Gas exhange and Oxygenation
A nurse is caring for a client who has a chest tube. Which of the following actions should the nurse take? A. Monitor the client for subcutaneous emphysema. B. Expect continuous bubbling in the water seal chamber. C. Keep the drainage system above the level of the client's chest. D. Clamp the chest tube tubing when the client ambulates.
A
A nurse is caring for a client who has left-sided heart failure. Which of the following findings should the nurse expect? A. Crackles in the lungs B. Edema of the lower extremities C. A rapid, irregular heart rate D. A systolic murmur
A
A nurse is caring for a client who requires 1 L of oxygen. Which of the following oxygen delivery devices should the nurse expect to use? A. Nasal cannula B. Nonrebreather mask C. Partial rebreather mask D. Simple face mask
A
Tactile fremitus
A vibration felt in the chest wall during palpation or auscultation found when speaking.
Jugular vein distention
A visual bulging of the jugular veins in the neck that can be caused by fluid overload, pressure in the chest, cardiac tamponade, or tension pneumothorax.
A nurse is providing teaching for a client who has a prescription for home oxygen. Which of the following instructions should the nurse include? (Select all that apply.) A. Post a "No Smoking" sign inside the home. B. Attach oxygen containers to a fixed object. C. Store spare oxygen containers in a closet. D. Notify the fire department that oxygen is used in the home. E. Ensure oxygen tubing is no longer than 60 feet in length.
A,B,D
Pneumothorax
Air in the pleural space causing the lung to completely or partially collapse.
Right Sided heart failure
Alters ability to pump to the lungs, blood backs up in systemic veins
Left sided heart failure
Alters hearts ability to pump blood to rest of body, blood backs up in pulmonary veins
hyperventilation
An increase in the rate and depth of breathing that leads to excessive loss of carbon dioxide from the blood.
A nurse is assessing a client who has COPD. The nurse should identify that which of the following is an expected finding? A. Jugular vein distension B. Clubbing of the fingers C. Heart murmur D. Paradoxical breathing
B
A nurse is assessing a client who is receiving oxygen therapy. The nurse should identify that which of the following findings can indicate oxygen toxicity? A. Hypertension B. Ringing in the ears C. Fever D. Dilated pupils
B
A nurse is auscultating a client's heart sounds and hears a low-pitched whooshing or blowing sound over the apex of the heart. The nurse should identify that this indicates which of the following? A.Tachycardia B. Murmur C. Gallop D. Stroke volume
B
A nurse is discussing ventilation and perfusion with a newly licensed nurse. The nurse should include in the discussion that the exchange of oxygen and carbon dioxide occurs at which of the following locations? A. Trachea B. Alveoli C. Diaphragm D. Bronchial tubes
B
A nurse is performing chest percussion therapy on a client. Which of the following actions should the nurse take? A. Perform chest percussion therapy six times per day. B. Listen for a hollow sound when performing chest percussion therapy. C. Use flat hands to perform chest percussion therapy. D. Apply chest percussion therapy over the client's ribs.
B
Pulse assessment
rate, rhythm, strength, equality
A nurse is caring for a client who has atelectasis. The nurse should identify that which of the following substances is required to keep the client's alveoli from collapsing and causing atelectasis? A. Lymphatic fluid B. Oxygenated blood C. Synovial fluid D. Surfactant
D
Intercostal Retractions
Muscles between ribs pull inward, caused by reduced pressure inside chest and can indicate airway blockage, medical emergency
Stenosis
Narrowing of a heart valve.
Cardiopulmonary Assessment
Objective Data, Inspection, Palpation, Percussion, Auscultation
Atelectasis causes
Often from surgery, or use of anesthesia or opioids
Upper airway
Pharynx and Larynx Nasopharynx refers to nasal Oropharynx refers to the mouth Larynx includes top of trachea
hypoventialtion
Shallow breathing with a lower than expected respiratory rate.
Flutter valve
Sit in chair elbows on table, head held upward slightly, inhale 2 counts, exhale 4 counts during flutter valve, repeat 10 times then cough 3 times
Nursing interventions Oxygenation
Sputum specimen collection, Chest physiotherapy, Incentive spirometer, pursed lipped breathing, flutter valve, coughing and deep breathing, huff coughing, suctioning, tracheostomy, closed chest drainage
A nurse is teaching a client who has an abdominal incision about coughing and deep breathing. In which order should the nurse instruct the client to perform the following steps?
