Nurs 208 Week 3 Lecture (NCLEX-RN) Style

A client receiving oxygen suddenly becomes restless and confused with rapid, shallow respirations. What should the nurse suspect?

Hypoxia. The lecture identifies restlessness/confusion and rapid shallow respirations as signs of hypoxia.

A nurse is assessing a client receiving oxygen therapy. Which assessments are most important?

Assess respiratory status, breathing pattern, fatigue, physical findings, pulse oximetry, oxygen equipment, and the client's response to therapy.

Which factors can affect oxygenation and pulse-ox readings?

Hemoglobin, circulation, activity, carbon monoxide poisoning, and equipment placement.

The nurse is caring for an older adult with an oxygenation problem. Which age-related changes should the nurse expect?

Loss of tissue/airway/alveolar elasticity, weaker respiratory muscles, less efficient diaphragm, decreased inspiration/expiration, easier airway collapse, and decreased heart function from deconditioning.

A healthy client has a pulse oximetry reading of 97%. How should the nurse interpret this?

Within the lecture's expected oxygenation goal of 95-100%.

A client has increased work of breathing, wheezing, cyanosis, and a change in respiratory rate. What assessment would be useful?

Pulse oximetry.

Which nursing action best promotes oxygenation in a hospitalized client?

Reposition the client for maximum chest expansion and encourage coughing and deep breathing.

A nurse teaches a client ways to improve oxygenation at home. Which instruction is appropriate?

Sit upright, exercise regularly, breathe through the nose, fully expand the chest, and avoid lung irritants.

A postoperative client is prescribed an incentive spirometer. How often does the lecture recommend its use?

10 times every hour while awake.

A client asks why oxygen requires careful monitoring. What is the best response?

Oxygen is a drug, requires a health-care provider order, and the client's response must be monitored.

The nurse changes a client's oxygen flow rate. What should the nurse do?

Stay with the client while increasing or decreasing the liter flow and monitor the response.

What is the concentration of oxygen in room air?

21%.

A client is prescribed oxygen at 3 L/min. What oxygen concentration does the lecture indicate the client receives?

32%.

How can the nurse calculate oxygen concentration without memorizing every flow rate?

Start with 24% at 1 L/min, then add 4 percentage points for each additional liter.

What oxygen concentration would the lecture calculation give for 2 L/min?

28%.

What oxygen concentration would the lecture calculation give for 4 L/min?

36%.

A client receiving oxygen through a nasal cannula asks why this device is commonly used. What should the nurse explain?

It is simple, safe, well tolerated, and allows the client to eat, talk, and ambulate.

Which problems should the nurse monitor for with a nasal cannula?

Dry mucous membranes, skin breakdown, dislodged tubing, flammability, and reduced effectiveness for mouth breathers.

A client is receiving oxygen through a nasal cannula at 5 L/min. Which nursing action should the nurse anticipate?

Consider humidification because the lecture recommends it above 4 L/min.

Which nursing action is appropriate for a client using a nasal cannula?

Assess nares patency, ensure proper fit, and use water-soluble gel for dry nares.

A client is prescribed oxygen by simple mask. What flow rate is appropriate according to the lecture?

5-8 L/min.

Why should the nurse not run a simple mask below 5 L/min?

The lecture states that flow rates below 5 L/min can cause carbon dioxide retention.

Which is an advantage of a simple mask?

It is more comfortable than a nasal cannula for some clients and provides humidified oxygen.

Which is a disadvantage of a simple mask?

It can impair eating, drinking, and talking and may cause anxiety, claustrophobia, moisture, pressure, and skin breakdown.

A client using a simple mask is eating lunch. What should the nurse consider?

Provide another appropriate oxygen-delivery method during the meal.

Which assessment is especially important with a simple mask?

Assess the fit and seal over the nose and mouth and monitor for skin breakdown.

A client at risk for aspiration is prescribed a simple mask. What should the nurse do?

Use the simple mask cautiously and monitor the client closely because the lecture identifies aspiration risk as a consideration.

How long does the lecture say it may take to see a change after an oxygen concentration is adjusted?

Approximately 20 minutes.

Which nursing diagnoses are appropriate for clients with oxygenation problems?

Ineffective Breathing Pattern and Impaired Gas Exchange.

A client has retained secretions, an ineffective cough, and thick yellow secretions. Which nursing diagnosis is most appropriate?

Ineffective Airway Clearance

A client has shortness of breath, pursed-lip breathing, and orthopnea. Which nursing diagnosis may apply?

