chap 39: oxygenation/respiratory
The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1.Bilateral wheezing 2.Inspiratory crackles 3.Intercostal retractions 4.Increased respiratory rate
increased respiratory rate.
The ball rises on the incentive spirometer when the patient ____
inhales, NOT exhales
What indicates that wet suctioning is working properly?
intermittent bubbles
The nurse is caring for a client with a chest tube. Stationary clots are noted in the tubing. What is the appropriate nursing action? Contact the healthcare provider. Document the finding. Contact the Rapid Response Team. Milk the tubing to strip it of clots
milking the tube although this is contraindicated in any other circumstance.
Which mask is used to deliver Fi02 at 100%?
nonbreather mask
rebreather vs nonrevreather mask
nonrebreather has bag and allows highest rate of oxygen delivery. rebreather has
oxygen tents are used for child patients with
pnemonia
what position should a patient receiving suctioning be placed?
semi Fowler
After complete exhilation into the spirometer, how long should the breath be held
2-3 seconds.
A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving? 23% 47% 32% 28%
32%
How does CO2 level affect PH.
<--CO2. more co2=more acidic
A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? A postoperative adult An adult with COPD A teenager with cystic fibrosis A child with pneumonia
A teenager with cystic fibrosis.
A client with closed-angle glaucoma and a cough has a prescription for a cough medicine. The nurse would question which cough medicine if prescribed for this client? Cough medicine with iodine Cough medicine with a high sugar content Cough medicine with a decongestant Cough medicine with an antihistamine
Cough medicine with an antihistamine. antihistamines such as diphenhydramide have anticholenergic effect.
A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level? Crackles Wheezes Clear sounds Bruits
Crackles are normal in NEWBORNS as fluid is clearing the lungs.
A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response? "I can assist you to the bathroom and back to bed." "You will need to use a bedpan while the chest tube is in position." "Let me get the unlicensed assistive personnel (UAP) for you." "The chest tube cannot be moved."
I can assist you to the bathroom and back to bed
What should be done if the nurse touches the plunger after medication is drawn.
NOTHING. plunger will not come into contact with part of the barrel surface that touches medication when pushing outside. This only happens when pulling inward while drawing the medication.
residual volume
amount of air left after maximum exhilation
How often should a patient's tracheostomy tube be suctioned?
as infrequently as possible
flow rate of cannula vs. simple mask vs. rebreather and nonrebreather mask. Which can deliver the highest amount?
cannula max. 6ml or 2-3L/min w/ COPD simple mask 5-8L/min. (no less than 5ml) partial rebreather-8-11 nonrebreather 12L/min. nonrebreather delivers the highest.
The nurse is caring for a client with acute respiratory distress syndrome (ARDS). What should the nurse expect to note in the client? 1.Pallor 2.Low arterial PaO2 3.Elevated arterial PaO2 4.Decreased respiratory rate
decreased respiratory rate.
Where to put an oximeter when both hands have edema and nails are thick?
earlobe is 2nd most accurate for oxygen measurement.
A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:
6L/min
What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? Checking the amount of oxygen in the cylinder before using it Using a cylinder for a patient transfer that indicates available oxygen is 500 psi Placing the oxygen cylinder on the stretcher next to the patient Discontinuing oxygen flow by turning the cylinder key counterclockwise until tight
Checking the amount of oxygen in the cylinder before using it
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? Elevate the ribs and sternum. Expand the thoracic cavity. Contract the abdominal muscles. Relax the respiratory muscles.
Contract the abdominal muscles.
An older adult client visits a health care facility for a scheduled physical assessment. During the assessment, the client reports difficulty breathing. Which suggestion could the nurse make to improve the client's respiratory function?
