Oxygenation pretest and post test, Oxygenation, WEEK 11 [ADN 200] OXYGENATION

Which breathing difficulty is associated with body​ position? Apnea Tachypnea Orthopnea Hypoxia

Orthopnea is difficulty breathing when supine. Tachypnea is rapid breathing. Apnea is the absence of respirations. Hypoxia is a low amount of oxygen in the bloodstream.​ Tachypnea, apnea, and hypoxia are not influenced by body position.

Posterior thorax

Right and left scapular lines, vertebral spine line

Secretion clearance

Secretion clearance can be accomplished by promoting coughing and deep breathing or through mechanical suctioning of the upper airway. The need for mechanical suction is a nursing decision based on assessment findings such as obvious distress, persistent rhonchi, cyanosis, or oxygen saturation <95%.

Thoracic catheters

A thoracic catheter, commonly referred to as a chest tube, is used to treat conditions in which fluid enters the pleural cavity, causing lung collapse. The catheter is inserted under emergency conditions and treated as a surgical procedure. The chest tube will typically remain in place for 2-5 days or until the client's x-rays indicate that all fluid from the pleural cavity has been removed. Nursing considerations when working with a client who has a thoracic catheter include: Ensuring oxygen therapy is immediately available at all times, if not already ordered and in place Monitoring dressings for drainage and air leakage and following agency protocol for replacing or securing dressings Monitoring the tubing to make sure it is free of kinks or other impediments Monitoring for and recording client vital signs as ordered Monitoring for and reporting any decrease in oxygen saturation, any changes in breath sounds, or any tympany or hollow sound with chest percussion Assessing for pain; administering pain medications as needed (PRN), and notifying physician of any increase in client restlessness or anxiety Monitoring and reporting any changes in respiration or any excessive bleeding.

Tachypnea

Abnormally rapid breathing. Greater than 20 breaths per minute in adults Manifestations: More than 20 respirations per minute with client at rest Shallow respirations Selected risk factors: Fever Metabolic derangements Panic attacks Pain Medication side effects

Bradypnea

Abnormally slow respirations. Less than 10 per minute Manifestations: May lead to apnea Selected risk factors: Cardiac failure Morbid obesity Narcotic or benzodiazepine or depressant overdose

Pulmonary circulation

Breathing exercises promote ventilation and perfusion. They also help the client to gain control of his or her breathing pattern. This will help the client avoid alterations to oxygenation secondary to tachypnea as a response to pain or anxiety for example, or bradypnea (slow respirations; less than 10 breaths per minute in an adult) as a side effect of narcotic administration.

Pneumothorax

Air trapped outside the lung in the pleural space placing pressure on the lung tissue and causing atelectasis or "collapsed lung" Manifestations: Unilateral (one sided) chest pain Client reports shortness of breath Selected Risk Factors: Trauma May be spontaneous

An adult client returns from the postanesthesia care unit​ (PACU) following a laparoscopic appendectomy. The nurse checks the postoperative notes and determines which factor is most important with regard to the client​'s immediate oxygenation​ status?

Amount of narcotics the client received over the last four hours

Which normal breath sound is heard when auscultating next to the​ trachea? A. Bronchial B. Stridor C. Rhonchi D. Vesicular

Bronchial sounds are heard when auscultating next to the trachea. Vesicular sounds are heard when listening to the lung fields. Stridor and rhonchi are adventitious breath sounds.

Bronchi

Anterior; the trachea bifurcates at about the level of the 6th thoracic vertebra forming the right and left main bronchi. Warm and moisten air as it moves through the respiratory tract to the alveoli in the lungs

Anticholinergics

Anticholinergics such as ipratropium bromide block the response of the parasympathetic nervous system thereby relaxing the smooth muscle of the airways and reducing the production of secretions. Common side effects are dry mouth, headache, and bronchitis.

Clavicles

Clavicles are long and slender, horizontal, and articulate with the sternum. Clavicles protect the upper anterior portion of the thoracic cage.

The landmarks of the thorax

Clavicles, Ribs, sternum

Auscultation

Auscultation of the lungs involves listening to the sounds of breathing through a stethoscope. Clear air movement though the upper airways and the lungs produces a tubular sound, as if produced through a tube. Changes in airway size and the presence of fluid or mucus can alter the sounds. Start at the apex and move side to side, comparing the left and right lungs in at least eight areas as you progress systematically down to the bilateral bases. Additional auscultation along the lateral aspects will complete this portion of the process. Sounds transmit differently depending upon the area being auscultated.

