Final exam review LPN to RN Questions and Answers

Final exam review LPN to RN Questions and Answers A client loses consciousness after strenuous exercise and needs to be admitted to a health care facility. The client is diagnosed with dehydration. The nurse knows that the client needs restoration of: electrolytes. Non-electrolytes are chemical compounds that remain bound together when dissolved in a solution. Interstitial fluid is the fluid in the tissue space between and around cells. Colloids are substances that do not dissolve into a true solution and do not pass through a semipermeable membrane. When the nurse is starting an intravenous infusion on a client who will be receiving multiple intravenous antibiotics, which guideline should the nurse follow? Use distal veins before proximal veins leaving the more proximal sites for later venipunctures. The primary extracellular electrolytes are: sodium, chloride, and bicarbonate. Potassium is needed for neural, muscle, and: cardiac function. A client reports she has lactose intolerance and questions the nurse about alternative sources of calcium. What options can be provided by the nurse? Spinach Sardines, whole grains, and green leafy vegetables also provide calcium. Which age group is at risk for fluid and electrolyte imbalances resulting from fad dieting? Adolescents A physician orders an infusion of 250 mL of NS in 100 minutes. The set is 20 gtt/mL. What is the flow rate? 50 gtt/min The flow rate (gtt/min) equals the volume (mL) times the drop factor (gtt/mL) divided by the time in minutes. The oncoming nurse is assigned to the following clients. Which client should the nurse assess first? a newly admitted 88-year-old with a 2-day history of vomiting and loose stools Mr. Jones is admitted to the nurse's unit from the emergency department with a diagnosis of hypocalcemia. His laboratory results show a serum calcium level of 8.2 mg/dL (2.05 mmol/L). For what assessment findings will the nurse be looking? muscle cramping and tetany (muscle spasms) hypercalcemia = nausea, vomiting, constipation, bone pain, excessive urination, thirst, confusion, lethargy, and slurred speech. hyperchloremia = diminished cognitive ability and hypertension Constipation is a sign of hypercalcemia. Which nursing diagnosis would the nurse make based on the effects of fluid and electrolyte imbalance on human functioning? Acute Confusion related to cerebral edema The student nurse asks, "what is interstitial fluid?" What is the appropriate nursing response? "Fluid in the tissue space between and around cells." Intracellular fluid (fluid inside cells) represents the greatest proportion of water in the body. The remaining body fluid is extracellular fluid (fluid outside cells). Extracellular fluid is further subdivided into interstitial fluid (fluid in the tissue space between and around cells) and intravascular fluid (the watery plasma, or serum, portion of blood). The nurse working at the blood bank is speaking with potential blood donor clients. Which client statement requires nursing intervention? "I received a blood transfusion in the United Kingdom." The nurse is preparing to administer granulocytes to a client admitted with a severe infection. Which teaching by the nurse is most appropriate? "Granulocytes are a type of white blood cell that can help fight infection." The nurse is calculating an infusion rate for the following order: Infuse 1000 ml of 0.9% Na Cl over 12 hours using an electronic infusion device. What is the infusion rate? 83 ml/hour When calculating the infusion rate with an electronic device, divide the total volume to be infused (1000 ml) by the total amount of time in hours (12). This is 83 ml/hour A client with dehydration will have an increase in: aldosterone Which of the following statements is an appropriate nursing diagnosis for an client 80 years of age diagnosed with congestive heart failure, with symptoms of edema, orthopnea, and confusion? Extracellular Volume Excess related to heart failure, as evidenced by edema and orthopnea The nurse is caring for a client, who was admitted after falling from a ladder. The client has a brain injury which is causing the pressure inside the skull to increase, which may result in a lack of circulation and possible death to brain cells. Considering this information, which intravenous solution would be most appropriate? Hypertonic Plasma is an isotonic solution. The nurse is caring for a client who was found without food or water for 2 days in the desert. What explanation for the need for fluid does the client have? Select all that apply. facilitates cellular metabolism helps maintain normal body temperature acts as a solvent for electrolytes A healthy client eats a regular, balanced diet and drinks 3,000 mL of liquids during a 24-hour period. In evaluating this client's urine output for the same 24-hour period, the nurse realizes that it should total approximately how many mL? 3,000 Fluid intake and fluid output should be approximately the same in order to maintain fluid balance. Any other amount could lead to a fluid volume excess or deficit The nurse is caring for elderly patients in a long-term care facility. What age-related alteration should the nurse consider when planning care for these patients? Cardiac volume intolerance A client admitted to the facility is diagnosed with metabolic alkalosis based on arterial blood gas values. When obtaining the client's history, which statement would the nurse interpret