CHAPTER 39 OXYGENATION

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

Adequate tissue perfusion

The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the clients tissue oxygenation. The nurse would use which appropriate method to assess this clients oxygenation ?

Arterial blood gas

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

Clubbing

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?

Confusion

The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is:

Ineffective breathing pattern related to hyperventilation related to increased anteroposterior diameter.

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

Instruct the client to inhale deeply and then cough

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?

Nasal cannula

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

Pneumonia

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 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)

A client requires low-flow oxygen. How will the oxygen be administered ? Select all that apply

Simple oxygen mask Nasal cannula Partial rebreather mask

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

True

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

a client taking opioids for cancer pain

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 performs a respiratory assessment on a healthy client. While listening to the clients lungs, the nurse hears them fill with air and then return to a resting position. The nurse deems the findings normal. Which is the best way to document this respiratory assessment and lung sounds ?

Respiratory rate 14, even, regular and easy depth with acceptable parameters lung sounds clear all lobes bilaterally absence of adventitious lung sounds; absence of spontaneous cough; oxygen saturation 98%

A nurse is preparing to use a wall unit to suction on endotracheal tube. At what pressure should the suction be set?

80 to 150;mm hg

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

Eat smaller meals that are high in protein.

A client has been put on oxygen therapy because of low oxygen saturation levels in the blood. What should the nurse use to regulate the amount of oxygen delivered to the client?

Flow meter

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

They are low pitched soft sounds heard over peripheral lung fields

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?

trauma to the tracheal mucosa