Foundations Exam 1 CH 39
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? a. respirations 26 breaths/minute b. clubbing of fingers c. SpO2 96% d. heart rate 110 beats/minute
An SpO2 at or above between 95% and 100% is normal, reflecting that oxygen therapy is being effective. Clubbing, respirations greater than 26 breaths/min, and a heart rate greater than 100 beats/min may indicate that more oxygen is needed.
A client is prescribed a corticosteroid for the treatment of asthma after having an asthma attack. What education should the nurse provide to the client regarding the administration of this medication? a. This medication may cause drowsiness and should be used with caution while driving. b. Increase sodium intake while taking this medication. c. Monitor blood pressure and blood sugar. d. Weigh yourself each night prior to going to bed.
Blood pressure and blood glucose levels may rise while taking corticosteroids and levels should be measured. The sodium intake should be decreased and not increased while taking corticosteroids. This medication will not cause drowsiness and may have the effect of sleeplessness. The best time to weigh yourself is first thing in the morning when rising.
The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier? a. mineral oil b. tap water c. normal saline d. distilled water
Distilled water is used when humidification is desired. Other answers are incorrect.
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? a. Perfusion b. Hyperventilation c. Atelectasis d. Hypoxia
Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia. Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements. Perfusion refers to the process by which oxygenated capillary blood passes through body tissues. Atelectasis refers to collapsed alveoli.
The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is: a. Hypoxia related to pneumonia and ineffective airway clearance related to dyspnea edema. b. Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter. c. Risk for Ineffective Airway Clearance related to infection as evidenced by dyspnea and yellow-green sputum. c. Impaired Gas Exchange related to increased carbon dioxide and irritability.
Ineffective breathing pattern is the state in which a person's inspiration and/or expiration pattern does not provide adequate ventilation.
An older adult client was recently placed on home oxygen. The client's caregiver reports that the client now refuses to leave the house. What teaching will the nurse provide the caregiver? Select all that apply. a. "Continued socialization with others is important." b. "Invite friends and family to the client's house." c. "Give the client time to adjust." d. "Remove the oxygen for times when the client wants to leave the house." e. "Discuss with the client switching to a portable oxygen device."
Socialization is important for older adults. Having a portable oxygen device increases functional mobility. Inviting friends and family provides socialization and may help the client feel more at ease with oxygen use. The nurse should not suggest that the caregiver ignore the issue or remove the oxygen are inappropriate; these are inappropriate actions.
A client, 90 years of age, has been in a motor vehicle collision and sustained four fractured ribs on the left side of the thorax. The nurse recognizes the client is experiencing respiratory complications when which signs are observed? Select all that apply. The client has uneven movements of the chest with respirations. The client's capillary refill is assessed at 4 seconds. The client has flaring nostrils The client is demonstrates restlessness. The client has a respiratory rate of 16 breaths per minute
The client has uneven movements of the chest with respirations. The client's capillary refill is assessed at 4 seconds. The client has flaring nostrils The client is demonstrates restlessness. Careful assessment of older adults who demonstrate restlessness or confusion is imperative for differentiating signs of inadequate oxygenation accurately from signs of delirium or dementia. While the nurse may be observing signs of cognitive impairment, restlessness is commonly accompanies respiratory distress. The nurse will not dismiss this sign and will consider it as part of the respiratory assessment. A prolonged capillary refill (any longer than 3 seconds) is indicative of poor perfusion secondary to poor oxygenation. This is a sign that the client may be experiencing respiratory complications. The nurse observes for paradoxical (uneven) chest movement that would indicate possible flail chest. These complications may require insertion of a chest tube or other surgery, blood transfusion or artificial ventilation. Flaring nostrils indicate increased work of breathing related to poor gas exchange. A respiratory rate that ranges from 12-16 breaths per minute is normal for the adult and older adult.
Which teaching about the humidifier is important for the nurse to provide to a client using oxygen? a. It determines whether the client is getting enough oxygen. b. It decreases dry mucous membranes via delivering small water droplets. c. It regulates the amount of oxygen received. d. It prescribes oxygen concentration.
The humidifier produces small water droplets that are delivered during oxygen administration to 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 provider prescribes concentration.
