NSG 420 Chapter 27 Respiratory Complete And Study material 12pages LEARNEXAMS

1. Which finding by the nurse most specifically indicates that a patient is notable to effectively clear the airway? a. Weak cough effort b. Profuse green sputum c. Respiratory rate of 28 breaths/min d. Resting pulse oximetry (SpO2) of 85%: Answer A The weak cough effort indicates that the patient is unable to clear the airway effectively. The other data suggest problems with gas exchange and breathingpattern. 2. A patient with bacterial pneumonia has coarse crackles and thick sputum.Which action should the nurse plan to promote airway clearance? a. Restrict oral fluids during the day. b. Encourage pursed-lip breathing technique. c. Help the patient to splint the chest when coughing. d. Encourage the patient to wear the nasal O2 cannula.: Answer C Coughing is less painful and more likely to be effective when the patient splints thechest during coughing.Fluidsshould be encouraged to help liquefy secretions.NasalO2 will improve gas exchange but will not improve airway clearance. Pursed-lip breathing can improve gas exchange in patients with chronic obstructive pulmonarydisease but will not improve airway clearance. 3. Which action should the nurse plan to prevent aspiration in a high-riskpatient? a. Turn and reposition an immobile patient at least every 2 hours. b. Place a patient with altered consciousness in a side-lying position. c. Insert a nasogastric tube for feeding a patient with high-calorie needs. d. Monitor respiratory symptoms in a patient who is immunosuppressed.: - Answer B With loss of consciousness, the gag and cough reflexes are depressed, and aspiration is more likely to occur. The risk for aspiration is decreased when patients with a decreased level of consciousness are placed in a side-lying or upright position.Frequent turning prevents pooling of secretions in immobilized patients but will not decrease the risk for aspiration inpatients at risk.