Chapter 39: Oxygenation and Perfusion

During assessment of a 4-year-old client, the nurse notes a respiratory rate of 30 breaths/min and a loud, harsh expiration that is longer than inspiration. The nurse would implement which appropriate nursing intervention next? Administer oxygen therapy Proceed with the assessment Notify the health care provider Obtain arterial blood sampling

Proceed with the assessment Explanation: When collecting respiratory data on a 4-year-old, loud, harsh expiration longer than inspiration breath sounds and respiratory rate of 25-32 breaths/min are normal findings; therefore, the nurse would continue with the assessment. Because the findings are normal, it is inappropriate at this time to administer oxygen therapy, obtain an arterial blood sampling, or notify the health care provider.

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered? nasal cannula simple oxygen mask Venturi mask partial rebreather mask

nasal cannula Explanation: Nasal cannula and tubing administer oxygen concentrations at 22% to 44%.

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? simple mask tracheostomy collar nasal cannula face tent

tracheostomy collar Explanation: A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. All other devices are less appropriate for this client.

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment? 5,000 mL (5,000 × 109/L) 5,550 mL (5,500 × 109/L) 5,850 mL (5,850 × 109/L) 6,000 mL (6,000 × 109/L)

5,850 mL (5,850 × 109/L) Explanation: Cardiac output is determined by multiplying the stroke volume by the heart rate/min, which equals 5,850 mL (5,850 × 109/L). Cardiac output and peripheral resistance determine both systolic and diastolic pressures.

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? Assist with intubation Apply oxygen Educate client on incentive spirometry Raise the head of the bed

Apply oxygen Explanation: The nurse should first apply oxygen, which will help to improve oxygen saturation and health status. The client may not require intubation, once oxygen is provided. Although the client may require education on incentive spirometry, the immediate priority intervention is to stabilize the client's oxygen saturation. Similarly, raising the head of the bed may help with the client's comfort but may not have sufficient effect on oxygen saturation.

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 False

True Explanation: After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A nurse caring for a client with a chest tube should monitor the patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.

he nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather? face tent simple mask nasal cannula tracheostomy collar

face tent Explanation: A face tent is used without a mask; it is open and loose around the face and is often used for patients with facial trauma or burns. A simple mask or nasal cannula would irritate the facial skin. The client does not have a tracheostomy.

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 encourages you to sit up straighter to increase expansion of the lungs during inhalation." "Breathing through your nose first will warm, filter, and humidify the air you are breathing." "If you breathe through the mouth first, you will swallow germs into your stomach." "We are concerned about you developing a snoring habit, so we encourage nasal breathing first."

"Breathing through your nose first will warm, filter, and humidify the air you are breathing." Explanation: Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring.

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 will require additional testing to determine the cause." "He is using his chest muscles to help him breathe." "His infection is causing him to breathe harder." "His lung muscles are swollen so he is using abdominal muscles."

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

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? Page the respiratory therapist STAT. Maintain the client's oxygenation and alert the health care provider immediately. Cover the tracheostomy stoma and apply oxygen by nasal cannula Assess the client's respiratory status and check vital signs every 1 minute for the next hour.

Maintain the client's oxygenation and alert the health care provider immediately. Explanation: If the tracheostomy becomes dislodged and is not easily replaced, the nurse should notify the primary care provider immediately, cover the tracheostomy stoma, and assess client's respiratory status.

A new graduate nurse is performing a focused respiratory assessment. The nurse preceptor will intervene if which action by the graduate nurse is noted? The graduate nurse explains the assessment procedure before performing it. The graduate nurse palpates the point of maximal impulse (PMI). The graduate nurse auscultates breath sounds as the client breathes through the nose. The graduate nurse attaches a pulse oximeter to the client's index finger.

The graduate nurse auscultates breath sounds as the client breathes through the nose. Explanation: Breath sounds should be auscultated while the client breathes slowly through an open mouth; nose breathing may produce false breath sounds. Explanation before procedures helps reduce a client's anxiety. Palpation of the PMI and attaching the pulse oximeter are included in the respiratory assessment.

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 weight loss increased urine output strong, rapid pulse

rapid respirations Explanation: Normal cardiac output averages from 3.5 to 8.0 liter/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing the respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display a thready pulse.

The health care provider has prescribed an oropharyngeal airway for a client with a decreased level of consciousness. The health care provider has noted gurgling respirations and the client's tongue is in the posterior pharynx. The client vomits as the airway is inserted. Which actions should the nurse take? Select all that apply. Position client onto the side immediately. Remove oropharyngeal airway. Provide oral suctioning and mouth care. Raise the head of the bed to 90 degrees. Assess for bleeding in the mouth.

Correct response: Position client onto the side immediately. Remove oropharyngeal airway. Provide oral suctioning and mouth care.

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? Stridor Crackles Wheezing Absent breath sounds in lower lobes

Wheezing Explanation: The nurse expects to document wheezing in the lungs of a client with asthma, which would be more pronounced when the client has a respiratory infection. Wheezing is a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration. Wheezing is caused by air passing through constricted passages caused by swelling or secretions. Stridor and crackles are other abnormal breath sounds caused by fluid, infection, or inflammation in the lungs. Absent breath sounds are not normally found in asthmatic clients; they are characteristic of pneumonia.

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather? face tent simple mask nasal cannula tracheostomy collar

ace tent Explanation: A face tent is used without a mask; it is open and loose around the face and is often used for patients with facial trauma or burns. A simple mask or nasal cannula would irritate the facial skin. The client does not have a tracheostomy.

The nurse is monitoring a client with continuous pulse oximetry. What action(s) by the nurse are important to obtain accurate results? Select all that apply. Correlate the pulse oximetry reading with the client's heart rate. Use the forehead sensor if cardiac output is low. Assess client for factors affecting circulation. Prepare the client to have an arterial line inserted. Determine if the client has a pre-existing condition affecting the oxygen saturation. Observe the monitor to record the respiratory rate.

Correlate the pulse oximetry reading with the client's heart rate. Use the forehead sensor if cardiac output is low. Determine if the client has a pre-existing condition affecting the oxygen saturation. Explanation: The nurse will correlate the pulse reading on the pulse oximeter with the client's heart rate. Variation between pulse and heart rate may indicate that not all pulsations are being detected and another sensor site may be required. In clients that have low cardiac output, it is best for the nurse to use a forehead sensor rather than the digital sensor. If the client has chronic bronchitis or emphysema, the readings may not be accurate. The nurse will obtain the heart rate with the pulse oximeter but not the respiratory rate. The nurse does not have to insert an arterial line to obtain continuous pulse oximetry readings. The arterial line is invasive and provides a portal for bacterial invasion.

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. Leave the airway in place and promptly notify the health care provider for further instructions. Suction the client's mouth through the oropharyngeal airway to prevent aspiration.

Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Explanation: If the client vomits as the oropharyngeal airway is inserted, quickly position the client onto his or her side to prevent aspiration, remove the oral airway, and suction the mouth, if needed. It would be inappropriate and unsafe to leave the airway in place. Rinsing the client's mouth with water is not a priority.