NU271 Week 3 PrepU: 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? "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." "If you breathe through the mouth first, you will swallow germs into your stomach." "Breathing through your nose first will warm, filter, and humidify the air you are breathing."
"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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1503
A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response? "There is very little that can be done for snoring." "Pursed-lip breathing can reduce your amount of snoring." "Let me teach you about incentive spirometry." "Have you tried nasal strips?"
"Have you tried nasal strips?" Explanation: Nasal strips are available over the counter and are used to widen the nasal passageways. A common use for nasal strips is to reduce or eliminate snoring. Other choices are incorrect. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019.
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 is using his chest muscles to help him breathe." "He will require additional testing to determine the cause." "His lung muscles are swollen so he is using abdominal muscles." "His infection is causing him to breathe harder."
"He is using his chest muscles to help him breathe." Explanation: The client will use accessory muscles to ease dyspnea and improve breathing. Reference: Chapter 39: Oxygenation and Perfusion - Page 1483-1503
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? Use a blood pressure cuff to increase circulation to the site. Shine available light on the equipment to facilitate accurate reading. Warm the client's hands and try again. Place the probe on the client's earlobe.
"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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1503
A client's spouse reports that the client snores loudly and incessantly every night. What is the appropriate nursing response when the client's spouse asks about nasal breathing strips? "Those do not work for snoring." "The nasal diameter is decreased by nasal strips." "Nasal strips may reduce or eliminate snoring." "You will need a prescription for nasal strips."
"Nasal strips may reduce or eliminate snoring." Explanation: Nasal strips are available over the counter and are used to widen the nasal passageways. A common use for nasal strips is to reduce or eliminate snoring. The other responses are inappropriate. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019.
The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier? "Small water droplets come from this, thus preventing dry mucous membranes." "The humidifier prescribes the concentration of oxygen." "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." "This is a gauge used to regulate the amount of oxygen that a client receives."
"Small water droplets come from this, thus preventing dry mucous membranes." Explanation: The humidifier produces small water droplets which are delivered during oxygen administration to prevent or decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen. Reference: Chapter 39: Oxygenation and Perfusion - Page 1503
The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach? "Take in as much air as possible, hold your breath briefly, and exhale slowly." "Take in a large volume of air and hold your breath as long as you can." "Take in a little air, hold your breath 15 seconds, and exhale slowly." "Take in a small amount of air and exhale quickly."
"Take in as much air as possible, hold your breath briefly, and exhale slowly." Explanation: This technique maximizes ventilation taking in a large volume of air fills alveoli to a greater capacity, which improves gas exchange. Deep breathing is useful for client's who has been inactive or in pain as associated with pneumonia. The other techniques do not promote improved gas exchange.
The nurse is demonstrating oxygen administration to a client. What teaching will the nurse include about the flowmeter? "This is a gauge used to regulate the amount of oxygen that a client receives." "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." "The flowmeter prescribes the concentration of oxygen." "Small water droplets come from this, thus preventing dry mucous membranes."
"This is a gauge used to regulate the amount of oxygen that a client receives." Explanation: The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The humidifier produces small water droplets, which are delivered during oxygen administration to prevent or decrease dry mucous membranes.
A client with a nonhealing pressure injury has been prescribed hyperbaric oxygen therapy (HBOT). The client tells the nurse, "This kind of treatment doesn't make any sense to me." What is the appropriate nursing response? "In the chamber, you will be treated for decompression sickness." "Wounds heal because HBOT helps to regenerate new tissue quickly." "When you become oxygen-toxic, the wound will heal faster." "It will help you breathe easier and feel better more quickly."
"Wounds heal because HBOT helps to regenerate new tissue quickly." Explanation: The rationale for using HBOT for a nonhealing wound is to help regenerate new tissue quickly. Other answers are incorrect. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019.
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? "You should never smoke when oxygen is in use." "I understand; I used to be a smoker also." "An occasional cigarette will not hurt you." "Oxygen is a flammable gas."
