Gas Exchange Mastery Quiz RSNG 1128

As status asthmaticus worsens, the nurse would expect which acid-base imbalance? 1. Respiratory acidosis 2. Metabolic alkalosis 3. Metabolic acidosis 4. Respiratory alkalosis

1. Respiratory acidosis As staticus asthmaticus worsens, the PaCO2 increases and the pH decreases, reflecting respiratory acidosis.

The nurse is caring for a client diagnosed with genitourinary tuberculosis (TB). Which statement, made by the client, about genitourinary TB demonstrates an understanding? 1. "It isn't infectious, and I can't pass it from one person to another." 2. "I can't pass it sexually to my partner." 3. "It's a late manifestation of respiratory tuberculosis." 4. "It's an early manifestation of an autoimmune disorder."

3. "It's a late manifestation of respiratory tuberculosis." Genitourinary TB is usually a late manifestation of respiratory TB and can occur if the disease spreads through the bloodstream from the lungs. Bacillus in the urine is infectious, and urine would be handled cautiously. A condom would be used during sex to prevent spread of the infection.

What type of diet should the nurse teach the parents to give an older infant with cystic fibrosis (CF)? 1. high-calorie diet 2. high-fat diet 3. low-protein diet 4. low-carbohydrate diet

1. high-calorie diet CF affects the exocrine glands. Mucus is thick and tenacious, sticking to the walls of the pancreatic and bile ducts and eventually causing obstruction. Because of the difficulty with digestion and absorption, a high-calorie, high-protein, high-carbohydrate, moderate-fat diet is indicated.

A client with acquired immunodeficiency syndrome (AIDS) develops Pneumocystis carinii pneumonia. Which nursing diagnosis has the highest priority? 1. Imbalanced nutrition: Less than body requirements 2. Activity intolerance 3. Impaired oral mucous membranes 4. Impaired gas exchange

4. Impaired gas exchange Although all of these nursing diagnoses are appropriate for a client with AIDS, Impaired gas exchange is the priority nursing diagnosis for a client with P. carinii pneumonia. Airway, breathing, and circulation take top priority for any client.

A client has an adrenal tumor and is scheduled for a bilateral adrenalectomy. During prepoperative teaching, the nurse teaches the client how to do deep breathing exercises after surgery by telling the client to: 1. "Hold your abdomen firmly with a pillow, and take several deep breaths." 2. "Sit in an upright position, and take a deep breath." 3. "Tighten your stomach muscles as you inhale, and breathe normally." 4. "Raise your shoulders to expand your chest."

1. "Hold your abdomen firmly with a pillow, and take several deep breaths." Effective splinting for a high incision reduces stress on the incision line, decreases pain, and increases the client's ability to deep-breathe effectively. Deep breathing should be done hourly by the client after surgery. Sitting upright ignores the need to splint the incision to prevent pain. Tightening the stomach muscles is not an effective strategy for promoting deep breathing. Raising the shoulders is not a feature of deep-breathing exercises.

The father of a 2-year-old phones the emergency department on a Sunday night and informs the nurse that his son put a bead in his nose. What is the most appropriate recommendation by the nurse? 1. "You should bring your child to the emergency department tonight so the bead can be removed as soon as possible." 2. "Try removing the bead at home as soon as possible. You might try using a pair of tweezers." 3. "Ask your child to blow his nose several times; this should dislodge the bead." 4. "Be sure to take your child to the pediatrician in the morning so the pediatrician can remove the bead in the office."

1. "You should bring your child to the emergency department tonight so the bead can be removed as soon as possible." The bead should be removed by a health care professional as soon as possible to prevent the risk of aspiration and tissue necrosis. Unskilled individuals should not attempt to remove an object from the nose as they may push the object further increasing the risk for aspiration. Two-year-old children are not skilled at blowing their nose and may breathe in, further increasing the risk of aspiration.

Which information should the nurse include in a teaching plan for the client newly diagnosed with chronic obstructive pulmonary disease? Select all that apply. 1. A bronchodilator with meter-dose inhaler should be readily available. 2. High humidity may increase your work of breathing. 3. Pulmonary rehabilitation programs offer very little benefit. 4. Pneumococcal vaccination is contraindicated for clients with lung disease. 5. Smoking cessation is important to slow or stop disease progression.

