorb oxygen given at a higher rate.

B. The client's respiratory center is so used to high carbon dioxide and low oxygen levels that changing these levels may eliminate his stimulus for breathing. Relatively low concentrations of oxygen are administered to clients with COPD so as not to eliminate their respiratory drive. Carbon dioxide content in the blood normally regulates respirations. Clients with COPD, though, are often accustomed to high carbon dioxide levels; the low oxygen blood level is their stimulus to breathe. If they receive excessive oxygen and experience a drop in the blood carbon dioxide level, they may stop breathing. Oxygen flow rate is not diminished at high levels when administered through a nasal cannula. The client's ability to absorb oxygen administered at a higher level is not affected. Increased oxygen levels and decreased carbon dioxide levels cannot cause cells to burst.

Which finding requires immediate intervention when planning care for an adolescent with cystic fibrosis (CF)? A. poor weight gain B. chest pain with dyspnea C. large, foul-smelling, and bulky stools D. delayed puberty

B. chest pain with dyspnea Chest pain and dyspnea are signs of a pneumothorax and should be treated immediately. Delayed puberty is common in adolescents with CF and is caused by poor nutrition. Poor weight gain is common in children with CF because so little is absorbed in the small intestine. Large, foul-smelling stools indicate noncompliance with taking enzymes and should be addressed, but respiratory complications are the greatest concern.

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: A. "His lung muscles are swollen so he is using abdominal muscles." B. "His infection is causing him to breathe harder." C. "He is using his chest muscles to help him breathe." D. "He will require additional testing to determine the cause."

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

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? A. Expiratory stridor B. Inspiratory stridor C. Crackles in the lower lobes D. Wheezing in the upper lobes

C. Crackles in the lower lobes People with chronic congestive 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.

A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention? A. Assist with positioning the client on the right side. B. Make sure that a thoracotomy tube is linked to open chest drainage. C. Encourage coughing to mobilize secretions. D. Restrict intravenous fluids for at least 24 hours.

C. Encourage coughing to mobilize secretions. The client is encouraged to cough frequently to mobilize secretions. The client will be placed in the semi-Fowler's position. Thoracotomy tubes are always attached to closed, sealed drainage to re-expand lung tissue and prevent pneumothorax. Restricting IV fluids in a client who is NPO while recovering from surgery would lead to dehydration.

A woman who is 4 months pregnant notices frequent heart palpitations and leg cramps. She is anxious to learn how to alleviate these. Which nursing diagnosis would best apply to her? A. Impaired urinary elimination related to inability to excrete creatine from her muscles B. Pain related to severe complications of pregnancy C. Health-seeking behaviors related to ways to relieve discomforts of pregnancy D. Risk for ineffective breathing pattern related to pressure of the growing uterus

C. Health-seeking behaviors related to ways to relieve discomforts of pregnancy Health-seeking behaviors is a diagnosis used to describe clients who are actively interested in learning ways to improve their health.

A 19-year-old male with cystic fibrosis (CF) is hospitalized for a serious lung infection and is in need of a lung transplant. However, he has a rare blood type that complicates the process of obtaining a donor organ. He has also been diagnosed with bipolar disorder and treated successfully since mid-adolescence with medication and therapy. The client requests to see a chaplain to help him make plans for a funeral and donation of his body to science after death. How should the nurse interpret the client's request? A. It is a signal of an exacerbation of the client's CF and warrants further assessment by his lung specialist. B. It is a signal of the depressive side of his bipolar disorder, and he should be checked for suicidal thoughts/plans. C. It is a signal of the client's growing awareness that he is likely to have a shortened lifespan and should be supported by unit staff. D. It is a signal of delirium as a result of the many medications the client is taking and requires further assessment by the pharmacist or health care provider (HCP).

C. It is a signal of the client's growing awareness that he is likely to have a shortened lifespan and should be supported by unit staff. A client who has endured serious chronic illness (both psychiatric and medical) would be well aware of his shortened lifespan, particularly if he is unable to get a lung transplant. It would not be unusual for him to want to plan ahead so his wishes would be honored in the event of his death. In the absence of other physical signs, an exacerbation of CF or delirium is not demonstrated. Likewise, his successful bipolar treatment in the absence of any other signs rules depression out as a reason for his behavior. Though it may be difficult to think about a young person in terms of dying, the client's consideration of the future is a rational decision.