as a possible underlying cause? "I've been taking antacids almost every 2 hours over the past several days." Metabolic alkalosis occurs when there is excessive loss of body acids or with unusual intake of alkaline substances. It can also occur in conjunction with an ECF deficit or potassium deficit. V or nasogastric suction diarrhea = metabolic acidosis The nurse is providing care to a client who has a serum potassium level of 5.2 mEq/L (5.2 mmol/L). Which findings would the nurse expect to assess? Select all that apply. Diarrhea Cardiac dysrhythmia The nurse works at an agency that automatically places certain clients on intake and output (I&O). For which client will the nurse document all I&O? 55-year old with congestive heart failure on furosemide clients who have undergone surgery until they are eating, drinking, and voiding in sufficient quantities; those on IV fluids or receiving tube feedings; those with wound drainage or suction equipment; those with urinary catheters; and those on diuretic drug therapy should be put on I&O The nurse is caring for a client who will be undergoing surgery in several weeks. The client states, "I would like to give my own blood to be used in case I need it during surgery." What is the appropriate nursing response? "Let me refer you to the blood bank so they can provide you with information." An older adult has fluid volume deficit and needs to consume more fluids. Which approach by the nurse demonstrates gerontologic considerations? Offer small amounts of preferred beverage frequently. A client has been receiving intravenous (IV) fluids that contain potassium. The IV site is red and there is a red streak along the vein that is painful to the client. What is the priority nursing action Remove the IV. likely has phlebitis, which is caused by prolonged use of the same vein or irritating fluid. A nurse is assessing the central venous pressure of a client who has a fluid imbalance. Which reading would the nurse interpret as suggesting an ECF volume deficit? 3.5 cm H2O normal pressure is approximately 4 to 11 cm H2O. The nurse reviews the laboratory test results of a client and notes that the client's potassium level is elevated. What would the nurse expect to find when assessing the client's gastrointestinal system? Diarrhea Abdominal distention, vomiting, and paralytic ileus would reflect hypokalemia. A 50-year-old client with hypertension is being treated with a diuretic. The client reports muscle weakness and falls easily. The nurse should assess which electrolyte? Potassium Diuretics, commonly given to treat high blood pressure and heart failure, can cause an extracellular deficit or loss of electrolytes including potassium, calcium, and magnesium. The nursing instructor is quizzing a group of students about fluid and electrolyte balance. Which statements made by students indicate an understanding of the efforts of the organs to maintain fluid and electrolyte balance? Select all that apply. "The kidneys regulate extracellular fluid volume by retention and excretion of body fluids." "The kidneys regulate pH of extracellular fluid by excreting and retaining hydrogen ions." The adrenal glands regulate blood volume by secreting aldosterone." "The nervous system regulates oral intake by sensing intracellular dehydration, which in turn stimulates thirst." The heart and blood vessels react to hypovolemia by stimulating fluid retention rather than the kidneys. The nurse is calculating the infusion rate for the following order: Infuse 1000 ml of 0.9% NaCl over 8 hours, with gravity infusion. Your tubing delivers 20 gtts/min. What is the infusion rate? 42 gtts/min When infusing by gravity, divide the total volume in ml (1000 ml) by the total time in minutes (480 minutes) times the drop factor, which is given as 20 gtts/min A client who is receiving total parenteral nutrition and lipids asks the nurse why the solution looks like milk. What is the most appropriate nursing response? "The white milky solution contains lipids or fat to provide extra calories." A parenteral lipid emulsion is a mixture of water and fats in the form of soybean or safflower oil, egg yolk phospholipids, and glycerin. Lipid solutions, which look milky white, are given intermittently with TPN solutions. They provide additional calories and promote adequate blood levels of fatty acids. Lipids cannot be mixed with TPN, as the lipid molecules tend to break or separate The nurse is caring for a client who had a parathyroidectomy. Upon evaluation of the client's laboratory studies, the nurse would expect to see imbalances in which electrolytes related to the removal of the parathyroid gland? calcium and phosphorus A decrease in arterial blood pressure will result in the release of: renin. Which is a common anion? Which is a common anion? Cl- Mg+, K+, and Ca+ A client is admitted to the intensive care unit with a calcium level of 4.2 mg/dL. What is the priority action by the nurse? Prepare to administer calcium gluconate as prescribed A client has been admitted with fluid volume excess related to left sided heart failure. Which assessment data would the nurse document related to the fluid volume excess? (Select all that apply.) crackles in the lungs distended neck veins and DECREASED URINE OUTPUT Which clients would be appropriate candidates for total parenteral nutrition? Select all that apply. Client who has second- and third-degree (partial- or full-thickness) burns over 40% of the body Client who had gastric