Fundamentals of Nursing: Chapter 39

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? "Breathing through your nose first will warm, filter, and humidify the air you are breathing." "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." "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.

A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response? "Let me teach you about incentive spirometry." "There is very little that can be done for snoring." "Pursed-lip breathing can reduce your amount of snoring." "Have you tried nasal strips?"

"Have you tried nasal strips?" Explanation: Nasal strips are available over the counter and are used to widen the nasal passageways. A common use for nasal strips is to reduce or eliminate snoring.

A client's spouse reports that the client snores loudly and incessantly every night. What is the appropriate nursing response when the client's spouse asks about nasal breathing strips? "You will need a prescription for nasal strips." "The nasal diameter is decreased by nasal strips." "Nasal strips may reduce or eliminate snoring." "Those do not work for snoring."

"Nasal strips may reduce or eliminate snoring." Explanation: Nasal strips are available over the counter and are used to widen the nasal passageways. A common use for nasal strips is to reduce or eliminate snoring.

The nurse determines that the student who has been instructed about lung function and smoking requires additional teaching when the student says a) "An older person may breathe more shallowly than a younger person." b) "Smoking only once in a while will not make a person addicted to smoking." c) "An upright position will help someone breathe with less effort." d) "A physically fit athlete breathes more slowly than a sedentary person."

"Smoking only once in a while will not make a person addicted to smoking." Explanation: During adolescence, more than 3000 young men and women begin smoking every day, and most will become addicted before age 20. One reason for this finding is that adolescents don't believe they will become addicted to tobacco when they start to smoke. 1357

The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach? "Take in a small amount of air and exhale quickly." "Take in a large volume of air and hold your breath as long as you can." "Take in as much air as possible, hold your breath briefly, and exhale slowly." "Take in a little air, hold your breath 15 seconds, and exhale slowly."

"Take in as much air as possible, hold your breath briefly, and exhale slowly." Explanation: This technique maximizes ventilation taking in a large volume of air fills alveoli to a greater capacity, which improves gas exchange. Deep breathing is useful for client's who has been inactive or in pain as associated with pneumonia. The other techniques do not promote improved gas exchange.

how would you do a physical assessment on a patient with pulmonary/cardio problems?

"look, listen, and feel" inspection- mood and behavior, level of consciousness, skin, mucous membranes, structural abnormalities breathing patterns- rate, rhythm, and depth

Lungs function in regulation of fluid and electrolyte balance

- remove approx 300mL of water/day through exhalation (insensible water loss) in adult -eliminate about 13,000 mEq of hydrogen ions daily as opposed to only 40-80 mEq excreted daily by kidneys - act promptly to correct metabolic acid-base disturbances; regulate H+ concentration (pH) by controlling the level of CO2 in tbe extracellular fluid as follows: 1. Metabolic alkalosis causes compensatory hypoventilation resulting in CO2 retention (increases acidity in ECF) 2. Metabolic acidosis causes compensatory hyperventilation resulting in CO2 excretion (decreases acidity in ECF)

Positive Airway Pressure (PAP)

- uses mild airway pressure to keep airways open - Helps maintain CO2 & O2 levels

During inspiration the diaphragm

-Contracts, descends (gives more space to thorax for expansion)

Ischemia

-Reduced blood flow. - Ischemia is generally caused by problems with blood vessels, with resultant damage to or dysfunction of tissue.

Hypoventilation

1) Decreased rate and depth of air movement into lungs. 2) Often causes hypoxia

Dyspnea

1) Difficulty breathing 2) Symptom of hypoxia

Expectorants

1) Drugs that facilitate the removal of respiratory tract secretions by *REDUCING the VISCOSITY of the secretions.* 2) Patients with extremely tenacious secretions may need the secretions liquefied for their cough to be effective 3) Guaifenescin (Robitussin) (OTC) 4) Some health care providers consider adequate fluid intake and air humidification as effecive expectorants.

Oxygen Therapy in the Home

1) Liquid oxygen and oxygen concentrators (rather than cylinders) are more commonly used in the home. 2) Liquid oxygen is kept inside a small thermal container that can be refilled form a larger storage tank. 3) An oxygen concentrator REMOVES nitrogen + concentrates oxygen. 4) Transtracheal oxygen delivery is an option

Tracheostomy

1) May be used to replace an ENDOTRACHIAL TUBE, to provide a method for mechanical ventilation of the patient to bypass an upper airway obstruciton or to remove trachobronchial secretions. 2) It is an artificial opening (made using local anesthesia) made into the trachea, usually at the level of the second or third cartilaginous ring 3) May be temporary or permanant

Positive Airway Pressure (PAP)

1) Uses mild air pressure to keep airways open 2) Can help the body better maintain carbon dioxide and oxygen levels in the blood 3) Used to treat: sleep apnea, obstructive sleep apnea, obesity, hypoventilation syndrome, and heart failure and infants whose lungs have not yet developed.

4 Breathing Techniques to Improve Breathing

1.) Deep Breathing 2.) Using Incentive Spirometry 3.) Pursed Lip Breathing 4.) Diaphragmatic Breathing

Adult normal respiratory rate

12-20 breaths per minute

A nurse is using a pulse oximeter to measure the arterial oxyhemoglobin saturation (SaO2 or SpO2) of a patient's arterial blood. What range is considered a normal value for SpO2? a) 65% to 70% b) 75% to 80% c) 85% to 90% d) 95% to 100%

95% to 100% Explanation: A range of 95% to 100% is considered normal SpO2; values less than 85% indicate that oxygenation to the tissues is inadequate. 1363

Normal SpO2 range

95-100%

Venturi mask

A face mask and reservoir bag device that delivers specific concentrations of oxygen by mixing oxygen with inhaled air.

Emphysema

A group of lung diseases that block airflow and make it difficult to breathe

Forced Expiratory Volume1

Amount of air exhaled IN THE FIRST SECOND after a full inspiration

Residual Volume (RV)

Amount of air remaining in the lungs after a maximal expiration

Hyponatremia s/s

Anorexia, N/V, Weakness, Lethargy, Confusion, Muscle cramps, Twitching, Seizures, coma, Urine specific gravity <1.010

hemothorax

Blood Collection in the thorax

Hemothoax

Blood in pleural space

The volume of blood ejected from the left side of the heart in one minute.

CARDIAC OUTPUT (CO) which average from 3.5 to 8.0 L/min in a healthy adult

Hypophosphatemia s/s

Cardiomyopathy Acute respiratory failure Seizures Decreased tissue oxygenation Joint stiffness Serum <2.5 mg/dL

Productive Cough

Cough that produces respiratory secretions

nasal cannula

Disposable plastic device with two protruding prongs that are inserted into the nostrils

A physician is choosing a chest drainage system for a client who is ambulating daily. Which of the following systems would be the best choice for this client? a) Dry suction water seal b) Dry suction/one-way valve system c) Traditional water seal d) Wet suction

Dry suction/one-way valve system Explanation: The dry suction or one-way valve system works even if knocked over, making it ideal for clients who are ambulatory. 1379

difficult or labored breathing

Dyspnea

During oxygen administration to the client, which of the following pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? a) Nasal cannula b) Oxygen analyzer c) Flow meter d) Humidifier

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. 1375

Pleural Effusion

Fluid in pleural space

Hypermagnesemia S/S

Flushing and sense of skin warmth, Hypotension, Drowsiness, Lethargy, Hypoactive reflexes, muscle weakness Depressed respirations, Bradycardia Early sign Serum 3-5 mEq/L

3 Types Chest Physiotherapy

Helps loosen and mobilize secretions, increasing mucous clearance. 1.) PERCUSSION 2.) VIBRATING 3.) POSTURAL DRAINAGE

Respiratory acidosis =

High PaCO2 due to alveolar hypoventilation

Up to 3 Days

How long does it take to restore normal fluid pH by the kidneys?

Pursed Lip Breathing

Improves the movement of air in and out of the lungs Opens the airways and removes trapped air Control our rate of breathing

Pneumonia

Infection that inflames air sacs in one or both lungs, which may fill with fluid

Hypoxemia

Insufficent oxygen in the blood

Factors Affecting Respiratory Functioning

Levels of health Developmental considerations Medications Lifestyle Environment Psychological health

Vital Capacity

Maximum amount of air EXHALED after a maximum inspiration

Hypercalemia S/S

Muscular weakness Tiredness,lethargy Constipation Anorexia, N/V Decreased memory, attention span Polyuria, polydipsia Renal stones Neurotic behavior Cardiac arrest Serum >10.5 mg/dL

Which of the following oxygen delivery systems is most commonly used because it does not impede eating or speaking? a) Oxygen hood b) Nasal cannula c) Oxygen mask d) Oxygen tent

Nasal cannula Explanation: A nasal cannula is commonly used because it does not impede eating or speaking and is easily used in the home. A mask is used when a patient requires a higher concentration of oxygen than a nasal cannula can deliver. Oxygen hoods and tents are generally used to deliver oxygen to infants and children. 1375

A client with chronic obstructive pulmonary disease requires low flow oxygen. How will the oxygen be administered? a) Simple oxygen mask b) Partial rebreather mask c) Venturi mask d) Nasal cannula

Nasal cannula Explanation: Nasal cannula and tubing administers oxygen concentrations at 22% to 44%. 1375

Air Embolus - Nursing considerations

Pinch off catheter or secure system to prevent air entry Place pt on left side in Trendelenburg position Call for immediate assistance Monitor VS pulse ox

Promoting Comfort

Positioning Maintaining adequate fluid intake Providing humidified air Performing chest physiotherapy Maintaining good nutrition

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?

Presence of sputum in the trachea (CRACKLES: - soft, high-pitched discontinuous popping sounds. -produced by air passing through fluid in the airways or alveoli and opening of deflated small airways and alveoli, produced by inflamation)

The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the client's care plan? a) Encourage the client to alternate eating and using a nebulizer during meal time. b) Encourage the client to eat immediately before breathing treatments. c) Provide six small meals daily. d) Provide three large meals daily.

Provide six small meals daily. Explanation: The nurse should consider providing six small meals distributed over the course of the day instead of three large meals. Meals should be eaten one to two hours after breathing treatments and exercises. 1365

MAIN BLOOD VESSELS THAT PROVIDE CORONARY CIRCULATION ARE:

RIGHT, LEFT CORONARY ARTERIES

Tachypnea

Rapid breathing

Air embolism S/S

Respiratory distress Increased HR Cyanosis Decreased BP Change in LOC

Electrical system of the heart

SA node AV node atrioventricular bumble (Bundle of His) Purkinje fibers

Calculate pulse pressure

Subtract diastolic number from systolic number to get pulse pressure.

MI symptoms

Symptoms include tightness or pain in the chest, neck, back, or arms, as well as fatigue, lightheadedness, abnormal heartbeat, and anxiety. Women are more likely to have atypical symptoms than men.(heart attack)

lung compliance refers to :

The ease with which the lungs can inflate

Peak Expiratory Flow Rate (PEFR)

The maximum flow attained during FORCED VITAL CAPACITY

sputum

The respiratory secretion expelled by coughing or clearing the throat.

You are preparing an educational inservice about endotracheal suctioning using an open suctioning system. Which of the following concepts should you plan to include? a) The patient should be suctioned until pulmonary secretions have been cleared. b) The suction catheter should be inserted to a predetermined length—no more than 1 cm past the end of the endotracheal tube. c) If the patient's endotracheal tube has been in place for longer than 7 days, the suction catheter can be reused but it needs to be replaced every 24 hours. d) Before suctioning, the wall suction unit should be adjusted to deliver 130 to 150 mm Hg of negative pressure.

The suction catheter should be inserted to a predetermined length—no more than 1 cm past the end of the endotracheal tube. Explanation: This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis.1404

arterial blood gas and pH analysis

The test is used to check the function of the patient's lungs and how well they are able to move oxygen and remove carbon dioxide.

Trx for Pneumothorax

Thoracentesis, Chest tube, O2

Sensible and Insensible losses

What 2 ways is fluid lost from the body?

9.0-10.5 Mg/dL

What is the normal range of Calcium(Ca)?

97-107 mEq/L

What is the normal range of Chloride?

1.3-2.1 mg/dL

What is the normal range of Magnesium(Mg)?

Infants and Elderly

Which 2 age groups are more prone to fluid imbalance?

Kidneys, Heart and Blood Vessels, Lungs, Adrenal Glands, Pituitary Glands, Thyroid Gland, Nervous System, GI Tract, Parathyroid Glands

Which organs/body systems help regulate fluid and electrolyte balance?

nasopharyngeal airway

a flexible breathing tube inserted through the patient's nostril into the pharynx to help maintain an open airway. -in a patient that is breathing spontaneously.

abdominal thrusts

a method of attempting to remove an object from the airway of someone who is choking

Increased PTH secretion

a. Elevated serum Ca2+ concentration b. Lowered serum HPO4 2- (phosphate) concentration

decreased PTH secretion

a. Lowered serum Ca2+ concentration b. Elevated serum HPO4 2- (phosphate) concentration

adventitious sounds

abnormal breath sounds such as wheezing or crackles

supplemental oxygen

administered when the patient is unable to maintain an adequate oxygen saturation level in the blood

_________, which is a decrease in the amount of RBC or erythrocytes, results in insufficient hemoglobin available to transport oxygen.

anemia

a condition of episodes of severe chest pain due to inadequate blood flow to the myocardium

angina

dry power inhaler (DPI)

another type of delivery method for inhaled medications. A QUICK DEEP BREATH BY THE PATIENT ACTIVATES THE FLOW OF MEDICATIONS

what affects internal respiration?

any abnormality in blood's components ex: hemorrhage or loss of blood can cause a decrease in CO.

incomplete lung expansion or the collapse of alveoli is known as _________.

atelectasis.

A client with no prior history of respiratory illness has been admitted to a postsurgical 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?

b) Educating the client on the use of incentive spirometry 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.

slow breathing

bradypnea

pleural friction rub

continuous dry grating sound loss of lubricating pleural fluid

During inspiration intercostal muscles

contract lifting the ribs upward and outward

visceral pleura

covers the lungs

A bluish discoloration of the skin and mucous membranes.

cyanosis

Bluish discoloration of the skin

cyanosis

narcotic or sedative drugs _____ heart rate

decrease

hypoventilation

decreased rate or depth of air movement into the lungs

Hypoxia

deficiency in the amount of oxygen reaching the tissues

myocardial ischemia

deficiency of blood supply to the myocardium

nebulizer

device used to deliver liquid medicine in a fine mist

A normal pulse oximetry reading indicates that the body's oxygen demands are being met. a) False b) True

false 1363

crackles

fine, crackling sounds made as air moves through wet secretions in the lungs

cardiovascular system is composed of

heart and blood vessels

chronic hypertension, coronary artery disease and disease of heart valves are examples of _____

heart failure

Tympany

high-pitched, loud, drum-like sound produced over the stomach

because oxygen dries and dehydrates the respiratory mucous membranes, ________ devices are commonly used when oxygen is delivered at higher flow rates.

humidifying (distilled or sterile water)

Hypoxia is often caused by

hypoventilation (decreased rate or depth of air movement into the lungs)

a condition in which an inadequate amount of oxygen is available to cells

hypoxia

what is angina?

imbalance between oxygen needed and oxygen delivered to heart

alteration in function=

impaired oxygenation

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? increase in the rate of respirations and decrease in the depth increase in rate and depth of respirations decrease in the rate of respirations and increase in depth decrease in rate and depth of respirations

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.

hyperventilation

increased rate and depth of ventilation, above the body's normal metabolic requirements.

rr and development

infant- 30-60 early childhood- 20-40 late childhood 15-25 aged adult 16-20

respiration rate is more rapid in ______ than at any other age.

infants

pneumonia

inflammation of the lungs

a contagious respiratory illness that causes mild to severe illness and even death

influenza (the flu)

bronchodilators

inhaled medications may be administered to open narrowed airways. (to liquefy or loosen thick secretions or to reduce inflammation in airways

what is pulmonary ventilation?

inspiration (the active phase of ventilation; brings air into the lung) expiration: the passive phase of ventilation (movement of air out of the lung)

spirometer

instrument used to measure breathing

what is heart failure?

insufficient pumping of heart= inadequate perfusion of blood

What are some factors essential to a normal functioning of the Respiratory System:

integrity of airway system (transport air to and from the lungs), properly functioning alveolar system (removes carbon dioxide from blood), properly functioning cardiovascular and hematologic system (carry nutrients and waste to and from the body cells)

the exchange of oxygen and carbon dioxide between the circulating blood and the tissue cells.

internal respiration

respiration

involves gas exchange between the atmospheric air in the alveoli and blood in the capillaries.

________,curvature of the spine, contributes to the older adults appearance of leaning forward and can limit respiratory ventilation

kyphosis

what are factors that affect cardiopulmonary functioning and oxygenation

level of health (acute or chronic illness), development considerations, medication considerations, lifestyle considerations

parietal pleura

lines the thoracic cavity

Mucolytic agents

liquefy or loosen thick secretions

bronchial

loud, high pitched sounds heard primarily over the trachea and larynx

Resonance

loud, hollow low-pitched sound heard over normal lungs

Hyperresonance

loud, low booming sound heard over emphysematous lungs

Respiratory alkalosis =

low PaCO2 due to alveolar hyperventilation

vesicular

low pitched, soft sounds heard over peripheral lung fields

what is the vesicular breath sound

low-pitched, soft sound during expiration. sound heard over most of the peripheral lung fields

peak expiratory flow rate

measurement of how fast a person can exhale using a small handheld device to monitor treatment in asthma or COPD (for patients with asthma)

cilia

microscopic hair- like projections, propel trapped material and accompanying mucus toward the upper airway so they can be removed by coughing.

what is diffusion?

movement of gas or particles from areas of higher pressure/ concentration to areas of lower pressure/ concentration

angina and myocardial infarction can result from __________ _________.

myocardial ischemia

oxygen can be administered by many different delivery systems. For example by a _________, also called nasal prongs, the most commonly used oxygen delivery device.

nasal cannula

Which is a sign of dyspnea specific to infants?

nasal flaring (occurs when your nostrils widen while breathing, and may be a sign that you're having difficulty breathing. It's most commonly seen in children and infants.)