A client who was prescribed CPAP reports nonadherence to treatment. What is the prioritynursing intervention? a. Contact the health care provider to report the client's current status. b. Document outcomes of modifications in care. c. Ask the patient of non adherence obstacles d. Explain the use of a BiPAP mask instead of a CPAP mask.
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.
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: a. "He is using his chest muscles to help him breathe." b. "He will require additional testing to determine the cause." c. "His lung muscles are swollen so he is using abdominal muscles." d. "His infection is causing him to breathe harder."
a. "He is using his chest muscles to help him breathe." The client will use accessory muscles to ease dyspnea and improve breathing.
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? a. 5,850 mL (5,850 × 109/L) b. 5,550 mL (5,500 × 109/L) c. 5,000 mL (5,000 × 109/L) d. 6,000 mL (6,000 × 109/L)
a. 5,850 mL (5,850 × 109/L) 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.
In which client should the nurse prioritize assessments for respiratory depression? a. A client taking opioids for cancer pain b. A client taking insulin for type 1 diabetes c. A client taking antibiotics for a urinary tract infection d. A client taking a beta-adrenergic blocker for hypertension
a. A client taking opioids for cancer pain 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.
The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? a. Be sure to shake the canister before using it. b. Inhale two sprays with one breath for faster action. c. Inhale the medication rapidly. d. Inhale through the nose instead of the mouth.
a. Be sure to shake the canister before using it. A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly. MDIs are inhaled through the mouth, into the lungs. The medication should be inhaled slowly to ensure a sufficient dose enters the lungs. If the order is for two sprays, these sprays are administered with one spray for each breath. The inhaled breath should be held briefly after each spray in order to prevent immediately exhaling the medication.
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? a. Check the fit of the oxygen mask. b. Contact the oxygen supplier to request an oxygen tent. c. Discontinue oxygen therapy until the client is reassessed by the healthcare provider. d. Increase the flow of oxygen.
a. Check the fit of the oxygen mask.
A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen? a. Instruct the client to inhale deeply and then cough. b. Have the client clear the nose and throat and gargle with salt water before beginning the procedure. c. Place the client in the dorsal recumbent position to collect the specimen. d. Discard the first sputum produced by the client.
a. Instruct the client to inhale deeply and then cough.
The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse would cause the charge nurse to intervene? a. The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). b. The newly hired nurse assesses the client's pain and administers pain medication. c. The newly hired nurse explains what she is doing and the reason to the client, even though the client does not appear to be alert. d. The newly hired nurse adjusts the bed to a comfortable working position.
a. The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). Care of a tracheostomy tube in a stable situation, such as long-term care and other community-based care settings, may be delegated to licensed practical/vocational nurses (LPN/LVN), but not in an acute instance. Adjusting the bed to a comfortable working position prevents back and muscle strain. Explanation alleviates fears; even if the client appears unconscious, the nurse should explain what is happening. When tracheostomy is new, pain medication may be needed before performing tracheostomy care.
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. a. True b. False
a. True After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A nurse caring for a client with a chest tube should monitor the patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.
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: a. adequate tissue perfusion. b. diminished stroke volume. c. heart failure. d. high cardiac output.
a. adequate tissue perfusion. 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.
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? a. chronic anemia b. Parkinson's disease c. pancreatitis d. Graves' disease
a. chronic anemia 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 auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: a. crackles. b. vesicular. c. bronchovesicular. d. wheezes.
a. crackles.
Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways? a. decreases the amount of air trapping and resistance b. increases carbon dioxide, which stimulates breathing c. helps liquefy his secretions d. teaches him to prolong inspiration and shorten expiration
a. decreases the amount of air trapping and resistance Exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration, which prevents air from being trapped in the alveoli and decreases resistance to exhalation. Increasing carbon dioxide levels to stimulate breathing is the natural stimulus for a person without COPD to breathe. Prolonging inspiration and shortening expiration does not assist the client because exhalation is difficult for the COPD client. Humidification and fluid intake help to liquefy secretions.
The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis? a. high respiratory rate b. high temperature c. low pulse rate d. low blood pressure
a. high respiratory rate A client diagnosed with Impaired Gas Exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.
A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered? a. nasal cannula b. partial rebreather mask c. simple oxygen mask d. Venturi mask
a. nasal cannula Nasal cannula and tubing administer oxygen concentrations at 22% to 44%.
A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response? a. "That will make it easier to carry with you." b. "The caregiver will need to place the oxygen tank back into the secure carrier." c. "That will help the oxygen flow more freely." d. "Call your oxygen supplier immediately."
b. "The caregiver will need to place the oxygen tank back into the secure carrier." Oxygen tanks are transported on a wheeled carrier to avoid accidental force. Accidental force could cause the tank to explode. The tank should not be carried, and taking it out of the carrier does not affect the flow of oxygen.
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: a. 1 L/minute. b. 6 L/minute. c. 4 L/minute. d. 10 L/minute.
b. 6 L/minute. 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.
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? a. Oxygen tent b. Ambu bag c. Nasal cannula d. Oxygen mask
b. Ambu bag If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Oxygen masks may cover only the nose and mouth and can vary in the amount of oxygen delivered. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostril. An oxygen tent is a tentlike enclosure within which the air supply can be enriched with oxygen to aid a client's breathing. Oxygen masks, nasal cannula, and oxygen tents are used for clients who have a respiratory drive.
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. Encourage the client to do deep-breathing exercises. b. Document this expected assessment finding. c. Review the medications that the client has taken in the past 90 minutes. d. Raise the head of the client's bed slightly, if tolerated.
b. Document this expected assessment finding. 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.
A client reports rarely leaving the house since starting use of home oxygen. What education should the nurse provide to the client? Select all that apply. a. The oxygen can be removed whenever the client leaves the home. b. Friends and family can be invited to visit the client at home. c. A portable oxygen device may be helpful. d. The client likely only needs time to adjust. e. Socialization is not as important for older adults.
b. Friends and family can be invited to visit the client at home. c. A portable oxygen device may be helpful. d. The client likely only needs time to adjust. Socialization is just as important for older adults as people of any other age group. Having a portable oxygen device increases functional mobility. Inviting friends and family provides socialization opportunities. Removing the oxygen could be life-threatening. The client will need time to adjust, but this is not the only need.
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 mostappropriate to this client's needs? a. Simple mask b. Nasal cannula c. Partial rebreather mask d. Nonrebreather mask
b. Nasal cannula A nasal cannula is used to deliver from 1 L/min to 6 L/min of oxygen. Masks are used with higher flow rates of oxygen.
A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply. a. Humidified venturi mask b. Partial rebreather mask c. Venturi mask d. Simple oxygen mask e. Nasal cannula
b. Partial rebreather mask d. Simple oxygen mask e. Nasal cannula Nasal cannula with tubing administers oxygen at low-flow rates and concentrations at 22%-44%. Simple masks and partial rebreathers both deliver a low-flow rate at concentrations of 40%-60%. Venturi masks mix oxygen with room air and create a high flow of oxygen.
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? a. Avoid exposure to large crowds. b. Stay indoors as much as possible. c. Practice good hand hygiene. d. Cut down on smoking.
b. Stay indoors as much as possible. 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 takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate? a. The client's respiratory rate is in the normal range. b. The client's oxygen demands are being met. c. The client's available hemoglobin is adequately saturated with oxygen. d. The client's red blood cell (RBC) count is in the normal range.
b. The client's oxygen demands are being met.
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? a. They are loud, high-pitched sounds heard primarily over the trachea and larynx. b. They are low-pitched, soft sounds heard over peripheral lung fields. c. They are medium-pitched blowing sounds heard over the major bronchi. d. They are soft, high-pitched discontinuous (intermittent) popping lung sounds.
b. They are low-pitched, soft sounds heard over peripheral lung fields. 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.
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? a. Place the probe on the client's earlobe. b. Warm the client's hands and try again. c. Use a blood pressure cuff to increase circulation to the site. d. Shine available light on the equipment to facilitate accurate reading.
b. Warm the client's hands and try again.
The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document? a. Crackles b. Wheezing c. Stridor d, Absent breath sounds in lower lobes
b. Wheezing 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 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: a. bronchitis. b. a bronchospasm. c. bronchiectasis. d. bronchiolitis.
b. a bronchospasm. 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 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: a. hypercapnia. b. apnea. c. orthopnea. d. dyspnea.
b. apnea. 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.
Oxygen and carbon dioxide move between the alveoli and the blood by: a. osmosis. b. diffusion. c. negative pressure. d. hyperosmolar pressure.
b. diffusion. 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 client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? a. "An occasional cigarette will not hurt you." b "I understand; I used to be a smoker also." c. "You should never smoke when oxygen is in use." d. "Oxygen is a flammable gas."
c. "You should never smoke when oxygen is in use."
Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? a. Snack on high-carbohydrate foods frequently. b. Eat one large meal at noon. c. Eat smaller meals that are high in protein. d. Contact the physician for nutrition shake.
c. Eat smaller meals that are high in protein. The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength.
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 a. Congestive heart failure b. Malnutrition c. Poor tissue perfusion d. Anemia
c. Poor tissue perfusion 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 with acute respiratory distress syndorme (ARDS). In what position does the nurse place the client in order to promote adequate oxygenation? a. Supine b. Semi-Fowler's c. Prone d. High Fowler's
c. Prone Research has demonstrated the prone position allows the lungs' posterior dependent sections to be better perfused and ventilated due to the recruitment of more alveoli. If a client is experiencing dyspnea and orthopnea, he or she will be more comfortable in the high Fowler's position. The client should not be turned to a supine or semi-Fowler's position.
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? a. spirometry b. thoracentesis c. Pulse oximetry d. peak expiratory flow rate
c. Pulse oximetry Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.
When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom? a. Mental alertness b. Increased urine output c. Rapid respirations d. Weight loss
c. Rapid respirations Normal cardiac output averages from 3.5 L/minute to 8.0 L/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 respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.
The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign? a. Orthostatic blood pressure b. Apical pulse c. Respiratory rate and depth d. Urinary intake and output
c. Respiratory rate and depth The client receiving narcotics/opioids needs monitoring of the respiratory rate and depth to ensure that respiratory depression does not result in progressive respiratory issues, physiologic damage from respiratory depression, or loss of consciousness. The pulse, blood pressure, and urinary intake and output are not as important as respiratory status when administering narcotics.
When caring for a client with a tracheostomy, the nurse would perform which recommended action? a. Assess a newly inserted tracheostomy every 3 to 4 hours. b. Use gauze dressings over the tracheostomy that are filled with cotton. c. Suction the tracheostomy tube using sterile technique. d. Clean the wound around the tube and inner cannula at least every 24 hours.
c. 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.
The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather? a. tracheostomy collar b. nasal cannula c. face tent d. simple mask
c. face tent
A client is diagnosed with hypoxia related to emphysema. The client's adult child will be assisting the client with daily hygiene. How will the nurse explain positioning of the client to the caregiver? a. "A standing position works best to allow your parent to move around in the bathroom and to allow you to help your parent in and out of the shower." b. "Place your parent at the sink to allow teeth brushing and stand outside of the shower to help if needed." c. "Whichever position helps your parent feel most comfortable and will allow you to help with hygiene is fine." d. "An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist."
d. "An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist." The best way to explain caregiving is to describe the specific position and type of chair to use as well as teach the caregiver why it is the best position and device. Teaching the caregiver to place the parent at the sink and then stand outside the shower does not provide the best position nor the device to obtain, plus it does not address the facts that the parent standing in the shower may not be possible due to hypoxia and is not safe. Teaching the caregiver to use whichever position is most comfortable for the parent does not address the safest position for the client nor the position that provides easiest breathing and energy conservation. Standing for the period of time it may take to complete daily hygiene is not feasible or safe for the client and should not be recommended by the nurse.
The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client? a. "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." b. "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." c. "If you breathe through the mouth first, you will swallow germs into your stomach." d. "Breathing through your nose first will warm, filter, and humidify the air you are breathing."
d. "Breathing through your nose first will warm, filter, and humidify the air you are breathing." Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring.
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? a. "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." b. "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." c. "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." d. "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."
d. "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." 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 preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? a. "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling." b."Take in a small amount of air very quickly and then exhale as quickly as possible." c. "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." d. "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."
d. "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.
