Prep U - Chapter 39: Oxygenation and Perfusion

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? a. 3-year old in croup tent b. 7-year old with nasal cannula c. 13-year old with nonrebreather mask d. 10-year old with simple mask

3-year old in croup tent

A nurse is providing home care instructions for a client who is being discharged to his home with a tracheostomy in place. Which statement accurately describes a guideline for care that should be included in the teaching plan? a. Clean, rather than sterile, technique can be used in the home setting. b. Sterile saline can be made at home using ¼ cup of salt in 1 quart of water and boiling it for 15 minutes. c. All the client's immediate family members should be taught how to perform tracheostomy care for the client. d. The client should avoid humid locations whenever possible.

Clean, rather than sterile, technique can be used in the home setting.

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. Review the medications that the client has taken in the past 90 minutes. b. Document this expected assessment finding. c. Encourage the client to do deep-breathing exercises. d. Raise the head of the client's bed slightly, if tolerated.

Document this expected assessment finding.

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. Maintain the client's oxygenation and alert the health care provider immediately. b. Cover the tracheostomy stoma and apply oxygen by nasal cannula c. Assess the client's respiratory status and check vital signs every 1 minute for the next hour. d. Page the respiratory therapist STAT.

Maintain the client's oxygenation and alert the health care provider immediately.

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? a. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. b. Leave the airway in place and promptly notify the health care provider for further instructions. c. Suction the client's mouth through the oropharyngeal airway to prevent aspiration. d. Remove the airway, turn the client to the side, and provide mouth suction, if necessary.

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? a. Forced Expiratory Volume (FEV) b. Residual Volume (RV) c. Total lung capacity (TLC) d. Tidal volume (TV)

Residual Volume (RV)

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? a. Urinary intake and output b. Orthostatic blood pressure c. Apical pulse d. Respiratory rate and depth

Respiratory rate and depth

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? a. Warm the client's hands and try again. b. Shine available light on the equipment to facilitate accurate reading. c. Use a blood pressure cuff to increase circulation to the site. d. Place the probe on the client's earlobe.

Warm the client's hands and try again.

Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway? a. The airways come in standard sizes determined by the height and weight of the client. b. When holding the airway on the side of the client's face, it should reach from the tip of the ear to the nostril times two. c. 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. d. When holding the airway on the side of the client's face, it should reach from the opening of the mouth to the back angle of the jaw.

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.

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. bronchiectasis. c. bronchiolitis. d. bronchitis.

a bronchospasm

In which client would the nurse assess for a depressed respiratory system? a. a client taking amlodipine for hypertension b. a client taking opioids for cancer pain c. a client taking insulin for diabetes d. a client taking antibiotics for a urinary tract infection

a client taking opioids for cancer pain

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia? a. edema b. hemoptysis c. clubbing d. diarrhea

clubbing

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia? a. hemoptysis b. clubbing c. edema d. diarrhea

clubbing

A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from: a. croup b. asthma c. pulmonary fibrosis d. atelactasis

croup

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather? a. face tent b. tracheostomy collar c. simple mask d. nasal cannula

face tent

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: a. sodium and potassium levels b. age c. hemoglobin level d. blood pH

hemoglobin level

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. Wheezes b. Pneumonia c. Tachypnea d. Pleural effusion

pleural effusion

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: a. asthma. b. pneumonia. c. croup. d. alcohol use.

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? a. air passing through narrowed airways b. presence of sputum in the trachea c. presence of fluid in the lungs d. inflammation of pleural surfaces

presence of fluid in the lungs

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. Residual Volume (RV) b. Forced Expiratory Volume (FEV) c. Total lung capacity (TLC) d. Tidal volume (TV)

residual volume (RV)

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. wheezing c. absent breath sounds in lower lobes d. crackles

wheezing

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? a. "If you breathe through the mouth first, you will swallow germs into your stomach." b. "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." c. "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." d. "Breathing through your nose first will warm, filter, and humidify the air you are breathing."

"Breathing through your nose first will warm, filter, and humidify the air you are breathing."

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 is using his chest muscles to help him breathe." b. "His infection is causing him to breathe harder." c. "His lung muscles are swollen so he is using abdominal muscles." d. "He will require additional testing to determine the cause."

"He is using his chest muscles to help him breathe."

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response? a. "Let me get the unlicensed assistive personnel (UAP) for you." b. "You will need to use a bedpan while the chest tube is in position." c. "I can assist you to the bathroom and back to bed." d. "The chest tube cannot be moved."

"I can assist you to the bathroom and back to bed."

An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize? a. "Did someone loosen the straps on your mask?" b. "Is your mask causing discomfort?" c. "Did you remove your dentures?" d. "Did someone take your mask off?"

"Is your mask causing discomfort?"

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? a. "You should never smoke when oxygen is in use." b. "Oxygen is a flammable gas." c. "I understand; I used to be a smoker also." d. "An occasional cigarette will not hurt you."

"You should never smoke when oxygen is in use."

