Ch. 39 Oxygenation and Perfusion

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? A. "I understand; I used to be a smoker also." B. "You should never smoke when oxygen is in use." C. "Oxygen is a flammable gas." D. "An occasional cigarette will not hurt you."

B. "You should never smoke when oxygen is in use." The nurse will educate the client about the dangers of smoking when oxygen is in use. Oxygen is not flammable, but it oxidizes other materials. Other answers are inappropriate.

What is the action of codeine when used to treat a cough? A. Antihistamine B. Suppressant C. Expectorant D. Antisuppressant

B. Suppressant Codeine, which is an ingredient in many cough preparations, is generally considered to be the preferred cough suppressant ingredient.

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing: A. bronchitis. B. a bronchospasm. C. bronchiectasis. D. bronchiolitis.

B. a bronchospasm. When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? A. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm. B. Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. C. Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm. D. Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm.

C. Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm. Guidelines to determine suction catheter depth include the following: Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm past the length of the endotracheal tube. Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Using a spare endotracheal or tracheostomy tube of the same size as being used for the client, insert the suction catheter to the end of the tube and note the length of catheter used to reach the end of the tube. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm.

The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as: A. hypercapnia. B. dyspnea. C. apnea. D. orthopnea.

C. apnea. The newborn's breathing pattern is characterized by occasional pauses of several seconds between breaths. This periodic breathing is normal during the first 3 months of life, but frequent or prolonged periods of apnea (cessation of breathing 20 seconds or longer) are abnormal. Dyspnea refers to shortness of breath. Orthopnea refers to difficulty breathing when lying flat. An elevation of carbon dioxide levels in the blood is termed hypercapnia.

The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach? A. "Take in a little air, hold your breath 15 seconds, and exhale slowly." B. "Take in a large volume of air and hold your breath as long as you can." C. "Take in a small amount of air and exhale quickly." D. "Take in as much air as possible, hold your breath briefly, and exhale slowly."

D. "Take in as much air as possible, hold your breath briefly, and exhale slowly." This technique maximizes ventilation taking in a large volume of air fills alveoli to a greater capacity, which improves gas exchange. Deep breathing is useful for client's who has been inactive or in pain as associated with pneumonia. The other techniques do not promote improved gas exchange.

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from: A. pulmonary embolism. B. myocardial infarction. C. lung cancer. D. congestive heart failure.

D. congestive heart failure. A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.

A nurse is overseeing the care of a client who is receiving oxygen via nasal cannula. Which aspects of the client's care can the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply. A. Inserting the client's nasal cannula after it has become dislodged B. Measuring the client's respiratory rate C. Auscultating the client's lungs to determine the effectiveness of treatment D. Increasing the flow rate of the client's oxygen when the client is short of breath E. Reapplying the client's nasal cannula after a bath

A, B, E Reapplication of the nasal cannula during nursing care activities, such as during bathing, may be performed by UAP. UAP may measure a client's respiratory rate in the context of measuring the client's vital signs. Chest auscultation and changes to oxygen delivery are beyond the scope of UAP.

In which client should the nurse prioritize assessments for respiratory depression? A. A client taking opioids for cancer pain B. A client taking antibiotics for a urinary tract infection C. A client taking a beta-adrenergic blocker for hypertension D. A client taking insulin for type 1 diabetes

A. A client taking opioids for cancer pain Many medications affect the function of the respiratory system and depress the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Beta-adrenergic blockers, antibiotics, and insulin do not appreciably affect the respiratory system.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order? A. Residual Volume (RV) B. Tidal volume (TV) C. Forced Expiratory Volume (FEV) D. Total lung capacity (TLC)

A. Residual Volume (RV) During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds.

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? A. They are low-pitched, soft sounds heard over peripheral lung fields. B. They are loud, high-pitched sounds heard primarily over the trachea and larynx. C. They are medium-pitched blowing sounds heard over the major bronchi. D. They are soft, high-pitched discontinuous (intermittent) popping lung sounds.

A. They are low-pitched, soft sounds heard over peripheral lung fields. Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? A. flow meter B. nasal cannula C. oxygen analyzer D. humidifier

A. flow meter In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. A humidifier is a device that produces small water droplets and may be used during oxygen administration because oxygen dries the mucous membranes. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen.

While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique? A. pattern of thoracic expansion B. fluid-filled portions of the lung C. presence of pleural rub D. consolidated portions of the lung

A. pattern of thoracic expansion The nurse can assess patterns of thoracic expansion through palpation. Fluid-filled and consolidated portions of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation.

A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client? A. pulse oximetry B. thoracentesis C. spirometry D. peak expiratory flow rate

A. pulse oximetry Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is: A. "His infection is causing him to breathe harder." B. "He is using his chest muscles to help him breathe." C. "His lung muscles are swollen so he is using abdominal muscles." D. "He will require additional testing to determine the cause."

B. "He is using his chest muscles to help him breathe." The client will use accessory muscles to ease dyspnea and improve breathing.

Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen? A. It prescribes oxygen concentration. B. It regulates the amount of oxygen received. C. It decreases dry mucous membranes via delivering small water droplets. D. It determines whether the client is getting enough oxygen.

B. It regulates the amount of oxygen received. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The oxygen analyzer measures the percentage of delivered oxygen. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function? A. Tachypnea B. Pleural effusion C. Pneumonia D. Wheezes

B. Pleural effusion Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis. Pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.

The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? A. "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling." B. "Take in a small amount of air very quickly and then exhale as quickly as possible." C. "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." D. "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly."

C. "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.

A client with chronic obstructive pulmonary disease (COPD) reports severe shortness of breath when it is raining. The nurse says to the client: A. "Have you had a stress test to determine if your airway is obstructed?" B. "The airway becomes occluded during periods of rain." C. "The humidity in the air makes harder for you to breathe." D. "You should use your inhaler as often as necessary during this time to help your breathing."

C. "The humidity in the air makes harder for you to breathe." People with chronic respiratory diseases often find breathing more difficult when the weather is hot and humid because humidity makes the air denser and harder to breathe.

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations? A. Hyperventilation B. Atelectasis C. Hypoxia D. Perfusion

C. Hypoxia Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia. Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements. Perfusion refers to the process by which oxygenated capillary blood passes through body tissues. Atelectasis refers to collapsed alveoli.

During a routine prenatal care visit, a pregnant woman in her last trimester of pregnancy reports that she has occasional shortness of breath. The nurse instructs her that: A. the nurse will assess her lung sounds and determine whether she has pneumonia. B. a prompt referral for follow up care will be made. C. breathing becomes increasingly difficult as the diaphragm is displaced. D. a chest x-ray is likely indicated.

C. breathing becomes increasingly difficult as the diaphragm is displaced. During the last weeks of pregnancy, breathing may become increasingly difficult in a supine position because the fetus displaces the diaphragm upward.

The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier? A. mineral oil B. normal saline C. distilled water D. tap water

C. distilled water Distilled water is used when humidification is desired. Other answers are incorrect.

A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from? A. chronic obstructive pulmonary disease (COPD) B. pneumonia C. sleep apnea D. chronic bronchitis

C. sleep apnea This client has all the risk factors of sleep apnea, which consists of multiple periods of apnea during sleep. These periods of apnea cause the person to move into a lighter sleep more often than someone without this disease, thus causing the daytime sleepiness.

The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis? A. high temperature B. low blood pressure C. low pulse rate D. high respiratory rate

D. high respiratory rate A client diagnosed with Impaired Gas Exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.