OXYGENATION

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."

Abdominal thrust

(AKA Heimlich maneuver) rescuer stands behind a patient and uses his/her hands to exert pressure on the bottom of the diaphragm. Technique compresses the lungs and exerts pressure on any object lodged in the trachea, hopefully expelling it.

what is the component to CPR?

(CAB) chest compression airway breathing this excludes newborns ventilation is done after 30 chest compressions

Cardiopulmonary resuscitation

(CPR) emergency medical procedures for restoring normal heartbeat and breathing to victims of heart failure, drowning, etc.

Orthostatic hypotension

(aka postural hypotension, orthostasis, head rush, dizzy spell) a form of hypotension in which a person's blood pressure suddenly falls when standing up or stretching. A fall in systolic blood pressure by 20 mm Hg or diastolic blood pressure of at least 10 mm Hg when a person stands.

Bronchial spasm

(bronchospasm) contraction of smooth muscle in the walls of the bronchi and bronchioles, causing narrowing of the lumen. (as in asthma)

Aerosol therapy

(nebulizer) a device that turns liquid medication into a mist so that it can be breathed directly into the lungs through a facemask or mouthpiece. Helps dilate the airways of the lungs, to facilitate secretion remove, and with overall respiratory efficiency.

Nares

(nostrils) one of the two channels of the nose.

Oropharynx

(oral part of the pharynx) reaches from the uvula to the level of the hyoid bone.

Palpable

(palpation) process of using your hands to examine the body, especially while perceiving/diagnosing a disease or illness.

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

Christmas tree

- a green adapter at the bottom of the flow meter. -connects the extension tubing and oxygen-delivery device to the flow meter.

compressed gas cylinders or tanks

- fairly inexpensive. -do not require an electrical source. -deliver oxygen up to 15 L/min. -bulky and heavy. -patients need to know how to read the regulator so they know when to call for a new tank. -different sizes available. -100% pure oxygen.

what are nursing diagnosis related to cardiopulmonary problems?

-Activity intolerance -Decreased cardiac output -Fatigue -Impaired gas exchange -Impaired verbal communication -Ineffective airway clearance -Risk for aspiration -Ineffective breathing pattern -Ineffective health maintenance

implementation: acute care what you should implement in acute care for pulmonary illness?

-Dyspnea management -Airway maintenance -Mobilization of pulmonary secretions -Hydration -Humidification -Nebulization -Coughing and deep-breathing techniques -chest percussion

what are some promoting healthy lifestyles in promoting pulmonary function and prevention of respiratory infections?

-Eliminating risk factors, -eating right, -regular exercise

Discuss circulation and respiratory changes (system-wise) in older adults. How can we prevent infection?

-Heart of an older adult is slow to increase under stress -Experience alterations in cardiac function as a result of calcification of the conduction pathways -Thicker and stiffer heart valves caused by lipid accumulation and fibrosis, -Decrease in number of pacemaker cells in the SA node -Atrial fibrillation is a common dysrhythmia SEE BOX 4-11 PG. 879

hypoventilation

-Irregular shallow breathing

Draw a label how the conduction system is visualized on an ECG tracing, PQRST. What is normal sinus rhythm (NSR)?

-Originates at the SA node, follows normal sequence through conduction system -P wave: Atrial depolarization (contraction) -PR interval -QRS complex: ventricular depolarization (contraction) AND atrial repolarization (relaxation) -QT interval: ventricular depolarization (relaxation) and repolarization (relaxation_

what are some nursing assessment question for those with problem with oxygen?

-Pain -Fatigue -Dyspnea -Cough -Wheezing -Smoking -Respiratory infection -Allergies -Health risks Medications

what are some environmental pollutants that can cause respiratory infections?

-Secondhand smoke, -work chemicals, -and pollutants

physical examination for pulmonary system what do you inspect for in pulmonary system?

-Skin and mucous membrane color, -level of consciousness (LOC), -breathing patterns, -chest wall movement, -general appearance, -circulation

nonrebreather mask

-The valves on the side ports of the mask allow exhalation but close on inspiration to prevent inhalation of room air. -The reservoir bag allows a higher FiO₂ to be administered. -used to deliver high flow rates and high concentrations of oxygen. -do not allow the reservoir bag to deflate or the oxygen source to deplete.

implementation: health promotion what are some health promoting factors related to the cardiopulmonary system?

-Vaccination -healthy lifestyle -environmental pollutants

oxygen tent

-a canopy that surrounds the patient, providing oxygen, humidification, and a cool environment to help control body temperature. -usually used for pediatric patients who have airway inflammation, croup, or other respiratory infections.

nasal cannula

-a common oxygen-delivery device consisting of a length of tubing with two small prongs that are inserted into the patient's nares. -Most patients tolerate this device well, and it is simpler to use than a mask. -delivers oxygen concentrations of 24% to 44% with flow rates from 1 to 6 L/min.

flow meter

-a device used to control the rate of oxygen being delivered in liters per minute. -attaches to the oxygen outlet.

maintenance and promotion of lung expansion what helps patients to increase lung expansion?

-ambulation -positioning -incentive spirometry

face tent

-an alternative to an aerosol mask for patients who feel claustrophobic, but it is sometimes difficult to keep in place. -convenient for providing humidification and oxygenation. -oxygen concentration cannot be controlled.

simple face mask

-an oxygen-delivery apparatus used for patients who require a moderate flow rate for a short period of time via a plastic mask that fits snugly over the mouth and nose. -requires a fairly high oxygen flow to prevent rebreathing of carbon dioxide. -An accurate FiO₂ is difficult to estimate. -do not use a flow rate lower than 6 L/min with this type of mask.

restorative and continuing care what emphasizes cardiopulmonary reconditioning?

-cardiopulmonary rehabilitation -respiratory muscle training -breathing exercises

what do you palpate in pulmonary examination?

-chest -feet -legs -pulses

chronic hypoxia

-clubbing of their fingers and toes. -peripheral edema. -right-sided heart failure. -respiratory acidosis. -an oxygen saturation below 87%.

late stages of hypoxia

-decreased level of consciousness. -decreased activity level. -hypotension. -bradycardia. -metabolic acidosis. -cyanosis.

what are the three basic techniques of breathing exercises?

-deep breathing and cough exercises -pursed lip breathing -diaphragmatic breathing

liquid oxygen systems

-deliver oxygen up to 6 L/min. -do not require electricity. -stored in a large stationary vessel from which the patient can fill a small portable tank. -expensive. -evaporation occurs when not in use and in warm weather. -good choice for more active patients. -100% pure oxygen.

tracheostomy collar

-designed to provide high humidity and the oxygen concentration prescribed for the patient. -a small oxygen-delivery apparatus that fits over a tracheostomy site and is held in place by an adjustable elastic strap that fits around the patient's neck; also called a tracheostomy mask.

FiO₂

-fraction of inspired oxygen. -varies depending on the flow of oxygen in L/min and the rate and depth of the patient's breathing.

pressure gauge

-indicates the pressure, or amount of oxygen, in the cylinder in pounds per square inch (psi).

what is plastic face mask with reservoir bad mask used for?

-it is capable of delivering higher concentrations of oxygen. -delivers 10-15 L/min

how ling is simple face mask used for?

-it is used for short term therapy -delivers oxygen concentrations from 6-12 L/min. -contraindicated for patients with carbon dioxide retention

Venturi mask

-most accurate form of oxygen delivery. -uses different size adaptors to deliver a fixed or predicted FiO₂. -FiO₂ delivered depends on the flow rate and/or entrainment port size. -used for patients who have COPD when an accurate FiO₂ is essential and carbon dioxide buildup must be kept to a minimum. -Humidifiers usually are not used with this device. -At the base of the mask and connected to the tubing are color-coded adaptors.

maintenance and promotion of lung expansion what are the types of chest tubes used?

-pneumothorax -hemothorax -special considerations

early stages of hypoxia

-restlessness. -confusion. -anxiety. -elevated blood pressure. -increased heart rate. -increased respiratory rate. -dyspnea.

carbon dioxide narcosis

-results when patients with COPD receive oxygen at too high a flow rate. -causes confusion, tremors, convulsions, and coma. -can ultimately lead to respiratory arrest if left untreated.

what are the types of oxygen masks used?

-simple face mask -plastic mask with reservoir bag -venturi mask

oxygen concentrator

-takes nitrogen, water vapor, and hydrocarbons from room air and delivers oxygen that is "concentrated" from room air. -least expensive mode of delivery. -a good choice to homebound patients as it is not an ambulatory unit. -oxygen concentration decreases as liter flow increases, and most units can deliver 4 or 5 L/min. -needs to be close to a power source.

tracheal suctioning

-through an artificial airway

What does the conduction system do?

-transmits electrical impulses -generates impulses needed to initiate the electrical chain of events for a normal heartbeat

aerosol mask

-used when high humidity levels are required. -fits over the patent's mouth and nose.

humidification

-usually accomplished by attaching a bottle of sterile water to the oxygen-delivery equipment. -Be sure to replace the sterile water at least every 24 hours or according to the facility's policy. -required with high flow rates (FiO₂ of 4 L/min or more).

Know A&P of blood flow through the heart, to the body, back to the heart.(12)

1 & 2. Superior vena cava and inferior vena cava 3. right atrium 4. tricuspid valve 5. right ventricle 6. pulmonary valve 7. pulmonary arteries (to lungs) 8. pulmonary veins (from lungs) 9. left atrium 10. mitral valve 11. left ventricle 12.aortic valve

____ 9. What is the rationale for wrapping petroleum gauze around a chest tube insertion site? 1) Prevents air from leaking around the site 2) Prevents infection at the insertion site 3) Absorbs drainage from the insertion site 4) Protects the tube from becoming dislodged

1) Prevents air from leaking around the site

What assessment findings might the nurse expect to see in a patient experiencing hypoxia? Select all that apply. 1) Altered level of consciousness 2) Peripheral pitting edema 3) Cyanosis of skin and mucous membranes 4) Weak or absent peripheral pulses 5) Jaundiced sclera

1) Altered level of consciousness 3) Cyanosis of skin and mucous membranes 4) Weak or absent peripheral pulses Rationale: Hypoxia leads to decreased oxygenation of organs and tissues. To determine adequacy of tissue oxygenation, you must assess both circulation and tissue/organ function. An altered level of consciousness may result from hypoxic central nervous system tissue. Poor peripheral circulation is characterized by weak or absent pulses; pale, ashen, or cyanotic skin and mucous membranes; and cool skin temperature. Peripheral edema does not result from hypoxia.

The nurse is caring for an older adult woman who was admitted 3 days ago following a cerebrovascular accident. She has had trouble swallowing and has been placed on aspiration precautions. Care of this patient will include the following. Select all that apply. 1) Ensure she is sitting upright or with the head of the bed elevated to eat and drink. 2) Break or crush her pills (if appropriate) before administration. 3) Provide only thin, clear liquids. 4) Keep suction setup available at all times.

1) Ensure she is sitting upright or with the head of the bed elevated to eat and drink. 2) Break or crush her pills (if appropriate) before administration. 4) Keep suction setup available at all times. Rationale: Aspiration is a risk for patients with a decreased level of consciousness, diminished gag or cough reflex, or difficulty with swallowing. You should keep suction setup available for routine and emergency use. Keeping the head of the bed elevated will also help to prevent aspiration. Breaking or crushing pills will make it easier for her to swallow her medications. Thin, clear liquids are more likely to be aspirated than are thickened liquids, and there is no indication for clear liquids.

Respiratory function involves, in addition to the respiratory system, which three body systems? Select all that apply. 1) Neurological 2) Endocrine 3) Cardiovascular 4) Musculoskeletal

1) Neurological 3) Cardiovascular 4) Musculoskeletal Rationale: The musculoskeletal and neurological systems regulate the movement of air into and out of the respiratory system. The cardiovascular system transports oxygen and carbon dioxide, which are exchanged in the lungs.

What is the rationale for wrapping petroleum gauze around a chest tube insertion site? 1) Prevents air from leaking around the site 2) Prevents infection at the insertion site 3) Absorbs drainage from the insertion site 4) Protects the tube from becoming dislodged

1) Prevents air from leaking around the site Rationale: Petroleum gauze creates a seal around the insertion site. Collapse of the lung can occur if there is a leak around the insertion site that causes loss of negative pressure within the system. Air leaks are one common cause of loss of negative pressure.

The nurse is caring for an adolescent with a history of asthma. The patient is currently being treated for acute bronchitis. A thorough nursing assessment of the patient's pulmonary status will include. Select all that apply. 1) Skin color 2) Temperature 3) Auscultation of breath sounds 4) Testing of cough reflex 5) Chest x-ray

1) Skin color 2) Temperature 3) Auscultation of breath sounds Rationale: Auscultation of the lungs will detect any adventitious breath sounds (e.g., wheezing) that may be present with asthma and bronchitis. Evaluation of skin color and temperature are indirect methods to assess tissue oxygenation. A chest x-ray requires a physician order and is not a part of the nursing assessment. The cough reflex should be assessed in clients with decreased levels of consciousness.

____ 2. A patient has a history of COPD. His pulse oximetry reading is 97%. What other findings would indicate adequate tissue and organ oxygenation? Choose all that apply. 1) Normal urine output 2) Strong peripheral pulses 3) Clear breath sounds bilaterally 4) Normal muscle strength

1,2,4

The nurse is caring for a patient who exhibits labored breathing, is using accessory muscles, and is coughing up pink frothy sputum. The patient has diminished breath sounds in bilateral lung bases. What are the priority nursing assessments for the nurse to perform prior to notifying the health care provider? (select all that apply) 1.SpO2 levels 2.Amount, color, and consistency of sputum production 3. Fluid status 4. Change in respiratory rate and pattern 5. Pain in lower leg

1,2,4 rationale:These are key respiratory assessments that provide data on patient's worsening respiratory status. While fluid status does impact respiratory status, it is not a priority assessment at this time. Pain in lower leg is assessed later.

Identify one or more choices that best complete the statement or answer the question. ____ 1. The nurse is counseling a 17-year-old girl on smoking cessation. The nurse should include which of the following helpful tips in her education? Choose all that apply. 1) "Keep healthy snacks or gum available to chew instead of smoking a cigarette." 2) "Don't tell your friends and family you are trying to quit, until you feel confident that you'll be successful." 3) "Plan a time to quit when you will not have many other demands or stressors in your life." 4) "Reward yourself with an activity you enjoy when you quit smoking."

1,3,4

____ 7. Which of the following factors influence normal lung volumes and capacities? Choose all that apply. 1) Age 2) Race 3) Body size 4) Activity level

1,3,4

____ 3. The nurse is teaching a patient about her chest drainage system. Which of the following should the nurse include in the teaching? Choose all that apply. 1) Perform frequent coughing and deep-breathing exercises. 2) Sit up in a chair but do not walk while the drainage system is in place. 3) Get out of bed without assistance as much as possible. 4) Immediately notify the nurse if she experiences increased shortness of breath.

1,4

____ 6. Which of the following is/are accurate about nasotracheal suctioning? Choose all that apply. 1) Apply suction for no longer than 10-15 sec during a single pass. 2) Apply suction while inserting and removing the catheter. 3) Reapply oxygen between suctioning passes for ventilator patients. 4) Gently rotate the suction catheter as you remove it.

1,4

A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (select all that apply) 1.Sharp pleuritic pain that worsens on inspiration 2.Crackles over lungs bases of affected lung 3.Tracheal deviation toward the affected lung 4. Worsening dyspnea 5. Absent lung sounds to auscultation on affected side

1,4,5 Rationale:When the lung collapses, as with a pneumothorax, the thoracic space fills with air, which irritates the parietal pleura causing inspiratory pain. Because of the collapsed lung there is reduced gas exchange in the affected area, reduced oxygenation and dyspnea result. When an area of the lung collapses, breath sounds over affected area are absent.

A patient has been newly diagnosed with chronic lung disease. In discussing the lung disease with the nurse, which of the patient's statements would indicate a need for further education?

1. "I'll make sure that I rest between activities so I don't get so short of breath." 2. "I'll practice the pursed-lip breathing technique to improve my exercise tolerance." 3. "If I have trouble breathing at night, I'll use two or three pillows to prop up." 4. "If I get short of breath, I'll turn up my oxygen level to 6 L/min." 4

Breathing, types of:

1. Abdominal - (diaphragmatic, abdominal, belly, and deep breathing are all the same) breathing that is done by contracting the diaphragm, a muscle located horizontally between the chest and stomach cavity. Air enters the lungs and the belly expands during this type of breathing. 2. Apnea - a term for the suspension of external breathing, during apnea there is no movement of the muscles of respiration and the volume of the lungs initially remains unchained. 3. Bradypnea - slow breathing rate 4. Deep 5. Diaphragmatic 6. Eupnea - normal, good, unlabored ventilation, sometimes known as quiet breathing or resting heart late. 7. Pursed-lip - act of exhaling through tightly pressed, pursed lips. Taught to patients to ease shortness of breath and to promote deep breathing. 8. Tachypnea - rapid breathing, any rate of breathing greater than 20 breaths per minute (normal is 12-20) 9. Thoracic - (shallow breathing, chest breathing) the drawing of minimal breath into the lungs, usually by drawing air into the chest using intercostal muscles rather than through the lungs via the diaphragm

Breath sounds:

1. Adventitious: (AKA abnormal) - Crackles (rales) - clicking, rattling, bubbling - Gurgles (rhonchi) - a coarse rattling respiratory sound somewhat like snoring, usually caused by secretion in bronchial airways. - Pleural friction rub - squeaking or grating sounds of the pleural linings rubbing together, described as the sound made by treading on fresh snow - Stridor - a harsh, vibratory sound caused by obstruction of the trachea - Wheezes - high-pitched whistling sound caused by obstruction of the bronchial tubes 2. Normal: - Bronchial - may be normally heard over the manubrium, expiratory phase is greater than inspiratory, the expiratory pitch is high and intensity is loud - Bronchovesicular - heard over the 1st and 2nd intercostal spaces and the interscapular area, the inspiratory and expiratory phases are roughly equal in length. - Vesicular - heard over most of the lungs, described as similar to soft rustle of leaves, the inspiratory sounds are faster, louder, and longer than expiratory sounds. Expiratory intensity is soft and the pitch is low die away after the first third of the expiratory phase.

For which of the following health problems is a patient who has a 40-year history of smoking at risk?

1. Alcoholism and hypertension 2. Obesity and diabetes 3. Stress-related illnesses 4. Cardiopulmonary disease and lung cancer 4

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication?

1. Antibiotics 2. Frequent change of position 3. Oxygen humidification 4. Chest physiotherapy 2

what are the signs and symptoms of left sided heart failure?

1. Awakening at night with 2. shortness of breath. 3. Shortness of breath during exercise or when lying flat. 4. Chronic coughing. 5. decreased cardiac output 6. dizziness 7. confused 8. hypoxia

Review CPR

1. Circulation 2. Airway 3. Breathing -Defibrillation (automatic external defibrillator [AED])

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning?

1. Coughing up sputum occasionally 2. Coughing up thin, watery sputum after nebulization 3. Decreased ability to clear airway through coughing 4. Lung sounds clear only after coughing 3

What are the 4 alterations in cardiac functioning (define them)?

1. Disturbances in Conduction: caused by electrical impulses that do NOT originate in the SA node (dysrhythmias) 2. Altered cardiac output: Insufficient volume is ejected into the systemic and pulmonary circulation; the result of left-sided or right-sided heart failure 3. Impaired Valvular function: Acquired or congenital disorder of a cardiac valve by stenosis or regurgitation 4. Myocardial Ischemia: Coronary artery flow to the myocardium insufficient to meet myocardial oxygen demands, results in angina, myocardial infarction (MI) and/or acute coronary syndrome (ACS).

