Prep U: Chapter 39 Oxygenation and Perfusion

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The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?

"An electric stove may be a safer choice for you."

The nurse is reviewing the results of a client's arterial blood gas and pH analysis. Which findings indicate to the nurse that intervention is not required? Select all that apply.

* pH 7.45 * PCO2 40 mm Hg * Base excess or deficit +2 mmol/L

A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient?

Ambu bag

What assessments would a nurse make when auscultating the lungs?

Cardiovascular function

The nurse assessing a client with chronic obstructive pulmonary disease (COPD) suspects chronic hypoxia based on which assessment finding?

Clubbing fingers

Which skin disorder is associated with asthma?

Eczema The client with asthma often recalls childhood allergies and eczema.

A normal pulse oximetry reading indicates that the body's oxygen demands are being met. a) True b) False

False

The nurse is delegating hygiene care to the UAP for a client with hypoxia. What position will the nurse tell the UAP to place the client in?

High Fowlers

The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is:

Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter.

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?

Nasal cannula Nasal cannula and tubing administers oxygen concentrations at 22% to 44%.

What structural changes to the respiratory system should a nurse observe when caring for older adults?

Respiratory muscles becomes weaker

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?

The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment.

What assessments would a nurse make when auscultating the lungs?

cardiovascular function

Oxygen and carbon dioxide move between the alveoli and the blood by:

diffusion

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

educating the client on the use of incentive spirometry Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.

the nurse is conducting a respiratory assessment of a client 71 years of age who has been recently admitted to the hospital unit. What assessment findings should the nurse interpret as abnormal?

fine crackles to the bases of the lungs bilaterally

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?

high-Fowler's position

what does air passing through narrowed airways produce?

wheezing sound

"Breathing through your nose first will warm, filter, and humidify the air you are breathing." 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.

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output?

"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute."

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."

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." Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the oxygen analyzer?

"It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed."

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include the humidifier?

"Small water droplets come from this, thus preventing dry mucous membranes." 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.

Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system? Select all that apply.

*slightly contoured chest with no sternal depression *anteroposterior diameter of the chest less than the transverse diameter *bronchial, vesicular, and bronchovesicular breath sounds

What are characteristics of a normal breathing pattern? Select all that apply.

-The average adult moves about a quarter of a liter of air per breath. -Normal breathing occurs at a rate of 12 to 20 breaths per minute in the adult. -Usually a person breathes slightly faster when awake than when asleep. -Exhaling normally takes twice as long as inhaling. -The athlete normally breathes more slowly and deeply while at rest than someone who is less fit. -Normally, each breath is the same size.

The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal? a) 12 to 15 breaths per minute b) 30 to 55 breaths per minute c) 20 to 30 breaths per minute d) 12 to 20 breaths per minute

30 to 55 breaths per minute Explanation: The nurse should expect the newborn to have a respiratory rate of 30 to 55 breaths per minute. Toddlers and preschoolers have a respiratory rate of 20 to 30 per minute. School-age children and adolescents have a respiratory rate of 12 to 20 breaths per minute

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines?

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.

The nurse is caring for a 70-year-old client with COPD. Which vaccine will the nurse offer the client?

All clients over 65 years old or anyone with a compromising chronic health condition should be offered Prevnar 13 ®. This vaccine is effective in reducing 13 strains of streptococcal pnuemoniae.

A nurse is preparing to perform oropharyngeal suctioning. Which of the following actions should the nurse perform?

Apply suction for no longer than 15 seconds at a time. Explanation: To prevent hypoxia, suction should never be applied for more than 15 seconds at one time. Analgesia is not normally necessary, and the patient should be seated upright. The catheter tip should be lubricated with water-soluble lubricant.

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 must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment. Then, the nurse can work with the healthcare provider to find alternate treatment options if necessary, and then document the care.

A newly hired nurse is performing a focused respiratory assessment. The nurse mentor will intervene if which action by the newly hired nurse is noted?

Breath sounds should be auscultated while the client breathes slowly through an open mouth; nose breathing may produce false breath sounds.

What is the action of codeine when used to treat a cough?

Codeine, which is an ingredient in many cough preparations, is generally considered to be the preferred cough suppressant ingredient.

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia? a) Decreased respiratory rate b) Decreased blood pressure c) Hyperactivity d) Confusion

Confusion Explanation: Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

When the client demonstrates soft, high pitched discontinuous sounds, the nurse documents the breath sounds heard as which of the following?

Crackles Crackles are soft, high pitched discontinuous sounds.

When the client demonstrates soft, high pitched discontinuous sounds, the nurse documents the breath sounds heard as which of the following?

Crackles are soft, high pitched discontinuous sounds.

Oxygen and carbon dioxide move between the alveoli and the blood by

Diffusion

The nurse is delegating hygiene care to the UAP for a client with hypoxia. What position will the nurse tell the UAP to place the client in?

High Fowlers position allows the client with hypoxia to breathe easier by promoting lung expansion, as the abdominal organs descend away from the diaphragm.

Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen?

It regulates the amount of oxygen received. 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.

Which of the following oxygen delivery systems is most commonly used because it does not impede eating or speaking?

Nasal cannula

The nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FIO2 of 100%. Which oxygen delivery system should the nurse utilize?

Non-rebreather mask Explanation: A non-rebreather mask is the only device that can deliver FIO2 of 100% to a client without a controlled airway. A Venturi mask delivers a maximum FIO2 of 55%. A nasal cannula delivers a maximum FIO2 of 44%. A simple mask delivers a maximum FIO2 of 60%.

Upon entering a client's room, the nurse notes the client's pulse oximetry to be 86%. What is the priority nursing action?

Perform a respiratory assessment.

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?

Pulmonary function testing is used to measure lung size and airway patency.

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?

Pulmonary function tests

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

Rapid respirations Explanation: Normal cardiac output averages from 3.5 L/minute to 8.0 L/minute. With decreased cardiac output, there is a reduction in the 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. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.

A hospital nurse has administered a patient's scheduled dose of salbutamol (Ventolin) by nebulizer. Shortly after receiving the medication, the patient rings her call bell and states, "I feel like my heart is racing." The nurse performs a rapid assessment and confirms that the patient's heart rate is 91 beats/min with a regular rate. What is the nurse's best action?

Reassure the patient that this is a common adverse effect of this medication. Explanation: Β2-Adrenergic agonists such as Ventolin frequently cause tachycardia. The nurse is correct to monitor this effect, but there is no obvious threat to the patient's health. Teaching the patient that this is an expected effect is consequently appropriate. Referrals, oxygen therapy, and repositioning are unnecessary.

