Chapter 87 - Saunders and ATI

The nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its purpose. The nurse should tell the client that the primary purpsoe of prused lip breathing is which?

Promote carbon dioxide elimination

The nurse is reinforcing discharge teaching to a client diagnosed with tuberculosis who has been taking medication for 1 and a half weeks. The nurse knows that the client has understood the information if which statement is made?

"I should not be contagious after 2 to 3 weeks of medication therapy"

A nurse is reinforcing teaching with the family of a client who has acute respiratory distress syndrome (ARDS) and is receiving vecuronium. Which of the following statements by a family member should the nurse identify as understanding of the teaching?

"This medication is given to facilitate ventilation"

A nurse is assisting with the plan of care for a client who has severe acute respiratory distress syystem (SARS). Which of the following interventions should the nurse recommend? (Select all that apply) (3)

1. Provide supplemental oxygen 2. Administer bronchodilators 3. Maintain ventilatory support

The nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. The nurse knows that the client understands the information if the client verbalizes which early sign of exacerbation?

Shortness of Breath

A nurse is reinforcing teaching with an adolescent about how to self-administer a corticosteroid medication using a dry powder inhaler (DPI). Which of the following instructions should the nurse include? (Select all that apply) (2)

1. Rinse and expectorate after adminstration 2. Inhale slowly with medication administration

A nurse is caring for a client who has a new prescription for oxygen therapy of 4 L/min using a nasal cannula. Which of the following actions should the nurse take?

Provide humidification - Humidification should be provided for flow rates of 3L/min or greater

A nurse is reviewing the health records of 5 clients. Which of the following clients are at risk for developing acute respiratory distress syndrome? (Select all that apply.) (4)

1. A client who experienced a near-drowning incident 2. A client following coronary artery bypass graft surgery 3. A client who has dysphagia 4. A client who experienced a drug overdose

The nurse is preparing a list of homecare instructions for the client who has been hospitalized and treat for TB. Which instructions should the nurse reinforce? Select all that apply.

1. Activities should be resumed gradually 2. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated 3. Respiratory isolation is not necessary because family members have already been exposed 4. Cover the mouth and nose when coughing or sneezing and confine used tissues to plastic abgs

A nurse at a long-term care facility is collecting data from a client who as a history of asthma and has developed pneumonia. Which of the following findings indicate the client is developing respiratory failure? (Select all that apply) (3)

1. Irritability 2. Orthopnea 3. Dyspnea

The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which?

Respiratory distress

The nurse is caring for a client with emphysema receiving oxygen. The nurse should consult with the registered nurse if the oxygen flow rate exceeded how many L/min of oxygen?

2 L/min

A nurse is assisting in the care of a client who has ARDS with absent breath sounds in the lower lobes and dyspnea. Which of the following actions should the nurse take first?

Administer oxygen via a high-flow mask

The nurse is caring for a client after a bronchoscopy and biopsy. Which finding should be reported immediately to the primary health care provider (PHCP)?

Bronchospasm

A nurse is collecting data from a client who is receiving mechanical ventilation. Which of the following findings indicates that the client might have developed an infection?

Change in sputum color - A change in color of sputum can be a manifestation of an infection

The nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position should the nurse instruct the client to assume?

Sitting on the side of the bed, leaning on an overbed table

The nurse is gathering data on a client with a dianosis of tuberculosis. The nurse should review the results of which diagnostic test to confirm this diagnosis?

Sputum culture

A nurse is caring for a child who is receiving oxygen. The nurse should identify which of the following findings as an indication of oxygen toxicity?

Unconsciousness

A nurse is collecting data from an infant who has a respiratory infection. Which of the following findings should the nurse identify as an indication of acute hypoxemia?

Pallor of mucous membranes

The nurse notes that a hospitalized client has experienced a positive reaction to the tuberculin skin test. Which action by the nurse is priority?

Report the findings

The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection?

A man who is an inspector for the U.S. Postal Service

A nurse is caring for a child who is receiving a bronchodilator medication by nebulized aerosol therapy. Which of the following actions should the nurse take? (Select all that apply) (4)

1. Obtain vital signs prior to the procedure 2. Tell the child to take slow deep breaths 3. Determine if the child should use a mask 4. Attach the device to an air source.

A nurse is caring for a client who is experiencing respiratory distress. Which of the following early manifestations of hypoxemia should the nurse recognize? (Select all that apply) (2)

1. Pale skin 2. Elevated Blood pressure - Pale skin is an early manifestation of hypoxemia - Elevated blood pressure is an early manifestation of hypoxemia

The client is diagnosed with pleurisy. The nurse should expect to see which signs and symptoms? Select all that apply. (4)

1. Pleural friction rub 2. Sharp, knife-like pain 3. Pain that occurs on both sides of the chest 4. Pain occurs most often during inspiration

A nurse is assiting with the plan of care for a client who has respiratory distress. Which of the following interventions should the nurse include in the plan? (Select all that apply) (3)

1. Provide emotional support to the client 2. Encourage the client to cough 3. Perform oral suctioning as needed - The nurse should provide emotional support to decrease anxiety - The nurse should encourage the client to cough to promote airway clearance - The nurse should perform oral suctioning as necessary to promote airway clearance

The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client?

Lateral position

A nurse is caring for a child who is receiving oxygen therapy and is on a continuous oxygen saturation monitor that is readying 89%. Which of the following actions should the nurse take first?

Ensure proper placement of the sensor probe

A client being discharged from the hospital to home with a diagnosis of tuberculosis is worried about the possibility of infecting family members and others. Which information should reassure the client that contaminating family members and others is not likely?

The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.

The low-pressure alarm sounds on the ventilator. The nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. Which initial action should the nurse take?

Ventilate the client manually

A nurse is caring for a client who has dyspnea and will receive oxygen continuously. Which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client?

Venturi mask - A Venturi mask incorporates an adapter that allows a prescise amount of oxygen to be delivered