(PrepU) Chapter 39: Oxygenation and Perfusion

A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first?

Apply oxygen as prescribed The nurse should first apply oxygen, which will help to improve oxygen saturation and health status. The client may not require intubation, once oxygen is provided. Although the client may require education on incentive spirometry, the immediate priority intervention is to stabilize the client's oxygen saturation. Similarly, raising the head of the bed may help with the client's comfort but may not have sufficient effect on oxygen saturation.

Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound?

Bronchial Bronchial breath sounds are loud, high-pitched sounds heard primarily over the trachea and larynx. Vesicular breath sounds are low-pitched, soft sounds heard over the peripheral lung fields. Bronchovesicular breath sounds are medium-pitched blowing sounds heard over the major bronchi. Vesicular, bronchial, and bronchovesicular breath sounds are normal breath sounds. Adventitious breath sounds are abnormal lung sounds.

A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level?

Crackles Normal breath sounds of an infant are harsh crackles at the end of deep inspiration. Wheezing is a whistling sound made while breathing. Clear sounds are usually not heard in an infant. A bruit is an audible vascular sound and not a pulmonary sound associated with turbulent blood flow.

A nurse using a pulse oximeter to measure a client's SpO2 obtains a reading of 95%. What is the nurse's most appropriate action?

Document this expected assessment finding. A range of 95% to 100% is considered normal oxygen saturation. As such, there is no need to change the client's position, encourage deep-breathing exercises and coughing, or to review the client's medication history.

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.

A client with a history of chronic obstructive pulmonary disease (COPD) has been ordered oxygen at 3 L/min as needed for treatment of dyspnea. What delivery mode is most appropriate to this client's needs?

Nasal cannula A nasal cannula is used to deliver from 1 L/min to 6 L/min of oxygen. Masks are used with higher flow rates of oxygen.

A client is taking albuterol via nebulizer. Which instruction will the nurse provide to teach the client how to use the nebulizer?

Place the mouthpiece in your mouth. Keep your lips firm around the mouthpiece so that all of the medicine goes into your lungs. A nebulizer is used to administer medications in the form of an inhaled mist. The nurse will instruct the client to place the mouthpiece in the mouth, keep the lips firm around the mouthpiece so that all of the medicine goes into the lungs, and continue until the mist stops. Any other option allows for the medication to be lost, rather than inhaled into the lungs.

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation?

Remove the airway, turn the client to the side, and provide mouth suction, if necessary. If the client vomits as the oropharyngeal airway is inserted, quickly position the client onto his or her side to prevent aspiration, remove the oral airway, and suction the mouth, if needed. It would be inappropriate and unsafe to leave the airway in place. Rinsing the client's mouth with water is not a priority.

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 assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action?

Warm the client's hands and try again. Finding an absent or weak signal, the nurse should check vital signs and client condition. If satisfactory, warming the extremity may facilitate a stronger reading. This should be attempted prior to resorting to using the client's earlobe. Bright light can interfere with the operation of light sensors and cause an unreliable report. A blood pressure cuff will compromise venous blood flow to the site leading to inaccurate readings.

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 The newborn's breathing pattern is characterized by occasional pauses of several seconds between breaths. This periodic breathing is normal during the first 3 months of life, but frequent or prolonged periods of apnea (cessation of breathing 20 seconds or longer) are abnormal. Dyspnea refers to shortness of breath. Orthopnea refers to difficulty breathing when lying flat. An elevation of carbon dioxide levels in the blood is termed hypercapnia.

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of:

atelectasis. Stiffer lungs tend to collapse and also cause their alveoli to collapse. This condition is called atelectasis.

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:

congestive heart failure. A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.

A woman comes to the emergency room with her 2-year-old son. She states he woke up and had a loud barking cough. The child is suffering from:

croup Croup and epiglottitis are common in young children. The child has an obstruction of the upper airways, with swelling of the throat tissue. Atelectasis results when the lungs collapse as a result of the alveoli being unable to expand. Symptoms include difficulty breathing and discomfort. Pulmonary fibrosis is a condition in which the lung tissue becomes stiff and unable to expand appropriately. Asthma is a condition associated with bronchoconstriction. The symptoms include nonproductive cough, dyspnea, and wheezing.

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 Cyanosis around the lips indicates serious hypoxemia. Cyanosis is caused by a desaturation of oxygen on the hemoglobin in the blood. Hypercapnia is caused by an abnormally high carbon dioxide level in the blood. Hypoxemia is caused by low oxygen levels in the blood. Eupnea is easy, free respiration.

The nurse is caring for a client who has been prescribed humidified oxygen at 6 L/minute. Which type of liquid will the nurse gather to set up the humidifier?

distilled water Distilled water is used when humidification is desired. Other answers are incorrect.