"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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1509
In which client should the nurse prioritize assessments for respiratory depression? A client taking insulin for type 1 diabetes A client taking opioids for cancer pain A client taking a beta-adrenergic blocker for hypertension A client taking antibiotics for a urinary tract infection
A client taking opioids for cancer pain Explanation: Many medications affect the function of the respiratory system and depress the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Beta-adrenergic blockers, antibiotics, and insulin do not appreciably affect the respiratory system. Reference: Chapter 39: Oxygenation and Perfusion - Page 1491
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? Ambu bag Oxygen mask Nasal cannula Oxygen tent
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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1519
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? Raise the head of the bed Educate client on incentive spirometry Apply oxygen as prescribed Assist with intubation
Apply oxygen as prescribed 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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1520
Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue? Antibiotics Corticosteroids Expectorants Bronchodilators
Corticosteroids Explanation: In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation. Reference: Chapter 39: Oxygenation and Perfusion - Page 1506-1507
The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? Be sure to shake the canister before using it. Inhale two sprays with one breath for faster action. Inhale the medication rapidly. Inhale through the nose instead of the mouth.
Be sure to shake the canister before using it. Explanation: A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly. MDIs are inhaled through the mouth, into the lungs. The medication should be inhaled slowly to ensure a sufficient dose enters the lungs. If the order is for two sprays, these sprays are administered with one spray for each breath. The inhaled breath should be held briefly after each spray in order to prevent immediately exhaling the medication. Reference: Chapter 39: Oxygenation and Perfusion - Page 1506
A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing: bronchitis. bronchiolitis. bronchiectasis. a bronchospasm.
a 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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1491-1492
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? Encourage the client to do deep-breathing exercises. Review the medications that the client has taken in the past 90 minutes. Document this expected assessment finding. Raise the head of the client's bed slightly, if tolerated.
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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1524-1527
Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? Contact the physician for nutrition shake. Eat smaller meals that are high in protein. Eat one large meal at noon. Snack on high-carbohydrate foods frequently.
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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1502
Which skin disorder is associated with asthma? Abrasions Seborrhea Eczema Psoriasis
Eczema Explanation: The client with asthma often recalls childhood allergies and eczema. Reference: Chapter 39: Oxygenation and Perfusion - Page 1480
A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention? Explain uses of BiPAP masks versus CPAP masks. Notify the healthcare provider of the client's current status. Document assessment and plan for intervention. Inquire about factors that contribute to non-adherence.
Inquire about factors that contribute to non-adherence. Explanation: The nurse must first assess the reasons that contribute to non-adherence; interventions cannot be determined without a thorough assessment. Other interventions take place after assessment. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019.
The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client? nasal cannula tracheostomy collar face tent simple mask
nasal cannula Explanation: A nasal cannula is ideal for administering low concentrations of oxygen to clients who are not extremely hypoxic or have chronic lung disease. The client does not have a tracheostomy. A simple mask is used to administer higher levels of oxygen than 2 L/min. A face tent is used without a mask. Reference: Chapter 39: Oxygenation and Perfusion - Page 1509
A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen? Discard the first sputum produced by the client. Place the client in the dorsal recumbent position to collect the specimen. Instruct the client to inhale deeply and then cough. Have the client clear the nose and throat and gargle with salt water before beginning the procedure.
Instruct the client to inhale deeply and then cough. Explanation: The client should be instructed to inhale deeply and cough; if this results in sputum, it should be collected in the container. The client should be placed in a semi-Fowler's position and instructed to clear the nose and throat and rinse the throat with water. Reference: Chapter 39: Oxygenation and Perfusion - Page 1504-1505
Which teaching about the humidifier is important for the nurse to provide to a client using oxygen? It regulates the amount of oxygen received. It decreases dry mucous membranes via delivering small water droplets. It determines whether the client is getting enough oxygen. It prescribes oxygen concentration.
It decreases dry mucous membranes via delivering small water droplets. Explanation: The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. Reference: Chapter 39: Oxygenation and Perfusion - Page 1490
A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered? partial rebreather mask nasal cannula Venturi mask simple oxygen mask
nasal cannula Explanation: Nasal cannula and tubing administer oxygen concentrations at 22% to 44%. Reference: Chapter 39: Oxygenation and Perfusion - Page 1509
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? Hyperventilation Atelectasis Hypoxia 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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1485
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? It regulates the amount of oxygen received. It prescribes oxygen concentration. It decreases dry mucous membranes via delivering small water droplets. It determines whether the client is getting enough oxygen.
It determines whether the client is getting enough oxygen. Explanation: The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes. Reference: Chapter 39: Oxygenation and Perfusion - Page 1509
Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen? It determines whether the client is getting enough oxygen. It prescribes oxygen concentration. It decreases dry mucous membranes via delivering small water droplets. It regulates the amount of oxygen received.
