Clinical #4

The preoperative nurse is teaching a client about deep-breathing exercises. The client asks, "Why do I need to learn about this?" Which response by the nurse is correct?

"After surgery, deep-breathing exercises help to remove anesthetic gases and mucus and improve oxygen supply to body tissues."

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."

A nurse is conducting discharge teaching for a postoperative client prescribed oral pain medication. The client states that pain medications always causes nausea. What is the appropriate response by the nurse?

"Do you take the medication on an empty stomach?"

The nurse is taking a history for a client who is being seen for chronic unrelieved back pain. Which assessment question helps the nurse assess duration of pain?

"How long have you experienced this pain?"

Which statement, if made by an adolescent preparing for abdominal surgery, would indicate to the nurse that the client requires additional instruction?

"I can have a hamburger and French fries as soon as I wake up."

A postoperative client states "I don't understand why you are checking my skin on my back. My surgery was on my stomach." What is the nurse's best response?

"The operating table is a firm surface; we need to be sure your skin looks okay."

A client has been prescribed patient-controlled analgesia and the nurse is setting up the system and educating the client about safe and effective use of PCA. Which teaching point should the nurse provide to the client?

"The pump is programmed so that it's not possible for you to overdose on your pain medication."

The nurse is caring for a client who reports pain as 10, on a 0 to 10 scale. After the administration of an opioid anesthesia, the nurse observes the client's respiratory rate decrease to 8 breaths per minute. What is the priority action by the nurse?

Administration of 0.4 mg of naloxone

What will the nurse place at the bedside of a client receiving epidural analgesia?

Ampule of 0.4 mg naloxone

A nurse is assigned to be the circulating nurse during a surgical procedure. The nurse would be responsible for which activity?

Anticipating the needs of other members of the surgical team

A client postoperative from an appendectomy reports feeling cold and has a temperature of 96.2°F (35.7°C). Which action should the nurse perform first?

Apply warm blankets to the client.

The nurse is admitting a dying client with osteosarcoma. Which nursing action is priority?

Examine the effectiveness of the current pain regimen

The nurse is supervising a nursing student who is providing postoperative education to a client with an abdominal incision. The nurse sees the student coaching the client to perform coughing exercises, as pictured above. What is the nurse's best action?

Instruct the student to provide the client with a pillow or folded blanket to hug.

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?

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

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

The healthy adult client is given a narcotic prior to a surgical procedure. The nurse is completing the chart and notices the consent form was not signed by the client. Which of the following should the nurse do first?

Notify the physician of the oversight.

Oxygen and carbon dioxide move between the alveoli and the blood by:

Oxygen and carbon dioxide move between the alveoli and the blood by diffusion, the process in which molecules move from an area of greater concentration or pressure to an area of lower concentration or pressure.

A nurse is taking care of a client who requests acetaminophen to help with a headache. The nurse checks to see if there is an order for acetaminophen and notices that the client is able to have 650 mg every 4 hours as needed for pain. What type of order is this considered?

PRN order

A nurse caring for clients in a PACU assesses a client who is displaying signs and symptoms of shock. What is the priority nursing intervention for this client?

Placing the client in a flat position with the legs elevated 45 degrees uses gravity to help direct blood to the vital organs. Removing extra coverings would cause the client's temperature to drop further during the blood loss occurring during shock. Medications will likely be ordered to help treat the shock. Prone position would be contraindicated.

A nurse is caring for an older adult following hip surgery. When teaching the client to use an incentive spirometer, the nurse should explain that this reduces the risk of what complication?

Pneumonia

Which methods would the nurse anesthetist use when administering regional anesthesia to surgical clients?

Spinal block Nerve block Epidural block Regional anesthesia occurs when an anesthetic agent is injected near a nerve or nerve pathway in or around the operative site, inhibiting the transmission of sensory stimuli to central nervous system receptors. Regional anesthesia includes spinal blocks, nerve blocks, and epidural blocks. Inhalation and intravenous administration of anesthesia are associated with general anesthesia. Anesthesia is not administered via the oral route.

After sedating a client, the nurse assesses that the client is frequently drowsy and drifts off during conversations. What number on the sedation scale would the nurse document for this client?

The Pasero Opioid-Induced Sedation Scale that can be used to assess respiratory depression is as follows:1 = awake and alert; no action necessary2 = occasionally drowsy but easy to arouse; requires no action3 = frequently drowsy and drifts off to sleep during conversation; decrease the opioid dose4 = somnolent with minimal or no response to stimuli; discontinue the opioid and consider use of naloxone.

A client who is scheduled to undergo coronary bypass surgery in a week asks the nurse whether he should discontinue taking his cholesterol medicine ahead of the surgery. Which should be the nurse's response?

The client may be permitted to take certain medications before surgery. The health care provider, not the nurse, should provide guidance about which medications should be taken and which ones should be held.

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.

Surgery can lead to hypothermia. Which client is at greatest risk for hypothermia?

The risk of hypothermia increases in the very young and the very old.

A nurse is preparing to give a client a massage. What action should the nurse perform during this intervention?

Using a light, gliding stroke, apply lotion to the client's shoulders, back, and sacral area.

When the male client on his first postoperative day after chest surgery appears stoic and does not ask for any pain medication, the nurse should:

actively solicit information about the client's pain level.

The physician has ordered a patient controlled analgesia (PCA) pump for a client. Which assessment finding would cause the nurse to question the order?

confused to time and place

The client has just returned from surgery. The client asks you for an extra dose of pain medication. What would be some signs that the client is in severe pain?

elevated respiratory rate decreased blood pressure

A client is undergoing surgery for an appendectomy. This would be considered what type of surgery?

emergency surgery

A nurse is employed in an operative setting. Which of these roles is within the registered nurse (RN) scope of practice?

positioning the client on the operating table counting sponges before and after surgery monitoring the client's vital signs

The nurse is visiting a client at home who is recovering from a bowel resection. The client reports constant pain and discomfort and displays signs of depression. When assessing this client for pain, what should be the nurse's focal point?

reviewing and revising the pain management treatment plan

A postoperative vaginal hysterectomy client complains of pain that is more intense than this morning. This factor should be explained to the client as

"Acute pain tends to increase during the day and is called a routine pain response"

The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain?

A client who has a sprained ankle

A client reports rarely leaving the house since starting use of home oxygen. What education should the nurse provide to the client?

A portable oxygen device may be helpful. The client likely only needs time to adjust. Friends and family can be invited to visit the client at home.

The nurse is caring for a client who has a long history of using opioid pain medication. Which action will the nurse take to further assess the client's pain and provide pain relief?

Acknowledge the pain as the client reports it and administer pain medication as prescribed.

The nurse is caring for a client who has had abdominal surgery. Which intervention(s) will the nurse include to prevent complications for this client?