Oxygen delivery systems:

1. Face mask - covers the mouth and nose 2. Nasal cannula - goes into the nostrils 3. Non-rebreather mask - (NRB) device used in medical emergencies that requires oxygen therapy, delivers higher concentrations of oxygen 4. Venturi mask - (aka air-entrainment mask) delivers a known oxygen concentration to patients on controlled oxygen therapy, considered high-flow oxygen device.

An 86-year-old woman is admitted to the unit with chills and a fever of 104° F. What physiological process explains why she is at risk for dyspnea?

1. Fever increases metabolic demands, requiring increased oxygen need. 2. Blood glucose stores are depleted and the cells do not have energy to use oxygen. 3. Carbon dioxide production increases due to hyperventilation. 4. Carbon dioxide production decreases due to hypoventilation. 1

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation as a result of the anemia?

1. Increased breathlessness but increased activity tolerance 2. Decreased breathlessness and decreased activity tolerance 3. Increased activity tolerance and decreased breathlessness 4. Decreased activity tolerance and increased breathlessness 4

Which of the following skills can the nurse delegate to nursing assistive personnel (NAP)? (Select all that apply.)

1. Nasotracheal suctioning 2. Oropharyngeal suctioning of a stable patient 3. Suctioning a new artificial airway 4. Permanent tracheostomy tube suctioning 5. Care of an endotracheal tube 2 and 4

Place the following in correct sequence for suctioning a patient.

1. Open kit and basin 2. Apply gloves 3. Lubricate catheter 4. Verify functioning of suction device and pressure 5. Connect suction tubing to suction catheter 6. Increase supplemental oxygen 7. Reapply oxygen 8. Suction airway 4, 6, 1, 3, 2, 5, 8, and 7

The nurse is reviewing the results of the patient's diagnostic testing. Of the following results, the finding that falls within expected or normal limits is:

1. Palpable, elevated hardened area around a tuberculosis skin testing site 2. Sputum for culture and sensitivity identifies mycobacterium tuberculosis 3. Presence of acid-fast bacilli in sputum 4. Arterial oxygen tension (PaO2) of 95 mm Hg 4

Factors affecting oxygentaion what are the condition affecting the chest wall movement?

1. Pregnancy 2. obesity 3. neuromuscular disease 4. musculoskeletal abnormalities 5. trauma 6. neuromuscular disease 7. CNS alterations

The nurse assesses a new patient and finds the patient short of breath with a respiratory rate of 32 and lying supine in bed. What is the priority nursing action?

1. Raise the head of the bed to 45 degrees or higher. 2. Get the oxygen saturation with a pulse oximeter. 3. Take the blood pressure and respiratory rate. 4. Notify the health care provider of the shortness of breath. 1

The nurse assesses a new patient and finds the patient short of breath with a respiratory rate of 32 and lying supine in bed. What is the priority nursing action? 1. Raise the head of the bed to 45 degrees or higher. 2.Get the oxygen saturation with a pulse oximeter. 3.Take the blood pressure and respiratory rate 4.Notify the health care provider of the shortness of breath

1. Raise the head of the bed to 45 degrees or higher. Rationale: Raising the head of the bed will bring the diaphragm down and allow for better chest expansion, thus improving oxygenation.

Two hours after surgery, the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 ml of dark red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform?

1. Record the amount and continue to monitor drainage. 2. Notify the physician. 3. Strip the chest tube starting at the chest. 4. Increase the suction by 10 mm Hg. 1

A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply.)

1. Sharp pleuritic pain that worsens on inspiration 2. Crackles over lung bases of affected lung 3. Tracheal deviation toward the affected lung 4. Worsening dyspnea 5. Absent lung sounds to auscultation on affected side 1, 4, and 5

A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation?

1. Sonorous wheezes in the left lower lung 2. Rhonchi mid sternum 3. Crackles only in apex of lungs 4. Inspiratory crackles in lung bases 4

The nurse is caring for a patient who exhibits labored breathing, is using accessory muscles, and is coughing up pink frothy sputum. The patient has diminished breath sounds in bilateral lung bases. What are the priority nursing assessments for the nurse to perform prior to notifying the patient's health care provider? (Select all that apply.)

1. SpO2 levels 2. Amount, color, and consistency of sputum production 3. Fluid status 4. Change in respiratory rate and pattern 5. Pain in lower leg 1, 2, and 4

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient's color is ruddy and not cyanotic, the nurse understands the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following:

1. Stimulates hyperventilation, causing respiratory alkalosis 2. Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs 3. Stimulates hypoventilation, causing respiratory acidosis 4. Causes alveoli to overinflate, leading to atelectasis 2

RESTORATION OF CARDIOPULMONARY FUNCTIONING what are the major components to doing CPR?

1. circulation 2. airway 3. vreathing -defibrilation (automatic defibrilator AED)

factors that can increase the work of breathing

1. decreased lung compliance 2. increased airway resistance 3. increase use of accessory muscles (COPD, edema)

physiological factors affecting oxygenation

1. decreased oxygen-carry capacity 2. hypovolemia 3. decreased inspired O2 concentration (high altitudes) 4. increased metabolic rate (fight or flight, heat, burn, drugs, cancer) 5. blood abnormalities (loss of blood, blood disorder)

In what three ways is carbon dioxide transported?

1. dissolved in solution 2. buffered with water as carbonic acid 3. Bound to proteins, particularly hemoglobin

what are the signs and symptoms of right sided heart failure?

1. swelling or congestion in the legs, 2. ankles and swelling within the abdomen such as the GI tract and liver (causing ascites). 3. Congestive heart failure. 4. JVD 5. backflow; weight gain 6. hematomegaly 7. Awakening at night with 8. shortness of breath 9. Shortness of breath during exercise or when lying flat 10. Coughing 11. Wheezing 12. Difficulty concentrating 13. Dizziness 14. Fatigue 15. Fluid retention causing swelling in the ankles, legs, feet and/or abdomen 16. Increased urge to urinate 17. Lack of appetite and nausea 18. Difficulty exercising 20. Sudden weight gain

what are the works of breathing?

1. the effort required to expand and contract the lungs. 2. Inspiration and expiration 3. Surfactant 4. Atelectasis 5. Compliance and airway resistance

Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? 1. Record the amount and continue to monitor drainage 2. Notify the health care provider 3. Strip the chest tube starting at the chest 4. Increase the suction by 10 mm Hg

1.Record the amount and continue to monitor drainage Rationale:Dark red drainage after surgery (50 to 200 mL per hour in first 3 hours) is expected but be aware of sudden increases greater than 100 mL per hour after the first 3 hours, especially if becomes bright red in color.

Risk of lung cancer is ____ x greater in a person who smokes than a nonsmoker.

10

Normal range of respirations

12-20 breaths per minute

When suctioning secretions that are collecting in an endotracheal tube, the nurse does not apply suction for longer than:

15 seconds Applying suction for too long can result in complications such as hypoxemia and cardiac dysrhythmias. Thus the nurse is always aware of the length of time that suctioning is applied to an airway. If the suctioning time is too short, the suction catheter may not remove the secretions. If the suctioning time is too long, hypoxemia and/or cardiac dysrhythmias could result.

A client with known chronic obstructive pulmonary disease (COPD) is admitted to the emergency department with multiple minor injuries following an automobile accident. To ensure adequate ventilation the nurse applies a nasal cannula providing oxygen at what rate and for what reason?

2 L/min to prevent elevating the arterial oxygen tension (PaO2), which would suppress the hypoxic drive

____ 2. The nurse is caring for a patient who is experiencing dyspnea. Which of the following positions would be most effective if incorporated into the patient's care? 1) Supine 2) Head of bed elevated 80° 3) Head of bed elevated 30° 4) Lying on left side

2) Head of bed elevated 80°

____ 5. The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure. The patient is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take? 1) Review and implement the primary care provider's prescriptions for treatments. 2) Perform a quick physical examination of breathing, circulation, and oxygenation. 3) Gather a thorough medical history, including current symptoms, from the family. 4) Administer oxygen to the patient through a nasal cannula.

2) Perform a quick physical examination of breathing, circulation, and oxygenation.

____ 15. When using sterile technique to perform tracheostomy care of a new tracheostomy, which of the following is correct? 1) You will need a single pair of sterile gloves. 2) Place the patient in semi-Fowler's position, if possible. 3) Clean the stoma under the faceplate with hydrogen peroxide. 4) Cut a slit in sterile 4 × 4 gauze halfway through to make a dressing.

2) Place the patient in semi-Fowler's position, if possible.

____ 10. You are caring for an adult patient with a tracheostomy who is being mechanically ventilated. His pulse oximetry reading is 85%, heart rate is 113, and respiratory rate is 30. The patient is very restless. His respirations are labored, and you hear gurgling sounds. You auscultate crackles and rhonchi in both lungs. What is the most appropriate action to take? 1) Call the respiratory therapist to check the ventilator settings. 2) Provide endotracheal suctioning. 3) Provide tracheostomy care. 4) Notify the physician of the patient's signs of fluid overload.

2) Provide endotracheal suctioning

In what structure of the pulmonary system does inhaled air come in contact with the blood of the pulmonary circulation? 1) Apex of the lungs 2) Alveolar-capillary membrane 3) Cilia in the bronchi 4) Right and left main-stem bronchi

2) Alveolar-capillary membrane Rationale: The lungs are composed of millions of alveoli. The alveoli are tiny air sacs with thin walls surrounded by a fine network of capillaries. Gases easily pass back and forth between the alveoli and capillaries. It is at the alveolar-capillary membrane that inhaled air comes in contact with the blood of the pulmonary circulation.

The nurse is caring for a patient who is experiencing dyspnea. Which of the following positions would be most effective if incorporated into the patient's care? 1) Supine 2) Head of bed elevated 80° 3) Head of bed elevated 30° 4) Lying on left side

2) Head of bed elevated 80° Rationale: Position affects ventilation. An upright or elevated position pulls abdominal organs down, thus allowing maximum diaphragm excursion and lung expansion.

____ 4. When providing safety education to the mother of a toddler, you would inform the mother that, based on the child's developmental stage, he is at high risk for which of the following factors that influence oxygenation? Choose all that apply. 1) Frequent, serious respiratory infections 2) Airway obstruction from aspiration of small objects 3) Drowning in small amounts of water around the home 4) Development of asthma

2,3

____ 5. Obesity is associated with higher risk for which of the following conditions that affect the pulmonary and cardiovascular systems? Choose all that apply. 1) Reduced alveolar-capillary gas exchange 2) Lower respiratory tract infections 3) Sleep apnea 4) Hypertension

2,3,4

Which one of these skills can the nurse delegate to nursing assistive personnel(NAP)? (select all that apply) 1.Nasotracheal suctioning 2.Oropharyngeal suctioning of a stable patient 3. Suctioning a new artificial airway 4.Permanent tracheotomy tube suctioning 5.Care of an endotracheal tube

2,4 Rationale:Oropharyngeal suctioning of a stable patient and permanent tracheostomy tube suctioning may be safely delegated to a NAP. The other skills require nursing assessment and clinical decision making as the skill progresses.

appropriate amount of supplemental oxygen

2-4 liters per minute (24%-40% concentration)

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complications? 1. Antibiotics 2. Frequent change of position 3. Oxygen humidification 4. Chest physiotherapy

2. Frequent change of position Rationale:Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting the effectiveness of gas exchange processes.

____ 1. The nurse is providing care to a pregnant woman in preterm labor. The patient is 32 weeks pregnant. Initially, the patient states, "I've gained 30 pounds. That should be enough for the baby. Everything will be OK if I deliver now." After teaching the patient about fetal development, the nurse will know her teaching is effective if the patient makes which of the following statements? 1) "The baby's lungs are well developed now, but he will be at increased risk for SIDS if I deliver early." 2) "We should try to stop this labor now because the baby will be born with sleep apnea if I deliver this early." 3) "If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening." 4) "Thanks for reassuring me; I was pretty sure there isn't much risk to the baby this far along in my pregnancy."

3) "If I deliver this early my baby is at risk for respiratory distress syndrome, a condition that can be life threatening."

____ 13. A 62-year-old man with emphysema says, "My doctor wants me to quit smoking. It's too late now, though; I already have lung problems." Which of the following would be the best response to his statement? 1) "You should quit so your family does not get sick from exposure to secondhand smoke." 2) "You will need to use oxygen, but remember it is a fire hazard to smoke with oxygen in your home." 3) "Once you stop smoking, your body will begin to repair some of the damage to your lungs." 4) "You should ask your primary care provider for a prescription for a nicotine patch to help you quit."

3) "Once you stop smoking, your body will begin to repair some of the damage to your lungs."

____ 8. Which of the following provide the most reliable data about the effectiveness of airway suctioning? 1) The amount, color, consistency, and odor of secretions 2) The patient's tolerance for the procedure 3) Breath sounds, vital signs, and pulse oximetry before and after suctioning 4) The number of suctioning passes required to clear secretions

3) Breath sounds, vital signs, and pulse oximetry before and after suctioning

____ 4. The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which of the following responses indicates to the nurse that the medication is effective? 1) The amount of sputum the patient expectorates decreases with each dose administered. 2) Cough is completely suppressed, and she is able to sleep through the night. 3) Dry, unproductive cough is reduced, but her voluntary coughing is more productive. 4) Involuntary coughing produces large amounts of thick yellow sputum.

3) Dry, unproductive cough is reduced, but her voluntary coughing is more productive.

____ 16. A patient has just had a chest tube inserted to dry-seal suction drainage. Which of the following is a correct nursing intervention for maintenance? 1) Keep the head of the bed flat for 6 hours. 2) Immobilize the patient's arm on the affected side. 3) Keep the drainage system lower than the insertion site. 4) Drain condensation into the humidifier when it collects in the tubing.

3) Keep the drainage system lower than the insertion site.

____ 11. Chest percussion and postural drainage would be an appropriate intervention for which of the following conditions? 1) Congestive heart failure 2) Pulmonary edema 3) Pneumonia 4) Pulmonary embolus

3) Pneumonia

Which of the following provides the most reliable data about the effectiveness of airway suctioning? 1) The amount, color, consistency and odor of secretions 2) The patient's tolerance for the procedure 3) Breath sounds, vital signs, and pulse oximetry noted before and after suctioning 4) The number of suctioning passes required to clear secretions

3) Breath sounds, vital signs, and pulse oximetry noted before and after suctioning Rationale: Breath sounds, vital signs, and oxygen saturation levels noted before and after suctioning provide data about the effectiveness of suctioning. Information about the amount and appearance of secretions provides data about the likelihood of airway infection and/or inflammation. Data about the patient's tolerance of suctioning provide information about the patient's overall condition. The number of suctioning passes required to clear the secretions provides information about the amount of secretions present.

A 45-year-old woman arrives at the emergency department with complaints of shortness of breath, anxiety, dizziness, and numbness and tingling around her mouth. Her respirations are deep, at a rate of 28 breaths/min. Her lungs are clear with good aeration throughout. Oxygen saturation is 100%. An arterial blood gas shows a PO2 of 110 and PCO2 of 29 mm Hg. Based on this assessment, an appropriate nursing diagnosis would be: 1) Ineffective Airway Clearance 2) Decreased Cardiac Output 3) Impaired Gas Exchange 4) Hypocarbia

3) Impaired Gas Exchange Rationale: Hypocarbia (hypocapnia) is a low level of dissolved CO2 in the blood because of hyperventilation. In most cases, blood oxygen levels remain normal. Severe hypocarbia stimulates the nervous system, leading to muscle twitching or spasm (especially in the hands and feet) and numbness and tingling in the face and lips. This patient is experiencing hypocarbia; however, this is a medical diagnosis. A corresponding nursing diagnosis is Impaired Gas Exchange. A person with Impaired Gas Exchange may very well be anxious. However, there are no defining characteristics given for Anxiety in this scenario.

Chest percussion and postural drainage would be an appropriate intervention for which of the following conditions? 1) Congestive heart failure 2) Pulmonary edema 3) Pneumonia 4) Pulmonary embolus

3) Pneumonia Rationale: Chest physiotherapy moves secretions to the large, central airways for expectoration or suctioning. This treatment is not effective for conditions that do not involve the development of airway secretions, including congestive heart failure, pulmonary edema, and pulmonary embolus.

While caring for a young adult being mechanically ventilated, the ventilator alarms sound. On entering the patient's room, the nurse notes that he is agitated and his skin is ashen and diaphoretic. His pulse oximetry shows an oxygen saturation of 78%. The nurse is unable to identify any obvious mechanical problems with the ventilator. The first step the nurse should take is to: 1) assess his breath sounds. 2) call the respiratory therapist to troubleshoot the problem. 3) manually ventilate him with an Ambu bag. 4) contact the physician.

3) manually ventilate him with an Ambu bag. Rationale: All the actions listed are appropriate and necessary. However, if you cannot quickly identify and correct a problem with the ventilator, you must ensure adequate ventilation until the problem can be identified and corrected. Your immediate response should be to manually ventilate the patient with an Ambu bag. Your colleagues should assist you by troubleshooting the problem, assessing breath sounds, and notifying the physician.

____ 8. Of the following interventions, which is/are likely to reduce the risk of postoperative atelectasis? Choose all that apply. 1) Administer bronchodilators. 2) Apply low-flow oxygen. 3) Encourage coughing and deep breathing. 4) Administer pain medication.

3,4

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? 1. Coughing up sputum occasionally 2. Coughing up thin, watery sputum after nebulization 3. Decreased ability to clear airway through coughing 4. Lung sounds clear only after coughing

3. Decreased ability to clear airway through coughing Rationale: Impaired ability to cough up mucus due to weakness or very thick secretions indicates a need for suctioning.

What is the correct sequence for suctioning a patient?1. Open kit and basin.2. Apply gloves.3. Lubricate catheter.4. Verify functioning of suction device and pressure.5. Connect suctioning tubing to suction catheter.6. Increase supplemental oxygen.7. Reapply oxygen.8. Suction airway.

4 6 1 3 2 5 8 7

myocardial blood blow occurs in how many valves?

4 valves and is unidirectional

____ 12. Which of the following blood levels normally provides the primary stimulus for breathing? 1) pH 2) Oxygen 3) Bicarbonate 4) Carbon dioxide

4) Carbon dioxide

____ 6. You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patient's respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern? 1) Biot's breathing 2) Kussmaul's respirations 3) Sleep apnea 4) Cheyne-Stokes respirations

4) Cheyne-Stokes respirations

____ 3. While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal chest drainage system (CDU). Which action should the nurse take immediately? 1) Clamp the chest tube close to the insertion site. 2) Set up a new drainage system, and connect it to the chest tube. 3) Have the patient take and hold a deep breath while the nurse reconnects the tube to the CDU. 4) Place the disconnected end nearest the patient into a bottle of sterile water.

4) Place the disconnected end nearest the patient into a bottle of sterile water.

____ 14. The nurse administers intravenous morphine sulfate to a patient for pain control. She will need to monitor her patient for which of the following adverse effects? 1) Decreased heart rate 2) Muscle weakness 3) Decreased urine output 4) Respiratory depression

4) Respiratory depression

____ 7. You are admitting a 54-year-old patient with chronic obstructive pulmonary disease (COPD). The physician prescribes O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient? 1) Nonrebreather mask 2) Nasal cannula 3) Partial rebreather mask 4) Venturi mask

4) Venturi mask

Which of the following goals is appropriate for a client without underlying cardiopulmonary disease who is being monitored with continuous pulse oximetry? 1) Patient will refrain from movement while monitored in order to ensure accurate readings. 2) Oxygen saturation will remain at 80% to 90% during hospitalization. 3) Patient will report pain as less than 3 on a scale of 1 to 10 during monitoring. 4) Oxygen saturation will remain at 95% to 100% while monitored.

4) Oxygen saturation will remain at 95% to 100% while monitored. Rationale: Normal oxygen saturation is 95% to 100%. Values of 94% or less are considered abnormal in healthy people and should be investigated to determine the cause. Although movement may affect oximetry monitoring, it is essential that patients move and turn in order to prevent atelectasis. Pulse oximetry is a noninvasive form of monitoring that involves placing a probe on a part of the body where capillary blood flow is near the surface (e.g., a nail bed, earlobe, nose, or forehead). It does not cause pain.

You are admitting a 54-year-old patient with chronic obstructive pulmonary disease (COPD). The physician prescribes O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient? 1) Nonrebreather mask 2) Nasal cannula 3) Partial rebreather mask 4) Venturi mask

4) Venturi mask Rationale: The Venturi mask is capable of delivering 24% to 50% FIO2. The cone-shaped adapter at the base of the mask allows a precise level of FIO2 to be delivered. This is very useful for patients with chronic lung disease. Rebreather masks are used when high concentrations of oxygen are required. A nasal cannula administers oxygen in liters per minute and does not allow administration of a precise level of FIO2.

Place the following in correct sequence for suctioning a patient. 1. Open kit and basin 2.Apply gloves 3.Lubricate catheter 4. Verify functioning of suctioning device and pressure 5.Connect suction tubing to suction catheter 6. Increase supplemental oxygen 7. Reapply oxygen 8. Suction airway

4,6,1,3,2,5,8,7 Rationale:These steps allow for smooth completion of procedure while helping to maintain patient's level of oxygenation.

A patient has been newly diagnosed with chronic lung disease. In discussing the lung disease with the nurse, which of the patient's statements would indicate a need for further education? 1. "I'll make sure that I rest between activities so I don't get so short of breath." 2."I'll practice the pursed-lip breathing technique to improve my exercise tolerance." 3. "If I have trouble breathing at night, I'll use two or three pillows to prop up." 4. "If i get short of breath, I'll turn up my oxygen level to 6 L/min."

4. "If i get short of breath, I'll turn up my oxygen level to 6 L/min." Rationale: Hypoxia is the drive to breathe in a COPD patient who has become used to acidic pH and elevated CO2 levels. Turning up to 6 L/min will increase oxygen level, which turns off the drive to breathe.

The nurse is reviewing the results of the patient's diagnostic testing. Of the following results, the finding that falls within expected or normal limit is: 1. Palpable, elevated hardened area around a tuberculosis skin testing site 2.Sputum for culture and sensitivity identifies mycobacterium tuberculosis 3. Presence of acid-fast bacilli in sputum 4. Arterial oxygen tension (PaO2) of 95 mm Hg

4. Arterial oxygen tension (PaO2) of 95 mm Hg Rationale:A palpable, elevated, hardened area surrounding a tuberculosis skin testing site is indicative of an antigen-antibody reaction and is considered a positive skin test. Sputum for culture and sensitivity noted the presence of an organism and acid fast bacilli. Normal arterial oxygen tension (PaO2) ranges between 95-100 mm Hg).

A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation? 1. Sonorous wheezes in the left lower lung 2. Rhonchi mid sternum 3. Crackles only in apex of lungs 4. Inspiratory crackles in lung bases

4. Inspiratory crackles in lung bases rationale: Decreased effective contraction of left side of heart leads to back up of fluid in the lungs, increasing hydrostatic pressure and causing pulmonary edema.

A patient has been admitted to the cardiac unit with the diagnosis of bradycardia. The patient states "I am confused about what the doctor said is wrong with me, he said my pacemaker is not working. I don't have a pacemaker." What is the nurse's best response? a. "The sinoatrial node is the 'pacemaker' of your heart." b. "Myocardial contractility determines your heart rate." c. "The atrioventricular node is the 'pacemaker' of your heart." d. "The ventricular Purkinje network determines your heart rate."

A

A patient reports chest pain. The nurse is attempting to assess the pain to differentiate the pain as cardiac, respiratory, or gastrointestinal. The nurse can properly identify the pain as cardiac in origin when the patient states that the cardiac pain: a. does not occur with respiratory variations. b. is peripheral and may radiate to the scapular areas. c. is aggravated by inspiratory movements. d. is nonradiating and occurs during inspiration.

A

A patient was admitted to the surgical unit after surgical removal of an abdominal tumor. As the nurse performs a postsurgical assessment, the patient's blood pressure is 90/54, heart rate is 94, and respiratory rate is 22. Based on these values, the nurse should be most concerned with which of the following conditions? a. Hypovolemia b. Left-sided heart failure c. Right-sided heart failure d. Hypervolemia

A

A patient with a tracheostomy is experiencing thick and tenacious secretions. To maintain this patient's airway, what is the most appropriate action for the nurse? a. Tracheal suctioning b. Oropharyngeal suctioning c. Nasotracheal suctioning d. Orotracheal suctioning

A

The guardians of a premature infant who was delivered at 31-weeks' gestation is expected to be discharged from the hospital within the next few days. The guardians have voiced concern regarding how to prevent respiratory syncytial virus (RSV) exposure to the baby. What is the best response from the nurse? a. "You will need to limit the baby's exposure to crowds of people." b. "You need to make sure that the car seat is facing backward in the back seat of your car." c. "You do not need to be concerned; the baby has a natural protection against this disease." d. "You must sterilize all the bottles for the first 6 months."

A

The patient is experiencing shortness of breath. Which of the following lab tests indirectly indicates the oxygen level in the blood system? a. Hemoglobin b. White blood cell count c. Electrolytes d. Creatinine

A

Which term should the nurse use to best describe the movement of air in and out of the patient's lungs? a. Ventilation b. Diffusion c. Respiration d. Perfusion

A

Two hours after surgery, the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 ml of dark red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform? A) Record the amount and continue to monitor drainage. B) Notify the physician. C) Strip the chest tube starting at the chest D) Increase the suction by 10 mm Hg

A (Dark red drainage after surgery (50-200 ml per hour in first 3 hours) is expected but be aware of sudden increases greater than 100 ml per hour after the first three hours especially if becomes bright red in color.)

The nurse goes to assess a new patient and finds him short of breath with a rate of 32 and lying supine in bed. What is the priority nursing action? Raise the head of the bed to 60 degrees or higher. Get his oxygen saturation with a pulse oximeter. Take his blood pressure and respiratory rate. Notify the health care provider of his shortness of breath.

A (Raising the head of the bed will bring the diaphragm down and allow for better chest expansion thus improving oxygenation.)

The finding of a barrel chest configuration in a patient may be related to which of the following disorders? a. Chronic obstructive pulmonary disease b. Acute asthma attack c. Cardiomyopathy d. Acute myocardial infarction

A (The air trapping that occurs in chronic obstructive pulmonary disease over time causes the chest to expand, leaving a ratio of 1:1 from side to front ratio instead of the normal 1:2 ratio.)

An 86 year old woman is admitted to the unit with chills and a fever of 104 degrees F. What physiological process explains why she is at risk for dyspnea? A) Fever increases metabolic demands requiring increased oxygen need. B) Blood glucose stores are depleted and the cells do not have energy to use oxygen. C) Carbon dioxide production increases due to hyperventilation. D) Carbon dioxide production decreases due to hypoventilation.

A (fever increases metabolic demands requiring increased oxygen need) (When the body cannot meet the increased oxygenation need, the increased metabolic rate causes breakdown of protein and wasting of respiratory muscles increasing the work of breathing.)

The nurse is caring for a patient who exhibits labored breathing, using accessory muscles, and is coughing up pink frothy sputum. The patient has bilateral lung bases and diminished breath sounds. What are the priority nursing assessments for the nurse to perform prior to notifying the patient's health care provider? Select all that apply. A) SpO2 levels B) Amount, color and consistency of sputum production C) Fluid status D) Change in respiratory rate and pattern (select all that apply)

A B D

A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply). A) Sharp pleuritic pain that worsens on inspiration B) crackles over lung bases of affected lung C) Tracheal deviation toward the affected lung D) worsening dyspnea E) absent lung sounds to auscultation on affected side

A C D E (When the lung collapses, as with a pneumothorax, the thoracic space fills with air, which irritates the parietal pleura causing inspiratory pain. Because of the collapsed lung there is reduced gas exchange in the affected area, reduced oxygenation and dyspnea result. When an area of the lung collapses, breath sounds over affected area are absent.)

Cyanosis, the blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is:

A late sign of hypoxia Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. The presence or absence of cyanosis is not a reliable measure of oxygen status.

vasodilation

A widening of the diameter of a blood vessel.

An adult collapsed at the grocery store. Before being transported to the emergency department, an automated external defibrillator (AED) was used. The nurse remembers learning that the AED is effective in saving a life because of which factors? (Select all that apply.) a. Use of an AED strengthens the chain of survival. b. The AED can be used by nonmedical personnel. c. The AED sends heart rhythm to the closest emergency room (ER) for the physician to analyze and give orders. d. Every minute without defibrillation decreases the survival rate by 7% to 10%. e. The AED will automatically deliver a shock to the victim after announcing, "Everyone stand back."

A,B,D

On entering the room, a nurse finds the patient sitting upright in bed with the upper torso resting on the over-bed table. The nurse assesses that this patient is experiencing acute hypoxemia. Which of the following are symptoms of acute hypoxemia? (Select all that apply.) a. Cyanosis b. Arrhythmias c. Eupnea d. Restlessness e. Diaphoresis

A,B,D,E

The home care nurse is admitting a patient with COPD. The primary healthcare provider has ordered O2 /nasal cannula at 3 L/min. To promote safety, the nurse would instruct the patient on which of the following safety measures? (Select all that apply.) a. Place "No smoking" signs in all areas where oxygen will be used. b. Instruct family and visitors who smoke that they must smoke a minimum of 10 feet from the patient. c. Store tanks in a small closet, trunk of a car, or near the hot water heater. d. Oxygen tanks should stay a minimum of 6 feet from space heaters, fireplaces, and appliances with an electric motor. e. Know the exit routes and where the fire extinguisher are located in the home.

A,D,E

QUICK QUIZ 1. A patient complains of chest pain. When assessing the pain, you decide that its origin is cardiac— rather than respiratory or gastrointestinal—when it:

A. does not occur with respiratory variations. B. is peripheral and may radiate to the scapular region. C. is aggravated by inspiratory movements. D. is nonradiating and occurs during inspiration. ANSWER: A. does not occur with respiratory variations.

QUICK QUIZ 3. When evaluating a postthoracotomy patient with a chest tube, the best method to properly maintain the chest tube would be to:

A. strip the chest tube every hour to maintain drainage. B. place the device below the patient's chest. C. double clamp the tube except during assessment. D. remove the tubing from the drainage device to check for proper suctioning. ANSWER: B. place the device below the patient's chest

QUICK QUIZ 2. A patient with a tracheostomy has thick tenacious secretions. To maintain the airway, the most appropriate action for the nurse includes:

A. tracheal suctioning. B. oropharyngeal suctioning. C. nasotracheal suctioning. D. orotracheal suctioning. ANSWER: A. tracheal suctioning.

A nurse is caring for a patient who has poor tissue perfusion as the result of hypertension. When the patient asks what to eat for breakfast, which meal should the nurse suggest? a. A cup of nonfat yogurt with granola and a handful of dried apricots b. Whole wheat toast with butter and a side of bacon c. A bowl of cereal with whole milk and a banana d. Omelet with sausage, cheese, and onions

ANS: A A 2000-calorie diet of fruits, vegetables, and low-fat dairy foods that are high in fiber, potassium, calcium, and magnesium and low in saturated and total fat helps prevent and reduce the effects of hypertension. Nonfat yogurt with granola is a good source of calcium, fiber, and potassium; dried apricots add a second source of potassium. Although cereal and a banana provide fiber and potassium, skim milk should be substituted for whole milk to decrease fat. An omelet with sausage and cheese is high in fat. Butter and bacon are high in fat.

A patient has carbon dioxide retention from lung problems. Which type of diet will the nurse most likely suggest for this patient? a. Low-carbohydrate b. Low-caffeine c. High-caffeine d. High-carbohydrate

ANS: A A low-carbohydrate diet is best. Diets high in carbohydrates play a role in increasing the carbon dioxide load for patients with carbon dioxide retention. As carbohydrates are metabolized, an increased load of carbon dioxide is created and excreted via the lungs. A low- or high-caffeine diet is not as important as the carbohydrate load

The patient is experiencing angina pectoris. Which assessment finding does the nurse expect when conducting a history and physical examination? a. Experiences chest pain after eating a heavy meal b. Experiences adequate oxygen saturation during exercise c. Experiences crushing chest pain for more than 20 minutes d. Experiences tingling in the left arm that lasts throughout the morning

ANS: A Angina pectoris is chest pain that results from limited oxygen supply. Often pain is precipitated by activities such as exercise, stress, and eating a heavy meal and lasts 3 to 5 minutes. Symptoms of angina pectoris are relieved by rest and/or nitroglycerin. Adequate oxygen saturation occurs with rest; inadequate oxygen saturation occurs during exercise. Pain lasting longer than 20 minutes or arm tingling that persists could be a sign of myocardial infarction

The nurse is careful to monitor a patient's cardiac output. Which goal is the nurse trying to achieve? a. To determine peripheral extremity circulation b. To determine oxygenation requirements c. To determine cardiac dysrhythmias d. To determine ventilation status

ANS: A Cardiac output indicates how much blood is being circulated systemically throughout the body to the periphery. The amount of blood ejected from the left ventricle each minute is the cardiac output. Oxygen status would be determined by pulse oximetry and the presence of cyanosis. Cardiac dysrhythmias are an electrical impulse monitored through ECG results. Ventilation status is measured by respiratory rate, pulse oximetry, and capnography. Capnography provides instant information about the patient's ventilation. Ventilation status does not depend solely on cardiac output.

A patient with chronic obstructive pulmonary disease (COPD) asks the nurse why clubbing occurs. Which response by the nurse is most therapeutic? a. "Your disease doesn't send enough oxygen to your fingers." b. "Your disease affects both your lungs and your heart, and not enough blood is being pumped." c. "Your disease will be helped if you pursed-lip breathe." d. "Your disease often makes patients lose mental status."

ANS: A Clubbing of the nail bed can occur with COPD and other diseases that cause prolonged oxygen deficiency or chronic hypoxemia. Pursed-lipped breathing helps the alveoli stay open but is not the cause of clubbing. Loss of mental status is not a normal finding with COPD and will not result in clubbing. Low oxygen and not low circulating blood volume is the problem in COPD that results in clubbing

The patient is breathing normally. Which process does the nurse consider is working properly when the patient inspires? a. Stimulation of chemical receptors in the aorta b. Reduction of arterial oxygen saturation levels c. Requirement of elastic recoil lung properties d. Enhancement of accessory muscle usage

ANS: A Inspiration is an active process, stimulated by chemical receptors in the aorta. Reduced arterial oxygen saturation levels indicate hypoxemia, an abnormal finding. Expiration is a passive process that depends on the elastic recoil properties of the lungs, requiring little or no muscle work. Prolonged use of the accessory muscles does not promote effective ventilation and causes fatigue.

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) who is receiving 2 L/min of oxygen. Which oxygen delivery device is most appropriate for the nurse to administer the oxygen? a. Nasal cannula b. Simple face mask c. Non-rebreather mask d. Partial non-rebreather mask

ANS: A Nasal cannulas deliver oxygen from 1 to 6 L/min. All other devices (simple face mask, nonrebreather mask, and partial non-rebreather mask) are intended for flow rates greater than 6 L/min.

The nurse is caring for a patient with fluid volume overload. Which physiological effect does the nurse most likely expect? a. Increased preload b. Increased heart rate c. Decreased afterload d. Decreased tissue perfusion

ANS: A Preload refers to the amount of blood in the left ventricle at the end of diastole; an increase in circulating volume would increase the preload of the heart. Afterload refers to resistance; increased pressure would lead to increased resistance, and afterload would increase. A decrease in tissue perfusion would be seen with hypovolemia. A decrease in fluid volume would cause an increase in heart rate as the body is attempting to increase cardiac output.

The patient has right-sided heart failure. Which finding will the nurse expect when performing an assessment? a. Peripheral edema b. Basilar crackles c. Chest pain d. Cyanosis

ANS: A Right-sided heart failure results from inability of the right side of the heart to pump effectively, leading to a systemic backup. Peripheral edema, distended neck veins, and weight gain are signs of right-sided failure. Basilar crackles can indicate pulmonary congestion from left-sided heart failure. Cyanosis and chest pain result from inadequate tissue perfusion.

A nurse is reviewing the electrocardiogram (ECG) results. Which portion of the conduction system does the nurse consider when evaluating the P wave? a. SA node b. AV node c. Bundle of His d. Purkinje fibers

ANS: A The P wave represents the electrical conduction through both atria; the SA node initiates electrical conduction through the atria. The AV node conducts down through the bundle of His and the Purkinje fibers to cause ventricular contraction.

A nurse explains the function of the alveoli to a patient with respiratory problems. Which information about the alveoli's function will the nurse share with the patient? a. Carries out gas exchange b. Regulates tidal volume c. Produces hemoglobin d. Stores oxygen

ANS: A The alveolus is a capillary membrane that allows gas exchange of oxygen and carbon dioxide during respiration. The alveoli do not store oxygen, regulate tidal volume, or produce hemoglobin

Which coughing technique will the nurse use to help a patient clear central airways? a. Huff b. Quad c. Cascade d. Incentive spirometry

ANS: A The huff cough stimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the word huff. The quad cough technique is for patients without abdominal muscle control such as those with spinal cord injuries. While the patient breathes out with a maximal expiratory effort, the patient or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough. With the cascade cough the patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then he or she opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in patients with large volumes of sputum. Incentive spirometry encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume. It promotes deep breathing and prevents or treats atelectasis in the postoperative patient.

A nurse is caring for a group of patients. Which patient should the nurse see first? a. A patient with hypercapnia wearing an oxygen mask b. A patient with a chest tube ambulating with the chest tube unclamped c. A patient with thick secretions being tracheal suctioned first and then orally d. A patient with a new tracheostomy and tracheostomy obturator at bedside

ANS: A The mask is contraindicated for patients with carbon dioxide retention (hypercapnia) because retention can be worsened; the nurse must see this patient first to correct the problem. All the rest are using correct procedures and do not need to be seen first. A chest tube should not be clamped when ambulating. Clamping a chest tube is contraindicated when ambulating or transporting a patient. Clamping can result in a tension pneumothorax. Use nasotracheal suctioning before pharyngeal suctioning whenever possible. The mouth and pharynx contain more bacteria than the trachea. Keep tracheostomy obturator at bedside with a fresh (new) tracheostomy to facilitate reinsertion of the outer cannula if dislodged

The nurse is caring for a patient who needs oxygen via a nasal cannula. Which task can the nurse delegate to the nursing assistive personnel? a. Applying the nasal cannula b. Adjusting the oxygen flow c. Assessing lung sounds d. Setting up the oxygen

ANS: A The skill of applying (not adjusting oxygen flow) a nasal cannula or oxygen mask can be delegated to nursing assistive personnel (NAP). The nurse is responsible for assessing the patient's respiratory system, response to oxygen therapy, and setup of oxygen therapy, including adjustment of oxygen flow rate.

The nurse is creating a plan of care for an obese patient who is suffering from fatigue related to ineffective breathing. Which intervention best addresses a short-term goal the patient could achieve? a. Sleeping on two to three pillows at night b. Limiting the diet to 1500 calories a day c. Running 30 minutes every morning d. Stopping smoking immediately

ANS: A To achieve a short-term goal, the nurse should plan a lifestyle change that the patient can make immediately that will have a quick effect. Sleeping on several pillows at night will immediately relieve orthopnea and open the patient's airway, thereby reducing fatigue. Running 30 minutes a day will improve cardiopulmonary health, but a patient needs to build up exercise tolerance. Smoking cessation is another process that many people have difficulty doing immediately. A more realistic short-term goal would be to gradually reduce the number of cigarettes smoked. Limiting caloric intake can help a patient lose weight, but this is a gradual process and is not reasonable for a shortterm goal.

