OXYGENATION
A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment?
5,850 mL (5,850 × 109/L) (Cardiac output is determined by multiplying the stroke volume by the heart rate/min, which equals 5,850 mL (5,850 × 109/L). Cardiac output and peripheral resistance determine both systolic and diastolic pressures.)
The nurse must obtain a blood specimen for blood gas analysis. What is the most important thing for the nurse to do immediately after the needle has been removed?
Apply steady, firm pressure on the puncture site for 5 to 15 minutes (Because the artery has been punctured, there is an increased risk for puncture site bleeding compared to venous blood draws. The nurse should apply steady, firm pressure on the puncture site for 5 to 15 minutes or until bleeding has completely stopped. An adhesive bandage should not be placed before bleeding is stopped. The blood specimen should be properly labeled; however, the priority for the nurse would be to ensure bleeding from the puncture site has stopped. Pressure should be applied prior to any extremity elevation)
The nurse is monitoring a client with continuous pulse oximetry. What action(s) by the nurse are important to obtain accurate results? Select all that apply. Assess client for factors affecting circulation. Prepare the client to have an arterial line inserted. Observe the monitor to record respiratory rate. Use the forehead sensor if cardiac output is low. Determine if the client has a pre-existing condition affecting the oxygen saturation. Correlate the pulse oximetry reading with the client's heart rate. SUBMIT ANSWER
Correlate the pulse oximetry reading with the client's heart rate. Use the forehead sensor if cardiac output is low. Determine if the client has a pre-existing condition affecting the oxygen saturation
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?
Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?
It determines whether the client is getting enough oxygen.
A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs? Nasal cannula Simple mask Nonrebreather mask Partial rebreather mask
Nasal cannula (A nasal cannula is used to deliver from 1 L/min to 6 L/min of oxygen. Masks are used with higher flow rates of oxygen.)
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 (During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds.)
When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding? The anteroposterior diameter should be greater than the transverse diameter. The skin at the thorax should be cool and moist. The contour of the intercostal spaces should be rounded. The chest should be slightly convex with no sternal depression.
The chest should be slightly convex with no sternal depression.
The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?
Wheezing
A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from
croup (Croup and epiglottitis are common in young children. The child has an obstruction of the upper airways, with swelling of the throat tissue. Atelectasis results when the lungs collapse as a result of the alveoli being unable to expand. Symptoms include difficulty breathing and discomfort. Pulmonary fibrosis is a condition in which the lung tissue becomes stiff and unable to expand appropriately. Asthma is a condition associated with bronchoconstriction. The symptoms include nonproductive cough, dyspnea, and wheezing.)
The nurse 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
A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?
educating the client on the use of incentive spirometry (Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery.)
A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?
flow meter
The nurse is preparing to provide hygiene care to a client with hypoxia. Into what position will the nurse place the client? prone high Fowlers Trendelenburg supine
high Fowlers
When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing
poor tissue perfusion
Which breathing technique(s) will the nurse teach to the client who has hypoxemia and hypercarbia? Select all that apply. apply nasal strips diaphragmatic breathing deep breathing incentive spirometry pursed-lip breathing
pursed-lip breathing diaphragmatic breathing
A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action? Raise the head of the client's bed slightly, if tolerated. Review the medications that the client has taken in the past 90 minutes. Encourage the client to do deep-breathing exercises. Document this expected assessment finding.
Document this expected assessment finding.
The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather? nasal cannula tracheostomy collar face tent simple mask
Face Tent (A face tent is used without a mask; it is open and loose around the face and is often used for patients with facial trauma or burns. A simple mask or nasal cannula would irritate the facial skin. The client does not have a tracheostomy.)
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?
low pulse rate (A client diagnosed with Impaired Gas Exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.)
A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered? simple oxygen mask Venturi mask nasal cannula partial rebreather mask
nasal cannula Nasal cannula and tubing administer oxygen concentrations at 22% to 44%.
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 (Normal ABG findings include a pH of 7.35-7.45, PCO2 35-45 mm Hg, PO2 80-100 mm Hg, and Base excess or deficit +2 mmol/L)
A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client? pulse oximetry peak expiratory flow rate spirometry thoracentesis
pulse oximetry (Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.)
A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client?
Ambu bag (If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Oxygen masks may cover only the nose and mouth and can vary in the amount of oxygen delivered. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostril. An oxygen tent is a tentlike enclosure within which the air supply can be enriched with oxygen to aid a client's breathing. Oxygen masks, nasal cannula, and oxygen tents are used for clients who have a respiratory drive.)
When reviewing data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom?
rapid respirations (Normal cardiac output averages from 3.5 to 8.0 liter/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing the respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display a thready pulse.)
The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select? tracheostomy collar face tent simple mask nasal cannula
tracheostomy collar (A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. Other devices are not appropriate for this client.)