240 Chapter 39: Oxygenation and Perfusion

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 client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?

"You should never smoke when oxygen is in use."

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

An infant with a respiratory rate of 20 bpm

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 client demonstrates soft, high-pitched, discontinuous sounds in the left lower lobe of the lung. How will the nurse accurately document this finding?

Crackles

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 skin disorder is associated with asthma?

Eczema

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

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.

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

Left-sided heart failure Pneumonia Pulmonary edema Bronchial obstruction

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

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 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?

SpO2 92%

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse would cause the charge nurse to intervene?

The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN).

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

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

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

Use a bag and mask.

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.

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?

Vesicular

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

a client taking opioids for cancer pain

A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:

adequate tissue perfusion.

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

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:

congestive heart failure.

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:

croup.

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 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

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

The home care nurse visits a client with compromised lung function. She has greenish-yellow sputum with a musty odor. This is indicative of:

infection.

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

nasal cannula

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? 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

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use?

nonrebreather mask

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?

pulse oximetry

The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select?

tracheostomy collar

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test?

Monitor the amount of oxygen saturation in the blood.

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?

Remove the airway, turn the client to the side, and provide mouth suction, if necessary.

The nurse is listening to the client's lungs and hears them fill with air and then return to a resting position. How will the nurse document this assessment data?

inspiration and expiration