Fundamentals of Nursing: Chapter 39: Oxygenation
In which of the following clients would the nurse assess for a depressed respiratory system? a) A client taking insulin for diabetes b) A client taking opioids for cancer pain c) A client taking amlodipine for hypertension d) A client taking antibiotics for a urinary tract infection
Correct response: A client taking opioids 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
The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of a) Bronchospasm b) Epiglottitis c) Atelectasis d) Croup
Correct response: Atelectasis Explanation: Stiffer lungs tend to collapse and their alveoli also collapse. This condition is called atelectasis
To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry technique? a) Monitor the pressure of oxygen dissolved in plasma b) Calculate the percentage of hemoglobin saturated with oxygen c) Calculate the pressure of carbon dioxide dissolved in plasma d) Monitor the amount of oxygen saturation in the blood
Monitor the amount of oxygen saturation in the blood Explanation: The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. The arterial blood gases test the client's blood for the partial pressure of oxygen dissolved in plasma, percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma
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) "His infection is causing him to breathe harder." b) "He will require additional testing to determine the cause." c) "He is using his chest muscles to help him breathe." d) "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 charge nurse is observing a new nurse care for a client who is receiving oxygen via a simple mask with an FIO2 of 40%. The client states, "This moisture on my face is bothersome. Can something be done about it?" Which of the following responses by the new nurse would require clarification by the charge nurse? a) "The mask and its moisture can be bothersome, so let me demonstrate some distraction techniques to help you cope with them." b) "Your mask should remain on, but I will help you dry your face when it becomes too wet." c) "After I dry your face, I can apply powder to absorb the moisture and protect your skin." d) "I will confer with your primary care provider to find out if a nasal cannula can be used."
Correct response: "After I dry your face, I can apply powder to absorb the moisture and protect your skin." Explanation: This statement acknowledges the client's discomfort and offers appropriate assistance.
The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal? a) 12 to 20 breaths per minute b) 20 to 30 breaths per minute c) 12 to 15 breaths per minute d) 30 to 60 breaths per minute
Correct response: 30 to 60 breaths per minute Explanation: The nurse should expect the baby to have a respiratory rate of 30 to 60 breaths per minute. Toddlers and preschoolers have a respiratory rate of 20 to 30 per minute. School-age children and adolescents have a respiratory rate of 12 to 20 breaths per minute
The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which of the following assessment findings is consistent with hypoxia? a) Decreased respiratory rate b) Decreased blood pressure c) Confusion d) Hyperactivity
Correct response: Confusion Explanation: Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.
A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from a) Pulmonary embolism b) Congestive heart failure c) Myocardial infarction d) Lung cancer
Correct response: Congestive heart failure Explanation: A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.
Which of the following dietary guidelines would be appropriate for the elderly homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? a) Snack on high-carbohydrate foods frequently b) Contact the physician for Ensure c) Eat one large meal at noon d) Eat smaller meals that are high in protein
Correct response: Eat smaller meals that are high in protein Explanation: The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength.
A client with no prior history of respiratory illness has been admitted to a postsurgical 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? a) Educating the client on pursed-lip breathing techniques b) Oropharyngeal suctioning twice daily c) Administration of inhaled corticosteroids d) Educating the client on the use of incentive spirometry
Correct response: Educating the client on the use of incentive spirometry. Explanation: Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.
The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is "Ineffective Airway Clearance related to copious and tenacious secretions." Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan? a) Encouraging the client to consume two to three quarts of clear fluids daily b) Creating an environment that is likely to reduce anxiety c) Positioning the client supine d) Encouraging the client to decrease the number of cigarettes smoked daily
Correct response: Encouraging the client to consume two to three quarts of clear fluids daily Explanation: Clients can help keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of clear fluids daily. Although it is important to create an environment that is likely to reduce a client's anxiety, doing so will not assist in promoting airway clearance. The nurse should not encourage the client to decrease the number of cigarettes smoked daily, but should encourage the client to stop smoking. Proper positioning to ease respirations includes placing the client in a high-Fowler's position.
