Prep U Chapter 39: Oxygenation and Perfusion
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? -Chest x-ray -Bronchoscopy -Skin tests -Pulmonary function tests
Pulmonary function tests. Explanation: Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.
The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider? -An infant with a respiratory rate of 16 bpm -A 4-year-old with a respiratory rate of 32 bpm -A 12-year-old with a respiratory rate of 20 bpm -A 70-year-old with a respiratory rate of 18 bpm
-An infant with a respiratory rate of 16 bpm Explanation The infant's normal respiratory rate is 20 to 40 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 32 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.
The client is reporting to the nurse that the continuous positive airway pressure (CPAP) mask is torture. What is the best response from the nurse? -Tell me more about why it bothers you. -Would you like to talk to your health care provider concerning this? -Can you explain to me what settings you are using? -Perhaps we need to change you to a different type of mask.
-Tell me more about why it bothers you. Explanation: First, the nurse should find out what is bothering or most concerning to the client. Then, the nurse will have a better idea of the best next step, which can include the other responses. It is possible this client will do better with a bilevel positive airway pressure (BiPAP) machine instead of a CPAP machine.
An adult client is discharged to home with a prescription for oxygen at 2 L/min. Which method of oxygen delivery should the nurse use in this situation? -nasal cannula -oxygen mask -oxygen hood -oxygen tent
-nasal cannula Explanation: A nasal cannula is commonly used because it does not impede eating or speaking and is easily used in the home. A mask is used when a client requires a higher concentration of oxygen than a nasal cannula can deliver or if the client is a mouth breather. Oxygen hoods and tents are generally used to deliver oxygen to infants and children.
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? -"It is important to eat at least five servings of vegetables daily." -"Remove your oxygen before cooking near the gas stove." -"An electric stove may be a safer choice for you." -"Be careful not to trip over your oxygen tubing while cooking."
"An electric stove may be a safer choice for you." Explanation: For safety purposes, oxygen tanks should be kept at least 10 feet away from gas stoves, fires, and other flammable devices. If the client removes the oxygen while cooking at a gas stove, hypoxia may occur and the client may become confused and sustain burns.
The nurse is teaching the client with a pulmonary disorder about 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 encourages you to sit up straighter to increase expansion of the lungs during inhalation." -"Breathing through your nose first will warm, filter, and humidify the air you are breathing." -"If you breathe through the mouth first, you will swallow germs into your stomach." -"We are concerned about you developing a snoring habit, so we encourage nasal breathing first."
"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 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 70 mL and heart rate is 70 beats per minute, then the cardiac output is 4.7 L/minute." -"If the client's stroke volume is 80 mL and heart rate is 80 beats per minute, then the cardiac output is 6.0 L/minute." -"If the client's stroke volume is 60 mL and heart rate is 60 beats per minute, then the cardiac output is 3.2 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."
"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 stroke volume is 60 and heart rate is 60 beats per minute, then the cardiac output is 3.6 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 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? -"Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." -"Take in a small amount of air very quickly and then exhale as quickly as possible." -"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." -"Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling."
"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.
An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize? -"Did you remove your dentures?" -"Is your mask causing discomfort?" -"Did someone take your mask off?" -"Did someone loosen the straps on your mask?"
"Is your mask causing discomfort?" Explanation: It is possible for anyone using a mask to try and readjust it if it is uncomfortable. Depending on the older adult's cognitive status, he or she may have tried to make it more comfortable and in the process caused it to no longer fit correctly. This could also occur if the client removed their dentures, as some individual's choose to let the dentures soak overnight. If the mask was fitted with the dentures in, the mask will likely be loose with the dentures removed. The other questions could possibly be asked to see if someone else may have tried to help the client feel more comfortable with the mask on.
An older adult client was recently placed on home oxygen. The client's caregiver reports that the client now refuses to leave the house. What teaching will the nurse provide the caregiver? Select all that apply.
-"Discuss with the client switching to a portable oxygen device." -"Continued socialization with others is important." -"Invite friends and family to the client's house." Explanation: Socialization is important for older adults. Having a portable oxygen device increases functional mobility. Inviting friends and family provides socialization and may help the client feel more at ease with oxygen use. The nurse should not suggest that the caregiver ignore the issue or remove the oxygen are inappropriate; these are inappropriate actions.
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." -"This is only an option if you live in a long-term care facility."
-"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." Explanation: An oxygen concentrator collects and concentrates oxygen from room air. It eliminates the need for a central reservoir of pipe oxygen and it is an economical choice. It may increase the client's electric bill. These can be used in homes, not long-term care facilities.
The nurse is administering oxygen to an older adult client who has been assessed to have increased work of breathing. If the intervention has been effective, what finding(s) will the nurse expect on the evaluation of the client? Select all that apply. -Respiratory rate is 33 breaths/min at rest. -Heart rate is 64 beats/min. -Oxygen saturation reads 88% on 5L of oxygen. -Mucous membranes are pink and moist. -The client is able to state the date, time, and location.
-Heart rate is 64 beats/min. -Mucous membranes are pink and moist. -The client is able to state the date, time, and location. Explanation: A normal resting heart rate indicates a tolerable work of breathing. When in respiratory distress, clients will also experience tachycardia or a heart rate higher than 100 beats/min. Skin color and mucous membranes are other indicators of the client's oxygenation status. When hypoxic, a client will present as pale-skinned, sometimes with bluish-ness around the mouth called cyanosis. Mucous membranes can also appear pale or blanched due to poor circulation. A client with normal work of breathing will have pink and moist mucous membranes. The level of consciousness is another indicator of normal oxygenation. If the client is oriented to day, time, and place, the client has an intact level of consciousness, a sign of normal oxygenation. A respiratory rate of 33 breaths/min indicates tachypnea related to increased work of breathing. This is a sign of hypoxia. The nurse will oxygenate the client with an aim to bring the client's oxygen saturation above 90%, to ease the work of breathing. Oxygen saturation of 88% with oxygen supplementation is too low and the nurse will need to re-evaluate the effectiveness of the intervention.
A nurse is overseeing the care of a client who is receiving oxygen via nasal cannula. Which aspects of the client's care can the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply. -uscultating the client's lungs to determine the effectiveness of treatment -Measuring the client's respiratory rate -Inserting the client's nasal cannula after it has become dislodged -Increasing the flow rate of the client's oxygen when the client is short of breath -Reapplying the client's nasal cannula after a bath
-Measuring the client's respiratory rate -Inserting the client's nasal cannula after it has become dislodged -Reapplying the client's nasal cannula after a bath Explanation: Reapplication of the nasal cannula during nursing care activities, such as during bathing, may be performed by UAP. UAP may measure a client's respiratory rate in the context of measuring the client's vital signs. Chest auscultation and changes to oxygen delivery are beyond the scope of UAP.
The nurse is obtaining a pulse oximetry reading for a client admitted with exacerbation of chronic obstructive pulmonary disease (COPD). When observing a reading of 89%, what action should the nurse perform? -No action is required, because this may be normal for the client -The nurse should prepare intubation equipment for the health care provider -Administer oxygen at 6 L/m by nasal cannula -Have the client breath into a paper bag
-No action is required, because this may be normal for the client Explanation: For clients with chronic lung disease, a level of 88%-92% may be considered within normal limits and there is no further action for the nurse to take. There is no indication that intubation is needed. Administering oxygen at levels too high may diminish the client's stimulus to breathe, because a higher CO2 level is tolerated. Breathing into a paper bag would elevate the level of carbon dioxide and would be dangerous for this client.
The nurse provides care for the client with asthma reporting shortness of breath. Which action(s) does the nurse take to promote client comfort and decrease anxiety? Select all that apply.
-Plan for periods of rest between activities -Instruct on effective breathing as needed -Assess the relationship of inspiration to expiration -Assess the client's level of anxiety and possible causes -Encourage relaxation activities such as music and reading Explanation: Because exacerbation of asthma can be triggered by stress the primary nursing interventions involve decreasing client stress and increasing client relaxation. Interventions include assessing the client's level of anxiety because it may result from the struggle of not being able to breathe properly, planning for periods of rest between activities because fatigue is common with the increased work of breathing from the ineffective breathing pattern and activity increases metabolic rate and oxygen requirements, and instruction for effective breathing if needed. In addition, the nurse assesses the relationship of inspiration to expiration because reactive airways allow air to move into the lungs more easily than out of the lungs and encourages relaxation activities such as music and reading to decrease anxiety, increase comfort, and promote relaxation. While the client is having shortness of breath is not the appropriate time to encourage exercise to reduce anxiety and stress.
The nurse is caring for a client at risk for pneumonia after having major abdominal surgery. Which nursing instruction(s) is essential for the use of an incentive spirometer? Select all that apply.
-Splint the abdomen with a pillow to decrease discomfort prior to use. -Instruct the client to exhale normally and then place -lips securely around the mouthpiece. -Encourage the client to complete breathing exercises about 5 to 10 times every 1 to 2 hours, if possible. -Assist the client to an upright or semi-Fowler position. Explanation: Pain medication may be required prior to using a spirometer so that the client will be able to adequately perform the exercise. Another comfort measure that may be used is to place a folded blanket or pillow across the abdomen to create a splint while using the spirometer. The client should not breathe through the nose when using the spirometer. Place the client in an upright or semi-Fowler position to promote optimal gas exchange. The client should use the incentive spirometer 5 to 10 times every 1 to 2 hours for optimal results. Be sure that the client is instructed to exhale normally and place lips securely around the mouthpiece to obtain an airtight seal.
A client has been receiving treatment with a nonrebreather mask for the past 96 hours. How should the nurse respond if the unlicensed assistive personnel (UAP) suddenly reports the client has vomited? -conduct a focused assessment -replace current mask with a new one -notify the health care provider -put client on NPO status
-conduct a focused assessment Explanation: The nurse should first conduct a focused assessment to gather more information. Individuals who have been receiving oxygen concentrations of more than 50% for longer than 72 hours are at an increased risk for oxygen toxicity. The signs are subtle and include nausea, vomiting, nonproductive cough, substernal chest pain, nasal stuffiness, fatigue, headache, sore throat and hypoventilation. After the nurse has finished assessing the client, then the health care provider should be notified of the findings of the assessment. The mask would need to be cleaned or replaced per the facilities policy. The client may already be on NPO status.
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? -tap water -normal saline -distilled water -mineral oil
-distilled water Explanation: Distilled water is used when humidification is desired. Other answers are incorrect.
The nurse has received a prescription to obtain an arterial blood gas (ABG) on a client who has a history of chronic obstructive pulmonary disease (COPD) and is receiving oxygen via nasal cannula. Which step is the most important for the nurse to fulfill? -ensure client is at rest at least 30 minutes before obtaining the specimen -notify laboratory personnel of the prescription -place the specimen in cold water after filling the tube -apply pressure to the puncture site for at least 15 minutes after the puncture
-ensure client is at rest at least 30 minutes before obtaining the specimen Explanation: Unless the procedure is an emergency, it is advisable for the client to be at rest at least 30 minutes prior to obtaining the specimen. The ABG represents the client status at the moment of sampling and activity can lower oxygen levels in the blood, which can lead to an incorrect interpretation of the results. Some facilities require laboratory personnel to obtain this sample which would require the nurse to notify the lab; however, with the current use of computers, they may already know and not need to be contacted. The specimen tube should be placed on ice for transport to the laboratory to help preserve the specimen as it slows metabolism and helps ensure accurate results. Manual pressure should be applied for 5 to 10 minutes after the puncture and followed with a pressure dressing to reduce the potential of arterial bleeding.
To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position? -left side with a pillow under the chest wall -side-lying position, half on the abdomen and half on the side -high-Fowler's position -Trendelenburg position
-high-Fowler's position Explanation: Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. High-Fowler's position is used to drain the apical sections of the upper lobes of the lungs. Placing the client lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.
When reviewing data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom? -rapid respirations -weight loss -increased urine output -strong, rapid pulse
-rapid respirations Explanation: Normal cardiac output averages from 3.5 to 8.0 liter/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 the respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display a thready pulse.
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 -reads 0.25 when checking oxygen in room air -reads 0.19 when positioned near oxygen device -reads 0.20 when positioned near oxygen device
-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).
A nurse is caring for a 3-year-old child that was admitted with pneumonia. The parent expresses concerns about the child's respirations. The nurse is providing education about respiratory-related developmental changes to help the parent differentiate what is normal from what is abnormal.
-respiratory rate of 28/min NORMAL -thoracic breathing ABNORMAL -inspiration longer than expiration ABNORMAL -irregular respiratory pattern NORMAL -round thoraxABNORMAL
A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving? -23% -28% -32% -47%
32% Explanation: A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44%
A nurse is preparing to use a wall unit to suction the endotracheal tube of a 9-year-old child. At what pressure should the suction be set? -60 to 80 mm Hg -80 to 125 mm Hg -100 to 130 mm Hg -100 to 150 mm Hg
80 to 125 mm Hg. Explanation: For a wall unit for an adult: 100 to 150 mm Hg; neonates: 60 to 80 mm Hg; infants: 80 to 125 mm Hg; children: 80 to 125 mm Hg; adolescents: 80 to 150 mm Hg.
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? -Hematocrit values -Hemoglobin levels -Pulmonary function -Arterial blood gas
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? -Atelectasis -Bronchitis -Bronchiectasis -Croup
Bronchitis. Explanation: Bronchitis refers to a condition in which the airways become inflamed, commonly due to respiratory irritants such as air pollution and high humidity. Exposure to such irritants leads to the release of inflammatory mediators, which in turn, lead to inflammation and narrowing of the airways and increased mucus production. Atelectasis refers to the partial or complete collapse of the small air sacs in the lungs, common after surgery or with obstruction or compression of the airways or lungs. Bronchiectasis results from chronic inflammation or infection causing an excess accumulation of mucus. Croup is an infection of the airways, most commonly viral in origin.
The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate? -Check the fit of the oxygen mask. -Increase the flow of oxygen. -Contact the oxygen supplier to request an oxygen tent. -Discontinue oxygen therapy until the client is reassessed by the healthcare provider.
Check the fit of the oxygen mask. Explanation: 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.
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? -It prescribes oxygen concentration. -It regulates the amount of oxygen received. -It determines whether the client is getting enough oxygen. -It decreases dry mucous membranes via delivering small water droplets.
It determines whether the client is getting enough oxygen. Explanation: 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 provider prescribes concentration. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.
A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs? -Nasal cannula -Simple mask -Partial rebreather mask -Nonrebreather mask
Nasal cannula Explanation: A nasal cannula is used to deliver from 1 L/min to 6 L/min of oxygen. Masks are used with higher flow rates of oxygen.
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 Explanation: 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 guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? -Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. -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. -Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. -For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.
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. Explanation: Guidelines to determine suction catheter depth include the following: 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 past the length of the endotracheal tube. Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Using a spare endotracheal or tracheostomy tube of the same size as being used for the client, insert the suction catheter to the end of the tube and note the length of catheter used to reach the end of the tube. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm.
During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting? -Crackles -Bronchovesicular -Bronchial -Vesicular
Vesicular. 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. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.
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. -bronchitis. -bronchiectasis. -bronchiolitis.
a bronchospasm. Explanation: 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 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: -dyspnea. -apnea. -orthopnea. -hypercapnia.
apnea. Explanation: The newborn's breathing pattern is characterized by occasional pauses of several seconds between breaths. This periodic breathing is normal during the first 3 months of life, but frequent or prolonged periods of apnea (cessation of breathing 20 seconds or longer) are abnormal. Dyspnea refers to shortness of breath. Orthopnea refers to difficulty breathing when lying flat. An elevation of carbon dioxide levels in the blood is termed hypercapnia.
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: -atelectasis. -pneumothorax. -hemothorax. -tachypnea.
atelectasis. Explanation: Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize atelectasis. Immobility is not commonly implicated in cases of pneumothorax or hemothorax. A pneumothorax is a collapsed lung. Hemothorax is a collection of blood in the space between the chest wall and the lung. Tachypnea, if present, would likely be a sign of atelectasis rather than an independent finding.
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: -crackles. -vesicular. -wheezes. -bronchovesicular.
crackles. Explanation: Crackles, frequently heard on inspiration, are soft, high-pitched discontinuous (intermittent) popping sounds. Wheezes are continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors. Vesicular sounds are low-pitched, soft sounds heard over peripheral lung fields. Bronchovesicular sounds are medium-pitched blowing sounds heard over the major bronchi.
The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather? -face tent -simple mask -nasal cannula -tracheostomy collar
face tent. A face tent is used without a mask; it is open and loose around the face and is often used for patients with facial trauma or burns. A simple mask or nasal cannula would irritate the facial skin. The client does not have a tracheostomy.
During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? -flow meter -oxygen analyzer -humidifier -nasal cannula
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 because 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.
To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position? -left side with a pillow under the chest wall -side-lying position, half on the abdomen and half on the side -high-Fowler's position -Trendelenburg position
high-Fowler's position Explanation: Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. High-Fowler's position is used to drain the apical sections of the upper lobes of the lungs. Placing the client lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.
When reviewing data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom? -rapid respirations -weight loss -increased urine output -strong, rapid pulse
rapid respirations. Explanation: Normal cardiac output averages from 3.5 to 8.0 liter/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 the respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display a thready pulse.
The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? -simple mask -tracheostomy collar -nasal cannula -face tent
tracheostomy collar Explanation: A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. All other devices are less appropriate for this client.
When caring for a client with a tracheostomy, the nurse would perform which recommended action? - Clean the wound around the tube and inner cannula at least every 24 hours. -Assess a newly inserted tracheostomy every 3 to 4 hours. -Use gauze dressings over the tracheostomy that are filled with cotton. -Suction the tracheostomy tube using sterile technique.
Suction the tracheostomy tube using sterile technique. Explanation: Sterile technique is required when suctioning a tracheostomy in order to prevent introduction of microorganisms into the respiratory tract. The area around a new tracheostomy may need to be assessed and cleaned every 1 to 2 hours. Gauze dressings that are not filled with cotton must be used to prevent aspiration of lint or cotton fibers into the trachea.
A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate: -adequate tissue perfusion. -diminished stroke volume. -high cardiac output. -heart failure.
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.
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 will require additional testing to determine the cause." -"He is using his chest muscles to help him breathe." -"His infection is causing him to breathe harder." -"His lung muscles are swollen so he is using abdominal muscles."
-"He is using his chest muscles to help him breathe." Explanation: The client will use accessory muscles to ease dyspnea and improve breathing.
A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving? -23% -28% -32% -47%
-32% Explanation: A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44%
Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue? -Antibiotics -Bronchodilators -Expectorants -Corticosteroids
-Corticosteroids Explanation: In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation.
A 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 use? -nonrebreather mask -Venturi mask -nasal cannula -simple mask
-nonrebreather mask Explanation: A nonrebreather mask is the only device that can deliver an 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%.
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: -atelectasis. -pulmonary fibrosis. -asthma. -croup.
Croup Explanation: 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's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function? -Pleural effusion -Tachypnea -Wheezes -Pneumonia
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. Pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.
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 -Anemia -Malnutrition -Poor tissue perfusion -Congestive heart failure
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.
The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order? -Tidal volume (TV) -Total lung capacity (TLC) -Forced Expiratory Volume (FEV) -Residual Volume (RV)
Residual Volume (RV) 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.
The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care? -Stay indoors as much as possible. -Cut down on smoking. -Avoid exposure to large crowds. -Practice good hand hygiene.
Stay indoors as much as possible. Explanation: Using the air quality index, a red color designation signifies that the air quality is unhealthy for all people, not just sensitive groups. Air pollution and high humidity are respiratory irritants. Pollutants cause increased mucus production and contribute to bronchitis and asthma. Reducing contact with irritants by staying indoors during times of increased air pollution will decrease their effect on the respiratory system. Clients should be encouraged to quit smoking, not just cut down. Avoiding large crowds and practicing good hand hygiene will prevent respiratory infections but not cut down on the effect of air pollution.
A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action? -Warm the client's hands and try again. -Place the probe on the client's earlobe. -Shine available light on the equipment to facilitate accurate reading. -Use a blood pressure cuff to increase circulation to the site.
Warm the client's hands and try again. Explanation: Finding an absent or weak signal, the nurse should check vital signs and client condition. If satisfactory, warming the extremity may facilitate a stronger reading. This should be attempted prior to resorting to using the client's earlobe. Bright light can interfere with the operation of light sensors and cause an unreliable report. A blood pressure cuff will compromise venous blood flow to the site leading to inaccurate readings.
The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document? -Stridor -Crackles -Wheezing -Absent breath sounds in lower lobes
Wheezing Explanation: The nurse expects to document wheezing in the lungs of a client with asthma, which would be more pronounced when the client has a respiratory infection. Wheezing is a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration. Wheezing is caused by air passing through constricted passages caused by swelling or secretions. Stridor and crackles are other abnormal breath sounds caused by fluid, infection, or inflammation in the lungs. Absent breath sounds are not normally found in asthmatic clients; they are characteristic of pneumonia.
