Oxygenation & Circulation

5. The nurse is instructing the patient on the collection of a sputum specimen. What should be included in the instructions? (Select all that apply.) • Initially, clear the nose and throat.

• Take a few deep breaths before coughing. • Use diaphragmatic contractions to aid in the expulsion of sputum.

10. A client with chronic bronchitis is admitted with an exacerbation of symptoms. During the nursing assessment, the nurse will expect which of the following findings? Select all that apply.

• Use of accessory muscles to breathe • Purulent sputum with frequent coughing

Rationale:

Because oxygen supports combustion, there is always a danger of fire when it is used. It is important to post "No Smoking" signs when oxygen is in use, particularly in facilities that are not smoke free.

Rationale:

Cheyne-Stokes breathing is characterized by a regular cycle where the rate and depth of breathing increase, then decrease until apnea occurs. The duration of apnea varies but progresses in length. This breathing pattern is associated with heart failure, damage to the respiratory center in the brain, or both.

Rationale:

Chronic bronchitis increases airway resistance and can thicken bronchial mucosa during an exacerbation. The client will have dyspnea requiring the use of accessory muscles to breathe, along with tachypnea and sputum production. Bronchial irritation and the need to expectorate mucus will lead to coughing. Percussion in this client would lead to resonant or hyperresonant sounds. (less)

Rationale:

Clinical manifestations associated with OSA include excessive daytime sleepiness, insomnia, loud snoring, impotence, and arrhythmias.

Rationale 2.

Funnel chest occurs when there is a depression in the lower portion of the sternum. This may compress the heart and great vessels, resulting in murmurs. Funnel chest may occur with rickets or Marfan's syndrome.

15. A hospitalized client with terminal heart failure is nearing the end of life. The nurse observes which of the following breathing patterns?

Image:

12. A patient with emphysema is placed on continuous oxygen at 2 L/min at home. Why is it important for the nurse to educate the patient and family that they must have No Smoking signs placed on the doors?

Oxygen supports combustion.

Rationale:

Oxygen toxicity can occur when clients receive too high a concentration of oxygen for an extended period. Symptoms include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia and mood swings are not symptoms of oxygen toxicity.

9. A young adult client has had a tonsillectomy and is in the immediate postoperative period. To make the client comfortable, the nurse intervenes by

Placing the client prone with the head turned to the side

Rationale:

SaO2 is the degree to which hemoglobin (Hb) is saturated with oxygen. It doesn't indicate the client's overall Hb adequacy. Thus, an individual with a subnormal Hb level could have normal SaO2 and still be short of breath, indicating a possible hematologic problem. Poor peripheral perfusion would cause subnormal SaO2. There isn't enough data to assume that the client's problem is psychosomatic. If the problem were left-sided heart failure, the client would exhibit pulmonary crackles.

Rationale:

Several mechanisms control ventilation. The respiratory center in the medulla oblongata and pons control rate and depth of respirations. The central chemo receptors in the medulla and peripheral chemo receptors in the aortic arch also provide a mechanism for detecting abnormalities and signal changes to alter the pH and levels of oxygen in the blood. The other options have an incorrect piece of the triad. (less)

Rationale:

Signs and symptoms include excessive daytime sleepiness, frequent nocturnal awakening, insomnia, loud snoring, morning headaches, intellectual deterioration, personality changes, irritability, impotence, systemic hypertension, dysrhythmias, pulmonary hypertension, corpulmonale, polycythemia, and enuresis. (less)

Rationale:

The most comfortable position for the client in the immediate postoperative period is prone, not semi-Fowler's. The client's head is turned to the side to allow drainage from the mouth. The oral airway is removed after the gag reflex has returned. An ice collar, not warm compress, is applied to the neck area. (less)

Rationale:

The nurse instructs the patient about methods to promote drainage of the sinuses, including humidification of the air in the home, the use of warm compresses to relieve pressure, and increasing fluid intake. (less)

Rationale:

The nurse must be well educated in screening clients before diagnostic procedures which include contrast medium for an allergy to iodine. A lung scan, fluoroscopy and pulmonary angiography all require contrast medium. (less)

11. A nurse is caring for a client who has frequent upper respiratory infections. Which structure is most helpful in protecting against infection?

