Oxygenation PREP-U

The nurse working on the intensive care unit is preparing to admit a client injured in a car accident. The client has damage to the medulla. The nurse would include which most important equipment when preparing to care for this client? Select all that apply.

* - Pulse oximeter* *- Endotracheal tube* The medulla houses the respiratory center, which regulates respirations. If damaged, the client will need monitoring of oxygenation (pulse oximeter) and a mechanism for breathing, getting oxygen, and clearing secretions from the airway (endotracheal tube). There is no indication that the client?s lungs have collapsed, so a chest drainage system is not needed. A communication board would be used if the client could not be understood. It is important to record temperature, but the most important items are pulse oximeter and endotracheal tube.

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) - Teach the client about relaxation exercises to be used during chest tube removal - Apply a semipermeable dressing to the insertion site immediately after the chest tube is removed - Administer prescribed pain medication 15 to 30 minutes before chest tube removal

*- Teach the client about relaxation exercises to be used during chest tube removal* *- Administer prescribed pain medication 15 to 30 minutes before chest tube removal* 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. Occlusive dressing versus a semipermeable dressing should be utilized.

The nurse is reviewing the results of a patient's arterial blood gas and pH analysis. Normal findings include: (Select all that apply.) - HCO3 30 mEq/L - PO2 70 mm Hg - pH 7.45 - PCO2 40 mm Hg - Base excess or deficit +2 mmol/L

*- pH 7.45* *- PCO2 40 mm Hg* *- Base excess or deficit +2 mmol/L* Normal ABG findings include a pH of 7.35-7.45, PCO2 35-45 mm Hg, PO2 80-100 mm Hg, and Base excess or deficit +2 mmol/L

A nurse caring for an 11-month-old infant with tenacious secretions is preparing to suction the infant's nasopharynx. The nurse using the wall unit suction machine would set the valve at which appropriate pressure before suctioning?

*100 mmHg* High pressure can cause trauma, hypoxemia, and atelectasis. The correct pressure on the wall unit for an infant is 80?125 mm Hg. The neonate?s wall unit pressure is 60 to 80 mm Hg; the adult?s wall unit pressure is 100?150 mm Hg.

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

*80 to 150mm/hg* When utilizing a wall unit to suction an endotracheal tube, the pressure should be set at 80 to 150mm/hg.

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

*Ambu bag* 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.

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 gas* Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.

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?

*Assess oxygen tubing connection* If the client suddenly becomes cyanotic, the nurse should assess the oxygen tubing to make sure it is still connected. Assessing lung sounds, repositioning the client, and elevating the head of the bed will not correct the problem if the tubing is disconnected.

The nurse is teaching an adolescent with asthma how to use a meter-dosed inhaler. Which teaching point follows recommended guidelines?

*Be sure to shake the canister before using it.* A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly. MDIs are inhaled through the mouth, into the lungs. The medication should be inhaled slowly to ensure a sufficient dose enters the lungs. If the order is for two sprays, these sprays are administered with one spray for each breath. The inhaled breath should be held briefly after each spray in order to prevent immediately exhaling the medication.

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?

*Child with asthma* 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.

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

*Confusion* 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.

Which of the following is a disadvantage of using a face tent to administer oxygen to a client with facial trauma?

*Delivers an inconsistent amount of oxygen* 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.

Oxygen and carbon dioxide move between the alveoli and the blood by

*Diffusion* Oxygen and carbon dioxide move between the alveoli and the blood by diffusion, the process in which molecules move from an area of greater concentration or pressure to an area of lower concentration or pressure.

A 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?

*Drink liberal amounts of fluids.* 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.

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?

*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.

A nurse is caring for a client who breathes very shallowly and has been complaining of severe back pain. What suggestion could the nurse make to the client to help the client breathe efficiently?

*Encourage the client to take deep breaths* To help the client breathe efficiently, the nurse could encourage the client to take deep breaths. Deep breathing maximizes the ventilation and fills the alveoli to a greater capacity, thus improving gas exchange. Pursed-lip breathing and diaphragmatic breathing help to eliminate the extra carbon dioxide from the lungs. A nasal strip reduces airflow resistance by widening the nasal breathing passageways, thus promoting easier breathing. It is used for reducing or eliminating snoring.

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

*Flowmeter* In order to regulate the amount of oxygen delivered to the client, the nurse should use a flowmeter. A flowmeter 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 because 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.

The nurse is caring for a patient who complains of difficulty breathing. In what position would the nurse place this patient?

*Fowler's position* People with dyspnea and orthopnea are most comfortable in a high Fowler's position because accessory muscles can easily be used to promote respiration. Prone position can be used on a routine basis to promote ventilation and perfusion of the posterior dependent sections of the lungs. Lateral and supine position would not accessory muscles are not supported as with a Fowler's position.

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?

*High respiratory rate* 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 with chronic obstructive pulmonary disease (COPD) who expresses concerns about the ability to breathe easier. The nurse will suggest which position to help alleviate the client's dyspnea?

*High-Fowler's position* Clients with COPD are most comfortable in high-Fowler?s position because it aids in the use of the accessory muscles to promote respirations. The supine position with one pillow, side-lying with head slightly elevated or lying with the head slightly lowered does not promote easier respirations.

The nurse assesses a patient 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* Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia. Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements. Perfusion refers to the process by which oxygenated capillary blood passes through body tissues. Atelectasis refers to collapsed alveoli.

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?

*Implement measures to prevent complications after arterial puncture.* 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.

You are preparing to teach a patient how to perform incentive spirometry. Which of the following concepts should you include?

*Incentive spirometry provides visual reinforcement of deep breathing* Incentive spirometry is used to enhance inspiratory effort.

When preparing to insert a nasopharyngeal airway (nasal trumpet), the nurse would use which measurement to determine the accurate tube size?

*Measure from the tragus of the ear to the nostril plus 1 inch* The correct measurement for selecting the right nasal trumpet is to measure from the tragus of the ear to the nostril plus 1 inch, not 2 inches. The correct measurement for selecting the right oropharyngeal tube is to measure from the opening of mouth to the back angle of the jaw. You should not add any inches for the oropharyngeal tube.

You are caring for a patient who has spontaneous respirations and needs to have oxygen administer at a FIO2 of 100%. Which of the following oxygen deliver systems should the nurse utilize?

*Nonrebreather mask* Nonrebreather mask is the only device that can deliver FIO2 of 100% to a patient without a controlled airway. Venturi mask delivers a maximum FIO2 of 55%. Nasal cannula delivers a maximum FIO2 of 44%. Simple mask delivers a maximum FIO2 of 60%.

The nurse is assessing an elderly client brought to the emergency department by her spouse. The spouse states, ?She is confused and had trouble when trying to take a breath.? The nurse would next implement which priority nursing intervention for this client who is experiencing these symptoms?

*Obtain baseline vital signs and oxygen saturation* Alteration in oxygenation can lead to an altered mental status. The nurse should first obtain baseline vital signs and oxygen saturation to assess the client?s needs. If required after obtaining baseline data, the client may require oxygen therapy and a complete assessment. There is no indication that the client needs a bronchoscopy at this time.

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?

*Pleural effusion* 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 vomits as a nurse is inserting his oropharyngeal airway. What would be the appropriate intervention in this situation?

*Remove the airway, turn the patient to the side and provide mouth suction, if necessary.* 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.

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 pulse, blood pressure, and urinary intake and output are not as important as respiratory status when administering narcotics.

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).* 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.

The nurse is performing an arterial blood gas sampling on a client at 1045. The nurse educator intervenes if which action is taken by the nurse?

*The nurse performs the Allen?s test after blood sample is taken.* The Allen?s test is done before puncture to ensure adequate ulnar blood flow when using radial artery. The arterial specimen is immediately placed on ice and taken to the laboratory. The radial, brachial, or femoral arteries are usually the sites of choice for an arterial blood sampling. The nurse should apply pressure for 5 to 10 minutes, longer if the client is on anticoagulant therapy

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

*Trauma to the tracheal mucosa* 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. Suctioning during insertion of the catheter would not compromise sterility.

You are preparing to perform tracheal suctioning on a 3-year-old child. Which of the following actions is most appropriate?

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

Which of the following is a recommended guideline for determining suction catheter depth when suctioning an endotracheal tube?

*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.* 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.

A nurse auscultates the lungs of a patient with asthma. Which lung sound is characteristic of this condition?

*Wheezes* Wheezes are continuous musical sounds, produced as air passes through airways that are constricted, as with asthma. Crackles are produced by fluid in the airways or alveoli and delayed reopening of collapsed alveoli. They occur due to inflammation or congestion and are associated with pneumonia, heart failure, bronchitis, and COPD. Bronchial sounds are normal sounds heard as loud, high-pitched sounds heard primarily over the trachea and larynx. Vesicular are normal sounds heard as low-pitched, soft sounds heard over peripheral lung fields

A 57-year-old patient is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the patient has been unwilling to mobilize despite the nurse's teaching about the benefits of early mobilization following surgery. The nurse would recognize that the patient's prolonged immobility creates a risk for:

*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.

While reading a physician's progress notes, a student notes that an assigned patient is having hypoxia. What abnormal assessments would the student expect to find?

*dyspnea, tachycardia, cyanosis* If a problem exists in ventilation, respiration, or perfusion, hypoxia (a condition in which an inadequate amount of oxygen is available to cells) may occur. The most common symptoms are dyspnea, elevated blood pressure, increased respirations and pulse, pallor, and cyanosis. Other common symptoms are anxiety and restlessness.

A nurse is percussing the thorax of a patient with chronic emphysema. What percussion sound would most likely be assessed?

*hyperresonance* Hyperresonance is a loud, low, booming sound typically heard with percussion over emphysematous (excessively air-filled) lungs.

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

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

A nurse is teaching a home care patient and his family about using prescribed oxygen. What is a critical factor that must be included in teaching?

*the safety measures necessary to prevent a fire* Oxygen, which constitutes 20% of normal air, is a tasteless, odorless, colorless gas. It supports combustion, and it is critical to provide safety measures to prevent fires and injury.