Fundamentals of Nursing III (Chap 38 Oxygenation & Perfusion Prep U)

The nurse educator is presenting a lecture on the respiratory and cardiovascular systems. Which response given by the nursing staff would indicate to the educator that they have an understanding of cardiac output?

"If the client's stroke volume is 50 mL and heart rate is 50 beats per minute, then the cardiac output is 2.5 L/minute." (Cardiac Output = Stroke Volume x Heart Rate).

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

The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood.

The nurse is caring for a 70-year-old client with COPD. Which vaccine will the nurse offer the client?

All clients over 65 years old or anyone with a compromising chronic health condition should be offered Prevnar 13 ®. This vaccine is effective in reducing 13 strains of streptococcal pnuemoniae.

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

Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH

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?

Care of a tracheostomy tube in a stable situation, such as long-term care and other community-based care settings, may be delegated to licensed practical/vocational nurses (LPN/LVN); not in an acute instance.

The nurse schedules a pulmonary function test to measure the amount of air left in a client's lungs at maximal expiration. What test does the nurse order?

During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume.

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?

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 nurse suctioning a client through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what condition to occur?

Occluding the Y-port on the suction tubing is what creates the suction. While suctioning would be difficult but possible, suctioning while advancing the tube would damage the tracheal mucosa and remove excessive amounts of oxygen, not carbon dioxide, from the respiratory tract

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:

Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize atelectasis

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The adult chest contour is slightly convex, with no sternal depression.

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

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

Which is a sign of dyspnea specific to infants?

In the infant, flaring of the nostrils and retractions of the ribs during inspiration are notable signs of air hunger and extraordinary work of breathing.

Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows?

Pulmonary function testing is used to measure lung size and airway patency.

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

A client diagnosed with impaired gas exchange has difficulty in breathing, so the nurse is likely to find a high respiratory rate. As a compensatory mechanism to impairment in gas exchange, the peripheral temperature drops, and the pulse rate and blood pressure increase.

Which oxygen delivery system is most commonly used because it does not impede eating or speaking?

A nasal cannula is commonly used because it does not impede eating or speaking and is easily used in the home.

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?

Breath sounds should be auscultated while the client breathes slowly through an open mouth; nose breathing may produce false breath sounds.

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

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

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

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

Erin is a 35-year-old woman being cared for in the emergency department for a cough and hemoptysis for 3 days. Erin states that she has smoked one-and-a-half packs of cigarettes per day for the last 5 years. In trying to identify risk factors for Erin, the nurse calculates her pack-year history to write on the intake form. What is Erin's pack-year of smoking?

One "pack-year" is equal to smoking one pack of cigarettes for a day for 1 year. Based on Erin's information, Erin has a 7.5 pack-year smoking history.

What structural changes to the respiratory system should a nurse observe when caring for older adults?

One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker.

When caring for a client with a tracheostomy, the nurse would perform which recommended action?

Sterile technique is required when suctioning a tracheostomy in order to prevent introduction of microorganisms into the respiratory tract.

The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner?

The correct amount delivered FiO2 for a nonrebreather mask is 12 L/min; 8-11 L/min for partial rebreather mask; 4-10 L/min for Venturi mask; and 1-6 L/min for nasal cannula. However, per nasal cannula it may be no more than 2-3 L/min to patient with chronic lung disease.

Which is NOT true regarding the structure of the respiratory system?

The lungs move actively. The lungs move only passively. They stretch and recoil in response to neuromuscular activity.

The nurse caring for a client with cystic fibrosis is performing chest physiotherapy. The nurse educator would INTERVENE if which actions performed by the nurse are noted? Select all that apply.

To prevent tissue damage, percussion should NOT be performed on bare skin or under the ribs. When vibrating, the nurse should use rhythmic contraction and relaxation of shoulder and arm muscles during client's exhalation. To drain the posterior section of the client's upper lobes, the client should be placed in a lying position, half on the side. The nurse's hands should be held in a rigid, dome-shaped position when percussing. Postural drainage should be performed for 20 to 30 minutes up to four times a day.

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?

"The caregiver will need to place the oxygen tank back into the secure carrier." 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.

What are characteristics of a normal breathing pattern? Select all that apply.

-The average adult moves about a quarter of a liter of air per breath. -Normal breathing occurs at a rate of 12 to 20 breaths per minute in the adult. -Usually a person breathes slightly faster when awake than when asleep. -Exhaling normally takes twice as long as inhaling. -The athlete normally breathes more slowly and deeply while at rest than someone who is less fit. -Normally, each breath is the same size.

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines?

A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly.

The nurse caring for a client who will have a chest tube removed within the next hour includes which of the following nursing interventions on the client's plan of care? (Select all that apply)

After the chest tube is removed, the plan of care should include the following nursing interventions: administration of prescribed pain medication 15 to 30 minutes before chest tube removal and teaching the client relaxation exercises to utilize during the procedure.

The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?