Tachycardia

normal fast heart rate 100-106 bpm normal response to sympathetic stimulation (exercise,fever or stress)

Bronchodilators

open narrowed airways

what is the transportation of oxygenated blood?

oxygen is carried in the body via plasma and RBC. carried in the form of oxyhemoglobin

what is perfusion?

oxygenated capillary blood passes through the tissues of the body

any disease or condition that results in THICKENING of the alveolar-capillary membrane makes diffusion more difficult. for example ______ or __________.

pneumonia pulmonary edema

tachypnea

rapid breathing

Bradycardia

regular, but slow heart rate less than 60 beats per minute

what is supplemental oxygen therapy used for?

relieve or prevent hypoxia, must be ordered by health care provider

the wall of each alveolus is made of _______

single cell layer of squamous epithelium

bradypnea

slow 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 a) "His infection is causing him to breathe harder." b) "He will require additional testing to determine the cause." c) "He is using his chest muscles to help him breathe." d) "His lung muscles are swollen so he is using abdominal muscles."

"He is using his chest muscles to help him breathe." Explanation: 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 a) "His infection is causing him to breathe harder." b) "He is using his chest muscles to help him breathe." c) "His lung muscles are swollen so he is using abdominal muscles." d) "He will require additional testing to determine the cause."

"He is using his chest muscles to help him breathe." Explanation: The client will use accessory muscles to ease dyspnea and improve breathing. 1352

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? "Take in a small amount of air very quickly and then exhale as quickly as possible." "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling." "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." "Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly." Explanation: Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include the humidifier? "This is a gauge used to regulate the amount of oxygen that a client receives." "Small water droplets come from this, thus preventing dry mucous membranes." "The humidifier prescribes the concentration of oxygen." "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed."

"Small water droplets come from this, thus preventing dry mucous membranes." Explanation: The humidifier produces small water droplets which are delivered during oxygen administration to prevent or decrease dry mucous membranes. 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 healthcare provider prescribed the concentration of oxygen.

The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach? "Take in a little air, hold your breath 15 seconds, and exhale slowly." "Take in a small amount of air and exhale quickly." "Take in a large volume of air and hold your breath as long as you can." "Take in as much air as possible, hold your breath briefly, and exhale slowly."

"Take in as much air as possible, hold your breath briefly, and exhale slowly." Explanation: This technique maximizes ventilation taking in a large volume of air fills alveoli to a greater capacity, which improves gas exchange. Deep breathing is useful for client's who has been inactive or in pain as associated with pneumonia. The other techniques do not promote improved gas exchange.

A client receiving home oxygen calls the telehealth nurse to report that her caretaker removed her oxygen tank from the wheeled carrier. What is the appropriate telehealth nurse response? "That will help the oxygen flow more freely." "That will make it easier to carry with you." "The caregiver will need to place the oxygen tank back into the secure carrier." "Call your oxygen supplier immediately."

"The caregiver will need to place the oxygen tank back into the secure carrier." Explanation: Oxygen tanks are transported on a wheeled carrier to avoid accidental force. Accidental force could cause the tank to explode. The tank should not be carried, and taking it out of the carrier does not affect the flow of oxygen.

The nurse is caring for a client with a nonhealing wound who has been prescribed hyperbaric oxygen therapy (HBOT). When the client asks, "How will this help me?" What is the appropriate nursing response? "Wounds heal because HBOT helps to regenerate new tissue quickly." "You will be treated for decompression sickness." "It will help you breathe much easier, and feel better." "HBOT treats aerobic infections."

"Wounds heal because HBOT helps to regenerate new tissue quickly." Explanation: Although HBOT treats a multitude of conditions, the reason for using HBOT for a nonhealing wound is to help regenerate new tissue quickly. HBOT is used to treat anaerobic infections.

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response? "Oxygen is a flammable gas." "You should never smoke when oxygen is in use." "An occasional cigarette will not hurt you." "I understand; I used to be a smoker also."

"You should never smoke when oxygen is in use." Explanation: The nurse will educate the client about the dangers of smoking when oxygen is in use. Oxygen is not flammable, but it oxidizes other materials.

Heart and blood vessel function in regulation of fluid and electrolyte balance

- circulate nutrients and water throughout the body -circulate blood through kidneys under sufficient pressure for urine to form - react to hypovolemia by stimulating fluid retention (stretch receptors in atria and blood vessels)

breathing exercises

- deep breathing -using incentive spirometry -pursed-lip breathing (abren la boca como si estuvisen soplando vela) -diaphragmatic breathing

most common symptoms of hypoxia:

- dyspnea ( a difficulty breathing ) - an elevated BP with a small pulse pressure, - increased respiratory and pulse rates, - pallor, - cyanosis.

oropharyngeal airway

- in a patient that is breathing spontaneously. -used to keep the tongue clear of the airway

Thyroid gland function in regulation of fluid and electrolyte balance

- increases blood flow in the body by releasing thyroxine leading to increased renal circulation and resulting in increased glomerular filtration and urinary output

Nervous system function in regulation of fluid and electrolyte balance

- inhibits and stimulates mechanisms influencing fluid balance acts cheifly to regulate sodium and water intake and excretion - regulates oral intake by sensing intracellular dehydration which triggers thirst center in hypothalamus - neurons called osmoreceptors sensitive to change in concentration of ECF send impulses to pituitary gland to release ADH or inhibit

Normal Findings of ABG

- pH: 7.35 - 7.45 - PCO2: 35 - 45 mm Hg - PO2: 80 - 100 mm Hg - HCO3: 22 - 26 mEq/L

Adrenal glands function in regulation of fluid and electrolyte balance

- regulate blood volume and sodium and potassium balance by secreting aldosterone a mineral corticoid from the adrenal cortex 1. The primary regulator of aldosterone appears to be angiotensin II: decrease in blood volume triggers RAAS and increases aldosterone secretion which causes sodium retention (and thus water retention) and potassium loss 2. Decreased aldosterone causes sodium and water loss and potassium retention - cortisol (adrenocortical hormone) has only a fraction of potency of aldosterone - secretion of cortisol in large quantities can produce sodium and water retention and potassium deficit

Parathyroid function in regulation of fluid and electrolyte balance

- regulate calcium and phosphate balance by means of PTH. PTH influences bone reabsorption, calcium absorption from intestines and calcium reabsorption from renal tubules

Kidneys function in regulation of fluid and electrolyte balance

- regulate extracellular fluid volume and osmolarity by selective retention and excretion of body fluids - regulate electrolyte levels in the ECF by selective retention of needed substances and excretion of unneeded - regulate pH of ECF by excretion or retention of hydrogen ions - excrete metabolic wastes (primarily acids) and toxic substances - normally filter 180L of plasma/day in adult while excreting only 1.5L of urine

Pituitary gland function in regulation of fluid and electrolyte balance

- stores and releases ADH (made in hypothalamus) which acts to allow body to retain water, acts chiefly to regulate sodium and water intake and excretion

Hypertonic IV solutions

-10% Dextrose in Water -5% Dextrose in 0.9% Saline -5% Dextrose in 0.45% Saline

simple face mask

-Assists in providing humidified oxygen. -used when increased delivery of oxygen is needed for SHORT periods (less than 12 hours) -NEVER apply with delivery flow rate less than 5 L/min

Respiratory Functioning in the Older Adult

-Bony landmarks are more prominent due to loss of subcutaneous fat. -Kyphosis contributes to appearance of leaning forward. -Barrel chest deformity may result in increased anteroposterior diameter. -Tissues and airways become more rigid; diaphragm moves less efficiently. -Older adults have an increased risk for disease, especially pneumonia

Guidelines for Obtaining a Nursing History

-Determine why the patient needs nursing care. -Determine what kind of care is needed to maintain a sufficient intake of air. -Identify current or potential health deviations. -Identify actions performed by the patient for meeting respiratory needs. -Make use of aids to improve intake of air and effects on patient's lifestyle and relationship with others

Respiratory Activity in the Infant

-Lungs are transformed from fluid-filled structures to air-filled organs. -The infant's chest is small, airways are short, and aspiration is a potential problem. -Respiratory rate is rapid and respiratory activity is primarily abdominal. -Synthetic surfactant can be given to the infant to reopen alveoli. -Crackles heard at the end of deep respiration are normal.

Assessment Parameters

-Skin turgor (sternum,inner aspect of thighs, forehead) -Tongue turgor (unlike skin turgor not affected by age but arid climate may not be reliable) -Moisture and oral cavity (dry mouth may be FVD or mouth breathing) -Tearing and salivation -Appearance of skin and temp -Facial appearance -Edema (pitting edema, measurement of body part, accumulation of interstitial fluid lower extremities of ambulatory pts and presacral of bedridden, periorbital or pedal edema should prompt one to look for edema in other parts of the body)

Respiratory Activity in the Child

-Some subcutaneous fat is deposited on the chest wall making landmarks less prominent. -Eustachian tubes, bronchi, and bronchioles are elongated and less angular. -The average number of routine colds and infections decreases until children enter daycare or school. -Good hand hygiene and tissue etiquette are encouraged. By end of late childhood, the immune system protects from most infections.

for chest tubes, what determines the placement of the tubes?

-The type of drainage. -when AIR is to be drained, tube is placed higher in chest -when FLUID needs to be drained, tube is inserted lower in the lung because fluids settle at base of lungs.

Non-Rebreather Mask (NRB)

-delivers the highesr concentration of oxygen. -two one-way valves prevent the patient from re-breathing exhaled air.

Cough Medications

-expectorants(reduce viscosity of respiration, for people that are CONGESTED) -cough suppressants (DEXTROMETHORPHAN) -lozenges

Nursing Dx for airway problem

-ineffective airway clearance - ineffective breathing pattern - impaired gas exchange

Oxygenation of body tissues depends on several factors:

-integrity of airway system to transport air to and from lungs -properly functioning alveolar system -properly functioning cardiovascular system and blood supply to carry nutrients and wastes to and from body cells.

commonly measured values from pulmonary function test

-tidal volume -vital capacity -force vital capacity -total lung capacity -residual volume -peak expiatory flow rate

A nurse uses an oxygen analyzer to measure the percentage of oxygen delivered to a client. When checking the percentage of oxygen in the room air, what should the reading of the analyzer be if there is a normal mixture of oxygen and other gases in the environment? a) 0.24 b) 0.25 c) 0.23 d) 0.21

0.21 Explanation: If there is a normal mixture of oxygen and other gases in the environment, the oxygen analyzer will indicate 0.21 (21%). 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. The nurse or respiratory therapist first checks the percentage of oxygen in the room air with the analyzer. If there is a normal mixture of oxygen and other gases in the environment, the analyzer indicates 0.21 (21%). When the analyzer is positioned near or within the device used to deliver oxygen, the reading should register at the prescribed amount (greater than 0.21). 1375

Hypotonic IV solutions

0.45% NaCl 0.33% NaCl - replace ICF

Isotonic IV solutions

0.9% Normal Saline 5% dextrose in water (D5W) Lactated Ringers Replace ECF

PHYSICAL HEALTH and cardiopulmonary functioning!

1) *Acute and chronic illnesses* can affect cardiopulmonary function. 2) *Renal and cardiac disorders* have compromised respiratory function because of fluid overload and impaired tissue perfusion. 3) Alterations in muscle function contribute to inadequate pulmonary ventilation and respiration, as well as inadequate functioning of the heart. 4) *Anemia* can result in inadequate oxygen supply due to lack of hemoglobin. 5) *Scoliosis* influences breathing patters and may cause AIR TRAPPING. 6) Statisitically significant correlation between *obesity and chronic bronchitis* as well as lack of stimulation of the alveoli at the base of the lungs.

Cough Suppressants

1) *Codeine* is considered the "gold standard" of cough suppressants 2) Dextromethorphan is found in many OTC cold and cough remedies. 3) Supression of the productive cough is usually not recommended unless the patient is trying to sleep as if secretions are retained that can lead to pulmonary infection. (PRODUCTIVE COUGHS SHOULD NOT BE STOPPED)

Bronchial Breath Sounds

1) *LOUD, HIGH pitched* sounds heard primarily over the TRACHEA + LARYNX

Vesicular Breath Sounds

1) *LOW pitched, SOFT sounds* heard over peripheral lung fields

Bronchovesicular

1) *MEDIUM-pitched* blowing sounds heard over the major BRONCHI

Hypoxia

1) A condition in which an INADEQUATE amount of oxygen is available to cells. 2) Symptoms: Dyspenia, elevated blood pressure, small pulse pressure, increased respiratory rate, increase pulse rates, pallor and cyanosis. 3) Often caused by hypoventilation (decreased rate or depth of air into the lungs) 4) May also be a CHRONIC condition 5) Can be detected in ALL body system and may manifest as: altered though processess, headaches, chest pain, enlarged heart, clubbing of the fingers, anorexia, constipation, decreased urinary output, decreaed libido, weakness of extremity muscles and muscle pain.

Oxygen Tent

1) A light, portable structure made of clear plastic and attached to a motor driven unit. 2) The moter helps to circulate and cool air. 3) A thermostat keeps the tent at the temperature considered most comfortable for the patient 4) Has side opening though which nursing care can be administered. 5) Commonly used with children who need a cool and highly humidified airflow (such as with pneumonia). 6) NOT a precise oxygen concentration 7) Oxygen delivery rate between 30-50% 8) The humidified airflow quickly creates moisture, leading to damp clothing and possibly hypothermia

Proper Position of Patients with Breathing Difficulties

1) A proper position for breathing is a position that allows for free movement of the diaphragm and expansion of chest wall. 2) People with DYSPENIA + ORTHOPENA are most comfortable in a HIGH FOWLER'S position because accessory muscles can easily be used to promote respiration 3) In patients with PULMONARY disease who are acutely ill, the PRONE position promotes oxygenation as the posterior dependent sections of the lungs are better ventilated and perfused.

How to auscultate breath sounds?

1) Auscultate as the patient breaths SLOWLY through an *OPEN mouth* 2) Breathing through the nose can produce falsely abnormal breath sounds

Precautions for Oxygen Administration

1) Avoid open flames 2) Place "no smoking' signs in conspicuous places in the patient's home 3) Make sure electrical equipment is in good working order 4) Avoid wearing fabrics that build up static electricity 5) Avoid using oils in the area. Oil can ignite spontaneously in the presence of oxygen

Dry Powder Inhalers (DPI)

1) BREATH activated 2) A quick deep breath by the patient activates the flow of medication, eliminating the need to coordinate activating the inhaler while inhaling the medicine at the same time. 3) One disadvantage is that they will clump if exposed to humidity. *Do NOT exhale into the DPI as it risks blowing out the medication*

Wheezes

1) CONTINUOUS MUSICAL sounds 2) Produced as air passes through airways CONSTRICTED by swelling, narrowing, secretions or tumors. 3) Often heard in patients with ASTHMA, TUMORS or a BUILDUP of secretions. 4) Also heard in patients with CHRONIC BRONCHITIS

Deep Breathing

1) Can be used to OVERCOME hypoventilation 2) Instruct the patient to make each breath deep enough to move the BOTTOM ribs. 3) Have the patient to start SLOWLY taking deep inspiration NASALLY and then expire SLOWLY through the mouth. 4) Breathing though the nose warms, filters and humidifies the air. 5) Should be done HOURLY while awake or FOUR times daily. *Using Incentive Spirometry can provide a visual reinforcement*

Pulse Oximetry

1) Cardiopulmonary DIAGNOSTIC test 2) A noninvasive technique that measures the arterial oxyhemoglobin saturation of arterial blood. 3) Results are shown as a percentage, showing what percentage of available hemoglobin has oxygen bound to it. 4) Useful for monitoring patients receiving oxygen therapy, TIRATING oxygen therapy, monitoring those at risk for hypoxia and monitoring postoperative patients. 5) Does NOT replace ABG analysis. 6) Desaturation indicates gas exchange abnormalities 7) Oxygen desaturation is considered a LATE sign of respiratory compromise in patients with reduced rate and depth of breathing. 8) Be aware of patient's hemoglobin level before evaluating oxygen saturation because the test measures ONLY the percentage of oxygen carried by the AVAILABLE hemologlobin - 95%- 100% is NORMAL - <90% is ABNORMAL

Pulmonary Function Studies

1) Cardiopulmonary DIAGNOSTIC test 2) Encompass a GROUP of tests used to assess respiratory function to assist in evaluating respiratory disorders 3) Evaluates lung dysfunction, diagnose disease, assess disease severity, assist in management of disease and evaluate respiratory interventions.

Capnography

1) Cardiopulmonary DIAGNOSTIC test 2) Monitors VENTILATION + BLOOD FLOW through the lungs. 3) Exhaled air passes though a sensor that measures the amount of carbon dioxide (CO2) exhaled with each breath. 4) It provides info about he respiratory rate and depth, the presence of apnea and the efficency of gas exchange. 5) Confirms the placement of advanced airways + placement of NASOGASTRIC tubes 6) Identifies patients with LOW cardiac output and hypoventilation EARLIER than pulse oximetry.

Peak Expiratory Flow Rate (PEFR)

1) Cardiopulmonary DIAGNOSTIC test 2) Refers to the point of HIGHEST flow during FORCED EXPIRATION 3) Reflects changes in the size of pulmonary airways and is measured using a peak flow meter. 4) Used for patients with moderate or severe ASTHMA. 5) With the patient standing or sitting with the back positioned as stright as possible, the patient takes a deep breath and places the peak flow meter in the mouth, closing the lips tightly around the mothpiece. The patient forcefully exhales into the meter and an indicator on the meter rises to a number. 6) Patient repeats this THREE times and only the HIGHEST number is recorded 7) Patients with ASTHMA commonly measure PEFR at home to monitor airflow 8) Results used to track disease progression and relegate treatment

Thoracentesis

1) Cardiopulmonary DIAGNOSTIC test 2) Requires PUNCTURING the chest wall and ASPIRATING the plural fluid. 3) Can be used to obtain a specimen for DIAGNOSTIC purposes or to REMOVE fluid. 4) Nurse is responsible to collect baseline data before the procedure and for preparing the patient physically and emotionally for the procedure 5) Assess vital signs after any procedure

Simple Face Mask

1) Connected to oxygen tubing, a humidifier and a flowmeter 2) Has VENTS on the side that allow room air to leak in at many places, therby diluting the source oxygen 3) The vents also allow exhaled carbon dioxide to escape 4) Used when an increased delivery of oxygen is needed for SHORT periods of less than 12 hours. 5) Skin breakdown is a possibility 6) Eating or talking with the mask are difficult 7) Because of the risk of RETAINING CARBON DIOXIDE, NEVER apply the mask with a delivery flow rate of LESS THAN 5 liters per minute. - 6-8 L/min

Age Related Changes in Oxygenation

1) Decreased gas exchange makes effective breathing more difficult. 1a) Decreased elastic recoil of lungs 1b) Expiration requiring use of accessory muscles 1c) Decreased ventilation (volume of air in/out) 2) Decreased cardiac output and ability to respond to stress. 2a) Reduction in the elasticity of the heart's tissues. 2b) Heart muscle becomes *less efficient* due to progressive atherosclerosis 3) Capillary walls thicken slightly, leading to a slower rate of exchange of gasses, nutrients and waste.

Venturi Mask

1) Delivers PRECISE concentrations of oxygen. 2) Has a large tube with an oxygen inlet. 3) As the tube narrows, the pressure drops, causing air to be pulled in though side ports. 4) The ports are adjusted according to the prescription for oxygen concentration 5) The ports are ALWAYS open 6) If the ports are occluded, the oxygen delivery may be at an unsafe concentration - 4-10 L/min

Metered Dose Inhaler (MDI)

1) Delivers a CONTROLLED dose of medication with each compression. 2) Common MISTAKES: failing to shake, holding it upside down, inhaling through nose instead of mouth, inhaling too fast, stopping the inhalation when med is felt in throat, failing to hold breath after inhalation, inhaling two sprays with one breath. 3) To use the patient must activate the device while continuing to inhale. 4) For some patients, especially young children and older adults, a spacer device may be necessary to aid delivery of medication by the inhalation route.

Nonrebreather Mask

1) Delivers the HIGHEST CONCENTRATION OF OXYGEN 2) Similar to the partial rebreather mask except there are two one-way valves that PREVENT the patient from rebreathing exhaled air. 3) The reservoir bag is filled with oxygen that enters the mask on inspiration. 4) Exhaled air escapes though side vents. 5) A malfunction of the bag could cause carbon dioxide buildup and suffocation 6) Can be used to administer OTHER GASSES such as HELIOX (a mixture of helium and oxygen that is used to reduce the work of breathing, deliver aerosols and reduce fear and anxiety for patients in respiratory distress) - 12 L/min

Nebulizer

1) Disperse fine particles of liquid medication into the DEEPER passages of the respirator tract, where absorption occurs 2) Require cleaning after each use

Pursed Lip Breathing

1) For patients experiencing dyspnea. 2) Exhaling though pursed lips creates a smaller opening for air movment, effectively slowing and PROLONGING expiration. 3) Prolonged expiration is though to result in decreased airway narrowing during expiration and PREVENT the COLLAPSE of small airways. 4) Results in improved AIR EXCHANGE and decreased DYSPNEA. 5) Helps the patient contol the rate and depth of repiration, helping to reduce FEELINGS of dyspnea. 6) Enourages relaxation, which aids the patient to gain control of dyspnea and reduce feelings of panic 7) Encourage patients with COPD to try this technique to help manage their daily activites - While sitting upright, the patient inhales though the nose while counting to THREE, then exhale slowly and evenly against pursed lips while TIGHTENING the abdominal muscles. During exhalation, the patient counts to SEVEN.

Diaphragmatic Breathing

1) Good for those with COPD 2) REDUCES the respiratory rate, INCREASES alveolar ventilation and helps decreases residual volume. 3) The patient places one hand on the stomach and the other on the middle of the chest, then breaths in slowly though the nose, letting the abdomen protrude as far as it will go, then breathes out though pursed lips while contracting the abdominal muscles, with one hand pressing inward and upward on the abdomen. Repeat for 1 minute, followed by a rest of 2 minutes. *Should be practiced several times during the day so that it eventually becomes automatic*

Optimal Diet for Patients with Cardiovascular Diseases

1) INCREASE: Fruit, vegetables, low fat diary products, nuts and legumes. 2) DECREASE: Fat, red meat, sugar. 3) Get HIGH amounts of: potassium, magnesium, calcium, protein, and fiber along with a LOW intake of: a) saturated fat b) sodium c) cholesterol d) total fat e) sugar

Cyanosis

1) Indicates decreased blood flow or poor blood oxygenation

Pallor

1) Indicates less than optimal oxygenation 2) Symptom of *hypoxia* 2a) Other symptoms of hypoxia include: Dyspnea, increased BP, RR and HR, cyanosis, and behavioral changes like anxiety, restlessness, confusion and drowziness.

Nasopharyngeal Catheter

1) Infrequently used as it is uncomfortable for the patient and may cause trauma to respiratory mucous membranes. 2) It is inserted into the nose though ONE nostril, with the end of the catheter rest in the OROPHARYNX. 3) Important to remove the catheter + clean and change it to the OTHER nostril every 12-24 hours 4) Gastric distention often occurs because the gas flow can be misdirectedinto the stomach

Oropharyngeal + Nasopharyngeal Airways

1) Inserted into the back of the pharynx though the mouth or nose. 2) For patients who are BREATHING SPONTANEOUSLY. 3) The oropharyngeal is used to keep the tounge clear of the airway and often used for postoperative patients until they regain consciousness. once the patient regains consciousness, the tube is removed. The tube is not taped as the patient should be able to expel the airway once they become alert. 4) The nasopharyngeal is inserted though the nare and protrudes into the back of the pharynx. 5) The nasal trumpet allows for frequent nasotracheal suctioning without trauma to the nasal passageway. May be left in place to the patient is alert and conscious.

Endotracheal Tube

1) Inserted though the nose or mouth into the trachea using a laryngoscope as a guide 2) Used to administer oxygen by mechanical ventilator to suction secretions easily or to bypass upper airway obstructions. 3) Prevents air leakage allowing more precise control of oxygen and mechanical ventilation 4) Careful monitoring of cuff pressure is necessary to decrease the risk for tracheal necrosis

PERCUSSION for Chest Physiotherapy

1) Involves the use of a cupped palm to loosen pulmonary secretions so they can be EXPECTORATED with greater ease. 2) With a hand held in a rigid, dome shaped position, strike the area over the lung lobes to be drained in a RHYTHMIC pattern. 3) Position the patient in a lateral, supine or prone position based on the lobes to be treated 4) NEVER done on bare skin, over surgical incisions, below the ribs or over the spine or breasts because of the danger of tissue damage. 5) Each area is percussed for 30 to 60 seconds several times a day. 6) If the patient has tenacious secretions, the area may be percussed for up to 3 to 5 minutes several times per day. 7) Patients may percuss the anterior surfaces of their own chest wall 8) Mechanical devices are available.

POSTURAL DRAINAGE for Chest Physiotherapy

1) Makes use of GRAVITY to drain secretions form the lungs 2) Position the patient in a way that promotes the drainage of secretions from smaller pulmonary branches into larger ones, where they can be removed by coughing 3) Vibration, percussion or both often PRECEDE postural drainage. 4) Have tissues or an emesis basin close at hand 5) Done 2 to 4 times a day for 20 to 30 minutes 6) Discontinue if the patient begins to feel weak or faint 7) Delay for 1 to 2 hours after meals to avoid provoking vomiting 8) HIGH FOWLERS: Drains the apical secretions of the UPPER LOBES 9) LYING POSITION, half on the abdomen and half on the side (either right or left) to drain the POSTERIOR secretions of the UPPER LOBES 10) LYING ON LEFT SIDE with a pillow UNDER the chest to drain the RIGHT LOBE 11) TRENDELENBURG to drain the LOWER LOBES of the lungs

Arterial Blood Gas

1) Measurement of blood pH and arterial oxygen and carbon dioxide.

SPIROMETRY

1) Measures the VOLUME of air in LITERS exhaled or inhaled by a patient over time. 2) Evaluates *LUNG FUNCTION and airway OBSTRUCTION*. 3) MEASURES the DEGREE of *airway obstruction.* 4) EVALUATES *response* to inhaled medications 5) The patient *INHALES DEEPLY + EXHALES FORCEFULLY* into a spirometer 6) Used to *PROMOTE deep breathing* while recovering from surgery (Incentive Spirometer) 7) Used to *MONITOR heath status* in management of CHRONIC ASTHMA

Nasal Cannula

1) Most commonly used oxygen delivery device 2) Connected to oxygen source with a flow meter and sometimes a humidifier. 3) Does not impede eating or speaking 4) Disadvantages: dislodged easily and can cause dryness of nasal mucosa and it is difficult to determine the AMOUNT of oxygen the patient is actually recieving. -Usually 1-6 L/min

Suctioning the Airway

1) PHARYNX: Indicated to maintain a patent airway and to remove saliva, pulmonary secretions, blood, vomitus or foreign material. 2) OROPHARYNX or NASOPHARYNX: May be indicated if the patient is able to raise secretions from the airways but unable to clear from the mouth. 3) If the patient is unable to raise secretions form the airways, tracheal suctioning may be indicated. 4) Suctioning irritates the mucosa and removes oxygen from the respiratory tract possibly causing HYPOXEMIA. 5) Important to PREOXYGENATE the patient before suctioning. 6) Anticipate the administration of analgesic medication to a patient who has had surgery or other trauma before suctioning because the cough reflex will be stimulated. - POSSIBLE COMPLICATIONS: infection, cardiac arrhythmias, hypoxia, mucosal trauma and death - Wear gloves, goggles and mask (gown if necessary). - Continuously monitor the patient's color and heart rate and the color, amount and consistency of secretions. - If CYANOSIS, an excessively SLOW or RAPID heart rate or suddenly BLOODY secretions are noted STOP IMMEDIATELY

Palpation of Chest

1) Palpate chest 2) Note *skin temp and color.* 3) Assess *chest expansion* (thoracic excursion) which should be symmetrical. 4) Palpate the point of maximal impulse (PMI). Abnormal size or location of the PMI or the presence of vibrations can indicate heart failure, myocardial infarction, diseases of the heart valves or other cardiac diseases. 5) Note the presence of *masses, edema, or tenderness/guarding,* which can also indicate alterations in cardiovascular function

Fluid Intake for Optimal Oxygentation

1) Patients can help keep their secretions thin by drinking 2 to 3 quarts of clear fluids daily. 2) Fluid should be increased to the maximum that the patient's health can tolerate. 3) Increased fluids are needed by patients who have an elevated temperature, who are breathing through the mouth, who are coughing or who are losing excessive body fluids in other ways. *EXCEPTION*: Encourage patients with HEART FAILURE or LOW SODIUM LEVELS to LIMIT their fluid intake to 1.5 L a day.

MEDICATIONS and cardiopulmonary functioning!

1) Patients receiving drugs that affect the CNS need to be monitored carefully for respratory complications. 2) Opioids DEPRESS the medullary respiratory center and as a result both the *RATE + DEPTH* of respirations *DECREASE*

PSYCHOLOGICAL HEALTH and cardiopulmonary functioning!

1) People responding to stress may sigh excessively or exhibit *HYPERVENTILATION* 2) Hyperventilation can lead to a *LOWERED* level of arterial carbon dioxide (Respiratory Acidosis) 3) Generalized anxiety has been shown to cause enough bronchospasm to produce an episode of *BRONCHIAL ASTHMA* 4) Chronic hypoxia caused by respiratory problems can cause patient to feel *anxiety as a symptom.*

Optimal Diet for Patients that Struggle with Breathing

1) People who work hard at breathing often do not have much energy for eating. 2) The medications used for treatment can cause anorexia and nausea. 3) Consider the use of SIX SMALL meals distributed over the course of the day instead of the usual three larger meals. 4) Provide frequent oral hygiene and rest periods before eating to help improve the patient's intake 5) Encourage patients to eat their meals 1 to 2 hours after breathing treatments and exercises.

Managing Chest Tubes

1) Placed during: Pleural effusion, hemothroax + pneumothroax 2) Drains substances in the pleural space 3) Allows the compressed lung to re-expand 4) May have a water filled or a dry suction chamber. 5) A water filled suction chamber is regulated by the amount of water in the chamber 6) A dry suction chamber has a one way mechanical valve system that allows air to leave the chest and prevents air from moving back into the chest and is automatically regulated to changes in the patient's pleural pressure. 7) Type of drainage DETERMINES THE PLACEMENT. 8) Air (pnumothorax): Tube is placed HIGHER in chest. 9) Fluid (hemothorax + pleural effusion): Tube is inserter LOWER in lung as fluid settles at the base of the lung

Incentive Spirometry to Promote Breathing

1) Provides a visual reinforcement of deep breathing by the patient. 2) The gauge on the spirometer allows the patient to measure one's own progress. 3) Encourages patient to maximize LUNG INFLATION and prevent or reduce ATELECTASIS. 4) Optimal gas exchange is supported and secretions can be cleared and expectorated. 5) Sit upright or Semi-Fowler's position 6) Repeat about 5 to 10 times every 1 to 2 hours 7) Remove dentures. *If the patient has recently undergone abdominal or chest surgery, place a pillow or folded blanket over a chest or abdominal incision for splinting*

Optimal Diet for Patients with COPD

1) Require *HIGH protein + HIGH calorie diet* to counter malnutrition. - 40-55% carbrohydrates - 30-40% fat - 12-20% protein 2) Antioxidants, vitamans A, B + C are important 3) If oxygen is used, reinforce the importance of wearing the camnula during and after meals because digestion require energy, which causes the body to use more oxygen.

Crackles

1) SOFT, HIGH pitched DISCONTINUOUS popping sounds. 2) Produced by *FLUID in the airways or alveoli* and delayed reopening of COLLAPSED alveoli. 3) Occur due to *INFLAMMATION or CONGESTION.* 4) Associated with *PNEUMONIA, HF, BRONCHITIS and EMPHYSEMA (COPD).* 5) May be normal in infants at end of expiration

Partial Rebreather Face Mask

1) Similar to a simple face mask but is equipped with a RESIVOR BAG fo rthe collection of the first part of the patient's exhaled air. 2) The remaining exhaled air exits though vents. 3) The air in the resivor bag is mixed with 100% oxygen for the next inhalation. 4) The patient rebreathes about 1/3 of the expired air from the reservoir bag. 5) Permits the CONSERVATION of oxygen. 6) The bag should deflate slightly with inspiration 7) If the bag deflates completely, the flow rate should be increased. - 8-11 L/min

Voluntary Coughing

1) Teaching the patient to cough voluntarily is an important aspect of preoperative and postoperative care. 2) Coughing is more effective when combines with deep breathing 3) Develop a specific schedule for coughing on the patient's plan of care 4) Coughing *early in the morning* removes secretions that have accumulated during the night 5) Coughing before meals improves the taste of food and oxygenation. 6) At bedtime, coughing removes any buildup of secretions + improves sleep patterns. 7) For a patient who is unable to cough voluntarily, manual stimulation over the trachea + prolonged exhalation can be helpful. If that dosen't work, endotracheal suctioning with a catheter may be necessary. 8) For an assisted cough, firm pressure is placed on the abdomen below the diaphragm in rhythm with exhalation (similar to the heimlich maneuver but with less force). This pressure is used to substitute of the weakened or paralyzed abdominal muscles

VIBRATING for Chest Physiotherapy

1) Uses manual compression and tremor on the patient's chest wall to help loosen respiratory secretions 2) Loosened secretions can be expectorated more easily 3) The practitioner uses both RHYTHMIC CONTRACTION and RELAXATION of arm and shoulder muscles while holding the hands flat on the patient's chest wall as the patient exhales. 4) Can be done several minutes, several times a day. 5) Never done over patients breasts, spine, sternum and lower rib cage.

Drag and Drop question - Click and drag the following steps to place them in the correct order. Question: You are preparing to insert an oropharyngeal airway into an adult patient's mouth. Arrange the following steps in the correct order. 1. Assess level of consciousness and gag reflex. 2.Glide the curved tip along the hard palate. 3. Rotate the airway 180 degrees as airway passes the uvula. 4.Auscultate breath sounds. 5.Measure for correct size. 6. Position patient on his or her side.

1. Assess level of consciousness and gag reflex. 5. Measure for correct size. 2. Glide the curved tip along the hard palate. 3. Rotate the airway 180 degrees as airway passes the uvula. 4. Auscultate breath sounds. 6. Position patient on his or her side P.1380

Functions of ADH

1. Maintains osmotic pressure of the cells by controlling renal water retention and excretion a. When osmotic pressure of the ECF is greater then that of the cells (as in hypernatremia, hyperglycemia), secretion in increased causing water retention b. When osmotic pressure of the ECF is less than that of the cells (as in hyponatremia), secretion is decreased causing renal excretion of water 2. Controls blood volume (less influential than aldosterone) a. Blood volume decreased, increased secretion, water conservation b. Blood volume increased, decreased secretion, water loss

what is the process of ventilation?

1. the diaphragm contracts and descends, lengthening the thoracic cavity 2. the external intercostal muscles contract, lifting the ribs upward and outward 3. the sternum is pushed forward, enlarging the chest from front to back 4. increased lung volume and decreased intrapulmonic pressure allow air to move from an area of greater pressure (outside lungs) to lesser pressure (inside the lungs) 5. the relaxation of these structures result in expiration

4 Laboratory Studies Used to Assess CARDIOPULMONARY Function

1.) ABG + PH ANALYSIS: - Examines arterial blood to determine the pressure exerted by oxygen and carbon dioxide in the blood and blood pH. Measures the adequacy of oxygenation, ventilation + perfusion. pH: (7.35-7.45) PO2: (80-100 mm Hg) PCO2: (35-45 mm Hg) HCO3: (22-26 mEq/L) 2.) CARDIAC BIOMARKERS: - CK, isoenzymes, and troponin are released when cardiac tissue is damaged. A blood test is done to determine the levels of these enzymes. These results can tell when the cardiac injury occured and the extent of the injury. 3.) COMPLETE BLOOD COUNT 4.) CYTOLOGIC STUDY: - A microscopic examination of *SPUTUM* and the cells it contains. - Done primarily to: a) Detect cells that may be malignant b) Determine organisms causing infection c) Identify small amounts of blood or pus in sputum.

7 Common Cardiopulmonary DIAGNOSTIC tests

1.) Electrocardiography (EKG) 2.) Pulmonary Function Studies 3.) Spirometry 4.) Pulse Oximetry 5.) Capnography 6.) Thoracentesis 7.) Peak Expiratory Flow Rate

4 Oxygen Delivery Systems

1.) Nasal Cannula 2.) Nasopharyngeal Catheter 3.) Face Masks (4 types) 4.) Oxygen Tent

6 Factors Affecting Cardiopulmonary Functioning

1.) PHYSICAL HEALTH 2.) DEVELOPMENT 3.) MEDICATION 4.) LIFESTYLE 5.) ENVIRONMENT 6.) PSYCHOLOGICAL HEALTH

4 Types of Face Masks

1.) Simple 2.) Partial Rebreather 3.) Nonrebreather 4.) Venturi

The nurse is preparing to perform nasopharyngeal suctioning on an adult using a wall unit. What is the appropriate suction pressure setting for an adult? a) 150 to 200 mm Hg b) 100 to 120 mm Hg c) 50 to 100 mm Hg d) 10 to 60 mm Hg

100 to 120 mm Hg Explanation: The appropriate suction pressure for a wall unit for an adult is 100 to 120 mm Hg. Higher pressures can cause excessive trauma, hypoxemia, and atelectasis. 1392

Adult Respiratory Rate

12-20 breaths/min 1) Aduts chest contour is *SLIGHTLY CONVEX* with NO sternal depression. 2) The anteroposterior diameter (front to back) should be LESS than the transverse diameter (side to side). 3) Thoracic breathing

Aged Adult (65 +)

16-24 breaths/min 1) May have a barrel shaped thorax 2) *KYPHOSIS* can limit respiriatory ventilation

The pediatric nurse is caring for four clients. Which client will receive the greatest benefit from the use of an oxygen analyzer to assure that the client is receiving the prescribed amount of oxygen?

3-year old in croup tent

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) 12 to 20 breaths per minute c) 30 to 60 breaths per minute d) 20 to 30 breaths per minute

30 to 60 breaths per minute Explanation: The nurse should expect the baby to have a respiratory rate of 30 to 60 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. 1355

Infants Respiratory Rate

30-55 breaths/min 1) Has large harsh *CRACKLES* at end of inspiration (Normal). 2) ROUNDED thorax 3) Abdominal breathing

average adult has ______ alveoli

300 million

A nurse is delivering 3 L/min oxygen to a patient via nasal cannula. What percentage of delivered oxygen is the patient receiving? a) 28% b) 23% c) 36% d) 32%

32% Explanation: A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44%. 1377

A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving?

32% (3-5 L/min =32-40%)

The obstetric nurse is assisting the delivery of a preterm neonate. In preparing for the respiratory needs of the neonate, the nurse is aware that surfactant is formed in utero around: a) 34 to 36 weeks. b) 36 to 38 weeks. c) 32 to 34 weeks. d) 30 to 32 weeks.

34 to 36 weeks. Explanation: Surfactant is formed in utero around 34 to 36 weeks. An infant born prior to 34 weeks may not have sufficient surfactant produced, leading to collapse of the alveoli and poor alveolar exchange. Synthetic surfactant can be given to the infant to help reopen the alveoli. 1356

The obstetric nurse is assisting the birth of a preterm neonate. In preparing for the respiratory needs of the neonate, the nurse is aware that surfactant is formed in utero around: a)34 to 36 weeks. b)36 to 38 weeks. c)32 to 34 weeks. d)30 to 32 weeks.

34 to 36 weeks. Rational: Surfactant is formed in utero around 34 to 36 weeks. An infant born prior to 34 weeks may not have sufficient surfactant produced, leading to collapse of the alveoli and poor alveolar exchange. Synthetic surfactant can be given to the infant to help reopen the alveoli.

the brain is sensitive to hypoxia and will sustain irreversible damage after ___ to ___ minutes of no oxygen.

4 to 6

A patient is complaining of slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed: a) 4 L/minute b) 6 L/minute c) 10 L/minute d) 1 L/minute

6 L/minute Explanation: In general, if a flow rate of 6 L/minute fails to raise a patient's oxygen saturation level satisfactorily, a mask should be used 1377

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 a) Bronchiolitis b) Bronchiectasis c) Bronchitis d) A bronchospasm

A bronchospasm Explanation: When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucous production increases, and inflammatory chemical mediators cause bronchospasm. 1364

The nurse would expect to recommend an oxygen tent fro which of the following patients? a) An elderly patient who is unable to get out of bed b) An adult patient who has COPD c) A comatose patient who has a head injury d) A child who will not leave a facemask or cannula in place

A child who will not leave a facemask or cannula in place Explanation: Oxygen tents are often used in children who will not leave a facemask or nasal cannula in place. The oxygen tent gives the patient freedom to move in the bed or crib while humidified oxygen is being delivered; however, it is difficult to keep the tent closed, because the child may want contact with his or her parents. It is also difficult to maintain a consistent level of oxygen and to deliver oxygen at a rate higher than 30% to 50%. 1377

In which of the following clients would the nurse assess for a depressed respiratory system? a) A client taking insulin for diabetes b) A client taking antibiotics for a urinary tract infection c) A client taking amlodipine for hypertension d) A client taking opioids for cancer pain

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. 1355

Emphysema

A collection of pus in any body cavity, but usually refers to the thorax

Pyothorax

A collection of pus in the pleura cavity

surfactant

A detergent like phospholipid reduces the surface tension between the mouse membranes of the alveoli preventing their collapse.

chronic obstructive pulmonary disease (COPD)

A group of lung diseases that block airflow and make it difficult to breathe.

wheeze

A high-pitched whistling sound made while breathing.

metered-dose inhaler (MDI)

A miniature spray canister used to direct medications through the mouth and into the lungs.

endotracheal tube

A polyvinychloride airway that is inserted through the nose or the mouth into the trachea using a laryngoscope as a guide

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:

ATELACTASIS( Incomplete lung expansion or the collapse of alveoli)

dysrhythmia

Abnormal heart rhythm

arrhythmia

Abnormal heart rhythm (dysrhythmia)

Adventitious Breath Sounds

Abnormal sounds of breathing. 1) Includes *CRACKLES and WHEEZING*

GI function in regulation of fluid and electrolyte balance

Absorbs water and nutrients that enter the body through this route

respiratory acidosis assessments

Acute: mental cloudiness, dizziness, muscular twitching, unconsciousness ABGs: pH <7.35, PaCO2 >45 mmHg, HCO3- normal or slightly elevated Chronic: weakness, dull headache ABGs: pH <7.35 or low normal, PaCO2 >45 mmHg (primary), HCO3- >26 mEq/L (compensatory)

Pneumothorax

Air in the pleural space

chest compressions

Airway- tip the head and check for breathing. breathing- if the victim does not start to breathe spontaneously after the airway is opened, give two breaths lasting 1.5 to 2 seconds Circulation—check the pulse; if victim has no pulse, initiate chest compressions

pulse oximetry

An assessment tool that measures oxygen saturation of hemoglobin in the capillary beds.

You are caring for a patient who has a chest tube in place that is draining blood from a hemothorax. Which of the following items should you place in the patient's room to respond appropriately to accidental disconnection of the chest tube from the drainage device? a) A Heimlich valve b) Two rubber-tipped clamps c) An unopened bottle of sterile water d) A spare chest tube insertion kit

An unopened bottle of sterile water Explanation: Keep bottle of sterial saline or water at bedside. If chest tube disconnects from drainage unit, submerge end in water. 1379

Hypomagnesemia s/s

Anorexia, Distention, Neuromuscular irritability Increased reflexes, course tremors, seizures Depression, Disorientation Cardiac manifestations Tachyarrhythmias Increased susceptibility to dig toxicity Serum <1.3 mEq/L

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which of the following assessment findings is consistent with hypoxia?

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.

Managing Chest Tubes

Assist with insertion and removal of chest tube. Monitor the patient's respiratory status and vital signs. Check the dressing. Maintain the patency and integrity of the drainage system.

A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction two 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 what? a) Atelectasis b) Pneumothorax c) Hemothorax d) Tachypnea

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. Tachypnea, if present, would likely be a sign of atelectasis rather than an independent finding. 1353

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of a) Epiglottitis b) Bronchospasm c) Croup d) Atelectasis

Atelectasis Explanation: Stiffer lungs tend to collapse and their alveoli also collapse. This condition is called atelectasis. 1352

Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath ? a)Bronchial b)Bronchovesicular c)Vesicular d)Adventitious sound

BRONCHIAL (loud, high-pitched sounds heard primarily over the TRACHEA and LARYNX) VESICULAR( are low-pitched, soft sounds heard over peripheral lung fields)

A nurse assessing a patient's respiratory effort notes that the patient is breathing eight shallow breaths/minute. Which of the following oxygen delivery systems should the nurse use for this patient? a) Oxygen mask b) Bag and mask c) Oxygen hood d) Nasal cannula

Bag and mask Explanation: If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a bag and mask may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube. Bag and mask devices are frequently referred to as Ambu bags ("air mask bag unit") or BVMs ("bag-valve-mask" device). 1383

Assessment Parameters VS significant findings

Body temp - elevated in hyoernatremia. Decreased in FVD without infection. Fever increases with loss of body fluids. Temp of 101 and 103 increases 24hr fluid requirement by at least 500mL. >103 increases it by at least 1,000 mL Pulse - tachycardia earliest sign of decreased vascular volume from FVD. Irregular pulse rates occur with potassium imbalances and magnesium deficits. Quality/amplitude is decreased in FVD and increased in FVE. Respirations - deep, rapid, respirations may be from metabolic acidosis or primary disorder causing respiratory acidosis. Slow, shallow may be from metabolic alkalosis or primary disorder causing respiratory alkalosis. Moist crackles in absence of cardiopulmonary disease indicates FVE. BP- fall in systolic >15mmHg from lying to sitting or standing usually indicates FVD

Assessment parameters VS

Body temp - fever increases loss of fluid. Pulse Respirations BP - whenever fluid imbalance is suspected take BP supine, sitting and standing to determine orthostatic changes

Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound? a) Vesicular b) Bronchovesicular c) Bronchial d) Adventitious

Bronchial Explanation: Bronchial breath sounds are loud, high-pitched sounds heard primarily over the trachea and larynx. Vesicular breath sounds are low-pitched, soft sounds heard over the peripheral lung fields. Bronchovesicular breath sounds are medium-pitched blowing sounds heard over the major bronchi. Vesicular, bronchial, and bronchovesicular breath sounds are normal breath sounds. Adventitious breath sounds are abnormal lung sounds. 1360

Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound?

Bronchial breath sounds are loud, high-pitched sounds heard primarily over the trachea and larynx. Vesicular breath sounds are low-pitched, soft sounds heard over the peripheral lung fields. Bronchovesicular breath sounds are medium-pitched blowing sounds heard over the major bronchi. Vesicular, bronchial, and bronchovesicular breath sounds are normal breath sounds. Adventitious breath sounds are abnormal lung sounds.

As a part of a regular check-up, the nurse performs a physical examination on the client. How should the nurse test for capillary refill time? a) By bending the client's foot upward toward the leg b) By assessing the apical and radial pulses simultaneously c) By noting localized skin discolorations d) By pressing a nail bed until it blanches

By pressing a nail bed until it blanches The nurse should perform capillary refill time test by pressing a nail bed until it blanches. Pressure is released, and the time it takes for the nail to return to its original color is noted. This capillary refill time is ordinarily less than 3 seconds. Localized skin colorations are assessed to determine bruises, redness, or mottling. Homan's sign is elicited by bending the client's foot upward toward the leg. Assessment of the apical and radial pulses simultaneously is done to determine whether all heartbeats are being perfused to distant pulse sites. 1388

CPR sequence

CHEST COMPRESSIONS: check pulse if no pulse, initiate chest compressions. AIRWAY: tilt the head and lift the chin, check for breathing. BREATHING: is person is not breathing spontaneously after the airway is opened, give two breaths lasting 1 second each. DEFIBRILLATION: apply AED

Cardiac output equation

CO = HR x SV

Which medication is administered in the home or the hospital to relieve inflammation in the lung tissue?

CORTICOSTEROIDS

Test for Pneumothorax

CRX

Drugs used to dilate bronchial airways interact with ________________.

Caffiene

Electrocardiography

Cardiopulmonary DIAGNOSTIC test 1) ECG (electrocardiogram) 2) Measures the heart's electrical activity 3) Impulses moving through the heart's conduction system create electric currents that can be monitored on the body's surface by electrodes. 4) The data are graphed as waveforms. 5) The standard ECG complex is called PQRST. 6) Can be used to identify myocardioal ischemia + infarction, heard damage, rhythm + conduction disturbances, chamber enlargement, electrolyte imbalances + drug toxicity 7) Electrodes provide views of the heart from the frontal plane as well as the horizontal plane

Four Factors Influencing Diffusion of Gases in the Lungs

Change in surface area available Thickening of alveolar-capillary membrane Partial pressure Solubility and molecular weight of the gas

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? Discontinue oxygen therapy until the client is reassessed by the healthcare provider. Check fit of oxygen mask. Increase the flow of oxygen. Contact the oxygen supplier to request an oxygen tent.

Check fit of oxygen mask. Explanation: The fit of the oxygen mask can be affected by the discontinuation of wearing dentures. The nurse should check the fit to make sure the client is getting the prescribed amount of oxygen. Other answers are inappropriate actions that do not address the problem.

Angina

Chest discomfort or shortness of breath caused when heart muscles receive insufficient oxygen-rich blood.

It is a red air-quality day in your city. This means the air is stagnant, with high pollution levels and high humidity. Which client is most likely to experience shortness of breath? a) Teenager with contact dermatitis b) Middle-aged adult with hypertension c) Child with asthma d) Young adult without disease

Child with asthma Explanation: Air pollution and high humidity are respiratory irritants. Pollutants cause increased mucous production and contribute to bronchitis and asthma. While pollution is not good for any group of individuals it would be less of an impact on the person with hypertension or dermatitis. 1357

A barrel chest should make you think of what diagnosis?

Chronic Obstructive Pulmonary Disease (COPD) OR BARREL CHEST DEFORMITY

The nurse is caring for a client who is diagnosed with an impaired gas exchange. While performing a physical assessment of the client, which of the following data is the nurse likely to find, keeping in mind the client's diagnosis?

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. A client diagnosed with an impaired gas exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. The options of high temperature, low pulse rate, and low blood pressure are incorrect; this is because, as a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.

Upon evaluation of a client's medical history, the nurse recognizes that which of the following conditions may lead to an inadequate supply of oxygen to the tissues of the body? a) Parkinson's disease b) Chronic anemia c) Graves' disease d) Pancreatitis

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. 1355

Assessment of a client with a respiratory disorder reveals rounded and enlarged fingers. The nurse documents this finding as which of the following? a) Hypoxemia b) Wheeze c) Clubbing d) Cyanosis

Clubbing Explanation: Clubbing refers to the finding that the tips of the fingers and toes become rounded and enlarged. It is believed that long-term tissue hypoxia causes the release of a substance that causes dilation of the vessels of the fingertips. Cyanosis is a bluish skin discoloration caused by a desaturation of oxygen on the hemoglobin in the blood. Wheeze is a low pitched snoring or moaning sound heart during expiration. Hypoxemia refers to low levels of oxygen in the blood. 1353

The nurse is assessing a patient with lung cancer. What manifestations may suggest that the patient has chronic hypoxia? a) Constipation b) Cyanosis c) Edema d) Clubbing

Clubbing Explanation: Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many patients with respiratory or cardiac disease. Clubbing is believed to be caused by long-term tissue hypoxia which causes the release of a substance that causes dilation of the vessels of the fingertips (Lewis, et al., 2007). Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD.Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and chronic obstructive pulmonary disease. 1353

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which of the following assessment findings 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. 1353

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 a) Congestive heart failure b) Lung cancer c) Myocardial infarction d) Pulmonary embolism

Congestive heart failure Explanation: A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure. 1361

A nurse is conducting a physical assessment of a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the client's oxygenation. What instruction should the nurse give the client? a) Expand the thoracic cavity. b) Elevate the ribs and sternum. c) Contract the abdominal muscles. d) Relax the respiratory muscles.

Contract the abdominal muscles. Explanation: The nurse should instruct the client to contract the abdominal muscles to exhale additional air. A person can forcibly exhale additional air by contracting abdominal muscles such as the rectus abdominis, transverse abdominis, and external and internal obliques. The client elevates the ribs and sternum and expands the thoracic cavity during inspiration. The client relaxes the respiratory muscles during normal expiration. 1352

Lozenges

Control coughs by the local anesthetic effect of the benzocaine or menthol.

The charge nurse is observing a new nurse care for a client who is receiving oxygen via a simple mask with an FIO2 of 40%. The client states, "This moisture on my face is bothersome. Can something be done about it?" Which of the following responses by the new nurse would require clarification by the charge nurse? a) "The mask and its moisture can be bothersome, so let me demonstrate some distraction techniques to help you cope with them." b) "Your mask should remain on, but I will help you dry your face when it becomes too wet." c) "After I dry your face, I can apply powder to absorb the moisture and protect your skin." d) "I will confer with your primary care provider to find out if a nasal cannula can be used."

Correct response: "After I dry your face, I can apply powder to absorb the moisture and protect your skin." Explanation: This statement acknowledges the client's discomfort and offers appropriate assistance.

The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal? a) 12 to 20 breaths per minute b) 20 to 30 breaths per minute c) 12 to 15 breaths per minute d) 30 to 60 breaths per minute

Correct response: 30 to 60 breaths per minute Explanation: The nurse should expect the baby to have a respiratory rate of 30 to 60 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

In which of the following clients would the nurse assess for a depressed respiratory system? a) A client taking insulin for diabetes b) A client taking opioids for cancer pain c) A client taking amlodipine for hypertension d) A client taking antibiotics for a urinary tract infection

Correct response: 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 caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of a) Bronchospasm b) Epiglottitis c) Atelectasis d) Croup

Correct response: Atelectasis Explanation: Stiffer lungs tend to collapse and their alveoli also collapse. This condition is called atelectasis

The nurse is informed while receiving a nursing report that the client has been hypoxic during the evening shift. Which of the following assessment findings is consistent with hypoxia? a) Decreased respiratory rate b) Decreased blood pressure c) Confusion d) Hyperactivity

Correct response: 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 has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from a) Pulmonary embolism b) Congestive heart failure c) Myocardial infarction d) Lung cancer

Correct response: Congestive heart failure Explanation: A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.

Which of the following dietary guidelines would be appropriate for the elderly homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? a) Snack on high-carbohydrate foods frequently b) Contact the physician for Ensure c) Eat one large meal at noon d) Eat smaller meals that are high in protein

Correct response: 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 with no prior history of respiratory illness has been admitted to a postsurgical 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) Educating the client on pursed-lip breathing techniques b) Oropharyngeal suctioning twice daily c) Administration of inhaled corticosteroids d) Educating the client on the use of incentive spirometry

Correct response: 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.

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is "Ineffective Airway Clearance related to copious and tenacious secretions." Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan? a) Encouraging the client to consume two to three quarts of clear fluids daily b) Creating an environment that is likely to reduce anxiety c) Positioning the client supine d) Encouraging the client to decrease the number of cigarettes smoked daily

Correct response: Encouraging the client to consume two to three quarts of clear fluids daily Explanation: Clients can help keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of clear fluids daily. Although it is important to create an environment that is likely to reduce a client's anxiety, doing so will not assist in promoting airway clearance. The nurse should not encourage the client to decrease the number of cigarettes smoked daily, but should encourage the client to stop smoking. Proper positioning to ease respirations includes placing the client in a high-Fowler's position.

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 cannula b) Flowmeter c) Nasal strip d) Oxygen analyzer

Correct response: Flowmeter Explanation: The nurse should use a flowmeter to regulate the amount of oxygen delivered to the client. A flowmeter 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.

The nurse is caring for a client who is diagnosed with an impaired gas exchange. While performing a physical assessment of the client, which of the following data is the nurse likely to find, keeping in mind the client's diagnosis? a) High temperature b) Low pulse rate c) Low blood pressure d) High respiratory rate

Correct response: High respiratory rate Explanation: A client diagnosed with an impaired gas exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. The options of high temperature, low pulse rate, and low blood pressure are incorrect; this is because, as a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.

The nurse is caring for a client who is diagnosed with an impaired gas exchange. While performing a physical assessment of the client, which of the following data is the nurse likely to find, keeping in mind the client's diagnosis? a) Low blood pressure b) High temperature c) Low pulse rate d) High respiratory rate

Correct response: High respiratory rate Explanation: A client diagnosed with an impaired gas exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. The options of high temperature, low pulse rate, and low blood pressure are incorrect; this is because, as a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.

Question: You are caring for a patient whose respirations are supported by a ventilator. You are preparing to suction the patient's endotracheal tube using a closed suctioning system. Arrange the following steps in the correct order. - Depress the suction button to apply intermittent suction. - Clear secretions from sheath. - Turn the catheter safety cap to disable the suction button. - Hyperventilate the patient. - Grasp the catheter and advance it to the predetermined length. - Turn the catheter safety cap to enable suction button.

Correct response: Hyperventilate the patient. Turn the catheter safety cap to enable suction button. Grasp the catheter and advance it to the predetermined length. Depress the suction button to apply intermittent suction. Clear secretions from sheath. Turn the catheter safety cap to disable the suction button. Explanation: Follow these steps when preparing to suction the patient's endotracheal tube using a closed suctioning system.

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula? a) It can cause anxiety in clients who are claustrophobic. b) It can cause the nasal mucosa to dry in case of high flow. c) It can result in an inconsistent amount of oxygen. d) It can create a risk of suffocation.

Correct response: It can cause the nasal mucosa to dry in case of high flow. Explanation: When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss.

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula? a) It can cause anxiety in clients who are claustrophobic. b) It can result in an inconsistent amount of oxygen. c) It can create a risk of suffocation. d) It can cause the nasal mucosa to dry in case of high flow.

Correct response: It can cause the nasal mucosa to dry in case of high flow. Explanation: When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss.

A client with chronic obstructive pulmonary disease requires low flow oxygen. How will the oxygen be administered? a) Venturi mask b) Simple oxygen mask c) Nasal cannula d) Partial rebreather mask

Correct response: Nasal cannula Explanation: Nasal cannula and tubing administers oxygen concentrations at 22% to 44%.

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client? a) Simple mask b) Non-rebreather mask c) Nasal cannula d) Face tent

Correct response: 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. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Non-rebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.

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) Pleural effusion b) Tachypnea c) Wheezes d) Pneumonia

Correct response: 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 caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the client's care plan? a) Encourage the client to eat immediately before breathing treatments. b) Encourage the client to alternate eating and using a nebulizer during meal time. c) Provide three large meals daily. d) Provide six small meals daily.

Correct response: Provide six small meals daily. Explanation: The nurse should consider providing six small meals distributed over the course of the day instead of three large meals. Meals should be eaten one to two hours after breathing treatments and exercises.

A patient returns to the telemetry unit after an operative procedure. Which of the following diagnostic tests will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the patient? a) Spirometry b) Pulse oximetry c) Peak expiratory flow rate d) Thoracentesis

Correct response: Pulse oximetry Explanation: Pulse oximetry is useful for monitoring patients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative patients. 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 and evaluate 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 physician prescribes the use of water-seal chest tube drainage for a client at a health care facility. What should the nurse ensure when using the water-seal chest tube drainage? a) A secondary source of oxygen should be available in case of power failure. b) Filters need to be cleaned regularly to avoid unpleasant taste or smell. c) The chest tube should not be separated from the drainage system unless clamped. d) A nasal cannula should be used to administer oxygen when cleaning the opening.

Correct response: The chest tube should not be separated from the drainage system unless clamped. Explanation: When using water-seal chest tube drainage, the nurse should never separate the chest tube from the drainage system unless clamped. Even then, the tube should be clamped only briefly. When using an oxygen concentrator as a source of oxygen, the nurse should clean the filter regularly to avoid an unpleasant taste or smell. A secondary source of oxygen should also be available in case of a power failure. When cleaning a transtracheal catheter, oxygen needs to be administered with a nasal cannula.

A physician prescribes the use of water-seal chest tube drainage for a client at a health care facility. What should the nurse ensure when using the water-seal chest tube drainage? a) The chest tube should not be separated from the drainage system unless clamped. b) A secondary source of oxygen should be available in case of power failure. c) A nasal cannula should be used to administer oxygen when cleaning the opening. d) Filters need to be cleaned regularly to avoid unpleasant taste or smell.

Correct response: The chest tube should not be separated from the drainage system unless clamped. Explanation: When using water-seal chest tube drainage, the nurse should never separate the chest tube from the drainage system unless clamped. Even then, the tube should be clamped only briefly. When using an oxygen concentrator as a source of oxygen, the nurse should clean the filter regularly to avoid an unpleasant taste or smell. A secondary source of oxygen should also be available in case of a power failure. When cleaning a transtracheal catheter, oxygen needs to be administered with a nasal cannula.

The nurse is caring for a client who requires long-term oxygen therapy. The client is adequately oxygenated at a lower flow. Which type of device may be used to deliver oxygen to this client? a) Nasal catheter b) Oxygen tent c) Transtracheal oxygen d) CPAP mask

Correct response: Transtracheal oxygen Explanation: The nurse should use a transtracheal oxygen device for a client who requires long-term oxygen therapy and who is adequately oxygenated at a lower flow. A transtracheal catheter is a hollow tube inserted within the trachea to deliver oxygen. A CPAP mask is used for clients with sleep apnea; oxygen tents are used to care for active toddlers. A nasal catheter is used for clients who tend to breathe through the mouth or experience claustrophobia when a mask covers their face.

Which of the following nursing skills requires the nurse to use sterile technique? a) Administering nebulizers b) Administering oxygen by face mask c) Suctioning a tracheostomy d) Providing oxygen by nasal cannula

Suctioning a tracheostomy Explanation: Suctioning is always a sterile procedure, whereas the administration of oxygen and nebulized medications require clean technique. 1383

Infiltration s/s

Swelling, pallor, coldness, or pain around infusion site Significant decrease in flow rate

Nursing Interventions Promoting Adequate Respiratory Functioning

Teaching about a pollution-free environment Promoting optimal function Promoting proper breathing Managing chest tubes Promoting and controlling coughing Promoting comfort Meeting respiratory needs with medications

Pursed-Lip

Techniques to property execute pursed Lip breathing Relax upper body (neck & shoulders) Breathe in through your nose for 2-3 seconds with your mouth closed Pucker or "purse" lips as if you were going to flicker the flame on a candle or act as if you are whistling Exhale slowly trying to double the length of time of your inhalation time

Total Lung Capacity

The amount of air contained within the lungs at maximum INSPIRATION

Residual Volume

The amount of air left in the lungs at maximal EXPIRATION

A physician prescribes the use of water-seal chest tube drainage for a client at a health care facility. What should the nurse ensure when using the water-seal chest tube drainage? a) A secondary source of oxygen should be available in case of power failure. b) The chest tube should not be separated from the drainage system unless clamped. c) Filters need to be cleaned regularly to avoid unpleasant taste or smell. d) A nasal cannula should be used to administer oxygen when cleaning the opening.

The chest tube should not be separated from the drainage system unless clamped. Explanation: When using water-seal chest tube drainage, the nurse should never separate the chest tube from the drainage system unless clamped. Even then, the tube should be clamped only briefly. When using an oxygen concentrator as a source of oxygen, the nurse should clean the filter regularly to avoid an unpleasant taste or smell. A secondary source of oxygen should also be available in case of a power failure. When cleaning a transtracheal catheter, oxygen needs to be administered with a nasal cannula. 1378-1379

Oxygen Flow Rate

The flow rate of oxygen 1) Measured in liters per minute 2) Determines the amount of ox ygen delivered to the patient 3) Does not necessarily reflect the oxygen concentration actually inspired by the patient because there is leaking + mixing with atmospheric air 4) To regulate the oxygen percentage concentration accurately, samples of the air mixture the patient is actually inhaling may be analyzed every 4 hours.

Cilia

The hairlike projections on the outside of cells that move in a wavelike manner

Upon evaluation of a client's medical history, the nurse recognizes that which of the following conditions may lead to an inadequate supply of oxygen to the tissues of the body? Pancreatitis Chronic anemia Parkinson's disease Graves' disease

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.

A newly hired nurse is performing a focused respiratory assessment. The nurse mentor will intervene if which action by the newly hired nurse is noted? The newly hired nurse palpates the point of maximal impulse (PMI). The newly hired nurse explains the assessment procedure before performing it. The newly hired nurse attaches a pulse oximetry to the client's index finger. The newly hired nurse auscultates breath sounds as the client breathes through the nose.

The newly hired nurse auscultates breath sounds as the client breathes through the nose. Explanation: Breath sounds should be auscultated while the client breathes slowly through an open mouth; nose breathing may produce false breath sounds. Explanation before procedures helps reduce a client's anxiety. Palpation of the PMI and attaching the pulse oximetry are included in the respiratory assessment.

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? The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). The newly hired nurse assesses the client's pain and administers pain medication. 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. 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. Adjusting the bed to a comfortable working position prevents back and muscle strain. Explanation alleviates fears; even if the client appears unconscious, the nurse should explain what is happening. When tracheostomy is new, pain medication may be needed before performing tracheostomy care.

While examining a client, the nurse palpates the client's chest and back. Which of the following would the nurse expect to identify with this technique?

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.

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client?

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. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Non-rebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.

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 soft, high-pitched discontinuous (intermittent) popping lung sounds. They are loud, high-pitched sounds heard primarily over the trachea and larynx. They are low-pitched, soft sounds heard over peripheral lung fields. They are medium-pitched blowing sounds heard over the major bronchi.

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) bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

Hypernatremia S/S

Thirst, Elevated body temp, Sticky mucous membranes, Dry swollen tongue, -SEVERE Hallucinations, Lethargy, Irritability, hyperactive focal or grand mal Seizures Coma Urine specific gravity >1.015

cytologic study

This involves a microscopic examination of sputum and the cells it contains. It is done primarily to detect cells that may be malignant, determine organisms causing infection, and identify blood or pus in the sputum

Tidal Volume

Total amount of air INHALED + EXHALED in ONE breath

The nurse is caring for a client who requires long-term oxygen therapy. However, the client is adequately oxygenated at a lower flow. What type of device should the nurse use to deliver oxygen to the client in this case? a) CPAP mask b) Nasal catheter c) Transtracheal oxygen d) Oxygen tent

Transtracheal oxygen Explanation: The nurse should use a transtracheal oxygen device for a client who requires long-term oxygen therapy and who is adequately oxygenated at a lower flow. A transtracheal catheter is a hollow tube inserted within the trachea to deliver oxygen. A CPAP mask is used for clients with sleep apnea; oxygen tents are used to care for active toddlers. A nasal catheter is used for clients who tend to breathe through the mouth or experience claustrophobia when a mask covers their face. 1378

Hypocalcemia S/S

Trousseau's (BP cuff 4 min. hand spasm), Chvostek's (tap on facial nerve facial spasm), Numbness and tingling of fingers/toes, Mental changes Seizures Spasm of laryngeal muscles ECG changes Cramps of muscles in extremities Serum <8.5 mg/dL

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

True Explanation: This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis.

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) True b) False

True Explanation: This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis. 1379

You are preparing to perform tracheal suctioning on a 3-year-old child. Which of the following actions is most appropriate? a) Use an 18F suction catheter and limit suction to no longer than 20 seconds. b) Use a 14F suction catheter and limit suction to no longer than 15 seconds. c) Use a 5F suction catheter and limit suction to no longer than 5 seconds. d) Use a 6F suction catheter and limit suction to no longer than 10 seconds.

Use a 6F suction catheter and limit suction to no longer than 10 seconds. Explanation: For a 3-year-old child, use a 6F suction catheter and limit suction to no longer than 10 seconds. 1406

Which of the following is a recommended guideline for determining suction catheter depth when suctioning an endotracheal tube? a) Using a spare endotracheal tube of the same size as being used for the patient, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. b) Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. c) For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm. d) 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.

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. 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 patient, 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. 1404

Hyperkalemia s/s

Vague muscle weakness Cardiac arrhythmias Paresthesia of face,tongue, feet, hands Flaccid muscle paralysis GI symptoms (N/D, intestinal colic) Serum >5 mEq/L

Which actions should a nurse perform when inserting an oropharyngeal airway? Select all that apply. Wash hands and put on PPE, as indicated. Insert the airway with the curved tip pointing down toward the base of the mouth. Rotate the airway 180 degrees as it passes the uvula. Remove airway for a brief period every 4 hours or according to facility policy. Position client flat on his or her back with the head turned to one side. Use an airway that reaches from the nose to the back angle of the jaw.

Wash hands and put on PPE, as indicated. Rotate the airway 180 degrees as it passes the uvula. Remove airway for a brief period every 4 hours or according to facility policy. Explanation: The nurse will come into contact with respiratory secretions during the insertion of the oral airway, making it necessary to wear appropriate PPE. The airway will need to be rotated 180 degrees as it passes the uvula because the airway is more easily inserted with the curved tip pointing up towards the roof of the mouth. The airway should be removed for brief periods every 4 hours (or according to facility policy) to prevent constant pressure on the surrounding structures. The airway should reach from the opening of the mouth to the back angle of the jaw. The client should be positioned in a semi-Fowler's position to ease insertion of the airway.

Lungs and Kidneys

What 2 organ systems play a part in the carbonic acid-sodium bicarbonate buffer system?

Age, Body Fat, and Gender

What are factors that cause variations in fluid content?

Evaporation through the skin, Expiration from the Lungs

What are some insensible fluid losses?

Urination, Defecation, Wounds

What are some sensible fluid losses?

1)Carbonic Acid-Sodium Bicarbonate 2)Phosphate 3)Protein

What are the 3 buffer systems of the body?

1) Chemical Buffer Systems 2)Respiratory Mechanisms 3)Renal Mechanisms

What are the 3 major homeostatic regulators of hydrogen ions?

-Role in blood coagulation and in transmission of nerve impulses -Helps regulate muscle contraction and relaxation -Activates enzymes that stimulate essential chemical reactions in the body -Major component of bones and teeth

What are the functions of Calcium in the body?

-Major component of interstitial and lymph fluid; gastric and pancreatic juices, sweat, bile, and saliva -Acts with sodium to maintain the osmotic pressure -Role in the body's acid-base balance; combines with hydrogen ions to produce hydrochloric acid

What are the functions of Chloride in the body?

-Metabolism of carbohydrates and proteins -Activator for many intracellular enzyme systems -Role in neuromuscular function -Acts on cardiovascular system, producing vasodilation

What are the functions of Magnesium in the body?

-Role in acid-base balance as a hydrogen buffer -Promotes energy storage; carbohydrate, protein, and fat metabolism -Bone and teeth formation -Regulation of hormone and coenzyme activity -Role in muscle and red blood cell function

What are the functions of Phosphate in the body?

-Controls intracellular osmolality -Regulator of cellular enzyme activity -Role in the transmission of electrical impulses in nerve, heart, skeletal, intestinal, and lung tissue; protein and carbohydrate metabolism; and cellular building -Regulation of acid-base balance by cellular exchange with H+

What are the functions of Potassium in the body?

-Regulates extracellular fluid volume; Na+ loss or gain accompanied by a loss or gain of water -Affects serum osmolality -Role in muscle contraction and transmission of nerve impulses -Regulation of acid-base balance as sodium bicarbonate

What are the functions of Sodium in the body?

Chloride(Cl), Bicarbonate(HCO3-), and Phosphate(PO43-)

What are the major anions in the body?

Sodium(Na), Potassium(K), Calcium(Ca), Hydrogen(H), and Magnesium(Mg)

What are the major cations in the body?

Sodium(Na), Chloride(Cl), Calcium(Ca), and Bicarbonate(HCO3)

What are the major electrolytes of the ECF?

Potassium(K), Phosphorus(P), and Magnesium(Mg)

What are the major electrolytes of the ICF?

Intracellular Fluid and Extracellular Fluid

What are the two main fluid compartments of the body?

A substance that can accept or trap a hydrogen ion

What is a base?

Substance that prevents body fluid from becoming overly acidic or alkaline

What is a buffer?

An Ion that carries a + electric charge

What is a cation?

A solution that has a greater concentration than the solution with which it is being compared

What is a hypertonic solution?

A solution that has lesser concentration than the solution with which it's being compared

What is a hypotonic solution?

Condition characterized by a proportionate excess of hydrogen ions in the extracellular fluid. When the ECF pH falls bellow 7.35

What is acidosis?

Movement of ions or molecules across cell membranes usually against a pressure gradient and with the expenditure of metabolic energy

What is active transport?

Condition characterized by a proportionate lack of hydrogen ions in the ECF. When the pH exceeds 7.45

What is alkalosis?

A substance containing a hydrogen ion that can be liberated or released

What is an acid?

An ion that carries a - electric charge

What is an anion?

A solution that has about the same concentration as the solution with which it is being compared

What is an isotonic solution?

Tendency of solutes to move freely throughout a solvent from an area of higher concentration to an area of lower concentration until equilibrium is established

What is diffusion?

Concentration of particles in a solution or a solution's pulling power

What is osmolarity?

Passage of a solvent through a semipermeable membrane from an area of lesser concentration to an area of greater concentration until equilibrium is established

What is osmosis?

Expression of hydrogen ion concentration and resulting acidity of a substance

What is pH?

2,600 ml/day

What is the average amount of fluid intake/day?

2,500-2,900 mL

What is the average amount of fluid output/day

Lungs

What is the body's main controller of carbonic acid?

25-29 mEq/L

What is the normal range of Bicarbonate?

2.5-4.5 Mg/dL

What is the normal range of Phosphate?

3.5-5.0 mEq/L

What is the normal range of Potassium(K)?

136-145 mEq/L

What is the normal range of Sodium(Na)?

Regulates acid-base balance

What is the primary function of Bicarbonate in the body?

Transcellular Fluid

What is the third minor fluid compartment?

Kidneys

What organ system is responsible for the phosphate buffer system?

Which of the following describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway? a) When holding the airway on the side of the patient's face, it should reach from the tragus of the ear to the nostril plus 1 inch. b) When holding the airway on the side of the patient's face, it should reach from the tip of the ear to the nostril times two. c) When holding the airway on the side of the patient's face, it should reach from the opening of the mouth to the back angle of the jaw. d) The airways come in standard sizes determined by the height and weight of the patient.

When holding the airway on the side of the patient's face, it should reach from the tragus of the ear to the nostril plus 1 inch. Explanation: The nasopharyngeal airway length is measured by holding the airway on the side of the patient's face. The airway should reach from the tragus of the ear to the nostril plus 1 inch. The diameter should be slightly smaller than the diameter of the nostril. Answer B describes the measurement for an oropharyngeal airway. 1393

endotracheal tube

a catheter inserted into the trachea to provide or protect an airway

In which client would the nurse assess for a depressed respiratory system? a client taking amlodipine for hypertension a client taking antibiotics for a urinary tract infection a client taking opioids for cancer pain a client taking insulin for diabetes

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.

Nasal Cannula (NC)

a plastic tube placed into the patient's nostrils. Doesn't impede eating or speaking, it used easily at home.

dry powder inhaler

a quick deep breath by the patient activates the flow of medication eliminating the need to coordinate activating the inhaler.

Ischemia

a restriction in blood supply to tissues, causing a shortage of oxygen that is needed for cellular metabolism (to keep tissue alive). Ischemia is generally caused by problems with blood vessels, with resultant damage to or dysfunction of tissue.

chest physiotherapy

a series of maneuvers including percussion, vibration, and postural drainage designed to promote clearance of excessive respiratory secretions.

nasal trumpet

a tube inserted through the nose and the pharynx to establish and maintain airway patency; also called a nasopharyngeal airway

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula?

a) It can cause the nasal mucosa to dry in case of high flow. When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss.

adventitious breath sounds

abnormal lung sounds, are categorized as either discontinous or continuous sounds

what is dysrhythmia or arrhythmia?

abnormal rhythm of the heart. (heart disease, hypertension, atrial fibrillation)

adventitious

accidental

Inspiration active or passive?

active

nursing diagnosis for people with cardio/pulmonary problems

activity intolerance r/t imbalance between oxygen supply and demand, ineffective airway clearance, ineffective breathing pattern

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: diminished stroke volume. high cardiac output. heart failure. adequate tissue perfusion.

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.

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: heart failure. diminished stroke volume. high cardiac output. adequate tissue perfusion.

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.

Alveoli

air sacs in the lungs

Bronchial constriction in asthma is an example of:

air way resistance related to a decrease in the size of air passages

what is a Venturi mask

allows the mask to deliver the most precise concentration of oxygen

Forced Expiratory Volume (FEV)

amount of air exhaled in the 1st, 2nd, and 3rd second of a forced vital capacity test

dysrhythmias are caused by:

an ABNORMAL RATE of electrical impulse generation from the SA node, or from impulses originating from a site or sites other than the SA node.

bradypnea

an abnormally slow rate of respiration usually of less than 10 breaths per minute

tracheostomy

an artificial opening made into the trachea usually at the level of the second or third cartilaginous ring

Heimlich maneuver

an emergency procedure to help someone who is choking because food is lodged in the trachea

spirometer

an instrument that measures lung volume and airflow

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of: atelectasis. bronchospasm. croup. epiglottitis.

atelectasis. Explanation: Stiffer lungs tend to collapse and also cause their alveoli to collapse. This condition is called atelectasis.

what are some oxygen precautions

avoid open flames in the patient's room, place "no smoking" signs in conspicuous places in the patient's home.

Choice Multiple question - Select all answer choices that apply. A client visits the health care facility for a scheduled physical assessment. What should the nurse do when physically assessing the quality of the client's oxygenation? Select all that apply. a) Monitor the client's respiratory rate. b) Check the devices used to deliver oxygen. c) Observe the breathing pattern and effort. d) Note the amount of oxygen administered. e) Check the symmetry of the client's chest.

a• Monitor the client's respiratory rate. e• Check the symmetry of the client's chest. c• Observe the breathing pattern and effort. Explanation: When physically assessing the quality of the client's oxygenation, the nurse should monitor the client's respiratory rate, check the symmetry of the client's chest, and observe the breathing pattern and effort of the client. The nurse should also auscultate for lung sounds. Additional assessments include recording the heart rate and blood pressure, determining the client's level of consciousness, and observing the color of the skin, mucous membranes, lips, and nailbeds. However, the nurse does not note the amount of oxygen administered to the client, or check the device that is used to deliver oxygen to the client during the physical assessment. 1358

Choice Multiple question - Select all answer choices that apply. Which of the following statements about oxygen tents are true? Select all that apply. a) They are often used for children who will not leave a mask or cannula in place. b) It is difficult to maintain a consistent level of oxygen in the tent. c) An oxygen tent restricts freedom of movement, leading to frequent noncompliance. d) The nurse must frequently assess for hyperthermia. e) Frequent linen and clothing changes should be anticipated. f) Use of an oxygen tent decreases the ability of a parent to comfort the child.

a• They are often used for children who will not leave a mask or cannula in place. e• Frequent linen and clothing changes should be anticipated. b• It is difficult to maintain a consistent level of oxygen in the tent. f• Use of an oxygen tent decreases the ability of a parent to comfort the child. Explanation: The purpose of an oxygen tent is to permit freedom of movement without the use of a nasal cannula or face mask. 1377

During oxygen administration to the client, which of the following pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

b) Flow meter 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 client with chronic obstructive pulmonary disease requires low-flow oxygen. How will the oxygen be administered? Select all that apply.

b) Nasal cannula c) Simple oxygen mask e) Partial rebreather mask Nasal cannula with tubing administers oxygen at low-flow rates and concentrations at 22-44%. Simple masks and partial rebreathers both deliver a low-flow rate at concentrations of 40-60%. Venturi masks mix oxygen with room air and create a high flow of oxygen.

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 ...

b) 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.

when performing a pulse oximetry why do you have to be aware of the patient's hemoglobin level before evaluating the oxygen saturation?

because the test measures only the % of oxygen carried by available hemoglobin.

cardiac biomarkers

blood test that measures the presence and amount of several substances released by the heart when it is damaged or under stress; also called cardiac enzyme test

what are some respiratory functioning in the older adults

bony landmarks are more prominent due to loss of subcutaneous fat, barrel chest deformity may result in increased anteroposterior diameter

During a routine prenatal care visit, a pregnant woman in her last trimester of pregnancy reports that she has occasional shortness of breath. The nurse instructs her that: a prompt referral for follow up care will be made. breathing becomes increasingly difficult as the diaphragm is displaced. the nurse will assess her lung sounds and determine whether she has pneumonia. a chest x-ray is likely indicated.

breathing becomes increasingly difficult as the diaphragm is displaced. Explanation: During the last weeks of pregnancy, breathing may become increasingly difficult in a supine position because the fetus displaces the diaphragm upward.

During a routine prenatal care visit, a pregnant woman in her last trimester of pregnancy reports that she has occasional shortness of breath. The nurse instructs her that: the nurse will assess her lung sounds and determine whether she has pneumonia. breathing becomes increasingly difficult as the diaphragm is displaced. a chest x-ray is likely indicated. a prompt referral for follow up care will be made.

breathing becomes increasingly difficult as the diaphragm is displaced. Explanation: During the last weeks of pregnancy, breathing may become increasingly difficult in a supine position because the fetus displaces the diaphragm upward.

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: bronchiolitis. bronchitis. bronchiectasis. a bronchospasm.

bronchospasm. Explanation: 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 client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction two 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 what?

c) Atelectasis 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. Tachypnea, if present, would likely be a sign of atelectasis rather than an independent finding.

measurement of carbon dioxide in exhaled breath is know as

capnography

_______________ is the combination of chest compressions, which circulate blood, and mount-to-mouth breathing, which supplies oxygen to lungs.

cardiopulmonary resuscitation

what are some factors that influence diffusion of gases in the lungs?

change in surface area available (removal of lung or section of the lung), thickening of alveolar-capillary membrane (pneumonia), partial pressure (less oxygen)

how would you palpate the patient?

chest expansion, skin temp, edema, pulses, tenderness, and capillary refill

COPD

chronic obstructive pulmonary disease

Continuous one way circuit of blood through the blood vessels, with the heart as pump.

circulation

Universal distress signal

clutching the throat with both hands

pneumonia

collection of air in the pleura cavity

hypoxia

condition in which an inadequate amount of oxygen is available to cells.

Atherosclerosis

condition in which fatty deposits called plaque build up on the inner walls of the arteries. Can cause Myocardial ischemia.

what is the function of the lower airways and components?

conduction of air, mucocilliary clearance, and production of pulmonary surfactant. components: trachea, right and left main stem bronchi, segmental bronchi, and terminal bronchioles

medulla function

controls heartbeat and breathing

supply blood to the heart

coronary arteries

what are some abnormal breath sounds?

crackles- intermittent sounds occurring when air moves through airways. due to inflammation or congestion wheezes- continuous sounds heard on expiration and sometimes on inspiration as air passes through constricted airways rhonchi- rumbling, course sounds, like a snore.

tracheostomy

creation of an artificial opening into the trachea

what is myocardial ischemia

decreased oxygen supply to the heart (ischemia) can be caused by a blood clot (atherosclerosis)

metered dose inhaler

delivers a controlled dose of medication with each compression of the canister

AED function

delivers an electric shock through the chest to the heart. The shock can potentially stop an irregular heart beat (arrhythmia) and allow a normal rhythm to resume following sudden cardiac arrest (SCA).

what is a nonrebreather mask

delivers the highest concentration of oxygen out of the mask two one way valves that prevent the patient from rebreathing the exhaled air

what are some planning: expected outcomes?

demonstrate improved gas exchange in lungs by absence of cyanosis or chest pain and pulse oximetry reading, relate the causative factors and demonstrate adaptive method of coping, presence pulmonary function by maintaining an optimal level of activity

propioreceptors

detect position, stretch, and movement

Flatness

detected over bone or heavy muscle

what is the assessment for people with cardio/pulmonary problems?

determine why the patient needs nursing care, what kind of care is needed to maintain sufficient intake of air

Dyspnea

difficulty breathing

dyspnea

difficulty breathing

nebulizers

disperse fine particles of liquid medication ingot he deeper passages of the respiratory tract, where absorption occurs.

what are common causes of hypoxia?

dyspnea, hyperventilation, hypoventilation

Choice Multiple question - Select all answer choices that apply. You are caring for a patient who will have a chest tube removed within the next hour. Which of the following interventions should you plan to implement. Select all that apply. a) Ask the patient to bear down, then slowly withdraw the chest tube. b) Apply a semipermeable dressing to the insertion site immediately after the chest tube is removed. c) Anticipate obtaining a chest x-ray after the chest tube has been removed. d) Administer prescribed pain medication 15 to 30 minutes before chest tube removal. e) Teach the patient about relaxation exercises to be used during chest tube removal.

d• Administer prescribed pain medication 15 to 30 minutes before chest tube removal. e• Teach the patient about relaxation exercises to be used during chest tube removal. c• Anticipate obtaining a chest x-ray after the chest tube has been removed. Explanation: An occlusive dressing should be used. 1379

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 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.

what is evaluations in cardio/pulmonary problems

evaluate the implemented nursing intervention, did you reach your outcome and goals?

what happens with excessive oxygen in COPD patients.

excessive oxygen is given to patient's with chronic lung disease, the stimulus (carbon dioxide) to breathe is removed= patient may stop breathing completely

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? vesicular breath sounds audible over peripheral lung fields fine crackles to the bases of the lungs bilaterally resonance on percussion of lung fields respiratory rate of 18 breaths per minute

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.

pulmonary edema

fluid in the lungs

crackles

heard on inspiration, are soft high pitched discontinuous ( intermittent popping sounds. They are produced by fluid in the airways or alveoli and delayed reopening of collapsed alveoli.

what is the involvement of cardiovascular system:

heart and blood vessels have to be functioning to transport blood, arteries move blood away from ventricles to capillaries, veins return the blood to the lungs

_________ occurs when the heart is unable to pump a sufficient blood supply, resulting in inadequate perfusion and oxygenation of tissues.

heart failure

what are some chest physiotherapy

helps loosen secretion and mobilize secretion. percussion- cupping your hands and striking patient vibrating- manual compression and tremors on chest wall to help loosen secretion providing postural drainage, appropriate positioning

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) blood pH b) sodium and potassium levels c) age d) hemoglobin level

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. 1361

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: blood pH. sodium and potassium levels. age. hemoglobin level.

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.

what is the bronchial breath sound

high-pitched and longer. heard over trachea and larynx

what is hypoxia? and some early/chronic symptoms?

inadequate amount of oxygen available to the cells early symptoms: shortness of breath, elevated blood pressure, increased respiratory rate, tachycardia chronic symptoms: bradycardia, extreme restlessness, dyspnea

atelectasis

incomplete lung expansion or the collapses of alveoli, prevents pressure changes ad the exchange of gas by diffusion in the lungs.

what are consideration in respiratory activity in infants?

lungs are transformed from fluid-filled structure to air-filled organs, infants chest is small, airways are short, and aspirations is a potential problem

what does the lung do and its components?

main organ of respiration for the body, located in the thoracic cavity. Right lung has 3 lobes and left lung has 2. composed of: alveoli (small air sacs; site for gas exchange), surfactant (detergent-like phospholipids; reduces surface tension to prevent alveoli collapse), pleura (serous membrane that covers and protects the lungs and thoracic activity)

what is a simple face mask

mask has vents on the sides that allow room air to leak in that dilutes the oxygen

sputum

material expelled from the lungs by coughing

Vital Capacity (VC)

maximum amount of air that can be expired after a maximum inspiratory effort

Force Vital Capacity (FVC)

maximum amount of air that can be forcefully exhaled after a full inspiration

pulse oximetry

measures the arterial oxyhemoglobin saturation of arterial blood.

bronchovesicular

medium pitched blowing sounds heard over the major bronchi

what is the bronchovesicular breath sound

medium-pitched blowing sounds during expiration. sound heard over the upper anterior chest and intercostal area.

Respiratory centers of the brain

medulla and pons

intermittent positive pressure breathing

method of artificial ventilation using mask connected to machine that produces pressure to assist air to fill lungs

what is a nasal cannula

most commonly used device to delivery oxygen (1-6 L/min) advantages- easy to wear, can be used while eating disadvantages- move around easily, can cause dryness of nasal cavity

wheezes

musical sounds, produced as air passes through airways constricted by swelling, narrowing secretions or tumors

one type of acute coronary syndrome characterized by the death of heart tissue due to lack of oxygen; also known as a heart attack

myocardial infarction

upper airway

nose, pharynx, larynx, and epiglottis (warms, filters, and humidifies inspired air)

implementation for people with cardio/pulmonary problems

nursing intervention are aimed to improve breathing to help the client to breath more comfortably example: lifestyle changes (stop smoking), patient education, vaccination, decrease environmental factors

medication can affect cardiopulmonary functioning and oxygenation. For example when someone is taking opioids. EXPLAIN

opioids are chemical agents that depress the medullary respiratory center. As a result, the rate and depth of respiration's decrease

what do you need to promote during implementation

optimal functioning (spirometer), comfort (proper positioning, maintaining adequate fluid intake, providing humidified air, proper breathing, promote controlled cough)

planning for people with cardio/pulmonary problems?

outcomes and goals need to be directed toward meeting the oxygenation needs of the client ex: the patient will be able to go to the bathroom without becoming short of breath

lack of color

pallor

method of tapping body parts with fingers, hands, or small instruments as part of a physical examination.

percussion

Cardiovascular

pertaining to the heart and blood vessels

cardiopulmonary

pertaining to the heart and lungs

thick respiratory secretions are sometimes called

phlegm

what are factors that affect oxygenation

pregnancy, obesity, musculoskeletal abnormalities

what are the oxygen flow rates

prescribed by health provider, rate varies depending on condition

thoracentesis

procedure of puncturing the chest wall and aspirating pleural fluid.

capnography

procedure to record carbon dioxide levels

Perfusion

process by which oxygenated blood passes through body tissues

movement of air into and out of lungs

pulmonary ventilation

noninvasive technique that measures the oxygen saturation (SaO2) of arterial blood

pulse oximetry

Tachypnea

rapid breathing

Corticosteroids

reduce inflammation in airways

what is the gas exchange?

refers to the intake of oxygen and release of carbon dioxide

gas exchange between the atmospheric air in the alveioli and blood in the capillaries.

respiration

Chemoreceptors

respond to chemicals

SpO2

saturation of peripheral oxygen (measures the percentage of hemoglobin binding sites in the bloodstream occupied by oxygen. At low partial pressures of oxygen, most hemoglobin is deoxygenated.)

what does the medulla do?

sends impulses down the spinal cord to the respiratory muscles to stimulate contractions, leading to inhalation.

Pneumococcal Disease

serious disease leading to infections of the lungs, the blood, and the meninges

heart failure symptoms

shortness of breath, edema, fatigue.

what is a partial rebreather mask

similar to a simple face mask but has a reservoir bag on it this bag collects the first part of the patients exhaled air with the remaining exhaled air existing through the vents.

Partial rebreather mask

simple mask with a reservoir bag. designed to get hold of the first 150ml of the breath that has been exhaled into the reservoir bag so that it can be used for inhalation in the next subsequent breath. This part of the breath will be delivered initially at the finish of the inhalation stage.

alveoli

small air sacs. The alveoli are the site of gas exchange.

what are respiratory activity in the child?

some subcutaneous fat is deposited on the chest wall, making landmarks less prominent

_________ measures the volume of air in liters exhaled or inhaled by a patient over time.

spirometry

respiratory secretions expelled by coughing or clearing the throat is called

sputum

the quantity of blood force out of the left ventricle with each contraction is called __________

stroke volume (SV)

What is the action of codeine when used to treat a cough?

suppressant Explanation: Codeine, which is an ingredient in many cough preparations, is generally considered to be the preferred cough suppressant ingredient.

thoracentesis

surgical puncture to remove fluid from the pleural space

inspiration

the active phase involves movement of muscles and the thorax to bring air into the lungs

Total lung capacity

the amount of air contained within the lungs at maximum inspiration

Vital capacity

the amount of air displaced by maximal exhalation.

Residual volume

the amount of air left in the lungs at maximal expiration.

Hyperventilation

the condition of taking abnormally fast, deep breaths

internal respiration

the exchange of oxygen and carbon dioxide between the circulating blood and the tissue cells

what is myocardial infarction

the heart needs more oxygen than it is getting. that is why people feel chest pain

Peak expiratory flow rate

the maximum flow attained during the forced expiratory maneuver.

pulmonary ventilation

the movement of air into and out of the lungs.

diffusion

the movement of gas or particles from areas of higher pressure or concentration to areas of lower pressure or concentrations.

expiration

the passive phase is the movement of air out of the lungs.

perfusion

the process by which oxygenated capillary blood passes through body tissues.

tracheobronchial tree

the structures of the trachea and the bronchi. (conduction of air, mucociliary clearance, production of surfactant)

what is the blood process in the heart?

the upper chambers (atria) receives blood from veins (superior/inferior vena cava and the left/right pulmonary veins) the lower chambers (ventricles) force blood out of the heart through the arteries ( right/left pulmonary arteries and the aorta)

during ______, fluid air can be removed from the pleural cavity with a syringe.

thoracentesis

Tidal Volume (TV)

total amount of air inhaled and exhaled with one breath

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? simple mask face tent tracheostomy collar nasal cannula

tracheostomy collar Explanation: A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. Other devices are not appropriate for this client.

The nurse is caring for a client who was 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? face tent nasal cannula tracheostomy collar simple mask

tracheostomy collar Explanation: 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.

what does the mucus coated lining do?

traps particles and infectious debris, protects underlying tissue from irritation and infection

hypoventilation

ventilation of the lungs that does not fulfill the body's gas exchange needs

what does the upper airway do and components?

warms, filter, and humidify inspired air. components: nose, pharynx, larynx, epiglottis

When is CPR needed?

when breathing, and heartbeat are absent

Dullness

with medium pitch and intensity heard over the liver

Infiltration nursing considerations

• Check infusion site every hour for S&S • Discontinue infusion if symptoms occur • Restart infusion at different site • Use site-stabilization device

Which of the following is a recommended guideline for determining suction catheter depth when suctioning an endotracheal tube? a) Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. b) Using a spare endotracheal tube of the same size as being used for the patient, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. c) 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. d) For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.

Correct response: 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. 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 patient, 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

During oxygen administration to the client, which of the following pieces of equipment would enable the nurse to regulate the amount of oxygen delivered? a) Nasal cannula b) Flow meter c) Oxygen analyzer d) Humidifier

Correct: 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

Which of the following medications are administered in the home or the hospital to relieve inflammation in the lung tissue? a) Bronchodilators b) Corticosteroids c) Expectorants d) Antibiotics

Corticosteroids Explanation: In many cases, bronchodilators and corticosteroids are required to open airways and ease breathing. Corticosteroids relieve inflammation. 1372

A nurse is assessing the breath sounds of a newborn. Which of the following is an expected finding for this developmental level? a) Bruits b) Clear sounds c) Wheezes d) Crackles

Crackles Explanation: Normal breath sounds of an infant are harsh crackles at the end of deep inspiration. 1355

The nurse auscultates a patient with soft high pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as a) Rales b) Wheezes c) Vesicular d) Crackles

Crackles Explanation: A coarse crackle is a low-pitched, rumbling sound in airways. When they are coarse and loud and occur with severe dyspnea, crackles may be a telling sign of pulmonary fibrosis, congestive heart failure, and pulmonary edema. 1361

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. What additional assessment would the nurse expect to observe? a) Wheezing in the upper lobes b) Expiratory stridor c) Crackles in the lower lobes d) Inspiratory stridor

Crackles in the lower lobes Explanation: People with chronic congestive heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels. Stridor is associated with respiratory infections such as croup. Wheezing may be heard in individuals who use tobacco products. 1361

what breathing exercise would you incorporate for someone with hypoventilation problems?

DEEP- BREATHING (patient has to take deep respirations nasally and then expiring slowly through the mouth breathing through nose warms, filters and humidifies air)

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) Diaphragmatic breathing c) Deep 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. Pursed-lip breathing is a form of controlled ventilation in which the client consciously prolongs the expiration phase of breathing, which helps clients 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. Incentive spirometry, a technique for deep breathing using a calibrated device, encourages clients to reach a goal-directed volume of inspired air. Diaphragmatic breathing is breathing that promotes the use of the diaphragm rather than the upper chest muscles. It is used to increase the volume of air exchanged during inspiration and expiration. 1368

Promoting Proper Breathing

Deep breathing Using incentive spirometry Pursed-lip breathing Abdominal or diaphragmatic breathing

Which of the following is a disadvantage of using a face tent to administer oxygen to a client with facial trauma? a) Delivers an inconsistent amount of oxygen b) Creates a risk of suffocation c) Permits condensation to form in the tubing d) Dries nasal mucosa at a higher flow

Delivers an inconsistent amount of oxygen Explanation: When using a face tent to administer oxygen to a client with facial trauma, the nurse should remember that the amount of oxygen the client actually receives may be inconsistent with what is prescribed because of environmental losses. A partial rebreather mask creates a risk of suffocation. A nasal cannula dries the nasal mucosa at a higher flow. A venturi mask permits condensation to form in tubing, which diminishes the flow of oxygen. 1376

Oxygen and carbon dioxide move between the alveoli and the blood by a) Osmosis b) Hyperosmolar pressure c) Diffusion d) Negative pressure

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. 1361

phlebitis nursing considerations

Discontinue the infusion immediately Apply warm, moist compresses to the affected site Avoid further use of the vein Restart the infusion in another vein

metabolic alkalosis assessments

Dizziness. Tingling fingers, toes. Hypertonic muscles. Depressed respirations (compensatory) ABGs: pH >7.45, HCO3- >26 (primary), PaCO2 >45 mm Hg (compensatory)

The nurse is assessing a client with a chest tube that has been inserted after experiencing blunt trauma that resulted in a pneumothorax. What nursing action is appropriate when constant bubbling is noted in the suction control chamber? a) Remove the chest tube. b)Remind the client to remain stationary in bed to stop the bubbling. c)Document the finding. d)Contact the Rapid Response Team.

Document the finding. Constant bubbling in the suction control chamber is normal and should be documented. Other actions are inappropriate.

A 55-year-old client visits a health care facility for a scheduled physical assessment. During the assessment, the client complains of difficulty breathing. What suggestion could the nurse make to improve the client's respiratory function in this case? Use a nasal strip. Receive annual immunizations. Drink liberal amounts of fluids. Avoid strenuous exercises.

Drink liberal amounts of fluids. Explanation: The nurse could suggest liberal fluid intake for the client in order to improve respiratory function. Older adults need encouragement to maintain liberal fluid intake, which keeps the mucous membranes moist. Unless contraindicated, the nurse should encourage the client to engage in regular exercise to maintain optimal respiratory function. A nasal strip reduces airflow resistance by widening the nasal breathing passageway, thus promoting easier breathing. An older adult may or may not use a nasal strip to improve respiratory function. The nurse should advise older adults to receive annual influenza immunizations and a pneumonia immunization after 65 years of age or earlier if there is a history of chronic illness.

A 55-year-old client visits a health care facility for a scheduled physical assessment. During the assessment, the client complains of difficulty breathing. What suggestion could the nurse make to improve the client's respiratory function in this case? a) Use a nasal strip. b) Receive annual immunizations. c) Drink liberal amounts of fluids. d) Avoid strenuous exercises.

Drink liberal amounts of fluids. Explanation: The nurse could suggest liberal fluid intake for the client in order to improve respiratory function. Older adults need encouragement to maintain liberal fluid intake, which keeps the mucous membranes moist. Unless contraindicated, the nurse should encourage the client to engage in regular exercise to maintain optimal respiratory function. A nasal strip reduces airflow resistance by widening the nasal breathing passageway, thus promoting easier breathing. An older adult may or may not use a nasal strip to improve respiratory function. The nurse should advise older adults to receive annual influenza immunizations and a pneumonia immunization after 65 years of age or earlier if there is a history of chronic illness. 1356

Nonproductive Cough

Dry cough

When performing a physical assessment of an adult patient complaining of dyspnea, the nurse is aware that which of the following is an abnormal finding? a) The chest contour is slightly convex, with no sternal depression b) Auscultation of low-pitched, soft sounds over the peripheral lung fields c) Symmetrical movement of the chest d) Dullness over the lung fields with percussion

Dullness over the lung fields with percussion Explanation: Percussion that produces dullness over the lung fields occurs when fluid or solid tissue replaces normal lung tissue. Normal assessment findings include a slightly convex chest contour with no sternal depression and symmetrical chest movement. Vesicular breath sounds described as low-pitched, soft sounds over the peripheral lung fields are also a normal respiratory assessment finding. 1360

electrocardiogram

ECG a record of the electrical activity of the myocardium

Which of the following dietary guidelines would be appropriate for the elderly homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat? a) Eat smaller meals that are high in protein b) Snack on high-carbohydrate foods frequently c) Eat one large meal at noon d) Contact the physician for Ensure

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. 1367

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. Snack on high-carbohydrate foods frequently. Contact the physician for nutrition shake. 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.

Which skin disorder is associated with asthma? Psoriasis Seborrhea Abrasions Eczema

Eczema Explanation: The client with asthma often recalls childhood allergies and eczema.

A client with no prior history of respiratory illness has been admitted to a postsurgical 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) Educating the client on the use of incentive spirometry c) Educating the client on pursed-lip breathing techniques d) Oropharyngeal suctioning twice daily

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. 1368

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is "Ineffective Airway Clearance related to copious and tenacious secretions." Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan? a) Encouraging the client to decrease the number of cigarettes smoked daily b) Encouraging the client to consume two to three quarts of clear fluids daily c) Positioning the client supine d) Creating an environment that is likely to reduce anxiety

Encouraging the client to consume two to three quarts of clear fluids daily Explanation: Clients can help keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of clear fluids daily. Although it is important to create an environment that is likely to reduce a client's anxiety, doing so will not assist in promoting airway clearance. The nurse should not encourage the client to decrease the number of cigarettes smoked daily, but should encourage the client to stop smoking. Proper positioning to ease respirations includes placing the client in a high-Fowler's position. 1367

What stimulates the patient to breathe?

Excessive levels of carbon dioxide in the blood

internal respiration

Exchange of gases between cells of the body and the blood

Hypokalemia s/s

Fatigue, Anorexia, N/V, Muscle weakness, Decreased GI motility, Dysrhythmias, Paresthesia, Polyuria,nocturia, dilute urine, postural hypotension, serum <3.5 mEq/L

The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which of the following assessment findings should the nurse interpret as abnormal? a) Respiratory rate of 18 breaths per minute b) Vesicular breath sounds audible over peripheral lung fields c) Resonance on percussion of lung fields d) Fine crackles to the bases of the lungs bilaterally

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. 1361

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) Flowmeter c) Nasal cannula d) Oxygen analyzer

Flowmeter Explanation: The nurse should use a flowmeter to regulate the amount of oxygen delivered to the client. A flowmeter 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. 1374

pulmonary function studies

Group of tests used to assess respiratory function to assist in evaluating respiratory disorders

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: "His infection is causing him to breathe harder." "His lung muscles are swollen so he is using abdominal muscles." "He is using his chest muscles to help him breathe." "He will require additional testing to determine the cause."

He is using his chest muscles to help him breathe." Explanation: The client will use accessory muscles to ease dyspnea and improve breathing.

metabolic acidosis assessments

Headache, confusion, drowsiness, increased respiratory rate and depth, N/V, peripheral vasodilation ABGs: pH <7.35, HCO3- <22 mEq/L (primary), PaCO2 <35 mm Hg Hyperkalemia often present

Comparison of healthy/problem I & O

Healthy : about equal when averaged 2-3 days. Range of 1500-3500 intake, loss 2000mL per day. Output of urine approx the ingestion of liquids; water from food and oxidation is balanced through water loss by feces, skin, respiratory process. Problem: total intake is substantially less than total output, danger of FVD. Total intake is substantially more than total output, danger of FVE

Comparison of healthy/problem Body weight

Healthy: dry weight should remain stable Problem: rapid loss of BW occurs when fluid intake is less than output (2%=mild FVD, 5% = moderate, 8% or more = severe) Rapid gain of BW occurs when total fluid intake is greater than total fluid output (2% gain mild FVE, 5% moderate, 8% or more severe)

Comparison of healthy/problem Urine volume concentration

Healthy: normal urinary output is about 1mL/kg BW per hr (average 40-80mL/hr). Stress can diminish 24hr urine volume from aldosterone and ADH. Specific gravity: 1.003-1.035. Urine osmolarity 500-800 mOsm/kg Problem: low urine volume and high specific gravity = FVD. Low urine volume, low specific gravity = renal disease High urine volume = FVE Urine volume is increased in conditions with high solute loads such as DM Hypovolemia causes decreased renal perfusion thus oliguria Hypervolemia causes increased urinary volume if kidneys are functioning

in a situation of shocking after complete airway obstruction has been determines, perform the ___________ ( abdominal thrusts)

Heimlich maneuver

metabolic alkalosis =

High pH and a high plasma bicarb concentration due to a gain of bicarb or a loss of hydrogen

The nurse is caring for a client who is diagnosed with an impaired gas exchange. While performing a physical assessment of the client, which of the following data is the nurse likely to find, keeping in mind the client's diagnosis? a) Low blood pressure b) High respiratory rate c) High temperature d) Low pulse rate

High respiratory rate Explanation: A client diagnosed with an impaired gas exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. The options of high temperature, low pulse rate, and low blood pressure are incorrect; this is because, as a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase. 1364-1365

Excrete or retain hydrogen ions and form or excrete bicarbonate ions in response to the pH of the blood

How do the kidneys help buffer pH?

2-3 days

How long does it take to have a balanced intake/output?

DEVELOPMENT and cardiopulmonary functioning!

INFANTS: (30-55 respirations per minute) 1) The infant's chest is small, airways short = *aspiration risk.* 2) *HIGHER* respiratory rate than any other age 3) As the *alveoli increase in number and size*, adequate oxygenation is accomplished at lower respiratory rates. 4) *Surfacant* is formed in utero at *34-36 weeks* 5) Infant born *before 34 weeks* may not have pruduced sufficient surfacant, leading to collapse of the alveoli and poor alveolar exchange. 6) Synthetic surfacant can be given to the infant to help reopen the alveoli. 7) Respriatory activity is primarily abdominal (diaphramiatic). 8) Pulse rate is more rapid in infancy than adulthood, limiting the infant's ability to increase cardiac output by increasing the heart rate. OLDER ADULTS: 1) Tissues and airways of the respiratory tract (including alveoli) become *less elastic.* 2) Power of the respiratory and abdominal muscles *is reduced*, therefore the diaphragm moves less efficently. 3) The chest is *unable to stretch as much*, resulting in a decline in maximum inspiration and expiration. 4) *Airways collapse more easily.* 5) Natural physical alterations increase the risk for disease, especially pneumonia and other chest infections.

A physician has ordered an arterial blood gas test for a client with a respiratory disorder. What is the most common role of the nurse in performing the arterial blood gas test? a) Measure the percentage of hemoglobin saturated with oxygen. b) Perform the arterial puncture to obtain the specimen. c) Measure the partial pressure of oxygen dissolved in plasma. d) Implement measures to prevent complications after arterial puncture.

Implement measures to prevent complications after arterial puncture. Explanation: During the arterial blood gas test, the nurse should implement measures to prevent complications after the arterial puncture. The nurse would not be involved in measuring the partial pressure of oxygen dissolved in plasma or the percentage of hemoglobin saturated with oxygen. Intensive care nurses commonly obtain arterial blood gases. 1362

A client with no prior history of respiratory illness has been admitted to a postsurgical 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?

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.

A client suffering from chronic obstructive pulmonary disease complains 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. 1370

The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is a) Risk for ineffective airway clearance related to infection as evidenced by dyspnea and yellow-green sputum b) Impaired gas exchange related to increased carbon dioxide and irritability c) Ineffective breathing pattern related to hyperventilation related to increased anteroposterior diameter d) Hypoxia related to pneumonia and ineffective airway clearance related to dyspnea edema

Ineffective breathing pattern related to hyperventilation related to increased anteroposterior diameter Explanation: Ineffective breathing pattern is the state in which a person's inspiration and/or expiration pattern does not provide adequate ventilation. 1364

A nurse is conducting a health promotion program for adolescents to educate them about the hazards of smoking. When describing the effects on the respiratory system, which of the following would the nurse most likely include? a) Inhibition of bacterial colonization b) Increase in the mucous escalator c) Inhibition of mucus removal d) Decreased production of mucus

Inhibition of mucus removal Explanation: Smoking inhibits mucus removal. By producing more mucus and by slowing the mucous escalator, smoking inhibits mucus removal and can cause airway blockage, promoting bacterial colonization and infection. 1366

A nurse is educating a postoperative client on how to use an incentive spirometer. Which of the following is an accurate step that should be included in the teaching plan? a) Encourage the client to perform incentive spirometry two to three times every one to two hours, if possible. b) Instruct the client to inhale normally and then place the lips securely around the mouthpiece. c) When the client cannot inhale anymore, the patient should hold his or her breath and count to 10. d) Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose.

Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose. Explanation: The client using an incentive spirometer should exhale normally and place the lips around the mouthpiece. He or she should inhale slowly and deeply without using the nose, and when the client cannot inhale anymore, hold the breath and count to 3 before exhaling normally. This should be performed 5 to 10 times every one to two hours, if possible. 1369

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula? a) It can cause anxiety in clients who are claustrophobic. b) It can cause the nasal mucosa to dry in case of high flow. c) It can result in an inconsistent amount of oxygen. d) It can create a risk of suffocation.

It can cause the nasal mucosa to dry in case of high flow. Explanation: When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss. 1375

Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen? It prescribes oxygen concentration. It determines whether the client is getting enough oxygen. It decreases dry mucous membranes via delivering small water droplets. It regulates the amount of oxygen received.

It regulates the amount of oxygen received. Explanation: The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The provider prescribes concentration. The oxygen analyzer measures the percentage of delivered oxygen. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.

respiratory alkalosis assessments

Lightheadedness, inability to concentrate, hyperventilation syndrome (tinnitus, palpitations, sweating, dry mouth, tremulousness, convulsions, loss of consciousness) ABGs: pH >7.45, PaCO2 <35 (primary), HCO3- <22 mEq/L (compensatory)

Phlebitis s/s

Local, acute tenderness; redness, warmth, and slight edema of the vein above the insertion site

Metabolic acidosis =

Low pH (increased H ion concentration) and a low plasma bicarb concentration due to a gain of hydrogen or loss of bicarb

The balance between the parasympathetic and sympathetic effects on the heart is maintained with the help of input from the ______ in the brainstem.

MEDULLA

Forced Vital Capacity

Maximum abount of air that can be FORCEFULLY EXHALED after a full inspiration

Barrel Chest

May be a result of *AGING or COPD*

Mucolic Agents

Medication that is administerd to liquefy or loosen thick secretions

Bronchodilators

Medication that is administered in order to OPEN narrowed airways. 1) Albuterol

Corticosteroids

Medication that is administered to reduce inflammation in airways. 1) Prednisone 2) Fluticasone

A nurse formulates the diagnosis of fluid volume excess for a client. Which of the following precautions should the nurse suggest to the client? a) Have small portions of meat b) Have nonfat or skim milk products c) Monitor intake and output carefully d) Have lean cuts of meat and fish

Monitor intake and output carefully Explanation: The nurse should suggest to the client with excess fluid volume to monitor intake and output carefully. The client who needs to restrict fat in the diet should use lean cuts of meat and fish, eat small portions of meat, and eat nonfat or skim milk products 1367

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 technique? a) Monitor the pressure of oxygen dissolved in plasma b) Calculate the percentage of hemoglobin saturated with oxygen c) Calculate the pressure of carbon dioxide dissolved in plasma d) Monitor the amount of oxygen saturation in the blood

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, percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma

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 technique? a) Monitor the amount of oxygen saturation in the blood b) Monitor the pressure of oxygen dissolved in plasma c) Calculate the pressure of carbon dioxide dissolved in plasma d) Calculate the percentage of hemoglobin saturated with oxygen

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, percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma. 1361

A nurse is caring for an asthmatic client who requires a low concentration of oxygen. Which of the following delivery devices should the nurse use in order to administer oxygen to the client? a) Nasal cannula b) Face tent c) Simple mask 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. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Non-rebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill. 1375

A patient with a diagnosis of stage II Alzheimer disease also has a history of chronic obstructive pulmonary disease (COPD). Which of the following medication delivery systems is most appropriate for this patient? a) Metered-dose inhaler without spacer b) Metered-dose inhaler with spacer c) Dry powder inhaler d) Nebulizer

Nebulizer Explanation: Inhalers differ in the amount of dexterity that is required in order to deliver an accurate dose, but each requires some degree of coordinated activity on the part of the patient. For a patient with decreased cognition, a nebulizer may be more appropriate on account of the fact that the patient passively inhales the entire dose. 1372

The nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FIO2 of 100%. Which of the following oxygen delivery systems should the nurse utilize? a) Simple mask b) Venturi mask c) Non-rebreather mask d) Nasal cannula

Non-rebreather mask Explanation: A non-rebreather mask is the only device that can deliver FIO2 of 100% to a client without a controlled airway. A Venturi mask delivers a maximum FIO2 of 55%. A nasal cannula delivers a maximum FIO2 of 44%. A simple mask delivers a maximum FIO2 of 60%. 1377

What structural changes to the respiratory system should a nurse observe when caring for older adults? a) Increased mouth breathing and snoring b) Diminished coughing and gag reflexes c) Increased use of accessory muscles for breathing d) Respiratory muscles becomes weaker

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. Diminished coughing and gag reflexes, increased use of accessory muscles for breathing, and increased mouth breathing and snoring are functional changes to the respiratory system in older adults.

While examining a client, the nurse palpates the client's chest and back. Which of the following would the nurse expect to identify with this technique? a) Consolidated portions of the lung b) Fluid-filled portions of the lung c) Pattern of thoracic expansion d) Presence of pleural rub

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. 1360

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? Tachypnea Wheezes Pneumonia Pleural effusion

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.

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? Tachypnea Pleural effusion Wheezes Pneumonia

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 pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.

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) Pneumonia b) Pleural effusion c) Tachypnea 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. 1378

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 which of the following? a) Asthma b) Pneumonia c) Alcohol abuse d) Croup

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 abuse do not lead to atelectasis. Croup is a common condition in young children that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol abuse depresses the central respiratory center. 1352

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 which of the following?

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 abuse do not lead to atelectasis. Croup is a common condition in young children that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol abuse depresses the central respiratory center.

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing a) Poor tissue perfusion b) Congestive heart failure c) Anemia d) Malnutrition

Poor tissue perfusion Explanation: Chronically poor perfusion may result in hair loss in the affected area, discolored skin, thickened nails, and shiny, dry skin indicative of inadequate tissue nutrition. 1353

While auscultating a client's chest, a nurse hears coarse crackles that are low-pitched and rumbling. The nurse interprets this finding as indicating which of the following? a) Air passing through narrowed airways b) Inflammation of pleural surfaces c) Presence of fluid in the lungs d) Presence of sputum in the airways

Presence of sputum in the airways Explanation: Coarse crackles heard on auscultation indicate the presence of sputum in the airways. Rales indicate presence of fluids in the lungs. Air passing through narrowed airways produces a wheezing sound, whereas inflammation of pleural surfaces gives rise to pleural rub.

A patient returns to the telemetry unit after an operative procedure. Which of the following diagnostic tests will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the patient? a) Spirometry b) Thoracentesis c) Pulse oximetry d) Peak expiratory flow rate

Pulse oximetry Explanation: Pulse oximetry is useful for monitoring patients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative patients. 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 and evaluate 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 patient returns to the telemetry unit after an operative procedure. Which of the following diagnostic tests will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the patient? a) Thoracentesis b) Pulse oximetry c) Peak expiratory flow rate d) Spirometry

Pulse oximetry Explanation: Pulse oximetry is useful for monitoring patients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative patients. 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 and evaluate 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. 1361

A patient vomits as a nurse is inserting his oropharyngeal airway. What would be the appropriate intervention in this situation? a) Remove the airway, turn the patient to the side and provide mouth suction, if necessary. b) Leave the airway in place and notify the physician for further instructions. c) Ask the patient to extend the neck slightly to adjust the airway. d) Immediately remove the airway and reinsert it because it has probably inadvertently caused the gag reflex.

Remove the airway, turn the patient to the side and provide mouth suction, if necessary. Explanation: If the patient vomits as the oropharyngeal airway is inserted, quickly position the patient onto his or her side to prevent aspiration, remove the oral airway, and suction the mouth, if needed. Reinsertion of airway, leaving it in place and extension of the neck can result in further complications related to aspiration. 1395

A nurse is delivering oxygen to a client via an oxygen mask. Which of the following is a recommended guideline for this procedure? a) Remove the mask and dry the skin every two to three hours if the oxygen is running continuously. b) If the client is experiencing redness around the mask, remove and apply powder to the mask. c) Adjust the mask so it fits tightly around the face. d) For a mask with a reservoir, fill the reservoir half-full of oxygen.

Remove the mask and dry the skin every two to three hours if the oxygen is running continuously. Explanation: To apply an oxygen mask, position the facemask over the client's nose and mouth and adjust the elastic strap so that the mask fits snugly, but comfortably, on the face. For a mask with a reservoir, be sure to allow oxygen to fill the bag before proceeding to the next step. Remove the mask and dry the skin every two to three hours if the oxygen is running continuously; do not use powder around the mask. 1400

What structural changes to the respiratory system should a nurse observe when caring for older adults? a) Respiratory muscles becomes weaker b) Increased mouth breathing and snoring c) Increased use of accessory muscles for breathing d) Diminished coughing and gag reflexes

Respiratory muscles becomes 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. Diminished coughing and gag reflexes, increased use of accessory muscles for breathing, and increased mouth breathing and snoring are functional changes to the respiratory system in older adults. 1356

A nurse is providing care to an infant who is at risk for developing respiratory complications. Which of the following would lead the nurse to notify the physician that the infant is experiencing breathing difficulties? a) Soft rustling sounds on auscultation b) Gasping c) Retraction of ribs d) Panting respirations

Retraction of ribs Explanation: An infant with breathing difficulty will have retraction of ribs during inspiration. Apart from this, flaring of the nostrils is another notable sign of air hunger and extraordinary breathing effort. Soft rustling sounds on auscultation are normal findings. Gasping, and panting respirations are more typically found in adults. 1358

Hyperphosphatemia s/s

Short-term: tetany symptoms; tingling of fingertips and around mouth, numbness and muscle spasms Long-term: precipitation of calcium phosphate in nonosseous sites such as kidneys, joints, arteries, skin or cornea Serum >4.5 mg/dL

Assessment Parameters significant findings

Skin turgor - FVD skin flattens more slowly may remain elevated for many seconds; severe malnutrition (infants) can cause depressed skin turgor even in absence of fluid depletion. Tongue turgor - FVD there are additional longitudinal furrows and the tongue is smaller; sodium excess causes tongue to look red and swollen Moisture and oral cavity- dryness of membrane where cheek and gums meet indicates FVD; dry sticky mucous membranes are noted in sodium excess Tearing and salivation - absence of in a child is a sign of FVD; becomes obvious with a fluid loss of 5% TBW Appearance of skin and skin temp - metabolic acidosis can cause warm flushed skin. Facial appearance- Person with severe FVD may have pinched and drawn facial expression. FVD of 10% BW causes decreased intraocular pressure causing eyes to appear sunken and feel soft Edema - not apparent until adult has 5-10 lb excess of fluid. Pitting is not evident until 10% increase in weight. Formation may be localized or generalized. Of CHF, liver cirrhosis, nephrotic syndrome is the result of sodium retention

Bradypnea

Slow breathing

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include the humidifier? "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." "This is a gauge used to regulate the amount of oxygen that a client receives." "The humidifier prescribes the concentration of oxygen." "Small water droplets come from this, thus preventing dry mucous membranes."

Small water droplets come from this, thus preventing dry mucous membranes." Explanation: The humidifier produces small water droplets which are delivered during oxygen administration to prevent or decrease dry mucous membranes. 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 healthcare provider prescribed the concentration of oxygen.

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? heart rate 110 beats/minute SpO2 92% respirations 26 breaths/minute clubbing of fingers

SpO2 92% Explanation: An SpO2 at or above 90% is normal, reflecting that oxygen therapy is being effective. Clubbing, respirations greater than 26 breaths/minute, and a heart rate greater than 100 beat per minute may indicate that more oxygen is needed.