A nurse is participating in a free community health clinic. Which clients will the nurse identify as being at risk for compromised​ oxygenation?

A​ 56-year-old male who has been working at a textile factory A​ 64-year-old female with osteoporosis and limited mobility A​ 28-year-old male who smokes with a​ 10-pack/year history A​ 46-year-old female with a history of anxiety attacks

Beta agonists

Beta agonists such as albuterol and levalbuterol act as bronchodilators. Tachycardia is a common side effect that may cause the client to feel anxious. This effect is less prominent with levalbuterol.

Thoracic cage

Bones, cartilage, and muscles of the thorax; sternum, vertebrae, 12 pairs of ribs, costal cartilage. Protects the vital organs contained within; supports shoulders and upper extremities, as well as muscles of the upper body

Michael Chin is a​ 34-year-old man with breathing difficulties after a fall. When listening for bronchial​ sounds, what is the sound if the findings are​ normal? Sounds medium in loudness and pitch ​Loud, high-pitched sounds Soft and​ low-pitched sounds ​Harsh, high-pitched sounds A client is being treated for his respiratory problem in a hospital.

Bronchial sounds are​ loud, high-pitched sounds next to the trachea.​ Harsh, high-pitched sounds are normal sounds heard over the trachea when the client inhales and exhales. Bronchovesicular sounds are medium in loudness and​ pitch, and are heard between the​ scapulae, posteriorly and next to the sternum. Vesicular sounds are soft and low​ pitched, and are heard over the remainder of the lung. Vesicular sounds are longer on inhalation than exhalation. Next Question

Comfort

Cells and tissues, inadequately supplied with oxygen for a sufficient time, will die. This condition is called ischemia. Ischemic events can cause significant pain.

Apnea

Cessation of breathing Manifestations: No visible respirations May lead to respiratory arrest Selected risk factors: Cardiac failure Morbid obesity Narcotic or benzodiazepine or depressant overdose

Imaging and direct visualization diagnostic tests

Chest x-ray shows a two-dimensional image of the chest cavity. It shows bony structures, fluids, or masses. MRI and CT scans show more detailed images of soft tissues. CT with injected contrast medium can help identify and locate vascular obstructions and abnormalities such as a pulmonary embolus. Bronchoscopy allows visualization of the interior of the trachea and bronchi through a fiberoptic scope inserted through the mouth.

Counseling / teaching clients

Clients should be counseled on the importance of controlling modifiable risk factors and environmental irritants that may adversely affect respiratory health and oxygenation status. Examples of how these alterations can affect oxygenation are as follows: Obesity alters thoracic anatomy and affects accessory muscles making it a risk factor for obstructive apnea. Diabetes affects vascular health and quality of circulation and perfusion. Nutrition is essential for maintaining a healthy weight and glycemic control. Foods and supplements rich in iron and B vitamins can correct nutritional anemia and mitigate some inherited anemias. Cardiovascular disease can have a profound effect on circulation and perfusion. Clients should be counseled on the importance of prescribed medication and exercises. Asthma is increasingly common and may lead to constricted or obstructed airways. Clients affected by moderate to severe persistent asthma should be counseled on daily use of prescribed medications and home surveillance of pulmonary function. Smoking leads to many respiratory and cardiovascular pathologies and exacerbates all others. Clients who smoke should be offered counseling and assistance with cessation.

Lungs

Cone-shaped air-filled sacs situated in the pleural cavities of the thorax on either side of the mediastinum. The upper apices extend superiorly to the area of the inner third of the clavicles; the base of each lung extends level with the diaphragm. Terminal bronchioles in each lung branch into the alveolar ducts, which lead into clusters of tiny alveolar sacs. The cells of the alveoli permit simple diffusion and gas exchange to occur.

Dyspnea

Difficulty or pain with breathing Manifestations: Anxiety Apparent distress Flared nostrils Posturing Pneumothorax Pulmonary embolus Lung mass Selected Risk factors: Airway obstruction or constriction Deconditioning

The nurse is assessing an adult client with a cough. A positive answer to which question about the cough would require further evaluation and questioning of this​ client?

Do you cough up blood and how​ often?"

The nurse is performing a respiratory assessment on a young adult. What findings are considered alterations of​ oxygenation? ​(Select all that​ apply.)

Dyspnea Orthopnea Retractions Tachypnea

Orthopnea

Dyspnea when lying down Manifestations: Apparent distress, which improves when client is upright Selected risk factors: COPD Heart disease Pneumonia Airway obstruction

The nurse is caring for a client who is receiving oxygen. Which intervention is appropriate by the​ nurse?

Ensuring the client is comfortable with the manner of administration

Genetic consideration and nonmodifiable risk factors

Genetic considerations and nonmodifiable risk factors associated with alterations in oxygenation are linked to hemoglobin and hematocrit. Various research studies have examined the genetic link to hemoglobin and hematocrit. These studies indicate that there is a significant inherited pattern of variation in hemoglobin concentration; however, the hematocrit shows a lower genetic effect. Differences among hemoglobin concentration and hematocrit between the genders add to this evidence of the genetic control of these variables. Therefore, hemoglobin and hematocrit variations influence the ability to oxygenate. Women typically have lower concentrations of hemoglobin and hematocrit when compared with men.

Which cause of alterations in oxygenation is a nonmodifiable risk​ factor? Obesity Cigarette smoke Hemoglobin concentration Cardiovascular disease

Hemoglobin concentration affects oxygenation and is considered a nonmodifiable risk factor for alterations in oxygenation. Cigarette​ smoking, obesity, and cardiovascular disease are all considered modifiable risk factors for alterations in oxygenation.

Cellular Regulation

Hemoglobin is a protein that makes up most of each red blood cell. Its function is to carry oxygen to the other cells in the body. When hemoglobin is decreased for any reason such as blood loss, or from inherited or nutritional anemia, less oxygen is carried to the cells. Impaired cardiac function may also result in systemically decreased perfusion.

The nurse in the emergency department is assessing an adult client with emphysema. What symptoms of emphysema would not be obvious from inspection and direct observation by the​ nurse?

Hyperresonance sounds from the lungs

Acid- Base Balance

In the presence of tachypnea, excessive CO2 is expelled from the body, which triggers a series of metabolic events that raise the cellular pH in the body. This is called respiratory alkalosis. In the presence of decreased ventilation, CO2 accumulates, leading to decreased cellular pH and respiratory acidosis.

Inhaled corticosteroids

Inhaled corticosteroids such as butesonide and mometasone furoate reduce airway inflammation. These are often formulated in combination with beta agonists when used to control moderate to severe persistent asthma.

Which independent nursing intervention is most appropriate for a client experiencing​ tachypnea?

Instructing the client to complete breathing exercises

Hypoxemia

Low levels of oxygen in the blood Manifestations: Anxiety Visible retraction of ribs and chest wall Cyanosis Posturing Selected risk factors: Airway obstruction or constriction (as in asthma or allergic reaction) Altered oxygen transport Impaired circulation

Trachea

Mediastinum, descending from the larynx in the neck to the main bronchi at the distal ends. Cilia within the trachea capture debris, and the act of coughing helps sweep the debris toward the mouth for removal via expectoration

Muscles of respiration

Muscles of the thoracic cage (internal and external costal), diaphragm, accessory muscles (trapezius, scalene, sternocleidomastoid), abdomen (rectus), and chest (pectorals). Accessory muscles play a major role, especially during periods of increased oxygen demand and with certain pathological conditions.

Respiratory rate in breaths/min counted over 60 seconds

Normal: Neonates: 30-60 Infants: 20-40 Children: 16-20 Teens: 12-20 Adults: 10-20 Older adults: 12-24 Abnormal: Irregularity Rate faster or slower than expected Lifespan considerations: Irregular respirations and < 15 second apneas are expected in neonates.

Breathing/chest expansion

Normal: Trachea remains midline Symmetric expansion with inspiration Abnormal: Tracheal deviation Asymmetry Apparent distress

Palpation

Nurses use palpation to feel the chest for symmetry. To palpate the posterior and anterior chest, gently place your fingers on the chest surface and rotate them, covering the entire chest wall area. Note any areas of tenderness, lumps, or masses. Be sure to assess any skin lesions that were identified during your initial inspection

