PrepU Chapter 21: Oxygenation
The home care nurse is visiting a client who is totally oxygen dependant and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide?
"An electric stove may be a safer choice for you."
A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response?
"Have you tried nasal strips?"
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."
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 may reduce or eliminate snoring."
The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include the humidifier?
"Small water droplets come from this, thus preventing dry mucous membranes."
A client with a nonhealing pressure injury has been prescribed hyperbaric oxygen therapy (HBOT). The client tells the nurse, "This kind of treatment doesn't make any sense to me." What is the appropriate nursing response?
"Wounds heal because HBOT helps to regenerate new tissue quickly."
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."
A client reports rarely leaveing 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 conducting a physical assessment of a client at the health care facility. To assess the quality of the client's oxygenation, the nurse requires the client to exhale additional air. What should the client do to exhale additional air?
Contract the abdominal muscles.
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 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
A client who was prescribed CPAP several months ago reports non-adherence to treatment. What is the appropriate priority nursing intervention?
Inquire about factors that contribute to non-adherence.
Which teaching about a flowmeter is important for the nurse to provide to a client using oxygen?
It regulates the amount of oxygen received.
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?
Monitor the amount of oxygen saturation in the blood.
A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?
Nasal cannula
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
The nurse would expect to recommend an oxygen tent for which client?
a child who will not leave a facemask or cannula in place
A nurse is studying a client's chart and sees that the client's pH is currently at a 7. What condition is the client experiencing?
acidosis
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:
adequate tissue perfusion.
The nurse is assessing a newborn in the nursery. The nurse notes the infant has episodes in which breathing ceased for 20 seconds on 2 occasions. The nurse correctly recognizes this condition as:
apnea
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
The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client?
nasal cannula
The nurse is caring for a 2-year-old client who experienced smoke inhalation during a house file. When oxygen is ordered, what delivery device will the nurse gather?
oxygen tent
A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure?
prolonging expiration to reduce airway resistance
