Quiz #8
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?
"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:
"He is using his chest muscles to help him breathe."
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?
"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."
The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include the humidifier?
"Small water droplets come from this, thus preventing dry mucous membranes."
The nurse is demonstrating oxygen administration to a client. What teaching will the nurse include about the flowmeter?
"This is a gauge used to regulate the amount of oxygen that a client receives."
A client with a nonhealing pressure ulcer has been prescribed hyperbaric oxygen therapy (HBOT). The client tells the nurse, "This kind of treatment doesn't make any sense to me." What is the appropriate nursing response?
"Wounds heal because HBOT helps to regenerate new tissue quickly."
The nurse is caring for a client with a nonhealing wound who has been prescribed hyperbaric oxygen therapy (HBOT). When the client asks, "How will this help me?" what is the appropriate nursing response?
"Wounds heal because HBOT helps to regenerate new tissue quickly."
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?
600 mL
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?
8 L/min oxygen via nasal cannula
A nurse is preparing to use a wall unit to suction an endotracheal tube. At what pressure should the suction be set?
80 to 150mm/hg
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?
Ambu bag
A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?
Ask the client what factors contribute to nonadherence.
The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines?
Be sure to shake the canister before using it.
The nurse is caring for an older adult client on home oxygen who has dentures, but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate?
Check fit of oxygen mask.
A nurse measuring the arterial oxyhemoglobin saturation (SaO2 or SpO2) of a client's arterial blood gets a weak signal from the pulse oximeter. What would be the appropriate intervention in this situation?
Check vital signs and client condition.
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?
Child with asthma
A nurse is conducting a physical assessment of a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the client's oxygenation. What instruction should the nurse give the client?
Contract the abdominal muscles.
The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe?
Crackles in the lower lobes
A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario?
Cyanosis
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?
Eat smaller meals that are high in protein.
A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?
Flow meter
The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?
Hypoxia
A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention?
Inquire about factors that contribute to non-adherence.
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?
It determines whether the client is getting enough oxygen.
Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen?
It regulates the amount of oxygen received.
To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test? Monitor the amount of oxygen saturation in the blood.
Monitor the amount of oxygen saturation in the blood.
A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?
Nasal cannula
The UAP reports to the nurse that the client's pulse oximetry is 89%. What is the priority nursing action?
Perform respiratory assessment.
A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function?
Pleural effusion
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?
Prevnar 13 ®
When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?
Rapid respirations
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?
Residual Volume (RV)
The nurse is caring for a postoperative client who has a prescription for meperidine (Demerol) 7 5mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering Demerol, the nurse would assess which most important sign?
Respiratory rate and depth
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?
They are low-pitched, soft sounds heard over peripheral lung fields.
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.
True
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?
Vesicular
The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?
a child who has pneumonia
A nurse is admitting a 6-year-old child status post tonsillectomy to the surgical unit. The nurse obtains his weight and places EKG and a pulse oximeter on the client's left finger. His heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:
adequate tissue perfusion.
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:
apnea
The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of:
atelectasis.
During a routine prenatal care visit, a pregnant woman in her last trimester of pregnancy reports that she has occasional shortness of breath. The nurse instructs her that:
breathing becomes increasingly difficult as the diaphragm is displaced.
Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways?
decreases the amount of air trapping and resistance
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?
distilled water
A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?
educating the client on the use of incentive spirometry
The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal?
fine crackles to the bases of the lungs bilaterally
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?
high respiratory rate
To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?
high-Fowler's position
The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client?
nasal cannula
The nurse is caring for a 3-year-old client who experienced smoke inhalation during a house fire, and now requires oxygen. What delivery device will the nurse select that is most appropriate for this client?
oxygen tent
What is the action of codeine when used to treat a cough?
suppressant
The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select?
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?
tracheostomy collar
A client's spouse reports that the client snores loudly and incessantly every night. What is the appropriate nursing response when the client's spouse asks about nasal breathing strips?
"Nasal strips may reduce or eliminate snoring."
The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach?
"Take in as much air as possible, hold your breath briefly, and exhale slowly."
A client with chronic obstructive pulmonary disease (COPD) reports severe shortness of breath when it is raining. The nurse says to the client:
"The air is thicker or more viscous with humidity, thus it is harder for you to breathe."
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?
Sleep apnea
A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response?
"The caregiver will need to place the oxygen tank back into the secure carrier."
A client using home oxygen asks the nurse about changing to an oxygen concentrator. What is the appropriate nursing response? (Select all that apply.)
- "It collects and concentrates oxygen from room air." -"It eliminates the need for a central reservoir of piped oxygen." - "You may notice an increase in your electric bill." -"It costs less than oxygen supplied in portable tanks."
Which statements about pulse oximetry are true? Select all that apply.
- Once the oximetry probe is correctly placed, a beam of red and infrared light travels through the tissue and blood vessels. -Sensors are available for use on the finger, toe, foot, earlobe, forehead, and bridge of the nose.
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?
3-year old in croup tent
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?
SpO2 92%
A woman comes to the emergency room with her 2-year-old. She states he woke up and had a loud barking cough. The child is suffering from:
croup.