Ch. 38: Oxygenation and Perfusion
A nurse is teaching a home care client and the family about using prescribed oxygen. What is a critical factor that must be included in teaching? a) the cost and source of supply for the oxygen b) the need to provide good skin care c) the safety measures necessary to prevent a fire d) the importance of communicating with the client
the safety measures necessary to prevent a fire Explanation: Oxygen, which constitutes 20% of normal air, is a tasteless, odorless, colorless gas. It supports combustion, and it is critical to provide safety measures to prevent fires and injury.
A normal pulse oximetry reading indicates that the body's oxygen demands are being met. a) True b) False
False
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? a) Residual Volume (RV) b) Total lung capacity (TLC) c) Tidal volume (TV) d) Forced Expiratory Volume (FEV)
Residual Volume (RV) Explanation: 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.
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? a) Chronic anemia b) Pancreatitis c) Graves' disease d) Parkinson's disease
Chronic anemia Explanation: The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the amount 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. Graves' disease, Parkinson's disease, and pancreatitis do not directly lead to a decrease in the number of red blood cells.
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? a) Contact the physician for nutrition shake. b) Snack on high-carbohydrate foods frequently. c) Eat smaller meals that are high in protein. d) Eat one large meal at noon.
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.
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? a) Nasal strip b) Oxygen analyzer c) Flow meter d) Nasal cannula
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.
The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds? a) They are medium-pitched blowing sounds heard over the major bronchi. b) They are soft, high-pitched discontinuous (intermittent) popping lung sounds. c) They are loud, high-pitched sounds heard primarily over the trachea and larynx. d) They are low-pitched, soft sounds heard over peripheral lung fields.
They are low-pitched, soft sounds heard over peripheral lung fields. Explanation: 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.
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? a) Vesicular b) Bronchial c) Crackles d) Bronchovesicular
Vesicular Explanation: Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields.
A nurse auscultates the lungs of a client with asthma. Which lung sound is characteristic of this condition? a) Crackles b) Wheezes c) Vesicular sounds d) Bronchial sounds
Wheezes Explanation: Wheezes are continuous musical sounds, produced as air passes through airways that are constricted, as with asthma. Crackles are produced by fluid in the airways or alveoli and delayed reopening of collapsed alveoli. They occur due to inflammation or congestion and are associated with pneumonia, heart failure, bronchitis, and COPD.
A nurse is admitting a 6-year-old child status post tonsillectomy to the surgical unit. The nurse obtains his weight and places EKG and a pulse oximeter on the client's left finger. His heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate: a) high cardiac output. b) adequate tissue perfusion. c) heart failure. d) diminished stroke volume.
adequate tissue perfusion. Explanation: Pulse oximetry is often used as a measure of tissue perfusion. An oxygen saturation of greater than 94% is typically indicative of good tissue perfusion.
Oxygen and carbon dioxide move between the alveoli and the blood by: a) hyperosmolar pressure. b) negative pressure. c) osmosis. d) diffusion.
diffusion. Explanation: Oxygen and carbon dioxide move between the alveoli and the blood by diffusion, the process in which molecules move from an area of greater concentration or pressure to an area of lower concentration or pressure.
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? a) administration of inhaled corticosteroids b) oropharyngeal suctioning twice daily c) educating the client on pursed-lip breathing techniques d) educating the client on the use of incentive spirometry
educating the client on the use of incentive spirometry Explanation: Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions. Corticosteroids are not typically used as a preventive measure for respiratory complications after surgery
An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the 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: a) sodium and potassium levels. b) blood pH. c) hemoglobin level. d) age.
hemoglobin level Explanation: 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
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? a) low blood pressure b) high temperature c) high respiratory rate d) low pulse rate
high respiratory rate Explanation: A client diagnosed with impaired gas exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.
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? a) pursed-lip breathing b) deep breathing c) diaphragmatic breathing d) incentive spirometry
deep breathing Explanation: The nurse should teach deep breathing techniques to the client who 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.
A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario? a) Cyanosis b) Eupnea c) Hypoxemia d) Hypercapnia
Cyanosis Explanation: Cyanosis around the lips indicates serious hypoxemia. Cyanosis is caused by a desaturation of oxygen on the hemoglobin in the blood. Hypercapnia is caused by an abnormally high carbon dioxide level in the blood. Hypoxemia is caused by low oxygen levels in the blood. Eupnea is easy, free respiration.
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? a) Perfusion b) Atelectasis c) Hypoxia d) Hyperventilation
Hypoxia Explanation: 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.
