Oxygenation and Perfusion Ch 40 prep u questions
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 . "
Which response ( s ) will the nurse provide to a client concerned about developing chronic bronchitis due to smoking cigarettes , working with printing chemicals , and living near a paper mill ? Select all that apply .
" Have you tried to stop smoking ? This can reduce your risk ? " " We can refer you to a smoking cessation program to help reduce developing any future pulmonary issues . " " How long have you lived near the paper mill ? This can increase you risk for chronic bronchitis and asthma . " " Exposure to printing chemicals increases the risk for allergies which can trigger chronic bronchitis , so wearing a breathing mask may be needed . "
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 ?
" 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 . "
A client who uses portable home oxygen states , " I still like to smoke cigarettes every now and then . " What is the appropriate nursing response ?
" You should never smoke when oxygen is in use . "
The pediatric nurse is caring for four clients . Which client will receive the greatest benefit from the use of an oxygen analyzer to assure that the client is receiving the prescribed amount of oxygen ?
3 - year old in croup tent
A nurse is delivering 3 L / min oxygen to a client via nasal cannula . What percentage of delivered oxygen is the client receiving ?
32 %
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 :
6 L / minute
A nurse is preparing to use a wall unit to suction an endotracheal tube . At what pressure should the suction be set ?
80 to 150 mm Hg
The nurse is providing an educational demonstration to an older , postsurgical client . The intervention is intended to minimize the effect of what age - related change specifically relevant to such a client ?
A decrease in ventilation and an ineffective cough related less air exchange , more excretions remaining in the lungs
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.
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 ?
Ambu bag
A client is admitted to the hospital with shortness of breath , cyanosis and an oxygen saturation of 82 % ( 0.82 ) on room air . Which action should the nurse implement first ?
Apply oxygen as prescribed
The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation . The nurse would use which appropriate method to assess this client's oxygenation ?
Arterial blood gas
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 caring for a client receiving oxygen therapy via nasal cannula . The client suddenly becomes cyanotic with a pulse oximetry reading of 91 % . What is the next most appropriate action the nurse should take ?
Assess oxygen tubing connection
The nurse is educating an adolescent with asthma on how to use a metered dose inhaler. Which instructions will the the nurse include in the teaching?
Be sure to shake the canister before using it.
Upon auscultation of the client's lungs , the nurse hears loud , high - pitched sounds over the larynx . What term will the nurse use in documentation to describe this breath sound ?
Bronchial
A nurse is providing care in an area which is plagued by high levels of air pollutants from industry and motor vehicles . The nurse will expect a high incidence and prevalence of what respiratory disease ?
Bronchitis
A nurse is volunteering at a day camp where a child is stung by a bee and develops wheezing in the upper airways . The nurse will provide interventions to address what health problem ?
Bronchospasm
The nurse is assessing a client with lung cancer who has been receiving treatment for many months . What manifestations may suggest that the client has chronic hypoxia ?
Clubbing
The home care nurse visits a client with compromised lung function . The client has greenish yellow sputum with a musty odor . Which action will the nurse perform first ?
Collect a sputum sample in a sterile container
A client has edema of the feet and ankles , along with crackles in the lower lobes and a frothy , productive cough . The nursing care plan will address implications of what medical diagnosis ?
Congestive heart failure
The nurse observes a newborn infant demonstrating an irregular abdominal breathing pattern , with a respiratory rate of 40 breaths / minute with occasional pauses in breathing of 5 - second duration . What is the most appropriate action by the nurse ?
Continue to assess the infant
2 A client has been diagnosed with asthma and has been prescribed inhaled medications to relieve inflammation in the lung tissue . What medication will the nurse administer ?
Corticosteroids
A nurse is assessing the breath sounds of a newborn . Which sound is an expected finding for this developmental level ?
Crackles
A nurse is assessing a neonate whose breathing ceased for 4 to 5 seconds on three different occasions. What is the nurse's best action?
Document these expected apneic episodes
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?
Document this expected assessment finding.
The nurse is caring for a client with a 35 % Venturi mask . Which administration considerations should the nurse use ? Select all that apply .
Ensure that air intake valves are not blocked . Examine the needed flow rate on the mask matches the rate on the oxygen flow meter . Use gauze pads under elastic strap to relieve irritation to scalp or ears .
Diagnostic Name Diagnostic Time Diagnostic Result 1845 7.50 PH 1845 105 mm Hg ( 13.96 kPa ) PaO₂ 1845 29 mm Hg ( 3.86 kPa ) PȧCO₂ 1845 99 % ( 0.99 ) SaO₂ 1845 29 mEq / ( 29 mmol / l ) HCO , rebreather mask . Which was drawn on a client The nurse has received the arterial upon after reviewing the ABG ? Select all that apply . assessment findings who has been receiving oxygen via partial blood gas ( ABG ) results . The ABG should the nurse act
Headache Sore throat Fatigue
The nurse is caring for a client with chronic obstructive pulmonary disease ( COPD ) who expresses concerns about the ability to breathe easier . The nurse will suggest which position to help alleviate the client's dyspnea ?
High Fowler's position
A client suffering from chronic obstructive pulmonary disease ( COPD ) reports that it is hard to cough up secretions and the secretions are thick and sticky . Which intervention will the nurse use to promote respiratory hygiene in this situation ?
Increased oral fluid intake
The nurse is preparing a client for a complete blood count test . Which actions would the nurse perform ? Select all that apply .
Inform the client that this test can assist in evaluating the body's response to illness . Inform the client that specimen collection takes approximately 5 to 10 minutes . Explain that , based on results , additional testing may be performed .
A nurse on a cardiac care unit oversees the care of diverse clients ' cardiac health problems . Which action can be most appropriately delegated to a licensed practical nurse ( LPN ) ?
Initiation of CPR for a client who is found unresponsive
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 ?
Instruct the client to inhale deeply and then cough .
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen ?
It determines whether the client is getting enough oxygen .
The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily . What is the nurse's most appropriate response ?
Maintain the client's oxygenation and alert the health care provider immediately .
A nurse is overseeing the care of a client who is receiving oxygen via nasal cannula . Which aspects of the client's care can the nurse safely delegate to unlicensed assistive personnel ( UAP ) ? Select all that apply .
Measuring the client's respiratory rate Inserting the client's nasal cannula after it has become dislodged Reapplying the client's nasal cannula after a bath
A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this clients needs?
Nasal cannula
A client requires low - flow oxygen . How will the oxygen be administered ? Select all that apply .
Nasal cannula Simple oxygen mask Partial rebreather mask
A client with a diagnosis of advanced Alzheimer disease is unable to follow directions required to use an inhaled bronchodilator . Which medication delivery system is most appropriate for this client ?
Nebulizer
The nurse is obtaining a pulse oximetry reading for a client admitted with exacerbation of chronic obstructive pulmonary disease ( COPD ) . When observing a reading of 89 % , what action should the nurse perform ?
No action is required , because this may be normal for the client .
A nurse must deliver oxygen at a concentration of 85 % to an infant . Which delivery device would be most appropriate for an infant ?
Oxygen hood
The nurse observes that the client's pulse oximetry is 89 % . What is the priority nursing action ?
Perform respiratory assessment .
A client is admitted to the emergency department with shortness of breath and oxygen saturation of 88 % . The client has a barrel chest and clubbed fingers . What is the nurse's priority intervention ?
Place client in the tripod position
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
Poor tissue perfusion .
The nurse is caring for an older adult homebound client with advanced respiratory disease who has inadequate nutrition. What recommendation will the nurse provide?
Provide suggestions of high protein, high calorie meals
Which diagnostic procedure measures lung size and airway patency , producing graphic representations of lung volumes and flows ?
Pulmonary function tests
Which diagnostic procedure measures lung size and airway patency , producing graphic representations of lung volumes and flows ?
Pulmonary function tests .
A client vomits as a nurse is inserting his oropharyngeal airway . What would be the most appropriate intervention in this situation ?
Remove the airway , turn the client to the side , and provide mouth suction , if necessary .
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)
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 ?
SpO₂ 96 %
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?
Stay indoors as much as possible.
When caring for a client with a tracheostomy , the nurse would perform which recommended action ?
Suction the tracheostomy tube using sterile technique .
When inspecting a client's chest to assess respiratory status , the nurse should be aware of which normal finding ?
The chest should be slightly convex with no sternal depression .
A nurse takes a client's pulse oximetry reading and finds that it is normal . What does this finding indicate ?
The client's available hemoglobin is adequately saturated with oxygen .
The nurse is caring for a client who is receiving continuous oxygen at 3 L / minute via nasal cannula . The client's oxygen saturation has consistently been 94 % to 96 % , but suddenly drops to 86 % as the nurse palpates the client's abdomen . The client denies respiratory difficulty or other distress . What is a likely reason for the client's decreasing oxygen saturation ?
The nurse has inadvertently stepped on the client's oxygen tubing , occluding the flow of oxygen .
The nurse is performing an arterial blood gas sampling on a client at 10:45 . The nurse educator intervenes if which action is taken by the nurse ?
The nurse performs the Allen test after blood sample is taken .
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
A nurse assessing a client's respiratory effort notes that the client is breathing 8 shallow breaths / min . Which action best meets this client's immediate oxygenation needs ?
Use a bag and mask .
A nurse has received an order to suction an adult client's endotracheal tube . Which action is most appropriate when performing this intervention ?
