CH 4o NURS402
A nurse assesses the vital signs of a healthy newborn infants. What respiratory rate(s) suggests the infant needs further assessment and possible interventions? Select all that apply.- 20 breaths/min- 35 breaths/min- 50 breaths/min- 65 breaths/min- 80 breaths/min
Answer: - 50 breaths/min- 65 breaths/min- 80 breaths/min Rationale: An infant's expected respiratory rate is 20 to 40 breaths/min. Results outside this range should prompt the nurse to perform further assessments and to consider interventions.
he nurse must obtain a blood specimen for blood gas analysis. What is the most important thing for the nurse to do immediately after the needle has been removed? Place an adhesive bandage over the puncture site and instruct the client to leave it on for 30 minutes. Label the blood specimen with the client's correct demographic information. Apply steady, firm pressure on the puncture site for 5 to 15 minutes. Instruct the client to elevate the arm over the head for 10 minutes.
Apply steady, firm pressure on the puncture site for 5 to 15 minutes.
The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response? Cover the tracheostomy stoma and apply oxygen by nasal cannula Maintain the client's oxygenation and alert the health care provider immediately. Page the respiratory therapist STAT. Assess the client's respiratory status and check vital signs every 1 minute for the next hour.
Maintain the client's oxygenation and alert the health care provider immediately. NOT Option A, which suggests covering the tracheostomy stoma and applying oxygen by nasal cannula, is indeed a reasonable initial step to help maintain the client's oxygenation while addressing the tracheostomy issue. It can provide some temporary relief and support for the client's breathing. However, it should not be the sole action taken. The reason option , "Maintain the client's oxygenation and alert the healthcare provider immediately," is often considered the more appropriate response is because, in the event of a dislodged tracheostomy, the primary concern is the compromised airway and the need for immediate intervention. Alerting the healthcare provider ensures that a qualified medical professional can assess the situation and provide guidance on the next steps, which may include reinserting the tracheostomy or taking other necessary measures to secure the airway. While option B can provide some immediate support, it should be done in conjunction with notifying the healthcare provider promptly to address the underlying issue and prevent potential complications. So, a combination of both options B and C would be a comprehensive and appropriate response to this situation.
The nurse must obtain a blood specimen for blood gas analysis. What is the most important thing for the nurse to do immediately after the needle has been removed? Place an adhesive bandage over the puncture site and instruct the client to leave it on for 30 minutes. Apply steady, firm pressure on the puncture site for 5 to 15 minutes. Label the blood specimen with the client's correct demographic information. Instruct the client to elevate the arm over the head for 10 minutes.
Place an adhesive bandage over the puncture site and instruct the client to leave it on for 30 minutes.
The nurse is caring for an older adult homebound client with advanced respiratory disease whose has inadequate nutrition. What recommendation will the nurse provide? Increase use of dietary supplements Provide suggestions of high-protein, high-calorie meals Replace meals with protein shakes Practice intermittent fasting to promote appetite
Provide suggestions of high-protein, high-calorie meals
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? Tidal volume (TV) Total lung capacity (TLC) Forced Expiratory Volume (FEV) Residual Volume (RV)
Residual Volume (RV)
The nurse determines that the student who has been instructed about lung function and smoking requires additional teaching when the student says "A physically fit athlete breathes more slowly than a sedentary person." "Smoking only once in a while will not make a person addicted to smoking." "An older person may breathe more shallowly than a younger person." "An upright position will help someone breathe with less effort."
Smoking only once in a while will not make a person addicted to smoking."
A nurse is volunteering at a day camp where a child is stung by a bee and develops wheezing in the upper airways. The nurse will provide interventions to address what health problem? Bronchospasm Bronchitis Bronchiectasis Bronchiolitis
The health problem that the nurse will provide interventions to address when a child is stung by a bee and develops wheezing in the upper airways is: Bronchospasm Bronchospasm refers to the sudden constriction or narrowing of the bronchial tubes (airways) in the lungs, which can lead to wheezing and difficulty breathing. In the context of a bee sting, an allergic reaction can trigger bronchospasm, and it may present as wheezing in the upper airways. Prompt intervention may include administering medication such as an epinephrine auto-injector to counteract the allergic response and alleviate bronchospasm.
