Oxygenation Exam
A nurse is discussing atrial fibrillation with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of atrial fibrillation?
"Atrial fibrillation is caused by electrical signals outside of the SA node."
A nurse is reinforcing teaching with a client who has a new prescription for a continuous positive airway pressure (CPAP) machine to treat obstructive sleep apnea. Which of the following statements should the nurse include?
"Cover your nose with the CPAP mask."
A nurse is reinforcing teaching with a client who has an abdominal incision about coughing and deep breathing. In which order should the nurse instruct the client to perform the following steps? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
"Take a deep breath" "Hold your breath for several seconds" "Exhale slowly" "Brace the incision with a pillow and try to cough deeply"
A nurse is reinforcing teaching with a client who has a new prescription for an incentive spirometer. Which of the following instructions should the nurse include?
"Use the incentive spirometer every hour while awake."
fenestrated tube with cuff
- large or multiple openings (fenestrations) in the posterior wall of the outer cannula with a balloon around the outside of the distal segment of the tube -also has an inner cannula -allows for mechanical ventilation -removing the inner cannula allows the fenestrations to permit air to flow through the openings -this device allows the client to speak
Early morning postural drainage
- mobilizes secretions that have accumulated through the night
Accidental decannulation
-If it occurs in the the first 72 hr after surgery, it is an emergency because the tracheostomy tract has not matured and replacement may be difficult - Always have an additional staff member present when moving the tube or during any situation in which decannulation may occur - Ventilate client with a BVM
What do you do if there is decannulation
-If unable to replace tracheostomy tube, administer oxygen through the stoma - If unable to put through the stoma then occlude stoma and put through the nose and mouth (except for clients who have had a laryngectomy
Nursing actions if there is damage to the trachea
-Keep cuff pressure between 14 and 20 mm -Check cuff pressure every 8 hours - Keep tile in the midline position and prevent pulling
What nursing actions should the nurse do with trachea care
-Keep two extra tracheostomy tubes at the bedside (one client size, one smaller), obturator, oxygen source, suction catheters, suction source, and BVM -Provide methods to communicate -Provide emergency call system (call light) -Provide adequate humidification -Give oral care every 2 hours -Provide tracheostomy care every 8 hours - Change nondisposable tubes every 6-8 weeks per protocol - Reposition client every 2 hours (prevents atelectasis and pneumonia) - Minimize dust in room (dont shake bedding) - If client wants to each put them upright and tip chin down - Assess for aspiration
Cuffless tube
-No balloon and is for clients who have long-term airway management needs -client must be at low risk for aspiration -not for clients on mechanical ventilation -client can speak
Cuffed tube
-balloon that inflates around the outside of the distal segment of the tube to protect the lower airway by producing a seal between the upper and lower airway -permits mechanical ventilation -do not hold the tube in place -pressure must be monitored to prevent tracheal tissue necrosis -client cannot speak -children don't require this
Fenestrated tube without a cuff
-has one large or multiple openings (fenestrations) in the posterior wall of the outer cannula with no balloon -also has an inner cannula -holes in the tube help wean the client from the tracheostomy -removing the inner cannula allows the fenestrations to permit air to flow through openings -this device allows clients to speak
Single lumen (cannula)
-long, single-cannula tube -for clients who have long or thick necks -do not use on clients with excessive secretions
Double lumen (cannula)
-outer cannula fits into stoma and keeps airway open -inner cannula fits inside outer cannula and locks in place -obturator (thin, solid tube) the provider places inside the tracheostomy and uses as a guide for inserting the outer cannula and then removes it after insertion -allows removing, cleaning, reusing, discarding and replacing the inner cannula with a disposable inner cannula -useful for clients who have excessive secretions
What are the advantages of a non-rebreather mask?
1. Able to deliver O2 concentration of 100% (except intubation) 2. Client inhales maximum O2 from the reservoir 3. Prevents room air from entering mask
What percentage of air is oxygen?
21%
What percentage counts as oxygen toxicity?
50% or greater
What is the minimum flow rate for a simple face mask?
6 L/min to ensure flushing of CO2 from mask
What could your pulse ox be whenever you are ill?
85-89%
What pulse oximetry reading is acceptable?
91-100%
A nurse is assisting with planning care for a group of clients on a cardiopulmonary unit. Which of the following clients should the nurse plan to see first?
A client who reports dyspnea when walking to the bathroom
A nurse is collecting data from a client. Which of the following findings should the nurse identify as risk factors for heart disease? (Select all that apply.)
A diet high in saturated fats A history of smoking for 25 years A sedentary lifestyle
A nurse is suctioning a client's tracheostomy using an open system. Which of the following actions should the nurse take?
Administer 100% oxygen before the procedure.
A nurse is discussing ventilation and perfusion with a newly licensed nurse. The nurse should include in the discussion that the exchange of oxygen and carbon dioxide occurs at which of the following locations?
Alveoli
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (SATA) A) Apply the oxygen source loosely if the SpO2 decreases during the procedure B) Use surgical asepsis to remove and clean the inner canula C) Clean the outer cannula surface in a circular motion from the stoma site outward D) Replace the tracheostomy ties with new ties E) Cut a slit in gauze squares to place beneath the tube holder
Answer: A, B, C
A nurse is assessing client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxemia? (Select all that apply) A. Restlessness B. Tachypnea C. Bradycardia D. Confusion E. Hypertension
Answer: A, B, D, E
A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (SATA) A) Apply suction while withdrawing the catheter B) Perform suctioning on a routine basis every 2 to 3 hours C) Maintain medical asepsis during suctioning D) Use a new catheter for each suctioning attempt E) Apply suction for 10 to 15 seconds
Answer: A, D, E
A nurse is caring for a client who is having difficult breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A) Increase the oxygen flow B) Assist the client to the fowlers position C) Promote removal of pulmonary secretions D) Obtain a specimen for arterial blood gases
Answer: B
A provider is discharging a client who has a prescription for home oxygen therapy via nasal canula. Client and family teaching by the nurse should include which of the following instructions? (SATA) A) Apply petroleum jelly around and inside the nares B) Remove the nasal canula during mealtimes C) Check the position of the cannula frequently D) Report nausea or difficulty breathing E) Post "No Smoking" signs in prominent locations
Answer: C, D, E
What actions should the nurse do for a client with a venturi mask?
Assess frequently for accurate flow rate Assess skin breakdown Make sure there are no kinks Ensure client wears nasal cannula during meals
What actions should the nurse take for a client with a nasal cannula?
Assess patency of the nares, Ensure prongs fit Use water soluble gel to prevent drying Provide humidification for flow rate of 4 L/min and greater
What actions should the nurse take for a client with a simple face mask?
Assess proper fit Make sure client wears nasal cannula during meals Use with caution for clients with high risk of aspiration or airway obstruction Monitor for skin breakdown
Nebulization:
Breaks up medications into minute particles that disperse throughout the respiratory tract and improves clearance of pulmonary secretions
What chronic respiratory problems does oxygen help?
Bronchitis, cystic fibrosis, asthma
What are the advantages of a partial rebreather mask?
Client can rebreathe up to 1/3 of exhaled air together with room air Client has easier humidification of oxygen
What kind of clients do you not do chest physiotherapy?
Clients who are pregnant, have rib, chest, head, or neck injury, increased intracranial pressure, abdominal surgery, pulmonary embolism, bleeding disorders, and has a "big gut"
A nurse is collecting data from a client who has COPD. The nurse should identify that which of the following is an expected finding?
Clubbing of the fingers
What are disadvantages of partial rebreather mask?
Complete deflation causes CO2 buildup FiO2 caries with breathing patterns Not good for clients with anxiety or claustrophobia Eating, drinking, and talking are impaired Bag can twist or kink easily
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect?
Crackles in the lungs
What factors can make low readings for pulse ox
Dark skin, older age, hypothermia, poor peripheral blood flow, too much light, low hemoglobin levels, jaundice, movement, edema, metal studs in nails, and nail polish
Signs for respiratory depression
Decreased respiratory rate and level of consciousness
What nursing actions should be taken for clients who need suctioning?
Don personal equipment Assist client to Fowler's or High Fowlers Encourage client to deep breath and cough Hyper oxygenate client Use medical asepsis for the mouth Use surgical asepsis for all other types of suctions Make suctioning not higher than 120-150mm Hg limit each suction for 10-15 seconds Limit total suctioning to 5 minutes
When are vibrations performed?
During exhalation
What are advantages of a simple face mask?
Easy to apply and can move, More comfortable than a nasal cannula Simplest delivery method Provides humidified oxygen
What actions should the nurse do for a client with an aerosol mask?
Empty condensation often Ensure adequate water in humidification canister Ensure aerosol mist leaves the vents Make sure tubing does not pull on tracheostomy
True or False: When client has hypoxia you need to run out and get help.
False; You need to remain in the room with client and call out for help
What is the FiO2 and the flow rate for a venturi mask?
FiO2 24-50% Flow rate 4-12 L/min
What are disadvantages of nasal cannulas?
FiO2 varies with flow rate and clients depth of breathing, Extended use leads to skin breakdown, Tubing is easily dislodged
What is the FiO2 and the flow rate for a Aerosol mask?
FiO2: 24-100% Flow rate: at least 10 L/min
What is the FiO2 and the flow rate for a nasal cannula?
FiO2: 24-44%, Flow rate: 1-6 L/min
What is the FiO2 and the flow rate for a simple face mask?
FiO2: 35-50% Flow rate: 6-12 L/min
What is the FiO2 and the flow rate for a partial rebreather mask?
FiO2: 60-75% Flow rate: 6-11 L/min
What is the FiO2 and the flow rate for a non-rebreather?
FiO2: 80-95% Flow rate: 10-15 L/min
Where can you put a pulse oximeter?
Fingers, forehead, earlobes, toes, and the bridge of the nose
What are disadvantages of aerosol mask?
High humidification requires frequent monitoring
Indications that a client needs help maintaining airway clearance:
Hypoxia, tachypnea, tachycardia, cyanosis, decreased level of consciousness, decreased SpO2 levels, adventitious breath sounds, visible secretions, absence of spontaneous cough
if accidental decannulation occurs after first 72 hours,
Immediately hyperextend the neck and put in obturator, Secure the tube Assess placement by auscultating
How should both lungs be positioned?
In high fowlers position
What clients are at risk for developing airway compromise?
Infants, ones with neuromuscular disorders, ones with quadriplegic, and clients with cystic fibrosis
What actions should the nurse perform for nasopharyngeal and nasotracheal suctioning?
Insert catheter during inhalation Don't apply suctioning while inserting Follow natural course of naris (slightly slanted downward) Advance 6-8 inches Apply suctioning intermittently Suction ONLY when withdrawing the catheter Don't do more than 2 passes Allow 1 min between each pass
How do you get rid of postural drainage?
It is positions that allow gravity to assist with the removal of secretions
What actions should the nurse take for a client with a partial rebreather?
Keep bag from deflating Keep bag 1/3 to 1/2 full on inspiration Assess skin breakdown Make sure client uses nasal cannula during meals Use with caution for clients that are high risk for aspirations
Hypoxia
Lack of oxygen, pulse ox less than 90%
A nurse is performing chest percussion therapy on a client. Which of the following actions should the nurse take?
Listen for a hollow sound when performing chest percussion therapy.
What are nursing priority's with airway management
Mobilizing secretions, suctioning the airway, managing artificial airways, and promote adequate gas exchange and lung expansion
What nursing actions should happen for oxygen induced hypoventilation?
Monitor respiratory patterns Provide oxygen therapy at lowest level If the client tolerates it, use a venturi mask to give precise oxygen Notify provider of impending respiratory depression
A nurse is assisting with the care of a client who has a chest tube. Which of the following actions should the nurse take?
Monitor the client for subcutaneous emphysema
A nurse is auscultating a client's heart sounds and hears a low-pitched whooshing or blowing sound over the apex of the heart. The nurse should identify that this indicates which of the following?
Murmur
Tracheal stenosis
Narrowing of the tracheal lumen due to scar formation, resulting from irritation of tracheal mucosa from the tracheal tube cuff
A nurse is caring for a client who requires 1 L of oxygen. Which of the following oxygen delivery devices should the nurse expect to use?
Nasal cannula
What are low-flow oxygen delivery systems?
Nasal cannula, simple face mask, partial rebreather mask, non-rebreather mask
Can you administer or adjust oxygen without a prescription?
