Respiratory Function

A nurse is preparing to orally suction a client with dysphagia following a stroke. Which suction device is appropriate? bulb syringe open suctioning Yankauer catheter closed suctioning

Yankauer catheter Explanation: Nurses perform oral suctioning (removing secretions from the mouth) with a suctioning device called a Yankauer-tip or tonsil-tip catheter. This is the appropriate device to use for a client with difficulty swallowing. The other types of suctioning (open and closed) are used for the lower airways. Bulb syringes are used with infants.

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? tap water normal saline distilled water mineral oil

distilled water Explanation: Distilled water is used when humidification is desired. Other answers are incorrect.

The nurse is teaching a client about performing postural drainage. Which teaching will the nurse include? Select all that apply. Take inhalant medications after performing postural drainage. Keep tissues and a waterproof container nearby for sputum. Remain in the prescribed position for at least 45 minutes. Resume a comfortable position if lightheadedness occurs. Perform this procedure two to four times daily.

Keep tissues and a waterproof container nearby for sputum. Resume a comfortable position if lightheadedness occurs. Perform this procedure two to four times daily. Explanation: The nurse will teach the client to take inhalant medications before performing postural drainage, to keep tissues and a waterproof container nearby to collect sputum, to remain in the prescribed position for 15-30 minutes (no longer than 45 minutes), to resume a comfortable position if lightheadedness occurs, and to perform this procedure 2-4 times daily.

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

"I can assist you to the bathroom and back to bed." Explanation: The client can move in bed, and ambulate while carrying the drainage system, as long as he or she has orders to do so. The nurse should supervise ambulation to the bathroom and back to bed while the client has the drain inserted to make sure it stays intact and to monitor for safety. Other answers are incorrect.

Which is the best response by the nurse to the client being prepared for a tracheostomy placement who verbalizes concern about not being able to speak after the procedure? "I hear you saying that not being able to speak is a concern so let's talk with your health care provider and speech therapist about the possibility of using a 'talking' tracheostomy tube." "There are other means of communication other than speaking that we can explore for you, so you do not have to be afraid of not being able to speak." "You will be able to nod or speak 'yes' or 'no' answers so we will tell people to try to phrase questions so that you can use these responses." "Do not worry about not being able to speak. I will show you hand gestures, word-and-phrase cards, picture boards, and writing pads that other clients with tracheostomies use."

"I hear you saying that not being able to speak is a concern so let's talk with your health care provider and speech therapist about the possibility of using a 'talking' tracheostomy tube." Explanation: The best response to the client addresses both the emotional and the physiological aspects of the client's concern, such as "I can understand how not being able to speak is a concern so let's talk with your health care provider and speech therapist about the possibility of using a 'talking' tracheostomy tube." Telling the client that there are other means of communication other than speaking that can be explored does not address the emotional side of the client's concerns and does not address the fear of not being able to speak; the client did not say that not being able to communicate is the concern but rather not being able to speak is the concern. Telling the client that being able to nod or speak "yes" or "no" answers is most likely not the answer the client is looking for, it does not address the client's emotional state, and clients can become easily frustrated when they cannot freely communicate everything that they want to in a simple manner. Telling the client that other clients with tracheostomies use hand gestures, word-and-phrase cards, picture boards, and writing pads provides a variety of communication aids to allow the client more channels through which information can be communicated but it does not address the emotional aspect of the tracheostomy experience and it does not address the specific concern about not being able to speak after the procedure.

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? "Did you remove your dentures?" "Is your mask causing discomfort?" "Did someone take your mask off?" "Did someone loosen the straps on your mask?"

"Is your mask causing discomfort?" Explanation: It is possible for anyone using a mask to try and readjust it if it is uncomfortable. Depending on the older adult's cognitive status, he or she may have tried to make it more comfortable and in the process caused it to no longer fit correctly. This could also occur if the client removed their dentures, as some individual's choose to let the dentures soak overnight. If the mask was fitted with the dentures in, the mask will likely be loose with the dentures removed. The other questions could possibly be asked to see if someone else may have tried to help the client feel more comfortable with the mask on.

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? "That will help the oxygen flow more freely." "The caregiver will need to place the oxygen tank back into the secure carrier." "That will make it easier to carry with you." "Call your oxygen supplier immediately."

"The caregiver will need to place the oxygen tank back into the secure carrier." Explanation: Oxygen tanks are transported on a wheeled carrier to avoid accidental force. Accidental force could cause the tank to explode. The tank should not be carried, and taking it out of the carrier does not affect the flow of oxygen.

What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home? "Although the test is uncomfortable, it is not painful." "You will be asked to forcefully exhale into a mouthpiece." "The test is used to determine how much air you inhale." "You will do this each morning while still lying in bed."

"You will be asked to forcefully exhale into a mouthpiece." Explanation: Peak expiratory flow rate (PEFR) refers to the volume of air that can be forcibly exhaled. While sitting or standing, the client takes a deep breath and forcibly exhales through a mouthpiece. The client does this three times, and the highest number is recorded. Clients commonly measure PEFR at home to monitor airflow when they have conditions such as asthma. The PEFR can be performed at any time of the day but not while lying in the bed. This test is not uncomfortable or painful.

A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply. Monitor the client's respiratory rate. Note the amount of oxygen administered. Check the symmetry of the client's chest. Observe the breathing pattern and effort. Check the devices used to deliver oxygen.

Monitor the client's respiratory rate. Check the symmetry of the client's chest. Observe the breathing pattern and effort. Explanation: When physically assessing the quality of the client's oxygenation, the nurse should monitor the client's respiratory rate, check the symmetry of the client's chest, and observe the breathing pattern and effort of the client. The nurse should also auscultate for lung sounds. Additional assessments include recording the heart rate and blood pressure, determining the client's level of consciousness, and observing the color of the skin, mucous membranes, lips, and nail beds. During the physical assessment, the nurse does not note the amount of oxygen administered to the client or check the device that is used to deliver oxygen to the client.

The nurse enters a client's room, observes the client coughing vigorously, and determines that the client is breathing but has a partially obstructed airway. Which action should the nurse take next? Palpate extremities for bilateral pulses. Observe the patient's respiratory effort. Check the patient's level of consciousness. Call a code.

Observe the patient's respiratory effort. Explanation: Other than encouraging and supporting the client, a partial airway obstruction requires no additional resuscitation efforts. If the client's independent efforts to relieve a partial obstruction are unsuccessful or if the situation worsens, activating the emergency medical system by calling a code is appropriate.

The nurse is caring for a client who has returned from the perioperative services department after the insertion of a tracheostomy tube. The nurse is unable to find the obturator that should have accompanied the client after surgery. What is the appropriate action for the nurse to take? Obtain a second tracheostomy set to keep by the bedside. Open up a sterile tracheostomy kit and remove the obturator to have at the bedside. Have sterile dressing supplies ready to cover the stoma in case the tube comes out. Obtain and keep a pair of clamps by the bedside to keep the stoma open if the tube comes out.

Obtain a second tracheostomy set to keep by the bedside. Explanation: The obturator is used when the tracheostomy tube is inserted to prevent the cannula edge from traumatizing tracheal tissue. When the tube is in place, the obturator is removed, placed in a plastic bag, and kept at the bedside in case the tracheostomy tube is inadvertently removed. If the obturator cannot be located, it is acceptable to place a second tracheostomy set by the bedside. It is not cost-efficient to open a kit only to remove the obturator. Dressing supplies will not be beneficial if the tube becomes dislodged, because the tube will need to be reinserted by the health care provider. Clamps are not to be used by the nurse to keep the stoma open if the tube becomes dislodged; the health care provider should be immediately notified if this occurs.

The client has a productive cough of thick yellow sputum. A prescription for a sputum culture has been obtained. Place the actions in the order the nurse will perform them to obtain the sputum specimen. All options must be used. Click an option, hold and drag it to the desired position, or click an option to highlight it and move it up or down in the order using the arrows to the left. 1 Obtain a sterile specimen cup. 2 Instruct the client about the proper technique for obtaining the specimen. 3 Collect at least 1- to 3-ml of sputum in the specimen cup. 4 Attach a client-identifying label to the specimen cup. 5 Immediately transport the sputum specimen to the laboratory.

Obtain a sterile specimen cup. Instruct the client about the proper technique for obtaining the specimen. Collect at least 1- to 3-ml of sputum in the specimen cup. Attach a client-identifying label to the specimen cup. Immediately transport the sputum specimen to the laboratory. Explanation: When performing a procedure, the nurse obtains needed equipment, such as a sterile specimen cup for the sputum collection. The nurse educates the client about the need for a sputum specimen and what the client must do to obtain the specimen. When collecting a sputum specimen, there needs to be at least 1- to 3-ml of sputum in the container for accurate diagnosis. A label identifying the client as the donor is attached to the specimen container. The specimen is immediately transported to the laboratory for accurate diagnosis.