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? Place the client in the dorsal recumbent position to collect the specimen. Have the client clear the nose and throat and gargle with salt water before beginning the procedure. Instruct the client to inhale deeply and then cough. Discard the first sputum produced by the client.
To ensure a usable sputum specimen for bacterial infection testing, the best action is: Instruct the client to inhale deeply and then cough. Instructing the client to take a deep breath and then cough forcefully helps in bringing up sputum from the lower respiratory tract, where it is more likely to contain bacteria. This is important for obtaining a specimen that is representative of the infection. Collecting sputum from the deeper airways can increase the chances of identifying the causative bacteria. The other options may not yield a specimen that is as representative or suitable for bacterial culture: Placing the client in the dorsal recumbent position is not necessary for collecting sputum. Having the client clear the nose and throat and gargle with salt water may not be as effective in obtaining sputum from the lower airways. Discarding the first sputum produced by the client may not provide the most accurate representation of the infection, as it may contain contaminants from the oral cavity.
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: croup. asthma. alcohol use. pneumonia.
pneumonia.
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 thoracentesis spirometry peak expiratory flow rate
pulse oximetry
The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly? small amount of subcutaneous air is detected at the site of tube insertion dressing is moist and intact respirations are at 20 breaths per minute drainage system is positioned slightly above chest level
respirations are at 20 breaths per minute
The nurse is assessing a client with lung cancer who has been receiving treatment for many months. What manifestations may suggest that the client has chronic hypoxia? Edema Hemoptysis Yellow or green sputum Clubbing
Clubbing
The nurse is assessing a neonate whose breathing ceased for 4 to 5 seconds on three different occasions. What is the nurse's best action? Arrange for immediate assessment by the primary care provider Document these expected apneic episodes Reposition the infant to promote adequate oxygenation Obtain an order for airway suctioning as needed
Document these expected apneic episodes. Apnea of brief duration (around 5 seconds) can be a normal occurrence in neonates, especially in premature infants. However, it's crucial to document these episodes in the medical record to track the infant's overall condition and to ensure that they are not associated with any concerning signs or symptoms. Routine apnea in neonates typically resolves on its own and does not require immediate intervention unless there are other concerning factors or symptoms present. Repositioning the infant, obtaining an order for airway suctioning, or arranging for immediate assessment by the primary care provider may not be necessary for brief episodes of apnea that are expected in some neonates. However, the nurse should continue to monitor the infant's respiratory status and overall condition closely and report any concerning changes to the healthcare provider as needed. Inocrrect: Obtain an order for airway suctioning as needed Obtaining an order for airway suctioning as needed is not the best initial action in this scenario for several reasons: Routine suctioning: Brief periods of apnea lasting 4 to 5 seconds can be normal in some neonates, especially premature infants. Routine suctioning without a clear indication can be invasive and may not be necessary. Risk of harm: Unnecessary suctioning can cause trauma to the infant's delicate airway and mucous membranes, potentially leading to complications such as bleeding or increased risk of infection. Lack of clear indication: Before performing any medical procedure, especially on a neonate, it's important to have a clear indication that the procedure is necessary. Routine suctioning should be based on clinical assessment and the presence of signs such as visible secretions or distress, not solely because of brief apneic episodes. Documentation: Documenting the apneic episodes is important for tracking the infant's condition and response to care. This documentation can help healthcare providers make informed decisions about whether further interventions, such as suctioning, are needed.
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. Leave the airway in place and promptly notify the health care provider for further instructions. Suction the client's mouth through the oropharyngeal airway to prevent aspiration.
Remove the airway, turn the client to the side, and provide mouth suction, if necessary.
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: asthma. croup. pneumonia. alcohol use.
