Oxygen Therapy

A patient who is prescribed oxygen therapy 24hr/day is concerned about being confined to bed. Which of the following would the nurse do to provide mobility fro this patient

make sure the patient has up to 50ft of connection tubing

diffusion

movement of O2 and CO2 between alveoli and capillaries (from higher pressure to lower pressure)

Ventilation is stimulated by....

increased CO2 in arterial blood (PaCO2) stimulates inspiration, decreased PaO2 also influences inspiration to a lesser degree.

ventilation

inspiration and expiration, the process of the exchange of air between the lungs and the environment

Nasogastric tube feedings are an appropriate choice for patients who

is postoperative following laryngectomy

To prevent a common complications of continuous enternal tube feedings ,a nurse should

limit the time the formula hangs to 4hr (if it hangs longer it is at risk fro bacterial contamination)

pre-school/ school-age

lots of upper respiratory infections

latex and latex free equipment

main source of concern with regards to medical equipment because a large majority contains latex material. Client should be assessed for latex allergy during initial assessment

The most reliable method for verifying initial placement of a small-bore feeding tube is by

obtaining an abdominal x-ray

Administering oxygen therapy with a nonbreather mask has which of the following advantages

offers the highest oxygen concentration of the low-flow systems

naris

one of the two external orifices of the nose; nostril (plural: nares)

bronchodilators

open up bronchioles

chest physiotherapy (CPT)

percussion and vibration

A nurse is testing a child for strabismus. Which of the following is the correct technique fro performing this examination

perform the cover-uncover test

A nurse is providing teaching to a patient who is receiving intermittent nasogastric feedings. Which of the following should the nurse instruct the patient to report immediately

persistant coughing

To prevent aspiration during the administration of an enternal tube feeding, a nurse should

place the patient in fowlers position

A nurse is performing an abortion examination on a preschooler. Which of the following instructions should the nurse give to the child when performing abdominal palpitation

place your hand under mine

Which of the following is appropriate fro a full liquid diet

plain yogurt, custard, pureed vegetables, gelatin

oxygen tents

provides cool, highly humidified airflow

A home health nurse is instruction a patient who has just started receiving oxygen therapy via mask. The nurse should emphasize that the patient must

reposition the elastic band frequently

infants

small chests, short airways; breath much more rapidly then later on

chronic hypoxia

someone used to living with lower oxygen levels, see long term affects i.e.clubbing, decreased urinary output, systemic issues

percussion

sounds like a horse clopping, cupping motion on back of lungs

hypercapnia

an excess of carbon dioxide in the blood

tracheostomy

an opening created by a surgical incision into the trachea for the purpose of establishing and maintaining an airway

A nurse is caring for an unconscious patient. Which of the following statements by the nurse indicates an understanding of providing good oral hygiene for the patient

"I'll swab the patient's mouth with diluted hydrogen peroxide."

A nurse is caring for an adult patient who is NPO. The patient is refusing oral care. Which of the following is appropriate by the nurse

"Oral care is still important even though you are not eating."

partial rebreather mask

6-15 L/min

nasal cannula

1-6 L/min, a common oxygen-delivery device consisting of a length of tubing with two small prongs that are inserted into the patient's nares

a nurse preparing a sterile field knows that the field has been contaminated when

1. a cotton ball dampened with normal saline touches the field 2. the nurse turns to answer the clients question 3. the procedure is post poned for 30min

proper cough etiquette involves what 5 things...

1. covering mouth and nose during coughing or sneezing 2. wear a surgical mask when coughing 3. using facial tissues to contain secretions 4. turn the head when coughing away from others atleast 3 feet 5. disinfecting hands after sneezing or coughing

Examples of Nursing Diagnoses:

1. ineffective Airway Clearance r/t secretions 2. impaired Gas Exchange r/t history of smoking 3. ineffective Breathing Pattern r/t anxiety 4. acute pain r/t pleural inflammation 5. acute confusion r/t impaired ventilation 6. anxiety r/t feeling of suffocation 7. fatigue r/t impaired oxygen transport 8. disturbed sleep pattern r/t orthopnea

cardiac output is affected by...

1. preload (volume) 2. afterload (resistance) 3. myocardial contractility

Examples of Nursing Interventions:

1. promoting Comfort (patient positioning, hydration) 2. patient Education (breathing exercise i.e. deep breathing, pursed lip breathing, diaphragmatic breathing; incentive spirometry) 3. chest PT & Postural Drainage 4. administering Medications 5. administration of Oxygen

O2 Transport affected by:

1. the amount of O2 entering lungs (ventilation) 2. pulmonary circulation 3. adequacy of diffusion 4. amount of hemoglobin to carry O2 5. cardiac output to transport blood to body tissues 6. peripheral circulation

A nurse should recognize that nasogastric intubation is indicated to relieve gastric distention for which patient

40 year old patient w/ a postoperative bowel obstruction

simple mask

6-12 L/min

normal SpO2=

95-100% (<85%= inadequate tissue oxygenation)

The nurse assesses an adult patient's SpO2 as 82%. The nurse would expect to see which of the following assessment findings? A. cyanosis B. capillary refill < 2 sec. C. unlabored breathing D. respiratory rate 16 breath/min.

A

When assessing a school age child for scoliosis, it is important to have the child

bend forward with the knees straight and the arms dangling

When planning morning hygiene care for a postoperative patient, which of the following actions should the nurse include

Ask the patient in what order she typically performs her morning routine

A nurse should recognize that which of the following is correct regarding albumin levels as a diagnostic marker for nutritional status

Albumin level is a poor short-term indicator poor short-term indicator of protein status

When planning care for a patient with chronic lung disease (COPD) who is receiving oxygen through a nasal cannula, the nurse expects that A. the oxygen must be humidified B. the rate will be 2 L/min or less C. arterial blood gases will be drawn every 4 hours to assess flow rate D. the rate will be 6 L/min or more

B

Which oxygen delivery device would the nurse expect to use to provide the highest concentration of oxygen to a patient who is breathing spontaneously? A. partial rebreather mask B. nonrebreather mask C. simple mask D. venturi mask

B

mechanical ventilator

breathing assistance provided by a ventilator, one of various types of devices that support and maintain respiratory function

Abdominal breathing at 30-60 breaths/min with an irregular pattern of rate and depth would closely describe the breathing pattern of what age group? A. Older adult B. Infant C. Children D. Adolescents

B (nervous system isn't mature)

Effective use of a metered-dose inhaler requires the patient to do which of the following? A. Breathe in through nose B. Inhale 2 sprays with 1 breath C. Hold breath for 5-10 seconds after inspiration D. Exhale quickly through open mouth

C

To drain the apical section of the upper lobes of the lungs, the nurse should place the patient in which position? A. left side with a pillow under the chest wall B. side-lying, half on abdomen and half on side C. High Fowler's D. Trendelenberg

C

COPD

Chronic Obstructive Pulmonary Disease; drive to breathe shifts, depends on oxygen levels not CO2

perfusion

delivery of oxygenated blood to body tissues

A nurse is assisting a patient with personal hygiene care. Which of the following actions by the nurse will reduce the risk of infection

Cleaning the lease-soiled areas prior to cleaning the most-soiled areas

A patient with a fractured rib is breathing less often and with less depth because of the pain. The nurse would document this finding using which term? A. fremitus B. hyperventilation C. pleural friction rub D. hypoventilation

D

A patient with dyspnea should be placed in which of the following positions? A. prone B. lateral C. supine D. Fowler's

D

David White is in the hospital with a medical diagnosis of viral pneumonia. He is receiving oxygen through a simple face mask. The nurse ensure that the mask fits snugly over the patient's face for which reason? A. To prevent mask movement and consequent skin breakdown B. To help the patient feel secure C. To maintain carbon dioxide retention D. To aid in maintaining expected oxygen delivery

D

Mr. Parks has COPD. The nurse has taught him that pursed-lip breathing helps him by A. increasing carbon dioxide, which stimulates breathing. B. prolonging inspiration and shortening expiration. C. liquefying his secretions. D. decreasing the amount of air trapping and resistance.

D

A patient who has difficulty breathing, increased respiratory and pulse rates, and pale skin with some cyanosis may be suffering from which of the following? A. hyperventilation B. hypoxia C. perfusion D. atelectasis

D (acute)

The primary purpose of surfactant is A. to propel sheet of mucus toward the upper airway B. to warm inspired air C. to produce watery mucous D. to reduce surface tension of the fluid lining of the alveoli

D (often an issue for premature babies)

acute hypoxia

a sudden difficulty breathing; leading to symptoms such as anxiety, restlessness, dyspnea, high BP, small pulse pressure, pallor, cyanosis

Making a clients bed does not require what

Documentation

Iced normal saline can cause a rapid loss of what

Electrolytes

An older adult patient in a long term care facility is receiving intermittent enternal feedings in his room. His affect is flat, and the nurse suspects that he is feeling isolated. which of the following interventions is appropriate for this patient

Encourage him to go to the dining room at meal times to talk with other patients

What is the nurse going to do when giving a patient a tub bath

First, nurse will gather all necessary supplies. Second, prepare the room by placing a rubber mat on the rub floor to prevent the patient from slipping and falling. Third, nurse will assist patient into the bathroom and give instructions regarding the use of bars to prevent slipping and falling when entering or exiting the bathtub. Lastly, nurse will instruct patient to remain in tub for no longer than 20 min due to possibility of vasodilation from warm water, which can cause light-headedness or dizziness.

When using chilled normal saline solution during gastric lavage, nurse should watch for which of the following complications

Hypothermia

A nurse is performing a nasogastric intubation. Which of the following actions should the nurse take immediately after inserting the tube to the predetermined length

Inspect the oropharynx with a penlight and a tongue blade

Why should soap not be added to the water in the basin when giving a bed bath

Irritation to the eyes can occur

A nurse is documenting findings from a physical examination. Which of the following statements indicates correct charting

Regular heart rate and rhythm: S1, S2 heard.

t-tube

a t-shaped conduit with a piece that connects an oxygen source to the patient's artificial airway

What is not appropriate for oral hygiene for a patient that removes moisture from the oral cavity and that damages tooth enamel

Lemon-glycerin swabs

Which of the following strategies for enhancing the intake of healthful foods is appropriate for an adolescent

Making healthful food choices more convenient and available for the adolescent

Pulse Oximetry

Measures amount of Hgb saturated with O2 in arterial blood (SaO2 or Sp02)

A nurse is caring for a patient who is on long-term bed rest and requires frequent linen changes due to excess diaphoresis. Which of the following is the priority rationale for frequent linen changes

Moisture from excessive diaphoresis can cause skin breakdown

oxygen

a tasteless, odorless gas that comprises 21% of atmospheric air and is used by the body to maintain adequate cellular function

A patient with a gastric ileus postoperatively requires nutritional support for approximately 2 weeks. Which of the following types of feeding tubes is appropriate for this patient

Nasointestinal tube

To assess a patient fro adequate swallowing, the nurse should do which of the following-

Place the fingers on the patients throat at the level of the larynx and ask him to swallow

positive-pressure ventilation

a technique that uses a mechanism such as a mechanical ventilator to force air into the lungs to provide breathing assistance

A patient recovering from gastric surgery remains NPO and has a nasogastric tube connected to suction. Which of the following actions should the nurse take to prevent dry mucous membranes

Provide frequent mouth care

While performing a complete bed bath for a patient, the nurse should

Raise the room temperature

A patient has been receiving oxygen PRN via nasal cannula fro 4 hr. Which of the following assessment findings helps indicate that oxygen therapy has been effective

Respiratory rate 14/min

CO=

SV X HR

During report, a nurse is informed that a patient has a nasogastric tube connected to continuous suction. The nurse should recognize that this patient must have which types of tube

Salem sump

A nurse should recognize that which of the following is an indication fro oxygen therapy

Tachypnea; SaO2 90%

A nurse observes an assistive personnel (AP) make a client's bed while the client is out of the room. Which of the following actions by the AP is appropriate for this task

The AP reuses the patient's blanket and spread

What should not be used for a patient who is NPO status and just underwent gastric surgery

Throat lozenges

Why is it important to perform oral care

To help reduce oral bacteria and keep the oral cavity moist

Which of the following techniques is appropriate when obtaining a blood pressure on a child

Use a cuff with bladder covering 80 to 100% of the arm circumference

Which of the following communication techniques is most appropriate fro a nurse to employ during the physical examination of a 10 year ol

Use books and other visual aids to advance the interview

vibration

Use rhythmic contraction and relaxation of arm and shoulder muscles while holding hands flat on chest wall as patient exhales

diaphragmatic breathing

Used for COPD patients who breathe shallow, rapid breaths- exhausting! Reduces respiratory rate, increases tidal volume, reduces functional residual capacity Educate patient: Place one hand on stomach & one hand on middle of chest Inhale slowly through nose while protruding abdomen Exhale through pursed lips while contracting abdominal muscles press in and up on abdomen Perform x 1 min followed by 2 min rest Practice several times/day so eventually becomes automatic

How should a bed bath be given

Using long, firm strokes and proceeding from the distal to the proximal areas

noninvasive ventilation

a type of breathing assistance used to maintain positive airway pressure and improve alveolar ventilation without the need for an artificial airway

A nurse is caring for a patient who has a newly inserted nasogastric tube. Which method is appropriate for verifying the initial placement

X-Ray examination of the chest and abdomen (it's the gold standard)

cyanosis

a bluish discoloration, especially of the skin and mucous membranes, due to excessive concentration of deoxyhemoglobin (hemoglobin not combined with oxygen) in the blood

oxygen tent

a canopy that surrounds the patient, providing oxygen, humidification, and a cool environment to help control body temperature

oxygen mask

a device that fits over the patient's nose and mouth and delivers oxygen, humidity, and/or heated humidity

flow meter

a device used to control the rate of oxygen being delivered in liters per minute

hypoxemia

a diminished amount (reduced saturation) of oxygen in arterial blood

emphysema

a disease that progressively destroys the walls of the alveoli

manual resuscitation bag

a hand-held device consisting of a flexible air chamber attached to a face mask via a shutter valve and used to provide ventilation to a patient who is not breathing or who is breathing inadequately; often referred to by the common brand name, Ambu bag

pulse oximeter

a noninvasive device that measures oxygen saturation indirectly via a finger or ear probe with a light-emitting diode (LED) and a photo detector attached by a cable to the device

continuous positive airway pressure (CPAP)

a noninvasive, ventilation-assistance modality that provides a set positive airway pressure throughout the patient's respiratory cycle

bi-level positive airway pressure (BiPAP)

a noninvasive, ventilation-assistance modality that provides higher airway pressure during inspiration and lower pressure during expiration, usually delivered by a face mask

hypoxia

a reduced supply of oxygen to tissues below physiological levels despite adequate perfusion of the tissue by blood

incentive spirometer

a resistive breathing device that helps patients exercise their breathing muscles, provides visual reference for deep breathing; educate patient: 1. exhale normally 2. place spirometer in mouth 3. inhale as deeply as possible through mouth & hold breath to count of 3 4. remove mouth from spirometer and exhale normally 5. perform 10x/ hour

tracheostomy mask

a small oxygen-delivery apparatus that fits over a tracheostomy site and is held in place by an adjustable elastic strap that fits around the patient's neck; also called a tracheostomy collar

tracheostomy collar

a small oxygen-delivery apparatus that fits over a tracheostomy site and is held in place by an adjustable elastic strap that fits around the patient's neck; also called a tracheostomy mask

face tent

a soft, oxygen-delivery mask that fits under the patient's chin, loosely covers the mouth and nose, and is held in place by an adjustable elastic strap

atelectasis

airlessness or collapse of a lung, usually as a result of hypoventilation or obstruction

venturi mask

an oxygen-delivery apparatus consisting of a mask with holes on each side that allow exhaled air to escape and color-coded entrainment ports that are adjustable to allow regulation of the concentration of oxygen delivered, MOST PRECISE, 4-10 L/min (24%-55% FiO2)

partial nonrebreather mask

an oxygen-delivery apparatus similar to a nonrebreather mask, but with a two-way valve allowing the patient to rebreathe exhaled air

simple face mask

an oxygen-delivery apparatus used for patients who require a moderate flow rate for a short period of time via a plastic mask that fits snugly over the mouth and nose

A nurse inserting a nasogastric tube asks the patient to flex her head toward her chest after the tube passes through the nasopharynx. This action facilitates proper insertion of the tube by

closing off the glottis

A patient admitted with community-acquired pneumonia has been receiving oxygen therapy for several days. Which of the following assessment findings indicates an adverse effect of oxygen therapy

cracks in the oral mucosa

older adult

decreased muscle tone leading to more difficulty using muscles, sometimes see kyphosis, at risk for respiratory disease