Drink liberal amounts of water
A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? Dyspnea Hypotension Decreased respiratory rate Decreased pulse rate
Dyspnea
The nurse is monitoring the respiratory status of a client after creation of a tracheostomy. The nurse understands that oxygen saturation measurements obtained by pulse oximetry may be inaccurate if the client has which coexisting problem?1. Fever2. Epilepsy3. Hypotension4. Respiratory failure
Hypotension
A client is admitted to the emergency department with shortness of breath and oxygen saturation of 88%. The client has a barrel chest and clubbed fingers. What is the nurse's priorityintervention? Teach the client deep-breathing exercises Ambulate the client Assist the client with incentive spirometer Place client in the tripod position
Place client in the tripod position
A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? Remove the catheter. Notify the primary care provider. Check that the airway is the appropriate size for the patient. Place the patient on his or her back.
Remove the catheter.When a patient vomits upon suctioning of an oropharyngeal airway, the nurse should remove the catheter; it has probably entered the esophagus inadvertently. If the patient needs to be suctioned again, the nurse should change the catheter, because it is probably contaminated. The nurse should also turn the patient to the side and elevate the head of the bed to prevent aspiration.
A client with a tracheostomy tube who is on a ventilator is at risk for impaired gas exchange. The nurse should assess for which finding as the best indicator of adequate ongoing respiratory status? 1.Oxygen saturation of 89% 2.Respiratory rate of 16 breaths/minute 3.Moderate amounts of tracheobronchial secretions 4.Small to moderate amounts of frank blood suctioned from the tube
Respirtory rate of 16 breaths per minute
When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding? The chest should be slightly convex with no sternal depression. The contour of the intercostal spaces should be rounded. The skin at the thorax should be cool and moist. The anteroposterior diameter should be greater than the transverse diameter.
The chest should be slightly convex with no sternal depression
The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly? 1.The client breathes in through the mouth. 2.The client breathes out slowly through the mouth. 3.The client avoids using the abdominal muscles to breathe out. 4.The client puffs out the cheeks when breathing out through the mouth.
The client breathes out slowly through the mouth.
T or F. oxygen levels of 98% could be dangerous for COPD patients
True. targer should be 88-92
Which scenario describes how carbon dioxide levels determine the frequency and depth of ventilation? An increase in circulating carbon dioxide causes an increase in the release of hydrogen ions, stimulating chemoreceptors in the aortic arch and carotid arteries, causing deeper and more rapid breathing. When carbon dioxide levels in the blood increase, chemoreceptors are stimulated, causing deeper and more rapid breathing. A decrease in the partial pressure of oxygen in arterial blood causes an increase in carbon dioxide levels, which in turn causes breathing to be slowed and more shallow. Breathing increases when carbon dioxide levels decrease.
When carbon dioxide levels in the blood increase, chemoreceptors are stimulated, causing deeper and more rapid breathing. IE HYPERVENTILATION to swing balance towards alkalosis
croup
an acute respiratory syndrome in children and infants characterized by obstruction of the larynx, hoarseness, and a barking cough
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: wheezes. rales. vesicular. crackles
crackles
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?
flow meter
To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position? left side with a pillow under the chest wall high-Fowler's position Trendelenburg position side-lying position, half on the abdomen and half on the side
high fowler's position.
A nurse is caring for a client who is receiving oxygen therapy via a nasal cannula. The nurse explains to the client that this method of oxygen delivery does which of the following?
relatively low rate concentration of oxygen
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
The nurse is suctioning an unconscious client who has a tracheostomy. The nurse should perform which actions when performing this procedure? Select all that apply.1. Keeping a supply of suction catheters at the bedside2. Auscultating breath sounds to determine the need for suctioning3. Hyperoxygenating the client before, during, and after suctioning4. Intermittently suctioning during insertion of the suction catheter5. Placing suction on the catheter for at least 30 seconds to ensure that all secretions are removed
1, 2, 3 plus laying in side lying position. high fowler for conscious patient.
What are ways to prevent complications caused by suctioning?
