Chapter 39 PrepU N204
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? Hyperventilation Hypoxia Perfusion Atelectasis
Hypoxia 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.
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 Tachypnea Wheezes Pneumonia
Pleural effusion 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 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 lung sounds Reposition client Elevate head of the bed Assess oxygen tubing connection
Assess oxygen tubing connection 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 edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from: pulmonary embolism. myocardial infarction. lung cancer. congestive heart failure.
congestive heart failure. A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.
The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier? "This is a gauge used to regulate the amount of oxygen that a client receives." "The humidifier prescribes the concentration of oxygen." "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." "Small water droplets come from this, thus preventing dry mucous membranes."
"Small water droplets come from this, thus preventing dry mucous membranes." The humidifier produces small water droplets which are delivered during oxygen administration to prevent or 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 healthcare provider prescribed the concentration of oxygen.
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. Administer prescribed pain medication 15 to 30 minutes before chest tube removal. Teach the client about relaxation exercises to be used during chest tube removal. Ask the client to bear down, then slowly withdraw the chest tube. Apply a semipermeable dressing to the insertion site immediately after the chest tube is removed. Apply a cold compress to the site prior to the removal.
Administer prescribed pain medication 15 to 30 minutes before chest tube removal. Teach the client about relaxation exercises to be used during chest tube removal. Apply a cold compress to the site prior to the removal. 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.
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? Assist with intubation Apply oxygen Educate client on incentive spirometry Raise the head of the bed
Apply oxygen 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.
When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom? Rapid respirations Weight loss Increased urine output Mental alertness
Rapid respirations Normal cardiac output averages from 3.5 L/minute to 8.0 L/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 respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.
The client is reporting to the nurse that the continuous positive airway pressure (CPAP) mask is torture. What is the best response from the nurse? Tell me more about why it bothers you. Would you like to talk to your health care provider concerning this? Can you explain to me what settings you are using? Perhaps we need to change you to a different type of mask.
Tell me more about why it bothers you.
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. 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. 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. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.
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. 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.
The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output? "If the client's stroke volume is 70 mL and heart rate is 70 beats per minute, then the cardiac output is 4.7 L/minute." "If the client's stroke volume is 80 mL and heart rate is 80 beats per minute, then the cardiac output is 6.0 L/minute." "If the client's stroke volume is 60 mL and heart rate is 60 beats per minute, then the cardiac output is 3.2 L/minute." "If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute."
"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute." The following formula is used to determine cardiac output: Cardiac Output = Stroke Volume x Heart Rate. A client with a stroke volume of 50 mL and heart rate of 50 beats per minute has a cardiac output of 2.5 L/minute. If stroke volume is 70 and heart rate is 70 beats per minute, then the cardiac output is 4.9 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute.
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 Ambu bag Oxygen tent
Ambu bag 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.
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? Atelectasis Bronchitis Bronchiectasis Croup
Bronchitis 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 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? Tidal volume (TV) Total lung capacity (TLC) Forced Expiratory Volume (FEV) Residual Volume (RV)
Residual Volume (RV) 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.
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 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 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? Warm the client's hands and try again. Place the probe on the client's earlobe. Shine available light on the equipment to facilitate accurate reading. Use a blood pressure cuff to increase circulation to the site.
Warm the client's hands and try again. 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.
Which scenario describes how carbon dioxide levels determine the frequency and depth of ventilation? Breathing increases when carbon dioxide levels decrease. An increase in circulating carbon dioxide causes an increase in the release of hydrogen ions, stimulating chemoreceptors in the aortic arch and carotid arteries, causing deeper and more rapid breathing. A decrease in the partial pressure of oxygen in arterial blood causes an increase in carbon dioxide levels, which in turn causes breathing to be slowed and more shallow. When carbon dioxide levels in the blood increase, chemoreceptors are stimulated, causing deeper and more rapid breathing.
When carbon dioxide levels in the blood increase, chemoreceptors are stimulated, causing deeper and more rapid breathing. Peripheral and central chemoreceptors in the aortic arch and carotid arteries and the medulla are sensitive to circulating blood levels of carbon dioxide and hydrogen ions. Increased carbon dioxide levels lead to more rapid and deep breathing, whereas decreased carbon dioxide levels lead to slower and shallower respirations.
A client has been receiving treatment with a nonrebreather mask for the past 96 hours. How should the nurse respond if the unlicensed assistive personnel (UAP) suddenly reports the client has vomited? conduct a focused assessment replace current mask with a new one notify the health care provider put client on NPO status
conduct a focused assessment The nurse should first conduct a focused assessment to gather more information. Individuals who have been receiving oxygen concentrations of more than 50% for longer than 72 hours are at an increased risk for oxygen toxicity. The signs are subtle and include nausea, vomiting, nonproductive cough, substernal chest pain, nasal stuffiness, fatigue, headache, sore throat and hypoventilation. After the nurse has finished assessing the client, then the health care provider should be notified of the findings of the assessment. The mask would need to be cleaned or replaced per the facilities policy. The client may already be on NPO status.
The nurse has received a prescription to obtain an arterial blood gas (ABG) on a client who has a history of chronic obstructive pulmonary disease (COPD) and is receiving oxygen via nasal cannula. Which step is the most important for the nurse to fulfill? ensure client is at rest at least 30 minutes before obtaining the specimen notify laboratory personnel of the prescription place the specimen in cold water after filling the tube apply pressure to the puncture site for at least 15 minutes after the puncture
ensure client is at rest at least 30 minutes before obtaining the specimen Unless the procedure is an emergency, it is advisable for the client to be at rest at least 30 minutes prior to obtaining the specimen. The ABG represents the client status at the moment of sampling and activity can lower oxygen levels in the blood, which can lead to an incorrect interpretation of the results. Some facilities require laboratory personnel to obtain this sample which would require the nurse to notify the lab; however, with the current use of computers, they may already know and not need to be contacted. The specimen tube should be placed on ice for transport to the laboratory to help preserve the specimen as it slows metabolism and helps ensure accurate results. Manual pressure should be applied for 5 to 10 minutes after the puncture and followed with a pressure dressing to reduce the potential of arterial bleeding.
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? fine crackles to the bases of the lungs bilaterally respiratory rate of 18 breaths per minute resonance on percussion of lung fields vesicular breath sounds audible over peripheral lung fields
fine crackles to the bases of the lungs bilaterally Except in the case of infants, fine crackles always constitute an abnormal assessment finding. 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 has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? simple mask tracheostomy collar nasal cannula face tent
tracheostomy collar A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. All other devices are less appropriate for this client.