Oxygenation Hassell
Which client would the nurse assess first after a shift report? A 6-month-old with a croupy cough and inspiratory stridor with exertion A 2-year-old with asthma who required a PRN albuterol treatment 2 hours ago A 3-year-old with CF and pneumonia who required 22% oxygen all night A 20-month-old with bronchiolitis and bilateral crackles who is receiving 23% oxygen
A 6-month-old with a croupy cough and inspiratory stridor with exertion
After change-of-shift report, which client could the nurse assess first? A client with possible lung cancer who is scheduled for bronchoscopy A client with left pleural effusion who is scheduled for a thoracentesis A client with a hospital-acquired pneumonia and decreased breath sounds A client with an acute asthma exacerbation and 85% oxygen saturation
A client with an acute asthma exacerbation and 85% oxygen saturation
Which goal is the priority for a client with asthma who has a prescription for an inhaled bronchodilator? Is able to obtain pulse oximeter readings Demonstrates use of a metered-dose inhaler Knows the health care provider's office hours Can identify triggers that may cause wheezing
Demonstrates use of a metered-dose inhaler
Which action would the nurse take first when a client with heart failure reports sudden dyspnea and has bilateral crackles throughout the lungs with a respiratory rate of 32? Elevate the head of the bed to 75 degrees Obtain an apical pulse and bp Notify the hospital rapid response team Check oxygen saturation with the pulse oximeter
Elevate the head of the bed to 75 degrees
A client with emphysema reports increased shortness of breath and becoming increasingly anxious. The health care provider prescribes oxygen at 1L/min via nasal cannula. The nurse recognizes that this prescription is appropriate for which reason? The client does not need any more than 1L/min High concentrations of oxygen cause Alveoli to rupture High concentrations of oxygen eliminate the respiratory drive in some patients The oxygen at 1L/min should be enough to diminish the anxiety
High concentrations of oxygen eliminate the respiratory drive in some patients.
A client with pneumonia is experiencing dyspnea because of difficulty expectorating thick respiratory secretions, which action by the nurse will be most helpful? Administer continuous oxygen Offer fluids at frequent intervals Place the client in a high-fowler position Administer prescribed steroid inhaler
Offer fluids at frequent intervals
A client admitted to the hospital with a diagnosis of COPD. Which action would the nurse take to prevent client fatigue? Provide small, frequent meals Encourage pursed-lip breathing Schedule nursing activities to allow for rest Encourage bed rest until energy level improves
Schedule nursing activities to allow for rest
Which nursing action has the highest priority when preparing to transfer an unconscious client who sustained a head injury from the ED to a neurological trauma unit? Notifying the receiving unit of the transfer Having the client's records ready for the transfer Verifying that the family has been notified of the transfer Validating availability of a bag-valve-mask during the transfer
Validating availability of a bag-valve-mask during the transfer
Which finding by the nurse is the best indicator that measures to prevent postoperative atelectasis after abdominal surgery have been effective? Vesicular breath sounds heard over both lungs Client reports no incisional pain with coughing Client's oral temperature is 98.2F Client uses incentive spirometer every 2 hours
Vesicular breath sounds heard over both lungs
A client with asthma and depression is admitted to the hospital. Which task assigned by the delegator is applicable to the RN? "Administer oral antidepressants" "Administer a painkiller intramuscularly" "Teach the client how to use a meter-dosed inhaler" "Reinforce tips for stress management with the client"
"Teach the client how to use a meter-dosed inhaler"
Which intervention would the nurse implement when caring for a newborn with ineffective airway clearance? (SATA) 1. Auscultating the neonate's lungs 2. Monitoring the neonate's RR 3. Placing the neonate on the back when sleeping 4. Observing the neonate for signs of respiratory distress 5. Suctioning the neonate's mouth with a bulb syringe, as needed
1. Auscultating the neonate's lungs 2. Monitoring the neonate's RR 3. Placing the neonate on the back when sleeping 4. Observing the neonate for signs of respiratory distress 5. Suctioning the neonate's mouth with a bulb syringe, as needed
Which nursing interventions would provide safe oxygen therapy? (SATA) 1. Check tubing for kinks 2. Run wires under carpeting 3. Post "no smoking" signs in the client's rooms 4. Place oxygen tanks flat in the carts when not in use 5. Make sure the client is using oil-based. products to lubricate the nose
1. Check tubing for kinks 3. Post "no smoking" signs in the client's rooms
Which observation by the nurse indicates a client. with pneumonia is able to use an incentive spirometer correctly? (SATA) 1. Records the volume of the air inspired 2. Performs 10 breaths per session every hour 3. Inhales air fully before inserting the mouthpiece 4. Takes a long, slow, deep breath keeping the mouthpiece in place 5. Exhales deep breaths with the mouthpiece in their mouth
1. Records the volume of the air inspired 2. Performs 10 breaths per session every hour 4. Takes a long, slow, deep breath keeping the mouthpiece in place
List in order the steps the nurse teaches the client to follow when using a meter-dosed. inhaler (MDI) 1. Shake the inhaler for 30 seconds. 2. Hold the inhaler upright in the mouth 3. Start breathing in and press down on the inhaler once 4. Exhale slowly and deeply to empty the air from the lungs
1. Shake the inhaler for 30 seconds 4. Exhale slowly and deeply to empty the air from the lungs 2. Hold the inhaler upright in the mouth 3. Start breathing in and press down on the inhaler once
The nurse caring for a client with a Venturi mask who is receiving 40% oxygen. Which nursing actions are indicated? Select all that apply. 1. Keep the oxygen source higher than the client's airway. 2. Adjust the liter flow according to the oxygen saturation. 3. Prevent the client's blanket from covering the adaptor's orifices. 4. Ensure that the bag does not deflate completely during inspiration. 5. Check that the appropriate adapter to deliver the prescribed FiO2 is attached to the mask
3. Prevent the client's blanket from covering the adaptor's orifices. 5. Check that the appropriate adapter to deliver the prescribed FiO2 is attached to the mask.
