Prep U: ch. 39: Oxygenation & perfusion
"He is using his chest muscles to help him breathe." ***The client will use accessory muscles to ease dyspnea and improve breathing.
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:
Provide oxygen therapy at the lowest liter flow rate that manages hypoexmia.
A client is on oxygen- induced hypoventilation what is the nursing action and sees signs of restlessness. Wat will the nurse do?
Nasal cannula ***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 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?
Document this expected assessment finding. Explanation: A range of 95% to 100% is considered normal oxygen saturation. As such, there is no need to change the client's position, encourage deep-breathing exercises and coughing, or to review the client's medication history
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?
Hypoxemia
A patient comes in with a less than 90% of oxygen saturation level. What does this reading mean?
True ***After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A nurse caring for a client with a chest tube should monitor the client's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.
Is your mask causing discomfort? ***It is possible for anyone using a mask to try and readjust it if it is uncomfortable. Depending on the older adult's cognitive status, he or she may have tried to make it more comfortable and in the process caused it to no longer fit correctly. This could also occur if the client removed their dentures, as some individual's choose to let the dentures soak overnight. If the mask was fitted with the dentures in, the mask will likely be loose with the dentures removed. The other questions could possibly be asked to see if someone else may have tried to help the client feel more comfortable with the mask on.
An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize?
Alveolar hypoventiliation
Clients who have conditions that cause ________________ ______________________ can be sensitive to the administration of oxygen.
Vesicular Explanation: Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.
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?
95%-100%
Normal ranges for oxygen saturation level?
Combustible
Oxygen is _________________.
Hypoxia
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?
True
Values can be slightly lower for older adult clients and clients who have dark skin. True or false?
Stupor Cyanotic skin, mucous membranes Bradypnea Bradycardia Hypotension Cardiac dysrhythmias
What are LATE manifestations of hypoxia ?
Partial rebreather mask, 60% to 75%, 6-11
_____________ ______________ mask delivers a fraction of inspired oxygen of _____% to ____% at flow rates of ____ to ____ L/min.
Apply oxygen as prescribed Explanation: The nurse should first apply oxygen, which will help to improve oxygen saturation and health status. The client may not require intubation, once oxygen is provided. Although the client may require education on incentive spirometry, the immediate priority intervention is to stabilize the client's oxygen saturation. Similarly, raising the head of the bed may help with the client's comfort but may not have sufficient effect on oxygen saturation.
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?
deep breathing Explanation: The nurse should teach deep breathing techniques to the client who is recovering from an injury and tends to breathe shallowly in order to help the client breathe more efficiently. Deep breathing is a technique for maximizing ventilation. Taking in a large volume of air fills alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing is a form of controlled ventilation in which the client consciously prolongs the expiration phase of breathing, which helps clients, especially with COPD, to eliminate more than the usual carbon dioxide from the lungs. It is used to increase the volume of air exchanged during inspiration and expiration.
During the physical assessment of a client who has been inactive due to a leg injury, the nurse notes that the client tends to breathe very shallowly. What technique should the nurse teach the client in order to breathe more efficiently?
Crackles ***Crackles are soft, high-pitched, discontinuous sounds. Wheezes are a whistling or rattling sound in the chest as a result of obstruction in the air passages. Vesicular breath sounds are heard across the lung surface. Bronchial sounds are loud, high-pitched sounds heard primarily over the trachea and larynx.
The client demonstrates soft, high-pitched, discontinuous sounds in the left lower lobe of the lung. How will the nurse accurately document this finding?
-Heart rate is 64 beats/min. - Mucous membranes are pink and moist. - The client is able to state the date, time, and location.
The nurse is administering oxygen to an older adult client who has been assessed to have increased work of breathing. If the intervention has been effective, what finding(s) will the nurse expect on the evaluation of the client? Select all that apply.
Distilled water
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?
Reads 0.21 when checking oxygen in room air ***An oxygen analyzer should read 0.21 when checking oxygen in room air if there is a normal mixture of oxygen and other gases in the environment. When the analyzer is positioned near or within the device used to prescribe oxygen, it should register at the prescribed amount (>0.21).
The nurse is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly?
Maintain the client's oxygenation and alert the health care provider immediately. ***If the tracheostomy becomes dislodged and is not easily replaced, the nurse should notify the primary care provider immediately, cover the tracheostomy stoma, and assess client's respiratory status.
