Respiratory Disorders & Oxygenation
This breathing technique helps improve ventilation in COPD clients by slowing exhalation and preventing air trapping
Which lab value indicates iron deficiency anemia?
Low hemoglobin and hematocrit, low serum iron, and low ferritin.
Which medication is used to prevent further blood clot formation in a client with pulmonary embolism?
Heparin or Warfarin or an anticoagulant
A nurse is caring for a client with a multidrug-resistant organism (MDRO) infection. What type of precautions should the nurse implement, and what PPE is required?
Contact precautions; gloves and gown required when entering the room, dedicated equipment for the client.
Swelling of the lips, tongue, and other tissues is a hallmark of what?
Angioedema
Which ABG finding would you expect in early respiratory distress?
Respiratory alkalosis with low PaCO₂
A client receiving a blood transfusion reports chills and back pain. What is the priority action?
Stop the transfusion immediately.
A client with asthma is prescribed albuterol. What common side effect should the nurse teach about?
Tachycardia, tremors, and palpitations.
A nurse is suctioning a client’s tracheostomy. How long should each suction pass last?
No more than 10 seconds.
A nurse assesses a client with anemia and notes pallor, fatigue, and dizziness. Which step of the nursing process is this?
Assessment
A client with pneumonia reports worsening dyspnea and has an SpO₂ of 88% on room air. What is the first nursing action?
Administer supplemental oxygen.
What are the hallmark signs of Disseminated Intravascular Coagulation (DIC)?
Widespread bleeding and clotting simultaneously, leading to petechiae, purpura, and hemorrhage.
A nurse is preparing to administer a blood transfusion. What are the two most critical checks before administration?
Verify blood type and crossmatch, and confirm two-client identifiers.
A nurse enters a client’s room and notices bubbling in the water-seal chamber of the chest tube drainage system. What does this indicate?
An air leak is present.
A nurse is evaluating a client’s response to diuretic therapy. Which finding indicates improvement?
Decreased weight, improved lung sounds, reduced edema.
A client diagnosed with pulmonary embolism is experiencing sudden chest pain and dyspnea. What two actions should the nurse do next?
Place the client in high Fowler’s position and apply oxygen.
A client with an autoimmune disorder is receiving corticosteroids. What major adverse effect should the nurse monitor for?
Increased risk for infection.
A client with ARDS is receiving IV fluids. What is the primary concern with fluid administration?
Risk of fluid overload and pulmonary edema.
A nurse is caring for a client who has a chest tube connected to a closed drainage system. What is the most important action to take during transport to the x-ray department?
Keep the drainage system below the level of the client’s chest at all times to prevent air and fluid from re-entering the pleural space.
A nurse is planning care for a client at risk for aspiration. What is the most effective intervention?
Positioning the client in a high Fowler’s position during meals.
A client with tuberculosis (TB) is on airborne precautions. Name three requirements for infection control.
Negative pressure room, N95 mask, and dedicated client equipment.
A client’s lab report shows a platelet count of 90,000. What condition is this, and what is the priority intervention?
Thrombocytopenia. Monitor for bleeding and avoid invasive procedures.
A nurse is caring for a client receiving a continuous heparin infusion. What lab value should be closely monitored?
PT and aPTT (Activated Partial Thromboplastin Time).
A nurse is caring for a client receiving mechanical ventilation. What alarm is most concerning and requires immediate intervention?
Low-pressure alarm (indicates a disconnection or leak).
Which client should the nurse see first?
1. A client with COPD on 2L O₂ who reports mild shortness of breath.
2. A client with pneumonia who has a fever of 100.8°F.
3. A post-op client with an indwelling catheter reporting bladder discomfort.
4. A client with a pulmonary embolism reporting sudden shortness of breath.
Client 4—PE is a medical emergency.