PrepU "Chapter 40: Oxygenation and Perfusion" !

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output? "If the client's stroke volume is 80 mL and heart rate is 80 beats per minute, then the cardiac output is 6.0 L/minute." "If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute." "If the client's stroke volume is 60 mL and heart rate is 60 beats per minute, then the cardiac output is 3.2 L/minute." "If the client's stroke volume is 70 mL and heart rate is 70 beats per minute, then the cardiac output is 4.7 L/minute."

"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute." Explanation: The following formula is used to determine cardiac output: Cardiac Output = Stroke Volume x Heart Rate. A client with a stroke volume of 50 mL and heart rate of 50 beats per minute has a cardiac output of 2.5 L/minute. If stroke volume is 70 and heart rate is 70 beats per minute, then the cardiac output is 4.9 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute. If stroke volume is 60 and heart rate is 60 beats per minute, then the cardiac output is 3.6 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute.

A nurse assessing a client's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which form of oxygen delivery should the nurse use for this client? Oxygen tent Ambu bag Nasal cannula Oxygen mask

Ambu bag Explanation: If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Oxygen masks may cover only the nose and mouth and can vary in the amount of oxygen delivered. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostril. An oxygen tent is a tentlike enclosure within which the air supply can be enriched with oxygen to aid a client's breathing. Oxygen masks, nasal cannula, and oxygen tents are used for clients who have a respiratory drive.

A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first? Apply oxygen as prescribed Assist with intubation Raise the head of the bed Educate client on incentive spirometry

Apply oxygen as prescribed Explanation: The nurse should first apply oxygen, which will help to improve oxygen saturation and health status. The client may not require intubation, once oxygen is provided. Although the client may require education on incentive spirometry, the immediate priority intervention is to stabilize the client's oxygen saturation. Similarly, raising the head of the bed may help with the client's comfort but may not have sufficient effect on oxygen saturation.

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?

Ask the client what factors contribute to nonadherence. Explanation: The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment. Then, the nurse can work with the health care provider to find alternate treatment options if necessary, and then document the care

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which instruction will the nurse include in the teaching?

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 volunteering at a day camp where a child is stung by a bee and develops wheezing in the upper airways. The nurse will provide interventions to address what health problem? Bronchospasm Bronchiectasis Bronchitis Bronchiolitis

Bronchospasm Explanation: When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm. Bronchitis and bronchiectasis are chronic respiratory effects and bronchiolitis is infectious.

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The nursing care plan will address implications of what medical diagnosis? Congestive heart failure Pulmonary embolism Myocardial infarction Lung cancer

Congestive heart failure Explanation: A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure as a result of alterations to circulation. Pulmonary embolism presents with more acute signs of hypoxia. MI and lung cancer are not characterized by productive cough and frothy sputum.

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe? Expiratory stridor Inspiratory stridor Wheezing in the upper lobes Crackles in the lower lobes

Crackles in the lower lobes Explanation: People with chronic heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels. Stridor is associated with respiratory infections such as croup. Wheezing may be heard in individuals who use tobacco products

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea? Side-lying with head slightly elevated Supine with one pillow High Fowler's position Lying with the head slightly lowered

High Fowler's position Explanation: Clients with COPD are most comfortable in high Fowler's position because it aids in the use of the accessory muscles to promote respirations. The supine position with one pillow, side-lying with head slightly elevated, or lying with the head slightly lowered does not promote easier respirations.

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?

It determines whether the client is getting enough oxygen.

The nurse assesses a client with suspected sleep apnea. Which concern(s) does the nurse expect the client to verbalize during the health history interview? Select all that apply. Fear of dying while sleeping Embarrassment about loud snoring Nocturnal panic attacks Disruptive daytime sleepiness Fear of using continuous positive air pressure (CPAP) machine

Nocturnal panic attacks Fear of dying while sleeping Disruptive daytime sleepiness Embarrassment about loud snoring

A nurse conducts a health history for a client with chronic bronchitis. Which action does the nurse take first when the client begins to experience respiratory distress? Place the client in a comfortable position, ensure an open airway and if oxygen is prescribed start administration Get assistance in case oxygen, medications, or further intervention is needed Assess the client's rate and quality of respirations Speak slowly and calmly to the client to facilitate relaxation and ease respirations

Place the client in a comfortable position, ensure an open airway and if oxygen is prescribed start administration Explanation: If a nurse is conducting a health history interview for a client diagnosed with chronic bronchitis when respiratory distress occurs, the nurse first places the client in a comfortable position, ensures a patent airway, and starts oxygen if prescribed. After ensuring an open airway, the next step is quickly assessing the respiratory rate and quality and then getting assistance in case the client's respiratory status starts to deteriorate. Speaking slowly and calmly to relax the client is valuable but does not help assess the client's respiratory distress or prepare to manage it. The condition may require further intervention so preparation is needed.

A nurse is preparing to assess the oxygen saturation level of a client with a history of peripheral vascular disease using pulse oximetry. The nurse plans to apply the sensor to the client's right index finger. Assessment reveals slow capillary refill and a weak pulse proximal to the planned site. Which action by the nurse is appropriate? Place the sensor on the client's earlobe. Apply the sensor to the client's right great toe. Use the client's right index finger as planned. Switch the sensor to the client's right middle finger.

Place the sensor on the client's earlobe. Explanation: Assessment reveals that circulation to the planned site is inadequate as evidenced by slow capillary refill and weak pulse. Therefore, using the planned site or a site close to it such as the right middle finger would lead to an inaccurate reading. The nurse should consider using the earlobe or forehead because these alternate sites are highly vascular. The toe should be used only if lower extremity circulation is not compromised. In this situation, however, the client has a history of peripheral vascular disease, which is common in lower extremities. Therefore, the toe would not be an appropriate site.

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing Malnutrition Congestive heart failure Poor tissue perfusion Anemia

Poor tissue perfusion Explanation: Chronically poor perfusion may result in hair loss in the affected area, discolored skin, thickened nails, and shiny, dry skin indicative of inadequate tissue nutrition.

The nurse is caring for an older adult homebound client with advanced respiratory disease whose has inadequate nutrition. What recommendation will the nurse provide? Replace meals with protein shakes Increase use of dietary supplements Practice intermittent fasting to promote appetite Provide suggestions of high-protein, high-calorie meals

Provide suggestions of high-protein, high-calorie meals Explanation: TThe client should have sufficient caloric and protein intake for respiratory muscle strength, so promotion of a high-calorie, high-protein diet is appropriate. Protein shakes and dietary supplements may be appropriate but should complement, rather than replace, meals. Intermittent fasting promotes weight loss, not increased calorie intake

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? Skin tests Chest x-ray Pulmonary function tests Bronchoscopy

Pulmonary function tests Explanation: Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.

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? Forced Expiratory Volume (FEV) Residual Volume (RV) Total lung capacity (TLC) 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.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding? The skin at the thorax should be cool and moist. The chest should be slightly convex with no sternal depression. The contour of the intercostal spaces should be rounded. The anteroposterior diameter should be greater than the transverse diameter.

The chest should be slightly convex with no sternal depression. Explanation: The adult chest contour is slightly convex, with no sternal depression. The skin of the thorax should be warm and dry, and the anteroposterior diameter of the chest should be less than the transverse diameter. The contour of the intercostal spaces should be flat or depressed.

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. False True

True Explanation: After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A nurse caring for a client with a chest tube should monitor the client's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.

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 Wheezing Absent breath sounds in lower lobes Crackles

Wheezing Explanation: The nurse expects to document wheezing in the lungs of a client with asthma, which would be more pronounced when the client has a respiratory infection. Wheezing is a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration. Wheezing is caused by air passing through constricted passages caused by swelling or secretions. Stridor and crackles are other abnormal breath sounds caused by fluid, infection, or inflammation in the lungs. Absent breath sounds are not normally found in asthmatic clients; they are characteristic of pneumonia

What assessments would a nurse make when auscultating the lungs?

air flow through the respiratory passages Auscultation of the lungs assesses air flow through the respiratory passages and lungs. The nurse listens for normal, as well as abnormal, breath sounds. Abnormal chest structures would be assessed when inspecting the chest and thoracic region. Presence of edema would be assessed as part of the cardiovascular status of the client. Volume of air exhaled and inhaled would be performed during a pulmonary function test.

The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client? face tent tracheostomy collar simple mask nasal cannula

tracheostomy collar Explanation: A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. All other devices are less appropriate for this client.

A nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur? loss of sterile field trauma to the tracheal mucosa prevention of suctioning suctioning of carbon dioxide

trauma to the tracheal mucosa Explanation: Occluding the Y-port on the suction tubing is what creates the suction. While suctioning would be difficult but possible, suctioning while advancing the tube would damage the tracheal mucosa and remove excessive amounts of oxygen, not carbon dioxide, from the respiratory tract. Suctioning during insertion of the catheter would not compromise sterility.

The nurse is teaching the client with a pulmonary disorder about deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client? "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." "If you breathe through the mouth first, you will swallow germs into your stomach." "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." "Breathing through your nose first will warm, filter, and humidify the air you are breathing."

"Breathing through your nose first will warm, filter, and humidify the air you are breathing." Explanation: Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring.

A nurse assesses the vital signs of a healthy newborn. What respiratory rate could be expected based on the developmental level of this client? 15 to 25 breaths/min 16 to 20 breaths/min 30 to 60 breaths/min 20 to 40 breaths/min

30 to 60 breaths/min Explanation: The normal range for a newborn through 1 year is 30 to 60 breaths/min. Normal respiratory rate for adults is 14 to 20 breaths/min. Other normal age-related variations in respiratory rates are: Toddler/preschooler (1 to 5 years): 20 to 40 breaths/min; school-age child (6 to 12 years): 15 to 25 breaths/min; and older adult (65+ years): 16 to 24 breaths/min.

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. Which additional assessment would the nurse expect to observe? Crackles in the lower lobes Inspiratory stridor Wheezing in the upper lobes Expiratory stridor

Crackles in the lower lobes Explanation: People with chronic heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels. Stridor is associated with respiratory infections such as croup. Wheezing may be heard in individuals who use tobacco products.

The client has an increased anterior-posterior chest diameter, dyspnea, and nasal flaring. Which nursing concern is most appropriate for this client's care plan? Altered airway clearance risk due to infection Altered gas exchange due to carbon monoxide toxicity Decreased oxygenation due to inability to fully exhale Hypoxia due to pneumonia and unproductive airway clearance

Decreased oxygenation due to inability to fully exhale Explanation: In COPD, the patient's chest becomes overinflated over time because of an inability to exhale fully. This increases the anterior-posterior chest diameter, resulting in a barrel-shaped appearance and ultimately in decreaed oxygenation. This is unrelated to carbon monoxide exposure or acute lung infections.

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?

Maintain the client's oxygenation and alert the health care provider immediately.

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.

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting? Crackles Bronchovesicular Bronchial Vesicular

Vesicular 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.

A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action? Warm the client's hands and try again. Shine available light on the equipment to facilitate accurate reading. Place the probe on the client's earlobe. Use a blood pressure cuff to increase circulation to the site.

Warm the client's hands and try again. Explanation: Finding an absent or weak signal, the nurse should check vital signs and client condition. If satisfactory, warming the extremity may facilitate a stronger reading. This should be attempted prior to resorting to using the client's earlobe. Bright light can interfere with the operation of light sensors and cause an unreliable report. A blood pressure cuff will compromise venous blood flow to the site leading to inaccurate readings.

Which is a major organ of the upper respiratory tract?

pharynx Explanation: The pharynx, mouth, and nose are major organs of the upper respiratory tract. The trachea, bronchi, and lungs are major organs of the lower respiratory tract.

While auscultating a client's chest, the nurse auscultates crackles in the lower lung bases. What condition does the nurse identify the client is experiencing? air passing through narrowed airways presence of fluid in the lungs presence of sputum in the trachea inflammation of pleural surfaces

presence of fluid in the lungs Explanation: Coarse crackles heard on auscultation indicate the presence of fluid in the lungs. Air passing through narrowed airways produces a wheezing sound, whereas inflammation of pleural surfaces gives rise to pleural rub. Sputum in the trachea produces stridor, a harsh, noisy squeak when something is blocking the airway.