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)

When caring for a client with a tracheostomy, the nurse would perform which recommended action?

Sterile technique is required when suctioning a tracheostomy in order to prevent introduction of microorganisms into the respiratory tract.

When caring for a client with a tracheostomy, the nurse would perform which recommended action?

Suction the tracheostomy tube using sterile technique.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The adult chest contour is slightly convex, with no sternal depression.

The nurse is assessing the respiratory rates of clients in a community health care facility. Which client exhibits an abnormal value?

The infant's normal respiratory rate is 30 to 55 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 40 breaths per minute. For a child 6 to 12 years of age the normal respiratory rate is 18 to 26 breaths per minute. The normal respiratory rate for an adult 65 years and older is 16 to 24 breaths per minute.

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?

The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen

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?

The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood.

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. Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

A nurse suctioning a patient through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?

Trauma to the tracheal mucosa

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?

Vesicular

A nurse is admitting a 6-year-old child status post tonsillectomy to the surgical unit. The nurse obtains his weight and places EKG and a pulse oximeter on the client's left finger. His heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:

adequate tissue perfusion. 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.

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

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of:

atelectasis. Stiffer lungs tend to collapse and also cause their alveoli to collapse. This condition is called atelectasis.

When the nurse observes a newborn infant demonstrating an irregular abdominal breathing pattern, with a respiratory rate of 50 breaths/minute with occasional pauses in breathing of 5-second durations. What is the most appropriate action by the nurse?

continue to assess the infant

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?

distilled water Distilled water is used when humidification is desired. Other answers are incorrect.

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? a) respiratory rate of 18 breaths per minute b) fine crackles to the bases of the lungs bilaterally c) vesicular breath sounds audible over peripheral lung fields d) 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.

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:

hemoglobin level

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. When a cough is productive, it is important to establish the source of the sputum and assess its color, volume, consistency, and other noteworthy characteristics. The nurse should instruct the client to increase fluid intake to thin secretions.

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: a) decrease exercise and increase rest periods. b) take a cough suppressant to decrease coughing. c) increase her fluid intake to thin secretions. d) eat small, frequent meals to conserve energy.

increase her fluid intake to thin secretions. Explanation: When a cough is productive, it is important to establish the source of the sputum and assess its color, volume, consistency, and other noteworthy characteristics. The nurse should instruct the client to increase fluid intake to thin secretions

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 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.

The nurse is reviewing the physical assessment and arterial blood gas (ABG) results of a patient who has COPD. Which of the following values are outside of reference ranges? Select all that apply.

pH 7.29 PCO2 51 mmHg HCO3 29 mEq/L Explanation: Normal ABG results are pH (7.35 to 7.45), PCO2 (35 to 45 mmHg), PO2 (80 to 100 mmHg), HCO3- (22 to 26 mEq/L), and base excess or deficit (-2 to +2 mmol/L). This patient is likely experiencing respiratory acidosis.

The nurse is caring for a client with respiratory alkalosis. Which arterial blood gas data does the nurse anticipate finding?

pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation In respiratory alkalosis, anticipated arterial blood gas results are anticipated to reflect pH greater than 7.45; HCO3 low; and PaCO2 low. Other answers are incorrect.

The nurse is caring for a client with respiratory alkalosis. Which arterial blood gas data does the nurse anticipate finding?

pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation Explanation: In respiratory alkalosis, anticipated arterial blood gas results are anticipated to reflect pH greater than 7.45; HCO3 low; and PaCO2 low. Other answers are incorrect.

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?

resonance on percussion of lung fields

What structural changes to the respiratory system should a nurse observe when caring for older adults?

respiratory muscles become weaker

What structural changes to the respiratory system should a nurse observe when caring for older adults? a) respiratory muscles become weaker b) increased mouth breathing and snoring c) diminished coughing and gag reflexes d) increased use of accessory muscles for breathing

respiratory muscles become weaker Explanation: One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker. The nurse should also observe other structural changes: the chest wall becomes stiffer as a result of calcification of the intercostals cartilage, kyphoscoliosis, and arthritic changes to costovertebral joints; the ribs and vertebrae lose calcium; the lungs become smaller and less elastic; alveoli enlarge; and alveolar walls become thinner.

A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?

trauma to the tracheal mucosa

The nurse is providing discharge teaching to a client going home with oxygen therapy. Which statements made by the client would indicate to the nurse that the teaching was effective? Select all that apply.

"I will not allow smoking within 10 feet (3 meters) of my oxygen." "I will keep the oxygen tank away from direct sunlight or heat." Oxygen is combustible, so keep it away from smoking or direct sunlight. It is important to allow adequate airflow around the oxygen concentrator, so it should not be placed flush against the wall. It's more important to follow the prescription, than to adjust the oxygen flow rate because too much or too little oxygen may be detrimental to the client. The client must use caution with both gas and electrical stoves.

"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute." Explanation: The following formula is used to determine cardiac output: Cardiac Output = Stroke Volume x Heart Rate. A client with a stroke volume of 50 mL and heart rate of 50 beats per minute has a cardiac output of 2.5 L/minute. If stroke volume is 70 and heart rate is 70 beats per minute, then the cardiac output is 4.9 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute.

"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute." (Cardiac Output = Stroke Volume x Heart Rate).

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." 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.

A client with chronic obstructive pulmonary disease (COPD) reports severe shortness of breath when it is raining. The nurse says to the client:

"The air is thicker or more viscous with humidity, thus it is harder for you to breathe." Explanation: People with chronic respiratory diseases often find breathing more difficult when the weather is hot and humid because humidity contributes to air viscosity.

A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response?

"The caregiver will need to place the oxygen tank back into the secure carrier." Oxygen tanks are transported on a wheeled carrier to avoid accidental force. Accidental force could cause the tank to explode. The tank should not be carried, and taking it out of the carrier does not affect the flow of oxygen.

A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response?

"The caregiver will need to place the oxygen tank back into the secure carrier." Explanation: Oxygen tanks are transported on a wheeled carrier to avoid accidental force. Accidental force could cause the tank to explode. The tank should not be carried, and taking it out of the carrier does not affect the flow of oxygen.

A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response?

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."

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." 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.

A client using home oxygen asks the nurse about changing to an oxygen concentrator. What is the appropriate nursing response? (Select all that apply.)

* "It collects and concentrates oxygen from room air." * "It eliminates the need for a central reservoir of piped oxygen." * "You may notice an increase in your electric bill." * "It costs less than oxygen supplied in portable tanks."

The nurse is caring for a client who will have a chest tube removed within the next hour. What action by the nurse will be included in the plan of care for this client for removal of the chest tube? Select all that apply

*Administer prescribed pain medication 15 to 30 minutes before chest tube removal *Teach the client about relaxation exercises to be used during chest tube removal *Apply a cold compress to the site prior to the removal

The nurse is monitoring a client who is receiving oxygen via a nonrebreather mask at 12 L/min. What actions by the nurse will promote the best outcomes for this client? Select all that apply.

*Maintain flow rate so that the reservoir bag collapses only slightly during inspiration. *Check that the valves and rubber flaps are functioning properly. *Monitor SaO2 with pulse oximeter.

Erin is a 35-year-old woman being cared for in the emergency department for a cough and hemoptysis for 3 days. Erin states that she has smoked one-and-a-half packs of cigarettes per day for the last 5 years. In trying to identify risk factors for Erin, the nurse calculates her pack-year history to write on the intake form. What is Erin's pack-year of smoking?

7.5 Explanation: One "pack-year" is equal to smoking one pack of cigarettes for a day for 1 year. Based on Erin's information, Erin's has a 7.5 pack-year smoking history.

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?

8 L/min oxygen via nasal cannula Explanation: The correct amount delivered FiO2 for a 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. However, per nasal cannula it may be no more than 2-3 L/min to patient with chronic lung disease.

The nurse is instructing the client with a pulmonary disorder on 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 will warm, filter, and humidify the air you are breathing.?

The nurse sets up an oxygen tent for a patient. Which patient is the best candidate for this oxygen delivery system?

A child who has pneumonia

Which oxygen delivery system is most commonly used because it does not impede eating or speaking?

A nasal cannula is commonly used because it does not impede eating or speaking and is easily used in the home.

Ambu bag If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag)may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube.

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?

Arterial blood gas Explanation: Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.

A nurse is reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would the nurse most likely identify as an effect of exposure to automobile pollutants?

Bronchitis

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse, if noted by the charge nurse, would cause the charge nurse to intervene?

Care of a tracheostomy tube in a stable situation, such as long-term care and other community-based care settings, may be delegated to licensed practical/vocational nurses (LPN/LVN); not in an acute instance.

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?

Corticosteroids Explanation: In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation.

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe?

Crackles in the lower lobes Explanation: People with chronic congestive heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels. Stridor is associated with respiratory infections such as croup. Wheezing may be heard in individuals who use tobacco products.

The pediatric nurse is instructing parents on safety when caring for toddlers and preschoolers. Which of the following teaching interventions is appropriate for this age group?

Cut a hot dog in half, then pieces Explanation: During the toddler and preschool years, children place things in their mouths, and caregivers must protect them against aspirating foreign objects that can obstruct small air passages. Providing safe toys and avoiding hard candy or small hard pieces of food are important ways to ensure normal respiratory function for children in this age group.

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 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.

The nurse is assessing a client with a chest tube that has been inserted after experiencing blunt trauma that resulted in a pneumothorax. What nursing action is appropriate when constant bubbling is noted in the suction control chamber?

Document the finding.

An older adult client visits a health care facility for a scheduled physical assessment. During the assessment, the client reports difficulty breathing. What suggestion could the nurse make to improve the client's respiratory function in this case?

Drink liberal amounts of fluids

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?

During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume.

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? a) Nasal strip b) Oxygen analyzer c) Flow meter d) Nasal cannula

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 Explanation: The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.

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?

Flowmeter

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? a) Perfusion b) Atelectasis c) Hypoxia d) Hyperventilation

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.

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.

The nurse is caring for a client receiving oxygen therapy via nasal cannula who suddenly becomes cyanotic with a pulse oximetry reading of 91%. Which is the next most appropriate action the nurse should take?

If the client suddenly becomes cyanotic, the nurse should assess the oxygen tubing to make sure it is still connected.

A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. What should the nurse use for this patient?

If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag)may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube.

A physician has ordered an arterial blood gas test for a client with a respiratory disorder. What is the most common role of the nurse in performing the arterial blood gas test?

Implement measures to prevent complications after arterial puncture. During the arterial blood gas test, the nurse should implement measures to prevent complications after the arterial puncture. The nurse would not be involved in measuring the partial pressure of oxygen dissolved in plasma or the percentage of hemoglobin saturated with oxygen. Intensive care nurses commonly obtain arterial blood gases.

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

In general, if a flow rate of 6 L/minute fails to raise a client's oxygen saturation level satisfactorily, a mask should be used.

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?

In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation.

Which is a sign of dyspnea specific to infants?

In the infant, flaring of the nostrils and retractions of the ribs during inspiration are notable signs of air hunger and extraordinary work of breathing.

Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions.

A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention?

Inquire about factors that contribute to non-adherence.

A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention?

Inquire about factors that contribute to non-adherence. 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.

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 pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. The arterial blood gases test the client's blood for the partial pressure of oxygen dissolved in plasma, the percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma. Spirometry measures the volume of air in liters exhaled or inhaled by a client over time.

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 The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Non-rebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.

Which is a sign of dyspnea specific to infants?

Nasal flaring

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields)

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?

Normal cardiac output averages from 3.5 L/minute to 8.0 L/minute. With decreased cardiac output, there is a reduction in the 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.

A hospital patient has been receiving oxygen by nasal prongs at 3 L/min to keep her SaO2 above 92%. The patient has rung her call bell and asked the nurse to assist her with ambulating to the bathroom next door to her room. What is the nurse's most appropriate action?

Obtain extension tubing so the patient's nasal prongs will reach to the bathroom. Explanation: To maintain an uninterrupted flow of oxygen, the nurse should add extension tubing to facilitate the patient's movement. A short-term increase in flow is of no real benefit, and a portable oxygen system is likely unnecessary. Whenever possible, the patient's oxygen therapy should not be removed.

A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?

Occluding the Y-port on the suction tubing is what creates the suction. While suctioning would be difficult but possible, suctioning while advancing the tube would damage the tracheal mucosa and remove excessive amounts of oxygen, not carbon dioxide, from the respiratory tract

One "pack-year" is equal to smoking one pack of cigarettes for a day for 1 year. Based on Erin's information, Erin has a 7.5 pack-year smoking history.

What structural changes to the respiratory system should a nurse observe when caring for older adults?

One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker.

