PrepU Ch.40; Fundamentals

The nurse provides care for the client with asthma reporting shortness of breath. Which action(s) does the nurse take to promote client comfort and decrease anxiety? Select all that apply. 1. Assess the client's level of anxiety and possible causes 2. Instruct on effective breathing as needed 3. Encourage exercise 4. Plan for periods of rest between activities 5. Encourage relaxation activities such as music and reading 6. Assess the relationship of inspiration to expiration

1. Assess the client's level of anxiety and possible causes 2. Instruct on effective breathing as needed 4. Plan for periods of rest between activities 5. Encourage relaxation activities such as music and reading 6. Assess the relationship of inspiration to expiration

The nurse is reviewing the results of a client's arterial blood gas and pH analysis. Which findings indicate to the nurse that intervention is not required? Select all that apply. 1. pH 7.45 2. Base excess or deficit +2 mmol/L 3. PO2 70 mm Hg 4. HCO3 30 mEq/L 5. PCO2 40 mm Hg

1. pH 7.45 2. Base excess or deficit +2 mmol/L 5. PCO2 40 mm Hg

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. False True

True

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

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

A nurse is volunteering at a day camp where a child is stung by a bee and develops wheezing in the upper airways. The nurse will provide interventions to address what health problem? a. Bronchospasm b. Bronchiectasis c. Bronchiolitis d. Bronchitis

a. Bronchospasm

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

a. Poor tissue perfusion

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

a. Pulmonary function tests

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

a. Residual Volume (RV)

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 low-pitched, soft sounds heard over peripheral lung fields. b. They are medium-pitched blowing sounds heard over the major bronchi. c. They are loud, high-pitched sounds heard primarily over the trachea and larynx. d. They are soft, high-pitched discontinuous (intermittent) popping lung sounds.

a. They are low-pitched, soft sounds heard over peripheral lung fields.

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? a. high respiratory rate b. low blood pressure c. low pulse rate d. high temperature

a. high respiratory rate

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use? a. nonrebreather mask b. simple mask c. Venturi mask d. nasal cannula

a. nonrebreather mask

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed: a. 1 L/minute. b. 6 L/minute. c. 4 L/minute. d. 10 L/minute.

b. 6 L/minute.

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse will document what breath sounds? a. Bronchovesicular b. Crackles c. Vesicular d. Wheezes

b. Crackles

What assessments would a nurse make when auscultating the lungs? a. abnormal chest structures b. air flow through the respiratory passages c. presence of edema d. volume of air exhaled or inhaled

b. air flow through the respiratory passages

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. nasal cannula c. simple mask d. face tent

b. nasal cannula

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. weight loss b. rapid respirations c. increased urine output d. strong, rapid pulse

b. rapid respirations

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. face tent b. tracheostomy collar c. simple mask d. nasal cannula

b. tracheostomy collar

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

b. trauma to the tracheal mucosa

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

c. 3-year old in croup tent

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation? a. Hemoglobin levels b. Hematocrit values c. Arterial blood gas d. Pulmonary function

c. Arterial blood gas

The nurse is assessing a client with lung cancer who has been receiving treatment for many months. What manifestations may suggest that the client has chronic hypoxia? a. Edema b. Hemoptysis c. Clubbing d. Yellow or green sputum

c. Clubbing

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. Simple mask c. Nasal cannula d. Nonrebreather mask

c. Nasal cannula

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.

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

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. mineral oil b. tap water c. distilled water d. normal saline

c. distilled water

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

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

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. "Did you remove your dentures?" c."Did someone take your mask off?" d. "Is your mask causing discomfort?"

d. "Is your mask causing discomfort?"

A nurse is providing care in an area which is plagued by high levels of air pollutants from industry and motor vehicles. The nurse will expect a high incidence and prevalence of what respiratory disease? a. Bronchiectasis b. Croup c. Atelectasis d. Bronchitis

d. Bronchitis

The nurse is caring for a client with a chest tube. Stationary clots are noted in the tubing. What is the appropriate nursing action? a. Clamp the tube. b. Contact the rapid response team. c. Strip the chest tubing of clots. d. Document the finding.

d. Document the finding.

A parents brings their 2-year-old to the emergency department in respiratory distress. SThe child's oxygen saturation is 81% and there is audible stridor. What intervention will the nurse anticipate? a. Corticosteroids by metered-dose inhaler b. Chest physiotherapy c. Deep breating and coughing exercises d. Placement in an oxygen tent

d. Placement in an oxygen tent

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. Vesicular

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. diminished stroke volume. b. heart failure. c. high cardiac output. d. adequate tissue perfusion.

d. adequate tissue perfusion.