Chapter 39: Oxygenation and Perfusion

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 Trendelenburg position side-lying position, half on the abdomen and half on the side left side with a pillow under the chest wall

high-Fowler's position

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 False

true

what is the most important risk factor in pulmonary disease? dangerous chemicals in the workplace loss of the ozone layer of the atmosphere air pollution from vehicles active and passive cigarette smoke

active and passive cigarette smoke

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 mostappropriate to this client's needs? Nonrebreather mask Nasal cannula Simple mask Partial rebreather mask

Nasal cannula

A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first? Assist with intubation Raise the head of the bed Educate client on incentive spirometry Apply oxygen as prescribed

Apply oxygen as prescribed

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding? The contour of the intercostal spaces should be rounded. The anteroposterior diameter should be greater than the transverse diameter. The skin at the thorax should be cool and moist. The chest should be slightly convex with no sternal depression.

The chest should be slightly convex with no sternal depression.

Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway? When holding the airway on the side of the client's face, it should reach from the tip of the ear to the nostril times two. When holding the airway on the side of the client's face, it should reach from the tragus of the ear to the tip of the nostril. When holding the airway on the side of the client's face, it should reach from the opening of the mouth to the back angle of the jaw. The airways come in standard sizes determined by the height and weight of the client.

When holding the airway on the side of the client's face, it should reach from the tragus of the ear to the tip of the nostril.

what assessments would a nurse make when auscultating the lungs? air flow through the respiratory passages presence of edema abnormal chest structures volume of air exhaled or inhaled

air flow through the respiratory passages

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: diminished stroke volume. high cardiac output. adequate tissue perfusion. heart failure.

adequate tissue perfusion.

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 increased urine output strong, rapid pulse weight loss

rapid respirations

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. asthma. alcohol use. croup.

pneumonia.

The nurse is preparing to provide hygiene care to a client with hypoxia. Into what position will the nurse place the client? prone supine Trendelenburg high Fowlers

high fowlers

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 Malnutrition Congestive heart failure Anemia Poor tissue perfusion

Poor tissue perfusion

During assessment of a 4-year-old client, the nurse notes a respiratory rate of 30 breaths/min and a loud, harsh expiration that is longer than inspiration. The nurse would implement which appropriate nursing intervention next? Administer oxygen therapy Proceed with the assessment Notify the health care provider Obtain arterial blood sampling

Administer oxygen therapy Proceed with the assessment

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. Assess the client's respiratory status and check vital signs every 1 minute for the next hour. Cover the tracheostomy stoma and apply oxygen by nasal cannula Maintain the client's oxygenation and alert the health care provider immediately.

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

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 Wheezes Pneumonia Tachypnea

Pleural effusion

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? Absent breath sounds in lower lobes Crackles Wheezing Stridor

Wheezing

A client has been receiving treatment with a nonrebreather mask for the past 96 hours. How should the nurse respond if the unlicensed assistive personnel (UAP) suddenly reports the client has vomited? put client on NPO status notify the health care provider replace current mask with a new one conduct a focused assessment

conduct a focused assessment

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: blood pH. sodium and potassium levels. age. hemoglobin level.

hemoglobin level.

The nurse is administering oxygen to an older adult client who has been assessed to have increased work of breathing. If the intervention has been effective, what finding(s) will the nurse expect on the evaluation of the client? Select all that apply. Oxygen saturation reads 88% on 5L of oxygen. Heart rate is 64 beats/min. Mucous membranes are pink and moist. The client is able to state the date, time, and location. Respiratory rate is 33 breaths/min at rest.

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

A nurse is overseeing the care of a client who is receiving oxygen via nasal cannula. Which aspects of the client's care can the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply. Reapplying the client's nasal cannula after a bath Measuring the client's respiratory rate Auscultating the client's lungs to determine the effectiveness of treatment Inserting the client's nasal cannula after it has become dislodged Increasing the flow rate of the client's oxygen when the client is short of breath

Reapplying the client's nasal cannula after a bath Measuring the client's respiratory rate Inserting the client's nasal cannula after it has become dislodged

When caring for a client with a tracheostomy, the nurse would perform which recommended action? Assess a newly inserted tracheostomy every 3 to 4 hours. Suction the tracheostomy tube using sterile technique. Use gauze dressings over the tracheostomy that are filled with cotton. Clean the wound around the tube and inner cannula at least every 24 hours.

Suction the tracheostomy tube using sterile technique.

A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate? The client's respiratory rate is in the normal range. The client's available hemoglobin is adequately saturated with oxygen. The client's red blood cell (RBC) count is in the normal range. The client's oxygen demands are being met.

The client's available hemoglobin is adequately saturated with oxygen.

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather? face tent nasal cannula simple mask tracheostomy collar

face tent

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: sodium and potassium levels. age. blood pH. hemoglobin level.

hemoglobin level.

While auscultating a client's chest, the nurse auscultates crackles in the lower lung bases. What condition does the nurse identify the client is experiencing? presence of sputum in the trachea presence of fluid in the lungs air passing through narrowed airways inflammation of pleural surfaces

presence of fluid in the lungs

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? thoracentesis spirometry peak expiratory flow rate pulse oximetry

pulse oximetry

The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care? Cut down on smoking. Stay indoors as much as possible. Avoid exposure to large crowds. Practice good hand hygiene.

Stay indoors as much as possible.

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

atelectasis.

A client is diagnosed with hypoxia related to emphysema. The client's adult child will be assisting the client with daily hygiene. How will the nurse explain positioning of the client to the caregiver? "Whichever position helps your parent feel most comfortable and will allow you to help with hygiene is fine." "An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist." "A standing position works best to allow your parent to move around in the bathroom and to allow you to help your parent in and out of the shower." "Place your parent at the sink to allow teeth brushing and stand outside of the shower to help if needed."

"An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist."

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? "If you breathe through the mouth first, you will swallow germs into your stomach." "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." "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."

"Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation."

the home health nurse is visiting a new client who has recently started using an oxygen concentrator. After assessing the home environment, which comment should the nurse prioritize? "Have you noticed an improvement in how you are feeling?" "Does your family help you with the concentrator?" "Have you discussed a back-up system with your health care provider in case your electricity goes out?" "Are you sleeping better now that you are using the concentrator?"

"Have you discussed a back-up system with your health care provider in case your electricity goes out?"

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 60 mL and heart rate is 60 beats per minute, then the cardiac output is 3.2 L/minute." "If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute." "If the client's stroke volume is 80 mL and heart rate is 80 beats per minute, then the cardiac output is 6.0 L/minute." "If the client's stroke volume is 70 mL and heart rate is 70 beats per minute, then the cardiac output is 4.7 L/minute."

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

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 someone take your mask off?" "Did you remove your dentures?" "Did someone loosen the straps on your mask?" "Is your mask causing discomfort?"

"Is your mask causing discomfort?"

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." "An occasional cigarette will not hurt you." "I understand; I used to be a smoker also." "Oxygen is a flammable gas."

"You should never smoke when oxygen is in use."

The obstetric nurse is assisting the birth of a preterm neonate. In preparing for the respiratory needs of the neonate, the nurse is aware that surfactant is formed in utero around: 36 to 38 weeks. 32 to 34 weeks. 30 to 32 weeks. 34 to 36 weeks.

34 to 36 weeks.

A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 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: 1 L/minute. 10 L/minute. 6 L/minute. 4 L/minute.

6 L/minute.

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

A client taking opioids for cancer pain

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 lung sounds Elevate head of the bed Reposition client Assess oxygen tubing connection

Assess oxygen tubing connection

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 one large meal at noon. Snack on high-carbohydrate foods frequently. Eat smaller meals that are high in protein. Contact the health care provider for nutrition shake.

Eat smaller meals that are high in protein.

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 Perfusion Hyperventilation Atelectasis

Hypoxia

A nurse on a cardiac care unit oversees the care of diverse clients' cardiac health problems. Which action can be most appropriately delegated to a licensed practical nurse (LPN)? Application of a client's cardiac monitor Collecting an arterial blood sample Initiation of manual external defibrillation Initiation of CPR for a client who is found unresponsive

Initiation of CPR for a client who is found unresponsive

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? Instruct the client to inhale deeply and then cough. Discard the first sputum produced by the client. Have the client clear the nose and throat and gargle with salt water before beginning the procedure. Place the client in the dorsal recumbent position to collect the specimen.