Assist the client with the use of incentive spirometry. Turn the client and change position frequently. Administer analgesic medication as required.

The nurse is implementing environmental changes to promote a client's comfort and pain management. Which action is an example of this type of intervention?

Closing the client's room door to reduce unnecessary noises

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

Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many clients with chronic hypoxia due to respiratory or cardiac disease. Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD. Hemoptysis does not result from hypoxia.

The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly?

Respirations of 20 breaths per minute indicate that the tube is functioning correctly. Other findings require nursing intervention.

A nurse is working with a 12-year-old boy who was involved in an MVA. He has several broken bones and contusions. He rates his pain as a 7/10. The nurse plans to administer intravenous hydromorphone to relieve the pain. What side effect is the nurse most worried about?

Respiratory depression is always a major concern in an opioid-naïve patient.

The nurse is caring for a client whose pain is being treated with epidural analgesia. Which nursing action is most appropriate?

The anesthesiologist/pain management team should be notified immediately if the client's respiratory rate is below 10 breaths/min.

An older adult client who is being treated in the hospital was given a hypnotic medication at bedtime. Which of the following possible consequences would indicate a paradoxical effect of this drug?

The client exhibits restless, uncharacteristic behavior after receiving the drug.

he nurse is preparing a care plan for a client receiving opioid analgesics. Which factors associated with opioid analgesic use will the nurse include in the plan of care?

The most common side effects associated with opioid use are sedation, nausea, and constipation. Respiratory depression is also a commonly feared side effect of opioid use. Urinary elimination and bowel incontinence are not affected by opioid use.

Which is a major organ of the upper respiratory tract?

The pharynx, mouth, and nose are major organs of the upper respiratory tract. The trachea, bronchi, and lungs are major organs of the lower respiratory tract.

A client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and the secretions are thick and sticky. Which intervention will the nurse use to promote respiratory hygiene in this situation?

When a cough is productive, it is important to establish the source of the sputum and assess its color, volume, consistency, and other noteworthy characteristics. The nurse should instruct the client to increase fluid intake to help thin secretions. Encouraging coughing and deep breathing should be done; however, the problem is thick secretions and increasing oral fluids will address the problem directly. Range-of-motion exercises and assisted ambulation help with mobility concerns but will not help to thin out the secretions.

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

crackles

The recovery nurse is caring for a surgical client in the PACU. The client's blood pressure is dropping and the heart rate is increasing. The nurse suspects the client is:

developing shock.

The nurse has delegated to the unlicensed assistive personnel (UAP) the application of antiembolism stockings to a client who had an endarterectomy earlier in the day. Which UAP action requires the nurse to immediately intervene?

massages legs prior to application

The nurse is performing a preoperative assessment for a client prior to surgery in the morning. What statement made by the client alerts the nurse that there is a potential for latex allergy?

"I am allergic to banana's" "I had a rash after using a condom." "I broke out in hives after eating sliced avocado"

After the nurse has instructed a client with low-back pain about the use of a transcutaneous electrical nerve stimulation (TENS) unit for pain management, the nurse determines that the client has a need for further instruction when the client states what?

"I could use the TENS unit if I feel pain somewhere else on my body."

The nurse is preparing a client for a total hip arthroplasty and is obtaining data preoperatively. Which statement made by the client is most important for the nurse to immediately report to the health care provider?

"I've been taking ibuprofen for my hip pain twice a day."

A client receiving epidural analgesia asks the nurse to put the head of the bed all the way down to sleep better. What is the correct response by the nurse?

"It is important that we keep the head of your bed elevated at least 30 degrees because this position helps to minimize the risk of respiratory depression."

A client has been reluctant to ask for breakthrough doses of the opioid prescribed, despite showing signs of pain. The client states to the nurse, "I don't want to become addicted to the medication." How should the nurse respond to the client's statement?

"There's only an extremely small chance that you will become addicted to this drug."

The nurse working in the holding area is performing an assessment on a client scheduled for surgery. Which question will the nurse ask prior to the client receiving general anesthesia?

"When was the last time you had anything to eat or drink?"

The nurse is caring for a client after breast augmentation. Before performing a bowel assessment, what education will the nurse provide the client?

"You can have decreased or absent bowel movement, called peristalsis because of administration of anesthetic agents or narcotics. By listening for bowel sounds, I can check for a return of peristalsis." A postoperative client can typically have decreased or absent peristalsis because of bowel manipulation and/or administration of anesthetic agents or narcotics. Auscultation of bowel sounds will help determine a return of peristalsis. Palpating the abdomen would not help with determining peristalsis return; the nurse may feel distention and firmness of the abdomen with decreased peristalsis, but this is not accurate in determining return of peristalsis. The symphysis pubis would be assessed to determine bladder fullness, not peristalsis. Giving the client sips of water would not help determine or promote the return of peristalsis; this also could be a safety issue if the client has decreased peristalsis due to emesis and subsequent potential aspiration.

Charles is an 86-year-old man with chronic lower back pain. He asks you what some appropriate treatments might be for his back pain. Which would you not expect to be ordered as first-line therapy?

A chronic opioid therapy plan

Which client in the postanesthesia care unit (PACU) requires the most immediate attention by the nurse?

A client with a crowing sound is exhibiting stridor, which is an indication of an airway obstruction and can be a respiratory emergency. This client needs immediate attention. The client with disorientation needs to be frequently reoriented and observed for safety reasons but is not a priority over respiratory distress. The client who needs pain medication or the pediatric client requesting a parent are also not priority over a client in respiratory distress.

The nurse is caring for a client with chronic obstructive pulmonary disease who has been admitted to the hospital unit for pneumonia. The nurse notes that the client has a nonproductive cough and has SpO2 of 92%. Before attempting to obtain a sputum specimen, which action will the nurse take first?

Administer inhalation therapy using a nebulized mixture of oxygen and humidification. While nurses use a variation of several interventions to mobilize secretions in clients who have a respiratory impairment, the nurse will first attempt to liquefy secretions prior to performing other interventions to promote secretion mobility. In the case of a client that requires a sputum specimen and has a nonproductive cough, liquefying secretions first is a priority. Carrying out any other intervention first will prove ineffective and can cause spasmodic coughing, leading to additional respiratory complications. Nurses may assist with inhalation therapy (respiratory treatments that provide a mixture of oxygen, humidification, and aerosolized medications directly to the lungs). The aerosol is delivered through a mask or a handheld mouthpiece. Aerosol therapy improves breathing, encourages spontaneous coughing, and helps clients raise sputum for diagnostic purposes. After secretions have been liquefied, they will be easier to mobilize and reduce the risk of lung spasms in the client. While postural drainage is within the nurse's scope of practice in most long-term care settings, many acute care setting policies require a referral to respiratory therapists to carry out this intervention. Nurses perform chest percussion to helps dislodge respiratory secretions that adhere to the bronchial walls. While this is in the nurse's scope and a sound action to take to promote mobilization of secretions, the nurse will carry out this action after an attempt to liquefy secretions has been completed and the client exhibits productive coughing. With low oxygenation and a nonproductive cough, the nurse will not perform suctioning until the client's SpO2 is higher and a productive cough is achieved. Suctioning can lead to hypoxemia and respiratory distress if not undertaken under the right client conditions.

A nurse is caring for a client who received naloxone to reverse respiratory depression due to opioid therapy. The client is now complaining of pain and wishes to receive the newly prescribed pain medication. What is the correct action by the nurse?

Administer the medication if respiratory rate is > 9.

A client is prescribed pain medication every 4 to 6 hours as needed. When the nurse enters the client's room to administer the medication, the client is laughing with visitors. The client's pulse rate is 64, respirations 16, and blood pressure 120/80. The client reports pain and wants the medication. What is the most appropriate action by the nurse?

Administer the pain medication.

A hospital client's pain is being treated with epidural analgesia. Which nursing action would pose a threat to the client's safety?

Administering an oral dose of morphine to treat the client's breakthrough pain

Which factor is most important in the nurse's decision on assessment data, outcomes, and the monitoring needs of a client in preparing for surgery?

Although all of these factors would need to be taken into account in planning care for a client going to surgery, the type of surgery is the most important influence on what type of care the client will require after surgery. Anesthesia and age play a role in monitoring needs postoperatively. The client needs an adequate support system when leaving the hospital, but the type of surgery influences the client's needs overall.

A nurse administers anticholinergics to a client as a postoperative medication. What condition does this medication help to prevent?

Anticholinergics such as atropine and glycopyrrolate decrease pulmonary and oral secretions to prevent laryngospasm. Cardiovascular complications, nausea, and shock are not affected by anticholinergic medications.

The nurse is conducting an admission assessment, and asks the client what medication is taken for pain. The client responds, "I take a little white pill to control my pain, but I don't know the name of it," and presents the nurse with a plastic baggie full of white pills. What is the priority nursing intervention?

Ask the client if he or she has the bottle the drug was dispensed in from the pharmacy.

A client prescribed pain medication around the clock experiences pain 1 hour before the next dose of the pain medication is due. Which is the most appropriate action by the nurse?

Assess for medication prescription for breakthrough pain.

The nurse is caring for a client who has experienced significant pain following a surgical procedure. Which nursing interventions are appropriate?

Assess for pain control 30 minutes after administering an analgesic. Consider cultural implications of the perception of pain. Provide pain medication before activity that may increase pain.

A nurse works with an older adult client who has two broken femurs. The client does not report pain. Which action will the nurse take?

Assess the client for nonverbal cues of pain.

Which postoperative complications can be reduced by appropriate client teaching about deep-breathing exercises?

Atelectasis Pneumonia Bronchitis Severe hypoxemia

A postoperative client is experiencing decreased lung sounds, dyspnea, cyanosis, crackles, restlessness, and apprehension. Which condition would the nurse suspect?

Atelectasis is the incomplete expansion or collapse of alveoli with retained mucus involving a portion of lung, and manifests as decreased lung sounds over the affected area; dyspnea; cyanosis; crackles; restlessness; and apprehension. Pneumonia signs and symptoms include a productive cough, fever and chills. Pulmonary embolus include dyspnea, chest pain, cough, cyanosis, rapid respirations, tachycardia, and anxiety. Thrombophlebitis manifests with signs and symptoms that include redness, swelling, and pain in the affected area.

A client with chronic pain uses a machine to monitor his physiologic responses to pain. The unit transforms the data into a visual display and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. This technique for pain control is known as:

Biofeedback is a technique that uses a machine to monitor physiologic responses through electrode sensors on the client's skin. The unit transforms the data into a visual display, and through seeing the pain responses, the client is taught to regulate his physiologic response and control pain through relaxation, imagery, or breathing exercises. Transcutaneous electrical nerve stimulation (TENS) is a noninvasive alternative technique that involves electrical stimulation of large-diameter fibers to inhibit transmission of painful stimuli carried over small-diameter fibers. Hypnosis is an alteration in a person's state of consciousness so that pain is not perceived as it normally would be. Therapeutic Touch involves using one's hands to direct an energy exchange consciously from the practitioner to the client in order to facilitate healing or pain relief.

A new graduate nurse is performing a focused respiratory assessment. The nurse preceptor will intervene if which action by the graduate nurse is noted?

Breath sounds should be auscultated while the client breathes slowly through an open mouth; nose breathing may produce false breath sounds. Explanation before procedures helps reduce a client's anxiety. Palpation of the PMI and attaching the pulse oximeter are included in the respiratory assessment.

The nurse needs to evaluate the effectiveness of a preoperative teaching session with a client scheduled for abdominal surgery. Which client statement indicates the need for further clarification?

Compression stockings and pneumatic compression devices help to decrease the formation of thrombus by helping to promote venous return to the heart. The nurse needs to clarify that the pneumatic compression device does not replace leg exercises because the exercises help keep the joints flexible and help strengthen muscles while the client is in bed. The client is correct that splinting the incision when coughing is important. The client should sit up in bed when using the incentive spirometer, taking deep breaths and coughing. The client should take deep breaths and cough at least every 2 hours while awake to help expand lungs, loosen secretions, and help prevent atelectasis and pneumonia.

The pediatric nurse is instructing parents on safety when caring for toddlers and preschoolers. Which of the following teaching interventions is appropriate for this age group?

Cut a hot dog in half, then pieces

The demonstration provided by the nurse is directed at helping the postsurgical client manage what type of pain?

Deep somatic

The young female client had emergency surgery for appendicitis. She is a cigarette smoker, is breast-feeding her infant, and expressed a desire to continue to breast-feed when discharged from the hospital. The surgeon has prescribed acetaminophen/oxycodone for pain relief at home. What instructions would the nurse include when providing discharge teaching?

Do not drive a vehicle while taking this medication. You must check with your primary care provider before breast-feeding your infant. Keep a diary to record level of pain and time medication is taken.

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?

During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds.

The nurse is developing a plan of care for a client in acute pain. Which nursing interventions should be included?

Encourage deep breathing. Play the client's favorite music. Promote a restful environment.

A client is experiencing acute pain following the amputation of a limb. What nursing interventions would be most appropriate when treating this client?

Encourage the use of nonpharmacologic complementary therapies as adjuncts to the medical regimen.

Which of the following is considered to be the most potent neuromodulators?

Endorphins and enkephalins are opioid neuromodulators. Endorphins are powerful pain blocking chemicals with prolonged analgesic effects. Enkephalins are considered less potent. There are no neuromodulators called efferent or afferent.

