Ch. 38 Questions from misc sources Flashcards


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1

Oxygen and carbon dioxide move between the alveoli and the blood by:
a)osmosis.
b)negative pressure.
c)hyperosmolar pressure.
d)diffusion.

diffusion

Oxygen and carbon dioxide move between the alveoli and the blood by diffusion, the process in which molecules move from an area of greater concentration or pressure to an area of lower concentration or pressure.

2

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

a client taking opioids for cancer pain

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.

3

The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal?
a)resonance on percussion of lung fields
b)respiratory rate of 18 breaths per minute
c)fine crackles to the bases of the lungs bilaterally
d)vesicular breath sounds audible over peripheral lung fields

fine crackles to the bases of the lungs bilaterally

Except in the case of infants, fine crackles always constitute an abnormal assessment finding. A respiratory rate of 18 is within acceptable range. Vesicular sounds over peripheral lung fields and resonance on percussion are expected assessment findings.

4

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?
a)They are medium-pitched blowing sounds heard over the major bronchi.
b)They are soft, high-pitched discontinuous (intermittent) popping lung sounds.
c)They are low-pitched, soft sounds heard over peripheral lung fields.
d)They are loud, high-pitched sounds heard primarily over the trachea and larynx.

They are low-pitched, soft sounds heard over peripheral lung fields.

Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

5

When inspecting a client’s chest to assess respiratory status, the nurse should be aware of which normal finding?
a)The chest should be slightly convex with no sternal depression.
b)The skin at the thorax should be cool and moist.
c)The anteroposterior diameter should be greater than the transverse diameter.
d)The contour of the intercostal spaces should be rounded.

The chest should be slightly convex with no sternal depression.

The adult chest contour is slightly convex, with no sternal depression. The skin of the thorax should be warm and dry, and the anteroposterior diameter of the chest should be less than the transverse diameter. The contour of the intercostal spaces should be flat or depressed.

6

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?
a)Face tent
b)Nasal cannula
c)Simple mask
d)Non-rebreather mask

Nasal cannula

The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Non-rebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill

7

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?
a)Nasal cannula
b)Oxygen analyzer
c)Flow meter
d)Humidifier

Flow meter

In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter 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. A humidifier is a device that produces small water droplets and may be used during oxygen administration, since oxygen dries the mucous membranes. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen.

8

A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?
a)educating the client on the use of incentive spirometry
b)educating the client on pursed-lip breathing techniques
c)administration of inhaled corticosteroids
d)oropharyngeal suctioning twice daily

educating the client on the use of incentive spirometry

Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.

9

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?
a)Weight loss
b)Increased urine output
c)Rapid respirations
d)Mental alertness

Rapid respirations

Normal cardiac output averages from 3.5 L/minute to 8.0 L/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.

10

What is the action of codeine when used to treat a cough?
a)suppressant
b)antisuppressant
c)expectorant
d)antihistamine

suppressant

Codeine, which is an ingredient in many cough preparations, is generally considered to be the preferred cough suppressant ingredient.

11

The nurse is caring for a postoperative client who has a prescription for meperidine (Demerol) 7 5mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering Demerol, the nurse would assess which most important sign?
a)Apical pulse
b)Respiratory rate and depth
c)Urinary intake and output
d)Orthostatic blood pressure

Respiratory rate and depth

The client receiving narcotics/opioids needs monitoring of the respiratory rate and depth to ensure that respiratory depression does not result in progressive respiratory issues, physiological damage from respiratory depression, or loss of consciousness. The pulse, blood pressure, and urinary intake and output are not as important as respiratory status when administering narcotics.

12

The nurse is caring for a client who is diagnosed with impaired gas exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis?
a)high temperature
b)low blood pressure
c)low pulse rate
d)high respiratory rate

high respiratory rate

A client diagnosed with impaired gas exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.

13

A nurse is admitting a 6-year-old child status post tonsillectomy to the surgical unit. The nurse obtains his weight and places EKG and a pulse oximeter on the client’s left finger. His heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:
a)adequate tissue perfusion.
b)heart failure.
c)diminished stroke volume.
d)high cardiac output.

adequate tissue perfusion.

Pulse oximetry is often used as a measure of tissue perfusion. An oxygen saturation of greater than 94% is typically indicative of good tissue perfusion.

