Respiratory And Oxygen Therapy

A nurse is performing a head to toe assessment of a client. Which of the following findings indicate the client may be experiencing respiratory difficulty? (select all that apply) a.) The client occasionally sighs b.) The client is sitting in a tripod position c.) The clients respiratory rate is 18/min d.) The client is using pursed lipped breathing e.) The client appears confused

b.) The client is sitting in a tripod position d.) The client is using pursed lipped breathing e.) The client appears confused

A charge nurse is reviewing the documentation newly Which of the following entries made by the newly licensed nurse is an example of correct documentation? a.) I cannot sleep at night because I get short of breath b.) Client seems to not like certain staff members c.) Client's partner does not visit the client enough d.) Inspiratory wheezes auscultated at left lateral chest

d.) Inspiratory wheezes ausculated at left lateral chest

Sound that is intermittent rattling, crackling, popping, or bubbling sound. These towns can be fine and high-pitched or coarse and low pitch in or not cleared by coughing

Coarse crackles

A nurse is preparing to osculate a client posterior and lateral chest. In which order shut the nurse perform the following actions?

1.) Exposed to posterior chest with a sling sitting with her arms folded across her chest 2.) Auscultate 8 cm (3in) to one side of the spine around C7, then auscultate the other side of the spine in the same location 3.) Auscultate down the spine, moving the stethoscope from one side to the other until the lower thoracic spine is reach 4.) Auscultate the lateral sides sliding below the axillary area, then down to the seventh or eighth rib

A nurse is caring for a client who is dying and is having periods of deep breathing alternating with periods of apnea. The nurse should identify this as which of the following types of breathing? a.) Thoracici breathing b.) Cheyne-Stokes breathing c.) Bradypnea d.) Kussmaul's breathing

b.) Cheyne-Stokes breathing

A respiratory sound that is whistling, high pitch musical sound made as air flows through the narrow passages. It can occur with conducive conditions such as asthma and bronchitis because the clients airways are narrow by edema

Wheeze

A charge nurse is teaching a newly licensed nurse how to recognize a pleural friction rub. Which of the following descriptions should the nurse use to describe a pleural friction rub? (select all that apply) a.) coarse grating tone b.) intermittent popping or bubbling sound c.) heard on inspiration and expiration d.) snoring sound on expiration e.) pain with breathing

a.) coarse grating tone c.) heard on inspiration and expiration e.) pain with breathing

A nurse is admitting a client who has a new diagnosis for COPD. Which of the following information documented by the nurse is subjective data? (select all that apply) a.) Pulse oximeter reading is 89% on 02 2/L per minute via nasal cannula b.) Report from client says they sleep well propped on two pills at night c.) Clients says they quit smoking 2 years ago d.) Respiratory rate increases to 28/min when client ambulates to restroom e.) Client states, "Being short of breath all of the time is making me depressed."

b.) Report from client says they sleep well propped on two pills at night c.) Clients says they quit smoking 2 years ago e.) Client states, "Being short of breath all of the time is making me depressed."

A charge nurse is observing a newly licensed nurse perform an anterior chest auscultation on a client. For which of the following actions should the charge nurse intervene? a.) The nurse ask the client to copy for beginning the auscultation. b.) The nurses auscultating through the clients gown c.) The nurse place is the stethoscope on the intercostal spaces d.) The nurse move down the chest in a ladder sequence.

b.) The nurses auscultating through the clients gown

A nurse is caring for a client who is having difficulty breathing. Which of the following action should the nurse take first? a.) Instruct the client to deep breathe and cough b.) Provide the client with an incentive spirometer c.) Elevate the head of the clients bed d.) Reassessed by auscultating the clients lungs

c.) Elevate the head of the clients bed

A nurse is providing discharge teaching to a client who has COPD regarding the influenza vaccine. Which of the following statements should the nurse make? a.) It's just a small number of people that get the flu from receiving the vaccine b.) Call your provider immediately if you have any flu-like symptoms after receiving the vaccine c.) You should make every effort to receive a flu vaccine every year d.) The vaccine becomes effective immediately after the injection

c.) You should make every effort to receive a flu vaccine every year

A nurse in the emergency department is assessing a client who has experienced thoracic trauma from a motor vehicle crash. Which of the following findings as an indication of a pneumothorax? a.) The clients ribs slow down word at a 45° angle b.) The client is making a high-pitched crowing sound they can be heard in the neck area c.) The diameter of the clients chest appears Pearl like with horizontal ribs d.) The client is experiencing an equal movement of the posterior chest

d.) The client is experiencing an equal movement of the posterior chest

A continuous, loud, low pitch snoring type sound heard during expiration. It is caused by fluid or mucus that accumulate in the larger airways

Rhonchi

Sound that is a high pitch crowing sound that is heard loudly in the neck area without a stethoscope. Generally starts in the larynx or trachea and can be caused by swelling that then causes narrowing, either from sticky mucus or a foreign body lodged in the throat area. Can be life-threatening

Stridor

A nurse is providing teaching to a client who has a new diagnosis of asthma and reported smoking history of 20 years. Which of the following statements should the nurse make when counseling the client about their tobacco use? (select all that apply) a.) "Smoking is linked to various forms of cancer." b.) "There are no risks associated with exposure to secondhand smoke." c.) "It might take several attempts to finally stop smoking" d.) "Smoking will cause you to die years earlier than if you didn't smoke." e.) "There are pharmacologic therapies that can help a person stop smoking."

a.) "Smoking is linked to various forms of cancer." d.) "Smoking will cause you to die years earlier than if you didn't smoke." e.) "There are pharmacologic therapies that can help a person stop smoking."

A nurse is caring for a client who is experiencing episodes of hyperventilation. Which of the following manifestations should the nurse expect during hyperventilation? (select all that apply) a.) Numbness and tingling of extremities b.) Decreased chest wall expansion c.) Lightheadedness d.) Periods of apnea e.) Chest pain

a.) Numbness and tingling of extremities c.) Lightheadedness e.) Chest pain

A nurse is providing discharge teaching with a client who is going home on continuous liquid oxygen therapy. Which of the following instruction should the nurse include? a.) Play some oxygen tank in a clutter-free environment b.) Keep the oxygen tank at least 6 feet away from me heat source c.) Ensure you are close to electricity to use your oxygen tank d.) Turn the valve on the oxygen tank until an alarm sounds

a.) Play some oxygen tank in a clutter free environment

A nurse is assessing a client who is dark skin. In which of the following areas of the client's body should the nurse assess the client for adequate oxygenation? (select all that apply) a.) Cheeks b.) Nail beds c.) Oral mucosa d.) Sclerae e.) Lips

b.) Nail beds c.) Oral mucosa e.) Lips

A charge nurse is teaching a newly licensed nurse how to recognize manifestations of decreased oxygenation in a client. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? a.) A client using thoracic breathing is experiencing a lack of oxygen b.) A pulse oximeter reading of less than 95% indicates respiratory distress c.) Clubbing of the fingers indicates a chronic state of impaired perfusion d.) A pinkish hue on the cheeks of a client who is light skinned indicates they are struggling to breathe

c.) Clubbing of the fingers indicates a chronic state of impaired perfusion