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?
Residual volume (RV) ***During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds.
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?
Assess the patency of the nares Ensure the prongs fit in the nares properly Use water-soluble gel to prevent dry nares Provide humidification for flow rates of 4 L/min & greater
What are some *NURSING ACTIONS* when a client is using a nasal cannula?
The FiO2 varies with flow rate, & the rate & depth of the clients breathing Extended use can lead to skin breakdown & dry mucous membranes Tubing is EASILY dislodged
What are some DISADVANTAGES of the nasal cannula
It's safe, simple, easy to apply Comfortable and well tolerated Client is able to eat, talk, and ambulate
What are some advantages of nasal cannula.
Easy to apply more comfortable than a nasal cannula Simple delivery method Provides more humidified oxygen
What re the ADVANTGES from using a simple mask?
rapid respirations Explanation: Normal cardiac output averages from 3.5 to 8.0 liter/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing the respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display a thready pulse.
When reviewing data collection on a client with a cardiac output of 2.5 liter/minute, the nurse inspects the client for which symptom?
atelectasis. Explanation: Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize atelectasis. Immobility is not commonly implicated in cases of pneumothorax or hemothorax. A pneumothorax is a collapsed lung. Hemothorax is a collection of blood in the space between the chest wall and the lung. Tachypnea, if present, would likely be a sign of atelectasis rather than an independent finding.
A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for:
Flow meter ***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. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.
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?
Congestive heart failure. Explanation: A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.
A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:
Pulse oximetry ***Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.
A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?
Remove the airway, turn the client to the side, and provide mouth suction, if necessary. ***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.
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?
" You should never smoke when oxygen is in use"
A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?
- simple mask - partial rebreather mask ****A simple mask, and partial rebreather mask accommodate a flow of 8 L/min. A venturi mask accommodates 4-6 L/min, and a nonrebreather mask accommodates 10-15 L/min. The client does not have a tracheostomy so a T-piece is inappropriate.
A health care provider has prescribed oxygen to be delivered at 8 L/minute for a client who does not have a tracheostomy. Which oxygen delivery device(s) will the nurse consider using? Select all that apply.
Instruct the client to inhale deeply and then cough. Explanation: The client should be instructed to inhale deeply and cough; if this results in sputum, it should be collected in the container. The client should be placed in a semi-Fowler's position and instructed to clear the nose and throat and rinse the throat with water.
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?
Use a bag and mask. Explanation: If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a bag and mask may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Suction is unnecessary unless there is an obvious obstruction. Nasal cannula is insufficient and an oxygen hood is not used in urgent situations.
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?
Ambu bag Explanation: If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Oxygen masks may cover only the nose and mouth and can vary in the amount of oxygen delivered. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostril. An oxygen tent is a tentlike enclosure within which the air supply can be enriched with oxygen to aid a client's breathing. Oxygen masks, nasal cannula, and oxygen tents are used for clients who have a respiratory drive.
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?
Warm the client's hands and try again. Explanation: Finding an absent or weak signal, the nurse should check vital signs and client condition. If satisfactory, warming the extremity may facilitate a stronger reading. This should be attempted prior to resorting to using the client's earlobe. Bright light can interfere with the operation of light sensors and cause an unreliable report. A blood pressure cuff will compromise venous blood flow to the site leading to inaccurate readings.
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?
Restlessness Tachycardia Confusion Hypertension ****monitor for restlessness, which is an early manifestation of hypoxia, along with tachycardia, elevated blood pressure, use of accessory muscles , nasal flaring, tracheal tugging , and adventitious lung sounds. Tachypnea, confusion & hypertension is an early manifestation of hypoxia.
A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia?
Pneumonia Explanation: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. Croup, asthma, and alcohol use do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol use depresses the central respiratory center.
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:
- auscultate bowel sounds - assist the client to an upright position - test the pH of gastric aspirate
A nurse is caring for a client in a long-term care facility who is receiving enteral feedings via an NG tube. Which of the following actions should the nurse complete prior to administering the tube feeding?
- apply the oxygen source loosely if the SpO2 decreases during the procedure - use surgical as pedis to remove and clean the inner cannula - clean the outer cannula surfaces in a circular motion from the stoma site outward ***provide supplemental oxygen in response to any decline in oxygen saturation while performing tracheostomy care. Use a sterile disposable tracheostomy cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure. Cleanse the exposed surfaces of the outer cannula and the rea around and under the faceplate in a circular motion from the stoma site outward.
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care?
Assist the client to Fowler's position ***the priority action to be taken when using the airway, breathing, circulation (ABC) approach. Dyspnea (difficulty breathing).
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurses priority?
Stop the feeding ***the realest risk to the client is aspiration pneumonia. The first action to take is to stop the feeding so that no more formula can enter the lungs.
A nurse is caring for a client who is receiving continuous enteral feedings. Which of the following nursing interventions is the highest priority when the nurse suspects aspiration of the feeding?
" water helps clear the tube so it doesn't get clogged" ***flush the tube after instilling the feeding to help keep the N tube patent by clearing any excess formula from the tube so that it doesn't clump or clog the tube.
A nurse is delivering an enteral feeding to a client who has an NG tube in place for intermittent feedings. When the nurse pours water into the syringe after the formula drains from the syringe, the client asks the nurse why the water is necessary. Which of the following responses should the nurse make?
- review a signal the client can use if feeling any distress - lay a towel across the clients chest
A nurse is preparing to insert an NG tube for a client who requires gastric decompression. Which of the following actions should the nurse perform before beginning the procedure?
Verify the placement of the NG tube
A nurse is preparing to instill an external feedings for a client who has an NG tube in place. Which of the following actions is the nurses highest assessment priority before performing this procedure?
- apply suction while withdrawing the catheter - use a new catheter for each suctioning attempt - apply suction for 10-15 seconds ***apply suction pressure only while withdrawing the catheter to prevent damaging the tracheal tissue. Use a new suction catheter, unless an in-line suctioning system is in place, to prevent contamination with micro-organisms that can cause an infection. To prevent hypoxemia, apply suction for only 10-15 seconds and allow 2-3 min between passes for ventilation and oxygenation.
A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines?
Bronchitis Explanation: 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. 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. Bronchiectasis results from chronic inflammation or infection causing an excess accumulation of mucus. Croup is an infection of the airways, most commonly viral in origin. Reference:
A nurse is reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would the nurse most likely identify as an effect of exposure to automobile pollutants?
A bronchospasm ***When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm.
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:
trauma to the tracheal mucosa Explanation: 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, not carbon dioxide, from the respiratory tract. Suctioning during insertion of the catheter would not compromise sterility.
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?
The client's available hemoglobin is adequately saturated with oxygen. Explanation: Pulse oximetry is a noninvasive technique that measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial blood. This test measures only the percentage of oxygen carried by the available hemoglobin. Thus, even a client with a low hemoglobin level could appear to have a normal SpO2 because most of that hemoglobin is saturated. However, the client may not have enough oxygen to meet body needs. A normal pulse oximetry reading does not necessarily indicate a normal RBC count or heart rate.
A nurse takes a client's pulse oximetry reading and finds that it is normal. What does this finding indicate?
Check the position of the cannula frequently. Report any nausea or difficulty breathing. Post "No smoking" signs in prominent locations ***teach the client to apply a water-based lubricant instead petroleum jelly to protectant the nares from drying during oxygen therapy. Teach the client that a disadvantage of the nasal cannula is that it dislodges easily, check it periodically. Teach client about oxygen toxicity, which is a complication of oxygen therapy, usually from high concentrations or lung duration. Manifestations include:nonproductive cough, substernal pain, nausea, and vomiting. Teach the client that oxygen is combustible and thus increases the risk of fire injuries.
A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions?
- increased work of breathing - wheezing - coughing - cyanosis - changes in respiratory rate or rhythm - adventitious breath sounds - restlessness, irritability, confusion - dyspnea - Orthopnea
A pulse oximetry is a device with a sensor probe that attaches curly to the fingertip, toe, bridge of nose , earlobe, or forehead with a clip or band. What findings will include a pulse oximetry ?
Croup ***Croup and epiglottitis are common in young children. The child has an obstruction of the upper airways, with swelling of the throat tissue. Atelectasis results when the lungs collapse as a result of the alveoli being unable to expand. Symptoms include difficulty breathing and discomfort. Pulmonary fibrosis is a condition in which the lung tissue becomes stiff and unable to expand appropriately. Asthma is a condition associated with bronchoconstriction. The symptoms include nonproductive cough, dyspnea, and wheezing
A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from:
True ***After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A nurse caring for a client with a chest tube should monitor the client's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.
Hemoglobin level ***Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.
An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's:
Stay indoors as much as possible. Explanation: Using the air quality index, a red color designation signifies that the air quality is unhealthy for all people, not just sensitive groups. Air pollution and high humidity are respiratory irritants. Pollutants cause increased mucus production and contribute to bronchitis and asthma. Reducing contact with irritants by staying indoors during times of increased air pollution will decrease their effect on the respiratory system. Clients should be encouraged to quit smoking, not just cut down. Avoiding large crowds and practicing good hand hygiene will prevent respiratory infections but not cut down on the effect of air pollution.
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?
-Position client onto the side immediately. -Remove oropharyngeal airway. -Provide oral suctioning and mouth care.
The health care provider has prescribed an oropharyngeal airway for a client with a decreased level of consciousness. The health care provider has noted gurgling respirations and the client's tongue is in the posterior pharynx. The client vomits as the airway is inserted. Which actions should the nurse take? Select all that apply.
Hypoxia ***Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia. Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements. Perfusion refers to the process by which oxygenated capillary blood passes through body tissues. Atelectasis refers to collapsed alveoli.
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?
crackles ***Crackles, frequently heard on inspiration, are soft, high-pitched discontinuous (intermittent) popping sounds. Wheezes are continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors. Vesicular sounds are low-pitched, soft sounds heard over peripheral lung fields. Bronchovesicular sounds are medium-pitched blowing sounds heard over the major bronchi.
The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as:
Wheezing Explanation: The nurse expects to document wheezing in the lungs of a client with asthma, which would be more pronounced when the client has a respiratory infection. Wheezing is a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration. Wheezing is caused by air passing through constricted passages caused by swelling or secretions. Stridor and crackles are other abnormal breath sounds caused by fluid, infection, or inflammation in the lungs. Absent breath sounds are not normally found in asthmatic clients; they are characteristic of pneumonia.
The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?
"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." Explanation: The following formula is used to determine cardiac output: Cardiac Output = Stroke Volume x Heart Rate. A client with a stroke volume of 50 mL and heart rate of 50 beats per minute has a cardiac output of 2.5 L/minute. If stroke volume is 70 and heart rate is 70 beats per minute, then the cardiac output is 4.9 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute. If stroke volume is 60 and heart rate is 60 beats per minute, then the cardiac output is 3.6 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute.
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?
Clubbing ***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. Hemoptysis, edema, and diarrhea do not result from hypoxia.
The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?
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), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?
Assess oxygen tubing connection Explanation: If the client suddenly becomes cyanotic, the nurse should assess the oxygen tubing to make sure it is still connected. Assessing lung sounds, repositioning the client, and elevating the head of the bed will not correct the problem if the tubing is disconnected.
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?
Arterial blood gas Explanation: Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. 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.
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?
Arterial blood gas ***Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. 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.
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?
Distilled water ***Distilled water is used when humidification is desired.
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?
Tracheostomy collar ***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 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?
respirations are at 20 breaths per minute Explanation: Respirations of 20 breaths per minute indicate that the tube is functioning correctly. Other findings require nursing intervention.
The nurse is caring for a client with a chest tube. Which assessment finding indicates that the tube is functioning correctly?
pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation Explanation: In respiratory alkalosis, anticipated arterial blood gas results are anticipated to reflect pH greater than 7.45; HCO3 low; and PaCO2 low
The nurse is caring for a client with respiratory alkalosis. Which arterial blood gas data does the nurse anticipate finding?
A client taking an opioid for cancer pain ***Many medications affect the function of, and depress, the respiratory system. The nurse should monitor clients taking certain medications, such as opioids, for rate and depth of respirations. Amlodipine is a calcium channel blocker and the medication decreases blood pressure, so the nurse would need to assess blood pressure. Muscle relaxants such as methocarbamol could depress respiratory status, but this occurs less often than with opioids. Methimazole is used to treat hyperthyroidism, thus lowering the body's metabolic functions, which can depress respirations; however, this is a very rare occurrence with this medication. The client at highest risk is the one taking an opioid.
The nurse is caring for the following clients. Which client is at highest risk for a depressed respiratory system?
Face tent ***A face tent is used without a mask; it is open and loose around the face and is often used for clients with facial trauma or burns. A simple mask or nasal cannula would irritate the facial skin. The client does not have a tracheostomy
The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather?
Confusion ***Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, elevated blood pressure with small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.
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?
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.
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?
- 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.
The nurse is preparing a client for a complete blood count test. Which actions would the nurse perform? Select all that apply.
"Breathing through your nose first will warm, filter, and humidify the air you are breathing." ***Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring.
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?
increase in rate and depth of respirations Explanation: 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. 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. A decrease in the rate of respiration and increase in depth could be Kussmaul respirations. An increase in the rate of respirations and decrease in the depth can be related to anxiety or pain. A decrease in the rate of respirations can cause an increase in carbon dioxide and decrease in hydrogen ions.
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?
- confirm probe placement - confirm that the oxygen delivery system us functioning and that the client is receiving the prescribed oxygen levels - place client in semi-Fowler's or Fowler's position to promote chest expansion - encourage deep breathing - remain withe client and provide emotional support to decrease anxiety.
What are some interventions for readings less than 90%
Post " no smoking signs" Know where to find the closest fire extinguisher Educate about fire hazard of smoking with oxygen in use Have clients wear a cotton gown because synthetic or wool fabrics can generate static electricity Ensure all electric devices (razors, hearing aids, radios) are working well Make sure all electric machinery (monitors, suction machines) is grounded Do not use volatile, flammable materials (alcohol, acetone ) near clients receiving oxygen.
What are some nursing actions to make sure the oxygen machine doesn't combust?
Assess proper fit to ensure a secure seal over the nose Use with caution for clients who have HIGH risk of aspiration or airway obstruction Monitor for skin breakdown
What are the NURSING ACTIONS for a simple mask?
Air flow through the respiratory passages ***Auscultation of the lungs assesses air flow through the respiratory passages and lungs. The nurse listens for normal, as well as abnormal, breath sounds. Abnormal chest structures would be assessed when inspecting the chest and thoracic region. Presence of edema would be assessed as part of the cardiovascular status of the client. Volume of air exhaled and inhaled would be performed during a pulmonary function test.
What assessments would a nurse make when auscultating the lungs?
6 L/min
What is the minimum flow rate to ensure flushing of CO2 from the simple mask?
The chest should be slightly convex with no sternal depression. Explanation: The adult chest contour is slightly convex, with no sternal depression. The skin of the thorax should be warm and dry, and the anteroposterior diameter of the chest should be less than the transverse diameter. The contour of the intercostal spaces should be flat or depressed.
When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?
Pulmonary function tests Explanation: Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?
Eat smaller meals that are high in protein. Explanation: The client should consume a diet in which the body can produce plasma proteins. The client should have sufficient caloric and protein intake for respiratory muscle strength.
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?
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.
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?
It determines whether the client is getting enough oxygen. Explanation: The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?
presence of fluid in the lungs Explanation: Coarse crackles heard on auscultation indicate the presence of fluid in the lungs. Air passing through narrowed airways produces a wheezing sound, whereas inflammation of pleural surfaces gives rise to pleural rub. Sputum in the trachea produces stridor, a harsh, noisy squeak when something is blocking the airway.
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?
pattern of thoracic expansion Explanation: The nurse can assess patterns of thoracic expansion through palpation. Fluid-filled and consolidated portions of lungs can be assessed through percussion, not through palpation. Presence of pleural rub can be assessed through auscultation.
While examining a client, the nurse palpates the client's chest and back. What would the nurse expect to identify with this technique?
Simple mask ,35% to 50%, 6 to 12
________ __________ covers the clients nose and mouth. It delivers a fraction of inspired oxygen (FiO2) of ____% to ____% at flow rates of ____ to ___ L/min
Nasal cannula, 6
__________ _____________ is a tubing with two small prongs for insertion into the nares. It delivers an FiO2 of 24% to 44% at a flow rate of 1 to __ L/min.
Oxygen
____________ is a therapuetic gas that treats hypoxemia
Oxygen toxicity, 50%, 24hr to 48hr
_____________ _____________ can result from high concentrations of oxygen. Typically greater than ____%, long durations more than _____ to _____ hr. The severity is lung disease.
