TEST 2

Question 1

what inhibits both diaphragmatic excursion and lung distensibility

Answer 1

shallow respirations

Question 2

what is the result of inadequate chest expansion

Answer 2

pooling of respiratory secretions which harbor microorganisms and promote infection.

Question 3

the use of slow, abdominal breathing can facilitate what?

Answer 3

pain relief and lowers blood pressure

Question 4

changing position frequently, ambulating, and exercising usually maintains adequate _____ and _____

Answer 4

ventilation and gas exchange

Question 5

people tend to breathe in a shallow fashion and o not draw air into the lowest region of the lungs, limiting what?

Answer 5

gas exchange

Question 6

alveolar collapse due to pooling of respiratory secretions can cause a lack of oxygen known as

Answer 6

hypoxemia

Question 7

hypoxemia is often caused by the use of

Answer 7

opiods

Question 8

what position allows for maximum chest expansion and encourages deeper breaths

Answer 8

semi-fowlers and high- fowlers

Question 9

what position is prohibited to those that are in respiratory distress

Answer 9

laying flat on back

Question 10

sitting up to relieve dyspnea or labored breathing is known as what position

Answer 10

orthopneic position - an adaptation of high-flowers

Question 11

when a client sits upright and lean on their arms or elbow, this position is known as

Answer 11

tripod position

Question 12

when coughing raises secretions high enough the client may either _____ or swallow them

Answer 12

expectorate (cough up)

Question 13

definition of expectorate

Answer 13

cough up

Question 14

a disease process that decreases the ability of the lungs to perform ventilation

Answer 14

COPD

Question 15

abdominal (diaphragmatic) breathing permits _____, ____ breathes with _____ effort

Answer 15

deep, full, little

Question 16

helps the client develop control over breathing and helps alleviate dyspnesa

Answer 16

pursed lip breathing

Question 17

what method of breathing creates a resistance to the air flowing out of the lungs, thereby prolonging exhalation and preventing airway collapse by maintaining positive airway pressure?

Answer 17

pursed lip breathing

Question 18

normal forceful coughing involves the client inhaling deeply and then coughing how many times while exhaling

Answer 18

2

Question 19

what coughing technique involves the client inhaling deeply and then coughing twice while exhaling

Answer 19

normal forceful cough

Question 20

what coughing technique involves the client exhaling through pursed lips but then exhale with a huff sound mid-exhalation

Answer 20

huff coughing

Question 21

who is huff coughing used for

Answer 21

pulmonary condition such as COPD

Question 22

what helps prevent high expiratory pressures that collapse diseased airways and helps keep the airways open while moving secretions up and out of the lungs

Answer 22

huff coughing

Question 23

what device is used for clients with excessive secretions caused by disorders such as cystic fibrosis, copd, and bronchiectasis

Answer 23

mucus clearance device (MCD)

Question 24

rapid respirations marked by quick, shallow breathes

Answer 24

tachypnea

Question 25

abnormally slow breathing

Answer 25

bradypnea

Question 26

cessation of breathing

Answer 26

apnea

Question 27

an increase in the amount of air in the lungs; characterized by prolonged and deep breaths

Answer 27

hyperventilation

Question 28

reduction in the mount of air in the lungs; characterized by shallow repsirations

Answer 28

hypoventilation

Question 29

rhythmic waxing and waning of respirations from very deep to very shallow breathing and temporary apnea

Answer 29

cheyne-stokes breathing

Question 30

difficult and labored breathing during which the individual has a persistent unsatisfied need for air and feel distressed

Answer 30

dyspnea

Question 31

ability to breathe only in upright sitting or standing positions

Answer 31

orthopnea

Question 32

a shrill harsh sound heard during inspiration with laryngeal obsturction

Answer 32

stridor

Question 33

continuous high pitched musical squeak or whistling sound occurring on expiration

Answer 33

wheezing

Question 34

what instrument measures the flow of air inhaled through the mouthpiece

Answer 34

incentive spirometers

Question 35

incentive spirometers help improve ______ _____

Answer 35

pulmonary ventilation

Question 36

instrument designed to mimic natural sighing or yawing by encouraging the client to take long slow deep breathes

Answer 36

incentive spirometer

Question 37

The nurse is telling a client with chronic obstructive pulmonary disease to breathe out slowly and gently like blowing out a candle to prolong exhalation. The nurse is teaching the client what type of breathing?