A client is being prepared for discharge home from the postanesthesia care unit (PACU). What action is essential for the nurse to take?

Ensure a client who is dizzy has help at home to prevent falls.

A client comes to the emergency department complaining of a shooting pain in his chest. When assessing the client's pain, which behavioral response would the nurse expect to find?

Guarding of the chest area

The nurse is assessing a client for the chronology of the pain she is experiencing. Which interview question is considered appropriate to obtain this data?

How does the pain develop and progress?

A 77-year-old woman is on the nurse's unit s/p left knee replacement. The client typically stools every morning but has not had a bowel movement in 3 days. The nurse knows that which medication places the client at increased risk for constipation?

Hydromorphone

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?

In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation.

A 9-month-old baby is scheduled for heart surgery. When preparing this client for surgery, the nurse should consider which surgical risk associated with infants?

Infants have difficulty maintaining stable body temperature during surgery because the shivering reflex is not well developed, making hypothermia or hyperthermia more likely. They are not at an increased risk for prolonged wound healing, congestive heart failure, or gastrointestinal upset.

When an older adult client is brought to the recovery room and presents with irregular, loud respirations, the nurse determines that this is most likely a result of:

Loud, irregular respirations may indicate obstruction of the airway, possibly from emesis, accumulated secretions, or client positioning that allows the tongue to fall to the back of the throat.

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

Many medications affect the function of the respiratory system and depress the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Beta-adrenergic blockers, antibiotics, and insulin do not appreciably affect the respiratory system.

After a client receives morphine sulfate for pain in the postanesthesia care unit (PACU), which assessment finding would the nurse obtain as a priority?

Measure respiratory rate.

A client had an open cholecystectomy (gallbladder removal) 36 hours earlier, and the nurse's assessment this morning confirms that the client has not yet had a bowel movement since prior to surgery. How should the nurse best respond to this assessment finding?

Monitor the client closely and promote fluid intake.

A client comes to the postoperative area and reports chest pain and palpitations. What priority intervention(s) will the nurse perform?

Obtain vital signs, especially heart rate and blood pressure Give sublingual nitroglycerin as prescribed Ask the client to rate pain on a scale from zero to ten

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?

Occluding the Y-port on the suction tubing is what creates the suction. While suctioning would be difficult but possible, suctioning while advancing the tube would damage the tracheal mucosa and remove excessive amounts of oxygen, not carbon dioxide, from the respiratory tract. Suctioning during insertion of the catheter would not compromise sterility.

A 92-year-old woman is on an inpatient unit following hip replacement surgery. The nurse asks her if she is in pain, and she tells the nurse that she is fine. The nurse knows what to be true regarding pain in the older adult?

Older adults have decreased opioid receptors. Older adults often believe that pain is a consequence of growing older. Older adults are more likely to be disabled by pain than younger adults.

A client describes pain in the lower leg and has been diagnosed with a herniated lumbar disk. The pain in the leg is what type of pain?

Pain from the abdominal, pelvic, or back region may be referred to areas far distant from the site of tissue damage. Acute pain is distinct from chronic pain and is relatively more sharp and severe and lasts from 3 to 6 months. Chronic pain is often defined as any pain lasting more than 12 weeks. Limited pain is not usually a term used.

Two hours after receiving a pain medication, the client reports still suffering from pain. Which response is most appropriate?

Pain intensity indicates the magnitude or amount of pain perceived. Terms used to describe pain intensity include none, mild, slight, moderate, severe, and excruciating. Pain intensity also may be described on a numeric scale. The most appropriate assessment is one which allows for all information and is broad.

The nurse recognizes that palliative surgery is performed for what purpose?

Palliative surgery is performed to help lessen the intensity of an illness; it is not meant to be curative but will help improve the client's quality of life. A diagnostic surgery makes or confirms a diagnosis such as with a biopsy to check for cancer. A removal of a body part that is diseased is ablative surgery, such as an appendectomy. Restoring function to traumatized tissue is reconstructive surgery, such as with plastic surgery.

A nurse is caring for an older adult client who had surgery for the removal of a cataract in the left eye. Which issue would prevent the client from being discharged on the day of surgery?

Recovery from anesthesia is usually much quicker when shorter-acting IV anesthetic agents, such used in same-day surgery. Before discharge from an ambulatory surgical unit, the client should: void (after a spinal or epidural anesthetic or after pelvic surgery), be able to ambulate, be alert and oriented, have minimal nausea and vomiting, have adequate pain/comfort control and exhibit no excess bleeding or drainage. The left eye would be covered with a dressing and the client would not be expected to see from that eye immediately.

The nurse prepares to apply the pulse oximeter to the client's hand. The fingers are edematous, cool to touch, and have black nail polish. Which actions should the nurse take?

Remove black nail polish and assess circulation. Assess mental status. Auscultate lungs. Use alternate site: earlobe or bridge of nose. Nail polish obstructs the ability to assess capillary refill and the color of the nail bed. Mental status is important to assess because changes occur early with hypoxia. Edema prevents adequate reading. Lungs should be assessed for adventitious sounds such as wheezes, crackles, or rhonchi. Since the fingers are edematous and cool to touch, the nurse should use an alternate site for the pulse oximeter to achieve the best reading, which includes the forehead, earlobe, or the bridge of the nose.

The nurse has admitted a client to the postoperative unit following a bowel resection and is providing postoperative health education on coughing and deep breathing. What does the nurse explain to the client about why these actions are important?

Shallow breathing or an infective cough can lead to mucus plugging, atelectasis, hypoxemia, and pneumonia. Taking deep breaths helps to expand alveoli and an effective cough pushes secretions upward out of the lungs. A client experiencing postoperative pain may be unable or unwilling to take the deep breath needed to cough. Medications used to control pain and splinting the incision by hugging a pillow or blanket increase compliance to deep breathing and coughing exercises. Shallow breathing or ineffective cough does not lead to aspiration pneumonia, inability to ambulate, or DVT. Acute respiratory distress syndrome is caused by sepsis, inhaling harmful substances, injury, and severe pneumonia that has infiltrated all five lobes and is not specific to postoperative-related pneumonia.

The nurse is performing assessments for clients admitted in the emergency department. Which client is most likely experiencing somatic pain?

Somatic pain is diffuse or scattered and originates in tendons, ligaments, bones, blood vessels, and nerves. Strong pressure on a bone or damage to tissue that occurs with a sprain causes deep somatic pain. Visceral pain, or splanchnic pain, is poorly localized and originates in body organs in the thorax, cranium, and abdomen. Visceral pain is one of the most common types of pain produced by disease, and occurs as organs stretch abnormally and become distended, ischemic, or inflamed such as with a ruptured peptic ulcer or appendicitis. A client having a myocardial infarction with chest pain is experiencing referred pain.

