nurs 111 o2/ gas exchange

After assessing a client, a nurse identifies the nursing diagnosis, "Ineffective Airway Clearance related to thick tracheobronchial secretions." The nurse would classify this nursing diagnosis as which type? Wellness Actual Risk Possible

Actual

A child is exhibiting symptomatic bradycardia that has been unresponsive to ventilation and oxygenation. Which of the following would the nurse expect to be administered? Atropine Sodium bicarbonate Naloxone Calcium carbonate

Atropine

In a patient who is to be given vecuronium (Norcuron), anesthesia is induced before neuromuscular blockade is started. What is the reason for this? Because it helps reduce the adverse effects of vecuronium Because it helps prevent the patient from undergoing the frightening experience of paralysis and the inability to breathe Because it ensures that vecuronium does not cross the blood-brain barrier Because it enhances the therapeutic effects of vecuronium

Because it helps prevent the patient from undergoing the frightening experience of paralysis and the inability to breathe

A client is being admitted from the emergency room reporting shortness of breath, wheezing, and coughing. What would the nurse formulate as an appropriate nursing diagnosis? Bronchial Pneumonia Ineffective Airway Clearance Acute Dyspnea Asthma Attack

Ineffective Airway Clearance

A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention? Inquire about factors that contribute to non-adherence. Notify the healthcare provider of the client's current status. Explain uses of BiPAP masks versus CPAP masks. Document assessment and plan for intervention.

Inquire about factors that contribute to non-adherence.

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal? Controlling bleeding Maintaining the airway Maintaining fluid volume Relieving the client's anxiety

Maintaining the airway

A client develops cardiogenic pulmonary edema and is extremely apprehensive. What medication can the nurse administer with physician orders that will relieve anxiety and slow respiratory rate? Furosemide Nitroglycerin Dopamine Morphine sulfate

Morphine sulfate

A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? Heart rate of 94 beats/minute Oxygen saturation (SaO2) of 89% Decreased cough and gag reflexes Blood-tinged stools

Oxygen saturation (SaO2) of 89%

In caring for the child with asthma, the nurse recognizes that bronchodilator medications are administered to children with asthma for which reason? Relief of acute symptoms Management of chronic pain To stabilize the cell membranes Prevention of mild symptoms

Relief of acute symptoms

The school nurse is caring for a 12-year-old boy with a bloody nose. Which action would be most appropriate for the nurse to do? Seat the child leaning forward and pinch the anterior portion of the nose closed. Seat the child with his head tipped back and apply ice or a cold cloth to the nose. With the child lying on his back, pinch the anterior portion of the nose closed. With the child lying on his back, apply pressure to the bridge of the nose.

Seat the child leaning forward and pinch the anterior portion of the nose closed.

A nurse is in the cafeteria at work. A fellow worker at another table suddenly stands up, leans forward with hands crossed at the neck, and makes gasping noises. The nurse first Stands behind the worker, who has hands across the neck Places both arms around the worker's waist Makes a fist with one hand with the thumb outside the fist Exerts pressure against the worker's abdomen

Stands behind the worker, who has hands across the neck

A neonate develops respiratory distress syndrome. Which would be used? Anti-infective agents Bronchodilators Surfactant replacements Antihistamines

Surfactant replacements

Which factor is a trigger for a child with asthma? Taking a nap Sweeping the floor Smiling a lot Living without pets

Sweeping the floor

A school nurse finds a 10-year-old's blood pressure is over the 95th percentile. The nurse advises the parent to seek medical attention for the child. What outcome would the nurse expect? The child will probably need surgery. The child will need the blood pressure checked two more times. Advise the child go to the emergency room. This is a normal result for a child this age.

The child will need the blood pressure checked two more times.

A client who works construction and has been demolishing an older building is diagnosed with pneumoconiosis. This lung inflammation is most likely caused by exposure to: asbestos. silica. coal dust. pollen.

asbestos.

When a client has increased difficulty breathing when lying flat, the nurse records that the client is demonstrating orthopnea. dyspnea upon exertion. hyperpnea. paroxysmal nocturnal dyspnea.

orthopnea.

A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. After surgery, the nurse implements measures to prevent complications. Which complications is the nurse seeking to prevent? Select all that apply. skin breakdown wound infection pneumonia diarrhea

skin breakdown, wound infection, & pneumonia

The nurse is caring for a 14-year-old girl with atrial fibrillation. Which medication would the nurse expect to be prescribed? Digoxin Alprostadil Furosemide Indomethacin

Digoxin

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome? Attains desired fluid balance Displays no signs or symptoms of infection Maintains a patent airway Demonstrates optimal cerebral tissue perfusion

Maintains a patent airway

The nurse is caring for an elderly client with a fractured hip who is on bed rest. Which nursing interventions would be included on the plan of care? Encourage coughing and deep breathing, and limit fluid intake. Provide only passive range of motion (ROM), and decrease stimulation. Have the client lie as still as possible, and give adequate pain medication. Turn the client every 2 hours, and encourage coughing and deep breathing.

Turn the client every 2 hours, and encourage coughing and deep breathing.