14

A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient?
a)Oxygen tent
b)Nasal cannula
c)Ambu bag
d)Oxygen mask

Ambu bag

If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag)may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube.

15

The charge nurse is observing a new nurse care for a client who is receiving oxygen via a simple mask with an FIO2 of 40%. The client states, "This moisture on my face is bothersome. Can something be done about it?" Which response by the new nurse would require clarification by the charge nurse?
a)"I will confer with your primary care provider to find out if a nasal cannula can be used."
b)"The mask and its moisture can be bothersome, so let me demonstrate some distraction techniques to help you cope with them."
c)"After I dry your face, I can apply powder to absorb the moisture and protect your skin."
d)"Your mask should remain on, but I will help you dry your face when it becomes too wet."

"After I dry your face, I can apply powder to absorb the moisture and protect your skin."

16

A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function?
a)Pleural effusion
b)Tachypnea
c)Pneumonia
d)Wheezes

Pleural effusion

Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis and pneumonia would necessitate the procedure only if the infection resulted in pleural effusion. (less)

17

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test?
a)Measure the volume of air exhaled or inhaled over time.
b)Calculate the pressure of carbon dioxide dissolved in plasma.
c)Monitor the pressure of oxygen dissolved in plasma.
d)Monitor the amount of oxygen saturation in the blood.

Monitor the amount of oxygen saturation in the blood.

The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. The arterial blood gases test the client's blood for the partial pressure of oxygen dissolved in plasma, the percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma. Spirometry measures the volume of air in liters exhaled or inhaled by a client over time.

18

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?
a)Eupnea
b)Hypercapnia
c)Hypoxemia
d)Cyanosis

Cyanosis

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

19

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

Residual Volume (RV)

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.

20

Which nursing skill requires the nurse to use sterile technique?
a)suctioning a tracheostomy
b)administering nebulizers
c)providing oxygen by nasal cannula
d)administering oxygen by face mask

suctioning a tracheostomy

Suctioning is always a sterile procedure, whereas the administration of oxygen and nebulized medications require clean technique.

21

A nurse teaches a patient how to use an incentive spirometer. Which projected patient outcome will support the conclusion that the use of the incentive spirometer was effective?

  1. Supplemental oxygen use will be reduced
  2. Inspiratory volume will be increased
  3. Sputum will be expectorated
  4. Coughing will be stimulated

2. An incentive spirometer provides a visual goal for and measurement of inspiration. It encourages the p/t execute and maintain sustained inspiration. A sustained inspiration opens airways, increases the inspiratory volume, and reduces the risk of atelectasis.

22

A primary health care provider orders chest physiotherapy with percussion and vibration for a newly admitted patient. Which information obtained by the nurse during the health history should alert the nurse to question the provider's order?

  1. Emphysema
  2. Osteoporosis
  3. Cystic Fibrosis
  4. Chronic Bronchitis

2. Implementing the primary health care providers order may compromise p/t safety because percussion and vibration in the presence of osteoporosis may cause fractures. Osteoporosis is an abnormal loss of bone mass and strength.

23

Which nursing assessment best indicates a patient's ability to tolerate activity?

  1. Vital signs that take 3 minutes to return to reactivity level
  2. Absence of adventitious breath sounds on auscultation
  3. Flexibility of muscles and joints
  4. Reports of weakness

1. Vital signs reflect cardiopulmonary functioning of the body. Vital signs obtained before and after activity provide data that can be compare to determine the body's response to the energy demands of ambulation. When the vital signs return to the reactivity level within 3 minutes it indicates that the p/t has tolerated the activity.

24

Which should a nurse do if an adult is choking of food?

  1. Apply sharp upward thrusts over the patient's xiphoid process
  2. Determine if the patient can make any verbal sounds
  3. Hit the middle of the patient's back firmly
  4. Sweep the patient's mouth with a finger

2. When a person is choking on food, the first intervention is to determine if the person can speak because the next intervention will depend on if it is a partial or total airway obstruction. Ask the person, "Are you choking?" With partial airway obstruction, the person will be able to make sounds because some air can pass from the lungs through the vocal cord. In this situation, the person's own efforts (gagging and coughing) should be allowed to clear the airway. With a total airway obstruction, the person will not be able to make a sound because the airway is blocked and the nurse should immediately initiate the abdominal thrust maneuver (Heimlich maneuver)

25

A p/t has thick tenacious respiratory secretions. Which should the nurse do to liquify the p/t's respiratory secretions?