A nurse is caring for a patient with continuous cardiac monitoring for heart dysrhythmias. Which rhythm will cause the nurse to intervene immediately? a. Ventricular tachycardia b. Atrial fibrillation c. Sinus rhythm d. Paroxysmal supraventricular tachycardia

ANS: A Ventricular tachycardia and ventricular fibrillation are life-threatening rhythms that require immediate intervention. Ventricular tachycardia is a life-threatening dysrhythmia because of the decreased cardiac output and the potential to deteriorate into ventricular fibrillation or sudden cardiac death. Atrial fibrillation is a common dysrhythmia in older adults and is not as serious as ventricular tachycardia. Sinus rhythm is normal. Paroxysmal supraventricular tachycardia is a sudden, rapid onset of tachycardia originating above the AV node. It often begins and ends spontaneously

A nurse is teaching about risk factors for cardiopulmonary disease. Which risk factor should the nurse describe as modifiable? a. Stress b. Allergies c. Family history d. Gender

ANS: A Young and middle-age adults are exposed to multiple cardiopulmonary risk factors: an unhealthy diet, lack of exercise, stress, over-the-counter and prescription drugs not used as intended, illegal substances, and smoking. Reducing these modifiable factors decreases a patient's risk for cardiac or pulmonary diseases. A nonmodifiable risk factor is family history; determine familial risk factors such as a family history of lung cancer or cardiovascular disease. Other nonmodifiable risk factors include allergies and gender.

The nurse determines that an older-adult patient is at risk for infection due to decreased immunity. Which plan of care best addresses the prevention of infection for the patient? a. Inform the patient of the importance of finishing the entire dose of antibiotics. b. Encourage the patient to stay up-to-date on all vaccinations. c. Schedule patient to get annual tuberculosis skin testing. d. Create an exercise routine to run 45 minutes every day

ANS: B A nursing care plan for preventative health measures should be reasonable and feasible. Keeping upto-date on vaccinations is important because vaccine reduces the severity of illnesses and serious complications. Determine if and when the patient has had a pneumococcal or influenza (flu) vaccine. This is especially important when assessing older adults because of their increased risk for respiratory disease. Although it is important to finish the full course of antibiotics, it is not a preventative health measure. Scheduling annual tuberculosis skin tests does not address prevention and is an unreliable indictor of tuberculosis in older patients. The exercise routine should be reasonable to increase compliance; exercise is recommended only 3 to 4 times a week for 30 to 60 minutes, and walking, rather than running, is an efficient method.

The nurse needs to closely monitor the oxygen status of an older-adult patient undergoing anesthesia because of which age-related change? a. Thinner heart valves cause lipid accumulation and fibrosis. b. Diminished respiratory muscle strength may cause poor chest expansion. c. Alterations in mental status prevent patients' awareness of ineffective breathing. d. An increased number of pacemaker cells make proper anesthesia induction more difficult.

ANS: B Age-related changes in the thorax that occur from ossification of costal cartilage, decreased space between vertebrae, and diminished respiratory muscle strength lead to problems with chest expansion and oxygenation,whereby the patient will have difficulty excreting anesthesia gas. The nurse needs to monitor the patient's oxygen status carefully to make sure the patient does not retain too much of the drug. Older adults experience alterations in cardiac function as a result of calcification of the conduction pathways, thicker and stiffer heart valves caused by lipid accumulation and fibrosis, and a decrease in the number of pacemaker cells in the SA node. Altered mental status is not a normal agerelated change; it indicates possible cardiac and/or respiratory problems.

A nurse teaches a patient about atelectasis. Which statement by the patient indicates an understanding of atelectasis? a. "Atelectasis affects only those with chronic conditions such as emphysema." b. "It is important to do breathing exercises every hour to prevent atelectasis." c. "If I develop atelectasis, I will need a chest tube to drain excess fluid." d. "Hyperventilation will open up my alveoli, preventing atelectasis."

ANS: B Atelectasis develops when alveoli do not expand. Breathing exercises, especially deep breathing and incentive spirometry, increase lung volume and open the airways, preventing atelectasis. Deep breathing also opens the pores of Kohn between alveoli to allow sharing of oxygen between alveoli. Atelectasis can affect anyone who does not deep breathe. A chest tube is for pneumothorax or hemothorax. It is deep breathing, not hyperventilation, that prevents atelectasis.

The home health nurse recommends that a patient with respiratory problems install a carbon monoxide detector in the home. What is the rationale for the nurse's action? a. Carbon monoxide detectors are required by law in the home. b. Carbon monoxide tightly binds to hemoglobin, causing hypoxia. c. Carbon monoxide signals the cerebral cortex to cease ventilations. d. Carbon monoxide combines with oxygen in the body and produces a deadly toxin.

ANS: B Carbon monoxide binds tightly to hemoglobin; therefore, oxygen is not able to bind to hemoglobin and be transported to tissues, causing hypoxia. A carbon monoxide detector is not required by law, does not signal the cerebral cortex to cease ventilations, and does not combine with oxygen but with hemoglobin to produce a toxin

The nurse is educating a student nurse on caring for a patient with a chest tube. Which statement from the student nurse indicates successful learning? a. "I should clamp the chest tube when giving the patient a bed bath." b. "I should report if I see continuous bubbling in the water-seal chamber." c. "I should strip the drains on the chest tube every hour to promote drainage." d. "I should notify the health care provider first, if the chest tube becomes dislodged."

ANS: B Correct care of a chest tube involves knowing normal and abnormal functioning of the tube. A constant or intermittent bubbling in the water-seal chamber indicates a leak in the drainage system, and the health care provider must be notified immediately. Stripping the tube is not routinely performed as it increases pressure. If the tubing disconnects from the drainage unit, instruct the patient to exhale as much as possible and to cough. This maneuver rids the pleural space of as much air as possible. Temporarily reestablish a water seal by immersing the open end of the chest tube into a container of sterile water. The chest tube should not be clamped unless necessary; if so, the length of time clamped would be minimal to reduce the risk of pneumothorax

The nurse is caring for a patient with a tracheostomy tube. Which nursing intervention is most effective in promoting effective airway clearance? a. Suctioning respiratory secretions several times every hour b. Administering humidified oxygen through a tracheostomy collar c. Instilling normal saline into the tracheostomy to thin secretions before suctioning d. Deflating the tracheostomy cuff before allowing the patient to cough up secretions

ANS: B Humidification from air humidifiers or humidified oxygen tracheostomy collars can help prevent drying of secretions that cause occlusion. Suctioning should be done only as needed; too frequent suctioning can damage the mucosal lining, resulting in thicker secretions. Normal saline should not be instilled into a tracheostomy; research showed no benefit with this technique. The purpose of the tracheostomy cuff is to keep secretions from entering the lungs; the nurse should not deflate the tracheostomy cuff unless instructed to do so by the health care provider.

A nurse is caring for a patient who was in a motor vehicle accident that resulted in cervical trauma to C4. Which assessment is the priority? a. Pulse b. Respirations c. Temperature d. Blood pressure

ANS: B Respirations and oxygen saturation are the priorities. Cervical trauma at C3 to C5 usually results in paralysis of the phrenic nerve. When the phrenic nerve is damaged, the diaphragm does not descend properly, thus reducing inspiratory lung volumes and causing hypoxemia. While pulse and blood pressure are important, respirations are the priority. Temperature is not a high priority in this situation.

The nurse is suctioning a patient with a tracheostomy tube. Which action will the nurse take? a. Set suction regulator at 150 to 200 mm Hg. b. Limit the length of suctioning to 10 seconds. c. Apply suction while gently rotating and inserting the catheter. d. Liberally lubricate the end of the suction catheter with a water-soluble solution

ANS: B Suctioning passes should be limited to 10 seconds to avoid hypoxemia. Suction for a tracheostomy should be set at 100 to 150 mm Hg. Excessive lubrication can clog the catheter or occlude the airway; lubricant is not necessary for oropharyngeal or artificial airway (tracheostomy) suctioning. Suction should never be applied on insertion

A nurse is teaching staff about the conduction of the heart. In which order will the nurse present the conduction cycle, starting with the first structure? 1. Bundle of His 2. Purkinje network 3. Intraatrial pathways 4. Sinoatrial (SA) node 5. Atrioventricular (AV) node a. 5, 4, 3, 2, 1 b. 4, 3, 5, 1, 2 c. 4, 5, 3, 1, 2 d. 5, 3, 4, 2, 1

ANS: B The conduction system originates with the SA node, the "pacemaker" of the heart. The electrical impulses are transmitted through the atria along intraatrial pathways to the AV node. It assists atrial emptying by delaying the impulse before transmitting it through the Bundle of His and the ventricular Purkinje network

A nurse is caring for a patient with left-sided hemiparesis who has developed bronchitis and has a heart rate of 105 beats/min, blood pressure of 156/90 mm Hg, and respiration rate of 30 breaths/min. Which nursing diagnosis is apriority? a. Risk for skin breakdown b. Impaired gas exchange c. Activity intolerance d. Risk for infection

ANS: B The most important nursing intervention is to maintain airway and circulation for this patient; therefore, Impaired gas exchange is the first nursing priority. Activity intolerance is a concern but is not the priority in this case. Risk for skin breakdown and Risk for infection are also important but do not address an immediate impairment with physiologic integrity

While the nurse is changing the ties on a tracheostomy collar, the patient coughs, dislodging the tracheostomy tube. Which action will the nurse take first? a. Press the emergency response button. b. Insert a spare tracheostomy with the obturator. c. Manually occlude the tracheostomy with sterile gauze. d. Place a face mask delivering 100% oxygen over the nose and mouth

ANS: B The nurse's first priority is to establish a stable airway by inserting a spare trach into the patient's airway; ideally an obturator should be used. The nurse could activate the emergency response team if the patient is still unstable after the tracheostomy is placed. A patient with a tracheostomy breathes through the tube, not the nose or mouth; a face mask would not be an effective method of getting air into the lungs. Manually occluding pressure over the tracheostomy site is not appropriate and would block the patient's only airway.

Upon auscultation of the patient's chest, the nurse hears a whooshing sound at the fifth intercostal space. What does this finding indicate to the nurse? a. The beginning of the systolic phase b. Regurgitation of the mitral valve c. The opening of the aortic valve d. Presence of orthopnea

ANS: B When regurgitation occurs, there is a backflow of blood into an adjacent chamber. For example, in mitral regurgitation the mitral leaflets do not close completely. When the ventricles contract, blood escapes back into the atria, causing a murmur, or "whooshing" sound. The systolic phase begins with ventricular filling and closing of the aortic valve, which is heard as the first heart sound, S1. Orthopnea is an abnormal condition in which a patient uses multiple pillows when reclining to breathe easier or sits leaning forward with arms elevated

The nurse suspects the patient has increased afterload. Which piece of equipment should the nurse obtain to determine the presence of this condition? a. Pulse oximeter b. Oxygen cannula c. Blood pressure cuff d. Yankauer suction tip catheter

ANS: C A blood pressure cuff is needed. The diastolic aortic pressure is a good clinical measure of afterload. Afterload is the resistance to left ventricular ejection. In hypertension the afterload increases, making cardiac workload also increase. A pulse oximeter is used to monitor the level of arterial oxygen saturation; it will not help determine increased afterload. While an oxygen cannula may be needed to help decrease the effects of increased afterload, it will not help determine the presence of afterload. A Yankauer suction tip catheter is used to suction the oral cavity

A patient has a myocardial infarction. On which primary blood vessel will the nurse focus care to reduce ischemia? a. Superior vena cava b. Pulmonary artery c. Coronary artery d. Carotid artery

ANS: C A myocardial infarction is the lack of blood flow due to obstruction to the coronary artery, which supplies the heart with blood. The superior vena cava returns blood back to the heart. The pulmonary artery supplies deoxygenated blood to the lungs. The carotid artery supplies blood to the brain.

A nurse auscultates heart sounds. When the nurse hears S2, which valves is the nurse hearing close? a. Aortic and mitral b. Mitral and tricuspid c. Aortic and pulmonic d. Mitral and pulmonic

ANS: C As the ventricles empty, the ventricular pressures decrease, allowing closure of the aortic and pulmonic valves, producing the second heart sound, S2. The mitral and tricuspid produce the first heart sound, S1. The aortic and mitral do not close at the same time. The mitral and pulmonic do not close at the same time

A patient has heart failure and cardiac output is decreased. Which formula can the nurse use to calculate cardiac output? a. Myocardial contractility × Myocardial blood flow b. Ventricular filling time/Diastolic filling time c. Stroke volume × Heart rate d. Preload/Afterload

ANS: C Cardiac output can be calculated by multiplying the stroke volume and the heart rate. The other options are not measures of cardiac output

A nurse is caring for a 5-year-old patient whose temperature is 101.2° F. The nurse expects this patient to hyperventilate. Which factor does the nurse remember when planning care for this type of hyperventilation? a. Anxiety over illness b. Decreased drive to breathe c. Increased metabolic demands d. Infection destroying lung tissues

ANS: C Increased body temperature (fever) increases the metabolic rate, thereby increasing carbon dioxide production. The increased carbon dioxide level stimulates an increase in the patient's rate and depth of respiration, causing hyperventilation. Anxiety can cause hyperventilation, but this is not the direct cause from a fever. Sleep causes a decreased respiratory drive; hyperventilation speeds up breathing. The cause of the fever in this question is unknown.

While performing an assessment, the nurse hears crackles in the patient's lung fields. The nurse also learns that the patient is sleeping on three pillows to help with the difficulty breathing during the night. Which condition will the nurse most likely observe written in the patient's medical record? a. Atrial fibrillation b. Myocardial ischemia c. Left-sided heart failure d. Right-sided heart failure

ANS: C Left-sided heart failure results in pulmonary congestion, the signs and symptoms of which include shortness of breath, cough, crackles, and paroxysmal nocturnal dyspnea (difficulty breathing when lying flat). Right-sided heart failure is systemic and results in peripheral edema, weight gain, and distended neck veins. Atrial fibrillation is often described as an irregularly irregular rhythm; rhythm is irregular because of the multiple pacemaker sites. Myocardial ischemia results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet myocardial oxygen demands, producing angina or myocardial infarction

A patient with a pneumothorax has a chest tube inserted and is placed on low constant suction. Which finding requires immediate action by the nurse? a. The patient reports pain at the chest tube insertion site that increases with movement. b. Fifty milliliters of blood gushes into the drainage device after the patient coughs. c. No bubbling is present in the suction control chamber of the drainage device. d. Yellow purulent discharge is seen leaking out from around the dressing site.

ANS: C No bubbling in the suction control chamber indicates an obstruction of the drainage system. An obstruction causes increased pressure, which can cause a tension pneumothorax, which can be life threatening. The nurse needs to determine whether the leak is inside the thorax or in the tubing and act from there. Occasional blood gushes from the lung owing to lung expansion, as during a cough; this is reserve drainage. Drainage over 100 mL/hr after 3 hours of chest tube placement is cause for concern. Yellow purulent drainage indicates an infection that should be reported to the health care provider but is not as immediately life threatening as the lack of bubbling in the suction control chamber.

A nurse is caring for a patient who is taking warfarin (Coumadin) and discovers that the patient is taking garlic to help with hypertension. Which condition will the nurse assess for in this patient? a. Increased cholesterol level b. Distended jugular vein c. Bleeding d. Angina

ANS: C Patients taking warfarin (Coumadin) for anticoagulation prolong the prothrombin time (PT)/international normalized ratio (INR) results if they are taking gingko biloba, garlic, or ginseng with the anticoagulant. The drug interaction can precipitate a life-threatening bleed. Increased cholesterol levels are associated with saturated fat dietary intake. A distended jugular vein and peripheral edema are associated with damage to the right side of the heart. Angina is temporary ischemia of the heart muscle.

A nurse is teaching the patient with mitral valve problems about the valves in the heart. Starting on the right side of the heart, describe the sequence of the blood flow through these valves. 1. Mitral 2. Aortic 3. Tricuspid 4. Pulmonic a. 1, 3, 2, 4 b. 4, 3, 2, 1 c. 3, 4, 1, 2 d. 2, 4, 1, 3

ANS: C The blood flows through the valves in the following direction: tricuspid, pulmonic, mitral, and aortic

Which nursing intervention is most effective in preventing hospital-acquired pneumonia in an older-adult patient? a. Discontinue the humidification delivery device to keep excess fluid from lungs. b. Monitor oxygen saturation, and frequently auscultate lung bases. c. Assist the patient to cough, turn, and deep breathe every 2 hours. d. Decrease fluid intake to 300 mL a shift

ANS: C The goal of the nursing action should be the prevention of pneumonia; the action that best addresses this is to cough, turn, and deep breathe to keep secretions from pooling at the base of the lungs. Humidification thins respiratory secretions, making them easier to expel and should be used. Monitoring oxygen status is important but is not a method of prevention. Hydration assists in preventing hospital-acquired pneumonia. The best way to maintain thin secretions is to provide a fluid intake of 1500 to 2500 mL/day unless contraindicated by cardiac or renal status. Restricting fluids is contraindicated in this situation since there is no data indicating cardiac or renal disease.

A nurse is preparing a patient for nasotracheal suctioning. In which order will the nurse perform the steps, beginning with the first step? 1. Insert catheter. 2. Apply suction and remove. 3. Have patient deep breathe. 4. Encourage patient to cough. 5. Attach catheter to suction system. 6. Rinse catheter and connecting tubing. a. 1, 2, 3, 4, 5, 6 b. 4, 5, 1, 2, 3, 6 c. 5, 3, 1, 2, 4, 6 d. 3, 1, 2, 5, 4, 6

ANS: C The steps for nasotracheal suctioning are as follows: Verify that catheter is attached to suction; have patient deep breathe; insert catheter; apply intermittent suction for no more than 10 seconds and remove; encourage patient to cough; and rinse catheter and connecting tubing with normal saline

A nurse is teaching a health class about the heart. Which information from the class members indicates teaching by the nurse is successful for the flow of blood through the heart, starting in the right atrium? a. Right ventricle, left ventricle, left atrium b. Left atrium, right ventricle, left ventricle c. Right ventricle, left atrium, left ventricle d. Left atrium, left ventricle, right ventricle

ANS: C Unoxygenated blood flows through the venae cavae into the right atrium, where it is pumped down to the right ventricle; the blood is then pumped out the pulmonary artery and is returned oxygenated via the pulmonary vein to the left atrium, where it flows to the left ventricle and is pumped out to the rest of the body via the aorta

A patient's heart rate increased from 94 to 164 beats/min. What will the nurse expect? a. Increase in diastolic filling time b. Decrease in hemoglobin level c. Decrease in cardiac output d. Increase in stroke volume

ANS: C With a sustained heart rate greater than 160 beats/min, diastolic filling time decreases, decreasing stroke volume and cardiac output. The hemoglobin level would not be affected.

The nurse is using a closed suction device. Which patient will be most appropriate for this suctioning method? a. A 5-year-old with excessive drooling from epiglottitis b. A 5-year-old with an asthma attack following severe allergies c. A 24-year-old with a right pneumothorax following a motor vehicle accident d. A 24-year-old with acute respiratory distress syndrome requiring mechanical ventilation

ANS: D Closed suctioning is most often used on patients who require invasive mechanical ventilation to support their respiratory efforts because it permits continuous delivery of oxygen while suction is performed and reduces the risk of oxygen desaturation. In this case, the acute respiratory distress syndrome requires mechanical ventilation. In the presence of epiglottitis, croup, laryngospasm, or irritable airway, the entrance of a suction catheter via the nasal route causes intractable coughing, hypoxemia, and severe bronchospasm, necessitating emergency intubation or tracheostomy. The 5year-old child with asthma would benefit from an inhaler. A chest tube is needed for the pneumothorax.