Use sterile saline to moisten the end of the suction catheter .
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?
Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm.
During data collection , the nurse auscultates fields . Which appropriate terminology would the nurse low - pitched , soft sounds over the lungs ' peripheral use to describe these lung sounds when documenting ?
Vesicular
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 ?
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?
Wheezing
Which scenario describes how carbon dioxide levels determine the frequency and depth of ventilation ?
When carbon dioxide levels in the blood increase , chemoreceptors are stimulated , causing deeper and more rapid breathing .
Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway ? When holding the airway on the side of the client's face , it should reach from the tragus of the ear to the tip of the nostril .
When holding the airway on the side of the client's face , it should reach from the tragus of the ear to the tip of the nostril .
The nurse is caring for the following clients. Which client is at highest risk for a depressed respiratory system?
a client taking an opioid for cancer pain
What assessments would a nurse make when auscultating the lungs ?
air flow through the respiratory passages
A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier . Since her surgery , the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery . The nurse would recognize that the client's prolonged immobility creates a risk for :
atelectasis .
A client has been receiving treatment with a nonrebreather mask for the past 96 hours . How should the nurse respond if the unlicensed assistive personnel ( UAP ) suddenly reports the client . has vomited ?
conduct a focused assessment
The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift . Which assessment finding is consistent with hypoxia ?
confusion
During the physical assessment of a client who has been inactive due to a leg injury, the nurse notes that the client tends to breathe very shallowly. What technique should the nurse teach the client in order to breathe more efficiently?
deep breathing
The nurse has received a prescription to obtain an arterial blood gas ( ABG ) on a client who has a history of chronic obstructive pulmonary disease ( COPD ) and is receiving oxygen via nasal cannula . Which step is the most important for the nurse to fulfill ?
ensure client is at rest at least 30 minutes before obtaining the specimen .
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
An older adult client is visibly pale with a respiratory rate of 30 breaths per minute . Upon questioning , the client states to the nurse , " I can't seem to catch my breath . " The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry , yielding a reading of 90 % . The nurse should interpret this oxygen saturation reading in light of the client's :
hemoglobin level .
To drain the apical sections of the upper lobes of the lungs , the nurse should place the client in which position ?
high - Fowler's position
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
The nurse is applying a pulse oximeter to a client with bronchitis . Which factor ( s ) does the nurse communicate to the client that could interfere with accurate pulse oximetry ? Select all that apply .
nail polish thickness of nails acrylic nails peripheral vascular disease
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
Which is a sign of dyspnea specific to infants ?
nasal flaring
A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO₂ of 100 % . Which oxygen delivery system should the nurse use ?
nonrebreather mask
The nurse is assessing a client's chest tube which was inserted 48 hours earlier . The nurse notes crackling in the skin around the insertion site . Which action should the nurse prioritize ?
notify the health care provider
The nurse is caring for a client with respiratory alkalosis . Which arterial blood gas data does the nurse anticipate finding ?
pH greater than 7.45 ; HCO3 low ; PaCO2 low ; hyperventilation
A nurse is caring for a client with metabolic acidosis whose breathing rate is 28 breaths per minute. Which arterial blood gas data does the nurse anticipate finding?
pH less than 7.35; HCO3 low; PaCO2 low In metabolic acidosis, anticipated arterial blood gas results are anticipated to reflect pH less than 7.35; HCO3 low; and PaCO2 low. Other answers are incorrect
While examining a client , the nurse palpates the client's chest and back . What would the nurse expect to identify with this technique ?
pattern of thoracic expansion
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 .
While auscultating a client's chest , the nurse auscultates crackles in the lower lung bases . What condition does the nurse identify the client is experiencing ?
presence of fluid in the lungs .
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
When reviewing data collection on a client with a cardiac output of 2.5 liter / minute , the nurse inspects the client for which symptom ?
rapid respirations
The nurse is performing a check with an oxygen analyzer . Which oxygen analyzer assessment finding indicates that the device is working properly ?
reads 0.21 when checking oxygen in room air
The nurse is caring for a client with a chest tube . Which assessment finding indicates that the tube is functioning correctly ?
respirations are at 20 breaths per minute
A nurse is caring for a 3 - year - old child that was admitted with pneumonia . The parent expresses concerns about the child's respirations . The nurse is providing education about respiratory - related developmental changes to help the parent differentiate what is normal from what is abnormal . For each assessment finding click to specify if the finding indicates the client's condition is normal or abnormal .
respiratory rate of 28 / min -Normal thoracic breathing-Abnormal inspiration longer than expiration-Abnormal irregular respiratory pattern- Normal round thorax-Abnormal
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
port when inserting the suction catheter because it would cause what condition to occur ? A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y
trauma to the tracheal mucosa
