Respiratory Devices
The nurse performs client rounds and notes that a client with a respiratory disorder is wearing this oxygen device. The nurse should document that the client is receiving oxygen by which type of low-flow oxygen delivery system? Refer to figure.
Simple Face Mask
A simple face mask is used to deliver oxygen concentrations of 40% to 60% for short term oxygen therapy. The simple face mask fits over the nose and mouth, has exhalation ports, and a tube that connects to the oxygen source. Other oxygen delivery devices are nasal cannula or the venturi vask, which is high flow (Silvestri & Silvestri, 2018).
Which finding is the best indication that a client with ineffective airway clearance needs suctioning? (Rinehart et al., 2017)
A. Oxygen saturation
B. Respiratory rate
C. Breath sounds
D. Arterial blood gases
C -
Changes in breath sounds are the best indication of the need for suctioning in the client with trouble clearing their airways
Answers A, B, and D are incorrect because they can be altered by other conditions (Rinehart et al., 2017).
A nurse is providing care to a client who is to be maintained on strict bed rest for three weeks. In order to help prevent atelectasis, the nurse teaches the client to: (BoardVitals, 2022)
A. Perform range of motion exercises several times a day
B. Deep-breathing and coughing several times a day
C. Wear antiembolism stockings daily as ordered
D. Flex and extend her feet every two hours
B
Atelectasis refers to total or partial collapse of the lungs usually due to obstruction which leads to impaired gas exchange. Deep-breathing and coughing will help expand the lungs.
Range of motion is appropriate for the client on bed rest, but not to prevent atelectasis.
Antiembolism stockings may be ordered to prevent thrombophlebitis, but they will not help prevent atelectasis nor will flexing and extending the feet.
The home care nurse assesses a client diagnosed with chronic obstructive pulmonary disease (COPD) who is reporting increased dyspnea. The client is on home oxygen via a concentrator at 2 L per minute, and has a respiratory rate of 22 breaths per minute. Which action should the nurse take? (Silvestri & Silvestri, 2018)
A. Determine the need to increase the oxygen.
B. Reassure the client that there is no need to worry.
C. Conduct further assessment of the client’s respiratory status.
D. Call emergency services to take the client to the emergency department.
C
With the client’s respiratory rate at 22 breaths per minute, the nurse should obtain further assessment. Oxygen is not increased without the approval of of the primary health care provider, especially because the client with COPD can retain carbon dioxide. Reassuring the client that there is “no need to worry” is inappropriate. Calling emergency services is a premature action (Silvestri & Silvestri, 2018).
A nurse is caring for an adult client who is being treated for pancreatitis and requires a mechanical ventilator for assistance with breathing. The physician orders an arterial blood gas, which provides the following results: pH: 7.28; pCO2 51 mmHg; HCO3 24 mEq/L; SaO2 92%. Based on these results, which of the following best describes this client's condition? (BoardVitals, 2022).
A. Respiratory acidosis
B. Respiratory alkalosis
C. Metabolic acidosis
D. Metabolic alkalosis
A
Respiratory acidosis because it's evidenced by the low pH and the elevated pCO2. The HCO3 levels are within normal limits so it indicates that the acidosis is respiratory and not metabolic. (BoardVitals, 2022)
A nursing is caring for a client who uses oxygen and who smokes. The client says, “ I know I shouldn’t smoke, but I can’t seem to quit”. Which response from the nurse is most appropriate? (BoardVitals, 2022)
A. “You are putting yourself in danger when you smoke around oxygen; let’s talk about some options to help you quit.”
B. “I know it is difficult to quit smoking, but if you continue to smoke we will have to discontinue using the oxygen.”
C. “You are negating the effect of the oxygen when you smoke, so we will discontinue the order until you are ready to quit smoking.”
D. “You should be able to smoke 1 to 2 cigarettes a day and still be safe, even if you use oxygen.”
A
This is a non-judgmental answer. The client does not need to stop using oxygen since it can help with his condition. Instead he should be educated about the dangers of using oxygen while smoking. By educating the patient, the nurse can establish an atmosphere of helpfulness and trust in the relationship with the client (BoardVitals, 2022).
A nurse if caring for a client who has a chest tube in place for treatment of a hemothorax. Which of the following is appropriate when caring for a client with a chest tube? (BoardVitals, 2022)
A. Keep the drainage system at the level of the client’s chest at all times
B. Assist the client to remain in the supine position to facilitate drainage
C. Ensure there is a small amount of crepitus at the chest tube insertion site
D. Avoid routinely stripping or milking the tubing to remove drainage
D
Stripping or milking the tube creates negative pressure and may compromise the patency of the chest tube. A chest tube is used to remove air and fluid from the pleural space and to restore negative pressure.
