A nurse is providing oral care for a client who is immoblie. Which of the following actions
should the nurse take? ✔️✔️Turn the client on his side before starting oral care.
A nurse is providing discharge teaching to a client who has asthma and a new prescription for
fluticasone/salmeterol. For which of the following adverse effects should the nurse instruct the
client to report to the provider? ✔️✔️White coating in the mouth
A nurse is preparing an adolescent client who has pneumonia for percussion, vibration, and
postural drainage. Prior to the procedure which of the following nursing actions should the nurse
complete first? ✔️✔️Auscultate lung fields.
A nurse is caring for four hospitalized clients. Which of the following clients should the nurse
identify as being at risk for fluid volume deficit? ✔️✔️The client who has gastroenteritis and is
febrile.
A nurse in an urgent care center is caring for a client who is having a acute asthma exacerbation.
Which of the following actions is the nurse's highest priority? ✔️✔️Administering a nebulized
beta-adrenergic
,A nurse caring for a client who has hypertension and asks the nurse about a prescription for
propranolol. The nurse should inform the client that this medication is contraindicated in clients
who have a history of which of the following condition? ✔️✔️Asthma
A client is admitted to the ED with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal
the following values. Which of the following is an appropriate of the ABG's?
ph 7.22
PaCO2 68mm Hg
Base excess -2
PaO2 78 mm Hg
Saturation 80%
Bicarbonate 26 mEq/q ✔️✔️Respiratory acidosis
Respiratory acidosis occurs when there is retention of CO2 due to an impairment of respiratory
function. It can be the result of respiratory depression, seen with anesthesia or opioid
administration; inadequate chest expansion, due to a weakness of the respiratory muscles or
constriction to the thorax; an obstruction of the airway, seen in aspiration, bronchoconstriction,
or laryngeal edema; or from an inability of the lungs to adequately diffuse gases (O2 and CO2),
resulting from conditions such as pneumonia, COPD, chest trauma, or pulmonary emboli.
Arterial blood gases will reveal a pH that is lower than the normal reference range (7.35 - 7.45)
and a CO2 level that is higher than the normal reference range (35 - 45 mm Hg).
,A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart
rate increases from 86/min to 110/min and becomes irregular. Which of the following actions
should the nurse take? ✔️✔️Perform pre-oxygenation prior to suctioning
A nurse is providing discharge teaching to a client who has a new prescription for home oxygen
therapy via a nasal cannula. Which of the following should the nurse include in the teaching?
(sata) ✔️✔️Check the cannula position on a regular basis
Check the tops of the ears for skin breakdown
Post "no smoking" signs in a prominent location in the home
A nurse is developing a plan of care for a client who is postoperative. Which of the following
interventions should the nurse included in the plan to prevent pulmonary complications?
✔️✔️Encourage the use of an incentive spirometer
A nurse is providing teaching to a client who is postoperative following coronary artery bypass
graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside form
managing plan, which of the following desired effects of medications should the nurse identify
as most important for the client's recovery? ✔️✔️It facilitates the client's deep breathing
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following
manifestations should the nurse expect? ✔️✔️Agitation
, due to neurological changes from poor oxygen exchange.
A nurse is caring for a client who has chronic obstructive pulmonary disease (COPD). The client
tells the nurse, I can feel the congestion in my lungs, and I certainly cough a lot, but I can't seem
to bring anything up". Which of the following actions should the nurse take to help this client
with tenacious bronchial secretions? ✔️✔️Encouraging the client to drink 2 to 3 L of water
daily
A nurse is caring for a client who has emphysema. Which of the following findings should the
nurse expect to assess in the client? (SATA) ✔️✔️Dyspnea
Barrel Chest
Clubbing of the fingers
Emphysema is a lung disease involving damage to the alveoli in which they become weakened
and collapse. Dyspnea is seen in clients with emphysema as the lungs try to increase the amount
of oxygen available to the tissues.
Clients with emphysema lose lung elasticity; the diaphragm becomes permanently flattened by
hyperinflation of the lungs; the muscles of the rib cage become rigid; and the ribs flare outward.
This produces the barrel chest typical of emphysema clients.
Clubbing results from chronic low arterial-oxygen levels. The tips of the fingers enlarge and the
nails become extremely curved from front to back.