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The nurse teaches a patient how to use an incentive spirometer. What patient outcome will support that the use of the incentive spirometer was effective?
1. supplemental oxygen will be reduced
2. inspiratory volume will be increased
3. sputum will be expectorated
4. coughing will be stimulated
Inspiratory volume will be increased
A nurse is applying a warm compress. What should the nurse explain to the patient is the primary reason why heat is used instead of cold?
1. minimizes muscle spasms
2. prevents hemorrhage
3. increases circulation
4. reduces discomfort
Which action is most effective in meeting the needs of a patient experiencing laryngospasm?
1. ensuring hyperextension of the head
2. providing positive pressure ventilation
3. instituting cardiopulmonary resuscitation
4. administering oxygen by using a face mask
which physiological factor places the older adult at the greatest risk during surgery?
1. skin elasticity
2. bladder emptying
3. tolerance for pain
4. respiratory excursion
A practitioner orders bed rest for a patient. What should the nurse explain to the patient is the primary purpose of bed rest?
1. conserve energy
2. maintain strength
3. reduce peristalsis
4. enhance protein synthesis
A nurse is reviewing the lab results of a patient with preliminary diagnosis of anemia. Which diagnostic test reflects a response to iron deficiency anemia?
2. platelet count
3. serum albumin
4. blood urea nitrogen
A patient is admitted with the diagnosis of lower extremity arterial disease. Which is a specific desirable outcome for a patient with this diagnosis?
1. respirations within the expected range
2. oriented to the environment
3. palpable peripheral pulses
4. prolonged capillary refill
palpable peripheral pulses
A nurse is planning to teach one patient pursed lip breathing and another patient diaghragmatic breathing. What technique associated with diaphragmatic breathing is different from pursed lip breathing?
1. inhales through the mouth
2. exhales through pursed lips
3. raises both shoulders while breathing deeply
4. tightens abdominal muscles while exhaling
tightens abdominal muscles while exhaling
(contraction of abdominal muscles at the end of expiration helps to reduce the amount of air left in the lungs and the end of expiration (residual volume))
Which nursing assessment best indicates a patients ability to tolerate activity?
1. vital signs take three minutes to return to preactivity level
2. adventitious breath sounds on auscultation
3. flexibility of muscles and joints
4. reports of weakness
vital signs take 3 minutes to return to pre-activity level
(vital signs reflect cardiopulmonary functioning of the boy. vital signs obtained before and after activity provide data that can be compared to determine the body's response to the energy demands of ambulation. when the vital signs return to pre-activity level within 3 minutes it indicates that the patient has tolerated the activity well)
A nurse is caring for a patient who has a chest tube after thoracic surgery. What should the nurse do when caring for this patient?
1. Clamp the tube when providing for activities of daily living?
2. position the collection device at the same level as the chest
3. maintain an airtight dressing over the puncture wound
4. empty chest tube drainage every shift
Maintain an airtight dressing over the puncture wound
(an airtight dressing seals the pleural space from the environment. if left open to the environment, atmospheric pressure causes air to enter the pleural space, which results in a tension pneumothorax)
A nurse is concerned about the risk for thrombophlebitis when caring for a patient with impaired mobility. For which clinical manifestation associated with thrombophlebitis should the nurse monitor the patient?
1. postural hypotension
2. blanchable erythema
3. dependent edema
4. acute chest pain
acute chest pain
(immobility promotes venous stasis, which in conjunction with hypercoagulability and injury to vessel walls pre-disposes patients to thrombophlebitis. A thrombus can break loose from the vein wall and travel through the circulation (embolus) where eventually it obstructs a pulmonary artery or one of its branches causing sudden acute chest pain, dyspnea, coughing, and frothy sputum)
An unconscious patient who had oral surgery is admitted to the postanasthesia care unit. In which position should the nurse place the patient?
(the lateral position facilitates 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 respirations)
The nurse raises the head of the bed for a patient who has difficulty breathing. Which science includes the principle that explains how this intervention facilitates respiration?
Which are the most effective leg exercises the nurse should encourage the patient to perform to prevent circulatory complications during the postoperative period?
1. flexing the knees
2. isometric exercises
4. passive range of motion
(alternating dorsiflexion and plantar flexion (calf pumping) alternately contracts and relaxes the calf muscles which promotes venous return, preventing venous stasis that contributes to the development of postoperative thrombophlebitis)
A nurse is assessing a patient with a respiratory problem. Which clinical manifestation is most reflective of an early response to hypoxia?
A nurse is teaching a patient how to use an incentive spirometer. Which position should the nurse assist the patient to assume during the procedure?
which complication has most likely occurred when a patient experiences purulent sputum, dyspnea, and chest pain?
1. hypostatic pneumonia
2. hypovolemic shock
sudden onset sharp pain
An obese patient has limited mobility after an open reduction and internal fixation of a fractured hip. For which most serious complication of increased blood coagulability should the nurse monitor the patient?
1. muscle atrophy
2. pain in calf
pain in calf
(immobility promotes venous vasodilation, venous stasis, and hypercoagulability of the blood, which can precipitate the formation of a blood clot in a vein of the leg (thrombosis) and inflammation of the vein (phlebitis)
A nurse is assessing a patient. Which clinical manifestation indicates respiratory distress?
1. productive cough
2. sore throat
(ability to breathe easily only in an upright standing or sitting position)
The nurse identifies that a patients hands are edematous when attempting to apply a pulse oximetry probe. What is the nurse's primary action?
1. Attach the probe to one of the patients toes
2. connect the probe to one of the patients earlobes
3. Wash the patients hand before attaching the probe to the finger
4. Encourage patient to perform active range of motion exercises of the hand
connect the probe to one of the patients earlobes
(this site is used for intermittent, not continuous monitoring)
what is the most important thing the nurse should do to increase both the respiratory and the circulatory functions of a patient in a coma?
1. encourage patient to cough
2. massage the patients bony areas
3. assist the patient with breathing exercises
4. change the patients position every 2 hours
the proportion of blood volume that is occupied by red blood cells.
A nurse is reviewing the lab results of a patient with preliminary diagnosis of anemia. which diagnostic test reflects a response to iron deficiency anemia?
3. serum albumin
4. blood urea nitrogen
The practitioner orders oxygen for a patient to be delivered at a high flow rate. Which additional nursing action is necessary when implementing a high-liter flow as oppose to low liter flow?
1. humidifying oxygen before it is delivered
2. using an oil-based lubricant when caring for nares
3 providing oral hygiene when necessary
4. attaching a flowmeter to wall outlet
to prevent aspiration while administering physical hygiene to a patient receiving nasogastric feeding, the nurse should
1. lower the height of the bed
2. seek additional assistance
3. slow the rate of flow
4. shut off the feeding
patient walking in the hall complains of sudden chest pain. the initial intervention by the nurse should be to:
1. take the patients vital signs
2. perform a detailed assessment
3. walk the patient back to bed slowly
4. get a chair so the patient can sit and rest
when oxygen therapy via nasal canula is ordered for a patient, the first action by the nurse is to
1. post an oxygen in use sign on the door
2. adjust the oxygen level before applying the cannula
3. explain the rules of fire safety and oxygen use
4. lubricate the nares with water soluble jelly
What should the nurse do first when a patient chokes on food and is unable to speak?
1. initiate abdominal thrust maneuver
2. clap between scapulae several times
3. instruct the patient to swallow forcefully
4. wait to see if the patient can cough up the obstruction
The adequacy of tissue oxygenation is most accurately measured by
3. arterial blood gases
4. pulmonary function tests
The nurse assesses that the patient understands diaphragmatic breathing when the patient says, "I should:"
1. feel my abdomen flatten on inspiration
2. raise my shoulders and chest when I breathe
3. hold my breath for 3 seconds at the height of inspiration
4. use my hands to put pressure against my abdomen when I inhale
hold my breath for 3 seconds at the height of inspiration
(diaphragmatic breathing involves a pattern of a slow deep inhalation followed by a slow exhalation with a tightening of the abdominal muscles to aid exhalation; the patient should hold the breath for 2-3 seconds at the height of inhalation, just before exhalation)
When do wheezing breath sounds occur?