The nurse is caring for a patient with respiratory problems. Which assessment finding indicates a late sign of hypoxia? a. Elevated blood pressure b. Increased pulse rate c. Restlessness d. Cyanosis

ANS: D Cyanosis, blue discoloration of the skin and mucous membranes caused by the presence of desaturated hemoglobin in capillaries, is a late sign of hypoxia. Elevated blood pressure, increased pulse rate, and restlessness are early signs of hypoxia.

The nurse is teaching about the process of exchanging gases through the alveolar capillary membrane. Which term will the nurse use to describe this process? a. Ventilation b. Surfactant c. Perfusion d. Diffusion

ANS: D Diffusion is the process of gases exchanging across the alveoli and capillaries of body tissues. Ventilation is the process of moving gases into and out of the lungs. Surfactant is a chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing. Perfusion is the ability of the cardiovascular system to carry oxygenated blood to tissues and return deoxygenated blood to the heart

The nurse is assessing a patient with emphysema. Which assessment finding requires further follow-up with the health care provider? a. Increased anterior-posterior diameter of the chest b. Accessory muscle used for breathing c. Clubbing of the fingers d. Hemoptysis

ANS: D Hemoptysis is an abnormal occurrence of emphysema, and further diagnostic studies are needed to determine the cause of blood in the sputum. Clubbing of the fingers, barrel chest (increased anteriorposterior chest diameter), and accessory muscle use are all normal findings in a patient with emphysema

A patient has inadequate stroke volume related to decreased preload. Which treatment does the nurse prepare to administer? a. Diuretics b. Vasodilators c. Chest physiotherapy d. Intravenous (IV) fluids

ANS: D Preload is affected by the circulating volume; if the patient has decreased fluid volume, it will need to be replaced with fluid or blood therapy. Preload is the amount of blood in the left ventricle at the end of diastole, often referred to as end-diastolic volume. Giving diuretics and vasodilators will make the situation worse. Diuretics causes fluid loss; the patient is already low on fluids or the preload would not be decreased. Vasodilators reduced blood return to the heart, making the situation worse; the patient does not have enough blood and fluid to the heart or the preload would not be decreased. Chest physiotherapy is a group of therapies for mobilizing pulmonary secretions. Chest physiotherapy will not help this cardiovascular problem

A nurse is preparing to suction a patient. The pulse is 65 and pulse oximetry is 94%. Which finding will cause the nurse to stop suctioning? a. Pulse 75 b. Pulse 80 c. Oxygen saturation 91% d. Oxygen saturation 88%

ANS: D Stop when oxygen saturation is 88%. Monitor patient's vital signs and oxygen saturation during procedure; note whether there is a change of 20 beats/min (either increase or decrease) or if pulse oximetry falls below 90% or 5% from baseline. If this occurs, stop suctioning. A pulse rate of 75 is only 10 beats different from the start of the procedure. A pulse rate of 80 is 15 beats different from the start of suctioning. Oxygen saturation of 91% is not 5% from baseline or below 90%

1. ____________________ is the movement of air into and out of the lungs through the act of breathing. ____________________ refers to the exchange of gases (oxygen and carbon dioxide) in the lungs.

ANS: Ventilation; Respiration

3. The amount of air moved into and out of the lungs with each normal breath is known as the ____________________. Normally, this volume is around ____________________ mL.

ANS: tidal volume; 500

Left Sided Heart Failure Risk Factors: Signs and Symptoms: Nursing Interventions:

Abnormal condition characterized by decreased functioning of the left ventricle. Results in decreased cardiac output. Risk Factors: S/S: fatigue, breathlessness, dizziness and confusion. Crackles in base of lungs, hypoxia, shortness of breath, cough, and paroxysmal nocturnal dyspnea. Nursing Intervention:

hyperventilation

Abnormally prolonged and deep breathing

What causes impaired valvular function?

Acquired or congenital disorder of cardiac valve by stenosis or regurgitation

in home oxygen therapy where do you administer oxygen?

Administered via nasal cannula or face mask

What are after load? What signs and symptoms does a patient with increased afterload have? What could this indicate?

Afterload: Resistance to left ventricular ejection S/S: May indicate: Hypertension, vasoconstriction

tidal volume

Air that moves in and out of lungs with each quiet inspiration, typically 500 ml

alterations in respiratory functioning what is hypoventilation?

Alveolar ventilation inadequate to meet the body's oxygen demand or to eliminate sufficient carbon dioxide

what is cardiac output?

Amount of blood ejected from the left ventricle each minute

what is stroke volume?

Amount of blood ejected from the left ventricle with each contraction

What is Cardiac Output? Why and how does the nurse assess cardiac output? How do you calculate it?

Amount of blood ejected from the left ventricle each minute WHY/HOW????? Cardiac Output (CO) = Stroke Volume (SV) x Heart Rate (HR)

where is bronchoscopy inserted?

An instrument is inserted into the airways, usually through the nose or mouth, or occasionally through a tracheostomy.

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 36-year-old patient diagnosed with meningitis has a fever of 102.3° F. A family member verbalizes a concern that the patient is "breathing fast." Upon assessment, the nurse notes a respiratory rate of 20 breaths/min, pulse oximetry is 92% on 2L/O2, and lungs clear to auscultation. What is the best explanation for the rapid respiratory rate that the nurse can give the family member? a. "He is most likely anxious because he is in the hospital." b. "His fever has increased his metabolic rate and is causing him to breathe faster." c. "He is hyperventilating because he needs more oxygen." d. "He has an acid-base imbalance, which is causing him to hyperventilate."

B

A college student who smokes asks a healthcare professional if there really is a connection between smoking and lung cancer. What is the healthcare worker's best response? a. The risk for lung cancer for smokers than for nonsmokers is 5 times greater. b. The risk for lung cancer for smokers than for nonsmokers is 10 times greater. c. The risk for lung cancer for smokers than for nonsmokers is 50 times greater. d. Lung cancer affects smokers and non-smokers equally due to occupational hazards.

B

A healthy 33-year-old mother of three children reports "having no energy." She asks the nurse, how she could increase her energy level. What is the best response for the nurse to give? a. "You should decrease iron intake." b. "Daily exercise has been shown to increase a person's energy level." c. "Energy caffeinated drinks are a good substitute for exercise." d. "Try to exercise 90 minutes every other day."

B

A nurse is being oriented to work for an intensive care unit. The hemodynamic data indicate that the patient has a decreased preload. Which information indicates the nurse has a correct understanding of the concept of preload? a. It is the amount of blood ejected from the left ventricle each minute. b. It is the amount of blood in the heart at the end of ventricular diastole. c. It is the resistance to the ejection of blood from the left ventricle. d. It is the rhythmic relaxation and contraction of the heart chambers.

B

A patient presents with an acute myocardial infarction that resulted in right ventricular damage. The nurse needs to assess the patient for right-sided heart failure, which includes which of the following? a. Crackles on auscultation b. Jugular neck vein distention c. Increased myocardial perfusion d. Orthopnea

B

A student nurse caring for a patient with a chest tube has been asked what equipment should be at the bedside to assess for an air leak. Which information indicates the student nurse has a correct understanding of the equipment needed? a. Suction equipment wrapped in plastic to keep instrument clean b. Hemostat covered with gauze to prevent penetration of the chest tube c. Cup of water to place the end of the chest tube d. Petroleum gauze to use as a dressing

B

The nurse is educating a patient who has recently been diagnosed with chronic obstructive pulmonary disease (COPD). The nurse explains how the gasses in the lungs move between the air spaces and the bloodstream. Which process is the nurse describing? a. Ventilation b. Diffusion c. Respiration d. Perfusion

B

The nurse is evaluating a patient who has a chest tube. To properly maintain chest tube function, what is the nurse's best action? a. Strip the tube every hour to maintain drainage. b. Place the device below the patient's chest. c. Double clamp the tubes except during assessments. d. Remove the tubing from the drainage device to check for proper suctioning.

B

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though her color is ruddy not cyanotic, the nurse understands the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon Monoxide does which of the following: A) Stimulates hyperventilation causing respiratory alkalosis B) Forms a strong bond with hemoglobin thus preventing oxygen binding in the lungs C) Stimulates hypoventilation causing respiratory acidosis D) Causes alveoli to overinflate leading to atelectasis

B (Carbon monoxide strongly binds to hemoglobin making it unavailable for oxygen binding and transport.)

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complication? Antibiotics Frequent change of position Oxygen humidification Chest physiotherapy

B (Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting the effectiveness of gas exchange processes.)

Which of the following is a recommended immunization for adults yearly? a. Pneumococcal b. Influenza c. Polio d. Tetanus

B (Influenza vaccines are recommended yearly for adults.)

The exchange of oxygen and carbon dioxide occurs in the alveoli. How is oxygen carried in the blood? a. The white blood cells b. The hemoglobin c. The platelets d. The neutrophils

B (Oxygen is carried on the hemoglobin to the tissues where some is released.)

Which of the following skills can be delegated to nursing assistive personnel (NAP)? A) Nasotracheal suctioning B) Oropharyngeal suctioning of a stable patient C)Suctioning a new artificial airway D)Permanent tracheostomy tube suctioning E)Care of an endotracheal tube (ETT)

B D (Oropharyngeal suctioning of a stable patient and permanent tracheostomy tube suctioning may be safely delegated to a NAP. The other skills require nursing assessment and clinical decision making as the skill progresses.)

what is the most common mode of support that provides both inspiratory positive airway (IPAP) and expiratory airway pressure(EPAP)?

BiPAP also known as positive end-expiratory pressure (PEEP)

diagnostic tests what are some tests when checking for cardiopulmonary functioning?

Blood specimens • X-rays • TB skin testing pg.885

alterations in respiratory functioning what is cyanosis?

Blue discoloration of the skin and mucous membranes

sternum

Breast bone

A client is admitted to the emergency department with a suspected cervical spine fracture at the C3 level. The nurse is most concerned about the client's ability to:

Breathe

inhale / inspiration

Breathe in

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

A 3-month-old infant is being seen for a well-child check at the pediatric clinic. The nurse is assessing the guardian's knowledge level about the infant's growth and development. One of the topics that the nurse has chosen to address in this session is the risk for airway obstruction. What is the main reason that the nurse has chosen this topic? a. Infants can have severe allergic reactions to food based on exposure to secondhand smoke. b. Infants are prone to lower airway infections that can become obstructive. c. Infants have a tendency to place foreign objects in their mouths. d. Infants can have airway obstruction from excessive drooling associated with teething.

C

A 45-year-old patient was diagnosed with an anterior myocardial infarction. The patient asks the nurse why his chest hurt when he had his heart attack. What is the best response from the nurse? a. "One of your heart valves wasn't working properly and caused an obstructed blood flow." b. "One of your coronary arteries had a spasm, and your heart muscle wasn't able to get enough blood." c. "Your heart muscle was deprived of oxygen, which caused chest pain." d. "The heart muscle is sensitive to changes in electrical conduction."

C

A 58-year-old Caucasian woman is at the clinic for her annual check-up. She tells the nurse that she noticed her blood pressure is higher than it was when she was younger. She asks the nurse why this would happen. What is the nurse's best response? a. "Your race and gender are predisposing factors for heart disease." b. "Well, if you stop smoking your blood pressure would go down." c. "As we age, our blood vessels become less elastic, which causes higher blood pressure." d. "I don't think it's anything to worry about."

C

A health care worker received an annual tuberculosis test administered 56 hours ago. The injection site is very red and flat. The certified nurse who is reading the test should take which action? a. Advise the health care worker another test must be done because the test was not read within the proper time. b. Tell the health care worker the results are positive and cannot return to work. c. Document the results as a negative reaction. d. Measure the area in millimeters.

C

A patient on the surgical unit is 1 day postoperative for surgery to remove stomach cancer. In addition to the physiological stress this patient has undergone, the nurse recognizes that this patient will have to deal with the psychological stress of finding out that the cancer has metastasized to the liver. Which physiological change would the nurse expect to see as a response to stress? a. Decreased heart rate b. Increased hemoptysis output c. Increased respiratory rate d. Decreased cardiac output

C

A patient who is 7 months pregnant with her first child is visiting the health care provider for her scheduled prenatal checkup. She tells the nurse that she is short of breath and fatigued. What is the best response from the nurse? a. "You should have let us know immediately instead of waiting until your appointment." b. "I'll make a note of it on your chart." c. "That is normal; your uterus is causing pressure on your diaphragm, making it more difficult to breathe." d. "Oxygen is needed for you and the baby. I will give you some oxygen to help you."

C

A patient with pulmonary congestion needs to cough to clear secretions. The nurse instructs the patient to inhale and perform a series of coughs during exhalation. What type of cough did the nurse teach the patient? a. Quad b. Huff c. Cascade d. Splinting

C

The RN and nursing assistive personnel (NAP) are caring for six patients on the pulmonary unit. Which of the following tasks would be most appropriate for the nurse to delegate to the NAP? a. Taking vital signs on a 56-year-old man with severe dyspnea b. Suctioning a patient with hemoptysis c. Encouraging a postoperative patient to use the incentive spirometer

C

The assistive personnel reports that an older patient is complaining of shortness of breath and palpitations. The nurse connects the patient to an electrocardiogram monitor and analyzes the rhythm with normal P wave and normal QRS and T waves. The rate is 116 beats per minute and regular. The nurse identifies this rhythm as which of the following? a. Sinus bradycardia b. Ventricular tachycardia c. Sinus tachycardia d. Normal sinus rhythm

C

The exchange of oxygen and carbon dioxide during cellular metabolism is best described as which of the following? a. Ventilation b. Diffusion c. Respiration d. Perfusion

C

The family member of a 73-year-old patient with chronic obstructive pulmonary disease (COPD) is concerned about the patient's recent weight loss. When questioned by the nurse, the patient denies any change in diet or activity, but admits to losing 10 lb in the past 6 weeks. What is the nurse's best response to the family member's concern? a. "Maybe the patient has a higher metabolic rate than you." b. "It doesn't seem fair that some people can lose weight so easily." c. "This disease affects the respiratory system and causes the body to burn more calories to supply the energy to breathe." d. "You need to discuss this with the health care provider so testing can be ordered for tuberculosis."

C

The nursing student is formulating a nursing care plan for a patient with pneumonia. The care plan is directed toward meeting the potential oxygenation needs of the patient. Which of the following examples would be the best way for the nursing student to write an expected outcome for the care plan? a. "The patient will have less pain." b. "The patient will be able to breathe better." c. "The patient's pulse oximetry reading will remain greater than 92%." d. "The patient's interactions will be normal."

C

Which of the following oxygen masks has holes at the side that allow air to enter the mask? a. Partial rebreathing mask b. Nonrebreathing mask c. Simple face mask d. Nebulizer mask

C (The holes in the mask allow the CO2 to escape on expiration, and if the oxygen is turned off, room air can be breathed through the holes.)

A patient is admitted with severe lobar pneumonia. Which of the following assessment findings would indicate that the patient needs airway suctioning? A. Coughing up thick sputum only occasionally B. Coughing up thin, watery sputum after nebulization C. Decreased ability to clear airway through couching D. Lung sounds clear only after coughing

C (Decreased Ability to clear airway through coughing) (impaired ability to cough up mucous due to weakness or very thick secretions indicates a need for suctioning)

what system controls respiratory rate, depth, and rhythm?

CNS

The nurse is caring for a client who has undergone cardiac catheterization. The client says to the nurse, "The doctor said my cardiac output was 5.5 L/min. What is normal cardiac output?" Which of the following is the nurse's best response?

CORRECT ANSWER IS C A) "It is best to ask your doctor." B) "Did the test make you feel upset?" C) "The normal cardiac output for an adult is 4 to 6 L/min." D) "Are you able to explain why are you asking this question?" The client asked a direct question that the nurse should be able to answer. Normal cardiac output for an adult is 4 to 6 L/min. Questions regarding diagnosis and prognosis may be referred to physicians. There is no harm in answering this question. When using therapeutic communication, the nurse should never ask a client to justify his or her feelings by inquiring why a question was asked. There is no evidence that this client is upset

Symptoms associated with anemia include which of the following? (Select all that apply.)

CORRECT ANSWERS ARE A & D A) Increased breathlessness B) Decreased breathlessness C) Increased activity tolerance D) Decreased activity tolerance Clients with anemia have fatigue, decreased activity tolerance, and increased breathlessness, as well as pallor (especially seen in the conjunctiva of the eye) and an increased heart rate.

Which of the following assessment data indicate that the client's airway needs suctioning? (Select all that apply.)

CORRECT ANSWERS ARE A, C & E Suctioning is necessary when the client is unable to clear respiratory secretions from the airways. Signs that a client's airway needs suctioning include a change in respiratory rate or adventitious sounds, nasal secretions, gurgling, drooling, restlessness, gastric secretions or vomitus in the mouth, and coughing without clearance of secretions from the airway.

A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and anxiety. The nurse helps the client to breathe better by doing which of the following? (Select all that apply.)

CORRECT ANSWERS ARE B & C A) Implementing guided imagery B) Instructing the client to perform pursed-lip breathing C) Elevating the head of the bed to semi-Fowler's or Fowler's position Elevating the head of the bed to Fowler's position (45-degree angle) or semi-Fowler's position (30- to 45-degree angle) causes the diaphragm to lower from gravity and thus increases the space for lung expansion. Pursed-lip breathing prolongs exhalation and maintains the alveoli open longer, thus extending the period of oxygen and carbon dioxide exchange. Too high an elevation of the head of the bed could force the diaphragm into the thorax and reduce lung expansion. Fluids could help liquify the pulmonary secretions in the future, but right now the client needs more acute care. Guided imagery may help in the future, but now is not the time to implement this intervention.

The nurse suspects left-sided heart failure in a newly admitted client when the nurse notes which of the following symptoms? (Select all that apply.)

CORRECT ANSWERS ARE B & D A) Distended neck veins B) Bilateral crackles in the lungs C) Weight gain of 2 lb in past 2 days D) Shortness of breath, especially at night Left-sided heart failure results in ineffective ejection of blood from the left ventricle. This causes a backup of blood into the lungs. Thus, symptoms of left-sided heart failure are usually related to the lungs.

what is capnography?

Capnography is the monitoring of the concentration or partial pressure of carbon dioxide (CO. 2) in the respiratory gases.

Fever increases the tissues' need for oxygen, and as a result:

Carbon dioxide production increases Fever increases the tissues' need for oxygen, and as a result, carbon dioxide production increases. When fever persists, the metabolic rate remains high and the body begins to break down protein stores, which results in muscle wasting and decreased muscle mass.

If cardiac after load increase ______ ALSO increases.

Cardiac workload

For which of the following health problems is a patient who has a 40-year history of smoking at risk? 1) Alcoholism and hypertension 2) Obesity and diabetes 3) Stress related illnesses 4) Cardiopulmonary disease and lung cancer

Cardiopulmonary disease and lung cancer Rationale: Effects of nicotine on blood vessels and lung tissue have increasing pathological effects on the cardiovascular and pulmonary systems.

Heart Murmur Risk Factors: Signs and Symptoms: Nursing Interventions:

Caused by backflow of blood through incompetent valve

A client asks why smoking is a major risk factor for heart disease. In formulating a response, the nurse incorporates the understanding that nicotine

Causes vasoconstriction

thoracic

Chest

What is systemic circulation?

Circulation of blood from the body TO the heart

Define/describe clubbing (fingernails), hemoptysis, sputum, accessory muscles.

Clubbing nails- w/ prolonged oxygen deficiency, endocarditis, congenital heart defects Hemoptysis-bloody sputum w/ basic pH Sputum- cough every 2 hours while awake

tracheostomy

Creation of an opening into the trachea through the neck and the insertion of a tube to create an airway.

A 47-year-old woman with a history of diabetes and hypertension calls the clinic complaining of epigastric pain and shortness of breath with activity. She has taken antacids with no relief. What type of pain is the patient experiencing? a. Pericardial pain b. Pleuritic chest pain c. Musculoskeletal pain d. Cardiac pain

D

A patient has been admitted to the pulmonary unit of the hospital with right lower lobe pneumonia and history of chronic obstructive pulmonary disease (COPD). During the initial assessment the nurse notes that the patient has a respiration rate of 18 with retractions, tachycardia, and complains of dyspnea and dizziness. The nurse identifies that these are clinical signs of which condition? a. Paroxysmal nocturnal dyspnea b. Orthopnea c. Hemoptysis d. Hypoxia

D

A patient has been newly diagnosed with chronic lung disease. In discussing his condition with the nurse, which of his statements would indicate a need for further education? A) "I'll make sure that I rest between activities so I don't get so short of breath." B) "I'll practice the pursed-lip breathing technique to improve my exercise tolerance." C) "If I have trouble breathing at night, I'll use two to three pillows to prop up." D) "If I get short of breath, I'll turn up my oxygen level to 6 L/min."

D

The nurse is admitting a patient with chronic obstructive pulmonary disease (COPD). During the initial head-to-toe assessment the patient's pulse oximetry reading is 89% on room air. What is the nurse's first priority? a. Administer oxygen immediately @ 4L/NC. b. Call the primary health care provider for an order for oxygen. c. Assist the patient into a recumbent position. d. Determine the patient's normal pulse oximetry reading.

D

What is the best indicator the nurse can use to determine the adequacy of a patient's cardiac output? a. Stroke volume b. Myocardial contractility c. Afterload d. Cardiac index

D

When giving CPR, compressions are causing the heart to pump blood into and out of the lungs to the body's organs. This movement of oxygenated blood is best described as which of the following? a. Ventilation b. Diffusion c. Respiration d. Perfusion

D

A patient is admitted with the diagnosis of severe left-sided heart failure. What adventitious lung sounds are expected on auscultation? Sonorous wheezes in the left lower lung Rhonchi mid sternum Crackles only in apex of lungs Inspiratory crackles in lung bases

D (Decreased effective contraction of left side of heart leads to back up of fluid in the lungs increasing hydrostatic pressure and causing pulmonary edema.)

Which of the following diagnosis is a patient who started smoking in adolescence and continues to smoke for 40 years at this risk for? Alcoholism and hypertension Obesity and diabetes Stress-related illnesses Cardiopulmonary disease and lung cancer

D (Effects of nicotine on blood vessels and lung tissue have increasing pathological effects on the cardiovascular and pulmonary systems.)

Which of the following artificial airways would the nurse anticipate to have a cuff at the end? a. Nasotracheal airway b. Pharyngeal airway c. Oral pharyngeal airway d. An endotracheal tube

D (An endotracheal tube enters the patient's trachea and has a cuff to prevent gastric contents from emptying into the lungs from the gastrointestinal tract.)

Which of the following conditions would be associated with a wheezing sound on inspiration in a patient's lower posterior chest? a. Myocardial infarction b. Congestive heart failure c. Pulmonary edema d. Asthma

D (Asthma causes a narrowing of small airways that results in a wheezing sound.)

Which of the following patients may need a pharyngeal airway? a. A patient who is alert and oriented b. A patient who has a tracheostomy c. A patient with a broken nose d. A patient with decreased level of consciousness

D (Pharyngeal airways are needed most often when a patient has a decreased level of consciousness and loss of muscle tone.)

When a person takes a breath in, what is the primary muscle of respiration? a. The intercostal muscles b. The neck muscles c. Muscles of the shoulder girdle d. The diaphragm

D (The diaphragm is the primary muscle of respiration. When it contracts, the intrathoracic is increased, forcing atmospheric air into the airways.)

The nurse is reviewing the results of the patient's diagnostic testing. Of the following results, the finding that falls within expected or normal limits is: A.) Palpable, elevated hardened area around a tuberculosis skin testing site. B.) Sputum for culture and sensitivity identifies mycobacterium tuberculosis C.) Presence of acid fast bacilli in sputum D.) Arterial oxygen tension (PaO2) of 95 mmHg

D (Arterial oxygen tension (PaO2) of 95 mmHg (A palpable, elevated, hardened area surrounding a tuberculosis skin testing site is indicative of an antigen-antibody reaction and is considered a positive skin test. Sputum for culture and sensitivity noted the presence of an organism and acid fast bacilli. Normal arterial oxygen tension (PaO2) ranges between 95-100 mmHg.)

vasoconstriction

Decrease in the diameter of blood vessels

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation? Increased breathlessness but increased activity tolerance Decreased breathlessness and decreased activity tolerance Increased activity tolerance and decreased breathlessness Decreased activity tolerance and increased breathlessness

Decreased activity tolerance and increased breathlessness (Hypoxia occurs due to decreased circulating blood volume which leads to decreased oxygen to muscles causing fatigue and decreased activity tolerance as well as a feeling of shortness of breath.)

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment, which of the following symptoms are associated with decreased oxygenation as a result of the anemia? 1) Increased breathlessness but increased activity tolerance 2) Decreased breathlessness and decreased activity tolerance 3) Increased activity tolerance and decreased breathlessness 4) Decreased activity tolerance and increased breathlessness

Decreased activity tolerance and increased breathlessness Rationale: Hypoxia occurs due to decreased hemoglobin, which leads to decreased oxygen to muscles, causing fatigue and decreased activity tolerance as well as a feeling of shortness of breath.

Left-sided heart failure is characterized by:

Decreased functioning of the left ventricle Left-sided heart failure is an abnormal condition characterized by decreased functioning of the left ventricle. If left ventricular failure is significant, the amount of blood ejected from the left ventricle drops greatly, which results in decreased cardiac output

if heart rate INCREASES, stroke volume _______.

Decreases

What is a Venturi mask? Why and how do we use it?

Delivers High Concentration Why (advantages): Provides specific amount of oxygen with humidity added. Administers low and constant O2 How:

what are the factors influencing oxygenation?

Developmental Lifestyle Environmental

The nurse is caring for a client with a chest tube in the right thorax. On first assessment the nurse notes that there is bubbling in the water-seal chamber. This client is scheduled to undergo a chest x-ray examination, and the transporters have arrived to take him by wheelchair to the radiology department. The nurse considers whether the chest tube should be clamped or not during the trip to the radiology department. The nurse makes the which correct decision?

Do not clamp the chest tube and disconnect it from the wall suction. A bubbling chest tube (in the water-seal portion) should never be clamped because it provides the only exit for air accumulating in the pleural space. If the tube is clamped, tension pneumothorax could occur, which could be fatal. There is no advantage to clamping the chest tube but venting the system. Clamping of the chest tube prevents communication of the chest tube with the venting system or with the wall suction. There is no such thing as "temporary suction" for a chest tube system.

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

What acute care techniques should be used for a patient who needs to manage dyspnea (difficulty breathing), airway maintenance, and mobilization of pulmonary secretions?

Dyspnea Management: Hydration Airway Maintenance: Humidification Mobilization of pulmonary secretions: Nebulization **COUGHING AND DEEP-BREATHING TECHNIQUES FOR ALL

What is the earliest and latest sign of hypoxia? In different cultures, where might we note signs and symptoms of hypoxia?

Earliest: Confusion, restlessness, and ??? Latest: Cyanosis caused by the presence of desaturated hemoglobin in capillaries

What does a spirometer do?

Encourages voluntary deep breathing

how does incentive spirometry help lung expansion?

Encourages voluntary deep breathing

what is diffusion?

Exchange of respiratory gases in the alveoli and capillaries

True or False 1. A positive TB skin test indicates that a patient has active tuberculosis.

F

An 86-year old woman is admitted to the unit with chills and a fever of 104°F. What physiological process explains why she is at risk for dyspnea? 1) Fever increases metabolic demands, requiring increased oxygen need 2)Blood glucose stores are depleted and the cells do not have energy to use oxygen. 3) Carbon dioxide production increases due to hyperventilation 4) Carbon dioxide production decreases due to hypoventilation

Fever increases metabolic demands, requiring increased oxygen need. Rationale: When the body cannot meet the increased oxygenation need, the increased metabolic rate causes breakdown of protein and wasting of respiratory muscles, increasing the work of breathing.

Face tent: oxygen concentration delivery capability

FiO₂: 24% to 100% — Flow: At least 10 L.

Flow: 1 to 2 L

FiO₂: 24% to 28%

nasal cannula: oxygen concentration delivery capability

FiO₂: 24% to 44% - Flow: 1 to 6 L/min.

Venturi mask: oxygen concentration delivery capability

FiO₂: 24% to 50% — Flow: 4 to 10 L

oxygen tent: oxygen concentration delivery capability

FiO₂: 28% to 85% — Flow: 10 to 15 L

Flow: 3 to 4 L

FiO₂: 32% to 36%

Flow: 5 to 6 L

FiO₂: 40% to 44%

simple face mask: oxygen concentration delivery capability

FiO₂: 40% to 60% — Flow: 5 to 8 L/min.

partial rebreather mask: oxygen concentration delivery capability

FiO₂: 60% to 75% — Flow: 6 to 11 L/min.

nonrebreather mask: oxygen concentration delivery capability

FiO₂: 80% to 95% — Flow: 10 to 15 L/min.

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

Flow meter

Carbon monoxide (CO) is a toxic inhalant that decreases the oxygen-carrying capacity of blood by:

Forming a strong bond with hemoglobin CO is the most common toxic inhalant and decreases the oxygen-carrying capacity of blood. In CO toxicity, hemoglobin strongly binds with carbon monoxide, creating a functional anemia. Because of the strength of the bond, carbon monoxide does not easily dissociate from hemoglobin, which makes hemoglobin unavailable for oxygen transport.

A patient admitted into the emergency department with suspected carbon monoxide positioning. Even though the patients color is ruddy and not cyanotic, the nurse understands the patient is at a risk of decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following: 1) stimulates hyperventilation, causing respiratory alkalosis 2) Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs. 3) Stimulates hypoventilation, causing respiratory acidosis 4) Causes alveoli to overinflate, leading to atelectasis

Forms a strong bond with hemoglobin, thus preventing oxygen binding in the lungs. Rationale: Carbon monoxide strongly binds to hemoglobin, making it unavailable for oxygen binding and transport.

A simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion is:

Frequent change of position Changing the client's position frequently is a simple and cost-effective method for reducing the risk of pneumonia associated with stasis of pulmonary secretions and decreased chest wall expansion. Oxygen humidification, chest physiotherapy, and use of antiinfectives are all helpful, but are not cost effective.

Discuss the function of the alveoli

Gas exchange

A person who starts smoking in adolescence and continues to smoke into middle age:

Has an increased risk for cardiopulmonary disease and lung cancer The risk of lung cancer is 10 times greater for a person who smokes than for a nonsmoker. Cigarette smoking worsens peripheral vascular and coronary artery disease. Inhaled nicotine causes vasoconstriction of peripheral and coronary blood vessels, increasing blood pressure and decreasing blood flow to peripheral vessels.

Patients with COPD who are breathing spontaneously should NEVER receive what?

High levels of oxygen therapy

Describe Hypoventilation, Hyperventilation, and Hypoxia

Hypoventilation: Alveolar ventilation inadequate to meet the body's oxygen demands or to eliminate sufficient carbon dioxide Hyperventilation: Ventilation in excess of that required to eliminate carbon dioxide produced by cellular metabolism Hypoxia: Inadequate tissue oxygenation at the cellular level

Conditions such as shock and severe dehydration resulting from extracellular fluid loss cause:

Hypovolemia Conditions such as shock and severe dehydration cause extracellular fluid loss and reduced circulating blood volume (hypovolemia).

Patients with sudden changes in their vital signs, LOC, or behavior are possibly experiencing profound _______.

Hypoxia

Right Sided Heart Failure Risk Factors: Signs and Symptoms: Nursing Interventions:

Impaired functioning of right ventricle Risk Factors: pulmonary disease, long term left sided failure, pulmonary vascular resistance (PVR) S/S: wight gain, distended neck veins, hepatomegaly and splenomegaly, and dependent peripheral edema. Nursing Interventions:

Assessment what assessment do you use for oxygenation?

In-depth history of a patient's normal and present cardiopulmonary function Past impairments in circulatory or respiratory functioning Methods that a patient uses to optimize oxygenation Review of drug, food, and other allergies Physical examination Laboratory and diagnostic tests

What is Ischemia?

Inadequate blood supply to an organ or part of the body, especially the heart muscles

iron deficiency anemia

Inadequate supply of iron to form normal RBC.

alterations in respiratory functioning what is hypoxia?

Inadequate tissue oxygenation at the cellular level

thoracotomy

Incision of the chest

hypostatic pneumonia

Inflammation of the lung from stasis or pooling of secretions.

another factor affecting oxygenation is?

Influences of chronic diseases

intubation

Insertion of a tube into the trachea to maintain an open airway

What may a nurse inspect, palpate, percuss, and auscultate when giving a patient a physical exam for oxygenation?

Inspect: -Skin and mucous membranes color -LOC (Level of consciousness) -Breathing patterns -Chest wall movement -Circulation Palpation: -Chest -Feet -Legs -Pulses Percussion: -Presence of abnormal fluid or air -Diaphragmatic excursion Auscultation: -Normal and abnormal heart/lung sounds

maintenance and promotion of lung expansion cont. what invasive mechanical ventilation used for?

Life-saving technique used with artificial airways (ET or tracheostomy) • Physiological indications • Clinical indications

What is hypovolemia?

Liquid portion of blood is too low

xiphoid process

Lower, narrow portion of the sternum

What is chemical regulation?

Maintains the rate and depth of respirations based on changes in the blood concentrations of CO2 and O2, and in hydrogen ion concentration (pH) Chemoreceptors sense changes in the chemical content and stimulate neural regulators to adjust.

should patients who have COPD receive levels of high oxygen therapy?

NO! COPD patients should not receive no more than 2L/min

Which is a sign of dyspnea specific to infants?

Nasal flaring

What is a noninvasive ventilation? What is an invasive mechanical ventilation?

Non-invasive: Purpose is to maintain a continuous positive airway pressure (CPAP) and improve alveolar ventilation Invasive: Life-saving technique used with artificial airways (ET or tracheostomy)

what prevents or treats actelasis?

Noninvasive positive pressure ventilation (NPPV) -by inflating the alveoli, reducing pulmonary edema by forcing fluid out of the lungs back into circulation, and improving oxygenation in those with sleep apnea.

what are you listening for when you auscultate for pulmonary examination?

Normal and abnormal heart and lung sounds

What does Hemoglobin carry?

O2 and CO2

What is open suctioning? What is closed suctioning?

OPEN: using a new sterile catheter for each session in suctioning. wear sterile gloves and follow standard precaution during suctioning procedure CLOSED: Using a reusable sterile suction catheter that is encased in plastic sheaths to protect it inbetween suction sessions

maintenance and promotion of oxygenation what is included in promotion of oxygenation?

Oxygen therapy • To prevent or relieve hypoxia Safety precautions • Supply of oxygen -Tanks or wall-piped system • Methods of oxygen delivery -Nasal cannula -Oxygen mask

Lungs + cardiovascular (CV) system =

Oxygen transport

What physiological factors may affect oxygenation? What conditional factors affect chest wall movement?

Physiological: -decreased oxygen-carrying capacity -Hypovolemia -Decreased inspired oxygen concentration -Increased metabolic rate -chronic diseases Conditions affecting chest wall movement: -Pregnancy -Obesity -Neuromuscular disease -Musculoskeletal abnormalities -CNS alterations

Conditions affecting chest wall movement

Pregnancy Obesity Musculoskeletal abnormalities Trauma Neuromuscular disease (bronchitis, emphysema) CNS alterations

What are preload? What signs and symptoms does a patient with increased preload have? What could this indicate?

Preload: End-diastolic pressure (stretch on the heart) S/S: May indicate: hypervolemia, regulation of cardiac valves, heart failure

what do you percuss in a pulmonary examination? (looking for)

Presence of abnormal fluid or air; diaphragmatic excursion

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

what is the purpose of noninvasive ventilation?

Purpose is to maintain a positive airway pressure and improve alveolar ventilation • Continuous positive airway pressure (CPAP) • Bilevel positive airway pressure (BiPAP)

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 is concerned when a client's heart rate, which is normally 95 beats per minute, rises to 220 beats per minute, because a rate this high will:

Reduce coronary artery perfusion Coronary arteries fill and perfuse the myocardium (heart muscle) during diastole. When the heart rate is elevated, more time is spent in systole and less in diastole; hence, the myocardium may not be perfused adequately. The client may be exhausted, but the primary concern is myocardial perfusion. Major organs will adjust to increased blood flow. This is usually not a problem. With a heart rate this high, metabolic rate will be increased, not decreased.

Discuss chemical receptors that stimulate inspiration. Where are they located?

Regulation of respiration- CO2, and H(pH)

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)

artificial airway cont. what is endotracheal and tracheal airways used for?

Short-term use to ventilate, relieve upper airway obstruction, protect against aspiration, clear secretions

What are the three main lifestyle risks that effect oxygenation?

Smoking -Associated with heart disease, COPD, and lung cancer -Risk of lung cancer is 10x greater in a smoker than a nonsmoker Substance Abuse -Excessive use of alcohol and other drugs impairs tissue oxygenation Stress -A continuous state of stress or severe anxiety increases metabolic rate and oxygen demands of the body

what is the formula for cardiac output?

Stroke volume (SV) × Heart rate (HR)

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

Suction the tracheostomy tube using sterile technique.

what is perfusion?

The ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs

A client is receiving oxygen via a nonrebreathing mask. A crucial nursing assessment the nurse performs is to be sure that:

The bag attached to the mask is inflated at all times If the bag attached to a nonrebreathing mask is deflated, the client is at risk for breathing in large amounts of exhaled carbon dioxide. The bag should be maximally inflated at all times

what happens after CO2 is diffused into carbonic acid?

The carbonic acid then dissociates into hydrogen (H) and bicarbonate (HCO3-) ions Hemoglobin buffers the hydrogen ion, the (HCO3-)diffuses into the plasma

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.

cyanotic

The condition of exhibiting cyanosis.

What is included (4) in work of breathing and what is it?

The effort required to expand and contract the lungs -Inspiration (active) -Expiration (passive) -Surfactant (used to keep lungs from collapsing) -Compliance and airway resistance

vital capacity

The maximum volume of air that a respiratory system can inhale and exhale.

what is ventilation?

The process of moving gases into and out of the lungs

Positive-pressure ventilation

The provision of air under pressure by a mechanical respirator, a machine designed to improve the exchange of air between the lungs and the atmosphere. The device is basically designed for administering artificial respiration, especially for a prolonged period, in the event of inadequate spontaneous ventilation or respiratory paralysis.

what is residual volume?

The volume of air remaining in the lungs after a maximal expiratory effort.

What is oxygen therapy used for?

To prevent or relieve hypoxia

conduction system what does the conduction system do?

Transmits electrical impulses Generates impulses needed to initiate the electrical chain of events for a normal heartbeat Normal sinus rhythm (NSR)

cardiovascular physiology cont. what is a myocardial pump?

Two atria and two ventricles As the myocardium stretches, the strength of the subsequent contraction increases (Starling's law).

What is Tracheal suctioning? What are the steps involved?

Used when a patient has an artificial airway Steps: Use endotracheal (ET) or tracheostomy tube. Size of catheter should be as small as possible but still large enough to remove secretions. Recommended is about half the ET tube diameter. NEVER apply suction while inserting. Maintain pressure of 120-150 mm Hg.

What is Orotracheal and nasotracheal suctioning? What are the steps involved?

Used when a patient is unable to manage secretions by coughing and does not have an artificial airway Steps: Pass a sterile Catheter through mouth or nose to trachea. Nose is preferred because of the gag reflex. Advance further intro trachea than you would for nasopharyngeal suctioning. Entire procedure lasts about 10 seconds. If patient is using oxygen cannula or mask, replace during rest periods.

alterations in respiratory functioning what is hyperventilation?

Ventilation in excess of that required to eliminate carbon dioxide produced by cellular metabolism

Define ventilation, perfusion, and diffusion

Ventilation: the process of moving gases into and out of the lungs. Perfusion: the ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs Diffusion: Exchange of respiratory gases in the alveoli and capillaries

what is forced vital capacity?

Vital capacity measured with subject exhaling as rapidly as possible.

What is Oropharyngeal and Nasopharyngeal suctioning? What are the steps involved?

When a patient can cough effectively but is not able to clear secretions Oropharyngeal Steps: -Remove oxygen mask if present, nasal cannula may stay -Insert Yankauer catheter, apply suction once in mouth -Encourage coughing -Suction water or saline though catheter until catheter is clean -Place catheter in clean, dry area for reuse Nasopharyngeal Steps: -Lightly coat distal 6-8 cm with water-soluble lube -If indicated, increase oxygen. Have patient breathe with oxygen delivery device -Remove oxygen-delivery device with non-dominant hand. Insert during inhalation WITHOUT suction

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.

what happens when someone had right sided heart failure?

When the right side loses pumping power, blood backs up in the body's veins.

A patient with chronic pneumonia may be evaluated by a speech therapist for which cause? a. Chronic aspiration of liquids b. Hypoventilation due to smoking c. Hyperventilation due to anxiety d. Decreased respiratory effort due to scolioses

a (The speech therapist can perform a swallow study to determine whether thin liquids are being aspirated into the lung and recommend a regimen of thickened liquids and swallow exercises to prevent aspiration. A speech therapist would not be consulted in cases of hypoventilation or hyperventilation. Nursing measures and consulting the primary care practitioner are proper steps for these problems. A physical therapist may be consulted if scoliosis is hampering the patient's respirations.)

Pulmonary embolus

a blockage of the main artery of the lung or one of its branches by a substance that has travelled from elsewhere in the body through the bloodstream (embolism).

cyanosis

a bluish discoloration, especially of the skin and mucous membranes, due to excessive concentration of deoxyhemoglobin (hemoglobin not combined with oxygen) in the blood.

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

endotracheal tune

a catheter that is inserted into the trachea through the mouth or nose in order to maintain an open airway

hypercapnia

a condition that results when PaCo2 rises above 45 mmHg

Metered-dose inhaler (MDI)

a device that delivers a specific amount of mediation to the lungs, in the form of a short burst of aerosolized medicine that is usually self-administered by the patient via inhalation.

oxygen mask

a device that fits over the patient's nose and mouth and delivers oxygen, humidity, and/or heated humidity.

incentive spirometer

a device used to help patients improve the functioning of their lungs

hypoxemia

a diminished amount (reduced saturation) of oxygen in arterial blood.

Nebulizer

a drug delivery device used to administer medication in the form of a mist inhaled into the lungs.

electrocardiogram

a graphic record of the heart's activity

what is chest physiotherapy?

a group of therapies for mobilizing pulmonary secretions.

manual resuscitation bag

a hand-held device consisting of a flexible air chamber attached to a face mask via a shutter valve and used to provide ventilation to a patient who is not breathing or who is breathing inadequately; often referred to by the common brand name, Ambu bag.

pulse oximeter

a noninvasive device that measures oxygen saturation indirectly via a finger or ear probe with a light-emitting diode (LED) and a photo detector attached by a cable to the device.

continuous positive airway pressure (CPAP)

a noninvasive, ventilation-assistance modality that provides a set positive airway pressure throughout the patient's respiratory cycle.

bi-level positive airway pressure (BiPAP)

a noninvasive, ventilation-assistance modality that provides higher airway pressure during inspiration and lower pressure during expiration, usually delivered by a face mask.

chest radiograph

a radiographic image of the chest used to evaluate the lungs and the heart (x-ray)

hypoxia

a reduced supply of oxygen to tissues below physiological levels despite adequate perfusion of the tissue by blood.

incentive spirometer

a resistive breathing device that helps patients exercise their breathing muscles.

chest physiotherapy

a series of maneuvers including percussion, vibration, and postural drainage designed to promote clearance of excessive respiratory secretions.

Mucus

a slippery secretion produced by and covering mucous membranes.

Alveoli

a small cavity, pit, or hollow, in particular. small air sacs in the lungs.

tracheostomy mask

a small oxygen-delivery apparatus that fits over a tracheostomy site and is held in place by an adjustable elastic strap that fits around the patient's neck; also called a tracheostomy collar.

Activity intolerance

a state in which an individual has insufficient physiological or psychological energy to endure or complete required or desired daily activities.

t-tube

a t-shaped conduit with a piece that connects an oxygen source to the patient's artificial airway (endotracheal tube or tracheostomy).

oxygen

a tasteless, odorless gas that comprises 21% of atmospheric air and is used by the body to maintain adequate cellular function. -extremely drying and can cause cracks in the nasal and oral mucosa when delivered long-term and/or without sufficient humidification.

pursed lip breathing

a technique of exhaling against pursed lips to prolong exhalation, preventing bronchiolar collapse and air trapping; done to increase expiratory airway pressure, improve oxygenation of the blood, and help prevent early airway closure.

positive-pressure ventilation

a technique that uses a mechanism such as a mechanical ventilator to force air into the lungs to provide breathing assistance.

noninvasive ventilation

a type of breathing assistance used to maintain positive airway pressure and improve alveolar ventilation without the need for an artificial airway.

Which questions are included in a focused history for a cardiac patient? (Select all that apply.) a. Are you having pain? b. Where is the pain located? c. Do you attend religious services regularly? d. Do you have increased fatigue? e. Do you have any episodes of dizziness?

a, b, d, e (All pain assessment is important to determine a pattern of pain. Cardiac events can contribute to fatigue, and abnormal heart rhythms may contribute to dizziness. Although knowledge of a patient's religious affiliation may be important in certain settings, it is not part of a focused assessment of a cardiac patient.)

Perfusion

ability of cardiovascular system to pump oxygenated blood to the tissues and deoxygenated blood to the lungs; movement of gases throughout the circulatory system

adventitious

abnormal breath sounds, crackles

dysrhythmias

abnormal heart rate of rhythm

tachypnea

abnormally rapid breathing.

83 to 100 mm Hg.

absence of hypoxemia, as indicated by a partial pressure of oxygen in arterial blood (PaO₂).

what is nebulization?

adds moisture or medication to inspired air by mixing particles of varying sizes with the air

Nebulization

adds moisture or medications to inspired air by mixing particles of varying sizes with the air

Oxygen liter-flow gauge

adjustable gauge that controls the flow rate of oxygen.

atelectasis

airlessness or collapse of a lung, usually as a result of hypoventilation or obstruction.

The most serious tracheostomy complication is _______ which can result in cardiac arrest.

airway obstruction

Airway obstruction

airway obstruction is a blockage of respiration in the airway, it can be broadly classified into being in the upper or lower airway.

what is the most serious tracheostomy complication occurring in a patient?

airway obstruction which can result in cardiac arrest.

Airway resistance

airway resistance is a concept in respiratory physiology that describes the resistance of the respiratory tract to airflow during inspiration and expiration, can be measured using body plethysmography.

Postural hypotension

also known as postural hypotension, orthostasis, and colloquially as head rush or dizzy spell, is a form of hypotension in which a person's blood pressure suddenly falls when standing up or stretching. In medical terms, it is defined as a fall in systolic blood pressure of at least 20 mm Hg or diastolic blood pressure of at least 10 mm Hg when a person assumes a standing position.

what is invasive mechanical ventilation?

also referred to as positive pressure ventilation, is a lifesaving technique used with artificial airways (ET or tracheostomy) for various physiological and clinical meds.

where does carbon dioxide transfer from blood to alveoli?

alveolar capillary membrane

hypoventilation

alveolar ventilation is insufficient to meet oxygen demands of the body or to eliminate CO2 (not getting gas exchange across alveoli)

where is oxygen exchanged to carbon dioxide?

alveoli

what is preload?

amount of blood in the left ventricle at the end of diastole, often referred to as end diastolic pressure.

Pneumothroax

an abnormal collection of air or gas in the pleural space that separates the lung from the chest wall and which may interfere with normal breathing.

bradypnea

an abnormally slow respiratory rate, usually less than 12 respirations per minute.

Heimlich maneuver

an emergency technique for preventing suffocation when a person's airway becomes blocked by a piece of food or other object

Bronchoscopy

an endoscopic technique of visualizing the inside of the airways for diagnostic and therapeutic purposes, bronchoscope is inserted into the airways through the nose or mouth or tracheostomy.

hypercapnia

an excess of carbon dioxide in the blood.

excursion

an instance of movement of something along a path or though an angle

carbon dioxide

an odorless, colorless gas resulting from the oxidation of carbon, formed in the tissues and eliminated by the lungs.

tracheostomy

an opening created by a surgical incision into the trachea for the purpose of establishing and maintaining an airway.

partial rebreather mask

an oxygen-delivery apparatus similar to a nonrebreather mask, but with a two-way valve allowing the patient to rebreathe exhaled air.

what are the two common outcome of myocardial ischemia?

angina myocardial infarction

what is closing in S2 of the heart?

aortic and pulmonic close

Chyne-Stokes

apnea alternating with deep rapid respirations; associated with dying

Oxygenation affected in babies

are more susceptible to upper respiratory infections due to exposure to other children and immature immune system

what delivers nutrients and oxygen and remove waste products?

arteries and veins

how can you indicate hemoptysis?

associated with coughing and bleeding from the upper respiratory tract, sinus drainage, or the gastrointestinal tract.

what causes a patient to have wheezing sounds?

asthma acute bronchitis pneumonia occurs during both inspriation and expiration.

conduction system cont. where does Normal Sinus Rhythm originate?

at the SA node, follows normal sequence through conduction system.

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

atelectasis

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD). Which finding does the nurse anticipate when inspecting the chest? a. A ratio of 1:2 when comparing the side and front views of the chest b. A barrel chest c. A concave shape to the sternum d. A severe lateral curvature of the spine

b (Chronic air trapping in COPD can cause a barrel-shaped chest. The intercostal spaces pull the chest out, and the accessory muscles of breathing may compensate to enlarge the chest cavity. The chest diameter ratio of 1:2 is the normal finding for a person who does not have overinflation of the lungs. A concave sternum is not an expected finding with COPD. A lateral curvature of the spine is consistent with scoliosis, which is not an expected finding for most patients with COPD.)

Which situation contributes to cyanosis in the pulmonary patient? a. Increased PaCO2 levels b. Hemoglobin that is not saturated with oxygen c. Elevated white blood cell count d. Decreased PaCO2 levels

b (Hemoglobin that is not saturated with oxygen causes a bluish decolorization of the skin. Increased or decreased levels of carbon dioxide (CO2) may indicate an acid-base imbalance. An elevated white blood cell count may indicate an infection.)

Which is a goal for a patient with the nursing diagnosis of Ineffective Airway Clearance? a. Patient's respiratory secretions will become thicker so they are not moved when coughing. b. Patient's respiratory secretions will have a thinner consistency after being given a mucolytic agent. c. Patient will have improved range of motion while in bed. d. Patient's respiratory rate will increase to 28 breaths/min during hospitalization.

b (The use of mucolytic agents may thin the secretions and allow easier removal. Thickened secretions in the airways can make it more difficult to cough effectively. The goal is to decrease the thickness of secretions. Improved range of motion is relates to musculoskeletal problems. The normal respiratory rate is 12 to 20 breaths/min, and 28 breaths/min is considered tachypnea and is not desired.)

why is ventricular dysrthmia life threatening?

because it causes a decrease in cardiac output and the the potential to deteriorate into ventricular fibrillation or sudden cardiac death.

where does the exchange of respiratory gases occur?

between the environment and the blood

tissue perfusion

blood flow through body tissues

circumoral cyanosis

bluish discoloration around the mouth with feeding

mechanical ventilator

breathing assistance provided by a ventilator, one of various types of devices that support and maintain respiratory function.

inspiration

breathing in, an active process

expiration

breathing out, a passive process (seen in those who take their last breath, they do not have the energy to breath in)

expiration

breathing out, exhalation

diaphragmatic breathing

breathing with the use of the diaphragm to achieve maximum inhalation and slow respiratory rate.

A patient with chronic obstructive pulmonary disease (COPD) uses which drive to breathe? a. Increased PaCO2 b. Decreased hemoglobin c. Decreased PaO2 levels d. Increased PaO2 levels

c (A person normally uses increased PaCO2 levels as the drive to breathe. A patient with COPD has chronic elevation of PaCO2 and has lost sensitivity to it as a drive to breathe. Instead, a decreased PaO2 level becomes the drive to breathe.)

Which action does a nurse anticipate when suctioning a patient with excessive secretions? a. Decrease the patient's oxygen flow rate before beginning the deep suctioning. b. Avoid lubricating the catheter tip to prevent getting the substance in the lung tissues. c. Limit the time that the catheter is suctioning to prevent excessive loss of oxygen during the process. d. Flush the artificial airway with 3 mL of tap water to loosen secretions before suctioning.

c (Oxygen is removed during the suctioning procedure, and the amount of time needs to be limited. In some cases, the nurse provides extra oxygen during suctioning procedures, and decreasing the oxygen is contraindicated. Lubrication of the catheter tip with normal saline solution (NSS) is indicated and does not damage the lungs. Tap water is not sterile and should not be introduced into the airway. Evidence-based practice show that flushing with sterile NSS has no benefit, because saline does not mix with secretions, and the procedure may have negative emotional effects for the patient.)

Which of the chambers of the heart becomes enlarged when mitral valve stenosis occurs? a. Right atrium b. Right ventricle c. Left atrium d. Left ventricle

c (When the mitral valve is narrowed as in mitral stenosis, the left atrium has to generate more force to empty its contents, and left atrial enlargement may occur. The other three chambers of the heart may also enlarge, depending on where in the cardiovascular system the problem is occurring.)

while inspecting a patients hand you see clubbing (chronic hypoxia) of fingertips, this may be a problem with the?

cardiopulmonary status

What assessments would a nurse make when auscultating the lungs?

cardiovascular function

what system of the body provides transport mechanism to distribute oxygen to cells and tissues of the body?

cardiovascular system

What controls respiratory rate, depth, and rhythm?

central nervous system

what regulates the voluntary control of respiration?

cerebral cortex

Apnea

cessation of breathing

apnea

cessation of respiration.

what are the first signs in older adults that indicates of cardiac and/or respiratory problems?

change in mental status and often include forgetfulness and irritability.

what do chemoreceptors sense changes in?

changes in the chemical content and stimulate neural regulators to adjust

what changes in older adults cause problems with chest expansion and oxygenation?

changes in thorax occur form ossification of costal cartilage, decreased space between vertebrae, and diminished respiratory muscle strength.

sedentary

characterized by sitting; little exercise

Surfactant

chemical in lungs that keep the alveoli from collapsing, allows ease in breathing and ensure alveoli does not stick together

what is surfactant?

chemical produced in the lungs to maintain the surface tension of the alveoli and keep them collapsing.

What is surfactant?

chemical produced in the lungs to maintain the surface tension of the alveoli and keep them from collapsing

chest tube

chest drain, thoracic catheter, tube thoracostomy, or intercostal drain - is a flexible plastic tube that is inserted through the chest wall and into the pleural space or mediastinum. Used to remove air, fluid, or pus.

what types of patients does home oxygen therapy benefit?

chronic cardiopulmonary disease

Atelectasis Risk Factors: Signs and Symptoms: Nursing Interventions:

collapse of alveoli that prevents exchange of o2 and co2 Risk factor: obese Signs and symptoms? Nursing intervention?

atelectasis

collapse of the alveoli, a hole in the lungs, incomplete expansion of the lungs

Aspects of the work of breathing

compliance, inspiration, expiration, surfactant

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

which test treats obstructive sleep apnea, heart failure, and infants with undeveloped lungs?

continuous positive airway pressure (CPAP)

Which oxygen delivery setting places a patient in danger of not receiving adequate oxygen? a. Nasal cannula at a flow rate of 2 L/min b. Nasal cannula at a rate of 5 L/min c. Simple mask at a flow rate of 5 L/min d. Non-rebreather mask at a flow rate of 5 L/min

d (A non-rebreather mask with a flow rate of 5 L/min does not give the patient adequate levels of oxygen in the reservoir bag and may result in the person developing hypoxemia. The accepted range of oxygen delivery with a non-rebreather mask is 10 to 15 L/min. The amount that can be delivered by nasal cannula is 1 to 6 L/min, and oxygen delivered at 2 or 5 L/min by nasal cannula is within the safe range. Oxygen delivered at 5 L/min by a simple face mask delivers adequate oxygen because the range for a face mask is 5 to 10 L/min.)

Which position is the priority for a patient experiencing acute shortness of breath? a. Supine position b. Reverse Trendelenburg position c. Face-down position d. Upright position

d (When a person is having difficulty breathing, placing her or him in an upright position helps to increase the effectiveness of breathing. The supine position may decrease respiratory efficiency, place pressure on the chest wall from the bed, and cause increased anxiety for the patient. The reverse Trendelenburg position increases the workload of breathing. The face-down (prone) position may inhibit the patient's ability to breathe.)

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

turning the knob on the flow meter to the right

decreases the flow rate.

oxygen outlet

designated by a green "oxygen" label.

pulmonary function tests

determines the ability of the lungs to efficiently exchange O2 and CO2

while assessing a patient with the nursing diagnosis of impaired gas exchange related to decreased lung expansion, what are the defining characters while inspect the skin?

diaphoresis pallor (pale color) cyanosis (bluish discoloration of the skin resulting from poor circulation or inadequate oxygenation of the blood.)

The _____ and ______ muscles contract to create a negative pleural pressure and increase the size of the thorax for inspiration. The normal intrapleural pressure is _____.

diaphragm and external intercostal muscles 760 mm Hg

dyspnea

difficult or labored breathing.

Thickness of alveolar capillary membrane affects the rate of _____.

diffusion

what is the process for the exchange of respiratory gases in the alveoli of the lungs and the capillaries of the body tissues

diffusion

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

nonproductive cough

dry and does not produce sputum - dry hacking

what do you do to manage dyspnea?

dyspnea is difficult to treat pharmalogical agents; bronchodialators, inhaled steoids, low dose antianxiety treatment is using; oxygen therapy physical techniques psychosocial techniques

electrical impulses that do not originate in SA node causes conduction disturbances is considered?

dysrhythmias

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

which test measures the heart structure, heart wall motion, and the overall cardiac performance?

echocardiography

hypovolemic shock

emergency condition where severe blood and fluid loss make the heart unable to pump enough blood to the body

what is incentive spirometry?

encourages voluntary deep breathing by providing visual feedback to patients about inspiratory volume.

hypertension

excess pressure in the arterial portion of circulatory system high blood pressure

oxygenation affected in Children and adolescents

exposure to respiratory tract infections and smoking/second hand smoke

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

face tent

when is a tracheostomy used?

for Long-term assistance, surgical incision made into trachea

when would you use closed suctioning in a patient?

for patients who require invasive mechanical ventilation to support their respiration efforts because it permits continuous delivery of oxygen while suction is performed and reduces risk of oxygen desaturation.

valsalva maneuver

forced exhalation against a closed glottis

what is exchanged in the circulatory system between blood and tissues?

gases, nutrients, and waste products are exchanged between the blood and the tissues.

cyanosis

gray to blue or purple skin color caused by deoxygenated hemoglobin

Goals of acute care

halt pathologic process, shorten the duration and severity of illness, prevent complications of illness and treatment

viscous secretions

having relatively high resistance to flow, viscid, sticky

Use caution when suctioning patients with a ______ injury.

head

how does cardiopulmonary rehabilitation help patients?

helps pts achieve and maintain optimal level of health through; -Controlled physical exercise; -nutrition counseling; -relaxation and stress management; -medications; -oxygen; -compliance; -systemic hydration

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

if a patient has bloody sputum what is this called?

hemoptysis

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

Cardiac workload

how hard your heart has to work to pump blood throughout the body, influenced by the strength and frequency of muscle contractions in the heart.

