Chapter 39 fundamentals PrepU

The nurse educator is presenting a lecture on emphysema with the aid of balloons. Which responses, if given by the nursing staff, would indicate to the educator that further teaching is needed? Select all that apply.

- "Respirations of the client with emphysema can be compared to a balloon that has been blown up before." - "Emphysema, like a new balloon, takes less effort to empty air out of the alveoli."

The nurse provides care for a client with chronic bronchitis and a decreasing oxygen saturation. Which factor(s), if assessed, indicate a deteriorating condition? Select all that apply.

- Tachypnea - Tachycardia - Shortness of breath - Wheezing - Crackles in lungs

A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first?

Apply oxygen as prescribed

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?

Clubbing

A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action?

Document this expected assessment finding.

A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determines that the education was successful when the students identify which activity as occurring during inspiration?

Intercostal muscles contract.

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing:

Poor tissue perfusion

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 low-pitched, soft sounds heard over peripheral lung fields.

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?

Vesicular

The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client?

"Breathing through your nose first will warm, filter, and humidify the air you are breathing."

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

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?

"Is your mask causing discomfort?"

In which client should the nurse prioritize assessments for respiratory depression?

A client taking opioids for cancer pain

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 ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs

A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client?

Ambu bag

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?

Apply steady, firm pressure on the puncture site for 5 to 15 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?

Hypoxia

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?

Instruct the client to inhale deeply and then cough.

The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's mostappropriate response?

Maintain the client's oxygenation and alert the health care provider immediately.

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?

Pleural effusion

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). In what position does the nurse place the client in order to promote adequate oxygenation?

Prone

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?

Pulmonary function tests

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?

Remove the airway, turn the client to the side, and provide mouth suction, if necessary.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

Residual Volume (RV)

The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign?

Respiratory rate and depth

A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate?

The client's available hemoglobin is adequately saturated with oxygen.

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

True

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

a bronchospasm.

A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:

adequate tissue perfusion.

What assessments would a nurse make when auscultating the lungs?

air flow through the respiratory passages

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:

congestive heart failure.

A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from:

croup.

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?

distilled water

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather?

face tent

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

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 respiratory rate

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:

pneumonia.

A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?

pulse oximetry

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?

tracheostomy collar

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

Eat smaller meals that are high in protein.

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?

It determines whether the client is getting enough oxygen.

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.

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?

nasal cannula

While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique?

pattern of thoracic expansion

While auscultating a client's chest, the nurse auscultates crackles in the lower lung bases. What condition does the nurse identify the client is experiencing?

presence of fluid in the lungs

A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action?

Warm the client's hands and try again.

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as:

crackles.

The nurse is talking with a client who has chronic obstructive pulmonary disease (COPD). The client reports chest shape seems to have changed over the past year. What information should be provided by the nurse?

"Your lung condition limits the ability of the lungs to fully exhale, causing this change in shape."

A nurse is overseeing the care of a client who is receiving oxygen via nasal cannula. Which aspects of the client's care can the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply.

- Measuring the client's respiratory rate - Inserting the client's nasal cannula after it has become dislodged - Reapplying the client's nasal cannula after a bath

A nurse must take a client's pulse oximetry reading. The nurse is explaining the technique to the client. Which statements about pulse oximetry are true? Select all that apply.

- Once the oximetry probe is correctly placed, a beam of red and infrared light travels through the tissue and blood vessels. - Sensors are available for use on the finger, toe, foot, earlobe, forehead, and bridge of the nose.