It regulates the amount of oxygen received. Explanation: The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The oxygen analyzer measures the percentage of delivered oxygen. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019.
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 mostappropriate to this client's needs? Simple mask Nonrebreather mask Partial rebreather mask Nasal cannula
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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1532-1534
A nurse must take a client's pulse oximetry reading. The nurse is explaining the technique to the client. Which statements about pulse oximetry are true? Select all that apply. Pulse oximetry measurement requires insertion of an arterial line. Once the oximetry probe is correctly placed, a beam of red and infrared light travels through the tissue and blood vessels. A range of 88% to 95% is considered normal oxygen saturation for infants. Pulse oximeters display oxygen saturation and respiratory rate. The pulse oximetry sensor can produce accurate results even if circulation to the sensor site is impaired. Sensors are available for use on the finger, toe, foot, earlobe, forehead, and bridge of the nose.
Once the oximetry probe is correctly placed, a beam of red and infrared light travels through the tissue and blood vessels. Sensors are available for use on the finger, toe, foot, earlobe, forehead, and bridge of the nose. Explanation: The oximetry sensor uses a beam of red and infrared light to calculate the amount of light absorbed by arterial blood. Sensors are available for use on the finger, toe, foot, earlobe, forehead, and bridge of the nose. Inadequate circulation will result in inaccurate readings. Pulse oximetry measurements are noninvasive. Normal range for an infant is 95% to 100%. Pulse oximeters display heart rate, not respiratory rate. Reference: Chapter 39: Oxygenation and Perfusion - Page 1524-1528
A client is taking albuterol via nebulizer. Which instruction will the nurse provide to teach the client how to use the nebulizer? Place the mouthpiece near your mouth. Inhale the medicine into your lungs. Place the mouthpiece in your mouth. Intermittently breathe through your nose and mouth so that all of the medicine goes into your lungs Place the mouthpiece in your mouth. Breath in the medication then remove the mouthpiece to breathe the medicine out. Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs.
Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs. Explanation: A nebulizer is used to administer medications in the form of an inhaled mist. The nurse will instruct the client to place the mouthpiece in the mouth, keep the lips firm around the mouthpiece so that all of the medicine goes into the lungs, and continue until the mist stops. Any other option allows for the medication to be lost, rather than inhaled into the lungs. Reference: Chapter 39: Oxygenation and Perfusion - Page 1506
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? Wheezes Pleural effusion Tachypnea Pneumonia
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. Pneumonia would necessitate the procedure only if the infection resulted in pleural effusion. Reference: Chapter 39: Oxygenation and Perfusion - Page 1497
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 Congestive heart failure Poor tissue perfusion Malnutrition Anemia
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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1489
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? Chest x-ray Pulmonary function tests Bronchoscopy 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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1496
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the mostappropriate intervention in this situation? Leave the airway in place and promptly notify the health care provider for further instructions. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. 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.
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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1515
The nurse caring for a client with cystic fibrosis is performing chest physiotherapy. The nurse educator would intervene if which actions performed by the nurse are noted? Select all that apply. During vibration, places flat hand, while using rhythmic contraction and relaxation of nurse's arms and shoulder muscles, on the client's chest wall during inhalation Holds hand in a rigid, dome-shaped position when percussing Places the client in a lying position, half on the abdomen and half on the side, right and left, to drain the anterior sections of the upper lobes of the lungs Removes the client's gown and percusses below the ribs Performs postural drainage four times a day for 20 to 30 minutes
Removes the client's gown and percusses below the ribs During vibration, places flat hand, while using rhythmic contraction and relaxation of nurse's arms and shoulder muscles, on the client's chest wall during inhalation Places the client in a lying position, half on the abdomen and half on the side, right and left, to drain the anterior sections of the upper lobes of the lungs Explanation: To prevent tissue damage, percussion should not be performed on bare skin or under the ribs. When vibrating, the nurse should use rhythmic contraction and relaxation of shoulder and arm muscles during client's exhalation. To drain the posterior section of the client's upper lobes, the client should be placed in a lying position, half on the side. The nurse's hands should be held in a rigid, dome-shaped position when percussing. Postural drainage should be performed for 20 to 30 minutes up to four times a day.
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? Total lung capacity (TLC) Tidal volume (TV) Forced Expiratory Volume (FEV) Residual Volume (RV)
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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1496
A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate? The client's oxygen demands are being met. The client's available hemoglobin is adequately saturated with oxygen. The client's respiratory rate is in the normal range. The client's red blood cell (RBC) count is in the normal range.