Nutrition and Pharmacologic Therapy

Nutrition can be inadequate for clients experiencing altered oxygenation. Use of accessory muscles for breathing leads to increased calorie expenditure while fatigue may lead to anorexia or insufficient endurance for finishing meals. Anemia is often a consequence of iron and B vitamin deficiency. A clinical nutritionist may review the client's status and make recommendations for smaller, more frequent meals, supplements, and foods containing iron and B vitamins. The nurse should assist the client in accomplishing his or her nutrition plan. Pharmacologic therapy will be ordered or prescribed by a physician or APRN. Nursing responsibilities regarding medications affecting the respiratory system are the same as with any pharmacologic regimen and include knowledge of the indication, mechanism of action, interactions, and side effects of the medications being administered. The nurse should also assess the client's understanding of these things, ability and inclination to adhere to a medication schedule, and barriers to doing so. Select each bulleted item to learn more about commonly ordered medications.

Miss Lopez is a fit and healthy​ 28-year-old hairdresser who lost her father to emphysema. She has been working in​ Washington, D.C. for 8 years and has come in for a consultation due to a cough that has lasted several months. Which item is most likely to be a factor in her chronic​ condition? Recent flu vaccine Early parental death from emphysema Workplace exposure to chemicals Lives in rural environment

Occupational exposure to chemicals is a risk factor associated with developing chronic respiratory conditions. History of parental emphysema is not a known risk factor for chronic respiratory conditions. Rural environments are not known for causing chronic respiratory conditions. Flu vaccines are associated with preventing respiratory​ conditions, not causing them.

The nurse is assessing an adult client who is complaining of chest congestion and cough. What​ skill(s) would the nurse expect to use to specifically assess for chest​ congestion?

Percussion and auscultation

Cognition:

Perfusion of the brain requires approximately one fourth of the oxygen taken in by the respiratory system. Hypoxemia can have a profound impact on level of consciousness

Which independent intervention is a priority for a client who is experiencing​ dyspnea?

Place the client in​ high- Fowler position

Tactile Fremitus

Place the ulnar surface of your hand or palmar surface of the base of your fingers posteriorly over each vibration area (trachea, bronchi, lung) separately as the client repeatedly speaks the words "ninety-nine" or "one, two, three." The strongest vibration should be felt over the trachea. It will diminish over the bronchi and become almost nonexistent over the alveoli of the lungs.

Positioning:

Positioning is useful in improving oxygenation. Upright positions allow greater thoracic expansion as they reduce the effects of gravity on the anteroposterior chest. Clients in Fowler's or high-Fowler's position are also at reduced risk of aspiration

Inependent interventions

Pulmonary circulation: Smoking cessation: Positioning: Secretion clearance:

Which independent nursing intervention is most appropriate for a client experiencing​ tachypnea? Suctioning the upper airway Administering oxygen Instructing the client to complete breathing exercises Repositioning the head of the bed to less than 30 degrees

Rationale A client who is experiencing tachypnea will benefit from the nurse implementing breathing​ exercises, as they promote ventilation and perfusion. These exercises will also help the client gain control of the breathing pattern. Administering oxygen can only be done with a prescribed order and should be based on pulse oximetry readings. The nurse would reposition the head of the bed to greater than 30 degrees to help with dyspnea. Suctioning the airway is done for secretion clearance.

The nurse is performing a respiratory assessment on a young adult. What findings are considered alterations of​ oxygenation? ​(Select all that​ apply.) Dyspnea Retractions Orthopnea Tachypnea Eupnea

Rationale Alterations of oxygenation are manifested by​ dyspnea, orthopnea,​ tachypnea, and retractions.​ Eupnea, or normal​ breathing, is not a finding that indicates an alteration in oxygenation.

The nurse is assessing an adult client who is complaining of chest congestion and cough. What​ skill(s) would the nurse expect to use to specifically assess for chest​ congestion? Auscultation Palpation and percussion Percussion and auscultation Inspection

Rationale An adult complaining of chest congestion must be thoroughly assessed to determine if the congestion is upper respiratory or cardiac in origin. Percussion is helpful in assessing density or​ fluid-filled spaces, and auscultation assesses the air exchanged during a respiratory cycle. The combination of percussion and auscultation would make for a complete assessment of the lungs when a client complains of chest congestion.

The nurse in the emergency department is assessing an adult client with emphysema. What symptoms of emphysema would not be obvious from inspection and direct observation by the​ nurse? Hyperresonance sounds from the lungs ​Pursed-lip breathing and clubbing of fingers Barrel chest Shortness of breath

Rationale Clients with emphysema and COPD would have hyperresonance sounds during an assessment using percussion. These sounds would not be obvious on inspection or observation. A client with emphysema may be obviously short of​ breath, even at rest. A barrel chest is common in those with emphysema and would be obvious on​ inspection, even if the client has a shirt on.​ Pursed-lip breathing and clubbing of the fingers can be observed without​ palpation, auscultation, or percussion.

A nurse is participating in a free community health clinic. Which clients will the nurse identify as being at risk for compromised​ oxygenation? ​(Select all that​ apply.) A​ 56-year-old male who has been working at a textile factory A​ 64-year-old female with osteoporosis and limited mobility A​ 28-year-old male who smokes with a​ 10-pack/year history A​ 70-year-old female who eats a​ well-balanced diet and exercises daily A​ 46-year-old female with a history of anxiety attacks

Rationale Clients with occupations that cause them to inhale chemicals and dust are at increased risk for developing lung disease. Individuals who live a sedentary lifestyle have diminished alveolar​ expansion, placing them at risk for altered respiratory function.​ Additionally, musculoskeletal impairment such as kyphosis​ (which may result from​ osteoporosis) diminishes lung capacity. Clients who smoke are at risk for pulmonary and cardiac disease. High levels of anxiety can cause bronchospasms and the onset of bronchial asthma. Some clients hyperventilate in response to stress. The​ client's arterial oxygen levels​ rise, and the arterial carbon dioxide levels decline. Intake of a diet high in fat predisposes clients to cardiovascular disease.

The nurse is assessing an adult client with a cough. A positive answer to which question about the cough would require further evaluation and questioning of this​ client? ​"Do you have clear drainage from the​ nose?" ​"Are you experiencing a dry​ cough?" ​"Do you cough up blood and how​ often?" ​"Do you cough up clear sputum and how​ often?"

Rationale Many questions arise when asking a client about a​ cough, but the nurse would determine first and foremost whether the client is suffering from​ hemoptysis, or coughing up blood. This is a serious symptom and would help the nurse to determine the line of questioning to pursue. Whether the client has clear drainage from the nose or is coughing up clear sputum are the least worrisome factors to consider. The kind of cough​ (dry, hacking,​ moist, barky, or​ wheezy) would give the assessment a direction but is not as important as discovering if the cough produces bloody sputum.

The nurse is assessing an​ 8-year-old client during a​ well-child visit at a clinic. Which anatomical differences does the nurse expect to finding during the assessment​ process? ​(Select all that​ apply.) Smaller nasopharynx Atrophy of the tonsils Small mouth with large tongue Larynx and glottis lower in the neck Soft tracheal cartilage

Rationale Normal findings for the pediatric client from infancy until the age of 12 include a smaller​ nasopharynx, a small mouth with a large​ tongue, and soft tracheal cartilage. The nurse would expect to find enlarged​ tonsils; atrophy does not occur until after 12 years of age. The nurse would expect the larynx and the glottis to be higher in the​ neck, not lower.

The nurse is caring for a client with a history of respiratory issues. Which lifestyle factor indicates a priority need for​ instruction? Age Weight Sexual orientation Smoking history

Rationale Smoking leads to many respiratory and cardiovascular pathologies and exacerbates all others. Clients who smoke should be offered counseling and assistance with cessation. Sexual orientation has no influence on respiratory status. Age and weight may affect the​ client's respiratory​ status, but they are not priorities.

The nurse is caring for a client who is diagnosed with bronchitis and wants to know the function of the bronchi. Which response by the nurse is the most​ appropriate? "The bronchi help to keep the lungs inflated. open double quote "The bronchi warm and moisten air as it moves through the respiratory tract to the alveoli in the lungs. "The bronchi capture debris and help to sweep the debris toward the mouth for removal when coughing. "The bronchi contain the​ heart, trachea,​ esophagus, and the great vessels.

