Chapter 39 Prep
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.
How much oxygen flow does a nasal cannula allow?
1L/min-6L/min
What is the normal cardiac output
3.5 L/minute to 8.0 L/minute
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 Cannule -Tracheostomy Collar -Simple face mask -Face tent
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.
A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client?
Ambu bag If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Oxygen masks may cover only the nose and mouth and can vary in the amount of oxygen delivered. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostril. An oxygen tent is a tentlike enclosure within which the air supply can be enriched with oxygen to aid a client's breathing. Oxygen masks, nasal cannula, and oxygen tents are used for clients who have a respiratory drive.
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: Wheezing Crackles Vesicular sounds Bronchovesicular sounds
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.
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.
A nurse is caring for a client who breathes very shallowly and has been reporting severe back pain. What suggestion could the nurse make to help the client breathe efficiently?
Encourage deep breathing -To help the client breathe efficiently, the nurse could encourage the client to take deep breaths. Deep breathing maximizes the ventilation and fills the alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing and diaphragmatic breathing help to eliminate the extra carbon dioxide from the lungs. A nasal strip reduces airflow resistance by widening the nasal-breathing passageways, thus promoting easier breathing. It is used for reducing or eliminating snoring.
The 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 -Hyperventilation -Perfusion -Atelectasis
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.
What is the primary source of paying hospice care
Medicare
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 ox -Peak expiratory flow rate -Spirometry -Thoracentesis
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 L/minute, the nurse inspects the client for which symptom?
Rapid respirations Normal cardiac output averages from 3.5 L/minute to 8.0 L/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 respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.
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 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? Respiratory rate and depth Urinary intake and output Blood pressure Pulse
Respiratory rate and depth The client receiving narcotics/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 narcotics.
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 -Crackles -Stridor
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 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? -flow meter -oxygen analyzer -nasal cannula
The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and 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. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.
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? -Nasal cannula -Simple mask -face tent -Nonrebreathable mask
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.
Which actions should a nurse perform when inserting an oropharyngeal airway? Select all that apply.
The nurse will come into contact with respiratory secretions during the insertion of the oral airway, making it necessary to wear appropriate PPE. The airway will need to be rotated 180 degrees as it passes the uvula because the airway is more easily inserted with the curved tip pointing up towards the roof of the mouth. The airway should be removed for brief periods every 4 hours (or according to facility policy) to prevent constant pressure on the surrounding structures. The airway should reach from the opening of the mouth to the back angle of the jaw. The client should be positioned in a semi-Fowler's position to ease insertion of the airway.
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? -"Oxygen is a flammable gas." -"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.
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? -notify laboratory personnel of the prescription -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.
A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:
a bronchospasm. When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm.
Oxygen and carbon dioxide move between the alveoli and the blood by:
diffusion Oxygen and carbon dioxide move between the alveoli and the blood by diffusion, the process in which molecules move from an area of greater concentration or pressure to an area of lower concentration or pressure.
Which are the goals of health care reform? Select all that apply. Improve access to health care Improve safety Make costs for the uninsured manageable Increase the quality of health care Decrease centralization
-Cost containment, improved access, and increased quality are goals of health care reform. A decrease in centralization is not a goal. Increased centralization is proposed to eliminate wasteful spending on duplicative services. Safety is not a goal of health care reform, it is a goal of Quality and Safety Education for Nurses.
A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario? -Cyanosis -Hypercapnia -Hypoxemia -Eupnea
-Cyanosis around the lips indicates serious hypoxemia. Cyanosis is caused by a desaturation of oxygen on the hemoglobin in the blood. Hypercapnia is caused by an abnormally high carbon dioxide level in the blood. Hypoxemia is caused by low oxygen levels in the blood. Eupnea is easy, free respiration.
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? Why do we teach pursed lips, what does it do?
-Inhale slowly over three seconds, purse your lips, contract abdominal muscles and exhale slowly. -decreases the amount of air trapping and resistance Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.
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.
The nurse educator would intervene with client teaching if which action by the staff nurse occurs when teaching voluntary coughing? -Develop a specific schedule for coughing -The nurse has the client lying in bed in semi-Fowler's position. -Patient should cough before meals. -Cough should be combined with deep breathing
-The nurse has the client lying in bed in semi-Fowler's position. The client should be sitting upright with feet flat on the floor to be most effective. As part of the client's plan of care, the nurse should develop a specific schedule for coughing. Coughing before meals improves the taste of food and oxygenation. When combined with deep breathing, coughing is most effective.
The home health nurse arrives at a client's home and immediately notes the client is experiencing increased dyspnea. The client has a 7-year history of chronic obstructive pulmonary disease (COPD). Which assessment finding should the nurse prioritize? -nasal cannula placed upside down -flow meter set at 5 liters of oxygen -Adjusting the flow meter
-flow meter set at 5 liters of oxygen High percentages of oxygen are contraindicated for a client with COPD, because the client has adapted to excessive levels of retained carbon dioxide and low blood oxygen levels to stimulate the drive to breathe. If a client with COPD receives more than 2 to 3 liters of oxygen over a sustained period, the respiratory rate slows or even stops. Adjusting the flow meter and performing necessary emergent care would be the priority. The other findings are also concerns which can occur when receiving oxygen and would be addressed after dealing with the dyspnea.
Define croup Define Atelectasis Define Pulmonary fibrosis Define Asthma
-loud barking cough -when the lungs collapse as a result of the alveoli being unable to expand. causing difficulty breathing and discomfort -lung tissue becomes stiff and unable to expand appropriately -associated with bronchoconstriction
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? -Total lung capacity (TLC) -Forced expiratory volume (FEV) -Residual Volume (RV) -Tidal volume (TV)
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.
