Oxygenation

A client has a history of chronic obstructive pulmonary disease (COPD). Following a coughing episode, the client reports sudden and unrelieved shortness of breath. Which of the following is the most important for the nurse to assess?

Lung sounds

A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following?

Lungs are clear on auscultation

A nurse assesses a 1-day-old neonate. Which finding indicates respiratory distress?

Nasal flaring

A client in the ED for COPD- what is the first action of the nurse?

Oxygen through nasal cannula at 2 L/minute.

A patient has been receiving 100% oxygen therapy by way of a non-rebreather mask for several days. Now the patient complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?

Oxygen toxicity

The nurse is caring for a 6-year-old with a congenital heart defect. To best relieve a hypercyanotic spell, what action would be the priority?

Place the child in knee-to-chest position

Which is a priority goal for the client with chronic obstructive pulmonary disease (COPD)?

Maintaining functional ability

A client who has been prescribed an inhaler points to the spacer and asks, "What is this for?" What is the appropriate nursing response?

Medication stays in the chamber so you can continue to inhale it

A client with cystic fibrosis may use which type of medication to reduce the viscosity of respiratory secretions?

Mucolytic

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?

Client's breathing becomes noisy

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?

Anxiety

A client is admitted to the ED following an OD of barbiturates. What should the nurse do first?

Assess ventilation and assist ventilation as needed.

A client with emphysema is receiving continuous oxygen therapy. Depressed ventilation can occur unless the nurse ensures that the oxygen is administered in which way?

At a low flow rate

The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client?

Breathing through your nose will warm, filter and humidify the air you breathe in

What is the benefit of chest percussion with CF?

Chest percussion helps clear secretions out of the lungs

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?

Eat smaller meals that are high in protein

The nurse is assessing the laboring client to determine fetal oxygenation status. Which assessment method will the nurse most likely use?

External electronic fetal monitoring.

Which burns can impair ventilation?

Face, neck, chest

The occupational nurse is completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?

Fibrotic changes in lungs

A nurse is concerned that a client may develop postoperative atelectasis. Which nursing diagnosis would be most appropriate if this complication occurs?

Impaired gas exchange

Which finding would indicate a decrease in pressure with mechanical ventilation?

Increase in compliance

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Light headedness and paresthesia

The caregiver of a child being treated at home for acute glomerulonephritis calls the nurse reporting that her daughter has just had a convulsion. The child is resting comfortably but the caregiver would like to know what to do. The nurse would instruct the caregiver to take which action?

Take the child's bp and report the findings to the nurse while on the phone

A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the RN and/or health care provider?

Weak and rapid pulse

The nurse is collecting data on a 6-year-old child admitted with acute glomerulonephritis.

Which vital sign would the nurse anticipate with this child's diagnosis? Bp of 136/84

How quickly after onset of an MI does nitroglycerin have to be administered?

Within 6 hours

A client with chronic obstructive pulmonary disease (COPD) is recovering from a myocardial infarction. Because the client is extremely weak and can't produce an effective cough, the nurse should monitor closely for:

atelectasis

A patient with CF has a barrel chest and clubbed fingers is caused by:

chronic lack of oxygen

Most important nursing dx for COPD:

impaired gas exchange related to airflow obstruction

Guillain- Barre syndrome:

lung auscultation and measurement of vital capacity and tidal volume.

The most important nursing priority of tx for a patient with an altered LOC is:

maintain a clear airway to ensure adequate ventilation.

Vitamin B and folic acid deficiencies are characterized by production of abnormal erythrocytes called:

megaloblasts

The classification of stage 1 COPD is defined as

mild COPD

Order of LOC:

oriented to person, place, and time; disorientation; obtundation; stupor; coma

Fluid in the pleural space that has to be removed via thoracentesis is called:

pleural effusion

During auscultation of the lungs of a person with left-sided HF the nurse should note:

wheezes with wet lung sounds

Manifestations of bronchospasm in a client with COPD:

wheezes, decreased airflow, compromised gas exchange.