Airway clearance techniques

hydration to liquefy secretions (1500-2500 ml/day unless having cardiac or renal issues), humidify and warmth in O2 therapy, nebulization adds moisture or medication to O2, coughing and deep breathing

how do you maintain airway clearance?

hydration to prevent thick, tenacious secretions proper coughing techniques suctioning

what occurs when there is a shortening of the QT interveal?

hyperkalemia and hypercalcemia

safety guidelines a patient is experiencing sudden changes in their vital signs, level of consciousness, or behavior, what is a possible cause of these changes?

hypoxia

what is dyspnea associated with?

hypoxia it is associated with shortness of breath usually associated with exercise or excitement.

in which cases does starlings law not apply?

in the diseased heart (cardiomyopathy or myocardial infarction).

Hypoxia

inadequate tissue oxygenation at cellular level (in serum and tissues, not respiratory system itself) (seen in decreased Hb, high altitudes, cyanide poisoning, pneumonia, shock, chest trauma)

what are breathing exercised used for?

includes techniques to improve ventilation and oxygenation.

S/s of hypoxia

increased pulse, respirations, and blood pressure in the body's effort to restore oxygen levels (unless in shock)

what does QRS represent?

indicates that the electrical impulse traveled through the ventricles.

Home oxygen therapy what is home oxygen therapy?

indications of home oxygen therapy includes; Arterial partial pressure (PaO2) of 55 mm Hg or less -or- • Arterial oxygen saturation (SaO2) of 88% or less on room air at rest, on exertion, or with exercise

thrombophlebitis

inflammation of a vein associated with a blood clot

what vaccination should someone get for promoting health and prevent respiratory infection?

influenza and pneumococcal

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

where does carbon dioxide diffuse into?

into red blood cells and is rapidly hydrated into carbonic acid (H2CO3)

what is pursed lip breathing?

involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse.

what is atelectasis?

is a collapse of the alveoil that prevents normal exchange of oxygen and carbon dioxide.

what is pneumothorax?

is a collection of air in the pleural space. -the loss of intrapleural pressure causes lung to collapse secondary pneumothorax is caused by chest trauma (stabbing, gunshot wound or rib fracture)

what is hemothorax?

is an accumulation of blood and fluid in the pleural space cavity between the parietal and visceral pleura, usually a result to trauma. this prevent lung from full expansion

hypotension

is low blood pressure

what is ventilate associated pneumonia?

is significant potential complication because the artificial airway tube bypass many of the the lungs normal defense mechanism. this is considered a health acquired infection

what is afterload?

is the resistance to the left ventricular ejection. heart works harder to overcome resistance so blood can be fully ejected from the left ventricle.

hemoptysis

is the spitting of blood that originated in the lungs or bronchial tunes

what is the purpose of Noninvasive positive pressure ventilation (NPPV)?

is to maintain a positive airway pressure and improve alveolar ventilation.

what is diaphragmatic breathing?

is useful for patients with pulmonary disease, postoperative patients, and women in labor to promote relaxation and provide pain control.

hemoglobin saturation

is when hemoglobin is loaded with oxygen molecules

what is venturi mask used for?

it has higher concentrations of 24% to 60% and usually requires oxygen flow rates of 4-12% L/min

is a tuberculin test a reliable test for TB?

it is unreliable indicator in older patients. they frequently display false-positive or false-negative skin test reactions.

fatigue

lack of energy and motivation and may be accompanied by drowsiness

oxygenation affected in adults

lifestyle factors of smoking, unhealthy diet, lack of exercise, stress, medications not used as intended, illegal substance use, aging process

Mucous membranes

linings of mostly endodermal origin covered in epithelium which are involved in absorption and secretion.

what does the oxygen support system consist of?

lungs cardiovascular system

Baralled chest

lungs stay in inspiration state, seen in those with COPD, unable to fully exhale as they lost compliance and elasticity of the lungs

Oxygen saturation

measure the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen.

Arterial blood gases

measurement of the pH level and the oxygen and CO2 concentrations in arterial blood; important in diagnosis of many respiratory diseases

choking

mechanical obstruction of the flow of air from the environment into the lungs.

Patency, patent

medical compounds of questionable effectiveness sold under a variety of names and labels

S/S of hypoventilation

mental status change, dysrrhythmias, convulsions, unconsciousness, potential cardiac arrest and death (seen in COPD patients if too much Oxygen is used as the brain learns not to breath as much due to excess oxygen)

what is closing in S1 of heart?

mitral and tricuspid close

what valves stay closed during systole phase?

mitral and tricuspid valve so all blood is moved forward to the aorta and pulmonary artery

chest vibration

move secretions from small airways into larger airway

sputum

mucous secretion from the lungs, bronchi, and trachea

Accessory muscles of respiration

muscles that allow inspiration and expiration (breathing) the principle muscles are the diaphragm, the external intercostal and the internal intercostal muscles.

what do coronary arteries supply to the myocardium?

myocardium with nutrients and remove wastes.

What is stenosis?

narrowing of a valve

thoracentesis

needle insertion into the pleural space to remove fluid accumulation

what controls the rate and depth of respiration in the response to changing tissue oxygen demands?

neural and chemical regulator

what does poor perfusion (cardiac arrest) of CO2 state?

no CO2 is transported to the lungs to be exhaled, so a low reading will occur.

is saline installation into airway before ET and tracheostomy suctioning a recommenced procedure?

no it is not recommended

pulse oximetry

noninvasive method for monitoring a patient's O2 saturation

95 to 100%

normal range for arterial oxygen saturation:

12 to 20/min

normal range of respirations

what is tidal volume?

normal volume of air displaced between normal inhalation and exhalation when extra effort is not applied.

what happens when someone has left sided heart failure?

occurs when the left ventricle doesn't pump efficiently. This prevents your body from getting enough oxygen-rich blood. The blood backs up into your lungs instead, which causes shortness of breath and a buildup of fluid.

Cardiovascular

of or relating to the heart and blood vessels.

naris

one of the two external orifices of the nose; nostril (plural: nares).

what are two types of suctioning methods?

open and closed

what is the simpliest type of artificial airway to use for a pateint?

oral airway -which prevents obstruction of the trachea by displacement of the tongue into the oropharynx.

if a patient is unable to manage secretions by coughing ad does not have an articifial airway present which sucitonng method should you use?

orotracheal and nasotracheal

if a patient is having shortness of breath while lying flay and only experiences better airway while sitting up, what is this patient experiencing?

orthopnea

turning the knob on the flow meter to the left

oxygen begins to flow from the cylinder to the patient, and you can increase the flow rate.

88% or more

oxygen in the home would be required if the patient is unable to maintain an oxygen saturation (SaO₂) of:

SaO₂

oxygen saturation

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

Pallor

pale color of the skin which can be caused by illness, emotional shock or stress, stimulant use, or anemia, and is the result of a reduced amount of oxyhaemoglobin in skin or mucous membrane.

Atelectasis

partial or complete collapse of the lung

Airway clearance

passage which air travels from nose or mouth to the lungs

Cascade cough

patient takes a slow, deep breath and holds it for 2 seconds while contracting expiratory muscles. Then he or she opens the mouth and performs a series of coughs throughout exhalation, thereby coughing at progressively lowered lung volumes. This technique promotes airway clearance and a patent airway in patients with large volumes of sputum.

the use of chest physiotherapy to mobilize pulmonary secretions involves the use of:

percussion

what should you look for on a patients SKIN that may be a cause of cardiopulmonary problems?

peripheral cyanosis (skin color changes caused form diminished blood floe) may have decreased skin turgor dependent edema (swelling of legs caused form fluids)

dyspneic

pertaining to or caused by dyspnea.

What is an oxygen face mask (low and high concentration)? Why and how do we use it?

plastic device that fits snugly over the mouth and nose and is secured in place with a strap. (for high concentration, has a reservoir bag attached) Why (advantages): Patients with carbon dioxide retention. Useful for short periods such as patient transportation How: ???

what helps to remove draining of the lungs in a pt.?

positioning helps by removing secretion into the trachea.

intrathoracic pressure

pressure within the thoracic cavity.

artificial airways What does oral airway prevent?

prevents obstruction of the trachea by the displacement of the tongue into the oropharynx.

Ventilation

process of moving gases in and out of lungs, physical motion of oxygenation, "breathing"

productive cough

produces phlegem or mucus. may be the last symptom left after a sore throat or nasal / sinus congestion.

expectorate

promoting or facilitating the secretion or expulsion of phlegm, mucus, or other matter from the respiratory tract

which types of pts lose elastic recoil of lung and thorax?

pts with COPD

which types of patients have thickened alveolar capillary membranes?

pts with pulmonary edema pulmonary infiltrates pulmonary effusion

cardiovascular physiology cont. does the right ventricle pump deoxygenated or oxygenated blood?

pumps deoxygenated blood through systemic circulation.

hemorrhage

rapid or excessive bleeding

S/S of hyperventilation

rapid respirations, sighing breaths, numbness, tingling of hands and feet, lightheadedness

Hyperventilation

remove CO2 faster than is produced by cellular metabolism (not enough CO2 in the blood) seen in acute anxiety, increased body temperature, chemically induced poisoning, ketoacidosis (DM)

oropharyngeal suctioning

removing secretions from the throat through an orally inserted catheter

the exchange of oxygen and carbon dioxide during cellular metabolism is considered?

respiration

ventilation, perfusion, and exchange of gases are the major purposes of:

respiration

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

respiratory muscles become weaker

alterations in cardiac functioning cont. also has impaired valvular function what is myocardial ischemia?

results when the supply of blood to the myocardium from the coronary arteries is insufficient to meet myocardial oxygen demands.

chest percussion

rhythmically tapping the chest wall with cupped hands

cardiovascular physiology where does oxygenated blood go through the heart?

right side of the heart and then to the lungs, where it is oxygenated.

Nail bed clubbing

seen in those with chronic hypoxemia

cilia

short hairline rhythmically beating organelles on the surface of that provide mobility and move fluids

dyspnea

shortness or difficulty breathing

What is a nasal cannula? Why and how do we use it?

simple, comfortable device used for precise oxygen therapy with two prongs Why (advantages): safe and simple, easily tolerated, effective for low concentrations, does not impede eating or talking, inexpensive and disposable How: -Two curved nasal prongs inserted into nostrils -Keep in place by putting behind ears and connecting under chin -Attach to a humidified oxygen source with a flow rate up to 1-6 L/min (24-44% oxygen)

physiology of capnography during respiration what is excreted via exhalation?

small amounts of CO2 produced from cellular respiration

which test is given with a booster affect to older adults who came out positive with TB?

standard 5-TU Mantoux tes and 250-TU strength to create a boosting affect.

Huff cough

stimulates a natural cough reflex and is generally effective only for clearing central airways. While exhaling, the patient opens the glottis by saying the word huff. With practice he or she inhales more air and is able to progress to the cascade cough.

nasal suctioning

suctioning the nasal passageway

2. Prolonged use of high oxygen concentrations reduces ____________________ production, which leads to alveolar collapse and reduced lung elasticity.

surfactant

premature babies do not have

surfactant, must give them corticosteriods to start surfactant production

quad cough

technique is for patients without abdominal muscle control such as those with spinal cord injuries. While the patient breathes out with a maximal expiratory effort, the patient or nurse pushes inward and upward on the abdominal muscles toward the diaphragm, causing the cough.

in poor ventilation what does CO2 state?

that CO2 is retained, so a high reading will occur.

Auscultation

the action of listening to sounds from the heart, lungs, or other organs, typically with a stethoscope, as a part of medical diagnosis.

Oxygen therapy

the administration of oxygen as a medical intervention, which can be for a variety of purposes in both chronic and acute patient care.

tidal volume

the amount of air normally breathed in and out with each respiratory cycle either spontaneously or delivered via mechanical ventilation.

What is stroke volume?

the amount of blood ejected from the left ventricle with each contraction

humidity

the amount of vapor in the air

what valves cause the second heart sound S2 "dub"

the aortic and pulmonic valves

what happens when ventricular diastole occurs?

the atrioventricular (mitral and tricuspid) valves close

diffusion

the continual intermingling of molecules in liquids, gases, or solids brought by the random movement of the molecules

oxygen therapy

the delivery of oxygen for therapeutic purposes.

whats a good clinical measure of afterload?

the diastolic aortic pressure

postural drainage vibration

the drainage by gravity of secretions from various lung segments

compliance

the ease with which the lungs can be expanded, aspect that is difficult for those with COPD as they lose elasticity

what does the P way represent?

the electrical conduction through both atria.

ventilation

the exchange of oxygen and carbon dioxide

what does the PR interval represent?

the impulse travel time form the SA node through the AV node, through bundle of his, and purkinje fibers.

intubation

the insertion of a tube into a body canal or cavity, as in endotracheal intubation.

pulse oximetry

the measurement of oxygen saturation indirectly via a finger or ear probe with a light-emitting diode (LED) and a photo detector attached by a cable to the oximeter device.

E cylinder

the most common oxygen cylinder size used in the home setting and in hospitals when transporting patients.

fraction of inspired oxygen (FiO₂)

the oxygen level inhaled by or delivered to the patient, expressed in a percentage of atmospheric air.

the movement of gases into and out of the lungs depends on:

the pressure gradient between the atmosphere and the alveoli

alterations in cardiac functioning what is conduction

the process by which heat or electricity is directly transmitted through a substance when there is a difference of temperature or of electrical potential between adjoining regions, without movement of the material. the process by which sound waves travel through a medium. the transmission of impulses along nerves.

what is humidification?

the process of adding water to gas.

ventilation

the process of the exchange of air between the lungs and the environment, including inhalation and exhalation.

flow rate

the quantity of oxygen delivered in liters per minute.

what does chemical regulation maintain?

the rate and depth of respirations based on changes in the blood concentrations of CO2 and O2, and in hydrogen ion concentration (pH).

extubation

the removal of a breathing tube

afterload refers to:

the resistance to left ventricular ejection

what happens in the systolic phase?

the semilunar (aortic and pulmonic) vales open, blood flows from ventricles into the aorta and pulmonary artery.

what does QT interval represent?

the time needed for ventricular depolarization and repolarization.

what makes the S1 sound lub?

the valve closure (mitral and tricuspid) closing

Cardiac output

the volume of blood being pumped by the heart, in particular by a left or right ventricle in the time interval of one minute.

what happens when there is no cellular respiration occurring, even if there is ventilation?

there will be no CO2 exhaled

tenacious secretions

thick sticky secretions; seen often with COPD

how do gases move in out of lungs?

through pressure changes.

where does oxygen transfer to the blood?

through the alveolar capillary membrane

How is blood oxygenated?

through the mechanisms of ventilation, perfusion, and transport of respiratory gases

what are the types of lung volumes?

tidal residual forced vital capacity

Capillary refill

time taken for the color to return to an external capillary bed after pressure is applied to cause blanching, measured by holding a hand higher than heart-level, pressing the soft pad of a finger until it turns white and then noting the time needed for color to return once pressed.

exhale / exhalation

to breath out

what does the diaphragm and external intercostal muscles contract to create?

to create negative pressure and increase the size of the thorax for inspiration.

Aspiration

to draw (something) into the lungs through inhalation.

oxygen therapy

to relieve or prevent tissue hypoxia, deliver O2 at concentration less than 21% of room air, treat it as a medication (careful to not cause toxicity

Perform ______ suctioning BEFORE ______ suctioning whenever possible.

tracheal BEFORE pharyngeal

which suctioning should you perform first, tracheal suctioning or pharyngeal suctioning?

tracheal suctioning before pharyngeal suctioning

A patient requires a long term assistance from an artificial airway, which suctioning equipment is considered?

tracheostomy

how does the airway of lungs transfer oxygen?

transfer oxygen from the atmosphere to the alveoli, where the oxygen is exchanged for carbon dioxide.

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

after deoxygenated blood is oxygenated through the lungs, where does the oxygenated blood travel?

travels from the lungs to the left side of the heart and the tissues.

What are the indications to suction a patient?

unable to clear secretions through coughing or other less invasive

Laryngeal spasm

uncontrolled/involuntary muscle contraction (spasm) of the laryngeal cords, usually lasts less than 60 seconds and causes a partial blocking of breathing in while breathing out remains easier.

is blood flow to the heart a one way flow or unidirectional?

unidirectional

Mr. Isaac comes to the emergency department complaining of difficulty breathing. An objective finding associated with his dyspnea might include:

use of accessory muscles of respiration

when is a T tube or tracheostomy collar used for a patient for home oxygen therapy?

used if patient has a permanent tracheostomy

what is Noninvasive positive pressure ventilation (NPPV)?

used to prevent using invasive artificial airways

while inspecting a patients neck, what would be a sign of a cardiopulmonary problem?

veins of the neck are distended, associated with right sided heart failure (JVD)

blood is oxygenated through which mechanisms?

ventilation perfusion transport of respiratory gases

what are considered life threatening rhythms that require immediate intervention?

ventricular tachycardia ventricular fibrilation

Kussmal Respirations

very deep and rapid respirations (seen in acidosis and kidney failure)

what is a bronchosopy used for?

visualizing the inside of the airways for diagnostic and therapeutic purposes.

if a patient has a high pitched musical sound in their lungs, what is this sound called?

wheezing

when is a oropharyngeal or nasopharyngeal suctioning used in a patient?

when a patient is able to cough effectively but unable to clear secretions by expectorating.

implementation: suctioning techniques when is Oropharyngeal and nasopharyngeal suctioning used?

when the patient can cough effectively but is not able to clear secretions

when do you use Orotracheal and nasotracheal suctioning?

when the patient is unable to manage secretions by coughing and does not have an artificial airway

which muscles do patients use while in dyspnea?

with exaggerated respiratory effort, use the accessory muscles of respiration.

air outlet

yellow "air" label.

does the thickness of the pulmonary membrane affect rate of diffusion?

yes

if a patient has a head injury, should you be cautious while suctioning?

yes

is carbon dioxide a product of cellular respiration?

yes

if you do not fully inflate the lungs

you increase your risk of getting pneumonia (seen in surgery patients)

what are the professional standard nurses use?

• Agency for Healthcare Research and Quality (AHRQ) • American Cancer Society (ACS) • American Heart Association (AHA) • American Lung Association (ALA) • American Thoracic Society (ATS) • American Nurses Association (ANA)

Factors affecting oxygentaion what are the physiological factors?

• Decreased oxygen-carrying capacity • Hypovolemia (a decreased volume of circulating blood in the body.) • Decreased inspired oxygen concentration • Increased metabolic rate

alterations in cardiac functioning what are the disturbances in conduction?

• Electrical impulses that do not originate from the SA node cause conduction disturbances • Dysrhythmias • Atrial fibrillation • Paroxysmal supraventricular tachycardia • Ventricular dysrhythmias

alterations in cardiac functioning cont. what are two types of altered cardiac output?

• Left-sided heart failure • Right-sided heart failure

what does pulmonary circulation do?

• Moves blood to and from the alveolar capillary membrane for gas exchange

what does positioning do to help increase expansion of lungs?

• Reduces pulmonarymstasis, maintains ventilation and oxygenation

when do you use tracheal suctioning?

• Used with an artificial airway