Oxygentation & Gas Exchange
The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client?
"Breathing through your nose first will warm, filter, and humidify the air you are breathing."
A mother is talking to the nurse and is concerned about managing her asthma while she is pregnant. Which response to the nurse's teaching indicates that the woman needs further instruction?
"I need to begin taking allergy shots like my friend to prevent me from having an allergic reaction this spring."
A client recently diagnosed with bronchiectasis asks what may have caused the condition. Which response by the nurse is accurate?
"It may have developed after you had a severe inflammation caused by aspiration pneumonia."
A client with asthma is confused by her primary care provider continuing her medication while she is pregnant, since she read online the medications can cause birth defects. What is the nurse's best response?
"Your primary care provider will order safe doses of your medication."
The nurse is administering 100% oxygen to a patient with carbon monoxide poisoning and obtains a carboxyhemoglobin level. Which level would the nurse interpret as indicating that oxygen therapy can be discontinued?
4%
A client has developed community-acquired pneumonia and is being treated at home. What does the nurse recognize are the methods in the diagnosis of community-acquired pneumonia? Select all that apply.
Age Coexisting health problems Severity of illness
A client is diagnosed with early pneumococcal pneumonia. What does the nurse recognize occurs during the first stage of pneumococcal pneumonia?
Alveoli become filled with protein-rich edema fluid containing numerous organisms and increase in red blood cells.
Atelectasis is the term used to designate an incomplete expansion of a portion of the lung. Depending on the size of the collapsed area and the type of atelectasis occurring, the nurse may see a shift of the mediastinum and trachea. Which way does the mediastinum and trachea shift in compression atelectasis?
Away from the affected lung
At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.
Bradycardia Hypertension Bradypnea
The nurse is caring for a client with a history of sickle cell anemia. The nurse understands that this predisposes the client to which renal or urologic disorder?
Chronic kidney disease
A nurse is caring for a client who experienced an MI. The client is ordered to receive metoprolol. The nurse understands that this medication has which therapeutic effect?
Decreases resting heart rate
What term is defined as the process by which oxygen and carbon dioxide are transferred between alveoli and blood and between blood and body cells?
Diffusion
Which nursing action would the nurse include when caring for a client with endemic goiter and experiencing respiratory symptoms?
Elevating the head of the bed.
The pulmonary rehabilitation specialist is educating medical students on a respiratory disease process that causes a severe compromise in exhalation due to air trapping. Air trapping is caused by the loss of elastic recoil, especially in the alveoli, which occurs after overstretching in which disease?
Emphysema
A client has had a left chest tube in place for several days. The nurse assesses the client and notes that there is no bubbling in the water seal chamber. Auscultation of the left lower lung reveals vesicular breath sounds. What is the most appropriate action by the nurse?
Further assess the client for reinflation of the lung.
What is the most important factor in myocardial oxygen demand?
Heart rate
In which grade of COPD is the forced expiratory volume (FEV) less than 30%?
IV
A client is brought into the emergency department with severe crushing injuries to the chest wall and signs of respiratory failure following a motor vehicle accident. Which laboratory value would be expected?
Increase in PCO2
A child is being discharged after being diagnosed with an asthma attack. What information regarding the rescue inhaler is most important for the nurse to include in discharge teaching?
Monitor heart rate.
A postoperative client is experiencing a flash pulmonary edema. What finding in the client's sputum is consistent with this problem?
Pink color
A client is admitted to the postsurgical unit after wiring of a fractured jaw. When the nurse completes an assessment, noisy, shallow breathing is noted and the oxygen saturation level is now 90%. What is the appropriate action by the nurse?
Position in Sims position with head to the side, administer oxygen as ordered, and suction if needed.
The nurse is assigned to care for a patient with COPD with hypoxemia and hypercapnia. When planning care for this patient, what does the nurse understand is the main goal of treatment?
Providing sufficient oxygen to improve oxygenation
A client in intensive care has been prescribed both lorazepam and hydromorphone. The nurse should prioritize what assessments for the client?
Respiratory rate and oxygen saturation
Which of the following is the most important potential nursing diagnosis for the client receiving opiate therapy?
Risk for impaired gas exchange
A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped?
Runs of ventricular tachycardia
A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply.
Substernal pain Dyspnea Fatigue
A nurse from the neonatal intensive care unit is called to the birth room for an infant requiring resuscitation. After placing the newborn in the sniffing position what would the nurse do next?
Suction the mouth then the nose.
What is the action of codeine when used to treat a cough?
Suppressant
Which consideration is the most important when performing tracheotomy suctioning?
The client should be hyperoxygenated, then suctioned for 10 to 15 seconds.
A nurse is caring for an infant who just had open-heart surgery and the parents are asking why there are wires coming out of the infant's chest. What is the best response by the nurse?
These wires are connected to the heart and will detect if your infant's heart gets out of rhythm.
An older adult client admitted to the hospital with tuberculosis becomes cyanotic, tachycardic, and develops a fever and cough. Chest x-ray reveals pus in the pleural space. What is the most likely diagnosis?
Tuberculous empyema due to primary progressive tuberculosis
A nurse is caring for a 4-month-old male client brought to the emergency department by the parents. Click to highlight the finding(s) that will require follow-up.
cold symptoms for the past few days including coughing, sneezing, and a runny nose. coughing has increased, with decreased appetite and increasing fussiness administered acetaminophen for a fever of 102.2°F (39°C) last night with effect Lips and mucous membranes are dry and cracked; skin very warm, ruddy have only changed diapers once since last night with very little urine, no bowel movement. lethargy, opens eyes to voice, nonproductive cough, rhinorrhea that is clear expiratory wheezes in bilateral upper lobes. temperature, 101.2°F (38.4°C);
A client with asthma comes to the emergency department very anxious due to increasing shortness of breath. Physical assessment reveals tachypnea, and an arterial blood gas shows decreased carbon dioxide levels and hypoxemia. What is the most likely cause of the decreased carbon dioxide levels?
hyperventilation
Which assessment finding places the neonate at risk for respiratory distress syndrome (RDS)?
maternal diabetes mellitus
A client received magnesium sulfate during labor. Which condition should the nurse anticipate as a potential problem in the neonate?
respiratory depression
A client arrives in the emergency department after a motor vehicle collision. Which clinical manifestation(s) leads the nurse to suspect a pneumothorax? Select all that apply.
respiratory rate 34 breaths/min. asymmetrical chest movements, especially on inspiration diminished breath sounds over painful chest area
What will the nurse include in the discharge plan of care for a newborn with ventricular septal defect? Select all that apply.
signs and symptoms to watch for information about cardiology appointments primary care contact for follow-up telephone number for questions
A premature infant develops respiratory distress syndrome. With this condition, circulatory impairment is likely to occur because, with increased lung tension,:
the ductus arteriosus remains open.
Which adrenergic receptor is responsible for vasodilation of peripheral vessels and bronchodilation?
β2 receptors