Which is a major organ of the upper respiratory tract? a) Trachea b) Pharynx c) Lungs d) Bronchi
Pharynx Explanation: The pharynx, mouth, and nose are major organs of the upper respiratory tract. The trachea, bronchi, and lungs are major organs of the lower respiratory tract
A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from? a) Chronic bronchitis b) Pneumonia c) Sleep apnea d) Chronic obstructive pulmonary disease (COPD)
Sleep apnea Explanation: This client has all the risk factors of sleep apnea, which consists of multiple periods of apnea during sleep. These periods of apnea cause the person to move into a lighter sleep more often than someone without this disease, thus causing the daytime sleepiness
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? a) respiratory rate of 18 breaths per minute b) fine crackles to the bases of the lungs bilaterally c) vesicular breath sounds audible over peripheral lung fields d) resonance on percussion of lung fields
fine crackles to the bases of the lungs bilaterally Explanation: Except in the case of infants, fine crackles always constitute an abnormal assessment finding. A respiratory rate of 18 is within acceptable range. Vesicular sounds over peripheral lung fields and resonance on percussion are expected assessment findings.
A client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and they are thick and sticky. The nurse should instruct the client to: a) decrease exercise and increase rest periods. b) take a cough suppressant to decrease coughing. c) increase her fluid intake to thin secretions. d) eat small, frequent meals to conserve energy.
increase her fluid intake to thin secretions. Explanation: When a cough is productive, it is important to establish the source of the sputum and assess its color, volume, consistency, and other noteworthy characteristics. The nurse should instruct the client to increase fluid intake to thin secretions
What is the action of codeine when used to treat a cough? a) suppressant b) antihistamine c) expectorant d) antisuppressant
suppressant Explanation: Codeine, which is an ingredient in many cough preparations, is generally considered to be the preferred cough suppressant ingredient.
A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient? a) Oxygen mask b) Oxygen tent c) Nasal cannula d) Ambu bag
Ambu bag Explanation: If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag)may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube
A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which delivery device should the nurse use in order to administer oxygen to the client? a) Face tent b) Simple mask c) Nasal cannula d) Non-rebreather mask
Nasal cannula Explanation: The nurse should use a nasal cannula to administer oxygen to an asthmatic client who requires a low concentration of oxygen. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It is used for administering a low concentration of oxygen to clients who are not extremely hypoxic and are diagnosed with chronic lung disease.
In which client would the nurse assess for a depressed respiratory system? a) a client taking antibiotics for a urinary tract infection b) a client taking insulin for diabetes c) a client taking opioids for cancer pain d) a client taking amlodipine for hypertension
a client taking opioids for cancer pain Explanation: 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.
The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal? a) 12 to 15 breaths per minute b) 30 to 55 breaths per minute c) 20 to 30 breaths per minute d) 12 to 20 breaths per minute
30 to 55 breaths per minute Explanation: The nurse should expect the newborn to have a respiratory rate of 30 to 55 breaths per minute. Toddlers and preschoolers have a respiratory rate of 20 to 30 per minute. School-age children and adolescents have a respiratory rate of 12 to 20 breaths per minute
The nurse is conducting the physical assessment of a client at the health care facility. The nurse uses the pulse oximetry technique to monitor the oxygen saturation in the client's blood. Which pulse oximeter range indicates that the client is adequately oxygenated? a) 80% to 90% b) 85% to 95% c) 95% to 100% d) 90% to 95%
95% to 100% Explanation: If the client is adequately oxygenated, the pulse oximeter reading should be between 95% and 100%. Pulse oximetry is a noninvasive, transcutaneous technique for periodically or continuously monitoring the oxygen saturation in the blood. The normal range of oxygen saturation in the blood is between 95% and 100%.
A nurse is caring for a client who breathes very shallowly and has been reporting severe back pain. What suggestion could the nurse make to help the client breathe efficiently? a) Instruct the client in the use of pursed-lip breathing technique. b) Teach the client diaphragmatic breathing. c) Inform the client about nasal strips. d) Encourage the client to take deep breaths.
Encourage the client to take deep breaths. Explanation: To help the client breathe efficiently, the nurse could encourage the client to take deep breaths. Deep breathing maximizes the ventilation and fills the alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing and diaphragmatic breathing help to eliminate the extra carbon dioxide from the lungs.
During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? a) Flow meter b) Nasal cannula c) Humidifier d) Oxygen analyzer
Flow meter Explanation: In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter 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. A humidifier is a device that produces small water droplets and may be used during oxygen administration, since oxygen dries the mucous membranes. A nasal cannula is a hollow tube with half-inch prongs placed into the client's nostrils. It provides a means for administering a low concentration of oxygen.
A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function? a) Tachypnea b) Pleural effusion c) Pneumonia d) Wheezes
Pleural effusion Explanation: Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion). Tachypnea and wheezes are not symptoms that directly indicate a need for thoracentesis and pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.
The nurse is instructing the client with a pulmonary disorder on 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? a) "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." b) "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." c) "Breathing through your nose first will warm, filter, and humidify the air you are breathing." d) "If you breathe through the mouth first, you will swallow germs into your stomach."