1. when fluid is in the lungs
2. when sitting in the orthopneic position
3. when air moves through a narrowed airway
4. when the pleural sack rubs against the lung surface
when air moves through a narrowed airway
(wheezes occur as air passes through airways narrowed by secretions, edema, or tumors. these high pitched squeaky musical sounds are best heard on expiration and are not usually changed by coughing.)
Which is most effective for maintaining a patent airway?
1. active coughing
2. incentive spirometry
3. nebulizer treatments
4. abdominal breathing
these structures produce mucous that moves up the respiratory passageway carrying with it dirt and other contaminants
A patient with a low pitched snoring sound most likely has an:
1. lower airway obstruction
2. upper airway obstruction
Which of the following signs or symptoms is the earliest clue that your patient has a problem with hypoxemia?
1. low pulse ox
2. dusky skin color
3. slow capillary refill
4. changes in respiratory rate
the most common cause of ischemia is
4. respiratory disorders
cyanosis, the blue discoloration of the skin and mucous membranes caused by desaturated hemoglobin in cappilaries is a __________ sign of hypoxia
The nurse is caring for a male client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do?
1. place the end of the chest tube in a container of sterile saline
2. apply an occlusive dressing
3. clamp the chest tube immediately
4. secure the chest tube immediately
a male client is admitted to health care facility for treatment of chronic obstructive pulmonary disease. which nursing diagnosis is most important for this client?
1. activity intolerance related to fatigue
2. anxiety related to actual threat to health status
3. risk for infection related to retained secretions
4. impaired gas exchange related to airflow obstruction
A male adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. prescribed respiratory treatment includes chest physiotherapy. when should the nurse perform this procedure?
1. immediately before a meal
2. at least 2 hours after a meal
3. when bronchospasms occur
4. when secretions have mobilized
at least 2 hours after a meal
Which nursing action best promotes adequate gas exchange in patients with COPD?
1. encouraging patient to drink 3 glasses of fluid daily
2. keeping the client in semi-fowlers position
3. using a high-flow venturi mask to deliver oxygen as prescribed
4. administering a sedative as prescribed
Nurse Joanna is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique.
1. it helps prevent early airway collapse
2. it increases inspiratory muscle strength
3. it decreases use of accessory breathing muscles
4. it prolongs inspiratory phase of respiration
helps prevent early airway collapse
A black male patient with asthma seeks emergency care for acute respiratory distress. Because of this clients dark skin, the nurse should assess for cyanosis by inspecting the
2. mucous membranes
3. nail beds
what is normal pH range for arterial blood?
2. 7.35 - 7.45
3. 7.5 - 7.6
4. 7.55 - 7.65
The amount of air inspired and expired with each breath is called
1. tidal volume
2. residual volume
3. vital capacity
4. dead-space volume
Air that develops in the pleural space is referred to as:
2. pleural effusion
When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal canula, what does the nurse expect?
1. oxygen must be humidified
2. rate will be 2L/min or less
3. arterial blood gases will be drawn every 4 hours to assess flow rate
4. rate will be 6 L/min or more
which oxygen delivery device would the nurse expect to use to provide the highest concentration of oxygen to a patient who is breathing spontaneously
1. partial rebreather
3. simple mask
4. venturi mask
which action would the nurse include when performing oropharyngeal suctioning on a patient?