Impaired Gas Exchange.

A client has COPD and is prescribed oxygen. Why is monitoring the oxygen flow rate important?

The lecture specifically identifies oxygen-flow monitoring as an important consideration for clients with COPD.

Which three nutrients provide energy?

Carbohydrates, proteins, and fats.

Which three nutrients regulate body processes?

Vitamins, minerals, and water.

A nurse assesses a client's nutritional status. Which factors should be considered?

Development, biological sex, health status, alcohol use, medications, nutrient supplements, economic factors, culture, and food intake.

Which diet would the nurse associate with diabetes?

Consistent-carbohydrate diet.

Which diet would the nurse associate with chronic cholecystitis or cardiovascular disease?

Fat-restricted diet.

Which diet would the nurse associate with constipation, IBS, or diverticulosis?

High-fiber diet.

Which diet would the nurse associate with bowel preparation or certain inflammatory bowel conditions?

Low-fiber diet.

Which diet would the nurse associate with hypertension or heart failure?

Sodium-restricted diet.

Which diet would the nurse associate with chronic kidney disease or diabetic kidney disease?

Renal diet.

What is the general progression of unrestricted diets?

NPO, clear liquid, full liquid, soft, then regular.

Which diet is used for bowel surgery preparation, lower endoscopy, acute GI disorders, or an initial postoperative diet?

Clear liquid diet.

Which modified-consistency diet may be used for chewing or swallowing difficulties?

Pureed or mechanically altered diet.

A client has dysphagia. Which action is the priority before feeding?

Position the client upright, preferably in a chair, or elevate the head of the bed to 90 degrees if on bedrest.

Which finding during feeding should make the nurse suspect aspiration?

Severe coughing, choking, cyanosis, voice change/hoarseness, gurgling, throat clearing, or regurgitation.

A client with dysphagia becomes tired during meals. What should the nurse do?

Allow a rest period before meals and avoid rushing or forcing the client to eat.

What should the nurse do to help a client with dysphagia eat safely?

Adjust bite size and feeding rate to tolerance, reduce distractions, alternate solids and liquids, and obtain appropriate speech/nutrition consultations.

Which groups are specifically identified in the lecture for cultural nutrition considerations?

African American, Arab, Chinese, Jewish, Mexican, and Navajo heritage.

In what unit should intake and output be documented?

Milliliters (mL).

Which items should the nurse count as intake?

Oral fluids, ice chips, IV fluids, blood administration, enteral feedings, gastric lavage, and bladder irrigation.

A nurse begins a shift caring for a client on strict intake and output. What should the nurse do to obtain accurate intake data?

Review the existing I&O record, identify all sources of intake, and measure and record intake amounts as they occur.

Which items should the nurse count as output?

Urine, liquid stool, gastric drainage, surgical drains, chest-tube drainage, emesis, and ostomy output.

A nurse begins a shift with a client on strict I&O. What is important for accurate output measurement?

Identify all sources of measurable output and measure and record them accurately throughout the shift.

What are insensible fluid losses?

Fluid losses through the lungs and skin that cannot be measured in mL.

Which body processes contribute to insensible losses?

Breathing, skin diffusion, fever, and perspiration.

What does 1 liter of fluid equal in body weight?

Approximately 1 kg or 2.2 lb.

A nurse is unsure what an electronic order says. What is the safest action?

Check and validate the order and never guess.

What are the key rules for nursing documentation?

Documentation should be complete, accurate, timely, concise, organized, current, and factual.

Which documentation actions are appropriate?

Include date and time, write legibly, use the required ink/system, avoid blank spaces and whiteout, and identify yourself with signature/name/title.

What should the nurse avoid when documenting?

Personal opinions and criticism.

Which are important considerations with electronic documentation?

Correct errors properly, validate orders, use standardized care plans appropriately, learn the system, and maintain security.

What is the purpose of an incident report?

To report and support the facility's quality-improvement process after an unusual or unexpected event.

Which event should be documented in an incident report?

Examples include medication errors, falls, prescription omissions, and needlesticks.

Is an incident report part of the patient's medical record?

No.

A nurse discovers an unclear prescription in the electronic record. What is the priority action?

Validate the order before carrying it out and never guess.

A nurse is documenting care for a patient. Which entry is most appropriate?

A complete, accurate, timely, concise, organized, and factual entry with no personal opinion.

A nurse is communicating a patient's condition to another health-care professional. What is the nurse's responsibility?

Report relevant, accurate, and timely patient information to support safe and continuous care.