Rationale The bronchi warm and moisten the air as it moves through the respiratory tract to the alveoli in the lung. The mediastinum contains the​ heart, trachea,​ esophagus, a portion of the right and left main​ bronchi, and the great vessels. Cilia within the trachea capture debris and help to sweep the debris toward the mouth for removal when coughing. Surface​ tension, created by fluid and negative​ pressure, keeps the lungs inflated

The nurse is caring for a client who is receiving oxygen. Which intervention is appropriate by the​ nurse? Increasing the flow if the client requests Assessing the client for anxiety Suctioning upper airways each shift Ensuring the client is comfortable with the manner of administration

Rationale The nurse ensures that the client is comfortable with the manner in which the oxygen is being administered. There are several choices and the client should be consulted in terms of which method is most comfortable. The nurse should not increase the flow of oxygen at the​ client's request, as the flow is prescribed by the healthcare provider. Clients who are prescribed oxygen are at risk for depression not anxiety. Suctioning the upper airway should only be done as​ required, if at all.

The nurse educator is teaching a group of students about the respiratory system. Which statement by the student indicates appropriate understanding of the role of the pleural​ membranes? ​"The pleural membranes help to keep the lungs​ inflated." ​"The pleural membranes warm and moisten​ air." ​"The pleural membranes contain the​ heart." ​"The pleural membranes permit gas​ exchange."

Rationale The pleural membranes help to keep the lungs​ inflated; this statement indicates appropriate understanding of the content. The mediastinum contains the heart. The alveoli permit gas exchange. The bronchi warm and moisten air.

Which independent intervention is a priority for a client who is experiencing​ dyspnea? Weigh the client daily in the morning Place the client in​ high- Fowler position Order oxygen 2 to 4 L per nasal cannula Turn the client once a shift

Rationale The priority independent intervention for a client who is experiencing dyspnea is to place the client in the​ high- Fowler position to improve oxygenation. Ordering oxygen is outside the scope of nursing practice. While weighing the client may be​ necessary, this is not the priority. Turning the client is an independent nursing intervention but is not the priority for a client with dyspnea and it should be done more than once per shift.

The nurse is caring for a client with a pneumothorax. Based on the client​'s ​history, which is the most likely cause for this alteration in​ oxygenation? Obesity Pneumonia Asthma Trauma

Rationale While a pneumothorax may occur​ spontaneously, most occur as the result of trauma. Obesity can cause apnea. Asthma and pneumonia can cause orthopnea.

Lateral thorax:

Right and left midaxillary lines

Anterior thorax

Right and left midclavicular lines, midsternal line

Children lifespan considerations

Smaller nasopharynx, easily occluded during infection. Tonsils and adenoids are enlarged and grow rapidly. These atrophy after age 12. Smaller nostrils are easily blocked. Smaller mouth and relatively large tongue increase risk of obstruction. Long, floppy epiglottis easily blocks the pharynx if swollen. Larynx and glottis are higher in neck, increasing risk of aspiration. The tracheal cartilage is softer and may easily collapse when neck is flexed. Fewer functional muscles in the airway and decreased ability to compensate for constriction or edema. Decreased soft tissue integrity and loosely anchored mucous membranes increase the risk of edema and obstruction. Narrow airways are more susceptible to inflammation and blockage through aspiration of small objects.

Smoking cessation

Smoking cessation is an extremely important step toward improving respiratory and overall health. Nurses should quantify and document the client's use of tobacco as well as marijuana and other inhaled substances. Assess the client's interest in quitting. Encourage smoking cessation or reduction. Give positive feedback on efforts at cessation. Express confidence in the client's ability to quit. Provide strategies and resources for community support. Nicotine replacement may be requested from the provider. Remind the client that the more often they attempt smoking cessation, the more likely they are to succeed.

The nurse is caring for a client with a history of respiratory issues. Which lifestyle factor indicates a priority need for​ instruction?

Smoking history

Psychosocial aspects

Some clients may feel they have lost their quality of life. The nurse can assist the client in understanding that supplemental oxygen will help the client maintain quality of life, and that the client can still participate in any number of activities. The nurse should be alert to any possible signs of depression in a client whose oxygen impairment is sufficient to warrant supplemental oxygen. Frustration, rising medical costs, and other issues can contribute to depression in a client with respiratory impairment.

Prevention

Some factors that cause alterations in oxygenation can be prevented. Two of these factors are air quality and vaccinations. Indoor air quality is an important factor in the prevention of respiratory alterations. Exposure to secondhand smoke, emissions from heat sources, occupational exposure to chemical vapors, use of cleaning agents, perfumes, and air fresheners should be assessed. Vaccination history should be reviewed for all clients. Immunization against communicable respiratory diseases such as pertussis, pneumococcal pneumonia, influenza, and screening for tuberculosis should be offered to appropriate populations.

