N2 CH.40 Oxy/perfussion
A client is diagnosed with hypoxia related to emphysema. The client's adult child will be assisting the client with daily hygiene. How will the nurse explain positioning of the client to the caregiver? "Place your parent at the sink to allow teeth brushing and stand outside of the shower to help if needed." "Whichever position helps your parent feel most comfortable and will allow you to help with hygiene is fine." "A standing position works best to allow your parent to move around in the bathroom and to allow you to help your parent in and out of the shower." "An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist."
"An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist." The best way to explain caregiving is to describe the specific position and type of chair to use as well as teach the caregiver why it is the best position and device. Teaching the caregiver to place the parent at the sink and then stand outside the shower does not provide the best position nor the device to obtain, plus it does not address the facts that the parent standing in the shower may not be possible due to hypoxia and is not safe. Teaching the caregiver to use whichever position is most comfortable for the parent does not address the safest position for the client nor the position that provides easiest breathing and energy conservation. Standing for the period of time it may take to complete daily hygiene is not feasible or safe for the client and should not be recommended by the nurse.
The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client? "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." "Breathing through your nose first will warm, filter, and humidify the air you are breathing." "If you breathe through the mouth first, you will swallow germs into your stomach." "We are concerned about you developing a snoring habit, so we encourage nasal breathing first."
"Breathing through your nose first will warm, filter, and humidify the air you are breathing." Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring.
A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is: "He will require additional testing to determine the cause." "He is using his chest muscles to help him breathe." "His infection is causing him to breathe harder." "His lung muscles are swollen so he is using abdominal muscles."
"He is using his chest muscles to help him breathe." The client will use accessory muscles to ease dyspnea and improve breathing.
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." "I will secure my tank by placing it flush against the wall." "I will adjust the oxygen flow according to my needs." "I will only use an electrical instead of gas stove."
"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." Oxygen is combustible, so keep it away from smoking or direct sunlight. It is important to allow adequate airflow around the oxygen concentrator, so it should not be placed flush against the wall. It's more important to follow the prescription than to adjust the oxygen flow rate because too much or too little oxygen may be detrimental to the client. The client must use caution with both gas and electric stoves.
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?" "Is your mask causing discomfort?" "Did someone take your mask off?" "Did someone loosen the straps on your mask?"
"Is your mask causing discomfort?" 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.
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 collects and concentrates oxygen from room air." "It eliminates the need for a central reservoir of piped oxygen." "You may notice an increase in your electric bill." "It costs less than oxygen supplied in portable tanks." "This is only an option if you live in a long-term care facility."
"It collects and concentrates oxygen from room air." "It eliminates the need for a central reservoir of piped oxygen." "You may notice an increase in your electric bill." "It costs less than oxygen supplied in portable tanks." An oxygen concentrator collects and concentrates oxygen from room air. It eliminates the need for a central reservoir of pipe oxygen and it is an economical choice. It may increase the client's electric bill. These can be used in homes, not long-term care facilities.
The nurse determines that the student who has been instructed about lung function and smoking requires additional teaching when the student says "A physically fit athlete breathes more slowly than a sedentary person." "Smoking only once in a while will not make a person addicted to smoking." "An older person may breathe more shallowly than a younger person." "An upright position will help someone breathe with less effort."
"Smoking only once in a while will not make a person addicted to smoking."
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 little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." "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."
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? "An occasional cigarette will not hurt you." "You should never smoke when oxygen is in use." "I understand; I used to be a smoker also." "Oxygen is a flammable gas."
"You should never smoke when oxygen is in use." The nurse will educate the client about the dangers of smoking when oxygen is in use. Oxygen is not flammable, but it oxidizes other materials. Other answers are inappropriate.
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 client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention? Ask the client what factors contribute to nonadherence. Contact the health care provider to report the client's current status. Explain the use of a BiPAP mask instead of a CPAP mask. Document outcomes of modifications in care.
Ask the client what factors contribute to nonadherence. The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment. Then, the nurse can work with the health care provider to find alternate treatment options if necessary, and then document the care.
The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which instruction will the nurse include in the teaching? Inhale through the nose instead of the mouth. Be sure to shake the canister before using it. Inhale the medication rapidly. Inhale two sprays with one breath for faster action.
