Question 1

The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client with asthma.Which action by the newly licensed nurse requires immediate intervention?
A) The newly licensed nurse is observed obtaining the pulse oximetry reading 10 minutes after the client used an albuterol inhaler.
B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment.
C) The newly licensed nurse is observed assessing the client's thoracic wall, skin, and nail beds.
D) The newly licensed nurse is observed auscultating breath sounds with a stethoscope.

Accepted Answer

A) The charge nurse should intervene immediately if the nurse observes the client is demonstrating impairment at or near respiratory failure; the client will not be able to respond to questions. Assessment questions should be tailored and asked of any family member or friend accompanying the client. The client's physician should be notified immediately on the client's arrival to the unit. The immediate concern is to return respiratory status as near to normal as possible. Although the pulse oximetry reading may not be a true indicator of the level of respiratory distress of the client because of the use of an albuterol inhaler within 30-60 minutes of this assessment, it is still an appropriate action for the newly licensed nurse to take and does not require the charge nurse to intervene immediately. The charge nurse may speak to the newly licensed nurse later with regard to this assessment. Assessing the client's thoracic wall, skin, and nail beds is an appropriate action at this time. Auscultating the client's breath sounds with the use of a stethoscope is appropriate.
B) The charge nurse should intervene immediately if the nurse observes the client is demonstrating impairment at or near respiratory failure; the client will not be able to respond to questions. Assessment questions should be tailored and asked of any family member or friend accompanying the client. The client's physician should be notified immediately on the client's arrival to the unit. The immediate concern is to return respiratory status as near to normal as possible. Although the pulse oximetry reading may not be a true indicator of the level of respiratory distress of the client because of the use of an albuterol inhaler within 30-60 minutes of this assessment, it is still an appropriate action for the newly licensed nurse to take and does not require the charge nurse to intervene immediately. The charge nurse may speak to the newly licensed nurse later with regard to this assessment. Assessing the client's thoracic wall, skin, and nail beds is an appropriate action at this time. Auscultating the client's breath sounds with the use of a stethoscope is appropriate.
C) The charge nurse should intervene immediately if the nurse observes the client is demonstrating impairment at or near respiratory failure; the client will not be able to respond to questions. Assessment questions should be tailored and asked of any family member or friend accompanying the client. The client's physician should be notified immediately on the client's arrival to the unit. The immediate concern is to return respiratory status as near to normal as possible. Although the pulse oximetry reading may not be a true indicator of the level of respiratory distress of the client because of the use of an albuterol inhaler within 30-60 minutes of this assessment, it is still an appropriate action for the newly licensed nurse to take and does not require the charge nurse to intervene immediately. The charge nurse may speak to the newly licensed nurse later with regard to this assessment. Assessing the client's thoracic wall, skin, and nail beds is an appropriate action at this time. Auscultating the client's breath sounds with the use of a stethoscope is appropriate.
D) The charge nurse should intervene immediately if the nurse observes the client is demonstrating impairment at or near respiratory failure; the client will not be able to respond to questions. Assessment questions should be tailored and asked of any family member or friend accompanying the client. The client's physician should be notified immediately on the client's arrival to the unit. The immediate concern is to return respiratory status as near to normal as possible. Although the pulse oximetry reading may not be a true indicator of the level of respiratory distress of the client because of the use of an albuterol inhaler within 30-60 minutes of this assessment, it is still an appropriate action for the newly licensed nurse to take and does not require the charge nurse to intervene immediately. The charge nurse may speak to the newly licensed nurse later with regard to this assessment. Assessing the client's thoracic wall, skin, and nail beds is an appropriate action at this time. Auscultating the client's breath sounds with the use of a stethoscope is appropriate.

Question 2

The nurse is providing care to a client who has a tracheostomy.The nurse will monitor the client for complications related to the loss of which protective mechanism?
A) The ability to cough
B) Filtration and humidification of inspired air
C) Decrease in oxygen-carrying capacity of the trachea
D) The sneeze reflex initiated by irritants in the nasal passages

Accepted Answer

A) When the nasal passages are bypassed, as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming of the nasal passages are also bypassed. The client can still cough and sneeze, and there is no decrease in the oxygen-carrying capacity of the trachea.
B) When the nasal passages are bypassed, as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming of the nasal passages are also bypassed. The client can still cough and sneeze, and there is no decrease in the oxygen-carrying capacity of the trachea.
C) When the nasal passages are bypassed, as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming of the nasal passages are also bypassed. The client can still cough and sneeze, and there is no decrease in the oxygen-carrying capacity of the trachea.
D) When the nasal passages are bypassed, as they would be in the case of a client with a tracheostomy, the filtration, humidification, and warming of the nasal passages are also bypassed. The client can still cough and sneeze, and there is no decrease in the oxygen-carrying capacity of the trachea.

Question 3

The nurse is reviewing the results of laboratory tests conducted on a client admitted with a respiratory disorder.Which laboratory finding would be most significant for this client?
A) Hemoglobin level 12 mg/dL
B) Oxygen saturation 96%
C) Serum sodium 140 mg/dL
D) Blood pH 7.32

Accepted Answer

A) Normal blood pH is 7.35-7.45. A decreased pH indicates that the client is experiencing acidosis, which indicates an alteration in oxygenation. The serum sodium does not impact the oxygen capacity of the body. The hemoglobin level affects the amount of oxygen that can be carried in the blood; however, the value is within normal limits. Oxygen saturation of 96% is within normal limits.
B) Normal blood pH is 7.35-7.45. A decreased pH indicates that the client is experiencing acidosis, which indicates an alteration in oxygenation. The serum sodium does not impact the oxygen capacity of the body. The hemoglobin level affects the amount of oxygen that can be carried in the blood; however, the value is within normal limits. Oxygen saturation of 96% is within normal limits.
C) Normal blood pH is 7.35-7.45. A decreased pH indicates that the client is experiencing acidosis, which indicates an alteration in oxygenation. The serum sodium does not impact the oxygen capacity of the body. The hemoglobin level affects the amount of oxygen that can be carried in the blood; however, the value is within normal limits. Oxygen saturation of 96% is within normal limits.
D) Normal blood pH is 7.35-7.45. A decreased pH indicates that the client is experiencing acidosis, which indicates an alteration in oxygenation. The serum sodium does not impact the oxygen capacity of the body. The hemoglobin level affects the amount of oxygen that can be carried in the blood; however, the value is within normal limits. Oxygen saturation of 96% is within normal limits.

Question 4

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD).Which clinical manifestations indicate the client's perfusion is affected? Select all that apply.
A) Bounding pulse
B) Pink nail beds
C) Acrocyanosis
D) Confusion
E) Wheezing

Accepted Answer

A) A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include acrocyanosis and confusion. A weak pulse and blue nailbeds would also indicate poor perfusion. Wheezing is an abnormal breath sound and is not an indication of poor perfusion.
B) A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include acrocyanosis and confusion. A weak pulse and blue nailbeds would also indicate poor perfusion. Wheezing is an abnormal breath sound and is not an indication of poor perfusion.
C) A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include acrocyanosis and confusion. A weak pulse and blue nailbeds would also indicate poor perfusion. Wheezing is an abnormal breath sound and is not an indication of poor perfusion.
D) A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include acrocyanosis and confusion. A weak pulse and blue nailbeds would also indicate poor perfusion. Wheezing is an abnormal breath sound and is not an indication of poor perfusion.
E) A client who is diagnosed with COPD may have alterations in both oxygenation and perfusion. Clinical manifestations associated with a decrease in perfusion include acrocyanosis and confusion. A weak pulse and blue nailbeds would also indicate poor perfusion. Wheezing is an abnormal breath sound and is not an indication of poor perfusion.

Question 5

The nurse is providing care to clients on a medical-surgical unit.Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation? Select all that apply.
A) Encouraging deep breathing exercises
B) Assisting with positioning
C) Providing suctioning
D) Prescribing bronchodilators
E) Monitoring activity intolerance

Accepted Answer

A) Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.
B) Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.
C) Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.
D) Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.
E) Examples of independent interventions that nurses can provide to clients with alterations in oxygenation include deep breathing exercises, positioning, encouraging smoking cessation, monitoring activity intolerance, promoting secretion clearance, suctioning, and assisting with activities of daily living (ADLs). It is outside the scope of nursing practice to prescribe a bronchodilator to a client. The nurse, however, can administer a prescribed bronchodilator. This is considered a collaborative nursing intervention.