The nurse is caring for a client who is diagnosed with bronchitis and wants to know the function of the bronchi. Which response by the nurse is the most​ appropriate?

The bronchi warm and moisten air as it moves through the respiratory tract to the alveoli in the lungs.

Ribs

The 12 pairs of ribs curve downward and forward as they emerge anteriorly. A number is assigned to each rib, and the intercostal space below the rib corresponds to the number that identifies the rib above it.

Nursing care for the client receiving supplemental oxygen includes ensuring

The flow is sufficient as required The client is reasonably comfortable with the manner of oxygen administration That indwelling catheters (lines) remain clear.

Which structures are contained within the​ mediastinum? ​(Select all that​ apply.) Esophagus Trachea Lungs Pleural membranes Heart

The mediastinum contains the​ heart, trachea,​ esophagus, a portion of the right and left main bronchi and the great vessels. The lungs and the pleural membranes are not contained in the mediastinum

Mediastinum

The middle section of the thoracic cavity surrounded by the right and left pleural cavities. Contains the heart, trachea, esophagus, a portion of the right and left main bronchi, and the great vessels.

Pleural membranes

The pleura are two serous-fluid-filled membranes that surround each lung cavity. The visceral membrane attaches directly as the covering of the lungs. The parietal membrane lines the thoracic wall and the superior aspect of the diaphragm. Surface tension created by fluid and negative pressure keeps the lungs inflated; as negative pressure changes, air moves in and out of the lungs.

The nurse educator is teaching a group of students about the respiratory system. Which statement by the student indicates appropriate understanding of the role of the pleural​ membranes?

The pleural membranes help to keep the lungs​ inflated

When performing tactile fremitus on a​ client, where is the strongest vibration​ felt? Over the alveoli Over the trachea Over the bronchi Over the sternum

The strongest vibration should be felt over the trachea. It will diminish over the bronchi and become almost nonexistent over the alveoli of the lungs.

Oxygenation

The term oxygenation refers to the body's ability to supply all of its cells with oxygen. The respiratory system transports air through the respiratory tract into the lungs through the act of inspiration or inhalation.

hypercarbia

The typical drive to breathe occurs due to hypercarbia, an increased level of carbon dioxide in the blood.

Sternum

The upper portion of the sternum is called the manubrium. The depression on the upper border of the sternum is termed the suprasternal notch. The manubrium joins the body of the sternum at a ridge called the sternal angle. The sternum ends at the xiphoid process, which is the location of the seventh rib anteriorly.

Which muscles of respiration are considered accessory​ muscles? ​(Select all that​ apply.) Rectus femoris Scalene Sternohyoid Sternocleidomastoid Trapezius

The​ scalene, sternocleidomastoid, and trapezius muscles are accessory muscles that play a major role in​ respiration, especially during periods of increased oxygen demand and with certain pathological conditions. The rectus femoris is a muscle in the​ thigh, and the sternohyoid is a muscle in the neck.

Other diagnostic tests

Thoracentesis is the insertion of a needle into the chest cavity in order to withdraw fluid from the pleural space. The fluid is examined for microorganisms, blood, and other substances. Thoracentesis also relieves pressure on the lung and atelectasis (collapse of lung tissue) by removing pathologic fluid accumulation or pleural effusion. Sputum culture identifies microorganisms present in a sample of expectorated material. Complete blood count (CBC) shows the quantity, type, and morphology of red and white blood cells and platelets in a blood sample. It is used in the diagnosis of anemia and infection.

The nurse is interviewing and educating a client about anatomy and knows that the ribs and muscles surround the​ thorax, or the chest. What explanation by the nurse would describe the primary purpose of the ribs in the​ chest?

To protect the lungs from external injury

The nurse is caring for a client with a pneumothorax. Based on the client​'s ​history, which is the most likely cause for this alteration in​ oxygenation

Trauma

Respiratory center in the brainstem

Two phases of the respiratory cycle: inspiration and expiration. Regions in the brainstem regulate respiratory rate and effort. Normal breathing is termed eupnea. Difficult breathing, such as shortness of breath, is termed dyspnea.

For the client being discharged to home with supplemental oxygen, teaching includes

Using the devices properly Checking oxygen levels in tanks Using a portable device for trips outside of the house Maintaining the lines and keeping them clear of obstruction.

