RN- OXYGENATION/GAS EXCHANGE
Teaching- post-surgical The nurse teaches the client how to do deep breathing exercises after surgery by telling the client to: "Hold your abdomen firmly with a pillow, and take several deep breaths." Explanation: Effective splinting for a high incision reduces stress on the incision line, decreases pain, and increases the client's ability to deep-breathe effectively. Deep breathing should be done hourly by the client after surgery. Sitting upright ignores the need to splint the incision to prevent pain. Tightening the stomach muscles is not an effective strategy for promoting deep breathing. Raising the shoulders is not a feature of deep-breathing exercises.
A client has an adrenal tumor and is scheduled for a bilateral adrenalectomy. During prepoperative teaching, the nurse teaches the client how to do deep breathing exercises after surgery by telling the client to: "Hold your abdomen firmly with a pillow, and take several deep breaths." Explanation: Effective splinting for a high incision reduces stress on the incision line, decreases pain, and increases the client's ability to deep-breathe effectively. Deep breathing should be done hourly by the client after surgery. Sitting upright ignores the need to splint the incision to prevent pain. Tightening the stomach muscles is not an effective strategy for promoting deep breathing. Raising the shoulders is not a feature of deep-breathing exercises.
ABGs indicating respiratory alkalosis The client is severely hypoxic. Explanation: Normal PaO2 level ranges from 80 to 100 mm Hg (10.6 to 13.3 kPa). When the PaO2 value falls to 50 mm Hg (6.7 kPa), the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The PaO2 is not within normal range. The client will require oxygenation at a concentration that maintains the PaO2 at 55 to 60 mm Hg or more (7.3 to 8 kPa).
A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3-, 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which conclusion would be accurate? The client is severely hypoxic. Explanation: Normal PaO2 level ranges from 80 to 100 mm Hg (10.6 to 13.3 kPa). When the PaO2 value falls to 50 mm Hg (6.7 kPa), the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The PaO2 is not within normal range. The client will require oxygenation at a concentration that maintains the PaO2 at 55 to 60 mm Hg or more (7.3 to 8 kPa).
INHALER: PROPER USE 6 STEPS "Take off the cap and shake the inhaler." "Attach the spacer." "Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it." "Press down on the inhaler once and breathe in slowly." "Hold your breath for at least 10 seconds, then breathe in and out slowly." "Rinse your mouth."
A client with asthma has been prescribed fluticasone, one puff every 12 hours per inhaler. Place in correct order the nurse's statements when teaching the client how to properly use the inhaler with a spacer. "Take off the cap and shake the inhaler." "Attach the spacer." "Breathe out all of your air. Hold the mouthpiece of your inhaler and spacer between your teeth with your lips closed around it." "Press down on the inhaler once and breathe in slowly." "Hold your breath for at least 10 seconds, then breathe in and out slowly." "Rinse your mouth." Explanation: Using a spacer, especially with inhaled corticosteroid, can make it easier for the medication to reach the lungs; it can also prevent excess medication remaining in the mouth and throat, which can cause minor irritation. It is important for the client to empty the lungs, breathe in slowly, and hold the breath to draw as much medication into the lungs as possible. Rinsing after using a corticosteroid inhaler may help prevent irritation and infection; rinsing will also reduce the amount of drug swallowed and absorbed systemically.
emphysema- ACID-BASE IMBALANCE OF- Chronic respiratory acidosis Correct Explanation: Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis.
A client with emphysema is at a greater risk for developing what acid-base imbalance? Chronic respiratory acidosis Correct Explanation: Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis.
Oprelvekin 5 mg SQ- used for thrombocytopenia not anemia Oprelvekin is used for thrombocytopenia, which would be assessed as bruising and fatigue. Cobalamin (Cyanocobalamin, Vitamin B12), folic acid (folate is a B vitamin. It is also referred to as vitamin M, vitamin B9, vitamin Bc (or folacin), pteroyl-L-glutamic acid, and pteroyl-L-glutamate), and epoetin (Epoetin Alfa (Erythropoietin; EPO) (PROCRIT) are given to increase hemoglobin and treat the symptoms of anemia.
