Chapter 21: Oxygenation

Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen?

It regulates the amount of oxygen received.

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?

Pulse oximetry

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?

cortcosteroids

A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response?

"Have you tried nasal strips?"

A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response?

"The caregiver will need to place the oxygen tank back into the secure carrier."

A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving?

32%

A client is experiencing hypoxia. Which nursing diagnosis would be appropriate?

Anxiety

What does pulse oximetry measure?

Arterial oxygen saturation

Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body?

Chronic anemia

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe?

Crackles in the lower lobes

The nurse is caring for a client with respiratory acidosis. Which arterial blood gas data does the nurse anticipate finding?

pH less than 7.35; HCO3 high; PaCO2 high

Which is a sign of dyspnea specific to infants?

Nasal flaring

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing

Poor tissue perfusion

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 bronchospasm.

The nurse would expect to recommend an oxygen tent for which client?

a child who will not leave a facemask or cannula in place

What prevents air from reentering the pleural space when chest tubes are inserted?

a closed water-seal drainage system

A nurse is studying a client's chart and sees that the client's pH is currently at a 7. What condition is the client experiencing?

acidosis

A nurse is admitting a 6-year-old child status post tonsillectomy to the surgical unit. The nurse obtains his weight and places EKG and a pulse oximeter on the client's left finger. His heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:

adequate tissue perfusion

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?

distilled water

Which skin disorder is associated with asthma?

eczema

The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client?

nasal cannula

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include the humidifier?

"Small water droplets come from this, thus preventing dry mucous membranes."

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

Eat smaller meals that are high in protein.

Oxygen hoods are generally used to deliver oxygen at rates approaching 100% to which developmental group?

Infants

A nurse is caring for a critically ill client who has been admitted to the intensive care unit at the health care facility. The client is unable to breathe on his own and requires a very high concentration of oxygen. Which oxygen delivery device is most appropriate for this client?

Non-rebreather mask

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

True

The nurse is for a patient admitted with chronic obstructive pulmonary disease. During shift assessment, the nurse finds that the client is experiencing a change in respiratory and mental status. The most accurate measurement of the concentration of oxygen in the patient's blood is:

an arterial blood gas study.

The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select?

tracheostomy collar

A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention?

Inquire about factors that contribute to non-adherence.

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?

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them?

"It is inserted into the space between the lining of the lungs and the ribs."

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the oxygen analyzer?

"It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed."

The nurse is caring for a client with a nonhealing wound who has been prescribed hyperbaric oxygen therapy (HBOT). When the client asks, "How will this help me?" what is the appropriate nursing response?

"Wounds heal because HBOT helps to regenerate new tissue quickly

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?

"You should never smoke when oxygen is in use."

A client is learning how to do diaphragmatic breathing. For how many minutes would the nurse advise the client to rest between repetitions of the exercise? Record your answer using a whole number.

2

The nurse is caring for an older adult client on home oxygen who has dentures, but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate

Check fit of oxygen mask.

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?

Flow meter

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:

He is using his chest muscles to help him breathe."

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?

It determines whether the client is getting enough oxygen.

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?

Nasal cannula

Which oxygen delivery system is most commonly used because it does not impede eating or speaking?

Nasal cannula

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?

Sleep apnea

The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective?

SpO2 92%

A client is ordered to receive oxygen therapy via nasal cannula at 4 L/minute. When providing care to this client, what would the nurse need to keep in mind? Select all that apply.

The maximum flow rate that can be used is 6 L/minute • The client must have clear, patent nasal passages • The oxygen needs to be humidified to prevent drying of the mucosa

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:

apnea

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of:

atelectasis.

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:

breathing becomes increasingly difficult as the diaphragm is displaced.

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:

congestive heart failure

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is Ineffective Airway Clearance related to copious and tenacious secretions. Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan?

encouraging the client to consume 2 to 3 quarts of clear fluids daily

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's:

hemoglobin level.

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?

high respiratory rate

The nurse is applying a pulse oximeter to a client with bronchitis. Which factor does the nurse communicate to the client that could interfere with accurate pulse oximetry? Select all that apply.

nail polish thickness of nails acrylic nails peripheral vascular disease

The nurse needs to assess arterial oxygen saturation (SaO2) in a client. What is the best procedure to accomplish this?

pulse oximetry

The nurse is caring for a client who has excess levels of carbon dioxide in the blood, and chronic hypoxemia. Which intervention will the nurse recommend?

pursed-lip breathing

A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?

educating the client on the use of incentive spirometry

The nurse is caring for a client with a chronic lung disorder who has been prescribed portable oxygen @ 2L/min. What delivery device will the nurse select that is most appropriate for this client?

nasal cannula

The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is:

Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter.