Chapter 39: Oxygenation and Perfusion

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. Chapter 39: Oxygenation and Perfusion - Page 1503

A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. "I will be careful not to shake up the canister before using it." "I will hold the canister upside down when using it." "I will inhale the medication through my nose." "I will continue to inhale when the cold propellant is in my throat." "I will only inhale one spray with one breath." "I will activate the device while continuing to inhale."

"I will continue to inhale when the cold propellant is in my throat." "I will only inhale one spray with one breath." "I will activate the device while continuing to inhale." Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, and inhaling two sprays with one breath.

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. Chapter 39: Oxygenation and Perfusion - Page 1535

In which client should the nurse prioritize assessments for respiratory depression? A client taking a beta-adrenergic blocker for hypertension A client taking antibiotics for a urinary tract infection A client taking insulin for type 1 diabetes A client taking opioids for cancer pain

A client taking opioids for cancer pain Explanation: Many medications affect the function of the respiratory system and depress the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Beta-adrenergic blockers, antibiotics, and insulin do not appreciably affect the respiratory system. Chapter 39: Oxygenation and Perfusion - Page 1491

A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? The patient vomits during suctioning. The secretions appear to be stomach contents. The catheter touches an unsterile surface. A nosebleed is noted with continued suctioning.

A nosebleed is noted with continued suctioning. When nosebleed (epistaxis) is noted with continued suctioning, the nurse should notify the health care provider and anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning.

A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? A postoperative adult An adult with COPD A teenager with cystic fibrosis A child with pneumonia

A teenager with cystic fibrosis Chest physiotherapy may help loosen and mobilize secretions, increasing mucus clearance. This is especially helpful for patients with large amounts of secretions or an ineffective cough, such as patients with cystic fibrosis. Chest physiotherapy has limited evidence for its effectiveness and is not recommended for use in numerous patient populations, including children with pneumonia, adults with COPD, and postoperative adults (Andrews et al., 2013; Lisy, 2014; Strickland et al., 2013).

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

A) Anxiety

20. 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.

18. A nurse is teaching a preoperative patient how to effectively deep breathe. Which of the following would be included? A) Make each breath deep enough to move the bottom ribs. B) Breathe through the mouth when you inhale and exhale. C) Breathe in through the mouth and out through the nose. D) Practice deep breathing at least once each week.

A) Make each breath deep enough to move the bottom ribs.

28. What is the rationale for placing a writing board in the room of a patient who has had surgery to insert a tracheostomy tube? A) The patient is not able to speak. B) Verbal communication will be too tiring. C) It will occupy the patients time. D) Voice rest will decrease pain levels.

A) The patient is not able to speak.

32. 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.

3. A nurse is caring for a patient with pneumonia. The patients oxygen saturation is below normal. What abnormal respiratory process does this demonstrate? A) changes in the alveolar-capillary membrane and diffusion B) alterations in the structures of the ribs and diaphragm C) rapid decreases in atmospheric and intrapulmonic pressures D) lower-than-normal concentrations of environmental oxygen

A) changes in the alveolar-capillary membrane and diffusion

2. Which of the following diseases may result in decreased lung compliance? A) emphysema B) appendicitis C) acne D) chronic diarrhea

A) emphysema

11. 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

7. A 90-year-old woman has been in an automobile crash and sustained four fractured ribs on the left side of her thorax. Based on her age and the injury, what complication is she at risk for? A) pneumonia B) altered thought processes C) urinary incontinence D) viral influenza

A) pneumonia

6. 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.

23. A nurse is teaching a patient who has congested lungs how to keep secretions thin and more easily coughed up and expectorated. What would be one self-care measure to teach? A) Limit oral intake of fluids to less than 500 mL per day. B) Increase oral intake of fluids to 2 to 3 quarts per day. C) Maintain bedrest for at least 3 days. D) Take warm baths every night for a week.

B) Increase oral intake of fluids to 2 to 3 quarts per day.

13. A nurse is caring for a toddler who is having an acute asthmatic attack with copious mucus and difficulty breathing. The childs skin is cyanotic, respirations are labored and rapid, and pulse is rapid. What nursing diagnosis would have priority for care of this child? A) Anxiety B) Ineffective Airway Clearance C) Excess Fluid Volume D) Disturbed Sensory Perception

B) Ineffective Airway Clearance

14. What information would a home care nurse provide to a patient who is measuring peak expiratory flow rate at home? A) Although the test is uncomfortable, it is not painful. B) You will be asked to forcefully exhale into a mouthpiece. C) The test is used to determine how much air you inhale. D) You will do this each morning while still lying in bed.

B) You will be asked to forcefully exhale into a mouthpiece.

8. Which of the following individuals is at greater risk for respiratory illnesses from environmental causes? A) a farmer on a large farm B) a factory worker in a large city C) a woman living in a small town D) a child living in a rural area

B) a factory worker in a large city

10. A nurse is percussing the thorax of a patient with chronic emphysema. What percussion sound would most likely be assessed? A) resonance B) hyperresonance C) flat D) tympany

B) hyperresonance

29. A student observes a nurse instilling a small amount of saline into a tracheostomy tube before suctioning. What should the student discuss with the nurse? A) a description of how the nurse is carrying out the skill B) saline is no longer recommended for routine suctioning C) nothing; the nurse has been doing this for years D) compliments for carrying out the procedure skillfully

B) saline is no longer recommended for routine suctioning

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

B) suppressant

25. 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? A) the importance of communicating with the patient B) the safety measures necessary to prevent a fire C) the cost and source of supply for the oxygen D) the need to provide good skin care

B) the safety measures necessary to prevent a fire

21. What prevents air from re-entering the pleural space when chest tubes are inserted? A) the location of the tube insertion B) the sutures that hold in the tube C) a closed water-seal drainage system D) respiratory inspiration and expiration

C) a closed water-seal drainage system

16. Of all factors, what is the most important risk factor in pulmonary disease? A) air pollution from vehicles B) dangerous chemicals in the workplace C) active and passive cigarette smoke D) loss of the ozone layer of the atmosphere

C) active and passive cigarette smoke

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

C) arterial oxygen saturation

30. A home care nurse finds a patient lying on the floor. The patient is not breathing. Her response is based on the ABCs of basic life support. What does the B stand for in these initials? A) blood B) beware C) breathing D) be sure

C) breathing

17. A nurse is caring for a patient who suddenly begins to have respiratory difficulty. In what position would the nurse place the patient to facilitate respirations? A) supine B) prone C) high Fowlers D) dorsal recumbent

C) high Fowlers

27. 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 An obturator, which guides the direction of the outer cannula, is inserted into the tube during placement and removed once the outer cannula of the tube is in place (Fig. 39-14). Many tubes also have inner cannulas that may or may not be disposable. The outer cannula remains in place in the trachea, and the inner cannula is removed for cleaning or replaced with a new one. Periodic cleaning or replacement of the inner cannula prevents airway obstruction from secretions that have accumulated on the tube's inner surface.

1.A patient has had a head injury affecting the brainstem. What is located in the brainstem that may affect respiratory function? A) chemoreceptors B) stretch receptors C) respiratory center D) oxygen center

C) respiratory center

What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? Checking the amount of oxygen in the cylinder before using it Using a cylinder for a patient transfer that indicates available oxygen is 500 psi Placing the oxygen cylinder on the stretcher next to the patient Discontinuing oxygen flow by turning the cylinder key counterclockwise until tight

Checking the amount of oxygen in the cylinder before using it The cylinder must always be checked before use to ensure that enough oxygen is available for the patient. It is unsafe to use a cylinder that reads 500 psi or less because not enough oxygen remains for a patient transfer. A cylinder that is not secured properly may result in injury to the patient. Oxygen flow is discontinued by turning the valve clockwise until it is tight.

Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. Closely assess the patient before, during, and after the procedure. Hyperoxygenate the patient before and after suctioning. Limit the application of suction to 20 to 30 seconds. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Use an appropriate suction pressure (80 to 150 mm Hg). Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.

Closely assess the patient before, during, and after the procedure. Hyperoxygenate the patient before and after suctioning Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Use an appropriate suction pressure (80 to 150 mm Hg). Close assessment of the patient before, during, and after the procedure is necessary to limit negative effects. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. The nurse should also take the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis related to the use of high negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis.

When the nurse observes a newborn infant demonstrating an irregular abdominal breathing pattern, with a respiratory rate of 40 breaths/minute with occasional pauses in breathing of 5-second duration. 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. Explanation: Infants breathe rapidly at 30 to 60 breaths/minute and may have occasional pauses of several seconds between breaths. Chapter 39: Oxygenation and Perfusion - Page 1489

9. A nurse is beginning to conduct a health history for a patient with respiratory problems. He notes that the patient is having respiratory distress. What would the nurse do next? A) Continue with the health history, but more slowly. B) Ask questions of the family instead of the patient. C) Conduct the interview later and let the patient rest. D) Initiate interventions to help relieve the symptoms.

