Chapter 39, Oxygenation and Perfusion

Which of the following diseases may result in decreased lung compliance? A) Emphysema B) Appendicitis C) Acne D) Chronic diarrhea

A) Emphysema Lung compliance refers to the stretchability of the lungs, or the ease with which lungs can be inflated. Emphysema, a chronic lung disease, and the normal changes associated with aging are examples of conditions that result in decreased elasticity of lung tissue, which in turn decreases lung compliance.

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

A) Crackles in the lower lobes People with chronic congestive 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.

A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them? A) "It is inserted into the space between the lining of the lungs and the ribs." B) "I don't exactly know, but I will make sure the doctor comes to explain." C) "It is inserted directly into the lung itself, connecting to a lung airway." D) "It is inserted into the peritoneal space and drains into the lungs."

A) "It is inserted into the space between the lining of the lungs and the ribs." A chest tube is a firm plastic tube with drainage holes in the proximal end that is inserted into the pleural space, thus allowing compressed lung tissue to re-expand.

A nurse is educating a preoperative client on how to effectively deep breathe. Which of the following would be included? A) "Make each breath deep enough to move the bottom ribs." B) "Breathe through the mouth when you inhale and exhale." C) "Breathe in through the mouth and out through the nose." D) "Practice deep breathing at least once each week."

A) "Make each breath deep enough to move the bottom ribs." Instruct the client to make each breath deep enough to move the bottom ribs. Start with deep breaths by inhaling through the nose and exhaling through the mouth. Deep breathing should be done hourly when awake, or four times a day.

A client is experiencing hypoxia. Which of the following nursing diagnoses would be appropriate? A) Anxiety B) Nausea C) Pain D) Hypothermia

A) Anxiety Clients who are hypoxic commonly experience anxiety and restlessness related to feelings of suffocation.

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of A) Atelectasis B) Bronchospasm C) Croup D) Epiglottitis

A) Atelectasis Stiffer lungs tend to collapse and their alveoli also collapse. This condition is called atelectasis.

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that apriority nursing diagnosis for this client is "Ineffective Airway Clearance related to copious and tenacious secretions." Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan? A) Encouraging the client to consume two to three quarts of clear fluids daily B) Creating an environment that is likely to reduce anxiety C) Positioning the client supine D) Encouraging the client to decrease the number of cigarettes smoked daily

A) Encouraging the client to consume two to three quarts of clear fluids daily Clients can help keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of clear fluids daily. Although it is important to create an environment that is likely to reduce a client's anxiety, doing so will not assist in promoting airway clearance. The nurse should not encourage the client to decrease the number of cigarettes smoked daily, but should encourage the client to stop smoking. Proper positioning to ease respirations includes placing the client in a high- Fowler's position.

An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur? A) Inspiration and expiration B) Only on inspiration C) Only on expiration D) When coughing

A) Inspiration and expiration Wheezes are continuous sounds heard on expiration and sometimes on inspiration. They originate as air passes through airways constricted by swelling (as in asthma), secretions, or tumors.

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula? A) It can cause the nasal mucosa to dry in case of high flow. B) It can cause anxiety in clients who are claustrophobic. C) It can create a risk of suffocation. D) It can result in an inconsistent amount of oxygen.

A) It can cause the nasal mucosa to dry in case of high flow When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss.

A nurse is caring for an older adult client who is to be discharged from the health care facility. The client has been prescribed the use of a liquid oxygen unit at home to continue with oxygen therapy. What should the nurse tell the client regarding the potential problems of using a liquid oxygen unit? Select all that apply. A) Liquid oxygen may leak during warm weather. B) The unit may give off a bad smell if not cleaned regularly. C) The unit's outlet may become occluded because of frozen moisture. D) Portable liquid oxygen is more expensive. E) The unit may require a secondary source of oxygen.

A) Liquid oxygen may leak during warm weather. C) The unit's outlet may become occluded because of frozen moisture. D) Portable liquid oxygen is more expensive. The nurse should inform the client who has been prescribed the use of a liquid oxygen unit that the unit may leak during warm weather; frozen moisture may occlude the outlet; and the unit is more expensive when compared with other portable sources of oxygen. Emission of a bad smell if filters are not cleaned, increase in the electric bill, and requirement of a secondary source of oxygen in case of failure are disadvantages of using an oxygen concentrator and are not related to the use of a liquid oxygen unit.

A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply. A) Monitor the client's respiratory rate. B) Note the amount of oxygen administered. C) Check the symmetry of the client's chest. D) Observe the breathing pattern and effort. E) Check the devices used to deliver oxygen.

A) Monitor the client's respiratory rate. C) Check the symmetry of the client's chest. D) Observe the breathing pattern and effort. When physically assessing the quality of the client's oxygenation, the nurse should monitor the client's respiratory rate, check the symmetry of the client's chest, and observe the breathing pattern and effort of the client. The nurse should also auscultate for lung sounds. Additional assessments include recording the heart rate and blood pressure, determining the client's level of consciousness, and observing the color of the skin, mucous membranes, lips, and nailbeds. However, the nurse does not note the amount of oxygen administered to the client, or check the device that is used to deliver oxygen to the client during the physical assessment.

A woman 90 years of age has been in an automobile crash and sustained four fractured ribs on the left side of her thorax. Based on her age and the injury, she is at risk for what complication? A) Pneumonia B) Altered thought processes C) Urinary incontinence D) Viral influenza

A) Pneumonia The normal changes in the respiratory system associated with aging (such as rigidity of tissues and airways and decreased movement of the diaphragm) coupled with fractured ribs would increase the risk of pneumonia in an older adult.

The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the client's care plan? A) Provide six small meals daily. B) Provide three large meals daily. C) Encourage the client to eat immediately before breathing treatments. D) Encourage the client to alternate eating and using a nebulizer during meal time.

A) Provide six small meals daily. The nurse should consider providing six small meals distributed over the course of the day instead of three large meals. Meals should be eaten one to two hours after breathing treatments and exercises.

While the nurse is providing morning hygiene for a client who has a chest tube, the client has rolled over quickly and the chest tube has become disconnected from the drainage unit. How should the nurse first respond to this event? A) Submerge the end of the tube in sterile water. B) Clamp the tube near the end and also near the insertion point. C) Place the end of the tube on a sterile surface and seek help promptly. D) Clean the end of the tube with an alcohol swab and reconnect it to the drainage unit.

A) Submerge the end of the tube in sterile water. If a chest tube becomes disconnected from the drainage unit, the nurse should submerge the end of the tube in a bottle of sterile water, thus preventing a pneumothorax but still allowing air to escape.

A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate? A) changes in the alveolar-capillary membrane and diffusion B) alterations in the structures of the ribs and diaphragm C) rapid decreases in atmospheric and intrapulmonic pressures D) lower-than-normal concentrations of environmental oxygen

A) changes in the alveolar-capillary membrane and diffusion Any change in the surface area of the lungs hinders diffusion of gas exchange. Any disease or condition that results in changes in the alveolar-capillary membrane, such as pneumonia or pulmonary edema, makes diffusion more difficult, assessed by decreased oxygen saturation measurement.

A father of a preschool-age child tells the nurse that his child "has had a constant cold since going to daycare." How would the nurse respond? A) "Your child must have a health problem that needs medical care." B) "Children in daycare have more exposure to colds." C) "Are you washing your hands before you touch the child?" D) "Be sure and have your child wear a protective mask at school."

B) "Children in daycare have more exposure to colds." The preschool-age child's eustachian tubes, bronchi, and bronchioles are elongated and less angular. Thus, the average number of routine colds and infections increases when the child enters daycare or school and is exposed more frequently to pathogens.

What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home? A) "Although the test is uncomfortable, it is not painful." B) "You will be asked to forcefully exhale into a mouthpiece." C) "The test is used to determine how much air you inhale." D) "You will do this each morning while still lying in bed."

B) "You will be asked to forcefully exhale into a mouthpiece." Peak expiratory flow rate (PEFR) refers to the volume of air that can be forcibly exhaled. While sitting or standing, the client takes a deep breath and forcibly exhales through a mouthpiece. The client does this three times, and the highest number is recorded. Clients commonly measure PEFR at home to monitor airflow when they have conditions such as asthma.

Which individual is at greater risk for respiratory illnesses from environmental causes? A) A farmer on a large farm B) A factory worker in a large city C) A woman living in a small town D) A child living in a rural area

B) A factory worker in a large city Researchers have demonstrated a high correlation between air pollution and lung diseases, including cancer. Air pollution puts people with certain occupations, and those who live in large cities, at a greater risk for these diseases.

