Acid Base Oxygenation PrepU

A home health nurse visits a client with chronic obstructive pulmonary disease who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use?

"I make sure my oxygen mask is on tightly so it won't fall off while I nap." Rationale: The client requires additional teaching if they state that they fit the mask tightly. Applying the oxygen mask too tightly can cause skin breakdown, so the client should be cautioned against wearing it too tightly.

Which family member would be restricted from the room of an infant receiving ribavirin?

Any pregnant female

Our ability to oxygenate the tissues and organs of our bodies depends on our ability to ventilate, or exchange gases in our respiratory system. The resultant distribution of ventilation in our respiratory system depends on what factors?

Effects of gravity and body position rationale: The distribution of ventilation between the apex and base of the lung varies with body position and the effects of gravity on intrapleural pressure.

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

The nurse prepares to apply the pulse oximeter to the client's hand. The fingers are edematous, cool to touch, and have black nail polish. Which actions should the nurse take? Select all that apply.

Remove black nail polish and assess circulation. Assess mental status. Auscultate lungs. Use alternate site: earlobe or bridge of nose.

A client has a nursing diagnosis of ineffective airway clearance related to excessive mucus production. The best short-term goal is for the client to

Report decreased congestion.

Which medication is a respiratory stimulant?

aminophylline rationale: Aminophylline is a respiratory stimulant and bronchodilator that opens the airway of the lungs. It relaxes the smooth muscles around the airways.

The nurse is providing discharge teaching to a client going home with oxygen therapy. Which statements made by the client would indicate to the nurse that the teaching was effective? Select all that apply.

-"I will not allow smoking within 10 feet (3 m) of my oxygen." -"I will keep the oxygen tank away from direct sunlight or heat."

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 costs less than oxygen supplied in portable tanks." -"It eliminates the need for a central reservoir of piped oxygen." -"It collects and concentrates oxygen from room air." -"You may notice an increase in your electric bill."

A child in the Emergency Department is experiencing difficulty breathing. Which assessment findings are consistent with this condition? Select all that apply.

-Circumoral pallor -Tachypnea Hypoventilation rationale:Circumoral pallor is a sign of poor oxygenation. Tachypnea is noted in children in respiratory distress and hypoventilation is a decrease in the depth and rate of respirations.

A nurse is caring for an older adult client who is to be discharged from the health care facility. The client has been prescribed an oxygen concentrator at home to continue oxygen therapy. What instructions would the nurse tell the client regarding the use of the oxygen concentrator in the home? Select all that apply.

-Do not smoke or use oxygen where open flames, such as a gas stove, are in use. -The oxygen concentrator needs to be used in a grounded electrical plug. -The oxygen concentrator is portable and cost-effective

The nurse is caring for a client with a 35% Venturi mask. Which administration considerations should the nurse use? Select all that apply.

-Ensure that air intake valves are not blocked. -Examine the needed flow rate on the mask matches the rate on the oxygen flow meter. -Use gauze pads under elastic strap to relieve irritation to scalp or ears.

A nurse is caring for an elderly client who is to be discharged from the health care facility. The client has been prescribed the use of a liquid oxygen unit at home to continue with oxygen therapy. What should the nurse tell the client regarding the potential problems of using a liquid oxygen unit? Select all that apply.

-Liquid oxygen may leak during warm weather. -The unit's outlet may become occluded because of frozen moisture. -Portable liquid oxygen is more expensive.

The nurse is caring for a client who is demonstrating signs of increased respiratory distress related to laryngeal obstruction. The nurse is calling the physician to report on the client's condition. Which of the following will the nurse report? Select all that apply.

-Nasal flaring with abdominal retractions -Arterial blood gases reporting a PaCO2 of 48 and a PaO2 of 84 -Increased respiratory effort -Lung sounds of wheezing

Put these steps in order to describe the process of oxygen transport from the alveolar to the cellular level.

-Oxygen moves from inspired air in the alveoli to the pulmonary capillaries through the process of diffusion. -Oxygen moves quickly to the red blood cells where it binds reversibly to hemoglobin. -Oxygen is released from the hemoglobin in the tissues capillaries. -Oxygen separates from the hemoglobin and moves into the tissues where the PO2 level is lower.

A nurse is performing CPR on a client who collapsed. Which guidelines should be used for this procedure? Select all that apply.

-Position the client supine on his or her back. -Use the head tilt-chin lift maneuver to open the airway. -Rest elbows on the flat surface under the client, grasp the angle of the client's lower jaw, and lift with both hands.

The nurse provides care for a client with pneumonia and acute respiratory distress syndrome whose oxygen saturation fluctuated between 86% and 90% over the past few days. The oxygenation saturation is consistently at 91%. Which step would the nurse take next?

-Provide oxygen for consistent -hypoxia

Which of the following interventions would be helpful for a client reporting nasal congestion, sneezing, sore throat, and muscle aches? Select all that apply.

-Provide warm salt-water gargles. -Administer oral ibuprofen. -Teach the client about handwashing. -Recommend guaifenesin. rationale: Described signs and symptoms are consistent with viral rhinitis (the common cold). Management consists of symptomatic therapy, such as gargling with warm salt-water gargles, taking nonsteroidal anti-inflammatory medications (e.g., ibuprofen [Motrin]), and using guaifenesin (Mucinex), which promotes removal of secretions. Handwashing is the most effective measure to prevent transmission of organisms

The child has been admitted to the hospital with a possible diagnosis of pneumonia. Which finding(s) is consistent with this diagnosis? Select all that apply.

-The child's chest x-ray indicates the presence of perihilar infiltrates. -The child's white blood cell count is elevated. -The child's respiratory rate is rapid. -The child is producing yellow purulent sputum.

Which infants are at high risk for acquiring the respiratory syncytial virus (RSV) infection? Select all that apply.

-The infant of an adult with an upper respiratory infection -The infant who has lung disease -The infant who had a transplant -The infant receiving chemotherapy rationale: The following infants are at high risk for acquiring RSV: the infant exposed to a respiratory virus; an infant whose lungs are compromised; an infant who has a diminished immune system such as a transplant or chemotherapy client.

Which breathing technique(s) will the nurse teach to the client who has hypoxemia and hypercarbia? Select all that apply.

-diaphragmatic breathing -pursed-lip breathing rationale Pursed-lip breathing and diaphragmatic breathing are helpful for clients who have excessive levels of carbon dioxide in the blood.

The nurse is applying a pulse oximeter to a client with bronchitis. Which factor(s) does the nurse communicate to the client that could interfere with accurate pulse oximetry? Select all that apply.

-nail polish -thickness of nails -acrylic nails -peripheral vascular disease

The nurse is caring for a client at risk for pneumonia after having major abdominal surgery. Which nursing instruction(s) is essential for the use of an incentive spirometer? Select all that apply.

-splint the abdomen with a pillow to decrease discomfort prior to use. -Instruct the client to exhale normally and then place lips securely around the mouthpiece. -Encourage the client to complete breathing exercises about 5 to 10 times every 1 to 2 hours, if possible. -Assist the client to an upright or semi-Fowler position

A 13-year-old soccer player presents to the emergency room with a fractured nose. The patient's mother is given which of the following post-discharge instructions? Select all that apply.

Check for any unusual changes in breathing during the first 48 hours. Observe for any clear drainage from either nostril. Elevate the head of the bed for sleeping during the first week. Restrict from sports activities for 6 weeks.

A client who underwent a cesarean delivery suddenly complains of shortness of breath and pain approximately 2 hours after delivery. Which action should the nurse prioritize?

Ensure the head of the bed is at 45 degrees. rationale: The immediate response by the nurse is to ensure the head of the bed is at 45 degrees. Then the LPN must notify the RN and/or health care provider. Applying oxygen, obtaining an arterial blood gas specimen, or increasing the IV fluid rate will be done on orders from the health care provider

The nurse is discussing the differences between children's and adult's respiratory systems. Which statements by the nurse are accurate? Select all that apply.

"The only time that newborns can breathe through their mouths is when they cry." rationale Until 4 weeks of age, newborns are obligatory nose breathers and breathe only through their mouths when they are crying. A newborn's respiratory tract makes very little mucus.

When preparing the room for an infant with bronchiolitis, which equipment is most important?

oxygen tubing and facemask rationale: The treatment is supportive oxygen therapy, suctioning, and hydration.

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 -Base excess or deficit +2 mmol/L -PCO2 40 mm Hg

The emergency department nurse is caring for a client with cystic fibrosis who is dyspneic and has a productive cough. Place in order the nursing interventions performed upon arrival to improve breathing.

Assess respiratory status. Place in bed in a semi-Fowler's position. Obtain oxygen saturation reading. Place on oxygen at 2 liters. Notify respiratory therapy. Instruct on energy conservation measures.

client is in the early stage of heart failure. During this time, which compensatory mechanism occurs?

Low blood pressure triggers the baroreceptors to increase sympathetic nervous system stimulation.