To drain the apical sections of the upper lobes of the lungs, the nurse should place the client in which position?

high-Fowler's position Postural drainage makes use of gravity to drain secretions from the lungs from smaller pulmonary branches into larger ones, where they can be removed by coughing. High-Fowler's position is used to drain the apical sections of the upper lobes of the lungs. Placing the client lying on the left side with a pillow under the chest wall helps to drain the right lobe of the lung. Placing the client in a side-lying position, half on the abdomen and half on the side, right and left, helps to drain the posterior sections of the upper lobes of the lungs. Trendelenburg position assists in draining the lower lobes of the lungs.

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?

nasal cannula Nasal cannula and tubing administer oxygen concentrations at 22% to 44%.

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 An oxygen tent is often used when caring for active toddlers who require oxygen because they are less likely to keep a mask on. Other devices are inappropriate for a child of this age.

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. 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. Croup, asthma, and alcohol use do not lead to atelectasis. Croup, which is common young children, is a condition that obstructs upper airways by swelling the throat tissues. Asthma causes the small airways to become inflamed and narrowed. Alcohol use depresses the central respiratory center.

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 A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. All other devices are less appropriate for this client.

A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, "Why is his chest sucking in above his stomach? The nurse's most accurate response is:

"He is using his chest muscles to help him breathe." The client will use accessory muscles to ease dyspnea and improve breathing.

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." The following formula is used to determine cardiac output: Cardiac Output = Stroke Volume x Heart Rate. A client with a stroke volume of 50 mL and heart rate of 50 beats per minute has a cardiac output of 2.5 L/minute. If stroke volume is 70 and heart rate is 70 beats per minute, then the cardiac output is 4.9 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute. If stroke volume is 60 and heart rate is 60 beats per minute, then the cardiac output is 3.6 L/minute. If stroke volume is 80 and heart rate is 80 beats per minute, then the cardiac output is 6.4 L/minute.

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?

"Take in as much air as possible, hold your breath briefly, and exhale slowly." 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. The other techniques do not promote improved gas exchange.

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?

"Wounds heal because HBOT helps to regenerate new tissue quickly." Although HBOT treats a multitude of conditions, the reason for using HBOT for a nonhealing wound is to help regenerate new tissue quickly. HBOT is used to treat anaerobic infections. The other responses are inappropriate.

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 humidifier produces small water droplets which are delivered during oxygen administration to prevent or decrease dry mucous membranes. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen.

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

a bronchospasm. When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm.

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 tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT. Other devices are not appropriate for this client.

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

flow meter In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter 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.

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?

nasal cannula 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. A simple mask allows the administration of higher levels of oxygen than a cannula. A face tent is used for clients with facial trauma and burns. Nonrebreather masks are used for clients requiring a high concentration of oxygen and who are critically ill.

A client tells the nurse, "My partner says I snore all night long." What is the appropriate nursing response?

"Have you tried nasal 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. Other choices are incorrect.

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." Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD. Other answers are incorrect techniques for deep breathing.

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.

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

"This is a gauge used to regulate the amount of oxygen that a client receives." The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount. The humidifier produces small water droplets, which are delivered during oxygen administration to prevent or decrease dry mucous membranes.

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

Ask the client what factors contribute to nonadherence. The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment. Then, the nurse can work with the health care provider to find alternate treatment options if necessary, and then document the care.

The nurse is caring for an older adult client on home oxygen who has dentures but has quit wearing them stating that the dentures irritate the gums. What nursing action is appropriate?

Check the fit of the oxygen mask. The fit of the oxygen mask can be affected by the discontinuation of wearing dentures. The nurse should check the fit to make sure the client is getting the prescribed amount of oxygen. Other answers are inappropriate actions that do not address the problem.

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 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 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. The nurse must first assess the reasons that contribute to non-adherence; interventions cannot be determined without a thorough assessment. Other interventions take place after assessment.

A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?

Instruct the client to inhale deeply and then cough. The client should be instructed to inhale deeply and cough; if this results in sputum, it should be collected in the container. The client should be placed in a semi-Fowler's position and instructed to clear the nose and throat and rinse the throat with water.

The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response?

Maintain the client's oxygenation and alert the health care provider immediately. If the tracheostomy becomes dislodged and is not easily replaced, the nurse should notify the primary care provider immediately, cover the tracheostomy stoma, and assess client's respiratory status.

A client requires low-flow oxygen. How will the oxygen be administered? Select all that apply.

Nasal cannula Simple oxygen mask Partial rebreather mask Nasal cannula with tubing administers oxygen at low-flow rates and concentrations at 22%-44%. Simple masks and partial rebreathers both deliver a low-flow rate at concentrations of 40%-60%. Venturi masks mix oxygen with room air and create a high flow of oxygen.

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 respirations 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. The client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.

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?

Residual Volume (RV) During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration. Forced expiratory volume measures the amount of air exhaled in the first second after a full inspiration; it can also be measured at 2 or 3 seconds.

The nurse is performing an arterial blood gas sampling on a client at 10:45. The nurse educator intervenes if which action is taken by the nurse?

The nurse performs the Allen test after blood sample is taken. The Allen test is done before puncture to ensure adequate ulnar blood flow when using the 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.

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.