The chest tube drainage system should be below the client’s chest to facilitate drainage.
The client should be in semi or high Fowler’s position to promote expansion of the lungs.
Crepitus is an abnormal finding at the insertion site and indicates air has collected in the subcutaneous tissues.
The nurse is assessing the respiratory status of the client after a thoracentesis has been performed. The nurse would become concerned with which assessment finding? (Silvestri & Silvestri, 2018)
A. Equal bilateral chest expansion
B. Respiratory rate of 22 breaths per minute
C. Diminished breath sounds on the affected side
D. Few scattered wheezes, unchanged from baseline
C - Diminished breath sounds on the affected side
The nurses should assess Vitals and breath sounds and pay attention to increased respiratory rates, dyspnea, retractions, diminished breath sounds, or cyanosis; these could all indicate pneumothorax. If noted, the nurse should report to the physician ASAP
(Silvestri & Silvestri, 2018).
A nurse is caring for a 62-year-old client who has been diagnosed with emphysema. The nurse understands that the client is at high-risk for pulmonary infection. Which of the following conditions predisposes the client to infection? (BoardVitals, 2022)
A. Weight gain
B. Fluid imbalances
C. Pooling of respiratory secretions
D. Small anteroposterior chest diameter
C. Pooling of respiratory secretions
People with emphysema have difficulty excreting lung secretions, therefore if their respiratory secretions pool in their lungs and they are unable to expel them, the client is then at risk for pulmonary infection (BoardVitals, 2022).
A client with pneumonia is complaining of difficulty breathing. Which of the following interventions is appropriate for this type of client (Select all that apply) (BoardVitals, 2022)
A. Encourage visualization
B. Administer antipyretic
C. Teach slow abdominal breathings
D. Elevate lower extremities
E. Encourage ambulation
A, C
The nurse needs to provide intervention that will gradually correct the ineffectiveness of breathing patterns, such as teaching slow abdominal breathing to promote lung expansion, encouraging visualization or imagery to reduce anxiety and slow the breathing pattern, providing reassurance to reduce levels of anxiety that tend to increase respiratory rate, and administration of oxygen to increase alveolar oxygenation.
A nurse in a pediatric clinic is assessing a child and after performing a sweat chloride test, the test results came back positive. The nurse can confirm that the child has _________. (BoardVitals, 2022)
Cystic Fibrosis
People who have cystic fibrosis have increased levels of sodium and chloride in both their sweat and saliva. (BoardVitals, 2022).
A nurse is caring for a client with an acute asthma exacerbation who is receiving treatment with nebulized epinephrine. Which of the following is an adverse effect of the medication? (BoardVitals, 2022)
A. Tremor
B. Headache
C. Nasal stinging
D. Heart rate of 160/min
D
A and C are expected side effects. Headaches are expected, but resolves without treatment. Epinephrine should be cautiously used in older adult clients or those with hypertension or heart disease. Tachyarrhythmia may occur, including ventricular fibrillation (BoardVitals, 2022).
Which instruction should be given to the client who has been prescribed a dry powder inhaler for treatment of COPD? Select all that apply. (Rinehart et al., 2017)
A. Remove the mouthpiece cap and shake before using.
B. Rinse the inhaler mouthpiece and spacer after each use.
C. Use a spacer or hold the canister two fingerbreadths away from the mouth.
D. Place the mouthpiece directly in the mouth.
E. Clean the mouthpiece weekly using a dry cloth.
D, E
A, B, and C are for the use of a metered dose inhaler (Rinehart et al., 2017).
A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. Which is the earliest clinical manifestation of acute respiratory distress syndrome (ARDS) the nurse should monitor for? (Silvestri & Silvestri, 2018)
A. Cyanosis with accompanying pallor
B. Diffuse crackles and rhonchi on chest auscultation
C. Increase in respiratory rate from 18 to 30 breaths per minute
D. Haziness or “white-out” appearance of lungs on chest radiograph
C -
ARDS are likely to develop within 24 to 48 hours an event such as chest trauma. Most of the time, tachypnea and dyspnea are the earliest manifestations as the body compensates for mild hypoxemia through hyperventilation (Silvestri & Silvestri, 2018).
The nurse asks the client to repeat "ninety-nine" in a normal voice while feeling for vibrations on their back. The nurse is assessing a client for ____________. (BoardVitals, 2022).
Tactile fremitus
This assessment uses the vibration of sounds through the chest wall. The vibrations may be decreased or absent from the larynx to the chest surface if things such as COPD, tumors, obstruction, pneumothorax, or pleural effusion block the vibrations.
Which actions should the nurse take when obtaining a from a client with a diagnosis of pneumonia? Select all that apply. (Silvestri & Silvestri, 2018)
A. Explain the procedure to the client.
B. Obtain the specimen early in the morning
C. Have the client brush his teeth before expectoration
D. Instruct the client to take deep breaths before coughing
E. Place the lid on the culture container face down on the bedside table.
A, B, C, D
The nurse always explains a procedure to the client. The specimen is obtained early in the morning whenever possible because increased amounts of sputum collect in the airways during sleep. The client should rinse the mouth or brush the teeth before specimen collection to avoid contaminating the specimen. The client should take deep breaths before expectoration for best sputum production. Placing the lid face down on the bedside table contaminates the lid and could result in inaccurate findings (Silvestri & Silvestri, 2018).
A nurse is educating a group of refugees about the initial signs of tuberculosis. Which of the following is an initial symptom of this condition? (BoardVitals, 2022)
A. Nausea and vomiting
B. Cough with bloody sputum
C. Pruritic rash
D. Headache and blurred vision
B
Initial manifestations include a persistent cough, hemoptysis, weight loss, fever, chills, night sweats, anorexia, and dyspnea. TB is an airborne disease and initial symptoms are related to the respiratory tract.
Fever can result in a headache, but a headache is not a primary symptom of TB, and blurred vision would not be expected. (BoardVitals, 2022)
A client’s arterial blood gas reveals the following results: pH 7.2, PCO2 50 mm Hg, HCO3 28 mEq/L. From these results, the nurse determines that the client is in ________________. (Fill in the blank). (Rinehart et al., 2017)
Respiratory acidosis
The pH 7.2 indicates acidosis (normal pH 7.35-7.45). The pCO2 of 55 mm Hg indicates acidosis (normal pCO2 is 35-45 mm Hg). The HCO3 of 28 is elevated (normal HCO3 is 22-26 mEq/L) (Rinehart et al., 2017).
A client diagnosed with acute respiratory distress syndrome has a prescription to be placed on a continuous positive airway pressure (CPAP) face mask. What intervention should the nurse implement for this procedure to be beneficial? (Silvestri & Silvestri, 2018)
A. Obtain baseline arterial blood gases
B. Obtain baseline pulse oximetry levels
C. Apply the mask to the face with a snug fit
D. Remove the mask for deep breathing exercises
C
The CPAP face mask must be applied over the nose and mouth with snug fit, which will help maintain positive pressure in the client’s airways. Baseline respiratory assessments and arterial blood gases evaluate the effectiveness of therapy, but do not increase the effectiveness of the procedure (Silvestri & Silvestri, 2018).
A nurse is assessing a client who was admitted with diabetic ketoacidosis (DKA). The client is taking very deep, rapid breaths at a rate of 24/minute. The nurse recognizes this respiratory pattern as which of the following?
A. Hypopnea
B. Cheyne-stokes respiration
C. Biot’s Respiration
D. Kussmaul respirations
D -
Kussmaul respirations are rapid, deep breaths at a rate of greater than 20 per minute are common in clients with DKA, metabolic acidosis, or renal failure.
Hypopnea refers to slow or shallow breathing.
Cheyne-Stokes respiration is an abnormal breathing rate and periods of apnea.
Biot’s respirations are rapid, shallow breaths followed by periods of apnea.
A nurse is completing the admission assessment on a client who has suspected lung cancer. Which of the following manifestations should the nurse expect? (Select all that apply). (BoardVitals, 2022).
A. Temperature of 38.9 degrees celsius (102 degrees F) for more than 36 hours
B. Night sweats
C. Dysphasia
D. Frothy sputum
E. Pain in the back of the legs
C, D
Dysphasia and the presence of frothy sputum is a potential indication or lung cancer. The nurse should complete an in-depth assessment to look for any manifestations that could indicate lung cancer because most cancers are not detectable in the early stage. (BoardVitals, 2022).
A nurse is caring for an adolescent client with Cystic fibrosis. Which of the finding requires immediate intervention when caring for this client?
A. Delayed puberty
B. Chest pain with dyspnea
C. Poor weight gain
D. Large foul-smelling bulky stool
B
Chest pain and dyspnea are signs of pneumothorax.
Delayed puberty may be an issue for an adolescent with CF but this does not require immediate intervention.
A client with CF may have poor weight gain, but the nurse would need to address the chest pain and dyspnea first.
Foul-smelling stools should be addressed but they do not require immediate intervention.
A nurse is assessing a client with emphysema. Which assessment findings does the nurse anticipate in this form of COPD? (Select all that apply). (BoardVitals, 2022)
A. Hyperresonance on percussion of the lung area
B. Increased respiratory effort
C. Family history of smoking
D. Increased chest diameter when measured anteriorly and posteriorly
E. Productive cough, chronic and increased in the morning
A, B, D - Hyperresonance on percussion, Increased respiratory effort, Increase chest diameter
Since Emphysema is a disease of the alveolar walls losing their elasticity it becomes more likely to collapse and the air is, therefore, harder to exit leading to Hyperventilation. Enlarged AP diameter, hyperresonance on percussion and increased respiratory efforts are all manifestations of Emphysema. (BoardVitals, 2022)
The physician orders an arterial blood gas (ABG) for a client receiving oxygen at 6 L/min. Results show pH 7.37, HCO3 26 mm Hg, pCO2 42 mm Hg, pO2 93 mm Hg. Which of the following should the nurse do first? (Kaplan, 2020)
A. Increase the rate of oxygen flow the client is receiving.
B. Elevate the head of the bed.
C. Document the results in the chart.
D. Instruct the client to cough and deep-breathe.
C
The ABGs are within normal limits.
The nurse is caring for a client with a closed chest drainage system. Place an X on the suction control chamber. (Rinehart et al., 2017)
The first chamber of a closed chest drainage system helps to re-establish negative intrathoracic pressure. The chamber is filled with water to a level that regulates the amount of suction.
The second chamber is the water seal chamber. It is filled to the 2cm mark with sterile water. Fluctuations in the water seal chamber indicates the client breathing.
The third chamber is the drainage collection chamber (Rinehart et al., 2017).
The nurse is assessing a client with pulmonary embolism. Which of the following are signs and symptoms consistent with pulmonary embolism?(Select all that apply) (BoardVitals, 2022)
A. Hypotension
B. Cardiac output is decreased
C. Anxiety
D. Hypercapnia
E. Slurred speech
F. Chest flailing
A, B, C - Hypotension, CO decreased, Anxiety
Pulmonary embolism (PE) obstructs blood flow and the pulmonary artery is obstructed as a result. This can lead to hypotension due to decreased Cardiac output. In this case, the patient can be very anxious and scared. (BoardVitals, 2022).
A nurse is assisting with the care of a child who is experiencing respiratory failure. Which of the following findings are considered early cardinal manifestations of this condition (Select all that apply). (BoardVitals, 2022)
A. Stupor behavior
B. Peripheral cyanosis
C. Tachycardia
D. Diaphoresis
E. Restlessness
C, D, E
Tachycardia is a manifestation of respiratory distress, the heart tries to pump harder in order to compensate for the lack of perfusion. Diaphoresis occurs because of decreased oxygenation and perfusion. Restlessness occurs as well with decreased oxygenation and lack of perfusion to the tissues. These 3 signs occur early in respiratory distress. Stupor and peripheral cyanosis occurs in late respiratory distress. (BoardVitals, 2022).
A patient comes into the emergency department and the nurse auscultates the patient's breath sounds. The nurse uses which term to document the findings. Refer to the video.
A. Stridor
B. Wheezing
C. Rhonchi
D. Rales
Stridor
Stridor is characterized by a high pitched turbulent sound which occurs when a patient inhales or exhales. It can indicate an obstruction or narrowing in the upper airway.
A nurse on a pediatric unit is teaching a group of student nurses about childhood diseases that are associated with pneumonia. Which of the following diseases can result in pneumonia? (Select all that apply) (BoardVitals, 2022)
A. Erythema infectiosum (Fifth disease)
B. Rubeola (Measles)
C. Pertussis (Whooping cough)
D. Varicella (Chickenpox)
E. Mumps
B, C, D - Rubeola (Measles), Pertussis, Varicella
Rubeola and Pertussis have symptoms that affect the respiratory tract. Chickenpox can cause pneumonia.
(BoardVitals, 2022).
A nurse is helping a newly licensed nurse care for a client who has COPD and is receiving mechanical ventilation. Which of the following statements by the newly licensed nurse about pressure support ventilation (PSV) indicates an understanding of the procedure? (BoardVitals, 2022)
A. “It keeps the alveoli open and prevents atelectasis.”
B. “It allows preset pressure to be delivered during spontaneous ventilation.”
C. “It provides partial support in response to the client’s inspiratory efforts.”
D. “It delivers a preset ventilatory rate and tidal volume to the client.”
B
PSV allows preset pressure to be delivered during the time the patient takes their spontaneous breath.
Positive end-expiratory pressure keeps the alveoli open.
Proportional assist ventilation provides partial support.
Assist control mode also known as continuous mandatory ventilation delivers a preset rate and tidal volume.