The nurse is caring for a client diagnosed with a hemorrhagic stroke. The nurse recognizes that which intervention is most important? A. Monitoring for seizure activity B. Administering a stool softener C. Maintaining a patent airway D. Elevating the head of the bed to 30 degrees

C. Maintaining a patent airway Maintaining the airway is the most important nursing intervention. Immediate complications of a hemorrhagic stroke include cerebral hypoxia, decreased cerebral blood flow, and extension of the area of injury. Providing adequate oxygenation of blood to the brain minimizes cerebral hypoxia. Brain function depends on delivery of oxygen to the tissues. Administering supplemental oxygen and maintaining hemoglobin and hematocrit at acceptable levels will assist in maintaining tissue oxygenation. All other interventions are appropriate, but the airway takes priority. The head of the bed should be elevated to 30 degrees, monitoring the client because of the risk for seizures, and stool softeners are recommended to prevent constipation and straining, but these are not the most important interventions.

Which clinical manifestation of acute nasopharyngitis is more of a concern for the infant than the older child? A. Fever B. Vomiting C. Nasal congestion D. Diarrhea

C. Nasal congestion The infant has smaller airways, making it more difficult to breathe when nasal congestion occurs. The older child can tolerate the congestion better than the infant with smaller airways. Depending upon the age of the child, younger infants are afebrile. Vomiting and diarrhea can occur at any age as the mucus from the nasal drainage enters the gastrointestinal tract.

A nurse is caring for a client admitted with a diagnosis of exacerbation of myasthenia gravis. Upon assessment of the client, the nurse notes the client has severely depressed respirations. The nurse would expect to identify which acid-base disturbance? A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis Respiratory acidosis is always from inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2 concentrations. Respiratory acidosis can occur in diseases that impair respiratory muscles such as myasthenia gravis.

Which nursing intervention should be done first when managing a pediatric client admitted to the emergency department with severe diabetic ketoacidosis (DKA)? A. Begin an insulin drip to lower the client's blood glucose level. B. Draw a blood glucose level and serum electrolyte panel. C. Secure the client's airway to ensure adequate ventilation. D. Correct any fluid deficit using an isotonic saline solution.

C. Secure the client's airway to ensure adequate ventilation. Treating pediatric clients with severe DKA is a medical emergency; therefore, attending to the airway, breathing, and circulation is the first priority. Once the airway is secured, the health care team should estimate the level of dehydration and begin replacement fluids of normal saline. An insulin drip should be started after the initial 1 to 2 hours of treatment at a rate of 0.1 units/kg per hour. Blood glucose should be tested every 1 to 2 hours until the client is stable, then it should be every 6 hours. Additionally, serum electrolytes should be drawn every 1 to 2 hours until the client is stable, then every 4 to 6 hours.

A pregnant client with a history of heart disease has been admitted to a health care center reporting breathlessness. The client also reports shortness of breath and easy fatigue when doing ordinary activity. The client's condition is markedly compromised. The nurse would document the client's condition using the New York Heart Association (NYHA) classification system as which class? A. class IV B. class I C. class III D. class II

C. class III The nurse should classify the client's condition as belonging to class III of NYHA. In class III of NYHA classification, the client will be symptomatic with ordinary activity, and her condition is markedly compromised. The client is asymptomatic with all kinds of activity and is in uncompromised state in class I. The client is symptomatic with increased activity and is in slight compromised state in class II. The client is symptomatic when resting and is incapacitated in class IV.

A client with type 1 diabetes mellitus is admitted to the emergency department. Which respiratory pattern in a client with diabetes mellitus requires immediate action? A. short expirations and inspirations B. shallow respirations alternating with long expirations C. deep, rapid respirations with long expirations D. regular depth of respirations with frequent pauses

C. deep, rapid respirations with long expirations Deep, rapid respirations with long expirations are indicative of Kussmaul's respirations, which occur in metabolic acidosis. The respirations increase in rate and depth, and the breath has a "fruity" or acetone-like odor. This breathing pattern is the body's attempt to blow off carbon dioxide and acetone, thus compensating for the acidosis. The other breathing patterns listed are not related to ketoacidosis and would not compensate for the acidosis.

A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for: A. alteration in urinary elimination. B. altered cardiac functioning. C. ineffective breathing pattern. D. alteration in level of consciousness.

