3A Oxygen and Perfusion

The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take? Assess oxygen tubing connection Assess lung sounds Reposition client Elevate head of the bed

Assess oxygen tubing connection Explanation: If the client suddenly becomes cyanotic, the nurse should assess the oxygen tubing to make sure it is still connected. Assessing lung sounds, repositioning the client, and elevating the head of the bed will not correct the problem if the tubing is disconnected.

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? nasal cannula oxygen analyzer nasal strip flow meter

flow meter Explanation: The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.

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

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Explanation: Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.

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? Oxygen mask Nasal cannula Oxygen tent Ambu bag

Ambu bag Explanation: 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.

During assessment of a 4-year-old client, the nurse notes a respiratory rate of 30 breaths/min and a loud, harsh expiration that is longer than inspiration. The nurse would implement which appropriate nursing intervention next? Proceed with the assessment Notify the health care provider Administer oxygen therapy Obtain arterial blood sampling

Proceed with the assessment Explanation: When collecting respiratory data on a 4-year-old, loud, harsh expiration longer than inspiration breath sounds and respiratory rate of 25-32 breaths/min are normal findings; therefore, the nurse would continue with the assessment. Because the findings are normal, it is inappropriate at this time to administer oxygen therapy, obtain an arterial blood sampling, or notify the health care provider.

A nurse is providing home care instructions for a client who is being discharged to his home with a tracheostomy in place. Which statement accurately describes a guideline for care that should be included in the teaching plan? Sterile saline can be made at home using ¼ cup of salt in 1 quart of water and boiling it for 15 minutes. The client should avoid humid locations whenever possible. Clean, rather than sterile, technique can be used in the home setting. All the client's immediate family members should be taught how to perform tracheostomy care for the client.

Clean, rather than sterile, technique can be used in the home setting. Explanation: Clean, rather than sterile technique, can be used in the home setting. The client and home caregiver should be instructed on how to perform tracheostomy care. Sterile saline can be made by mixing 1 teaspoon of table salt in 1 quart of water and boiling for 15 minutes. There is no need for the client to avoid humid locations.

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response? "You will need to use a bedpan while the chest tube is in position." "I can assist you to the bathroom and back to bed." "Let me get the unlicensed assistive personnel (UAP) for you." "The chest tube cannot be moved."

"I can assist you to the bathroom and back to bed." Explanation: The client can move in bed, and ambulate while carrying the drainage system, as long as he or she has orders to do so. The nurse should supervise ambulation to the bathroom and back to bed while the client has the drain inserted to make sure it stays intact and to monitor for safety. Other answers are incorrect.

The nurse is caring for a client with emphysema. A review of the client's chart reveals pH 7.36, PaO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription if prescribed by the health care practitioner? 4 L/minute O2 (66 mL/second) nasal cannula Pulse oximetry Increase fluid intake to 3 L/day (3000 mL/day) High-Fowler's position

4 L/minute O2 (66 mL/second) nasal cannula Explanation: The client with chronic lung disease, such as emphysema, becomes insensitive to carbon dioxide and responds to hypoxia to stimulate breathing. If given excessive oxygen (4 L/minute or 66 mL/second), the stimulus to breathe is removed. Clients with emphysema are most comfortable in high Fowler's position because it aids in the use of the accessory muscles to promote respirations. Increasing fluid intake helps keep the client's secretions thin. Pulse oximetry monitors the client's arterial oxyhemoglobin saturation while receiving oxygen therapy.

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? Position the infant side-lying. Begin resuscitation efforts. Elevate the head of the crib. Continue to assess the infant.

Continue to assess the infant. Explanation: Infants breathe rapidly at 30 to 60 breaths/minute and may have occasional pauses of several seconds between breaths.

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? Contact the physician for nutrition shake. Eat smaller meals that are high in protein. Eat one large meal at noon. Snack on high-carbohydrate foods frequently.

Eat smaller meals that are high in protein. Explanation: 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.

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen? Have the client clear the nose and throat and gargle with salt water before beginning the procedure. Discard the first sputum produced by the client. Place the client in the dorsal recumbent position to collect the specimen. Instruct the client to inhale deeply and then cough.

Instruct the client to inhale deeply and then cough. Explanation: The client should be instructed to inhale deeply and cough; if this results in sputum, it should be collected in the container. The client should be placed in a semi-Fowler's position and instructed to clear the nose and throat and rinse the throat with water.

A client is admitted to the emergency department with shortness of breath and oxygen saturation of 88%. The client has a barrel chest and clubbed fingers. What is the nurse's priority intervention? Ambulate the client Teach the client deep-breathing exercises Assist the client with incentive spirometer Place client in the tripod position

Place client in the tripod position Explanation: Placing the client in the tripod position would relieve shortness of breath and increase the client's oxygen saturation level. Ambulating the client would exacerbate the symptoms, and assisting the client with the incentive spirometer is not appropriate at this time. The client will be unable to perform deep breathing exercises if hypoxic.

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? Chest x-ray Skin tests Pulmonary function tests Bronchoscopy

Pulmonary function tests Explanation: Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.

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

True Explanation: 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 patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.

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: bronchiectasis. bronchiolitis. bronchitis. a bronchospasm.

a bronchospasm. Explanation: When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm.

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: congestive heart failure. pulmonary embolism. myocardial infarction. lung cancer.

congestive heart failure. Explanation: A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.

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? mineral oil distilled water normal saline tap water

distilled water Explanation: Distilled water is used when humidification is desired

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather? tracheostomy collar nasal cannula simple mask face tent

face tent Explanation: 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.

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. age. sodium and potassium levels. blood pH.

hemoglobin level. Explanation: 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 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: asthma. croup. pneumonia. alcohol use.

pneumonia. Explanation: 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.

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

rapid respirations Explanation: 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 vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? Suction the client's mouth through the oropharyngeal airway to prevent aspiration. Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. Leave the airway in place and promptly notify the health care provider for further instructions.

Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Explanation: If the client vomits as the oropharyngeal airway is inserted, quickly position the client onto his or her side to prevent aspiration, remove the oral airway, and suction the mouth, if needed. It would be inappropriate and unsafe to leave the airway in place. Rinsing the client's mouth with water is not a priority.

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? 5,000 mL (5,000 × 109/L) 5,550 mL (5,500 × 109/L) 6,000 mL (6,000 × 109/L) 5,850 mL (5,850 × 109/L)

5,850 mL (5,850 × 109/L) Explanation: 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 is caring for a client with chronic obstructive pulmonary disease who has been admitted to the hospital unit for pneumonia. The nurse notes that the client has a nonproductive cough and has a SpO2 of 92%. Before attempting to obtain a sputum specimen, which action will the nurse take first? Reposition the client and perform postural drainage therapy. Perform nasopharyngeal suctioning to remove secretions from the throat. Administer chest percussion for 3 to 5 minutes with the client in postural drainage position. Administer inhalation therapy using a nebulized mixture of oxygen and humidification

Administer inhalation therapy using a nebulized mixture of oxygen and humidification. Explanation: While nurses use a variation of several interventions to mobilize secretions in clients who have respiratory impairment, the nurse will first attempt to liquefy secretions prior to performing other interventions to promote secretion mobility. In the case of a client that requires a sputum specimen and has a nonproductive cough, liquefying secretions first is a priority.

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? Pulmonary function Hematocrit values Arterial blood gas Hemoglobin levels

Arterial blood gas Explanation: 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 nursing assessment reveals reduced fremitus. This manifestation is consistent with which conditions? Select all that apply. Left-sided heart failure Pneumonia Right-sided heart failure Pulmonary edema Bronchial obstruction

Left-sided heart failure Pneumonia Pulmonary edema Bronchial obstruction Explanation: Fremitus refers to the vibration of air movement through the chest wall. It is best felt by placing the balls of the palms of your hand on the client's back as the client says "99." The intrascapular space is a good area to feel tactile fremitus because it diminishes as you move out in the lung fields. Decreased fremitus may occur with pleural effusion, pulmonary edema, emphysema, or bronchial obstruction. Left-sided heart failure will result in pulmonary edema, causing decreased fremitus.

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? Assess the client's respiratory status and check vital signs every 1 minute for the next hour. Maintain the client's oxygenation and alert the health care provider immediately. Cover the tracheostomy stoma and apply oxygen by nasal cannula Page the respiratory therapist STAT.

Maintain the client's oxygenation and alert the health care provider immediately. Explanation: 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 caring for a client with a tracheostomy, the nurse would perform which recommended action? Assess a newly inserted tracheostomy every 3 to 4 hours. Suction the tracheostomy tube using sterile technique. Clean the wound around the tube and inner cannula at least every 24 hours. Use gauze dressings over the tracheostomy that are filled with cotton.

Suction the tracheostomy tube using sterile technique. Explanation: Sterile technique is required when suctioning a tracheostomy in order to prevent introduction of microorganisms into the respiratory tract. The area around a new tracheostomy may need to be assessed and cleaned every 1 to 2 hours. Gauze dressings that are not filled with cotton must be used to prevent aspiration of lint or cotton fibers into the trachea.

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

They are low-pitched, soft sounds heard over peripheral lung fields. Explanation: 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 assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action? Use a blood pressure cuff to increase circulation to the site. Shine available light on the equipment to facilitate accurate reading. Warm the client's hands and try again. Place the probe on the client's earlobe.

Warm the client's hands and try again. Explanation: Finding an absent or weak signal, the nurse should check vital signs and client condition. If satisfactory, warming the extremity may facilitate a stronger reading. This should be attempted prior to resorting to using the client's earlobe. Bright light can interfere with the operation of light sensors and cause an unreliable report. A blood pressure cuff will compromise venous blood flow to the site leading to inaccurate readings.

A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for: atelectasis. tachypnea. hemothorax. pneumothorax.

atelectasis. Explanation: Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize atelectasis. Immobility is not commonly implicated in cases of pneumothorax or hemothorax. A pneumothorax is a collapsed lung. Hemothorax is a collection of blood in the space between the chest wall and the lung. Tachypnea, if present, would likely be a sign of atelectasis rather than an independent finding.

The nurse is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly? reads 0.21 when checking oxygen in room air reads 0.20 when positioned near oxygen device reads 0.25 when checking oxygen in room air reads 0.19 when positioned near oxygen device

reads 0.21 when checking oxygen in room air Explanation: An oxygen analyzer should read 0.21 when checking oxygen in room air if there is a normal mixture of oxygen and other gases in the environment. When the analyzer is positioned near or within the device used to prescribe oxygen, it should register at the prescribed amount (>0.21).

The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly? drainage system is positioned slightly above chest level respirations are at 20 breaths per minute small amount of subcutaneous air is detected at the site of tube insertion dressing is moist and intact

respirations are at 20 breaths per minute Explanation: Respirations of 20 breaths per minute indicate that the tube is functioning correctly. Other findings require nursing intervention.

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? suctioning of carbon dioxide prevention of suctioning loss of sterile field trauma to the tracheal mucosa

trauma to the tracheal mucosa Explanation: Occluding the Y-port on the suction tubing is what creates the suction. While suctioning would be difficult but possible, suctioning while advancing the tube would damage the tracheal mucosa and remove excessive amounts of oxygen, not carbon dioxide, from the respiratory tract. Suctioning during insertion of the catheter would not compromise sterility.

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? Raise the head of the bed Educate client on incentive spirometry Apply oxygen Assist with intubation

Apply oxygen Explanation: 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.

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? Croup Bronchiectasis Atelectasis Bronchitis

Bronchitis Explanation: 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.

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. It regulates the amount of oxygen received. It decreases dry mucous membranes via delivering small water droplets. It prescribes oxygen concentration.

It determines whether the client is getting enough oxygen. Explanation: The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.

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?

Pleural effusion Explanation: 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.

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. The anteroposterior diameter should be greater than the transverse diameter. The contour of the intercostal spaces should be rounded. The skin at the thorax should be cool and moist.

The chest should be slightly convex with no sternal depression. Explanation: The adult chest contour is slightly convex, with no sternal depression. The skin of the thorax should be warm and dry, and the anteroposterior diameter of the chest should be less than the transverse diameter. The contour of the intercostal spaces should be flat or depressed.

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? "Did you remove your dentures?" "Did someone loosen the straps on your mask?" "Is your mask causing discomfort?" "Did someone take your mask off?"

"Is your mask causing discomfort?" Explanation: 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

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations? Atelectasis Perfusion Hypoxia Hyperventilation

Hypoxia Explanation: Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia. Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements. Perfusion refers to the process by which oxygenated capillary blood passes through body tissues. Atelectasis refers to collapsed alveoli.