1. only suction when needed 2. limit to 15 seconds 3. hyperoxygenate before performing 4. suction pressure <150 mm Hg 5. cathetor should only be inserted 1 cm into 6. allow 30 seconds between each pass.
How long should suctioning occur
10-15 seconds with 60 second breaks in between
A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 to 4 L/min. The nurse responds that this would be harmful because a higher oxygen flow rate could lead to which physical responses?1. Drying of nasal passages2. Decrease in the client's oxygen-based respiratory drive3. Increase for the risk of pneumonia from drier air passages4. Decrease in the client's carbon dioxide-based respiratory drive
2. Decrease in the client's oxygen-based respiratory drive
A client is on continuous mechanical ventilation (CMV), and the low-pressure alarm sounds. The nurse should take which action? 1.Make sure that the client is not lying on the ventilator tubing. 2.Determine if there are any disconnections in the ventilator tubing. 3.Check to see if the client is biting on the endotracheal tube (ETT). 4.Auscultate the lungs to determine if the client needs to be suctioned.
2.Determine if there are any disconnections in the ventilator tubing.
A client arrives in the hospital emergency department with a bloody nose. What is the initial nursing action?1. Place the client in supine position.2. Apply an ice collar around the client's neck.3. Assist the client to a sitting position with the head tilted forward.4. Instruct the client to swallow the blood until the bleeding can be controlled.
3. Assist the client to a sitting position with the head tilted forward
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 (66 mL/second) nasal cannula Increase fluid intake to 3 L/day (3000 mL/day) Pulse oximetry High-Fowler's position
4L nasal cannula oxygen due to hypoxic drive risk. high Fowler positions IS preferred.
A nurse is preparing to use a wall unit to suction the endotracheal tube of a 9-year-old child. At what pressure should the suction be set? 60 to 80 mm Hg 80 to 125 mm Hg 100 to 150 mm Hg 100 to 130 mm Hg
80-12 children; 100-130 adults
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 partial rebreather mask 12 L/min oxygen via nonrebreather mask 10 L/min oxygen via Venturi mask 8 L/min oxygen via nasal cannula
8ml via cannula (2-3 max for COPD)
A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? Instruct the assistant to notify the primary care provider. Assess the patient's vital signs. Remove the tape, adjust the depth to ordered depth and reapply the tape. No action is required as depth will adjust automatically.
Remove the tape, adjust the depth to ordered depth and reapply the tape.
A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? The nurse assures that the oxygen is flowing into the prongs. The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. The nurse encourages the patient to breathe through the nose with the mouth closed. The nurse adjusts the flow rate to 6 L/min or more.
The nurse encourages the patient to breathe through the nose with the mouth closed.
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: sodium and potassium levels. hemoglobin level. age. blood pH.
hemoglobin level
While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique?
lung expansion
How should the nurse handle removing a chest tube from a patient leaving the unit for surgery?
never clamp but disconnect from suction tubing to continue gravity to drain.
What should the a patient not breath through when using spirometer?
nose. only mouth breathing in and out
The nurse is caring for a client with respiratory acidosis. Which arterial blood gas data does the nurse anticipate finding? pH less than 7.35; HCO3 high; PaCO2 high pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation pH greater than 7.45; HCO3 high; PaCO2 high pH less than 7.35; HCO3 low; PaCO2 low
pH less than 7.35; HCO3 high; PaCO2 high
A client did not seek medical treatment for a previous respiratory infection, and subsequently an empyema developed in the left lung. The nurse should assess the client for which signs and symptoms associated with this problem? 1. Pleural pain and fever 2.Decreased respiratory rate 3.Diaphoresis during the day 4.Hyperresonant breath sounds over the left thorax
pleural pain and fever. Dull resonance would be auscultated. increased respiration, weight loss, and infection would be noted.
