practice questions concepts

he nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach?

"Take in as much air as possible, hold your breath briefly, and exhale slowly."

A nurse is preparing to use a wall unit to suction an endotracheal tube. At what pressure should the suction be set?

80-150 mmhg

Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound?

Bronchial

he nurse is preparing a client for a complete blood count test. Which actions would the nurse perform? Select all that apply.

Explain that, based on results, additional testing may be performed. Inform the client that specimen collection takes approximately 5 to 10 minutes. Inform the client that this test can assist in evaluating the body's response to illness.

A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client?

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

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use?

Nonrebreather mask A nonrebreather mask is the only device that can deliver an FiO2 of 100% to a client without a controlled airway. A Venturi mask delivers a maximum FiO2 of 55%. A nasal cannula delivers a maximum FiO2 of 44%. A simple mask delivers a maximum FiO2 of 60%.

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

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

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?

Vesicular

The nurse is caring for a client with a nonhealing wound who has been prescribed hyperbaric oxygen therapy (HBOT). When the client asks, "How will this help me?" what is the appropriate nursing response?

Wounds heal because HBOT helps to regenerate new tissue quickly."

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?

a child who has pneumonia

The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier?

distilled water

A client with no prior history of respiratory illness has been admitted to a postoperative 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?

educating the client on the use of incentive spirometry

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

flow meter

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?

high-Fowler's position

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?

hypoxia

Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen?

it regulates the amount of oxygen received

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?

nasal cannula

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?

pleural effusion

A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?

pulse oximetry

What is the action of codeine when used to treat a cough?

suppresant

he nurse is caring for a client who was had a percutaneous tracheostomy (PCT) following a motor vehicle accident, and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?

tracheostomy collar

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?

trauma to the tracheal mucosa

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

true

he 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 first will warm, filter, and humidify the air you are breathing."

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the oxygen analyzer?

"It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed."

The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach?

"Take in as much air as possible, hold your breath briefly, and exhale slowly."

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.

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?

Encourage the client to take deep breaths

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:

He is using his chest muscles to help him breathe."

The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is:

Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter.

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?

Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale

n which client would the nurse assess for a depressed respiratory system?

a client taking opioids for cancer pain

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

bronchospasm

35s 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?

confusion

Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate to observe in a client with these arterial blood gas results?

increase in rate and depth of respirations

The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client?

nasal cannula

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing

poor tissue perfusion

Which breathing technique(s) will the nurse teach to the client who has hypoxemia and hypercarbia? (Select all that apply.)

pursed-lip breathing diaphragmatic breathing

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?

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.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

residual volume

The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign?

resp rate and depth

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?

you should never smoke when oxygen is being used