The client's available hemoglobin is adequately saturated with oxygen. Explanation: Pulse oximetry is a noninvasive technique that measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial blood. This test measures only the percentage of oxygen carried by the available hemoglobin. Thus, even a client with a low hemoglobin level could appear to have a normal SpO2 because most of that hemoglobin is saturated. However, the client may not have enough oxygen to meet body needs. A normal pulse oximetry reading does not necessarily indicate a normal RBC count or heart rate. Reference: Chapter 39: Oxygenation and Perfusion - Page 1524-1528
The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select? tracheostomy collar simple mask face tent nasal cannula
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. Other devices are not appropriate for this client. Reference: Chapter 39: Oxygenation and Perfusion - Page 1517
A nurse assessing a client's respiratory effort notes that the client is breathing 8 shallow breaths/min. Which action best meets this client's immediate oxygenation needs? Use a bag and mask. Establish an oxygen hood. Apply nasal cannula at 6 L/min Suction the client's upper airway.
Use a bag and mask. Explanation: If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a bag and mask may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Suction is unnecessary unless there is an obvious obstruction. Nasal cannula is insufficient and an oxygen hood is not used in urgent situations. Reference: Chapter 39: Oxygenation and Perfusion - Page 1519
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? 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. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm. Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. 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.
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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1518
During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting? Crackles Bronchovesicular Vesicular Bronchial
Vesicular Explanation: Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx. Reference: Chapter 39: Oxygenation and Perfusion - Page 1494
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? Absent breath sounds in lower lobes Stridor Wheezing Crackles
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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1494
The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system? a child who has pneumonia an older adult client who has COPD an adult who is receiving oxygen at home an adolescent who has asthma
a child who has pneumonia Explanation: An oxygen tent is commonly used with children who need a cool and highly humidified airflow. It is also more effective for children because they often do not like to keep oxygen administration devices in place. Since the tent does not allow the maintenance of a satisfactory or precise oxygen concentration, is difficult to maintain a consistent level of oxygen. The oxygen tent does not adequately deliver oxygen at a rate higher than 30% to 50%; thus, it is rarely used with other clients. Reference: Chapter 39: Oxygenation and Perfusion - Page 1480
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: heart failure. high cardiac output. diminished stroke volume. adequate tissue perfusion.
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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1497
The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as: apnea. dyspnea. hypercapnia. orthopnea.
apnea. 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. Dyspnea refers to shortness of breath. Orthopnea refers to difficulty breathing when lying flat. An elevation of carbon dioxide levels in the blood is termed hypercapnia. Reference: Chapter 39: Oxygenation and Perfusion - Page 1489
The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of: croup. epiglottitis. atelectasis. bronchospasm.
atelectasis. Explanation: Stiffer lungs tend to collapse and also cause their alveoli to collapse. This condition is called atelectasis. Reference: Chapter 39: Oxygenation and Perfusion - Page 1485
During a routine prenatal care visit, a pregnant woman in her last trimester of pregnancy reports that she has occasional shortness of breath. The nurse instructs her that: a prompt referral for follow up care will be made. the nurse will assess her lung sounds and determine whether she has pneumonia. a chest x-ray is likely indicated. breathing becomes increasingly difficult as the diaphragm is displaced.
breathing becomes increasingly difficult as the diaphragm is displaced. Explanation: During the last weeks of pregnancy, breathing may become increasingly difficult in a supine position because the fetus displaces the diaphragm upward. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019.
Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body? chronic anemia Parkinson's disease pancreatitis Graves' disease
chronic anemia Explanation: The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the number of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissues of the body. Graves' disease, Parkinson's disease, and pancreatitis do not directly lead to a decrease in the number of red blood cells. Graves' disease is an immune system disorder that results in the overproduction of thyroid hormones (hyperthyroidism). Parkinson's disease (PD) is a neurodegenerative disorder that affects predominately dopamine-producing ("dopaminergic") neurons in a specific area of the brain called substantia nigra that causes a movement disorder. Pancreatitis is inflammation in the pancreas. Reference: Chapter 39: Oxygenation and Perfusion - Page 1487
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: congestive heart failure. pulmonary embolism. myocardial infarction. lung cancer.
congestive heart failure. Explanation: A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure. Reference: Chapter 39: Oxygenation and Perfusion - Page 1488
A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from: asthma. atelectasis. pulmonary fibrosis. croup.