Take a deep breath Hold you breath Exhale slowly Brace incision and try to cough deeply
Exhalation
The passive part of the breathing process in which the diaphragm and the intercostal muscles relax, forcing air out of the lungs.
lung compliance
The point to which a lung can expand in response to increased pressure within the alveoli. Diseases can increase or decrease this
Pleural Cavity
The space between the visceral and parietal layers of the lung
inspiratory reserve volume
The volume of air breathed in after a typical inspiration.
Cardiac output
The volume of blood ejected by the heart ventricles in one minute; calculated by multiplying the stroke volume and pulse rate of the heart.
Stroke volume
The volume of blood pumped from the left ventricle of the heart in one contraction
Lower airway
Trachea, bronchi, bronchioles and aveoli
tidal volume
Volume of air inspired and expired with each breath.
Residual Volume
Volume of air remaining in the alveoli after expiration.
Forced vital capacity
Volume of air remaining in the lung after maximal inspiration.
Total lung capacity
Volume of air remaining in the lung after maximal inspiration.
Left sided heart failure symptoms
hypoxia, crackles, shortness of breath
Partial rebreather mask
10-15 L
Pleural effusion
A buildup of fluid in the pleural space.
A nurse is obtaining a health history from a client. Which of the following findings should the nurse identify as risk factors for heart disease? (Select all that apply.) A. A diet high in saturated fats B. A history of an overactive bladder C. A history of smoking for 25 years D. A sedentary lifestyle E. A waist circumference of 84 cm (33 in)
A, C, D
A nurse is caring for a client who is receiving supplemental oxygen for hypoxia. The nurse should identify which of the following can cause hypoxia. A. Diabetic ketoacidosis B. Smoke inhalation C. Administration of a stimulant medication D. Right-sided heart failure
B
bronchodilation
Expansion of the airway in the Bronchus
Tachycardia
Heart rate above the expected reference range.
Factors affecting oxygenation
Hyper and hypoventilation, hypoxia
Hypoxemia
Low amount of oxygen in the blood. Low PaO2
Ventilation
The flow of air inside or outside of the alveoli.
Perfusion
The flow of blood by the cardiopulmonary system into the alveolar capillaries where deoxygenated blood is exchanged for oxygenated blood in the heart and delivered to the rest of the body.
Contracility
The force required to eject blood from the left ventricle.
Pulmonary circulation
The movement of blood from the heart to the lungs from the capillaries for gas exchange and back.
Sinoatrial node
The pacemaker of the heart.
Percussion
Will sound dull if fluid is under where percussed
A nurse is reviewing the medical history of a client who has heart disease and a narrowed valve. Which of the following findings should the nurse expect? A. Regurgitation B. Stenosis C. Muscle atrophy D. Hypotension
B.
Cardiopulmonary risk factors
Dietary Habits, Exercise, Smoking, Stress, Environmental Factors
Sequence of electrical conduction in the heart
SA node AV node Bundle of HIS right and left bundle branches Purkinje fibers
bronchoconstriction
TIghtening of the bronchus due to the contraction of the smooth muscle.
Afterload
The amount of resistance or force that occurs when the heart ejects blood from the left ventricle.
Preload
The blood remaining in the left ventricle at the end of diastole causing it to stretch.
atelectasis
The collapse of airways and small sections of the lung as a result of shallow breathing. The collapsing of the lung during expansion.
Airway resistance
The pressure or opposition of the tissues in the airway to the flow of air.
Dyspnea
difficulty breathing
Capillary refill time
less than 3 seconds
Nasal Cannula
1-4 L
Nonrebreather mask
10-15L
Simple Face Mask
5-8 L
Bradycardia
A heart rate that is less than the expected reference range.
Atrial fibrillation
irregular heartbeat that quivers instead of contracting
Hypoxia
Below the expected level of oxygen in tissue.
A nurse is caring for a client who requires 7 L of oxygen to maintain oxygen saturation. Which of the following oxygen delivery devices should the nurse expect to use? A. Nasal cannula B. Nonrebreather mask C. Partial rebreather mask D. Simple face mask
D
four point edema scale
1+ 2mm 2+ 4mm 3+ 6mm 4+ 8mm
Incentive spirometer use
10 repetitions per hour, each breath held 3 to 5 seconds,
A nurse is assessing a client who is being discharged. The nurse notes regularly and quite breathing. Which of the following is it? A. Normal B. Kussmaul C. Cheyne Stokes D. Apnea
A
A nurse is planning care for a group of clients on a cardiopulmonary unit. Which of the following clients should the nurse plan to see first? A. A client who requires teaching about a new cholesterol-lowering medication B. A client who reports dyspnea when walking to the bathroom C. A client who has a new diagnosis of aortic valve stenosis and needs a referral to a cardiologist D. A client who has asthma and is being discharged to home
B
A nurse is providing teaching for a client who has a new prescription for a continuous positive airway pressure (CPAP) machine to treat obstructive sleep apnea. Which of the following statements should the nurse include? A. Use the CPAP mask during the daytime." B. "Cover your nose with the CPAP mask." C. "Medications to assist with breathing can be administered through the CPAP machine." D. "You will need supplemental oxygen to use the CPAP machine."
B
A nurse is providing teaching for a client who has a new prescription for an incentive spirometer. Which of the following instructions should the nurse include? A. Exhale into the incentive spirometer." B. "Use the incentive spirometer every hour while awake." C. "Hold your breath for 10 seconds when using the incentive spirometer." D. "Use the incentive spirometer two times each session."
B
A nurse is teaching a newly licensed nurse about pulmonary function tests. The nurse should include that which of the following is the vital capacity? A. The volume of air inspired and expired with a regular breath. B. The maximum volume of air that is expired after a maximum inspiration. C. The amount of additional air that can be inspired after a regular inspiration. D. The amount of air in the lung after maximal inspiration.
B
Blood flow into the heart
Blood enters through the vena cavae throught the coronary sinus into the right atrium through the tricuspic valve to the right ventricle, then through the pulmonary valve to the pulmonary trunk, into the right and left pulmonary arteries to the lungs, then leaves through the pulmonary veins, flows into the left atrium through the mitral valve, into the left ventricle, then through the aortic valve to aorta and rest of the body
Pursed lipped breathing
Breath in 2 counts through nose, exhale 4 counts through pursed lips
A nurse is caring for a client who has a history of asthma and is wheezing. Which of the following actions should the nurse take first? A. Auscultate the lung sounds. B. Document the respiratory rate. C. Obtain the oxygen saturation. D. Check the capillary refill.
C
A nurse is discussing atrial fibrillation with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of atrial fibrillation? A. "Atrial fibrillation is caused by electrical signals that come from the ventricles." B. "Atrial fibrillation causes a lower-than-expected heart rate." C. "Atrial fibrillation is caused by electrical signals outside of the SA node." D. "Atrial fibrillation causes diaphoresis in most clients."
C
A nurse is planning to measure the cardiac output of a client who had a myocardial infarction. Which of the following data should the nurse use to calculate the client's cardiac output? A. Respiratory rate B. Blood pressure C. Stroke volume D. Vital capacity
C
A nurse is suctioning a client's tracheostomy using an open system. Which of the following actions should the nurse take? A. Use clean technique to perform the procedure. B. Apply suction when inserting the catheter. C. Administer 100% oxygen before the procedure. D. Suction the tracheostomy for 20 seconds each time.
C
Manifestations of hypoxemia and hypoxia
Confusion, irritability and restlessness, intercostal retractions
Factors affecting Cardiovascular function
Disturbances of electrical conduction, mechanical function, valvular heart disease, impaired perfusion, myocardial ischemia
Right sided heart failure symptoms
Edema
Regurgitation
Leaking heart valves that do not close (CDC).
Surfactant
Lubricant made in lungs to keep alveoli from collapsing during expiration
vital capacity
Maximum volume of air that is expelled after maximal inspiration
Pleura
Membrane surrounding the lungs
Clubbed fingers
rounding of ends and swelling of fingers in children with congenital heart disease and in older children and adults with long-standing pulmonary disease
Inhalation
the act of taking in air as the diaphragm contracts and pulls downward