Oxygenation

(ch 49.1) a client with chronic pulmonary disease has a bluish tinge around the lips. The nurse charts which term to most accurately describe the clients condition?

1. hypoxia

2. hypoxemia

3. dyspnea

4. cyanosis

(ch 49.2) to prevent postoperative complications the nurse assists the client with coughing and deep-breathing exercises. This is best accomplished by implementing which of the follow?

1. Couching exercises 1 hr ac (before meals) and deep breathing 1 hr pc (after meals)

2. Forceful coughing as many times as tolerated

3. Huff coughing every 2 hours or as needed

4. Diaphragmatic and pursed lip breathing 5-10 times, q.i.d.

(ch 49.5) Which of the following client conditions Can alter respiratory function? (select all that apply)

1. A client who has increasing thick secretions

2. A client with eupnea

3. A client with GI bleeding resulting in a large blood loss

4. A client with heart failure

5. A client with a temp of 103.6ºF (39.7ºC) and experiencing severe pain

(ch 49.7) The nurse makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues?

1. anemia

2. An infection

3. A fractured rib

4. A tumor of the medulla

(ch49.8) which term does the nurse document to best describe a client experiencing shortness of breath when lying down who must assume an upright or sitting position to breathe more comfortably and effectively?

1. dyspnea

2. hyperpnea

3. orthopnea

4. acapnea

(ch 49.9) a client with emphysema is prescribed corticosteroid therapy on a short term basis for acute bronchitis. The client asks the nurse how the steroids will help him. The nurse responds by saying that the corticosteroids will do which of the following?

1. Promote bronchodilaton

2. Help the client to cough

3. Prevent respiratory infection

4. Decrease inflammation in the airways

(ch 49.10) the nurse is planning to perform percussion and postural drainage. Which is an important aspect of planning the clients care?

1. Percussion and postural drainage should be done before lunch

2. The order should be coughing, percussion, positioning, and then suctioning.

3. A good time to perform percussion and postural drainage is in the morning after breakfast when the client is well rested.

4. Percussion and postural drainage should always be preceded by 3 minutes of 100% oxygen.

(ch 28.1) the clients temp at 0800 using an oral electronic thermometer is 36.1ºC (97.2ºF). If the reparation, pulse, and blood pressure were within normal range, what would the nurse do next?

1. wait 15 minutes and retake it

2. Check what the client's temperature was the last time it was taken.

3. Retake it using a different thermometer

Chart the temp; it is normal

(ch 28.2) which client meets the criteria for selection of the apical site for assessment of the pulse rather than a radial pulse?

1. Client who is in shock

2. A client whose pulse changes with body position changes

3. A client with an arrhythmia

4. A client who had surgery less than 24 hours ago

(ch 28.3) when the nurse enters a clients room to measure routine vital signs, the client is on the phone. What technique should the nurse use to determine the respiratory rate?

1. Count the respirations during conversational pauses

2. Ask the client to end the phone call and resume it at a later time.

3. Wait at the clients bedside until the phone call is completed and then count respirations

4. Since there is no evidence of distress or urgency, postpone the measurement until later.

5. Discharge the client because they aren't sick if they Can talk on the phone

6. Smash the phone

7. Take the phone and assume the call

(ch 28.4) for a client with a previous blood pressure of 138/74 mmHg and pulse of 64 beats/min, approximately how long should the nurse take to release the blood pressure cuff in order to obtain an accurate reading?

(ch 28.5) it would be appropriate to assign the taking of vital signs of which client to assistive personnel?

1. A client being prepared for elective facial surgery with a history of stable hypertension

2. A client receiving a blood transfusion with a history of transfusion reaction

3. A client recently started on a new anti-arrhythmic agent

4. A client who is admitted frequently with asthma attacks

5. If you want it done right do it yourself

(ch 28.6) an 85 year old client has had a stroke resulting in right-sided facial drooping, difficulty swallowing, and the inability to move self or maintain position unaided. The nurse determines that which sites are most appropriate for taking the temperature? (select all that apply)

(ch 28.7) a nursing diagnosis of impaired perfusion of peripheral tissue would be validated by which one of the following?

1. Bounding radial pulse

2. Irregular apical pulse

3. Carotid pulse stronger on left side than the right

4. Absent posterior tibial and pedal pulses

(ch 28.8) the nurse reports that the client has dyspnea when ambulating. The nurse is most likely to have assessed which of the following?

1. Shallow respirations

2. wheezing

3. Shortness of breath

4. Coughing up blood

Oxygenation

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