Oxygenation and Perfusion chapter 39
A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is: "He will require additional testing to determine the cause." "He is using his chest muscles to help him breathe." "His infection is causing him to breathe harder." "His lung muscles are swollen so he is using abdominal muscles."
"He is using his chest muscles to help him breathe." Explanation: The client will use accessory muscles to ease dyspnea and improve breathing.
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include? Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly. Take in a small amount of air very quickly and then exhale as quickly as possible. Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly. Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling
"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Explanation: Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.
A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention? Ask the client what factors contribute to nonadherence. Contact the health care provider to report the client's current status. Explain the use of a BiPAP mask instead of a CPAP mask. Document outcomes of modifications in care.
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 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? Set the flow meter to deliver oxygen at 2 L/min Monitor the client for oxygen toxicity Assess the client for anxiety due to claustrophobia Target the client's oxygen saturation to be 88% to 92% 90.88 to 0.92)
Assess the client for anxiety due to claustrophobia Explanation: A simple mask may cause anxiety in clients who experience claustrophobia due to the mask covering the nose and mouth. The flow meter for the simple mask is set at 5 L/min or higher to prevent rebreathing exhaled carbon dioxide. The client is not at risk for oxygen toxicity due to the level of oxygen administration with the simple mask. The client's target oxygen saturation would be 88% to 92% (0.88 to 0.92) if the client had chronic obstructive pulmonary disease (COPD). There is no information in the question to indicate the client has COPD.
A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply. Nasal cannula Simple oxygen mask Venturi mask Partial rebreather mask Humidified venturi mask
Nasal cannula Simple oxygen mask Partial rebreather mask Explanation: Nasal cannula with tubing administers oxygen at low-flow rates and concentrations at 22%-44%. Simple masks and partial rebreathers both deliver a low-flow rate at concentrations of 40%-60%. Venturi masks mix oxygen with room air and create a high flow of oxygen.
The nurse is caring for a client with shortness of breath who is receiving oxygen at 4 L/minute. Which assessment finding will demonstrate that oxygen therapy is effective? clubbing of fingers respirations 26 breaths/minute heart rate 110 beats/minute SpO2 92%
SpO2 92% Explanation: An SpO2 at or above 90% is normal, reflecting that oxygen therapy is being effective. Clubbing, respirations greater than 26 breaths/minute, and a heart rate greater than 100 beat per minute may indicate that more oxygen is needed.
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? They are loud, high-pitched sounds heard primarily over the trachea and larynx. They are medium-pitched blowing sounds heard over the major bronchi. They are low-pitched, soft sounds heard over peripheral lung fields. They are soft, high-pitched discontinuous (intermittent) popping lung sounds.
They are low-pitched, soft sounds heard over peripheral lung fields. Normal breath sounds include: vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), bronchovesicula: (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.
Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body?
chronic anemia Explanation: The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the number of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissues of the body. pancreas.
A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client? oxygen analyzer nasal strip nasal cannula flow meter
flow meter Explanation: The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen. 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 adhesive nasal strip increases the nasal diameter and promotes easier breathing.
The nurse is delegating hygiene care to the unlicensed assistive personnel (UAP) for a client with hypoxia, deficiency in the amount of oxygen reaching the tissues. In which position will the nurse tell the UAP to place the client? high Fowler supine Trendelenburg lithotomy
high Fowler Explanation: High Fowler position allows the client with hypoxia to breathe easier by promoting lung expansion, as the abdominal organs descend away from the diaphragm. The other positions compromise lung expansion.
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? simple mask tracheostomy collar nasal cannula face tent
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.
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? Pulse oximetry High-Fowler's position 4 L/minute O2 (66 mL/second) nasal cannula Increase fluid intake to 3 L/day (3000 mL/day)
4 L/minute O2 (66 mL/second) nasal cannula Explanation: 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. Clients with emphysema are most comfortable in high Fowler's position because it aids in the use of the accessory muscles to promote respirations. Increasing fluid intake helps keep the client's secretions thin. Pulse oximetry monitors the client's arterial oxyhemoglobin saturation while receiving oxygen therapy.
The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as:
Apnea The newborn's breathing pattern is characterized by occasional pauses of several seconds between breaths. This periodic breathing is normal during the first 3 months of life, but frequent or prolonged periods of apnea (cessation of breathing 20 seconds or longer) are abnormal. Dyspnea :refers to shortness of breath. Orthopnea: refers to difficulty breathing when lying flat. hypercapnia: elevation of carbon dioxide levels in the blood is termed
The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client? nasal cannula tracheostomy collar simple mask face tent
Nasal cannula Explanation: A nasal cannula is ideal for administering low concentrations of oxygen to clients who are not extremely hypoxic or have chronic lung disease. The client does not have a tracheostomy. A simple mask is used to administer higher levels of oxygen than 2 L/min. A face tent is used without a mask.
A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs? Nasal cannula Simple mask Partial rebreather mask Nonrebreather mask
Nasal cannula Explanation: A nasal cannula is used to deliver from 1 L/min to 6 L/min of oxygen. Masks are used with higher flow rates of oxygen.
A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered? nasal cannula simple oxygen mask Venturi mask partial rebreather mask
Nasal cannula Nasal cannula and tubing administer oxygen concentrations at 22% to 44%.
The nurse is obtaining a pulse oximetry reading for a client admitted with exacerbation of chronic obstructive pulmonary disease (COPD). When observing a reading of 89%, what action should the nurse perform? No action is required, because this may be normal for the client The nurse should prepare intubation equipment for the health care provider Administer oxygen at 6 L/m by nasal cannula Have the client breath into a paper bag
No action is required, because this may be normal for the client Explanation: For clients with chronic lung disease, a level of 88%-92% may be considered within normal limits and there is no further action for the nurse to take. There is no indication that intubation is needed. Administering oxygen at levels too high may diminish the client's stimulus to breathe, because a higher CO2 level is tolerated. Breathing into a paper bag would elevate the level of carbon dioxide and would be dangerous for this client.
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the mostappropriate intervention in this situation? Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. Leave the airway in place and promptly notify the health care provider for further instructions. Suction the client's mouth through the oropharyngeal airway to prevent aspiration.
Remove the airway, turn the client to the side, and provide mouth suction, if necessary. Explanation: If the client vomits as the oropharyngeal airway is inserted, quickly position the client onto his or her side to prevent aspiration, remove the oral airway, and suction the mouth, if needed. It would be inappropriate and unsafe to leave the airway in place. Rinsing the client's mouth with water is not a priority.
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. 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. Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.
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. Explanation: Guidelines to determine suction catheter depth include the following: 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 past the length of the endotracheal tube. Combine the length of the endotracheal tube and any adapter being used, and add an additional 1 cm. Using a spare endotracheal or tracheostomy tube of the same size as being used for the client, insert the suction catheter to the end of the tube and note the length of catheter used to reach the end of the tube. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 1 cm.
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? "An occasional cigarette will not hurt you." "You should never smoke when oxygen is in use." "I understand; I used to be a smoker also." "Oxygen is a flammable gas."
You should never smoke when oxygen is in use. Explanation: The nurse will educate the client about the dangers of smoking when oxygen is in use. Oxygen is not flammable, but it oxidizes other materials. Other answers are inappropriate.