Oxygenation

The nurse is teaching nursing students about the risks that late preterm infants may experience. The nurse feels confident learning has taken place when the students make which statement?

*"A late preterm newborn may have more clinical problems compared with full-term newborns."* The most common complications for late preterm infants are cold stress, respiratory distress, hypoglycemia, sepsis, cognitive delays, hyperbilirubinemia, and feeding difficulties. These are similar to those facing the preterm newborn and require similar management. Late preterm newborns have more clinical problems, longer lengths of stay, higher costs when compared with full-term newborns, and increased mortalities.

A client is returning from the operating room after inguinal hernia repair. The nurse notes that he has fluid volume excess from the operation and is at risk for left-sided heart failure. Which sign or symptom indicates left-sided heart failure?

*Bibasilar crackles* Bibasilar crackles are a sign of alveolar fluid, a sequelae of left ventricular fluid, or pressure overload and indicate left-sided heart failure. Jugular vein distention, right upper quadrant pain (hepatomegaly), and dependent edema are caused by right-sided heart failure, usually a chronic condition.

Which statement is true about both lung transplant and bullectomy?

*Both procedures improve the overall quality of life of a client with COPD.* Treatments for COPD are aimed more at treating the symptoms and preventing complications, thereby improving the overall quality of life of a client with COPD. In fact, there is no cure for COPD. Lung transplant is aimed at treating end-stage emphysema and bullectomy is used to treat clients with bullous emphysema.

Which of the following assessment factors would indicate a need for oropharyngeal suctioning?

*Breathing rate of 36 breaths/min and noisy, gurgling respirations* *An increase in the breathing rate indicates hypoxia in the body.* The signs of noisy, *gurgling respirations indicate airway interference and the need for suctioning.* Clients should be able to cough up thin sputum, and tonsil enlargement should not interfere. Crackles in lower lobes signify lung congestion, not airway impairment. Oxygen saturation levels of 95% are normal.

A woman with cardiac disease at 32 weeks' gestation reports she has been having spells of light-headedness and dizziness every few days. Which instruction should the nurse prioritize?

*Decrease activity and rest more often.* If the client is developing symptoms associated with her heart condition, the first intervention is to monitor activity levels, decrease activity, and treat the symptoms. At 32 weeks' gestation, the suggestion to induce labor is not appropriate, and without knowledge of the type of heart condition one would not recommend increase of fluids or vitamins. Total bed rest may be required if the symptoms do not resolve with decreased activity.

A 68-year-old male patient has been admitted to the surgical unit from the PACU after surgical repair of an inguinal hernia. When performing the patient's admission assessment, the nurse notes that the patient has a barrel chest. This assessment finding should suggest to the nurse that the patient may have a history of what health problem?

*Emphysema* Barrel chest occurs as a result of lung hyperinflation, as in emphysema. There is an increase in the anteroposterior diameter of the thorax so that it approximates a 1:1 ratio. This assessment finding is not associated with asthma, bronchitis, or tuberculosis.

A nurse is caring for a patient diagnosed with empyema. Which of the following interventions does a nurse implement for patients with empyema?

*Encourage breathing exercises.* The nurse teaches the patient with empyema to do breathing exercises as prescribed. The nurse should institute droplet precautions, isolate suspected and confirmed influenza patients in private rooms, or place suspected and confirmed patients together, and not allow visitors with symptoms of respiratory infection to visit the hospital to prevent outbreaks of influenza from occurring in health care settings.

The nurse is developing a plan of care for a client with toxic epidermal necrolysis (TEN) or Stevens-Johnson syndrome. Which action should the nurse include?

*Frequently inspect the oral cavity.* The nurse should frequently inspect the oral cavity of a client with TEN or Stevens-Johnson syndrome. Additionally, care should be taken to reduce friction and shear when turning or repositioning the client. Fluids should not be limited because these clients are susceptible to dehydration. A continuous current of warm air on denuded skin can worsen dehydration.

What would be an appropriate action for the nurse prior to performing deep tracheal suctioning due to increased secretions?

*Hyperoxygenate the client before suctioning.* Preoxygenation and deep breathing assist in reducing suction-induced hypoxemia because it decreases the risk of atelectasis caused by negative pressure of suctioning. Deflating the cuff is not necessary and there is no reason to instill acetylcysteine into the tracheotomy before suctioning. Pressure is applied only with the removal of the catheter.

A client is breathing 40 breaths/minute. He is diaphoretic and confused. Which nursing diagnosis should be the priority for the client at this time?

*Impaired gas exchange* Impaired gas exchange is the priority nursing diagnosis for this client. Insomnia, Anxiety, and Risk for injury due to confusion are also appropriate nursing diagnoses, but they are less important at this time.

Which oxygen administration device has the advantage of providing a high oxygen concentration?

*Nonrebreathing mask* The nonrebreathing mask provides high oxygen concentration, but it usually fits poorly. However, if the nonrebreathing mask fits the client snugly and both side exhalation ports have one-way valves, it is possible for the client to receive 100% oxygen, making the nonrebreathing mask a high-flow oxygen system. The Venturi mask provides low levels of supplemental oxygen. The catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention. A face tent provides a fairly accurate fraction of inspired oxygen but is bulky and uncomfortable. It would not be the device of choice to provide a high oxygen concentration.

A patient has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the patient complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?

*Oxygen toxicity* Oxygen toxicity may occur when too high a concentration of oxygen (greater than 50%) is administered for an extended period (longer than 48 hours) (Urden, Stacy, & Lough, 2010). Signs and symptoms of oxygen toxicity include substernal discomfort, paresthesias, dyspnea, restlessness, fatigue, malaise, progressive respiratory difficulty, refractory hypoxemia, alveolar atelectasis, and alveolar infiltrates evident on chest x-rays.

A woman visits the family planning clinic to request a prescription for birth control pills. Which factor would indicate that an ovulation suppressant would not be the best contraceptive method for her?

*She has a family history of thromboembolism.* The estrogen content of birth control pills may lead to increased blood clotting, leading to an increased incidence of thromboembolism. Women who already are prone to this should not increase their risk further.

A client is given amiodarone in the emergency department for a dysrhythmia. Which finding indicates the drug is having the desired effect?

*The number of premature ventricular contractions is decreasing.* Amiodarone is used for the treatment of premature ventricular contractions, ventricular tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial therapy for a pulseless dysrhythmia

A client experiences a head injury in a motor vehicle accident. The client's level of consciousness is declining, and respirations have become slow and shallow. When monitoring a client's respiratory status, which area of the brain would the nurse realize is responsible for the rate and depth?

*The pons* The pons in the brainstem controls rate and depth of respirations. When injury occurs or increased intracranial pressure results, respirations are slowed. The frontal lobe completes executive functions and cognition. The central sulcus is a fold in the cerebral cortex called the central fissure. The Wernicke's area is the area linked to speech.

What emergency procedures would the nurse anticipate being implemented during a myasthenia gravis crisis?

*Tracheotomy with mechanical ventilation* Initiation and maintenance of mechanical ventilation is a priority emergency procedure in a myasthenia gravis crisis. Prompt action is lifesaving in this crisis situation. An endotracheal tube may be inserted if the problem is temporary, but the length of time it will be needed will depend on the client's response and healing.

A 2-year-old child is being examined in the emergency department for epiglottitis. Which assessment finding supports this diagnosis?

*Tripod position* The child being in the tripod position (sitting up and leaning forward) supports the diagnosis of epiglottitis because this position facilitates breathing. Epiglottitis presents with a sudden onset of signs and symptoms, such as high fever, muffled speech, inspiratory stridor, and drooling.

A postpartum client is recovering from the birth and emergent repair of a cervical laceration. Which sign on assessment should the nurse prioritize and report to the RN and/or health care provider?

*Weak and rapid pulse* *Excessive hemorrhage puts the client at risk for hypovolemic shock.* Signs of impending shock include a *weak and rapid pulse, decreased blood pressure, tachypnea, and cool and clammy skin.* These findings should be reported immediately to the RN and/or health care provider so that proper intervention for the client may be instituted.

An apartment fire spreads to seven apartment units. Victims suffer burns, minor injuries, and broken bones from jumping from windows. Which client should be transported first?

*a middle-aged man with no injuries who has rapid respirations and coughs* The man with respiratory distress and coughing should be transported first because he is probably experiencing smoke inhalation. The pregnant woman is not in imminent danger or likely to have a precipitous childbirth. The 10-year-old is not at risk for infection and could be treated in an outpatient facility. First-degree burns are considered less urgent.

The nurse observes that a client who has received midazolam for conscious sedation is having shallow respirations. The nurse should do all except: -encourage the client to deep-breathe. -have respiratory resuscitation equipment in the room. -administer oxygen as prescribed. -administer naloxone.

*administer naloxone* The nurse does not administer naloxone because naloxone is the antidote for morphine, not midazolam. The benzodiazepine-receptor antagonist for midazolam is flumazenil. The nurse can promote oxygenation by encouraging deep breathing and administering oxygen. Resuscitation equipment should be accessible if needed.

A 4-year-old child who has been ill for 4 hours is admitted to the hospital with difficulty swallowing, a sore throat, and severe substernal retractions. The child's temperature is 104° F (40° C), and the apical pulse is 140 bpm. The white blood cell count is 16,000/mm3 (16,000 X 109/L). What is priority for nursing intervention?

*airway obstruction* The child's signs and symptoms in conjunction with the acute onset suggest possible croup or epiglottitis. The priority diagnosis at this time is airway obstruction. The airway may become completely occluded by the epiglottis at any time. Although the child has an infection, and the client has respiratory distress, the immediate priority is to establish and maintain a patent airway. No evidence is provided to support the potential for aspiration.

For a client with asthma, the health care provider (HCP) prescribes albuterol, two puffs twice a day via MDI, and beclomethasone, two puffs twice a day via MDI. The nurse should instruct the client to administer:

*albuterol first and follow with beclomethasone 2 times a day.* The nurse instructs the client to administer the bronchodilator first (the beta-2 agonist always leads) in order to open the airway and allow for improved delivery of the corticosteroid to the lung tissue, which follows after 1 minute between puffs. Using a spacer device with an MDI provides the best delivery of medication to the lungs.

After suctioning a client, a nurse should expect to find:

*clear breath sounds.* Clear breath sounds, which indicate that secretions have been removed, indicate effective suctioning. An above-normal respiratory rate, such as a rate of 28 breaths/minute, may indicate that the airway isn't clear of secretions and the client's respiratory rate has increased to compensate. A slightly increased heart rate, such as a rate of 104 beats/minute, may indicate health concerns unrelated to suctioning. Brisk capillary refill indicates adequate cardiovascular function and is unrelated to suctioning.

A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:

*cover the opening with petroleum gauze.* If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. *The nurse should then observe the client for respiratory distress because tension pneumothorax may develop.* If tension pneumothorax does develop, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions.

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?

Nasal cannula

A nurse is providing end-of-life care to a terminally ill client. Which actions should the nurse take to remove mucus and saliva from the client's mouth?

Perform suction in the client's mouth. Suctioning helps to remove mucus and saliva that the client cannot swallow or expectorate. A lateral, not supine, position keeps the mouth and throat free of accumulating secretions. The lips may need periodic lubrication because they may become dried from mouth breathing or administration of oxygen.

The nurse in the emergency department receives a patient who sustained a severe burn injury. What is the priority action by the nurse in this situation?

*Establish a patent airway.* Nursing assessment in the emergent phase of burn injury focuses on the major priorities for any trauma patient; the burn wound is a secondary consideration to stabilization of airway, breathing, and circulation.

Postoperatively, a client with a radical neck dissection should be placed in which position?

*Fowler* The client should be placed in the Fowler position to facilitate breathing and promote comfort. This position also promotes expansion of the lungs because the diaphragm is pulled downward and the abdominal viscera are pulled away from the lungs. The other positions are not the position of choice postoperatively.

When planning care for a client with burns on the upper torso, which nursing diagnosis should take the highest priority?

*Ineffective airway clearance related to edema of the respiratory passages*

A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient?

Ambu bag* If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag) may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube.

Which is a true statement regarding severe acute respiratory syndrome (SARS)?

*It is most contagious during the second week of illness.* Based on available information, SARS is most likely to be contagious only when symptoms are present, and clients are most contagious during the second week of illness. Diarrhea and hyperthermia may occur with SARS. Respiratory droplets spread the SARS virus when an infected person coughs or sneezes.

The nurse is caring for a pregnant client with severe preeclampsia. Which nursing intervention should a nurse perform to institute and maintain seizure precautions in this client?

*Keep the suction equipment readily available.* The nurse should institute and maintain seizure precautions such as padding the side rails and having oxygen, suction equipment, and call light readily available to protect the client from injury. The nurse should provide a quiet, darkened room to stabilize the client. The nurse should maintain the client on complete bed rest in the left lateral lying position and not in a supine position. Keeping the head of the bed slightly elevated will not help maintain seizure precautions.

The nurse is planning care for a client diagnosed with cardiogenic shock. Which nursing intervention is most helpful to decrease myocardial oxygen consumption?

*Maintain activity restriction to bedrest.* Restricting activity to bedrest provides the best example of decreasing myocardial oxygen consumption. Inactivity reduces the heart rate and allows the heart to fill with more blood between contractions. The other options may be helpful, but the best option is limiting activity.

A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention?

*Inquire about factors that contribute to non-adherence.* The nurse must first assess the reasons that contribute to non-adherence; interventions cannot be determined without a thorough assessment. Other interventions take place after assessment.

The nurse realizes the educational session conducted on due dates was successful when a participant is overheard making which statement?

*"The ability of my placenta to provide adequate oxygen and nutrients to my baby after 42 weeks' gestation is thought to be compromised."* The ability of the placenta to provide adequate oxygen and nutrients to the fetus after 42 weeks' gestation is thought to be compromised, leading to perinatal mortality and morbidity. After 42 weeks the placenta begins aging. Deposits of fibrin and calcium, along with hemorrhagic infarcts, occur and the placental blood vessels begin to degenerate. All of these changes affect diffusion of oxygen to the fetus. As the placenta loses its ability to nourish the fetus, the fetus uses stored nutrients to stay alive, and wasting occurs.

A nurse has come upon an unresponsive, pulseless victim. She has placed a 911 call and begins CPR. The nurse understands that if the patient has not been defibrillated within which time frame, the chance of survival is close to zero?

*10 minutes* The survival rate decreases for every minute that defibrillation is delayed. If the patient has not been defibrillated within 10 minutes, the chance of survival is close to zero.

While reviewing the arterial blood gas values of a client with emphysema, the nurse should identify which PaCO2 values as indicating the need for immediate intervention?

*80 mm Hg* Although normal PaCO2 values range from 35 to 45 mm Hg, the client with long-standing emphysema has chronic carbon dioxide retention, leading to elevated PaCO2 levels. A PaCO2 level of 80 mm Hg is life threatening and always requires immediate intervention, possibly mechanical ventilation, to reduce the PaCO2 level. The client with emphysema and a PaCO2 level of 60 mm Hg may not be in immediate danger, but the nurse should further evaluate the client with this level.

Which respiratory disorder in a neonate is usually mild and runs a self-limited course?

*Transient tachypnea* Transient tachypnea has an invariably favorable outcome after several hours to several days. The outcome of pneumonia depends on the causative agent involved and may have complications. Meconium aspiration, depending on severity, may have long-term adverse effects. In persistent pulmonary hypertension, mortality is more than 50%.

The membranes of a 26-year-old primigravida at 40 weeks' gestation admitted for induction of labor rupture spontaneously with evidence of meconium staining. After 1 hour of intravenous oxytocin, the nurse observes late fetal heart rate decelerations. What should the nurse do next?

*Administer oxygen at 8 to 10 L by mask.* Late decelerations signal poor placental perfusion. Therefore, oxygen should be administered at 8 to 10 L by mask to improve fetal hypoxia. The nurse should also stop the oxytocin infusion, turn the client onto her side, and report the pattern to the health care provider. Informing the client about fetal well-being occurs throughout the labor process, not just if problems arise. If the late deceleration pattern persists or if decreased variability occurs, then cesarean birth may be indicated. Although the contraction pattern should be monitored throughout the induction of labor, the priority here is to provide oxygen to the compromised fetus.

A client's face, neck, and chest have been burned in a fire. What is the nurse's priority potential health concern in this situation?

*Airway obstruction* Airway obstruction is the priority because of mucosal edema, impaired ciliary action, and bronchospasm. Additionally, there could be soft-tissue damage and swelling around the neck, mouth, and nose that could result in airway obstruction. Airway concerns would always take priority over any other concerns.

The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect:

*inspiratory and expiratory wheezing.* The hallmark signs of asthma are chest tightness, audible wheezing, and coughing. Inspiratory and expiratory wheezing is the result of bronchoconstriction. Even between exacerbations there may be some soft wheezing, so a finding of normal breath sounds would be expected in the absence of asthma. The expected finding is decreased forced expiratory volume (forced expiratory flow [FEF] is the flow [or speed] of air coming out of the lung during the middle portion of a forced expiration) due to bronchial constriction. Morning headaches are found in more advanced cases of COPD and signal nocturnal hypercapnia or hypoxemia.

A client had a Mantoux test result of an 8-mm induration. The test is considered positive when the client:

*is immunocompromised.* An induration (palpable raised hardened area of skin) of more than 5 to 15 mm (depending upon the person's risk factors) to 10 Mantoux units is considered a positive result, indicating TB infection. An induration of greater than 5 mm is found in HIV-positive individuals, those with recent contacts with persons with TB, persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB, or clients with organ transplants or immunosuppressed. An induration of greater than 10 mm is positive, and the client may be a recent arrival (less than 5 years) from high-prevalent countries, injection drug user, resident or an employee of high-risk congregate settings (e.g., prisons, long-term care facilities, hospitals, homeless shelters), or mycobacteriology lab personnel. Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight), a child less than 4 years of age, or a child or adolescents exposed to adults in high-risk categories.

During a difficult labor of an infant in the face presentation, the nurse notes the infant has a large amount of facial edema with bruising and ecchymosis. Which assessment would be the priority for this infant?

*patent airway* Babies born after a face presentation have a great deal of facial edema and may be purple from ecchymotic bruising. The nurse must observe the infant closely for a patent airway. Arching of eyebrows is not a priority. Ability to swallow and palpation of fontanels are routine assessments for all newborns, but they are not the priority.

A client returns to the recovery room following a mastectomy. An initial postoperative assessment is performed by the nurse. What is the nurse's priority assessment?

*Assessing the vital signs and oxygen saturation levels.* The nurse prioritizes vital signs and breathing based on principles of ABCs.

Which nursing assessment finding indicates the client with renal dysfunction has not met expected outcomes?

*Client reports increasing fatigue.* Fatigue, shortness of breath, and exercise intolerance are consistent with unexplained anemia, which can be secondary to gradual renal dysfunction.

Which of the following is the most important consideration when performing tracheotomy suctioning?

*The client should be hyperoxygenated, then suctioned for the duration of 10 to 15 seconds.* The most important aspect is to ensure the client is hyperoxygenated to increase oxygen saturation levels. Then suctioning should be limited to 10-15 seconds. This helps to prevent desaturation so that breathing is not compromised. It is not enough to apply oxygen if desaturation occurs. Suctioning should be done when necessary, not as a routine. Fluid intake is increased to help liquefy the secretions.

A nurse caring for a client recently admitted to the ICU observes the client coughing up large amounts of pink, frothy sputum. Lung auscultation reveals course crackles to lower lobes bilaterally. Based on this assessment, the nurse recognizes this client is developing

*decompensated heart failure with pulmonary edema.* Large quantities of frothy sputum, which is sometimes pink or tan (blood tinged), may be produced, indicating acute decompensated heart failure with pulmonary edema. These signs can be confused with pneumonia and tuberculosis, however the patient reveals course crackles upon auscultation which is indicitive of pulmonary edema. A patient with acute COPD would have diminished lung sounds bilaterally.

A nurse is caring for a client who is in labor. For which fetal response should the nurse monitor?

*decrease in circulation and perfusion to the fetus* When monitoring fetal responses in a client experiencing labor, the nurse should monitor for a decrease in circulation and perfusion to the fetus secondary to uterine contractions. The nurse should monitor for an increase, not a decrease, in arterial carbon dioxide pressure. The nurse should also monitor for a decrease, not an increase, in fetal breathing movements throughout labor. The nurse should monitor for a decrease in fetal oxygen pressure with a decrease in the partial pressure of oxygen.

A nurse is monitoring a client with PROM who is in labor and observes meconium in the amniotic fluid. What does the observation of meconium indicate?

*fetal distress related to hypoxia* When meconium is present in the amniotic fluid, it typically indicates fetal distress related to hypoxia. Meconium stains the fluid yellow to greenish brown, depending on the amount present. A decreased amount of amniotic fluid reduces the cushioning effect, thereby making cord compression a possibility. A foul odor of amniotic fluid indicates infection. Meconium in the amniotic fluid does not indicate CNS involvement.

A nurse is caring for a pregnant client who is in labor. Which maternal physiologic responses should the nurse monitor for in the client as the client progresses through birth? Select all that apply.

*increase in heart rate increase in respiratory rate increase in blood pressure* When caring for a client in labor, the nurse should monitor for an increase in the heart rate by 10 to 20 bpm, an increase in blood pressure by as much as 35 mm Hg, and an increase in respiratory rate. During labor, the nurse should monitor for a slight elevation in body temperature as a result of an increase in muscle activity. The nurse should also monitor for decreased gastric emptying and gastric pH, which increases the risk of vomiting with aspiration.