No you must have a prescription to administer or adjust oxygen on a client.
A nurse is collecting data from a client who is being discharged. The nurse notes the client has regular and quiet breathing. The nurse should identify this breathing pattern as which of the following?
Normal breathing
What are the nursing actions for sputum specimen collection?
Obtain specimen early in the morning Wait 1-2 hours after the client eats to obtain specimen Perform chest physiotherapy Use a sterile specimen container Use a container with a preservative for cytology Use a sterile container for routine cultures Expectorate sputum into the container if client cannot cough
A nurse is caring for a client who has a history of asthma and is wheezing. Which of the following actions should the nurse take first?
Obtain the oxygen saturation.
How should the right lower lobe, LATERAL segment be positioned?
On the left side in Trendelenburg
How should the right upper lobe, POSTERIOR segment be positioned?
On the left side with a pillow under the right side of chest
How should the left lower lobe, LATERAL segment be positioned?
On the right side in Trendelenburg
How should the left upper lobe, POSTERIOR segment be positioned?
On the right side with a pillow under the left side of the chest
A nurse is reinforcing teaching with a client who has a prescription for home oxygen. Which of the following instructions should the nurse include? (Select all that apply.)
Post a "No Smoking" sign inside the home Attach oxygen containers to a fixed object Notify the fire department that oxygen is used in the home
What actions should the nurse take for clients who have a non-rebreather mask?
Preform an hourly assessment for the valve and flap Assess skin breakdown Make sure client uses nasal cannula during meals
How should both lower lobes POSTERIOR segments be positioned
Prone in Trendelenburg
How should the right middle lobe, POSTERIOR segment be positioned?
Prone with thorax and abdomen elevation
What are advantages of aerosol mask?
Provides high humidification with oxygen delivery * Used for clients who do not tolerate masks well Useful for clients with facial trauma, burns. and thick secretions
Nursing actions for endotracheal suctioning
Remove bag from tracheostomy and insert catheter into lumen of the airway Advance catheter until resistance Should reach level of the carina Pull back 1 cm before suctioning Apply suctioning intermittently Only do it while withdrawing the catheter Reattach the BVM or ventilator and give 100% oxygen Rinse catheter with sterile saline until clear DO NOT reuse the suctioning catheter for subsequent suctioning sessions
A nurse is collecting data from a client who is receiving oxygen therapy. The nurse should identify that which of the following findings can indicate oxygen toxicity?
Ringing in the ears
A nurse is explaining the sequence of electrical conduction in the heart to a newly licensed nurse. What should the nurse include as the correct sequence of the transmission of electrical impulses? (Move the steps into the box on the right, placing them in the selected order of performance. Use all the steps.)
SA node is the first step. AV node is the second step. Bundle of His is the third step. Right and left bundle branches is the fourth step. Purkinje fibers is the fifth step.
What are advantages of nasal cannulas?
Safe, simple, easy to apply, comfortable, client can eat, talk, and ambulate
What nursing actions should be initiated for chest physiotherapy?
Schedule treatments 1 hr before meals or 2 hr after Administer bronchodilator medication or nebulizer 30 min-1 hr before postural drainage Offer client emesis basin and facial tissue Place hands on affected area and create vibrations (Have client cough after each vibration) Leave client in each position for 10-15 mins
A nurse is caring for a client who requires 7 L of oxygen to maintain oxygen saturation. Which of the following oxygen delivery devices should the nurse expect to use?
Simple face mask
How small should the diameter of the tracheostomy tube be?
Smaller than the trachea
A nurse is caring for a client who is receiving supplemental oxygen for hypoxia. The nurse should identify that which of the following can cause hypoxia?
Smoke inhalation
What do uncuffed tubes allow?
Speech. Cuffed impairs sound and speech
A nurse is reviewing the medical history of a client who has heart disease and a narrowed valve. Which of the following findings should the nurse expect?
Stenosis
A nurse is assisting with planning to measure the cardiac output of a client who had a myocardial infarction. Which of the following data should the nurse use to calculate the client's cardiac output?
Stroke volume
What are LATE signs of hypoxia?
Stupor Cyanotic skin, mucous membranes Bradypnea, bradycardia Hypotension Cardiac dysrhythmias
How should both lower lobes ANTERIOR segments be positioned
Supine in Trendelenburg
How should the left upper lobe, ANTERIOR segment be positioned?
Supine with head elevation
How should the right upper lobe, ANTERIOR segment be positioned?
Supine with head elevation
A nurse is caring for a client who has atelectasis. The nurse should identify that which of the following substances is required to keep the client's alveoli from collapsing and causing atelectasis?
Surfactant
What kind of asepsis is used for suctioning?
Surgical asepsis
What are EARLY signs of hypoxia?
Tachypnea, tachycardia, restlessness, anxiety, confusion Pale skin, Mucous membranes Elevated blood pressure Use of accessory muscles, nasal flaring, adventitious lung sounds
When client has hypoxia how many liters of oxygen should you administer through oxygen therapy?
The lowest liter flow possible that will correct the hypoxia
A nurse is reinforcing teaching with a newly licensed nurse about pulmonary function tests. The nurse should include that which of the following is the vital capacity?
The maximum volume of air that is expired after a maximum inspiration.
How should the right middle lobe, ANTERIOR segment be positioned?
Three- quarters supine with dependent lung in Trendelenburg
Tracheal wall necrosis
Tissue damage that results when the pressure of the inflated cuff impairs blood flow to the tracheal wall
True or False: There is no standard tracheostomy sizing system
True
True or False: You discontinue supplemental oxygen gradually for clients with hypoxia.
True
True or False: clients who have a cuffed tube can be off mechanical ventilation and can use a specific valve for speech?
True, they can
For nasopharyngeal and nasotracheal suctioning
Use a flexible catheter and lubricate (2-3 inches)
What are disadvantages of a venturi mask?
Use is expensive; eating, drinking, and talking are impaired Mask adds humidity causing skin breakdown
What actions should a nurse take for oxygen toxicity?
Use lowest level of oxygen necessary Monitor ABG's Notify provider if SpO2 is outside reference range Decrease the FiO2 as SpO2 improves
for endotracheal suctioning
Use suction catheter, catheter should not exceed one half of the internal diameter of the endotracheal tube No larger than a 16 French suction (8mm endotracheal tube) Hyperoxygenate client
What are some disadvantages for a non-rebreather mask?
Valve and flap must be intact with each breath Poorly tolerated by clients with anxiety and claustrophobia Eating, drinking, and talking are impaired Use with caution for clients of high risk of aspirations
What are high-flow oxygen delivery systems?
Venturi mask, aerosol mask, face tent, tracheostomy collar
When should you use a pulse ox?
When a client experiences increased work of breathing, wheezing, coughing. cyanosis. changes in the respiratory rate of rhythm, adventitious breath sounds, restlessness, dyspnea, and orthopnea
When do you know SpO2 is reliable?
When it is above 70%
When should you discontinue chest physiotherapy?
When the client reports faintness or dizziness
What is a tracheostomy collar?
a small mask that covers the surgically created opening of the trachea
Oxygen induced hypoventilation
clients who have conditions that cause alveolar hypoventilation can be sensitive to the administration of oxygen.
What are the advantages of a venturi mask?
delivers the most precise oxygen concentration humidification is not required best for clients who have chronic lung disease
What are disadvantages of simple face mask?
flow rates less than 6 L/min can result in rebreathing of CO2 Clients who have anxiety or claustrophobia do not tolerate it well Eating, drinking, and talking are impaired Moisture and pressure can collect under the mask and cause skin breakdown Greater risk for aspiration
What are manifestations of oxygen toxicity?
nonproductive cough substernal pain nasal stuffiness nausea vomiting fatigue dyspnea restlessness parethesias
What does chest physiotherapy consist of ?
percussion, vibration, postural drainage
What can be risk factors for hypoxia
respiratory illness and circulation impairment
What positions are best for a client with hypoxia?
semi-Fowlers or Fowlers
How should apical segments of both lobes be positioned?
sitting on the side of the bed
What should you encourage for clients with hypoxia?
turning, coughing, deep breathing, use of incentive spirometry and suctioning
What is a Face Tent?
type of aerosol mask that fits loosely around the face and neck
for oropharyngeal suctioning
use a Yankauer or tonsil-tipped rigid suctioning catheter and go around the mouth
