PrepU Chapter 39
congestive heart failure. Chapter 39: Oxygenation and Perfusion - Page 1488
A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:
Croup Chapter 39: Oxygenation and Perfusion - Page 1489-1490
A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from:
A client taking opioids for cancer pain Chapter 39: Oxygenation and Perfusion - Page 1491
In which client should the nurse prioritize assessments for respiratory depression?
a client taking opioids for cancer pain Chapter 39: Oxygenation and Perfusion - Page 1492
In which client would the nurse assess for a depressed respiratory system?
Crackles Chapter 39: Oxygenation and Perfusion - Page 1494
The client demonstrates soft, high-pitched, discontinuous sounds in the left lower lobe of the lung. How will the nurse accurately document this finding?
It determines whether the client is getting enough oxygen. Chapter 39: Oxygenation and Perfusion - Page 1509
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?
"He is using his chest muscles to help him breathe." Chapter 39: Oxygenation and Perfusion - Page 1483-1503
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:
Apply oxygen as prescribed Chapter 39: Oxygenation and Perfusion - Page 1520
A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first?
Simple oxygen mask Nasal cannula Partial rebreather mask Chapter 39: Oxygenation and Perfusion - Page 1509
A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply.
pulse oximetry Chapter 39: Oxygenation and Perfusion - Page 1496
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?
Ask the client what factors contribute to nonadherence. Chapter 39: Oxygenation and Perfusion - Page 1512
A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?
nasal cannula Chapter 39: Oxygenation and Perfusion - Page 1509
A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?
Pleural effusion Chapter 39: Oxygenation and Perfusion - Page 1497
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?
Warm the client's hands and try again. Chapter 39: Oxygenation and Perfusion - Page 1524-1527
A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action?
Crackles Chapter 39: Oxygenation and Perfusion - Page 1489-1494
A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level?
pneumonia. Chapter 39: Oxygenation and Perfusion - Page 1485
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 bronchospasm. Chapter 39: Oxygenation and Perfusion - Page 1491-1492
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:
hemoglobin level. Chapter 39: Oxygenation and Perfusion - Page 1497
An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to 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:
"Is your mask causing discomfort?" Chapter 39: Oxygenation and Perfusion - Page 1535
An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize?
Stay indoors as much as possible. Chapter 39: Oxygenation and Perfusion - Page 1483
The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care?
Tell me more about why it bothers you. Chapter 39: Oxygenation and Perfusion - Page 1512
The client is reporting to the nurse that the continuous positive airway pressure (CPAP) mask is torture. What is the best response from the nurse?
Hypoxia Chapter 39: Oxygenation and Perfusion - Page 1485
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?
Wheezing Chapter 39: Oxygenation and Perfusion - Page 1494
The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?
The client is able to state the date, time, and location. Heart rate is 64 beats/min. Mucous membranes are pink and moist. Chapter 39: Oxygenation and Perfusion - Page 1490
The nurse is administering oxygen to an older adult client who has been assessed to have increased work of breathing. If the intervention has been effective, what finding(s) will the nurse expect on the evaluation of the client? Select all that apply.
thickness of nails nail polish peripheral vascular disease acrylic nails Chapter 39: Oxygenation and Perfusion - Page 1525
The nurse is applying a pulse oximeter to a client with bronchitis. Which factor(s) does the nurse communicate to the client that could interfere with accurate pulse oximetry? Select all that apply.
Clubbing Chapter 39: Oxygenation and Perfusion - Page 1485
The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?
notify the health care provider Chapter 39: Oxygenation and Perfusion - Page 1514
The nurse is assessing a client's chest tube which was inserted 48 hours earlier. The nurse notes crackling in the skin around the insertion site. Which action should the nurse prioritize?
Determine if the client has a pre-existing condition affecting the oxygen saturation. Use the forehead sensor if cardiac output is low. Correlate the pulse oximetry reading with the client's heart rate. Chapter 39: Oxygenation and Perfusion - Page 1497
The nurse is monitoring a client with continuous pulse oximetry. What action(s) by the nurse are important to obtain accurate results? Select all that apply.
"Respiratory rate 14, even, regular, and easy; depth with acceptable parameters; lung sounds clear all lobes bilaterally; absence of adventitious lung sounds; absence of spontaneous cough; oxygen saturation 98%." Chapter 39: Oxygenation and Perfusion - Page 1491
The nurse performs a respiratory assessment on a healthy client. While listening to the client's lungs, the nurse hears them fill with air and then return to a resting position. The nurse deems the findings normal. Which is the best way to document this respiratory assessment and lung sounds?
Poor tissue perfusion Chapter 39: Oxygenation and Perfusion - Page 1489
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
The chest should be slightly convex with no sternal depression. Chapter 39: Oxygenation and Perfusion - Page 1492
When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?
Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Chapter 39: Oxygenation and Perfusion - Page 1515
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?
"You should never smoke when oxygen is in use." Chapter 39: Oxygenation and Perfusion - Page 1509
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?
Instruct the client to inhale deeply and then cough. Chapter 39: Oxygenation and Perfusion - Page 1504-1505
A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?
Ambu bag Chapter 39: Oxygenation and Perfusion - Page 1519
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?
5,850 mL Chapter 39: Oxygenation and Perfusion - Page 1487
A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL and a pulse of 78 beats/min. What number would the nurse document for this assessment?
trauma to the tracheal mucosa Chapter 39: Oxygenation and Perfusion - Page 1518
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?
apnea. Chapter 39: Oxygenation and Perfusion - Page 1489
The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as:
tracheostomy collar Chapter 39: Oxygenation and Perfusion - Page 1517
The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select?
high respiratory rate Chapter 39: Oxygenation and Perfusion - Page 1492
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?
The nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen. Chapter 39: Oxygenation and Perfusion - Page 1535
The nurse is caring for a client who is receiving continuous oxygen at 3 L/minute via nasal cannula. The client's oxygen saturation has consistently been 94% to 96%, but suddenly drops to 86% as the nurse palpates the client's abdomen. The client denies respiratory difficulty or other distress. What is a likely reason for the client's decreasing oxygen saturation?
Examine the needed flow rate on the mask matches the rate on the oxygen flow meter. Use gauze pads under elastic strap to relieve irritation to scalp or ears. Ensure that air intake valves are not blocked. Chapter 39: Oxygenation and Perfusion - Page 1511, 1535-1538
The nurse is caring for a client with a 35% Venturi mask. Which administration considerations should the nurse use? Select all that apply.
Respiratory rate and depth Chapter 39: Oxygenation and Perfusion - Page 1492
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?
Check the fit of the oxygen mask. Chapter 39: Oxygenation and Perfusion - Page 1510-1511
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?
fine crackles to the bases of the lungs bilaterally Chapter 39: Oxygenation and Perfusion - Page 1499
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?
confusion Chapter 39: Oxygenation and Perfusion - Page 1485
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?
"Your lung condition limits the ability of the lungs to fully exhale, causing this change in shape." Chapter 39: Oxygenation and Perfusion - Page 1494
The nurse is talking with a client who has chronic obstructive pulmonary disease (COPD). The client reports chest shape seems to have changed over the past year. What information should be provided by the nurse?