1. A bronchodilator with meter-dose inhaler should be readily available. 2. High humidity may increase your work of breathing. 5. Smoking cessation is important to slow or stop disease progression. High humidity has been shown to increase the work of breathing. Carrying a metered-dose inhaler can facilitate early intervention if bronchospasm and shortness of breath should occur. Smoking cessation is difficult to achieve but very important in preventing COPD progression. Pulmonary rehabilitation programs are a great source of support for health promotion and maintenance for clients with COPD. Both the pneumococcal and influenza vaccines can help protect again respiratory infections.

Which client would be considered to be at the highest risk for respiratory failure? 1. A client with Guillain-Barré syndrome 2. A client with breast cancer 3. A client with cervical sprains 4. A client with a fractured hip

1. A client with Guillain-Barré syndrome Guillain-Barré syndrome is a progressive neuromuscular disorder that can affect the respiratory muscles and cause respiratory failure. The other conditions don't typically affect the respiratory system.

A client is admitted to the emergency department following an overdose of barbiturates. What should the nurse do first? 1. Assess ventilation and assist ventilation as needed. 2. Prepare to administer blood products. 3. Place the client in the Trendelenburg position. 4. Monitor the blood pressure.

1. Assess ventilation and assist ventilation as needed. Barbiturates can cause significant respiratory depression. The nurse's first action is to immediately assess the respiratory status and assist in bag-mask-valve ventilation as needed. Monitoring the vital signs is important, but respiratory care takes precedence over the blood pressure. Without other injury, blood products are not necessary. Placing the client in the Trendelenburg position will put pressure from the abdominal contents onto the diaphragm and further impair breathing.

Which complication is common in neonates who receive prolonged mechanical ventilation at birth? 1. Bronchopulmonary dysplasia 2. Esophageal atresia 3. Hydrocephalus 4. Renal failure

1. Bronchopulmonary dysplasia Bronchopulmonary dysplasia commonly results from the high pressures that must sometimes be used to maintain adequate oxygenation. Esophageal atresia, a structural defect in which the esophagus and trachea communicate with each other, isn't related to mechanical ventilation. Hydrocephalus and renal failure don't typically occur in neonates who receive mechanical ventilation.

When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, then a couple of small breaths, then 10 to 20 seconds of no breaths. The nurse should record the breathing pattern as: 1. Cheyne-Stokes respiration. 2. obstructive sleep apnea. 3. Biot's respiration. 4. hyperventilation.

1. Cheyne-Stokes respiration. Cheyne-Stokes respiration is defined as a regular cycle that starts with normal breaths, which increase and then decrease followed by a period of apnea. It can be related to heart failure or a dysfunction of the respiratory center of the brain. Hyperventilation is associated with an increased rate and depth of respirations. Obstructive sleep apnea is recurring episodes of upper airway obstruction and reduced ventilation. Biot's respiration, also known as "cluster breathing," is periods of normal respirations followed by varying periods of apnea.

During the first feeding, the nurse observes that the neonate becomes cyanotic after gagging on mucus. What should the nurse do first? 1. Clear the neonate's airway with suction or gravity. 2. Contact the neonatal resuscitation team. 3. Raise the neonate's head and pat the back gently. 4. Start mouth-to-mouth resuscitation.

1. Clear the neonate's airway with suction or gravity. If a neonate gags on mucus and becomes cyanotic during the first feeding, the airway is most likely closed. The nurse should clear the airway by gravity (by lowering the infant's head) or suction. Starting mouth-to-mouth resuscitation is not indicated unless the neonate remains cyanotic, and lowering the head or suctioning does not clear the airway. Contacting the neonatal resuscitation team is not warranted unless the infant remains cyanotic even after measures to clear the airway. Raising the neonate's head and patting the back are not appropriate actions for removing mucus. Doing so allows the mucus to remain lodged causing further breathing difficulties.