In which client would the nurse assess for a depressed respiratory system? -a client taking amlodipine for hypertension -a client taking antibiotics for a urinary tract infection -a client taking insulin for diabetes -a client taking opioids for cancer pain
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. Amlodipine is a calcium channel blocker and the medication decreased blood pressure, so the nurse would need to assess blood pressure. Antibiotics are used for urinary tract infections as well as other infections and the infections do not affect the respiratory system. Insulin decreases blood sugar which a person with diabetes may need to take every day. Insulin does not affect the respiratory system.
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? -Encourage the client to take deep breaths. -Instruct the client in the use of pursed-lip breathing technique. -Inform the client about nasal strips. -Teach the client diaphragmatic breathing.
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. A nasal strip reduces airflow resistance by widening the nasal-breathing passageways, thus promoting easier breathing. It is used for reducing or eliminating snoring.
The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse would cause the charge nurse to intervene? -The newly hired nurse adjusts the bed to a comfortable working -position. -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. -The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). -The newly hired nurse assesses the client's pain and administers pain medication.
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), but not in an acute instance. Adjusting the bed to a comfortable working position prevents back and muscle strain. Explanation alleviates fears; even if the client appears unconscious, the nurse should explain what is happening. When tracheostomy is new, pain medication may be needed before performing tracheostomy care.
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? -simple mask -nasal cannula -face tent -nonrebreather 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 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. Nonrebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.
A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of: -croup. -asthma. -alcohol use. -pneumonia.
pneumonia. 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. Croup, asthma, and alcohol use do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol use depresses the central respiratory center.
The home health nurse is visiting a new client who has recently started using an oxygen concentrator. After assessing the home environment, which comment should the nurse prioritize?
-"Have you discussed a back-up system with your health care provider in case your electricity goes out?" Explanation: The concentrator depends on electricity to work correctly, so each client should have a backup system in case the electricity goes out to ensure he or she will still be able to obtain the oxygen level needed. Some of the newer models are now using the DC outlets found in motor vehicles and have rechargeable batteries; however, the client should still have a backup plan. The questions could be asked during the assessment; however, asking about a backup system is the priority.
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? -Chest x-ray -Bronchoscopy -Skin tests -Pulmonary function tests
-Pulmonary function tests Explanation: Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.
During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting? -Crackles -Bronchovesicular -Bronchial -Vesicular
-Vesicular 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. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.
A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action? -Encourage the client to do deep-breathing exercises. -Raise the head of the client's bed slightly, if tolerated. -Review the medications that the client has taken in the past 90 minutes. -Document this expected assessment finding.
Document this expected assessment finding. Explanation: A range of 95% to 100% is considered normal oxygen saturation. As such, there is no need to change the client's position, encourage deep-breathing exercises and coughing, or to review the client's medication history.
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? -Hyperventilation -Hypoxia -Perfusion -Atelectasis
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.
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? -Remove the airway, turn the client to the side, and provide mouth suction, if necessary. -Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. -Leave the airway in place and promptly notify the health care provider for further instructions. -Suction the client's mouth through the oropharyngeal airway to prevent aspiration.
Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Explanation: If the client vomits as the oropharyngeal airway is inserted, quickly position the client onto his or her side to prevent aspiration, remove the oral airway, and suction the mouth, if needed. It would be inappropriate and unsafe to leave the airway in place. Rinsing the client's mouth with water is not a priority.
A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client? -Oxygen mask -Nasal cannula -Ambu bag -Oxygen tent
Ambu bag Explanation: If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Oxygen masks may cover only the nose and mouth and can vary in the amount of oxygen delivered. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostril. An oxygen tent is a tentlike enclosure within which the air supply can be enriched with oxygen to aid a client's breathing. Oxygen masks, nasal cannula, and oxygen tents are used for clients who have a respiratory drive.
A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first? -Assist with intubation -Apply oxygen as prescribed -Educate client on incentive spirometry -Raise the head of the bed
Apply oxygen as prescribed. Explanation: The nurse should first apply oxygen, which will help to improve oxygen saturation and health status. The client may not require intubation, once oxygen is provided. Although the client may require education on incentive spirometry, the immediate priority intervention is to stabilize the client's oxygen saturation. Similarly, raising the head of the bed may help with the client's comfort but may not have sufficient effect on oxygen saturation.
The nurse must obtain a blood specimen for blood gas analysis. What is the most important thing for the nurse to do immediately after the needle has been removed? -Place an adhesive bandage over the puncture site and instruct the client to leave it on for 30 minutes. -Label the blood specimen with the client's correct demographic information. -Apply steady, firm pressure on the puncture site for 5 to 15 minutes. Instruct the client to elevate the arm over the head for 10 minutes.
Apply steady, firm pressure on the puncture site for 5 to 15 minutes. Explanation: Because the artery has been punctured, there is an increased risk for puncture site bleeding compared to venous blood draws. The nurse should apply steady, firm pressure on the puncture site for 5 to 15 minutes or until bleeding has completely stopped. An adhesive bandage should not be placed before bleeding is stopped. The blood specimen should be properly labeled; however, the priority for the nurse would be to ensure bleeding from the puncture site has stopped. Pressure should be applied prior to any extremity elevation.
Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue? -Antibiotics -Bronchodilators -Expectorants -Corticosteroids
Corticosteroids. Explanation: In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation.
A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen? -Place the client in the dorsal recumbent position to collect the specimen. -Have the client clear the nose and throat and gargle with salt water before beginning the procedure. -Instruct the client to inhale deeply and then cough. -Discard the first sputum produced by the client
Instruct the client to inhale deeply and then cough. Explanation: The client should be instructed to inhale deeply and cough; if this results in sputum, it should be collected in the container. The client should be placed in a semi-Fowler's position and instructed to clear the nose and throat and rinse the throat with water.
When caring for a client with a tracheostomy, the nurse would perform which recommended action? -Clean the wound around the tube and inner cannula at least every 24 hours. -Assess a newly inserted tracheostomy every 3 to 4 hours. -Use gauze dressings over the tracheostomy that are filled with cotton. -Suction the tracheostomy tube using sterile technique.
Suction the tracheostomy tube using sterile technique. Explanation: Sterile technique is required when suctioning a tracheostomy in order to prevent introduction of microorganisms into the respiratory tract. The area around a new tracheostomy may need to be assessed and cleaned every 1 to 2 hours. Gauze dressings that are not filled with cotton must be used to prevent aspiration of lint or cotton fibers into the trachea.
When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding? -The contour of the intercostal spaces should be rounded. -The skin at the thorax should be cool and moist. -The anteroposterior diameter should be greater than the transverse diameter. -The chest should be slightly convex with no sternal depression.
The chest should be slightly convex with no sternal depression. Explanation: The adult chest contour is slightly convex, with no sternal depression. The skin of the thorax should be warm and dry, and the anteroposterior diameter of the chest should be less than the transverse diameter. The contour of the intercostal spaces should be flat or depressed.
A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate? -The client's available hemoglobin is adequately saturated with oxygen. -The client's oxygen demands are being met. -The client's red blood cell (RBC) count is in the normal range. -The client's respiratory rate is in the normal range.
The client's available hemoglobin is adequately saturated with oxygen. Explanation: Pulse oximetry is a noninvasive technique that measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial blood. This test measures only the percentage of oxygen carried by the available hemoglobin. Thus, even a client with a low hemoglobin level could appear to have a normal SpO2 because most of that hemoglobin is saturated. However, the client may not have enough oxygen to meet body needs. A normal pulse oximetry reading does not necessarily indicate a normal RBC count or heart rate.
The nurse is caring for a client who is receiving continuous oxygen at 3 L/minute via nasal cannula. The client's oxygen saturation has consistently been 94% to 96%, but suddenly drops to 86% as the nurse palpates the client's abdomen. The client denies respiratory difficulty or other distress. What is a likely reason for the client's decreasing oxygen saturation? -The nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen. -The client is holding his or her breath. -The client's appendix has ruptured. -The client has developed a pulmonary embolism and has a ventilation-perfusion mismatch.
The nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen. Explanation: A sudden drop in oxygen saturation without clinical signs or symptoms may be caused by disruption of oxygen flow. The information in the question does not support a pulmonary embolism, the client holding his or her breath, or an appendix rupturing.
Oxygen and carbon dioxide move between the alveoli and the blood by: -osmosis. -hyperosmolar pressure. -diffusion. -negative pressure.
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.
