Prep U - Ch 25 Respiratory Function

A nurse is teaching a home care patient and his family about using prescribed oxygen. What is a critical factor that must be included in teaching?

the safety measures necessary to prevent a fire

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 two to three quarts of clear fluids daily

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 technique?

Monitor the amount of oxygen saturation in the blood

In which of the following clients would the nurse assess for a depressed respiratory system?

A client taking opioids for cancer pain

A nurse is caring for a client who suffered a head trauma. The client is in a medically induced coma and on mechanical ventilation. The client's mother is at the bedside in tears. The mother states, "I just want him to know I am here with him." To address the needs of the mother and the client, the nurse should:

Place a chair next to the bed and encourage the mother to hold the son's hand.

What does pulse oximetry measure?

Arterial oxygen saturation

A nurse is performing the Heimlich maneuver on a young client to relieve a mechanical airway obstruction. Which of the following actions should the nurse perform to increase intrathoracic pressure?

Give five quick abdominal thrusts above the navel.

The nurse assesses a patient 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?

Hypoxia

A patient vomits as a nurse is inserting his oropharyngeal airway. What would be the appropriate intervention in this situation?

Remove the airway, turn the patient to the side and provide mouth suction, if necessary.

The nurse is teaching an adolescent with asthma how to use a meter-dosed inhaler. Which teaching point follows recommended guidelines?

Be sure to shake the canister before using it.

A nurse assesses the vital signs of a healthy newborn infant. What respiratory rate could be expected based on the developmental level of this patient?

30 to 60 breaths/minute

An infant's breath per minute is 30 to 60, a 6- to 12-year-old's rate is 15 to 25, an aged adult's rate is 16 to 20, and a 1- to 5-year-old's rate is 20 to 40.

Upon evaluation of a client's medical history, the nurse recognizes that which of the following conditions may lead to an inadequate supply of oxygen to the tissues of the body?

Chronic anemia

A patient returns to the telemetry unit after an operative procedure. Which of the following diagnostic tests will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the patient?

Pulse oximetry

A group of nursing students are reviewing information about artificial airways in preparation for a class discussion the next day. The students demonstrate understanding of the information when they identify which of the following as an artificial airway consisting of a plastic tube surgically implanted just below the larynx into the trachea?

Tracheostomy

A nurse uses a simple mask to administer oxygen to a client with nasal trauma who breathes through the mouth. What is the minimum amount of oxygen delivered to the client using a simple mask?

5 L/min

A nurse needs to perform the Heimlich maneuver on an 8-month-old infant with a partial airway obstruction. Which of the following actions should the nurse perform?

Use the heel of one hand to administer back blows.

What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home?

"You will be asked to forcefully exhale into a mouthpiece."

A nurse is caring for a client with influenza who requires an external source of oxygen in order to breathe efficiently. In which of the following situations is oxygen humidified?

When more than 4 L/min of oxygen is administered for an extended period

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?

92%

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

The nurse is caring for a client who is diagnosed with an impaired gas exchange. While performing a physical assessment of the client, which of the following data is the nurse likely to find, keeping in mind the client's diagnosis?

High respiratory rate

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

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client?

Nasal cannula

The nurse is auscultating the lungs of a patient and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

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

The nurse is assessing the respiratory rates of patients in a community health care facility. Which patient exhibits an abnormal value?

An infant with a respiratory rate of 20 bpm

The nurse sets up an oxygen tent for a patient. Which patient is the best candidate for this oxygen delivery system?

A child who has pneumonia

During oxygen administration to the client, which of the following pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

Flow meter

A patient has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy tube is removed for cleaning?

inner cannula

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?

Position hands on the client's chest or back during inhalation

A client with no prior history of respiratory illness has been admitted to a postsurgical 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?

Educating the client on the use of incentive spirometry

The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal?

30 to 60 breaths per minute

The nurse schedules a pulmonary function test to measure the amount of air left in a patient's lungs at maximal expiration. What test does the nurse order?

Residual Volume (RV)

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 which of the following?

Pneumonia

A nurse is giving chest thrusts with two fingers to an infant with a partial obstruction. Which of the following places is most suitable for giving chest thrusts to an infant?

Middle of the sternum

A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?

Prolonging expiration to reduce airway resistance

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?

Flowmeter

Which of the following techniques would the nurse employ to maximize the effectiveness of postural drainage?

Combine it with percussion and vibration.

A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them?

"It is inserted into the space between the lining of the lungs and the ribs."

Oxygen hoods are generally used to deliver oxygen at rates approaching 100% to which of the following developmental groups?

Infants