FORMATIVE ASSESSMENT 3 1.. The nurse is preparing care for a client receiving oxygen therapy. Which of the following normal conditions within this expect to find when performing a physical assessment of a patient respiratory system? (select all that apply) a. the anteroposterior diameter should be less than the transverse diameter b. The chest contour is slightly convex with no sternal depression c. the contour of the intercostal spaces should be rounded and the movement of charge should be symmetric d. When assessing tile framed by placing a palm to the patient's chest wall the vibration from the patient repeat that word should be equally bilaterally in different areas in the chest wall 2. Nurse maribette is teaching a client with oxygenation problem how to perform pursedlip breathing. The client asked the nurse to explain the purpose of this breathing technique. which explanation should the nurse avoid to provide (select all that apply) a. it decreases use of accessory breathing musclesb. it prolongs the inspiratory phase of respiration c. it increases inspiratory muscle strength d. it helps prevent early airway collapse 3. Mr Marcelo has oxygenation disorder and is being prepared by nurse marisol for oxygen therapy. he has been taught pursed lip breathing and its rationale. Which of thefollowing statements mentioned by nurse marissal needs further teaching? (select all that apply) a. purse lip breathing teaches him to prolong inspiration and shorten expiration b. Purse lip breathing decreases the amount of air trapping and resistance c. purse lip breathing increases carbon dioxide which stimulates breathingd. Purse lip breathing helps his liquefied secretions 4. Nurse marisol is all is preparing to perform suctioning for a client. which of the following are appropriate guidelines for nurse Marisol to follow? (select all that apply) a. Perform suctioning on a routine basis every 2 to 3 hoursb. Use a new catheter for each suctioning attempt c. Limit suctioning 2 to 3 attempts d. apply suction while withdrawing the catheter 5. the nurse is to teach a client with chronic obstructive pulmonary disease safety precautions for using oxygen at home. Then there's no that the client needs further teaching about the safety principles discussed when he says which of the following?select all that apply a. fire extinguisher do not need to be stored b. Avoid materials that generate static electricityc. Smoking is permitted when oxygen is in use d. Acetone, oil, and alcohol are appropriate substances to use with clients whoare using oxygen 6. The nurse is preparing to care for a client receiving oxygen therapy which of the following is an appropriate nursing action when performing oropharyngeal suctioning? Select all that apply a. Apply suction during withdrawal of the suction catheter tipb. place the client in semi fowlers or lateral position c. lubricate suction catheter tip with alcohol d. measure length of catheter from tip of the nose to tip earlobe to the xiphoid process 7. Then there's is preparing to care for a client receiving oxygen therapy. adult is receiving oxygen by nasal prongs. which statement by the client indicates that client teaching regarding oxygen therapy has been ineffective? select all the apply a. I was feeling fine so I removed my nasal prongs b. my family was angry when I told them they could not smoke in my room c. I've increased my fluids to six glasses of water daily d. don't forget to come back quickly when you Get Me Out of bed I don't like tobe without my oxygen for too long 8. nurse Gemma is caring for an elderly adult in a nursing home. which age related changes may affect the respiratory functioning of the clients leaving there? select allthat apply a. increase in vital capacity and residual volume b. less air exchange more secretions in lungs c. increased elastic recoil of the lungs d. less fibrous tissue in alveoli e. greater risk for aspiration due to slower gastric motility 9. The nurse is caring for 15 year old client admitted in the medical ward who is receiving the B Adrenergic agonist bronchodilator albuterol (accuneb) In the prescribed nebulizer treatments. which side effects would the nurse expect to assess following administration? select all that apply. NOT SURE a. Insomnia b. increased respiration c. increased somnolenced. tachycardia e. anxiety 10. Nurse Ligaya Dimayacyac is caring for a 16 year old male patient who has been hospitalized for an acute asthma exacerbation. which testing methods might nurse ligaya used to measure that her patients oxygen saturation? Select all that applya. spirometry b. maximal respiratory pressurec. peak expiratory flow rate d. thoracentesis e. pulse oximetry 11. The nurse is preparing to care for a client receiving oxygen therapy. The nurse is choosing a catheter to use to suction the patient’s endotracheal tube via an open system. on which the nurse would the nurse base the size of the catheter to use? a. b. c. d. The size of the endotracheal tube That type of secretions to be suctioned the height and weight of the patient the age of the patient 12. The long term COPD client is receiving oxygen at 1 L/min. her visiting cousin decides she “doesn't look too good”. And increases her oxygen to 7 L/ minute, whatshould the nurse initial action be? a. Think the clients cousin and continue to observe the client b. notify the physician c. elevate the clients head and take vital signsd. immediately decrease the oxygen I did 13. A type of oxygenated therapy device used for babies who can breathe on their ownbut still need extra oxygen a. Oxygen hood/ head box b. oxygen cannula c. venturi mask d. oxygen tent 14. Abnormal anterior posterior curvature of spinea. kyphosis b. pectus excavatum c. scoliosis d. pectus carinatum 15. Purposes of suctioning is to maintain patient patent airway on clients whose swallowing reflex is limited in case/s of the following: a. Client recovering from anesthesia b. critically ill patients c. unconscious client d. all of the following 16. The nurse recognized that witch pathophysiologic changes are occurring whencaring for a client with respiratory acidosis? a. decreased oxygen b. increased carbon dioxide c. decreased intracranial pressure d. vasoconstriction e. increased pulse rate 17. The nurse is