A nurse is educating a client who has congested lungs how to keep secretions thin, and more easily coughed up and expectorated. What would be one self-care measure to teach? A) Limit oral intake of fluids to less than 500 mL per day. B) Increase oral intake of fluids to two to three quarts per day. C) Maintain bed rest for at least three days. D) Take warm baths every night for a week.

B) Increase oral intake of fluids to two to three quarts per day. Clients can keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of clear fluids daily. Fluid intake should be increased to the maximum the client's health state can tolerate.

A nurse is caring for a toddler who is having an acute asthmatic attack with copious mucus and difficulty breathing. The child's skin is cyanotic, respirations are labored and rapid, and pulse is rapid. What nursing diagnosis would have priority for care of this child? A) Anxiety B) Ineffective Airway Clearance C) Excess Fluid V olume D) Disturbed Sensory Perception

B) Ineffective Airway Clearance The nursing diagnosis Ineffective Airway Clearance indicates the child is unable to clear secretions or obstructions from the respiratory tract to maintain a clear airway. Although the child is anxious, this is not the priority of care. The other two diagnoses are not supported by the data.

A nurse is conducting a health promotion program for adolescents to educate them about the hazards of smoking. When describing the effects on the respiratory system, which of the following would the nurse most likely include? A) Decreased production of mucus B) Inhibition of mucus removal C) Increase in the mucous escalator D) Inhibition of bacterial colonization

B) Inhibition of mucus removal Smoking inhibits mucus removal. By producing more mucus and by slowing the mucous escalator, smoking inhibits mucus removal and can cause airway blockage, promoting bacterial colonization and infection.

A nurse is educating a postoperative client on how to use an incentive spirometer. Which of the following is an accurate step that should be included in the teaching plan? A) Instruct the client to inhale normally and then place the lips securely around the mouthpiece. B) Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose. C) When the client cannot inhale anymore, the patient should hold his or her breath and count to 10. D) Encourage the client to perform incentive spirometry two to three times every one to two hours, if possible.

B) Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose. The client using an incentive spirometer should exhale normally and place the lips around the mouthpiece. He or she should inhale slowly and deeply without using the nose, and when the client cannot inhale anymore, hold the breath and count to 3 before exhaling normally. This should be performed 5 to 10 times every one to two hours, if possible.

A physician prescribes the use of water-seal chest tube drainage for a client at a health care facility. What should the nurse ensure when using the water-seal chest tube drainage? A) Filters need to be cleaned regularly to avoid unpleasant taste or smell. B) The chest tube should not be separated from the drainage system unless clamped. C) A nasal cannula should be used to administer oxygen when cleaning the opening. D) A secondary source of oxygen should be available in case of power failure.

B) The chest tube should not be separated from the drainage system unless clamped. When using water-seal chest tube drainage, the nurse should never separate the chest tube from the drainage system unless clamped. Even then, the tube should be clamped only briefly. When using an oxygen concentrator as a source of oxygen, the nurse should clean the filter regularly to avoid an unpleasant taste or smell. A secondary source of oxygen should also be available in case of a power failure. When cleaning a transtracheal catheter, oxygen needs to be administered with a nasal cannula.

What prevents air from re-entering the pleural space when chest tubes are inserted? A) The location of the tube insertion B) The sutures that hold in the tube C) A closed water-seal drainage system D) Respiratory inspiration and expiration

C) A closed water-seal drainage system After insertion, the chest tube is secured with a suture and tape, covered with an airtight dressing, and usually attached to a closed water-seal drainage system that prevents air from reentering the pleural space.

Of all factors, what is the most important risk factor in pulmonary disease? A) Air pollution from vehicles B) Dangerous chemicals in the workplace C) Active and passive cigarette smoke D) Loss of the ozone layer of the atmosphere

C) Active and passive cigarette smoke The effects of both active and passive cigarette smoke increase airway resistance, reduce ciliary action, increase mucus production, and thicken alveolar-capillary membranes and bronchial walls. Cigarette smoke is the most important risk factor in pulmonary disease.

What does pulse oximetry measure? A) Cardiac output B) Peripheral blood flow C) Arterial oxygen saturation D) V enous oxygen saturation

C) Arterial oxygen saturation Pulse oximetry is a noninvasive technique that measures the oxygen saturation of arterial blood. The normal range is 95% to 100%. It does not measure cardiac output, peripheral blood flow, or venous oxygen saturation.

A nurse is caring for a client who suddenly begins to have respiratory difficulty. In what position would the nurse place the client to facilitate respirations? A) Supine B) Prone C) High-Fowler's D) Dorsal recumbent

C) High-Fowler's During inspiration, the diaphragm contracts and descends, lengthening the thoracic cavity. This movement isfacilitated by a high-Fowler's position in which the abdominal contents move downward, providing more room for the descent of the diaphragm and greater lung expansion.

A nurse is delivering oxygen to a client via an oxygen mask. Which of the following is a recommended guideline for this procedure? A) Adjust the mask so it fits tightly around the face. B) For a mask with a reservoir, fill the reservoir half-full of oxygen. C) Remove the mask and dry the skin every two to three hours if the oxygen is running continuously. D) If the client is experiencing redness around the mask, remove and apply powder to the mask.

C) Remove the mask and dry the skin every two to three hours if the oxygen is running continuously. To apply an oxygen mask, position the facemask over the client's nose and mouth and adjust the elastic strap so that the mask fits snugly, but comfortably, on the face. For a mask with a reservoir, be sure to allow oxygen to fill the bag before proceeding to the next step. Remove the mask and dry the skin every two to three hours if the oxygen is running continuously; do not use powder around the mask.

A client has had a head injury affecting the brain stem. What is located in the brain stem that may affect respiratory function? A) Chemoreceptors B) Stretch receptors C) Respiratory center D) Oxygen center

C) Respiratory center The medulla in the brain stem, immediately above the spinal cord, is the respiratory center. Stretch receptors are located in muscles. Chemoreceptors that affect respirations are located in the aortic arch and the carotid bodies.

A nurse assesses the vital signs of a healthy newborn infant. What respiratory rate could be expected based on the developmental level of this client? A) 15 to 25 breaths/minute B) 16 to 20 breaths/minute C) 20 to 44 breaths/minute D) 30 to 55 breaths/minute

D) 30 to 55 breaths/minute The normal range for an infant's breath per minute is 30 to 60.

What category of medications may be administered by nebulizer or metered-dose inhaler to open narrowed airways? A) Bronchoconstrictors B) Antihistamines C) Narcotics D) Bronchodilators

D) Bronchodilators A nebulizer is used to adminster medications in the form of an inhaled mist. Bronchodilators are medications that may be administered by nebulizer or metered-dose inhaler to open narrowed airways. Antihistamines are not administeredvia nebulizer; they are prescribed to manage allergy-related symptoms. Narcotics are not administered via nebulizer; they are used to manage complaints of pain.

A physician is choosing a chest drainage system for a client who is ambulating daily. Which of the following systems would be the best choice for this client? A) Traditional water seal B) Wet suction C) Dry suction water seal D) Dry suction/one-way valve system

D) Dry suction/one-way valve system The dry suction or one-way valve system works even if knocked over, making it ideal for clients who are ambulatory.

In what age group would a nurse expect to assess the most rapid respiratory rate? A) Older adults B) Middle adults C) Adolescents D) Infants

D) Infants The normal infant's chest is small and the airways are short. There are fewer and smaller alveoli in infants. As a result, the respiratory rate is more rapid in infants than any other age group.

A nurse is beginning to conduct a health history for a client with respiratory problems. He notes that the client is having respiratory distress. What would the nurse do next? A) Continue with the health history, but more slowly. B) Ask questions of the family instead of the client. C) Conduct the interview later and let the client rest. D) Initiate interventions to help relieve the symptoms.

D) Initiate interventions to help relieve the symptoms. Before beginning the interview for a health history, the nurse should ascertain that the client is not in acute distress. If the client is experiencing any respiratory distress, the nurse immediatelyinitiates interventions to help relieve symptoms.

A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure? A) Using upper chest muscles more effectively B) Replacing the use of incentive spirometry C) Reducing the need for p.r.n. pain medications D) Prolonging expiration to reduce airway resistance

D) Prolonging expiration to reduce airway resistance Pursed-lip breathing can help clients with dyspnea and feelings of panic gain control of their respirations. This exercise trains the muscles to prolong expiration, increasing airway pressure during expiration, and reducing the amount of airway trapping and resistance.