A nurse conducts a health history for a client with chronic bronchitis. Which action does the nurse take first when the client begins to experience respiratory distress? Place the client in a comfortable position, ensure an open airway and if oxygen is prescribed start administration Assess the client's rate and quality of respirations Get assistance in case oxygen, medications, or further intervention is needed Speak slowly and calmly to the client to facilitate relaxation and ease respirations

Place the client in a comfortable position, ensure an open airway and if oxygen is prescribed start administration Explanation: If a nurse is conducting a health history interview for a client diagnosed with chronic bronchitis when respiratory distress occurs, the nurse first places the client in a comfortable position, ensures a patent airway, and starts oxygen if prescribed. After ensuring an open airway, the next step is quickly assessing the respiratory rate and quality and then getting assistance in case the client's respiratory status starts to deteriorate. Speaking slowly and calmly to relax the client is valuable but does not help assess the client's respiratory distress or prepare to manage it. The condition may require further intervention so preparation is needed.

A client is taking albuterol via nebulizer. Which instruction will the nurse provide to teach the client how to use the nebulizer? Place the mouthpiece in your mouth. Breath in the medication then remove the mouthpiece to breathe the medicine out. Place the mouthpiece in your mouth. Intermittently breathe through your nose and mouth so that all of the medicine goes into your lungs Place the mouthpiece near your mouth. Inhale the medicine into your lungs. Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs.

Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs. Explanation: A nebulizer is used to administer medications in the form of an inhaled mist. The nurse will instruct the client to place the mouthpiece in the mouth, keep the lips firm around the mouthpiece so that all of the medicine goes into the lungs, and continue until the mist stops. Any other option allows for the medication to be lost, rather than inhaled into the lungs.

A client returns to the unit following an insertion of a tracheostomy tube. Where should the nurse place the obturator? Attach the obturator to a string and tie it to the bed. Place the obturator in a plastic bag and put it at the bedside. Send the obturator home with the client's family. Keep the obturator in the nursing station.

Place the obturator in a plastic bag and put it at the bedside. Explanation: The obturator is a curved guide with a bullet-shaped tip. The obturator is used at the time of tube insertion to prevent the edge of the cannula from traumatizing tracheal tissue. Once the tube is in place, the obturator is removed, placed in a plastic bag, and retained at the bedside in the event of an accidental extubation.

The physician directs a nurse at the health care facility to perform vibration on a client with chest congestion. How should the nurse perform vibration on this client to relieve the congestion? Apply a cupped hand to the client's chest. Perform the technique for 3 to 5 minutes in each position. Position hands on the client's chest or back during inhalation. Cup the hand, keeping fingers and thumb together.

Position hands on the client's chest or back during inhalation. Explanation: The nurse performs vibration by positioning the hands on the client's chest or back during inhalation and then vibrates them as the client exhales to increase intensity of expiration. When performing percussion on a client, the nurse cups the hands, keeping the fingers and thumbs together and applies the cupped hands to the client's chest. This technique is performed for 3 to 5 minutes in each postural position.

A nurse is preparing to insert an oral airway on an unconscious client. How should the nurse proceed? Position the client with the neck hyperextended. Hold the airway so the curved tip points downward. Use a block wedge to hold the mouth open during insertion. Elevate the head of the bed.

Position the client with the neck hyperextended. Explanation: Position the client supine with the neck hyperextended unless contraindicated. This position opens the airway and facilitates insertion. Open the client's mouth using a gloved finger and thumb or a tongue blade. Doing so prevents injury to the teeth during insertion. Hold the airway so that the curved tip points upward toward the roof of the mouth or the side of the cheek. Insert it about halfway. Such placement prevents pushing the tongue into the pharynx during insertion.

A nurse is caring for a client with a tracheostomy tube in place who has rhonchi bilaterally and a SaO2 of 94%. If the client is unsuccessful in coughing up secretions, what action should the nurse take? Encourage the use of an incentive spirometer. Assist the client to increase oral fluid intake. Put on sterile gloves and use a sterile catheter to suction. Increase the flow rate of oxygen.

Put on sterile gloves and use a sterile catheter to suction. Explanation: This client required suctioning to secure a patent airway. Sterile gloves and a sterile catheter are used when suctioning a tracheostomy. The incentive spirometer opens alveoli and can induce coughing, which can mobilize secretions; however, the client with a tracheostomy may not be able to use an incentive spirometer. Increasing oral fluid intake would not moisten and help mobilize secretions in a timely manner for this client. Increasing the oxygen flow rate will not help mobilize secretions.

A nurse is delivering oxygen to a client via an oxygen mask. Which guideline is recommended for this procedure? Adjust the mask so it is fully airtight around the face. For a mask with a reservoir, fill the reservoir half full of oxygen. Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously. If the client is experiencing redness around the mask, remove and apply powder to the mask.

Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously. Explanation: To apply an oxygen mask, position the facemask over the client's nose and mouth and adjust the elastic strap so that the mask fits snugly but comfortably on the face. For a mask with a reservoir, be sure to allow oxygen to fill the bag before proceeding with application. Remove the mask and dry the skin every 2 to 3 hours if the oxygen is running continuously, and do not use powder around the mask.

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) Forced Expiratory Volume (FEV) Residual Volume (RV)

Residual Volume (RV) Explanation: During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds.

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 False

True Explanation: 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 nurse caring for a client with a chest tube should monitor the patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.

A nurse is caring for a client who requires a sputum collection, but is unable to produce sufficient sputum for a sample. What is the nurse's best action? Leave the container at the bedside for collection later. Notify the physician that a sample was unable to be obtained. Use a suction catheter with a mucus trap. Have the client repeatedly attempt a forceful cough to produce sputum.

Use a suction catheter with a mucus trap. Explanation: The nurse should use a suction catheter with a mucus trap if the client cannot produce sufficient sputum for a specimen. Negative pressure pulls mucus into the trap for collection. The other actions are not the best action in this scenario.

A nurse needs to perform the Heimlich maneuver on an 8-month-old infant with a partial airway obstruction. Which action should the nurse perform? Support the client with a safety belt on a table. Use the heel of one hand to administer back blows. Use finger sweeps to locate the obstruction. Give a series of subdiaphragmatic thrusts.

Use the heel of one hand to administer back blows. Explanation: For infants, the nurse or rescuer uses the heel of one hand to administer five back blows between the shoulder blades. The rescuer supports the baby over his forearm, not with a safety belt on a table or stretcher. The nurse does not use finger sweeps unless the nurse can see the obstructing object. The nurse does not give a series of subdiaphragmatic thrusts to infants but, rather, to children between 1 and 8 years of age.

A client has just returned from getting a new tracheostomy inserted. When the nurse enters the room, the client is cyanotic, with the tracheostomy tube lying on the bed. What is the nurse's priority action? Auscultate the client's breath sounds. Ventilate the client with a resuscitation bag with mask. Call a code. Insert the obturator into the neck.

Ventilate the client with a resuscitation bag with mask. Explanation: Tube dislodgment in the first 72 hours after surgery is an emergency because the tracheostomy tract has not matured and replacement is difficult. Oxygenation of the client is the nurse's priority. First, ventilate the client using a manual resuscitation bag and face mask while another nurse calls for help. Reinsertion of a fresh tracheostomy tube will require the physician's intervention.

Which actions should a nurse perform when inserting an oropharyngeal airway? Select all that apply. Use an airway that reaches from the nose to the back angle of the jaw. Wash hands and put on PPE, as indicated. Position client flat on his or her back with the head turned to one side. Insert the airway with the curved tip pointing down toward the base of the mouth. Rotate the airway 180 degrees as it passes the uvula. Remove airway for a brief period every 4 hours or according to facility policy.

Wash hands and put on PPE, as indicated. Rotate the airway 180 degrees as it passes the uvula. Remove airway for a brief period every 4 hours or according to facility policy. Explanation: The nurse will come into contact with respiratory secretions during the insertion of the oral airway, making it necessary to wear appropriate PPE. The airway will need to be rotated 180 degrees as it passes the uvula because the airway is more easily inserted with the curved tip pointing up towards the roof of the mouth. The airway should be removed for brief periods every 4 hours (or according to facility policy) to prevent constant pressure on the surrounding structures. The airway should reach from the opening of the mouth to the back angle of the jaw. The client should be positioned in a semi-Fowler's position to ease insertion of the airway

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? Stridor Crackles Wheezing Absent breath sounds in lower lobes

Wheezing Explanation: The nurse expects to document wheezing in the lungs of a client with asthma, which would be more pronounced when the client has a respiratory infection. Wheezing is a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration. Wheezing is caused by air passing through constricted passages caused by swelling or secretions. Stridor and crackles are other abnormal breath sounds caused by fluid, infection, or inflammation in the lungs. Absent breath sounds are not normally found in asthmatic clients; they are characteristic of pneumonia.