A client with left-sided heart failure complains of increasing shortness of breath and is agitated and coughing up pink-tinged, foamy sputum. The nurse should recognize these findings as signs and symptoms of: right-sided heart failure. acute pulmonary edema. pneumonia. cardiogenic shock.

acute pulmonary edema.

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? deep, rapid respirations with long expirations shallow respirations alternating with long expirations regular depth of respirations with frequent pauses short expirations and inspirations

deep, rapid respirations with long expirations

A client with bronchitis is ordered 300 mg of liquid guaifenesin every 4 hours. The container indicates that there is 200 mg/5 mL. How many milliliters should the nurse administer per dose? Record your answer using one decimal place.

7.5

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

Check fit of oxygen mask.

A client is breathing 40 breaths/minute. He is diaphoretic and confused. Which nursing diagnosis should be the priority for the client at this time? Insomnia Anxiety Risk for injury due to confusion Impaired gas exchange

Impaired gas exchange

Sympathetic nervous system stimulation of the respiratory tract would result in: Diaphragmatic contraction Bronchoconstriction Increased respiratory rate Inspiratory movement

Increased respiratory rate

A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease (COPD). The first action of the nurse is to administer which of the following prescribed treatments? Oxygen through nasal cannula at 2 L/minute Intravenous methylprednisolone (Solu-Medrol) 120 mg Ipratropium bromide (Alupent) by metered-dose inhaler Vancomycin 1 gram intravenously over 1 hour

Oxygen through nasal cannula at 2 L/minute

The nurse is assessing a newborn by auscultating the heart and lungs. Which natural phenomenon will the nurse explain to the parents is happening in the cardiovascular system? Oxygen is exchanged in the lungs. Fluid is removed from the alveoli and replaced with air. Pressure changes occur and result in closure of the ductus arteriosus. The oxygen in the blood decreases.

Pressure changes occur and result in closure of the ductus arteriosus.

The nurse has been assigned to care for the following six clients. Which clients would the nurse expect to be at risk for the development of pulmonary embolism? Select all that apply. a. A client who is on complete bed rest following extensive spinal surgery. b. A client who has a large venous stasis ulcer on the right ankle area. c. A client who has recently been admitted with a broken femur and is awaiting surgery. d. A client who has a pleural effusion secondary to infection. A client who is receiving supplemental oxygen following shoulder surgery. e. A client who has undergone a total vaginal hysterectomy and is now on estrogen replacement therapy.

a, b, c, & e

A client with a suspected diagnosis of lung cancer has a bronchoscopy with biopsy. Following the procedure the nurse should: encourage the client to gargle with oral lidocaine to decrease throat irritation. monitor the client for signs of pneumothorax. administer pain medication as needed to relieve mediastinal discomfort. advise the client not to talk until the gag reflex returns.

monitor the client for signs of pneumothorax.

In general, chest drainage tubes are not used for a patient undergoing lobectomy. pneumonectomy. wedge resection. segmentectomy.

pneumonectomy.

A patient in the emergency department who presented with shortness of breath has been informed by her health care provider that her chest X-ray is suggestive of a pleural effusion. The health care provider recently outlined the proposed course of treatment, but the patient has just asked the nurse, "Can you tell me exactly what's wrong with me?" What response would be most accurate? "The small air sacs that make up your lungs have become infected." "A large amount of fluid has accumulated in your lungs and made it difficult to breathe." "Fluid has built up between your lungs and the lining that surrounds your lungs." "Bacteria have entered the fluid surrounding your lungs and these bacteria must be eliminated."

"Fluid has built up between your lungs and the lining that surrounds your lungs."

Which complication is common in neonates who receive prolonged mechanical ventilation at birth? Bronchopulmonary dysplasia Esophageal atresia Hydrocephalus Renal failure

Bronchopulmonary dysplasia

A client severely injured in a motor vehicle accident is rushed to the health care facility with severe head injuries and profuse loss of blood. Which sign indicates approaching death? The frequency of urination decreases. The arms and legs are warm to touch. The client is calm and peaceful. Client's breathing becomes noisy.

Client's breathing becomes noisy.

A 33-year-old male client returns to the medical-surgical unit following a thyroidectomy. Which assessment finding requires an immediate intervention by the nurse? The client makes noises when he breathes. The client reports thirst. The client reports pain at the surgical site. The client is sleepy from the anesthesia.

The client makes noises when he breathes.

Cystic fibrosis is a hereditary disease that affects the respiratory system. In people with the disease, breathing performance is affected by: bronchospasm. infection. excessive secretions. chemical irritation of the respiratory tract.

excessive secretions.

A client has been admitted to the cardiac step-down unit with acute pulmonary edema. Which symptoms would the nurse expect to find during assessment? moist, gurgling respirations drowsiness, numbness increased cardiac output hypertension

moist, gurgling respirations

A client at 28 weeks' gestation is complaining of contractions. Following admission and hydration, the physician writes an order for the nurse to give 12 mg of betamethasone I.M. This medication is given to: slow contractions. enhance fetal growth. prevent infection. promote fetal lung maturity.

promote fetal lung maturity.