Chapter 41: Oxygenation (Oxygenation and the Nursing Process)

Which nursing intervention is appropriate for preventing atelectasis in the postoperative patient?

A. Postural drainage B. Chest percussion *C. Incentive spirometer* D. Suctioning Rationale: An incentive spirometer is used to encourage deep breathing to inflate alveoli and open pores of Kohn. Postural drainage, chest percussion, and suctioning are used to treat atelectasis and increased mucus production. Study Tip: If you have not had the opportunity to use an incentive spirometer, ask your instructor for the chance. Try your best on your first attempt. On your second attempt, have classmates cheer you on. See if you can improve with encouragement. Discuss how it felt to watch the visual indicator of your lung capacity. Understanding the value of the incentive spirometer firsthand is an excellent way to help remember its benefits. Pg. 896

A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min. While in the supine position for a bath, the patient complains of shortness of breath. Which is the most appropriate first nursing action?

A. Increase the flow of oxygen. B. Perform tracheal suctioning. C. Report this to the healthcare provider. *D. Assist the patient to semi-Fowler's position.* Rationale: Breathing is easier in semi-Fowler's position because it permits greater expansion of the chest cavity. If repositioning does not improve the situation, then oxygenation and contacting the health care provider might be appropriate. The patient would not benefit from tracheal suctioning. Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action. Pg. 889, 890, 896

Which condition may cause hypoxia due to decreased movement of the chest wall?

A. Microcytic anemia B. Anaphylactic shock *C. Guillain-Barré syndrome* D. Carbon monoxide toxicity Rationale: Decreased chest movements may cause hypoxia in patients who have neuromuscular diseases such as Guillain-Barré syndrome and myasthenia gravis. Decreased oxygen-carrying capacity causes hypoxia in patients who have microcytic anemia. Hypovolemia causes hypoxia in patients who have anaphylactic shock. Decreased oxygen-carrying capacity causes hypoxia in patients who have carbon monoxide toxicity. Pg. 877

A primary health care provider diagnoses fractures of the C3, C4, and C5 vertebrae in a patient who was in a car accident. The patient also developed cyanosis due to decreased tissue oxygenation. Which statement about the condition of the patient is incorrect?

A. Phrenic nerve paralysis may be attributed to a fractured C5 vertebrae. B. Phrenic nerve paralysis may result in reduced inspiratory lung volumes. *C. The vagus nerve may be paralyzed in this patient due to fracture of the C3 vertebrae.* D. Improper descending of the diaphragm might have caused decreased tissue oxygenation. Rationale: The vagus nerve is unaffected by a C3-C5 fracture. The other statements, however, may further clarify information about the patient's condition. Phrenic nerve paralysis due to fractures of the C3, C4, or C5 vertebrae. Phrenic nerve paralysis may result in decreased inspiratory volume due to improper descending of the diaphragm. This finally results in decreased tissue oxygenation. Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Pg. 877

While assessing a patient, the nurse notices bluish discoloration of the skin and mucous membrane. Which condition might the nurse suspect the patient is experiencing?

*A. Hypoxia* B. Dehydration C. Hyperlipidemia D. Right-sided cardiac failure Rationale: Bluish discoloration of the skin and mucous membrane is cyanosis, which is a clinical manifestation of hypoxia, or reduced tissue oxygenation. Decreased skin turgor is a clinical manifestation of dehydration. Xanthelasma (yellow lipid lesions on the eyelids) is a clinical manifestation of hyperlipidemia. Distention of the veins of the neck is associated with right-sided heart failure. Pg. 877, 884

The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which oxygen-delivery system should the nurse select to administer the oxygen to the patient needing low flow delivery?

*A. Nasal cannula* B. Venturi mask C. Simple face mask without inflated reservoir bag D. Plastic face mask with inflated reservoir bag Rationale: A nasal cannula delivers precise rates of oxygen via a low flow delivery system. A venturi mask delivers at precise rates, but is a high-flow delivery system. Other face masks are less precise delivery methods. Study Tip: Make a chart of the advantages and disadvantages of the various oxygen delivery methods. Include indications and contraindications for each method. Pg. 902-903

A nurse is assessing patients with hypoxia. Which patients might be experiencing hypoxia due to increased metabolic rates? Select all that apply.

*A. Patient who has a fever* B. Patient who is in shock C. Patient who has anemia D. Patient who has myasthenia gravis *E. Patient in the third trimester of pregnancy* Rationale: Increased metabolic rate increases oxygen demand which can cause hypoxia. Fever and pregnancy can increase a patient's metabolic rate. Hypovolemia causes hypoxia in patients who are in shock. Decreased oxygen-carrying capacity causes hypoxia in patients who have anemia. Decreased chest wall movements cause hypoxia in patients who have myasthenia gravis. Pg. 876

Two hours after surgery the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform?

*A. Record the amount and continue to monitor drainage.* B. Notify the health care provider. C. Strip the chest tube starting at the chest. D. Increase the suction by 10 mm Hg. Rationale: Dark-red drainage after surgery (50 to 200 mL per hour in the first 3 hours) is expected, so it is not necessary to notify the health care provider. However, the nurse should document the amount in the chart and continue to monitor, being aware of sudden increases greater than 100 mL per hour after the first 3 hours, especially if the drainage becomes bright red in color. Stripping the chest tube is not needed in this situation and should only be done according to hospital policy, because it can cause increased intrapleural pressure. Increasing suction in not appropriate or necessary in this situation. Pg. 899, 925-926

A patient is admitted to a hospital with a pneumothorax following a blunt injury to the chest. Which signs and symptoms should the nurse expect to find in this patient? Select all that apply.

*A. Sharp pain in the chest* *B. Difficulty in breathing* C. Oozing from the chest wall D. Excessive expectoration of mucus *E. Pain that increases on inspiration* Rationale: Pneumothorax is the accumulation of air between the parietal and visceral pleura. It causes sharp pain in the chest as atmospheric air irritates the pleura. The pain makes it difficult for the patient to breathe normally. The pain is more on inspiration of air. There is no external wound or oozing. There is no overproduction of mucus in pneumothorax. Pg. 898

Which person is at the lowest risk for developing pulmonary disease?

*A. A person who lives in a rural region* B. A person who smokes C. A person who lives in a smoggy city D. A person who works in a factory where asbestos is present Rationale: Of these people, the person living in a rural area is less exposed to pollution and is therefore at a lesser risk for developing pulmonary disease. Smoking, exposure to pollution and smog, and exposure to a health-hazardous substance like asbestos all increase the risk for pulmonary disease. Pg. 880

While caring for a patient with respiratory disease, the nurse observes that the oxygen saturation drops from 94% to 85% when the patient ambulates. Which is the most appropriate nursing action?

*A. Administer supplemental oxygen.* B. Obtain arterial blood gas (ABG) values to verify the oxygen saturation reading. C. Continue to monitor the patient as this finding is a normal response to activity. D. Move the oximetry probe from the finger to the earlobe for an accurate oxygen saturation measurement during activity. Rationale: Oxygen saturation lower than 90% indicates inadequate oxygenation. If the drop is related to activity of some type, supplemental oxygen is indicated. Arterial blood gas (ABG) measurements will not be helpful. Even though the drop in oxygen saturation is not necessarily a response to activity, the nurse should continue to monitor the patient. Only the earlobe probe should be used to determine the oximetry reading. However, the earlobe is very susceptible to vasoconstriction and may give false readings. Pg. 877

The nurse is assessing the respiratory pattern of a patient. Which statements are true about various patterns of respiration? Select all that apply.

*A. Apnea is the absence of respiration for 15 seconds or longer.* B. Apnea is the increase in rate and depth of respiration. *C. Kussmaul respiration is the increase in rate and depth of respiration.* D. Kussmaul respiration is the body's attempt to compensate for an increase in carbon dioxide levels. *E. Cheyne-Stokes breathing is the period of apnea following a period of deep breathing and then shallow breathing.* Rationale: Apnea is the cessation of breathing for 15 seconds or longer. Kussmaul respiration is the increased rate and depth of breathing due to an acid pH. This respiratory pattern will allow the body to compensate by decreasing carbon dioxide levels. Cheyne-Stokes breathing is characterized by a period of apnea followed by deep breathing and then shallow breathing. This type is generally seen after injury to the brainstem or reduced flow of oxygenated blood to the brainstem. Pg. 884

The nurse is performing a routine physical examination of a patient and observes the patient's breathing patterns. Which factors might the nurse observe? Select all that apply.

*A. Bradypnea is less than 12 breaths per minute.* *B. Tachypnea is greater than 20 breaths per minute.* C. Apnea is the increased number of breaths per minute. *D. Apnea is the absence of respirations for some time.* E. Increased blood flow to the brain causes Cheyne-Stokes respiration. Rationale: At rest the breathing rate for normal adults is 12 to 20 regular breaths per minute. Bradypnea occurs when the respiratory rate decreases below 12 breaths per minute. Tachypnea occurs when the respiratory rate increases above 20 breaths per minute. Apnea is the absence of respiration for a period of time, when the patient will not have any breath sounds. An increase in the number of breaths per minute is called tachypnea. Cheyne-Stokes respiration is caused by decreased blood flow or injury to the brainstem and is characterized by periods of apnea followed by periods of deep breathing, then shallow breathing, followed by more apnea. Study Tip: Reviewing a medical terminology textbook glossary or flashcards would be an excellent check of your memory of Latin and Greek word parts (such as brady-, tachy-, and a-), which would be a big help in answering this question. Pg. 884

Which is a clinical manifestation of hypoxia?

*A. Cyanosis* B. Xanthelasma C. Periorbital edema D. Splinter hemorrhages Rationale: Cyanosis indicates decreased tissue oxygenation or hypoxia. Xanthelasma is an ophthalmic abnormality indicative of hyperlipidemia. Periorbital edema is a clinical manifestation of renal disease. Splinter hemorrhages is a clinical manifestation of bacterial endocarditis. Pg. 884

The nurse is teaching a group of patients about preventing respiratory problems. Which intervention should the nurse include in the teaching?

*A. Discourage the patients from playing with pets.* B. Encourage patients to restrict their activities. C. Limit intake of green leafy vegetables. D. Provide antibiotic therapy while cultures are obtained. Rationale: Pet dander may cause allergic respiratory symptoms in susceptible patients. These patients should avoid contact with pets. Routine exercise is part of a prudent lifestyle. Many green leafy vegetables are rich in vitamins, minerals, and proteins, which incorporate healthy lifestyle patterns into the patients' daily living routines. For patients with respiratory problems, the physical and psychosocial effects of ambulation can enhance feelings of well-being and strength and increase physical endurance. Antibiotic therapy is initiated after cultures are obtained so that sensitivity to the organism can be readily identified. Pg. 883

While caring for a patient who has hypoxia, the nurse finds that the patient's airway clearance is ineffective due to retention of thick pulmonary secretions. Which nursing interventions may be beneficial for the patient? Select all that apply.

*A. Encouraging fluid intake* *B. Teaching cascade cough* C. Administering antipyretic drugs D. Administering intravenous antibiotics E. Placing the patient in a low Fowler's position Rationale: Ineffective airway clearance due to the accumulation of thick pulmonary secretions can be relieved by increasing fluid intake and practicing cascade coughing. Antipyretics and intravenous antibiotics should be administered when the body temperature is imbalanced and if infection exists, but these interventions will not immediately improve airway clearance. Patients who have impaired gas exchange should be kept in a high, not low, Fowler's position. Test-Taking Tip: Be alert for details about what you are being asked to do. In this question type, you are asked to select all options that apply to a given situation or patient. All options likely relate to the situation, but only some of the options may relate directly to the situation. Pg. 889-890

A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104° F (40° C). Which physiological process explains why the child is at risk for developing dyspnea?

*A. Fever increases metabolic demands, requiring increased oxygen need.* B. Blood glucose stores are depleted, and the cells do not have energy to use oxygen. C. Carbon dioxide production increases as a result of hyperventilation. D. Carbon dioxide production decreases as a result of hypoventilation. Rationale: When the body cannot meet the increased oxygenation need, the increased metabolic rate causes the breakdown of protein and wasting of respiratory muscles, increasing the work of breathing. Carbon dioxide production increases due to the increased metabolism stemming from the fever, not as a result of hyperventilation. Pg. 878

Which statement made by the student nurse indicates the need for further teaching about suctioning a patient with an endotracheal tube?

A. "Suctioning the patient requires sterile technique." B. "I'll apply suction while rotating and withdrawing the suction catheter." C. "I'll suction the mouth after I suction the endotracheal tube." *D. "I'll instill 5 mL of normal saline into the tube before hyperoxygenating the patient."* Rationale: Saline has been found to cause more side effects when suctioning and does not increase the amount of secretions removed. All the other selections are correct. Pg. 894-895

A patient with chronic obstructive pulmonary disorder is trying to do diaphragmatic breathing exercises for the first time. The patient is sitting and feels uncomfortable doing the exercise. Which would be the most appropriate response by the nurse?

A. "You need to do diaphragmatic breathing exercises in a standing posture initially." B. "Diaphragmatic breathing exercises are contraindicated for you, so don't do them." C. "You have to tighten your chest muscles while taking deep inspirations in this exercise." *D. "You have to practice these exercises first in the supine position and then in the sitting position."* Rationale: In diaphragmatic exercise, a patient needs to relax the chest muscles during inspiration. The patient needs to practice these exercises first in a posture in which it is easy to do and then move on to difficult postures. Therefore, the patient needs to perform these exercises first in supine, then sitting, and finally in standing positions. The exercises are not performed initially in the standing position. Diaphragmatic breathing exercises are not contraindicated in chronic obstructive pulmonary disease (COPD); they are helpful in promoting lung expansion. During diaphragmatic breathing, the abdominal muscles are tightened up, and not the chest muscles. Study Tip: Practice diaphragmatic breathing by yourself or in your study group to get the hang of it. Lie supine and put your hand below your ribcage, below your diaphragm, and on your abdomen. Make your hand rise up as you inhale. See your hand go back down as you exhale. It takes some concentration at first, but practicing will make it easier for you to teach diaphragmatic breathing! Once you can do it lying supine, try it while sitting and standing and notice the differences. Pg. 905

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of stasis of pulmonary secretions and decreased chest wall expansion?

A. Antibiotics *B. Frequent change of position* C. Oxygen humidification D. Chest physiotherapy Rationale: Movement not only mobilizes secretions but helps strengthen respiratory muscles by impacting the effectiveness of gas exchange processes. Antibiotics and oxygen humidification do not help mobilize secretions. Chest physiotherapy can help mobilize pulmonary secretions but does not directly help with chest wall expansion. Pg. 896

During assessment a patient states, "It's hard for me to breathe and I feel short-winded all the time." Which is the most appropriate terminology for the nurse to use when documenting this assessment?

A. Apnea B. Dyspnea C. Tachypnea *D. Respiratory fatigue* Rationale: Dyspnea is a subjective description reflective of the patient's statement indicating difficulty in breathing. Apnea refers to absence of breathing. Tachypnea refers to an increased rate of breathing, usually greater than 20 breaths per minute. Respiratory fatigue is a subjective description. It usually refers to the patient exhibiting signs and symptoms associated with a comprehensive respiratory assessment. The respiratory assessment includes laborious breathing, use of accessory muscles, and slowing of respirations. Study Tip: Be sure to review medical terminology, so that you recall the meanings of the Latin and Greek word parts, such as dys-, which means difficult, and - pnea, which means breathing. Pg. 881

Which diagnostic test provides instant feedback about a patient's oxygenation status?

A. Capnography B. Bronchoscopy C. Thoracentesis *D. Pulse oximetry* Rationale: Pulse oximetry is a diagnostic test provides instant feedback about a patient's oxygenation level. Capnography is a diagnostic test that provides instant information about the patient's ventilation and perfusion. Bronchoscopy allows for visual examination of the tracheobronchial tree. Thoracentesis is a surgical procedure done on the chest wall and pleural space to take a biopsy specimen. Pg. 880

Which age-related changes in the older adult may result in decreased tissue oxygenation due to impaired chest expansion? Select all that apply.

