Chapter 39: Oxygenation and Perfusion
The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?
"An electric stove may be a safer choice for you."
A client is diagnosed with hypoxia related to emphysema. The client's adult child will be assisting the client with daily hygiene. How will the nurse explain positioning of the client to the caregiver?
"An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist."
Which response(s) will the nurse provide to a client concerned about developing chronic bronchitis due to smoking cigarettes, working with printing chemicals, and living near a paper mill? Select all that apply.
"Have you tried to stop smoking? This can reduce your risk?" "We can refer you to a smoking cessation program to help reduce developing any future pulmonary issues." "How long have you lived near the paper mill? This can increase you risk for chronic bronchitis and asthma." "Exposure to printing chemicals increases the risk for allergies which can trigger chronic bronchitis, so wearing a breathing mask may be needed."
The nurse determines that the student who has been instructed about lung function and smoking requires additional teaching when the student says
"Smoking only once in a while will not make a person addicted to smoking."
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." Smoking around oxygen is extremely dangerous and may cause clothing and hair to catch fire and burn much more vigorously than in air. Never smoke or allow someone else to smoke nearby whilst using your oxygen equipment.
In which client should the nurse prioritize assessments for respiratory depression?
A client taking opioids for cancer pain
Nasal Cannula
A device that delivers low concentrations of oxygen through two prongs that rest in the patient's nostrils.
respiratory acidosis
A drop in blood pH due to hypoventilation (too little breathing) and a resulting accumulation of Co2.
Emphysema
A serious disease that destroys lung tissue and causes breathing difficulties.
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
A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first?
Apply oxygen as prescribed
The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?
Arterial blood gas
A nurse is reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would the nurse most likely identify as an effect of exposure to automobile pollutants?
Bronchitis
A nurse is providing home care instructions for a client who is being discharged to his home with a tracheostomy in place. Which statement accurately describes a guideline for care that should be included in the teaching plan?
Clean, rather than sterile, technique can be used in the home setting.
A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from:
Croup generally occurs in children. In addition to a barking cough, symptoms include fever, hoarseness, and labored or noisy breathing. Most cases clear up with home care in three to five days. A doctor may prescribe a steroid for a persistent case. Rarely, a severe case may need hospital care.
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?
Destilled water
The nurse observes that the client's pulse oximetry is 89%. What is the priority nursing action?
Document hypoxemia.
A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action?
Document this expected assessment finding.
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.
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 The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen
A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?
Instruct the client to inhale deeply and then cough.
An older adult client was recently placed on home oxygen. The client's caregiver reports that the client now refuses to leave the house. What teaching will the nurse provide the caregiver? Select all that apply.
It determines whether the client is getting enough oxygen.
The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response?
Maintain the client's oxygenation and alert the health care provider immediately.
A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs?
Nasal Cannula
A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client?
Nasal cannula
PaCO2 < 40 and pH > 7.4 indicates a respiratory alkalosis (but is often from hyperventilation from anxiety or compensation for a metabolic acidosis).
PaCO2 > 40 with a pH < 7.4 indicates a respiratory acidosis,
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?
Pulmonary function tests
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?
Residual Volume (RV)
The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care?
Stay indoors as much as possible.
A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate?
The client's available hemoglobin is adequately saturated with oxygen.
During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?
Vesicular
A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action?
Warm the client's hands and try again.
The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?
Wheezing
The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?
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.
What is the most important risk factor in pulmonary disease?
active and passive cigarette smoke
Bronchietctasis
chronic dilation of a bronchus, usually secondary to infection
atelectasis
collapsed lung; incomplete expansion of alveoli
Hemoptysis is defined as:
coughing up blood or bloody secretions
The nurse is assessing a client's chest tube which was inserted 48 hours earlier. The nurse notes crackling in the skin around the insertion site. Which action should the nurse prioritize?
document finding
chronic hypoxia
increases 2,3-DPG production in blood and can result from anemia.
A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of:
pneumonia.
While auscultating a client's chest, the nurse auscultates crackles in the lower lung bases. What condition does the nurse identify the client is experiencing?
presence of sputum in the trachea
When reviewing data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom?
rapid respirations
The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?
tracheostomy collar
The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output?
"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute."
When the nurse observes a newborn infant demonstrating an irregular abdominal breathing pattern, with a respiratory rate of 40 breaths/minute with occasional pauses in breathing of 5-second duration. What is the most appropriate action by the nurse?
Continue to assess the infant.
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.
Hypoxia
Low oxygen saturation of the body, not enough oxygen in the blood
A client with a medical history of valvular dysfunction is admitted to the medical floor for management of heart failure exacerbation. The nurse reviews the client's chart to identify related findings.
Lower extremity edema B- type natriuretic peptide fluid volume excess
The nurse observes that the client's pulse oximetry is 89%. What is the priority nursing action?
Perform respiratory assessment.
What is the most important risk factor in pulmonary disease?
air pollution from vehicles
arterial blood gases
clinical test on arterial blood to identify the levels of oxygen and carbon dioxide
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 auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as:
crackles.
A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of:
croup.
The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather?
face tent
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
The nurse is assessing a client's chest tube which was inserted 48 hours earlier. The nurse notes crackling in the skin around the insertion site. Which action should the nurse prioritize?
notify the health care provider
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
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as:
wheezes