Prep U Chapter 39 Oxygen and Perfusion
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?
"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."
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."
In which client should the nurse prioritize assessments for respiratory depression?
A client taking opioids for cancer pain
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
A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?
Ask the client what factors contribute to nonadherence.
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 oxygen tubing connection
The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate?
Check the fit of the oxygen mask.
To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test?
Monitor the amount of oxygen saturation in the blood
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?
Residual Volume (RV)
The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective?
SpO2 92%
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.
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?
cyanosis
The nurse is preparing to provide hygiene care to a client with hypoxia. Into what position will the nurse place the client?
high Fowlers
he 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
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?
They are low-pitched, soft sounds heard over peripheral lung fields.
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:
adequate tissue perfusion.
A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?
educating the client on the use of incentive spirometry
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?
hypoxia
A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment?
5,850 mL (5,850 × 10^9/L)
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
A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?
nasal cannula
A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client?
nasal cannula
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."
The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign?
Respiratory rate and depth
The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse would cause the charge nurse to intervene?
The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN).
In which client would the nurse assess for a depressed respiratory system?
a client taking opioids for cancer pain
During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?
flow meter
The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?
tracheostomy collar
A nurse assesses the vital signs of a healthy newborn infant. What respiratory rates suggest a need for further assessment and possible interventions? Select all that apply.
20 breaths/min 65 breaths/min 80 breaths/min
The nurse is caring for a client with emphysema. A review of the client's chart reveals pH 7.36, PaO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription if prescribed by the health care practitioner?
4 L/minute O2 (66 mL/second) nasal cannula
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?
Eat smaller meals that are high in protein.
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?
Remove the airway, turn the client to the side, and provide mouth suction, if necessary.
Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound?
bronchial
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
A nurse is conducting a physical assessment of a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the client's oxygenation. What instruction should the nurse give the client?
contract the abdominal muscles
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:
croup
A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?
flow meter
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?
high respiratory rate
A client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and they are thick and sticky. The nurse should instruct the client to:
increase her fluid intake to thin secretions.
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?
pleural effusion