An oxygen tent is commonly used with children who need a cool and highly humidified airflow. It is also more effective for children because they often do not like to keep oxygen administration devices in place. Since the tent does not allow the maintenance of a satisfactory or precise oxygen concentration, is difficult to maintain a consistent level of oxygen. The oxygen tent does not adequately deliver oxygen at a rate higher than 30% to 50%; thus, it is rarely used with other clients.

The nurse is caring for a 3-year-old client who experienced smoke inhalation during a house fire, and now requires oxygen. What delivery device will the nurse select that is most appropriate for this client?

An oxygen tent is often used when caring for active toddlers who require oxygen, since they are less likely to keep a mask on.

The UAP reports to the nurse that the client's pulse oximetry is 89%. What is the priority nursing action?

As the nurse enters the room the respiratory assessment immediately begins by visualizing client skin color, observing chest symmetry, vocalization, and auditory adventitious lung sounds. The nurse can then proceed to check the placement of the pulse oximeter

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

Clubbing refers to the rounding and enlargement of the tips of the fingers and toes. It is a common phenomenon seen in many clients with chronic hypoxia due to respiratory or cardiac disease. Clubbing occurs in lung cancer, cystic fibrosis, and lung diseases such as lung abscess and COPD.

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. 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.

The nurse is delegating hygiene care to the UAP for a client with hypoxia. What position will the nurse tell the UAP to place the client in?

High Fowlers position allows the client with hypoxia to breathe easier by promoting lung expansion, as the abdominal organs descend away from the diaphragm.

The nurse assesses a client and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What condition would the nurse suspect as causing these respiratory alterations?

Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia.

The nurse is caring for a client receiving oxygen therapy via nasal cannula who suddenly becomes cyanotic with a pulse oximetry reading of 91%. Which is the next most appropriate action the nurse should take?

If the client suddenly becomes cyanotic, the nurse should assess the oxygen tubing to make sure it is still connected.

A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. What should the nurse use for this patient?

If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag)may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube.

A client is reporting 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:

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

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

Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields)

When reviewing data collection on a client with a cardiac output of 2.5 L/minute, the nurse inspects the client for which symptom?

Normal cardiac output averages from 3.5 L/minute to 8.0 L/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing respiratory rate to increase oxygen delivery to the tissues.

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

Pneumonia, 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

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:

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.

The nurse is caring for a postoperative client who has a prescription for meperidine (Demerol) 7 5mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering Demerol, the nurse would assess which most important sign?

Respiratory rate and depth. The client receiving narcotics/opioids needs monitoring of the respiratory rate and depth to ensure that respiratory depression does not result in progressive respiratory issues, physiological damage from respiratory depression, or loss of consciousness.

The nurse is demonstrating oxygen administration to a client. What teaching will the nurse include about the flowmeter?

The flowmeter is a gauge used to regulate the amount of oxygen that a client receives.

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?

The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment.

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?

The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen

A 55-year-old obese man reports excessive daytime sleepiness, morning headaches, and sore throat. His wife states that he snores a lot. Which disease is this client most likely suffering from?

This client has all the risk factors of sleep apnea, which consists of multiple periods of apnea during sleep. These periods of apnea cause the person to move into a lighter sleep more often than someone without this disease, thus causing the daytime sleepiness.

The caregiver of an older adult client who was recently placed on home oxygen reports that the client now refuses to leave the house. What teaching will the nurse select? (Select all that apply.)

continued socialization with others is important consider a portable oxygen device invite friends and family to the client's house

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?

Although HBOT treats a multitude of conditions, the reason for using HBOT for a nonhealing wound is to help regenerate new tissue quickly.

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?

Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions.

A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?

Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients.

The nurse is caring for a client with emphysema. A review of the client's chart reveals pH 7.36, paO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription, if prescribed by the health care practitioner?

The client with chronic lung disease, such as emphysema, becomes insensitive to carbon dioxide and responds to hypoxia to stimulate breathing. If given excessive oxygen (4 L/minute), the stimulus to breathe is removed.

The nurse is assessing the respiratory rates of clients in a community health care facility. Which client exhibits an abnormal value?

The infant's normal respiratory rate is 30 to 55 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 40 breaths per minute. For a child 6 to 12 years of age the normal respiratory rate is 18 to 26 breaths per minute. The normal respiratory rate for an adult 65 years and older is 16 to 24 breaths per minute.

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

The nurse can assess patterns of thoracic expansion through palpation.

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?

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).

Martin is a 58-year-old smoker who was admitted to the hospital with worsening shortness of breath over the last 2 days. He states that he is having some chest discomfort. The nurse asks him further about this in order to characterize whether this may be cardiac related, musculoskeletal related, or respiratory related. Martin states that when he breathes in, he feels as if the air passing into his lungs is burning him. It is also very painful to swallow. Based on what Martin is stating, which illness does the nurse suspect is causing Martin's chest discomfort?

Acute bronchitis is caused by inflammation. Inflammatory mediators such as histamine may directly stimulate nerve endings made hypersensitive by the disease process. This process causes a sensation of pain as air travels over those nerve endings.

When the client demonstrates soft, high pitched discontinuous sounds, the nurse documents the breath sounds heard as which of the following?

Crackles are soft, high pitched discontinuous sounds.

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

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.

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?

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.