A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD):
Arterial Blood Gas Results
Vital Signs
pH = 7.32
PaCO2 = 62 mm Hg
PaO2 = 46 mm Hg
HCO3- = 28 mEq/L
Heart rate = 110 beats/min
Respiratory rate = 12 breaths/min
Blood pressure = 145/65 mm Hg
Oxygen saturation = 76
Which action should the nurse take first?
a.
Administer a short-acting beta2 agonist inhaler.
b.
Document the findings as normal for a client with COPD.
c.
Teach the client diaphragmatic breathing techniques.
d.
Initiate oxygenation therapy to increase saturation to 92.
Question 2A nurse assesses a client with asthma and notes bilateral wheezing, decreased pulse oxygen saturation, and suprasternal retraction on inhalation. Which actions should the nurse take? (Select all that apply.)
a. Administer prescribed salmeterol (Serevent) inhaler.
b. Assess the client for a tracheal deviation.
c. Administer oxygen to keep saturations greater than 94.
d. Perform peak expiratory flow readings.
e. Administer prescribed albuterol (Proventil) inhaler.
Question 3The nurse instructs a client on how to correctly use an inhaler with a spacer. In which order should these steps occur?
1. Press down firmly on the canister to release one dose of medication.
2. Breathe in slowly and deeply.
3. Shake the whole unit vigorously three or four times.
4. Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer.
5. Place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece.
6. Remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds.
a.
2, 3, 4, 5, 6, 1
b.
3, 4, 5, 1, 6, 2
c.
4, 3, 5, 1, 2, 6
d.
5, 3, 6, 1, 2, 4
Question 4A nurse auscultates a client's lung fields. Which action should the nurse take based on the lung sounds? (Click the media button to hear the audio clip.)
a. Assess for airway obstruction.
b. Initiate oxygen therapy.
c. Assess vital signs.
d. Elevate the client's head.
Question 5A nurse auscultates a client's lung fields. Which pathophysiologic process should the nurse associate with this breath sound? (Click the media button to hear the audio clip.)
a. Inflammation of the pleura
b. Constriction of the bronchioles
c. Upper airway obstruction
d. Pulmonary vascular edema
Question 6The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur?
1. Take as deep a breath as possible.
2. Stand up (unless you have a physical disability).
3. Place the meter in your mouth, and close your lips around the mouthpiece.
4. Make sure the device reads zero or is at base level.
5. Blow out as hard and as fast as possible for 1 to 2 seconds.
6. Write down the value obtained.
7. Repeat the process two additional times, and record the highest number in your chart.
a.
4, 2, 1, 3, 5, 6, 7
b.
3, 4, 1, 2, 5, 7, 6
c.
2, 1, 3, 4, 5, 6, 7
d.
1, 3, 2, 5, 6, 7, 4
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