Prep U Ch 38 Oxygenation and Perfusion
atelectasis
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:
True
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.
a client taking opioids for cancer pain
In which client would the nurse assess for a depressed respiratory system?
Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter.
The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is:
crackles
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as:
Clubbing
The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?
SpO2 92%
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?
Residual volume
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 child who has pneumonia
The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?
respiratory muscles become weaker
What structural changes to the respiratory system should a nurse observe when caring for older adults?
poor tissue perfusion
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
Eczema
Which skin disorder is associated with asthma?
•Nasal cannula •Partial rebreather mask •Simple oxygen mask
A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply.
increase her fluid intake to thin secretions
A client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and they are thick and sticky. The nurse should instruct the client to:
Inquire about factors that contribute to non-adherence.
A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention?
Prevnar 13
A client with Type II diabetes has come for an annual wellness check-up with the healthcare provider. Which vaccine will the nurse discuss with the client?
Acute bronchitis
Martin is a 58-year-old smoker who was admitted to the hospital with worsening shortness of breath over the last 2 days. He states that he is having some chest discomfort. The nurse asks him further about this in order to characterize whether this may be cardiac related, musculoskeletal related, or respiratory related. Martin states that when he breathes in, he feels as if the air passing into his lungs is burning him. It is also very painful to swallow. Based on what Martin is stating, which illness does the nurse suspect is causing Martin's chest discomfort?
Assess oxygen tubing connection
The nurse is caring for a client receiving oxygen therapy via nasal cannula who suddenly becomes cyanotic with a pulse oximetry reading of 91%. Which is the next most appropriate action the nurse should take?
"This is a gauge used to regulate the amount of oxygen that a client receives."
The nurse is demonstrating oxygen administration to a client. What teaching will the nurse include about the flowmeter?
"Breathing through your nose first will warm, filter, and humidify the air you are breathing."
The nurse is instructing the client with a pulmonary disorder on 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?
600 mL
The nurse is palpating the suprapubic region of the abdomen on a hospitalized patient. The nurse notes bladder fullness. This is may be assessed by palpation when there is what quantity of urine in the bladder?
reads 0.21 when checking oxygen in room air
The nurse is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly?
Pulmonary function tests
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?
Corticosteroids
Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?
Suction the tracheostomy using sterile technique
When caring for a client with a tracheostomy, the nurse would perform which recommended action?
sleep apnea
A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from?
infant with respiratory rate of 20 bpm
The nurse is assessing the respiratory rates of clients in a community health care facility. Which client exhibits an abnormal value?
be sure to shake canister before using it.
The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines?
face tent
The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather?
80 to 150mm/hg
A nurse is preparing to use a wall unit to suction an endotracheal tube. At what pressure should the suction be set?
trauma to the tracheal mucosa
A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?
Child with asthma
It is a red air-quality day in the city. This means the air is stagnant, with high pollution levels and high humidity. Which client is most likely to experience shortness of breath?
4/L per minute
A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:
"The air is thicker or more viscous with humidity, thus it is harder for you to breathe."
A client with chronic obstructive pulmonary disease (COPD) reports severe shortness of breath when it is raining. The nurse says to the client:
pneumonia
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:
hemoglobin level
An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the 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:
Vesicular
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?
"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."
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?
apnea
The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as:
high respiratory rate
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?
tracheostomy collar
The nurse is caring for a client who was 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?
"It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed."
The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the oxygen analyzer?
Confusion
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?
"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."
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?
8/L per minute via nasal cannula
The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner?
"Your lung condition limits the ability of the lungs to fully exhale, causing this change in shape."
The nurse is talking with a client who has COPD. The client reports her chest shape seems to have changed over the past year. What information should be provided by the nurse?
the chest should be slightly convex with no sternal depression
When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?
continue to assess the infant
When the nurse observes a newborn infant demonstrating an irregular abdominal breathing pattern, with a respiratory rate of 50 breaths/minute with occasional pauses in breathing of 5-second durations, the most appropriate action by the nurse is to:
congestive heart failure
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:
partial rebreather mask non rebreather mask
A healthcare provider has ordered oxygen to be delivered at 8 L/minute for a client who does not have a tracheostomy. Which oxygen delivery device will the nurse consider using? (Select all that apply.)
•partial rebreather mask •non-rebreather mask
A healthcare provider has ordered oxygen to be delivered at 8 L/minute for a client who does not have a tracheostomy. Which oxygen delivery device will the nurse consider using? (Select all that apply.)
Ambu bag
A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient?
7.5 (It is calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the person has smoked)
Erin is a 35-year-old woman being cared for in the emergency department for a cough and hemoptysis for 3 days. Erin states that she has smoked one-and-a-half packs of cigarettes per day for the last 5 years. In trying to identify risk factors for Erin, the nurse calculates her pack-year history to write on the intake form. What is Erin's pack-year of smoking?
pH less than 7.35; HCO3 low; PaCO2 low
The 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?
pulmonary function tests
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?
Eat smaller meals that are high in protein.
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?
determines whether the client is getting enough oxygen.
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?
pattern of thoracic expansion
While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique?
•Provide frequent oral hygiene especially before meals. •Distribute six small meals over the course of the day.
The nurse is caring for a client with a North America Diagnosis Association-International (NANDA-I) diagnosis of Imbalanced nutrition: Less than body requirements, related to difficulty breathing. The nurse would implement which measures to maintain an adequate nutritional status for this client? Select all that apply.