A neonatal nurse is caring for a 2-day-old infant who experienced shoulder subluxation during delivery. What pain assessment scale should the nurse use to assess this client's pain?

The CRIES scale is appropriate for neonates (0 to 6 months). The Wong-Baker Faces Pain Rating scale requires children to be at least 3 years old. The FLACC scale is used for infants and children (2 months to 7 years) unable to validate the presence of or quantify pain severity; and the PAINAD scale is specific to the needs of clients with dementia.

While assessing an infant, the nurse notes that the infant displays an occasional grimace and is withdrawn; legs are kicking, body is arched, and the infant is moaning during sleep. When awakened, the infant is inconsolable. Which scale/score should the nurse use while assessing pain in this infant?

The FLACC scale (face, legs, activity, cry, and consolability) is used to measure pain for children between the ages of 2 months and 7 years. The Braden scale is used to predict pressure sore risk. The FACES scale is used to assess pain in older children using a series of faces, ranging from a happy face to a crying face. Apgar score is done at birth to assess how well the baby tolerated the birthing process.

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?

The client can move in bed, and ambulate while carrying the drainage system, as long as he or she has orders to do so. The nurse should supervise ambulation to the bathroom and back to bed while the client has the drain inserted to make sure it stays intact and to monitor for safety. Other answers are incorrect.

A middle-age client with cancer has been prescribed patient-controlled analgesia (PCA). The nurse caring for the client explains the functioning of PCA. What is the main advantage of PCA?

The client is actively involved in pain management.

The nurse is caring for a client who had a procedure under moderate sedation at the ambulatory surgical center. Which assessment finding indicates to the nurse that the client may be ready for discharge to home?

The client is alert and oriented with a blood pressure 118/70 mm Hg and respirations 18 breaths/minute, is able to ambulate, is not nauseated or vomiting, pain is controlled with medication, and has no excessive bleeding and drainage is as expected.

A client with an amputated arm tells a nurse that sometimes he experiences throbbing pain or a burning sensation in the amputated arm. What kind of pain is the client experiencing?

The client is experiencing neuropathic pain or functional pain. Neuropathic pain is often experienced days, weeks, or even months after the source of the pain has been treated and resolved. In cutaneous pain, the discomfort originates at the skin level. In visceral pain, the discomfort arises from internal organs caused from a disease or injury. In chronic pain, the discomfort lasts longer than 6 months.

A nurse is caring for a client who complains of an aching pain in the abdomen. The nurse also noted that the client is guarding the area. The client is experiencing:

The client is experiencing visceral pain, which is poorly localized and originates in body organs in the thorax, cranium, and abdomen. A reflex contraction or spasm of the abdominal wall, called guarding, may occur as a protective mechanism to prevent additional trauma to underlying structures. In cutaneous pain, the discomfort originates at the skin level, and is a commonly experienced sensation resulting from some form of trauma. Somatic pain develops from injury to structures such as muscles, tendons, and joints. Neuropathic pain is experienced days, weeks, or even months after the source of the pain has been treated and resolved.

Which surgical client does the nurse in the preoperative setting anticipate having the greatest potential for surgical complications?

The client who is elderly with renal and lung disease has the most risk factors preoperatively for surgery. This client will have concerns over administration of anesthesia and medication, with the kidneys being able to clear these from the body, as well as with the lungs and potential postoperative complications of atelectasis and pneumonia. Clients who are young, have chronic disease, or are obese have risk factors as well, but not as many as the elderly client with both renal and pulmonary disease.

A female client age 54 years has been scheduled for a bunionectomy (removal of bone tissue from the base of the great toe) which will be conducted on an ambulatory basis. Which characteristic applies to this type of surgery?

The client will be admitted the day of surgery and return home the same day.

A nurse is caring for a postoperative client and preparing to apply a pneumatic compression device. How does the nurse explain the device to the client prior to application?

The device fills with air and squeezes the legs, which increases blood flow through the veins of the legs and helps to prevent blood clots.

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider?

The infant's normal respiratory rate is 20 to 40 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 32 breaths per minute. For a child 6 to 12 years of age the normal respiratory rate is 18 to 26 breaths per minute. The normal respiratory rate for an adult 65 years and older is 16 to 24 breaths per minute.

A client has required frequent scheduled and breakthrough doses of opioid analgesics in the 6 days since admission to the hospital. The client's medication regimen may necessitate which intervention?

The most common side effect of opioid use is constipation. Consequently, stool softeners and increased fluid intake may be indicated. Opioids may cause respiratory depression, but this fact in and of itself does not create a need for oxygen supplementation or chest physiotherapy. The use of opioids does not create a need for calorie restriction, supplements, frequent turns, or the use of skin emollients.

The nurse preparing to admit a client receiving epidural opioids should make sure that which of the following medications is readily available on the unit?

The nurse should ensure that naloxone is readily available on the unit, as it can reverse the respiratory depressant effects of opioids. Naloxone is an opioid antagonist—meaning that it binds to opioid receptors and can reverse and block the effects of other opioids. Furosemide is a loop diuretic and used to treat hypertension (high blood pressure) and edema. Lisinopril is an angiotensin converting enzyme (ACE) inhibitor used for treating high blood pressure, heart failure and for preventing kidney failure due to high blood pressure and diabetes. Digoxin is used to treat congestive heart failure.

How should the nurse position the head of the bed for a client receiving epidural opioids?

The nurse should position the head of the bed so that it is elevated 30 degrees unless contraindicated. Elevation of the client's head minimizes upward migration of the opioid in the spinal cord, thereby decreasing the risk for respiratory depression. The Trendelenburg position is when the feet are higher than the head. Reverse Trendelenburg position or supine position is when the head is higher than the feet.

Which of the following is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump?

The priority assessment for the nurse caring for a client with a PCA pump is respiratory, with particular attention to the respiratory rate and pattern. Too much narcotic or a displaced catheter may allow the medication to have a depressant effect on the brainstem center, causing life-threatening respiratory depression. The cardiac system can be affect by a opioid PCA by decreasing the blood pressure and heart rate as the pain decreases. It is expected but not the priority. The neuromuscular and peripheral vascular system are not affected by the PCA.

The nurse-anesthetist is monitoring the client during surgery. He notices a ventricular dysrhythmia and unstable blood pressure. He notifies the surgeon. The operative team suspects:

The symptoms of malignant hyperthermia are masseter muscle rigidity, ventricular dysrhythmia, tachypnea, cyanosis, skin mottling, and unstable blood pressure.

The nurse is teaching a client about postoperative pain management. The client states, "I would like to use as little medication as possible after surgery. Will anything else help to relieve my pain?" Which response is appropriate?

There are several nonpharmacologic methods to reduce pain and anxiety. Let me teach you about some of them."

