Respiratory System

At which interval are humidified oxygen systems replaced to prevent infection? 1 1 day 2 3 days 3 5 days 4 7 days

1 1 day Humidified oxygen delivery needs to be changed out daily to prevent infection. Every 3 to 5 days is too long to wait and may promote infection. Oxygen delivery without humidification will need to be changed out every 7 days.

Which risk factor for head and neck cancer would the nurse assess for in a client with a persistent, nagging cough? Select all that apply. One, some, or all responses may be correct. 1 Type of employment 2 Presence of ear pain 3 History of tobacco use 4 Oral hygiene practices 5 Amount of alcohol intake

1 Type of employment 2 Presence of ear pain 3 History of tobacco use 4 Oral hygiene practices 5 Amount of alcohol intake

The nurse described a client's abnormal breath sounds and included crackles, rhonchi, wheezes, and pleural friction rubs. Which breath sounds did the nurse hear? 1 Vesicular 2 Bronchial 3 Adventitious 4 Bronchovesicular

3 Adventitious Adventitious sounds are described as abnormal extra breath sounds to include crackles, rhonchi, wheezes, and pleural friction rubs. Vesicular sounds are relatively soft, low-pitched, gentle, rustling sounds. Bronchial sounds are louder and higher pitched and resemble air blowing through a hollow pipe. Bronchovesicular sounds have a medium pitch and intensity and are heard over the mainstem bronchi on either side of the sternum and posteriorly between the scapulae.

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. What are the priority nursing assessments? 1 Level of consciousness and pupil size 2 Characteristics of pain and blood pressure 3 Quality of respirations and presence of pulses 4 Observation of abdominal contusions and other wounds

3 Quality of respirations and presence of pulses

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO2) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis

3 Respiratory acidosis

Soft swishing sounds of breathing are heard when the nurse auscultates a client's chest. Which term would be used when documenting this assessment finding? 1 Fine crackles 2 Adventitious sounds 3 Vesicular breath sounds 4 Diminished breath sounds

3 Vesicular breath sounds

Which amount is the normal value of a client's inspiratory reserve volume? 1 0.5 L 2 1.0 L 3 1.5 L 4 3.0 L

4 3.0 L The normal value of inspiratory reserve volume is 3.0 L. The normal value of tidal volume is 0.5 L. The normal value of expiratory reserve volume is 1.0 L. The normal value of residual volume is 1.5 L.

Which rationale would the nurse use when explaining the purpose of pursed-lip breathing to a client with emphysema? 1 Prevents bronchial spasm 2 Decreases air trapping in lung 3 Improves alveolar surface area 4 Strengthens diaphragmatic contraction

2 Decreases air trapping in lung Pursed-lip breathing provides positive pressure in the airways during expiration, prolonging expiration and decreasing the air trapping, which is characteristic of emphysema. Pursed-lip breathing will not decrease bronchospasm, which is characteristic of asthma. Alveolar surface area is not changed by pursed-lip expiration. Diaphragmatic contraction is not strengthened by pursed-lip breathing.

A client is extubated in the postanesthesia care unit after surgery. For which common response would the nurse be alert when monitoring the client for acute respiratory distress? 1 Bradycardia 2 Restlessness 3 Constricted pupils 4 Clubbing of the fingers

2 Restlessness Inadequate oxygenation of the brain from acute respiratory distress may produce restlessness or behavioral changes. The pulse increases with cerebral hypoxia from acute respiratory distress. The pupils dilate with cerebral hypoxia. Clubbing of the fingers is the result of prolonged hypoxia.

Which parameter describes the maximum volume of air a client's lungs may contain? 1 Vital capacity 2 Total lung capacity 3 Inspiratory capacity 4 Functional residual capacity

2 Total lung capacity

After auscultating the chest, how will the nurse document findings of bilateral, high-pitched, continuous whistling sounds heard during each expiration? 1 Crackles 2 Wheezes 3 Rhonchus 4 Pleural friction rub

2 Wheezes Wheezing, an adventitious breath sound, is a high-pitched continuous whistling that does not clear with coughing. Crackles are popping, discontinuous sounds caused by air moving into previously deflated airways. Rhonchus is a lower-pitched, coarse, continuous snoring sound that arises from the large airways. Pleural friction rub is a loud, rough, grating sound produced by inflammation of the pleural lining.