Oxygenation & Perfusion
True or False: 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 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 most appropriate to this client's needs? (a) Nasal cannula (b) Simple mask (c) Partial rebreather mask (d) Nonrebreather mask
a--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'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) Pleural effusion (b) Tachypnea (c) Wheezes (d) Pneumonia
a--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)
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? (a) Page the respiratory therapist STAT. (b) Maintain the client's oxygenation and alert the health care provider immediately. (c) Cover the tracheostomy stoma and apply oxygen by nasal cannula (d) Assess the client's respiratory status and check vital signs every 1 minute for the next hour.
b--If the tracheostomy becomes dislodged and is not easily replaced, the nurse should notify the primary care provider immediately, cover the tracheostomy stoma, and assess client's respiratory status.
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? (a) oxygen analyzer (b) nasal strip (c) nasal cannula (d) flow meter
d
A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered? (a) nasal cannula (b) simple oxygen mask (c) Venturi mask (d) partial rebreather mask
a
Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system? Select all that apply. (a) slightly contoured chest with no sternal depression (b) anteroposterior diameter of the chest less than the transverse diameter (c) quiet and nonlabored respiration occurring at a rate of 18 to 30 bpm (d) barrel chest appearance in older adults (e) bronchial, vesicular, and bronchovesicular breath sounds (f) crackles heard on inspiration.
a,b,e
What assessments would a nurse make when auscultating the lungs? (a) cardiovascular function (b) abnormal chest structures (c) presence of edema (d) volume of air exhaled or inhaled
a--If cardiovascular function is not adequate, the results will lead to impaired oxygenation
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 smaller meals that are high in protein. (c) Contact the physician for nutrition shake. (d) Eat one large meal at noon.
b
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 little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." (b) "Take in a small amount of air very quickly and then exhale as quickly as possible." (c) "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." (d) "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling."
c
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) tap water (b) normal saline (c) distilled water (d) mineral oil
c--Distilled water is used when humidification is desired
In which client should the nurse prioritize assessments for respiratory depression? (a) A client taking a beta-adrenergic blocker for hypertension (b) A client taking antibiotics for a urinary tract infection (c) A client taking insulin for type 1 diabetes (d) A client taking opioids for cancer pain
d
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? (a) Tidal volume (TV) (b) Total lung capacity (TLC) (c) Forced Expiratory Volume (FEV) (d) Residual Volume (RV)
d
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) a bronchospasm. (b) bronchitis. (c) bronchiectasis. (d) bronchiolitis.
a
The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system? (a) an older adult client who has COPD (b) a child who has pneumonia (c) an adult who is receiving oxygen at home (d) an adolescent who has asthma
b
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 medium-pitched blowing sounds heard over the major bronchi. (c) They are low-pitched, soft sounds heard over peripheral lung fields. (d) They are soft, high-pitched discontinuous (intermittent) popping lung sounds.
c
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? (a) Remove the airway, turn the client to the side, and provide mouth suction, if necessary. (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) Suction the client's mouth through the oropharyngeal airway to prevent aspiration.
a
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) high cardiac output. (d) heart failure.
a
A client with chronic obstructive pulmonary disease who uses supplemental oxygen via mask requires oral suctioning. Which action(s) demonstrates the components of appropriate oral suctioning technique by the nurse? Select all that apply. (a) Allowing client to rest for 30 to 60 seconds in between suctionings (b) Removing the client's oxygen and inserting the yankauer catheter into client's mouth (c) Applying suction by covering the thumb hole on the catheter for a maximum of 45 to 60 seconds (d) Replacing oxygen on client and clearing out suction catheter by placing yankauer in the basin of water (e) Running the catheter along the client's gum line to the pharynx in a circular motion while keeping yankauer moving
a,b,d,e
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 will require additional testing to determine the cause." (b) "He is using his chest muscles to help him breathe." (c) "His infection is causing him to breathe harder." (d) "His lung muscles are swollen so he is using abdominal muscles."
b
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? (a) simple mask (b) tracheostomy collar (c) nasal cannula (d) face tent
b
A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery? (a) educating the client on the use of incentive spirometry (b) educating the client on pursed-lip breathing techniques (c) oropharyngeal suctioning twice daily (d) administration of inhaled corticosteroids
a
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) wheezes. (d) bronchovesicular.
a
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) Rapid respirations (b) Weight loss (c) Increased urine output (d) Mental alertness
a--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.
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 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. (c) 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. (a) For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.
b
The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly? (a) small amount of subcutaneous air is detected at the site of tube insertion (b) dressing is moist and intact (c) respirations are at 20 breaths per minute (d) drainage system is positioned slightly above chest level
c--Respirations of 20 breaths per minute indicate that the tube is functioning correctly. Other findings require nursing intervention.
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) Stridor (b) Crackles (c) Wheezing (d) Absent breath sounds in lower lobes
c--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
A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from: (a) pulmonary embolism. (b) myocardial infarction. (c) lung cancer. (d) congestive heart failure.
d
During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting? (a) Crackles (b) Bronchovesicular (c) Bronchial (d) Vesicular
d
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) Raise the head of the client's bed slightly, if tolerated. (c) Review the medications that the client has taken in the past 90 minutes. (d) Document this expected assessment finding.
d--A range of 95% to 100% is considered normal oxygen saturation