NURS271: Oxygenation PrepU

The nurse is teaching a patient the proper technique for diaphragmatic breathing. Place the following steps for this procedure in the correct sequence.

- Breathe in slowly and deeply through the nose, letting the abdomen protrude as far as possible. - Press firmly inward and upward on the abdomen while breathing out. - Place one hand on the abdomen and the other hand on the middle of the chest to increase the awareness of the position of the diaphragm and its function in breathing. - Repeat for 1 minute; follow with a rest period of 2 minutes. - Breathe out through pursed lips while tightening the abdominal muscles.

The nurse is caring for a patient in the ICU who required emergent endotracheal (ET) intubation with mechanical ventilation. The nurse receives an order to obtain arterial blood gases (ABGs) following the procedure. The nurse recognizes that ABGs should be obtained at which timeframe following the initiation of mechanical ventilation?

20 minutes The nurse records minute volume and obtains ABGs to measure carbon dioxide partial pressure (PaCO2), pH, and PaO2 after 20 minutes of continuous mechanical ventilation.

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?

84 mmHg In general, clients with respiratory conditions are given oxygen therapy only to increase the arterial oxygen pressure (PaO2) back to the client's normal baseline, which may vary from 60 to 95 mm Hg.

The nurse is assigned the care of a patient with a chest tube. The nurse should ensure that which of the following items is kept at the patient's bedside?

A bottle of sterile water It is essential that the nurse ensure that a bottle of sterile water is readily available at the patient's bedside. If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent the development of a pneumothorax, a temporary water seal can be established by immersing the chest tube's open end in a bottle of sterile water. There is no need to have an Ambu bag, incentive spirometer, or a set of hemostats at the bedside

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for

A kink in the ventilator tubing One reason an alarm on the ventilator, indicating increased peak airway pressure, could sound is from a kink in the ventilator tubing. After making this and other assessments without correction, then it could be a malfunction of the alarm button. Higher than normal endotracheal cuff pressure could cause client tissue damage but would not make the ventilator alarms sound. A cut or slice in the tubing from the ventilator would result in decreased pressure.

A patient with newly diagnosed emphysema is admitted to the medical-surgical unit for evaluation. Which of the following does the nurse recognize is a deformity of the chest wall that occurs as a result of over inflation of the lungs in this patient population?

Barrel chest A barrel chest occurs as a result of over inflation of the lungs. There is an increase in the anteroposterior diameter of the thorax. It occurs with aging and is a hallmark sign of emphysema and chronic obstructive pulmonary disease (COPD). In a patient with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge on expiration.

A client presents to the emergency department with fluid overload. The nurse is concerned about fluid accumulation in the lungs. On which of the following areas would the nurse focus the lung assessment?

Bilateral lower lobes Assessment of the anterior and posterior lungs is part of the nurse's routine evaluation.

Late sign of hypoxia?

Cyanosis

A _______ percussed sound, heard over the chest wall, is indicative of little or no air movement in that area of the lung

Dull

The nurse should monitor a client receiving mechanical ventilation for which of the following complications?

GI hemorrhage Gastrointestinal hemorrhage occurs in approximately 25% of clients receiving prolonged mechanical ventilation. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis. Immunosuppression and pulmonary emboli are not direct consequences of mechanical ventilation.

A _____ _____ sound is an abnormal lower pitched sound that occurs when free air exists in disease processes such as pneumothorax.

Hyper resonant

Which of the following would indicate a decrease in pressure with mechanical ventilation?

Increase in compliance A decrease in pressure in the mechanical ventilator may be caused by an increase in compliance.

Which of the following is the key underlying feature of asthma?

Inflammation Inflammation is the key underlying feature and leads to recurrent episodes of asthma symptoms: cough, chest tightness, wheeze, and dyspnea.

A young male client has muscular dystrophy. His PaO2 is 42 mm Hg with a FiO2 of 80%. Which of the following treatments would be least invasive and most appropriate for this client?

Negative-pressure ventilator This client needs ventilatory support. His PaO2 is low despite receiving a high dose of oxygen. The iron lung or drinker respiratory tank is an example of a negative-pressure ventilator. This type of ventilator is used mainly with chronic respiratory failure associated with neurological disorders, such as muscular dystrophy.

A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease (COPD). The first action of the nurse is to administer which of the following prescribed treatments?

Oxygen through nasal cannula at 2 L/minute O2 is first line tx

In general, chest drainage tubes are not used for the patient undergoing

Pneumonectomy Usually, no drains are used for the pneumonectomy patient because the accumulation of fluid in the empty hemothorax prevents mediastinal shift. With lobectomy, two chest tubes are usually inserted for drainage, the upper tube for air and the lower tube for fluid. With wedge resection, the pleural cavity usually is drained because of the possibility of an air or blood leak. With segmentectomy, drains are usually used because of the possibility of an air or blood leak.

Normal lung tissue sounds?

Resonant

A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. Which of the following describes these sounds?

Rhonchi Rhonchi are deep, low-pitched, rumbling sounds heard usually on expiration. The etiology of rhonchi is associated with chronic bronchitis.

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:

Symmetry of the client's chest expansion Immediately after intubation, the nurse should check for symmetry of chest expansion. This is one finding that indicates successful endotracheal placement. The tracheal cuff pressure is set between 15 and 20 mm Hg. Routine deflation of the tracheal cuff is not recommended, because the client could then aspirate secretions during the period of deflation.

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:

Symmetry of the client's chest expansion Immediately after intubation, the nurse should check for symmetry of chest expansion. This is one finding that indicates successful endotracheal placement. The tracheal cuff pressure is set between 15 and 20 mm Hg. Routine deflation of the tracheal cuff is not recommended, because the client could then aspirate secretions during the period of deflation. Warm, high, humidified air is administered through the endotracheal tube.

A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to:

Take prescribed albuterol (Ventolin) before performing postural drainage. When a client is to perform postural drainage, the nurse should instruct the client to use the prescribed bronchodilator (eg, albuterol) first. This will open airways and promote drainage. The client is to perform postural drainage before meals, not after. This will aid in preventing nausea, vomiting, and aspiration. For secretions accumulated in the upper lobes, the client will sit up or even lean forward while sitting. Head on a pillow is not a sufficient increase in height. The client is also to lay in each position for 10 to 15 minutes.

A patient is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which of the following actions first?

Troubleshoot to identify the malfunction The nurse should first immediately attempt to identify and correct the problem and, if the problem cannot be identified and/or corrected, the patient must be manually ventilated with an Ambu bag. The respiratory therapist may be notified, but this is not the first action by the nurse. The nurse should not reposition the ET tube as a first response to an alarm.

A ________ sound is a high-pitched sound commonly heard over the stomach or bowel

Tympanic

Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?

Venturi mask The Venturi mask is the most reliable and accurate method for delivering a precise concentration of oxygen through noninvasive means. The mask is constructed in a way that allows a constant flow of room air blended with a fixed flow of oxygen. Nasal cannula, T-piece, and partial-rebreathing masks are not the most reliable and accurate methods of oxygen administration.