Chapter 39: Oxygenation and Perfusion

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?

"Is your mask causing discomfort?" *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.

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 *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.

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

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.

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

pulmonary function tests *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 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?

Maintain the client's oxygenation and alert the health care provider immediately. *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.

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

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

The nurse is 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 will warm, filter, and humidify the air you are breathing." *Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring.

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is:

"He is using his chest muscles to help him breathe." *The client will use accessory muscles to ease dyspnea and improve breathing.

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?

"I can assist you to the bathroom and back to bed."; *The client can move in bed, and ambulate while carrying the drainage system as long as he or she has orders to do so. The nurse should supervise ambulation to the bathroom and back to bed while the client has the drain inserted, to make sure it stays intact and to monitor for safety

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

"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute." *The 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 demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier?

"Small water droplets come from this, thus preventing dry mucous membranes." *The humidifier produces small water droplets which are delivered during oxygen administration to prevent or decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen.

The nurse determines that the student who has been instructed about lung function and smoking requires additional teaching when the student says

"Smoking only once in a while will not make a person addicted to smoking." *During adolescence, more than 3000 young men and women begin smoking every day, and most will become addicted before age 20. One reason for this finding is that adolescents don't believe they will become addicted to tobacco when they start to smoke.

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

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

The nurse is caring for a client with emphysema. A review of the client's chart reveals pH 7.36, Pa0273 mm Hg, PaCO, 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription if prescribed by the health care practitioner?

4 L/minute O2 (66 mL/second) nasal cannula *The client with chronic lung disease, such as emphysema, becomes insensitive to carbon dioxide and responds to hypoxia to stimulate breathing. If given excessive oxygen (4 L/minute or 66 mL/second), the stimulus to breathe is removed. Clients with emphysema are most comfortable in high Fowler's position because it aids in the use of the accessory muscles to promote respirations. Increasing fluid intake helps keep the client's secretions thin. Pulse oximetry monitors the client's arterial oxyhemoglobin saturation while receiving oxygen therapy.

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's Sa02 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:

6 L/minute *In general, if a flow rate of 6 L/minute fails to raise a client's oxygen saturation level satisfactorily, a mask should be used. 1-4 L/minute flow rates per nasal cannula are standard flow rates. Greater than 6 L/minute flow rate per nasal cannula is very uncomfortable for the client. A flow rate of 10 L /minute per nasal cannula is not acceptable.

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

Acute bronchitis *Acute bronchitis is caused by inflammation. Inflammatory mediators such as histamine may directly stimulate nerve endings made hypersensitive by the disease process. This process causes a sensation of pain as air travels over those nerve endings. Clients with pneumonia often experience pain with deep breathing because each breath increases pressure on pain receptors that are already compressed and irritated by swollen, inflamed lung tissue. Coronary artery disease should be ruled out in anyone reporting chest pain, but Martin's sensation of burning in his airway with each breath is more suspicious for a respiratory issue. Emphysema is a more chronic illness that causes a slow progression of increasing shortness of breath. Martin is definitely at risk for emphysema but it would not explain his worsening shortness of breath over the last 2 days.

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

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

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

Bronchitis *Bronchitis refers to a condition in which the airways become inflammed, 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.

Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body?

Chronic anemia *The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the amount of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissues of the body. Graves' disease, Parkinson's disease, and pancreatitis do not directly lead to a decrease in the number of red blood cells.

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 (UP) suddenly reports the client has vomited?

Conduct a focused assessment *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.

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

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

The client demonstrates soft, high-pitched, discontinuous sounds in the left lower lobe of the lung. How will the nurse accurately document this finding?

Crackles *Crackles are soft, high-pitched, discontinuous sounds. Wheezes are a whistling or rattling sound in the chest as a result of obstruction in the air passages. Vesicular breath sounds are heard across the lung surface. Bronchial sounds are loud, high-pitched sounds heard primarily over the trachea and larynx.

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

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

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

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

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?

Document this expected assessment finding. *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.

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

Eat smaller meals that are high in protein. *The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength.

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?

Hypoxia *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 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)?

Inserting the client's nasal cannula after it has become dislodged Reapplying the client's nasal cannula after a bath Measuring the client's respiratory rate *Reapplication of the nasal cannula during nursing care activities, such as during bathing, may be performed by UAP. UP 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 prepares the client for a 12-lead electrocardiogram (ECG). Which actions should the nurse provide?

Instruct the client to relax arms away from waist and legs not touching the footboard. Prepare skin, removing excess oil and clip areas of excessive hair. Place self-stick electrodes and place according to anatomical locations. *The client needs to be in a relaxed position without limbs, or electrode lead wires touching each other to provide the best ECG recording. The nurse needs to prepare the skin removing excess oil, moisture, trim excessive amounts of hair, and slightly abrade the skin surface so the electrode pads will make proper contact. The lead wires should not be taut because that will cause electrical interference providing a poor ECG recording. Electrodes and ECG cables must be placed in anatomical correct positions to provide an accurate ECG tracing.

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

It determines whether the client is getting enough oxygen. *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.

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?

The client is able to state the date, time, and location. Heart rate is 64 beats/min. Mucous membranes are pink and moist. *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.

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

The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). *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 noting 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.

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

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

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm. *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?

Vesicular *Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds, whereas bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

In which client should the nurse prioritize assessments for respiratory depression?

a client taking opioids for cancer pain *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.

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. *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.

What assessments would a nurse make when auscultating the lungs?

air flow through the respiratory passages *Auscultation of the lungs assesses air flow through the respiratory passages and lungs. The nurse listens for normal, as well as abnormal, breath sounds. Abnormal chest structures would be assessed when inspecting the chest and thoracic region. Presence of edema would be assessed as part of the cardiovascular status of the client. Volume of air exhaled and inhaled would be performed during a pulmonary function test.

During the physical assessment of a client who has been inactive due to a leg injury, the nurse notes that the client tends to breathe very shallowly. What technique should the nurse teach the client in order to breathe more efficiently?

deep breathing *The nurse should teach deep breathing techniques to the client who is recovering from an injury and tends to breathe shallowly in order to help the client breathe more efficiently. Deep breathing is a technique for maximizing ventilation. Taking in a large volume of air fills alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing is a form of controlled ventilation in which the client consciously prolongs the expiration phase of breathing, which helps clients, especially with COPD, to eliminate more than the usual carbon dioxide from the lungs. It is used to increase the volume of air exchanged during inspiration and expiration. Incentive spirometry, a technique for deep breathing using a calibrated device, encourages clients to reach a goal- directed volume of inspired air; however, it is not always recommended for routine prophylactic use in postoperative adult and pediatric clients. Diaphragmatic breathing is breathing that promotes the use of the diaphragm rather than the upper chest muscles. It is used to increase the volume of air exchanged during inspiration and expiration in client with COPD.

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 *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.

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

flow meter *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.

An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's:

hemoglobin level. *Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.

The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis?

high respiratory rate *A client 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.

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

high-Fowler's position *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.

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

pattern of thoracic expansion *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.

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

pulse oximetry *Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.

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 *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 *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).

The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly?

respirations are at 20 breaths per minute *Respirations of 20 breaths per minute indicate that the tube is functioning correctly. Other findings require nursing intervention.

The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?

tracheostomy collar *A 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.

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?

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.

A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of:

Pneumonia *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

A nurse has received an order to suction an adult client's endotracheal tube. Which action is most appropriate when performing this intervention?

Use sterile saline to moisten the end of the suction catheter. *Upright positioning best facilitates safe and effective suctioning. The wall unit should be set between 100 and 150 mm Hg for an adult, and sterile gloves are donned after the field is established.

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?

"You should never smoke when oxygen is in use." *The nurse will educate the client about the dangers of smoking when oxygen is in use. Oxygen is not flammable, but it oxidizes other materials. Other answers are inappropriate.

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

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

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing

Poor tissue perfusion *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.

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. *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.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

Residual Volume (RV) *During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds.

A health care provider has prescribed oxygen to be delivered at 8 L/minute for a client who does not have a tracheostomy. Which oxygen delivery device(s) will the nurse consider using?

Simple mask Partial rebreather mask *A simple mask, and partial rebreather mask accommodate a flow of 8 L/min. A venturi mask accommodates 4-6 L/min, and a nonrebreather mask accommodates 10-15 L/min. The client does not have a tracheostomy so a T-piece is inappropriate.

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

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

A nurse 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. *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.

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:

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

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

presence of fluid in the lungs *Coarse crackles heard on auscultation indicate the presence of fluid in the lungs. Air passing through narrowed airways produces a wheezing sound, whereas inflammation of pleural surfaces gives rise to pleural rub. Sputum in the trachea produces stridor, a harsh, noisy squeak when something is blocking the airway.

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

Suction the tracheostomy tube using sterile technique. *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.

The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client?

nasal cannula *A nasal cannula is ideal for administering low concentrations of oxygen to clients who are not extremely hypoxic or have chronic lung disease. The client does not have a tracheostomy. A simple mask is used to administer higher levels of oxygen than 2 L/min. A face tent is used without a mask.