surgery and is unable to eat for a few weeks Client with anorexia nervosa A client is taking a diuretic such as furosemide. When implementing client education, what information should be included? Decreased potassium levels Many diuretics such as furosemide are potassium wasting; hence, potassium levels are measured to detect hypokalemia. The passageways of the kidney permit the urine to flow to the bladder and: selectively reabsorb or secrete substance to maintain fluids and electrolytes. The nurse writes a nursing diagnosis of "Fluid Volume: Excess." for a client. What risk factor would the nurse assess in this client? renal failure Excess fluid volume may result from increased fluid intake or from decreased excretion, such as occurs with progressive renal disease. Excessive use of laxatives, diaphoresis, and increased cardiac output may lead to a fluid volume deficit. The nurse is educating a client about the function of sodium in the body. What education points would the nurse make? Select all that apply. Sodium is the primary regulator of ECF volume Sodium is normally maintained in the body within a relatively narrow range, and deviations quickly result in serious health problems. Sodium participates in the generation and transmission of nerve impulses. A client is admitted to the facility after experiencing uncontrolled diarrhea for the past several days. The client is exhibiting signs of a fluid volume deficit. When reviewing the client's laboratory test results, which electrolyte imbalance would the nurse most likely find? Hypokalemia Intestinal secretions contain bicarbonate. For this reason, diarrhea may result in metabolic acidosis due to depletion of base. Intestinal contents also are rich in sodium, chloride, water, and potassium, possibly contributing to an ECF volume deficit and hypokalemia A nurse is providing care to a client with hypocalcemia. The nurse would monitor the client's laboratory test results for which imbalance? Hyperphosphatemia Calcium and phosphorus have a reciprocal relationship A nurse is providing care to a client with an extracellular fluid (ECF) volume deficit. The nurse suspects that the deficit involves a decrease in vascular volume based on which finding? Select all that apply. orthostatic hypotension decreased urine output slow-filling peripheral veins The signs and symptoms of decreased interstitial volume include dry mucous membranes and poor skin turgor. Which statement most accurately describes the process of osmosis? Water moves from an area of lower solute concentration to an area of higher solute concentration. A client age 80 years, who takes diuretics for management of hypertension, informs the nurse that she takes laxatives daily to promote bowel movements. The nurse assesses the client for possible symptoms of: hypokalemia. When educating a client about foods that affect fluid balance, the nurse would advise the client to decrease: Na+ Sodium (Na+) is the most abundant electrolyte in the extracellular fluid (ECF). Na+ regulates extracellular fluid volume; Na+ loss or gain is accompanied by a loss or gain of water. Potassium (K+) is the major intracellular electrolyte. Calcium (Ca++) is a major component of bones and teeth. Magnesium (Mg++) is the most abundant intracellular cation after potassium. The nurse is caring for a client with "hyperkalemia related to decreased renal excretion secondary to potassium-conserving diuretic therapy." What is an appropriate expected outcome? ECG will show no cardiac dysrhythmias within 48 hours after removing salt substitutes, coffee, tea, and other K+-rich foods from diet. Supplemental potassium should not be added to the client's intake Many chronic medical problems adversely affect a person's ability to maintain normal fluid, electrolyte, and acid-base homeostasis. What describes complications related to liver disease? Increased plasma levels of antidiuretic hormone lead to water excess. In addition to increased plasma levels of antidiuretic hormones, plasma levels of albumin decrease, so that the distribution of extracellular fluid changes, vascular volume decreases, and interstitial volume increases. Complications often lead to ascites Sodium is the most abundant cation in the extracellular fluid. Which is true regarding sodium? Sodium is regulated by the renin-angiotensin-aldosterone system. Potassium is essential for normal cardiac, neural, and muscle function and contractility of all muscles. Which is false about potassium? Normal serum potassium ranges from 5.5 to 6.0 mEq/L (5.5 to 6.0 mmol/L). Normal serum potassium ranges from 3.5 to 5.0 mEq/L (3.5 to 5.0 mmol/L). A client with uncontrolled diabetes develops hypophosphatemia. Which finding would the nurse most likely assess? Select all that apply. respiratory muscle weakness confusion ventricular dysrhythmia A client has been admitted with fluid volume deficit. Which assessment data would the nurse anticipate? (Select all that apply.) respiratory muscle weakness confusion ventricular dysrhythmia Fluid volume deficit causes a low BP (100/48 mm Hg), poor skin turgor, and an elevated heart rate (128/bpm). Fluid excess can cause crackles and distended neck veins. A nursing instructor is discussing administration of total parenteral nutrition (TPN) with a nursing student. Which statement by the student would require further teaching? "I will be sure to change the TPN tubing every other day." Which client will have more adipose tissue and less fluid? A woman