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10 Cards in this Set
- Front
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A client with no prior history of respiratory illness has been admitted to a postoperative 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
Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery. |
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The nurse schedules a pulmonary function test to measure the amount of air left in a client’s lungs at maximal expiration. What test does the nurse order? |
Residual Volume (RV)
During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds. |
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The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate? |
Check the fit of the oxygen mask.
The fit of the oxygen mask can be affected by the discontinuation of wearing dentures. The nurse should check the fit to make sure the client is getting the prescribed amount of oxygen. Other answers are inappropriate actions that do not address the problem. |
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The home health nurse is visiting a new client who has recently started using an oxygen concentrator. After assessing the home environment, which comment should the nurse prioritize? |
"Have you discussed a back-up system with your health care provider in case your electricity goes out?"
The concentrator depends on electricity to work correctly, so each client should have a backup system in case the electricity goes out to ensure he or she will still be able to obtain the oxygen level needed. Some of the newer models are now using the DC outlets found in motor vehicles and have rechargeable batteries; however, the client should still have a backup plan. The questions could be asked during the assessment; however, asking about a backup system is the priority. |
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When the nurse observes a newborn infant demonstrating an irregular abdominal breathing pattern, with a respiratory rate of 40 breaths/minute with occasional pauses in breathing of 5-second duration. What is the most appropriate action by the nurse? |
Continue to assess the infant
Infants breathe rapidly at 30 to 60 breaths/minute and may have occasional pauses of several seconds between breaths. |
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A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing: |
a bronchospasm
When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm. |
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In which client would the nurse assess for a depressed respiratory system? |
a client taking opioids for cancer pain
Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Amlodipine is a calcium channel blocker and the medication decreased blood pressure, so the nurse would need to assess blood pressure. Antibiotics are used for urinary tract infections as well as other infections and the infections do not affect the respiratory system. Insulin decreases blood sugar which a person with diabetes may need to take every day. Insulin does not affect the respiratory system. |
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A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response? |
“The caregiver will need to place the oxygen tank back into the secure carrier.”
Oxygen tanks are transported on a wheeled carrier to avoid accidental force. Accidental force could cause the tank to explode. The tank should not be carried, and taking it out of the carrier does not affect the flow of oxygen. |
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Which teaching about the humidifier is important for the nurse to provide to a client using oxygen? |
It decreases dry mucous membranes via delivering small water droplets.
The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. |
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The nurse provides care for a client with chronic bronchitis and a decreasing oxygen saturation. Which factor(s), if assessed, indicate a deteriorating condition? Select all that apply. |
Tachypnea Tachycardia Shortness of breath Wheezing and crackles in lungs
The nurse providing care for the client with chronic bronchitis and a decreasing oxygenation saturation assesses for tachypnea, tachycardia, shortness of breath, and wheezing and crackles in lungs, all of which indicate hypoxia and may require immediate intervention as oxygenation deteriorates and respiratory failure progresses. Bradycardia is not associated with decreasing oxygen saturation because the heart rate increases in response to decreasing oxygenation. |