preparing to care for a client receiving oxygen therapy. a mouthpiece should be used instead of a face mask when giving a nebulizer. During health teaching,which of the following is an incorrect explanation of the nurse? select all that apply a. it often feels more comfortable for the patient b. it provides a higher level of drug deposition c. patients breathe through their mouths d. this is the only method that all drugs can be given by 18. A 92 year old female patient is being admitted to the emergency department with severe shortness of breath. being aware of the patient's condition what approach shouldthe nurse used to assess the patient's lung? select all that apply a. anterior then posterior b. apex to base c. posterior than anterior d. base to apex e. lateral sequence 19. The nurse is preparing to care for a client receiving oxygen therapy. Which ofthe following is not to be included in the nursing interventions for a client receiving oxygen therapy? NOT SURE A. B. C. D. Place the client in semi-fowler’s position ✓ Place sterile water into the oxygen humidifier Place No smoking sign at the bed side Lubricate nare with oil to prevent dryness of the mucuos membrane. 20. Nurse Christian is caring for a client who is having difficulty breathing. The client islying in bed and is already receiving oxygen therapy via nasal cannula, which of the following interventions is the nurse priority? A. Increase the oxygen flow B. Attain a specimen for arterial blood gases C. Promote removal of pulmonary secretionsD. Assist the client to Fowlers position 21. A nurse is caring for a 16 year old male patient who has been hospitalized for an acute asthma exacerbation. Which of the following testing methods will the nurse not use to measure the patient’s oxygen saturation? A. B. C. D. Spirometry Pulse oximetry Maximal respiratory pressure Peak expiratory flow rate 22. A practitioner orders chest physiotherapy with percussion and vibration for a newly admitted patient. Which information obtained by the nurse during the health history should alert the nurse to question the practitioners order? A. B. C. D. Emphysema Cystic Fibrosis Chronic bronchitis Osteoporosis 23. The nurse is preparing care for a client receiving oxygen therapy. While suctioning aclient in ICU , the nurse notices that the activity brings about deep breathing and coughing manuevers by the client. This is considered a good action because: A. Deep breathing is impossible to perform when one has a respiratory disease and coughing is a relflex action B. Deep breathing is impossible to perform when one has a respiratory dissease and coughing is a reflex action C. Deep breathing has no effect on the lungs or the ability of the client to coughD. Deep breathing oxgenates the lungs and coughing loosens and moves secretions in the lungs. 24. Sternum sunken into the chestA. Pectus excavatum B. Pectus carinatum C. Scoliosis D. Kyphosis 25. A type of oxygen face mask wherein the client breathes only the source gas fromthe bag A. B. C. D. Partial rebreather mask Simple face mask Venturi mask Non- rebreather mask 26. All are abnormal findings during inspections except: A. Activity of sternocleidomastoid muscles B. Used of pursed lips during expiration C. Presence of jugular vein distentionD. Presence of crackles 27. Type of abnormal breath sounds characterized by a rasping noise during inspirationA. Stridor B. Rhonchi C. Wheeze D. Crackle 28. Abnormal respiratory patterns characterized by increasing rate and tidal volumewhich increases to a maximum, then gradually decreases. A. B. C. D. Biot’s Cheyne-stokes Agonal Kussmaul’s 29. A male client abruptly sits up in bed, reports having difficulty breathing and has anaterial oxygen saturation of 88% which mode of oxygen delivery would most likely reverse the manifestation? A. B. C. D. Non-rebreather mask Facen tent Nasal cannula Simple mask 30. Nurse clarence is taking care a client with oxygenation disorder. A cleient has beenplaced on 6 L humidified oxygen via nasal cannula. Which action by the nurse is most appropriate? a. Turn down the humidity when condensation begins to collect in the tubing b. Keep the water sterile by draining it from the water trap back into the humidifier c. Drain condensation back into the humidifier, maintaining a closed systemd. Remove condensation in the tubing by disconnecting and emptying it appropriately. 31. Irregular pattern and volume with intermittent periods of apneaA. Biot’s B. Kussmauls C. Cheyne- stokes D. Agonal 32. A deep gasping respirations representing hyperventilation, blowing off of excess carbon dioxide and compensation for an abnormal accumulation of metabolic acids inthe blood. A. Cheyne- stokes B. Agonal C. Kussmauls D. Biot’s 33. The most common device used to administer oxygen therapy a. Oxygen hood b. Nasal cannula c. Oxygen tent d. Face mask 34. Nurse Marisol is preparing to perform suctioning for a client. Which of the following are appropriate guidelines for Nurse Marisol to follow? (Select all) A. Limit suctioning to 2 to 3 attempts B. Apply suction while withdrawing the catheter C. Use a new catheter for each suctioning attempt D. Perform suctioning on a routine basis every 2 to 3 hours 35. The nurse is preparing to care for a client receiving oxygen therapy. Which is the nurse’s priority for a confused client who is to start oxygen therapy? a. Instruct the client about the importance of leaving the oxygen delivery device on b. Determine which method of oxygen delivery the client will best tolerate c. Monitor the client’s ability to tolerate removal of oxygen while eating d. explain to the client that he will not be allowed to smoke while receiving oxygen 36. Nurse stephanie is assessing Mrs. Zexy Lucero, 30 years old, G1P0, who has an acute respiratory infection that puts her at risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that Mrs. Lucero is developing hypoxemia A. Pallor b. Restlesness c. Bradycardia d. Tachypnea 37. A nurse is caring for a client who was admitted in the Emergency Department with a traumatic injury and developing tension pneumothorax. Which assessment data would the nurse anticipate? (Select all) a. bradypnea b. decreased cardiac output c. tracheal deviation to the affected side d. Flattened neck veins e. hypotension 38.