What structural changes to the respiratory system should a nurse observe when caring for older adults? increased mouth breathing and snoring increased use of accessory muscles for breathing respiratory muscles become weaker diminished coughing and gag reflexes
respiratory muscles become weaker
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? loss of sterile field trauma to the tracheal mucosa suctioning of carbon dioxide prevention of suctioning
trauma to the tracheal mucosa. Occluding the Y-port on the suction tubing is what creates the suction. While suctioning would be difficult but possible, suctioning while advancing the tube would damage the tracheal mucosa and remove excessive amounts of oxygen, not carbon dioxide
A nurse assessing a client's respiratory effort notes that the client is breathing 8 shallow breaths/min. Which action best meets this client's immediate oxygenation needs? Use a bag and mask. Establish an oxygen hood. Suction the client's upper airway. Apply nasal cannula at 6 L/min
use a bag and mask . this is used in emergency situations. Ambu bag
The nurse is caring for a client on a mechanical ventilator. The high-pressure alarm on the ventilator sounds. The nurse suspects that the most likely cause of the alarm is which finding? 1.A disconnection of the ventilator tubing 2.An exaggerated client inspiratory effort 3.Accumulation of respiratory secretions 4.Generation of extreme negative pressure by the client
3.Accumulation of respiratory secretions. Low pressure would indicate disconnection
An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? Tilt the patient's head forward. Hold the mask tightly over the patient's nose and mouth. Pull the patient's jaw backward. Compress the bag twice the normal respiratory rate for the patient.
Hold the mask tightly over the patient's nose and mouth. Bag is compressed at normal respiratory rate (16breath/min)
A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. "I will be careful not to shake up the canister before using it." "I will hold the canister upside down when using it." "I will inhale the medication through my nose." "I will continue to inhale when the cold propellant is in my throat." "I will only inhale one spray with one breath." "I will activate the device while continuing to inhale."
I will continue to inhale when the cold propellant is in my throat." "I will only inhale one spray with one breath." "I will activate the device while continuing to inhale."
The nurse is preparing to teach a client how to perform incentive spirometry. Which concept should the nurse include? Oxygen saturation is expected to decrease during the first few minutes of incentive spirometry. Incentive spirometry provides visual reinforcement of deep breathing. Proper, frequent use of incentive spirometry can improve pulmonary circulation. The client should forcefully exhale into the incentive spirometer and continue to exhale until unable to continue.
Incentive spirometry provides visual reinforcement of deep breathing.
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? Discard the first sputum produced by the client. Instruct the client to inhale deeply and then cough. Have the client clear the nose and throat and gargle with salt water before beginning the procedure. Place the client in the dorsal recumbent position to collect the specimen
Instruct the client to inhale deeply and then cough.
A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? Notify the health care provider. Apply an occlusive dressing on the site. Assess the patient for signs of respiratory distress. Put on gloves and insert the chest tube in a bottle of sterile saline.
Put on gloves and insert the chest tube in a bottle of sterile saline. This creates a water seal. This is done instead of clamping to prevent another pneumothorax. Then the nurse should assess vital signs and notify the health care provider.
A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. Refrain from exercise. Reduce anxiety. Eat meals 1 to 2 hours prior to breathing treatments. Eat a high-protein/high-calorie diet. Maintain a high-Fowler's position when possible. Drink 2 to 3 pints of clear fluids daily.
Reduce anxiety Eat a high-protein/high-calorie diet. Maintain a high-Fowler's position when possible. meals should be eaten 1-2 hours AFTER 2-3 QUARTS, not pints of water
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? The client has developed a pulmonary embolism and has a ventilation-perfusion mismatch. The client is holding his or her breath. The client's appendix has ruptured. The nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen.
The nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen.
The nurse educator would intervene with client teaching if which action by the staff nurse occurs when teaching voluntary coughing? The nurse has the client lying in bed in semi-Fowler's position. The nurse develops a specific schedule for coughing. The nurse reminds the client to combine coughing and deep breathing. The nurse encourages the client to cough before meals.