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? a) Nasal cannula b) Flowmeter c) Nasal strip d) Oxygen analyzer
Correct response: Flowmeter Explanation: The nurse should use a flowmeter to regulate the amount of oxygen delivered to the client. A flowmeter 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 physician. 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 an impaired gas exchange. While performing a physical assessment of the client, which of the following 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
Correct response: High respiratory rate Explanation: A client diagnosed with an impaired gas exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. The options of high temperature, low pulse rate, and low blood pressure are incorrect; this is because, as a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.
The nurse is caring for a client who is diagnosed with an impaired gas exchange. While performing a physical assessment of the client, which of the following data is the nurse likely to find, keeping in mind the client's diagnosis? a) Low blood pressure b) High temperature c) Low pulse rate d) High respiratory rate
Correct response: High respiratory rate Explanation: A client diagnosed with an impaired gas exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. The options of high temperature, low pulse rate, and low blood pressure are incorrect; this is because, as a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.
Question: You are caring for a patient whose respirations are supported by a ventilator. You are preparing to suction the patient's endotracheal tube using a closed suctioning system. Arrange the following steps in the correct order. - Depress the suction button to apply intermittent suction. - Clear secretions from sheath. - Turn the catheter safety cap to disable the suction button. - Hyperventilate the patient. - Grasp the catheter and advance it to the predetermined length. - Turn the catheter safety cap to enable suction button.
Correct response: Hyperventilate the patient. Turn the catheter safety cap to enable suction button. Grasp the catheter and advance it to the predetermined length. Depress the suction button to apply intermittent suction. Clear secretions from sheath. Turn the catheter safety cap to disable the suction button. Explanation: Follow these steps when preparing to suction the patient's endotracheal tube using a closed suctioning system.
A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula? a) It can cause anxiety in clients who are claustrophobic. b) It can cause the nasal mucosa to dry in case of high flow. c) It can result in an inconsistent amount of oxygen. d) It can create a risk of suffocation.
Correct response: It can cause the nasal mucosa to dry in case of high flow. Explanation: When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss.
A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula? a) It can cause anxiety in clients who are claustrophobic. b) It can result in an inconsistent amount of oxygen. c) It can create a risk of suffocation. d) It can cause the nasal mucosa to dry in case of high flow.
Correct response: It can cause the nasal mucosa to dry in case of high flow. Explanation: When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss.
A client with chronic obstructive pulmonary disease requires low flow oxygen. How will the oxygen be administered? a) Venturi mask b) Simple oxygen mask c) Nasal cannula d) Partial rebreather mask
Correct response: Nasal cannula Explanation: Nasal cannula and tubing administers oxygen concentrations at 22% to 44%.
A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client? a) Simple mask b) Non-rebreather mask c) Nasal cannula d) Face tent
Correct response: Nasal cannula Explanation: The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Non-rebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.
A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function? a) Pleural effusion b) Tachypnea c) Wheezes d) Pneumonia
Correct response: Pleural effusion Explanation: 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 and pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.
The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the client's care plan? a) Encourage the client to eat immediately before breathing treatments. b) Encourage the client to alternate eating and using a nebulizer during meal time. c) Provide three large meals daily. d) Provide six small meals daily.
Correct response: Provide six small meals daily. Explanation: The nurse should consider providing six small meals distributed over the course of the day instead of three large meals. Meals should be eaten one to two hours after breathing treatments and exercises.
A patient returns to the telemetry unit after an operative procedure. Which of the following diagnostic tests will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the patient? a) Spirometry b) Pulse oximetry c) Peak expiratory flow rate d) Thoracentesis
Correct response: Pulse oximetry Explanation: Pulse oximetry is useful for monitoring patients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative patients. 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 and evaluate lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.
A physician prescribes the use of water-seal chest tube drainage for a client at a health care facility. What should the nurse ensure when using the water-seal chest tube drainage? a) A secondary source of oxygen should be available in case of power failure. b) Filters need to be cleaned regularly to avoid unpleasant taste or smell. c) The chest tube should not be separated from the drainage system unless clamped. d) A nasal cannula should be used to administer oxygen when cleaning the opening.
Correct response: The chest tube should not be separated from the drainage system unless clamped. Explanation: When using water-seal chest tube drainage, the nurse should never separate the chest tube from the drainage system unless clamped. Even then, the tube should be clamped only briefly. When using an oxygen concentrator as a source of oxygen, the nurse should clean the filter regularly to avoid an unpleasant taste or smell. A secondary source of oxygen should also be available in case of a power failure. When cleaning a transtracheal catheter, oxygen needs to be administered with a nasal cannula.
A physician prescribes the use of water-seal chest tube drainage for a client at a health care facility. What should the nurse ensure when using the water-seal chest tube drainage? a) The chest tube should not be separated from the drainage system unless clamped. b) A secondary source of oxygen should be available in case of power failure. c) A nasal cannula should be used to administer oxygen when cleaning the opening. d) Filters need to be cleaned regularly to avoid unpleasant taste or smell.
Correct response: The chest tube should not be separated from the drainage system unless clamped. Explanation: When using water-seal chest tube drainage, the nurse should never separate the chest tube from the drainage system unless clamped. Even then, the tube should be clamped only briefly. When using an oxygen concentrator as a source of oxygen, the nurse should clean the filter regularly to avoid an unpleasant taste or smell. A secondary source of oxygen should also be available in case of a power failure. When cleaning a transtracheal catheter, oxygen needs to be administered with a nasal cannula.
The nurse is caring for a client who requires long-term oxygen therapy. The client is adequately oxygenated at a lower flow. Which type of device may be used to deliver oxygen to this client? a) Nasal catheter b) Oxygen tent c) Transtracheal oxygen d) CPAP mask
Correct response: Transtracheal oxygen Explanation: The nurse should use a transtracheal oxygen device for a client who requires long-term oxygen therapy and who is adequately oxygenated at a lower flow. A transtracheal catheter is a hollow tube inserted within the trachea to deliver oxygen. A CPAP mask is used for clients with sleep apnea; oxygen tents are used to care for active toddlers. A nasal catheter is used for clients who tend to breathe through the mouth or experience claustrophobia when a mask covers their face.
Which of the following is a recommended guideline for determining suction catheter depth when suctioning an endotracheal tube? a) Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. b) Using a spare endotracheal tube of the same size as being used for the patient, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. c) 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. 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.
Correct response: 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. 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 patient, 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
During oxygen administration to the client, which of the following pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? a) Nasal cannula b) Flow meter c) Oxygen analyzer d) Humidifier
Correct: Flow meter Explanation: In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter 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 physician. A humidifier is a device that produces small water droplets and may be used during oxygen administration, since oxygen dries the mucous membranes. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen
While auscultating a client's chest, a nurse hears coarse crackles that are low-pitched and rumbling. The nurse interprets this finding as indicating which of the following? a) Air passing through narrowed airways b) Inflammation of pleural surfaces c) Presence of fluid in the lungs d) Presence of sputum in the airways
Presence of sputum in the airways Explanation: Coarse crackles heard on auscultation indicate the presence of sputum in the airways. Rales indicate presence of fluids in the lungs. Air passing through narrowed airways produces a wheezing sound, whereas inflammation of pleural surfaces gives rise to pleural rub.
A patient returns to the telemetry unit after an operative procedure. Which of the following diagnostic tests will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the patient? a) Spirometry b) Thoracentesis c) Pulse oximetry d) Peak expiratory flow rate
Pulse oximetry Explanation: Pulse oximetry is useful for monitoring patients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative patients. 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 and evaluate lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.