Laboratory results for a child with a congenital heart defect with decreased pulmonary blood flow reveal an elevated hemoglobin (Hb) level, hematocrit (HCT), and red blood cell (RBC) count. These data suggest which condition? 1. Compensation for hypoxia 2. Jaundice 3. Dehydration 4. Anemia

1. Compensation for hypoxia A congenital heart defect with decreased pulmonary blood flow alters blood flow through the heart and lungs, resulting in hypoxia. To compensate, the body increases the oxygen-carrying capacity of RBCs by increasing RBC production, which causes the Hb level and Hct to rise. In anemia, the Hb level and Hct typically decrease. Altered electrolyte levels and other laboratory values are better indicators of dehydration. An elevated Hb level and HCT aren't associated with jaundice.

A client with no known history of peripheral vascular disease comes to the emergency department complaining of sudden onset of lower leg pain. Inspection and palpation reveal absent pulses; paresthesia; and a mottled, cyanotic, cold, and cadaverous left calf. While the physician determines the appropriate therapy, the nurse should: 1. keep the affected leg level or slightly dependent. 2. place a heating pad around the affected calf. 3. shave the affected leg in anticipation of surgery. 4. elevate the affected leg as high as possible.

1. keep the affected leg level or slightly dependent. While the physician makes treatment decisions, the nurse should maintain the client on bed rest, keeping the affected leg level or slightly dependent (to aid circulation) and protecting it from pressure and other trauma. Warming the leg with a heating pad (or chilling it with an ice pack) would further compromise tissue perfusion and increase injury to the leg. Elevating the leg would worsen tissue ischemia. Shaving an ischemic leg could cause accidental trauma from cuts or nicks.

A client is scheduled to undergo transurethral resection of the prostate. The procedure is to be done under spinal anesthesia. Postoperatively, the nurse should assess the client for: 1. respiratory paralysis. 2 seizures. 3. cardiac arrest. 4. renal shutdown.

1. respiratory paralysis. If paralysis of vasomotor nerves in the upper spinal cord occurs when spinal anesthesia is used, the client is likely to develop respiratory paralysis. Artificial ventilation is required until the effects of the anesthesia subside. Seizures, cardiac arrest, and renal shutdown are not likely results of spinal anesthesia.

The nurse is caring for a client that is experiencing increasing shortness of breath. The client is pale and slight circumoral cyanosis is developing. Which laboratory test best measures the adequacy of tissue oxygenation? 1. Red blood cell count 2. Arterial blood gases 3. Pulmonary function test 4. Hemoglobin level

2. Arterial blood gases Arterial blood levels include levels of oxygen in the body and determines the adequacy of alveolar gas exchange. Red blood cell count provides information on the quantity of red blood cells in the system. Pulmonary function tests measures lung volume and capacity. Although hemoglobin is the red pigment in the red blood cells that carries oxygen, it is not the best measurement of tissue oxygenation.

What is the nurse's priority intervention for a client diagnosed with a pulmonary embolism? 1. Monitoring the oxygen delivery device 2. Assessing oxygenation status 3. Determining need for a ventilation-perfusion scan 4. Monitoring for other sources of clots

2. Assessing oxygenation status Nursing care should focus on assessing oxygenation status and ensuring that treatment is adequate. If the client's status begins to deteriorate, the nurse should contact the provider and attempt to improve oxygenation. Ensuring that the oxygen delivery device is working properly and monitoring for other clot sources aren't the primary focus of care. The provider would determine if the client required another ventilation-perfusion scan.

A client with chronic obstructive pulmonary disease (COPD) has developed tachypnea, dyspnea, and oxygen saturation (SaO2) of 90%. Which of the following actions by the nurse is most appropriate? 1. Place the client in the Trendelenburg position 2. Assist the client to sit in a chair and lean slightly forward with hands on the knees 3. Place the client on bed rest 4. Position the client in a low Fowler's position with the knees flexed

2. Assist the client to sit in a chair and lean slightly forward with hands on the knees Dyspnea is the primary disabling symptom of COPD and the most common. Persistent labored breathing is triggered by increased ventilation secondary to increased work of breathing. Dyspnea also has psychophysiologic components, triggered by such factors as anxiety and fear causing clients to avoid exercise and abandon activities, leading to a downward spiral of disability. To help manage dyspnea, teach clients activities that reduce or control it such as sitting up in the "tripod" position where the client sits or stands leaning forward with the arms supported, forces the diaphragm down and forward, and stabilizes the chest while reducing the work of breathing. COPD clients require exercise, better exercise capacity decreases dyspnea and improves quality of life. Continued bed rest is not recommended. If the client is in bed, the head should bed elevated to high Fowler's position and their arms should be supported on pillows or over the bed side table resting the elbows on a surface. This reduces competing demands of the arm, chest, and neck muscles needed for breathing. The Trendelenburg position is used for treatment of severe hypotension.