The nurse is caring for a client with emphysema. When teaching the client pursed-lip breathing, the nurse will include which instruction(s)? Select all that apply. - Ensure that the exhale lasts twice as long as the inhale. - Shape the lips as if you were about to blow a whistle. - Inhale slowly through the nose for a count of three. - Keep abdominal muscles in a relaxed state. - Over time, begin to increase the length of the exhale. - Exhale slowly through pursed lips.

- Inhale slowly through the nose for a count of three. - Shape the lips as if you were about to blow a whistle. - Over time, begin to increase the length of the exhale. - Exhale slowly through pursed lips. - Ensure that the exhale lasts twice as long as the inhale.

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL and a pulse of 78 beats/min. What number would the nurse document for this assessment? a. 5,650 mL b. 5,450 mL c. 5,850 mL d. 6,050 mL

5,850 mL

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? a. Nasal cannula b. Ambu bag c. Oxygen mask d. Oxygen tent

Ambu bag

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention? a. Document outcomes of modifications in care. b. Ask the client what factors contribute to nonadherence. c. Contact the health care provider to report the client's current status. d. Explain the use of a BiPAP mask instead of a CPAP mask.

Ask the client what factors contribute to nonadherence.

The nurse is planning care for a client who is prescribed a simple mask for oxygen delivery. What intervention will the nurse include in the plan of care? a. Target the client's oxygen saturation to be 88% to 92% 90.88 to 0.92) b. Set the flow meter to deliver oxygen at 2 L/min c. Monitor the client for oxygen toxicity d. Assess the client for anxiety due to claustrophobia

Assess the client for anxiety due to claustrophobia

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? a. Have the client breath into a paper bag b. No action is required, because this may be normal for the client c. The nurse should prepare intubation equipment for the health care provider d. Administer oxygen at 6 L/m by nasal cannula

No action is required, because this may be normal for the client

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? a. Skin tests b. Bronchoscopy c. Chest x-ray d. Pulmonary function tests

Pulmonary function tests

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? a. Avoid exposure to large crowds. b. Cut down on smoking. c. Stay indoors as much as possible. d. Practice good hand hygiene.

Stay indoors as much as possible.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? 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. 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. d. Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm.

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.

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. congestive heart failure. b. pulmonary embolism. c. myocardial infarction. d. lung cancer.

congestive heart failure.

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

crackles

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. mineral oil d. distilled water

distilled water

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. Partial rebreather mask b. Nonrebreather mask c. Nasal cannula d. Simple mask

nasal cannula

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? a.

nasal cannula

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? a. nonrebreather mask b. simple mask c. face tent d. nasal cannula

nasal cannula

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? a. inflammation of pleural surfaces b. air passing through narrowed airways c. presence of fluid in the lungs d. presence of sputum in the trachea

presence of fluid in the lungs

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? a. inflammation of pleural surfaces b. presence of sputum in the trachea c. air passing through narrowed airways d. presence of fluid in the lungs

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? a. thoracentesis b. pulse oximetry c. spirometry d. peak expiratory flow rate

pulse oximetry

In which client should the nurse prioritize assessments for respiratory depression? a. A client taking antibiotics for a urinary tract infection b. A client taking insulin for type 1 diabetes c. A client taking a beta-adrenergic blocker for hypertension d. A client taking opioids for cancer pain

A client taking opioids for cancer pain

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? a. Place the client in the dorsal recumbent position to collect the specimen. b. Instruct the client to inhale deeply and then cough. c. Discard the first sputum produced by the client. d. Have the client clear the nose and throat and gargle with salt water before beginning the procedure.

Instruct the client to inhale deeply and then cough.

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 a. Poor tissue perfusion b. Malnutrition c. Congestive heart failure d. Anemia

Poor tissue perfusion

A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate? a. The client's respiratory rate is in the normal range. b. The client's red blood cell (RBC) count is in the normal range. c. The client's available hemoglobin is adequately saturated with oxygen. d. The client's oxygen demands are being met.

The client's available hemoglobin is adequately saturated with oxygen.

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse would cause the charge nurse to intervene? a. The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). b. The newly hired nurse assesses the client's pain and administers pain medication. c. The newly hired nurse explains what she is doing and the reason to the client, even though the client does not appear to be alert. d. The newly hired nurse adjusts the bed to a comfortable working position.

The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN).

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? a. Educate client on incentive spirometry b. Assist with intubation c. Raise the head of the bed d. Apply oxygen as prescribed

apply oxygen as prescribed

A nurse is reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would the nurse most likely identify as an effect of exposure to automobile pollutants? a. Bronchitis b. Bronchiectasis c. Atelectasis d. Croup

bronchitis

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue? a. corticosteroids b. bronchodilators c. expectorants d. antibiotics

corticosteroids

When reviewing data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom? a. rapid respirations b. weight loss c. increased urine output d. strong, rapid pulse

rapid respirations

When reviewing data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom? a. strong, rapid pulse b. weight loss c. rapid respirations d. increased urine output

rapid respirations

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? a. suctioning of carbon dioxide b. trauma to the tracheal mucosa c. prevention of suctioning d. loss of sterile field

trauma to the tracheal mucosa

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

vesicular

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. wheezing c. crackles d. absent breath sounds in lower lobes

wheezing