A male client with hemoglobin of 12 g/dL is pale and reports parathesia to the lower extremities. Which order would the nurse question? Oprelvekin 5 mg SQ Explanation: The client has signs and symptoms of anemia. Typically iron deficiency and pernicious anemia will present as pallor, low hemoglobin and in severe cases paresthesia. Cobalamin, folic acid, and epoetin are given to increase hemoglobin and treat the symptoms of anemia. Oprelvekin is used for thrombocytopenia, which would be assessed as bruising and fatigue.
priority intervention for someone who has had an MI Control the pain and support breathing and oxygenation. Explanation: Support of breathing and ensuring adequate oxygenation are the two most important priorities. Reducing the substernal pain is also important because upset and anxiety will increase the demand for oxygen in the body. Controlling nausea, vomiting, and anxiety are all secondary in importance. Prevention of complications is important following initial stabilization and control of pain.
A nurse is caring for a client with type 2 diabetes who has had a myocardial infarction (MI) and is reporting nausea, vomiting, dyspnea, and substernal chest pain. Which of the following is the priority intervention? Control the pain and support breathing and oxygenation. Explanation: Support of breathing and ensuring adequate oxygenation are the two most important priorities. Reducing the substernal pain is also important because upset and anxiety will increase the demand for oxygen in the body. Controlling nausea, vomiting, and anxiety are all secondary in importance. Prevention of complications is important following initial stabilization and control of pain.
Teaching- COPD "I should try to eat several small meals during the day." Explanation: The respiratory workload is increased in individuals with COPD. Because digestion also is energy consuming, clients with COPD may feel full after only a small meal. They may tolerate smaller, more frequent, high-calorie meals better than larger meals. Bronchodilators will increase insomnia. Activities should be regulated throughout the day. Eating followed by activity based on intra-abdominal pressure will increase shortness of breath.
A nurse is teaching a client with chronic obstructive pulmonary disease (COPD) who is being discharged after treatment for an acute exacerbation. Which statement by the client indicates proper understanding of the discharge instructions? "I should try to eat several small meals during the day." Explanation: The respiratory workload is increased in individuals with COPD. Because digestion also is energy consuming, clients with COPD may feel full after only a small meal. They may tolerate smaller, more frequent, high-calorie meals better than larger meals. Bronchodilators will increase insomnia. Activities should be regulated throughout the day. Eating followed by activity based on intra-abdominal pressure will increase shortness of breath.
OLIGURIA IS EVIDENCE OF REDUCED BLOOD FLOW TO THE KIDNEYS- urine output Explanation: Oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys. Typical signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decreased urine output, and signs of diminished blood flow to the brain, such as confusion and restlessness. Cardiogenic shock is a serious complication of MI, with a mortality rate approaching 90%. Fever is not a typical sign of cardiogenic shock. The other changes in vital signs on the client's chart are not as significant as the decreased urinary output.
The nurse is monitoring a client admitted with a myocardial infarction (MI) who is at risk for cardiogenic shock. The nurse should report which change on the client's chart to the health care provider (HCP)? urine output Correct Explanation: Oliguria occurs during cardiogenic shock because there is reduced blood flow to the kidneys. Typical signs of cardiogenic shock include low blood pressure, rapid and weak pulse, decreased urine output, and signs of diminished blood flow to the brain, such as confusion and restlessness. Cardiogenic shock is a serious complication of MI, with a mortality rate approaching 90%. Fever is not a typical sign of cardiogenic shock. The other changes in vital signs on the client's chart are not as significant as the decreased urinary output.
Nursing Process: evaluation- REDUCE BREATHING PROBLEMS • Anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min • Lung sounds clear bilaterally with non-labored respirations noted Explanation: A decrease in anxiety with an increase in oxygen saturation and clear lung sounds with non-labored respirations show documentation that breathing has improved. The other answers indicate abnormal data of the respiratory status.
