Chapter 37. Oxygenation

What is the rationale for wrapping petroleum gauze around a chest tube insertion site? 1)Prevents air from leaking around the site 2)Prevents infection at the insertion site 3)Absorbs drainage from the insertion site 4)Protects the tube from becoming dislodged

ANS: 1 Petroleum gauze creates a seal around the insertion site. Collapse of the lung can occur if there is a leak around the insertion site that causes loss of negative pressure within the system. Air leaks are one common cause of loss of negative pressure. PTS:1DIF:EasyREF:p. 1322 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

A patient has a history of COPD. His pulse oximetry reading is 97%. What other findings would indicate adequate tissue and organ oxygenation? Choose all that apply. 1)Normal urine output 2)Strong peripheral pulses 3)Clear breath sounds bilaterally 4)Normal muscle strength

ANS: 1, 2, 4 To determine adequacy of tissue oxygenation, assess respiration, circulation, and tissue/organ function. Good peripheral circulation is characterized by strong peripheral pulses. Impaired tissue oxygenation to the kidneys would result in abnormal kidney function (e.g., poor urine output). Hypoxic limb tissue would result in abnormal muscle functioning (e.g., muscle weakness and pain with exercise). Adequacy of tissue oxygenation cannot be determined by assessing pulmonary ventilation alone; circulation must also be assessed. PTS:1DIFgrinifficult REF: p. 1300; higher-order item, some of answer implied in text KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

Which of the following factors influence normal lung volumes and capacities? Choose all that apply. 1)Age 2)Race 3)Body size 4)Activity level

ANS: 1, 3, 4 Normal lung volumes and capacities vary with body size, age, and exercise level. Volumes and capacities are higher in men, in large people, and in athletes. Race does not influence normal lung volumes and capacities. PTS:1DIF:EasyREF:p. 1305 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension

The nurse is counseling a 17-year-old girl on smoking cessation. The nurse should include which of the following helpful tips in her education? Choose all that apply. 1)"Keep healthy snacks or gum available to chew instead of smoking a cigarette." 2)"Don't tell your friends and family you are trying to quit, until you feel confident that you'll be successful." 3)"Plan a time to quit when you will not have many other demands or stressors in your life." 4)"Reward yourself with an activity you enjoy when you quit smoking."

ANS: 1, 3, 4 People who are trying to quit smoking often are more successful when they are accountable to other people who are encouraging and supportive. Having something to chew (e.g., carrot sticks, gum, nuts, or seeds) can distract from the desire to smoke a cigarette. Setting a date to stop smoking and choosing a time of low stress are two strategies that help people be more successful with smoking cessation. Self-reward for meeting goals is a form of positive reinforcement. PTS:1DIF:ModerateREF:p. 1311, ESG Self-Care: Smoking Cessation Tips KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension

Which of the following is/are accurate about nasotracheal suctioning? Choose all that apply. 1)Apply suction for no longer than 10-15 sec during a single pass. 2)Apply suction while inserting and removing the catheter. 3)Reapply oxygen between suctioning passes for ventilator patients. 4)Gently rotate the suction catheter as you remove it.

ANS: 1, 4 Limiting suctioning to 10 seconds or less and reapplying oxygen between suctioning passes prevent hypoxia. Suction should be applied only while withdrawing the catheter, using a continuous rotating motion to prevent trauma to the airway. Endotracheal suctioning is used when the patient is being mechanically ventilated, and most ventilator patients have in-line suctioning, so there is no need to reapply oxygen. PTS: 1 DIF: Moderate REF: p. 1347 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

The nurse is teaching a patient about her chest drainage system. Which of the following should the nurse include in the teaching? Choose all that apply. 1)Perform frequent coughing and deep-breathing exercises. 2)Sit up in a chair but do not walk while the drainage system is in place. 3)Get out of bed without assistance as much as possible. 4)Immediately notify the nurse if she experiences increased shortness of breath

ANS: 1, 4 Patients should regularly perform coughing and deep-breathing exercises to promote lung reexpansion. Also to promote lung reexpansion, the nurse should encourage the patient to be as active as her condition permits, rather than telling her not to walk. Chest drainage systems are bulky, but patients with disposable systems can still get out of bed and ambulate. However, the patient will need assistance from one or two staff members to protect and monitor the system and to monitor her responses to activity; she should not get out of bed on her own. If a patient with a chest drainage system becomes acutely short of breath, the patient should immediately notify the nurse so the nurse can check for occlusion of the system, which can result in a tension pneumothorax. PTS:1DIF:ModerateREF:pp. 1313, 1358 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

You are caring for an adult patient with a tracheostomy who is being mechanically ventilated. His pulse oximetry reading is 85%, heart rate is 113, and respiratory rate is 30. The patient is very restless. His respirations are labored, and you hear gurgling sounds. You auscultate crackles and rhonchi in both lungs. What is the most appropriate action to take? 1)Call the respiratory therapist to check the ventilator settings. 2)Provide endotracheal suctioning. 3)Provide tracheostomy care. 4)Notify the physician of the patient's signs of fluid overload.

ANS: 2 Increased pulse and respiratory rates, decreased oxygen saturation, gurgling sounds during respiration, auscultation of adventitious breath sounds, and restlessness are signs that indicate the need for suctioning. Airways are suctioned to remove secretions and maintain patency. The patient's symptoms should subside once the airway is cleared. PTS: 1 DIF: Moderate REF: p. 1318, 1342 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

The nurse is caring for a patient who is experiencing dyspnea. Which of the following positions would be most effective if incorporated into the patient's care? 1)Supine 2)Head of bed elevated 80° 3)Head of bed elevated 30° 4)Lying on left side

ANS: 2 Position affects ventilation. An upright or elevated position pulls abdominal organs down, thus allowing maximum diaphragm excursion and lung expansion. PTS:1DIF:EasyREF:p. 1303 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

When using sterile technique to perform tracheostomy care of a new tracheostomy, which of the following is correct? 1)You will need a single pair of sterile gloves. 2)Place the patient in semi-Fowler's position, if possible. 3)Clean the stoma under the faceplate with hydrogen peroxide. 4)Cut a slit in sterile 4 × 4 gauze halfway through to make a dressing

ANS: 2 Semi-Fowler's position promotes lung expansion and prevents back strain for the nurse. You will need two pairs of sterile gloves: one pair for dressing removal, and a clean pair for the rest of the procedure. You should clean the stoma under the faceplate with sterile saline. Never cut a 4 × 4 gauze for the dressing because lint and fibers from the cut edge could enter the trachea and cause respiratory distress. PTS: 1 DIF: Easy REF: p. 1338 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

The nurse is admitting to the medical-surgical unit an older adult woman with a diagnosis of pulmonary hypertension and right-sided heart failure. The patient is complaining of shortness of breath, and the nurse observes conversational dyspnea. What is the first action the nurse should take? 1)Review and implement the primary care provider's prescriptions for treatments. 2)Perform a quick physical examination of breathing, circulation, and oxygenation. 3)Gather a thorough medical history, including current symptoms, from the family. 4)Administer oxygen to the patient through a nasal cannula.

ANS: 2 The first action the nurse should take is to make a quick assessment of the adequacy of breathing, circulation, and oxygenation in order to determine the type of immediate intervention required. The nurse's assessment should include simple questions about current symptoms. A more thorough medical history can be gathered once the patient's oxygenation needs are addressed. Following a quick assessment, the nurse should then review and implement physician's orders. Administering oxygen is not appropriate without knowing what treatments the primary care provider has prescribed. PTS:1DIF:ModerateREF:pp. 1301-1302 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

When providing safety education to the mother of a toddler, you would inform the mother that, based on the child's developmental stage, he is at high risk for which of the following factors that influence oxygenation? Choose all that apply. 1)Frequent, serious respiratory infections 2)Airway obstruction from aspiration of small objects 3)Drowning in small amounts of water around the home 4)Development of asthma

ANS: 2, 3 As a toddler's respiratory and immune systems mature, the risk for frequent and serious infections is less than in infanthood. Most children recover from upper respiratory infections without difficulty. Toddlers' airways are relatively short and small and may be easily obstructed, and they often put objects in their mouth as part of exploring their environment, thus increasing their risk for aspiration and airway obstruction. In addition, toddlers are at high risk for drowning in very small amounts of water around the home (e.g., in a bucket of water or toilet bowl). The risk for developing asthma is not significantly influenced by the child's developmental stage. PTS:1DIF:ModerateREF:p. 1297 KEY: Nursing process: Interventions | Client need: HPM | Cognitive level: Comprehension

Obesity is associated with higher risk for which of the following conditions that affect the pulmonary and cardiovascular systems? Choose all that apply. 1)Reduced alveolar-capillary gas exchange 2)Lower respiratory tract infections 3)Sleep apnea 4)Hypertension

ANS: 2, 3, 4 Obesity causes multiple health problems, many of which affect the lungs, heart, and circulation. Large abdominal fat stores press upward on the diaphragm, preventing full chest expansion and leading to hypoventilation and dyspnea on exertion. The risk for respiratory infection increases because lower lung segments are poorly ventilated, and secretions are not removed effectively. When an obese person lies down, chest expansion is limited even more. Excess neck girth and fat stores in the upper airway often lead to obstructive sleep apnea. Obesity also increases the risk of developing atherosclerosis and hypertension. Obesity does not cause reduced alveolar-capillary gas exchange. PTS: 1 DIF: Easy REF: p. 1299 KEY: Nursing process: Assessment | Client need: HPM | Cognitive level: Comprehension

The nurse administers an antitussive/expectorant cough preparation to a patient with bronchitis. Which of the following responses indicates to the nurse that the medication is effective? 1)The amount of sputum the patient expectorates decreases with each dose administered. 2)Cough is completely suppressed, and she is able to sleep through the night. 3)Dry, unproductive cough is reduced, but her voluntary coughing is more productive. 4)Involuntary coughing produces large amounts of thick yellow sputum.

ANS: 3 Antitussives are cough suppressants that reduce the frequency of an involuntary, dry, nonproductive cough. Antitussives are useful for adults when coughing is unproductive and frequent, leading to throat irritation or interrupted sleep. Expectorants help make coughing more productive. The goal of an antitussive/expectorant combination is to reduce the frequency of dry, unproductive coughing while making voluntary coughing more productive. PTS:1DIFgrinifficultREF:p. 1310 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

Which of the following provide the most reliable data about the effectiveness of airway suctioning? 1)The amount, color, consistency, and odor of secretions 2)The patient's tolerance for the procedure 3)Breath sounds, vital signs, and pulse oximetry before and after suctioning 4)The number of suctioning passes required to clear secretions

ANS: 3 Breath sounds, vital signs, and oxygen saturation levels before and after suctioning provide data about the effectiveness of suctioning. Information about the amount and appearance of secretions provides data about the likelihood of airway infection and/or inflammation. Data about the patient's tolerance of suctioning provide information about the patient's overall condition. The number of suctioning passes required to clear the secretions provides information about the amount of secretions present. PTS: 1 DIF: Moderate REF: p. 1351 KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Application

Chest percussion and postural drainage would be an appropriate intervention for which of the following conditions? 1)Congestive heart failure 2)Pulmonary edema 3)Pneumonia 4)Pulmonary embolus

ANS: 3 Chest physiotherapy moves secretions to the large, central airways for expectoration or suctioning. This treatment is not effective for conditions that do not involve the development of airway secretions, including congestive heart failure, pulmonary edema, and pulmonary embolus. PTS:1DIF:ModerateREF:p. 1313 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Comprehension

A patient has just had a chest tube inserted to dry-seal suction drainage. Which of the following is a correct nursing intervention for maintenance? 1)Keep the head of the bed flat for 6 hours. 2)Immobilize the patient's arm on the affected side. 3)Keep the drainage system lower than the insertion site. 4)Drain condensation into the humidifier when it collects in the tubing.

ANS: 3 The drainage system must be below the insertion site to prevent fluid flowing back into the pleural cavity and compromising the patient's respiratory status. Maintain patient in semirecumbent position (head of bed elevated 30 to 45 degrees), not flat. This is extremely important to promote lung expansion, reduce gastric reflux, and prevent ventilator-associated pneumonia (VAP), if the person is being mechanically ventilated. Patients being mechanically ventilated are at high risk for developing VAP, which is associated with high mortality rates. Mouth rinses and mouthwashes are a part of the recommended routine for preventing VAP. They also provide comfort and preserve integrity of the mucous membranes. Encourage the patient to move the arm on the affected side; if he cannot, perform passive range-of-motion. You should check the ventilator tubing frequently for condensation, and drain the fluid into a collection device or waste receptacle because condensation in the ventilator tubing can cause resistance to airflow. Moreover, the patient can aspirate it if it backflows down into the endotracheal tube. The fluid should not be drained into the humidifier because the patient's secretions may have contaminated it. PTS: 1 DIF: Difficult REF: p. 1353 KEY: Nursing process: Interventions | Client need: SECE | Cognitive level: Application

A 62-year-old man with emphysema says, "My doctor wants me to quit smoking. It's too late now, though; I already have lung problems." Which of the following would be the best response to his statement? 1)"You should quit so your family does not get sick from exposure to secondhand smoke." 2)"You will need to use oxygen, but remember it is a fire hazard to smoke with oxygen in your home." 3)"Once you stop smoking, your body will begin to repair some of the damage to your lungs." 4)"You should ask your primary care provider for a prescription for a nicotine patch to help you quit."

ANS: 3 The nurse's response should focus on correcting the patient's misinformation rather than on convincing him to stop smoking. Once a person stops smoking, the body begins to repair the damage. During the first few days, the person will cough more as the cilia begin to clear the airways. Then the coughing subsides, and breathing becomes easier. Even long-time smokers can benefit from smoking cessation. The suggestions that the patient's family will become ill and that oxygen is a fire hazard appear to be scare tactics, which can be seen as coercive, and would not be effective in motivating the patient to stop smoking. Although asking the primary care provider for a prescription may help the patient to stop smoking, it does not address his incorrect belief that it is "too late" for him to do so. PTS:1DIF:ModerateREF:p. 1299 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

Of the following interventions, which is/are likely to reduce the risk of postoperative atelectasis? Choose all that apply. 1)Administer bronchodilators. 2)Apply low-flow oxygen. 3)Encourage coughing and deep breathing. 4)Administer pain medication.

ANS: 3, 4 Pain alters the rate and depth of respirations. Often, patients in pain breathe shallowly, which puts them at risk for atelectasis. Regularly assess all patients for pain. Once you have medicated the patient, reassess breath sounds, and encourage the patient to cough and breathe deeply. This will help to open air sacs and mobilize secretions in the airways. PTS: 1 DIF: Moderate REF: pp. 1303, 1313 ; critical-thinking item that requires synthesis of information KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Synthesis

Which of the following blood levels normally provides the primary stimulus for breathing? 1)pH 2)Oxygen 3)Bicarbonate 4)Carbon dioxide

ANS: 4 Carbon dioxide (CO2) level provides the primary stimulus to breathe. High CO2 levels stimulate breathing to eliminate the excess CO2. A secondary, although important, drive to breathe is hypoxemia. Low blood O2 levels stimulate breathing to bring more oxygen into the lungs. PTS:1DIF:ModerateREF:p. 1296 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Recall

The nurse administers intravenous morphine sulfate to a patient for pain control. She will need to monitor her patient for which of the following adverse effects? 1)Decreased heart rate 2)Muscle weakness 3)Decreased urine output 4)Respiratory depression

ANS: 4 Opioids are potent respiratory depressants. Patients receiving opioids should be monitored for decreased rate and depth of respirations. PTS:1DIF:ModerateREF:pp. 1299, 1305; critical-thinking and synthesis required KEY: Nursing process: Evaluation | Client need: PHSI | Cognitive level: Comprehension

While a patient is receiving hygiene care, her chest tube becomes disconnected from the water-seal chest drainage system (CDU). Which action should the nurse take immediately? 1)Clamp the chest tube close to the insertion site. 2)Set up a new drainage system, and connect it to the chest tube. 3)Have the patient take and hold a deep breath while the nurse reconnects the tube to the CDU. 4)Place the disconnected end nearest the patient into a bottle of sterile water.

ANS: 4 Recollapse of the lung can occur because of loss of negative pressure within the system. This is commonly caused by air leaks, disconnections, or cracks in the bottles or chambers. If any of these occur, the nurse should immediately place the disconnected end nearest the patient into a bottle of sterile water or saline to a depth of 2 cm to serve as an emergency water seal until a new system can be connected. Do not clamp the chest tube because this can rapidly lead to a tension pneumothorax. A new drainage system should be set up to decrease the risk of infection, but the immediate action is to place the disconnected end into a bottle of sterile water. PTS:1DIF:ModerateREF:p. 1322 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Analysis

You are admitting a 54-year-old patient with chronic obstructive pulmonary disease (COPD). The physician prescribes O2 at 24% FIO2. What is the most appropriate oxygen delivery method for this patient? 1)Nonrebreather mask 2)Nasal cannula 3)Partial rebreather mask 4)Venturi mask

ANS: 4 The Venturi mask is capable of delivering 24% to 50% FIO2. The cone-shaped adapter at the base of the mask allows a precise FIO2 to be delivered. This is very useful for patients with chronic lung disease. Rebreather masks are used when high concentrations of oxygen are required. A nasal cannula administers oxygen in liters per minute and does not allow administration of a precise FIO2. PTS:1DIFgrinifficultREF:p. 1335 KEY: Nursing process: Interventions | Client need: PHSI | Cognitive level: Application

You are caring for a young adult patient with an intracranial hemorrhage secondary to a closed head injury. During your assessment, you notice that the patient's respirations follow a cycle progressively increasing in depth, then progressively decreasing in depth, followed by a period of apnea. Which of the following appropriately describes this respiratory pattern? 1)Biot's breathing 2)Kussmaul's respirations 3)Sleep apnea 4)Cheyne-Stokes respirations

ANS: 4 This respiratory pattern is known as Cheyne-Stokes respirations. It is often associated with damage to the medullary respiratory center or high intracranial pressure due to brain injury. PTS:1DIF:EasyREF:p. 1303 KEY: Nursing process: Assessment | Client need: PHSI | Cognitive level: Comprehension