What is the lab test commonly used in the assessment and treatment of acid-base balance? Arterial Blood Gas A client with a diagnosis of colon cancer has opted for a treatment plan that will include several rounds of chemotherapy. What vascular access device is most likely to meet this clients needs? AN implanted central venous access device A nurse needs to select a venipuncture site to administer a prescribed amount of IV fluid to a client. THe nurse looks for a large vein when using a needle with a large guage. What explains the nurse's action? To prevent cocmpromising circulation. The nursing instructor is discussing IV fluid overload with the nursing students. What will the nurse include in her discussion? The use of packed cells instead of whole blood will decrease the fluid volume delivered to the client. A symptom of fluid overload is distended neck veins. Fluid overload is more likely in very young children. The infusion rate must be carefully monitored during the admin of blood. A client who recently had surgery is bleeding. What blood product does the nurse anticipate administering for this client? Platelets The nurse's morning assessment of a client who has a history of heart failure reveals the presence of 2+ pitting edema in the client's ankles and feet bilaterally. This assessment finding is suggestive of: Fluid volume excess A physician has asked the nurse to use microdrip tubing to administer a prescribed dosage of the IV solution to a client. WHat is the standard drop factor of microdrip tubing? 60 drops/mL Rich source of potassium? Apricots Which solution is a crystalloid solution that has the same osmotic pressure as that found within the cells of the body and is used to expand the intravascular volume? Isotonic The student nurse asks the instructor how buffer systems work in the body to maintain the pH of the blood. The instructor explains each of the buffer systems to the students. Which are buffer systems that will be discussed by the instructor? Carbonic acid-sodium bicarbonate buffer system. Phosphate buffer system. Protein buffer system. A nurse is measuring intake and output for a patient who has congestive heart failure. What does not need to be recorded? Fruit consumption Verification for blood transfusion? Clients name ID number Unit number ABO group The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia? confusion decreased blood pressure decreased respiratory rate hyperactivity confusion Explanation: Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, elevated blood pressure with small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis. A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client? pulse oximetry thoracentesis spirometry peak expiratory flow rate pulse oximetry Explanation: Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes. Study blue A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery? educating the client on the use of incentive spirometry educating the client on pursed-lip breathing techniques oropharyngeal suctioning twice daily administration of inhaled corticosteroids educating the client on the use of incentive spirometry Explanation: Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery. The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis? high temperature high respiratory rate low pulse rate low blood pressure high respiratory rate Explanation: A client diagnosed with Impaired Gas Exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase. To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test? Monitor the pressure of oxygen dissolved in plasma. Measure the volume of air exhaled or inhaled over time. Calculate the pressure of carbon dioxide dissolved in plasma. Monitor the amount of oxygen saturation in the blood. Monitor the amount of oxygen saturation in the blood. Explanation: The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. The arterial blood gases test the client's blood for the partial pressure of oxygen dissolved in plasma, the percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma. Spirometry measures the volume of air in liters exhaled or inhaled by a client over time. A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client? oxygen analyzer nasal strip nasal cannula flow meter flow meter Explanation: The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client. A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing: a bronchospasm. bronchitis. bronchiectasis. bronchiolitis. a bronchospasm. Explanation: When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm. Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? Snack on high-carbohydrate foods frequently. Eat smaller meals that are high in protein. Contact the physician for nutrition shake. Eat one large meal at noon. Eat smaller meals that are high in protein. Explanation: The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength. A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is: "He will require additional testing to determine the cause." "He is using his chest muscles to help him breathe." "His infection is causing him to breathe harder." "His lung muscles are swollen so he is using abdominal muscles." "He is using his chest muscles to help him breathe." Explanation: The client will use accessory muscles to ease dyspnea and improve breathing. When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing Anemia Malnutrition Poor tissue perfusion Congestive heart failure Poor tissue perfusion Explanation: Chronically