Be sure to shake the canister before using it. A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly. MDIs are inhaled through the mouth and into the lungs. The medication should be inhaled slowly to ensure a sufficient dose enters the lungs. If the order is for two sprays, these sprays are administered with one spray for each breath. The inhaled breath should be held briefly after each spray in order to prevent the client from immediately exhaling the medication.
A nurse is volunteering at a day camp where a child is stung by a bee and develops wheezing in the upper airways. The nurse will provide interventions to address what health problem? Bronchospasm Bronchitis Bronchiectasis Bronchiolitis
Bronchospasm 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. Bronchitis and bronchiectasis are chronic respiratory effects and bronchiolitis is infectious.
The nurse is assessing a client with lung cancer who has been receiving treatment for many months. What manifestations may suggest that the client has chronic hypoxia? Edema Hemoptysis Yellow or green sputum Clubbing
Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many clients with chronic hypoxia due to respiratory or cardiac disease. Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD. Hemoptysis, edema, and discolored sputum do not result from hypoxia.
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? Page the respiratory therapist STAT. Maintain the client's oxygenation and alert the health care provider immediately. Cover the tracheostomy stoma and apply oxygen by nasal cannula Assess the client's respiratory status and check vital signs every 1 minute for the next hour.
Cover the tracheostomy stoma and apply oxygen by nasal cannula 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.
The client demonstrates soft, high-pitched, discontinuous sounds in the left lower lobe of the lung. How will the nurse accurately document this finding? Crackles Vesicular Wheezes Bronchial
Crackles Crackles are soft, high-pitched, discontinuous sounds. Wheezes are a whistling or rattling sound in the chest as a result of obstruction in the air passages. Vesicular breath sounds are heard across the lung surface. Bronchial sounds are loud, high-pitched sounds heard primarily over the trachea and larynx.
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse will document what breath sounds? Crackles Vesicular Wheezes Bronchovesicular
Crackles Crackles, frequently heard on inspiration, are soft, high-pitched discontinuous (intermittent) popping sounds. Wheezes are continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors. Vesicular sounds are low-pitched, soft sounds heard over peripheral lung fields. Bronchovesicular sounds are medium-pitched blowing sounds heard over the major bronchi.
The nurse is caring for a client with emphysema. When teaching the client pursed-lip breathing, the nurse will include which instruction(s)? Select all that apply. Inhale slowly through the nose for a count of three. Keep abdominal muscles in a relaxed state. Shape the lips as if you were about to blow a whistle. Over time, begin to increase the length of the exhale. Exhale slowly through pursed lips. Ensure that the exhale lasts twice as long as the inhale.
Inhale slowly through the nose for a count of three. Shape the lips as if you were about to blow a whistle. Over time, begin to increase the length of the exhale. Exhale slowly through pursed lips. Ensure that the exhale lasts twice as long as the inhale. Pursed-lip breathing is a form of controlled ventilation in which the client consciously prolongs the expiration phase of breathing. This is another technique for improving gas exchange, which helps clients eliminate more than the usual amount of carbon dioxide from the lungs when done correctly. Pursed-lip breathing and diaphragmatic breathing are especially helpful for clients who have chronic obstructive pulmonary disorders (COPD), such as emphysema. The key with this intervention is to encourage the client to slow down breathing to allow for the development of increased lung capacity over time to ease the work of breathing. The longer exhale supports the removal of carbon dioxide, which can lead to impaired cognition for individuals with this disease. The nurse will teach the client to contract the abdominal muscles during pursed-lip breathing as this aids in longer exhalations. Keeping the abdominal wall relaxed will limit the effectiveness of this intervention.
A nurse on a cardiac care unit oversees the care of diverse clients' cardiac health problems. Which action can be most appropriately delegated to a licensed practical nurse (LPN)? Application of a client's cardiac monitor Initiation of manual external defibrillation Initiation of CPR for a client who is found unresponsive Collecting an arterial blood sample
Initiation of CPR for a client who is found unresponsive The initiation and provision of cardiopulmonary resuscitation is appropriate for all health care providers. Depending on the state's nurse practice act and the organization's policies and procedures, an LPN may or may not be able to perform the other listed actions.
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? Place the client in the dorsal recumbent position to collect the specimen. Have the client clear the nose and throat and gargle with salt water before beginning the procedure. Instruct the client to inhale deeply and then cough. Discard the first sputum produced by the client.
Instruct the client to inhale deeply and then cough. 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.
The nurse is caring for a client who is wearing oxygen via nasal cannula. The client asks about the bubbling water attached to the oxygen. Which response by the nurse is appropriate? It prescribes oxygen concentration. It regulates the amount of oxygen received. It determines whether you are getting enough oxygen. It decreases dry mucous membranes by delivering small water droplets.
It decreases dry mucous membranes by 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 flow meter is a gauge used to regulate the amount of oxygen that a client receives. The health care provider prescribes concentration.
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? It prescribes oxygen concentration. It regulates the amount of oxygen received. It determines whether the client is getting enough oxygen. It decreases dry mucous membranes via delivering small water droplets.
It determines whether the client is getting enough oxygen. 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 parents brings their 2-year-old to the emergency department in respiratory distress. The child's oxygen saturation is 81% and there is audible stridor. What intervention will the nurse anticipate? Deep breating and coughing exercises Corticosteroids by metered-dose inhaler Chest physiotherapy Placement in an oxygen tent
Placement in an oxygen tent Stridor often accompanies croup in young children. Due to the child's age, an oxygen tent would be an appropriate oxygen delivery device. The child is too young for metered-dose inhalers or deep breathing and coughing exercises.
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.
When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing Anemia Malnutrition Poor tissue perfusion Congestive heart failure
Poor tissue perfusion Chronically poor perfusion may result in hair loss in the affected area, discolored skin, thickened nails, and shiny, dry skin indicative of inadequate tissue nutrition.
The health care provider has prescribed an oropharyngeal airway for a client with a decreased level of consciousness. The health care provider has noted gurgling respirations and the client's tongue is in the posterior pharynx. The client vomits as the airway is inserted. Which actions should the nurse take? Select all that apply. Position client onto the side immediately. Remove oropharyngeal airway. Provide oral suctioning and mouth care. Raise the head of the bed to 90 degrees. Assess for bleeding in the mouth.
Position client onto the side immediately. Remove oropharyngeal airway. Provide oral suctioning and mouth care. The nurse should quickly position client into a lateral position to prevent aspiration, remove the oropharyngeal airway, and then suction or provide oral hygiene as needed. Raising the head of bed to 90 degrees is unnecessary, because the client should be positioned on one side. There is no indication that trauma to the mouth has occurred, so the nurse would not need to assess for bleeding.
The nurse is caring for an older adult homebound client with advanced respiratory disease whose has inadequate nutrition. What recommendation will the nurse provide? Increase use of dietary supplements Provide suggestions of high-protein, high-calorie meals Replace meals with protein shakes Practice intermittent fasting to promote appetite
Provide suggestions of high-protein, high-calorie meals The client should have sufficient caloric and protein intake for respiratory muscle strength, so promotion of a high-calorie, high-protein diet is appropriate. Protein shakes and dietary supplements may be appropriate but should complement, rather than replace, meals. Intermittent fasting promotes weight loss, not increased calorie intake.
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? 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. 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. 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.
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.
The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care? Stay indoors as much as possible. Cut down on smoking. Avoid exposure to large crowds. Practice good hand hygiene
Stay indoors as much as possible. Using the air quality index, a red color designation signifies that the air quality is unhealthy for all people, not just sensitive groups. Air pollution and high humidity are respiratory irritants. Pollutants cause increased mucus production and contribute to bronchitis and asthma. Reducing contact with irritants by staying indoors during times of increased air pollution will decrease their effect on the respiratory system. Clients should be encouraged to quit smoking, not just cut down. Avoiding large crowds and practicing good hand hygiene will prevent respiratory infections but not cut down on the effect of air pollution.
The nurse educator would intervene with client teaching if which action by the staff nurse occurs when teaching voluntary coughing? The nurse has the client lying in bed in semi-Fowler's position. The nurse develops a specific schedule for coughing. The nurse encourages the client to cough before meals. The nurse reminds the client to combine coughing and deep breathing.
The nurse has the client lying in bed in semi-Fowler's position. The client should be sitting upright with feet flat on the floor to be most effective. As part of the client's plan of care, the nurse should develop a specific schedule for coughing. Coughing before meals improves the taste of food and oxygenation. When combined with deep breathing, coughing is most effective.
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 loud, high-pitched sounds heard primarily over the trachea and larynx. 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 low-pitched, soft sounds heard over peripheral lung fields.
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 client's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.
A nurse has received an order to suction an adult client's endotracheal tube. Which action is most appropriate when performing this intervention? Assist the client into a supine position in preparation for suctioning. Set the wall suction to a maximum of 80 mm Hg. Put on sterile gloves in preparation for setting up the equipment field. Use sterile saline to moisten the end of the suction catheter.
Use sterile saline to moisten the end of the suction catheter. Upright positioning best facilitates safe and effective suctioning. The wall unit should be set between 100 and 150 mm Hg for an adult, and sterile gloves are donned after the field is established.
During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting? Crackles Bronchovesicular Bronchial Vesicular
Vesicular
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.
The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document? Stridor Crackles Wheezing Absent breath sounds in lower lobes
Wheezing The nurse expects to document wheezing in the lungs of a client with asthma, which would be more pronounced when the client has a respiratory infection. Wheezing is a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration. Wheezing is caused by air passing through constricted passages caused by swelling or secretions. Stridor and crackles are other abnormal breath sounds caused by fluid, infection, or inflammation in the lungs. Absent breath sounds are not normally found in asthmatic clients; they are characteristic of pneumonia.
The nurse is caring for the following clients. Which client is at highest risk for a depressed respiratory system? a client taking amlodipine for hypertension a client taking methocarbamol for low back spasms a client taking methimazole for hyperthyroidism a client taking an opioid for cancer pain
a client taking an opioid 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 decreases blood pressure, so the nurse would need to assess blood pressure. Muscle relaxants such as methocarbamol could depress respiratory status, but this occurs less often than with opioids. Methimazole is used to treat hyperthyroidism, thus lowering the body's metabolic functions, which can depress respirations; however, this is a very rare occurrence with this medication. The client at highest risk is the one taking an opioid.
What is the most important risk factor in pulmonary disease? air pollution from vehicles dangerous chemicals in the workplace active and passive cigarette smoke loss of the ozone layer of the atmosphere
active and passive cigarette smoke Cigarette smoking (active or passive) is a major contributor to lung disease and respiratory distress, heart disease, and lung cancer. Cigarette smoking is the most important risk factor for chronic COPD, according to the National Heart, Lung, and Blood Institute. The effects of both active and passive cigarette smoke increase airway resistance, reduce ciliary action, increase mucus production, and thicken alveolar-capillary membranes and bronchial walls. While air pollution, ozone layer, and dangerous chemicals in the workplace seem important, they are less of a major contributor to smoking and the direct action to the lungs.
A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate: adequate tissue perfusion. diminished stroke volume. high cardiac output. heart failure.
adequate tissue perfusion. Pulse oximetry is often used as a measure of tissue perfusion. An oxygen saturation of greater than 94% is typically indicative of good tissue perfusion.
What assessments would a nurse make when auscultating the lungs? air flow through the respiratory passages abnormal chest structures presence of edema volume of air exhaled or inhaled
air flow through the respiratory passages Auscultation of the lungs assesses air flow through the respiratory passages and lungs. The nurse listens for normal, as well as abnormal, breath sounds. Abnormal chest structures would be assessed when inspecting the chest and thoracic region. Presence of edema would be assessed as part of the cardiovascular status of the client. Volume of air exhaled and inhaled would be performed during a pulmonary function test.
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? a. Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. b. 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. c. 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. d. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.
b. 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 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? tap water normal saline distilled water mineral oil
distilled water Distilled water is used when humidification is desired. Other answers are incorrect.
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? oxygen analyzer nasal strip nasal cannula flow meter
flow meter 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 health care provider. 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.
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? oxygen analyzer nasal strip nasal cannula flow meter
flow meter 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 health care provider. 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 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? high temperature high respiratory rate low pulse rate low blood pressure
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.
A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client? simple mask nasal cannula face tent nonrebreather mask
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 half-inch prongs placed into the 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. Nonrebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.
The nurse is assessing a client's chest tube which was inserted 48 hours earlier. The nurse notes crackling in the skin around the insertion site. Which action should the nurse prioritize? notify the health care provider apply a new dressing over the tube reinforce adhesive material over insertion site document finding
notify the health care provider The health care provider should be notified as feeling or hearing air crackling can indicate a subcutaneous air leak and an internal displacement of the drainage tube. This requires emergent care to prevent the recurrence or further damage to the lung. Applying a new dressing or more tape would be inappropriate. The nurse would document after providing the client care.
