Chapter 30: Respiratory Function

The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide? - "It is important to eat at least five servings of vegetables daily." - "Remove your oxygen before cooking near the gas stove." - "An electric stove may be a safer choice for you." - "Be careful not to trip over your oxygen tubing while cooking."

- "An electric stove may be a safer choice for you." Explanation: For safety purposes, oxygen tanks should be kept at least 10 feet away from gas stoves, fires, and other flammable devices. If the client removes the oxygen while cooking at a gas stove, hypoxia may occur and the client may become confused and sustain burns.

A client is receiving supplemental oxygen and the nurse is monitoring the client's oxygen saturation level using pulse oximetry. The nurse notifies the physician if the client reaches which oxygen saturation level? - 98% - 96% - 94% - 92%

- 92% Explanation: An oxygen saturation level less than 93% usually indicates the need for increased supplemental oxygen.

A nurse has an order to obtain a sputum specimen on a newly admitted client. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? - Auscultate the client's lung sounds before the sputum specimen is collected. - Label the sputum specimen and take it to the lab. - Instruct the client on how to use a nebulizer. - Perform chest physiotherapy.

- Label the sputum specimen and take it to the lab. Explanation: Labeling of specimens and transporting them to the lab is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel.

A 72 year-old client has come for an annual wellness check-up with the health care provider. Which vaccine will the nurse discuss with the client? - Diphtheria, tetanus, and pertussis (DTaP) - Hepatitis A - Measles, mumps, rubella (MMR) - Pneumococcal 13-valent conjugate

- Pneumococcal 13-valent conjugate Explanation: Clients over the age of 65 years old OR those who have a compromising chronic health condition should be offered Pneumococcal 13-valent conjugate, which reduces strains of streptococcal pneumonia. Other options are not appropriate for the scenario.

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? - confusion - decreased blood pressure - decreased respiratory rate - hyperactivity

- confusion Explanation: Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, elevated blood pressure with small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

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? - high temperature - high respiratory rate - low pulse rate - low blood pressure

- high respiratory rate Explanation: A client diagnosed with Impaired Gas Exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.

The nurse enters a client's room, observes the client coughing vigorously, and determines that the client is breathing but has a partially obstructed airway. Which action should the nurse take next? - Palpate extremities for bilateral pulses. - Observe the client's respiratory effort. - Check the client's level of consciousness. - Call a code.

- Observe the client's respiratory effort. Explanation: Other than encouraging and supporting the client, a partial airway obstruction requires no additional resuscitation efforts. If the client's independent efforts to relieve a partial obstruction are unsuccessful or if the situation worsens, activating the emergency medical system by calling a code is appropriate.

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? - Chest x-ray - Bronchoscopy - Skin tests - Pulmonary function tests

- Pulmonary function tests Explanation: Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding? - 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 chest should be slightly convex with no sternal depression. Explanation: The adult chest contour is slightly convex, with no sternal depression. The skin of the thorax should be warm and dry, and the anteroposterior diameter of the chest should be less than the transverse diameter. The contour of the intercostal spaces should be flat or depressed.

Which physiologic change does the nurse anticipate will be found in the older adult client with an ongoing nonproductive cough? - laryngeal atrophy - moist mucous membranes - increased lung capacity - flexibility of the chest wall

- laryngeal atrophy Explanation: The older adult client experiences laryngeal atrophy as the body ages, drier mucous membranes, diminished lung capacity, and increased rigidity of the chest wall.

A client is diagnosed with hypoxia related to emphysema. The client's adult child will be assisting the client with daily hygiene. How will the nurse explain positioning of the client to the caregiver? - "Place your parent at the sink to allow teeth brushing and stand outside of the shower to help if needed." - "Whichever position helps your parent feel most comfortable and will allow you to help with hygiene is fine." - "A standing position works best to allow your parent to move around in the bathroom and to allow you to help your parent in and out of the shower." - "An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist."

- "An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist." Explanation: The best way to explain caregiving is to describe the specific position and type of chair to use as well as teach the caregiver why it is the best position and device. Teaching the caregiver to place the parent at the sink and then stand outside the shower does not provide the best position nor the device to obtain, plus it does not address the facts that the parent standing in the shower may not be possible due to hypoxia and is not safe. Teaching the caregiver to use whichever position is most comfortable for the parent does not address the safest position for the client nor the position that provides easiest breathing and energy conservation. Standing for the period of time it may take to complete daily hygiene is not feasible or safe for the client and should not be recommended by the nurse.

An older adult client was recently placed on home oxygen. The client's caregiver reports that the client now refuses to leave the house. What teaching will the nurse provide the caregiver? Select all that apply. - "Continued socialization with others is important." - "Discuss with the client switching to a portable oxygen device." - "Give the client time to adjust." - "Invite friends and family to the client's house." - "Remove the oxygen for times when the client wants to leave the house."

- "Continued socialization with others is important." - "Discuss with the client switching to a portable oxygen device." - "Invite friends and family to the client's house." Explanation: Socialization is important for older adults. Having a portable oxygen device increases functional mobility. Inviting friends and family provides socialization and may help the client feel more at ease with oxygen use. The nurse should not suggest that the caregiver ignore the issue or remove the oxygen are inappropriate; these are inappropriate actions.