Instruct the client to inhale deeply and then cough.

The nurse is caring for a client who is wearing oxygen via nasal cannula. The client asks about the bubbling water attached to the oxygen. Which response by the nurse is appropriate? It prescribes oxygen concentration. It decreases dry mucous membranes by delivering small water droplets. It regulates the amount of oxygen received. It determines whether you are getting enough oxygen.

It decreases dry mucous membranes by delivering small water droplets.

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? It decreases dry mucous membranes via delivering small water droplets. It prescribes oxygen concentration. It determines whether the client is getting enough oxygen. It regulates the amount of oxygen received.

It determines whether the client is getting enough oxygen.

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? Pulmonary function tests Bronchoscopy Chest x-ray Skin tests

Pulmonary function tests

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. Leave the airway in place and promptly notify the health care provider for further instructions. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. Suction the client's mouth through the oropharyngeal airway to prevent aspiration.

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

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

Residual Volume (RV)

Which actions should a nurse perform when inserting an oropharyngeal airway? Select all that apply. Rotate the airway 180 degrees as it passes the uvula. Insert the airway with the curved tip pointing down toward the base of the mouth. Wash hands and put on PPE, as indicated. Position client flat on his or her back with the head turned to one side. Remove airway for a brief period every 4 hours or according to facility policy. Use an airway that reaches from the nose to the back angle of the jaw.

Rotate the airway 180 degrees as it passes the uvula. Wash hands and put on PPE, as indicated. Remove airway for a brief period every 4 hours or according to facility policy.

A client, 90 years of age, has been in a motor vehicle collision and sustained four fractured ribs on the left side of the thorax. The nurse recognizes the client is experiencing respiratory complications when which sign(s) is observed? Select all that apply. The client has flaring nostrils. The client's capillary refill is assessed at 4 seconds. The client has a respiratory rate of 16 breaths/min. The client has uneven movements of the chest with respirations. The client demonstrates restlessness.

The client has flaring nostrils. The client's capillary refill is assessed at 4 seconds. The client has uneven movements of the chest with respirations. The client demonstrates restlessness.

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. 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. Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. 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.

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. Use a blood pressure cuff to increase circulation to the site. Place the probe on the client's earlobe. Shine available light on the equipment to facilitate accurate reading.

Warm the client's hands and try again.

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

a client taking an opioid for cancer pain

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client? oxygen analyzer nasal strip flow meter nasal cannula

flow meter

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client? nasal strip flow meter nasal cannula oxygen analyzer

flow meter

The nurse is admitting a new client who has had a chest tube inserted on the right side. Which action should the nurse prioritize for this client? limit movement of the right arm while tube is in place provide bedside commode for client maintain bed in at least semi-Fowler position at all times coughing and deep breathing at least q2h while awake

coughing and deep breathing at least q2h while awake

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

crackles

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

croup.

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? mineral oil normal saline distilled water tap water

distilled water

The nurse has received a prescription to obtain an arterial blood gas (ABG) on a client who has a history of chronic obstructive pulmonary disease (COPD) and is receiving oxygen via nasal cannula. Which step is the most important for the nurse to fulfill? ensure client is at rest at least 30 minutes before obtaining the specimen notify laboratory personnel of the prescription apply pressure to the puncture site for at least 15 minutes after the puncture place the specimen in cold water after filling the tube

ensure client is at rest at least 30 minutes before obtaining the specimen

The nurse is caring for a client with respiratory acidosis. Which arterial blood gas data does the nurse anticipate finding? pH less than 7.35; HCO3 high; PaCO2 high pH less than 7.35; HCO3 low; PaCO2 low pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation pH greater than 7.45; HCO3 high; PaCO2 high

pH less than 7.35; HCO3 high; PaCO2 high

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? nasal cannula face tent tracheostomy collar simple mask

tracheostomy collar

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? suctioning of carbon dioxide loss of sterile field prevention of suctioning trauma to the tracheal mucosa

trauma to the tracheal mucosa