assignment of O2
The nurse is caring for a patient with COPD. The patient is receiving oxygen therapy via nasal cannula. The nurse understands that the goal of oxygen therapy is to maintain the patient's SaO2 level at or above what percent? a) 90% b) 30% c) 70% d) 50%
90% Explanation: The goal of supplemental oxygen therapy is to increase the baseline resting partial arterial pressure of oxygen (PaO2) to at least 60 mm Hg at sea level and arterial oxygen saturation (SaO2) to at least 90%. (less) Chapter 24: Management of Patients With Chronic Pulmonary Disease - Page 626
The nurse is caring for an adolescent client injured in a snowboarding accident. The client has a head injury, a fractured right rib, and various abrasions and contusions. The client has a blood pressure of 142/88 mm Hg, pulse of 102 beats/minute, and respirations of 26 breaths/minute. Which laboratory test best provides data on a potential impairment in ventilation? a) Blood gases b) Serum alkaline phosphate c) Complete blood count d) Blood chemistry
Blood gases Explanation: Blood gases report the partial pressure of oxygen, which is dissolved in the blood. Normal readings are 80 to 100 mm Hg. By documenting oxygen levels in the blood, the nurse recognizes the current ventilation. The complete blood count provides information regarding number of blood cells, which can relate to the disease processes such as anemia and infection. The blood chemistry provides information on liver/renal function and electrolytes within the system. Serum alkaline phosphate is a laboratory test used to help detect liver disease and bone disorders. (less) Chapter 20: Assessment of Respiratory Function - Page 484
What would be an appropriate action for the nurse prior to performing deep tracheal suctioning due to increased secretions? a) Hyperoxygenate the client before suctioning. b) Deflate the cuff of the tracheotomy during suctioning. c) Apply negative pressure as the catheter is being inserted. d) Instill acetylcysteine into the tracheotomy before suctioning.
Instill acetylcysteine into the tracheotomy before suctioning. Incorrect Correct response: Hyperoxygenate the client before suctioning. Explanation: Preoxygenation and deep breathing assist in reducing suction-induced hypoxemia because it decreases the risk of atelectasis caused by negative pressure of suctioning. Deflating the cuff is not necessary and there is no reason to instill acetylcysteine into the tracheotomy before suctioning. Pressure is applied only with the removal of the catheter. (less) Remediation: Nasotracheal suctioning
A 10-month-old infant with tetralogy of Fallot (TOF) experiences an cyanotic episode. To improve oxygenation during such an episode, the nurse should place the infant in which position? a) Fowler's b) Prone c) Trendelenburg's d) Knee-to-chest
Knee-to-chest Explanation: TOF involves four defects: pulmonary stenosis, right ventricular hypertrophy, ventricular-septal defect (VSD), and dextroposition of the aorta with overriding of the VSD. Pulmonary stenosis decreases pulmonary blood flow and right-to-left shunting via the VSD, causing desaturated blood to circulate. The nurse should place the child in the knee-to-chest position because this position reduces venous return from the legs and increases systemic vascular resistance, maximizing pulmonary blood flow and improving oxygenation status. Fowler's, Trendelenburg's, and the prone positions don't improve oxygenation. (less) Remediation: Tetralogy of Fallot, pediatric
When assessing a client, which adaptation indicates the presence of respiratory distress? a) Respiratory rate of 14 breaths per minute b) Orthopnea c) Sore throat d) Productive cough
Orthopnea Explanation: Orthopnea is the inability to breathe easily except when upright. This positioning can mean while in bed and propped with a pillow or sitting in a chair. If a client cannot breathe easily while lying down, there is an element of respiratory distress. Chapter 20: Assessment of Respiratory Function - Page 472