A nurse is caring for a patient who has a diagnosis of chronic obstructive pulmonary disease (COPD). When planning this patient's care, the nurse has reviewed the normal anatomy and physiology of the respiratory system. Which of the following statements describe the expected structure and function of this system? Select all that apply.

Oxygen diffuses from areas of high concentration to areas of low concentration. External respiration takes place between the alveoli and the pulmonary capillaries.

Which is a major organ of the upper respiratory tract? a) Trachea b) Pharynx c) Lungs d) Bronchi

Pharynx Explanation: The pharynx, mouth, and nose are major organs of the upper respiratory tract. The trachea, bronchi, and lungs are major organs of the lower respiratory tract

A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function? a) Tachypnea b) Pleural effusion c) Pneumonia d) Wheezes

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 and pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.

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:

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

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

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.

While auscultating a client's chest, the nurse auscultates crackles in the lower lung bases. What condition does the nurse identify the client is experiencing?

Presence of sputum in the trachea

During data collection of a 4-year-old client, the nurse notes a respiratory rate of 35 breaths/min and a loud, harsh expiration that is longer than inspiration. The nurse would implement which appropriate nursing intervention next? a) Notify the health care provider b) Administer oxygen therapy c) Proceed with the data collection d) Obtain arterial blood sampling

Proceed with the data collection Explanation: When collecting respiratory data on a 4-year-old, loud, harsh expiration longer than inspiration breath sounds and respiratory rate of 20-40 breaths/min are normal findings; therefore, the nurse would continue with the assessment. Because the findings are normal, it is inappropriate at this time to administer oxygen therapy, obtain an arterial blood sampling, or notify the health care provider.

A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for:

Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize atelectasis

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?

Pulse oximetry 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.

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) 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.

The nurse is caring for a postoperative client who has a prescription for meperidine (Demerol) 7 5mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering Demerol, the nurse would assess which most important sign?

Respiratory rate and depth. The client receiving narcotics/opioids needs monitoring of the respiratory rate and depth to ensure that respiratory depression does not result in progressive respiratory issues, physiological damage from respiratory depression, or loss of consciousness.

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 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.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression.

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?

The client with chronic lung disease, such as emphysema, becomes insensitive to carbon dioxide and responds to hypoxia to stimulate breathing. If given excessive oxygen (4 L/minute), the stimulus to breathe is removed.

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?

The correct amount delivered FiO2 for a 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. However, per nasal cannula it may be no more than 2-3 L/min to patient with chronic lung disease.

The nurse is demonstrating oxygen administration to a client. What teaching will the nurse include about the flowmeter?

The flowmeter is a gauge used to regulate the amount of oxygen that a client receives.

Which is NOT true regarding the structure of the respiratory system?

The lungs move actively. The lungs move only passively. They stretch and recoil in response to neuromuscular activity.

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse, if noted by the charge 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).

While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique?

The nurse can assess patterns of thoracic expansion through palpation.

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? a) They are medium-pitched blowing sounds heard over the major bronchi. b) They are soft, high-pitched discontinuous (intermittent) popping lung sounds. c) They are loud, high-pitched sounds heard primarily over the trachea and larynx. d) They are low-pitched, soft sounds heard over peripheral lung fields.

They are low-pitched, soft sounds heard over peripheral lung fields. Explanation: Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

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?

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.

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).

T or F After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

True

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

True This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis.

Vesicular Explanation: Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields.

Vesicular 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, whereas bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

Which actions should a nurse perform when inserting an oropharyngeal airway? Select all that apply.

Wash hands and put on PPE, as indicated. Rotate the airway 180 degrees as it passes the uvula. Remove airway for a brief period every 4 hours or according to facility policy. Explanation: The nurse will come into contact with respiratory secretions during the insertion of the oral airway, making it necessary to wear appropriate PPE. The airway will need to be rotated 180 degrees as it passes the uvula because the airway is more easily inserted with the curved tip pointing up towards the roof of the mouth. The airway should be removed for brief periods every 4 hours (or according to facility policy) to prevent constant pressure on the surrounding structures. The airway should reach from the opening of the mouth to the back angle of the jaw. The client should be positioned in a semi-Fowler's position to ease insertion of the airway.

A nurse auscultates the lungs of a client with asthma. Which lung sound is characteristic of this condition? a) Crackles b) Wheezes c) Vesicular sounds d) Bronchial sounds

Wheezes Explanation: Wheezes are continuous musical sounds, produced as air passes through airways that are constricted, as with asthma. Crackles are produced by fluid in the airways or alveoli and delayed reopening of collapsed alveoli. They occur due to inflammation or congestion and are associated with pneumonia, heart failure, bronchitis, and COPD.

Which scenario describes how carbon dioxide levels determine the frequency and depth of ventilation?

When carbon dioxide levels in the blood increase, chemoreceptors are stimulated, causing deeper and more rapid breathing.

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:

a bronchospasm

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:

a bronchospasm. 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.

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

In which client would the nurse assess for a depressed respiratory system? a) a client taking antibiotics for a urinary tract infection b) a client taking insulin for diabetes c) a client taking opioids for cancer pain d) a client taking amlodipine for hypertension

a client taking opioids for cancer pain Explanation: Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations.

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.

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of:

atelectasis

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:

breathing becomes increasingly difficult as the diaphragm is displaced. During the last weeks of pregnancy, breathing may become increasingly difficult in a supine position because the fetus displaces the diaphragm upward.

When the emergency room nurse assesses the pulse oximeter on a client and it reveals 105%, the nurse determines that the most likely explanation for the value is:

carbon monoxide poisoning. Carbon monoxide poisoning results in false high readings; edema at the sensor site produces false low readings.

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. A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.

The caregiver of an older adult client who was recently placed on home oxygen reports that the client now refuses to leave the house. What teaching will the nurse select? (Select all that apply.)

continued socialization with others is important consider a portable oxygen device invite friends and family to the client's house

a nurse is assessing the breath sounds of a newborn. Which of the following is an expected finding for this developmental level?

crackles

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

Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways?

decreases the amount of air trapping and resistance

During the physical assessment of a client who has been inactive due to a leg injury, the nurse notes that the client tends to breathe very shallowly. What technique should the nurse teach the client in order to breathe more efficiently? a) pursed-lip breathing b) deep breathing c) diaphragmatic breathing d) incentive spirometry

deep breathing Explanation: The nurse should teach deep breathing techniques to the client who tends to breathe shallowly in order to help the client breathe more efficiently. Deep breathing is a technique for maximizing ventilation. Taking in a large volume of air fills alveoli to a greater capacity, thus improving gas exchange.

