Oxygenation

A meal tray arrives for a patient who is receiving 24% oxygen via a Venturi mask. To meet this patient's needs, the nurse should: 1. Request an order to use a nasal cannula during meals 2. Discontinue the oxygen when the patient is eating meals 3. Obtain an order to change the mask to a nonrebreather mask during meals 4. Arrange for liquid supplements that can be administered via a straw through a valve in the mask

1. Request an order to use a nasal cannula during meals Rationale: This meets the nutritional + oxygenation goals

The community nurse is educating a family about infection control measures. What teaching will the nurse include? Select all that apply. 1. Hand hygiene is not needed in the home environment. 2. Wear personal protective equipment (PPE) when appropriate. 3. Standard precautions should be used when family members have active infections. 4. Do not share drinking glasses with family members who are ill. 5. Keep the entire living environment as clean as possible.

2. Wear personal protective equipment (PPE) when appropriate. 3. Standard precautions should be used when family members have active infections. 4. Do not share drinking glasses with family members who are ill. 5. Keep the entire living environment as clean as possible.

The nurse is caring for a patient who has a chest tube after thoracic surgery. The nurse should: 1. Clamp the tube when providing for activities of daily living 2. Position the collection device at the same level as the chest 3. Maintain an airtight dressing over the puncture wound 4. Empty chest tube drainage every eight hours

3. Maintain an airtight dressing over the puncture wound Rationale: 2. Should be below level of insertion site = promotes flow of drainage from pleural space. 3. Airtight dressing seals the pleural space from the environment. If open to the environment, atomospheric pressure causes air to enter the pleural space = tension pneumothorax. 4. You dont have to drain it because it is self-contained systems with chambers for drainage.

A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving? 23% 28% 32% 47%

32% Rationale: 1 LPM = 24%, 2 LPM = 28%, 3 = 32%, 4L/min = 26%, 5 = 40%, 6L/min = 44% NC is low-flow Simple mask low-flow = 6-8 L/min = 40%-60% Partial rebreather mask low-flow 8-11 L/min 50-75% Nonrebreather mask Low flow 12/min 80-100% Venturi mask HIGH FLOW 4-10 L'min = 24%-40%

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? Snack on high-carbohydrate foods frequently. Eat smaller meals that are high in protein. Contact the physician for nutrition shake. Eat one large meal at noon.

Eat smaller meals that are high in protein. Rationale: Nursing intervention of maintaining good nutrition. Patient's with trouble breathing may not have the energy to eat. The diet should help the patient produce plasma proteins, also a sufficient caloric and protein intake for respiratory muscle strength. Consider use of 6 small meals distributed over the course of the day instead of larger meals. -Eat their meals 1-2 hours AFTER breathing tx and exercises. COPD = high-protein/high-calorie diet to counter malnutrition.

A client is prescribed a corticosteroid for the treatment of asthma after having an asthma attack. What education should the nurse provide to the client regarding the administration of this medication? This medication may cause drowsiness and should be used with caution while driving. Increase sodium intake while taking this medication. Monitor blood pressure and blood sugar. Weigh yourself each night prior to going to bed.

Monitor blood pressure and blood sugar. Rationale: BP and BS may rise while taking corticosteroids.

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom? Rapid respirations Weight loss Increased urine output Mental alertness

Rapid respirations Rationale: Normal cardiac output averages from 3.5 L/min-8.0 L/min. With a decrease in cardiac output, there are "less (stops)" or amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing respiratory rate to increase oxygen delivery to the tissues. This causes rapid respirations, decreased urine output, display mental confusion.

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? Tidal volume (TV) Total lung capacity (TLC) Forced Expiratory Volume (FEV) Residual Volume (RV)

Residual Volume (RV) Rationale: RV is amount of air left int he lungs at the end of maximal expiration. TV is the total amount of air inhaled and exhaled with one breath. Total Lung capacity = air in lungs after max. inspiration. Forced expiratory volume = Amount of air exhaled in the first second after a full inspiration.

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 Bronchial Vesicular

Vesicular Rationale: Vesicular are LoVV-pitched, soft sounds over the peripheral fields. Medium blowing sounds over the major bronchi are bronchovesicular. Bronchial sounds are loud, high-pitched sounds over trachea and larynx.

The nurse is caring for a client who requires frequent airway suctioning. Which precautions will the nurse select for the client? airborne droplet contact respiratory

droplet Rationale: Patient's can sneeze on ya girl, that's droplet

The nurse is caring for a client who has excess levels of carbon dioxide in the blood, and chronic hypoxemia. Which intervention will the nurse recommend? deep breathing incentive spirometry pursed-lip breathing diaphragmatic breathing

pursed-lip breathing Rationale: Smaller entry for air and slows down expiratory rate so more CO2 comes out from the body. This is helpful for patients with CO2 in the blood and chronic hypoxemia (lack of O2 in BLOOD). Reduces feelings of dyspnea. Inhale thru nose while counting to three, then exhales slowly and evenly thru pursed lips while tightening the ab muscles. Exhalation = count to 7 Also for patients with feelings of panic.

Which outcome best reflects achievement of the goal, "The patient will expectorate lung secretions with no signs of respiratory complications?" 1. Absence of adventitious breath sounds 2. Deep breathing and coughing nonproductively 3. Drinking 3000 mL of fluid in the last 24 hours 4. Expectorating sputum three times between 3 PM and 11 PM

1. Absence of adventitious breath sounds Rationale: Absence of adventitious or abnormal sounds is desirable.

A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply. 1. Nasal cannula 2. Simple oxygen mask 3. Venturi mask 4. Partial rebreather mask 5. Humidified venturi mask

1. Nasal cannula, 2. Simple oxygen mask, 4. Partial rebreather mask Rationale: Nasal cannula = low-flow rates and concentrations at 22-44%, simple masks and partial rebreathers (they don't have the one-way valve like true NRBs) both at 40-60%. Venturi masks mix oxygen and room air to create high flow oxygen.

The nurse performs assessments of cardiopulmonary functioning and oxygenation during regular physical assessments. Based on developmental variations, which findings would the nurse consider normal? Select all that apply. 1. Blood pressure increases over time until it reaches the adult level around age 8. 2. The power of the respiratory and abdominal muscles is reduced in older adults, and therefore the diaphragm moves less efficiently. 3. The normal infant's chest is small and the airways are short, making aspiration a potential problem. 4. Alterations in respiratory function due to aging in older adults increase the risk for disease, especially pneumonia and other chest infections. 5.The respiratory rate is more rapid in infants until the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates. 6. The chest in the older adult is unable to stretch as much, resulting in an increase in maximum inspiration and expiration.

2. The power of the respiratory and abdominal muscles is reduced in older adults, and therefore the diaphragm moves less efficiently. 3. The normal infant's chest is small and the airways are short, making aspiration a potential problem. 4. Alterations in respiratory function due to aging in older adults increase the risk for disease, especially pneumonia and other chest infections. 5.The respiratory rate is more rapid in infants until the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates. Rationale: Older adults have WEAKER muscles and they may not work as effectively

A physician orders chest physiotherapy with percussion and vibration for a patient. After the physician leaves, the patient says, "I still don't understand the purpose of this therapy." The nurse's best reply is, "It: 1. Eliminates the need to cough." 2. Limits the production of bronchial mucus." 3. Helps clear the airways of excessive secretions." 4. Promotes the flow of secretions to the base of the lungs."

3. Helps clear the airways of excessive secretions." Rationale: Side/lateral position flows secretions out of mouth by gravity, keeps the tongue to the side of the mouth = maintaining the airway, permits effective assessment of the oropharynx and respiratory status. 4. Isn't right because an unconscious patient is unable to maintain an upright position.

A patient's hemoglobin sat via pulse oximetry indicates inadequate oxygenation. What should the nurse do first? 1. Administer oxygen at three liters per minute 2. Encourage deep breathing 3. Raise the head of the bed 4. Call the physician

3. Raise the head of the bed Rationale: 1. Don't admin more than 2 LPM of O2 in an emergency, as high levels of oxygen can depress respirations in people with chronic obstructive lung diseases. Obtaining and setting up this intervention is timely, so there is another intervention that you can implement instead. Which is to raise the head of the bed = this is an independent nursing action. Raising the head of the bed facilitates the dropping of abdominal organs by gravity away from diaphragm = greater lung expansion. Meet patient's needs first before calling MD.

Which adaptation is of most concern when the nurse assesses pulmonary changes associated with immobility? 1. Shallow respirations 2. Increased oxygen saturation 3. Decreased chest wall expansion 4. Respirations that sound gurgling

4. Respirations that sound gurgling Rationale: Gurgling sounds (rhonchi) indicate air passing through narrowed air passages because of secretions, swelling, or tumors. Partial or total obstruction of the airway can occur, which is life threatening.

The major difference between pursed-lip breathing and diaphragmatic breathing is with diaphragmatic breathing the patient: 1. Inhales through the mouth 2. Exhales through pursed lips 3. Raises both shoulders while breathing deeply 4. Tightens the abdominal muscles while exhaling

4. Tightens the abdominal muscles while exhaling Rationale: Contraction of ab muscles at the end of expiration helps to reduce the amount of air left in the lungs at the end of expiration (residual volume).

The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner? 10 L/min oxygen via Venturi mask 8 L/min oxygen via partial rebreather mask 8 L/min oxygen via nasal cannula 12 L/min oxygen via nonrebreather mask

8 L/min oxygen via nasal cannula Rationale: The correct amount of FiO2 for nonrebreather mask is 12 L/min; 8-11 L/min for partial rebreather mask; 4-10 L/min for Venturi mask; and 1-6 L/min for nasal cannula. With chronic lung disease patients, per nasal cannula may be no more than 2-3 L/min.

The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take? Assess lung sounds Reposition client Elevate head of the bed Assess oxygen tubing connection

Assess oxygen tubing connection Rationale: The other interventions won't work if the oxygen tubing isn't connected.

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system? an older adult client who has COPD a child who has pneumonia an adult who is receiving oxygen at home an adolescent who has asthma

a child who has pneumonia Rationale: Normally used for children who need a cool and highly humidified airflow. More effective for children because they tend to remove oxygen admin devices. Maintains consistent level of oxygen. 30-50%; rarely used with other clients.

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: croup. asthma. alcohol use. pneumonia.

pneumonia. Rationale: Atelectasis = "complete lung expansion or collapse of alveoli", which prevents pressure changes and gas exchange by diffusion in the lungs. Conditions that predispose patients to atelectasis are obstructions of the airway by disease or condition that results in thickening of alveolar-capillary membranes, like pna or pulmonary edema, which makes diffusion difficult. Stiffer lungs also tends to collapse and their alveoli also collapse.