Oxygenation PrepU

A client in the emergency department reports squeezing substernal pain that radiates to the left shoulder and jaw. The client also complains of nausea, diaphoresis, and shortness of breath. What is the nurse's priority action?

Administer oxygen, attach a cardiac monitor, take vital signs, and administer sublingual nitroglycerin.

The nurse is caring for a postpartum woman who exhibits a large amount of bleeding. Which areas would the nurse need to assess before the woman ambulates?

Blood pressure, pulse, reports of dizziness

A patient who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe?

Brain Stem

Which teaching about the humidifier is important for the nurse to provide to a client using oxygen?

It decreases dry mucous membranes via delivering small water droplets.

The home care nurse is caring for a client who has sustained phrenic nerve damage from a skiing accident. The nurse understands that the client must be on a ventilator for which reason?

Loss of diaphragmatic function.

What does the nurse recognize as one of the most common postoperative respiratory complications in elderly clients?

Pneumonia

What is the nurse's expectation about a client's ability to compensate for a metabolic blood gas disorder?

The client will compensate with the respiratory system.

A newborn is diagnosed with respiratory distress syndrome (RDS). While assessing the newborn, the nurse realizes that which maternal factor would most place the infant at risk for RDS?

maternal gestational diabetes

In relation to the structure of the larynx, the cricoid cartilage is

the only complete cartilaginous ring in the larynx.

A client has had surgical repair of a hip injury after joint manipulation was unsuccessful. After surgery, the nurse implements measures to prevent complications. Which complications is the nurse seeking to prevent? Select all that apply.

- skin breakdown - wound infection - pneumonia

A nurse who is a member of an emergency response team anticipates that several patients with airway obstruction may need a cricothyroidotomy. For which of the following patients would this procedure be appropriate? Select all that apply.

-Patient with laryngeal edema secondary to anaphylaxis -Patient with an obstructed larynx -Patient with extensive facial trauma

A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client.

1. "Inhale through your nose." 2. "Slowly count to 3." 3. "Exhale slowly through pursed lips." 4. "Slowly count to 7."

The goal for oxygen therapy in COPD is to support tissue oxygenation, decrease the work of the cardiopulmonary system, and maintain the resting partial arterial pressure of oxygen (PaO2) of at least ______ mm Hg and an arterial oxygen saturation (SaO2) of at least ___%.

60 mm Hg; 90%

The nurse is using continuous central venous oximetry (ScvO2) to monitor the blood oxygen saturation of a patient in shock. What value would the nurse document as normal for the patient?

70%

A client experiences burning muscle pain at the peak of high intensity physical training for an athletic competition. What is the best explanation for the cause of this occurrence?

Anaerobic glycolysis creates pyruvate, which converts to lactic acid.

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?

Anxiety

The nurse is caring for a client undergoing conscious sedation. The nurse knows the client is at risk for ineffective breathing patterns. What nursing intervention will help the client demonstrate a normal breathing pattern?

Encourage the client to take deep breaths and cough at least every hour.

The nurse cares for a client with clubbing of the fingers and toes. The nurse should complete which action given these findings?

Obtain an oxygen saturation level.

A client recently had surgery for a hip fracture. Which nursing intervention would be most effective for preventing pulmonary emboli in this client?

Prevention of the development of a deep vein thrombosis

A 3-year-old child has been admitted to the pediatric unit for the treatment of croup. The nurse should include which action in the child's plan of care?

Providing cool, moist air for the child to breathe

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS?

Rapid onset of severe dyspnea

Which of the following is the priority assessment for a nurse caring for a client with a Patient Controlled Analgesia (PCA) pump?

Respiratory

A client has undergone surgery for a spinal cord tumor that was located in the cervical area. The nurse would be especially alert for which of the following?

Respiratory Dysfunction

The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign?

Respiratory rate and depth

A neonate develops respiratory distress syndrome. Which would be used?

Surfactant replacements

A client is brought in by ambulance in a nauseous and confused state and demonstrating carpopedal spasm. Initial arterial blood gases show increased pH and HCO3 and normal PaCO2levels. Breathing is slow and shallow. As the nurse caring for this client, you know that potassium salt should be a part of the treatment for this client when?

When hypokalemia is present

A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?

assessing the client's respiratory status, orientation, and skin color

A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor?

decrease in circulation and perfusion to the fetus

Four weeks before the birth of a client's already large child, the primary care provider has told the client that if the baby gets bigger and the baby's lungs are ready, the care provider would like to perform a cesarean birth. The woman asks the nurse what the downside is to having a cesarean rather than a vaginal birth. What is an appropriate response by the nurse?

"As the baby passes through the birth canal some of the excess fluid is expelled from the lungs; if that doesn't happen there's a higher risk of respiratory distress."

An older adult client who was recently diagnosed with emphysema asks the nurse what caused the disease. Which statement is the best response?

"One of the causes of emphysema is a history of cigarette smoking that causes damage to the lungs. Have you ever smoked?"