NU230 therapeutics chapter 30 respiratory function
A client is receiving supplemental oxygen and the nurse is monitoring the client's oxygen saturation level using pulse oximetry. The nurse notifies the physician if the client reaches which oxygen saturation level?
92%
An 18-month-old client had a small toy in the mouth and is now drooling and appears distressed, but the client is not crying. Which intervention is the priority?
Administer five abdominal thrusts.
An unconscious adolesecent is brought to the emergency department with a respiratory rate of 6 breaths/min following a suspected opioid drug overdose. What is the nurse's most appropriate action?
Administer prescribed naloxone.
A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?
Ask the client what factors contribute to nonadherence.
The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines?
Be sure to shake the canister before using it.
A nurse working in a pediatric unit finds an infant unresponsive without respirations or a pulse. After calling for help, what is the nurse's most appropriate action?
Begin chest compressions.
The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate?
Check the fit of the oxygen mask.
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?
Hypoxia
Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen?
It regulates the amount of oxygen received.
The nurse is evaluating the effectiveness of therapy for a client who has received inhalation therapy treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective?
Oxygen saturation is > 94%.
A client returns to the unit following an insertion of a tracheostomy tube. Where should the nurse place the obturator?
Place the obturator in a plastic bag and put it at the bedside.
A 72 year-old client has come for an annual wellness check-up with the health care provider. Which vaccine will the nurse discuss with the client?
Pneumococcal 13-valent conjugate
The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?
Residual Volume (RV)
A nurse walks into a client's room and finds the client unresponsive. The client is not breathing and does not have a pulse, and the nurse immediately calls out for help. Which is the next nursing action?
Start chest compressions.
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?
They are low-pitched, soft sounds heard over peripheral lung fields.
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.
True
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?
Wheezing
What prevents air from reentering the pleural space when chest tubes are inserted?
a closed water-seal 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:
adequate tissue perfusion.
What does pulse oximetry measure?
arterial oxygen saturation
A conscious client is brought to the emergency department after falling through the ice while ice fishing. Which assessment will the nurse obtain first?
breath sounds
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?
chronic anemia
The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier?
distilled water
When performing a physical assessment of an adult client reporting dyspnea, the nurse is aware that which of the following is an abnormal finding?
dullness over the lung fields with percussion
The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is Ineffective Airway Clearance related to copious and tenacious secretions. Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan?
encouraging the client to consume 2 to 3 qt (1.9 L to 2.9 L) of clear fluids daily
A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?
flow meter
During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?
flow meter
A home care nurse finds an adult client slumped in a chair. The client is not breathing. Which method should the nurse use to open and maintain the client's airway?
head tilt-chin lift method
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?
high respiratory rate
Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system? Select all that apply.
ightly contoured chest with no sternal depression anteroposterior diameter of the chest less than the transverse diameter bronchial, vesicular, and bronchovesicular breath sounds
A client has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy tube is removed for cleaning?
inner cannula
The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client?
nasal cannula
A client with a 26-year history of cigarette smoking is recovering from pneumonia. Which information will be most important for the nurse to include in the discharge teaching?
options for smoking cessation
The nurse is caring for a 3-year-old client who experienced smoke inhalation during a house fire, and now requires oxygen. What delivery device will the nurse select that is most appropriate for this client?
oxygen tent
A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of:
pneumonia.
A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?
prolongs expiration to reduce airway resistance
A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?
pulse oximetry
A nurse is providing care to an infant who is at risk for developing respiratory complications. What would lead the nurse to notify the physician that the infant is experiencing breathing difficulties?
retraction of ribs
The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?
tracheostomy collar
A client with a head injury will require long-term airway support. Which device will be required for this client?
tracheostomy tube
The nurse is assessing a client with a history of asthma. Which assessment finding indicates that the nurse should take immediate action?
use of accessory muscles in breathing
The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?
"An electric stove may be a safer choice for you."
The home health nurse is visiting a new client who has recently started using an oxygen concentrator. After assessing the home environment, which comment should the nurse prioritize?
"Have you discussed a back-up system with your health care provider in case your electricity goes out?"
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?
"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."
An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize?
"Is your mask causing discomfort?"
The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier?
"Small water droplets come from this, thus preventing dry mucous membranes."
The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach?
"Take in as much air as possible, hold your breath briefly, and exhale slowly."
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?
"The caregiver will need to place the oxygen tank back into the secure carrier."
What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home?
"You will be asked to forcefully exhale into a mouthpiece."
The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal?
30 to 60 breaths per minute
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?
"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%."
A nurse is performing the Heimlich maneuver on a young client to relieve a mechanical airway obstruction. Which action should the nurse perform to increase intrathoracic pressure?
Give five quick abdominal thrusts above the navel.
A nurse has an order to obtain a sputum specimen on a newly admitted client. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)?
Label the sputum specimen and take it to the lab.
The unlicensed assistive personnel (UAP) has just completed morning care for several older adult clients with respiratory difficulties and reports to the nurse several observations. Which client should the nurse prioritize for intervention?
difficulty coughing
A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?
nasal cannula
