Acid/Base Balance
The nurse is preparing to perform nasopharyngeal suctioning on an adult using a wall unit. What is the appropriate suction pressure setting for an adult?
100 to 120 mm Hg
The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal?
30 to 55 breaths per minute
A nurse is delivering 3 L/min oxygen to a patient via nasal cannula. What percentage of delivered oxygen is the patient receiving?
32%
The nurse is caring for a client with emphysema. A review of the client's chart reveals pH 7.36, paO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription, if prescribed by the health care practitioner?
4 L/minute O2 nasal cannula
A patient is complaining of slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:
6 L/minute
The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner?
8 L/min oxygen via nasal cannula
The nurse is instructing the client with a pulmonary disorder on 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 providing information about the pneumococcal vaccine at a community setting. Which statement, if given by the participants, would indicate that further teaching is necessary?
?I will make an appointment for my 6-year-old child to receive the vaccine.?
The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output?
?If the client?s stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute.?
The nurse is caring for a client with a dysrhythmia with a prescription for oxygen therapy. The client is concerned and asks the nurse, ?Why am I getting oxygen when I came in with a heart problem?" What appropriate response would the nurse give this client?
?The dysrhythmia interferes with the heart?s circulation, leading to changes in oxygenation.?
The nurse sets up an oxygen tent for a patient. Which patient is the best candidate for this oxygen delivery system?
A child who has pneumonia
The nurse caring for a client on the medical-surgical unit collects the following data during head-to-toe assessment; mid-sternal chest pain, nausea, and pulse oximetry (SpO2) of 86%. The nurse would next implement which priority nursing intervention for this client who is experiencing these symptoms?
Administer oxygen
A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient?
Ambu bag
The nurse is assessing the respiratory rates of patients in a community health care facility. Which patient exhibits an abnormal value?
An infant with a respiratory rate of 20 bpm
The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?
Arterial blood gas
The nurse is informed while receiving a nursing report that the patient has been hypoxic during the evening shift. Which of the following assessment findings is consistent with hypoxia?
Confusion
A nurse is conducting a physical assessment of a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the client's oxygenation. What instruction should the nurse give the client?
Contract the abdominal muscles.
When the client demonstrates soft, high pitched discontinuous sounds, the nurse documents the breath sounds heard as which of the following?
Crackles
Which of the following dietary guidelines would be appropriate for the elderly 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 conducting a respiratory assessment of a 71-year-old patient who has been recently admitted to the hospital unit. Which of the following assessment findings should the nurse interpret as abnormal?
Fine crackles to the bases of the lungs bilaterally
A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?
Flowmeter
The nurse is caring for a client who is diagnosed with an impaired gas exchange. While performing a physical assessment of the client, which of the following data is the nurse likely to find, keeping in mind the client's diagnosis?
High respiratory rate
The nurse assesses a patient 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
A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determines that the teaching was successful when the students identify which activity as occurring during inspiration?
Intercostal muscles contract
When preparing to insert a nasopharyngeal airway (nasal trumpet), the nurse would use which measurement to determine the accurate tube size?
Measure from the tragus of the ear to the nostril plus 1 inch
To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry technique?
Monitor the amount of oxygen saturation in the blood
A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client?
Nasal cannula
A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply.
Nasal cannula Simple oxygen mask Partial rebreather mask
You are caring for a patient who has spontaneous respirations and needs to have oxygen administer at a FIO2 of 100%. Which of the following oxygen deliver systems should the nurse utilize?
Nonrebreather mask
The nurse is assessing an elderly client brought to the emergency department by her spouse. The spouse states, ?She is confused and had trouble when trying to take a breath.? The nurse would next implement which priority nursing intervention for this client who is experiencing these symptoms?
Obtain baseline vital signs and oxygen saturation
The nurse should assess for respiratory depression before and after the administration of what drugs?
Opioid analgesics
While examining a client, the nurse palpates the client's chest and back. Which of the following would the nurse expect to identify with this technique?
Pattern of thoracic expansion
A nurse is assigned to care for a client admitted to the healthcare facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of which of the following?
Pneumonia
The nurse working on the intensive care unit is preparing to admit a client injured in a car accident. The client has damage to the medulla. The nurse would include which most important equipment when preparing to care for this client? Select all that apply.
Pulse oximeter Endotracheal tube
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
The nurse schedules a pulmonary function test to measure the amount of air left in a patient's lungs at maximal expiration. What test does the nurse order?
Residual Volume (RV)
A patient with no prior history of respiratory illness has been admitted to a postsurgical 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?
Teaching the patient to use incentive spirometry
You are preparing an educational in service about endotracheal suctioning using an open suctioning system. Which of the following concepts should you plan to include?
The suction catheter should be inserted to a predetermined length—no more than 1 cm past the end of the endotracheal tube.
The nurse is auscultating the lungs of a patient 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.
Which of the following statements about oxygen tents are true? Select all that apply.
They are often used for children who will not leave a mask or cannula in place. Frequent linen and clothing changes should be anticipated. It is difficult to maintain a consistent level of oxygen in the tent. Use of an oxygen tent decreases the ability of a parent to comfort the child.
A nurse suctioning a patient 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
Which of the following is a recommended guideline for determining suction catheter depth when suctioning an endotracheal tube?
Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align and insert the suction catheter no further than an additional 1 cm.
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
Which of the following describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway?
When holding the airway on the side of the patient's face, it should reach from the tragus of the ear to the nostril plus 1 inch.
While reading a physician's progress notes, a student notes that an assigned patient is having hypoxia. What abnormal assessments would the student expect to find?
dyspnea, tachycardia, cyanosis
An older adult patient is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the patient informs the nurse that, "I can't seem to catch my breath." The nurse has responded by repositioning the patient and measuring the patient's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the patient's:
hemoglobin level.
