Respiratory Ch 39 PrepU Fundamentals

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

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

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." "This is only an option if you live in a long-term care facility." "It costs less than oxygen supplied in portable tanks." "You may notice an increase in your electric bill." "It eliminates the need for a central reservoir of piped oxygen."

"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."

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? 5,850 mL 5,450 mL 5,650 mL 6,050 mL

5,850 mL

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

Ask the client what factors contribute to nonadherence.

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? Discontinue oxygen therapy until the client is reassessed by the healthcare provider. Check the fit of the oxygen mask. Contact the oxygen supplier to request an oxygen tent. Increase the flow of oxygen.

Check the fit of the oxygen mask.

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia? Clubbing Edema Diarrhea Hemoptysis

Clubbing

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

Document this expected assessment finding.

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

Instruct on effective breathing as needed Assess the relationship of inspiration to expiration Assess the client's level of anxiety and possible causes Encourage relaxation activities such as music and reading

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

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

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? Partial rebreather mask Nasal cannula Simple mask Nonrebreather mask

Nasal cannula

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? Tidal volume (TV) Total lung capacity (TLC) Residual Volume (RV) Forced Expiratory Volume (FEV)

Residual Volume (RV)

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

Stay indoors as much as possible.

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.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? 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. 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. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 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.

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

a client taking opioids for cancer pain

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

a client taking opioids for cancer pain

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: bronchiolitis. bronchiectasis. a bronchospasm. bronchitis.

bronchospasm

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: vesicular. crackles. bronchovesicular. wheezes.

crackles

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: asthma. atelectasis. croup. pulmonary fibrosis.

croup

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

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

face tent

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 assessing a client's chest tube which was inserted 48 hours earlier. The nurse notes crackling in the skin around the insertion site. Which action should the nurse prioritize? reinforce adhesive material over insertion site document finding apply a new dressing over the tube notify the health care provider

notify the health care provider

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? thoracentesis peak expiratory flow rate spirometry pulse oximetry

pulse oximetry

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? tracheostomy collar face tent simple mask nasal cannula

tracheostomy collar