(Summary) NR 324 Adult Health I Week 2 Questions and Correct Answers 2023/2024.

(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." 1.Fluid overload 2. Bacterial respiratory infection 3. Asthma 4. Lung inflammation 5. Fungal lung infection 6. Chronic obstructive pulmonary disease 7. Acidosis (respiratory or metabolic) Medication Class 1. Diuretics 2. Antibiotics 3. Bronchodilators 4. Steroids 5. Antifungals 6. Anticholinergics 7. Bicarbonate Nursing Considerations 1. Monitor electrolytes and blood pressure 2. Check for allergies to antibiotics 3. Can cause tachycardia and high blood pressure 4. Long term side effects can be common 5. Usually requires prolonged treatment 6. Can lead to anticholinergic toxicity 7. Monitor arterial blood gasses frequently The registered nurse (RN) is delegating nursing care to an unlicensed assistive personnel (UAP). Which of the following tasks are appropriate to delegate for a client experiencing altered gas exchange? Select all that apply. *Repositioning the client from supine to a semi-fowlers position *Checking a client's oxygen saturation and reporting an abnormality An ABG is collected using blood from the 1.____________In reviewing the results, if a client has a pH of 7.31, it means they are 2.________________If a client has a pH of 7.48 it means they are 3._____________A PaCO2 over 45 means they are retaining 4._______________A PoCO2 under 35 means they are removing 5._______________A PaO2 under 75 means they need more 6._______________ 1. Radial artery 2. acidotic 3. alkalotic 4. carbon dioxide 5. carbon dioxide 6. oxygen In caring for a client with an endotracheal tube, which of the following statements suggests that more education on endotracheal tube safety is needed? Select all that apply. *Having a bag-valve-mask available is not necessary if a ventilator is in the room. *Monitoring the client for signs of normal ventilation ensures gas exchange is normal. *Clients do not need to be restrained or sedated while the endotracheal tube is in place. What are some possible clinical manifestations of pneumonia? Select all that apply. *Fever *RR 25 breaths/ minute *Confusion The client is transferred from assisted living facility to emergency department due to fever, chills and shortness of breath, and confusion. Pneumonia is the suspected cause. Which diagnostic tests could help identify pneumonia? Select all that apply. *Chest x-ray *Sputum culture Which assessment information is pertinent for a patient being admitted with an altered gas exchange in which pneumonia is suspected? *shortness of breath *productive cough chills. *T101º F *RR 26 breaths per minute *oxygen saturation of 90% in room air. *COPD (20 pack years) *albuterolinhalerPRN for shortness of breath*methylprednisolone 4 mg IVP daily *oxygen therapy 2LPM as needed for respiratory distress 1. A client who has been discharged home after a cerebral vascular accident and has trouble swallowing 2. A hospitalized patient with a decreased level of consciousness and a closed head injury 3. A patient hospitalized while recovering from a transurethral prostatectomy 4. An elderly client attending a class at the recreation center 5. A young adult having outpatient surgery for a torn meniscus 6. Client gastric tube receiving intermittent tube feedings on a medical/surgical floor a. Nosocomial Pneumonia