The nurse performs a respiratory assessment on a healthy client. While listening to the client's lungs, the nurse hears them fill with air and then return to a resting position. The nurse deems the findings normal. Which is the best way to document this respiratory assessment and lung sounds? a. "Respiratory rate 22, regular; lungs sounds clear bilaterally; spontaneous, nonproductive cough, yellow drainage from nostrils." b. "Client breathing without difficulty; respiratory rate 22 and regular on 2 liters of oxygen per nasal cannula; dry, hacky, intermittent cough; reports slight shortness of breath with exertion." c. "Client sitting upright in bed, respirations 24 and shallow, lungs clear bilaterally, oxygen at 2 liters per nasal cannula, productive cough." d. "Respiratory rate 14, even, regular, and easy; depth with acceptable parameters; lung sounds clear all lobes bilaterally; absence of adventitious lung sounds; absence of spontaneous cough; oxygen saturation 98%."
d. "Respiratory rate 14, even, regular, and easy; depth with acceptable parameters; lung sounds clear all lobes bilaterally; absence of adventitious lung sounds; absence of spontaneous cough; oxygen saturation 98%." The most accurate and complete nursing documentation of normal lungs sounds in a health client is "Respiratory rate 14, even, regular, and easy; depth with acceptable parameters; lung sounds clear all lobes bilaterally; absence of adventitious lung sounds; absence of spontaneous cough; oxygen saturation 98%" because it provides the respiratory type, rate, depth, ventilation efficiency, clarity of all lobes of both lungs, absence of any abnormality and the oxygen saturation rate to provide a total respiratory picture of the healthy client. The other documentations are not complete, and each has an abnormal respiratory factor included.
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? a. Pulmonary function b. Hemoglobin levels c. Hematocrit values d. Arterial blood gas
d. Arterial blood gas 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.
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? a. It decreases dry mucous membranes via delivering small water droplets. b. It prescribes oxygen concentration. c. It regulates the amount of oxygen received. d. It determines whether the client is getting enough oxygen.
d. It determines whether the client is getting enough oxygen.
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? a. Tachypnea b. Wheezes c. Pneumonia d. Pleural effusion
d. Pleural effusion 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.
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? a. Chest x-ray b. Bronchoscopy c. Skin tests d. Pulmonary function tests
d. Pulmonary function tests 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.
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the mostappropriate intervention in this situation? a. Suction the client's mouth through the oropharyngeal airway to prevent aspiration. b. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. c. Leave the airway in place and promptly notify the health care provider for further instructions. d. Remove the airway, turn the client to the side, and provide mouth suction, if necessary.
d. Remove the airway, turn the client to the side, and provide mouth suction, if necessary. 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.
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? a. Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. b. Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. c. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm. d. 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.
d. 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. Guidelines to determine suction catheter depth include the following: 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 past the length of the endotracheal tube. Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Using a spare endotracheal or tracheostomy tube of the same size as being used for the client, insert the suction catheter to the end of the tube and note the length of catheter used to reach the end of the tube. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm.
In which client would the nurse assess for a depressed respiratory system? a. a client taking amlodipine for hypertension b. a client taking insulin for diabetes c. a client taking antibiotics for a urinary tract infection d. a client taking opioids for cancer pain
d. a client taking opioids for cancer pain Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Amlodipine is a calcium channel blocker and the medication decreased blood pressure, so the nurse would need to assess blood pressure. Antibiotics are used for urinary tract infections as well as other infections and the infections do not affect the respiratory system. Insulin decreases blood sugar which a person with diabetes may need to take every day. Insulin does not affect the respiratory system.
A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario? a. hypercapnia b. hypoxemia c. eupnea d. cyanosis
d. cyanosis Cyanosis around the lips indicates serious hypoxemia. Cyanosis is caused by a desaturation of oxygen on the hemoglobin in the blood. Hypercapnia is caused by an abnormally high carbon dioxide level in the blood. Hypoxemia is caused by low oxygen levels in the blood. Eupnea is easy, free respiration.
During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? a. nasal cannula b. oxygen analyzer c. humidifier d. flow meter
d. flow meter In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter 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. A humidifier is a device that produces small water droplets and may be used during oxygen administration because oxygen dries the mucous membranes. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen.
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? a. face tent b. nonrebreather mask c. simple mask d. nasal cannula
d. nasal cannula 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.
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. simple mask b. face tent c. nasal cannula d. tracheostomy collar
d. tracheostomy collar 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.