A. Change in cough mechanism B. Impairment of the immune system *C. Ossification of costal cartilage* *D. Decreased intervertebral space* *E. Diminished respiratory muscle strength* Rationale: Ossification of costal cartilage, decreased intervertebral space, and diminished respiratory strength will all impair chest expansion, which leads to decreased tissue oxygenation. A change in the cough mechanism may lead to atelectasis, due to retained pulmonary secretions. An impaired immune system can cause respiratory infections but won't impair chest expansion. Pg. 879

A patient is admitted with severe lobar pneumonia. Which assessment findings would indicate that the patient needs airway suctioning?

A. Coughing up thick sputum only occasionally B. Coughing up thin, watery sputum easily after nebulization *C. Decreased independent ability to cough* D. Lung sounds clear only after coughing Rationale: Impaired ability to cough up mucus caused by weakness or very thick secretions indicates a need for suctioning when the patient has pneumonia. The other choices indicate that the patient has the ability to cough. Test-Taking Tip: Be alert for similarities in choices. All incorrect choices suggest that the patient is coughing so would not need help with suctioning. Pg. 890-891

A patient reports having shortness of breath for 2 months. The nurse asks the patient to rate the shortness of breath on a scale of 0 to 10 and state whether it is affecting daily activities. The nurse also asks about exposure to passive smoking and whether the patient feels comfortable when sleeping in a reclining chair. Which question asked by the nurse is about orthopnea?

A. Exposure of patient to passive smoking B. Shortness of breath affecting daily activities C. Rating the shortness of breath on a scale of 0 to 10 *D. Feeling of comfort when sleeping in a reclining chair* Rationale: Orthopnea occurs when the patient feels short of breath while sleeping, but comfortable when sleeping in a reclining chair. In a reclined position, the patient may also use multiple pillows to facilitate breathing. Orthopnea is quantified based on the number of pillows used. The question about exposure to passive smoking gives information about the predisposing factors to the complaints. The question about symptoms affecting daily activities indicates the severity of the symptoms. The question to rate dyspnea gives information about severity of the complaints. Study Tip: Remember that ortho- means straight, as in orthodontics, the branch of dentistry that straightens teeth. In orthopnea (- pnea means breathing), a patient can breathe more easily sitting up (straight) than lying down. Pg. 882

An elderly patient has had a dry cough in the mornings for several weeks, which is aggravated when lying down flat. On examination, the patient's mucous membranes and skin are dry. On auscultation, there are crackles in the lower lobes bilaterally. Occasionally, the patient coughs up thick, yellow-green sputum in small quantities. What is the most appropriate nursing diagnosis?

A. Geriatric health problems *B. Impaired airway clearance* C. Risk for tuberculosis infection D. Risk for pulmonary aspiration Rationale: A chronic dry cough in the morning, along with dehydration and bilateral respiratory crackles, indicates impaired airway clearance of secretion. Geriatric health problems are not an appropriate diagnosis, because presence of crackles is not an age-related change. The patient's history is not suggestive of tuberculosis, so the risk for tuberculosis is an unlikely diagnosis. The patient is not debilitated to be at risk of aspiration. Thus, risk for pulmonary aspiration is not an appropriate diagnosis. Pg. 886, 889, 891

A patient reports having chronic dry cough in the mornings, with occasional production of thick, yellow-green sputum in small quantities. The nurse finds that the patient has dry skin and the mucous membranes are dry. On auscultation, crackles are heard in lower lobes bilaterally. Which intervention will relieve dryness of the mucous membranes?

A. Giving a nebulizer treatment *B. Giving plenty of oral fluids* C. Administering 2 L/min of oxygen D. Instilling normal saline into airways Rationale: A patient with chronic dry cough should be given plenty of oral fluids. Fluids help moisten the secretions and promote secretion removal. Adequate hydration helps treat dryness of oral mucosa and skin dryness. A nebulizer treatment maintains open airways but does not help in the treatment of dryness. Oxygen therapy treats dyspnea associated with exercise or hypoxemia. The evidence supporting the use of normal saline instillation in improving secretion removal is inconclusive. Test-Taking Tip: Make certain that the answer you select is reasonable and obtainable under ordinary circumstances and that the action can be carried out in the given situation. Pg. 889

A patient with chronic obstructive pulmonary disorder (COPD) is administered oxygen therapy using a simple oxygen face mask. After some time, the patient's blood analysis reveals abnormally high levels of carbon dioxide. Which should be the nurse's immediate next step?

A. Remove the mask and apply a new oxygen mask. B. Reset the mask to cover the patient's nose only. *C. Remove the mask and use a nasal cannula for oxygen supply.* D. Reset the mask to cover the patient's mouth and nose. Rationale: Simple face masks are designed to deliver 6 L/min or more of oxygen. However, in patients with chronic obstructive pulmonary disorder (COPD), this results in hypoventilation. These patients have adapted to a high level of carbon dioxide so their carbon dioxide-sensitive chemoreceptors are essentially not functioning. Because the stimulus to breathe is a decreased arterial oxygen level, administration of oxygen greater than 1 to 3 L/min prevents the PaO 2 from falling to a level that stimulates the peripheral receptors. This destroys the stimulus to breathe. The resulting hypoventilation causes excessive retention of carbon dioxide. Additionally, the patient may inhale exhaled carbon dioxide retained in the mask. Therefore, masks are contraindicated in patients with COPD. However, a nasal cannula does not cause rebreathing of exhaled carbon dioxide and allows for safe delivery of lower rates of oxygen. Hence, the nurse should immediately remove the mask and use a nasal cannula for oxygen supply. Applying a new mask or resetting the mask will not improve the patient's condition. Pg. 887, 902, 906

A patient who has a history of chronic obstructive pulmonary disease (COPD) and diabetes mellitus develops hypoventilation. What does the nurse suspect is the cause of the hypoventilation?

A. Salicylate poisoning B. Diabetic ketoacidosis C. Amphetamine overdose *D. Overdose of oxygen therapy* Rationale: Patients who have chronic obstructive pulmonary disease (COPD) will be treated with oxygen therapy, and an overdose of this may result in hypoventilation. Salicylate overdose, diabetic ketoacidosis, and amphetamine overdose may result in hyperventilation, not hypoventilation. Pg. 877

A patient is admitted with the diagnosis of severe left-sided heart failure. The nurse expects to auscultate which adventitious lung sounds?

A. Sonorous wheezes in the left lower lung B. Rhonchi midsternum C. Crackles only in apex of lungs *D. Inspiratory crackles in lung bases* Rationale: Decreased effective contraction of the left side causes fluid to back up in the lungs, increasing hydrostatic pressure and causing pulmonary edema, resulting in crackles in lung bases, not in the apex of the lungs or midsternum. Lungs would be affected bilaterally so sonorous wheezes in the left lower lung are not a likely diagnostic finding with left-sided heart failure. Pg. 878

Why would a primary health care provider ask the nurse to perform pulse oximetry on a patient who is cyanotic?

A. To assess ventilation *B. To assess oxygenation level* C. To obtain a biopsy specimen D. To visualize the tracheobronchial tree Rationale: Pulse oximetry is a diagnostic test done to obtain the patient's oxygenation level. If the provider wanted to assess the patient's ventilation, the nurse would perform capnography. To obtain a specimen for biopsy, the patient would undergo a thoracentesis. To visualize the tracheobronchial tree, the health care team would perform a bronchoscopy. Pg. 880

During assessment, which finding indicates the presence of pneumothorax?

A. Tracheal deviation toward the affected side B. Inability to auscultate tracheal breath sounds *C. Pleuritic pain that worsens on inspiration* D. Pursed-lip breathing Rationale: Pneumothorax is caused by a rapid accumulation of air in the pleural space, causing severely high intrapleural pressure. Patients will report sudden onset of sharp pleuritic pain that worsens with inspiration, because the atmospheric air irritates the pleura. The trachea will deviate toward the unaffected side (the side with lower intrapleural pressure). Inability to auscultate tracheal breath sounds and pursed-lip breathing are associated with chronic lung diseases, not pneumothorax, and are related to the development of an increased anterior-posterior diameter (barrel chest) associated with diseases such as COPD. Pg. 898