Chapter 39: Oxygenation and Perfusion (2)
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? pg. 1494
Bronchial
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? pg. 1524-1527
Document this expected assessment finding.
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? pg. 1502
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? pg. 1509
It determines whether the client is getting enough oxygen.
A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs? pg. 1532-1534
Nasal cannula
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? pg. 1492
Respiratory rate and depth
The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective? pg. 1497
SpO2 96%
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: pg. 1491-1492
a bronchospasm.
A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery? pg. 1503
educating the client on the use of incentive spirometry
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? pg. 1492
high respiratory rate
The nurse is caring for a client who has excess levels of carbon dioxide in the blood, and chronic hypoxemia. Which intervention will the nurse recommend? pg. 1503
pursed-lip breathing
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? pg. 1517
tracheostomy collar
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? pg. 1509
"You should never smoke when oxygen is in use."
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? pg. 1519
Ambu bag
A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention? pg. 1512
Ask the client what factors contribute to nonadherence.
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? pg. 1497
Pleural effusion
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? pg. 1515
Remove the airway, turn the client to the side, and provide mouth suction, if necessary.
The client is reporting to the nurse that the continuous positive airway pressure (CPAP) mask is torture. What is the best response from the nurse? pg. 1512
Tell me more about why it bothers you.
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? pg. 1494
presence of fluid in the lungs
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? pg. 1535
"Is your mask causing discomfort?"