C. ineffective breathing pattern. The diaphragm is the major muscle of respiration; it is made up of two hemidiaphragms, each innervated by the right and left phrenic nerves. Injury to the phrenic nerve results in hemidiaphragm paralysis on the side of the injury and an ineffective breathing pattern. Consciousness, cardiac function, and urinary elimination are not affected by the phrenic nerve.

The nurse is educating a group of parents about respiratory disorders in young children. One of the mothers tells the nurse that she has noticed her child's nostrils flaring when the child has a respiratory infection. The mother asks the nurse if she should be concerned. What is the most appropriate response by the nurse? A. "Nasal flaring is a common respiratory symptom in children and adults." B. "A child exhibiting nasal flaring should be seen by a physician." C. "When a child is breathing deeply, nasal flaring will occur." D. "Nasal flaring occurs when a child has to work hard to breathe."

D. "Nasal flaring occurs when a child has to work hard to breathe." Nasal flaring refers to the enlargement of the opening of the nostrils during breathing. Nasal flaring is seen primarily in infants and younger children. Any condition that causes the infant to work harder to obtain enough air can cause nasal flaring. Although many causes of nasal flaring are not serious, some can be life threatening. In young infants, nasal flaring can be a very important sign of respiratory distress.

A client has just had an epidural placed. Before the procedure, her vital signs were as follows: BP 120/70, P90 bmp, R18 per min, and O2 sat 98%. Now, 3 minutes after the procedure, the client says she feels lightheaded and nauseous. Her vital signs are BP 80/40, P100 bmp, R20 per min, and O2 sat 96%. Which interventions should the nurse perform? A. Assist the client to a sitting position, assess the fetal heart rate, give naloxone, and administer oxygen via face mask. B. Assist the client to the supine position, recheck the blood pressure, and administer an IV bolus of 1000 mL. C. Assist the client to Trendelenburg's, assess the fetal heart rate, and administer oxygen via face mask. D. Assist the client to semi-Fowler's position, assess the fetal heart rate, start an IV bolus of 500 mL, and administer oxygen via face mask.

D. Assist the client to semi-Fowler's position, assess the fetal heart rate, start an IV bolus of 500 mL, and administer oxygen via face mask. In a pregnant woman, hypotension is best managed in the left lateral or semi-Fowler's position owing to risk of supine hypotension in the supine position and in Trendelenburg's position. The sitting position could exacerbate hypotension. Naloxone is administered for respiratory depression. When the mother experiences a change in vital signs, this may affect the fetal heart rate.

The nurse is monitoring a laboring client with continuous fetal monitoring and notes a decrease in FHR with variable deceleration to 75 bpm. Which intervention should the nurse prioritize? A. Increase her IV fluids. B. Notify the primary care provider. C. Administer oxygen. D. Change the position of the client.

D. Change the position of the client. Variable decelerations often indicate a type of cord compression. The initial response is to change the position and try to release the cord compression. If this does not work, apply oxygen while using the call light to alert others. If this continues, her fluid status needs to be assessed before increasing her IV rate.

The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis? A. Direct lung damage B. Drug ingestion C. Aspiration D. Chemical irritation

D. Chemical irritation Chemical irritation from noxious fumes, gases, and air contaminants induces acute bronchitis. Aspiration related to near drowning or vomiting, drug ingestion or overdose, and direct damage to the lungs are factors associated with the development of acute respiratory distress syndrome.

A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which of the following is the priority intervention? A. Decrease the anxiety and reduce the workload on the heart. B. Monitor and manage potential complications. C. Reduce the nausea and vomiting and stabilize the blood glucose. D. Control the pain and support breathing and oxygenation.

D. Control the pain and support breathing and oxygenation. Support of breathing and ensuring adequate oxygenation are the two most important priorities. Reducing the substernal pain is also important because upset and anxiety will increase the demand for oxygen in the body. Controlling nausea, vomiting, and anxiety are all secondary in importance. Prevention of complications is important following initial stabilization and control of pain.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client? A. Evaluation of nutritional status and metabolic state B. Evaluation for signs and symptoms of increased intracranial pressure (ICP) C. Evaluation of pain and discomfort D. Lung auscultation and measurement of vital capacity and tidal volume

D. Lung auscultation and measurement of vital capacity and tidal volume In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia? A. PCO2 B. pH C. HCO3 D. PaO2

D. PaO2 Hypoxemic hypoxia, or hypoxemia, is a decreased oxygen level in the blood (PaO2) resulting in decreased oxygen diffusion into the tissues.