Question 6

A client with chronic obstructive pulmonary disease (COPD)is prescribed oxygen 24% 2 L/min.Which is the best method to administer oxygen to this client?
A) Face mask
B) Nasal cannula
C) Nonrebreather mask
D) Venturi mask

Accepted Answer

A) The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2 liters per minute is through nasal cannula. The other delivery devices are better suited for higher percentages of oxygen and higher flow rates.
B) The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2 liters per minute is through nasal cannula. The other delivery devices are better suited for higher percentages of oxygen and higher flow rates.
C) The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2 liters per minute is through nasal cannula. The other delivery devices are better suited for higher percentages of oxygen and higher flow rates.
D) The oxygen delivery device that would safely administer 24% oxygen at the flow rate of 2 liters per minute is through nasal cannula. The other delivery devices are better suited for higher percentages of oxygen and higher flow rates.

Question 7

When auscultating the lungs of a client experiences dyspnea,the nurse hears a low-pitched sound that is continuous throughout inspiration.What does this lung sound indicate to the nurse?
A) Narrow bronchi
B) Narrow trachea passages
C) Blocked large airway passages
D) Inflamed pleural surfaces

Accepted Answer

A) The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout inspiration. Rhonchi suggests blockage of large airway passages, which may be cleared with coughing. Stridor is the sound created by narrow tracheal passages. A low-pitched grating sound is created by inflamed pleural surfaces. Wheezing is created by narrow bronchi.
B) The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout inspiration. Rhonchi suggests blockage of large airway passages, which may be cleared with coughing. Stridor is the sound created by narrow tracheal passages. A low-pitched grating sound is created by inflamed pleural surfaces. Wheezing is created by narrow bronchi.
C) The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout inspiration. Rhonchi suggests blockage of large airway passages, which may be cleared with coughing. Stridor is the sound created by narrow tracheal passages. A low-pitched grating sound is created by inflamed pleural surfaces. Wheezing is created by narrow bronchi.
D) The nurse auscultated rhonchi, which are low-pitched sounds that are continuous throughout inspiration. Rhonchi suggests blockage of large airway passages, which may be cleared with coughing. Stridor is the sound created by narrow tracheal passages. A low-pitched grating sound is created by inflamed pleural surfaces. Wheezing is created by narrow bronchi.

Question 8

The nurse is providing care to a client experiencing the acid-base balance of respiratory acidosis.Which effects does the nurse anticipate based on this diagnosis? Select all that apply. A) Increased CO₂ B) Vasoconstriction C) Decreased O₂ D) Decreased intracranial pressure (ICP) E) Increased pulse rate

Accepted Answer

A) Respiratory acidosis is considered an alteration of acid-base balance. The client who is experiencing respiratory acidosis will have an increased CO₂ causing vasodilation (not vasoconstriction) and an increase in ICP (not decreased) and pulse rate. The nurse would also expect decreased O₂. B) Respiratory acidosis is considered an alteration of acid-base balance. The client who is experiencing respiratory acidosis will have an increased CO₂ causing vasodilation (not vasoconstriction) and an increase in ICP (not decreased) and pulse rate. The nurse would also expect decreased O₂. C) Respiratory acidosis is considered an alteration of acid-base balance. The client who is experiencing respiratory acidosis will have an increased CO₂ causing vasodilation (not vasoconstriction) and an increase in ICP (not decreased) and pulse rate. The nurse would also expect decreased O₂. D) Respiratory acidosis is considered an alteration of acid-base balance. The client who is experiencing respiratory acidosis will have an increased CO₂ causing vasodilation (not vasoconstriction) and an increase in ICP (not decreased) and pulse rate. The nurse would also expect decreased O₂. E) Respiratory acidosis is considered an alteration of acid-base balance. The client who is experiencing respiratory acidosis will have an increased CO₂ causing vasodilation (not vasoconstriction) and an increase in ICP (not decreased) and pulse rate. The nurse would also expect decreased O₂.

