NU271 EAQ: Oxygenation (week 12)

Which action would the nurse take when caring for a client with pneumothorax who has a chest tube and closed drainage system in place?

Check the water-seal chamber for evidence of bubbling during expiration. - With a pneumothorax, air will escape from the pleural space and into the water-seal chamber; because intrapleural pressure increases with expiration, bubbling in the water-seal chamber is usually seen during expiration. Water evaporates from the suction control chamber and the nurse will need to add water to keep the suction at the prescribed level. Milking chest tubes should generally be avoided and will not be needed with a pneumothorax because there will be only a few milliliters of bleeding. Bubbling in the suction control chamber is expected.

Which pathophysiological abnormality is present in cystic fibrosis?

Dysfunction of mucus-secreting glands - Cystic fibrosis is a genetic disorder affecting all mucus-secreting (exocrine) glands. A sweat gland abnormality is not involved in cystic fibrosis; children with cystic fibrosis lose excessive amounts of sodium through perspiration caused by exocrine gland dysfunction. Cilia action may be influenced by the thickened secretions, but the cilia are not affected by cystic fibrosis. Exocrine, not endocrine, glands are involved in cystic fibrosis.

In which position would the nurse place an 8-year-old child with asthma who is short of breath?

High-Fowler - Clients find it easier to breathe while sitting up than lying down. Helping them get into a comfortable sitting position is crucial. The high-Fowler position gives the lungs more room to expand, thereby promoting respiration and affording more comfort. The supine, left lateral, and Trendelenburg positions will all increase dyspnea; they do not permit chest expansion.

The nurse is caring for a client with an endotracheal tube. Which is the most effective way for the nurse to loosen respiratory secretions?

Humidify the prescribed oxygen - Because the client has an endotracheal tube in place, secretions can be loosened by administering humidified oxygen and by frequent turning. A client with an endotracheal tube in place is not permitted fluids by mouth. Providing chest physiotherapy is too vigorous for a client with an endotracheal tube. Potassium is never instilled into the lungs.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). The client's arterial blood gases deteriorate, and respiratory failure is impending. Which clinical indicator is consistent with the client's condition?

Mental confusion - Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).

A client suffers hypoxia and a resultant increase in deoxygenated hemoglobin in the blood. Which is/are the best site(s) to assess this condition? Select all that apply. One, some, or all responses may be correct.

lips, mouth + nail beds - Prolonged hypoxia resulting in increased amounts of deoxygenated blood causes cyanosis, which can be best evaluated in lips, mouth, nail beds, and skin (in extreme conditions). Sclera is the site of assessment for jaundice, whereas shoulders are assessed to confirm the condition of erythema.

A client is diagnosed with a spontaneous pneumothorax. Which physiological effect of a spontaneous pneumothorax would the nurse include in a teaching plan for the client?

Air will move from the lung into the pleural space. - As a person with a tear in the lung inhales, air moves through that opening into the intrapleural space; this creates a positive pressure and causes partial or complete collapse of the lung. Mediastinal shift occurs toward the unaffected side. Greater negative pressure within the chest cavity is normal; with a pneumothorax, there is a loss of intrathoracic negative pressure. "Collapse of the other lung will occur if not treated immediately" is not an impending problem.

When a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest?

Decreased sounds - Because the right lung is collapsed with a right pneumothorax, the nurse would expect very decreased or absent breath sounds on the right. Crackles occur with movement of air through fluid, such as with pulmonary edema, and would not be expected with pneumothorax. Wheezes occur with air movement through narrowed airways and would not be heard when there is no air movement because of lung collapse. Vesicular sounds are the normal sounds heard with inspiration and expiration and would not be heard on the right side.

When the nurse manager is evaluating the care of a client receiving oxygen through a nasal cannula, which finding indicates a need for more staff education about oxygen therapy?

Oxygen flow rate is set to 8 L/min. - Flow rates for nasal cannulas should be set no higher than 6 L/min, higher flows do not lead to an increase in FIO2, and high oxygen flow increases drying and irritation of mucous membranes. Bubbling of oxygen through the humidifier indicates that humidification of oxygen is occurring. Padding of pressure areas on the oxygen tubing decreases skin irritation and breakdown. Smoking and open flame prohibition signs are posted in places where oxygen is used to decrease the risk for fire.

The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning?

Preoxygenate the client before suctioning. - Administration of 100% oxygen for a few minutes before suctioning reduces the risk of hypoxia, the major complication of suctioning. Suction is applied as the catheter is withdrawn, not during insertion, to prevent hypoxia. Tracheostomy cuffs are indicated when the client is on mechanical ventilation. Although a saline solution may be instilled into a tracheostomy, this practice is not recommended.

In the team nursing model, which team member would be assigned a client with a tracheostomy, chest tube, and blood transfusion?

Registered nurse (RN) - The team leader assigns the professional, technical, and ancillary personnel to the type of client care they are prepared to deliver and must be knowledgeable about the legal and organizational limits of each role. The RN is qualified to meet all of the client's needs. The charge nurse does not receive a client assignment in team nursing. The client assignment is beyond the scope of UAP. The LPN/LVN may be qualified to address the client's tracheostomy and chest tube but is not able to support the blood transfusion.

Which education would the nurse reinforce for a 9-year-old child with cystic fibrosis?

"Your mucus is thick because cystic fibrosis interferes with how your mucous glands work." - An explanation of the mechanism of cystic fibrosis takes into account the child's capacity to understand cause-and-effect relationships and offers information to increase the child's understanding of the illness. Telling the child that the treatment will improve the condition is too general and does not explain why the child will feel better. Telling the child that others will make schedules is too authoritarian; the child needs information that will increase understanding and foster compliance with the regimen.

The nurse is preparing to perform endotracheal suctioning on a client. Before beginning the procedure, which intervention would the nurse do?

Administer 100% oxygen to the client. - Before suctioning, regardless of the means, oxygen should be administered, because the suctioning procedure depletes oxygen from the respiratory tract, causing a potential drop in oxygen saturation levels. In a client with an endotracheal tube, manually bagging with 100% oxygen will hyperoxygenate the lungs. The client who has an endotracheal tube may not be able to follow commands to take deep breaths or cough or have the strength to do either, which is why manual bagging is preferred. A new sterile suction catheter should be used each time the client is suctioned, but the suction tubing and equipment need not be changed.

Which condition will be given the highest priority for a client admitted in the emergency department who has airway obstruction, chest wall trauma, external hemorrhage, and hypoglycemia?

Airway obstruction - The highest priority intervention is to establish a patent airway because inadequate oxygen supply to the brain may cause brain death. Assessing the metabolic conditions is done after the airway is cleared. Once the airway is cleared, then the chest wall of the client is assessed. Hemorrhage is assessed after the airway of the client is cleared.

Which nursing action is of highest priority when a client's chest tube has accidentally dislodged?

Apply a petroleum gauze dressing over the site. - A petroleum gauze dressing will prevent air from being sucked into the pleural space, causing a pneumothorax. The petroleum gauze dressing should be taped only on three sides to allow for excessive air to escape, preventing a tension pneumothorax. The health care provider should be notified immediately and the client assessed for signs of respiratory distress. Positioning the client on the left side will not make a difference in outcome. There is no indication that the client is experiencing respiratory distress. Preparing to insert a new chest tube is not a priority of the nurse at this moment.

The nurse is suctioning a client's airway. Which nursing action will limit hypoxia?

Apply suction only after the catheter is inserted. - The negative pressure from suctioning removes oxygen and secretions; suction should be applied only after the catheter is inserted and is being withdrawn. Limiting suctioning with the catheter to half a minute is too long; suctioning should be limited to 10 seconds. Lubrication will facilitate insertion and minimize trauma; it will not prevent hypoxia. The use of a sterile catheter helps prevent infection, not hypoxia.

When suctioning a client with a tracheostomy, which nursing intervention is correct?

Apply suction only as the catheter is being withdrawn. - Use of suction on withdrawal of a suction catheter reduces unnecessary removal of oxygen. In addition, suction should be applied intermittently during the withdrawal procedure to prevent hypoxia. A sterile catheter is used to prevent infection and the catheter should be inserted only approximately 1 to 2 cm past the end of the tracheostomy tube to prevent tissue trauma. Hyperventilating a client before suctioning should always be with oxygen, not room air. Inserting the catheter until the cough reflex is stimulated frequently occurs and does help mobilize secretions, but is not a safety measure. Removal of the inner cannula before inserting the suction catheter is not necessary.

The nurse is caring for a client admitted with chronic obstructive pulmonary disease (COPD). Which laboratory test would the nurse monitor for hypoxia?

Arterial blood gas - Red blood cell count, sputum culture, and total hemoglobin tests assist in the evaluation of a client with respiratory difficulties; however, arterial blood gas analysis is the only test that evaluates gas exchange in the lungs. This provides accurate information about the client's oxygenation status.

The nurse is suctioning a client's tracheostomy. What is the correct order of nursing actions when performing this procedure?

Auscultate the lungs and check the heart rate. → Prepare by turning suction on to between 80 and 120 mm Hg pressure. → Hyperoxygenate using 100% oxygen. →Don sterile gloves. →Guide the catheter into the tracheostomy tube using a sterile-gloved hand. - The status of the client should be ascertained as a baseline before starting the procedure. The suction should be turned on to check its adequacy before beginning. Because oxygen will be lost during suctioning, the client should be oxygenated using 100% oxygen before initiating the procedure. Then the nurse should don sterile gloves to protect the client from infection and guide the catheter into the tracheostomy tube without using negative pressure.

Which actions will the nurse include in the plan of care for a client with a left pneumothorax who has a chest tube in place? Select all that apply. One, some, or all responses may be correct.

Check the water-seal chamber for air bubbling. + Assist the client to cough and deep breathe every hour while awake. - The nurse would assess for air bubbling in the water-seal chamber to determine whether the client's pneumothorax is resolved. Hourly coughing and deep breathing helps reexpand the lung and prevents atelectasis. Immobilization of the left arm is not needed and may lead to decreased shoulder and arm function. Nonsteroidal anti-inflammatory drugs are helpful in decreasing pain from the chest tube. Bed rest is not needed and would increase risk for complications such as deep vein thrombosis. With a pneumothorax, there will be minimal drainage in the collection chamber.

The client has a closed chest tube drainage system connected to suction. Which assessment finding requires additional evaluation by the nurse?

Constant bubbling in the water-seal chamber - Constant bubbling in the water-seal chamber is indicative of an air leak. The nurse would assess the entire length of the system from the container to the client's chest wall tube insertion site to find the source of the air leak. If the source of the air leak is not found in the system and bubbling continues, the leak is most likely within the client's chest or at the insertion site. This could cause the lung to collapse because of a buildup of air pressure within the plural cavity, and the health care provider should be notified. In this type of surgical procedure, 75 mL of blood in the chest tube collection chamber is an expected finding in the early postoperative period. A column of water 20 cm high in the suction control chamber and an intact occlusive dressing at the chest tube insertion site are also expected assessment findings.

Which clinical manifestation would the nurse expect when assessing a client with atelectasis?

Crackles at the bases - Atelectasis involves collapsing of alveoli distal to the bronchioles, and fine crackles at the lung bases are typically heard as the alveoli expand with deep breathing. Dullness to percussion may occur with atelectasis because the alveoli are collapsed. Rhonchi and wheezes are associated with narrowing or obstruction of the larger airways, not with collapse of the alveoli. Atelectasis occurs more gradually when clients do not take deep breaths, and it is not sudden in onset.

Which nursing assessment supports a diagnosis of atelectasis in a postoperative client?

Diminished breath sounds on auscultation - Atelectasis refers to the collapse of alveoli; breath sounds over the area are diminished. A productive cough most often is associated with inflammation or infection, not atelectasis. Clubbing of the fingertips is a late sign of chronic hypoxia related to prolonged obstructive lung disease. Rhonchi are most commonly heard in clients with infectious or inflammatory diagnoses such as pneumonia or chronic bronchitis.

Which action will the nurse take when a client's chest x-ray shows atelectasis?

Encourage incentive spirometer use. - Atelectasis signifies alveolar collapse and indicates a need for the client to take deep breaths that will expand the alveoli. Oxygen administration does not improve atelectasis. Suctioning is not indicated for atelectasis and is unnecessarily invasive and uncomfortable. Postural drainage is used to help clients clear airways of secretions, but would not help decrease atelectasis.

Which information would the nurse educator include in a presentation on how to care for clients with a chest tube drainage system? Select all that apply. One, some, or all responses may be correct.

Ensure the chest tube dressing is tight and intact. Palpate the skin to detect subcutaneous emphysema. Place the chest tube drainage system below the chest. - Care of clients with chest tubes includes ensuring the chest tube dressing is tight and intact to prevent tube dislodgement and air leak. The nurse will palpate the skin to detect subcutaneous emphysema. The chest tube drainage system is placed below the chest. If a chest tube falls out, the nurse will cover the site with sterile gauze and immediately notify the health care provider. The chest tube should not be stripped because this causes negative pressure that can cause trauma to the pleura.

Which finding best indicates that the chest tube for a client with a pneumothorax may be discontinued?

Full re-expansion of the lungs seen on chest x-ray - Chest x-ray films reveal the degree to which the lung fills the pleural cavity and also the presence or absence of pneumothorax. Clear breath sounds heard bilaterally do help indicate that the lung has re-expanded, but a chest x-ray is needed to confirm lung re-expansion. Oxygen saturations improve with resolution of pneumothorax, but a chest x-ray is needed for confirmation. Because intrapleural air is expelled into the water-seal chamber, lack of bubbling in the water-seal chamber indicates possible resolution of the pneumothorax, but a chest x-ray is needed for confirmation.

Which intervention would the nurse implement for a client admitted for an exacerbation of asthma?

Give prescribed medications to promote bronchiolar dilation. - Asthma involves spasms of the bronchi and bronchioles as well as increased production of mucus; this decreases the size of the lumina, interfering with inhalation and exhalation. Bronchiolar dilation will reduce airway resistance and improve the client's breathing. Although identifying and addressing a client's emotional state is important, maintaining airway and breathing are the priority. In addition, emotional stress is only one of many precipitating factors, such as allergens, temperature changes, odors, and chemicals. Although recent studies indicate a genetic correlation along with other factors that may predispose a person to the development of asthma, exploring this issue is not the priority. The use of an incentive spirometer is not helpful because of mucosal edema, bronchoconstriction, and secretions, all of which cause airway obstruction.

A client with a history of chronic obstructive pulmonary disease (COPD) is admitted with acute pneumonia. The client is in moderate respiratory distress. The nurse would place the client in which position to enhance comfort?

High Fowler using the bedside table to rest the arms - The high-Fowler position elevates the clavicles and helps the lungs expand, thus easing respirations. The side-lying, Sims, and semi-Fowler positions do not promote more comfortable breathing.

A client with cystic fibrosis asks why the percussion procedure is being performed. Which rationale would the nurse give to the client?

It loosens pulmonary secretions. - Postural drainage and percussion, also known as chest physical therapy (CPT), is a way to help clients with cystic fibrosis (CF) breathe with less difficulty and stay healthy. This intervention uses gravity and clapping the chest to loosen the thick, sticky mucus in the lungs so it can be removed by coughing. Percussion does not relieve bronchial spasms. Once pulmonary secretions are loosened by percussion and the client has a clearer airway, the depth of respirations may increase and facilitate removal of carbon dioxide from the lungs.

Which education would the nurse provide to a school-aged child with cystic fibrosis who asks why he or she has to undergo chest physiotherapy?

It mobilizes secretions. - Cupping and clapping over the chest helps mobilize secretions so they can be expectorated, thereby relieving discomfort. Chest physiotherapy will not alter the physical changes that occur as a result of the disease process. Medications are required to dilate the bronchioles. Chest physiotherapy does not humidify the bronchial tree.

A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" Which information would the nurse provide about the purpose of the chest tube?

It removes air from the pleural space. - With a pneumothorax, a chest tube attached to a closed chest drainage system removes trapped air and helps reestablish negative pressure within the pleural space; this results in lung reinflation. A closed chest drainage system may be inserted to remove blood related to a hemothorax, not to assess for bleeding. Monitoring the function of the lung is not the purpose of inserting chest tubes; the function of the lungs is monitored through the assessment of vital signs, breath sounds, arterial blood gases, and chest x-ray. Draining fluid from the pleural space is the reason for use of a closed chest drainage system when there is fluid in the pleural space.

Which finding in a client with asthma exacerbation requires the most rapid action by the nurse?

Markedly decreased breath sounds - Markedly decreased breath sounds may indicate very limited airflow and life-threatening asthma exacerbation. The nurse would immediately check oxygen saturation and anticipate possible need for mechanical ventilation. Clients with asthma exacerbation frequently report chest tightness, but this finding does not indicate possible impending respiratory arrest. Tachycardia is common with asthma exacerbation because of stress and increased work of breathing, but a heart rate of 110 beats per minute is not life-threatening. Expiratory wheezes are heard early in asthma exacerbation; inspiratory wheezes are a more ominous finding and indicate further progression of airway obstruction.

A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and closed chest drainage system are effective, which type of pressure will be reestablished?

Negative pressure in the pleural space - Removal of air and fluid from the pleural space reestablishes negative pressure, resulting in lung expansion. Neutral pressure in the pleural space will cause collapse of the lung. Atmospheric pressure in the thoracic cavity will cause collapse of the lung. Intrapulmonic pressure refers to pressure within the lung itself, not the pressure within the thoracic cavity.

Which action would the nurse take to determine patency of the chest tube and closed chest drainage system in a client after left lower lobectomy?

Observe for fluctuations of the fluid in the water-seal chamber. - Fluctuations of the fluid in the water-seal chamber indicate effective communication between the pleural cavity and the drainage system. Milking the chest tube toward the drainage unit should be avoided because it raises pressure in the pleural space, which can result in a tension pneumothorax. Bubbling in the suction control chamber occurs whenever the chest drainage system is connected to suction and is not a sign that the chest drainage system is patent. Extent of chest expansion in relation to breath sounds does not directly reflect the patency of the chest tube.

Which action will the nurse take to check for subcutaneous emphysema in a client with a chest tube?

Palpate around the tube insertion sites for crepitus. - Subcutaneous emphysema occurs when air leaks from the intrapleural space through the thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sound heard when tissues containing gas are palpated. Crackles and atelectasis are unrelated to crepitus. They occur within the lung; subcutaneous emphysema occurs in the soft tissues. Observing the client for the presence of a barrel-shaped chest is related to prolonged trapping of air in the alveoli associated with emphysema, a chronic obstructive pulmonary disease. Comparing the length of inspiration with the length of expiration is unrelated to subcutaneous emphysema, which involves gas in the soft tissues from a pleural leak.

A client has chest tubes attached to a chest tube drainage system. Which intervention would the nurse perform when caring for this client?

Palpate the surrounding area for crepitus. - Leakage of air into the subcutaneous tissue is evidenced by a crackling sound when the area is gently palpated; this is referred to as crepitus. Although hemostats should be readily available for any client with chest tubes in the event of a break in the drainage system, clamping the tube is not otherwise necessary and could cause backpressure. The dressing is not routinely changed to minimize the risk for pneumothorax. The system is kept closed to prevent the pressure of the atmosphere from causing a pneumothorax; drainage levels are marked on the drainage chamber to measure output. The chambers are not emptied; if they are filled, a new system will be attached.

A client develops subcutaneous emphysema after a chest injury with a suspected pneumothorax. Which method would the nurse use to assess for this complication?

Palpating the neck or face - Subcutaneous emphysema refers to the presence of air in the tissue that surrounds an opening in the normally closed respiratory tract; the tissue appears puffy and a crackling sensation is detected when trapped air is compressed between the nurse's palpating fingertips and the client's tissue. Percussion is not an appropriate method for assessment; breath sounds are not affected. Asymmetry of chest movements may occur because of the pneumothorax but is not indicative of subcutaneous emphysema.

The nurse is providing hygiene care to a immobile client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing intervention is correct when the client becomes short of breath during the care?

Put the client in a high Fowler position. - Putting the client in the high Fowler position will help expand the lungs and decrease the severity of shortness of breath. Leaving the client to obtain a pulse oximeter while the client is experiencing shortness of breath places the client in danger. Providing a rest period of at least 15 minutes may be appropriate but is not the priority. The nurse needs to acknowledge the change in the client's condition, such as shortness of breath, and take care of this immediate client need before continuing the hygiene activities.

A client with chronic obstructive pulmonary disease (COPD) is breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. Which action would the nurse take?

Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula. - Sitting facilitates breathing by increasing lung expansion; 2 L of oxygen promotes respirations while preventing carbon dioxide narcosis. However, the results of one recent study of clients with stable COPD indicate that the hypercarbic drive is preserved with oxygen higher than 2 L. More research is needed before this theory is applied clinically. Five liters of oxygen may cause respiratory depression and carbon dioxide narcosis in a client with COPD. Chest physiotherapy (postural drainage) may be done later after the client's condition improves. Delaying intervention is likely to worsen the respiratory distress.

A child had an emergency tracheotomy and is receiving humidified air through a tracheotomy collar. Which early clinical manifestations of hypoxia would alert the nurse to suction the tracheotomy?

Restlessness and increase in pulse - Restlessness and increase in pulse are some of the first signs of hypoxia; the airway must be kept patent to promote oxygenation. The other options are late signs of respiratory difficulty; suctioning and other measures should have been implemented before this time.

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears moist rumbling sounds that improve after the client coughs. How will the nurse document the lung sounds?

Rhonchi - Rhonchi are coarse and moist sounds caused by obstruction of the airway with thick mucus, and they usually clear or change with coughing as the mucus moves or is expectorated. Wheezes are high-pitched, continuous sounds. Fine crackles are high-pitched popping noises. Vesicular sounds are the normal breath sounds.

A postoperative client with a tracheostomy tube in place suddenly develops noisy, increased respirations and an elevated heart rate. The nurse would take which action immediately?

Suction the tracheostomy. - Noisy, increased respirations and increased pulse are signs that the client needs immediate suctioning to clear the airway of secretions. After suctioning, a complete respiratory assessment should be performed. After suctioning, then performing a respiratory assessment, further problem-solving may require readjustment of the tracheostomy tube and ties or a health care provider changing the tracheostomy tube.

Parents whose child has cystic fibrosis (CF) have no history of CF in their family and ask how their child inherited this disorder. How would the nurse clarify the way in which the disease was inherited?

The inheritance is autosomal recessive. - Both parents are carriers; the gene for CF is recessive, not dominant, and the parents do not have the disease. The gene for CF is not a mutant gene, nor is it located on the X or Y chromosome.

Which actions will the nurse include when doing tracheostomy care? Select all that apply. One, some, or all responses may be correct.

Use sterile technique when cleaning the inner cannula. + Don sterile gloves before removing the inner cannula. - Sterile technique is used when cleaning the inner cannula to avoid transmitting microorganisms to the lungs. Sterile gloves are worn when removing the inner cannula. There is no need to suction the client before starting tracheostomy care, although the client may be preoxygenated before removing the inner cannula. A brush is used to clean the inner cannula. Hydrogen peroxide is used to clean secretions from the inner cannula, the cannula is rinsed with normal saline. Because hydrogen peroxide can be irritating to tissue, normal saline is used to clean the skin around the tracheostomy stoma.

Which type of breathing pattern is manifested with hypercarbia?

Which type of breathing pattern is manifested with hypercarbia? - Hypercarbia may occur during hypoventilation. The respiratory rate is abnormally low and the depth of ventilation is depressed in hypoventilation. In eupnea, the normal rate and depth of respiration are interrupted while singing. The rate of breathing is regular, but abnormally rapid in tachypnea. Respirations are abnormally deep, regular, and the rate is increased in Kussmaul respiration.