"Breathing through your nose first will warm, filter, and humidify the air you are breathing." Explanation: 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 educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? a) Inhale two sprays with one breath for faster action. b) Inhale through the nose instead of the mouth. c) Inhale the medication rapidly. d) Be sure to shake the canister before using it.
Be sure to shake the canister before using it. Explanation: A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly. MDIs are inhaled through the mouth, into the lungs. The medication should be inhaled slowly to ensure a sufficient dose enters the lungs. If the order is for two sprays, these sprays are administered with one spray for each breath. The inhaled breath should be held briefly after each spray in order to prevent immediately exhaling the medication
The nurse is caring for a client who reports difficulty breathing. In what position would the nurse place this client? a) prone position b) Fowler's position c) supine position d) lateral position
Fowler's position Explanation: People with dyspnea and orthopnea are most comfortable in a high Fowler's position because accessory muscles can easily be used to promote respiration. Prone position can be used on a routine basis to promote ventilation and perfusion of the posterior dependent sections of the lungs. Lateral and supine position would not be beneficial as accessory muscles are not supported as with a Fowler's position.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea? a) Lying with the head slightly lowered b) Side lying with head slightly elevated c) Supine with one pillow d) High-Fowler's position
High-Fowler's position Explanation: Clients with COPD are most comfortable in high-Fowler's position because it aids in the use of the accessory muscles to promote respirations. The supine position with one pillow, side-lying with head slightly elevated or lying with the head slightly lowered does not promote easier respirations
When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom? a) Weight loss b) Rapid respirations c) Increased urine output d) Mental alertness
Rapid respirations Explanation: Normal cardiac output averages from 3.5 L/minute to 8.0 L/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 respiratory rate to increase oxygen delivery to the tissues. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.
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? a) Monitor the amount of oxygen saturation in the blood. b) Measure the volume of air exhaled or inhaled over time. c) Calculate the pressure of carbon dioxide dissolved in plasma. d) Monitor the pressure of oxygen dissolved in plasma.
Monitor the amount of oxygen saturation in the blood. Explanation: The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. The arterial blood gases test the client's blood for the partial pressure of oxygen dissolved in plasma, the percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma. Spirometry measures the volume of air in liters exhaled or inhaled by a client over time.
During data collection of a 4-year-old client, the nurse notes a respiratory rate of 35 breaths/min and a loud, harsh expiration that is longer than inspiration. The nurse would implement which appropriate nursing intervention next? a) Notify the health care provider b) Administer oxygen therapy c) Proceed with the data collection d) Obtain arterial blood sampling
Proceed with the data collection Explanation: When collecting respiratory data on a 4-year-old, loud, harsh expiration longer than inspiration breath sounds and respiratory rate of 20-40 breaths/min are normal findings; therefore, the nurse would continue with the assessment. Because the findings are normal, it is inappropriate at this time to administer oxygen therapy, obtain an arterial blood sampling, or notify the health care provider.
The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner? a) 10 L/min oxygen via Venturi mask b) 12 L/min oxygen via nonrebreather mask c) 8 L/min oxygen via partial rebreather mask d) 8 L/min oxygen via nasal cannula
8 L/min oxygen via nasal cannula Explanation: The correct amount delivered FiO2 for a nonrebreather mask is 12 L/min; 8-11 L/min for partial rebreather mask; 4-10 L/min for Venturi mask; and 1-6 L/min for nasal cannula. However, per nasal cannula it may be no more than 2-3 L/min to patient with chronic lung disease
A nurse measuring the arterial oxyhemoglobin saturation (SaO2 or SpO2) of a client's arterial blood gets a weak signal from the pulse oximeter. What would be the appropriate intervention in this situation? a) Use a blood pressure cuff to increase circulation to the site. b) Shine available light on the equipment to facilitate accurate reading. c) If extremity is hot, place a cold compress on the site. d) Check vital signs and client condition.
Check vital signs and client condition. Explanation: If a nurse finds an absent or weak signal, the nurse should check vital signs and client condition. If satisfactory, check connections and circulation to site. Hypotension makes an accurate recording difficult. Equipment (restraint, blood pressure cuff) may compromise circulation to the site and cause venous blood to pulsate, giving an inaccurate reading. If the extremity is cold, the nurse should cover it with a warm blanket. Bright light can interfere with the operation of light sensors and cause an unreliable report.
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? a) Decreased respiratory rate b) Decreased blood pressure c) Hyperactivity d) Confusion
Confusion Explanation: Anxiety, restlessness, confusion, or drowsiness are common signs of hypoxia. Hyperactivity is not associated with hypoxia. Other common symptoms of hypoxia are dyspnea, an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.
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? a) Spirometry b) Peak expiratory flow rate c) Thoracentesis d) Pulse oximetry
Pulse oximetry Explanation: 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.
The nurse is observing the unlicensed assistive personnel (UAP) perform oropharyngeal suctioning on a client. Which action, performed by the UAP, would indicate to the nurse that suctioning is being properly performed? a) The UAP advances the catheter approximately 5" to 6" to reach the pharynx. b) The UAP advances the catheter approximately 3" to 4" to reach the pharynx. c) The UAP applies lubricant to the first 2 to 3" of the catheter. d) The UAP allows 30-second to 1-minute intervals between suctioning passes.
The UAP advances the catheter approximately 3" to 4" to reach the pharynx. Explanation: When performing oropharyngeal suctioning, the catheter should be placed along the side of the mouth toward the trachea and advanced 3" to 4" to reach the pharynx. In nasopharyngeal suctioning, the catheter should be inserted through the naris and along the floor of the nostril toward the trachea; it should be advanced approximately 5" to 6" to reach the pharynx. Applying lubricant to the first 2 to 3" of the catheter facilitates passage of the catheter and reduces trauma to mucous membranes. Allowing 30-second to 1-minute intervals between suction passes allow for reventilation and reoxygenation of airways.
The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse, if noted by the charge nurse, would cause the charge nurse to intervene? a) The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). b) The newly hired nurse assesses the client's pain and administers pain medication. c) The newly hired nurse explains what she is doing and the reason to the client, even though the client does not appear to be alert. d) The newly hired nurse adjusts the bed to a comfortable working position.
The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). Explanation: Care of a tracheostomy tube in a stable situation, such as long-term care and other community-based care settings, may be delegated to licensed practical/vocational nurses (LPN/LVN); not in an acute instance.
The nurse is performing an arterial blood gas sampling on a client at 1045. The nurse educator intervenes if which action is taken by the nurse? a) The nurse stops holding pressure at 1055. b) The nurse immediately places the arterial specimen on ice. c) The nurse selects the radial artery as choice of site. d) The nurse performs the Allen's test after blood sample is taken.
The nurse performs the Allen's test after blood sample is taken. Explanation: The Allen's test is done before puncture to ensure adequate ulnar blood flow when using radial artery. The arterial specimen is immediately placed on ice and taken to the laboratory. The radial, brachial, or femoral arteries are usually the sites of choice for an arterial blood sampling. The nurse should apply pressure for 5 to 10 minutes, longer if the client is on anticoagulant therapy.
The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system? a) an adult who is receiving oxygen at home b) a child who has pneumonia c) an older adult client who has COPD d) an adolescent who has asthma
a child who has pneumonia Explanation: An oxygen tent is commonly used with children who need a cool and highly humidified airflow. It is also more effective for children because they often do not like to keep oxygen administration devices in place. Since the tent does not allow the maintenance of a satisfactory or precise oxygen concentration, is difficult to maintain a consistent level of oxygen. The oxygen tent does not adequately deliver oxygen at a rate higher than 30% to 50%; thus, it is rarely used with other clients.
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: a) alcohol abuse. b) asthma. c) croup. d) pneumonia.
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.
What structural changes to the respiratory system should a nurse observe when caring for older adults? a) respiratory muscles become weaker b) increased mouth breathing and snoring c) diminished coughing and gag reflexes d) increased use of accessory muscles for breathing
respiratory muscles become weaker Explanation: One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker. The nurse should also observe other structural changes: the chest wall becomes stiffer as a result of calcification of the intercostals cartilage, kyphoscoliosis, and arthritic changes to costovertebral joints; the ribs and vertebrae lose calcium; the lungs become smaller and less elastic; alveoli enlarge; and alveolar walls become thinner.
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. a) The power of the respiratory and abdominal muscles is reduced in older adults, and therefore the diaphragm moves less efficiently. b) Blood pressure increases over time until it reaches the adult level around age 8. c) Alterations in respiratory function due to aging in older adults increase the risk for disease, especially pneumonia and other chest infections. d) The respiratory rate is more rapid in infants until the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates. e) The normal infant's chest is small and the airways are short, making aspiration a potential problem. f) The chest in the older adult is unable to stretch as much, resulting in an increase in maximum inspiration and expiration.
• 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. Explanation: Muscles tend to lose strength in older adults, causing the diaphragm to be less efficient. Infants are at an increased risk for aspiration during feedings because of the small size of the chest and length of the airway. The chest and lungs lose elasticity as a person ages, increasing the potential for infections of the respiratory tract. There is a decreased number and size of alveoli in the infant, causing the respiratory rate to be higher in an attempt to adequately exchange oxygen and carbon dioxide. Blood pressure reaches the adult level during the preteen to teen years. A decrease in maximum inspiration and expiration occurs in the older adult because of decreased elasticity