Oxygen and carbon dioxide move between the alveoli and the blood by: a) hyperosmolar pressure. b) negative pressure. c) osmosis. d) diffusion.

diffusion. Explanation: Oxygen and carbon dioxide move between the alveoli and the blood by diffusion, the process in which molecules move from an area of greater concentration or pressure to an area of lower concentration or pressure.

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather?

face tent

Why are fine crackles to the bases of the lungs bilaterally abnormal breath sounds for a 71 year old?

fine crackles always constitute an abnormal finding.

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

high respiratory rate 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.

The home care nurse visits a client with compromised lung function. She has greenish-yellow sputum with a musty odor. This is indicative of:

infection. Sputum that is yellow or greenish or has a musty odor usually indicates an infection. The sputum associated with congestive heart failure is frothy or pink-tinged. Sputum associated with asthma is thick and mucoid not yellow or green in color.

The nurse is listening to the client's lungs and hears them fill with air and then return to a resting position. How will the nurse document this assessment data?

inspiration and expiration

The nurse is caring for a 2-year-old client who experienced smoke inhalation during a house file. When oxygen is ordered, what delivery device will the nurse gather?

oxygen tent

The nurse is caring for a client with metabolic acidosis whose breathing rate is 28 breaths per minute. Which arterial blood gas data does the nurse anticipate finding?

pH less than 7.35; HCO3 low; PaCO2 low In metabolic acidosis, anticipated arterial blood gas results are anticipated to reflect pH less than 7.35; HCO3 low; and PaCO2 low. Other answers are incorrect.

While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique?

pattern of thoracic expansion Explanation: The nurse can assess patterns of thoracic expansion through palpation. Fluid-filled and consolidated portions of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation.

The nurse is auscultating the lungs of a patient and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

pitched

what does pleural surfaces give rise to

pleural rub

The nurse is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly?

reads 0.21 when checking oxygen in room air Explanation: An oxygen analyzer should read 0.21 when checking oxygen in room air if there is a normal mixture of oxygen and other gases in the environment. When the analyzer is positioned near or within the device used to prescribe oxygen, it should register at the prescribed amount (>0.21).

Which nursing skill requires the nurse to use sterile technique?

suctioning a tracheostomy Suctioning is always a sterile procedure, whereas the administration of oxygen and nebulized medications require clean technique.

What is the action of codeine when used to treat a cough?

suppressant

What is the action of codeine when used to treat a cough?

suppressant Codeine, which is an ingredient in many cough preparations, is generally considered to be the preferred cough suppressant ingredient.

What is the action of codeine when used to treat a cough? a) suppressant b) antihistamine c) expectorant d) antisuppressant

suppressant Explanation: Codeine, which is an ingredient in many cough preparations, is generally considered to be the preferred cough suppressant ingredient.

A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?

trauma to the tracheal mucosa Explanation: Occluding the Y-port on the suction tubing is what creates the suction. While suctioning would be difficult but possible, suctioning while advancing the tube would damage the tracheal mucosa and remove excessive amounts of oxygen, not carbon dioxide, from the respiratory tract. Suctioning during insertion of the catheter would not compromise sterility.

The nurse is instructing the client with a pulmonary disorder on 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? a) "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." b) "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." c) "Breathing through your nose first will warm, filter, and humidify the air you are breathing." d) "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." 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

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." 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.

A client with chronic obstructive pulmonary disease (COPD) reports severe shortness of breath when it is raining. The nurse says to the client:

"The air is thicker or more viscous with humidity, thus it is harder for you to breathe." People with chronic respiratory diseases often find breathing more difficult when the weather is hot and humid because humidity contributes to air viscosity.

A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response?

"The caregiver will need to place the oxygen tank back into the secure carrier."

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." 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.

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." 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.

The nurse is caring for a client with a nonhealing wound who has been prescribed hyperbaric oxygen therapy (HBOT). When the client asks, "How will this help me?" what is the appropriate nursing response?

"Wounds heal because HBOT helps to regenerate new tissue quickly." Although HBOT treats a multitude of conditions, the reason for using HBOT for a nonhealing wound is to help regenerate new tissue quickly. HBOT is used to treat anaerobic infections. The other responses are inappropriate.

A client who is scheduled for a bronchoscopy has arrived at the clinical facility. When preparing for the test, the client reports feeling hungry and asks the nurse when he will be able to eat. What information should be provided by the nurse?

"You will not be able to eat or drink until your gag reflex has returned." Explanation: The bronchoscopy allows for the visualization of the airways. Nursing interventions for a bronchoscopy include ensuring informed consent, teaching before the procedure, and maintaining n.p.o. status until the gag reflex returns after the procedure.

The nurse is caring for a client with a North America Diagnosis Association-International (NANDA-I) diagnosis of Imbalanced nutrition: Less than body requirements, related to difficulty breathing. The nurse would implement which measures to maintain an adequate nutritional status for this client? Select all that apply.

*Provide frequent oral hygiene especially before meals. *Distribute six small meals over the course of the day.

The nurse working in the intensive care unit is preparing to admit a client from the emergency department that had a stroke located in the medulla. What equipment should the nurse have present in the room upon the client's arrival into the unit related to the client's condition? Select all that apply.

*Pulse oximeter *Ventilator

The nurse is planning a diet for a patient with Chronic Obstructive Pulmonary Disease (COPD). Which recommended nutritional guidelines would the nurse discuss with the client? Select all that apply

*The diet should consist of 40% to 55% carbohydrates. *The diet should be rich in antioxidants and vitamin A, C, and B. *The diet should contain 12% to 20% protein.

The pediatric nurse is caring for four clients. Which client will receive the greatest benefit from the use of an oxygen analyzer to assure that the client is receiving the prescribed amount of oxygen?

3-year old in croup tent An oxygen analyzer is used most commonly when caring for newborns in isolettes, children in croup tents, and clients who are mechanically ventilated. Other answers are incorrect.

A patient is complaining of slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

6 L/minute

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?