The nurse is preparing a client for a tracheostomy insertion with a fenestrated tracheostomy tube. Which statement made by the client indicates an accurate understanding of the fenestrated tube? - "I'm glad I will still be able to talk once I get this tube inserted." - "This type of tube does not have to be cleaned." - "This tube will never become dislodged." - "Since this tube has holes, I won't be able to swallow."

- "I'm glad I will still be able to talk once I get this tube inserted." Explanation: A fenestrated tube has a hole in it and allows air to flow over the vocal chords, so the client will be able to speak. The tube still needs to be cleaned and suctioned. The tube may still become dislodged, and the client is able to swallow.

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? - "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." - "Take in a small amount of air very quickly and then exhale as quickly as possible." - "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." - "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling."

- "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Explanation: Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.

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? - "Did you remove your dentures?" - "Is your mask causing discomfort?" - "Did someone take your mask off?" - "Did someone loosen the straps on your mask?"

- "Is your mask causing discomfort?" Explanation: It is possible for anyone using a mask to try and readjust it if it is uncomfortable. Depending on the older adult's cognitive status, he or she may have tried to make it more comfortable and in the process caused it to no longer fit correctly. This could also occur if the client removed their dentures, as some individual's choose to let the dentures soak overnight. If the mask was fitted with the dentures in, the mask will likely be loose with the dentures removed. The other questions could possibly be asked to see if someone else may have tried to help the client feel more comfortable with the mask on.

A client using home oxygen asks the nurse about changing to an oxygen concentrator. What is the appropriate nursing response? Select all that apply. - "It collects and concentrates oxygen from room air." - "It eliminates the need for a central reservoir of piped oxygen." - "You may notice an increase in your electric bill." - "It costs less than oxygen supplied in portable tanks." - "This is only an option if you live in a long-term care facility."

- "It collects and concentrates oxygen from room air." - "It eliminates the need for a central reservoir of piped oxygen." - "You may notice an increase in your electric bill." - "It costs less than oxygen supplied in portable tanks." Explanation: An oxygen concentrator collects and concentrates oxygen from room air. It eliminates the need for a central reservoir of pipe oxygen and it is an economical choice. It may increase the client's electric bill. These can be used in homes, not long-term care facilities.

The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach? - "Take in a small amount of air and exhale quickly." - "Take in as much air as possible, hold your breath briefly, and exhale slowly." - "Take in a large volume of air and hold your breath as long as you can." - "Take in a little air, hold your breath 15 seconds, and exhale slowly."

- "Take in as much air as possible, hold your breath briefly, and exhale slowly." Explanation: This technique maximizes ventilation taking in a large volume of air fills alveoli to a greater capacity, which improves gas exchange. Deep breathing is useful for client's who has been inactive or in pain as associated with pneumonia. The other techniques do not promote improved gas exchange.

he health care provider has prescribed a long-acting bronchodilator for a client with a history of bronchospasm. What teaching about this drug will the nurse include? - "You only need this drug if you are exercising." - "Take this drug when you need quick relief." - "This drug is to be used as a rescue inhalant." - "Use this drug daily to prevent bronchospasm."

- "Use this drug daily to prevent bronchospasm." Explanation: Long-acting bronchodilators are used daily for preventing asthma attacks or exercise-induced bronchospasm. SABAs are used for quick relief and in rescue situations. They are not to be used only when exercising.

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? - "An occasional cigarette will not hurt you." - "You should never smoke when oxygen is in use." - "I understand; I used to be a smoker also." - "Oxygen is a flammable gas."

- "You should never smoke when oxygen is in use." Explanation: The nurse will educate the client about the dangers of smoking when oxygen is in use. Oxygen is not flammable, but it oxidizes other materials. Other answers are inappropriate.

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 - 10 to 60 mm Hg - 50 to 100 mm Hg - 150 to 200 mm Hg

- 100 to 120 mm Hg Explanation: The appropriate suction pressure for a wall unit for an adult is 100 to 120 mm Hg. Higher pressures can cause excessive trauma, hypoxemia, and atelectasis.

A nurse needs to use a wall suction machine on an adult client with breathing difficulties due to chest congestion, as per the order from the client's physician. What amount of negative pressure should the nurse apply for this client? - 100 to 140 mm Hg - 145 to 150 mm Hg - 95 to 100 mm Hg - 50 to 95 mm Hg

- 100 to 140 mm Hg Explanation: The nurse needs to apply a negative pressure between 100 and 140 mm Hg, depending on institutional policy, for adult clients when a wall suction machine is used. When using a wall suction machine, 95 to 100 mm Hg of negative pressure is applied for children and 50 to 95 mm Hg of negative pressure is applied for infants.

The nurse is caring for four clients. Which client does the nurse identify who would best benefit from chest physiotherapy? - 21-year-old client with cystic fibrosis - 34-year-old client with appendicitis - 45-year-old client with influenza - 51-year-old client with diabetic ketoacidosis

- 21-year-old client with cystic fibrosis Explanation: Clients with chronic respiratory diseases who have difficulty coughing or raising thick mucus, such as those with cystic fibrosis, will benefit best from chest physiotherapy. Chest physiotherapy is not as beneficial to those with appendicitis, influenza, or diabetic ketoacidosis.