Question 9

The nurse is providing care to a client with an infected leg wound.The client is exhibiting symptoms of a systemic infection and is receiving intravenous antibiotics.The client states to the nurse,"I am having trouble breathing." Based on this data,which does the nurse suspect the client is experiencing?
A) Allergic response from antibiotic therapy
B) Deep vein thrombosis
C) Acute respiratory distress syndrome
D) Anemia

Accepted Answer

A) Sepsis is the most common cause of acute respiratory distress syndrome (ARDS). The client has a systemic infection, which is sepsis, and is complaining that it is getting hard to breathe. The nurse should suspect the client is developing acute respiratory distress. Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may not be associated with a systemic infection from an infected leg wound and are not associated with the development of ARDS.
B) Sepsis is the most common cause of acute respiratory distress syndrome (ARDS). The client has a systemic infection, which is sepsis, and is complaining that it is getting hard to breathe. The nurse should suspect the client is developing acute respiratory distress. Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may not be associated with a systemic infection from an infected leg wound and are not associated with the development of ARDS.
C) Sepsis is the most common cause of acute respiratory distress syndrome (ARDS). The client has a systemic infection, which is sepsis, and is complaining that it is getting hard to breathe. The nurse should suspect the client is developing acute respiratory distress. Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may not be associated with a systemic infection from an infected leg wound and are not associated with the development of ARDS.
D) Sepsis is the most common cause of acute respiratory distress syndrome (ARDS). The client has a systemic infection, which is sepsis, and is complaining that it is getting hard to breathe. The nurse should suspect the client is developing acute respiratory distress. Deep vein thrombosis, anemia, or allergic response from antibiotic therapy may or may not be associated with a systemic infection from an infected leg wound and are not associated with the development of ARDS.

Question 10

The nurse is providing care for a client admitted during an acute exacerbation of asthma.Which medication does the nurse anticipate to relieve the acute symptoms exhibited by the client?
A) Inhaled short-acting beta-agonists
B) Oral corticosteroids
C) Inhaled long-acting beta-agonists
D) Oral anticholinergics

Accepted Answer

A) The client admitted with an acute exacerbation of asthma will require a rescue medication, such as an inhaled short-acting beta-agonist. Oral corticosteroids, inhaled long-acting beta agonists, and oral anticholinergics are maintenance medications used to treat asthma.
B) The client admitted with an acute exacerbation of asthma will require a rescue medication, such as an inhaled short-acting beta-agonist. Oral corticosteroids, inhaled long-acting beta agonists, and oral anticholinergics are maintenance medications used to treat asthma.
C) The client admitted with an acute exacerbation of asthma will require a rescue medication, such as an inhaled short-acting beta-agonist. Oral corticosteroids, inhaled long-acting beta agonists, and oral anticholinergics are maintenance medications used to treat asthma.
D) The client admitted with an acute exacerbation of asthma will require a rescue medication, such as an inhaled short-acting beta-agonist. Oral corticosteroids, inhaled long-acting beta agonists, and oral anticholinergics are maintenance medications used to treat asthma.

Question 11

A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%.Which nursing diagnosis is a priority for this client?
A) Risk for Infection
B) Impaired Spontaneous Ventilation
C) Risk for Acute Confusion
D) Decreased Cardiac Output

Accepted Answer

A) A priority nursing intervention for a client with a respiratory rate of 8 breaths per minutes and an oxygen saturation of 82% is Impaired Spontaneous Ventilation. If the current pattern continues without intervention, the client could experience respiratory arrest. While the other nursing diagnoses may also be appropriate, they are not the priority for this client.
B) A priority nursing intervention for a client with a respiratory rate of 8 breaths per minutes and an oxygen saturation of 82% is Impaired Spontaneous Ventilation. If the current pattern continues without intervention, the client could experience respiratory arrest. While the other nursing diagnoses may also be appropriate, they are not the priority for this client.
C) A priority nursing intervention for a client with a respiratory rate of 8 breaths per minutes and an oxygen saturation of 82% is Impaired Spontaneous Ventilation. If the current pattern continues without intervention, the client could experience respiratory arrest. While the other nursing diagnoses may also be appropriate, they are not the priority for this client.
D) A priority nursing intervention for a client with a respiratory rate of 8 breaths per minutes and an oxygen saturation of 82% is Impaired Spontaneous Ventilation. If the current pattern continues without intervention, the client could experience respiratory arrest. While the other nursing diagnoses may also be appropriate, they are not the priority for this client.

