Oxygenation and Perfusion 39

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 will warm, filter, and humidify the air you are breathing."

%. Simple masks and partial rebreathers both deliver a low-flow rate at concentrations of

40%-60%.

A nurse is preparing to use a wall unit to suction the endotracheal tube of a 9-year-old child. At what pressure should the suction be set?

80 to 125 mm Hg

The client's target oxygen saturation would be ____________ if the client had chronic obstructive pulmonary disease (COPD).

88% to 92%

Nasal cannula percent oxygen

A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44%

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation?

ABG

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

The nurse is planning care for a client who is prescribed a simple mask for oxygen delivery. What intervention will the nurse include in the plan of care?

Assess the client for anxiety due to claustrophobia

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which assessment finding is consistent with hypoxia?

Confusion

The nurse is preparing a client for a complete blood count test. Which actions would the nurse perform? Select all that apply.

Inform the client that this test can assist in evaluating the body's response to illness. Inform the client that specimen collection takes approximately 5 to 10 minutes. Explain that, based on results, additional testing may be performed.

A nurse is overseeing the care of a client who is receiving oxygen via nasal cannula. Which aspects of the client's care can the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply.

Measuring the client's respiratory rate Inserting the client's nasal cannula after it has become dislodged Reapplying the client's nasal cannula after a bath

A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply.

Nasal cannula Simple oxygen mask Partial rebreather mask

A nurse must take a client's pulse oximetry reading. The nurse is explaining the technique to the client. Which statements about pulse oximetry are true? Select all that apply.

Once the oximetry probe is correctly placed, a beam of red and infrared light travels through the tissue and blood vessels. Sensors are available for use on the finger, toe, foot, earlobe, forehead, and bridge of the nose.

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?

Pulmonary function tests

The nurse is observing the unlicensed assistive personnel (UAP) perform oropharyngeal suctioning on a client. Which action, performed by the UAP, would indicate to the nurse that suctioning is being properly performed?

The UAP advances the catheter approximately 3 to 4 inches to reach the pharynx.

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression.

The nurse performs assessments of cardiopulmonary functioning and oxygenation during regular physical assessments. Based on developmental variations, which findings would the nurse consider normal? Select all that apply.

The power of the respiratory and abdominal muscles is reduced in older adults, and therefore the diaphragm moves less efficiently. The normal infant's chest is small and the airways are short, making aspiration a potential problem. Alterations in respiratory function due to aging in older adults increase the risk for disease, especially pneumonia and other chest infections. The respiratory rate is more rapid in infants until the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates.

A nurse assessing a client's respiratory effort notes that the client is breathing 8 shallow breaths/min. Which action best meets this client's immediate oxygenation needs?

Use a bag and mask.

A decrease in the rate of respirations can cause

an increase in carbon dioxide and decrease in hydrogen ions.

Sputum that is yellow or greenish and/or has a musty odor usually indicates

an infection. As such, the nurse should auscultate breath sounds to help determine the extent of the infection.

Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize

atelectasis.

Medium-pitched blowing sounds heard over the major bronchi describe

bronchovesicular breath sounds

The nurse is admitting a new client who has had a chest tube inserted on the right side. Which action should the nurse prioritize for this client?

coughing and deep breathing at least q2h while awake Coughing and deep breathing will help promote lung re-expansion because it will help evacuate the air and fluid.

Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways

decreases the amount of air trapping and resistance

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an

expected and normal finding.

The home health nurse arrives at a client's home and immediately notes the client is experiencing increased dyspnea. The client has a 7-year history of chronic obstructive pulmonary disease (COPD). Which assessment finding should the nurse prioritize?

flow meter set at 5 liters of oxygen

Alterations in respiratory function due to aging in older adults

increase the risk for disease, especially pneumonia and other chest infections.

