NURS (FUNDAMENTAL): NCLEX Oxygenation and Perfusion

The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal? a) 30 to 55 breaths per minute b) 20 to 30 breaths per minute c) 12 to 15 breaths per minute d) 12 to 20 breaths per minute

a) 30 to 55 breaths per minute The nurse should expect the newborn to have a respiratory rate of 30 to 55 breaths per minute. Toddlers and preschoolers have a respiratory rate of 20 to 30 per minute. School-age children and adolescents have a respiratory rate of 12 to 20 breaths per minute

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

a) 32% A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44%

Erin is a 35-year-old woman being cared for in the emergency department for a cough and hemoptysis for 3 days. Erin states that she has smoked one-and-a-half packs of cigarettes per day for the last 5 years. In trying to identify risk factors for Erin, the nurse calculates her pack-year history to write on the intake form. What is Erin's pack-year of smoking? a) 7.5 b) 5 c) 5.5 d) 7

a) 7.5

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? a) Arterial blood gas b) Hemoglobin levels c) Hematocrit values d) Pulmonary function

a) Arterial blood gas 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.

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? a) Checking the amount of oxygen in the cylinder before using it b) Using a cylinder for a patient transfer that indicates available oxygen is 500 psi c) Placing the oxygen cylinder on the stretcher next to the patient d) Discontinuing oxygen flow by turning cylinder key counterclockwise until tight

a) Checking the amount of oxygen in the cylinder before using it

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? a) Confusion b) Decreased blood pressure c) Decreased respiratory rate d) Hyperactivity

a) Confusion Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue? a) Corticosteroids b) Bronchodilators c) Antibiotics d) Expectorants

a) Corticosteroids In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation.

A nurse is caring for a client who breathes very shallowly and has been reporting severe back pain. What suggestion could the nurse make to help the client breathe efficiently? a) Encourage the client to take deep breaths. b) Instruct the client in the use of pursed-lip breathing technique. c) Inform the client about nasal strips. d) Teach the client diaphragmatic breathing.

a) Encourage the client to take deep breaths. To help the client breathe efficiently, the nurse could encourage the client to take deep breaths. Deep breathing maximizes the ventilation and fills the alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing and diaphragmatic breathing help to eliminate the extra carbon dioxide from the lungs. A nasal strip reduces airflow resistance by widening the nasal-breathing passageways, thus promoting easier breathing. It is used for reducing or eliminating snoring.

A normal pulse oximetry reading indicates that the body's oxygen demands are being met. a) False b) True

a) False

A physician has ordered an arterial blood gas test for a client with a respiratory disorder. What is the most common role of the nurse in performing the arterial blood gas test? a) Implement measures to prevent complications after arterial puncture. b) Measure the partial pressure of oxygen dissolved in plasma. c) Measure the percentage of hemoglobin saturated with oxygen. d) Perform the arterial puncture to obtain the specimen.

a) Implement measures to prevent complications after arterial puncture. During the arterial blood gas test, the nurse should implement measures to prevent complications after the arterial puncture. The nurse would not be involved in measuring the partial pressure of oxygen dissolved in plasma or the percentage of hemoglobin saturated with oxygen. Intensive care nurses commonly obtain arterial blood gases.

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client? a) Nasal cannula b) Face tent c) Simple mask d) Non-rebreather mask

a) Nasal cannula

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? a) Pulmonary function tests b) Chest x-ray c) Skin tests d) Bronchoscopy

a) Pulmonary function tests Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.

A nurse is inserting an oropharyngeal airway for a patient who vomits when it is inserted. Which action would be the first that should be taken by the nurse related to this occurrence? a) Quickly position the patient on his or her side. b) Put on disposable gloves and remove the oral airway. c) Check that the airway is the appropriate size for the patient. d) Put on sterile gloves and suction the airway.

a) Quickly position the patient on his or her side.

The nurse is caring for a postoperative client who has a prescription for meperidine (Demerol) 7 5mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering Demerol, the nurse would assess which most important sign? a) Respiratory rate and depth b) Urinary intake and output c) Orthostatic blood pressure d) Apical pulse

a) Respiratory rate and depth

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? a) They are low-pitched, soft sounds heard over peripheral lung fields. b) They are loud, high-pitched sounds heard primarily over the trachea and larynx. c) They are medium-pitched blowing sounds heard over the major bronchi. d) They are soft, high-pitched discontinuous (intermittent) popping lung sounds.

a) They are low-pitched, soft sounds heard over peripheral lung fields. 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.

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. a) True b) False

a) True This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis.

A nurse is admitting a 6-year-old child status post tonsillectomy to the surgical unit. The nurse obtains his weight and places EKG and a pulse oximeter on the client's left finger. His heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate: a) adequate tissue perfusion. b) diminished stroke volume. c) heart failure. d) high cardiac output.

a) adequate tissue perfusion.

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the 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: a) hemoglobin level. b) sodium and potassium levels. c) age. d) blood pH.

a) hemoglobin level. 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? a) high respiratory rate b) low pulse rate c) high temperature d) low blood pressure

a) high respiratory rate

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position? a) high-Fowler's position b) left side with a pillow under the chest wall c) side-lying position, half on the abdomen and half on the side d) Trendelenburg position

a) high-Fowler's position

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

a) pattern of thoracic expansion 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: a) pneumonia. b) croup. c) asthma. d) alcohol abuse.

a) pneumonia. 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 abuse 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 abuse depresses the central respiratory center.

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. a) Closely assess the patient before, during, and after the procedure. b) Hyperoxygenate the patient before and after suctioning. c) Limit the application of suction to 20 to 30 seconds. d) Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. e) Use an appropriate suction pressure (80-150 mm Hg). f) Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.

a, b, d, e. Close assessment of the patient before, during, and after the procedure is necessary to limit negative effects. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. The nurse should also take the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80-150 mm Hg) will help prevent atelectasis related to the use of high negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis

The nurse assessing a patient with COPD suspects chronic hypoxia due to which of the following assessment findings? a) constipation b) cyanosis c) clubbing of toes d) edema

a, c The effects of chronic hypoxia can be detected in all body systems and are manifested as altered thought processes, headaches, chest pain, enlarged heart, clubbing of the fingers and toes, anorexia, constipation, decreased urinary output, decreased libido, weakness of extremity muscles, and muscle pain. Cyanosis is a symptom of acute hypoxia.

A nurse caring for a patient with chronic obstructive pulmonary disease (COPD) knows that hypoxia may occur in patients with respiratory problems. What are signs of this serious condition? Select all answers that apply. a) Dyspnea b) Hypotension c) Small pulse pressure d) Decreased respiratory rate e) Pallor f) Increased pulse rate

a, c, e, f If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

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? a) Pulse oximetry b) 4 L/minute O2 nasal cannula c) High-Fowler's position d) Increase fluid intake to 3 L/day

b) 4 L/minute O2 nasal cannula 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), 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.

The nurse is assessing the respiratory rates of clients in a community health care facility. Which client exhibits an abnormal value? a) A 12-year-old with a respiratory rate of 20 bpm b) An infant with a respiratory rate of 20 bpm c) A 4-year-old with a respiratory rate of 40 bpm d) A 70-year-old with a respiratory rate of 18 bpm

b) An infant with a respiratory rate of 20 bpm The infant's normal respiratory rate is 30 to 55 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 40 breaths per minute. For a child 6 to 12 years of age the normal respiratory rate is 18 to 26 breaths per minute. The normal respiratory rate for an adult 65 years and older is 16 to 24 breaths per minute.

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? a) Relax the respiratory muscles. b) Contract the abdominal muscles. c) Expand the thoracic cavity. d) Elevate the ribs and sternum.

b) Contract the abdominal muscles.

A client with no prior history of respiratory illness has been admitted to a postsurgical unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery? a) Administration of inhaled corticosteroids b) Educating the client on the use of incentive spirometry c) Educating the client on pursed-lip breathing techniques d) Oropharyngeal suctioning twice daily

b) Educating the client on the use of incentive spirometry Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions.

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) Oxygen analyzer b) Flow meter c) Nasal strip d) Nasal cannula

b) 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 emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? a) Tilt the patient's head forward. b) Hold the mask tightly over the patient's nose and mouth. c) Pull the patient's jaw backward. d) Compress the bag twice the normal respiratory rate for the patient.

b) Hold the mask tightly over the patient's nose and mouth.

A nurse is providing postural drainage for a patient with cystic fibrosis. In which position should the nurse place the patient to drain the right lobe of the lung? a) High Fowler's position b) Left side with pillow under chest wall c) Lying position/half on abdomen and half on side d) Trendelenberg position

b) Left side with pillow under chest wall

Which is a major organ of the upper respiratory tract? a) Bronchi b) Pharynx c) Trachea d) Lungs

b) Pharynx The pharynx, mouth, and nose are major organs of the upper respiratory tract. The trachea, bronchi, and lungs are major organs of the lower respiratory tract.

Which is not true regarding the structure of the respiratory system? a) Oxygen crosses the epithelium of the alveoli and into the bloodstream. b) The lungs move actively. c) Branches that come off of the bronchi are called bronchioles. d) The trachea is part of the lower respiratory tract.

b) The lungs move actively. The lungs move only passively. They stretch and recoil in response to neuromuscular activity.

A newly hired nurse is performing a focused respiratory assessment. The nurse mentor will intervene if which action by the newly hired nurse is noted? a) The newly hired nurse palpates the point of maximal impulse (PMI). b) The newly hired nurse auscultates breath sounds as the client breathes through the nose. c) The newly hired nurse attaches a pulse oximetry to the client's index finger. d) The newly hired nurse explains the assessment procedure before performing it.

b) The newly hired nurse auscultates breath sounds as the client breathes through the nose. Breath sounds should be auscultated while the client breathes slowly through an open mouth; nose breathing may produce false breath sounds. Explanation before procedures helps reduce a client's anxiety. Palpation of the PMI and attaching the pulse oximetry are included in the respiratory assessment.

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse, if noted by the charge nurse, would cause the charge nurse to intervene? a) The newly hired nurse adjusts the bed to a comfortable working position. b) The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). c) The newly hired nurse explains what she is doing and the reason to the client, even though the client does not appear to be alert. d) The newly hired nurse assesses the client's pain and administers pain medication.

b) The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). Care of a tracheostomy tube in a stable situation, such as long-term care and other community-based care settings, may be delegated to licensed practical/vocational nurses (LPN/LVN); not in an acute instance.

When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal cannula, what does the nurse expect? a) The oxygen must be humidified. b) The rate will be no more than 2 to 3 L/min or less. c) Arterial blood gases will be drawn every 4 hours to assess flow rate. d) The rate will be 6 L/min or more.

b) The rate will be no more than 2 to 3 L/min or less. A rate higher than 3 L/min may destroy the hypoxic drive that stimulates respirations in the medulla in a patient with chronic lung disease. Oxygen delivered at low rates does not necessarily have to be humidified, and arterial blood gases are not required at regular intervals to determine the flow rate.

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the catheter to use? a) The age of the patient b) The size of the endotracheal tube c) The type of secretions to be suctioned d) The height and weight of the patient

b) The size of the endotracheal tube

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. a) False b) True

b) True This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis.

A patient with a diagnosis of advanced Alzheimer disease who is unable to follow directions requires an inhaled bronchodilator. Which of the following medication delivery systems is most appropriate for this patient? a) metered-dose inhaler with spacer b) nebulizer c) metered-dose inhaler without spacer d) dry powder inhaler

b) nebulizer Inhalers differ in the amount of dexterity that is required in order to deliver an accurate dose, but each requires some degree of coordinated activity and the ability to follow directions on the part of the patient. For a patient with decreased cognition, a nebulizer may be more appropriate on account of the fact that the patient passively inhales the entire dose

What structural changes to the respiratory system should a nurse observe when caring for older adults? a) increased use of accessory muscles for breathing b) respiratory muscles become weaker c) increased mouth breathing and snoring d) diminished coughing and gag reflexes

b) respiratory muscles become weaker 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.