The nurse is reflecting on the evaluation step of the nursing process. Which documentation would indicate nursing actions were effective in reducing breathing problems for a client? Select all that apply. • Anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min • Lung sounds clear bilaterally with non-labored respirations noted Explanation: A decrease in anxiety with an increase in oxygen saturation and clear lung sounds with non-labored respirations show documentation that breathing has improved. The other answers indicate abnormal data of the respiratory status.
ASTHMA- ANXIOUS AND WHEEZING Position in high Fowler's position and administer an albuterol sulfate inhaler. Correct Explanation: Following an asthma attack, it is important to ensure optimal positioning (Fowler's) and adequate oxygen levels. The client is still experiencing wheezing, so coughing to remove secretions is important. A bronchodilator would also help by enlarging the size of the bronchioles. Asking the client to calm down is incorrect because it does not explore concerns. Semi-prone positioning would not assist with breathing.
The nurse observes that a client admitted with asthma is anxious, has audible wheezing, and is using the neck muscles when breathing. What actions would be appropriate? Position in high Fowler's position and administer an albuterol sulfate inhaler. Correct Explanation: Following an asthma attack, it is important to ensure optimal positioning (Fowler's) and adequate oxygen levels. The client is still experiencing wheezing, so coughing to remove secretions is important. A bronchodilator would also help by enlarging the size of the bronchioles. Asking the client to calm down is incorrect because it does not explore concerns. Semi-prone positioning would not assist with breathing.
DVT- best mode of O2 Nonrebreather mask
A client admitted with a deep vein thrombosis abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to improve these manifestations? Nonrebreather mask Explanation: A nonrebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.
PNEUMONIA
ENCOURAGE FLUID INTAKE
CF (CYSTIC FIBROSIS)- most important nursing interventions applying an oximeter and initiating respiratory therapy Correct Explanation: Clients with cystic fibrosis commonly die from respiratory problems. The mucus in the lungs is tenacious and difficult to expel, leading to lung infections and interference with oxygen and carbon dioxide exchange. The client will likely need supplemental oxygen and respiratory treatments to maintain adequate gas exchange, as identified by the oximeter reading. The child will be on bed rest due to respiratory distress. However, although blood gases will probably be prescribed, the oximeter readings will be used to determine oxygen deficit and are, therefore, more of a priority. A diet high in calories, proteins, and vitamins with pancreatic granules added to all foods ingested will increase nutrient absorption and help the malnutrition; however, this intervention is not the priority at this time. Inserting an IV to administer antibiotics is important, and can be done after ensuring adequate respiratory function.
An adolescent with cystic fibrosis has been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive. Which initial nursing actions are most important? applying an oximeter and initiating respiratory therapy Correct Explanation: Clients with cystic fibrosis commonly die from respiratory problems. The mucus in the lungs is tenacious and difficult to expel, leading to lung infections and interference with oxygen and carbon dioxide exchange. The client will likely need supplemental oxygen and respiratory treatments to maintain adequate gas exchange, as identified by the oximeter reading. The child will be on bed rest due to respiratory distress. However, although blood gases will probably be prescribed, the oximeter readings will be used to determine oxygen deficit and are, therefore, more of a priority. A diet high in calories, proteins, and vitamins with pancreatic granules added to all foods ingested will increase nutrient absorption and help the malnutrition; however, this intervention is not the priority at this time. Inserting an IV to administer antibiotics is important, and can be done after ensuring adequate respiratory function.
the child in a squatting position- purpose congenital heart disease "This position may help control breathlessness after exercise." .
The nurse is caring for a child with a cyanotic heart disease. The mother tells the nurse that she often finds the child in a squatting position and asks if this is normal. Which of the following responses by the nurse is most appropriate? "This position may help control breathlessness after exercise." Explanation: Children with congenital heart disease squat or assume a knee-to-chest position to trap blood in the lower extremities. This allows them to more easily oxygenate the blood remaining in the upper body. This is a method children use to relieve dyspnea after exercise or exertion.
