CNF Exam 2: Oxygenation and Perfusion (38)

The home care nurse is visiting a client who uses home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?

"An electric stove may be a safer choice for you." For safety purposes, oxygen tanks should be kept at least 10 feet away from gas stoves, fires, and other flammable devices.

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.

The nursing student is conducting a health history interview with a patient who has a long-standing diagnosis of asthma. Which of the following assessment questions is most appropriate? - "How often do you have to use your prescribed bronchodilators?" - "Did you complete a full course of antibiotics?" - "Is there any history of lung cancer in your family?" - "Have you received the meningococcal vaccination?"

"How often do you have to use your prescribed bronchodilators?" Asthma usually requires treatment with bronchodilators. It has a noninfectious etiology, so antibiotics are unnecessary unless a secondary infection occurs. Lung cancer and the meningococcal vaccine are not directly relevant to the patient's history or present condition.

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include the humidifier? - "This is a gauge used to regulate the amount of oxygen that a client receives." - "The humidifier prescribes the concentration of oxygen." - "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." - "Small water droplets come from this, thus preventing dry mucous membranes.

"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.

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? - "That will help the oxygen flow more freely." - "The caregiver will need to place the oxygen tank back into the secure carrier." - "That will make it easier to carry with you." - "Call your oxygen supplier immediately."

"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.

A client who was prescribed CPAP 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 healthcare provider to find alternate treatment options if necessary, and then document the care.

The nurse is caring for an older adult client on home oxygen who has dentures, but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate?

Check fit of oxygen mask. The fit of the oxygen mask can be affected by the discontinuation of wearing dentures. The nurse should check the fit to make sure the client is getting the prescribed amount of oxygen.

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 - eupnea - hypercapnia - hypoxemia

Cyanosis 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.

A nurse is working with an older adult patient who has been diagnosed with pneumonia. Which of the following are age-related changes that may have increased the patient's susceptibility to respiratory infections? - Increased permeability of the alveoli - Decreased numbers of functional cilia - Increased production of alveolar surfactant - Hypertrophy of the diaphragm

Decreased numbers of functional cilia With age, the number of cilia declines, increasing the older adult's susceptibility to respiratory infections. The alveoli do not become more permeable with age, and surfactant is not produced in increased quantities. The diaphragm, like most muscles, does not increase in size or strength with age.

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

It regulates the amount of oxygen received. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The oxygen analyzer measures the percentage of delivered oxygen. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.

The nurse is caring for a 3-year-old client who experienced smoke inhalation during a house fire, and now requires oxygen. What delivery device will the nurse select that is most appropriate for this client? - nasal catheter - oxygen tent - venturi mask - non-rebreather mask

O2 tent An oxygen tent is often used when caring for active toddlers who require oxygen, since they are less likely to keep a mask on. Nasal catheters and masks are inappropriate, as the child will attempt to remove them and not receive the benefit of oxygen therapy.

T/F: 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. This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis.

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of:

atelectasis Stiffer lungs tend to collapse and also cause their alveoli to collapse. This condition is called atelectasis

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.

The nurse is delegating hygiene care to the UAP for a client with hypoxia. What position will the nurse tell the UAP to place the client in?

high Fowlers High Fowlers position allows the client with hypoxia to breathe easier by promoting lung expansion, as the abdominal organs descend away from the diaphragm. The other positions compromise lung expansion.

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 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.

The nurse is listening to the client's lungs and hears them fill with air and then return to a resting position. How will the nurse document this assessment data?

inspiration and expiration Lungs stretch and fill with air during inspiration and return to a resting position following expiration. Ventilation is the movement of air in and out of the lungs. Respiration is the exchange of oxygen and carbon dioxide.

The nurse is caring for a client who will be wearing a simple mask for oxygen delivery. What planning regarding the mask will the nurse include in the plan of care? - will accommodate up to 10 L/min of oxygen administration - will create a risk for oxygen toxicity - may cause anxiety in client with claustrophobia - may pull on tracheostomy tubing

may cause anxiety in client with claustrophobia A simple mask may cause anxiety in clients with claustrophobia. The simple mask provides 5-8 L/min of oxygen administration. It does not create a risk for oxygen toxicity, nor will it be used for a client with a tracheostomy.

What is the action of codeine when used to treat a cough?

suppressant Codeine, which is an ingredient in many cough preparations, is generally considered to be the preferred cough suppressant ingredient.

The nurse is instructing the client with a pulmonary disorder on 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." 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 client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response? - "Have you tried nasal strips?" - "There is very little that can be done for snoring." - "Pursed-lip breathing can reduce your amount of snoring." - "Let me teach you about incentive spirometry."

"Have you tried nasal strips?" Nasal strips are available over the counter and are used to widen the nasal passageways. A common use for nasal strips is to reduce or eliminate snoring. Other choices are incorrect.

The nurse is providing discharge teaching to a client going home with oxygen therapy. Which statements made by the client would indicate to the nurse that the teaching was effective? Select all that apply. - "I will not allow smoking within 10 feet (3 meters) of my oxygen." - "I will keep the oxygen tank away from direct sunlight or heat." - "I will secure my tank by placing it flush against the wall." - "I will adjust the oxygen flow according to my needs." - "I will only use an electrical instead of gas stove."

"I will not allow smoking within 10 feet (3 meters) of my oxygen." "I will keep the oxygen tank away from direct sunlight or heat." Oxygen is combustible, so keep it away from smoking or direct sunlight. It is important to allow adequate airflow around the oxygen concentrator, so it should not be placed flush against the wall. It's more important to follow the prescription, than to adjust the oxygen flow rate because too much or too little oxygen may be detrimental to the client. The client must use caution with both gas and electrical stoves.