poor perfusion may result in hair loss in the affected area, discolored skin, thickened nails, and shiny, dry skin indicative of inadequate tissue nutrition. In which client would the nurse assess for a depressed respiratory system? a client taking amlodipine for hypertension a client taking antibiotics for a urinary tract infection a client taking insulin for diabetes a client taking opioids for cancer pain a client taking opioids for cancer pain Explanation: Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Amlodipine is a calcium channel blocker and the medication decreased blood pressure, so the nurse would need to assess blood pressure. Antibiotics are used for urinary tract infections as well as other infections and the infections do not affect the respiratory system. Insulin decreases blood sugar which a person with diabetes may need to take every day. Insulin does not affect the respiratory system. A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client? Oxygen mask Nasal cannula Ambu bag Oxygen tent Ambu bag Explanation: If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Oxygen masks may cover only the nose and mouth and can vary in the amount of oxygen delivered. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostril. An oxygen tent is a tentlike enclosure within which the air supply can be enriched with oxygen to aid a client's breathing. Oxygen masks, nasal cannula, and oxygen tents are used for clients who have a respiratory drive. When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom? Rapid respirations Weight loss Increased urine output Mental alertness Rapid respirations Explanation: Normal cardiac output averages from 3.5 L/minute to 8.0 L/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion. The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign? Apical pulse Orthostatic blood pressure Respiratory rate and depth Urinary intake and output Respiratory rate and depth Explanation: The client receiving narcotics/opioids needs monitoring of the respiratory rate and depth to ensure that respiratory depression does not result in progressive respiratory issues, physiologic damage from respiratory depression, or loss of consciousness. The pulse, blood pressure, and urinary intake and output are not as important as respiratory status when administering narcotics. The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? They are loud, high-pitched sounds heard primarily over the trachea and larynx. They are medium-pitched blowing sounds heard over the major bronchi. They are low-pitched, soft sounds heard over peripheral lung fields. They are soft, high-pitched discontinuous (intermittent) popping lung sounds. They are low-pitched, soft sounds heard over peripheral lung fields. Explanation: Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds. The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? Inhale through the nose instead of the mouth. Be sure to shake the canister before using it. Inhale the medication rapidly. Inhale two sprays with one breath for faster action. Be sure to shake the canister before using it. Explanation: A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly. MDIs are inhaled through the mouth, into the lungs. The medication should be inhaled slowly to ensure a sufficient dose enters the lungs. If the order is for two sprays, these sprays are administered with one spray for each breath. The inhaled breath should be held briefly after each spray in order to prevent immediately exhaling the medication. The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier? "This is a gauge used to regulate the amount of oxygen that a client receives." "The humidifier prescribes the concentration of oxygen." "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." "Small water droplets come from this, thus preventing dry mucous membranes." "Small water droplets come from this, thus preventing dry mucous membranes." Explanation: The humidifier produces small water droplets which are delivered during oxygen administration to prevent or decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen. The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? simple mask tracheostomy collar nasal cannula face tent tracheostomy collar Explanation: A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. All other devices are less appropriate for this client. A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? "An occasional cigarette will not hurt you." "You should never smoke when oxygen is in use." "I understand; I used to be a smoker also." "Oxygen is a flammable gas." "You should never smoke when oxygen is in use." Explanation: The nurse will educate the client about the dangers of smoking when oxygen is in use. Oxygen is not flammable, but it oxidizes other materials. Other answers are inappropriate. Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm. Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm. Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm. Explanation: Guidelines to determine suction catheter depth include the following: Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm past the length of the endotracheal tube. Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Using a spare endotracheal or tracheostomy tube of the same size as being used for the client, insert the suction catheter to the end of the tube and note the length of catheter used to reach the end of the tube. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm.