Ch 39 Oxygenation and Perfusion

The charge nurse is observing a new nurse care for a client who is receiving oxygen via a simple mask with an FIO2 of 40%. The client states, "This moisture on my face is bothersome. Can something be done about it?" Which response by the new nurse would require clarification by the charge nurse? a- I will confer with your primary care provider to find out if a nasal cannula can be used. b- After I dry your face, I can apply powder to absorb the moisture and protect your skin. c- The mask and its moisture can be bothersome, so let me demonstrate some distraction techniques to help you cope with them. d- your mask should remain on, but I will help you dry your face when it becomes too wet.

b- After I dry your face, I can apply powder to absorb the moisture and protect your skin. The new nurse should be corrected by the charge nurse to not apply powder to the face to absorb the moisture. Applying powder can accidentally be inhaled and cause a inhalation issue. Drying the face when the moisture becomes too wet is an appropriate response. The new nurse should attempt to change the simple mask to a nasal cannula if allowed. Teaching the client about distraction techniques is also appropriate.

The nurse auscultates a client's lung sounds, hears them clearly fill with air, and then return to the resting position. How will the nurse document this finding? a- clear on respiration and inspiration b- clear on inspiration and expiration c- clear on ventilation and respiration d- clear on expiration and ventilation

b- clear on inspiration and expiration. Lungs stretch and fill with air during inspiration and return to a resting position following expiration. Therefore, this is how the nurse would document teh finding. Ventilation is the movement of air in and out of the lungs. Respiration is the exchange of oxygen and carbon dioxide.

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? a- humidifier b- flow meter c- nasal cannula d- oxygen analyzer

b- flow meter In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter 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 receiveing the amount prescribed by the physician. A humidifier is a device that produces small water droplets and may be used during oxygen administration, since oxygen dries the mucous membranes. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen.

Which teaching about the humidifier is important for the nurse to provide to a client using oxygen? a- it determines whether the client is getting enough oxygen b- it decreases dry mucous membranes via delivering small water droplets c- it prescribes oxygen concentration d- it regulates the amount of oxygen received.

b- it decreases dry mucous membranes via delivering small water droplets. 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 flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration.

Which oxygen delivery system is most commonly used because it does not impede eating or speaking? a- oxygen tent b- nasal cannula c- oxygen hood d- oxygen mask

b- nasal cannula. A nasal cannula is commonly used because it does not impede eating or speaking and is easily used in the home. A mask is used when a client requires a higher concentration of oxygen than a nasal cannula can deliver or if the client is a mouth breather. Oxygen hoods and tents are generally used to deliver oxygen to infants and children.

The nurse is caring for a client who reports difficulty breathing. In what position would the nurse place this client? a- supine position b- prone position c- Fowler's position d- lateral position

c- Fowler's position. People with dyspnea and orthopnea are most comfortable in a high fowler's position because accessory muscles can easily be used o promote respiration. Prone position can be used on a routine basis to promote ventilation and perfusion of the posterior dependent sections of the lungs. Lateral and supine position would not be beneficial as accessory muscles are not supported as with a Fowler's position.

A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction two 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: a- tachypnea b- pneumothorax c- atelectasis d- hemothorax

c- atelectasis 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. Tachypnea, if present, would likely be a sign of atelectasis rather than an independent finding.

A client who utilizes a portable oxygen device reports planning to attend an upcoming bonfire on the beach. What is the appropriate nursing response? a- you should not leave the house with portable oxygen b- saltwater can increase the potential for oxygen toxicity c- be sure to avoid the actual area of fire, and anyone who is smoking d- have an enjoyable time

c- be sure to avoid the actual area of fire, and anyone who is smoking. Although freedom to move about comes with portable oxygen, the client should be educated about the dangers of oxygen near fire; therefore, fires and anyone smoking should be avoided. Saltwater does not increase the potential for oxygen toxicity.

Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound? a- vericular b- bronchovesicular c- bronchial d- adventitious

c- bronchial Bronchial breath sounds are loud, high-pitched sounds hard primarily over the trachea and larynx. Vesicular breath sounds are low-pitched, soft sounds heard over the peripheral lung fiends. Bronchovesiculare breath sounds are medium-pitched blowing sounds heard over the major bronchi. Vesicular, bronchial, and bronchovesicular breath sounds are normal breath sounds. Adventitious breath sounds are abnormal lung sounds.

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- hemoglobin level d- sodium and potassium levels

c- hemoglobin level 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 orer to administer oxygen to teh client? a- simple mask b- face tent c- nasal cannula d- non-rebreather mask

c- nasal cannula. 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 hald-inch prongs placed into teh 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. Non-rebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.

A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply? a- humidified venturi mask b- venturi mask c- partial rebreather mask d- simple oxygen mask e- nasal cannula

c- partial rebreather mask d- simple oxygen mask e- nasal cannula Nasal cannula with tubing administers oxygen at low flow rates and concentrations at 22-44%. Simple masks and partial rebreathers both deliver a low-flow rate at concentrations of 40-60%. Venturimasks mix oxygen with room air and create a high flow of oxygen.

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- pneumonia d- alcohol abuse

c- pneumonia Pneumonia, which causes the lungs to sell 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, 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 abuse depresses the central respiratory center.

Was structural changes to the respiratory system should a nurse observe when caring for older adults? a- increased mouth breathing and snoring b- diminished coughing and gag reflexes c- respiratory muscles become weaker d- increased use of accessory muscles for breathing

c- respiratory muscles become weaker. One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker. The nurse should also observe other structural changes: the chest wall becomes stiffer as a result of calcification of the intercostals cartilage, kyphoscoliosis, and arthritic changes to costovertebral joints; the ribs and vertebrae lose calcium; the lungs become smaller and less elastic; alveoli enlarge; and alveolar walls become thinner. Diminished coughing and gag reflexes, increased use of accessory muscles for breathing, and increased mouth breathing and snoring are functional changes to the respiratory system in older adults.

Which nursing skill requires the nurse to use sterile technique? a- providing oxygen by nasal cannula b- administering nebulizers c- suctioning a tracheostomy d- administering oxygen by face mask

c- suctioning a tracheostomy. Suctioning is always a sterile procedure, whereas the administration of oxygen by face mask or by nasal cannula and nebulized medications require clean technique.

Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body? a - parkinson's disease b - pancreatitis c - graves' disease d - chronic anemia

d - chronic anemia The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the amount of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissue of the body. Graves' disease, Parkinson's disease, and pancreatitis do not directly lead to a decrease in the number of red blood cells.

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia? a - decreased blood pressure b- hyperactivity c - decreased respiratory rate d - confusion

d - confusion Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.

A nurse is using a pulse oximeter to measure the arterial oxyhemoglobin saturation (SaO2 or SpO2) of a client's arterial blood. What range is considered a normal value for SpO2? a- 75% to 80% b- 85% to 90% c- 65% to 70% d- 95% to 100%

d- 95% to 100%. A range of 95% to 100% is considered normal SpO, values less than 85% indicate that oxygenation to the tissues is inadequate.

The nurse is preparing to educate a client on how to perform incentive spirometry. Which concepts should the nurse include? a- Incentive spirometry provides visual reinforcement of deep breathing. b- Proper, frequent use of incentive spirometry can improve pulmonary circulation. c- decrease of oxygen saturation is expected during the first few minutes of incentive spirometry. d- The client should forcefully exhale into the incentive spirometer and continue to exhale until unable to continue.

a- Incentive spirometry provides visual reinforcement of deep breathing. Incentive spirometry is used to enhance inspiratory effort.

In which client would the nurse assess for a depressed respiratory system? a- a client taking amlodipine for hypertension b- a client taking insulin for diabetes c- a client taking antibiotics for a urinary tract infection d- a client taking opioids for cancer pain

d- a client taking opioids for cancer pain. Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Amlodipine is a calcium channel blocker and the medication decreased blood pressure, so the nurse would need to assess blood pressure. Antibiotics are used for urinary tract infections as well as other infections and the infections do not affect the respiratory system. Insulin decreases blood sugar which a person with diabetes may need to take every day. Insulin does not affect the respiratory system.

A nurse is caring for a client who breathes very shallowly and has been reporting severe back pain. What suggestion could the nurse make to help the client breathe efficiently? a- instruct the client in the use of pursed-lip breathing technique b- inform the client about nasal strips c- teach the client diaphragmatic breathing d- encourage the client to take deep breaths

d- encourage the client to take deep breaths. To help the client breathe efficiently, the nurse could encourage the client to take deep breaths. Deep breathing maximizes the ventilation and fills the alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing and diaphragmatic breathing help to eliminate the extra carbon dioxide from the lungs. A nasal strip reduces airflow resistance by widening the nasal-breathing passageways, thus promoting easier breathing. It is used for reducing or eliminating snoring.

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? a- educating the client on the use of incentive spirometry b- educating the client on pused-lip breathing techniques c- oropharyngeal suctioning twice daily d- administration of inhaled corticosteroids

a- educating the client on the use of incentive spirometry. incentive spirometrymaximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspena 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.

The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal? a- fine crackles to the bases of the lungs bilaterally b- vesicular breath sounds audible over peripheral lung fields c- respiratory rate of 18 breaths per minute d- resonance on percussion of lung fields

a- fine crackles to the bases of the lungs bilaterally Except in the case of infants, fine crackles always constitute an abnormal assessment findnig. A respiratory rate of 18 is within acceptable range. Vesicular sounds over peripheral lung fields and resonance on percussion are expected assessment findings.

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 respiratory rate b- high temperature c- low blood pressure d- low pulse rate

a- high respiratory 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.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea? a- high-fowler's position b- lying with the head slightly lowered c- supine with one pillow d- side lying with head slightly elevated

a- high-fowler's position. Clients with COPD are most comfortable in high-Fowler's position because it aids in the use of the accessory muscles to promote respirations. The supine position with one pillow, side-lying with head slightly elevated or lying with the head slightly lowered does not promote easier respirations.

The nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FIO2 of 100%. Which oxygen delivery system should the nurse utilize? a- non-rebreather mask b- nasal cannula c- venturi mask d- simple mask

a- non-rebreather mask. A non-rebreather mask is the only device that can deliver FIO2 of 100% to a client without a controlled airway. A Venturi mask delivers a maximum FIO2 of 44%. A simple mask delivers a maximum FIO2 of 60%.

While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique? a- pattern of thoracic expansion b- fluid-filled portions of the lung c- consolidated portions of the lung d- presence of pleural rub

a- pattern of thoracic expansion. The nurse can assess patterns of thoracic expansion of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation.

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula? a- it can create a risk of suffocation b- it can cause anxiety in clients who are claustrophobic c- it can result in an inconsistent amount of oxygen d- it can cause the nasal mucosa to dry in case of high flow

d- it can cause the nasal mucosa to dry in case of high flow. When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss.

The nurse should assess for respiratory depression before and after the administration of which drugs? a- diuretics b- antibiotics and antivirals c- proton-pump inhibitors d- opioid analgesics

d- opioid analgesics opioids depress the medullary respiratory center, resulting in decreased respiratory rate. Antibiotics, antivirals, diuretics, and proton-pump inhibitors do not have this effect. Antibiotics affect bacterial invasion and antivirals reduce the viral complications and neither affect the respiratory center. Diuretics are used to decrease blood pressure by increasing excretion of urine. Proton-pump inhibitors decrease gastric secretions which reduce acid production in the gastrointestinal tract.

A nurse auscultates the lungs of a client with asthma. Which lung sound is characteristic of this condition? a- vesicular sounds b- crackles c- bronchial sounds d- wheezes

d- wheezes. Wheezes are continuous musical sounds, produced as air passes through airways that are constricted, as with asthma. Crackles are produced by fluid in the airways or alveoli and delayed reopening of congestion and are associated with pneumonia, heart failure, bronchitis, and COPD. Bronchial sounds are normal sounds heard as loud, high-pitched sounds heard primarily over the trachea and larynx. Vesicular sounds are normal sounds heard as low-pitched, soft sounds over peripheral lung fields.