The nurse is performing an assessment for a client related to pain. In order to determine the need for pain medication, what should the nurse base the decision on?

Verbal reports by the client indicate more clearly its location, intensity, quality, and temporal pattern. Level of consciousness and objective signs are assessments the nurse makes.

The nurse is obtaining a history from a client before surgery. Which areas would be important for the nurse to ask about to determine potential risk factors?

What medications the client is currently taking, including over-the-counter supplements If the client has had previous surgeries and any complications from surgery Does the client abuse alcohol or any illicit drugs Who will be accompanying the client and assisting postoperatively at home

You are a new nurse in an ambulatory care setting. You know that the Joint Commission requires that pain be addressed at each visit. When is the most appropriate time to do so?

When obtaining patient vital signs

A nurse is preparing to use a wall unit to suction an endotracheal tube. At what pressure should the suction be set?

When utilizing a wall unit to suction an endotracheal tube, the pressure should be set at 80 to 150 mm Hg. This level will provide enough pressure to suction out secretions from the endotracheal tube.

The nurse is performing a preoperative screening of laboratory work prior to a client's surgery in the morning. What test results should be immediately discussed with the surgeon and anesthesia care provider?

a white blood cell count of 18,000 a hemoglobin of 7.2 gm/dL a sodium level of 128 mEq/L

A client has presented to a clinic for a preoperative consult, during which the client has expressed concern about having to fast before surgery. What should the nurse discuss with the client reflecting current standards by the American Society of Anesthesiologists related to fasting prior to surgery?

allowing clear liquids up to 2 hours before surgery with an order by the health care provider

The nurse is caring for a client who had a below-the-knee amputation of the left leg 8 months ago. The client is reporting left foot pain of 7 on a 1-to-10 scale. The pain began earlier today. How will the nurse document this type of pain?

neuropathic acute

A client tells a nurse, "I have this pounding feeling on the side of my head, like someone is hitting my head with a hammer." The nurse should identify what characteristic of pain assessment?

quality

When preparing a client who has diabetes mellitus for surgery, the nurse should be aware of what surgical risk associated with this disease?

slow wound healing

The nurse is caring for a client who has had unrelieved back pain for 3 years. How will the nurse document this type of pain?

somatic chronic

A nurse is caring for a client with cancer who is experiencing pain. What would be the most appropriate assessment of the client's pain?

the client's pain based on a pain rating

A male college student age 20 years has been experiencing increasingly sharp pain in the right, lower quadrant of his abdomen over the last 12 hours. A visit to the emergency department and subsequent diagnostic testing have resulted in a diagnosis of appendicitis. What category of pain is the client most likely experiencing?

visceral pain

The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?

"An electric stove may be a safer choice for you."

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."

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."

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

Chronically poor perfusion may result in hair loss in the affected area, discolored skin, thickened nails, and shiny, dry skin indicative of inadequate tissue nutrition.

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 is used when humidification is desired. Other answers are incorrect.

Which is a sign of dyspnea specific to infants?

In the infant, flaring of the nostrils and retractions of the ribs during inspiration are notable signs of air hunger and extraordinary work of breathing.

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

Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.

The nurse is educating a client who is preparing for abdominal surgery tomorrow. A teaching demonstration has just been completed by the nurse related to splinting the incision site with a pillow. Which statement by the client best indicates the instructions provided by the nurse were effective?

Splinting the incision site when moving helps to minimize pain or discomfort postoperatively when coughing or moving. Clients should not hold their breath when trying to cough or move to prevent the Valsalva maneuver, which can change the heart rate and blood pressure of a client. Placing the pillow on the incision site after coughing is ineffective at reducing pain. The pillow should remain over the incision until the coughing exercises are completed.

When caring for a client with a tracheostomy, the nurse would perform which recommended action?

Suction the tracheostomy tube using sterile technique. Sterile technique is required when suctioning a tracheostomy in order to prevent introduction of microorganisms into the respiratory tract. The area around a new tracheostomy may need to be assessed and cleaned every 1 to 2 hours. Gauze dressings that are not filled with cotton must be used to prevent aspiration of lint or cotton fibers into the trachea.

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

The nurse can assess patterns of thoracic expansion through palpation. Fluid-filled and consolidated portions of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation.

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?

The nurse expects to document wheezing in the lungs of a client with asthma, which would be more pronounced when the client has a respiratory infection. Wheezing is a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration. Wheezing is caused by air passing through constricted passages caused by swelling or secretions. Stridor and crackles are other abnormal breath sounds caused by fluid, infection, or inflammation in the lungs. Absent breath sounds are not normally found in asthmatic clients; they are characteristic of pneumonia.

A client has arrived to the postanesthesia care unit (PACU) and is drowsy with a respiratory rate of 12 breaths per minute. What would be an accurate interpretation by the nurse?

This is an expected finding in the immediate postoperative period.

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 breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

A client using home oxygen asks the nurse about changing to an oxygen concentrator. What is the appropriate nursing response?

"It collects and concentrates oxygen from room air." "It eliminates the need for a central reservoir of piped oxygen." "You may notice an increase in your electric bill." "It costs less than oxygen supplied in portable tanks."

A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving?

A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44%

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use?

A nonrebreather mask is the only device that can deliver an FiO2 of 100% to a client without a controlled airway. A Venturi mask delivers a maximum FiO2 of 55%. A nasal cannula delivers a maximum FiO2 of 44%. A simple mask delivers a maximum FiO2 of 60%.

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?

A range of 95% to 100% is considered normal oxygen saturation. As such, there is no need to change the client's position, encourage deep-breathing exercises and coughing, or to review the client's medication history.

The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select?

A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. Other devices are not appropriate for this client.

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?

Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.

A nurse is reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would the nurse most likely identify as an effect of exposure to automobile pollutants?

Bronchitis refers to a condition in which the airways become inflamed, commonly due to respiratory irritants such as air pollution and high humidity. Exposure to such irritants leads to the release of inflammatory mediators, which in turn, lead to inflammation and narrowing of the airways and increased mucus production. Atelectasis refers to the partial or complete collapse of the small air sacs in the lungs, common after surgery or with obstruction or compression of the airways or lungs. Bronchiectasis results from chronic inflammation or infection causing an excess accumulation of mucus. Croup is an infection of the airways, most commonly viral in origin.

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?

Cardiac output is determined by multiplying the stroke volume by the heart rate/min, which equals 5,850 mL (5,850 × 109/L). Cardiac output and peripheral resistance determine both systolic and diastolic pressures.

Which surgical clients will return to activities in their everyday lives more quickly?

Clients who have surgery using a laparoscope are able to return to previous activity levels much sooner.

The nurse is assessing a client with a chest tube that has been inserted after experiencing blunt trauma that resulted in a pneumothorax. What nursing action is appropriate when constant bubbling is noted in the suction control chamber?