Question 12

The nurse is providing care to a client on a medical-surgical unit.The client's arterial blood gas analysis is as follows: PaO₂ of 82,PaCO₂ of 49,HCO₃ of 26,and pH of 7.55.Which acid-base imbalance is this client experiencing based on this data? A) Respiratory acidosis B) Respiratory alkalosis C) Metabolic alkalosis D) Metabolic acidosis

Accepted Answer

A) An arterial blood gas analysis is often prescribed for client's experiencing alterations in oxygenation. Both the pH and the carbon dioxide levels represent acidosis. Furthermore, the carbon dioxide levels are regulated by the lungs. Therefore, a blood gas that has a pH greater than 7.45 indicates acidosis. If the same blood gas has a carbon dioxide greater than 45 mmHg, respiratory acidosis is present. The PaO₂ of 82 is on the low end of normal and the bicarbonate level is normal. B) An arterial blood gas analysis is often prescribed for client's experiencing alterations in oxygenation. Both the pH and the carbon dioxide levels represent acidosis. Furthermore, the carbon dioxide levels are regulated by the lungs. Therefore, a blood gas that has a pH greater than 7.45 indicates acidosis. If the same blood gas has a carbon dioxide greater than 45 mmHg, respiratory acidosis is present. The PaO₂ of 82 is on the low end of normal and the bicarbonate level is normal. C) An arterial blood gas analysis is often prescribed for client's experiencing alterations in oxygenation. Both the pH and the carbon dioxide levels represent acidosis. Furthermore, the carbon dioxide levels are regulated by the lungs. Therefore, a blood gas that has a pH greater than 7.45 indicates acidosis. If the same blood gas has a carbon dioxide greater than 45 mmHg, respiratory acidosis is present. The PaO₂ of 82 is on the low end of normal and the bicarbonate level is normal. D) An arterial blood gas analysis is often prescribed for client's experiencing alterations in oxygenation. Both the pH and the carbon dioxide levels represent acidosis. Furthermore, the carbon dioxide levels are regulated by the lungs. Therefore, a blood gas that has a pH greater than 7.45 indicates acidosis. If the same blood gas has a carbon dioxide greater than 45 mmHg, respiratory acidosis is present. The PaO₂ of 82 is on the low end of normal and the bicarbonate level is normal.

Question 13

The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance.Which action by the nurse is the most appropriate?
A) Encourage strenuous activity.
B) Consult a dietitian for low-calorie meals.
C) Consult physical therapy for endurance and musculoskeletal function.
D) Encourage dependence with activities of daily living.

Accepted Answer

A) The client with shortness of breath will experience activity intolerance due to a lack of oxygen and fatigue. The nurse should consult with physical therapy for endurance and musculoskeletal function. Clients with respiratory disorders often need an increase, not a decrease, in calories to maintain body functions. The client will be weak, so the nurse should not encourage strenuous activity. The nurse would want the client to be as independent as possible and would not encourage dependence with activities of daily living. It will often be appropriate to cluster this client's care to allow for periods of rest.
B) The client with shortness of breath will experience activity intolerance due to a lack of oxygen and fatigue. The nurse should consult with physical therapy for endurance and musculoskeletal function. Clients with respiratory disorders often need an increase, not a decrease, in calories to maintain body functions. The client will be weak, so the nurse should not encourage strenuous activity. The nurse would want the client to be as independent as possible and would not encourage dependence with activities of daily living. It will often be appropriate to cluster this client's care to allow for periods of rest.
C) The client with shortness of breath will experience activity intolerance due to a lack of oxygen and fatigue. The nurse should consult with physical therapy for endurance and musculoskeletal function. Clients with respiratory disorders often need an increase, not a decrease, in calories to maintain body functions. The client will be weak, so the nurse should not encourage strenuous activity. The nurse would want the client to be as independent as possible and would not encourage dependence with activities of daily living. It will often be appropriate to cluster this client's care to allow for periods of rest.
D) The client with shortness of breath will experience activity intolerance due to a lack of oxygen and fatigue. The nurse should consult with physical therapy for endurance and musculoskeletal function. Clients with respiratory disorders often need an increase, not a decrease, in calories to maintain body functions. The client will be weak, so the nurse should not encourage strenuous activity. The nurse would want the client to be as independent as possible and would not encourage dependence with activities of daily living. It will often be appropriate to cluster this client's care to allow for periods of rest.