B12- IM injection- Administer using Z-track technique
The nurse is preparing to administer vitamin B12 intramuscularly (IM). Which nursing intervention is appropriate? Administer using Z-track technique Explanation: B12 can discolor the skin with injections and thus requires the nurse to use the Z-Track method of injection to reduce the risk of site complications. Increasing oral B12 would be inappropriate in clients receiving B12 injections typically because they are missing the intrinsic factor necessary for absorption. Vitamin C is helpful to improve iron absorption. Rubbing the injection site of a Z-track injection is contraindicated.
Positioning- dyspnea What position would be contraindicated for a client who has dyspnea? Supine In the supine position, the abdominal contents press against the diaphragm, impeding expansion of the lungs. The other choices are correct to assist with ease of breathing.
The nurse understands that client position is important when treating dyspnea. What position would be contraindicated for a client who has dyspnea? Supine Explanation: In the supine position, the abdominal contents press against the diaphragm, impeding expansion of the lungs. The other choices are correct to assist with ease of breathing.
cystic fibrosis (CF)- DIET high-calorie diet Explanation: CF affects the exocrine glands. Mucus is thick and tenacious, sticking to the walls of the pancreatic and bile ducts and eventually causing obstruction. Because of the difficulty with digestion and absorption, a high-calorie, high-protein, high-carbohydrate, moderate-fat diet is indicated
What type of diet should the nurse teach the parents to give an older infant with cystic fibrosis (CF)? high-calorie diet Explanation: CF affects the exocrine glands. Mucus is thick and tenacious, sticking to the walls of the pancreatic and bile ducts and eventually causing obstruction. Because of the difficulty with digestion and absorption, a high-calorie, high-protein, high-carbohydrate, moderate-fat diet is indicated
Acute Respiratory Failure- ABGs pH 7.24 Explanation: Acute respiratory failure (ARF) is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with a decreased arterial pH.
Arterial blood gas analysis would reveal which of the following related to acute respiratory failure? pH 7.24 Explanation: Acute respiratory failure (ARF) is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with a decreased arterial pH.
Respiratory acidosis- ABG results Explanation: Respiratory acidosis is correct because the pH is decreased and the PCO2 is increased. All of the other choices are incorrect.
A client has the following arterial blood gas results: pH 7.32; PaCO2 50; HCO3 23; SaO2 80%. The nurse would interpret the arterial blood gases to be which of the following? Respiratory acidosis Explanation: Respiratory acidosis is correct because the pH is decreased and the PCO2 is increased. All of the other choices are incorrect.
A POSITIVE MANTOUX TEST is immunocompromised. Explanation: An induration (palpable raised hardened area of skin) of more than 5 to 15 mm (depending upon the person's risk factors) to 10 Mantoux units is considered a positive result, indicating TB infection. An induration of greater than 5 mm is found in HIV-positive individuals, those with recent contacts with persons with TB, persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB, or clients with organ transplants or immunosuppressed. An induration of greater than 10 mm is positive, and the client may be a recent arrival (less than 5 years) from high-prevalent countries, injection drug user, resident or an employee of high-risk congregate settings (e.g., prisons, long-term care facilities, hospitals, homeless shelters), or mycobacteriology lab personnel. Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight), a child less than 4 years of age, or a child or adolescents exposed to adults in high-risk categories.
A client had a Mantoux test result of an 8-mm induration. The test is considered positive when the client: is immunocompromised. Explanation: An induration (palpable raised hardened area of skin) of more than 5 to 15 mm (depending upon the person's risk factors) to 10 Mantoux units is considered a positive result, indicating TB infection. An induration of greater than 5 mm is found in HIV-positive individuals, those with recent contacts with persons with TB, persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB, or clients with organ transplants or immunosuppressed. An induration of greater than 10 mm is positive, and the client may be a recent arrival (less than 5 years) from high-prevalent countries, injection drug user, resident or an employee of high-risk congregate settings (e.g., prisons, long-term care facilities, hospitals, homeless shelters), or mycobacteriology lab personnel. Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight), a child less than 4 years of age, or a child or adolescents exposed to adults in high-risk categories.