What is the action of codeine when used to treat a cough? a) antisuppressant b) suppressant c) antihistamine d) expectorant

b) suppressant

The nurse assessing a patient with COPD suspects chronic hypoxia due to which of the following assessment findings? a) cyanosis b) clubbing of toes c) constipation d) edema

b, c The effects of chronic hypoxia can be detected in all body systems and are manifested as altered thought processes, headaches, chest pain, enlarged heart, clubbing of the fingers and toes, anorexia, constipation, decreased urinary output, decreased libido, weakness of extremity muscles, and muscle pain. Cyanosis is a symptom of acute hypoxia.

A nurse is caring for a 16-year-old male patient who has been hospitalized for an acute asthma exacerbation. Which testing methods might the nurse use to measure the patient's oxygen saturation? Select all that apply. a) Thoracentesis b) Spirometry c) Pulse oximetry d) Peak expiratory flow rate e) Diffusion capacity f) Maximal respiratory pressure

b, c, d Spirometers are used to monitor the health status of patients with respiratory disorders, such as asthma. Pulse oximetry is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma, along with PEFR to monitor airflow. These three tests may be administered by the nurse.

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a) Refrain from exercise. b) Reduce anxiety. c) Eat meals 1 to 2 hours prior to breathing treatments. d) Eat a high-protein/high-calorie diet. e) Maintain a high-Fowler's position when possible. f) Drink 2 to 3 pints of clear fluids daily.

b, d, e When caring for patients with COPD, it is important to create an environment that is likely to reduce anxiety and ensure that they eat a high-protein/high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high Fowler's position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises, and drinking 2 to 3 quarts (1.9-2.9 L) of clear fluids daily is recommended.

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? a) Eat one large meal at noon. b) Snack on high-carbohydrate foods frequently. c) Eat smaller meals that are high in protein. d) Contact the physician for nutrition shake.

c) Eat smaller meals that are high in protein.

A patient with COPD is unable to perform activities of daily living (ADLs) without becoming exhausted. Which nursing diagnosis best describes this alteration in oxygenation as the etiology? a) Decreased Cardiac Output related to difficulty breathing b) Impaired Gas Exchange related to use of bronchodilators c) Fatigue related to impaired oxygen transport system d) Ineffective Airway Clearance related to fatigue

c) Fatigue related to impaired oxygen transport system

The nurse is caring for a client who reports difficulty breathing. In what position would the nurse place this client? a) supine position b) lateral position c) Fowler's position d) prone position

c) Fowler's position People with dyspnea and orthopnea are most comfortable in a high Fowler's position because accessory muscles can easily be used to promote respiration. Prone position can be used on a routine basis to promote ventilation and perfusion of the posterior dependent sections of the lungs.

The nurse is preparing to educate a client on how to perform incentive spirometry. Which concepts should the nurse include? a) Proper, frequent use of incentive spirometry can improve pulmonary circulation. b) The client should forcefully exhale into the incentive spirometer and continue to exhale until unable to continue. c) Incentive spirometry provides visual reinforcement of deep breathing. d) Decrease of oxygen saturation is expected during the first few minutes of incentive spirometry.

c) Incentive spirometry provides visual reinforcement of deep breathing. Incentive spirometry is used to enhance inspiratory effort.

Which is a sign of dyspnea specific to infants? a) A forward-leaning position b) Increased respiratory rate c) Nasal flaring d) Panting respirations

c) Nasal flaring 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 patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function? a) Pneumonia b) Wheezes c) Pleural effusion d) Tachypnea

c) Pleural effusion 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).

The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the client's care plan? a) Encourage the client to alternate eating and using a nebulizer during meal time. b) Encourage the client to eat immediately before breathing treatments. c) Provide six small meals daily. d) Provide three large meals daily.

c) Provide six small meals daily. The nurse should consider providing six small meals distributed over the course of the day instead of three large meals. Meals should be eaten one to two hours after breathing treatments and exercises.

A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? a) Instruct assistant to notify the primary care provider. b) Assess the patient's vital signs. c) Remove the tape, adjust the depth to ordered depth and reapply the tape. d) No action is required as depth will adjust automatically.

c) Remove the tape, adjust the depth to ordered depth and reapply the tape.

When caring for a client with a tracheostomy, the nurse would perform which recommended action? a) Clean the wound around the tube and inner cannula at least every 24 hours. b) Assess a newly inserted tracheostomy every 3 to 4 hours. c) Suction the tracheostomy tube using sterile technique. d) Use gauze dressings over the tracheostomy that are filled with cotton.

c) Suction the tracheostomy tube using sterile technique. Sterile technique is required when suctioning a tracheostomy in order to prevent introduction of microorganisms into the respiratory tract. The area around a new tracheostomy may need to be assessed and cleaned every 1 to 2 hours. Gauze dressings that are not filled with cotton must be used to prevent aspiration of lint or cotton fibers into the trachea.

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system? a) an adult who is receiving oxygen at home b) an older adult client who has COPD c) a child who has pneumonia d) an adolescent who has asthma

c) a child who has pneumonia An oxygen tent is commonly used with children who need a cool and highly humidified airflow. It is also more effective for children because they often do not like to keep oxygen administration devices in place. Since the tent does not allow the maintenance of a satisfactory or precise oxygen concentration, is difficult to maintain a consistent level of oxygen. The oxygen tent does not adequately deliver oxygen at a rate higher than 30% to 50%; thus, it is rarely used with other clients.

Oxygen and carbon dioxide move between the alveoli and the blood by: a) osmosis. b) negative pressure. c) diffusion. d) hyperosmolar pressure.

c) diffusion. Oxygen and carbon dioxide move between the alveoli and the blood by diffusion, the process in which molecules move from an area of greater concentration or pressure to an area of lower concentration or pressure.

The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal? a) resonance on percussion of lung fields b) vesicular breath sounds audible over peripheral lung fields c) fine crackles to the bases of the lungs bilaterally d) respiratory rate of 18 breaths per minute

c) fine crackles to the bases of the lungs bilaterally Except in the case of infants, fine crackles always constitute an abnormal assessment finding.

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? a) "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." b) "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." c) "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." d) "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."

d) "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." 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.

Martin is a 58-year-old smoker who was admitted to the hospital with worsening shortness of breath over the last 2 days. He states that he is having some chest discomfort. The nurse asks him further about this in order to characterize whether this may be cardiac related, musculoskeletal related, or respiratory related. Martin states that when he breathes in, he feels as if the air passing into his lungs is burning him. It is also very painful to swallow. Based on what Martin is stating, which illness does the nurse suspect is causing Martin's chest discomfort? a) Emphysema b) Pneumonia c) Coronary artery disease d) Acute bronchitis

d) Acute bronchitis Acute bronchitis is caused by inflammation. Inflammatory mediators such as histamine may directly stimulate nerve endings made hypersensitive by the disease process. This process causes a sensation of pain as air travels over those nerve endings. Clients with pneumonia often experience pain with deep breathing because each breath increases pressure on pain receptors that are already compressed and irritated by swollen, inflamed lung tissue. Coronary artery disease should be ruled out in anyone reporting chest pain, but Martin's sensation of burning in his airway with each breath is more suspicious for a respiratory issue. Emphysema is a more chronic illness that causes a slow progression of increasing shortness of breath. Martin is definitely at risk for emphysema but it would not explain his worsening shortness of breath over the last 2 days.

A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient? a) Oxygen tent b) Oxygen mask c) Nasal cannula d) Ambu bag

d) Ambu bag If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag)may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube.

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? a) The patient vomits during suctioning. b) The secretions appear to be stomach contents. c) The catheter touches an unsterile surface. d) Epistaxis is noted with continued suctioning.

d) Epistaxis is noted with continued suctioning. When epistaxis is noted with continued suctioning, the nurse should notify the physician and anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning.

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? a) Monitor the pressure of oxygen dissolved in plasma. b) Calculate the pressure of carbon dioxide dissolved in plasma. c) Measure the volume of air exhaled or inhaled over time. d) Monitor the amount of oxygen saturation in the blood.

d) Monitor the amount of oxygen saturation in the blood. 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 chronic obstructive pulmonary disease requires low flow oxygen. How will the oxygen be administered? a) Simple oxygen mask b) Partial rebreather mask c) Venturi mask d) Nasal cannula

d) Nasal cannula

Which is a sign of dyspnea specific to infants? a) Panting respirations b) Increased respiratory rate c) A forward-leaning position d) Nasal flaring

d) Nasal flaring 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 providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? a) Notify the physician. b) Apply an occlusive dressing on the site. c) Assess the patient for signs of respiratory distress. d) Put on gloves and insert the chest tube in a bottle of sterile saline.

d) Put on gloves and insert the chest tube in a bottle of sterile saline. When a chest tube becomes separated from the drainage device, the nurse should first put on gloves, open a sterile bottle of normal saline or water, and insert the chest tube into the bottle without contaminating the chest tube. This creates a water seal until a new drainage unit can be attached. Then the nurse should assess vital signs and notify the physician.

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom? a) Mental alertness b) Increased urine output c) Weight loss d) Rapid respirations

d) Rapid respirations Normal cardiac output averages from 3.5 L/minute to 8.0 L/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 respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.

A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from? a) Chronic obstructive pulmonary disease (COPD) b) Chronic bronchitis c) Pneumonia d) Sleep apnea

d) Sleep apnea This client has all the risk factors of sleep apnea, which consists of multiple periods of apnea during sleep. These periods of apnea cause the person to move into a lighter sleep more often than someone without this disease, thus causing the daytime sleepiness.

A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur? a) suctioning of carbon dioxide b) prevention of suctioning c) loss of sterile field d) trauma to the tracheal mucosa

d) trauma to the tracheal mucosa

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. a) "I will be careful not to shake up the canister before using it." b) "I will hold the canister upside-down when using it." c) "I will inhale the medication through my nose." d) "I will continue to inhale when the cold propellant is in my throat." e) "I will only inhale one spray with one breath." f) "I will activate the device while continuing to inhale."

d, e, f

Which actions would a nurse perform when correctly providing postural drainage? Select all that apply. a) Carry out postural drainage 2 to 4 times a day for 20 to 30 minutes. b) Perform postural drainage 15 minutes after meals to aid digestion. c) Place the client lying on the right side with a pillow under the chest wall to drain the right lobe of the lung. d) Place the client in a lying position, half on the abdomen and half on the side, right and left, to drain the posterior sections of the upper lobes of the lungs. e) Place the client in a high- Fowler's position to drain the apical sections of the upper lobes of the lungs. f) Place the client in the Trendelenburg position to drain the right lobe of the lung.

d, e, f Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. Proper technique for postural drainage includes: · Use high-Fowler's position to drain the apical sections of the upper lobes of the lungs. · Postural drainage should be performed 2 to 4 times a day for 20 to 30 minutes. · Place the client in a lying position, half on the abdomen and half on the side, right and left, to drain the posterior sections of the upper lobes of the lungs. · Place the client in the Trendelenburg position to drain the lower lobes of the lungs. · Delay postural drainage for 1 to 2 hours after meals to avoid provoking vomiting. · Place the client lying on the left side with a pillow under the chest wall to drain the right lobe of the lung.