  1. Change the p/t's position every 2 hours
  2. Get a rx for an antitussive agent
  3. Encourage the p/t to drink more fluid
  4. Teach effective deep breathing

3. A fluid intake of 2,500 to 3,00 mL is recommended to maintain the moisture of the respiratory mucous membranes. Adequate fluid keeps respiratory secretions thin so that they can be moved by ciliary action or coughed up and spat out (expectorated).

26

Which action is effective in meeting the needs of a p/t experiencing laryngospasm after extubation?

  1. Ensuring hyperextension of the head
  2. Providing positive-pressure ventilation
  3. Instituting cardiopulmanary resuscitation
  4. Administering oxygen by using a face mask

2. Positive pressure will push the vocal cords backward toward the wall of the larynx, opening the glottis (space between the vocal cords), which allows ventilation of the lung.

27

A p/t's hemoglobin saturation via pulse oximetry indicates inadequate oxygenation. Which should the nurse do first?

  1. Notify the primary health-care provider
  2. Encourage breathing deeply
  3. Raise the head of the bed
  4. Administer oxygen

3. A nurse can implement this immediate, independent action. Nurses are permitted to treat human responses. Raising the head of the bed facilitates the dropping of the abdominal organs by gravity away from the diaphragm, which permits the greatest lung expansion.

28

A nurse is reviewing the laboratory results of a p/t with the preliminary dx of anemia. An abnormal response of which diagnostic test reflects iron deficiency anemia?

  1. Hemoglobin
  2. Platelet count
  3. Serum albumin
  4. Blood urea nitrogen

1. Iron is necessary for hemoglobin synthesis. Therefore, reduced intake of dietary iron results in iron deficiency anemia. Hemoglobin is the main component of red blood cells and transports oxygen and carbon dioxide through the bloodstream.

29

A p/t is admitted with the dx of lower extremity arterial disease (LEAD). Which is a specific desirable outcome for this p/t?

  1. Respirations within the expected range
  2. Oriented to the environment
  3. Palpable peripheral pulses
  4. Prolonged capillary refill

3. Palpable peripheral pulses are a appropriate expected outcome for a p/t with arterial vascular disease, which is a decrease in nutrition and respiration at the peripheral cellular level because of decrease in capillary blood supply. A physiological response associated with LEAD is diminished or absent arterial pulses.

30

A primary health-care provider orders bed rest for a p/t. Which should the nurse explain to the p/t is the primary purpose of bedrest?

  1. Conserve energy
  2. Maintain strength
  3. Enhance protein synthesis
  4. Reduce intestinal peristalsis

1. Bedrest reduces cardiopulmonary demands, muscle contraction, and other bodily functions. All of this reduces basal metabolic rate, which conserves energy.

31

A nurse is planning to teach one p/t pursed-lip breathing and another p/t diaphragmatic breathing. Which technique associated with diaphragmatic breathing is different from pursed-lip breathing that the nurse should include in the teaching plan?

  1. Inhale through the mouth
  2. Exhale through pursed lips
  3. Raise both shoulders while breathing deeply
  4. Tighten the abdominal muscles while exhaling

4. With diaphragmatic breathing the contraction of abdominal muscles at the end of expiration helps to reduce the amount of air left in the lungs (residual volume).

32

A meal tray arrives for a p/t who is receiving 24% oxygen via a Venturi mask. Which should the nurse do to meet this p/t's needs?

  1. Request an order to use a nasal cannula during eating
  2. Discontinue the oxygen when the p/t is eating meals
  3. Obtain an order to change the mask to a nonrebreather mask during meals
  4. Arrange for liquid supplements that can be administered via a straw through a valve in the mask

1. A venturi mask interferes with eating because it covers the nose and mouth, Using a nasal cannula during meals will help meet both nutritional and oxygen needs of the p/t. A nasal cannula delivers oxygen via prongs placed in the p/t's nares, leaving the mouth unobstructed, which promotes talking and eating. Specific oxygen delivery systems require an order and are a dependent function of the nurse, except in emergency situations.