D) Initiate interventions to help relieve the symptoms.

26. 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.

24. 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

4. While reading a physicians progress notes, a student notes that an assigned patient is having hypoxia. What abnormal assessments would the student expect to find? A) abdominal pain, hyperthermia, dry skin B) diarrhea, flatulence, decreased skin turgor C) hypotension, reddened skin, edema D) dyspnea, tachycardia, cyanosis

D) dyspnea, tachycardia, cyanosis

5. In what age group would a nurse expect to assess the most rapid respiratory rate? A) older adults B) middle adults C) adolescents D) infants

D) infants

31. 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

19. A nurse is teaching a home care patient how to do pursed-lip breathing. What is the therapeutic effect of this procedure? A) using upper chest muscles more effectively B) replacing the use of incentive spirometry C) reducing the need for p.r.n. pain medications D) prolonging expiration to reduce airway resistance

D) prolonging expiration to reduce airway resistance

A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? Dyspnea Hypotension Decreased respiratory rate Decreased pulse rate

Dyspnea If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient? Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone. Teach the patient not to talk about the procedure, just to perform it at the best of his or her ability. Teach the patient to take short shallow breaths when performing hygiene measures. Group personal care activities into smaller steps, allowing rest periods between activities.

Group personal care activities into smaller steps, allowing rest periods between activities. For a patient who is too fatigued to complete daily hygiene on his or her own, the nurse should group personal care activities into smaller steps and allow rest periods between the activities. The nurse should assist with bathing and hygiene tasks as needed and only when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits, and teach the patient to coordinate diaphragmatic breathing with the activity.

An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? Tilt the patient's head forward. Hold the mask tightly over the patient's nose and mouth. Pull the patient's jaw backward. Compress the bag twice the normal respiratory rate for the patient.

Hold the mask tightly over the patient's nose and mouth. With the patient's head tilted back, jaw pulled forward, and airway cleared, the mask is held tightly over the patient's nose and mouth. The bag also fits easily over tracheostomy and endotracheal tubes. The operator's other hand compresses the bag at a rate that approximates normal respiratory rate (e.g., 16 to 20 breaths/min in adults).

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. Chapter 39: Oxygenation and Perfusion - Page 1485

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. Chapter 39: Oxygenation and Perfusion - Page 1504-1505

The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response? Page the respiratory therapist STAT. Maintain the client's oxygenation and alert the health care provider immediately. Cover the tracheostomy stoma and apply oxygen by nasal cannula Assess the client's respiratory status and check vital signs every 1 minute for the next hour.

Maintain the client's oxygenation and alert the health care provider immediately. Explanation: If the tracheostomy becomes dislodged and is not easily replaced, the nurse should notify the primary care provider immediately, cover the tracheostomy stoma, and assess client's respiratory status. Chapter 39: Oxygenation and Perfusion - Page 1503

A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing method might the nurse use to measure the patient's oxygen saturation? Thoracentesis Pulse oximetry Diffusion capacity Maximal respiratory pressure

Pulse oximetry Pulse oximetry is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma. Diffusion capacity estimates the patient's ability to absorb alveolar gases and determines if a gas exchange problem exists. Maximal respiratory pressures help evaluate neuromuscular causes of respiratory dysfunction. Both tests are usually performed by a respiratory therapist. The physician or other advanced practice professional can perform a thoracentesis at the bedside with the nurse assisting, or in the radiology department.

A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? Notify the health care provider. Apply an occlusive dressing on the site. Assess the patient for signs of respiratory distress. Put on gloves and insert the chest tube in a bottle of sterile saline.

Put on gloves and insert the chest tube in a bottle of sterile saline. When a chest tube becomes separated from the drainage device, the nurse should submerge the end in water, creating a water seal, but allowing air to escape, until a new drainage unit can be attached. This is done instead of clamping to prevent another pneumothorax. Then the nurse should assess vital signs and notify the health care provider.

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. Refrain from exercise. Reduce anxiety. Eat meals 1 to 2 hours prior to breathing treatments. Eat a high-protein/high-calorie diet. Maintain a high-Fowler's position when possible. Drink 2 to 3 pints of clear fluids daily.

Reduce anxiety. Eat a high-protein/high-calorie diet. Maintain a high-Fowler's position when possible. When caring for patients with COPD, it is important to create an environment that is likely to reduce anxiety and ensure that they eat a high-protein/high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high-Fowler's position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises, and drinking 2 to 3 quarts (1.9 to 2.9 L) of clear fluids daily is recommended.