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client? 1. Full-liquid 2. High-protein 3. Low-fat 4. 1,800-calorie ADA

2. High-protein Breathing is more difficult for clients with COPD, and increased metabolic demand puts them at risk for nutritional deficiencies. These clients must have a high intake of protein for increased calorie consumption. Full liquids, 1,800-calorie ADA, and low-fat diets aren't appropriate for a client with COPD.

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? 1. Decreased heart rate 2. Increased restlessness 3. Decreased level of consciousness (LOC) 4. Increased blood pressure

2. Increased restlessness In ALS, an early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress.

The nurse is caring for a client with cystic fibrosis (CF) who has increased dyspnea. Which of the following interventions should the nurse include in the plan of care? 1. Schedule a sweat chloride test 2. Perform chest physiotherapy 3. Suction the client's upper airway 4. Place the client on a fluid restriction

2. Perform chest physiotherapy Airway clearance techniques are treatments that help people with cystic fibrosis (CF) stay healthy and breathe easier. ACTs loosen thick, sticky lung mucus so it can be cleared by coughing. Clearing the airways reduces lung infections and improves lung function. Routine scheduling of airway clearance using chest physiotherapy is an essential intervention for clients with CF. Fluid restrictions will worsen the thickening of secretions and suctioning the upper airway will not reach thick secretions in the lower lungs. A sweat chloride test is used to diagnose CF it is not a treatment.

Which intervention should the nurse anticipate using when caring for a term neonate diagnosed with transient tachypnea at 2 hours after birth? 1. Obtain extracorporeal membrane oxygenation equipment. 2. Provide warm, humidified oxygen in a warm environment. 3. Feed the neonate with a bottle every 3 hours. 4. Monitor the neonate's color and cry every 4 hours.

2. Provide warm, humidified oxygen in a warm environment. Symptoms of transient tachypnea include respirations as high as 150 breaths/minute, retractions, flaring, and cyanosis. Treatment is supportive and includes provision of warm, humidified oxygen in a warm environment. The nurse should continuously monitor the neonate's respirations, color, and behaviors to allow for early detection and prompt intervention should problems arise. Feedings are given by gavage rather than bottle to decrease respiratory stress. Obtaining extracorporeal membrane oxygenation equipment is not necessary but may be used for the neonate diagnosed with meconium aspiration syndrome.

A community health nurse is administering pneumococcal polysaccharide vaccinations and flu vaccinations to clients with asthma, chronic bronchitis, and emphysema. A client asks the nurse why these vaccines are recommended. What is the nurse's best response? 1. These vaccines produce bronchodilation and improve oxygenation. 2. Respiratory infections can cause severe hypoxia and possibly death in these clients. 3. These vaccines are recommended for all clients. 4. These vaccines help reduce the tachypnea these clients experience.

2. Respiratory infections can cause severe hypoxia and possibly death in these clients. It's highly recommended that clients with respiratory disorders receive vaccines to protect against respiratory infections. These clients may require intubation and mechanical ventilation if they become infected. The vaccines have no effect on bronchodilation or respiratory rate.

Which nursing intervention should be done first when managing a pediatric client admitted to the emergency department with severe diabetic ketoacidosis (DKA)? 1. Begin an insulin drip to lower the client's blood glucose level. 2. Secure the client's airway to ensure adequate ventilation. 3. Correct any fluid deficit using an isotonic saline solution. 4. Draw a blood glucose level and serum electrolyte panel.

2. Secure the client's airway to ensure adequate ventilation. Treating pediatric clients with severe DKA is a medical emergency; therefore, attending to the airway, breathing, and circulation is the first priority. Once the airway is secured, the healthcare team should estimate the level of dehydration and begin replacement fluids of normal saline. An insulin drip should be started after the initial 1 to 2 hours of treatment at a rate of 0.1 units/kg/hr. Blood glucose should be tested every 1 to 2 hours until the client is stable, then it should be every 6 hours. Additionally, serum electrolytes should be drawn every 1 to 2 hours until the client is stable, then every 4 to 6 hours.

A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the health care provider (HCP)? 1. lack of adventitious lung sounds 2. arterial oxygen level of 46 mm Hg (6.1 kPa) 3. oxygen saturation of 96% on room air 4. respirations of 12 breaths/min

2. arterial oxygen level of 46 mm Hg (6.1 kPa) Manifestations of adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen level below 50 mm Hg. The nurse should report the arterial oxygen level of 46 mm Hg (6.1 kPa) to the HCP. A respiratory rate of 12 is normal and not considered a sign of respiratory distress. Adventitious lung sounds, such as crackles, are typically found in clients with ARDS. Oxygen saturation of 96% is satisfactory and does not represent hypoxemia or low arterial oxygen saturation.

For a child who's admitted to the emergency department with an acute asthma attack, nursing assessment is most likely to reveal: 1. apneic periods. 2. expiratory wheezing. 3. inspiratory stridor. 4. fine crackles throughout.

2. expiratory wheezing. Expiratory wheezing is common during an acute asthma attack and results from narrowing of the airway caused by edema. Acute asthma rarely causes apneic periods. Inspiratory stridor more commonly accompanies croup. The child may have some fine crackles but wheezing is much more common in an acute asthma attack.

Which is a priority goal for the client with chronic obstructive pulmonary disease (COPD)? 1. treating infectious agents 2. maintaining functional ability 3. minimizing chest pain 4. increasing carbon dioxide levels in the blood

2. maintaining functional ability A priority goal for the client with COPD is to manage the signs and symptoms of the disease process so as to maintain the client's functional ability. Chest pain is not a typical symptom of COPD. The carbon dioxide concentration in the blood is increased to an abnormal level in clients with COPD; it would not be a goal to increase the level further. Preventing infection would be a goal of care for the client with COPD.

Assessing a neonate at 8 hours of age, the nurse records findings on the medical record below: Time 1100 Respiration 92, no nasal flaring, retractions, grunting. Heart rate 128, no murmur noted. Temperature 98.9°F (37.2°C). At 1130, the nurse notices the neonate has central cyanosis, and the respiratory rate is now 102; no nasal flaring, retractions, or grunting was noted, and breath sounds were clear. The nurse should: 1. encourage the baby to cry. 2. notify the health care provider (HCP). 3. change the neonate's position. 4. suction nose and mouth.

2. notify the health care provider (HCP). The neonate is experiencing quiet tachypnea with central cyanosis, which is a sign of possible congenital heart disease, so notifying the HCP is the correct answer. The baby is showing no signs of increased work of breathing, except increased respiratory rate. Breath sounds are clear; therefore, suctioning is not necessary and may cause further distress due to trauma to the nasal passage. Changing the neonate's position would have no impact on the cyanosis. Encouraging the baby to cry would increase the distress by decreasing oxygen consumption.

A school nurse is evaluating a 7-year-old child who is having an asthma attack. The child is cyanotic and unable to speak, with decreased breath sounds and shallow respirations. Based on these physical findings, the nurse should first: 1. contact the child's parent or guardian. 2. prepare to ventilate the child. 3. monitor the child with a pulse oximeter in her office. 4. return the child to class.

2. prepare to ventilate the chil The nurse should recognize these physical findings as signs and symptoms of impending respiratory collapse. Therefore, the nurse's top priority is to assess airway, breathing, and circulation, and prepare to ventilate the child if necessary. The nurse should then notify the emergency medical systems to transport the child to a local hospital. Because the child's condition requires immediate intervention, simply monitoring pulse oximetry would delay treatment. This child shouldn't be returned to class. When the child's condition allows, the nurse can notify the parents or guardian.

