NR 324 Adult Health I Week 2
Study online at https://quizlet.com/_brks5c
1. Looking for a cause of this altered gas exchange, Collect the sputum in
the healthcare provider orders a sputum collection the morning
for gram stain, culture and sensitivity. What action
is appropriate when collecting this sputum?
2. The healthcare provider orders albuterol 2.5 mg in- *Assess lung sounds
haler via nebulization three times a day, and pred- before and after
nisone 30 mg orally daily for 14 days. What are medications admin-
the appropriate nursing actions when administering istration
these medications? Select all that apply. *Assess respiratory
rate and oxygen sat-
uration
*Administer albuterol
first, then prednisone
3. Review the client's medication list and select the *oxygen therapy
items that should improve gas exchange. Select all *prednisone
that apply. *albuterol inhaler
4. Select the assessment data that support altered gas *episodes of short-
exchange. ness of breath
*confused
*emphysema
RR 27 breaths/
minute
*88% oxygen satura-
tion
5. Based on the assessment data, which nursing ac- *Administer oxygen
tions could improve gas exchange? Select all that as prescribed.*Ed-
apply. ucate patient on
pursed-lip breath-
ing techniques.*Ele-
vate the head of the
bed from 45 degrees
to 90 degrees.
6.
, NR 324 Adult Health I Week 2
Study online at https://quizlet.com/_brks5c
The client will have 1.___________________ bilat- 1. improved lung
erally.The client will have 2.___________________ sounds
pain in the site where the thoracentesis is done 2. decreased
7. After receiving report from the morning shift, you Respiratory rate in-
visit each of your clients in the rehabilitation cen- creased to 30 in
ter. Which of the following identified issues is your a client with a tra-
highest priority? cheostomy
8. Which of the following would give the nurse the Arterial blood gas
most accurate information about an alteration in
gas exchange?
9. The client is transferred from the assisted living *Most chest tube
facility to emergency department due to acute respi- systems should be
ratory distress secondary to pneumothorax. When stored below the lev-
preparing for chest tube insertion, the nurse takes el of chest tube inser-
into consideration which facts? Select all that apply. tion.
*A chest tube re-
quires an occlusive
dressing like petrole-
um gauze.
*Monitor fluid
drainage frequently,
and if it is exces-
sive, the healthcare
provider should be
notified.
10. A client presents to the emergency department due *Simple face mask
to episodes of stools with streaks of blood. The *Venturi mask
spouse verbalizes that this has been happening for *Partial rebreather
the past 3 days. Upon assessment, the client seems mask
pale, lips are dry, and they are confused. The vital *Non-rebreather
signs are T 97º F, RR 24 breaths/minute, HR 105 mask
beats/minute, BP 90/50 mm Hg and 88% oxygen
saturation on room air. What are the best options
for delivering oxygen to this client? Select all that
apply.
, NR 324 Adult Health I Week 2
Study online at https://quizlet.com/_brks5c
11. 1. Elevate the head of the bed (45-90 degrees/semi 1. This will expand
to high Fowler's position) the lungs by taking
2. Monitor respiratory rate, breathing pattern and pressure off the di-
oxygen saturation. aphragm and forcing
3. Assess for adventitious lung sounds (crackles, any fluid in the lungs
rales, stridor or absent etc). towards the bottom
4. Encourage deep/purse lip breathing exercises, so more surface area
ambulation, active/passive range of motion (ROM) is available for gas
and use of incentive spirometer. exchange.
5. Report new abnormal findings or changes to 2. Change in respi-
health care provider. ratory rate, breath-
ing pattern, and oxy-
genation can sug-
gest the need for fur-
ther action.
3. This may help clar-
ify the cause of an
alteration in gas ex-
change, and can also
be used to evaluate
results before and af-
ter nursing actions.
4. These are tech-
niques used to ex-
pand the lungs, slow
a client's breathing,
and offer some com-
fort for shortness of
breath.
5. This facilitates
the need for fur-
ther testing, medica-
tion, or other thera-
pies that will identi-
fy and treat underly-
ing causes of altered
gas exchange.
12.
Study online at https://quizlet.com/_brks5c
1. Looking for a cause of this altered gas exchange, Collect the sputum in
the healthcare provider orders a sputum collection the morning
for gram stain, culture and sensitivity. What action
is appropriate when collecting this sputum?
2. The healthcare provider orders albuterol 2.5 mg in- *Assess lung sounds
haler via nebulization three times a day, and pred- before and after
nisone 30 mg orally daily for 14 days. What are medications admin-
the appropriate nursing actions when administering istration
these medications? Select all that apply. *Assess respiratory
rate and oxygen sat-
uration
*Administer albuterol
first, then prednisone
3. Review the client's medication list and select the *oxygen therapy
items that should improve gas exchange. Select all *prednisone
that apply. *albuterol inhaler
4. Select the assessment data that support altered gas *episodes of short-
exchange. ness of breath
*confused
*emphysema
RR 27 breaths/
minute
*88% oxygen satura-
tion
5. Based on the assessment data, which nursing ac- *Administer oxygen
tions could improve gas exchange? Select all that as prescribed.*Ed-
apply. ucate patient on
pursed-lip breath-
ing techniques.*Ele-
vate the head of the
bed from 45 degrees
to 90 degrees.
6.
, NR 324 Adult Health I Week 2
Study online at https://quizlet.com/_brks5c
The client will have 1.___________________ bilat- 1. improved lung
erally.The client will have 2.___________________ sounds
pain in the site where the thoracentesis is done 2. decreased
7. After receiving report from the morning shift, you Respiratory rate in-
visit each of your clients in the rehabilitation cen- creased to 30 in
ter. Which of the following identified issues is your a client with a tra-
highest priority? cheostomy
8. Which of the following would give the nurse the Arterial blood gas
most accurate information about an alteration in
gas exchange?
9. The client is transferred from the assisted living *Most chest tube
facility to emergency department due to acute respi- systems should be
ratory distress secondary to pneumothorax. When stored below the lev-
preparing for chest tube insertion, the nurse takes el of chest tube inser-
into consideration which facts? Select all that apply. tion.
*A chest tube re-
quires an occlusive
dressing like petrole-
um gauze.
*Monitor fluid
drainage frequently,
and if it is exces-
sive, the healthcare
provider should be
notified.
10. A client presents to the emergency department due *Simple face mask
to episodes of stools with streaks of blood. The *Venturi mask
spouse verbalizes that this has been happening for *Partial rebreather
the past 3 days. Upon assessment, the client seems mask
pale, lips are dry, and they are confused. The vital *Non-rebreather
signs are T 97º F, RR 24 breaths/minute, HR 105 mask
beats/minute, BP 90/50 mm Hg and 88% oxygen
saturation on room air. What are the best options
for delivering oxygen to this client? Select all that
apply.
, NR 324 Adult Health I Week 2
Study online at https://quizlet.com/_brks5c
11. 1. Elevate the head of the bed (45-90 degrees/semi 1. This will expand
to high Fowler's position) the lungs by taking
2. Monitor respiratory rate, breathing pattern and pressure off the di-
oxygen saturation. aphragm and forcing
3. Assess for adventitious lung sounds (crackles, any fluid in the lungs
rales, stridor or absent etc). towards the bottom
4. Encourage deep/purse lip breathing exercises, so more surface area
ambulation, active/passive range of motion (ROM) is available for gas
and use of incentive spirometer. exchange.
5. Report new abnormal findings or changes to 2. Change in respi-
health care provider. ratory rate, breath-
ing pattern, and oxy-
genation can sug-
gest the need for fur-
ther action.
3. This may help clar-
ify the cause of an
alteration in gas ex-
change, and can also
be used to evaluate
results before and af-
ter nursing actions.
4. These are tech-
niques used to ex-
pand the lungs, slow
a client's breathing,
and offer some com-
fort for shortness of
breath.
5. This facilitates
the need for fur-
ther testing, medica-
tion, or other thera-
pies that will identi-
fy and treat underly-
ing causes of altered
gas exchange.
12.