Constant bubbling in the suction control chamber is normal and should be documented. Other actions are inappropriate.

The client demonstrates soft, high-pitched, discontinuous sounds in the left lower lobe of the lung. How will the nurse accurately document this finding?

Crackles are soft, high-pitched, discontinuous sounds. Wheezes are a whistling or rattling sound in the chest as a result of obstruction in the air passages. Rales are small clicking, bubbling, or rattling sounds in the lungs. They are heard when a person breathes in (inhales). Vesicular breath sounds are heard across the lung surface.

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

Crackles, frequently heard on inspiration, are soft, high-pitched discontinuous (intermittent) popping sounds. Wheezes are continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors. Vesicular sounds are low-pitched, soft sounds heard over peripheral lung fields. Bronchovesicular sounds are medium-pitched blowing sounds heard over the major bronchi.

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 and epiglottitis are common in young children. The child has an obstruction of the upper airways, with swelling of the throat tissue. Atelectasis results when the lungs collapse as a result of the alveoli being unable to expand. Symptoms include difficulty breathing and discomfort. Pulmonary fibrosis is a condition in which the lung tissue becomes stiff and unable to expand appropriately. Asthma is a condition associated with bronchoconstriction. The symptoms include nonproductive cough, dyspnea, and wheezing.

The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal?

Except in the case of infants, fine crackles always constitute an abnormal assessment finding. A respiratory rate of 18 is within acceptable range. Vesicular sounds over peripheral lung fields and resonance on percussion are expected assessment findings.

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?

Finding an absent or weak signal, the nurse should check vital signs and client condition. If satisfactory, warming the extremity may facilitate a stronger reading. This should be attempted prior to resorting to using the client's earlobe. Bright light can interfere with the operation of light sensors and cause an unreliable report. A blood pressure cuff will compromise venous blood flow to the site leading to inaccurate readings.

The nurse is administering oxygen to an older adult client who has been assessed to have increased work of breathing. If the intervention has been effective, what finding(s) will the nurse expect on evaluation of the client?

Heart rate is 64 beats/min. Mucous membranes are pink and moist. Client is able to state the date, time and location.

The nurse is preparing to provide hygiene care to a client with hypoxia. Into what position will the nurse place the client?

High Fowlers position allows the client with hypoxia to breathe easier. This promotes lung expansion because the abdominal organs descend away from the diaphragm. Other answers are incorrect.

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?

If the client suddenly becomes cyanotic, the nurse should assess the oxygen tubing to make sure it is still connected. Assessing lung sounds, repositioning the client, and elevating the head of the bed will not correct the problem if the tubing is disconnected.

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

If the client vomits as the oropharyngeal airway is inserted, quickly position the client onto his or her side to prevent aspiration, remove the oral airway, and suction the mouth, if needed. It would be inappropriate and unsafe to leave the airway in place. Rinsing the client's mouth with water is not a priority.

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

In general, if a flow rate of 6 L/minute fails to raise a client's oxygen saturation level satisfactorily, a mask should be used. 1-4 L/minute flow rates per nasal cannula are standard flow rates. Greater than 6 L/minute flow rate per nasal cannula is very uncomfortable for the client. A flow rate of 10 L /minute per nasal cannula is not acceptable.

The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is:

Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter.

The nurse is providing education about deep-breathing exercises to a postoperative client whose surgery took place earlier today. Which instruction should the nurse provide?

Instruct the client that deep-breathing exercises should be performed every 1 to 2 hours for the first 24 hours after surgery.

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

When the nurse observes a newborn infant demonstrating an irregular abdominal breathing pattern, with a respiratory rate of 50 breaths/minute with occasional pauses in breathing of 5-second durations. What is the most appropriate action by the nurse?

Newborns breathe rapidly at 30 to 60 breaths per minute and may have occasional pauses of several seconds between breaths.

When reviewing data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom?

Normal cardiac output averages from 3.5 to 8.0 liter/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing the respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display a thready pulse.

What structural changes to the respiratory system should a nurse observe when caring for older adults?

One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker. The nurse should also observe other structural changes: the chest wall becomes stiffer as a result of calcification of the intercostals cartilage, kyphoscoliosis, and arthritic changes to costovertebral joints; the ribs and vertebrae lose calcium; the lungs become smaller and less elastic; alveoli enlarge; and alveolar walls become thinner. Diminished coughing and gag reflexes, increased use of accessory muscles for breathing, and increased mouth breathing and snoring are functional changes to the respiratory system in older adults.

A client is admitted to the emergency department with shortness of breath and oxygen saturation of 88%. The client has a barrel chest and clubbed fingers. What is the nurse's priority intervention?

Placing the client in the tripod position would relieve shortness of breath and increase the client's oxygen saturation level. Ambulating the client would exacerbate the symptoms, and assisting the client with the incentive spirometer is not appropriate at this time. The client will be unable to perform deep breathing exercises if hypoxic.

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, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol use do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol use depresses the central respiratory center.

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?

Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. High-Fowler's position is used to drain the apical sections of the upper lobes of the lungs. Placing the client lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.

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:

Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize atelectasis. Immobility is not commonly implicated in cases of pneumothorax or hemothorax. A pneumothorax is a collapsed lung. Hemothorax is a collection of blood in the space between the chest wall and the lung. Tachypnea, if present, would likely be a sign of atelectasis rather than an independent finding.

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

Pulse oximetry is a noninvasive technique that measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial blood. This test measures only the percentage of oxygen carried by the available hemoglobin. Thus, even a client with a low hemoglobin level could appear to have a normal SpO2 because most of that hemoglobin is saturated. However, the client may not have enough oxygen to meet body needs. A normal pulse oximetry reading does not necessarily indicate a normal RBC count or heart rate.

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:

Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.

The obstetric nurse is assisting the birth of a preterm neonate. In preparing for the respiratory needs of the neonate, the nurse is aware that surfactant is formed in utero around:

Surfactant is formed in utero around 34 to 36 weeks. An infant born prior to 34 weeks may not have sufficient surfactant produced, leading to collapse of the alveoli and poor alveolar exchange. Synthetic surfactant can be given to the infant to help reopen the alveoli.

The nurse is performing an arterial blood gas sampling on a client at 10:45. The nurse educator intervenes if which action is taken by the nurse?

The Allen test is done before puncture to ensure adequate ulnar blood flow when using the radial artery. The arterial specimen is immediately placed on ice and taken to the laboratory. The radial, brachial, or femoral arteries are usually the sites of choice for an arterial blood sampling. The nurse should apply pressure for 5 to 10 minutes, longer if the client is on anticoagulant therapy.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The adult chest contour is slightly convex, with no sternal depression. The skin of the thorax should be warm and dry, and the anteroposterior diameter of the chest should be less than the transverse diameter. The contour of the intercostal spaces should be flat or depressed.