A nurse is obtaining a problem-oriented history from a preschool-aged child. The nurse should consider that children form this age group typically can

describe the symptoms

A nurse is caring for a patient who is dyspenic and slightly cyanotic, with a respiratory rate of 28/min. The nurse determines that the patient has impaired gas exchange during which of the following phases of the nursing process

diagnosis

dyspnea

difficult or labored breathing

When teaching the parents of a toddler about feeding and eating, the nurse should include which of the following safety measures

do not offer the child raw vegetables

When performing an otoscopy examination on a 2-year old child, the nurse should pull the pinna

down and back

Which of the following dietary modifications should an adolescent engaging in sports implement

drink water before and after sports activates

Which of the following formulas is appropriate to administer to a patient who has dysfunctional gastrointestinal tract

elemental

A nurse is caring for a patient who has impaired swallowing due to a cerebralvascular accident. Which of the following interventions should the nurse use to assist the patient with feeding

elevate the head of the bed 45 to 90 degrees

Oxygen therapy is prescribed fro a patient who is brought to an emergency department in the early stages of hypoxia. When assessing this patient, the nurse should expect to find which of the following clinical indicators

elevated blood pressure

postural drainage

force of gravity assists drainage of secretions

hand hygeine

hand hygeine refers to both the actual process of washing the hands with soap and water as well as the use of an antimicrobial agent. The use of antimicrobial agent is acceptable except when the hands are visibly soiled or coming into contact with specific bateria's that could potentially become harmful

waste managment

handle sharps and dispose of them in a "sharps container"; dispose of blood or bodily fluids in the agencies "flush system"; and always transport linen in a closed liquid-containable bag NEVER A KNIT OR DRAWSTRING BACK THAT COULD SPREAD BODILY FLUID

A nurse is examining an 18-month-old child ears during a well child visit. Which of the following techniques should the nurse use

have the parent hold the child securely in their lap

birth

have to switch to breathing air

nonrebreather mask

highest concentration of O2, 6-15 L/min, an oxygen-delivery apparatus used to deliver high flow rates and high concentrations of oxygen via a mask that fits snugly over the patient's mouth and nose

when opening a sterile pack, which of the following would compromise sterility

holding the sterile contents below the waist when opening

airway resistance

how hard it is to pull air into lungs

Problems with ventilation, diffusion, or perfusion lead to...

hypoxia.

Which of the following interventions should a nurse use at mealtimes for a patient who has visual deficits

identify the food location as though the plate were a clock

A nurse is providing discharge teaching to a patient who will continue oxygen therapy at home. The nurse should instruct the patient that turning the knob on the oxygen flow meter all the way to the right

stops the oxygen flow

compliance

stretchability

A nurse caring for a patient who has sustained a head injury and whose level of consciousness fluctuates. The provider prescribes a full liquid diet progressing to a pureed diet as tolerated. Before initiating feedings, it is essential that this patient undergo which of following

swallowing exam

tidal volume

the amount of air normally breathed in and out with each respiratory cycle either spontaneously or delivered via mechanical ventilation

oxygen therapy

the delivery of oxygen for therapeutic purposes

pulse oximetry

the measurement of oxygen saturation indirectly via a finger or ear probe with a light-emitting diode (LED) and a photo detector attached by a cable to the oximeter device

fraction of inspired oxygen (FiO2)

the oxygen level inhaled by or delivered to the patient, expressed in a percentage of atmospheric air

A nurse is performing an annual physical examination on an adolescent. Which of the following should be included in the general survey

the patient makes good eye contact

A nurse is performing a nutritional assessment. When obtaining and interpreting anthropometric values, the nurse should recognize which of the following

the patient should be weighed on that same scale at the same time each day

flow rate

the quantity of oxygen delivered in liters per minute

mucolytics

thin out secretions

Which of the following is the primary purpose fro asking a patient to keep a 3-7 day food diary

to assess the pattern of intake and compare with daily reference intakes

pursed lip breathing

to gain control of rate & depth of respiration, goal is to prolong exhalation; educate to patient: 1. sit or stand upright 2. onhale through nose- count to 3 3. exhale through pursed lips, tighten abdomen- count to 7

A nurse is caring fro a patient who has a tracheostromy. Which of the following must the nurse use when administering oxygen to the patient

tracheostomy collar

A nurse is caring for a critically ill patient with COPD who requires delivery of a precise concentration of oxygen. Which of the following types of oxygen-delivery device is indicated fro this patient

venturi mask

oropharyngeal airways

when muscles relax, tongue falls back and occludes the airway, used to keep tongue clear of airway, used during recovery from anesthesia, comatose patients, to prevent biting ET tubes; do not tape airway in place- patient should be able to spit it out when alert

To determine how much of the length of a nasogastric tube to insert, a nurse should measure the distance from the tip of the patients nose to the earlobe to the

xiphoid process plus 20 to 30 cm more