1. use clean technique
2. apply suction as the catheter is introduced
3. flush catheter with saline between catheter insertions
4. limit suctioning to 25-30 second intervals at one time
flush catheter with saline between insertions
(suctioning should be limited to 15 second intervals, use sterile technique and should not apply suction as catheter is introduced)
Effective use of a metered dose inhaler requires that the patient accomplish which action
1. breathe in through the nose
2. inhale two sprays with one breath
3. hold the breath for 5 to 10 seconds
4. exhale quickly through an open mouth
hold breath 5 - 10 seconds
(should breathe in through nose, use one spray, and exhale slowly)
Mr. Parks has COPD. the nurse has taught him that pursed lip breathing helps him by:
1. increasing carbon dioxide, which stimulates breathing
2. prolonging inspiration and shortening expiration
3. liquefying secretions
4. decreasing amount of air trapping an resistance
decreasing amount of air trapping and resistance
(it diminishes CO2 levels, prolongs expiration)
a patient develops sudden cardiac arrest. It is imperative to begin CPR as soon as possible. What is the critical time that the nurse must keep in mind before irreversible brain damage occurs?
1. 1 to 3 mins
2. 2 to 4 mins
3. 4 to 6 mins
4. 8 to 10 mins
the nurse ensures that the mask fit snugly over the patients face for which reason?
1. to prevent mask movement and consequent skin breakdown
2. to help patient feel secure
3. maintain carbon dioxide retention
4. to aid in maintaining expected oxygen delivery
A patient who has difficulty breathing, increased respiratory pulse rates, and pale skin with regions of cyanosis may be suffering from which of the following?
When percussing a normal lung, which of the following sounds should be heard?
Which of the following breath sounds should be heard over the trachea?
To drain the apical sections of the upper lobes of the lungs, the nurse should place the patient in which of the following positions?
1. left side with a pillow under the chest wall
2. side-lying position, half on the abdomen half on the side
3. high fowlers
(posterior section of upper lobes = side lying, right lobe = left side w pillow under chest wall, left lobe = trendelenburg)
Which of the following inhalers is used to liquefy or loosen thick secretions?
2. mucolytic agents
4. metered-dose inhalers
A nurse suctioning a patient through a tracheostomy tube should be careful not to occlude te Y-port when inserting the suction catheter because it would cause which of the following to occur?
1. trauma to the tracheal mucosa
2. prevention of suctioning
3. loss of sterile field
4. suctioning of carbon dioxide
trauma to the tracheal mucosa
When caring for a patient with a tracheotomy, the nurse should be aware of which of the following?
1. the wound around the tube and inner canula should be cleaned every 24 hrs
2. the patien has no impairment of speaking function
3. newly inserted tracheostomy tube requires no immediate attention
4. suctioning of the tracheostomy tube must be done using sterile technique
suctioning of the trach tube must be done using sterile technique
When percussing the lungs of a patient with empyhysema, the nurse would probably hear which of the following?
which of the following is a function of the upper airway
1. conduction of air
2. mucociliary clearance
3. production of pulmonary surfactant
4. purification of inspired air
which of the following are components of the upper airway
medulla (and pons)
the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. what respiratory assessment findings would the nurse anticipate to observe in a patient with these arterial blood gas results
1. decrease in rate and depth respirations
2. decr in rate of respirations and increase in depth
3. increase in rate and decrease in depth
4. increase in rate and depth
The medulla in the brainstem is the respiratory center. The medulla is stimulated by an increased concentration of carbon dioxide and hydrogen ions and, to a lesser degree, by the decreased amount of oxygen in the arterial blood. Stimulation of the medulla increases the rate and depth of ventilation to blow off carbon dioxide and hydrogen and increase oxygen levels. This compensatory mechanism causes the patient to breathe faster and more deeply
which of the following is an accurate step that should be included in the teaching plan r/t incenctive spir.
1. instruct the patient to inhale slowly and as deeply as possible through the mouthpiece wout using nose
2. encourage the patient to perform incentive spirometry two to three times every 1 to 2 hours
3. when the patient cannot inhale anymore, the patient should hold his breath and count to 10
4.inhale normally and then place lips securely around the mouthpiece
The nurse is reviewing the client's arterial blood gas results. The test reveals a pH of 7.52, a PaO2 level of 49 mmHg and an HCO3 level of 28 mEq/L, the nurse suspects the client is most likely experiencing which of the following conditions?
1. Metabolic acidosis
2. Respiratory alkalosis
3. Metabolic alkalosis
4. Respiratory acidosis
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