The nurse is assessing a woman with Class III heart disease who is in for a prenatal visit. What would be the first recognizable sign that this client is in heart failure? A. Elevated blood pressure B. Low blood pressure C. Audible wheezes D. Persistent rales in the bases of the lungs

D. Persistent rales in the bases of the lungs The earliest warning sign of cardiac decompensation is persistent rales in the bases of the lungs.

The nurse observes that a client admitted with asthma is anxious, has audible wheezing, and is using the neck muscles when breathing. What actions would be appropriate? A. Position in Fowler's position and administer oxygen. B. Position in a semi-prone position and encourage deep breathing. C. Position in orthopneic position and encourage the client to calm down. D. Position in high Fowler's position and administer an albuterol sulfate inhaler.

D. Position in high Fowler's position and administer an albuterol sulfate inhaler. Following an asthma attack, it is important to ensure optimal positioning (Fowler's) and adequate oxygen levels. The client is still experiencing wheezing, so coughing to remove secretions is important. A bronchodilator would also help by enlarging the size of the bronchioles. Asking the client to calm down is incorrect because it does not explore concerns. Semi-prone positioning would not assist with breathing.

An older adult client with a history of chronic obstructive pulmonary disease (COPD) develops a fever of 38.3ºC (101ºF). What is the primary reason for the nurse to implement temperature lowering measures? A. Prevent hyperkalemia B. Decrease heart rate C. Promote general comfort D. Reduce oxygen demand

D. Reduce oxygen demand Fever can be beneficial under certain circumstances. Relatively small increases in fever can stimulate immune response by T lymphocyte proliferation. The growth of many microbes is inhibited at temperatures in the fever range. Fever can cause discomfort such as headache and body aches. Fever above 42.2ºC (108ºF) can cause cell damage and life-threatening acidosis, hypoxia, and hyperkalemia. Older adults with cardiac or pulmonary conditions who develop fever are at risk of hypoxia because each degree of temperature elevation in Celsius raises the basal metabolic rate by about 7%. In a client with an average body temperature of about 37ºC (98.6ºF), the rise to 38.3ºC would increase the metabolic demand by more than 7%. A client with longstanding COPD would have difficulty maintaining adequate oxygen saturation.

The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample? A. Use the secretions present in the oral cavity. B. Drink 8 oz of water to thin the secretions for expectoration. C. Tickle the back of the throat to produce the gag reflex. D. Take deep breaths and cough forcefully.

D. Take deep breaths and cough forcefully. Taking deep breaths moves air around the sputum and coughing forcefully moves the sputum up the respiratory tract. Once in the pharynx, the sputum can be expectorated into a specimen container. Producing a gag reflex elicits stomach contents and not respiratory sputum. Dilute and thinned secretions are not helpful in aiding expectoration. A sputum culture is not a component of oral secretions.

A child with asthma has a heart rate of 160 bpm and a respiratory rate of 36 breaths/minute. The child appears restless and anxious and is given albuterol via nebulizer. Which finding would indicate that the nebulizer treatment has been effective? A. expiratory wheezing B. nonproductive cough C. pulse oximeter reading of 91% D. increase in peak expiratory flow rate

D. increase in peak expiratory flow rate The best indicator of the effectiveness of the albuterol is an increase in peak expiratory flow rate. Albuterol, a bronchodilator, opens and relaxes the airways, allowing a greater exchange of air, which is reflected as a higher peak expiratory flow rate. Pulse oximetry reflects how well the client is oxygenating: the higher the reading, the better the client's oxygenation. Typically, a pulse oximeter reading of 95% or greater is the goal. Furthermore, a pulse oximeter reading of 91% is meaningless in this scenario unless previous readings are available for comparison. As the airways open, the child should begin to have a productive cough. Wheezing may or may not be a reliable indicator for determining the effectiveness of the albuterol treatment. The nebulizer treatment may increase wheezing by opening the airways enough so that air can travel through the excessively mucus-filled bronchioles. Because this child is still experiencing respiratory distress, some wheezing would be expected. However, wheezing in a child with asthma who is in acute distress may indicate an improvement, demonstrating the movement of air through the airways that were previously blocked.