Question 14

While performing nasotracheal suctioning,the nurse notes the older adult client is moving the head around and pulling at the nurse's hand to remove the suction catheter.Which actions by the nurse are appropriate? Select all that apply.
A) Remove the suction catheter
B) Lower the head of the bed
C) Hyperinflate the client's lungs
D) Apply restraints to the client's arms and legs
E) Hyperoxygenate the client

Accepted Answer

A) The older adult client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, hyperinflate the client's lungs, and hyperoxygenate the client. The client does not need to have restraints applied to all 4 extremities. The client should be in the Fowler or high-Fowler position.
B) The older client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, hyperinflate the client's lungs, and hyperoxygenate the client. The client does not need to have restraints applied to all 4 extremities. The client should be in the Fowler or high-Fowler position.
C) The older client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, hyperinflate the client's lungs, and hyperoxygenate the client. The client does not need to have restraints applied to all 4 extremities. The client should be in the Fowler or high-Fowler position.
D) The older client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, hyperinflate the client's lungs, and hyperoxygenate the client. The client does not need to have restraints applied to all 4 extremities. The client should be in the Fowler or high-Fowler position.
E) The older client is demonstrating signs of hypoxemia. The nurse should remove the suction catheter, hyperinflate the client's lungs, and hyperoxygenate the client. The client does not need to have restraints applied to all 4 extremities. The client should be in the Fowler or high-Fowler position.

Question 15

The nurse is providing care to a client admitted to the emergency department with the diagnosis of acute respiratory distress syndrome (ARDS).When educating the client's family on the disease progress,in which order will the nurse present the material?
A) Initiation of ARDS
B) Onset of pulmonary edema
C) End-stage ARDS
D) Alveolar collapse

Accepted Answer

The answer of The nurse is providing care to a...

Question 16

The nurse is providing care to a client who is diagnosed with acute respiratory distress syndrome (ARDS).Which clinical manifestation does the nurse anticipate for this client who is experiencing hypoxia as a result of the ARDS diagnosis?
A) Fluid imbalance
B) Hypertension
C) Bradycardia
D) Dyspnea

Accepted Answer

A) Dyspnea is a clinical manifestation that clients experiencing hypoxia secondary to ARDS. Fluid and electrolyte imbalances occur due to the nutritional imbalances associated with ARDS. The nurse would expect tachycardia, not bradycardia, as a result of hypoxia.
B) Dyspnea is a clinical manifestation that clients experiencing hypoxia secondary to ARDS. Fluid and electrolyte imbalances occur due to the nutritional imbalances associated with ARDS. The nurse would expect tachycardia, not bradycardia, as a result of hypoxia.
C) Dyspnea is a clinical manifestation that clients experiencing hypoxia secondary to ARDS. Fluid and electrolyte imbalances occur due to the nutritional imbalances associated with ARDS. The nurse would expect tachycardia, not bradycardia, as a result of hypoxia.
D) Dyspnea is a clinical manifestation that clients experiencing hypoxia secondary to ARDS. Fluid and electrolyte imbalances occur due to the nutritional imbalances associated with ARDS. The nurse would expect tachycardia, not bradycardia, as a result of hypoxia.

Question 17

A client with acute respiratory distress syndrome (ARDS)is being weaned from ventilatory support.Which nursing actions are appropriate for this client? Select all that apply.
A) Increase percentage of oxygen being provided through the ventilator.
B) Place in the Fowler position.
C) Provide morning care during the weaning procedures.
D) Begin weaning procedures in the morning.
E) Medicate with morphine for pain as needed.

Accepted Answer

A) Weaning a client from ventilatory support should begin in the morning when the client is well-rested. The client should be in the Fowler or high-Fowler position, as this facilitates lung expansion and reduces the work of breathing. Activities and care should be limited during the weaning process to reduce the demand for oxygen. The client should not be given any medication known to suppress respirations, as this would interfere with the weaning process. Medicating for pain would be appropriate when the client is back on the ventilator after concluding the weaning procedures. The percentage of oxygen is typically reduced during the weaning process.
B) Weaning a client from ventilatory support should begin in the morning when the client is well-rested. The client should be in the Fowler or high-Fowler position, as this facilitates lung expansion and reduces the work of breathing. Activities and care should be limited during the weaning process to reduce the demand for oxygen. The client should not be given any medication known to suppress respirations, as this would interfere with the weaning process. Medicating for pain would be appropriate when the client is back on the ventilator after concluding the weaning procedures. The percentage of oxygen is typically reduced during the weaning process.
C) Weaning a client from ventilatory support should begin in the morning when the client is well-rested. The client should be in the Fowler or high-Fowler position, as this facilitates lung expansion and reduces the work of breathing. Activities and care should be limited during the weaning process to reduce the demand for oxygen. The client should not be given any medication known to suppress respirations, as this would interfere with the weaning process. Medicating for pain would be appropriate when the client is back on the ventilator after concluding the weaning procedures. The percentage of oxygen is typically reduced during the weaning process.
D) Weaning a client from ventilatory support should begin in the morning when the client is well-rested. The client should be in the Fowler or high-Fowler position, as this facilitates lung expansion and reduces the work of breathing. Activities and care should be limited during the weaning process to reduce the demand for oxygen. The client should not be given any medication known to suppress respirations, as this would interfere with the weaning process. Medicating for pain would be appropriate when the client is back on the ventilator after concluding the weaning procedures. The percentage of oxygen is typically reduced during the weaning process.
E) Weaning a client from ventilatory support should begin in the morning when the client is well-rested. The client should be in the Fowler or high-Fowler position, as this facilitates lung expansion and reduces the work of breathing. Activities and care should be limited during the weaning process to reduce the demand for oxygen. The client should not be given any medication known to suppress respirations, as this would interfere with the weaning process. Medicating for pain would be appropriate when the client is back on the ventilator after concluding the weaning procedures. The percentage of oxygen is typically reduced during the weaning process.

