NU 231 Chapter 39: Oxygenation and Perfusion - prep
Older Adult (65+)
16-24 breaths/min Thoratic regular Clear sounds
Holter moniter test
24-hour ECG tracing taken with a small, portable recording system
The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia? Hemoptysis Clubbing Edema Diarrhea
Clubbing
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 determines whether you are getting enough oxygen. It regulates the amount of oxygen received. It decreases dry mucous membranes by delivering small water droplets.
It decreases dry mucous membranes by delivering small water droplets.
Angina
Pain in the heart region caused by lack of oxygen
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? Use a blood pressure cuff to increase circulation to the site. Place the probe on the client's earlobe. Shine available light on the equipment to facilitate accurate reading. Warm the client's hands and try again.
Warm the client's hands and try again.
Question 10 of 20 A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing: bronchiolitis. a bronchospasm. bronchitis. bronchiectasis.
a bronchospasm.
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: diminished stroke volume. adequate tissue perfusion. heart failure. high cardiac output.
adequate tissue perfusion
Force Vital Capacity (FVC)
amount of air that can be exhaled with force after full inspiration
cytology study
assess for cancer
cardiac biomarkers
chemicals are measured in the blood as evidence of a heart attack
atelectasis
collapse of alveoli
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: myocardial infarction. congestive heart failure. lung cancer. pulmonary embolism.
congestive heart failure.
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: bronchovesicular. crackles. wheezes. vesicular.
crackles.
dysrhythmiami
disturbance of the rhythm of the heart
internal respiration
exchange of gases between blood and tissue cells
pulmonary ventilation
movement of air into and out of the lungs
sinoatrial (SA) node
pacemaker of the heart causing contractions of the atrium
Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? Contact the physician for nutrition shake. Eat one large meal at noon. Snack on high-carbohydrate foods frequently. Eat smaller meals that are high in protein.
Eat smaller meals that are high in protein.
Perfusion
The supply of oxygen to and removal of wastes from the cells and tissues of the body as a result of the flow of blood through the capillaries.
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 Absent breath sounds in lower lobes Wheezing
Wheezing
heart failure
a chronic condition in which the heart is unable to pump out all of the blood that it receives
The nurse is caring for the following clients. Which client is at highest risk for a depressed respiratory system? a client taking methimazole for hyperthyroidism a client taking methocarbamol for low back spasms a client taking amlodipine for hypertension a client taking an opioid for cancer pain
a client taking an opioid for cancer pain
lung scan/radiography
assessors ofor anomalies or masses in lungs
A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? a) Instruct assistant to notify the primary care provider. b) Assess the patient's vital signs. c) Remove the tape, adjust the depth to ordered depth and reapply the tape. d) No action is required as depth will adjust automatically.
c) Remove the tape, adjust the depth to ordered depth and reapply the tape.
What assessment would the nurse make prior to usung a pulse oximeter
capillary refill
arterial blood gases
clinical test on arterial blood to identify the levels of oxygen and carbon dioxide in the blood
Respiration
involves gas exchange between atmospheric air in the alveoli and blood in the capillaries
The nurse is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly? reads 0.19 when positioned near oxygen device reads 0.21 when checking oxygen in room air reads 0.25 when checking oxygen in room air reads 0.20 when positioned near oxygen device
reads 0.21 when checking oxygen in room air
the nurse is turning on the pulse oximeter and notices a bar form what does that indicate?
signal strength
total lung capacity
the amount of air contained within the lungs at maximal inspiration
Hyperventilation
the condition of taking abnormally fast, deep breaths - lowered levels of co2
vital capacity
the maximum amount of air that can be exhaled after a maximum inhalation
echocardiogram
ultrasound of a heart and lung
the nurse is checking a client's oxygen saturation level using a pulse oximeter. How should the probe be placed on the finger?
with the light emitting sensor and light receiving sensor opposite each other
the nurse has finished suctioning the airways of a client with bronchial pneumonia. What would the nurse do first when disposing of the catheter and supplies?
wrap the catheter around a gloved hand and remove gloves
late childhood respiratory rate 6-12
18-26 breaths/min Thoracic breathing regular Clear inspiration is longer than expiration
infant respiratory rate
20-40 breaths/min Abdominal breathing irregular in rate and depth Loud harsh crackle at the end ofdeep inspiration
early childhood respiratory rate 1-5
25-32 breaths per minute Abdominal breathing irregular Loud harsh expiration longer than inspiration
A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from: pulmonary fibrosis. atelectasis. croup. asthma.
croup.
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? 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. Place the client in the dorsal recumbent position to collect the specimen. Discard the first sputum produced by the client.