The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner? - 10 L/min oxygen via Venturi mask - 8 L/min oxygen via partial rebreather mask - 8 L/min oxygen via nasal cannula - 12 L/min oxygen via nonrebreather mask

8 L/min oxygen via nasal cannula The correct amount delivered FiO2 for a nonrebreather mask is 12 L/min; 8-11 L/min for partial rebreather mask; 4-10 L/min for Venturi mask; and 1-6 L/min for nasal cannula. However, per nasal cannula it may be no more than 2-3 L/min to patient with chronic lung disease.

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines?

Be sure to shake the canister before using it. A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly. MDIs are inhaled through the mouth, into the lungs. The medication should be inhaled slowly to ensure a sufficient dose enters the lungs. If the order is for two sprays, these sprays are administered with one spray for each breath. The inhaled breath should be held briefly after each spray in order to prevent immediately exhaling the medication.

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

Bronchospasm 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.

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe? - Crackles in the lower lobes - Inspiratory stridor - Expiratory stridor - Wheezing in the upper lobes

Crackles in the lower lobes People with chronic congestive heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels. Stridor is associated with respiratory infections such as croup. Wheezing may be heard in individuals who use tobacco products.

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?

Distilled water is used when humidification is desired.

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.

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 is caring for a client with a chest tube. Stationary clots are noted in the tubing. What is the appropriate nursing action?

Milk the tubing to strip it of clots. When stationary clots are noted, a process of compressing and stripping of the tubing (known as milking) can be done. This should never be done routinely since it can cause high negative intrapleural pressure.

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.

The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective? - clubbing of fingers - respirations 26 breaths/minute - heart rate 110 bpm - SpO2 92%

SpO2 92% An SpO2 at or above 90% is normal, reflecting that oxygen therapy is being effective. Clubbing, respirations greater than 26 breaths/minute, and a heart rate greater than 100 beat per minute may indicate that more oxygen is needed.

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? - Crackles - Bronchovesicular - Bronchial - Vesicular

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.

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

educating the client on the use of incentive spirometry Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.

The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach?

"Take in as much air as possible, hold your breath briefly, and exhale slowly." This technique maximizes ventilation taking in a large volume of air fills alveoli to a greater capacity, which improves gas exchange. Deep breathing is useful for client's who has been inactive or in pain as associated with pneumonia.

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

Croup 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.

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system? - an older adult client who has COPD - a child who has pneumonia - an adult who is receiving oxygen at home - an adolescent who has asthma

a child who has pneumonia An oxygen tent is commonly used with children who need a cool and highly humidified airflow. It is also more effective for children because they often do not like to keep oxygen administration devices in place. Since the tent does not allow the maintenance of a satisfactory or precise oxygen concentration, is difficult to maintain a consistent level of oxygen. The oxygen tent does not adequately deliver oxygen at a rate higher than 30% to 50%; thus, it is rarely used with other clients.

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 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 client with chronic obstructive pulmonary disease (COPD) reports severe shortness of breath when it is raining. The nurse says to the client:

"The air is thicker or more viscous with humidity, thus it is harder for you to breathe." People with chronic respiratory diseases often find breathing more difficult when the weather is hot and humid because humidity contributes to air viscosity.

The nurse is talking with a client who has COPD. The client reports her chest shape seems to have changed over the past year. What information should be provided by the nurse?

"Your lung condition limits the ability of the lungs to fully exhale, causing this change in shape." In COPD, the client's chest becomes overinflated over time because of an inability to exhale fully. This increases the anterior-posterior chest diameter, resulting in a barrel-shaped appearance.

A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient? - Oxygen mask - Nasal cannula - Ambu bag - Oxygen tent

Ambu bag If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag)may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube.

A nursing student is providing care for a patient who is recovering in hospital from abdominal surgery. What intervention should the student perform in order to promote and protect the patient's respiratory function while the patient is recovering? - Administer prophylactic antibiotics. - Administer supplementary oxygen by face mask during waking hours. - Keep the patient's head of bed ≥45° at all times. - Encourage the patient to perform deep breathing and coughing exercises.

Encourage the patient to perform deep breathing and coughing exercises. The nurse can promote airway clearance and respiratory function by encouraging a patient to deep breathe and cough to remove secretions. For most patients, antibiotics are not administered as a preventive measure. Similarly, supplementary oxygen is not given unless there is a clear indication for its use. Increasing the height of the bed is not usually necessary in order to prevent respiratory complications.

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

Rapid respirations 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.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order? - Tidal volume (TV) - Total lung capacity (TLC) - Forced Expiratory Volume (FEV) - Residual Volume (RV)

Residual Volume (RV) 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.

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 - tracheostomy collar - simple mask - face tent

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.

The nurse is caring for a client who was 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 collor A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT.

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 - Nasal cannula - Flow meter

Flow meter 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.

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test? - Monitor the pressure of oxygen dissolved in plasma. - Measure the volume of air exhaled or inhaled over time. - Calculate the pressure of carbon dioxide dissolved in plasma. - Monitor the amount of oxygen saturation in the blood

Monitor the amount of oxygen saturation in the blood. The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. The arterial blood gases test the client's blood for the partial pressure of oxygen dissolved in plasma, the percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma. Spirometry measures the volume of air in liters exhaled or inhaled by a client over time