croup. Explanation: Croup and epiglottitis are common in young children. The child has an obstruction of the upper airways, with swelling of the throat tissue. Atelectasis results when the lungs collapse as a result of the alveoli being unable to expand. Symptoms include difficulty breathing and discomfort. Pulmonary fibrosis is a condition in which the lung tissue becomes stiff and unable to expand appropriately. Asthma is a condition associated with bronchoconstriction. The symptoms include nonproductive cough, dyspnea, and wheezing. Reference: Chapter 39: Oxygenation and Perfusion - Page 1489-1490
A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario? eupnea cyanosis hypoxemia hypercapnia
cyanosis Explanation: Cyanosis around the lips indicates serious hypoxemia. Cyanosis is caused by a desaturation of oxygen on the hemoglobin in the blood. Hypercapnia is caused by an abnormally high carbon dioxide level in the blood. Hypoxemia is caused by low oxygen levels in the blood. Eupnea is easy, free respiration. Reference: Chapter 39: Oxygenation and Perfusion - Page 1492
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? normal saline distilled water tap water mineral oil
distilled water Explanation: Distilled water is used when humidification is desired. Other answers are incorrect. Reference: Chapter 39: Oxygenation and Perfusion - Page 1503
The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather? face tent tracheostomy collar nasal cannula simple mask
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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1509
The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal? respiratory rate of 18 breaths per minute vesicular breath sounds audible over peripheral lung fields fine crackles to the bases of the lungs bilaterally resonance on percussion of lung fields
fine crackles to the bases of the lungs bilaterally Explanation: Except in the case of infants, fine crackles always constitute an abnormal assessment finding. A respiratory rate of 18 is within acceptable range. Vesicular sounds over peripheral lung fields and resonance on percussion are expected assessment findings. Reference: Chapter 39: Oxygenation and Perfusion - Page 1499
The nurse is observing the unlicensed assistive personnel (UAP) perform oropharyngeal suctioning on a client. Which action, performed by the UAP, would indicate to the nurse that suctioning is being properly performed? The UAP allows 30-second to 1-minute intervals between suctioning passes. The UAP applies lubricant to the first 2 to 3 inches of the catheter. The UAP advances the catheter approximately 5 to 6 inches to reach the pharynx. The UAP advances the catheter approximately 3 to 4 inches to reach the pharynx.
he UAP advances the catheter approximately 3 to 4 inches to reach the pharynx. Explanation: When performing oropharyngeal suctioning, the catheter should be placed along the side of the mouth toward the trachea and advanced 3 to 4 inches to reach the pharynx. In nasopharyngeal suctioning, the catheter should be inserted through the naris and along the floor of the nostril toward the trachea; it should be advanced approximately 5 to 6 inches to reach the pharynx. Applying lubricant to the first 2 to 3 inches of the catheter facilitates passage of the catheter and reduces trauma to mucous membranes. Allowing 30-second to 1-minute intervals between suction passes allows for reventilation and reoxygenation of airways. Reference: Chapter 39: Oxygenation and Perfusion - Page 1530
An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's: blood pH. sodium and potassium levels. age. hemoglobin level.
hemoglobin level. Explanation: Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry. Reference: Chapter 39: Oxygenation and Perfusion - Page 1526
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? low blood pressure high temperature high respiratory rate low pulse 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. Reference: Chapter 39: Oxygenation and Perfusion - Page 1492
A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of: alcohol use. croup. pneumonia. asthma.
pneumonia. Explanation: Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol use do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol use depresses the central respiratory center. Reference: Chapter 39: Oxygenation and Perfusion - Page 1485
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? spirometry thoracentesis peak expiratory flow rate pulse oximetry
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 physician to aspirate pleural fluid for diagnostic or therapeutic purposes. Reference: Chapter 39: Oxygenation and Perfusion - Page 1487
A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from? sleep apnea chronic bronchitis chronic obstructive pulmonary disease (COPD) pneumonia
sleep apnea Explanation: This client has all the risk factors of sleep apnea, which consists of multiple periods of apnea during sleep. These periods of apnea cause the person to move into a lighter sleep more often than someone without this disease, thus causing the daytime sleepiness. Reference: Taylor, C., Lynn, P., & Bartlett, J., Fundamentals of Nursing, 9th ed., Philadelphia, Wolters Kluwer, 2019.