33

A nurse evaluates that the p/t understood teaching about the purpose of pursed-lip breathing when the p/t includes which information when explaining its purpose to a relative?

  1. Precipitates coughing
  2. Helps maintain open airways
  3. Decreases intrathoracic pressure
  4. Facilitates expectoration of mucus

2. Pursed-lip breathing involves deep inspiration and prolonged expiration against slightly closed lips. The pursed lips create a resistance to the air flowing out of the lungs, which prolongs exhalation and maintains positive airway pressure, thereby maintaining an open airway and preventing airway collapse.

34

An unconscious p/t is who had oral sx is admitted to the postanesthesia care unit. Which position should the nurse place the p/t?

  1. Prone
  2. Supine
  3. Fowler
  4. Lateral

4. The lateral position supports the flow of secretions out of the mouth by gravity, keeps the tongue to the side of the mouth, maintaining the airway, and permits effective assessment of the oropharynx and respiratory status.

35

A primary health-care provider orders chest physiotherapy with percussion and vibration for a p/t. After the pcp leaves, the p/t says, "I still don't understand the purpose of this therapy." Which statement should be included in the nurse's response?

  1. It eliminates the need to cough
  2. It limits the production of bronchial mucus
  3. It helps clear the airways of excessive secretions
  4. It promotes the flow of secretions to the base of the lungs

3. The forceful striking of the skin over the lung (percussion, clapping) and fine, vigorous, shaking pressure with the hands on the chest wall during exhalation (vibration) mobilize secretions so that they can be coughed up and expectorated.

36

The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal?
a)12 to 20 breaths per minute
b)20 to 30 breaths per minute
c)12 to 15 breaths per minute
d)30 to 55 breaths per minute

30 to 55 breaths per minute

The nurse should expect the newborn to have a respiratory rate of 30 to 55 breaths per minute. Toddlers and preschoolers have a respiratory rate of 20 to 30 per minute. School-age children and adolescents have a respiratory rate of 12 to 20 breaths per minute

37

The nurse is caring for a client who reports difficulty breathing. In what position would the nurse place this client?
a)Fowler’s position
b)lateral position
c)prone position
d)supine position

Fowler’s position

People with dyspnea and orthopnea are most comfortable in a high Fowler’s position because accessory muscles can easily be used to promote respiration. Prone position can be used on a routine basis to promote ventilation and perfusion of the posterior dependent sections of the lungs. Lateral and supine position would not be beneficial as accessory muscles are not supported as with a Fowler’s position.

38

The nurse is instructing the client with a pulmonary disorder on deep breathing. The client asks, “Why is it important to start by breathing through my nose, then exhaling through my mouth?” Which appropriate response would the nurse give this client?
a)“Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation.”
b)“Breathing through your nose first will warm, filter, and humidify the air you are breathing.”
c)“We are concerned about you developing a snoring habit, so we encourage nasal breathing first.”
d)“If you breathe through the mouth first, you will swallow germs into your stomach.”

“Breathing through your nose first will warm, filter, and humidify the air you are breathing.”

Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring.

39

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?
a)Perfusion
b)Atelectasis
c)Hypoxia
d)Hyperventilation

Hypoxia

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.

40

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?
a)Expectorants
b)Bronchodilators
c)Antibiotics
d)Corticosteroids

Corticosteroids

In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation.

41

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?
a)Eat smaller meals that are high in protein.
b)Contact the physician for nutrition shake.
c)Eat one large meal at noon.
d)Snack on high-carbohydrate foods frequently.

Eat smaller meals that are high in protein.

The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength.

42

A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?
a)Peak expiratory flow rate
b)Thoracentesis
c)Pulse oximetry
d)Spirometry

Pulse oximetry

Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.

43

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output?
a)“If the client’s stroke volume is 70 mL and heart rate is 70 beats per minute, then the cardiac output is 4.7 L/minute.”
b)“If the client’s stroke volume is 60 mL and heart rate is 60 beats per minute, then the cardiac output is 3.2 L/minute.”
c)“If the client’s stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute.”
d)“If the client’s stroke volume is 80 mL and heart rate is 80 beats per minute, then the cardiac output is 6.0 L/minute.”

“If the client’s stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute.”

The following formula is used to determine cardiac output: Cardiac Output = Stroke Volume x Heart Rate. A client with a stroke volume of 50 mL and heart rate of 50 beats per minute has a cardiac output of 2.5 L/minute. If stroke volume is 70 and heart rate is 70 beats per minute, then the cardiac output is 4.9 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute

44

A normal pulse oximetry reading indicates that the body's oxygen demands are being met.
a)False
b)True

False

45

A physician has ordered an arterial blood gas test for a client with a respiratory disorder. What is the most common role of the nurse in performing the arterial blood gas test?
a)Measure the partial pressure of oxygen dissolved in plasma.
b)Implement measures to prevent complications after arterial puncture.
c)Measure the percentage of hemoglobin saturated with oxygen.
d)Perform the arterial puncture to obtain the specimen.

Implement measures to prevent complications after arterial puncture.

During the arterial blood gas test, the nurse should implement measures to prevent complications after the arterial puncture. The nurse would not be involved in measuring the partial pressure of oxygen dissolved in plasma or the percentage of hemoglobin saturated with oxygen. Intensive care nurses commonly obtain arterial blood gases.

46

While auscultating a client's chest, a nurse hears coarse crackles that are soft, high-pitched and discontinuous. The nurse interprets this finding as indicating which of the following?
a)Air passing through narrowed airways
b)Presence of fluid in the lungs
c)Inflammation of pleural surfaces
d)Presence of sputum in the airways

Presence of sputum in the airways

Coarse crackles heard on auscultation indicate the presence of sputum in the airways. Rales indicate presence of fluids in the lungs. Air passing through narrowed airways produces a wheezing sound, whereas inflammation of pleural surfaces gives rise to pleural rub.

47

What assessments would a nurse make when auscultating the lungs?
a)abnormal chest structures
b)volume of air exhaled or inhaled
c)presence of edema
d)cardiovascular function

cardiovascular function

If cardiovascular function is not adequate, the results will lead to impaired oxygenation; therefore, it is important to assess cardiovascular function when assessing respiratory function. Both systems work in conjunction with each other, and the proximity of lung auscultation lends itself to assessment of cardiovascular function. Abnormal chest structures would be assessed when inspecting the chest and thoracic region. Presence of edema would be assessed as part of the cardiovascular status of the client. Volume of air exhaled and inhaled would be performed during a pulmonary function test.

48

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs’ peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?
a)Crackles
b)Bronchovesicular
c)Vesicular
d)Bronchial

Vesicular

Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs’ peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds, whereas bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

49

What structural changes to the respiratory system should a nurse observe when caring for older adults?
a)increased use of accessory muscles for breathing
b)diminished coughing and gag reflexes
c)respiratory muscles become weaker
d)increased mouth breathing and snoring

respiratory muscles become weaker

One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker. The nurse should also observe other structural changes: the chest wall becomes stiffer as a result of calcification of the intercostals cartilage, kyphoscoliosis, and arthritic changes to costovertebral joints; the ribs and vertebrae lose calcium; the lungs become smaller and less elastic; alveoli enlarge; and alveolar walls become thinner. Diminished coughing and gag reflexes, increased use of accessory muscles for breathing, and increased mouth breathing and snoring are functional changes to the respiratory system in older adults

50

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?
a)Chest x-ray
b)Skin tests
c)Pulmonary function tests
d)Bronchoscopy

Pulmonary function tests

Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.

51

The 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 utilize?
a)Simple mask
b)Nasal cannula
c)Non-rebreather mask
d)Venturi mask

Non-rebreather mask

A non-rebreather mask is the only device that can deliver 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%

52

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)True
b)False

True

This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis

53

A nurse raises the head of the bed for a p/t who has difficulty breathing. Which science includes the principle that explains how this intervention facilitates respiration?

  1. Physics
  2. Biology
  3. Anatomy
  4. Chemistry

1. Raising the head of the bed drops the abdominal organs away from the diaphragm via the principle of gravity, facilitating breathing. Gravity, the tendency of weight to be pulled toward the center of the earth, is a physics principle.

54

Which clinical manifestation is of most concern when the nurse assesses a p/t who has impaired mobility?

  1. Shallow respirations
  2. Increased oxygen saturation
  3. Decreased chest wall expansion
  4. Gurgling sounds when breathing

4. Respirations that sound gurgling (gurgles, rhonchi) indicate air passing through narrowed air passages because of secretions, swelling, or a tumor. A partial or total obstruction of the airway can occur, which is life-threatening.

55

A nurse teaches a p/t to make a series of short, forceful exhalations (huffing) just before actually coughing. Which information should the nurse include when explaining the purpose of this action?

  1. Conserves energy
  2. Liquifies respiratory secretions
  3. Limits pain precipitated by cough
  4. Raises sputum to a level where it can be expectorated

4. The huff cough stimulates the natural cough reflex and is effective for clearing the central airways of sputum. Saying the word huff with short, forceful exhalations keeps the glottis open and raise sputum to a level where it can be coughed up and expectorated.

56

Which are effective leg exercises the nurse should encourage a p/t to perform to prevent circulatory complications during the postoperative period?

  1. Flexing the knees
  2. Isometric exercises
  3. Dorsiflexion exercises
  4. Passive range of motion

3. Alternating dorsiflexion and plantar flexion (calf pumping) contracts and relaxes the calf muscles, including the gastrocnemius muscles. This muscle contraction promotes venous return, preventing veinous stasis that contributes to the development of postoperative thrombophlebitis.

57

Which outcome best reflects achievement of the goal, "The p/t will expectorate lung secretions with no signs of respiratory complications"?

  1. Absence of adventitious breath sounds
  2. Deep breathing and coughing nonproductively
  3. Drinking 3,000 mL of fluid in the last 24 hours
  4. Expectorating sputum three times before 3pm. and 11pm.

1. Adventitious breath sounds are abnormal breath sounds that occur when pleural linings are inflamed or when air passes through the narrowed airways or through airways filled with fluid. The absence of abnormal sounds is desirable.

58

Which should the nurse do first when caring for a nonverbal p/t who is restless, agitated, and irritable?

  1. Administer oxygen
  2. Suction the oropharynx
  3. Reduce environmental stimuli
  4. Determine potency of the airway

4. Early signs of hypoxia are restlessness, agitation, and irritability resulting from reduced oxygen to brain cells. A partial or complete obstructed airway prevents the passage of gases into and out of the lungs. The ABC's (Airway, Breathing, and Circulation) of emergency care identify airway as the priority.

59

Which action should the nurse implement to increase both the respiratory and the circulatory functions of a p/t in a coma?

  1. Encourage the p/t to cough
  2. Massage the p/t's bony areas
  3. Assist the p/t with breathing exercises
  4. Change the p/t's position every 2 hours

4. Changing the p/t's position every 2 hours helps respiration by preventing fluid from collecting in the lung, which causes infection; it helps circulation because activity increases circulation, and it relieves local pressure.

60

The nurse is caring for a client with emphysema. A review of the client’s chart reveals pH 7.36, paO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription, if prescribed by the health care practitioner?
a)High-Fowler’s position
b)4 L/minute O2 nasal cannula
c)Increase fluid intake to 3 L/day
d)Pulse oximetry

4 L/minute O2 nasal cannula

The client with chronic lung disease, such as emphysema, becomes insensitive to carbon dioxide and responds to hypoxia to stimulate breathing. If given excessive oxygen (4 L/minute), the stimulus to breathe is removed. Clients with emphysema are most comfortable in high-Fowler’s position because it aids in the use of the accessory muscles to promote respirations. Increasing fluid intake helps keep the client’s secretions thin. Pulse oximetry monitors the client’s arterial oxyhemoglobin saturation while receiving oxygen therapy.

61

The nurse is educating a client on the proper use of inhaled medications. What are appropriate education points to include? Select all that apply.
a)When using an MDI, the client must activate the device before and after inhaling.
b)Bronchodilators are used to liquefy or loosen thick secretions or reduce inflammation in airways.
c)Nebulizers are used to deliver a controlled dose of medication with each compression of the canister.
d)Metered-dose inhalers deliver a controlled dose of medications with each compression of the canister.
e)DPIs are actuated by the client’s inspiration, so there is no need to coordinate the delivery of puffs with inhalation.

When using an MDI, the client must activate the device before and after inhaling.
• DPIs are actuated by the client’s inspiration, so there is no need to coordinate the delivery of puffs with inhalation.
• Metered-dose inhalers deliver a controlled dose of medications with each compression of the canister.
DPIs are dry powder inhalers that are activated by a quick, deep inhalation, thus there is no need to coordinate the delivery of puffs with inhalation, as there is with metered-dose inhalers (MDIs). MDIs deliver a controlled a dose of medication with each compression of the canister. Therefore, it is important that the client uses the MDI as directed and not whenever he wants to use it, as serious side effects (such as dysrhythmias) can occur. Bronchodilators dilate the bronchi; inhaled mucolytics loosen secretions and inhaled corticosteroids reduce inflammation. Nebulizers disperse fine particles of liquid medication into the deeper passages of the respiratory tract, where absorption occurs. The treatment continues until all the medication in the nebulizer cup has been inhaled. To use an MDI, the client must activate the device while continuing to inhale.

62

During the physical assessment of a client who has been inactive due to a leg injury, the nurse notes that the client tends to breathe very shallowly. What technique should the nurse teach the client in order to breathe more efficiently?
a)diaphragmatic breathing
b)incentive spirometry
c)pursed-lip breathing
d)deep breathing

deep breathing

The nurse should teach deep breathing techniques to the client who tends to breathe shallowly in order to help the client breathe more efficiently. Deep breathing is a technique for maximizing ventilation. Taking in a large volume of air fills alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing is a form of controlled ventilation in which the client consciously prolongs the expiration phase of breathing, which helps clients to eliminate more than the usual carbon dioxide from the lungs. It is used to increase the volume of air exchanged during inspiration and expiration. Incentive spirometry, a technique for deep breathing using a calibrated device, encourages clients to reach a goal-directed volume of inspired air. Diaphragmatic breathing is breathing that promotes the use of the diaphragm rather than the upper chest muscles. It is used to increase the volume of air exchanged during inspiration and expiration.

63

A client with closed-angle glaucoma and a cough has a prescription for a cough medicine. The nurse would question which cough medicine if prescribed for this client?
a)Cough medicine with iodine
b)Cough medicine with a high sugar content
c)Cough medicine with a decongestant
d)Cough medicine with an antihistamine

Cough medicine with an antihistamine

The client with closed-angle glaucoma should avoid cough medicine because of its anticholinergic action. The client with diabetes should avoid cough medicine with a high sugar content. The client with thyroid disorders should avoid cough medicine containing iodine. The client with hypertension should avoid cough medicine with decongestants.

64

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:
a)6 L/minute
b)1 L/minute
c)4 L/minute
d)10 L/minute

6 L/minute

In general, if a flow rate of 6 L/minute fails to raise a client's oxygen saturation level satisfactorily, a mask should be used.

65

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the 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:
a)sodium and potassium levels.
b)hemoglobin level.
c)age.
d)blood pH.

hemoglobin level.

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.

66

Which normal conditions would a nurse expect to find when performing a physical assessment of a client’s respiratory system? Select all that apply.
a)slightly contoured chest with no sternal depression
b)anteroposterior diameter of the chest less than the transverse diameter
c)barrel chest appearance in older adults
d)quiet and nonlabored respiration occurring at a rate of 18 to 30 bpm
e)bronchial, vesicular, and bronchovesicular breath sounds
f)crackles heard on inspiration.

slightly contoured chest with no sternal depression
• anteroposterior diameter of the chest less than the transverse diameter
• bronchial, vesicular, and bronchovesicular breath sounds
The adult chest contour is slightly convex, with no sternal depression. The anteroposterior diameter should be less than the transverse diameter for normal respirations. Bronchial, vesicular, and bronchovesicular are normal breath sounds, depending on the lung fields being assessed. Respirations should be nonlabored with a normal rate of 12 to 20 breaths per minute. Crackles should not be heard on inspiration as this is a sign of mucus or fluid in the lung tissue.

67

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?
a)an older adult client who has COPD
b)an adult who is receiving oxygen at home
c)an adolescent who has asthma
d)a child who has pneumonia

...

68

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:
a)croup.
b)alcohol abuse.
c)asthma.
d)pneumonia.

...