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

a client taking opioids for cancer pain Explanation: Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Amlodipine is a calcium channel blocker and the medication decreased blood pressure, so the nurse would need to assess blood pressure. Antibiotics are used for urinary tract infections as well as other infections and the infections do not affect the respiratory system. Insulin decreases blood sugar which a person with diabetes may need to take every day. Insulin does not affect the respiratory system.

What prevents air from reentering the pleural space when chest tubes are inserted? the location of the tube insertion the sutures that hold in the tube a closed water-seal drainage system respiratory inspiration and expiration

a closed water-seal drainage system Explanation: After insertion, the chest tube is secured with a suture and tape, covered with an airtight dressing, and is usually attached to a closed water-seal drainage system that prevents air from reentering the pleural space. The pleural space is the tiny area between the two layers of the pleura (the thin covering that protects and cushions the lungs) between the lungs and chest cavity. The sutures hold the tube next to the skin to keep it in place. The tube is placed in the pleural space. The respiratory phase includes the inspiratory and expiratory components.

The nurse is creating a plan of care for a client with ineffective airway clearance related to a weak, persistent cough. What expected outcome will the nurse identify for the client? clear airway as evidenced by clear lung sounds by Friday client smokes two packs of cigarettes daily performs oral/pharyngeal suctioning as needed maintains 2,000-3,000 mL/fluid intake over 24-hour period

clear airway as evidenced by clear lung sounds by Friday Explanation: A reasonable expected outcome is that the client will achieve a clear airway as evidenced by clear lung sounds by a certain time frame. Smoking two packs of cigarettes daily is an assessment finding. Performing suctioning as needed and maintaining fluid intake are interventions.

The nurse is caring for an older adult client with pathologic pulmonary changes. The nurse should be aware that which conditions cause pathologic pulmonary change? Select all that apply. clients with a history of smoking occupations where clients have inhaled pollutants clients residing in an area with toxic emission clients with reduced air exchanges clients with reduced efficiency in ventilation

clients with a history of smoking occupations where clients have inhaled pollutants clients residing in an area with toxic emission Explanation: The nurse should understand that many older adult clients with pathologic pulmonary changes have a history of smoking cigarettes since their youth, working in occupations in which they inhaled pollutants that affected their lungs, or living for an extended time in industrial areas known for toxic emissions. Reduced air exchange and efficiency in ventilation are the primary age-related changes affecting the older adult's respiratory system.

A nurse is administering a prescribed dose of IV medication to a client who is recovering from partial airway obstruction. What are common reasons for airway obstruction to occur? Select all that apply. compromised swallowing aspiration of vomitus continuous laughing or talking excess intake of high-fiber food insufficient chewing

compromised swallowing aspiration of vomitus insufficient chewing Explanation: The common causes of airway obstruction are compromised swallowing, aspiration of vomitus, insufficient chewing, and eating when intoxicated, as well as other causes. Eating high-fiber food items or laughing and talking continuously do not cause airway obstruction.

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? confusion decreased blood pressure decreased respiratory rate hyperactivity

confusion Explanation: Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, elevated blood pressure with small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

The nurse assesses that a client's Sp02 is 88%. What other assessment findings does the nurse anticipate? pulse rate 60 blood pressure 100/60 mmHg fever of 101 degrees F cool extremities

cool extremities Explanation: The client with hypoxia will generally have an increased pulse rate and blood pressure, a cooler temperature, and cool extremities. Therefore, the nurse does not anticipate a higher fever, lower blood pressure, or slower pulse rate.

The nurse is admitting a new client who has had a chest tube inserted on the right side. Which action should the nurse prioritize for this client? coughing and deep breathing at least q2h while awake provide bedside commode for client limit movement of the right arm while tube is in place maintain bed in at least semi-Fowler position at all times

coughing and deep breathing at least q2h while awake Explanation: Coughing and deep breathing will help promote lung re-expansion because it will help evacuate the air and fluid. It would be improper to tell the client not to move the right arm. The shoulder should be exercised as per orders to help prevent hazards of immobility. This can be accomplished while the tube suction is disconnected as long as the water seal remains intact. The client may be able to walk to the rest room so a bedside commode may not be a priority. Depending on the client's additional health issues, the head of the bed may not need to be in a semi-Fowler position at all times.

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? increases carbon dioxide, which stimulates breathing teaches him to prolong inspiration and shorten expiration helps liquefy his secretions decreases the amount of air trapping and resistance

decreases the amount of air trapping and resistance Explanation: Exhaling through pursed lips creates a smaller opening for air movement, effectively slowing and prolonging expiration, which prevents air from being trapped in the alveoli and decreases resistance to exhalation. Increasing carbon dioxide levels to stimulate breathing is the natural stimulus for a person without COPD to breathe. Prolonging inspiration and shortening expiration does not assist the client because exhalation is difficult for the COPD client. Humidification and fluid intake help to liquefy secretions.

The unlicensed assistive personnel (UAP) has just completed morning care for several older adult clients with respiratory difficulties and reports to the nurse several observations. Which client should the nurse prioritize for intervention? difficulty coughing reluctant to take shower because it is hard to breathe coughed up approximately 5 mL of thick yellow mucus after shower reporting frontal headache

difficulty coughing Explanation: Clients with respiratory problems are at risk for airway patency to be jeopardized and compromised by several factors such as ineffective cough. The nurse should evaluate this client's difficulty with coughing to determine if suctioning may be needed. Other factors include an increased volume of sputum, thick mucus, fatigue or weakness, decreased level of consciousness, or impaired airway. Coughing up 5 mL thick yellow mucus would be considered okay and should be documented. Being reluctant to take the shower and the report of headache should be investigated after assuring the client who is having difficulty coughing does not have a compromised airway.

The nurse is obtaining data from an older adult client upon admission to the long-term care facility. Which age-related respiratory change(s) will the nurse identify as placing the client at risk for respiratory illness? Select all that apply. difficulty swallowing (dysphagia) due to structural changes respiratory muscles diminish in strength cough reflex diminishes increased rigidity of the chest wall respiratory cilia are less efficient

difficulty swallowing (dysphagia) due to structural changes respiratory muscles diminish in strength cough reflex diminishes increased rigidity of the chest wall respiratory cilia are less efficient Explanation: Difficulty swallowing (dysphagia) may occur in clients that have had strokes or have late-stage dementia, but is not associated with structural changes in the larynx. The older adult client has overall diminished muscle strength which includes respiratory muscles. The cough reflex diminishes and makes it more difficult for the client to mobilize secretions. The chest wall becomes more rigid, creating a decrease in respiratory volume. the respiratory cilia are less efficient at filtering out particles that may predispose the client to infection.

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is Ineffective Airway Clearance related to copious and tenacious secretions. Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan? encouraging the client to consume 2 to 3 qt (1.9 L to 2.9 L) of clear fluids daily creating an environment that is likely to reduce anxiety positioning the client supine encouraging the client to decrease the number of cigarettes smoked daily

encouraging the client to consume 2 to 3 qt (1.9 L to 2.9 L) of clear fluids daily Explanation: Clients can help keep their secretions thin by drinking 2 to 3 quarts (1.9 L to 2.9 L) of clear fluids daily. Although it is important to create an environment that is likely to reduce a client's anxiety, doing so will not assist in promoting airway clearance. The nurse should not encourage the client to decrease the number of cigarettes smoked daily, but should encourage the client to stop smoking. Proper positioning to ease respirations includes placing the client in a high-Fowler's position.

The nurse has received a prescription to obtain an arterial blood gas (ABG) on a client who has a history of chronic obstructive pulmonary disease (COPD) and is receiving oxygen via nasal cannula. Which step is the most important for the nurse to fulfill? ensure client is at rest at least 30 minutes before obtaining the specimen notify laboratory personnel of the prescription place the specimen in cold water after filling the tube apply pressure to the puncture site for at least 15 minutes after the puncture

ensure client is at rest at least 30 minutes before obtaining the specimen Explanation: Unless the procedure is an emergency, it is advisable for the client to be at rest at least 30 minutes prior to obtaining the specimen. The ABG represents the client status at the moment of sampling and activity can lower oxygen levels in the blood, which can lead to an incorrect interpretation of the results. Some facilities require laboratory personnel to obtain this sample which would require the nurse to notify the lab; however, with the current use of computers, they may already know and not need to be contacted. The specimen tube should be placed on ice for transport to the laboratory to help preserve the specimen as it slows metabolism and helps ensure accurate results. Manual pressure should be applied for 5 to 10 minutes after the puncture and followed with a pressure dressing to reduce the potential of arterial bleeding.

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? oxygen analyzer nasal strip nasal cannula flow meter

flow meter Explanation: The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.

The home health nurse arrives at a client's home and immediately notes the client is experiencing increased dyspnea. The client has a 7-year history of chronic obstructive pulmonary disease (COPD). Which assessment finding should the nurse prioritize? flow meter set at 5 liters of oxygen nasal cannula placed upside down redness behind both ears nasal mucosa appears crusty

flow meter set at 5 liters of oxygen Explanation High percentages of oxygen are contraindicated for a client with COPD, because the client has adapted to excessive levels of retained carbon dioxide and low blood oxygen levels to stimulate the drive to breathe. If a client with COPD receives more than 2 to 3 liters of oxygen over a sustained period, the respiratory rate slows or even stops. Adjusting the flow meter and performing necessary emergent care would be the priority. The other findings are also concerns which can occur when receiving oxygen and would be addressed after dealing with the dyspnea.

A home care nurse finds an adult client slumped in a chair. The client is not breathing. Which method should the nurse use to open and maintain the client's airway? head tilt method jaw thrust method head tilt-chin lift method support neck-open mouth method

head tilt-chin lift method Explanation: To open the airway of a client who is not breathing, the nurse should use either the head tilt-chin lift method or the jaw thrust method. The head tilt method alone will not be effective because, by not lifting the chin, the airway will not open. The jaw thrust method is not effective because there is not a comfortable way to pull the jaw from below and stabilize the head. The neck support-open mouth method will not be effective.

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: hemoglobin level. age. blood pH. sodium and potassium levels.

hemoglobin level. Explanation: Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position? left side with a pillow under the chest wall side-lying position, half on the abdomen and half on the side high-Fowler's position Trendelenburg position

high-Fowler's position Explanation: Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. High-Fowler's position is used to drain the apical sections of the upper lobes of the lungs. Placing the client lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.

A nurse is conducting a health promotion program for adolescents to educate them about the hazards of smoking. When describing the effects on the respiratory system, what would the nurse most likely include? decreased production of mucus inhibition of mucus removal increase in the mucous escalator inhibition of bacterial colonization

inhibition of mucus removal Explanation: Smoking inhibits mucus removal. By producing more mucus and by slowing the mucous escalator, smoking inhibits mucus removal and can cause airway blockage, promoting bacterial colonization and infection.

A client has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy tube is removed for cleaning? obturator outer cannula inner cannula cuff

inner cannula Explanation: A tracheostomy tube consists of an outer cannula, an inner cannula, and an obturator. The obturator guides the tube into place and is removed. The outer cannula remains in place in the trachea while the inner cannula is removed for cleaning or replacement.

An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur? inspiration and expiration only on inspiration only on expiration when coughing

inspiration and expiration Explanation: Wheezes are continuous sounds heard on expiration and sometimes on inspiration. They originate as air passes through airways constricted by swelling (as in asthma), secretions, or tumors. Coughing, by forcing air out of the lungs under high pressure, attempts to clear the throat of foreign particles.

An older adult client with COVID-19 is in the intensive care unit (ICU) with a tracheostomy tube. Which factor should the nurse prioritize when removing respiratory secretions from this client? new atrial fibrillation on cardiac monitor SaO2 drops to 94% (0.94) secretions are light yellow and thick blood pressure is 130/90 mm Hg

new atrial fibrillation on cardiac monitor Explanation: Older adults are at increased risk for cardiac dysrhythmias during suctioning due to possible pre-existing hypoxemia related to pre-existing conditions and age-related changes in ventilation. The atrial fibrillation would need to be reported and monitored. The other findings would possibly be expected depending on the client's overall condition. If the SaO2 and blood pressure continue at those levels, then further intervention may also be needed.

The nurse is preparing to suction a client's mouth to remove secretions. Which type of suctioning will the nurse perform? oropharyngeal nasopharyngeal nasotracheal oral

oral Explanation: Oral suctioning removes secretions from the mouth. Oropharyngeal suctioning removes secretions from the throat through a nasally inserted catheter. Nasopharyngeal suctioning removes secretions from the throat through a nasally inserted catheter. Nasotracheal suctioning removes secretions from the upper portion of the lower airway through a nasally inserted catheter.

A nurse is caring for a critically ill client who is receiving oxygen through a nonrebreather mask. The nurse should remember that which situation could lead to oxygen toxicity in the client? oxygen concentration of more than 25% given for longer than 24 hours oxygen concentration of more than 30% given for longer than 48 hours oxygen concentration of more than 25% given for longer than 36 hours oxygen concentration of more than 50% given for longer than 48 hours

oxygen concentration of more than 50% given for longer than 48 hours Explanation: When administering oxygen to a critically ill client using a nonrebreather mask, the nurse should remember that an oxygen concentration of more than 50% given for longer than 48 hours can cause oxygen toxicity in the client. Oxygen toxicity refers to lung damage that develops when oxygen concentrations of more than 50% are administered for longer than 48 to 72 hours. The best way to prevent oxygen toxicity is to administer the lowest FiO2 possible for the shortest amount of time.

The nurse is caring for a 2-year-old client who experienced smoke inhalation during a house fire. When oxygen is prescribed, what delivery device will the nurse gather? Venturi mask oxygen tent nasal catheter nonrebreather mask

oxygen tent Explanation: An oxygen tent is often used when caring for active toddlers who require oxygen because they are less likely to keep a mask on. Other devices are inappropriate for a child of this age.

The nurse is caring for a client with respiratory acidosis. Which arterial blood gas data does the nurse anticipate finding? pH less than 7.35; HCO3 low; PaCO2 low pH greater than 7.45; HCO3 high; PaCO2 high pH less than 7.35; HCO3 high; PaCO2 high pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation

pH less than 7.35; HCO3 high; PaCO2 high Explanation: In respiratory acidosis, anticipated arterial blood gas results are anticipated to reflect pH less than 7.35; HCO3 high; and PaCO2 high. Other answers are incorrect.

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? pH less than 7.35; HCO3 low; PaCO2 low pH greater than 7.45; HCO3 high; PaCO2 high pH less than 7.35; HCO3 high; PaCO2 high pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation

pH less than 7.35; HCO3 low; PaCO2 low Explanation: In metabolic acidosis, anticipated arterial blood gas results are anticipated to reflect pH less than 7.35; HCO3 low; and PaCO2 low. Other answers are incorrect.

Which is a major organ of the upper respiratory tract? trachea bronchi lungs pharynx

pharynx Explanation: The pharynx, mouth, and nose are major organs of the upper respiratory tract. The trachea, bronchi, and lungs are major organs of the lower respiratory tract.

A client at a health care facility who requires prolonged mechanical ventilation has a tracheostomy tube inserted through a surgically created opening into the trachea. The tracheostomy tube also has a balloon cuff. How does the inflated balloon cuff aid the client? prevents the aspiration of oral fluids keeps the tongue in a relaxed position eliminates the need for frequent suctioning facilitates insertion of the tracheostomy tube

prevents the aspiration of oral fluids Explanation: A tracheostomy tube may have a balloon cuff; when inflated, the cuff seals the upper airway to prevent aspiration of oral fluids and provide more efficient ventilation. An oral airway is a curved device that keeps a relaxed tongue positioned forward within the mouth, preventing the tongue from obstructing the upper airway. During insertion of a tracheostomy tube, an obturator, a curved guide, is used. Most clients with tracheostomy tubes require frequent suctioning.

The physician directs the nurse to use oropharyngeal suctioning to remove liquid secretions for a client with a respiratory problem. What is oropharyngeal suctioning? removing secretions from the upper portion of the lower airway through a nasally inserted catheter removing secretions from the mouth using a Yankauer-tip or tonsil-tip catheter removing secretions from the throat through an orally inserted catheter removing secretions from the throat through a nasally inserted catheter

removing secretions from the throat through an orally inserted catheter Explanation: Oropharyngeal suctioning is the removal of secretions from the lung through an orally inserted catheter. Nasotracheal suctioning is the removal of the secretion from the upper portion of the lower airway through a nasally inserted catheter. Oral suctioning is the removal of secretions from the mouth using a Yankauer-tip or tonsil-tip catheter. Nasopharyngeal suctioning means removing secretions from the throat through a nasally inserted catheter.

A nurse is providing care to an infant who is at risk for developing respiratory complications. What would lead the nurse to notify the physician that the infant is experiencing breathing difficulties? retraction of ribs soft rustling sounds on auscultation nasal breathing respirations that are audible without a stethoscope

retraction of ribs Explanation: An infant with breathing difficulty will have retraction of ribs during inspiration. Apart from this, flaring of the nostrils is another notable sign of air hunger and extraordinary breathing effort. Soft rustling sounds on auscultation and nasal breathing are normal findings. It is common to be able to hear respirations without a stethoscope.

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? simple mask tracheostomy collar nasal cannula face tent

tracheostomy collar Explanation: A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. All other devices are less appropriate for this client.

A client with a head injury will require long-term airway support. Which device will be required for this client? oropharyngeal airway endotracheal tube tracheostomy tube home oxygen

tracheostomy tube Explanation: Clients who require prolonged airway support via mechanical ventilation and oxygenation are more likely to be candidates for a tracheostomy to maintain the airway and provide a new route for ventilation. Therefore, the tracheostomy tube is the device required for this client. The other devices are not required for the client with a head injury and long-term airway support needs.

A nurse is caring for a client with a tracheostomy tube. The last tracheostomy care was completed at 0800. When will the nurse plan to complete tracheostomy care? 1200 1400 1600 1800

1600 Explanation: Nurses perform tracheostomy care at least every 8 hours, or as often as clients need to keep the secretions from becoming dried, then narrowing or occluding the airway. The other answer choices are too frequent or too infrequent.

A client is experiencing hypoxia. Which nursing diagnosis would be appropriate? Anxiety Nausea Pain Hypothermia

Anxiety Explanation: Clients who are hypoxic commonly experience anxiety and restlessness related to feelings of suffocation. Pain, nausea, and hypothermia is not associated with a client experiencing hypoxia.

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? Hyperventilation Hypoxia Perfusion Atelectasis

Hypoxia Explanation: Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia. Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements. Perfusion refers to the process by which oxygenated capillary blood passes through body tissues. Atelectasis refers to collapsed alveoli.

A nurse is observing a new graduate suctioning a client's tracheostomy tube. Which intervention would cause the nurse to intervene? The new graduate put on a face shield and sterile gloves. The client was hyperoxygenated after removing the suction catheter. Suction was completed using intermittent suction. Suction was applied when the catheter was inserted.

Suction was applied when the catheter was inserted. Explanation: Applying suction as the catheter is introduced allows the tubing to adhere to the airway and destroy cells, which can injure the airway. It also puts the client at risk for sneezing and gagging. All other interventions are appropriate.

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 eupnea hypercapnia pallor

cyanosis Explanation: Cyanosis around the lips indicates serious hypoxemia. Cyanosis is caused by a desaturation of oxygen on the hemoglobin in the blood. Hypercapnia is caused by an abnormally high carbon dioxide level in the blood. Hypoxemia is caused by low oxygen levels in the blood. Eupnea is easy, free respiration.

The nurse observes a client practice pursed-lip breathing in preparation for discharge. Which action should the nurse point out needs correcting? exhales to a count of 4 inhales slowly through the nose to a count of 3 contracts abdominal muscles to exhale holds lips as though to whistle

exhales to a count of 4 Explanation: Expiration should be two to three times longer than inspiration, so it should be to the count of 6 or more. This will help remove more carbon dioxide from the lungs. The other actions demonstrate correctly performed pursed-lip breathing.

A nurse has to perform nasotracheal suctioning for a client with difficulty breathing due to congestion. Which statement describes the purpose of nasotracheal suctioning? removes secretions from the upper portion of the lower airway through a nasally inserted catheter removes secretions from the bottom portion of the lower airway through a nasally inserted catheter removes secretions from the mouth using a Yankauer-tip or tonsil-tip catheter removes secretions from the throat through a nasally inserted catheter

removes secretions from the upper portion of the lower airway through a nasally inserted catheter Explanation: Nasotracheal suctioning is the removal of secretions from the upper portion of the lower airway through a nasally inserted catheter. Oral suctioning is the removal of secretions from the mouth using a Yankauer-tip or tonsil-tip catheter. Nasopharyngeal suctioning means removing secretions from the throat through a nasally inserted catheter.

A nurse is educating a preoperative client on how to effectively deep breathe. Which instruction would be included? "Make each breath deep enough to move the bottom ribs." "Breathe through the mouth when you inhale and exhale." "Breathe in through the mouth and out through the nose." "Practice deep breathing at least once each week."

"Make each breath deep enough to move the bottom ribs." Explanation: The nurse should instruct the client to make each breath deep enough to move the bottom ribs. The client should start each deep breath by inhaling through the nose and exhaling through the mouth. Deep breathing should be done hourly when awake, or 4 times a day.

The nurse is caring for four clients. Which client does the nurse identify who would best benefit from chest physiotherapy? 21-year-old client with cystic fibrosis 34-year-old client with appendicitis 45-year-old client with influenza 51-year-old client with diabetic ketoacidosis

21-year-old client with cystic fibrosis Explanation: Clients with chronic respiratory diseases who have difficulty coughing or raising thick mucus, such as those with cystic fibrosis, will benefit best from chest physiotherapy. Chest physiotherapy is not as beneficial to those with appendicitis, influenza, or diabetic ketoacidosis.

A client is ordered to receive oxygen therapy via nasal cannula at 4 L/minute. When providing care to this client, what would the nurse need to keep in mind? Select all that apply. The maximum flow rate that can be used is 6 L/minute. The client's mouth breathing will decrease the amount of oxygen delivered. The client must have clear, patent nasal passages. The oxygen needs to be humidified to prevent drying of the mucosa. The oxygen concentration delivered will remain constant despite changes in breathing pattern.

The maximum flow rate that can be used is 6 L/minute. The client must have clear, patent nasal passages. The oxygen needs to be humidified to prevent drying of the mucosa. Explanation: When oxygen is delivered via nasal cannula, the maximum flow rate that can be used is 6 liters/minute. Mouth breathing does not appreciably diminish the oxygen delivered. Nasal passages must be patent for the client to receive the oxygen. Oxygen is drying to the nasal mucosa and thus should be humidified. The delivered oxygen concentration can vary depending on the client's breathing pattern.

A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate? changes in the alveolar-capillary membrane and diffusion alterations in the structures of the ribs and diaphragm rapid decreases in atmospheric and intrapulmonic pressures lower-than-normal concentrations of environmental oxygen

changes in the alveolar-capillary membrane and diffusion Explanation: Any change in the surface area of the lungs hinders diffusion of gas exchange. Any disease or condition that results in changes in the alveolar-capillary membrane, such as pneumonia or pulmonary edema, makes diffusion more difficult. Diffusion is assessed by a decreased oxygen saturation measurement. The environmental oxygen which comprises the atmospheric pressure, ribs, and diaphragm do not influence the diffusion of gas exchange inside the lungs.

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? nonrebreather mask Venturi mask nasal cannula simple mask

nonrebreather mask Explanation: A nonrebreather mask is the only device that can deliver an FiO2 of 100% to a client without a controlled airway. A Venturi mask delivers a maximum FiO2 of 55%. A nasal cannula delivers a maximum FiO2 of 44%. A simple mask delivers a maximum FiO2 of 60%.

Which response(s) will the nurse provide to a client concerned about developing chronic bronchitis due to smoking cigarettes, working with printing chemicals, and living near a paper mill? Select all that apply. "Have you tried to stop smoking? This can reduce your risk?" "Living near a paper mill increases the risk the risk for mesothelioma, so maybe you should consider moving." "We can refer you to a smoking cessation program to help reduce developing any future pulmonary issues." "How long have you lived near the paper mill? This can increase you risk for chronic bronchitis and asthma." "Exposure to printing chemicals increases the risk for allergies which can trigger chronic bronchitis, so wearing a breathing mask may be needed."

"Have you tried to stop smoking? This can reduce your risk?" "We can refer you to a smoking cessation program to help reduce developing any future pulmonary issues." "How long have you lived near the paper mill? This can increase you risk for chronic bronchitis and asthma." "Exposure to printing chemicals increases the risk for allergies which can trigger chronic bronchitis, so wearing a breathing mask may be needed." Explanation: The nurse recognizes that smoking increases the client's risk for chronic bronchitis because of exposure to tar, nicotine and other chemicals in cigarettes. Living near a paper mill poses a risk of asthma and chronic bronchitis because of exposure to carbon monoxide, nitrogen oxides, sulfur oxides, and particulate matter .The nurse recognizes that smoking also increases the risk for emphysema and lung cancer and living near the paper mill increases the risk for allergies which contribute to chronic bronchitis. Living near the paper mill does not increase the risk for mesothelioma; mesothelioma is caused by exposure to asbestos and asbestos is not associated with paper mills.

The nurse provides care for the client with chronic obstructive pulmonary disease and a low oxygen saturation level despite oxygen therapy. Which intervention(s) does the nurse utilize to help increase the client's oxygenation? Select all that apply. Advise client to increase water intake Teach the client to do pursed lip breathing Assist the client to do diaphragmatic breathing Ensure that the client is actually using the prescribed oxygen correctly Encourage client to increase salt intake

Advise client to increase water intake Teach the client to do pursed lip breathing Assist the client to do diaphragmatic breathing Ensure that the client is actually using the prescribed oxygen correctly Explanation: The nurse advises the client to increase water intake because water is made up of oxygen. By increasing the water consumption, the client can increase the amount of oxygen in the body. The nurse teaches the client to purse the lips and try to exhale longer than inhaling; this will help ensure that the client is bringing in enough oxygen while expelling the carbon dioxide trapped in the lungs. The client should also do pursed lip breathing while relaxing, 2 or 3 times per day, or when the client feels winded. The nurse teaches the client to do diaphragmatic breathing by laying on the back with the head supported by a pillow, and the knees bent. One hand is placed on the upper chest and the other right below the rib cage, so that the client can feel the diaphragm moving to make sure the client is doing this effectively. The nurse instructs the client to breathe in slowly through the nose, and make sure only the hand under the rib cage is moving. The one on the upper chest can move slightly, but not nearly as much as the other. When client is ready to exhale, tell the client to purse the lips and tighten the stomach muscles while breathing out. This strengthens the diaphragm and trains it to help the client breathe deeper. Client should practice this for three times per day, 5 to 10 minutes each time. The nurse will not encourage the client to increase salt in the diet but will instead encourage the client to cut out salt because a diet low in sodium can lead to increased oxygenation via the kidney and the blood.

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? Set the flow meter to deliver oxygen at 2 L/min Monitor the client for oxygen toxicity Assess the client for anxiety due to claustrophobia Target the client's oxygen saturation to be 88% to 92% 90.88 to 0.92)

Assess the client for anxiety due to claustrophobia Explanation: A simple mask may cause anxiety in clients who experience claustrophobia due to the mask covering the nose and mouth. The flow meter for the simple mask is set at 5 L/min or higher to prevent rebreathing exhaled carbon dioxide. The client is not at risk for oxygen toxicity due to the level of oxygen administration with the simple mask. The client's target oxygen saturation would be 88% to 92% (0.88 to 0.92) if the client had chronic obstructive pulmonary disease (COPD). There is no information in the question to indicate the client has COPD.

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 education plan? At least two caregivers should be taught how to perform tracheostomy care for the client. Clean rather than sterile technique can be used in the home setting. Sterile saline can be made at home using ¼ cup of salt in 1 quart of water and boiling it for 15 minutes. A client should be discouraged from performing self-care in case an emergency situation occurs.

Clean rather than sterile technique can be used in the home setting. Explanation: Clean, rather than sterile technique, can be used in the home setting. The client and home caregiver should be instructed on how to perform tracheostomy care. Sterile saline can be made by mixing 1 teaspoon of table salt in 1 quart of water and boiling for 15 minutes. The client who is performing self-care could use a mirror to view the steps in the procedure.

The nurse provides care for a postoperative client with decreased lung sounds in the lower lobes. Which strategy(ies) does the nurse teach the client to improve respiratory function? Select all that apply. Drink 4 to 6 glasses of water per day Ambulate at least three times per day Elevate the head of the bed to at least 30 degrees and sit up for all meals Cough and deep breathe, or use an incentive spirometer every hour Take prescribed opioid pain medication as frequently as possible according to directions

Drink 4 to 6 glasses of water per day Ambulate at least three times per day Elevate the head of the bed to at least 30 degrees and sit up for all meals Cough and deep breathe, or use an incentive spirometer every hour Explanation: The nurse can best facilitate coughing and deep breathing in the postoperative client with decreased breath sounds by encouraging the client to drink 4 to 6 glasses (960 to 1440 mL) of water per day, ambulate with good pain control, maintain head-of-bed elevation of at least 30 degrees and sit up for all meals, coughing and deep breathe or use incentive spirometry every hour. The nurse does not encourage taking the pain medication as often as it is prescribed because it can depress respiratory effort, encourage too much sleeping rather than being active and consequently increasing rather than decreasing atelectasis in the lungs.

A nurse is caring for a client who breathes very shallowly and has been reporting severe back pain. What suggestion could the nurse make to help the client breathe efficiently? Encourage the client to take deep breaths. Instruct the client in the use of pursed-lip breathing technique. Inform the client about nasal strips. Teach the client diaphragmatic breathing.

Encourage the client to take deep breaths. Explanation: To help the client breathe efficiently, the nurse could encourage the client to take deep breaths. Deep breathing maximizes the ventilation and fills the alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing and diaphragmatic breathing help to eliminate the extra carbon dioxide from the lungs. A nasal strip reduces airflow resistance by widening the nasal-breathing passageways, thus promoting easier breathing. It is used for reducing or eliminating snoring.

A nurse is performing the Heimlich maneuver on a pregnant client who has an airway obstruction. Which action should the nurse perform to aid the client? Give five subdiaphragmatic thrusts to the client. Turn the client supine and give five back blows. Give five chest thrusts to the client. Perform abdominal thrusting for 5 to 6 seconds.

Give five chest thrusts to the client. Explanation: For obese and pregnant clients, the nurse gives five chest thrusts. Nurses give a series of five quick subdiaphragmatic thrusts to increase intrathoracic pressure of clients younger than 8 years of age. For children older than 8 years to adults, the nurse performs abdominal thrusts for 5 to 6 seconds. For infants, nurses turn the client supine and give five back blows between the shoulder blades.

Which should the nurse teach the family about caring for a client with emphysema at home? Select all that apply. Maintain a smoke-free environment. Watch for increased wheezing or signs of a flare-up. Take advantage of pulmonary rehabilitation programs. Follow health care provider's prescription for oxygen administration. Create a long-term caregiving plan.

Maintain a smoke-free environment. Watch for increased wheezing or signs of a flare-up. Take advantage of pulmonary rehabilitation programs. Follow health care provider's prescription for oxygen administration. Create a long-term caregiving plan. Explanation: Even if the person with emphysema is not smoking anymore, the person may be living in a home where family members still smoke. Family must understand why it is important to keep tobacco smoke out of the house. Caregivers need to be ready and know the signs of a flare-up. For instance, the client may wheeze more, get increasingly short of breath, cough more than usual, or have more or a change in color of mucus. If there is a flare-up, the sooner the client can get treatment, the less likely the client will require hospitalization. It is worthwhile for clients with emphysema to look into pulmonary rehabilitation programs. These programs combine exercise, support, and education that will improve one's breathing and health. People with emphysema can live a really long time. Therefore, the family will require a clear plan to address caregiving long term. Oxygen therapy in a client with emphysema is often necessary but too much oxygen may result in knocking out the hypoxic drive, causing further depression of the respiratory drive.

The nurse performs assessments of cardiopulmonary functioning and oxygenation during regular physical assessments. Based on developmental variations, which findings would the nurse consider normal? Select all that apply. Blood pressure increases over time until it reaches the adult level around age 8. The power of the respiratory and abdominal muscles is reduced in older adults, and therefore the diaphragm moves less efficiently. The normal infant's chest is small and the airways are short, making aspiration a potential problem. Alterations in respiratory function due to aging in older adults increase the risk for disease, especially pneumonia and other chest infections. The respiratory rate is more rapid in infants until the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates. The chest in the older adult is unable to stretch as much, resulting in an increase in maximum inspiration and expiration.

The power of the respiratory and abdominal muscles is reduced in older adults, and therefore the diaphragm moves less efficiently. The normal infant's chest is small and the airways are short, making aspiration a potential problem. Alterations in respiratory function due to aging in older adults increase the risk for disease, especially pneumonia and other chest infections. The respiratory rate is more rapid in infants until the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates. Explanation: Muscles tend to lose strength in older adults, causing the diaphragm to be less efficient. Infants are at an increased risk for aspiration during feedings because of the small size of the chest and length of the airway. The chest and lungs lose elasticity as a person ages, increasing the potential for infections of the respiratory tract. There is a decreased number and size of alveoli in the infant, causing the respiratory rate to be higher in an attempt to adequately exchange oxygen and carbon dioxide. Blood pressure reaches the adult level during the preteen to teen years. A decrease in maximum inspiration and expiration occurs in the older adult because of decreased elasticity.

The school nurse is reviewing the record of a new fourth grade student with a history of asthma. Which action should the nurse take when the student drops off an inhaler with salmeterol to be used in case of an asthma attack? contact the parents for clarification store inhaler in designated area question the child concerning the medication ensure the office staff knows the inhaler is available

contact the parents for clarification Explanation: The nurse should contact the parents concerning this. Salmeterol is a long-acting bronchodilator which is used on a daily basis and not used in an emergent situation. Albuterol is a common rescue inhaler which would be more appropriate. It would be inappropriate to question the child, as a child this age would most likely not know or understand the difference. The nurse should not keep this at school but should have a more appropriate rescue inhaler available if needed. There would be no need to tell the office staff the location of the medication.

The physician at the health care facility directs the nurse to perform vibration along with percussion on a frail client with a respiratory diagnosis. What is a possible outcome of performing vibration on the client? helps shake underlying tissue and loosen the retained secretion helps dislodge respiratory secretions adhered to surface of the trachea promotes drainage of secretion from the lobes of the lung helps to raise sputum for diagnostic purposes

helps shake underlying tissue and loosen the retained secretion Explanation: The nurse should be aware that vibration helps shake the underlying tissue and loosen the retained secretion. Secretions do not normally adhere to the trachea. Vibration is used with (or as an alternative to) percussion, especially for frail clients. Percussion helps dislodge respiratory secretion that adheres to the bronchial wall. Postural drainage promotes gravity drainage of secretion from the various lobes or segments of the lungs. Aerosol therapy helps the client raise sputum for diagnostic purposes.

The nurse is caring for a client who has excess levels of carbon dioxide in the blood, and chronic hypoxemia. Which intervention will the nurse recommend? deep breathing incentive spirometry pursed-lip breathing diaphragmatic breathing

pursed-lip breathing Explanation: Pursed-lip breathing is most helpful for clients who have excessive levels of carbon dioxide in the blood and chronic hypoxemia. Other choices do not eliminate as much carbon dioxide from the blood.

The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide? "It is important to eat at least five servings of vegetables daily." "Remove your oxygen before cooking near the gas stove." "An electric stove may be a safer choice for you." "Be careful not to trip over your oxygen tubing while cooking."

"An electric stove may be a safer choice for you." Explanation: For safety purposes, oxygen tanks should be kept at least 10 feet away from gas stoves, fires, and other flammable devices. If the client removes the oxygen while cooking at a gas stove, hypoxia may occur and the client may become confused and sustain burns.

An older adult client was recently placed on home oxygen. The client's caregiver reports that the client now refuses to leave the house. What teaching will the nurse provide the caregiver? Select all that apply. "Continued socialization with others is important." "Discuss with the client switching to a portable oxygen device." "Give the client time to adjust." "Invite friends and family to the client's house." "Remove the oxygen for times when the client wants to leave the house."

"Continued socialization with others is important." "Discuss with the client switching to a portable oxygen device." "Invite friends and family to the client's house." Explanation: Socialization is important for older adults. Having a portable oxygen device increases functional mobility. Inviting friends and family provides socialization and may help the client feel more at ease with oxygen use. The nurse should not suggest that the caregiver ignore the issue or remove the oxygen are inappropriate; these are inappropriate actions.

A nurse assesses the vital signs of a healthy newborn infant. What respiratory rate could be expected based on the developmental level of this client? 15 to 25 breaths/minute 16 to 20 breaths/minute 20 to 40 breaths/minute 30 to 60 breaths/minute

30 to 60 breaths/minute Explanation: Normal breathing rate (breaths per minute) for an infant is 30 to 60; for a 6- to 12-year-old the rate is 15 to 25 breaths/min; for an older adult the rate is 16 to 20 breaths/min; and for a 1- to 5-year-old the rate is 20 to 40 breaths/min.

The obstetric nurse is assisting the birth of a preterm neonate. In preparing for the respiratory needs of the neonate, the nurse is aware that surfactant is formed in utero around: 34 to 36 weeks. 30 to 32 weeks. 32 to 34 weeks. 36 to 38 weeks.

34 to 36 weeks. Explanation: Surfactant is formed in utero around 34 to 36 weeks. An infant born prior to 34 weeks may not have sufficient surfactant produced, leading to collapse of the alveoli and poor alveolar exchange. Synthetic surfactant can be given to the infant to help reopen the alveoli.

A nurse is preparing to use a wall unit to suction the endotracheal tube of a 9-year-old child. At what pressure should the suction be set? 60 to 80 mm Hg 80 to 100 mm Hg 100 to 120 mm Hg 100 to 150 mm Hg

80 to 100 mm Hg Explanation: For a wall unit for an adult: 100 to 120 mm Hg (Roman, 2005) neonates: 60 to 80 mm Hg infants: 80 to 100 mm Hg children: 80 to 100 mm Hg adolescents: 80 to 120 mm Hg

A client is receiving supplemental oxygen and the nurse is monitoring the client's oxygen saturation level using pulse oximetry. The nurse notifies the physician if the client reaches which oxygen saturation level? 98% 96% 94% 92%

92% Explanation: An oxygen saturation level less than 93% usually indicates the need for increased supplemental oxygen.

A nurse working in a pediatric unit finds an infant unresponsive without respirations or a pulse. After calling for help, what is the nurse's most appropriate action? Begin chest compressions. Begin rescue breathing. Call the infant's parents. Bring the crash cart into the room.

Begin chest compressions. Explanation: Resuscitation must proceed with CAB (circulation, airway, breathing). Chest compressions would be the nurse's priority action.

A team of students nurses are performing care to a computerized adult mannequin when it suddenly indicates the "client" is choking and unable to breathe. During the feedback session, which action should the instructor point out as inappropriate? Blind finger sweep at the beginning of the session Asking the "client" what was wrong Quickly assess the "client's" circulation Quickly give 5 quick abdominal thrusts

Blind finger sweep at the beginning of the session Explanation: A blind finger sweep should be avoided on all people older than 1 year of age unless an object is visible in the mouth. It should always be avoided in infants younger than 1 year of age. A blind sweep can actually have the reverse effect by pushing the object further into the client, creating a full blockage. The other options would be appropriate steps for the students to perform.

A nurse is caring for a client who has tachypnea, tachycardia, and oxygen saturation of 90%. What are the nurse's appropriate actions? Select all that apply. Elevate the head of the bed. Auscultate lung sounds. Administer humidified oxygen. Monitor SaO2. Suction with a Yankauer-tip catheter.

Elevate the head of the bed. Auscultate lung sounds. Administer humidified oxygen. Monitor SaO2. Explanation: When caring for a client experiencing hypoxia, the nurse should raise the head of the bed to a high Fowler's position, apply humidified oxygen, assess lung sounds, and monitor the client's SaO2. Oral suctioning with a Yankauer-tip catheter would not be appropriate at this time.

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. Notify the healthcare provider of the client's current status. Explain uses of BiPAP masks versus CPAP masks. Document assessment and plan for intervention.

Inquire about factors that contribute to non-adherence. Explanation: The nurse must first assess the reasons that contribute to non-adherence; interventions cannot be determined without a thorough assessment. Other interventions take place after assessment.

A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determines that the education was successful when the students identify which activity as occurring during inspiration? Intercostal muscles contract. Chest pressure increases. Thorax size reduces. Air flows out of the lungs.

Intercostal muscles contract. Explanation: During inspiration, the diaphragm and external intercostal muscles contract. Their contraction enlarges the thorax volume and decreases intrathoracic pressure. The expanding chest wall pulls the lungs outward. As the lungs expand, pressure drops within the airways. During exhalation, the diaphragm and intercostal muscles relax, causing the thorax to return to its smaller resting size. During exhalation, the pressure in the chest increases, allowing air to flow out of the lungs.

A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determines that the education was successful when the students identify which activity as occurring during inspiration? Intercostal muscles contract. Chest pressure increases. Thorax size reduces. Air flows out of the lungs.

Intercostal muscles contract. Explanation: During inspiration, the diaphragm and external intercostal muscles contract. Their contraction enlarges the thorax volume and decreases intrathoracic pressure. The expanding chest wall pulls the lungs outward. As the lungs expand, pressure drops within the airways. During exhalation, the diaphragm and intercostal muscles relax, causing the thorax to return to its smaller resting size. During exhalation, the pressure in the chest increases, allowing air to flow out of the lungs.

A nurse is performing the Heimlich maneuver on a young client to relieve a mechanical airway obstruction. Which action should the nurse perform to increase intrathoracic pressure? Give five quick abdominal thrusts above the navel. Assist the client onto the floor and into a prone position. Activate the emergency response system. Avoid opening the client's airway with the head-tilt maneuver.

Give five quick abdominal thrusts above the navel. Explanation: For all people older than 1 year of age, the rescuer gives a series of five quick abdominal upward thrusts slightly above the navel to increase intrathoracic pressure. The rescuer opens the client's airway with the head-tilt or chin-lift maneuver and continues administering upward thrusts if initial efforts are not successful. Only if the client becomes unconscious should nurses assist clients to the floor, activate the emergency response system, and begin performing cardiopulmonary resuscitation (CPR).

A nurse is performing the Heimlich maneuver on a young client to relieve a mechanical airway obstruction. Which action should the nurse perform to increase intrathoracic pressure? Give five quick abdominal thrusts above the navel. Assist the client onto the floor and into a prone position. Activate the emergency response system. Avoid opening the client's airway with the head-tilt maneuver.

Give five quick abdominal thrusts above the navel. Explanation: For all people older than 1 year of age, the rescuer gives a series of five quick abdominal upward thrusts slightly above the navel to increase intrathoracic pressure. The rescuer opens the client's airway with the head-tilt or chin-lift maneuver and continues administering upward thrusts if initial efforts are not successful. Only if the client becomes unconscious should nurses assist clients to the floor, activate the emergency response system, and begin performing cardiopulmonary resuscitation (CPR).

A nurse has an order to obtain a sputum specimen on a newly admitted client. Which action is appropriate for the nurse to delegate to unlicensed assistive personnel (UAP)? Auscultate the client's lung sounds before the sputum specimen is collected. Label the sputum specimen and take it to the lab. Instruct the client on how to use a nebulizer. Perform chest physiotherapy.

Label the sputum specimen and take it to the lab. Explanation: Labeling of specimens and transporting them to the lab is within the scope of practice of UAP. The other actions require nursing judgment and should be done by licensed nursing personnel.

A 72 year-old client has come for an annual wellness check-up with the health care provider. Which vaccine will the nurse discuss with the client? Diphtheria, tetanus, and pertussis (DTaP) Hepatitis A Measles, mumps, rubella (MMR) Pneumococcal 13-valent conjugate

Pneumococcal 13-valent conjugate Explanation: Clients over the age of 65 years old OR those who have a compromising chronic health condition should be offered Pneumococcal 13-valent conjugate, which reduces strains of streptococcal pneumonia. Other options are not appropriate for the scenario.

What can a nurse ask a client to do before suctioning to prevent hypoxemia? Sit in an upright position and cough. Breathe normally for at least 5 minutes. Lie flat in bed and practice relaxation. Take several deep breaths.

Take several deep breaths. Explanation: Suctioning removes oxygen from the respiratory tract, possibly causing hypoxemia (insufficient oxygen in the blood). The client should be hyperoxygenated before suctioning, so the nurse should ask him to take several deep breaths before the nurse inserts the suction catheter.

The client is reporting to the nurse that the continuous positive airway pressure (CPAP) mask is torture. What is the best response from the nurse? Tell me more about why it bothers you. Would you like to talk to your health care provider concerning this? Can you explain to me what settings you are using? Perhaps we need to change you to a different type of mask.

Tell me more about why it bothers you. Explanation: First, the nurse should find out what is bothering or most concerning to the client. Then, the nurse will have a better idea of the best next step, which can include the other responses. It is possible this client will do better with a bilevel positive airway pressure (BiPAP) machine instead of a CPAP machine.

A client, 90 years of age, has been in a motor vehicle collision and sustained four fractured ribs on the left side of the thorax. The nurse recognizes the client is experiencing respiratory complications when which sign(s) is observed? Select all that apply. The client demonstrates restlessness. The client's capillary refill is assessed at 4 seconds. The client has uneven movements of the chest with respirations. The client has flaring nostrils. The client has a respiratory rate of 16 breaths/min.

The client demonstrates restlessness. The client's capillary refill is assessed at 4 seconds. The client has uneven movements of the chest with respirations. The client has flaring nostrils. Explanation: Careful assessment of older adults who demonstrate restlessness or confusion is imperative for accurately differentiating signs of inadequate oxygenation from signs of delirium or dementia. While the nurse may be observing signs of cognitive impairment, restlessness commonly accompanies respiratory distress. The nurse will not dismiss this sign and will consider it as part of the respiratory assessment. A prolonged capillary refill time (any time longer than 3 seconds) is indicative of poor perfusion secondary to poor oxygenation. This is a sign that the client may be experiencing respiratory complications. The nurse observes for paradoxical (uneven) chest movement that would indicate a possible flail chest. These complications may require insertion of a chest tube or other surgery, blood transfusion or artificial ventilation. Flaring nostrils indicate increased work of breathing related to poor gas exchange. A respiratory rate that ranges from 12 to 16 breaths/min is normal for adults and older adults.

The nurse has been assisting a client with pneumonia with postural drainage. Which position will be most beneficial for the client when the chest x-ray indicates the lateral lower lobes are still congested? ** this is a question with photos**

There are several positions that are used to assist with postural drainage. To facilitate drainage out of the lower lobe, lateral basal segment, the client should be in the Trendelenburg position with pillows under the hips, client laying on the side with upper arm towards the bed. The lower lobe, anterior basal segment is similar except the lower arm is placed under the head and the upper arm is across the side of the body. For the lower lobes, superior segment, the client is placed in the prone position with pillows under the hips and both arms crossed and under the head. If the focus is on the upper lobes, anterior segment, the client is placed in the supine position with pillows under the hips, knees bent, head flat against the bed and arms at the side.

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: croup. asthma. alcohol use. pneumonia.

pneumonia. Explanation: Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol use do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol use depresses the central respiratory center.

The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly? small amount of subcutaneous air is detected at the site of tube insertion dressing is moist and intact respirations are at 20 breaths per minute drainage system is positioned slightly above chest level

respirations are at 20 breaths per minute Explanation: Respirations of 20 breaths per minute indicate that the tube is functioning correctly. Other findings require nursing intervention.

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider? An infant with a respiratory rate of 16 bpm A 4-year-old with a respiratory rate of 32 bpm A 12-year-old with a respiratory rate of 20 bpm A 70-year-old with a respiratory rate of 18 bpm

An infant with a respiratory rate of 16 bpm Explanation: The infant's normal respiratory rate is 20 to 40 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 32 breaths per minute. For a child 6 to 12 years of age the normal respiratory rate is 18 to 26 breaths per minute. The normal respiratory rate for an adult 65 years and older is 16 to 24 breaths per minute.

An older adult client with a history of chronic obstructive pulmonary disease is admitted to the hospital with a cough and acute shortness of breath. Which priority action should the nurse take during the initial assessment of the client? Assist the client to lie down to complete a full physical assessment. Ask specific questions about the history of the cough and shortness of breath. Assess for allergies before treatment. Administer pulmonary function tests.

Ask specific questions about the history of the cough and shortness of breath. Explanation: Inquiring about a current history of coughing, determining how long the cough has been present, and observing and describing any sputum are important when assessing older adults. The client may have difficulty lying down for the assessment. Allergies should be assessed, but are not the priority. Administration of pulmonary function tests would be completed after the initial assessment.

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? Inhale through the nose instead of the mouth. Be sure to shake the canister before using it. Inhale the medication rapidly. Inhale two sprays with one breath for faster action.

Be sure to shake the canister before using it. Explanation: A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly. MDIs are inhaled through the mouth, into the lungs. The medication should be inhaled slowly to ensure a sufficient dose enters the lungs. If the order is for two sprays, these sprays are administered with one spray for each breath. The inhaled breath should be held briefly after each spray in order to prevent immediately exhaling the medication.

The nurse is evaluating the effectiveness of therapy for a client who has received inhalation therapy treatment during an asthma attack. Which assessment finding is the best indicator that the therapy has been effective? No wheezes are audible. Oxygen saturation is > 94%. Use of accessory muscles has decreased. The respiratory rate is 18 breaths/minute.

Oxygen saturation is > 94%. Explanation: The goal for treatment of an asthma attack is to keep the oxygen saturation > 90%. The other client data may occur when the client is too fatigued to continue with the increased work of breathing required in an asthma attack.

The nurse observes that the client's pulse oximetry is 89%. What is the priority nursing action? Document hypoxemia. Report pulse oximetry to the health care provider. Perform respiratory assessment. Check the placement of the pulse oximeter.

Perform respiratory assessment. Explanation: As the nurse enters the room, the respiratory assessment immediately begins by visualizing the client's skin color, observing chest symmetry, vocalization, and auditory adventitious lung sounds. The nurse can then proceed to check the placement of the pulse oximeter, report findings to the health care provider, and document.

The nurse is caring for an older adult client who has been admitted for an asthma exacerbation. While assessing the client's vital signs, the nurse observes the client's oxygen saturation is 88% on room air. Which additional assessment(s) related to this finding will the nurse undertake? Select all that apply. Check skin turgor. Count capillary refill time. Listen for bowel sounds. Obtain level of consciousness. Observe movement of the chest.

Count capillary refill time. Obtain level of consciousness. Observe movement of the chest. Explanation: Capillary refill time provides information about the client's oxygenation and perfusion status. Capillary refill time (the time it takes blood to resume flowing in the base of the nail beds) is normally less than 3 seconds after compression and release of the nail bed. If a client is hypoxemic, the level of consciousness can be decreased. Assessing if the client is oriented to person, place and time will assist the nurse in determining the degree to which the client's difficulty breathing has impaired oxygenation to the brain. The nurse will assess for symmetrical movement of the chest as well as the presence of any intercostal indrawing and tachypnea, all signs of increased work of breathing due to impaired oxygenation. While it is not relevant for the nurse to assess skin turgor in a focused respiratory assessment, this assessment would be relevant if the nurse observed signs of dehydration or fluid overload. Auscultating for bowel sounds is part of the abdominal assessment which is associated with a focused assessment of the client's elimination. Generally, this assessment is undertaken when the client is experiencing bowel irregularity or for signs of flatus postoperatively. This assessment will not provide any additional priority data for the respiratory assessment.

A client with a diagnosis of stage II Alzheimer's disease also has a history of chronic obstructive pulmonary disease (COPD). Which medication delivery system is most appropriate for this client? Nebulizer Metered-dose inhaler with spacer Metered-dose inhaler without spacer Dry powder inhaler

Nebulizer Explanation: Inhalers differ in the amount of dexterity that is required in order to deliver an accurate dose, but each requires some degree of coordinated activity on the part of the client. For a client with decreased cognition, a nebulizer may be more appropriate on account of the fact that the client passively inhales the entire dose.

A client has had a head injury affecting the brain stem. What is located in the brain stem that may affect respiratory function? Chemoreceptors Stretch receptors Respiratory center Oxygen center

Respiratory center Explanation: The medulla in the brain stem, immediately above the spinal cord, is the respiratory center. Stretch receptors are located in muscles. Chemoreceptors that affect respirations are located in the aortic arch and the carotid bodies. There is not a oxygen center in the body.