Instruct the client to inhale deeply and then cough. Explanation: 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. Reference:
A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs? Nonrebreather mask Partial rebreather mask Nasal cannula Simple mask
Nasal cannula Explanation: A nasal cannula is used to deliver from 1 L/min to 6 L/min of oxygen. Masks are used with higher flow rates of oxygen.
A nurse has received an order to suction an adult client's endotracheal tube. Which action is most appropriate when performing this intervention? Put on sterile gloves in preparation for setting up the equipment field. Use sterile saline to moisten the end of the suction catheter. Assist the client into a supine position in preparation for suctioning. Set the wall suction to a maximum of 80 mm Hg.
Use sterile saline to moisten the end of the suction catheter. Explanation: 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.
the nurse is setting up equipment needed to deliver to a postsurgical client via nasal cannula. After connecting the nasal cannula to the oxygen source and flow meter what is the next action the nurse should perform
adjust the flow rate to the prescribed amount (before attached to patient )
Question 2 of 20 The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as: dyspnea. hypercapnia. orthopnea. apnea.
apnea.
CBC (complete blood count)
check for anemia
A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet?: a. The patient vomits during suctioning b. The secretions appear to be stomach contents c. The catheter touches an unsterile surface d. A nosebleed is noted with continual suctioning
d. When nosebleed epitaxis is noted - nurse should contact the physician and anticipate the use of a nasal trumpet
What action does the nurse perform to follow safe techniques when using a portable oxygen cylinder? A. Checking the amount of oxygen in the cylinder before using it B. Using a cylinder for a patient transfer that indicates available oxygen is 500 psi C. Placing the oxygen cylinder on the stretcher next to the patient D. Discontinuing oxygen flow by turning the cylinder key counterclockwise until tight
a. The cylinder must always be checked before use! It is unsafe to use a cylinder that says 500 psi or less because not enough oxygen is left for transfer A cylinder that is not secured properly can injure a patient. Oxygen gliw is discontinued by turning the valve clockwise (righty tighty)
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? "Is your mask causing discomfort?" "Did someone loosen the straps on your mask?" "Did you remove your dentures?" "Did someone take your mask off?"
"Is your mask causing discomfort?"
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 low-pitched, soft sounds heard over peripheral lung fields. They are soft, high-pitched discontinuous (intermittent) popping lung sounds. They are medium-pitched blowing sounds heard over the major bronchi. They are loud, high-pitched sounds heard primarily over the trachea and lary
They are low-pitched, soft sounds heard over peripheral lung fields. Explanation: Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds. Reference:
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 respiratory rate low pulse rate high temperature low blood pressure
high respiratory rate Explanation: 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 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: "His lung muscles are swollen so he is using abdominal muscles." "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."
"He is using his chest muscles to help him breathe."
a nurse is caring for a client receiving 2 mL of oxygen via nasal cannula. Nurse notes reddened areas at the top of ears and neck - check all the actions a nurse should take
-apply padding to the tubing over the ears an lossen neck tubing -Loosen the nasal cannula tubing to insure its not too toght -Request a consult with a skincare team
atrioventricular (AV) node
A small mass of specialized cardiac muscle fibers, located in the bottom wall of the right atrium of the heart, that receives heartbeat impulses from the sinoatrial node and directs them to the walls of the ventricles.
residual volume
Amount of air remaining in the lungs after a forced exhalation
A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a. Refrain from exercise. b. Reduce anxiety. c. Eat meals 1 to 2 hours prior to breathing treatments. d. Eat a high-protein/high-calorie diet. e. Maintain a high-Fowler's position when possible. f. Drink 2 to 3 pints of clear fluids daily.
B, d,e Reduce anxiety, eat a high protein/high-calorie meal, and maintain a high fowlers position when possible.
A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What is the first action that should be taken by the nurse in this situation? A. Notify the healthcare provider B. Apply an occlusive dressing on the site C. Assess the patient for signs of respiratory distress D. put on sterile gloves and insert the chest tube in a bottle of sterile water
D. Nurse must create a water seal to allow air to escape - do not clamp chest tube
A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action? Raise the head of the client's bed slightly, if tolerated. Document this expected assessment finding. Review the medications that the client has taken in the past 90 minutes. Encourage the client to do deep-breathing exercises.
Document this expected assessment finding. Explanation: A range of 95% to 100% is considered normal oxygen saturation. As such, there is no need to change the client's position, encourage deep-breathing exercises and coughing, or to review the client's medication history.
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. Discard the first sputum produced by the client. Instruct the client to inhale deeply and then cough. 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.
A nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant? Nasal cannula Venturi mask Simple mask Oxygen hood
Oxygen hood
Forced Expiratory Volume (FEV)
amount of gas expelled during specific time intervals of FVC
spirometer
an instrument used to measure respiratory volumes and airflow
An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? a. Tilt the patient's head forward. b. Hold the mask tightly over the patient's nose and mouth. c. Pull the patient's jaw backward. d. Compress the bag twice the normal respiratory rate for the patient.
b. Hold mask tightly tover patients nose and mouth
the nurse is inserting a nasal cannula into the client's nostrils to improve oxygenation. To correctly insert the curved prongs of the cannula what would the nurse do?
follow the angle of the nose with the prongs pointing downward
The nurse has finished suctioning the airways of a client with cystic fibrosis,what ppe would the nurse remove first?
gloves
The external diameter of the suctioning catheter should not exceed
half of the internal diameter of the endotracheal tube to avoid trauma and hypoxemia
A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client? spirometry thoracentesis peak expiratory flow rate pulse oximetry
pulse oximetry
A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing might the nurse use to measure the patient's oxygen saturation? A. Thoracentesis B. Pulse oximetry C. Diffusion capacity D. Maximal respiratory pressure
pulse oximetry
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? "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 small amount of air very quickly and then exhale as quickly as possible." "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly."
"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Explanation: Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.
tidal volume
Amount of air that moves in and out of the lungs during a normal breath
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 the medication rapidly. Be sure to shake the canister before using it. Inhale two sprays with one breath for faster action. Inhale through the nose instead of the mouth.
Be sure to shake the canister before using it. Explanation: 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 assisting a respiratory therapist with chest physiotherapy for patients with ineffective coughs. For which patient might this therapy be recommended? A. A postoperative adult B. An adult with COPD C. A teenager with cystic fibrosis D. A child with pneumonia
C. A teenager with cystic fibrosis Not recommended for other populations
A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? A. The nurse assures the oxygen is flowing into the prongs B. The nurse adjusts the fit of the cannula so it fits snugly and tight against the skin. C. The nurse encourages the patient to breathe through the nose with the mouth closed. D. The nurse adjusts the flow rate to 6.1 L/m or more
C. Note : also Cannula should be snug but not tight .
The nurse is caring for a client receiving oxygen at 8 mL via face mask. While monitoring the client for skin irritation, what is the best action by the nurse?
Remove the mask and dry the skin every 2 to 3 hours
Peak Expiratory Flow Rate (PEFR)
The maximum flow attained during the FVC
a nurse is suctioning a client's airway with a nasopharyngeal catheter. During the suctioning, the client is gagging and seems likely to vomit. What should the nurse do?
Turn the client to the side and elevate the head to prevent aspiration Remove the catheter to avoid entering the esophagus inadvertently.
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? Bronchovesicular Vesicular Bronchial Crackles
Vesicular Explanation: Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx. Reference:
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: vesicular. bronchovesicular. wheezes. crackles.
crackles. Explanation: 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.
A nurse is overseeing the care of a client who is receiving oxygen via nasal cannula. Which aspects of the client's care can the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply. Increasing the flow rate of the client's oxygen when the client is short of breath Auscultating the client's lungs to determine the effectiveness of treatment Reapplying the client's nasal cannula after a bath Measuring the client's respiratory rate Inserting the client's nasal cannula after it has become dislodged
Measuring the client's respiratory rate Inserting the client's nasal cannula after it has become dislodged Reapplying the client's nasal cannula after a bath
To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test? Monitor the pressure of oxygen dissolved in plasma. Monitor the amount of oxygen saturation in the blood. Measure the volume of air exhaled or inhaled over time. Calculate the pressure of carbon dioxide dissolved in plasma.
Monitor the amount of oxygen saturation in the blood. Explanation: The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. The arterial blood gases test the client's blood for the partial pressure of oxygen dissolved in plasma, the percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma. Spirometry measures the volume of air in liters exhaled or inhaled by a client over time.
The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign? Apical pulse Orthostatic blood pressure Urinary intake and output Respiratory rate and depth
Respiratory rate and depth Explanation: The client receiving opioids needs monitoring of the respiratory rate and depth to ensure that respiratory depression does not result in progressive respiratory issues, physiologic damage from respiratory depression, or loss of consciousness. The pulse, blood pressure, and urinary intake and output are not as important as respiratory status when administering opioids
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. Practice good hand hygiene. Cut down on smoking. Avoid exposure to large crowds.
Stay indoors as much as possible.
The nurse is teaching a patient how to use a metered dose inhaler for her asthma. Which comments from the patient assure the teaching has been effective? A. I will be careful to not shake the canister before using it B. I will hold the canister upside down while using it.. C. I will inhale the medication through my nose D. I will continue to inhale when the cold propellant is in my throat E. I will only inhale one spray with one breath F I will activate the device while continuing to inhale
d, e, f
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? mineral oil tap water distilled water normal saline
distilled water
a nurse is caring for five clients on a busy surgical unit. Which tasks can a nurse delegate to an unlicensed assistive personnel?
- perform oropharyngeal suctioning for a client who was admitted with a stroke - complete oral hygiene for a client with reoccurring falls and dementia - feeding lunch to a client admitted with a new bilateral upper extremity fracture
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? "I understand; I used to be a smoker also." "Oxygen is a flammable gas." "An occasional cigarette will not hurt you." "You should never smoke when oxygen is in use."
"You should never smoke when oxygen is in use."
A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? A. Dyspnea B. Hypotension C. Decreased respiratory rate D. Decreased pulse rate
A. Dyspnea
A client with closed-angle glaucoma and a cough has a prescription for a cough medicine. The nurse would question which cough medicine if prescribed for this client? Cough medicine with a high sugar content Cough medicine with a decongestant Cough medicine with an antihistamine Cough medicine with iodine
Cough medicine with an antihistamine Explanation: The client with closed-angle glaucoma should avoid cough medicine because of its anticholinergic action. The client with diabetes should avoid cough medicine with a high sugar content. The client with thyroid disorders should avoid cough medicine containing iodine. The client with hypertension should avoid cough medicine with decongestants.
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? Assess the client's respiratory status and check vital signs every 1 minute for the next hour. Maintain the client's oxygenation and alert the health care provider immediately. Cover the tracheostomy stoma and apply oxygen by nasal cannula Page the respiratory therapist STAT.
Maintain the client's oxygenation and alert the health care provider immediately.
The nurse is caring for a client currently on a mechanical ventilator. What should the nurse determine when comparing arterial blood gas (ABG) results from the current day (4/27) with the results obtained 24 hours earlier (4/26)? Both results indicate within normal limits. Oxygenation is improving. The oxygen will be adjusted. The client can be weaned from the ventilator.
Oxygenation is improving. Explanation: This client is showing improvement over the 24-hour period. The first day showed slight hypoxemia while the second set is closer to being within normal limits. Only the PaCO2 is only slightly elevated. The most likely current treatment will continue as is. The decision to wean the client off the ventilator will be determined based on more factors in the client's overall condition. The health care provider may decide to adjust the flow rate depending on the client's overall condition. ABG normal results are pH 7.35-7.45, PaO2 80 to 100 mm Hg (10.64 to 13.30 kPa), PaCO2 35 to 45 mm Hg (4.66 to 5.99 kPa), SaO2 95% to 100% (0.95 to 1.0), and HCO3 22 to 26 mEq/l (22 to 36 mmol/l).
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? Tachypnea Pneumonia Wheezes Pleural effusion
Pleural effusion Explanation: 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 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? Residual Volume (RV) Total lung capacity (TLC) Forced Expiratory Volume (FEV) Tidal volume (TV)
Residual Volume (RV) Explanation: 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.
which assessment and intervention should the nurse consider when performing f tracheal suctioning? Select all that apply A. Closely assess the patient before, during, and after the procedure B. Hyperoxygenate the patient before and after suctioning C. Limit the application of suction to 20-30 seconds D. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve E. Use appropriate suctioning pressure ( 80 to 150 mm Hg) F. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.
a, b, d, e
A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? A. Remove the catheter B. Notify the primary care provider C.Check that the airway is the appropriate size for the patient D. Place the patient on his or her back
a. Nurse should remove the catheter - if patient needs to be suctioned again- change the catheter -it is probably contaminated. Nurse should turn patient on their side and elevate the head to avoid aspiration
ischemia
an inadequate blood supply to an organ or part of the body, especially the heart muscles. Modt commonly caused by atherosclerosis
The nurse is preparing to suction the nasopharyngeal airway of a client admitted with COPD. What will the nurse do?
apply suction when withdrawing the catheter
the nurse on a telemetry unit is assessing oxygen saturation of a client with severe peripheral edema using a pulse oximeter. What actions constitute the correct response by the nurse? Select all that apply
using an ear pulsometer probe Request a prescription for arterial blood gas level by the lab
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? Hypoxia Hyperventilation Atelectasis Perfusion
Hypoxia
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. 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. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider.
Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Explanation: 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.
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? face tent nasal cannula simple mask nonrebreather mask
nasal cannula Explanation: 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.
A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient ? a. Assist with bathing and hygiene tasks even if the patient feels capable of doing it themselves B. Teach the patient not to talk about the procedure but yo just do it the best they can. C. Teach the patient to take short shallow breaths when performing hygiene measures D. Group personal care activities into smaller steps allowing rest periods between activities
D. Group personal care activities into smaller steps allowing rest periods between activities.
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? 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. Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. 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. Explanation: 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.
A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter? a. The age of the patient b. The size of the endotracheal tube c. The type of secretions to be suctioned d. The height and weight of the patient
b. The size of the endotracheal tube