FA Davis: Oxygenation

The home care nurse visits a client who wears oxygen at bedtime. She smells cigarette smoke when entering the home. What should she say to the client? "That's a strange smell; I wonder what it could be." "Have you been smoking? You shouldn't with oxygen present." "Have you been wearing your oxygen, or is it turned off?" "It smells like someone has been smoking in here. Do you realize that oxygen is highly combustible?"

"It smells like someone has been smoking in here. Do you realize that oxygen is highly combustible?"

As the nurse is placing the oxygen, she reflects on the percentage of oxygen being delivered via nasal cannula (NC) at 2 L. What would be the correct amount? 21% 24% 28% 32% 36%

28%. Room air oxygen at sea level is 21%. 1 L/NC = 24%; 2 L/NC = 28%; 3 L/NC = 32%; 4 L/NC = 36%, etc. When delivering oxygen per nasal cannula, anything above 3 L/NC should be humidified to prevent drying of the mucous membranes of the nasal passage. The nurse should never administer more than 6 L/NC.

The nurse performs a routine assessment on Mr. Martin and discovers that his pulse oximetry reading is 89%. She contacts the healthcare provider and receives an order for oxygen at 2 L/nasal cannula. What hazards should be considered with the use of oxygen? Select all that apply. High oxygen concentration can lead to alveolar collapse. Toxicity can develop if too much oxygen is delivered. Oxygen tanks are pressurized and can turn into an unguided missile. Oxygen is highly combustible. Oxygen is not harmful and should be used regularly for sick clients.

A, B, C, D. Oxygen is often considered "safe" by healthcare personnel and patients because it is so readily used and available. Nurses must remember that oxygen is a drug and should be treated with the same level of caution.

A child has an inflamed epiglottis from a viral infection, causing stridor and partially blocking the flow of air. Which type of breathing problem is present? Altered infection Altered breathing pattern Altered gas exchange Altered airway

Altered airway

As the nurse suctions Mr. Martin via the nasopharyngeal airway, what would be an anticipated response? Apnea Harsh coughing Worsening of lung sounds Severe drop in pulse oximeter readings Excessive saliva production

Harsh coughing. The catheter used during nasotracheal suctioning should be advanced during inspiration to prevent it entering the esophagus. Once it is in the trachea, it will stimulate coughing.

Upon further assessment, the nurse discovers that Mr. Martin has conversational dyspnea and use of accessory muscles. His sputum is dark yellow-green and thick. He is having difficulty expectorating. What is the best position for Mr. Martin? Low Fowler's High Fowler's Side-lying Trendelenburg Prone

High fowler's. A high Fowler's position maximizes lung expansion to promote ventilation. Mr. Martin may even be more comfortable sitting on the side of the bed in a tripod position, leaning over the overbed table, or resting on pillows.

The nurse is caring for a patient experiencing dyspnea. Which position would be most effective to support ventilation? Supine High Fowler's Side-lying Low Fowler's

High-fowler's

The nurse is caring for a client with diabetic ketoacidosis, an acid-base disturbance. What type of breathing pattern should the nurse anticipate? Tachypnea Kussmaul's breathing Cheyne-Stokes respiration Biot's breathing

Kussmaul's breathing

The nurse is encouraging a client to cough and deep breathe as well as use the incentive spirometer. She also performs chest physiotherapy twice a day. What is the purpose of these interventions? Reduce infection rate Prevent aspiration Mobilize secretions Increase oxygen levels

Mobilize secretions

Over the next few days, Mr. Martin's infection gets worse and he is sleeping most of the time. The nurse must place an artificial airway to suction the secretions from his lungs. Which type of artificial airway would work best? Oropharyngeal airway Nasopharyngeal airway Endotracheal tube Tracheostomy tube Chest tube Check Answer

Nasopharyngeal airway. Pharyngeal airways include the oropharyngeal and nasopharyngeal airways. They work to prevent airway obstruction from the tongue. The oropharyngeal airway can only be used on the unconscious client, whereas the nasopharyngeal airway can be used for the semiconscious client because it does not stimulate the gag reflex. Endotracheal tube and tracheostomy tubes open the airways through the trachea and are used for complete upper airway blockage or mechanical ventilation. A chest tube is used to restore negative pressure in the pleural space.

Eldon Martin is a 75-year-old retired Marine Corps officer. He smoked cigarettes most of his adult life, but quit 10 years ago when he learned he had allergy-induced asthmatic lung disease. He comes to the hospital today with a high fever, productive cough, and pain in his chest. He is diagnosed with pneumonia.What additional assessment findings would be important for the nurse to gather in relation to oxygenation concerns? Select all that apply. Pulse oximetry reading Arterial blood gas Normal diet Lung sounds Number of years of smoking

Pulse oximetry, arterial blood gas, lung sounds, number of years smoking.

As Mr. Martin's oxygenation deteriorates, the nurse has an order to titrate pulse oximetry to keep it greater than 90%. Because Mr. Martin is currently at 6 L/NC (44% oxygen), what would be the best options for delivery of oxygen should the levels drop below 90%? Select all that apply. Simple mask Partial rebreather mask Nonrebreather mask Venturi mask Face tent

Simple mask, Partial rebreather mask, Venturi mask Face tent. A simple mask can deliver 40%-60% Fio2; a partial rebreather mask delivers 50%-90% Fio2; a Venturi mask delivers 24%-50% Fio2; and a face tent delivers 30%-55% Fio2. A nonrebreather mask delivers 70%-100% Fio2, which would be too large a jump from Mr. Martin's current delivery.

The nurse notes that the client is experiencing respiratory distress. Which assessment changes support this finding? Select all that apply. Eupnea Stridor Wheezing Grunting Nasal flaring

Stridor, wheezing, grunting, nasal flaring

To promote mobilization of the pneumonia secretions, which actions should the nurse include in the plan of care? Select all that apply. Encourage cough and deep breathing. Promote a balanced diet. Maintain hydration. Ambulate in hallway five times a day. Perform chest physiotherapy.

To mobilize the secretions of pneumonia the nurse should promote coughing and deep breathing, hydration, and chest physiotherapy. Additional interventions to consider include smoking cessation, incentive spirometry, and aspiration precautions. Although the promotion of a balanced diet is important, it is not likely that Mr. Martin has much of an appetite and that is not the most important step to improve the pneumonia symptoms. Ambulating can mobilize secretions but this is not an option with his current state of poor health.