NURS 3000 Exam 4 UPDATED ACTUAL Questions and
CORRECT Answers
nursing interventions for client receiving o2 via nasal -make sure pt is receiving right rate of o2
canula (treating supplemental oxygen as a med) -assist pt in applying nasal cannula
-record pt's pulse & respiratory rate
-asses patency of nostrils
-Ensure that prongs are in the nares properly. A poorly fitting nasal cannula leads
to hypoxemia and skin breakdown.
-Provide emotional support to the patient who feels claustrophobic. Emotional
support decreases anxiety, which contributes to a claustrophobic feeling.
-Assess the patient for changes in respiratory rate and depth. The respiratory
pattern affects the amount of oxygen delivered. A different delivery system may
be needed.
nursing interventions to promote circulation in -maintain ideal body weight
hospitalized clients -decrease fat, decrease salt in diet
-reg. exercise program
-decrease stress
-monitor cholesterol & triglycerides
-B/P checked manually
-no smoking
interventions to promote oxygenation in hospitalized -manage oxygen therapy and equipment (nasal cannula, face masks, CPAP)
patients -raise HOB to high fowler's position
-use tripod positioning
-provide suctioning if needed
-maintain airway patency
-breathing & coughing exercises (pursed lip breathing, cough & DB, incentive
spirometry)
-monitor VS
-monitor pt's anxiety
priority nursing actions for a client exhibiting s/s of -prevent or treat hypoxia
impaired oxygenation -optimize oxygen delivery
-monitor oxygen saturation levels
-administer oxygen therapy
-Position the client in a high Fowler's position to optimize lung expansion.
Administer bronchodilators and nebulizers as prescribed. Encourage coughing
and deep breathing exercises.
-Encourage fluid intake to help thin secretions and promote hydration. Provide
nutritional support as needed.
-Collaborate with other healthcare professionals, such as respiratory therapists
and pulmonologists, to optimize the client's care.
independent nursing interventions to maintain a patent -teach effective coughing; breathing
airway in a client w/ ineffective airway clearance -TCDB
-postural drainage w/ percussion
-hydration
-positioning: fowler's or high fowler's position
, therapeutic communication with a client who doesn't use -explain to pt why it's necessary to wear CPAP and could avoid complications
CPAP as ordered -assess & see if they are having issues with the fit and comfort
actions for client experiencing sudden onset chest pain -STOP ambulating ASAP
while ambulating in hall -give pt o2 and notify dr
-follow chest pain procedure
What is atelectasis? collapse of the alveoli in the lung
prevents normal exchange of O2 and co2
hypoventilation occurs
how does atelectasis affect lung sounds? -decreased or absent breath sounds
-shallow breathing; inspiratory crackles
o2 administration in a client with COPD (what's important -it should be given in controlled amts & only if a SaO2 of 88-92% is aimed for
to remember) -high levels of O2 can lead to respiratory failure & suppress the resipiratory drive
What is incentive spirometry? Used to measure air that moves into and out of the lungs. -encourages deep
breathing
purpose of incentive spirometry helps pt take a deep breath
-improves pulmonary ventilation
client teaching needs for incentive spirometry -hold the device upright, take a deep breath in & exhale normally (breathe
through mouth rather than nose)
-frequency:
CORRECT Answers
nursing interventions for client receiving o2 via nasal -make sure pt is receiving right rate of o2
canula (treating supplemental oxygen as a med) -assist pt in applying nasal cannula
-record pt's pulse & respiratory rate
-asses patency of nostrils
-Ensure that prongs are in the nares properly. A poorly fitting nasal cannula leads
to hypoxemia and skin breakdown.
-Provide emotional support to the patient who feels claustrophobic. Emotional
support decreases anxiety, which contributes to a claustrophobic feeling.
-Assess the patient for changes in respiratory rate and depth. The respiratory
pattern affects the amount of oxygen delivered. A different delivery system may
be needed.
nursing interventions to promote circulation in -maintain ideal body weight
hospitalized clients -decrease fat, decrease salt in diet
-reg. exercise program
-decrease stress
-monitor cholesterol & triglycerides
-B/P checked manually
-no smoking
interventions to promote oxygenation in hospitalized -manage oxygen therapy and equipment (nasal cannula, face masks, CPAP)
patients -raise HOB to high fowler's position
-use tripod positioning
-provide suctioning if needed
-maintain airway patency
-breathing & coughing exercises (pursed lip breathing, cough & DB, incentive
spirometry)
-monitor VS
-monitor pt's anxiety
priority nursing actions for a client exhibiting s/s of -prevent or treat hypoxia
impaired oxygenation -optimize oxygen delivery
-monitor oxygen saturation levels
-administer oxygen therapy
-Position the client in a high Fowler's position to optimize lung expansion.
Administer bronchodilators and nebulizers as prescribed. Encourage coughing
and deep breathing exercises.
-Encourage fluid intake to help thin secretions and promote hydration. Provide
nutritional support as needed.
-Collaborate with other healthcare professionals, such as respiratory therapists
and pulmonologists, to optimize the client's care.
independent nursing interventions to maintain a patent -teach effective coughing; breathing
airway in a client w/ ineffective airway clearance -TCDB
-postural drainage w/ percussion
-hydration
-positioning: fowler's or high fowler's position
, therapeutic communication with a client who doesn't use -explain to pt why it's necessary to wear CPAP and could avoid complications
CPAP as ordered -assess & see if they are having issues with the fit and comfort
actions for client experiencing sudden onset chest pain -STOP ambulating ASAP
while ambulating in hall -give pt o2 and notify dr
-follow chest pain procedure
What is atelectasis? collapse of the alveoli in the lung
prevents normal exchange of O2 and co2
hypoventilation occurs
how does atelectasis affect lung sounds? -decreased or absent breath sounds
-shallow breathing; inspiratory crackles
o2 administration in a client with COPD (what's important -it should be given in controlled amts & only if a SaO2 of 88-92% is aimed for
to remember) -high levels of O2 can lead to respiratory failure & suppress the resipiratory drive
What is incentive spirometry? Used to measure air that moves into and out of the lungs. -encourages deep
breathing
purpose of incentive spirometry helps pt take a deep breath
-improves pulmonary ventilation
client teaching needs for incentive spirometry -hold the device upright, take a deep breath in & exhale normally (breathe
through mouth rather than nose)
-frequency:
