Review 1
A postoperative client is at risk for atelectasis. Which intervention should the nurse implement?
Encourage use of the incentive spirometer every hour while awake.
The nurse finds a patient with pneumonia lying supine in bed, complaining of shortness of breath. The patient's Sp02 is 88%. Which nursing action should the nurse perform first?
A.) Notify the health care provider.
B.) Take the patient's blood pressure and respiratory rate.
C.) Raise the head of the bed to 45 degrees.
D.) Increase the oxygen flow rate.
What is C.) Raise the head of the bed to 45 degrees.
A client with chronic obstructive pulmonary disease (COPD) is using oxygen at home. Which statement by the client indicates a need for further teaching?
A.) "I will keep my oxygen tank at least five feet away from my stove."
B.) "I will use petroleum jelly on my nose when it gets dry."
C.) "I will check that my oxygen tubing is not kinked."
D.) "I will make sure my visitors do not smoke near my oxygen."
What is B.) "I will use petroleum jelly on my nose when it gets dry."
A patient with COPD is prescribed low-flow oxygen. Which delivery device is most appropriate to deliver a consistent, low concentration of oxygen?
A.) Simple face mask
B.) Nonrebreather mask
C.) Venturi mask
D.) Nasal cannula
What is D.) Nasal cannula
A client receiving oxygen via nasal cannula complains of dry nasal passages. What is the best intervention?
A.) Discontinue oxygen
B.) Apply petroleum jelly
C.) Increase oxygen flow
D.) Add humidification
What is D.) Add humidification
A nurse is caring for a client experiencing an acute asthma exacerbation. Which assessment finding requires immediate intervention?
A.) Loud wheezing heard throughout all lung fields
B.) Respiratory rate of 26 breaths per minute
C.) Sudden absence of wheezing with continued dyspnea
D.) Use of accessory muscles during breathing
What is C.) Sudden absence of wheezing with continued dyspnea
A nurse is teaching a client with COPD about home oxygen therapy. Which statement by the client indicates the need for further teaching?
A.) “I should use water-based lubricants on my lips and nose.”
B.) “I can increase my oxygen flow rate when I feel short of breath.”
C.) “I need to avoid smoking while using oxygen.”
D.) “I should clean my nasal cannula regularly with soap and water.”
What is B.) “I can increase my oxygen flow rate when I feel short of breath.”
A nurse is caring for an older adult client admitted with bacterial pneumonia. Which nursing intervention is the priority?
A.) Administering antibiotics as prescribed
B.) Encouraging fluid intake of 2-3 liters daily
C.) Teaching effective coughing techniques
D.) Monitoring oxygen saturation levels
What is A.) Administering antibiotics as prescribed
A nurse is teaching a client newly diagnosed with active pulmonary tuberculosis. Which instruction is most important to include?
A.) “Eat a high-calorie, high-protein diet to promote healing.”
B.) “Take all prescribed medications for the full duration, even if you feel better.”
C.) “Wear a mask when leaving your home for appointments.”
D.) “Avoid contact with children and pregnant women.”
What is B.) “Take all prescribed medications for the full duration, even if you feel better.”
A nurse is caring for a client with a chest tube for a pneumothorax. Which assessment finding requires immediate notification of the healthcare provider?
A.) Continuous bubbling in the water seal chamber
B.) Tidaling (fluctuation) in the water seal chamber
C.) 100 mL of serosanguineous drainage in the last hour
D.) Client reports pain at the insertion site
What is A.) Continuous bubbling in the water seal chamber
A patient presents with restlessness, tachycardia, nasal flaring, and an SpO₂ of 84% on room air. The patient is anxious and using accessory muscles to breathe. What problem is the patient experiencing?
What is Hypoxemia
A patient with severe COPD is placed on high-flow oxygen. Shortly after, the patient becomes drowsy, has a decreased respiratory rate, and ABGs show elevated PaCO₂ levels. What complication is the patient experiencing?
What is Respiratory Acidosis (CO₂ narcosis)
A patient is hyperventilating after a panic attack. ABGs show pH 7.48, PaCO₂ 30 mmHg, HCO₃ 24 mEq/L. What condition is the patient experiencing?
What is Respiratory Alkalosis
A patient suddenly develops sharp unilateral chest pain and severe shortness of breath. Assessment reveals absent breath sounds on the right side and tracheal deviation to the left. What condition is the patient experiencing?
What is a Tension Pneumothorax
A postoperative patient is shallow breathing due to incisional pain. The nurse notes diminished breath sounds at the lung bases and a low-grade fever on postoperative day 1. What complication is most likely developing?
What is Atelectasis