Respiratory System EVOLVE
after the nurse has taught a client with asthma about use of peak flow meter, which client statements indicate that the teaching has been effective? select all that apply "readings in the green zone mean that my asthma is under control" "if I get a reading in the yellow zone, I need to stop what I'm doing and rest for a while" "if I get a reading in the red zone, then I need to use the quick relief inhaler and have my family take me to the hospital" "i should check the peak flow readings at least twice a day until my baseline is established" "I don't need to check my peak flow readings if I use quick relief meds"
answer: 1,3,4 peak flow meters are used to measure how well the client's asthma is controlled. Readings in the green zone mean that asthma is under control. Readings in the red zone indicate serious airflow problems; the client should use the quick relief inhaler and plan to see the HCP or go to the emergency room. Peak flow readings should be done 2-4 times daily for the first few weeks to establish a baseline. With yellow zone, the client should use quick relief inhaler and recheck peak flows in an hour. Clients who need the quick relief med should continue to check peak flows to assure that peak flow improve.
which information is needed to determine oxygen administration for a client with COPD and oxygen stat of 87%? Select all that apply level of orientation ABGs Bilateral lung sounds complete blood count pulmonary function test
Answer: ABGs Clients with COPD who have low oxygen respond to oxygen administration. However, some clients with COPD have a respiratory drive that stimulates breathing that is dependent on CO2. The administration of too much oxygen in these clients lowers respiratory drive and decreases breathing. Therefore, the nurse would assess the ABGs to determine how much oxygen to administer. Level of orientation shows the amount of hypoxia the client is experiencing. Clients may have abnormal lung sounds that can impede oxygenation, but this is not he basis for determining oxygen administration. A CBC assesses RBCs, hemoglobin, and hematocrit; these values can be diminished in pts with COPD, but they do not determine oxygen needs. PFTs are used to diagnose pulmonary disorders.
When caring for a client who has had bronchoscopy in the ambulatory surgery unit, which action would the nurse take? Offer ice chips to decrease throat pain Avoid turning head side to side Keep the patient in the semi -Fowlers position Suggest medicated lozenges for sore throat
Answer: keep the client in the semi-Fowler position With the head elevated, fluid will not collect in the interstitial spaces around the trachea. Because the clients gag reflex may not be intact, ice chips or fluids would not be offered. There are no restrictions on turning the head after the bronchoscopy. Medicated lozenges would not be suggested because they may numb the throat, further decreasing the gag reflex.
when a nurse needs to administer oxygen at a fraction of inspired oxygen of about 40% to keep client's oxygen saturation greater than 94%, which method would be best? face tent venturi mask nasal cannula simple face mask
Answer: nasal cannula All of the options are capable of delivering 40% oxygen, but the nasal cannula is the most comfortable and least intrusive. A face tent would provide humidification, but is more intrusive and there is no indication that the pt needs additional humidification. A venturi mask is more intrusive and uncomfortable. A simple face mask would be more uncomfortable.
which instruction would the nurse include when teaching a client with asthma how to use peak flow meter? Sit up straight in a firm chair check flow early in the morning take the deepest breath you can, then blow out hard and fast calculate the average of 3 readings to obtain peak flow
Answer: take the deepest breath you can, then blow out hard and fast A peak flow meter measures the peak expiratory flow rate and is used by taking the deepest breath possible, then forcefully exhaling as quickly as possible. The client is taught to stand when measuring peak flows to assure accurate readings. Should be done between 12 and 2pm, when the peak flows are the highest. Done 3 times, and the highest reading is recorded as the peak flow.
After a client has had bronchoscopy, which finding indicates the client's gag reflex has returned? alert and orientated able to swallow saliva speaks without difficulty denies sore throat
answer: able to swallow saliva The ability to swallow indicates that the gag reflex is intact. clients may be alert and still have a diminished gag reflex, especially if a topical anesthetic was used to numb the throat. Clients may be able to speak and still have a decreased gag reflex. Because bronchoscopy does cause trauma to the structures in the pharynx, a client who denies a sore throat may have ongoing numbness of the throat and a decreased gag reflex.
a client has COPD. To decrease the risk of CO2 intoxication, which should the nurse do? Initiate pulmonary hygiene to clear air passages of trapped mucus instruct to deep breathe slowly with inhalation longer than exhalation encourage continuous rapid panting to promote respiratory exchange administer oxygen at low concentration to maintain respiratory drive
answer: administer oxygen at low concentration to maintain respiratory drive With chronically high levels of carbon dioxide, it is believed that decreased oxygen levels become stimulus to breathe; high oxygen concentration negates this mechanism. Initiating pulmonary hygiene to clear air passages of rapped mucus is an appropriate intervention but is not directly related to CO2 intoxication. Encouraging continuous rapid panting to promote respiratory exchange will not bring oxygen into the alveoli for exchange, nor will it adequately remove CO2 because it will increase bronchiolar obstruction. Inhalation should be of regular depth, and expiration should be prolonged to prevent CO2 trapping.
which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? select all that apply mold cold air pet dander air pollution cigarette smoke
answer: all apply
which action will the nurse include in the plan of care for a client after bronchoscopy examination? check for gag reflex send the client for chest x ray exam assess breathing every 30 mins have client avoid the Valsalva maneuver
answer: check for gag reflex The nurse will assess for the return of the gag reflex before providing anything by mouth. A chest x ray is not needed after bronchoscopy, but would be prescribed after diagnostic procedures such as thoracentesis. Breathing should be assess every 15 mins for 2 hours after bronchoscopy. The Valsalva maneuver is safe to perform after bronchoscopy.
which rationale would the nurse use when teaching a client with COPD to use pursed lip breathing? decrease air trapping prevent bronchial dilation strengthen intercostal muscles reduce diaphragmatic excursion
answer: decrease air trapping pursed-lip breathing prolongs the expiratory phase and increases airway positive pressure, leading to more complete expiration and reduced air trapping. bronchi and bronchioles stay open longer and are expanded during pursed lip breathing. Pursed lip breathing does not strengthen the intercostal muscles or reduce diaphragmatic excursion.
which action would the clinic nurse take when a client with COPD has a 10-mm area of induration after Mantoux testing? document the result as a negative finding teach the client about the need for chest x ray discuss latent TB wit client notify the local public health department
answer: document the result as negative finding a 10 mm induration in a client with COPD would be interpreted as negative and no further action is needed. In this client, a chest x ray to check for evidence of TB would be needed if the induration was 15 mm or more. Because the client's Mantoux test is negative, no discussion of latent TB is needed. The public health department does not need notification fro negative Mantoux testing.
which finding for a client who has just returned to the nursing unit after bronchoscopy and lung biopsy would be most important to report to the HCP? client rousable, but lethargic cough productive of bloody mucus heart rate 126 beats per minute client report of dry and sore throat
answer: heart rate of 126 beats per minute tachycardia may indicate hemorrhage, a possible complication of bronchoscopy and lung biopsy, and should be immediately reported to the HCP. The nurse will expect prescriptions for frequent viral signs, complete blood count, and perhaps a return to the operating room. Because sedation is used for bronchoscopy, lethargy is expected for a few hours after the procedure. blood mucus is expected due to trauma to the trachea and tissue injury from the biopsy. A dry and sore throat is common after bronchoscopy because of the trauma to the pharynx.
Which finding in a client with asthma exacerbation requires the most rapid action by the nurse? report of chest tightness heart rate of 112 beats per min expiratory wheezes in both lungs markedly decreased breath sounds
answer: markedly decreased breath sounds markedly decreased breath sounds may indicate very limited airflow and life threatening asthma exacerbation. The nurse would immediately check oxygen sat and anticipate possible need for ventilation. Clients with asthma exacerbation frequently report chest tightness, but this finding does not indicate possible impending respiratory arrest. Tachycardia is common with asthma because of stress and increased work of breathing. Expiratory wheezes are heard early in asthma exacerbation; more ominous finding and indicate further progression of airway obstruction.
which method of oxygen delivery would the nurse anticipate will be prescribed for a client with a pulse ox of 65%? face tent venturi mask nasal cannula nonrebreather mask
answer: nonrebreather mask the expected value of pulse ox is 95-100%. Nonrebreather mask will deliver high oxygen concentrations (up to 90%) at a liter flow of 10 to 15 L/min. when using a nonrebreather mask, the client breathes only the oxygen source from the bag. A face tent delivers 30-50% oxygen when set at flow rate of 4 to 8 L/min. A venturi mask delivers 24-50% oxygen when set at oxygen rate of 4-10 L/min. A nasal cannula delivers 24-45% oxygen when set at flow rate of 2 to 6 L/min.
When the nurse manager is evaluating care of a client receiving oxygen through nasal cannula, which finding indicates a need for more staff education about oxygen therapy? oxygen flow rate is set to 8 L/min There is bubbling present in the humidifier pressure areas of tubing along the ears are padded smoking and open flames prohibited signs are clearly posted
answer: oxygen flow rate is set to 8 L/min flow rates for nasal cannulas should be set no higher than 6 L/min, higher flows do not lead to an increased FIO2, and high oxygen flow increases drying and irritation of mucous membranes. Bubbling of oxygen through the humidifier indicates that humidification of oxygen is occurring. Padding of pressure areas on the oxygen tubing decreases skin irritation and breakdown. smoking and open flame prohibition signs are posted in places where oxygen is used to decrease the risk for fire.
which diagnostic testing is most useful in evaluating the effectiveness of treatment for asthma? chest x ray pulmonary function tests serum eosinophil counts immunoglobulin E levels
answer: pulmonary function tests The most useful test when evaluating the effectiveness of asthma treatment is PFT, which measures airflow. A chest x ray might be used to check for complications of asthma such as respiratory infection, but is not used to evaluate the effectiveness of asthma treatment. Serum eosinophil counts might be used to determine if the asthma was caused by allergies, but are not commonly used to check the effectiveness of treatment. Immunoglobulin E levels might be checked to determine if a client had allergic asthma, but would not be used to check for whether treatment was effective.
a client with COPD is breathing rapidly and using accessory muscles of respiration. the nurse auscultates the lungs and hears crackles and wheezes. Which action would the nurse take? encourage the client to take slow, deep breaths and administer 5 L/min oxygen per nasal cannula place the client in a side lying position and perform chest physiotherapy using clapping and vibration raise the head of the bed to high-Fowler position and administer 2 L/min oxygen per nasal cannula assist the client in assuming a position of comfort and perform postural drainage
answer: raise the head of the bed to high-Fowler position and administer 2 L/min oxygen per nasal cannula sitting facilitates breathing by increasing lung expansion; 2 L of oxygen promotes respirations while preventing CO2 narcosis. 5 L of oxygen may cause respiratory depression and CO2 narcosis in a client with COPD. chest physiotherapy (postural drainage) may be done layer after the condition improves. Delaying intervention is likely to worsen the respiratory distress.
A client is admitted to the hospital with a diagnosis of COPD. Which action would the nurse take to prevent client fatigue? provide small, frequent meals encourage pursed lip breathing schedule nursing activities to allow for rest encourage bed rest until energy level improves
answer: schedule nursing activities to allow for rest rest limits muscle contractions, which diminishes oxygen needs and decreases fatigue. Although small, frequent meals may decrease pressure on the diaphragm and facilitate breathing, this does not address fatigue. Although pursed lip breathing facilitates gas exchange, it does not reduce the metabolic demand for oxygen. Best rest promotes pooling of pulmonary secretions, which may aggravate the client's respiratory status.
which action by a client with asthma indicates that the client teaching about use of peak flow meter has been effective? calls the health care provider when peak flows are in the green zone does deep breathing and relaxation when peak flow is in the red zone use quick relief inhaled medication when the peak zone is in the yellow zone stops taking the daily inhaled corticosteroid when peak flow is in the yellow zone
answer: use quick relief inhaled medication when the peak zone is in the yellow zone peak flows in the yellow zone are between 50% and 80% of personal best and indicate a need to use quick relief inhaler such as albuterol to improve breathing. There is no need to call provider when peak flows are in the green zone, which is a 80-100% of personal best. Peak flows in the red zone indicate that peak flows are less than 50% of personal best. The client should use quick relief inhaler then call the HCP or go to the hospital when peak flows are this low. The client would continue the usual long-term control meds when the peak flows are in the yellow zone while adding a quick relief inhaler to improve peak flow.