A client is receiving oxygen therapy via a nasal cannula at 3 L/min. The nurse estimates that the client is receiving which concentration of oxygen? - 22% - 26% - 30% - 34%

- 30% Explanation: Using the 'rule of four" for each L/min, the oxygen concentration increases by 4%. Therefore, 1 L/min provides 22% oxygen and 2 L/min provides 26%. The nurse would estimate that 3 L/min would provide 30% oxygen. A flow rate of 4 L/min would provide an oxygen concentration of 34%.

Erin is a 35-year-old woman being cared for in the emergency department for a cough and hemoptysis for 3 days. Erin states that she has smoked one-and-a-half packs of cigarettes per day for the last 5 years. In trying to identify risk factors for Erin, the nurse calculates her pack-year history to write on the intake form. What is Erin's pack-year of smoking? - 5 - 7.5 - 5.5 - 7

- 7.5 Explanation: One "pack-year" is equal to smoking one pack of cigarettes for a day for 1 year. Based on Erin's information, Erin's has a 7.5 pack-year smoking history.

An unconscious adolesecent is brought to the emergency department with a respiratory rate of 6 breaths/min following a suspected opioid drug overdose. What is the nurse's most appropriate action? - Assess the client using the Glascow Coma Scale. - Obtain the client's blood pressure. - Administer prescribed naloxone. - Contact the parents/guardians of the adolescent.

- Administer prescribed naloxone. Explanation: Opioid overdose can cause a person to stop breathing. In situations where naloxone, a single-dose autoinjector opioid antagonist, is available, it should be used. If the naloxone works, the respiratory rate will improve. After the client has been stabilized, the nurse may assess consciousness and blood pressure as well as contact the adolescent's parents/guardians.

An older adult client with a history of chronic obstructive pulmonary disease is admitted to the hospital with a cough and acute shortness of breath. Which priority action should the nurse take during the initial assessment of the client? - Assist the client to lie down to complete a full physical assessment. - Ask specific questions about the history of the cough and shortness of breath. - Assess for allergies before treatment. - Administer pulmonary function tests.

- Ask specific questions about the history of the cough and shortness of breath. Explanation: Inquiring about a current history of coughing, determining how long the cough has been present, and observing and describing any sputum are important when assessing older adults. The client may have difficulty lying down for the assessment. Allergies should be assessed, but are not the priority. Administration of pulmonary function tests would be completed after the initial assessment.

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention? - Ask the client what factors contribute to nonadherence. - Contact the health care provider to report the client's current status. - Explain the use of a BiPAP mask instead of a CPAP mask. - Document outcomes of modifications in care.

- Ask the client what factors contribute to nonadherence. Explanation: The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment. Then, the nurse can work with the health care provider to find alternate treatment options if necessary, and then document the care.

While jogging through the neighborhood, a nurse witnesses the collapse of a nearby jogger and suspects cardiac arrest. Which action should the nurse take first? - Assess the victim for consciousness. - Activate the emergency medical services. - Begin chest compressions. - Initiate rescue breathing.

- Assess the victim for consciousness. Explanation: The priority action is to check the victim for consciousness. With the victim in a supine position on a dry, firm surface, a quick assessment taking no more than 10 seconds is performed to determine unresponsiveness and the absence of normal breathing or a pulse. The other actions are not the priority.

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which instruction will the nurse include in the teaching? - Inhale through the nose instead of the mouth. - Be sure to shake the canister before using it. - Inhale the medication rapidly. - Inhale two sprays with one breath for faster action.

- Be sure to shake the canister before using it. Explanation: A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly. MDIs are inhaled through the mouth and into the lungs. The medication should be inhaled slowly to ensure a sufficient dose enters the lungs. If the order is for two sprays, these sprays are administered with one spray for each breath. The inhaled breath should be held briefly after each spray in order to prevent the client from immediately exhaling the medication.

Which technique would the nurse employ to maximize the effectiveness of postural drainage? - Combine it with percussion and vibration. - Conduct it before administering inhalant medications. - Encourage the client to increase the frequency to eight times a day. - Maximize how long the client holds each position to 60 minutes.

- Combine it with percussion and vibration. Explanation: Combining postural drainage with percussion and vibration enhances overall effectiveness. The technique should be done after inhalant medications are administered. The nurse should not encourage the client to do postural drainage more than four times a day and should advise the client to hold each position for no more than 45 minutes.

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? - Hyperventilation - Hypoxia - Perfusion - Atelectasis

- Hypoxia Explanation: Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia. Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements. Perfusion refers to the process by which oxygenated capillary blood passes through body tissues. Atelectasis refers to collapsed alveoli.

Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen? - It prescribes oxygen concentration. - It regulates the amount of oxygen received. - It determines whether the client is getting enough oxygen. - It decreases dry mucous membranes via delivering small water droplets.

- It regulates the amount of oxygen received. Explanation: The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The oxygen analyzer measures the percentage of delivered oxygen. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.

A nurse is caring for a client who sustained head trauma. The client is in a medically induced coma and on mechanical ventilation. The client's parent is at the bedside in tears. The parent states, "I just want my child to know I am here." To address the needs of the parent and the client, what would be the nurse's most appropriate response? - Place a chair next to the bed and encourage the parent to hold the client's hand. - Place the client's hand on the parent's hand and reassure the parent that things will be fine. - Place a chair next to the bed and then leave the room to allow the parent to grieve. - Encourage the parent to bring in pictures of the family that can be displayed in the room.

- Place a chair next to the bed and encourage the parent to hold the client's hand. Explanation: Despite its individuality, touch is viewed as one of the most effective nonverbal ways to express feelings of comfort, love, affection, security, anger, frustration, aggression, excitement, and many others. The nurse may feel it is appropriate to place the client's hand on the parent's hand; however, the nurse should not provide false hope. The nurse should not leave the parent alone to grieve; the nurse should show the parent how to use comforting communication. The client is in a chemically induced coma and will not be able to see pictures that are displayed in the room.

A nurse conducts a health history for a client with chronic bronchitis. Which action does the nurse take first when the client begins to experience respiratory distress? - Place the client in a comfortable position, ensure an open airway and if oxygen is prescribed start administration - Assess the client's rate and quality of respirations - Get assistance in case oxygen, medications, or further intervention is needed - Speak slowly and calmly to the client to facilitate relaxation and ease respirations

- Place the client in a comfortable position, ensure an open airway and if oxygen is prescribed start administration Explanation: If a nurse is conducting a health history interview for a client diagnosed with chronic bronchitis when respiratory distress occurs, the nurse first places the client in a comfortable position, ensures a patent airway, and starts oxygen if prescribed. After ensuring an open airway, the next step is quickly assessing the respiratory rate and quality and then getting assistance in case the client's respiratory status starts to deteriorate. Speaking slowly and calmly to relax the client is valuable but does not help assess the client's respiratory distress or prepare to manage it. The condition may require further intervention so preparation is needed.

A client is taking albuterol via nebulizer. Which instruction will the nurse provide to teach the client how to use the nebulizer? - Place the mouthpiece in your mouth. Breath in the medication then remove the mouthpiece to breathe the medicine out. - Place the mouthpiece in your mouth. Intermittently breathe through your nose and mouth so that all of the medicine goes into your lungs - Place the mouthpiece near your mouth. Inhale the medicine into your lungs. - Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs.

- Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs. Explanation: A nebulizer is used to administer medications in the form of an inhaled mist. The nurse will instruct the client to place the mouthpiece in the mouth, keep the lips firm around the mouthpiece so that all of the medicine goes into the lungs, and continue until the mist stops. Any other option allows for the medication to be lost, rather than inhaled into the lungs.

A client returns to the unit following an insertion of a tracheostomy tube. Where should the nurse place the obturator? - Attach the obturator to a string and tie it to the bed. - Place the obturator in a plastic bag and put it at the bedside. - Send the obturator home with the client's family. - Keep the obturator in the nursing station.

- Place the obturator in a plastic bag and put it at the bedside. Explanation: The obturator is a curved guide with a bullet-shaped tip. The obturator is used at the time of tube insertion to prevent the edge of the cannula from traumatizing tracheal tissue. Once the tube is in place, the obturator is removed, placed in a plastic bag, and retained at the bedside in the event of an accidental extubation.

A nurse is caring for a client with a tracheostomy tube in place who has rhonchi bilaterally and a SaO2 of 94%. If the client is unsuccessful in coughing up secretions, what action should the nurse take? - Encourage the use of an incentive spirometer. - Assist the client to increase oral fluid intake. - Put on sterile gloves and use a sterile catheter to suction. - Increase the flow rate of oxygen.

- Put on sterile gloves and use a sterile catheter to suction. Explanation: This client required suctioning to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The incentive spirometer opens alveoli and can induce coughing, which can mobilize secretions; however, the client with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner for this client. Increasing the oxygen flow rate will not help mobilize secretions.

A nurse is delivering oxygen to a client via an oxygen mask. Which guideline is recommended for this procedure? - Adjust the mask so it is fully airtight around the face. - For a mask with a reservoir, fill the reservoir half full of oxygen. - Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously. - If the client is experiencing redness around the mask, remove and apply powder to the mask.

- Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously. Explanation: To apply an oxygen mask, position the facemask over the client's nose and mouth and adjust the elastic strap so that the mask fits snugly but comfortably on the face. For a mask with a reservoir, be sure to allow oxygen to fill the bag before proceeding with application. Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously, and do not use powder around the mask.

A client has had a head injury affecting the brain stem. What is located in the brain stem that may affect respiratory function? - Chemoreceptors - Stretch receptors - Respiratory center - Oxygen center

- Respiratory center Explanation: The medulla in the brain stem, immediately above the spinal cord, is the respiratory center. Stretch receptors are located in muscles. Chemoreceptors that affect respirations are located in the aortic arch and the carotid bodies. There is not a oxygen center in the body.

A nurse walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action? - Get the crash cart with automatic defibrillator. - Open the airway. - Start chest compressions. - Give the client oxygen.

- Start chest compressions. Explanation: Resuscitation must proceed with CAB (circulation, airway, breathing). Chest compressions are used to keep blood moving through the body and to the vital areas, such as the brain. After 2 minutes of compressions, the rescuer opens the victim's airway.

When caring for a client with a tracheostomy, the nurse would perform which recommended action? - Clean the wound around the tube and inner cannula at least every 24 hours. - Assess a newly inserted tracheostomy every 3 to 4 hours. - Use gauze dressings over the tracheostomy that are filled with cotton. - Suction the tracheostomy tube using sterile technique.

- Suction the tracheostomy tube using sterile technique. Explanation: Sterile technique is required when suctioning a tracheostomy in order to prevent introduction of microorganisms into the respiratory tract. The area around a new tracheostomy may need to be assessed and cleaned every 1 to 2 hours. Gauze dressings that are not filled with cotton must be used to prevent aspiration of lint or cotton fibers into the trachea.

What can a nurse ask a client to do before suctioning to prevent hypoxemia? - Sit in an upright position and cough. - Breathe normally for at least 5 minutes. - Lie flat in bed and practice relaxation. - Take several deep breaths.

- Take several deep breaths. Explanation: Suctioning removes oxygen from the respiratory tract, possibly causing hypoxemia (insufficient oxygen in the blood). The client should be hyperoxygenated before suctioning, so the nurse should ask him to take several deep breaths before the nurse inserts the suction catheter.

What is the rationale for placing a writing board in the room of a client who has had surgery to insert a tracheostomy tube? - The client is not able to speak. - Verbal communication will be too tiring. - It will occupy the client's time. - Voice rest will decrease pain levels.

- The client is not able to speak. Explanation: A client with a tracheostomy tube is unable to speak. Keep communication tools, such as a writing board or vocabulary cards, close at hand along with the call light or bell.

A client is ordered to receive oxygen therapy via nasal cannula at 4 L/minute. When providing care to this client, what would the nurse need to keep in mind? Select all that apply. - The maximum flow rate that can be used is 6 L/minute. - The client's mouth breathing will decrease the amount of oxygen delivered. - The client must have clear, patent nasal passages. - The oxygen needs to be humidified to prevent drying of the mucosa. - The oxygen concentration delivered will remain constant despite changes in breathing pattern.

- The maximum flow rate that can be used is 6 L/minute. - The client must have clear, patent nasal passages. - The oxygen needs to be humidified to prevent drying of the mucosa. Explanation: When oxygen is delivered via nasal cannula, the maximum flow rate that can be used is 6 liters/minute. Mouth breathing does not appreciably diminish the oxygen delivered. Nasal passages must be patent for the client to receive the oxygen. Oxygen is drying to the nasal mucosa and thus should be humidified. The delivered oxygen concentration can vary depending on the client's breathing pattern.

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. Explanation: Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

A nurse is preparing to orally suction a client with dysphagia following a stroke. Which suction device is appropriate? - bulb syringe - open suctioning - Yankauer catheter - closed suctioning

- Yankauer catheter Explanation: Nurses perform oral suctioning (removing secretions from the mouth) with a suctioning device called a Yankauer-tip or tonsil-tip catheter. This is the appropriate device to use for a client with difficulty swallowing. The other types of suctioning (open and closed) are used for the lower airways. Bulb syringes are used with infants.

The nurse is caring for the following clients. Which client is at highest risk for a depressed respiratory system? - a client taking amlodipine for hypertension - a client taking methocarbamol for low back spasms - a client taking methimazole for hyperthyroidism - a client taking an opioid for cancer pain

- a client taking an opioid for cancer pain Explanation: Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Amlodipine is a calcium channel blocker and the medication decreases blood pressure, so the nurse would need to assess blood pressure. Muscle relaxants such as methocarbamol could depress respiratory status, but this occurs less often than with opioids. Methimazole is used to treat hyperthyroidism, thus lowering the body's metabolic functions, which can depress respirations; however, this is a very rare occurrence with this medication. The client at highest risk is the one taking an opioid.

A client is experiencing hypoxia. Which nursing concern is appropriate to address when planning care? - anxiety - nausea - pain - hypothermia

- anxiety Explanation: Clients who are hypoxic commonly experience anxiety and restlessness related to feelings of suffocation. Pain, nausea, and hypothermia is not associated with a client experiencing hypoxia.

What does pulse oximetry measure? - cardiac output - peripheral blood flow - arterial oxygen saturation - venous oxygen saturation

- arterial oxygen saturation Explanation: Pulse oximetry is a noninvasive technique that measures the oxygen saturation of arterial blood. The normal range is 95% to 100%. It does not measure cardiac output, peripheral blood flow, or venous oxygen saturation.

A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate? - changes in the alveolar-capillary membrane and diffusion - alterations in the structures of the ribs and diaphragm - rapid decreases in atmospheric and intrapulmonic pressures - lower-than-normal concentrations of environmental oxygen

- changes in the alveolar-capillary membrane and diffusion Explanation: Any change in the surface area of the lungs hinders diffusion of gas exchange. Any disease or condition that results in changes in the alveolar-capillary membrane, such as pneumonia or pulmonary edema, makes diffusion more difficult. Diffusion is assessed by a decreased oxygen saturation measurement. The environmental oxygen which comprises the atmospheric pressure, ribs, and diaphragm do not influence the diffusion of gas exchange inside the lungs.

The nurse receives a change-of-shift report on the following clients with chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? - client with loud expiratory wheezing - client with a respiratory rate of 36 breaths/minute - client who has a productive cough of thick, green mucus - client with a day-old tracheostomy

- client with a respiratory rate of 36 breaths/minute Explanation: A respiratory rate of 36 breaths/minute indicates severe respiratory distress, and the client needs immediate assessment and intervention to prevent possible respiratory arrest. Lack of oxygen for more than 4 to 6 minutes can result in death or permanent brain damage. Therefore, it is essential to identify respiratory problems and to plan care accordingly for clients at risk. The other clients also need assessment as soon as possible, but they do not need to be assessed as urgently as the tachypneic client.

A nurse is administering a prescribed dose of IV medication to a client who is recovering from partial airway obstruction. What are common reasons for airway obstruction to occur? Select all that apply. - compromised swallowing - aspiration of vomitus - continuous laughing or talking - excess intake of high-fiber food - insufficient chewing

- compromised swallowing - aspiration of vomitus - insufficient chewing Explanation: The common causes of airway obstruction are compromised swallowing, aspiration of vomitus, insufficient chewing, and eating when intoxicated, as well as other causes. Eating high-fiber food items or laughing and talking continuously do not cause airway obstruction.

A client has been receiving treatment with a nonrebreather mask for the past 96 hours. How should the nurse respond if the unlicensed assistive personnel (UAP) suddenly reports the client has vomited? - conduct a focused assessment - replace current mask with a new one - notify the health care provider - put client on NPO status

- conduct a focused assessment Explanation: The nurse should first conduct a focused assessment to gather more information. Individuals who have been receiving oxygen concentrations of more than 50% for longer than 72 hours are at an increased risk for oxygen toxicity. The signs are subtle and include nausea, vomiting, nonproductive cough, substernal chest pain, nasal stuffiness, fatigue, headache, sore throat and hypoventilation. After the nurse has finished assessing the client, then the health care provider should be notified of the findings of the assessment. The mask would need to be cleaned or replaced per the facilities policy. The client may already be on NPO status.

The nurse assesses that a client's Sp02 is 88%. What other assessment findings does the nurse anticipate? - pulse rate 60 - blood pressure 100/60 mmHg - fever of 101 degrees F - cool extremities

- cool extremities Explanation: The client with hypoxia will generally have an increased pulse rate and blood pressure, a cooler temperature, and cool extremities. Therefore, the nurse does not anticipate a higher fever, lower blood pressure, or slower pulse rate.

The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier? - tap water - normal saline - distilled water - mineral oil

- distilled water Explanation: Distilled water is used when humidification is desired. Other answers are incorrect.

When performing a physical assessment of an adult client reporting dyspnea, the nurse is aware that which of the following is an abnormal finding? - dullness over the lung fields with percussion - the chest contour is slightly convex, with no sternal depression - symmetrical movement of the chest - auscultation of low-pitched, soft sounds over the peripheral lung fields

- dullness over the lung fields with percussion Explanation: Percussion that produces dullness over the lung fields occurs when fluid or solid tissue replaces normal lung tissue. Normal assessment findings include a slightly convex chest contour with no sternal depression and symmetrical chest movement. Vesicular breath sounds described as low-pitched, soft sounds over the peripheral lung fields are also a normal respiratory assessment finding.

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing concern for this client is altered airway clearance related to copious and tenacious secretions. What is an appropriate nursing intervention to include in the client's care plan? - encouraging the client to consume at least 1.5 to 2 L of fluids daily of clear fluids daily - creating an environment that is likely to reduce anxiety - positioning the client supine - encouraging the client to decrease the number of cigarettes smoked daily

- encouraging the client to consume at least 1.5 to 2 L of fluids daily of clear fluids daily Explanation: Clients can help keep their secretions thin by drinking at least 1.5 to 2 L of fluids daily. Although it is important to create an environment that is likely to reduce a client's anxiety, doing so will not assist in promoting airway clearance. The nurse should not encourage the client to decrease the number of cigarettes smoked daily, but should encourage the client to stop smoking. Proper positioning to ease respirations includes placing the client in a high-Fowler position.

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? - oxygen analyzer - nasal strip - nasal cannula - flow meter

- flow meter Explanation: The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.

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: - hemoglobin level. - age. - blood pH. - sodium and potassium levels.

- hemoglobin level. Explanation: Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.

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 - side-lying position, half on the abdomen and half on the side - high-Fowler's position - Trendelenburg position

- high-Fowler's position Explanation: Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. High-Fowler's position is used to drain the apical sections of the upper lobes of the lungs. Placing the client lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.

An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur? - inspiration and expiration - only on inspiration - only on expiration - when coughing

- inspiration and expiration Explanation: Wheezes are continuous sounds heard on expiration and sometimes on inspiration. They originate as air passes through airways constricted by swelling (as in asthma), secretions, or tumors. Coughing, by forcing air out of the lungs under high pressure, attempts to clear the throat of foreign particles.

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use? - nonrebreather mask - Venturi mask - nasal cannula - simple mask

- nonrebreather mask Explanation: A nonrebreather mask is the only device that can deliver an FiO2 of 100% to a client without a controlled airway. A Venturi mask delivers a maximum FiO2 of 55%. A nasal cannula delivers a maximum FiO2 of 44%. A simple mask delivers a maximum FiO2 of 60%.

A nurse is caring for a critically ill client who has been admitted to the intensive care unit at the health care facility. The client is unable to breathe on his own and requires a very high concentration of oxygen. Which oxygen delivery device is most appropriate for this client? - simple mask - partial rebreather mask - nonrebreather mask - Venturi mask

- nonrebreather mask Explanation: The nurse should use a nonrebreather mask for a client who is critically ill and requires a high concentration of oxygen. A nonrebreather mask contains one-way valves that allow inhalation of only oxygen from the source and the reservoir bag; no atmospheric air is inhaled, and all exhaled air is vented from the mask. A simple mask, partial breather mask, and Venturi mask cannot be used for this client. A simple mask delivers a higher level of oxygen than a nasal cannula and is used for clients with nasal trauma and mouth breathing. A partial rebreather mask delivers a mixture of atmospheric air, oxygen from its source, and oxygen from the reservoir bag. A Venturi mask mixes a precise amount of oxygen and atmospheric air and delivers the prescribed amount.

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? - notify the health care provider - apply a new dressing over the tube - reinforce adhesive material over insertion site - document finding

- notify the health care provider Explanation: The health care provider should be notified as feeling or hearing air crackling can indicate a subcutaneous air leak and an internal displacement of the drainage tube. This requires emergent care to prevent the recurrence or further damage to the lung. Applying a new dressing or more tape would be inappropriate. The nurse would document after providing the client care.

A client with a 26-year history of cigarette smoking is recovering from pneumonia. Which information will be most important for the nurse to include in the discharge teaching? - options for smoking cessation - reasons for annual sputum cytology testing - needing to have a CT screening for lung cancer - how to perform chest physiotherapy

- options for smoking cessation Explanation: Because smoking is the major cause of lung cancer, the most important role for the nurse is to advocate for smoking cessation following recovery from acute illness. The nurse should provide teaching about the benefits of and means of smoking cessation. CT scanning is currently being investigated as a screening test for high-risk clients. However, if there is a positive finding, the person already has lung cancer. Performance of chest physiotherapy is usually completed by health care providers.

A nurse is caring for a critically ill client who is receiving oxygen through a nonrebreather mask. The nurse should remember that which situation could lead to oxygen toxicity in the client? - oxygen concentration of more than 25% given for longer than 24 hours - oxygen concentration of more than 30% given for longer than 48 hours - oxygen concentration of more than 25% given for longer than 36 hours - oxygen concentration of more than 50% given for longer than 48 hours

- oxygen concentration of more than 50% given for longer than 48 hours Explanation: When administering oxygen to a critically ill client using a nonrebreather mask, the nurse should remember that an oxygen concentration of more than 50% given for longer than 48 hours can cause oxygen toxicity in the client. Oxygen toxicity refers to lung damage that develops when oxygen concentrations of more than 50% are administered for longer than 48 to 72 hours. The best way to prevent oxygen toxicity is to administer the lowest FiO2 possible for the shortest amount of time.

The nurse is reviewing the results of a client's arterial blood gas and pH analysis. Which findings indicate to the nurse that intervention is not required? Select all that apply. - pH 7.45 - PCO2 40 mm Hg - PO2 70 mm Hg - HCO3 30 mEq/L - Base excess or deficit +2 mmol/L

- pH 7.45 - PCO2 40 mm Hg - Base excess or deficit +2 mmol/L Explanation: Normal ABG findings include a pH of 7.35-7.45, PCO2 35-45 mm Hg, PO2 80-100 mm Hg, and Base excess or deficit +2 mmol/L

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 low; PaCO2 low - pH greater than 7.45; HCO3 high; PaCO2 high - pH less than 7.35; HCO3 high; PaCO2 high - pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation

- pH less than 7.35; HCO3 high; PaCO2 high Explanation: In respiratory acidosis, anticipated arterial blood gas results are anticipated to reflect pH less than 7.35; HCO3 high; and PaCO2 high. Other answers are incorrect.

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. Explanation: Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol use do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol use depresses the central respiratory center.