The history that the nurse would anticipate when caring for a client diagnosed with atelectasis is: Pneumonia. Atelectasis is often associated with conditions or factors that lead to the collapse or closure of a portion of the lung, resulting in reduced or absent air exchange in that area. Pneumonia can lead to atelectasis because the inflammation, mucus production, and infection can cause airway obstruction and the collapse of small lung segments. Asthma is more commonly associated with bronchoconstriction and airway inflammation rather than atelectasis. Croup is a condition that primarily affects the upper airway, specifically the larynx and trachea, and it does not typically lead to atelectasis. Alcohol use, while it can have various health effects, is not a direct cause of atelectasis.
To make "They are medium-pitched blowing sounds heard over the major bronchi" a correct choice for the question, you can rephrase the question like this: "The nurse is auscultating the lungs of a client and detects abnormal breath sounds suggestive of bronchial breath sounds. What is a characteristic of bronchial breath sounds?" In this revised question, you are specifically asking about bronchial breath sounds, which are indeed medium-pitched blowing sounds heard over the major bronchi when there is an abnormal transmission of sound through the lung, often due to lung pathologies like consolidation.
They are medium-pitched blowing sounds heard over the major bronchi"
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. 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. Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.
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.
A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action? Encourage the client to do deep-breathing exercises. Raise the head of the client's bed slightly, if tolerated. Review the medications that the client has taken in the past 90 minutes. Document this expected assessment finding
A SpO2 reading of 95% generally indicates adequate oxygen saturation, and no immediate intervention is necessary. Encouraging deep-breathing exercises or raising the head of the bed may not be warranted in this case, as the oxygen saturation is within a normal range. Reviewing medications taken in the past 90 minutes may be relevant in certain clinical situations, but it's not the primary action needed when the SpO2 reading is normal. It's essential to document all assessment findings, including normal ones, for the client's medical record and ongoing care.
A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action? Encourage the client to do deep-breathing exercises. Raise the head of the client's bed slightly, if tolerated. Review the medications that the client has taken in the past 90 minutes. Document this expected assessment finding.
Document this expected assessment finding.
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? Place the client in the dorsal recumbent position to collect the specimen. Have the client clear the nose and throat and gargle with salt water before beginning the procedure. Instruct the client to inhale deeply and then cough. Discard the first sputum produced by the client.
Instruct the client to inhale deeply and then cough.
The nurse is caring for a client who is wearing oxygen via nasal cannula. The client asks about the bubbling water attached to the oxygen. Which response by the nurse is appropriate? It prescribes oxygen concentration. It regulates the amount of oxygen received. It determines whether you are getting enough oxygen. It decreases dry mucous membranes by delivering small water droplets.
It decreases dry mucous membranes by delivering small water droplets.
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. Leave the airway in place and promptly notify the health care provider for further instructions. Suction the client's mouth through the oropharyngeal airway to prevent aspiration.
Remove the airway, turn the client to the side, and provide mouth suction, if necessary.
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 loud, high-pitched sounds heard primarily over the trachea and larynx. They are medium-pitched blowing sounds heard over the major bronchi. They are low-pitched, soft sounds heard over peripheral lung fields. They are soft, high-pitched discontinuous (intermittent) popping lung sounds.
They are low-pitched, soft sounds heard over peripheral lung fields. Vesicular breath sounds are indeed different from the description "They are medium-pitched blowing sounds heard over the major bronchi." Vesicular breath sounds are characterized by being low-pitched, soft, and heard over the peripheral lung fields. They represent the normal, gentle airflow in the smaller airways and alveoli during quiet, relaxed breathing. On the other hand, the description "medium-pitched blowing sounds heard over the major bronchi" is more characteristic of bronchial breath sounds, which are heard when there is an abnormal transmission of sound through the lung, often due to consolidation or other lung pathologies. Bronchial breath sounds are typically higher-pitched and louder compared to vesicular breath sounds. So, to clarify, vesicular breath sounds are low-pitched and heard over the peripheral lung fields, while medium-pitched blowing sounds over the major bronchi are characteristic of bronchial breath sounds and may indicate an issue with the lung.