An 8-year-old child with a history of asthma is brought to the emergency department with respiratory distress. After elevating the client's HOB and administering oxygen via face mask, which order would the nurse carry out next? Teach incentive spirometer use Administer the nebulizer treatment Obtain a blood specimen for a complete blood count Notify the respiratory therapist to perform chest physiotherapy
Administer the nebulizer treatment
When performing a focused respiratory assessment, which action would the nurse take first? Examine for any abnormal respiratory patterns Inspect for changes in skin color or temperature Check for any evidence of respiratory distress Determine the shape and symmetry of the chest
Check for any evidence of respiratory distress
When caring for a client with emphysema who becomes more restless, which action would the nurse take first? Auscultate lung sounds Check oxygen saturation Observe for increased respiratory effort Ask about any increased shortness of breath
Check oxygen saturation
Which activity would the nurse expect to cause most distress when assessing a client with heart failure for activity tolerance? Getting up from bed in the morning Walking to visit the next-door neighbor Climbing a flight of stairs to the bedroom Leaving the table immediately after a meal
Climbing a flight of stairs to the bedroom
Which action will the nurse take when a client's chest x-ray shows atelectasis? Administer oxygen Suction the upper airway Position for postural drainage Encourage incentive spirometer use
Encourage incentive spirometer use
Which assessment finding indicates to the nurse the need for oropharyngeal suctioning of a client? Gurgling sounds with each breath Fine crackles at the base of the lungs Cyanosis in the nailbeds of the fingers Dry cough at increasingly frequent intervals
Gurgling sounds with each breath
Which explanation would the nurse provide to the parents of a child with spasmodic croup who ask why their child is receiving humidified oxygen? It helps prevent drying of membranes It provides a mode of giving inhalant medications It increases the surface tension of the respiratory tract It provides an environment free of pathogenic organisms
It helps prevent drying of membranes
The nurse is teaching pursed-lip breathing to a client with COPD. The client asks about the benefit of exercises. Which explanation would the nurse give? Prevents complications that are associated with COPD Relieves shortness of breath by increasing the breath rate Increases the amount of air that the client can inhale with each breath Keeps the airway open longer to decrease the work that goes into breathing
Keeps the airway open longer to decrease the work that goes into breathing
Which method of oxygen delivery would the nurse anticipate will be prescribed for a client with a pulse oximetry reading 65%? Face tent Venturi mask Nasal cannula Nonrebreather mask
Nonrebreather mask
Which action would the nurse take first when a client with acute bronchitis and emphysema reports feeling anxious and short of breath? Obtain the oxygen saturation Provide oxygen at 2L/min Offer the prescribed rescue inhaler Suggest use of pursed-lip breathing
Obtain the oxygen saturation
When the nurse manager is evaluating the care of a client receiving oxygen through a nasal cannula, which finding indicates for more staff education about oxygen therapy? Oxygen flow rate is set to 8L/min There is bubbling present in the humidifier Pressure areas of tubing along the ears are padded Smoking and open flame prohibited signs are clearly posted
Oxygen flow rate is set to 8L/min
The nurse instructs a client to breath deeply to open collapsed alveoli. Which explanation could the nurse offer to explain the relationship between alveoli and improved oxygenation? The alveoli need oxygen to live The alveoli have no direct effect on oxygenation Collapsed alveoli increase oxygen demand Oxygen is exchanged for carbon dioxide in the alveolar membrane
Oxygen is exchanged for carbon dioxide in the alveolar membrane
A client asks about the purpose of a pulse oximeter. Which measurement is a pule oximeter used for? Respiratory rate Amount of oxygen in the blood Percentage of oxygen carrying hemoglobin Amount of carbon dioxide in the blood
Percentage of oxygen-carrying hemoglobin
Diagnosed with COPD, a 50-year-old client's clinical data after treatment is: heart rate of 100bpm, BP 138/82, RR 32, tympanic temp 98.2F, and an oxygen saturation of 80%. Which vital sign obtained by the nurse indicates a positive outcome? (SATA) Radial pulse: 70bpm Temp: 98.6F RR: 14 BP: 110/70 Oxygen saturation: 92%
RR: 14 BP: 110/70 Oxygen saturation: 92%
A client with COPD is breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. Which action would the nurse take? Encourage the client to take a slow, deep breaths and administer 5L/min oxygen per nasal cannula Place the client in a side-lying position and perform chest physiotherapy using clapping and vibration Raise the head of the bed to a high-fowler position and administer 2L/min oxygen per nasal cannula Assist the client in assuming a position of comfort and perform postural drainage
Raise the head of the bed to a high-fowler position and administer 2L/min oxygen per nasal cannula