Chapter 40: Oxygenation and Perfusion

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? A. Snack on high-carbohydrate foods frequently. B. Eat smaller meals that are high in protein. C. Contact the health care provider for nutrition shake. D. Eat one large meal at noon.

B. Eat smaller meals that are high in protein.

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? A. high temperature B. high respiratory rate C. low pulse rate D. low blood pressure

B. high respiratory rate

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? A. simple mask B. tracheostomy collar C. nasal cannula D. face tent

B. tracheostomy collar

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? A. tap water B. normal saline C. distilled water D. mineral oil

C. distilled water

The nurse is caring for a client who is wearing oxygen via nasal cannula. The client asks about the bubbling water attached to the oxygen. Which response by the nurse is appropriate? A. It prescribes oxygen concentration. B. It regulates the amount of oxygen received. C. It determines whether you are getting enough oxygen. D. It decreases dry mucous membranes by delivering small water droplets.

D. It decreases dry mucous membranes by delivering small water droplets.

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: A. atelectasis. B. pulmonary fibrosis. C. asthma. D. croup.

D. croup.

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? A. oxygen analyzer B. nasal strip C. nasal cannula D. flow meter

D. flow meter

The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document? A. Stridor B. Crackles C. Wheezing D. Absent breath sounds in lower lobes

C. Wheezing

The nurse observes a client practice pursed-lip breathing in preparation for discharge. Which action should the nurse point out needs correcting? A. exhales to a count of 4 B. inhales slowly through the nose to a count of 3 C. contracts abdominal muscles to exhale D. holds lips as though to whistle

A. exhales to a count of 4

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? A. Place the client in the dorsal recumbent position to collect the specimen. B. Have the client clear the nose and throat and gargle with salt water before beginning the procedure. C. Instruct the client to inhale deeply and then cough. D. Discard the first sputum produced by the client.

C. Instruct the client to inhale deeply and then cough.

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? A. "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." B. "Breathing through your nose first will warm, filter, and humidify the air you are breathing." C. "If you breathe through the mouth first, you will swallow germs into your stomach." D. "We are concerned about you developing a snoring habit, so we encourage nasal breathing first."

B. "Breathing through your nose first will warm, filter, and humidify the air you are 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? A. "Did you remove your dentures?" B. "Is your mask causing discomfort?" C. "Did someone take your mask off?" D. "Did someone loosen the straps on your mask?"

B. "Is your mask causing discomfort?"

The nurse is caring for a client with a 35% Venturi mask. Which administration considerations should the nurse use? Select all that apply. 1. Ensure that air intake valves are not blocked. 2. Examine the needed flow rate on the mask matches the rate on the oxygen flow meter. 3. Assess the mask is tight against the face so oxygen does not leak. 4. Inflate the reservoir bag with oxygen before placing mask. 5. Use gauze pads under elastic strap to relieve irritation to scalp or ears.

1. Ensure that air intake valves are not blocked. 2. Examine the needed flow rate on the mask matches the rate on the oxygen flow meter. 5. Use gauze pads under elastic strap to relieve irritation to scalp or ears.

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? 1. Tidal volume (TV) 2. Total lung capacity (TLC) 3. Forced Expiratory Volume (FEV) 4. Residual Volume (RV)

4. Residual Volume (RV)

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? A. Nasal cannula B. Simple mask C. Partial rebreather mask D. Nonrebreather mask

A. Nasal cannula

What assessments would a nurse make when auscultating the lungs? A. air flow through the respiratory passages B. abnormal chest structures C. presence of edema D. volume of air exhaled or inhaled

A. air flow through the respiratory passages

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? A. Inhale through the nose instead of the mouth. B. Be sure to shake the canister before using it. C.Inhale the medication rapidly. D. Inhale two sprays with one breath for faster action.

B. Be sure to shake the canister before using it.

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: 1. crackles. 2. vesicular. 3. wheezes. 4. bronchovesicular.

1. crackles.

The nurse is providing an educational demonstration to an older, postsurgical client. (APPLYING PRESSURE WITH A PILLOW AGAINST THE ABDOMEN). The intervention is intended to minimize the effect of what age-related change specifically relevant to such a client? A. A decrease in gas exchange and an increase in the work of breathing related to decreased elastic recoil of the lungs B. A decrease in ventilation and an ineffective cough related less air exchange, more excretions remaining in the lungs C. A decrease in the ability to respond to stress related to ineffective cardiac muscle function D. A decrease in cardiac output related to progressive atherosclerosis

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

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? A. Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. B. Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm. C. Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. D. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.

B. Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm.