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."

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

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

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 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?

Ambu bag

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?

Ask the client what factors contribute to nonadherence.

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines?

Be sure to shake the canister before using it.

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 the fit of the oxygen mask.

What is the action of codeine when used to treat a cough?

Suppressant

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

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.

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

atelectasis.

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 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?

Hypoxia

In which client would the nurse assess for a depressed respiratory system?

a client taking opioids for cancer pain

The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client?

"Breathing through your nose first will warm, filter, and humidify the air you are breathing."

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."

Which skin disorder is associated with asthma?

Eczema

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

They are low-pitched, soft sounds heard over peripheral lung fields.

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.

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

A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario?

cyanosis

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

A nurse has received an order to suction an adult client's endotracheal tube. Which action is most appropriate when performing this intervention?

Use sterile saline to moisten the end of the suction catheter.

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather?

face tent