During a scheduled cesarean birth for a primigravid client with a fetus at 39 weeks' gestation in a breech presentation, a neonatologist is present in the operating room. The nurse explains to the client that the neonatologist is present because neonates born by cesarean birth tend to have an increased incidence of which problem? 1. meconium aspiration syndrome 2. respiratory distress syndrome 3. pulmonary hypertension 4. congenital anomalies

2. respiratory distress syndrome

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? 1. pH 2. Bicarbonate (HCO3-) 3. Partial pressure of arterial oxygen (PaO2) 4. Partial pressure of arterial carbon dioxide (PaCO2)

3. Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? 1. pH 2. Partial pressure of arterial carbon dioxide (PaCO2) 3. Partial pressure of arterial oxygen (PaO2) 4. Bicarbonate (HCO3-)

3. Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2

A client is brought to the emergency department following an automobile accident. Physical assessment reveals tachycardia, dyspnea, and absent breath sounds over the right lung. Which of the following actions is the nurse's most appropriate action? 1. Preparing the client for a pericardiocentesis 2. Preparing the client for a tracheostomy 3. Preparing the client for a chest tube insertion 4. Preparing the client for an emergency thoracotomy

3. Preparing the client for a chest tube insertion The client's history and absent breath sounds suggest a right-sided pneumothorax or hemothorax, which will require treatment with a chest tube. The other options would not be appropriate actions.

A client, diagnosed with asthma, is experiencing an anaphylactic reaction to a medication. After administering initial emergency care, the nurse would: 1. have the client lie flat in the bed. 2. administer beta-adrenergic blockers. 3. administer bronchodilators. 4. obtain serum electrolyte levels.

3. administer bronchodilators. Bronchodilators will open the client's airway and improve oxygenation status. Beta-adrenergic blockers aren't indicated in the management of asthma because they may cause bronchospasm. Obtaining laboratory values wouldn't be done during an emergency, and having the client lie flat in bed could impede his ability to breathe.

The nurse is caring for a client diagnosed with chronic obstructive pulmonary disease (COPD) and experiencing respiratory acidosis. The decrease in pH exists because the client's lungs: 1. have ineffective cilia from years of smoking. 2. are unable to inspire sufficient oxygen. 3. are not able to blow off carbon dioxide. 4. are unable to exchange oxygen and carbon dioxide.

3. are not able to blow off carbon dioxide. In clients with chronic respiratory acidosis, the client is unable to blow off carbon dioxide leaving in increased amount of hydrogen in the system. The increase in hydrogen ions leads to acidosis. In COPD, the client is able to breathe in oxygen and gas exchange can occur, but the lungs' ability to remove carbon dioxide from the system is compromised. Although individuals with COPD frequently have a history of smoking, impaired ciliary function is not the cause of the acidosis.

After suctioning a client, a nurse should expect to find: 1. brisk capillary refill. 2. a respiratory rate of 28 breaths/minute. 3. clear breath sounds. 4. a heart rate of 104 beats/minute.

3. clear breath sounds. Clear breath sounds, which indicate that secretions have been removed, indicate effective suctioning. An above-normal respiratory rate, such as a rate of 28 breaths/minute, may indicate that the airway isn't clear of secretions and the client's respiratory rate has increased to compensate. A slightly increased heart rate, such as a rate of 104 beats/minute, may indicate health concerns unrelated to suctioning. Brisk capillary refill indicates adequate cardiovascular function and is unrelated to suctioning.

After the client returns from surgery for a deviated nasal septum, the nurse should place the client in what position? 1. supine 2. left side lying 3. semi-Fowler's 4. reverse Trendelenburg's

3. semi-Fowler's To assist in breathing, promote comfort, and decrease edema formation after surgery, the client is most appropriately placed in semi-Fowler's position. The supine position will result in increased swelling, which will increase pain and interfere with breathing. Lying on either side will increase dependent swelling. Reverse Trendelenburg's provides no advantages over semi-Fowler's.

What is an expected outcome for an adult client with well-controlled asthma? 1. Chest X-ray demonstrates minimal hyperinflation. 2. Temperature remains lower than 100° F (37.8° C). 3. Arterial blood gas analysis demonstrates a decrease in PaO2. 4. Breath sounds are clear.

4. Breath sounds are clear. Between attacks, breath sounds should be clear on auscultation with good air flow present throughout lung fields. Chest x-rays should be normal. The client should remain afebrile. Arterial blood gases should be normal.

