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Oxygenation/Pneumonia

Terms in this set (26)

The nurse recognizes that which pathophysiologic changes are occurring when caring for the client with respiratory acidosis? Select all that apply.
A) Increased CO2
B) Vasoconstriction
C) Decreased O2
D) Decreased intracranial pressure (ICP)
E) Increased pulse rate
A,C,E
The nurse is providing care to a client diagnosed with chronic obstructive pulmonary disease (COPD). Which clinical manifestations are the direct result of altered perfusion? Select all that apply.
A) Bounding pulse
B) Pink nail beds
C) Cyanosis
D) Confusion
E) Wheezing
C,D
The nurse is providing care to an adult client with a long history of chronic obstructive pulmonary disease (COPD). The client is admitted to the intensive care unit with a pneumothorax. Which interventions are appropriate for this client? Select all that apply.
A) Elevate head of the bed
B) Administer a high rate of oxygen by nasal cannula
C) Prepare for a chest tube insertion
D) Administer prescribed antihypertensive medications
E) Administer intravenous caffeine per order
A,C
The nurse is reviewing the results of laboratory tests conducted on a client admitted with an alteration in respiratory function. Which laboratory finding would be most significant for this client?
A) Hemoglobin level 14 g/dL
B) Oxygen saturation 96%
C) Serum sodium 140 mg/dL
D) Blood pH 7.32
D
A client with chronic obstructive pulmonary disease (COPD) is prescribed oxygen 24% 2 L/min. Which is the best method to administer oxygen to this client?
A) Face mask
B) Nasal cannula
C) Nonrebreather mask
D) Venturi mask
B
The nurse is planning care for a client experiencing dyspnea and a subsequent activity intolerance. Which action by the nurse is the most appropriate?
A) Encourage strenuous activity.
B) Consult a dietitian for low-calorie meals.
C) Space periods of activity with periods of rest.
D) Encourage dependence with activities of daily living.
C
The nurse is conducting an assessment for a client on a medical-surgical unit. Which findings are indicative of a client who is experiencing tachypnea? Select all that apply.
A) Excessive rapid breathing
B) Chest pain
C) Rapid breathing at rest
D) Shallow breathing
E) Cyanosis
A,C,D
The charge nurse is observing a newly licensed nurse conduct an admission assessment on a client with asthma. Which action by the newly licensed nurse requires immediate intervention?
A) The newly licensed nurse is observed obtaining the pulse oximetry reading 10 minutes after the client used an albuterol inhaler.
B) The newly licensed nurse is observed continuing to ask the client questions regarding history while the client demonstrates difficulty breathing and signs of respiratory impairment.
C) The newly licensed nurse is observed assessing the client's thoracic wall, skin, and nail beds.
D) The newly licensed nurse is observed auscultating breath sounds with a stethoscope.
B
Which independent nursing interventions are appropriate for a client who is experiencing an alteration in oxygenation? Select all that apply.
A) Encouraging deep breathing exercises
B) Assisting with positioning
C) Providing suctioning
D) Prescribing bronchodilators
E) Monitoring activity intolerance
A,B,C,E
While performing nasotracheal suctioning, the nurse notes the older adult client with an alteration in oxygenation is moving the head around and pulling at the nurse's hand to remove the suction catheter. Which actions by the nurse are appropriate? Select all that apply.
A) Remove the suction catheter
B) Lower the head of the bed
C) Decrease the suction pressure
D) Apply restraints to the client's arms and legs
E) Hyperoxygenate the client
A,C,E
Vaccinations can help promote healthy oxygenation by
A) reducing the transmission of preventable diseases.
B) increasing the exchange of oxygen for carbon dioxide in the lungs.
C) promoting adequate blood circulation to organs and tissues.
D) preventing all respiratory infections.
A
A client with a respiratory rate of 8 breaths per minute has an oxygen saturation of 82%. Which nursing diagnosis is a priority for this client?
A) Risk for Infection
B) Impaired Spontaneous Ventilation
C) Risk for Acute Confusion
D) Decreased Cardiac Output
B
A client admitted with smoke inhalation injuries develops signs and symptoms of acute respiratory distress syndrome (ARDS). The nurse anticipates the healthcare provider will prescribe which course of action with regard to oxygenation?
A) Oxygen via a nasal cannula
B) Mechanical ventilation
C) Oxygen via a face mask
D) Oxygen via a Venturi mask
B
A client diagnosed with asthma has a respiratory rate of 28 at rest with audible wheezes upon inspiration. Based on this data, which nursing diagnosis is the most appropriate?
A) Ineffective Airway Clearance
B) Impaired Tissue Perfusion
C) Ineffective Breathing Pattern
D) Activity Intolerance
C
The nurse is providing care to a client with asthma. When developing the client's plan of care, which intervention would be most appropriate to promote effective gas exchange?
A) Provide adequate rest periods
B) Reduce excessive stimuli
C) Assist with activities of daily living
D) Place in Fowler position
D
Because of the way the influenza virus is transmitted from person to person, nurses who are working with clients with influenza should implement
A) droplet precautions.
B) isolation precautions.
C) airborne precautions.
D) contact precautions.
A
An older adult client is admitted with pneumonia. Which manifestations would the nurse expect to find when assessing this client? Select all that apply.
A) Hemoptysis
B) Increased appetite
C) Cough
D) Tachypnea
E) Fever
A,C,D,E
An older adult client asks the nurse what can be done to decrease the risk of developing pneumonia. Which responses by the nurse are most appropriate? Select all that apply.
A) "Once per day, you should eat yogurt that is supplemented with L. casei immunitas cultures."
B) "Eliminating habits like smoking can help."
C) "You can get the pneumonia vaccination, which may help decrease your risk in the future."
D) "Avoiding alcohol will reduce your risk."
E) "There is nothing you can do to decrease your risk of pneumonia in the future."
B,C,D
The nurse is caring for an older adult client who is hospitalized with a second episode of pneumonia in the past 18 months. The client has expressed frustration to the nurse and states, "I never got sick when I was younger. Why is this happening?" Which response by the nurse is most appropriate?
A) "As you grow older, your immune system just quits working."
B) "As you grow older, there is a decrease in the immune response, which puts you at greater risk for developing an infection."
C) "As you grow older, there in an overall increase in the speed and strength of your immune response."
D) "As you grow older, there is an increase in the number of B cells in the circulation, which hinders the immune response."
B
The nurse is caring for a client with pneumonia. Which intervention should the nurse include in this client's plan of care to promote effective airway clearance?
A) Perform chest percussion every 4 hours and prn.
B) Administer the pneumococcal vaccine prior to discharge.
C) Limit fluid intake to 1000 mL per day.
D) Provide the client with smoking cessation education.
A
The nurse is providing discharge teaching to a client recovering from pneumonia. Which client statement indicates that additional teaching is needed?
A) "I can't get the influenza vaccine due to my allergy to eggs."
B) "I will get the influenza vaccine every year."
C) "I will get the pneumococcal vaccine every fall."
D) "The pneumococcal vaccine protects against bacterial pneumonia."
C
Which intervention should the nurse carry out to manage fever in a client with pneumonia? Select all that apply.
A) Increase the temperature of the room environment to prevent shivering.
B) Administer antipyretic medications.
C) Restrict fluids during periods of hyperthermia because of the risk of electrolyte imbalance.
D) Use ice packs and a tepid bath every 2 hours.
E) Promote frequent rest periods to increase energy reserve.
B,E
The nurse is caring for a client who develops a fever and productive cough after abdominal surgery. Which orders should the nurse expect from the healthcare provider? Select all that apply.
A) Sputum cultures
B) Antibiotics
C) Chest physiotherapy
D) Bronchial washing for culture
E) Isolation precautions
A,B,C
Which of the following is not one of the four distinct patterns of pneumonia?
A) Lobar pneumonia
B) Bronchopneumonia
C) Alveolar pneumonia
D) Interstitial pneumonia
C
Which type of pneumonia rarely occurs in individuals with normal immune function?
A) Pneumonia caused by the influenza virus
B) Pneumonia caused by Pneumocystis jiroveci
C) Pneumonia caused by Mycoplasma pneumoniae
D) Pneumonia caused by Streptococcus pneumoniae
B
What is the primary rationale for maintaining adequate hydration in clients with pneumonia?
A) It helps maintain urine output to clear toxins from the blood.
B) It helps increase blood pressure to maintain perfusion to vital organs.
C) It helps keep the mucus membranes moist to prevent further infection.
D) It helps keep the airway clear by making secretions easier to expectorate.
D
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