Chapter 40: Oxygenation and Perfusion
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? a) "Breathing through your nose first will warm, filter, and humidify the air you are breathing." b) "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." c) "If you breathe through the mouth first, you will swallow germs into your stomach." d) "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." 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: a) "He will require additional testing to determine the cause." b) "His lung muscles are swollen so he is using abdominal muscles." c) "His infection is causing him to breathe harder." d) "He is using his chest muscles to help him breathe."
"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 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." Explanation: Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.
An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize? a) "Did someone loosen the straps on your mask?" b) "Is your mask causing discomfort?" c) "Did someone take your mask off?" d) "Did you remove your dentures?"
"Is your mask causing discomfort?" Explanation: It is possible for anyone using a mask to try and readjust it if it is uncomfortable. Depending on the older adult's cognitive status, he or she may have tried to make it more comfortable and in the process caused it to no longer fit correctly. This could also occur if the client removed their dentures, as some individual's choose to let the dentures soak overnight. If the mask was fitted with the dentures in, the mask will likely be loose with the dentures removed. The other questions could possibly be asked to see if someone else may have tried to help the client feel more comfortable with the mask on.
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) "Oxygen is a flammable gas." b) "I understand; I used to be a smoker also." c) "An occasional cigarette will not hurt you." d) "You should never smoke when oxygen is in use."
"You should never smoke when oxygen is in use." Explanation: 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.
The obstetric nurse is assisting the birth of a preterm neonate. In preparing for the respiratory needs of the neonate, the nurse is aware that surfactant is formed in utero around: a) 30 to 32 weeks. b) 34 to 36 weeks. c) 32 to 34 weeks. d) 36 to 38 weeks.
34 to 36 weeks.
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? a) Oxygen tent b) Ambu bag c) Oxygen mask d) Nasal cannula
Ambu bag Explanation: If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Oxygen masks may cover only the nose and mouth and can vary in the amount of oxygen delivered. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostril. An oxygen tent is a tentlike enclosure within which the air supply can be enriched with oxygen to aid a client's breathing. Oxygen masks, nasal cannula, and oxygen tents are used for clients who have a respiratory drive.
The nurse is caring for a client who will have a chest tube removed within the next hour. What action by the nurse will be included in the plan of care for this client for removal of the chest tube? Select all that apply. a) Apply a semipermeable dressing to the insertion site immediately after the chest tube is removed. b) Apply a cold compress to the site prior to the removal. c) Teach the client about relaxation exercises to be used during chest tube removal. d) Ask the client to bear down, then slowly withdraw the chest tube. e) Administer prescribed pain medication 15 to 30 minutes before chest tube removal.
Apply a cold compress to the site prior to the removal. Teach the client about relaxation exercises to be used during chest tube removal. Administer prescribed pain medication 15 to 30 minutes before chest tube removal.
A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?
Ask the client what factors contribute to nonadherence. Explanation: The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment. Then, the nurse can work with the health care provider to find alternate treatment options if necessary, and then document the care.
The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take? a) Assess lung sounds b) reposition the client c) elevating the head of the bed d) Assess oxygen tubing connection
Assess oxygen tubing connection Explanation: If the client suddenly becomes cyanotic, the nurse should assess the oxygen tubing to make sure it is still connected. Assessing lung sounds, repositioning the client, and elevating the head of the bed will not correct the problem if the tubing is disconnected.
A nurse is volunteering at a day camp where a child is stung by a bee and develops wheezing in the upper airways. The nurse will provide interventions to address what health problem? a) Bronchitis b) Bronchospasm c) Bronchiolitis d) Bronchiectasis
Bronchospasm Explanation: 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. Bronchitis and bronchiectasis are chronic respiratory effects and bronchiolitis is infectious.
The nurse is assessing a client with lung cancer who has been receiving treatment for many months. What manifestations may suggest that the client has chronic hypoxia? a) Yellow or green sputum b) Clubbing c) Hemoptysis d) Edema
Clubbing Explanation: Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many clients with chronic hypoxia due to respiratory or cardiac disease. Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD. Hemoptysis, edema, and discolored sputum do not result from hypoxia.
A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The nursing care plan will address implications of what medical diagnosis? a) Lung Cancer b) Congestive Heart Failure c) Pulmonary Embolism d) MI
Congestive heart failure Explanation: A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure as a result of alterations to circulation. Pulmonary embolism presents with more acute signs of hypoxia. MI and lung cancer are not characterized by productive cough and frothy sputum.
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse will document what breath sounds? a) Bronchovesicular b) Vesicular c) Crackles d) Wheezes
Crackles Explanation: Crackles, frequently heard on inspiration, are soft, high-pitched discontinuous (intermittent) popping sounds. Wheezes are continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors. Vesicular sounds are low-pitched, soft sounds heard over peripheral lung fields. Bronchovesicular sounds are medium-pitched blowing sounds heard over the major bronchi.
A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level?
Crackles Explanation: Normal breath sounds of an infant are harsh crackles at the end of deep inspiration. Wheezing is a whistling sound made while breathing. Clear sounds are usually not heard in an infant. A bruit is an audible vascular sound and not a pulmonary sound associated with turbulent blood flow.
The nurse is assessing a neonate whose breathing ceased for 4 to 5 seconds on three different occasions. What is the nurse's best action? a) Obtain an order for airway suctioning as needed b) Arrange for immediate assessment by the primary care provider c) Reposition the infant to promote adequate oxygenation d) Document these expected apneic episodes
Document these expected apneic episodes Explanation: 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. In the absence of symptoms of hypoxia, referrals and further interventions such as suctioning are unnecessary.
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. Explanation: A range of 95% to 100% is considered normal oxygen saturation. As such, there is no need to change the client's position, encourage deep-breathing exercises and coughing, or to review the client's medication history.
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) Hypoxia c) Atelectasis d) Perfusion
Hypoxia Explanation: 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.
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? a) Page the respiratory therapist STAT. b) Cover the tracheostomy stoma and apply oxygen by nasal cannula c) Maintain the client's oxygenation and alert the health care provider immediately. d) 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 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? a) Nasal cannula b) Nonrebreather mask c) Partial rebreather mask d) Simple mask
Nasal cannula Explanation: A nasal cannula is used to deliver from 1 L/min to 6 L/min of oxygen. Masks are used with higher flow rates of oxygen.
Which statement accurately describes a general consideration when performing CPR on a client?
Perform CPR on an obese client the same as on a non-obese client. Explanation: Perform CPR in the same manner if the client is obese. If the nurse is unsure whether the client has a pulse, CPR should be initiated anyhow. Hands-only CPR is not recommended for victims of drowning, trauma, airway obstruction, and acute respiratory distress. If available, use a one-way valve mask over a child's nose and mouth when performing CPR.
The nurse observes that the client's pulse oximetry is 89%. What is the priority nursing action? a)Check the placement of the pulse oximeter. b) Document hypoxemia. c) Perform respiratory assessment. d) Report pulse oximetry to the health care provider.
Perform respiratory assessment. Explanation: As the nurse enters the room, the respiratory assessment immediately begins by visualizing the client's skin color, observing chest symmetry, vocalization, and auditory adventitious lung sounds. The nurse can then proceed to check the placement of the pulse oximeter, report findings to the health care provider, and document.
A parents brings their 2-year-old to the emergency department in respiratory distress. SThe child's oxygen saturation is 81% and there is audible stridor. What intervention will the nurse anticipate? a) Corticosteroids by metered-dose inhaler b) Placement in an oxygen tent c) Deep breathing and coughing exercises d) Chest physiotherapy
Placement in an oxygen tent Explanation: Stridor often accompanies croup in young children. Due to the child's age, an oxygen tent would be an appropriate oxygen delivery device. The child is too young for metered-dose inhalers or deep breathing and coughing exercises.
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) wheezes d) Pneumonia
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.
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 a) Poor tissue perfusion b) Congestive heart failure c) Anemia d) Malnutrition
Poor tissue perfusion Explanation: Chronically poor perfusion may result in hair loss in the affected area, discolored skin, thickened nails, and shiny, dry skin indicative of inadequate tissue nutrition.
The nurse is caring for an older adult homebound client with advanced respiratory disease whose has inadequate nutrition. What recommendation will the nurse provide?
Provide suggestions of high-protein, high-calorie meals Explanation: TThe client should have sufficient caloric and protein intake for respiratory muscle strength, so promotion of a high-calorie, high-protein diet is appropriate. Protein shakes and dietary supplements may be appropriate but should complement, rather than replace, meals. Intermittent fasting promotes weight loss, not increased calorie intake.
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? a) Bronchoscopy b) Chest x-ray c) Pulmonary function tests d) Skin tests
Pulmonary function tests Explanation: Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? a) Remove the airway, turn the client to the side, and provide mouth suction, if necessary. b) Rinsing the client's mouth with water c) leave the airway in place
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.
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) Explanation: 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 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. Explanation: Using the air quality index, a red color designation signifies that the air quality is unhealthy for all people, not just sensitive groups. Air pollution and high humidity are respiratory irritants. Pollutants cause increased mucus production and contribute to bronchitis and asthma. Reducing contact with irritants by staying indoors during times of increased air pollution will decrease their effect on the respiratory system. Clients should be encouraged to quit smoking, not just cut down. Avoiding large crowds and practicing good hand hygiene will prevent respiratory infections but not cut down on the effect of air pollution.
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.
They are low-pitched, soft sounds heard over peripheral lung fields. Explanation: 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.
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? a) 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. b) 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. c) Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. d) For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.
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. Explanation: 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.
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? a)Use a blood pressure cuff to increase circulation to the site. b) Warm the client's hands and try again. c) Place the probe on the client's earlobe. d) Shine available light on the equipment to facilitate accurate reading.
Warm the client's hands and try again. Explanation: Finding an absent or weak signal, the nurse should check vital signs and client condition. If satisfactory, warming the extremity may facilitate a stronger reading. This should be attempted prior to resorting to using the client's earlobe. Bright light can interfere with the operation of light sensors and cause an unreliable report. A blood pressure cuff will compromise venous blood flow to the site leading to inaccurate readings.
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? a) Absent breath sounds in lower lobes b) Crackles c) Stridor d) Wheezing
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 caring for the following clients. Which client is at highest risk for a depressed respiratory system?
a client taking an opioid for cancer pain Explanation: Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Amlodipine is a calcium channel blocker and the medication decreases blood pressure, so the nurse would need to assess blood pressure. Muscle relaxants such as methocarbamol could depress respiratory status, but this occurs less often than with opioids. Methimazole is used to treat hyperthyroidism, thus lowering the body's metabolic functions, which can depress respirations; however, this is a very rare occurrence with this medication. The client at highest risk is the one taking an opioid.
The nurse is caring for the following clients. Which client is at highest risk for a depressed respiratory system? a) a client taking an opioid for cancer pain b) a client taking amlodipine for hypertension c) a client taking methimazole for hyperthyroidism d) a client taking methocarbamol for low back spasms
a client taking an opioid for cancer pain Explanation: Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Amlodipine is a calcium channel blocker and the medication decreases blood pressure, so the nurse would need to assess blood pressure. Muscle relaxants such as methocarbamol could depress respiratory status, but this occurs less often than with opioids. Methimazole is used to treat hyperthyroidism, thus lowering the body's metabolic functions, which can depress respirations; however, this is a very rare occurrence with this medication. The client at highest risk is the one taking an opioid.
The nurse is applying a pulse oximeter to a client with bronchitis. Which factor(s) does the nurse communicate to the client that could interfere with accurate pulse oximetry? Select all that apply. a) acrylic nails b) thickness of nails c) peripheral vascular disease d) respiratory rate e) nail polish
a) acrylic nails b) thickness of nails c) peripheral vascular disease e) nail polish Explanation: If the client is wearing nail polish, has thick nails or is wearing acrylic nails, this will interfere with the probe detecting an accurate oxygen saturation. Peripheral vascular disease reduces or diminishes blood flow to fingers and toes. For these reasons, the nurse will need to determine a site to ensure monitor readings are accurate. Where circulation may be reduced or diminished, the pulse oximeter will not read well. The pulse oximeter reading will vary with the rate and depth that the respirations but should not be deemed inaccurate because of them. Instead, the nurse will be aware to note changes in the oxygen saturation based on changes in the respiratory rate. Brief, transient changes are not remarkable and do not require intervention.
A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate: a) adequate tissue perfusion. b) heart failure. c) high cardiac output. d) diminished stroke volume.
adequate tissue perfusion. Explanation: Pulse oximetry is often used as a measure of tissue perfusion. An oxygen saturation of greater than 94% is typically indicative of good tissue perfusion.
What assessments would a nurse make when auscultating the lungs? a) air flow through the respiratory passages b) presence of edema c) abnormal chest structures d) volume of air exhaled or inhaled
air flow through the respiratory passages Explanation: Auscultation of the lungs assesses air flow through the respiratory passages and lungs. The nurse listens for normal, as well as abnormal, breath sounds. Abnormal chest structures would be assessed when inspecting the chest and thoracic region. Presence of edema would be assessed as part of the cardiovascular status of the client. Volume of air exhaled and inhaled would be performed during a pulmonary function test.
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) Auscultating the client's lungs to determine the effectiveness of treatment b) Measuring the client's respiratory rate c) Inserting the client's nasal cannula after it has become dislodged 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
b) Measuring the client's respiratory rate c) Inserting the client's nasal cannula after it has become dislodged e) Reapplying the client's nasal cannula after a bath Explanation: 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.
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) tap water d) distilled water
distilled water Explanation: Distilled water is used when humidification is desired. Other answers are incorrect.
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 Explanation: 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. 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 health care provider. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.
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 pulse rate c) low blood pressure d) high respiratory rate
high respiratory rate Explanation: 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.
To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?
high-Fowler's position Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. High-Fowler's position is used to drain the apical sections of the upper lobes of the lungs. Placing the client lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.
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) peak expiratory flow rate b) pulse oximetry c) thoracentesis d) spirometry
pulse oximetry Explanation: 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 health care provider to aspirate pleural fluid for diagnostic or therapeutic purposes.
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 Explanation: 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 health care provider to aspirate pleural fluid for diagnostic or therapeutic purposes.
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 Explanation: Pursed-lip breathing is most helpful for clients who have excessive levels of carbon dioxide in the blood and chronic hypoxemia. Other choices do not eliminate as much carbon dioxide from the blood.
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? a) face tent b) nasal cannula c) simple mask d) tracheostomy collar
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.