The nurse is to teach a client with Chronic Obstructed Pulmonary Disease safety precautions for using oxygen at home. The nurse knows that the client understands the safety principles discussed when he says the following:
"Acetone, oil, and alcohol are appropriate substances to use with clients who are using oxygen."
"Fire extinguishers do not need to be stored."
"Avoid materials that generate static electricity."
"Smoking is permitted when oxygen is in use."
The nursing intervention that is inappropriate for use with clients having an endotracheal tube is:
Communicating frequently with the client, providing a notepad or picture board for the client to use to communicating
Providing room air
Frequently assessing nasal and oral mucosa for redness and irritation
Placing client in a side-lying position
Which is the appropriate method to use when a client is suffering respiratory difficulty and in need of suctioning?
Dextrose-and-water solution
Goggles or face shield not needed
Nasal cannula
Portable or wall suction machine with tubing and collection receptacle
Appropriate follow-up evaluation of a client after suctioning does not include which of the following assessments?
Assessment of vital signs
Only document findings abnormal in the client record; the doctor will see the results when rounds on the client are done
Compare findings to previous assessment data
Chart appearance if secretions
While suctioning a client in ICU, the nurse notices that the activity brings about deep breathing and coughing maneuvers by the client. This is considered a good action because:
Deep breathing oxygenates the lungs, and coughing loosens and moves secretions in the lungs.
Deep breathing has no effect on the lungs or the ability of the client to cough.
Deep breathing is impossible to perform when one has a respiratory disease, and coughing is a reflex action.
Deep breathing allows secretions to build up in the lungs, and coughing helps to determine their location.
An appropriate nursing responsibility in caring for clients with chest drainage systems would be:
Evaluating respiratory rate every four hours after the tube is inserted
Not filling the water seal area of the unit
Never using clamps with the drainage tubing
Monitoring the patency and integrity of the drainage system
Which client is most at risk for developing an upper respiratory infection?
A 20-year-old healthy adult
A 3-year-old in preschool
A 50-year-old non-smoker
A 13-year-old with a broken leg
The nurse is providing wellness teaching to a group of seniors in the community. Which action is not appropriate to follow in promoting healthy breathing?
Making sure furnaces, ovens, and wood stoves are correctly ventilated
Eliminating or reduce the use of household pesticides and irritating chemical substances
Providing for rest periods during the day
Sitting straight and standing erect to permit full lung expansion
Which clinical signs are indicative of hypoxia? Select all that apply.
rapid pulse
cyanosis
deep, rapid breaths
flaring of nostrils
mouth breathing
substernal or intercostal retractions