8 L/min oxygen via nasal cannula

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? a) 10 L/min oxygen via Venturi mask b) 12 L/min oxygen via nonrebreather mask c) 8 L/min oxygen via partial rebreather mask d) 8 L/min oxygen via nasal cannula

The nurse is conducting the physical assessment of a client at the health care facility. The nurse uses the pulse oximetry technique to monitor the oxygen saturation in the client's blood. Which pulse oximeter range indicates that the client is adequately oxygenated? a) 80% to 90% b) 85% to 95% c) 95% to 100% d) 90% to 95%

95% to 100% Explanation: If the client is adequately oxygenated, the pulse oximeter reading should be between 95% and 100%. Pulse oximetry is a noninvasive, transcutaneous technique for periodically or continuously monitoring the oxygen saturation in the blood. The normal range of oxygen saturation in the blood is between 95% and 100%.

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.

Martin is a 58-year-old smoker who was admitted to the hospital with worsening shortness of breath over the last 2 days. He states that he is having some chest discomfort. The nurse asks him further about this in order to characterize whether this may be cardiac related, musculoskeletal related, or respiratory related. Martin states that when he breathes in, he feels as if the air passing into his lungs is burning him. It is also very painful to swallow. Based on what Martin is stating, which illness does the nurse suspect is causing Martin's chest discomfort?

Acute bronchitis is caused by inflammation. Inflammatory mediators such as histamine may directly stimulate nerve endings made hypersensitive by the disease process. This process causes a sensation of pain as air travels over those nerve endings.

The nurse caring for a client who will have a chest tube removed within the next hour includes which of the following nursing interventions on the client's plan of care? (Select all that apply)

Administer prescribed pain medication 15 to 30 minutes before chest tube removal Teach the client about relaxation exercises to be used during chest tube removal The plan of care should include the following nursing interventions: administration of prescribed pain medication 15 to 30 minutes before chest tube removal and teaching the client relaxation exercises to utilize during the procedure. Occlusive dressing, not a semipermeable dressing, should be used.

Administer prescribed pain medication 15 to 30 minutes before chest tube removal. Teach the client about relaxation exercises to be used during chest tube removal. Apply a cold compress to the site prior to the removal.

The nurse caring for a client who will have a chest tube removed within the next hour includes which of the following nursing interventions on the client's plan of care? (Select all that apply)

After the chest tube is removed, the plan of care should include the following nursing interventions: administration of prescribed pain medication 15 to 30 minutes before chest tube removal and teaching the client relaxation exercises to utilize during the procedure.

Although HBOT treats a multitude of conditions, the reason for using HBOT for a nonhealing wound is to help regenerate new tissue quickly.

Ambu bag Explanation: If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag)may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?

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.

The nurse is caring for a 3-year-old client who experienced smoke inhalation during a house fire, and now requires oxygen. What delivery device will the nurse select that is most appropriate for this client?

An oxygen tent is often used when caring for active toddlers who require oxygen, since they are less likely to keep a mask on.

Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH

The UAP reports to the nurse that the client's pulse oximetry is 89%. What is the priority nursing action?

As the nurse enters the room the respiratory assessment immediately begins by visualizing client skin color, observing chest symmetry, vocalization, and auditory adventitious lung sounds. The nurse can then proceed to check the placement of the pulse oximeter

Assess oxygen tubing connection Explanation: If the client suddenly becomes cyanotic, the nurse should assess the oxygen tubing to make sure it is still connected. Assessing lung sounds, repositioning the client, and elevating the head of the bed will not correct the problem if the tubing is disconnected.

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? a) Inhale two sprays with one breath for faster action. b) Inhale through the nose instead of the mouth. c) Inhale the medication rapidly. d) Be sure to shake the canister before using it.

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

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 fit of oxygen mask. The fit of the oxygen mask can be affected by the discontinuation of wearing dentures. The nurse should check the fit to make sure the client is getting the prescribed amount of oxygen. Other answers are inappropriate actions that do not address the problem.

A nurse measuring the arterial oxyhemoglobin saturation (SaO2 or SpO2) of a client's arterial blood gets a weak signal from the pulse oximeter. What would be the appropriate intervention in this situation? a) Use a blood pressure cuff to increase circulation to the site. b) Shine available light on the equipment to facilitate accurate reading. c) If extremity is hot, place a cold compress on the site. d) Check vital signs and client condition.

Check vital signs and client condition. Explanation: If a nurse finds an absent or weak signal, the nurse should check vital signs and client condition. If satisfactory, check connections and circulation to site. Hypotension makes an accurate recording difficult. Equipment (restraint, blood pressure cuff) may compromise circulation to the site and cause venous blood to pulsate, giving an inaccurate reading. If the extremity is cold, the nurse should cover it with a warm blanket. Bright light can interfere with the operation of light sensors and cause an unreliable report.

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 The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the amount 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.

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? a) Chronic anemia b) Pancreatitis c) Graves' disease d) Parkinson's disease

Chronic anemia Explanation: The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the amount 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.

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?

Clubbing Explanation: Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many clients with chronic hypoxia due to respiratory or cardiac disease. Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD. Hemoptysis does not result from hypoxia.

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?

Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many clients with chronic hypoxia due to respiratory or cardiac disease. Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD.

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.

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. 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.

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

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.

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?

A nurse is caring for a client who breathes very shallowly and has been reporting severe back pain. What suggestion could the nurse make to help the client breathe efficiently? a) Instruct the client in the use of pursed-lip breathing technique. b) Teach the client diaphragmatic breathing. c) Inform the client about nasal strips. d) Encourage the client to take deep breaths.

Encourage the client to take deep breaths. Explanation: To help the client breathe efficiently, the nurse could encourage the client to take deep breaths. Deep breathing maximizes the ventilation and fills the alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing and diaphragmatic breathing help to eliminate the extra carbon dioxide from the lungs.

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

Flow meter

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 should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? a) Flow meter b) Nasal cannula c) Humidifier d) Oxygen analyzer

Flow meter Explanation: In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. A humidifier is a device that produces small water droplets and may be used during oxygen administration, since oxygen dries the mucous membranes. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen.

The nurse is caring for a client who reports difficulty breathing. In what position would the nurse place this client? a) prone position b) Fowler's position c) supine position d) lateral position

Fowler's position Explanation: People with dyspnea and orthopnea are most comfortable in a high Fowler's position because accessory muscles can easily be used to promote respiration. Prone position can be used on a routine basis to promote ventilation and perfusion of the posterior dependent sections of the lungs. Lateral and supine position would not be beneficial as accessory muscles are not supported as with a Fowler's position.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea? a) Lying with the head slightly lowered b) Side lying with head slightly elevated c) Supine with one pillow d) High-Fowler's position

High-Fowler's position Explanation: Clients with COPD are most comfortable in high-Fowler's position because it aids in the use of the accessory muscles to promote respirations. The supine position with one pillow, side-lying with head slightly elevated or lying with the head slightly lowered does not promote easier respirations

Hypoxia 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.

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? a) Monitor the amount of oxygen saturation in the blood. b) Measure the volume of air exhaled or inhaled over time. c) Calculate the pressure of carbon dioxide dissolved in plasma. d) Monitor the pressure of oxygen dissolved in plasma.

Monitor the amount of oxygen saturation in the blood. Explanation: The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. The arterial blood gases test the client's blood for the partial pressure of oxygen dissolved in plasma, the percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma. Spirometry measures the volume of air in liters exhaled or inhaled by a client over time.

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? a) Face tent b) Simple mask c) Nasal cannula d) Non-rebreather mask

Nasal cannula Explanation: The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease.

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?

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.

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? a) Spirometry b) Peak expiratory flow rate c) Thoracentesis d) 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.

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.

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?

Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients.

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 Normal cardiac output averages from 3.5 L/minute to 8.0 L/minute. With decreased cardiac output, there is a reduction in the 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. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?

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

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.

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? a) Chronic bronchitis b) Pneumonia c) Sleep apnea d) Chronic obstructive pulmonary disease (COPD)

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

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? a) The UAP advances the catheter approximately 5" to 6" to reach the pharynx. b) The UAP advances the catheter approximately 3" to 4" to reach the pharynx. c) The UAP applies lubricant to the first 2 to 3" of the catheter. d) The UAP allows 30-second to 1-minute intervals between suctioning passes.

The UAP advances the catheter approximately 3" to 4" 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" 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" to reach the pharynx. Applying lubricant to the first 2 to 3" of the catheter facilitates passage of the catheter and reduces trauma to mucous membranes. Allowing 30-second to 1-minute intervals between suction passes allow for reventilation and reoxygenation of airways.

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse, if noted by the charge nurse, would cause the charge nurse to intervene? a) The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). b) The newly hired nurse assesses the client's pain and administers pain medication. c) The newly hired nurse explains what she is doing and the reason to the client, even though the client does not appear to be alert. d) The newly hired nurse adjusts the bed to a comfortable working position.

The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). Explanation: Care of a tracheostomy tube in a stable situation, such as long-term care and other community-based care settings, may be delegated to licensed practical/vocational nurses (LPN/LVN); not in an acute instance.

The nurse is performing an arterial blood gas sampling on a client at 1045. The nurse educator intervenes if which action is taken by the nurse? a) The nurse stops holding pressure at 1055. b) The nurse immediately places the arterial specimen on ice. c) The nurse selects the radial artery as choice of site. d) The nurse performs the Allen's test after blood sample is taken.

The nurse performs the Allen's test after blood sample is taken. Explanation: The Allen's test is done before puncture to ensure adequate ulnar blood flow when using radial artery. The arterial specimen is immediately placed on ice and taken to the laboratory. The radial, brachial, or femoral arteries are usually the sites of choice for an arterial blood sampling. The nurse should apply pressure for 5 to 10 minutes, longer if the client is on anticoagulant therapy.

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?

The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease.

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.

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 sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system? a) an adult who is receiving oxygen at home b) a child who has pneumonia c) an older adult client who has COPD d) 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.

In which client would the nurse assess for a depressed respiratory system?

a client taking opioids for cancer pain Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations.

A woman comes to the emergency room with her 2-year-old. She states he woke up and had a loud barking cough. The child is suffering from:

croup. 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.

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? a) administration of inhaled corticosteroids b) oropharyngeal suctioning twice daily c) educating the client on pursed-lip breathing techniques d) educating the client on the use of incentive spirometry

educating the client on the use of incentive spirometry Explanation: Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the 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: a) sodium and potassium levels. b) blood pH. c) hemoglobin level. d) age.

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

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.

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.

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: a) alcohol abuse. b) asthma. c) croup. d) pneumonia.

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.

what do rales indicate?

presence of fluids in the lungs

what do crackles heard on auscultation indicate

presence of sputum in the airways

while auscultating a client's chest, a nurse hears coarse crackles that are low- pitched and rumbling. The nurse interprets this finding as indicating what?

presence of sputum in the airways

A nurse is teaching a home care patient and his family about using prescribed oxygen. What is a critical factor that must be included in teaching?

the safety measures necessary to prevent a fire

A nurse is teaching a home care client and the family about using prescribed oxygen. What is a critical factor that must be included in teaching? a) the cost and source of supply for the oxygen b) the need to provide good skin care c) the safety measures necessary to prevent a fire d) the importance of communicating with the client

the safety measures necessary to prevent a fire Explanation: Oxygen, which constitutes 20% of normal air, is a tasteless, odorless, colorless gas. It supports combustion, and it is critical to provide safety measures to prevent fires and injury.

why are crackles normal breath sounds of an infant?

they are harsh crackles at the end of deep inspiration

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 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.

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. a) The power of the respiratory and abdominal muscles is reduced in older adults, and therefore the diaphragm moves less efficiently. b) Blood pressure increases over time until it reaches the adult level around age 8. c) Alterations in respiratory function due to aging in older adults increase the risk for disease, especially pneumonia and other chest infections. d) The respiratory rate is more rapid in infants until the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates. e) The normal infant's chest is small and the airways are short, making aspiration a potential problem. f) The chest in the older adult is unable to stretch as much, resulting in an increase in maximum inspiration and expiration.

• The power of the respiratory and abdominal muscles is reduced in older adults, and therefore the diaphragm moves less efficiently. • The normal infant's chest is small and the airways are short, making aspiration a potential problem. • Alterations in respiratory function due to aging in older adults increase the risk for disease, especially pneumonia and other chest infections. • The respiratory rate is more rapid in infants until the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates. Explanation: Muscles tend to lose strength in older adults, causing the diaphragm to be less efficient. Infants are at an increased risk for aspiration during feedings because of the small size of the chest and length of the airway. The chest and lungs lose elasticity as a person ages, increasing the potential for infections of the respiratory tract. There is a decreased number and size of alveoli in the infant, causing the respiratory rate to be higher in an attempt to adequately exchange oxygen and carbon dioxide. Blood pressure reaches the adult level during the preteen to teen years. A decrease in maximum inspiration and expiration occurs in the older adult because of decreased elasticity

A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response?

"Have you tried nasal strips?"

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."

"Wounds heal because HBOT helps to regenerate new tissue quickly."

The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal?

30 to 55 breaths per minute

A nurse is performing CPR on a patient who is in cardiac arrest. What action would the nurse perform second?

Activate the emergency response system.

The nurse is assessing the respiratory rates of patients in a community health care facility. Which patient exhibits an abnormal value?

An infant with a respiratory rate of 20 bpm

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 teaching an adolescent with asthma how to use a meter-dosed inhaler. Which teaching point follows recommended guidelines?

Be sure to shake the canister before using it.

Which of the following dietary guidelines would be appropriate for the elderly 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

The nurse is conducting a respiratory assessment of a 71-year-old patient who has been recently admitted to the hospital unit. Which of the following assessment findings should the nurse interpret as abnormal?

Fine crackles to the bases of the lungs bilaterally

A physician has ordered an arterial blood gas test for a client with a respiratory disorder. What is the most common role of the nurse in performing the arterial blood gas test?

Implement measures to prevent complications after arterial puncture.

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 technique?

Monitor the amount of oxygen saturation in the blood

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 patient vomits as a nurse is inserting his oropharyngeal airway. What would be the appropriate intervention in this situation?

Remove the airway, turn the patient to the side and provide mouth suction, if necessary.

The nurse schedules a pulmonary function test to measure the amount of air left in a patient'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 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.

Which of the following is a recommended guideline 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.

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, whereas bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

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 The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the amount 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

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?

distilled water

A nurse uses an oxygen analyzer to measure the percentage of oxygen delivered to a client. When checking the percentage of oxygen in the room air, what should the reading of the analyzer be if there is a normal mixture of oxygen and other gases in the environment?

0.21

The nurse caring for a client on the medical-surgical unit collects the following data during head-to-toe assessment; mid-sternal chest pain, nausea, and pulse oximetry (SpO2) of 86%. The nurse would next implement which priority nursing intervention for this client who is experiencing these symptoms?

Administer oxygen

Assess oxygen tubing connection

Upon auscultation of the patient'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

The nurse is caring for a client who is diagnosed with an impaired gas exchange. While performing a physical assessment of the client, which of the following data is the nurse likely to find, keeping in mind the client's diagnosis?

High respiratory rate

When caring for a patient with a tracheotomy, the nurse would perform which recommended action?

Suction the tracheostomy tube using sterile technique.

What is the action of codeine when used to treat a cough?

Suppressant

The nurse is preparing to perform nasopharyngeal suctioning on an adult using a wall unit. What is the appropriate suction pressure setting for an adult?

100 to 120 mm Hg

The nurse is caring for a client with a dysrhythmia with a prescription for oxygen therapy. The client is concerned and asks the nurse, ?Why am I getting oxygen when I came in with a heart problem?" What appropriate response would the nurse give this client?

?The dysrhythmia interferes with the heart?s circulation, leading to changes in oxygenation.?

Abu bag If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag)may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube.

Arterial blood gas

The nurse is teaching a patient the proper use of inhaled medications. What are appropriate teaching points to include? (Select all that apply.)

Bronchodilators are used to liquefy or loosen thick secretions or reduce inflammation in airways. DPIs are actuated by the patient's inspiration, so there is no need to coordinate the delivery of puffs with inhalation. Metered-dose inhalers deliver a controlled dose of medications with each compression of the canister.

Deep breathing

Document the finding. Constant bubbling in the suction control chamber is normal and should be documented. Other actions are inappropriate.

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.

The nurse assesses a patient 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 caring for older adults in a nursing home. Which age-related changes may affect the respiratory functioning of the clients living there? Select all that apply.

Less air exchange, more secretions in lungs. Greater risk for aspiration due to slower gastric motility

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?

Nasal cannula Nasal cannula and tubing administers oxygen concentrations at 22% to 44%.

You are caring for a patient who has spontaneous respirations and needs to have oxygen administer at a FIO2 of 100%. Which of the following oxygen deliver systems should the nurse utilize?

Nonrebreather mask

While examining a client, the nurse palpates the client's chest and back. Which of the following would the nurse expect to identify with this technique?

Pattern of thoracic expansion

Pleural effusion

Pleural effusion 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 and pneumonia would necessitate the procedure only if the infection resulted in pleural effusion

A nurse is assigned to care for a client admitted to the healthcare facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of which of the following?

Pneumonia

A patient returns to the telemetry unit after an operative procedure. Which of the following diagnostic tests will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the patient?

Pulse oximetry

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

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

A patient with no prior history of respiratory illness has been admitted to a postsurgical 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?

Teaching the patient to use incentive spirometry

When inspecting a patient's chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression.

The power of the respiratory and abdominal muscles is reduced in older adults, and therefore the diaphragm moves less efficiently. The normal infant's chest is small and the airways are short, making aspiration a potential problem. Alterations in respiratory function due to aging in older adults increase the risk for disease, especially pneumonia and other chest infections. The respiratory rate is more rapid in infants until the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates.

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?

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.

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

True

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

True After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A nurse caring for a client with a chest tube should monitor the patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.

Which of the following describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway?

When holding the airway on the side of the patient's face, it should reach from the tragus of the ear to the nostril plus 1 inch.

Wounds heal because HBOT helps to regenerate new tissue quickly.

The nurse assessing a patient with COPD suspects chronic hypoxia due to which of the following assessment findings?

clubbing of toes constipation

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.

hypoxia

The nurse educator is presenting a lecture on emphysema with the aid of balloons. Which responses, if given by the nursing staff, would indicate to the educator that further teaching is needed? Select all that apply

• "Respirations of the client with emphysema can be compared to a balloon that has been blown up before." • "Emphysema, like a new balloon, takes less effort to empty air out of the alveoli." The lungs in a client with emphysema are stiff and noncompliant. The lungs (alveoli) are compared to a new balloon that takes more effort to blow up and release air out. As in emphysema, a new balloon takes extra effort to blow up; the client with emphysema has to exert more effort to breathe in and out, leading to shortness of breath. The new balloon is difficult to expand, representing decreased elasticity leading to decreased compliance.

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?

The nurse is assessing an elderly client brought to the emergency department by her spouse. The spouse states, ?She is confused and had trouble when trying to take a breath.? The nurse would next implement which priority nursing intervention for this client who is experiencing these symptoms?

Obtain baseline vital signs and oxygen saturation

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?

Pulse oximetry

A 57-year-old patient is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the patient has been unwilling to mobilize despite the nurse's teaching about the benefits of early mobilization following surgery. The nurse would recognize that the patient's prolonged immobility creates a risk for:

atelectasis.

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as:

crackles.

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

Prep U: Chapter 39 Oxygenation and Perfusion

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