Ventilation

Ventilation occurs within the lungs. Through this, oxygen from the atmospheric air is exchanged for carbon dioxide, which is then expelled through expiration or exhaling

Perfusion diagnostic tests

Ventilation/perfusion scan (V/Q scan) provides information about the client's ventilation/ perfusion status. A radionuclide gas is inhaled and an image taken to determine if it has reached all parts of the lungs. CT with contrast is replacing this in the process of diagnosing pulmonary embolus. Arterial blood gas (ABG) measures the pH, oxygen saturation (SaO2), which is oxygen bound to hemoglobin, free oxygen (PaO2), carbon dioxide (PaCO2) and bicarbonate (HCO3) in an arterial blood sample. Pulse oximetry measures oxygen saturation through a bedside spectrometer applied to the client's finger, toe, or ear. The normal value is >95%.

Symmetrical expansion

Warm your hands and place them on the posterolateral chest wall with your thumbs at the level of T9 to T10. Gently pinch a skinfold between your thumbs and ask the client to take in a deep breath and then exhale Movement and pressure against your skin should feel smooth and even. Your thumbs will move away from the spine, and the skin should move smoothly as the chest moves with inspiratory effort.

The nurse is assessing the respiratory system of​ Tamara, a​ preschool-age client. Which difference does the nurse expect while assessing Tamara when compared to an adult​ client? Larger nasopharynx More functional muscles ​Long, floppy epiglottis Atrophy of the tonsils A nurse is assessing the respiratory status of a preschool child during the assessment phase of the nursing process.

When assessing a​ preschool-age client's respiratory​ system, the nurse expects to find a​ long, floppy epiglottis. The nasopharynx is smaller in pediatric clients. Enlarged tonsils are​ expected, atrophy does not occur until the age of 12 years. Pediatric clients have fewer functional muscles for respiration.

Assessing order

When assessing the lungs and thorax the nurse first​ inspects, then​ palpates, next performs​ percussion, and then finally auscultates. Next Question

Xanthines

Xanthines such as theophylline dilate the distal airways and promote increased heart rate and blood flow. These may be used in chronic obstructive pulmonary disease (COPD) but require careful monitoring of their narrow therapeutic range. For this reason, they are being replaced in practice by long acting beta agonists when possible.

The nurse is caring for a client with a thoracic​ catheter, also known as a chest tube. Which interventions are appropriate for this​ client? ​(Select all that​ apply.)

assessing for pain ensuring o2 is available monitoring for air leaks

Nasal exterior and mucosa (using flashlight)

normal findings: Midline Symmetric Mucosa moist and pink Nares patent abnormal findings: Trauma Lesions Asymmetry Pallor Redness Exudate Flaring Occlusion Lifespan considerations: Nasal flaring in infants is an early sign of compromise. Children may insert foreign bodies.

Thoracic wall

normal: Anteroposterior diameter is ~ ½ the transverse diameter Intercostal muscles raise chest symmetrically with inspiration abnormal: Barrel chest Asymmetry Intercostal retraction Life consideration: Babies and small children are more likely to exhibit intercostal retraction than adults.

Nail beds

normal: Should be pink. Nail beds form a ~160 degree angle in relation to finger. abnormal: Blue or gray color Clubbed nails with an angle greater than 180 degrees. Lifespan considerations: Clubbed nails occur in the setting of chronic hypoxia. Be aware of client history.

Skin color

normal: Should be uniformly pink. This indicates adequate perfusion abnormal: Cyanosis, a blue, green, or gray coloring around the mouth or extremities. life considerations: Cyanotic hands and feet are expected findings in neonates.

Measures of mechanical diagnostic tests

pulmonary function and capacity: Incentive spirometry measures the volume of a client's exhalation using a simple, handheld tool. It is often used to monitory pulmonary function and encourage deep breathing for clients who are in a period of immobility or decreased activity such as postoperatively or on strict bed rest. Peak flow is a measure of the volume of air a client is able to exhale, also using a simple, handheld tool. It is often used by clients with asthma to monitor the effectiveness of medications. Pulmonary functions tests (PFTs) are performed using a device called a spirometer, which measures and records inspiratory, expiratory, total, and reserve lung volumes.

The nurse is assessing an​ 8-year-old client during a​ well-child visit at a clinic. Which anatomical differences does the nurse expect to finding during the assessment​ process? ​(Select all that​ apply.)

smaller nasopharynx small mouth with large tongue soft tracheal cartilage