Question 1

A nurse is caring for an older adult client who is to be discharged from the health care facility. The client has been prescribed the use of a liquid oxygen unit at home to continue with oxygen therapy. What should the nurse tell the client regarding the potential problems of using a liquid oxygen unit? Select all that apply.

Accepted Answer

Liquid oxygen units can leak during warm weather due to the expansion of the liquid as it warms, potentially leading to a loss of oxygen. The outlet of the unit may become occluded because of frozen moisture, which can block the flow of oxygen. Portable liquid oxygen systems are generally more expensive than other types of oxygen delivery systems, such as compressed gas cylinders or oxygen concentrators, due to the cost of the liquid oxygen and the technology required to store and vaporize it for use.

Question 2

What prevents air from re-entering the pleural space when chest tubes are inserted?

Accepted Answer

A closed water-seal drainage system is designed to prevent the re-entry of air into the pleural space. The system creates a one-way valve that allows air and fluid to exit the pleural space, while preventing them from re-entering. The location of the tube insertion and the sutures that hold in the tube do not prevent air from re-entering the pleural space, and respiratory inspiration and expiration can actually create a negative pressure that can draw air into the pleural space.

Question 3

A nurse is conducting a health promotion program for adolescents to educate them about the hazards of smoking. When describing the effects on the respiratory system, which of the following would the nurse most likely include?

Accepted Answer

Smoking inhibits the movement of cilia in the respiratory tract, which are responsible for removing mucus and harmful particles. This can lead to an accumulation of mucus in the respiratory system, making it more difficult to breathe and increasing the risk of respiratory infections.

Question 4

A nurse is delivering oxygen to a client via an oxygen mask. Which of the following is a recommended guideline for this procedure?

Accepted Answer

Removing the mask every few hours to dry the skin can help prevent skin breakdown and irritation. Adjusting the mask tightly may cause discomfort and pressure sores. Filling the reservoir half-full is not a standard guideline, and applying powder to the mask can create a risk of inhalation or infection.

Question 5

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

Accepted Answer

Newborns typically have a higher respiratory rate, ranging from 30 to 55 breaths per minute, due to their smaller lung capacity and higher metabolic rate.

Question 6

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. What additional assessment would the nurse expect to observe?

Accepted Answer

Dyspnea and pitting edema in the feet and ankles are indicative of heart failure, which often presents with crackles in the lower lobes due to fluid accumulation in the lungs. Inspiratory and expiratory stridor as well as wheezing in the upper lobes are not commonly associated with heart failure.

Question 7

A physician prescribes the use of water-seal chest tube drainage for a client at a health care facility. What should the nurse ensure when using the water-seal chest tube drainage?

Accepted Answer

The chest tube should not be separated from the drainage system unless clamped to avoid air entering the pleural space and disrupting the negative pressure that assists with lung inflation. The other options are not necessary precautions when using a water-seal chest tube drainage.

Question 8

A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply.

Accepted Answer

When physically assessing the quality of the client's oxygenation, the nurse should monitor the client's respiratory rate, check the symmetry of the client's chest, and observe the breathing pattern and effort. The amount of oxygen administered and the devices used to deliver oxygen are important to note but are not specifically related to assessing the quality of the client's oxygenation.

Question 9

A nurse is educating a postoperative client on how to use an incentive spirometer. Which of the following is an accurate step that should be included in the teaching plan?

Accepted Answer

The correct step is to instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose, to maximize lung expansion and improve respiratory function.

Question 10

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula?

Accepted Answer

The most important thing to remember when using a nasal cannula is that it can cause the nasal mucosa to dry in case of high flow. This can be uncomfortable and even cause damage to the delicate nasal tissues. To prevent this, the nurse should monitor the flow rate and adjust it as needed to ensure that the client is receiving enough oxygen without causing harm.

Question 11

What category of medications may be administered by nebulizer or metered-dose inhaler to open narrowed airways?

Accepted Answer

Bronchodilators work to open narrowed airways, which can be administered through a nebulizer or metered-dose inhaler. A) Bronchoconstrictors have the opposite effect, narrowing airways. B) Antihistamines are used to treat allergies and do not target airway constriction. C) Narcotics are not typically used to treat respiratory issues and may actually depress respiratory function.

Question 12

A nurse is educating a client who has congested lungs how to keep secretions thin, and more easily coughed up and expectorated. What would be one self-care measure to teach?

Accepted Answer

Increasing oral intake of fluids to two to three quarts per day helps to keep secretions thin, making them easier to cough up and expectorate. Limiting oral intake of fluids to less than 500 mL per day can lead to dehydration and thickening of secretions, worsening the condition. Bed rest and warm baths do not have a direct impact on thinning secretions.

Question 13

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

Accepted Answer

The chest tube is inserted into the space between the lining of the lungs and the ribs, known as the pleural space. It allows for the drainage of air or fluid that may have built up in this area.

Question 14

A physician is choosing a chest drainage system for a client who is ambulating daily. Which of the following systems would be the best choice for this client?

Accepted Answer

The dry suction/one-way valve system is the best choice for a client who is ambulating daily as it allows greater mobility without the risk of backflow of air or fluid into the chest. Wet suction and traditional water seal systems require the client to remain relatively stationary, while dry suction water seal systems can have issues with maintaining suction during movement.

Question 15

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of

Accepted Answer

Pneumonia increases the risk of developing atelectasis, which is a partial or complete collapse of a lung or a section (lobe) of a lung. Atelectasis can cause symptoms such as shortness of breath, chest pain, and coughing. It is important to assess for atelectasis in postoperative clients who have pneumonia because it can lead to further respiratory complications. Bronchospasm, croup, and epiglottitis are not commonly associated with pneumonia.

Quiz 38: Oxygenation and Perfusion