Tonsils

Rationale:

Tonsils and adenoids do not contribute to respiration but protect against infection. Palatine tonsils are composed of lymphoid tissue. Cilia are fine hairs that move particles and liquid, preventing irritation and contamination of the airway. Sinuses are nasal cavity structures. Turbinates warm and add moisture to the inspired air. (less)

14. A client is chronically short of breath and yet has normal lung ventilation, clear lungs, and an arterial oxygen saturation SaO2 of 96% or better. The client most likely has:

a possible hematologic problem

7. The nurse is educating the patient diagnosed with acute pharyngitis on methods to alleviate discomfort. What interventions should the nurse include in the information? (Select all that apply.)

• Apply an ice collar. • Try a liquid or soft diet during the acute stage of the disease. • Stay on bed rest during the febrile stage of the illness.

3. When the nurse is assessing the older adult patient, what gerontologic changes in the respiratory system should the nurse be aware of? (Select all that apply.)

• Decreased gag reflex • Increased presence of collagen in alveolar walls • Decreased presence of mucus

6. The nurse is educating a patient diagnosed with acute bacterial rhinosinusitis about interventions that may assist with symptom control. What should the nurse include in this information? (Select all that apply.)

• Ensure an adequate fluid intake. • Increase the humidity in the home. • Apply local heat to promote drainage.

1. Which of the following are clinical manifestations associated with obstructive sleep apnea (OSA)? Select all that apply.

• Insomnia • Arrhythmias• Loud snoring • Excessive daytime sleepiness • Impotence

2. The nurse is working on a busy respiratory unit. In caring for a variety of clients, the nurse must be knowledgeable of diagnostic studies. With which diagnostic studies would the nurse screen the client for an allergy to iodine? Select all that apply.

• Lung scan • Fluoroscopy • Pulmonary angiography

8. The nurse is assessing a patient for obstructive sleep apnea (OSA). Which of the following are signs and symptoms of OSA? Select all that apply.

• Polycythemia • Loud snoring • Insomnia

Rationale:

2. Barrel chest occurs as a result of overinflation of the lungs, which increases the anteroposterior diameter of the thorax. It occurs with aging and is a hallmark sign of emphysema and COPD. In a patient with emphysema, the ribs are more widely spaced and the intercostal spaces tend to bulge on expiration.

Rationale:

A liquid or soft diet is provided during the acute stage of the disease, depending on the patient's appetite and the degree of discomfort that occurs with swallowing. Cool beverages, warm liquids, and flavored frozen desserts such as ice pops are often soothing. The nurse instructs the patient to stay in bed during the febrile stage of illness and to rest frequently once up and about. Depending on the severity of the pharyngitis and the degree of pain, warm saline gargles or throat irrigations are used. An ice collar also can relieve severe sore throats. (less)

Rationale 3:

A pigeon chest occurs as a result of the anterior displacement of the sternum, which also increases the anteroposterior diameter. This may occur with rickets, Marfan syndrome, or severe kyphoscoliosis. Kyphoscoliosis is characterized by elevation of the scapula and a corresponding S-shaped spine. This deformity limits lung expansion within the thorax. It may occur with osteoporosis and other skeletal disorders that affect the thorax. (less)

Rationale:

Age-related changes in the respiratory system include a decrease in mucus, decrease in gag reflex, increase in collagen in the alveolar walls of the lungs, and increase in alveolar duct diameter. (less)

4. The nurse is caring for clients on the neurological unit. Which triad of neurological mechanisms does the nurse identify as most responsible when there is abnormality in ventilation control?

Aortic arch, pons, and CO2 receptor sites

13. A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply.

• Substernal pain • Dyspnea • Fatigue