Question 18

The nurse assigned to the newborn nursery is conducting shift assessments.While assessing one newborn,the nurse notes the respiratory rate is 52 breaths per minute.Which action by the nurse is appropriate?
A) Notify the healthcare provider of this assessment finding.
B) Obtain an arterial blood gas for further respiratory assessment.
C) Begin monitoring the respiratory rate every 5 minutes.
D) Continue to monitor the newborn per facility policy.

Accepted Answer

A) A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate or newborn is 30-60 breaths per minute.
B) A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate or newborn is 30-60 breaths per minute.
C) A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate or newborn is 30-60 breaths per minute.
D) A respiratory rate of 52 breaths per minute is a normal finding in a newborn. Respiratory rates are highest and most variable in newborns. The respiratory rate of a neonate or newborn is 30-60 breaths per minute.

Question 19

The nurse is providing care to an adult client with a long history of chronic obstructive pulmonary disease (COPD).The client is admitted to the intensive care unit with a pneumothroax.Which interventions are appropriate for this client? Select all that apply.
A) Elevate head of the bed
B) Administer a high rate of oxygen by nasal cannula
C) Prepare for a chest tube insertion
D) Administer prescribed antihypertensive medications
E) Administer intravenous caffeine per order

Accepted Answer

A) The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed due to the client's dyspnea and orthopnea and prepare for a chest tube insertion. Because clients with COPD have a decreased response to hypercarbia which stimulates breathing, a high rate of oxygen by nasal cannula is inappropriate. This client is stimulates to breathe by decreased levels of oxygen. Too much oxygen will cause apnea. There is no indication that the client is experiencing hypertension. IV caffeine is administered to premature infants as a respiratory stimulant. This intervention is not appropriate for an adult client diagnosed with COPD and a pneumothorax.
B) The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed due to the client's dyspnea and orthopnea and prepare for a chest tube insertion. Because clients with COPD have a decreased response to hypercarbia which stimulates breathing, a high rate of oxygen by nasal cannula is inappropriate. This client is stimulates to breathe by decreased levels of oxygen. Too much oxygen will cause apnea. There is no indication that the client is experiencing hypertension. IV caffeine is administered to premature infants as a respiratory stimulant. This intervention is not appropriate for an adult client diagnosed with COPD and a pneumothorax.
C) The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed due to the client's dyspnea and orthopnea and prepare for a chest tube insertion. Because clients with COPD have a decreased response to hypercarbia which stimulates breathing, a high rate of oxygen by nasal cannula is inappropriate. This client is stimulates to breathe by decreased levels of oxygen. Too much oxygen will cause apnea. There is no indication that the client is experiencing hypertension. IV caffeine is administered to premature infants as a respiratory stimulant. This intervention is not appropriate for an adult client diagnosed with COPD and a pneumothorax.
D) The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed due to the client's dyspnea and orthopnea and prepare for a chest tube insertion. Because clients with COPD have a decreased response to hypercarbia which stimulates breathing, a high rate of oxygen by nasal cannula is inappropriate. This client is stimulates to breathe by decreased levels of oxygen. Too much oxygen will cause apnea. There is no indication that the client is experiencing hypertension. IV caffeine is administered to premature infants as a respiratory stimulant. This intervention is not appropriate for an adult client diagnosed with COPD and a pneumothorax.
E) The nurse providing care to a client with COPD and a pneumothorax would elevate the head of the bed due to the client's dyspnea and orthopnea and prepare for a chest tube insertion. Because clients with COPD have a decreased response to hypercarbia which stimulates breathing, a high rate of oxygen by nasal cannula is inappropriate. This client is stimulates to breathe by decreased levels of oxygen. Too much oxygen will cause apnea. There is no indication that the client is experiencing hypertension. IV caffeine is administered to premature infants as a respiratory stimulant. This intervention is not appropriate for an adult client diagnosed with COPD and a pneumothorax.

Question 20

The nursing student is conducting an assessment for a client on a medical-surgical unit.Which findings are indicative of a client who is experiencing tachypnea? Select all that apply.
A) Excessive rapid breathing
B) Chest pain
C) Rapid breathing at rest
D) Shallow breathing
E) Cyanosis

Accepted Answer

A) Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations of tachypnea. Chest pain is a manifestation of a pneumothorax. Cyanosis is a late manifestation of hypoxemia.
B) Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations of tachypnea. Chest pain is a manifestation of a pneumothorax. Cyanosis is a late manifestation of hypoxemia.
C) Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations of tachypnea. Chest pain is a manifestation of a pneumothorax. Cyanosis is a late manifestation of hypoxemia.
D) Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations of tachypnea. Chest pain is a manifestation of a pneumothorax. Cyanosis is a late manifestation of hypoxemia.
E) Excessive rapid breathing, rapid breathing at rest, and shallow breathing are all manifestations of tachypnea. Chest pain is a manifestation of a pneumothorax. Cyanosis is a late manifestation of hypoxemia.

Quiz 15: Oxygenation

The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client with asthma.Which action by the newly licensed nurse requires immediate intervention?

The nurse is providing care to a client who has a tracheostomy.The nurse will monitor the client for complications related to the loss of which protective mechanism?

The nurse is reviewing the results of laboratory tests conducted on a client admitted with a respiratory disorder.Which laboratory finding would be most significant for this client?

The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD) .Which clinical manifestations indicate the client's perfusion is affected? Select all that apply.

The nurse is providing care to clients on a medical-surgical unit.Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation? Select all that apply.

A client with chronic obstructive pulmonary disease (COPD) is prescribed oxygen 24% 2 L/min.Which is the best method to administer oxygen to this client?

When auscultating the lungs of a client experiences dyspnea,the nurse hears a low-pitched sound that is continuous throughout inspiration.What does this lung sound indicate to the nurse?

The nurse is providing care to a client experiencing the acid-base balance of respiratory acidosis.Which effects does the nurse anticipate based on this diagnosis? Select all that apply.

The nurse is providing care for a client admitted during an acute exacerbation of asthma.Which medication does the nurse anticipate to relieve the acute symptoms exhibited by the client?

A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%.Which nursing diagnosis is a priority for this client?

The nurse is providing care to a client on a medical-surgical unit.The client's arterial blood gas analysis is as follows: PaO₂ of 82,PaCO₂ of 49,HCO₃ of 26,and pH of 7.55.Which acid-base imbalance is this client experiencing based on this data?

The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance.Which action by the nurse is the most appropriate?

While performing nasotracheal suctioning,the nurse notes the older adult client is moving the head around and pulling at the nurse's hand to remove the suction catheter.Which actions by the nurse are appropriate? Select all that apply.

The nurse is providing care to a client who is diagnosed with acute respiratory distress syndrome (ARDS) .Which clinical manifestation does the nurse anticipate for this client who is experiencing hypoxia as a result of the ARDS diagnosis?

A client with acute respiratory distress syndrome (ARDS) is being weaned from ventilatory support.Which nursing actions are appropriate for this client? Select all that apply.

The nurse assigned to the newborn nursery is conducting shift assessments.While assessing one newborn,the nurse notes the respiratory rate is 52 breaths per minute.Which action by the nurse is appropriate?

The nurse is providing care to an adult client with a long history of chronic obstructive pulmonary disease (COPD) .The client is admitted to the intensive care unit with a pneumothroax.Which interventions are appropriate for this client? Select all that apply.

The nursing student is conducting an assessment for a client on a medical-surgical unit.Which findings are indicative of a client who is experiencing tachypnea? Select all that apply.