SQUATTING- A child with a cardiac defect assumes a squatting position. The nurse should determine that the position is effective for the child by noting: less dyspnea. Explanation: A child with a cardiac defect finds that squatting decreases venous return and workload to the heart and increases comfort and blood flow to the lungs. Squatting traps blood in the lower extremities so less blood is returned to the right atrium. Squatting does not make it easier for the child to play with toys. Squatting does not relieve abdominal pressure; it may even increase it slightly. Squatting has no effect on muscle tone. When done by a child with a cardiac defect, it is not meant as an exercise but is a compensatory process used to reduce dyspnea.
A child with a cardiac defect assumes a squatting position. The nurse should determine that the position is effective for the child by noting: less dyspnea. Explanation: A child with a cardiac defect finds that squatting decreases venous return and workload to the heart and increases comfort and blood flow to the lungs. Squatting traps blood in the lower extremities so less blood is returned to the right atrium. Squatting does not make it easier for the child to play with toys. Squatting does not relieve abdominal pressure; it may even increase it slightly. Squatting has no effect on muscle tone. When done by a child with a cardiac defect, it is not meant as an exercise but is a compensatory process used to reduce dyspnea.
amiodarone- Desired effect of The number of premature ventricular contractions is decreasing. Explanation: Amiodarone is used for the treatment of premature ventricular contractions, ventricular tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial therapy for a pulseless dysrhythmia.
A client is given amiodarone in the emergency department for a dysrhythmia. Which finding indicates the drug is having the desired effect? The number of premature ventricular contractions is decreasing. Explanation: Amiodarone is used for the treatment of premature ventricular contractions, ventricular tachycardia with a pulse, atrial fibrillation, and atrial flutter. Amiodarone is not used as initial therapy for a pulseless dysrhythmia.
Recovery from moderate sedation- SpO2 95-100% normal Oxygen saturation (SaO2) of 89% Explanation: Normal SaO2 is 95% to 100%. Oxygen saturation below 94% indicates inadequate oxygenation, which may be a consequence of the moderate sedation. Appropriate nursing actions include rousing the client, if necessary, assisting the client with coughing and deep breathing, and evaluating the need for additional oxygen.
A nurse is monitoring a client recovering from moderate sedation that was administered during a colonoscopy. Which finding requires the nurse's immediate attention? Oxygen saturation (SaO2) of 89% Explanation: Normal SaO2 is 95% to 100%. Oxygen saturation below 94% indicates inadequate oxygenation, which may be a consequence of the moderate sedation. Appropriate nursing actions include rousing the client, if necessary, assisting the client with coughing and deep breathing, and evaluating the need for additional oxygen. A heart rate of 84 beats/minute is within normal limits. Colonoscopy doesn't affect cough and gag reflexes, although these reflexes may be slightly decreased from the administration of sedation. These findings don't require immediate intervention. Blood-tinged stools are a normal finding after colonoscopy, especially if the client had a biopsy.
Cheyne-Stokes respiration. Explanation: Cheyne-Stokes respiration is defined as a regular cycle that starts with normal breaths, which increase and then decrease followed by a period of apnea. It can be related to heart failure or a dysfunction of the respiratory center of the brain. Hyperventilation is associated with an increased rate and depth of respirations. Obstructive sleep apnea is recurring episodes of upper airway obstruction and reduced ventilation. Biot's respiration, also known as "cluster breathing," is periods of normal respirations followed by varying periods of apnea.
When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, then a couple of small breaths, then 10 to 20 seconds of no breaths. The nurse should record the breathing pattern as: Cheyne-Stokes respiration. Explanation: Cheyne-Stokes respiration is defined as a regular cycle that starts with normal breaths, which increase and then decrease followed by a period of apnea. It can be related to heart failure or a dysfunction of the respiratory center of the brain. Hyperventilation is associated with an increased rate and depth of respirations. Obstructive sleep apnea is recurring episodes of upper airway obstruction and reduced ventilation. Biot's respiration, also known as "cluster breathing," is periods of normal respirations followed by varying periods of apnea.
