Gas Exchange/EAQ

which assesment would the nurse perform first for a client with severe trauma

Airway

nursing action after a client has had general anesthesia are directed at preventing which postoperative respiratory complications

Atelectasis

A client who is receiving peritoneal dialysis reports severe respiratory difficulty. Which immediate action would the nurse implement?

Auscultate the lungs.

The nurse is caring for a client with a respiratory tract infection that started with a common cold but has progressed to whooping cough. The client also has coughing fits that last for several minutes. Which organism is responsible for the client's condition?

Bordetella pertussis This disease is caused by Bordetella pertusis. Pertussis is a respiratory tract infection that begins with the common cold and progresses to whooping cough. The client also develops coughing fits that last for several minutes. Inhalation anthrax is caused by Bacillus anthracis. Streptococcus pneumoniae may cause pneumonia. Mycobacterium tuberculosis infection leads to tuberculosis.

The nurse provides immediate postoperative care to a client. the client reports a sudden onset of shortness of breath and chest pain. which action would the nurse take?

Provide supplemental oxygen

which complication of cycstic fibrosis is related to frequent stools and tenacious mucus

Rectal Prolapse

a client has a closed chest drainage system in place. How would the nurse determine the amount of chest tube drainage

Refer to the date and time markings on the outside of the collection chamber.

before beginning administration of morphone wia patient-controlled analgesia which assesment would the nurse perform first

Respirations morphine decreases respiratory center function of the brain.

Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety?

Respiratory Alkalosis

A client is admitted to the hospital with a diagnosis of acute Guillain Barre syndrome. which assessment is the priority

Respiratory Exchange Clients with GBS have muscle weakness, possibly to the point of paralysis. If respiratory muscles are paralyzed, the client may need mechanical ventilation, so the respiratory system is the priority. The nurse will complete urinary, cognitive, and sensory assessments as part of a thorough evaluation.

When a preterm newborn requires oxygen, the nurse in the neonatal intensive care unit monitors and adjusts the oxygen concentration. What complication do these adjustments attempt to prevent?

Retinopathy of prematurity

Which intervention would the nurse offer the client to help relieve the symptoms of sinusitis?

Saline irrigation

A client is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease Which action would the nurse take to prevent client fatigue

Schedule nursing activities to allow for rest

In which position will the nurse place a client who has been transferred from the postanesthesia care unit to the intensive care unit after a radical neck dissection

Semi-Fowlers

when auscultating a clients chest the nurse hears swishing sounds of normal breathing how would the nurse document this finding

Vesicular breath sounds

Which condition would the nurse give the highest priority for a client admitted in the emergency department who has airway obstruction chest wall trauma, external hemorrhage and hypoglycemia

airway obstruction

which action would the nurse plan to take to prevent respiratory complications after abdominal surgery

assist client with spirometer

when the client has a right pneumothorax which type of breath sounds wil the nurse expect to hear on the right chest

decreased breath sounds

which pathophysiological abnormality is present in cyctic fibrosis

dysfunction of mucus secreting gland

what color tag would the triage nurse working at a train accident use to label a client experiencing respiratory distress

red

Which agent of terrorism can cause death within a few minutes?

sarin gas Sarin gas is an agent for bioterrorism that can cause death within minutes of exposure by paralyzing respiratory muscles. Uranium and Iodine-131 can be dangerous in close proximities but are not as harmful as sarin gas. Mustard gas causes blisters on the skin but does not cause death within a few minutes.

Which disease is caused by coronaviruses

severe acute respiratory syndrome

Which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema?

Decreases air trapping in lung

which clinical manifestation would the nurse expect when a client experiences fat embolism syndrome

Dyspnea Due to low levels of arterial oxygen.

Which is the priority nursing interventions to prevent thrombus formation in a child with sickle cell anemia

Encourage Fluids

which nursing intervention would be the priority for a client with multiple injuries from an accident

Establish a patent airway

Which instruction would the nurse include when teaching a client how to preform diaphragmatic breathing

Expand the abdomen on inhalation Expanding the abdomen on inhalation aids descent of the diaphragm so that more air can enter and fill the lungs. Rapid breathing promotes respiratory alkalosis; diaphragmatic breathing includes slow deep breathing. The hands should be placed lightly on the abdomen to verify abdominal excursion. Diaphragmatic breathing may be performed in any position, but the best is supine; leaning forward may prevent the client from moving the abdomen properly.

A NURSE IS CARING FOR A SCHOOL AGED CHILD WITH CYSTIC FIBROSIS WHICH PATHOPHYSIOLOGICAL FACTOR HAS THE GREATEST EFFECT ON THE CHILDS HEALTH STATUS

Extremely thick mucus causes obstructed airways.

After the nurse has finished teaching a client about sickle cell anemia, which statement indicates that the client has a correct understanding of the condition?

"I have abnormal hemoglobin. "The patient with sickle cell anemia has abnormal hemoglobin, hemoglobin S, causing the red blood cells to stiffen and elongate into a sickle. Although it can affect hematocrit, it is really a result of the abnormal hemoglobin. The disorder affects hemoglobin rather than platelets or white blood cells.

When caring for a client with pneumonia, which nursing intervention is the highest priority?

Employ breathing exercises and controlled coughing.

which assessment finding is consistent with bronchospasms

Wheezing, a high-pitched, musical, continuous sound that does not clear with coughing, is caused by airway narrowing, which occurs with bronchospasm, for example. Rhonchi are associated with obstruction by a foreign body or thick mucus. Pleural friction rub can be heard in cases of pleurisy. Pneumonia may be present in a client who exhibits low-pitched crackles.

which client would the triage nurse provide care for bases on condition

severe resp distress

After reviewing information about oxygenation for 4 clients with chronic obstruction pulmonary disease, which client will the nurse plan to teach about use of home long-term continuous oxygen therapy?

PaO2 of 55; SpO2 of 88

How should the nurse monitor for the complication of subcutaneous emphysema after the insertion of chest tubes?

Palpate around the tube insertion sites for crepitus.

the nurse notes that a child with cystic fibrosis who was admitted with reparatory infection is cyanotic, has barrel shaped chest and is in the 10th percentile for both height and weight . Which action would the nurse take

Perform Postural Drainage

Nurse is caring for a client with tracheostomy which action would the nurse implement when preforming tracheal suctioning

Preoxygenate the client before suctioning.

which is the function of the water seal chamber on a closed chest drainage system for a client with hemothorax

Prevents reflux of air back into the pleural space

When a client with a health care-acquired respiratory tract infection asks the nurse what this means, which response will the nurse give?

"Your infection occurred because of exposure to a health care facility.

Which statement by the nurse regarding anesthetic drugs in pediatric clients require correction.

' 'During general anesthesia, the upper airway obstruction risk is less in pediatrics.

the nurse assesses the integumentary system of four client's Which client has the least chance of a false positive result while undergoing assessment of capillary refill time.

A client with epilepsy They do not have any circulatory inadequacy. Therefore the capillary refill time of this client, as assessed in the nails, is a reliable indicator (i.e., does not reveal a false-positive result). A client with shock has decreased oxygen saturation levels that further prolong the capillary refill time. Capillary refill time is not a reliable indicator of blood circulation for clients with anemia, peripheral vascular disease, or diabetes.

Which medication would the nurse instruct a client to avoid while taking alprazolam? Select all that apply. One, some, or all responses may be correct.

A, B, C RAT- Respiratory depression can occur if a client combines benzodiazepines with opioids, alcohol, or barbiturates. Antidepressants and first-generation antipsychotics are safe to take with benzodiazepines

Which life-threatening wounds are treated with hyperbaric oxygen therapy? Select all that apply.

A. Burns C. Osteomyelitis D. Diabetic ulcers

which technique would the nurse employ for an obstetrical client with a foreign body airway obstruction

Chest Thrust preformed on a client with a foreign airway

Applying the emergency severity index (ESI) criteria, which client condition is considered least severe?

Closed extremity trauma

Which manifestation is an adverse effect of intravenous lorazepam? Select all that apply. One, some, or all responses may be correct.

Correct 1 Amnesia Correct 2 Drowsiness Correct 3 Sleep driving Correct 4 Blurred vision Correct 5 Respiratory depression Benzodiazepines such as lorazepam have a range of side effects, many of which are related to central nervous system depression. Anterograde amnesia, drowsiness, sleep driving, blurred vision, and respiratory depression are all potential adverse effects of lorazepam.

While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse?

Initiate oxygen via a nasal cannula Supplemental oxygen supports the body while the cause of the problem is identified; supplemental oxygen can be instituted without a prescription in an emergency. Morphine is used in the treatment of chest pain, but it is not the priority intervention. Endotracheal intubation is not the priority intervention. If the client's condition deteriorates and the client becomes unconscious or experiences respiratory failure or obstruction, endotracheal intubation is warranted. Nitroglycerin is available in most client acute care areas and does lessen chest pain if the pain is cardiac in origin, but it is not the priority intervention and requires a prescription.

a client presenting with acute asthma attack is being assessed in the emergency department. The clients spouse reports that the client currently is undergoing treatment for an upper respiratory infection the nurse would understand that the client most likely has which type of asthma

Intrinsic

which medication would the nurse initiate immediately for a client experiencing an anaphylactic attack

Isoproterenol this is a beta adrenergic, sympathomimetic med. This is considered to be the first -line of medication for the management of anaphylaxis.

A client with cystic fibrosis asks why the percussion procedure is being performed. The nurse explains that the primary purpose of percussion is to do what?

Loosen pulmonary secretions

which is the purpose of an occlusive dressing over a client's sucking chest wound

Maintain negative pressure with the chest cavity

A client is admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do?

Mark the time and fluid level on the side of the drainage chamber

Which action would the nurse take to prevent complications when caring for a client with a chest tube water seal drainage system for a pneumothorax

Marking the time on the drainage unit every shift

WHICH CLIENT RESPONSE IS MOST IMPORTANT FOR THE NURSE IN THE POST ANESTHESIA CARE UNIT TO MINITOR WHEN CARING FOR A CLIENT WHO HAD A THYROIDECTOMY

Signs of respiratory obstruction

in which order would the nurse teach the client the steps to follow while performing expansion breathing

Sit in an upright position with knees slightly bent. Place hands on each side of lower ribcage, just above the waist. Take a deep breath through your nose, using shoulder muscles to expand your lower ribcage outward during inhalation. Exhale, first moving the chest and then lower ribs inward while gently squeezing the ribcage, forcing air out of the base of lungs.

A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen?

To increase oxygen concentration to heart cells

How would the nurse position a client to practice supraglottic swallowing after tracheostomy?

Upright

How would the nurse position a client with epistaxis?

Upright leaning forward

Which condition would the nurse associate with a client's regular and slow respiratory rate

Bradypnea In bradypnea the breathing rate is regular, but it is abnormally slow. Respirations cease for several seconds in apnea. The rate of breathing is regular, but abnormally rapid in tachypnea. In hyperpnea, the respirations are labored, the depth is increased, and the rate is increased.

Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax? Select all that apply.

D. Marking the time on the drainage unit every shift

child with acute spamodic bronchitis who is receiving humidified air removes their mask during bathing, and notes increasing respiratory distress which action would the nurse take

Replace mask

which assessment finding of a client being treated in the emergency department after a motor vehicle collision indicates the need for immediate health care provider intervention

all are correct Facial edema and septal deviation indicate that the client has sustained facial injuries. Clear nasal drainage is an indication of a cerebrospinal fluid leak, and the nurse would immediately report the finding and send the drainage to be tested for glucose. An oxygen level of 89% would be reported to the health care provider as it could indicate nonvisible injuries. "Raccoon eyes" or bilateral periorbital bruising indicates a basilar skull fracture and requires immediate medical treatment.

a child in respiratory distress is admitted to the hospital and diagnosed with acute spasmodic laryngitis .at the time of discharge which recommendation would the nurse make to the parent for handling another attack at home

place them near a cool mist humidifier