Prep U's - Chapter 39 - Oxygenation and Perfusion (TF)

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? A. inflammation of pleural surfaces. B. presence of fluid in the lungs. C. air passing through narrowed airways. D. presence of sputum in the trachea.

Answer: B Rationale: Coarse crackles heard on auscultation indicate the presence of fluid in the lungs. Air passing through narrowed airways produces a wheezing sound, whereas inflammation of pleural surfaces gives rise to pleural rub. Sputum in the trachea produces stridor, a harsh, noisy squeak when something is blocking the airway.

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? A. Hematocrit levels. B. Hemoglobin levels. C. Arterial blood gas. D. Pulmonary function.

Answer: C Rationale: Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia? A. Diarrhea B. Hemoptysis C. Clubbing D. Edema

Answer: C Rationale: Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many clients with chronic hypoxia due to respiratory or cardiac disease. Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD. Hemoptysis, edema, and diarrhea do not result from hypoxia.

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? A. Bronchitis B. Bronchiectasis C. Atelectasis D. Croup

Answer: A Rationale: Bronchitis refers to a condition in which the airways become inflamed, commonly due to respiratory irritants such as air pollution and high humidity. Exposure to such irritants leads to the release of inflammatory mediators, which in turn, lead to inflammation and narrowing of the airways and increased mucus production. Atelectasis refers to the partial or complete collapse of the small air sacs in the lungs, common after surgery or with obstruction or compression of the airways or lungs. Bronchiectasis results from chronic inflammation or infection causing an excess accumulation of mucus. Croup is an infection of the airways, most commonly viral in origin.

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? A. They are low-pitched, soft sounds heard over peripheral lung fields. B. They are medium-pitched blowing sounds heard over the major bronchi. C. They are loud, high-pitched sounds heard primarily over the trachea and larynx. D. They are soft, high-pitched discontinuous (intermittent) popping lung sounds.

Answer: A Rationale: Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm, and the pulse oximeter reads 99%. These readings best indicate: A. adequate tissue perfusion. B. heart failure. C. diminished stroke volume. D. high cardiac output.

Answer: A Rationale: Pulse oximetry is often used as a measure of tissue perfusion. An oxygen saturation of greater than 94% is typically indicative of good tissue perfusion.

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? A. "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." B. "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." C. "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling." D. "Take in a small amount of air very quickly and then exhale as quickly as possible."

Answer: A Rationale: Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.

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? A. Eat smaller meals that are high in protein. B. Eat one large meal at noon. C. Contact the health care provider for nutrition shake. D. Snack on high-carbohydrate foods frequently.

Answer: A Rationale: The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength.

The nurse is caring for a client who is wearing oxygen via nasal cannula. The client asks about the bubbling water attached to the oxygen. Which response by the nurse is appropriate? A. It decreases dry mucous membranes by delivering small water droplets. B. It prescribes oxygen concentration. C. It regulates the amount of oxygen received. D. It determines whether you are getting enough oxygen.

Answer: A Rationale: The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flow meter is a gauge used to regulate the amount of oxygen that a client receives. The health care provider prescribes concentration.

A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first? A. Apply oxygen as prescribed. B. Raise the head of the bed. C. Educate client on incentive spirometry. D. Assist with intubation.

Answer: A Rationale: The nurse should first apply oxygen, which will help to improve oxygen saturation and health status. The client may not require intubation, once oxygen is provided. Although the client may require education on incentive spirometry, the immediate priority intervention is to stabilize the client's oxygen saturation. Similarly, raising the head of the bed may help with the client's comfort but may not have sufficient effect on oxygen saturation.

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. A. Apply a cold compress to the site prior to the removal. B. Apply a semipermeable dressing to the insertion site immediately after the chest tube is removed. C. Ask the client to bear down, then slowly withdraw the chest tube. D. Administer prescribed pain medication 15 to 30 minutes before chest tube removal. E. Teach the client about relaxation exercises to be used during chest tube removal.

Answer: A, D, E Rationale: The plan of care should include the following nursing interventions: administration of prescribed pain medication 15 to 30 minutes before chest tube removal and teaching the client relaxation exercises to utilize during the procedure. Occlusive dressing, not a semipermeable dressing, should be used. The application of cold to the chest prior to removal may also be implemented to decrease client discomfort during chest tube removal. Nurses do not remove chest tubes.

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: A. wheezes. B. crackles. C. vesicular. D. bronchovesicular.

Answer: B Rationale: Crackles, frequently heard on inspiration, are soft, high-pitched discontinuous (intermittent) popping sounds. Wheezes are continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors. Vesicular sounds are low-pitched, soft sounds heard over peripheral lung fields. Bronchovesicular sounds are medium-pitched blowing sounds heard over the major bronchi.

The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged, and the nurse is unable to replace it easily. What is the nurse's most appropriate response? A. Page the respiratory therapist STAT. B. Maintain the client's oxygenation and alert the health care provider immediately. C. Cover the tracheostomy stoma and apply oxygen by nasal cannula. D. Assess the client's respiratory status and check vital signs every 1 minute for the next hour.

Answer: B Rationale: If the tracheostomy becomes dislodged and is not easily replaced, the nurse should notify the primary care provider immediately, cover the tracheostomy stoma, and assess client's respiratory status.

When the nurse observes a newborn infant demonstrating an irregular abdominal breathing pattern, with a respiratory rate of 40 breaths/minute with occasional pauses in breathing of 5-second duration. What is the most appropriate action by the nurse? A. Position the infant side-lying. B. Continue to assess the infant. C. Begin resuscitation efforts. D. Elevate the head of the crib.

Answer: B Rationale: Infants breathe rapidly at 30 to 60 breaths/minute and may have occasional pauses of several seconds between breaths.

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is: A. "His lung muscles are swollen so he is using abdominal muscles." B. "He is using his chest muscles to help him breathe." C. "He will require additional testing to determine the cause." D. "His infection is causing him to breathe harder."

Answer: B Rationale: The client will use accessory muscles to ease dyspnea and improve breathing.

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? A. Crackles. B. Wheezing. C. Stridor. D. Absent breath sounds in lower lobes.

Answer: B Rationale: The nurse expects to document wheezing in the lungs of a client with asthma, which would be more pronounced when the client has a respiratory infection. Wheezing is a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration. Wheezing is caused by air passing through constricted passages caused by swelling or secretions. Stridor and crackles are other abnormal breath sounds caused by fluid, infection, or inflammation in the lungs. Absent breath sounds are not normally found in asthmatic clients; they are characteristic of pneumonia.

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function? A. Wheezes B. Pleural effusion C. Pneumonia D. Tachypnea

Answer: B Rationale: Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis. Pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.

The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care? A. Avoid exposure to large crowds. B. Stay indoors as much as possible. C. Practice good hand hygiene. D. Cut down on smoking.

Answer: B Rationale: Using the air quality index, a red color designation signifies that the air quality is unhealthy for all people, not just sensitive groups. Air pollution and high humidity are respiratory irritants. Pollutants cause increased mucus production and contribute to bronchitis and asthma. Reducing contact with irritants by staying indoors during times of increased air pollution will decrease their effect on the respiratory system. Clients should be encouraged to quit smoking, not just cut down. Avoiding large crowds and practicing good hand hygiene will prevent respiratory infections but not cut down on the effect of air pollution.

The nurse provides care for the client with chronic obstructive pulmonary disease and a low oxygen saturation level despite oxygen therapy. Which intervention(s) does the nurse utilize to help increase the client's oxygenation? Select all that apply. A. Encourage client to increase salt intake. B. Assist the client to do diaphragmatic breathing. C. Teach the client to do pursed lip breathing. D. Ensure that the client is actually using the prescribed oxygen correctly. E. Advise client to increase water intake.

Answer: B, C, D, E Rationale: The nurse advises the client to increase water intake because water is made up of oxygen. By increasing the water consumption, the client can increase the amount of oxygen in the body. The nurse teaches the client to purse the lips and try to exhale longer than inhaling; this will help ensure that the client is bringing in enough oxygen while expelling the carbon dioxide trapped in the lungs. The client should also do pursed lip breathing while relaxing, 2 or 3 times per day, or when the client feels winded. The nurse teaches the client to do diaphragmatic breathing by laying on the back with the head supported by a pillow, and the knees bent. One hand is placed on the upper chest and the other right below the rib cage, so that the client can feel the diaphragm moving to make sure the client is doing this effectively. The nurse instructs the client to breathe in slowly through the nose, and make sure only the hand under the rib cage is moving. The one on the upper chest can move slightly, but not nearly as much as the other. When client is ready to exhale, tell the client to purse the lips and tighten the stomach muscles while breathing out. This strengthens the diaphragm and trains it to help the client breathe deeper. Client should practice this for three times per day, 5 to 10 minutes each time. The nurse will not encourage the client to increase salt in the diet but will instead encourage the client to cut out salt because a diet low in sodium can lead to increased oxygenation via the kidney and the blood.

Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system? Select all that apply. A. crackles heard on inspiration. B. bronchial, vesicular, and bronchovesicular breath sounds. C. anterior-posterior diameter of the chest less than the transverse diameter. D. barrel chest appearance in older adults. E. quiet and nonlabored respiration occurring at a rate of 18 to 30 bpm. F. slightly contoured chest with no sternal depression.

Answer: B, C, F Rationale: The adult chest contour is slightly convex, with no sternal depression. The anteroposterior diameter should be less than the transverse diameter for normal respirations. Bronchial, vesicular, and bronchovesicular are normal breath sounds, depending on the lung fields being assessed. Respirations should be nonlabored with a normal rate of 12 to 20 breaths per minute. Crackles should not be heard on inspiration as this is a sign of mucus or fluid in the lung tissue.

What assessments would a nurse make when auscultating the lungs? A. abnormal chest structures. B. presence of edema. C. air flow through the respiratory passages. D. volume of air exhaled or inhaled.

Answer: C Rationale: Auscultation of the lungs assesses air flow through the respiratory passages and lungs. The nurse listens for normal, as well as abnormal, breath sounds. Abnormal chest structures would be assessed when inspecting the chest and thoracic region. Presence of edema would be assessed as part of the cardiovascular status of the client. Volume of air exhaled and inhaled would be performed during a pulmonary function test.

What is the most important risk factor in pulmonary disease? A. loss of the ozone layer of the atmosphere. B. dangerous chemicals in the workplace. C. active and passive cigarette smoke. D. air pollution from vehicles.

Answer: C Rationale: Cigarette smoking (active or passive) is a major contributor to lung disease and respiratory distress, heart disease, and lung cancer. Cigarette smoking is the most important risk factor for chronic COPD, according to the National Heart, Lung, and Blood Institute. The effects of both active and passive cigarette smoke increase airway resistance, reduce ciliary action, increase mucus production, and thicken alveolar-capillary membranes and bronchial walls. While air pollution, ozone layer, and dangerous chemicals in the workplace seem important, they are less of a major contributor to smoking and the direct action to the lungs.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? A. Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. B. Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. C. Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm. D. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.

Answer: C Rationale: Guidelines to determine suction catheter depth include the following: Using a suction catheter with centimeter increments on it, insert the suction catheter into the endotracheal tube until the centimeter markings on both the endotracheal tube and catheter align, and insert the suction catheter no further than an additional 1 cm past the length of the endotracheal tube. Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Using a spare endotracheal or tracheostomy tube of the same size as being used for the client, insert the suction catheter to the end of the tube and note the length of catheter used to reach the end of the tube. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm.

An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize? A. "Did you remove your dentures?" B. "Did someone take your mask off?" C. "Is your mask causing discomfort?" D. "Did someone loosen the straps on your mask?"

Answer: C Rationale: It is possible for anyone using a mask to try and readjust it if it is uncomfortable. Depending on the older adult's cognitive status, he or she may have tried to make it more comfortable and in the process caused it to no longer fit correctly. This could also occur if the client removed their dentures, as some individual's choose to let the dentures soak overnight. If the mask was fitted with the dentures in, the mask will likely be loose with the dentures removed. The other questions could possibly be asked to see if someone else may have tried to help the client feel more comfortable with the mask on.

When reviewing data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom? A. increased urine output. B. strong, rapid pulse C. rapid respirations D. weight loss

Answer: C Rationale: 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.

A client with closed-angle glaucoma and a cough has a prescription for a cough medicine. The nurse would question which cough medicine if prescribed for this client? A. Cough medicine with iodine. B. Cough medicine with a high sugar content. C. Cough medicine with an antihistamine. D. Cough medicine with a decongestant.

Answer: C Rationale: The client with closed-angle glaucoma should avoid cough medicine because of its anticholinergic action. The client with diabetes should avoid cough medicine with a high sugar content. The client with thyroid disorders should avoid cough medicine containing iodine. The client with hypertension should avoid cough medicine with decongestants.

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention? A. Document outcomes of modifications in care. B. Contact the health care provider to report the client's current status. C. Ask the client what factors contribute to nonadherence. D. Explain the use of a BiPAP mask instead of a CPAP mask.

Answer: C Rationale: The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment. Then, the nurse can work with the health care provider to find alternate treatment options if necessary, and then document the care.

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting? A. Crackles B. Bronchovesicular C. Vesicular D. Bronchial

Answer: C Rationale: Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

The nurse is observing the unlicensed assistive personnel (UAP) perform oropharyngeal suctioning on a client. Which action, performed by the UAP, would indicate to the nurse that suctioning is being properly performed? A. The UAP applies lubricant to the first 2 to 3 inches of the catheter. B. The UAP allows 30-second to 1-minute intervals between suctioning passes. C. The UAP advances the catheter approximately 3 to 4 inches to reach the pharynx. D. The UAP advances the catheter approximately 5 to 6 inches to reach the pharynx.

Answer: C Rationale: When performing oropharyngeal suctioning, the catheter should be placed along the side of the mouth toward the trachea and advanced 3 to 4 inches to reach the pharynx. In nasopharyngeal suctioning, the catheter should be inserted through the naris and along the floor of the nostril toward the trachea; it should be advanced approximately 5 to 6 inches to reach the pharynx. Applying lubricant to the first 2 to 3 inches of the catheter facilitates passage of the catheter and reduces trauma to mucous membranes. Allowing 30-second to 1-minute intervals between suction passes allows for reventilation and reoxygenation of airways.

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. A. Observe the monitor to record the respiratory rate. B. Prepare the client to have an arterial line inserted. C. Correlate the pulse oximetry reading with the client's heart rate. D. Assess client for factors affecting circulation. E. Use the forehead sensor if cardiac output is low. F. Determine if the client has a pre-existing condition affecting the oxygen saturation.

Answer: C, E, F Rationale: The nurse will correlate the pulse reading on the pulse oximeter with the client's heart rate. Variation between pulse and heart rate may indicate that not all pulsations are being detected and another sensor site may be required. In clients that have low cardiac output, it is best for the nurse to use a forehead sensor rather than the digital sensor. If the client has chronic bronchitis or emphysema, the readings may not be accurate. The nurse will obtain the heart rate with the pulse oximeter but not the respiratory rate. The nurse does not have to insert an arterial line to obtain continuous pulse oximetry readings. The arterial line is invasive and provides a portal for bacterial invasion.

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? A. high temperature B. low blood pressure C. low pulse rate D. high respiratory rate

Answer: D Rationale: 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 has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from: A. pulmonary embolism. B. lung cancer. C. myocardial infarction. D. congestive heart failure.

Answer: D Rationale: A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.

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? A. Instruct the client to elevate the arm over the head for 10 minutes. B. Place an adhesive bandage over the puncture site and instruct the client to leave it on for 30 minutes. C. Label the blood specimen with the client's correct demographic information. D. Apply steady, firm pressure on the puncture site for 5 to 15 minutes.

Answer: D Rationale: 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 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? A. Total lung capacity (TLC) B. Tidal volume (TV) C. Forced Expiratory Volume (FEV) D. Residual Volume (RV)

Answer: D Rationale: 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.

In which client should the nurse prioritize assessments for respiratory depression? A. A client taking antibiotics for a urinary tract infection. B. A client taking insulin for type 1 diabetes. C. A client taking a beta-adrenergic blocker for hypertension. D. A client taking opioids for cancer pain.

Answer: D Rationale: Many medications affect the function of the respiratory system and depress the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Beta-adrenergic blockers, antibiotics, and insulin do not appreciably affect the respiratory system.

A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of: A. croup. B. asthma. C. alcohol use. D. pneumonia.

Answer: D Rationale: Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol use do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol use depresses the central respiratory center.

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? A. spirometry B. peak expiratory flow rate C. thoracentesis D. pulse oximetry

Answer: D Rationale: 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 health care provider to aspirate pleural fluid for diagnostic or therapeutic purposes.

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: A. age B. blood pH C. sodium and potassium levels D. hemoglobin levels

Answer: D Rationale: Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client? A. simple mask B. face tent C. nonrebreather mask D. nasal cannula

Answer: D Rationale: The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Nonrebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.

True OR false: After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

Answer: True Rationale: After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A nurse caring for a client with a chest tube should monitor the client's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.