Chp 39 PrepU-Oxygenation and Perfusion
Which skin disorder is associated with asthma? -Seborrhea -Eczema -Abrasions - Psoriasis
Eczema
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? -Place the client in the dorsal recumbent position to collect the specimen. -Discard the first sputum produced by the client. -Have the client clear the nose and throat and gargle with salt water before beginning the procedure. -Instruct the client to inhale deeply and then cough.
Instruct the client to inhale deeply and then cough.
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? -Skin tests -Chest x-ray -Pulmonary function tests -Bronchoscopy
Pulmonary function tests
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? - SpO2 92% -heart rate 110 beats/minute -respirations 26 breaths/minute -clubbing of fingers
SpO2 92%
When caring for a client with a tracheostomy, the nurse would perform which recommended action? - Assess a newly inserted tracheostomy every 3 to 4 hours. -Suction the tracheostomy tube using sterile technique. -Clean the wound around the tube and inner cannula at least every 24 hours. -Use gauze dressings over the tracheostomy that are filled with cotton.
Suction the tracheostomy tube using sterile technique.
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 sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?
a child who has pneumonia
A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for:
atelectasis
The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? -Inhale two sprays with one breath for faster action. -Inhale through the nose instead of the mouth. -Be sure to shake the canister before using it. -Inhale the medication rapidly.
Be sure to shake the canister before using it.
The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate? -Check the fit of the oxygen mask. -Contact the oxygen supplier to request an oxygen tent. -Increase the flow of oxygen. -Discontinue oxygen therapy until the client is reassessed by the healthcare provider.
check the fit of the oxygen mask
The nurse is preparing to provide hygiene care to a client with hypoxia. Into what position will the nurse place the client? -Trendelenburg - high Fowlers -prone -supine
high fowlers
What structural changes to the respiratory system should a nurse observe when caring for older adults?
respiratory muscles become weaker
A nurse is using a pulse oximeter to measure the arterial oxyhemoglobin saturation (SaO2 or SpO2) of a client's arterial blood. What range is considered a normal value for SpO2?
95% to 100%
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 -spirometry -peak expiratory flow rate thoracentesis
pulse oximetry
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 -nonrebreather mask -simple mask -face tent
nasal canula
The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output? "If the client's stroke volume is 80 mL and heart rate is 80 beats per minute, then the cardiac output is 6.0 L/minute." -"If the client's stroke volume is 70 mL and heart rate is 70 beats per minute, then the cardiac output is 4.7 L/minute." -"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute." -"If the client's stroke volume is 60 mL and heart rate is 60 beats per minute, then the cardiac output is 3.2 L/minute
"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute."
Which is a sign of dyspnea specific to infants? panting respirations -nasal flaring -a forward-leaning position increased respiratory rate
nasal flaring
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." -"Take in a small amount of air very quickly and then exhale as quickly as possible." -"Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling." -"Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly."
"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."
A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment? -5,550 mL (5,500 × 109/L) -6,000 mL (6,000 × 109/L) -5,850 mL (5,850 × 109/L) - 5,000 mL (5,000 × 109/L)
5,850 mL (5,850 × 109/L)
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 -Oxygen mask -Oxygen tent -Nasal cannula
Ambu bag
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? -Assist with intubation - Apply oxygen -Raise the head of the bed -Educate client on incentive spirometry
Apply oxygen
The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take? -Assess oxygen tubing connection -Assess lung sounds -Reposition client -Elevate head of the bed
Assess oxygen tubing connection
Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body? -Parkinson's disease -chronic anemia -Graves' disease - pancreatitis
Chronic anemia
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 most appropriate response? -Cover the tracheostomy stoma and apply oxygen by nasal cannula -Maintain the client's oxygenation and alert the health care provider immediately. -Assess the client's respiratory status and check vital signs every 1 minute for the next hour. - Page the respiratory therapist STAT.
Maintain the client's oxygenation and alert the health care provider immediately.
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. -Suction the client's mouth through the oropharyngeal airway to prevent aspiration. - Leave the airway in place and promptly notify the health care provider for further instructions. -Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider
Remove the airway, turn the client to the side, and provide mouth suction, if necessary.
The nurse is observing the unlicensed assistive personnel (UAP) perform oropharyngeal suctioning on a client. Which action, performed by the UAP, would indicate to the nurse that suctioning is being properly performed? -The UAP advances the catheter approximately 5 to 6 inches to reach the pharynx. -The UAP advances the catheter approximately 3 to 4 inches to reach the pharynx. -The UAP applies lubricant to the first 2 to 3 inches of the catheter. -The UAP allows 30-second to 1-minute intervals between suctioning passes.
The UAP advances the catheter approximately 3 to 4 inches to reach the pharynx.
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: -pulmonary embolism. -lung cancer. -myocardial infarction. -congestive heart failure.
congestive heart failure
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? -mineral oil -tap water - distilled water -normal saline
distilled water
While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique? -fluid-filled portions of the lung -pattern of thoracic expansion -consolidated portions of the lung -presence of pleural rub
pattern of thoracic expansion
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. - alcohol use. -asthma. -croup.
pneumonia
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? -loss of sterile field - prevention of suctioning -trauma to the tracheal mucosa -suctioning of carbon dioxide
trauma to the tracheal mucosa
The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner?
8 L/min oxygen via nasal cannula
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 -Perfusion -Hypoxia -Atelectasis
Hypoxia
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 soft, high-pitched discontinuous (intermittent) popping lung sounds. -They are low-pitched, soft sounds heard over peripheral lung fields. - -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.
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 -False
True
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? -educating the client on the use of incentive spirometry -oropharyngeal suctioning twice daily -educating the client on pursed-lip breathing techniques -administration of inhaled corticosteroids
educating the client on the use of incentive spirometry
A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is: -"He is using his chest muscles to help him breathe." -"He will require additional testing to determine the cause." -"His infection is causing him to breathe harder." -"His lung muscles are swollen so he is using abdominal muscles."
"He is using his chest muscles to help him breathe."
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? -Contact the physician for nutrition shake. -Eat one large meal at noon. -Eat smaller meals that are high in protein. -Snack on high-carbohydrate foods frequently.
Eat smaller meals that are high in protein
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? -Total lung capacity (TLC) -Forced Expiratory Volume (FEV) -Tidal volume (TV) -Residual Volume (RV)
Residual Volume (RV)
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? "You should never smoke when oxygen is in use." -"Oxygen is a flammable gas." -"An occasional cigarette will not hurt you." -"I understand; I used to be a smoker also."
You should never smoke when oxygen is in use.
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. - high cardiac output. -diminished stroke volume. - heart failure.
adequate tissue perfusion
A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level?
crackles
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? Nonrebreather mask -Partial rebreather mask -Simple mask -Nasal cannula
nasal canula
The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier? -"The humidifier prescribes the concentration of oxygen." -"Small water droplets come from this, thus preventing dry mucous membranes." -"It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." -"This is a gauge used to regulate the amount of oxygen that a client receives."-
"Small water droplets come from this, thus preventing dry mucous membranes."
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: -asthma. -atelectasis. -croup. -pulmonary fibrosis.
croup
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? -face tent -nasal cannula -simple mask -tracheostomy collar
tracheostomy collar
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. - Encourage the client to do deep-breathing exercises. - Raise the head of the client's bed slightly, if tolerated. -Review the medications that the client has taken in the past 90 minutes.
Document this expected assessment finding
