Oxygenation PrepU Questions

A client is diagnosed with hypoxia related to emphysema. The client's adult child will be assisting the client with daily hygiene. How will the nurse explain positioning of the client to the caregiver?

"An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist."

A client reports rarely leaving the house since starting use of home oxygen. What education should the nurse provide to the client? Select all that apply

A portable oxygen device may be helpful. The client likely only needs time to adjust. Friends and family can be invited to visit the client at home

A nurse is preparing to suction a client using an open system endotracheal tube. After removing the ventilator tubing from the endotracheal tube, what would the nurse do next? A. Attach the manual resuscitation bag to the endotracheal tube to hyperventilate the client B. Deliver three breaths with the manual resuscitation bag with the non-dominant hand C. Open the adapter on the mechanical ventilator tubing with the dominant hand D. Advance the suction catheter no more than 1 cm past the endotracheal tube

A. Attach the manual resuscitation bag to the endotracheal tube to hyperventilate the client Reason: "first, the nurse would attach the manual resuscitation bag. Then, the nurse should hyperventilate the client with three to six breaths, open the adapter on the mechanical ventilator, and, lastly, advance the suction catheter to the predetermined length"

A 24-year-old woman was admitted to the hospital for an exacerbation of symptoms related to her cystic fibrosis. During a nurse's assessment of the client, the nurse notices a bluish color around her lips. What is the client exhibiting in this scenario?

Cyanosis

A nurse is preparing to insert a nasopharyngeal airway in a client. Before doing so, however, the nurse assess the client and reviews the client's health record. Which findings would contraindicate insertion of the airway? Select all that apply. A. Enlarged tongue B. Clenched teeth C. Frequent Nasopharyngeal suctioning required D. Recent nasal surgery E. Traumatic brain injury F. Deviated septum

D. Recent nasal surgery E. Traumatic brain injury F. Deviated septum Reason: "The nurse should assess the client for the presence of nasal conditions, such as a deviated septum or recent nasal or oral surgery, traumatic brain injury, central facial fractures, basilar skill or cribriform fractures, and increased risk for bleeding such as anticoagulant therapy, which would contraindicate the use of nasopharyngeal airway. Nasopharyngeal airways may be indicated, not contraindicated, if the teeth re clenched, the tongue is enlarged, or the client needs frequent nasopharyngeal suctioning"

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

Diffusion

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

Flow Meter

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

Rapid respiration

The nurse is caring for a postoperative client who has a prescription for meperidine 75 mg intramuscularly (IM) every 4 hours as needed for pain. Before and after administering meperidine, the nurse would assess which most important sign?

Respiratory rate and depth

A client who uses portable home oxygen states, "I still like to smoke cigarettes every now and then." What is the appropriate nursing response?

You should never smoke when oxygen is in use.

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

client taking opioids for cancer pain

A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?

educating the client on the use of incentive spirometry

The nurse 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?

high respiratory rate Reason: "impaired gas exchange likely means difficulty breathing so the patient is trying to breath fast to take in more air. As compensatory mechanisms to impaired gas exchange temper would drop, pulse rate and bp would increase"

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

shake the canister before using it.

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?

tracheostomy collar

A nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant? A. Nasal cannula B. Venturi msk C. Oxygen hood D. Simple Mask

C. Oxygen hood Reason: "an oxygen hood is a device for infants that can deliver oxygen concretions up to 80-90%. None of the other devices listed can deliver oxygen that high"

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?

Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly.

The nurse is caring for a client whose respirations are supported by a ventilator. The nurse is preparing to suction the client's endotracheal tube using a closed suctioning system. Place the following steps in the correct order. A. Turn the catheter safety cap to disable the suction button B. Turn the catheter safety cap to enable the suction button C. Hyperventilate the client D. Clear secretions from the sheath E. Grasp the catheter and advance it to the predetermined length F. Depress the suction button and apply intermittent suction

1. Hyperventilate the client 2. Turn the catheter safety cap to enable suction bottom 3. Grasp the catheter and advance ti to the predetermined length 4. Depress the suction button to apply intermittent suction 5. Clear the secretions from the sheath 6. Turn the catheter safety cap to disable the suction button Reason: "hyper-oxygenating and hyperventilating before suctioning helps to decrease the effects of oxygen removal during suctioning. The safety button keeps the client from accidentally depressing the button and decreasing the oxygen saturation. Insertion no more than 1 cm past the endotracheal tube, avoid contact with the trachea and carina, reducing the effects of tracheal mucosal damage. Flushing cleanses and clears the catheter and lubricates it for the next insertion"

A nurse is preparing to retape a client's endotracheal tube. What should the nurse do? Select all that apply. A. measure the clients oxygen saturation level B. Assess the clients lung sounds C. Inspect the chest for any skin breakdown D. Provide pain medication to the client E. Verify the endotracheal tube length

A. Measure the clients oxygen saturation level B. Assess the client's lung sounds D. Provide pain medication to the client E. Verify the endotracheal tube length Reason: "the nurse should assess the endotracheal tube length to ensure t is not moving during retaping. Assessing the lung sounds provides a baseline for assessments after the procedure. Measuring the client's oxygen saturation level will provide a baseline that can be used to assess changes in the saturation levels in the event that the tube is dislodged during retaping. Providing pain medication to the client offers comfort and sedation that decrease the risk of accidental extubation during retaping. The nurse would inspect the skin on the face and neck, not the chest, for any breakdown"

The health care provider has prescribed an oropharyngeal airway for a client with a decreased level of consciousness. The healthcare provider has noted gurgling respirations and the clients tongue is posterior pharynx. The client vomits as the airway is inserted. Which action should the nurse take? Select all that apply. A. Remove oropharyngeal airway B. Provide oral suctioning and mouth care C. Raise the head of the bed 90 decrease D. Position client onto the side immediately E. Assess for bleeding in the mouth

A. Remove oropharyngeal airway B. Provide oral suctioning and mouth care C. position client onto the side immediately Reason: "The nurse should quickly reposition the client into a lateral position to prevent aspiration, remove the oropharyngeal airway, and then suction or provide oral hygiene as needed. Raising the head of the bed to 90 degrees is unnecessary because the patient should be positioned on the side. There is no indication tat trauma to the mouth has occurred so the nurse would not need to assess for bleeding"

The nurse is suctioning a client on a mechanical ventilator using a closed system endotracheal tube. In the process of advancing the catheter, the nurse meets resistance. What should the nurse do? A. Withdrawal the catheter at least o.5 (1.25 cm) before applying suction B. Remove the catheter and start the process over to prevent infection C. Turn the catheter counterclockwise then advance at least 0.5 in (1.25 cm) D. Continue to apply such as this means the catheter is in the carina

A. Withdraw the catheter at least 0.5 in (1.25 cm) before applying suction Reason: "if resistance is met the carina or tracheal mucosa has been hit, the catheter is past the length of the endotracheal tube. The nurse should withdraw the catheter at least 0.5 in (1.25 cm) before applying suction. There is no need to start over. Turing the catheter is done while withdrawing the catheter to help clean surfaces of the respiratory tract. Turing the catheter counterclockwise and advancing it will not bring ht catheter out of the airway mucosa or carina. Continuing to apply suction would cause damage to the airway mucosa"

The nurse has just completed open system endotracheal suctioning tube on a client. The client now has decreased oxygen saturation readings. Which actions should the nurse take? Select all that apply. A. Obtain an immediate portable chest x-ray B. Hyper-oxygenate the client C. Auscultate lung sounds D. Call the health care provider E. Remain with the client

B. Hyper-oxygenate the client C. Auscultate lung sounds E. Remain with the client Reason: "The nurse should remain with the client, hype-oxygenate the client, and then assess lung sounds. No additional actions should be necessary. However, if the nurse observes that lung sounds are absent over one lobe or the client does not re-oxygenate, the nurse should call the health care provider. The health care provider may then prescribe an immediate portable chest X-ray, because there may be a pneumothorax or displaced endotracheal tube"

A nurse is caring for a client who has spontaneous respirations and needs to have oxygen administered at a FiO2 of 100%. Which oxygen delivery system should the nurse use? A. Nonrebreather mask B. Venturi mask C. Simple mask D. Nasal cannula

B. Nonrebreather mask Reason: "a nonrebreather mask is the only device that can administer an FiO2 of 100% to a client without a controlled airway. A venturi makes delivers a maximum FiO2 of 55%. A nasal cannula delivers a maximum FiO2 of 44% and a simple mask delivers a maximum FiO2 of 60%

A nurse takes a client's pulse oximetry reading and finds that it is normal. What does the finding indicate? A. The client's oxygen demands are being met B. The client's available hemoglobin is adequately saturated with oxygen C. The client's red blood cell (RBC) count is in the normal range D. The client's respiratory rate is in the normal range

B. The client's available hemoglobin is adequately saturated with oxygen Reason: "pulse oximetry is a noninvasive technique that measures the arterial oxyhemoglobin saturation (SaO2 or SpO2) of arterial blood. This test measures only the percentage of oxygen carried by the availble hemoglobin. Thus, even a client with a low hemoglobin level could appear to have a normal SpO2 because most of that hemoglobin is saturated. However, the client may not have enough oxygen to meet body needs. A normal pulse oximetry reading does not necessarily indicate a normal RBS count or heart rate."

The nurse is caring for a client who is receiving continuous oxygen at 3 L/minute via nasal cannula. The client's oxygen saturation has consistently been 94% to 96% but suddenly drops to 86% as the nurse palpates the client's abdomen. The client denies respiratory difficulty or other distress. Which is a likely reason for the client's decreasing oxygen saturation? A. The clients holding his or her breath B. The nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen C. The client has developed a pulmonary embolism and has a ventiation-perfusion mismatch D. The Client's appendix has ruptured

B. The nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen Reason: "a sudden drop in oxygen saturation without clinical signs or symptoms may be caused by disruption of oxygen flow."

The nurse is preparing to teach a client how to perform incentive spirometry. Which concepts should the nurse include? A. Proper, frequent use of incentive spirometry can improve pulmonary circulation B. The client should forcefully exhale into the incentive spirometer and continue to exhale until unable to continue C. Incentive spirometry provides visual reinforcement for deep breathing D. Oxygen saturation is expected to decrease during the first few minutes of incentive spirometry

C. Incentive spirometry provides visual reinforcement for deep breathing Reason: "Incentive spirometry assists the client to perform adequate deep breathing. Incentive spirometer affects ventilation rather than perfusion. Oxygen saturation should increase with the use of I.S. and I.S. is used to enhance inspiratory efforts, thus, the client should inhale through the incentive spirometer, not exhale"

Which factors indicate that the nurse should stop delivery of breaths via a manual resuscitation bag and mask device? Select all that apply. A. Another nurse has begun chest compressions at a rate of 100 per minute B. The client's oxygen saturation has improved to 95% during the use of the device C. The client has a return of spontaneous breathing at 15 breaths per minute D. The health care provider has ended the cardiopulmonary resuscitation effort E. The client has been intubated and is connected to a mechanical ventilator

C. The client has a return of spontaneous breathing at 15 breaths per minute. D. The health care provider has ended the cardiopulmonary resuscitation effort E. The client has been intubated and is connected to a mechanical ventilator Reason: "manual resuscitation by bag and mask device should be stopped when: the client has had a return of spontaneous breathing; the client has been intubated and connected to mechanical ventilator; or the health care provider has ended the cardiopulmonary resuscitation effort. It is an expected outcome that the client 's oxygenation saturations will increase when using a device, but not an indicator that use of the device should end. Unless the client has adequate spontaneous breathing, the oxygen saturation will simply decrease again once use of the bad and mask has stopped. Unless the health care provider calls an end to the code, the combination of manual resuscitation and chest compressions is not needed because it indicates the patient isn't breathing and has no pulse"

A nurse must take a clients pulse oximetry reading. The nurse is explaining the technique to the client. Which statements about pulse oximetry are true? Select all that apply. A. Pulse oximeters display oxygen saturation and respiratory rate B. Pulse oximetry measurement requires insertion of an arterial line C. The pulse oximetry sensor can produce accurate results even if circulation to the sensor is impaired D. Once the oximetry probe is correctly placed, a beam of red and infrared light travels through the tissues and blood vessels E. Sensors are available for use on the finger, toes, food, earlobe, forehead and bridge of the nose F. A range of 88% to 95% is considered normal oxygenation saturation for infants

D. Once the oximetry probe is correctly placed, a beam of red and infrared light travels through the tissue and blood vessels E. Sensors are available for use on the finger, toes, foot, earlobe, forehead and bridge of the nose Reason: "The oximetry sensor uses a beam of red and infrared light to calculate the amount of light absorbed by arterial blood. Sensors are available for all of the sites mentions. Inadequate circulation will result in an inaccurate reading. Pulse OX is noninvasive. Normal range is 95 to 100%. Pulse oximeters display heart rate not RR"

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 Reason: "a condition in which an inadequate amount of oxygen is available to the cells. Difficulty breathing, increased RR and pulse rates, pale skin and cyanosis are signs"

A client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and the secretions are thick and sticky. Which intervention will the nurse use to promote respiratory hygiene in this situation?

Increased oral fluid intake Reason: "when a cough is productive, it is important to establish the source of the sputum and assess its color, volume, consistency and characteristics. The nurse should instruct the client to increase fluid volume to help thin secretions and encourage coughing and deep breathing"

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

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

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

Small water droplets come from this, thus preventing dry mucous membranes

The nurse is caring for a client who has 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?

Tracheostomy collar

The nurse auscultates the lungs of a client with asthma who reports shortness of breath, sore throat, and congestion. Which finding does the nurse expect to document?

Wheezing