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?

The client should be instructed to inhale deeply and cough; if this results in sputum, it should be collected in the container. The client should be placed in a semi-Fowler's position and instructed to clear the nose and throat and rinse the throat with water.

The nurse educator would intervene with client teaching if which action by the staff nurse occurs when teaching voluntary coughing?

The client should be sitting upright with feet flat on the floor to be most effective. As part of the client's plan of care, the nurse should develop a specific schedule for coughing. Coughing before meals improves the taste of food and oxygenation. When combined with deep breathing, coughing is most effective.

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?

The fit of the oxygen mask can be affected by the discontinuation of wearing dentures. The nurse should check the fit to make sure the client is getting the prescribed amount of oxygen. Other answers are inappropriate actions that do not address the problem.

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?

The following formula is used to determine cardiac output: Cardiac Output = Stroke Volume x Heart Rate. A client with a stroke volume of 50 mL and heart rate of 50 beats per minute has a cardiac output of 2.5 L/minute. If stroke volume is 70 and heart rate is 70 beats per minute, then the cardiac output is 4.9 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute.

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier?

The humidifier produces small water droplets which are delivered during oxygen administration to prevent or decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen.

What is the nurse's role in the informed consent process for a surgical procedure?

The nurse may witness the signed informed consent document. The health care provider will explain what takes place during the procedure, and provide benefits and risks. The client grants permission for surgery to be done.

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?

The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment. Then, the nurse can work with the health care provider to find alternate treatment options if necessary, and then document the care.

The nurse cares for a client following surgery to repair an abdominal aortic aneurysm. Which nursing intervention assists with healing and maintaining client comfort?

The nurse should plan for adequate periods of rest and sleep and maintain a quiet, restful environment. Nursing interventions that can help promote rest include maintaining a calm environment and limiting interruptions to the client's sleep (including frequent family visits). Providing solid food and keeping the client recumbent will not assist with healing and maintaining client comfort and may be contraindicated.

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

The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.

The nurse has received a prescription to obtain an arterial blood gas (ABG) on a client who has a history of chronic obstructive pulmonary disease (COPD) and is receiving oxygen via nasal cannula. Which step is the most important for the nurse to fulfill?

Unless the procedure is an emergency, it is advisable for the client to be at rest at least 30 minutes prior to obtaining the specimen. The ABG represents the client status at the moment of sampling and activity can lower oxygen levels in the blood, which can lead to an incorrect interpretation of the results. Some facilities require laboratory personnel to obtain this sample which would require the nurse to notify the lab; however, with the current use of computers, they may already know and not need to be contacted. The specimen tube should be placed on ice for transport to the laboratory to help preserve the specimen as it slows metabolism and helps ensure accurate results. Manual pressure should be applied for 5 to 10 minutes after the puncture and followed with a pressure dressing to reduce the potential of arterial bleeding.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

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.

The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care?

Using the air quality index, a red color designation signifies that the air quality is unhealthy for all people, not just sensitive groups. Air pollution and high humidity are respiratory irritants. Pollutants cause increased mucus production and contribute to bronchitis and asthma. Reducing contact with irritants by staying indoors during times of increased air pollution will decrease their effect on the respiratory system. Clients should be encouraged to quit smoking, not just cut down. Avoiding large crowds and practicing good hand hygiene will prevent respiratory infections but not cut down on the effect of air pollution.

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:

When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm.

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?

When performing oropharyngeal suctioning, the catheter should be placed along the side of the mouth toward the trachea and advanced 3 to 4 inches to reach the pharynx. In nasopharyngeal suctioning, the catheter should be inserted through the naris and along the floor of the nostril toward the trachea; it should be advanced approximately 5 to 6 inches to reach the pharynx. Applying lubricant to the first 2 to 3 inches of the catheter facilitates passage of the catheter and reduces trauma to mucous membranes. Allowing 30-second to 1-minute intervals between suction passes allows for reventilation and reoxygenation of airways.

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?

Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.

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:

Pulse oximetry is often used as a measure of tissue perfusion. An oxygen saturation of greater than 94% is typically indicative of good tissue perfusion.

The nurse is caring for a client with emphysema. A review of the client's chart reveals pH 7.36, PaO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription if prescribed by the health care practitioner?

The client with chronic lung disease, such as emphysema, becomes insensitive to carbon dioxide and responds to hypoxia to stimulate breathing. If given excessive oxygen (4 L/minute or 66 mL/second), the stimulus to breathe is removed. Clients with emphysema are most comfortable in high Fowler's position because it aids in the use of the accessory muscles to promote respirations. Increasing fluid intake helps keep the client's secretions thin. Pulse oximetry monitors the client's arterial oxyhemoglobin saturation while receiving oxygen therapy.

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?

The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the number of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissues of the body. Graves' disease, Parkinson's disease, and pancreatitis do not directly lead to a decrease in the number of red blood cells. Graves' disease is an immune system disorder that results in the overproduction of thyroid hormones (hyperthyroidism). Parkinson's disease (PD) is a neurodegenerative disorder that affects predominately dopamine-producing ("dopaminergic") neurons in a specific area of the brain called substantia nigra that causes a movement disorder. Pancreatitis is inflammation in the pancreas.

The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as:

The newborn's breathing pattern is characterized by occasional pauses of several seconds between breaths. This periodic breathing is normal during the first 3 months of life, but frequent or prolonged periods of apnea (cessation of breathing 20 seconds or longer) are abnormal. Dyspnea refers to shortness of breath. Orthopnea refers to difficulty breathing when lying flat. An elevation of carbon dioxide levels in the blood is termed hypercapnia.

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?

The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.

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?

The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Nonrebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.

As a circulating nurse caring for a 45-year-old man undergoing left knee arthroscopic exploratory surgery, which task ensures that the team is on the same page and will perform the procedure on the right client and at the right site?

The procedural pause (time-out) must be done prior to any procedure to ensure client safety and to verify the client identity, staff roles, and procedure being performed.

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test?

The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. The arterial blood gases test the client's blood for the partial pressure of oxygen dissolved in plasma, the percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma. Spirometry measures the volume of air in liters exhaled or inhaled by a client over time.

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?

Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis. Pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.

The nurse recognizes the value of leg exercises in the prevention of postoperative thrombophlebitis. When should the nurse teach the correct technique for leg exercises to a client?

Though leg exercises are begun after surgery, such preventive measures should ideally be taught to the client during the preoperative period. In the postanesthesia care areas, the client has just arrived from the operating room where local or general anesthesia has been used. The client will be sedated but arousable and teaching would be inappropriate. Early signs of venous status is too late for leg exercises to begin, as the clot may have formed.