Answer 37

pursed lip breathing

Question 38

The nurse is caring for a client who is 36 hours postoperative following chest surgery. On entering the client room, the nurse finds the client learning forward and coughing while exhaling. The nurse recognized that the client is

Answer 38

is properly performing huff coughing

Question 39

A postoperative surgical client has a respiratory rate of 22 per minute, audible rhonchi in the lower lobes, and an oxygen saturation of 90%, The nurse uses which strategies to improve has exchange? 1. position the client in the orthopneic position 2. position the client in a supine or prone position 3. encourage bed rest 4. encourage ambulation 5. encourage fluids

Answer 39

1,4,5

Question 40

the nurse assesses the postoperative clients respirations and finds that the client is breathing shallowly. when encouraged to take deep breaths the client says "it hurts when i take deep breath" To assist the client to breathe deeply the nurse would use which strategy

Answer 40

teach the client to use a pillow to splint the incision site whole deep breathing

Question 41

when assessing the clients breath sounds, the nurse auscultates a continuous high pitched musical squeak/ whistle on expiration. The nurse recognizes this is the result of

Answer 41

narrowed or partially obstructed airways

Question 42

the nurse assesses the clients respiratory effort and notes in drawing of muscles beneath the breastbone with inspiration. how would the nurse document this assessment

Answer 42

substernal retractions

Question 43

the client is providing a return demonstration of abdominal breathing. which action by the client determines that the nurses teaching has been effective 1. breathes quickly in and out through the mouth 2. arches the back while breathing 3. takes a deep breath through the nose 4. places the hands behind the head

Answer 43

3

Question 44

after teaching the client how to use abdominal breathing. The nurse goes on to teach the client how to huff cough. the nurse has the client do which action prior to coughing

Answer 44

inhale deeply and hold the breath for a few seconds

Question 45

The nurse is caring for a client who is 36 hours postoperative following chest surgery. after teach the client how to use an incentive spirometer, the nurse recognizes that further teaching is needed when the client does which action? 1. uses the SMI immediately after eating 2. takes slow deep breaths 3. assumes an upright sitting position 4. exceeds the set volume level

Answer 45

1

Question 46

the nurse is choosing an incentive spirometer for the postoperative client and knows that a disadvantage of low oriented sustain maximal inspiration devices is

Answer 46

the client is unable to determine effectiveness without the nurses evaluation

Question 47

One complication of wound healing is

Answer 47

infection

Question 48

surgical infection is most likely to become apparent how many days after surgery

Answer 48

2 to 11

Question 49

fluid containing cells that have escaped from blood vessels during the inflammatory phase of wound healing and is deposited in tissues or on tissue surfaces is called

Answer 49

exudate

Question 50

what are the 3 types of exudate

Answer 50

serous, purulent, and sanguineous

Question 51

clear watery exudate

Answer 51

serous

Question 52

exudate that his thick because of the presence of pus; varies in color,

Answer 52

purulent

Question 53

exudate that is dark or bright red

Answer 53

sanguineous

Question 54

growing only in the presence of oxygen

Answer 54

aerobic

Question 55

growing only in the absence of oxygen

Answer 55

anaerobic

Question 56

the withdrawal of fluid that has abnormally collected

Answer 56

aspiration

Question 57

the removal and examination of tissue

Answer 57

biopsy

Question 58

True of false | Sterile technique is used during cultures

Answer 58

true

Question 59

The nurse is preparing to collect a wound drainage specimen for culture and sensitivity from postoperative wound. what action would the nurse take before collecting the specimen?

Answer 59

apply sterile gown and gloves