True After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. A nurse caring for a client with a chest tube should monitor the patient's respiratory status and vital signs, check the dressing, and maintain the patency and integrity of the drainage system.

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

a child who has pneumonia 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 conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal?

fine crackles to the bases of the lungs bilaterally Except in the case of infants, fine crackles always constitute an abnormal assessment finding. A respiratory rate of 18 is within acceptable range. Vesicular sounds over peripheral lung fields and resonance on percussion are expected assessment findings.

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 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. 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. An adhesive nasal strip increases the nasal diameter and promotes easier breathing. A nasal cannula is a hollow tube used for delivering a small concentration of oxygen. However, these devices are not used to regulate the amount of oxygen delivered to the client.

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 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.

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 A nasal cannula is ideal for administering low concentrations of oxygen to clients who are not extremely hypoxic or have chronic lung disease. The client does not have a tracheostomy. A simple mask is used to administer higher levels of oxygen than 2 L/min. A face tent is used without a mask.

A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder 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. Pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.

During assessment of a 4-year-old client, the nurse notes a respiratory rate of 30 breaths/min and a loud, harsh expiration that is longer than inspiration. The nurse would implement which appropriate nursing intervention next?

Proceed with the assessment When collecting respiratory data on a 4-year-old, loud, harsh expiration longer than inspiration breath sounds and respiratory rate of 25-32 breaths/min are normal findings; therefore, the nurse would continue with the assessment. Because the findings are normal, it is inappropriate at this time to administer oxygen therapy, obtain an arterial blood sampling, or notify the health care provider.

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 The nurse expects to document wheezing in the lungs of a client with asthma, which would be more pronounced when the client has a respiratory infection. Wheezing is a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration. Wheezing is caused by air passing through constricted passages caused by swelling or secretions. Stridor and crackles are other abnormal breath sounds caused by fluid, infection, or inflammation in the lungs. Absent breath sounds are not normally found in asthmatic clients; they are characteristic of pneumonia.

Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system? Select all that apply.

slightly contoured chest with no sternal depression anteroposterior diameter of the chest less than the transverse diameter bronchial, vesicular, and bronchovesicular breath sounds The adult chest contour is slightly convex, with no sternal depression. The anteroposterior diameter should be less than the transverse diameter for normal respirations. Bronchial, vesicular, and bronchovesicular are normal breath sounds, depending on the lung fields being assessed. Respirations should be nonlabored with a normal rate of 12 to 20 breaths per minute. Crackles should not be heard on inspiration as this is a sign of mucus or fluid in the lung tissue.

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

They are low-pitched, soft sounds heard over peripheral lung fields. Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

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 Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients. Peak expiratory flow rate is used to monitor severe respiratory diseases and the degree of disease control. Spirometry is used in the postoperative period to measure the volume of air in liters exhaled or inhaled. Spirometry also evaluates lung function and airway obstruction but does not specifically monitor the effectiveness of oxygen therapy. Thoracentesis is a procedure that allows the physician to aspirate pleural fluid for diagnostic or therapeutic purposes.

Which guideline is recommended 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 past the length of the endotracheal tube. 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 client, 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.

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?

Vesicular Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds. Bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

A nurse is admitting a 6-year-old child after a tonsillectomy to the surgical unit. The nurse obtains the client's weight and places electrocardiogram (EKG) leads on the chest and a pulse oximeter on the left finger. The client's heart rate reads 100 bpm and the pulse oximeter reads 99%. These readings best indicate:

adequate tissue perfusion. 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 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 most accurate and complete nursing documentation of normal lungs sounds in a health client is "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%" because it provides the respiratory type, rate, depth, ventilation efficiency, clarity of all lobes of both lungs, absence of any abnormality and the oxygen saturation rate to provide a total respiratory picture of the healthy client. The other documentations are not complete, and each has an abnormal respiratory factor included.

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

Ambu bag If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Oxygen masks may cover only the nose and mouth and can vary in the amount of oxygen delivered. A nasal oxygen cannula is a device that consists of a plastic tube that fits behind the ears, and a set of two prongs that are placed in the nostril. An oxygen tent is a tentlike enclosure within which the air supply can be enriched with oxygen to aid a client's breathing. Oxygen masks, nasal cannula, and oxygen tents are used for clients who have a respiratory drive.

Upon evaluation of a client's medical history, the nurse recognizes that which condition may lead to an inadequate supply of oxygen to the tissues of the body?

chronic anemia The majority of oxygen is carried by the red blood cells. Anemia, a decrease in the number of red blood cells or erythrocytes, results in insufficient hemoglobin available to transport oxygen. This may lead to an inadequate supply of oxygen to the tissues of the body. Graves' disease, Parkinson's disease, and pancreatitis do not directly lead to a decrease in the number of red blood cells. Graves' disease is an immune system disorder that results in the overproduction of thyroid hormones (hyperthyroidism). Parkinson's disease (PD) is a neurodegenerative disorder that affects predominately dopamine-producing ("dopaminergic") neurons in a specific area of the brain called substantia nigra that causes a movement disorder. Pancreatitis is inflammation in the pancreas.