The nurse has the client lying in bed in semi-Fowler's position.The client should be sitting upright with feet flat on the floor to be most effective. As part of the client's plan of care, the nurse should develop a specific schedule for coughing. Coughing before meals improves the taste of food and oxygenation. When combined with deep breathing, coughing is most effective.
A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter? The age of the patient The size of the endotracheal tube The type of secretions to be suctioned The height and weight of the patient
The size of the endotracheal tube. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. Larger catheters can contribute to trauma and hypoxemia.
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? decreased respiratory rate confusion decreased blood pressure hyperactivity
confusion
The nurse is monitoring the function of a client's chest tube that is attached to a Pleur-Evac drainage system. The nurse notes that the fluid in the water-seal chamber rises with inspiration and falls with expiration. The nurse determines that which is occurring?1. The system is patent.2. There is a leak in the system.3. The client has residual pneumothorax.4. Suction should be added to the system
1. The system is patent.
The nurse is caring for a client with an endotracheal tube attached to a mechanical ventilator. The high-pressure alarm sounds, and the nurse assesses the client. The nurse determines that the cause of the alarm is most likely to be due to which complication? 1.A kink in the ventilator circuit 2.A leak in the endotracheal tube cuff 3.Displacement of the endotracheal tube 4.A disconnection of the ventilator tubin
1.A kink in the ventilator circuit
The nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding? 1.A tubing obstruction or kink 2.The accumulation of secretions 3.Disconnection of the ventilator tubing 4.Condensation of water in the ventilator tubing
1.A tubing obstruction or kink
The nurse is planning care for a client who is prescribed a simple mask for oxygen delivery. What intervention will the nurse include in the plan of care? Set the flow meter to deliver oxygen at 2 L/min Target the client's oxygen saturation to be 88% to 92% 90.88 to 0.92) Assess the client for anxiety due to claustrophobia Monitor the client for oxygen toxicity
Assess the client for anxiety due to claustrophobia
The nurse is monitoring a client who is receiving oxygen via a nonrebreather mask at 12 L/min. What actions by the nurse will promote the best outcomes for this client? Select all that apply. Take the mask off frequently to allow the client to have rest periods. Use petroleum jelly around the nose and mouth to prevent the drying effects from the oxygen. Check that the valves and rubber flaps are functioning properly. Maintain flow rate so that the reservoir bag collapses only slightly during inspiration. Monitor SaO2 with pulse oximeter.
Check that the valves and rubber flaps are functioning properly. Maintain flow rate so that the reservoir bag collapses only slightly during inspiration. Monitor SaO2 with pulse oximeter.
A new graduate nurse is performing a focused respiratory assessment. The nurse preceptor will intervene if which action by the graduate nurse is noted? The graduate nurse explains the assessment procedure before performing it. The graduate nurse palpates the point of maximal impulse (PMI). The graduate nurse auscultates breath sounds as the client breathes through the nose. The graduate nurse attaches a pulse oximeter to the client's index finger.
The graduate nurse auscultates breath sounds as the client breathes through the nose.
suctioning uses clean or sterile technique
both; sterile for dominant hand that feeds device and clean for opposing hand.
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 Perfusion Atelectasis Hyperventilation
hypoxia
What should be done if the tracheostomy comes unlodged?
maintain oxygen with manual bag, contact provider, cover stoma with ?, and assess respiration status
While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique? consolidated portions of the lung fluid-filled portions of the lung pattern of thoracic expansion presence of pleural rub
pattern of thoracic expansion
An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? 1.Face tent 2.Venturi mask 3.Aerosol mask 4.Tracheostomy collar
2.Venturi mask. it delivers the most accurate level of oxygen.
The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made?1. The skin color becomes cyanotic.2. Secretions are becoming bloody.3. Coughing occurs with suctioning.4. Heart rate decreases from 78 to 54 beats per minute.
3. Coughing occurs with suctioning.
The nurse is providing an educational demonstration to an older, postsurgical client. The intervention is intended to minimize the effect of what age-related change specifically relevant to such a client? A decrease in gas exchange and an increase in the work of beathing related to decreased elastic recoil of the lungs A decrease in the ability to respond to stress related to ineffective cardiac muscle function A decrease in ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs A decrease in cardiac output related to progressive atherosclerosis
A decrease in ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs. All changes are true but coughing phlegm stasis most important post surgery.
Martin is a 58-year-old smoker who was admitted to the hospital with worsening shortness of breath over the last 2 days. He states that he is having some chest discomfort. The nurse asks him further about this in order to characterize whether this may be cardiac related, musculoskeletal related, or respiratory related. Martin states that when he breathes in, he feels as if the air passing into his lungs is burning him. It is also very painful to swallow. Based on what Martin is stating, which illness does the nurse suspect is causing Martin's chest discomfort? Acute bronchitis Pneumonia Emphysema Coronary artery disease
Acute bronchitis
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? 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. Apply steady, firm pressure on the puncture site for 5 to 15 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.
The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take? Assess oxygen tubing connection Elevate head of the bed Reposition client Assess lung sounds
Assess oxygen tubing connection
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? Adventitious Bronchovesicular Bronchial Vesicular
Bronchial-high pitched heard of trachea Broncovesticular--medium pitched heard over bronchi vesticular-low pitched over lungs
Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. Closely assess the patient before, during, and after the procedure. Hyperoxygenate the patient before and after suctioning. Limit the application of suction to 20 to 30 seconds. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Use an appropriate suction pressure (80 to 150 mm Hg). Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube
Closely assess the patient before, during, and after the procedure. Hyperoxygenate the patient before and after suctioning. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Use an appropriate suction pressure (80 to 150 mm Hg). ithe suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube
The nurse is monitoring a client with continuous pulse oximetry. What actions by the nurse are important to obtain accurate results? Select all that apply. The sensor can produce accurate results even if circulation to the sensor site is impaired. Correlate the pulse oximetry reading with the client's heart rate. If the client has low cardiac output, use the forehead sensor. To provide continuous measurement of oxygen saturation, anticipate an arterial line be inserted. If the client has emphysema, the reading may be inaccurate. An oxygen saturation as well as the respiratory rate may be obtained with the pulse oximeter
Correlate the pulse oximetry reading with the client's heart rate. If the client has low cardiac output, use the forehead sensor. If the client has emphysema, the reading may be inaccurate.
Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways? increases carbon dioxide, which stimulates breathing helps liquefy his secretions decreases the amount of air trapping and resistance teaches him to prolong inspiration and shorten expiration
decreases the amount of air trapping and resistance. this prolongs expiration, NOT inspiration. slower expiration helps prevent the collapse of the alveoli, thus increasing oxygenation.
During the physical assessment of a client who has been inactive due to a leg injury, the nurse notes that the client tends to breathe very shallowly. What technique should the nurse teach the client in order to breathe more efficiently? incentive spirometry pursed-lip breathing diaphragmatic breathing deep breathing
deep breathing
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? 1.A low respiratory rate 2.Diminished breath sounds 3.The presence of a barrel chest 4.A sucking sound at the site of injury
diminished breath sounds. sounds would be diminished as there is a layer of air in pleural cavity blocked sound transmission. respiratory rate would increase as compensation.
The nurse is providing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because in normal respiration, as the diaphragm contracts, it takes which action? 1.Aids in exhalation 2.Moves up and inward 3.Moves downward and out 4.Makes the thoracic cage smaller
downward and out to allow for INHILATION
A client is prescribed a corticosteroid for the treatment of asthma after having an asthma attack. What education should the nurse provide to the client regarding the administration of this medication? Weigh yourself each night prior to going to bed. Monitor blood pressure and blood sugar. Increase sodium intake while taking this medication. This medication may cause drowsiness and should be used with caution while driving.
monitor blood pressure and blood sugar.