(Summary) NR 324 Adult Health I Week 2 Questions
and Correct Answers 2023/2024.
Looking for a cause of this altered gas exchange, the healthcare provider orders a sputum collection
for gram stain, culture and sensitivity. What action is appropriate when collecting this sputum?
Collect the sputum in the morning
The healthcare provider orders albuterol 2.5 mg inhaler via nebulization three times a day, and
prednisone 30 mg orally daily for 14 days. What are the appropriate nursing actions when
administering these medications? Select all that apply.
*Assess lung sounds before and after medications administration
*Assess respiratory rate and oxygen saturation
*Administer albuterol first, then prednisone
Review the client's medication list and select the items that should improve gas exchange. Select all
that apply.
*oxygen therapy
*prednisone
*albuterol inhaler
Select the assessment data that support altered gas exchange.
*episodes of shortness of breath
*confused
*emphysema
RR 27 breaths/ minute
*88% oxygen saturation
Based on the assessment data, which nursing actions could improve gas exchange? Select all that
apply.
Administer oxygen as prescribed.Educate patient on pursed-lip breathing techniques.*Elevate the head
of the bed from 45 degrees to 90 degrees.
The client will have 1.___________________ bilaterally.The client will have 2.___________________
pain in the site where the thoracentesis is done
1. improved lung sounds
2. decreased
After receiving report from the morning shift, you visit each of your clients in the rehabilitation center.
Which of the following identified issues is your highest priority?
Respiratory rate increased to 30 in a client with a tracheostomy
, Which of the following would give the nurse the most accurate information about an alteration in gas
exchange?
Arterial blood gas
The client is transferred from the assisted living facility to emergency department due to acute
respiratory distress secondary to pneumothorax. When preparing for chest tube insertion, the nurse
takes into consideration which facts? Select all that apply.
*Most chest tube systems should be stored below the level of chest tube insertion.
*A chest tube requires an occlusive dressing like petroleum gauze.
*Monitor fluid drainage frequently, and if it is excessive, the healthcare provider should be notified.
A client presents to the emergency department due to episodes of stools with streaks of blood. The
spouse verbalizes that this has been happening for the past 3 days. Upon assessment, the client seems
pale, lips are dry, and they are confused. The vital signs are T 97º F, RR 24 breaths/minute, HR 105
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.
*Simple face mask
*Venturi mask
*Partial rebreather mask
*Non-rebreather mask
1. Elevate the head of the bed (45-90 degrees/semi to high Fowler's position)
2. Monitor respiratory rate, breathing pattern and oxygen saturation.
3. Assess for adventitious lung sounds (crackles, rales, stridor or absent etc).
4. Encourage deep/purse lip breathing exercises, ambulation, active/passive range of motion (ROM)
and use of incentive spirometer.
5. Report new abnormal findings or changes to health care provider.
1. This will expand the lungs by taking pressure off the diaphragm and forcing any fluid in the lungs
towards the bottom so more surface area is available for gas exchange.
2. Change in respiratory rate, breathing pattern, and oxygenation can suggest the need for further
action.
3. This may help clarify the cause of an alteration in gas exchange, and can also be used to evaluate
results before and after nursing actions.
4. These are techniques used to expand the lungs, slow a client's breathing, and offer some comfort for
shortness of breath.
5. This facilitates the need for further testing, medication, or other therapies that will identify and treat
underlying causes of altered gas exchange.
A client is admitted for an elective surgery. Prior surgery, the nurse teaches the client about the ways
to prevent respiratory complications after surgery. Which of the following statements from the client
may suggest further teaching is necessary?
"Staying in bed and resting as long as possible is the best way to get better sooner."
and Correct Answers 2023/2024.
Looking for a cause of this altered gas exchange, the healthcare provider orders a sputum collection
for gram stain, culture and sensitivity. What action is appropriate when collecting this sputum?
Collect the sputum in the morning
The healthcare provider orders albuterol 2.5 mg inhaler via nebulization three times a day, and
prednisone 30 mg orally daily for 14 days. What are the appropriate nursing actions when
administering these medications? Select all that apply.
*Assess lung sounds before and after medications administration
*Assess respiratory rate and oxygen saturation
*Administer albuterol first, then prednisone
Review the client's medication list and select the items that should improve gas exchange. Select all
that apply.
*oxygen therapy
*prednisone
*albuterol inhaler
Select the assessment data that support altered gas exchange.
*episodes of shortness of breath
*confused
*emphysema
RR 27 breaths/ minute
*88% oxygen saturation
Based on the assessment data, which nursing actions could improve gas exchange? Select all that
apply.
Administer oxygen as prescribed.Educate patient on pursed-lip breathing techniques.*Elevate the head
of the bed from 45 degrees to 90 degrees.
The client will have 1.___________________ bilaterally.The client will have 2.___________________
pain in the site where the thoracentesis is done
1. improved lung sounds
2. decreased
After receiving report from the morning shift, you visit each of your clients in the rehabilitation center.
Which of the following identified issues is your highest priority?
Respiratory rate increased to 30 in a client with a tracheostomy
, Which of the following would give the nurse the most accurate information about an alteration in gas
exchange?
Arterial blood gas
The client is transferred from the assisted living facility to emergency department due to acute
respiratory distress secondary to pneumothorax. When preparing for chest tube insertion, the nurse
takes into consideration which facts? Select all that apply.
*Most chest tube systems should be stored below the level of chest tube insertion.
*A chest tube requires an occlusive dressing like petroleum gauze.
*Monitor fluid drainage frequently, and if it is excessive, the healthcare provider should be notified.
A client presents to the emergency department due to episodes of stools with streaks of blood. The
spouse verbalizes that this has been happening for the past 3 days. Upon assessment, the client seems
pale, lips are dry, and they are confused. The vital signs are T 97º F, RR 24 breaths/minute, HR 105
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.
*Simple face mask
*Venturi mask
*Partial rebreather mask
*Non-rebreather mask
1. Elevate the head of the bed (45-90 degrees/semi to high Fowler's position)
2. Monitor respiratory rate, breathing pattern and oxygen saturation.
3. Assess for adventitious lung sounds (crackles, rales, stridor or absent etc).
4. Encourage deep/purse lip breathing exercises, ambulation, active/passive range of motion (ROM)
and use of incentive spirometer.
5. Report new abnormal findings or changes to health care provider.
1. This will expand the lungs by taking pressure off the diaphragm and forcing any fluid in the lungs
towards the bottom so more surface area is available for gas exchange.
2. Change in respiratory rate, breathing pattern, and oxygenation can suggest the need for further
action.
3. This may help clarify the cause of an alteration in gas exchange, and can also be used to evaluate
results before and after nursing actions.
4. These are techniques used to expand the lungs, slow a client's breathing, and offer some comfort for
shortness of breath.
5. This facilitates the need for further testing, medication, or other therapies that will identify and treat
underlying causes of altered gas exchange.
A client is admitted for an elective surgery. Prior surgery, the nurse teaches the client about the ways
to prevent respiratory complications after surgery. Which of the following statements from the client
may suggest further teaching is necessary?
"Staying in bed and resting as long as possible is the best way to get better sooner."