A client at a health care facility who requires prolonged mechanical ventilation has a tracheostomy tube inserted through a surgically created opening into the trachea. The tracheostomy tube also has a balloon cuff. How does the inflated balloon cuff aid the client? - prevents the aspiration of oral fluids - keeps the tongue in a relaxed position - eliminates the need for frequent suctioning - facilitates insertion of the tracheostomy tube

- prevents the aspiration of oral fluids Explanation: A tracheostomy tube may have a balloon cuff; when inflated, the cuff seals the upper airway to prevent aspiration of oral fluids and provide more efficient ventilation. An oral airway is a curved device that keeps a relaxed tongue positioned forward within the mouth, preventing the tongue from obstructing the upper airway. During insertion of a tracheostomy tube, an obturator, a curved guide, is used. Most clients with tracheostomy tubes require frequent suctioning.

A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure? - uses upper chest muscles more effectively - replaces the use of incentive spirometry - reduces the need for PRN pain medications - prolongs expiration to reduce airway resistance

- prolongs expiration to reduce airway resistance Explanation: Pursed-lip breathing can help clients with dyspnea and feelings of panic gain control of their respirations. This exercise trains the muscles to prolong expiration, increasing airway pressure during expiration, and reducing the amount of airway trapping and resistance. Pursed-lip breathing does not replace incentive spirometry but is a way to train a client to have more control of their dyspnea. This does not use upper thoracic muscles more effectively.

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 Explanation: Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.

The physician directs the nurse to use oropharyngeal suctioning to remove liquid secretions for a client with a respiratory problem. What is oropharyngeal suctioning? - removing secretions from the upper portion of the lower airway through a nasally inserted catheter - removing secretions from the mouth using a Yankauer-tip or tonsil-tip catheter - removing secretions from the throat through an orally inserted catheter - removing secretions from the throat through a nasally inserted catheter

- removing secretions from the throat through an orally inserted catheter Explanation: Oropharyngeal suctioning is the removal of secretions from the lung through an orally inserted catheter. Nasotracheal suctioning is the removal of the secretion from the upper portion of the lower airway through a nasally inserted catheter. Oral suctioning is the removal of secretions from the mouth using a Yankauer-tip or tonsil-tip catheter. Nasopharyngeal suctioning means removing secretions from the throat through a nasally inserted catheter.

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 Explanation: Respirations of 20 breaths per minute indicate that the tube is functioning correctly. Other findings require nursing intervention.

What structural changes to the respiratory system should a nurse observe when caring for older adults? - respiratory muscles become weaker - diminished coughing and gag reflexes - increased use of accessory muscles for breathing - increased mouth breathing and snoring

- respiratory muscles become weaker Explanation: One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker. The nurse should also observe other structural changes: the chest wall becomes stiffer as a result of calcification of the intercostals cartilage, kyphoscoliosis, and arthritic changes to costovertebral joints; the ribs and vertebrae lose calcium; the lungs become smaller and less elastic; alveoli enlarge; and alveolar walls become thinner. Diminished coughing and gag reflexes, increased use of accessory muscles for breathing, and increased mouth breathing and snoring are functional changes to the respiratory system in older adults.

The nurse is caring for a client who is experiencing an acute exacerbation of asthma. The nurse will explain to the client that after receiving the nebulized albuterol, the client can expect to experience which potential side effect(s) of this medication? Select all that apply. - tachycardia - nausea - lightheadedness - sore throat - nervousness - paradoxical bronchospasm

- tachycardia - nausea -lightheadedness - sore throat - nervousness Explanation: Albuterol acts on beta-2 adrenergic receptors to relax the bronchial smooth muscle. Because of this mechanism of action, common side effects of albuterol include cardiac and respiratory changes such as an increase in heart rate, lightheadedness and nervousness. In addition, the client should be informed about possibly experiencing a sore throat (often related to chemical irritants in the medication) and nausea. These common or expected side effects diminish within a short period of time and generally do not require any intervention. Paradoxical bronchospasm is life-threatening and the nurse will stop the medication immediately. This is not an expected side effect.

The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? - simple mask - tracheostomy collar - nasal cannula - face tent

- tracheostomy collar Explanation: A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. All other devices are less appropriate for this client.

A client with a head injury will require long-term airway support. Which device will be required for this client? - oropharyngeal airway - endotracheal tube - tracheostomy tube - home oxygen

- tracheostomy tube Explanation: Clients who require prolonged airway support via mechanical ventilation and oxygenation are more likely to be candidates for a tracheostomy to maintain the airway and provide a new route for ventilation. Therefore, the tracheostomy tube is the device required for this client. The other devices are not required for the client with a head injury and long-term airway support needs.

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 - prevention of suctioning - loss of sterile field - suctioning of carbon dioxide

- trauma to the tracheal mucosa Explanation: 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, from the respiratory tract. Suctioning during insertion of the catheter would not compromise sterility.

The nurse is assessing a client with a history of asthma. Which assessment finding indicates that the nurse should take immediate action? - pulse oximetry reading of 92% - respiratory rate of 20 breaths/minute - use of accessory muscles in breathing - heart rate of 98 beats/min

- use of accessory muscles in breathing Explanation: Ineffective airway clearance related to retained secretions are manifested by weak and persistent cough without raising sputum, rapid and shallow respirations, and use of accessory muscles. Use of accessory muscle indicates that the client is experiencing respiratory distress and rapid intervention is needed. The other data indicate the need for ongoing monitoring and assessment, but do not suggest that immediate treatment is required.