A nurse is monitoring an older adult client immediately following a bronchoscopy. The nurse's priority is to monitor the client for which of the following? Observing for confusion Auscultating breath sounds Confirming the gag reflex Measuring blood pressure
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- The nurse is assessing a newly intubated patient and detects normal breath sounds on the right side of the patient's chest and diminished, distant breath sounds on the left side of the chest. What likely cause for these clinical signs should the nurse suspect?A. inadequate mechanical ventilationB. Intubation in the right mainstream bronchusC. Left hemothoraxD. Right hemothoraxA nurse auscultates the thorax and lungs and hears coarse,low-pitched, continuous sounds on expiration. When thepatient coughs, the sounds clear up somewhat. The nursewould document these sounds as:a. Adventitious breath soundsb. Bronchovesicular breath soundsc. Vesicular breath soundsd. Bronchial soundsWhen assessing a patient’s breath sounds, the nurse hears ahigh-pitched continuous sound. What type of breath soundwould the nurse document?a. Rhonchib. Cracklesc. Stridord. Wheezes
- A nurse is caring for a client who presented to the emergency department with an acute asthma exacerbation. The respiratory rate is 36 breaths/min, and a pulse oximeter is 85% on room air with accessory muscle use to breathe. The nurse placed the client on oxygen 4 liters nasal cannula. The arterial blood gas (ABG) is as follows: pH: 7.28, PaCO2: 50 mm Hg, PaO2: 75 mm Hg, and HCO3: 26 mEq/L. Which of the following treatments is the nurse's highest priority? A) Administer bronchodilators B) Administer sodium bicarbonate Administer methylprednisolone (D) Perform a chest x-rayWhen planning care for a patient with chronic lung diseasewho is receiving oxygen through a nasal cannula, what doesthe nurse expect?a. The oxygen must be humidified.b. The rate will be no more than 2 to 3 L/min or less.c. Arterial blood gases will be drawn every 4 hours to assessflow rate.d. The rate will be 6 L/min or more.A client with chronic obstructive pulmonary disease (COPD) asks the nurse to explain what their newly prescribed salmeterol (long acting Beta 2 agonist) and budesonide (Pulmicort) inhalers do. What would be the most appropriate response by the nurse? O The medications that have been ordered for you are what the physician thinks will help your breathing the most" O The medications that have been ordered for you are designed to work together to reduce your oxygen requirements." O The medications that have been ordered for you are to help open your airways and relieve airway inflammation." O The medications that have been ordered for you are to help you breathe with less resistance from your diaphragm."
- A client scheduled for bronchoscopy in the morning is anxious and asks the nurse numerous questions about the procedure. In preparing the client for the procedure, which intervention has the HIGHEST priority? A. Allow the client to gargle with warm salt water. B. Administer a sedative to alleviate the anxiety. C. Instruct the client to write down the questions. D. Deny client's request for a midnight snack.A nurse is inserting an oropharyngeal airway for a patientwho vomits when it is inserted. Which action would bethe first that should be taken by the nurse related to thisoccurrence?a. Quickly position the patient on his or her side.b. Put on disposable gloves and remove the oral airway.c. Check that the airway is the appropriate size for thepatient.d. Put on sterile gloves and suction the airway.A nurse is caring for a 16-year-old male patient who has beenhospitalized for an acute asthma exacerbation. Which testingmethods might the nurse use to measure the patient’s oxygensaturation? Select all that apply.a. Thoracentesisb. Spirometryc. Pulse oximetryd. Peak expiratory flow ratee. Diffusion capacityf. Maximal respiratory pressure
- A nurse is assessing the vital signs of patients who presentedat the emergency department. Based on the knowledge ofage-related variations in normal vital signs, which patientswould the nurse document as having a normal vital sign?Select all that apply.a. A 4-month old infant whose temperature is 38.1°C(100.5°F)b. A 3-year old whose blood pressure is 118/80c. A 9-year old whose temperature is 39°C (102.2°F)d. An adolescent whose pulse rate is 70 bpme. An adult whose respiratory rate is 20 bpmf. A 72-year old whose pulse rate is 42 bpmAt 11 p.m., a patient is admitted to the Emergency Department (ED) with a respiratory rate of 44 breaths/minute and SaO2 85%. They are anxious with audible wheezes. The patient is immediately given nebulised Salbutamol follow by oxygen via face mask and Hydrocortisone intravenously (I.V). 2. Provide two (2) nursing interventions with rationales to improve airway clearance and/ or improve breathing patternWhile assessing a client who had and brought me the previous day, the nurse notices that 300 ML of dark red fluid has drained from the nasogastric tube in the last hour which action should the nurse take first?