While nurses use a variation of several interventions to mobilize secretions in clients who have respiratory impairment, the nurse will first attempt to

liquefy secretions prior to performing other interventions to promote secretion mobility. In the case of a client that requires a sputum specimen and has a nonproductive cough, liquefying secretions first is a priority.

Bronchial breath sounds are

loud, high-pitched sounds heard over the trachea and larynx.

The trachea, bronchi, and lungs are major organs of the

lower respiratory tract.

In the infant, flaring of the nostrils and retractions of the ribs during inspiration are

notable signs of air hunger and extraordinary work of breathing.

The nurse is teaching a client and caregiver how to properly use an incentive spirometer. Place the following steps in the correct order. Use all options.

note the goal for inhalation exhale normally seal the lips around the mouthpiece inhale slowly until reach desired volume hold breath for 4 seconds remove mouthpiece and breathe normally

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?

presence of fluid in the lungs

A humidifier is a device that

produces small water droplets and may be used during oxygen administration because oxygen dries the mucous membranes.

What structural changes to the respiratory system should a nurse observe when caring for older adults?

respiratory muscles become weaker

The normal infant's chest is

small and the airways are short, making aspiration a potential problem.

The health care provider should be notified as feeling or hearing air crackling on a chest tube site can indicate a

subcutaneous air leak and an internal displacement of the drainage tube. This requires emergent care to prevent the recurrence or further damage to the lung

The respiratory rate is more rapid in infants until

the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates

A nurse caring for a client with a chest tube should monitor

the patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system

An oxygen analyzer is a device that measures

the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician

An older adult client was recently placed on home oxygen. The client's caregiver reports that the client now refuses to leave the house. What teaching will the nurse provide the caregiver? Select all that apply.

"Continued socialization with others is important." "Discuss with the client switching to a portable oxygen device." "Invite friends and family to the client's house

The home health nurse is visiting a new client who has recently started using an oxygen concentrator. After assessing the home environment, which comment should the nurse prioritize?

"Have you discussed a back-up system with your health care provider in case your electricity goes out?"

Which response(s) will the nurse provide to a client concerned about developing chronic bronchitis due to smoking cigarettes, working with printing chemicals, and living near a paper mill? Select all that apply.

"Have you tried to stop smoking? This can reduce your risk?" "We can refer you to a smoking cessation program to help reduce developing any future pulmonary issues." "How long have you lived near the paper mill? This can increase you risk for chronic bronchitis and asthma." "Exposure to printing chemicals increases the risk for allergies which can trigger chronic bronchitis, so wearing a breathing mask may be needed."

A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response?

"I can assist you to the bathroom and back to bed." The client can move in bed, and ambulate while carrying the drainage system, as long as he or she has orders to do so.

Nasal cannula with tubing administers oxygen at low-flow rates and concentrations at

22%-44%.

When utilizing a wall unit to suction an endotracheal tube, the pressure should be set at

80 to 150 mm Hg. This level will provide enough pressure to suction out secretions from the endotracheal tube.

A client with chronic obstructive pulmonary disease who uses supplemental oxygen via mask requires oral suctioning. Which action(s) demonstrates the components of appropriate oral suctioning technique by the nurse? Select all that apply.

Allowing client to rest for 30 to 60 seconds in between suctionings Removing the client's oxygen and inserting the yankauer catheter into client's mouth Replacing oxygen on client and clearing out suction catheter by placing yankauer in the basin of water Running the catheter along the client's gum line to the pharynx in a circular motion while keeping yankauer moving

The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider?

An infant with a respiratory rate of 16 bpm

The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take?

Assess oxygen tubing connection

When the nurse observes a newborn infant demonstrating an irregular abdominal breathing pattern, with a respiratory rate of 40 breaths/minute with occasional pauses in breathing of 5-second duration. What is the most appropriate action by the nurse?

Continue to assess the infant. Infants breathe rapidly at 30 to 60 breaths/minute and may have occasional pauses of several seconds between breaths.

A nurse is conducting a physical assessment of a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the client's oxygenation. What instruction should the nurse give the client?

Contract the abdominal muscles.

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?

Corticosteroids

The nurse is assessing a client with a chest tube that has been inserted after experiencing blunt trauma that resulted in a pneumothorax. What nursing action is appropriate when constant bubbling is noted in the suction control chamber?

Document the finding. Constant bubbling in the suction control chamber is normal and should be documented.

An older adult client visits a health care facility for a scheduled physical assessment. During the assessment, the client reports difficulty breathing. Which suggestion could the nurse make to improve the client's respiratory function?

Drink liberal amounts of fluids.

The nurse is caring for a client with emphysema who has been prescribed portable oxygen, 2 L/min. Which action(s) does the nurse take to administer low concentrations of oxygen to the client? Select all that apply.

Ensure that the oxygen concentrator is turned on Confirm that the nasal cannula is worn properly by the client Verify the oxygen concentrator is set on the prescribed flow rate

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

Flow meter

Setting Suction for Airways:

For a wall suction unit for an adult: 100 to 150 mm Hg; neonates: 60 to 80 mm Hg; infants: 80 to 125 mm Hg; children: 80 to 125 mm Hg; adolescents: 80 to 150 mm Hg.

The nurse prepares the client for a 12-lead electrocardiogram (ECG). Which actions should the nurse provide? Select all that apply.

Instruct the client to relax arms away from waist and legs not touching the footboard. Prepare skin, removing excess oil and clip areas of excessive hair. Place self-stick electrodes and place according to anatomical locations. Explain that the client needs to lie still and not talk during the ECG recording.

The nursing assessment reveals reduced fremitus. This manifestation is consistent with which conditions? Select all that apply.

Left-sided heart failure Pneumothorax Pulmonary edema Bronchial obstruction

Upon entering a client's room, the nurse notes the client's pulse oximetry to be 86%. What is the priority nursing action?

Perform a respiratory assessment.

During assessment of a 4-year-old client, the nurse notes a respiratory rate of 30 breaths/min and a loud, harsh expiration that is longer than inspiration. The nurse would implement which appropriate nursing intervention next?

Proceed with the assessment When collecting respiratory data on a 4-year-old, loud, harsh expiration longer than inspiration breath sounds and respiratory rate of 25-32 breaths/min are normal findings; therefore, the nurse would continue with the assessment

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?

Vesicular

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.

Blood gases determine the

adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.

Asthma is a condition associated with

bronchoconstriction. The symptoms include nonproductive cough, dyspnea, and wheezing

Bronchiectasis results from

chronic inflammation or infection causing an excess accumulation of mucus.

During exhalation, the pressure in the chest

increases, allowing air to flow out of the lungs

The client elevates the ribs and sternum and expands the thoracic cavity during

inspiration.

Which is a sign of dyspnea specific to infants?

nasal flaring

Arterial blood gases include the levels of

oxygen, carbon dioxide, bicarbonate, and pH

The nurse is reviewing the results of a client's arterial blood gas and pH analysis. Which findings indicate to the nurse that intervention is not required? Select all that apply

pH 7.45 PCO2 40 mm Hg Base excess or deficit +2 mmol/L

· Normal ABG findings include a

pH of 7.35-7.45, PCO2 35-45 mm Hg, PO2 80-100 mm Hg, and Base excess or deficit +2 mmol/L

Atelectasis refers to the

partial or complete collapse of the small air sacs in the lungs, common after surgery or with obstruction or compression of the airways or lungs.

The nurse is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly?

reads 0.21 when checking oxygen in room air

The pharynx, mouth, and nose are major organs of the

upper respiratory tract.

The nurse is talking with a client who has chronic obstructive pulmonary disease (COPD). The client reports chest shape seems to have changed over the past year. What information should be provided by the nurse?

"Your lung condition limits the ability of the lungs to fully exhale, causing this change in shape." · In COPD, the client'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.

The obstetric nurse is assisting the birth of a preterm neonate. In preparing for the respiratory needs of the neonate, the nurse is aware that surfactant is formed in utero around:

34 to 36 weeks.

The flow meter for the simple mask is set at

5 L/min or higher to prevent rebreathing exhaled carbon dioxide

High percentages of oxygen are contraindicated for a client with

COPD, because the client has adapted to excessive levels of retained carbon dioxide and low blood oxygen levels to stimulate the drive to breathe. If a client with COPD receives more than 2 to 3 liters of oxygen over a sustained period, the respiratory rate slows or even stops

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 scenario describes how carbon dioxide levels determine the frequency and depth of ventilation?

When carbon dioxide levels in the blood increase, chemoreceptors are stimulated, causing deeper and more rapid breathing.

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?

high-Fowler's position

Anxiety, restlessness, confusion, or drowsiness are common signs of

hypoxia.

The nurse could suggest liberal fluid intake for the client in order to

improve respiratory function. Older adults need encouragement to maintain liberal fluid intake, which keeps the mucous membranes moist

Peripheral and central chemoreceptors in the aortic arch and carotid arteries and the medulla are sensitive to circulating blood levels of carbon dioxide and hydrogen ions. Increased carbon dioxide levels lead to

more rapid and deep breathing, whereas decreased carbon dioxide levels lead to slower and shallower respirations.

Vesicular breath sounds are

normal and described as low-pitched, soft sounds over the lungs' peripheral fields.

The nurse is assessing a client's chest tube which was inserted 48 hours earlier. The nurse notes crackling in the skin around the insertion site. Which action should the nurse prioritize?

notify the health care provider

To begin the oral suctioning the nurse

removes the client's oxygen and inserts the Yankauer catheter into client's mouth. The nurse applies suction by covering the thumb hole for a maximum of 10 to 15 seconds, not 45 to 60 seconds. Applying suction too long can result in shortness of breath, anxiety, and discomfort for the client

During inspiration,

the diaphragm and external intercostal muscles contract. Their contraction enlarges the thorax volume and decreases intrathoracic pressure. The expanding chest wall pulls the lungs outward. As the lungs expand, pressure drops within the airways.

The power of the respiratory and abdominal muscles is reduced in older adults, and therefore

the diaphragm moves less efficiently.

Pulmonary fibrosis is a condition in which

the lung tissue becomes stiff and unable to expand appropriately

A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determines that the education was successful when the students identify which activity as occurring during inspiration?

Intercostal muscles contract

Which factors indicate that the nurse should stop delivery of breaths via a manual resuscitation bag and mask device? Select all that apply.

The client has a return of spontaneous breathing at 15 breaths per minute. The client has been intubated and is connected to a mechanical ventilator. The health care provider has ended the cardiopulmonary resuscitation effort

A client has been receiving treatment with a nonrebreather mask for the past 96 hours. How should the nurse respond if the unlicensed assistive personnel (UAP) suddenly reports the client has vomited?

conduct a focused assessment The nurse should first conduct a focused assessment to gather more information. Individuals who have been receiving oxygen concentrations of more than 50% for longer than 72 hours are at an increased risk for oxygen toxicity. The signs are subtle and include nausea, vomiting, nonproductive cough, substernal chest pain, nasal stuffiness, fatigue, headache, sore throat and hypoventilation. After the nurse has finished assessing the client, then the health care provider should be notified of the findings of the assessment. The mask would need to be cleaned or replaced per the facilities policy

Crackles are soft, high-pitched, discontinuous popping sounds heard

on inspiration.

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?

trauma to the tracheal mucosa 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

For a child 6 to 12 years of age the normal respiratory rate is

18 to 26 breaths per minute.

A client is learning how to do diaphragmatic breathing. For which length of time will the nurse advise the client to rest between repetitions of the exercise?

2 minutes

The normal range for a child age 1 to 5 years is

20 to 32 breaths per minute.

The infant's normal respiratory rate is

20 to 40 breaths per minute.

The nurse is caring for a client with chronic obstructive pulmonary disease who has been admitted to the hospital unit for pneumonia. The nurse notes that the client has a nonproductive cough and has a SpO2 of 92%. Before attempting to obtain a sputum specimen, which action will the nurse take first?

Administer inhalation therapy using a nebulized mixture of oxygen and humidification.

Which should the nurse teach the family about caring for a client with emphysema at home? Select all that apply.

Maintain a smoke-free environment. Watch for increased wheezing or signs of a flare-up. Take advantage of pulmonary rehabilitation programs. Follow health care provider's prescription for oxygen administration. Create a long-term caregiving plan

Nurses may assist with inhalation therapy (respiratory treatments that provide a mixture of oxygen, humidification, and aerosolized medications directly to the lungs). The aerosol is delivered through a mask or a handheld mouthpiece. Aerosol therapy

improves breathing, encourages spontaneous coughing, and helps clients raise sputum for diagnostic purposes. After secretions have been liquefied, they will be easier to mobilize and reduce the risk of lung spasms in the client

Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate to observe in a client with these arterial blood gas results?

increase in rate and depth of respirations

Stimulation of the medulla

increases the rate and depth of ventilation to blow off carbon dioxide and hydrogen and increase oxygen levels. This compensatory mechanism causes the client to breathe faster and more deeply.

· Venturi masks

mix oxygen with room air and create a high flow of oxygen.

One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker. The nurse should also observe

other structural changes: the chest wall becomes stiffer as a result of calcification of the intercostals cartilage, kyphoscoliosis, and arthritic changes to costovertebral joints; the ribs and vertebrae lose calcium; the lungs become smaller and less elastic; alveoli enlarge; and alveolar walls become thinner. Diminished coughing and gag reflexes, increased use of accessory muscles for breathing, and increased mouth breathing and snoring are functional changes to the respiratory system in older adults.

A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving?

32%

The nurse is caring for a client with emphysema. A review of the client's chart reveals pH 7.36, PaO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription if prescribed by the health care practitioner?

4 L/minute O2 (66 mL/second) nasal cannula The client with chronic lung disease, such as emphysema, becomes insensitive to carbon dioxide and responds to hypoxia to stimulate breathing. If given excessive oxygen (4 L/minute or 66 mL/second), the stimulus to breathe is removed.

Bronchitis refers to a condition in which the

airways become inflamed, commonly due to respiratory irritants such as air pollution and high humidity. Exposure to such irritants leads to the release of inflammatory mediators, which in turn, lead to inflammation and narrowing of the airways and increased mucus production

The medulla in the brainstem is the respiratory center. The medulla is stimulated by

an increased concentration of carbon dioxide and hydrogen ions and, to a lesser degree, by the decreased amount of oxygen in the arterial blood.

A person can forcibly exhale additional air by

contracting abdominal muscles such as the rectus abdominis, transverse abdominis, and external and internal obliques.

Clubbing refers to the

rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many clients with chronic hypoxia due to respiratory or cardiac disease. Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD.

When performing oropharyngeal suctioning,

the catheter should be placed along the side of the mouth toward the trachea and advanced 3 to 4 inches to reach the pharynx. In nasopharyngeal suctioning, the catheter should be inserted through the naris and along the floor of the nostril toward the trachea; it should be advanced approximately 5 to 6 inches to reach the pharynx. Applying lubricant to the first 2 to 3 inches of the catheter facilitates passage of the catheter and reduces trauma to mucous membranes. Allowing 30-second to 1-minute intervals between suction passes allows for reventilation and reoxygenation of airways.

During exhalation,

the diaphragm and intercostal muscles relax, causing the thorax to return to its smaller resting size.

Atelectasis results when

the lungs collapse as a result of the alveoli being unable to expand. Symptoms include difficulty breathing and discomfort.

Pneumonia, which causes

the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases.