Test 5 111

A nasal cannula is used to deliver from _____ L/min to _____L/min of oxygen.

1-6

normal respiratory rate for older adults

16-24

normal respiratory rate for late child hood

18-26

Ejection fraction is usually around

55-65%

attempting to take last breaths, death is imminent

Agonal

high pitched, loud sounds heard primarily over the trachea and larynx

Bronchial

medium-pitched blowing sounds heard over the major bronchi

Bronchovesicular

What does pulse oximetry measure? A) cardiac output B) peripheral blood flow C) arterial oxygen saturation D) venous oxygen saturation

C) arterial oxygen saturation

A patient has had a tracheostomy and the nurse is prepared to conduct tracheostomy care. What part of the tracheostomy tube is removed for cleaning? A) obturator B) outer cannula C) inner cannula D) cuff

C) inner cannula

formula for cardiac output

CO = HR x SV

central chemoreceptors, located in the base of the brain, measures the amount of ____________ to adjust breathing rates

CO2 in the blood

the amount of blood pumped in one minute is called

Cardiac output

chemical sensors in the brain, blood vessels, muscles, and lungs that identify changing levels of oxygen and carbon dioxide

Chemoreceptors

end of life, near death breathing pattern, increase and decrease followed by periods of apnea

Cheyne-stokes

The ability of muscle fibers to shorten during contraction is called

Contractility

What can a nurse ask a patient to do before suctioning to prevent hypoxemia? A) Sit in an upright position and cough. B) Breathe normally for at least 5 minutes. C) Lie flat in bed and practice relaxation. D) Take several deep breaths.

D) Take several deep breaths.

A nurse is caring for older adults in a nursing home. Which of the following age-related changes may affect the respiratory functioning of the patients living there? Select all that apply. A) increased elastic recoil of the lungs B) less fibrous tissue in alveoli C) increase in vital capacity and residual volume D) less air exchange, more secretions in lungs E) greater risk for aspiration due to slower gastric motility F) impaired mobility and inactivity, effects of medication

D) less air exchange, more secretions in lungs E) greater risk for aspiration due to slower gastric motility F) impaired mobility and inactivity, effects of medication

The amount of blood in the ventricles before contraction is called

Preload

S2 "DUB" is the closure of which valves

Pulmonic and aortic (leads to lungs/body)

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)

S wave represents

Right ventricle contraction- pulmonary valve to lungs

Which occurs simultaneously with the pulse, S1 or S2

S1

which is higher in pitch and shorter than the other, S1 or S2

S2 (dub)

An abnormal sound occurring after S2 is called

S3 , Ventricular gallop

What abnormal sound is heard when blood attempts to enter a stiff ventricle during atrial contraction

S4, atrial gallop

The nurse provides care for a client with chronic bronchitis and a decreasing oxygen saturation. Which factor(s), if assessed, indicate a deteriorating condition? Select all that apply. Tachypnea Tachycardia Bradycardia Shortness of breath Wheezing and crackles in lungs

Tachypnea Tachycardia Shortness of breath Wheezing and crackles in lungs

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.

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.

The force required for ventricles to push against to get blood out into the body is called

afterload

Atrial gallops are best heard with the bell over the ________ area with the patient in left lateral position

apical

S1 LUB, is heard best at

apical/ apex area. 5th intercostal space

P wave represents

atrial contraction

S2 is heard loudest where?

base of the heart, aortic area

Abnormal heart sounds are best heard with which side of the stethoscope

bell

Ventricular gallops are caused by

blood from left atrium entering an overfilled ventricle during diastole

Rhonchi is caused by what?

clogged mucous

pumping ability of the heart shown by a percentage is called the

ejection fraction

sympathetic nervous system

fight or flight, increase HR and blood flow

During inspiration O2 is higher or lower in the alveoli than capillaries

higher

R wave represents

left ventricle contraction- aortic valve to body

Low contractility equals _______ SV

low

S1 "LUB" is the closure of which valves

mitral and tricuspid "leads to ventricles"

Ventricular gallops are best heard with the bell over the ________ area with the patient in what position

mitral, lying on left side flat

An abnormal sounds caused by blood flowing through a defective valve or caused by a mechanical valve is called ____________.

murmurs and clicks

parasympathetic nervous system

rest and digest, decrease HR, increase secretions

Q wave represents

signal divides at bundle of his into left and right branches

function of cardiovascular system

to deliver oxygen and nutrients and to remove carbon dioxide and other waste products

T wave represents

ventricle relaxation

Systole occurs when

ventricles are contracting

Functions of the Respiratory System:

•Conduct air •Eliminate waste •Protect the airway from infection •Produce surfactant

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."

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."

Stroke volume usually ranges around

60-100ml/ per beat (usually 70)

An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur? A) inspiration and expiration B) only on inspiration C) only on expiration D) when coughing

A) inspiration and expiration

A father of a preschool-aged child tells the nurse that his child has had a constant cold since going to daycare. How would the nurse respond? A) Your child must have a health problem that needs medical care. B) Children in daycare have more exposure to colds. C) Are you washing your hands before you touch the child? D) Be sure and have your child wear a protective mask at school.

B) Children in daycare have more exposure to colds.

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.

Functions of the Respiratory System

Conduct air Eliminate waste Protect airway from infection Produce surfactant

What category of medications may be administered by nebulizer or metered-dose inhaler to open narrowed airways? A) bronchoconstrictors B) antihistamines C) narcotics D) bronchodilators

D) bronchodilators

Pediatric Symptoms of Hypoxia

Feeding difficulty Inspiratory stridor Nares flare Expiratory grunting Sternal retractions

hyperventilation- deep and rapid, body is attempting to release excess acids

Kussmaul's

The respiratory center is located in what part of the brain?

Medulla Oblongata

x 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

Upper Respiratory Tract Structure

Nose, epiglottis, pharynx, larynx

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

Rapid respirations

The amount of blood pumped with each beat following contraction is referred to as

Stroke Volume

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).

low-pitched, soft sounds heard over peripheral lung fields

Vesicular

continuous, musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors

Wheezes

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.

Hyper-resonance indicates

air, collapsed lung, or influenza

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: pulmonary embolism. myocardial infarction. lung cancer. congestive heart failure.

congestive heart failure.

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? begin resuscitation efforts. elevate the head of the crib. continue to assess the infant. position the infant side-lying.

continue to assess the infant.

Oxygen and carbon dioxide move between the alveoli and the blood by: osmosis. hyperosmolar pressure. diffusion. negative pressure.

diffusion.

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

A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery? -educating the client on the use of incentive spirometry -educating the client on pursed-lip breathing techniques -oropharyngeal suctioning twice daily -administration of inhaled corticosteroids

educating the client on the use of incentive spirometry

Bronchial sounds are longer on ____________

expiration

Wheezes are louder on _______

expiration

adventitious breath sounds

extra, abnormal breath sound heard over the lungs

if CO2 is increased you will breathe ____________ to get rid of CO2 and increase O2

faster and deeper

during diastole, the ventricles

fill with blood

How do you measure nasopharyngeal airway support?

from earlobe to nose

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 temperature -high respiratory rate -low pulse rate -low blood pressure

high respiratory rate

Diffusion is exchange of O2 and CO2 through alveolar capillary membranes and move from a:

higher concentration to a lower concentration

With vesicular sounds, which is longer insp. or exp.?

inspiration is 3x longer

Crackles are frequently heard on ____________, are soft, high pitched intermittent __________ sounds

inspiration, popping

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 -thoracentesis -spirometry -peak expiratory flow rate

pulse oximetry

Peripheral chemoreceptors cause

rapid shallow breathing

Early symptoms of hypoxia

restlessness, anxiety, tachycardia/tachypnea

Friction rub is a low pitched sound caused by

2 inflamed surfaces rubbing together

normal respiratory rate for infants

20-40

normal respiratory rate for early childhood

25-32

Cardiac output is usually how much

4-8L/min

What is considered normal oxygen saturation?

95-100%

hypoxic drive

A "backup system" to control respiration; senses drops in the oxygen level in the blood.

A patient is experiencing hypoxia. Which of the following nursing diagnoses would be appropriate? A) Anxiety B) Nausea C) Pain D) Hypothermia

A) Anxiety

A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them? A) It is inserted into the space between the lining of the lungs and the ribs. B) I dont exactly know, but I will make sure the doctor comes to explain. C) It is inserted directly into the lung itself, connecting to a lung airway. D) It is inserted into the peritoneal space and drains into the lungs.

A) It is inserted into the space between the lining of the lungs and the ribs.

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. 95% to 100% is considered normal oxygen saturation

increased rate and depth, CO2 is released faster than produced, stress, anxiety

Hyperventilation

peripheral chemoreceptors respond to a change in _________ first

O2

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

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? Apical pulse Orthostatic blood pressure Respiratory rate and depth Urinary intake and output

Respiratory rate and depth

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

Once O2 is in the capillaries it is carried into the

arteries

The force of blood against the arterial wall is called

blood pressure

Are bronchovesicular sounds best heard on insp. or exp.?

both are equal

Oropharyngeal suctioning is a ___________ procedure

clean

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? confusion decreased blood pressure decreased respiratory rate hyperactivity

confusion

Which adventitious breath sounds are not cleared by coughing?

crackles, friction rub

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? -fine crackles to the bases of the lungs bilaterally -respiratory rate of 18 breaths per minute -resonance on percussion of lung fields -vesicular breath sounds audible over peripheral lung fields

fine crackles to the bases of the lungs bilaterally

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

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

If circulation is bad in the index, middle, or ring finger, you can use which parts of the body to get a pulse oximetry reading

nose, toe, ear lobe

Nasopharyngeal suction is a __________ procedure

sterile

Lower Respiratory Tract Structures

trachea, bronchi, bronchioles, alveoli

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

Diastole occurs when

ventricles relax

Chronic levels of CO2, can cause what to happen if too much O2 is supplied?

wipe out the bodies hypoxic drive

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."

The nurse is talking with a client who has chronic obstructive pulmonary disease (COPD). The client reports chest shape seems to have changed over the past year. What information should be provided by the nurse? -"Your chest diameter has increased as the musculature has matured in an effort to obtain increased amounts of oxygen." -"Your lung condition limits the ability of the lungs to fully exhale, causing this change in shape." -"Chronic lung conditions such as this are associated with fluid retention in the lower lung fields, causing the change in the chest shape." -"The corticosteroids prescribed to manage the condition have caused a change in the shape of the chest wall."

"Your lung condition limits the ability of the lungs to fully exhale, causing this change in shape."

Which of the following statements accurately describe a step for inserting an oropharyngeal airway? Select all that apply. A) Use an airway that is the correct size (size 90 mm is appropriate for the average adult). B) Airway should reach from opening of mouth to the back angle of the jaw. C) Position patient on his or her stomach with neck hyperextended (unless this is inappropriate). D) Open patients mouth by using your thumb and index finger to gently pry teeth apart. E) Insert the airway with the curved tip pointing up toward the roof of the mouth. F) Rotate the airway 360 degrees as it passes the uvula

A) Use an airway that is the correct size (size 90 mm is appropriate for the average adult). B) Airway should reach from opening of mouth to the back angle of the jaw. D) Open patients mouth by using your thumb and index finger to gently pry teeth apart. E) Insert the airway with the curved tip pointing up toward the roof of the mouth.

What is the action of codeine when used to treat a cough? A) antisuppressant B) suppressant C) antihistamine D) expectorant

B) suppressant

Dullness on percussion

Fluid or mass under area being percussed

Primary vehicle for O2 transport

Hemoglobin

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.

Late symptoms of hypoxia

bradycardia, extreme restlessness, dyspnea (severe)

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: -bronchospasm. -bronchitis. -bronchiectasis. -bronchiolitis.

bronchospasm.

peripheral chemoreceptors are located

carotid arteries and aorta (outside the brain)

during diffusion O2 moved from the arteries into the

cells

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.