After a stroke, a client is admitted to the facility. The client has left-sided weakness and an absent gag reflex. He's incontinent and has a tarry stool. His blood pressure is 90/50 mm Hg, and his hemoglobin is 10 g. Which nursing intervention is a priority for this client? 1. Checking stools for occult blood 2. Performing range-of-motion (ROM) exercises on the left side 3. Keeping skin clean and dry 4. Elevating the head of the bed to 30 degrees

4. Elevating the head of the bed to 30 degrees Because the client's gag reflex is absent, elevating the head of the bed to 30 degrees helps minimize the client's risk of aspiration. Checking the stools, performing ROM exercises, and keeping the skin clean and dry are important, but preventing aspiration through positioning is the priority.

A client is admitted to a health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client? 1. Activity intolerance related to shortness of breath 2. Anxiety related to difficulty breathing 3. Risk for infection related to retained secretions 4. Impaired gas exchange related to airflow obstruction

4. Impaired gas exchange related to airflow obstruction A patent airway and an adequate breathing pattern are the top priority for any client, making Impaired gas exchange related to airflow obstruction the most important nursing diagnosis. Although Activity intolerance, Anxiety and Risk for infection may also apply to this client, they aren't as important as Impaired gas exchange.

Which nursing intervention is the priority for an infant with neonatal bronchopulmonary dysplasia (chronic lung disease)? 1. Give the infant higher calorie formula as ordered 2. Monitor strict input and output 3. Weigh the infant on the same scale, at the same time each day 4. Monitor oxygen status via pulse oximetry

4. Monitor oxygen status via pulse oximetry The infant will have impaired gas exchange related to retention of carbon dioxide and borderline oxygenation secondary to fibrosis of the lungs. Although the infant may require increased caloric intake, and may have excess fluid volume, the priority intervention is to maintain effective gas exchange.

A healthcare provider has entered orders for a client with chronic obstructive pulmonary disease (COPD). Which of the following orders should the nurse question? 1. Albuterol nebulizer treatments every 4 hours as needed 2. Keep head of bed elevated 30-45° 3. Oxygen via nasal canula at 2 L/minute 4. Oxygen increased to 3 L/minute if oxygen saturation is less than 94% on room air

4. Oxygen increased to 3 L/minute if oxygen saturation is less than 94% on room air People with COPD retain CO2, which is the normal trigger for respiratory rate. In clients with COPD and high levels of CO2, oxygen levels trigger breathing. Too much oxygen and the body slows breathing. Clients with COPD may quit breathing completely when given oxygen at very high levels (greater than 2 L).

What type of diet should the nurse teach the parents to give an older infant with cystic fibrosis (CF)? 1. low-carbohydrate diet 2. low-protein diet 3. high-fat diet 4. high-calorie diet

4. high-calorie diet CF affects the exocrine glands. Mucus is thick and tenacious, sticking to the walls of the pancreatic and bile ducts and eventually causing obstruction. Because of the difficulty with digestion and absorption, a high-calorie, high-protein, high-carbohydrate, moderate-fat diet is indicated.

A client was brought to the emergency department following a motor vehicle accident and has phrenic nerve involvement. The nurse should assess the client for: 1. alteration in urinary elimination. 2. alteration in level of consciousness. 3. altered cardiac functioning. 4. ineffective breathing pattern.

4. ineffective breathing pattern. The diaphragm is the major muscle of respiration; it is made up of two hemidiaphragms, each innervated by the right and left phrenic nerves. Injury to the phrenic nerve results in hemidiaphragm paralysis on the side of the injury and an ineffective breathing pattern. Consciousness, cardiac function, and urinary elimination are not affected by the phrenic nerve.

A client with bronchitis is ordered 300 mg of liquid guaifenesin every 4 hours. The container indicates that there is 200 mg/5 mL. How many milliliters should the nurse administer per dose? Record your answer using one decimal place.

7.5 mL The following formula is used to calculate the drug dosage: Dose on hand/Quantity on hand = Dose desired/X. Plug in the values for this equation: 200 mg/5 mL = 300 mg/X = 7.5 mL