Chapter 40 Oxygenation and Perfusion

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider?

- An infant with a respiratory rate of 16 bpm The infant's normal respiratory rate is 20 to 40 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 32 breaths per minute. For a child 6 to 12 years of age the normal respiratory rate is 18 to 26 breaths per minute. The normal respiratory rate for an adult 65 years and older is 16 to 24 breaths per minute.

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?

- Confusion Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, elevated blood pressure with small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

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 fluid in the lungs Coarse crackles heard on auscultation indicate the presence of fluid in the lungs. Air passing through narrowed airways produces a wheezing sound, whereas inflammation of pleural surfaces gives rise to pleural rub. Sputum in the trachea produces stridor, a harsh, noisy squeak when something is blocking the airway.

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." The following formula is used to determine cardiac output: Cardiac Output = Stroke Volume x Heart Rate. A client with a stroke volume of 50 mL and heart rate of 50 beats per minute has a cardiac output of 2.5 L/minute. If stroke volume is 70 and heart rate is 70 beats per minute, then the cardiac output is 4.9 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute. If stroke volume is 60 and heart rate is 60 beats per minute, then the cardiac output is 3.6 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute.

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?

- Assess oxygen tubing connection 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 providing care in an area which is plagued by high levels of air pollutants from industry and motor vehicles. The nurse will expect a high incidence and prevalence of what respiratory disease?

- Bronchitis Bronchitis refers to a condition in which the airways become inflamed, commonly due to respiratory irritants such as air pollution and high humidity. Exposure to such irritants leads to the release of inflammatory mediators, which in turn, lead to inflammation and narrowing of the airways and increased mucus production. Atelectasis refers to the partial or complete collapse of the small air sacs in the lungs, common after surgery or with obstruction or compression of the airways or lungs. Bronchiectasis results from chronic inflammation or infection causing an excess accumulation of mucus. Croup is an infection of the airways, most commonly viral in origin.

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?

- Congestive Heart Failure 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.

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 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.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

- The chest should be slightly convex with no sternal depression. The adult chest contour is slightly convex, with no sternal depression. The skin of the thorax should be warm and dry, and the anteroposterior diameter of the chest should be less than the transverse diameter. The contour of the intercostal spaces should be flat or depressed.

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.