Fundamentals Nursing Prep U Chapter 39 Oxygenation and Perfusion

The home care nurse is visiting a client who is totally oxygen dependent and using 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."

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 nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the oxygen analyzer?

"It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed."

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."

A client using home oxygen asks the nurse about changing to an oxygen concentrator. What is the appropriate nursing response? (Select all that apply.)

* "It collects and concentrates oxygen from room air." * "It eliminates the need for a central reservoir of piped oxygen." * "You may notice an increase in your electric bill." * "It costs less than oxygen supplied in portable tanks."

The nurse is reviewing the results of a client's arterial blood gas and pH analysis. Which findings indicate to the nurse that intervention is not required? Select all that apply.

* pH 7.45 * PCO2 40 mm Hg * Base excess or deficit +2 mmol/L

The nurse is caring for a client who will have a chest tube removed within the next hour. What action by the nurse will be included in the plan of care for this client for removal of the chest tube? Select all that apply

*Administer prescribed pain medication 15 to 30 minutes before chest tube removal *Teach the client about relaxation exercises to be used during chest tube removal *Apply a cold compress to the site prior to the removal

The nurse is monitoring a client who is receiving oxygen via a nonrebreather mask at 12 L/min. What actions by the nurse will promote the best outcomes for this client? Select all that apply.

*Maintain flow rate so that the reservoir bag collapses only slightly during inspiration. *Check that the valves and rubber flaps are functioning properly. *Monitor SaO2 with pulse oximeter.

The nurse is caring for a client with a North America Diagnosis Association-International (NANDA-I) diagnosis of Imbalanced nutrition: Less than body requirements, related to difficulty breathing. The nurse would implement which measures to maintain an adequate nutritional status for this client? Select all that apply.

*Provide frequent oral hygiene especially before meals. *Distribute six small meals over the course of the day.

The nurse working in the intensive care unit is preparing to admit a client from the emergency department that had a stroke located in the medulla. What equipment should the nurse have present in the room upon the client's arrival into the unit related to the client's condition? Select all that apply.

*Pulse oximeter *Ventilator

The nurse is planning a diet for a patient with Chronic Obstructive Pulmonary Disease (COPD). Which recommended nutritional guidelines would the nurse discuss with the client? Select all that apply

*The diet should consist of 40% to 55% carbohydrates. *The diet should be rich in antioxidants and vitamin A, C, and B. *The diet should contain 12% to 20% protein.

Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system? Select all that apply.

*slightly contoured chest with no sternal depression *anteroposterior diameter of the chest less than the transverse diameter *bronchial, vesicular, and bronchovesicular breath sounds

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?

Arterial blood gas

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

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.

An older adult client visits a health care facility for a scheduled physical assessment. During the assessment, the client reports difficulty breathing. What suggestion could the nurse make to improve the client's respiratory function in this case?

Drink liberal amounts of fluids

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

Flow meter

Which is a sign of dyspnea specific to infants?

Nasal flaring

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

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

Pulmonary function tests

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

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)

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

Suction the tracheostomy tube using sterile technique.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression.

Which scenario describes how carbon dioxide levels determine the frequency and depth of ventilation?

When carbon dioxide levels in the blood increase, chemoreceptors are stimulated, causing deeper and more rapid breathing.

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

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

atelectasis

What assessments would a nurse make when auscultating the lungs?

cardiovascular function

When the nurse observes a newborn infant demonstrating an irregular abdominal breathing pattern, with a respiratory rate of 50 breaths/minute with occasional pauses in breathing of 5-second durations. What is the most appropriate action by the nurse?

continue to assess the infant

Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways?

decreases the amount of air trapping and resistance

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

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

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:

hemoglobin level

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

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

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

The nurse is caring for a 2-year-old client who experienced smoke inhalation during a house file. When oxygen is ordered, what delivery device will the nurse gather?

oxygen tent

What structural changes to the respiratory system should a nurse observe when caring for older adults?

respiratory muscles become weaker

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