PNU 120 Taylor PrepU Chapter 39: Oxygenation and Perfusion

Which response would 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?

"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 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 is using his chest muscles to help him breathe."

The nurse is providing discharge teaching to a client going home with oxygen therapy. Which statements made by the client would indicate to the nurse that the teaching was effective? Select all that apply.

"I will not allow smoking within 10 feet (3 m) of my oxygen." "I will keep the oxygen tank away from direct sunlight or heat."

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 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute."

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?

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment?

5,850 mL (5,850 × 109/L)

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?

Ambu bag

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines?

Be sure to shake the canister before using it.

The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate?

Check the fit of the oxygen mask.

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?

Clubbing

A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action?

Document this expected assessment finding.

Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?

Eat smaller meals that are high in protein.

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?

Hypoxia

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?

Instruct the client to inhale deeply and then cough.

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

It decreases dry mucous membranes via delivering small water droplets.

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 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 is a sign of dyspnea specific to infants?

Nasal flaring

A nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant?

Oxygen hood

The nurse is caring for a client currently on a mechanical ventilator. What should the nurse determine when comparing today's arterial blood gas (ABG) results with the results obtained 24 hours earlier?

Oxygenation is improving.

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?

Pleural effusion

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

Poor tissue perfusion

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). In what position does the nurse place the client in order to promote adequate oxygenation?

Prone

The nurse provides care for a client with pneumonia and acute respiratory distress syndrome whose oxygen saturation fluctuated between 86% and 90% over the past few days. The oxygenation saturation is consistently at 91%. Which step would the nurse take next?

Provide oxygen for consistent hypoxia

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?

Rapid respirations

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?

Residual Volume (RV)

The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care?

Stay indoors as much as possible.

When caring for a client with a tracheostomy, the nurse would perform which recommended action?

Suction the tracheostomy tube using sterile technique.

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 is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

They are low-pitched, soft sounds heard over peripheral lung fields.

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.

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.

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

a bronchospasm.

In which client would the nurse assess for a depressed respiratory system?

a client taking opioids for cancer pain

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as:

crackles.

Oxygen and carbon dioxide move between the alveoli and the blood by:

diffusion.

The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier?

distilled water

A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?

educating the client on the use of incentive spirometry

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather?

face tent

The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal?

fine crackles to the bases of the lungs bilaterally

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?

flow meter

The nurse is caring for a client who is diagnosed with Impaired Gas Exchange. While performing a physical assessment of the client, which data is the nurse likely to find, keeping in mind the client's diagnosis?

high respiratory rate

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?

nasal cannula

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

A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of:

pneumonia.

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?

tracheostomy collar