A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? Remove the catheter. Notify the primary care provider. Check that the airway is the appropriate size for the patient. Place the patient on his or her back.

Remove the catheter. When a patient vomits upon suctioning of an oropharyngeal airway, the nurse should remove the catheter; it has probably entered the esophagus inadvertently. If the patient needs to be suctioned again, the nurse should change the catheter, because it is probably contaminated. The nurse should also turn the patient to the side and elevate the head of the bed to prevent aspiration.

A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? Instruct the assistant to notify the primary care provider. Assess the patient's vital signs. Remove the tape, adjust the depth to ordered depth and reapply the tape. No action is required as depth will adjust automatically.

Remove the tape, adjust the depth to ordered depth and reapply the tape. The tube depth should be maintained at the same level unless otherwise ordered by the health care provider. If the depth changes, the nurse should remove the tape, adjust the tube to ordered depth, and reapply the tape.

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 Explanation: The client receiving opioids needs monitoring of the respiratory rate and depth to ensure that respiratory depression does not result in progressive respiratory issues, physiologic damage from respiratory depression, or loss of consciousness. The pulse, blood pressure, and urinary intake and output are not as important as respiratory status when administering opioids. Chapter 39: Oxygenation and Perfusion - Page 1492

A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? The nurse assures that the oxygen is flowing into the prongs. The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. The nurse encourages the patient to breathe through the nose with the mouth closed. The nurse adjusts the flow rate to 6 L/min or more.

The nurse encourages the patient to breathe through the nose with the mouth closed. The nurse should encourage the patient to breathe through the nose with the mouth closed. The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should adjust the fit of the cannula so it is snug but not tight against the skin. The nurse should adjust the flow rate as ordered.

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter? The age of the patient The size of the endotracheal tube The type of secretions to be suctioned The height and weight of the patient

The size of the endotracheal tube The nurse would base the size of the suctioning catheter on the size of the endotracheal tube. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. Larger catheters can contribute to trauma and hypoxemia.

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.

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 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.

The nurse is caring for the following clients. Which client is at highest risk for a depressed respiratory system? a client taking amlodipine for hypertension a client taking methocarbamol for low back spasms a client taking methimazole for hyperthyroidism a client taking an opioid for cancer pain

a client taking an opioid 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 decreases blood pressure, so the nurse would need to assess blood pressure. Muscle relaxants such as methocarbamol could depress respiratory status, but this occurs less often than with opioids. Methimazole is used to treat hyperthyroidism, thus lowering the body's metabolic functions, which can depress respirations; however, this is a very rare occurrence with this medication. The client at highest risk is the one taking an opioid. Chapter 39: Oxygenation and Perfusion - Page 1492

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. Chapter 39: Oxygenation and Perfusion - Page 1489

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. 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. Chapter 39: Oxygenation and Perfusion - Page 1489-1494

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. Chapter 39: Oxygenation and Perfusion - Page 1489-1490

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 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. Chapter 39: Oxygenation and Perfusion - Page 1492

The nurse is applying a pulse oximeter to a client with bronchitis. Which factor(s) does the nurse communicate to the client that could interfere with accurate pulse oximetry? Select all that apply. nail polish thickness of nails acrylic nails respiratory rate peripheral vascular disease

nail polish thickness of nails acrylic nails respiratory rate peripheral vascular disease If the client is wearing nail polish, has thick nails or is wearing acrylic nails, this will interfere with the probe detecting an accurate oxygen saturation. Peripheral vascular disease reduces or diminishes blood flow to fingers and toes. For these reasons, the nurse will need to determine a site to ensure monitor readings are accurate. Where circulation may be reduced or diminished, the pulse oximeter will not read well. The pulse oximeter reading will vary with the rate and depth that the respirations but should not be deemed inaccurate because of them. Instead, the nurse will be aware to note changes in the oxygen saturation based on changes in the respiratory rate. Brief, transient changes are not remarkable and do not require intervention. Chapter 39: Oxygenation and Perfusion - Page 1525

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. Chapter 39: Oxygenation and Perfusion - Page 1509

While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique? fluid-filled portions of the lung pattern of thoracic expansion consolidated portions of the lung presence of pleural rub

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. Chapter 39: Oxygenation and Perfusion - Page 1494

A client returns to the telemetry unit after an operative procedure. Which 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 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. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes. Chapter 39: Oxygenation and Perfusion - Page 1496

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. Chapter 39: Oxygenation and Perfusion - Page 1517