1011 Gas Exchange
A nurse is administering oxygen to a client with chest pain who is restless. What method of oxygen administration will most likely prevent a further increase in the client's anxiety level? Cannula Catheter Venturi mask Rebreather mask
Cannula Oxygen via nasal cannula is the most comfortable and least intrusive, because the cannula extends minimally into the nose. Use of the catheter is intrusive and may increase anxiety. A Venturi mask and a rebreather mask are oppressive, and clients complain of feeling "suffocated" when they are used.
A client just had a thoracentesis. For which response is it most important for the nurse to observe the client? Signs of infection Expectoration of blood Increased breath sounds Decreased respiratory rate
Expectoration of blood Expectoration of blood is an indication that the lung itself was damaged during the procedure; a pneumothorax or hemothorax may occur. It is too soon after a thoracentesis for an infection to develop. Signs of infection are important for the client to assess for several days after the procedure. Increased breath sounds are anticipated because the lung is closer to the chest wall after the fluid in the pleural space is removed. A decreased rate may indicate improved gaseous exchange and is not evidence that the client is in danger.
A nurse is caring for a client who experienced a crushing chest injury. A chest tube was inserted. Which observation indicates a desired response to this treatment? Increased breath sounds Increased respiratory rate Crepitus detected on palpation of the chest Constant bubbling in the drainage collection chamber
Increased breath sounds The chest tube normalizes intrathoracic pressure, drains fluid and air from the pleural space, and improves pulmonary function. Increased respiratory rate may be a sign of pain, respiratory obstruction, or bleeding. Crepitus detected on palpation of the chest indicates that air has entered the subcutaneous tissue (subcutaneous emphysema). Constant bubbling in the drainage collection chamber indicates a probable leak in the drainage system.
After emergency surgery, the nurse teaches a client how to use an incentive spirometer. What client behavior indicates to the nurse that the spirometer is being used correctly? Inhales deeply through the mouthpiece, relaxes, and then exhales. Inhales deeply, seals the lips around the mouthpiece, and exhales. Uses the incentive spirometer for 10 consecutive breaths per hour. Coughs several times before inhaling deeply through the mouthpiece.
Inhales deeply through the mouthpiece, relaxes, and then exhales. Inhaling deeply through the mouthpiece, relaxing, and then exhaling are correct techniques; deep inhalation promotes alveolar expansion, and exhalation promotes lung recoil. Inhaling deeply, sealing the lips around the mouthpiece, and exhaling are incorrect techniques; inhalation should occur through the mouthpiece. The breaths should not be taken in succession; they should be spaced by several normal breaths to avoid fatigue. Coughing is done after deep breathing.
The nurse observes a client collapse while walking down the hallway. The nurse rushes to the client and determines that the client is in cardiopulmonary arrest. What will the nurse do first? Do a blind finger sweep Begin chest compressions Check for a carotid pulse Perform the abdominal thrust maneuver
Check for a carotid pulse According to the 2010 American Heart Association guidelines, assessing for a carotid pulse is the first step in CPR. A blind finger sweep is not performed. Chest compressions are done only after it is determined that the carotid pulse is absent. The abdominal thrust (Heimlich) maneuver is used to relieve airway obstruction and is not appropriate in this instance.
The nurse is caring for a client who recently returned from another country who exhibits signs and symptoms suspicious of severe acute respiratory syndrome (SARS). Which clinical manifestations support this diagnosis? (multiple) Dry cough Chest pain Hemoptysis Shortness of breath Fever greater than 100.4° F
Dry cough Shortness of breath Fever greater than 100.4° F Between two and seven days after the onset of SARS, which is caused by a coronavirus, clients exhibit a dry cough. SARS is an acute viral respiratory infection that results in respiratory signs and symptoms, including difficulty breathing and shortness of breath. SARS, a viral infection, generally begins with a fever greater than 100.4º F, headache, and muscle weakness. Although clients may exhibit sinus tachycardia, chest pains are not a typical symptom associated with SARS. The cough associated with SARS is nonproductive and hemoptysis does not occur.
A nurse is observing a newborn's respiratory rate. What clinical findings indicate that the rate is within the expected range? Regular, thoracic, 40 to 60/min Irregular, thoracic, 30 to 60/min Regular, abdominal, 40 to 50/min Irregular, abdominal, 30 to 60/min
Irregular, abdominal, 30 to 60/min The expected breathing pattern is abdominal and irregular in rhythm and depth (alternating between shallow and deep); the expected rate ranges from 30 to 60 breaths/min. are irregular and abdominal.
A nurse knows that when routine oxygen therapy is being administered to a 7-year-old child, the oxygen: Should be labeled as flammable Is warmed before administration May be administered without a prescription Is closely monitored for the correct concentration
Is closely monitored for the correct concentration The oxygen concentration must be closely monitored to minimize side effects. Oxygen does not ignite and is not flammable, but it supports fire. Oxygen is not warmed before administration; it is cool when routinely administered. Oxygen is considered a medication and therefore must be prescribed when administered routinely.
A client with a history of hypertension develops dyspnea on exertion. What does the nurse conclude is the most likely cause of the client's dyspnea? Cor pulmonale Left heart failure Bronchial spasms Right ventricular failure
Left heart failure The failing left ventricle cannot accept blood that is returning from the lungs; this results in increased vascular pressure in the lungs. Cor pulmonale is associated with right ventricular failure. Bronchial spasms are associated with asthma. There is no evidence that the client has asthma. Right ventricular failure is associated with distended neck veins, hepatomegaly, anorexia, diminished urinary output, and respiratory distress.
What is the priority nursing intervention for a client during the immediate postoperative period? Monitoring vital signs Observing for hemorrhage Maintaining a patent airway Recording the intake and output
Maintaining a patent airway Maintenance of a patent airway is always the priority, because airway obstruction impedes breathing and may result in death. Monitoring vital signs, observing for hemorrhage, and recording the intake and output is important; however, a patent airway is the priority.
A client is admitted to the hospital with a diagnosis of emphysema and dyspnea. The nurse should encourage the client to assume what position? Supine Contour Orthopneic Semi-Fowler
Orthopneic The orthopneic position lowers the diaphragm and provides for maximum thoracic expansion. The supine position will not facilitate thoracic expansion because it permits abdominal organs to press against the diaphragm. The contour position will not facilitate thoracic expansion because it permits abdominal organs to press against the diaphragm. Although the semi-Fowler position can help, it is not as beneficial as the orthopneic position.
A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain? Retrospective 24-hour calorie count Elimination pattern during the last 30 days Complete gynecological and sexual history Presence of a cough and pulmonary secretions
Presence of a cough and pulmonary secretions Presence of a cough and pulmonary secretions, in addition to a history of rheumatic fever, require an assessment for other cardiopulmonary problems. Anorexia and weight gain do not indicate a nutritional problem but a fluid balance problem. Loss of appetite in conjunction with shortness of breath and the history of rheumatic fever make gastrointestinal symptoms secondary in importance. There is no reason to investigate the gynecological and sexual history in relation to the current problem.
A toddler with cystic fibrosis has been hospitalized with bacterial pneumonia. The nurse determines that the child has no known allergies. What does the nurse conclude is the reason that the health care provider selected a specific antibiotic? Tolerance of the child Sensitivity of the bacteria Selectivity of the bacteria Preference of the health care provider
Selectivity of the bacteria When the causative organism is isolated, it is tested for antimicrobial susceptibility (sensitivity) to various antimicrobial agents. When a microorganism is sensitive to a medication, the medication is capable of destroying the microorganism. The tolerance of the child of the particular antibiotic is unknown because up to this time the child has not exhibited any allergies. Bacteria are not selective. Although the health care provider may have a preference for a particular antibiotic, it first must be determined whether the bacteria are sensitive to it.
The parents of an infant with newly diagnosed cystic fibrosis ask a nurse what causes the foul-smelling, frothy stool. What is the best response by the nurse? Undigested fat Sodium and chloride Partially digested carbohydrates Lipase, trypsin, and amylase release
Undigested fat Because of a lack of the pancreatic enzyme lipase, fats remain unabsorbed and are excreted in excessive amounts in the stool. Sodium, chloride, and partially digested carbohydrates do not cause the typical characteristics of the stools. Lipase, trypsin, and amylase are the pancreatic enzymes whose passage into the intestine is prevented by blocked pancreatic ducts.
Supplemental oxygen is ordered for a preterm neonate with respiratory distress syndrome (RDS). What action does the nurse take to reduce the possibility of retinopathy of prematurity? Humidifying oxygen flow to prevent dehydration Uncovering the entire body to increase exposure to the oxygen Applying eye patches to both eyes to protect them from the oxygen Verifying oxygen saturation frequently to adjust flow on the basis of need
Verifying oxygen saturation frequently to adjust flow on the basis of need Determining oxygen saturation identifies the need for oxygen supplementation; prolonged use of oxygen concentrations exceeding those required to maintain adequate oxygenation contributes to the occurrence of retinopathy of prematurity. Preventing dehydration by humidifying the oxygen will not prevent retinopathy of prematurity. The skin does not absorb oxygen; it must enter the lungs through inhalation. Retinopathy of prematurity is caused by a high blood concentration of oxygen, not by exposure of the eyes to oxygen.
After a thoracentesis is performed for pleural effusion, a client returns to the health care provider's office for a follow-up visit. Which client statement leads the nurse to suspect a recurrence of the pleural effusion? "I can breathe well only if I sit up." "I sometimes have chills during the night." "I get a sharp pain when I take a deep breath." "I have been coughing up large amounts of thicker mucus lately."
"I get a sharp pain when I take a deep breath." Tension placed on pleura at the height of inspiration causes pain. The client only being able to breathe when sitting up is typical of congestive heart failure. Chills during the night may indicate pulmonary infection. Coughing up large amounts of mucus may indicate pulmonary infection.
A nurse provides teaching for a client who is scheduled for a cholecystectomy. In the initial postoperative period, the nurse explains that the most important part of the treatment plan is: Early ambulation Coughing and deep breathing Wearing anti-embolic elastic stockings Maintenance of a nasogastric tube
Coughing and deep breathing The client who has a cholecystectomy will have difficulty taking deep breaths and coughing because of the location of the surgical incision. Therefore it is important to instruct the client preoperatively to improve compliance with the procedure in the early post-op period. Although ambulation, antiembolism stockings, and maintaining a nasogastric tube, if ordered, are important postoperative procedures, maintaining the airway and prevention of further pulmonary problems is the priority.
A client with a history of recurrent cholecystitis is scheduled for an abdominal cholecystectomy. What should the nurse specifically emphasize when planning preoperative teaching for this client? Possible complications Food and fluid restrictions Coughing and deep breathing Isometric exercises of the extremities
Coughing and deep breathing The operative site's proximity to the diaphragm results in the client taking shallow respirations to limit pain; failure to expand the lungs can cause hypostatic pneumonia. The health care provider explores possible complications when providing information for an informed consent. The nurse should not emphasize possible complications because it may increase the client's anxiety. Preoperative teaching should focus on the interventions that prevent complications. Food and fluid restrictions should be included in preoperative teaching; however, this is not the priority. Isometric exercises of the extremities are unnecessary; the client will be allowed out of bed within several hours after surgery.
A nurse is assessing a client and suspects diabetic ketoacidosis (DKA). What clinical findings support this conclusion? Nervousness and tachycardia Erythema toxicum rash and pruritus Diaphoresis and altered mental state Deep respirations and fruity odor to the breath
Deep respirations and fruity odor to the breath Deep respirations and a fruity odor to the breath are classic signs of DKA because of the respiratory system's attempt to compensate by blowing off excess carbon dioxide, a component of carbonic acid. Nervousness and tachycardia are indicative of an insulin reaction (diabetic hypoglycemia). When the blood glucose level decreases, the sympathetic nervous system is stimulated, resulting in an increase in epinephrine and norepinephrine; this causes clinical findings such as nervousness, tachycardia, palpitations, sweating, tremor, and hunger. Erythema toxicum rash and pruritus are unrelated to diabetes; they indicate a hypersensitivity reaction. Although an altered mental state is associated with both hypoglycemia and DKA, diaphoresis is associated only with hypoglycemia. Diaphoresis occurs when the blood glucose level decreases and stimulates an increase in epinephrine and norepinephrine.
A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline at 125 mL/hr has been started. One hour after the IV initiation the client begins screaming, "I can't breathe!" The nursing priority action is: Discontinue the IV site and contact the primary health care provider Elevate the head of the bed and obtain vital signs Contact the primary health care provider to obtain a prescription for a sedative Assess for allergies and change the IV to an intermittent infusion device
Elevate the head of the bed and obtain vital signs The client's ability to speak indicates that the client is breathing. Elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Checking the vital signs after this is the first step in assessing the cause of the distress. Discontinuing the IV access line may cause unnecessary discomfort if it must be restarted; there are too few data to call the health care provider at this time. There is not enough information to support calling the health care provider and obtaining a prescription for a sedative; further assessment is required. There is no information to support assessing for allergies and changing the IV to an intermittent infusion device; assessment for allergies should be done on admission.
When caring for a client with pneumonia, which nursing intervention is the highest priority? Increase fluid intake. Employ breathing exercises and controlled coughing. Ambulate as much as possible. Maintain an NPO status.
Employ breathing exercises and controlled coughing. For most clients, the most effective means of preventing fluid consolidation in the lungs with a diagnosis of pneumonia is to keep active by deep breathing and controlled coughing exercises. Increased fluid intake and ambulation are important aspects of care if not contraindicated, but they are secondary to deep breathing and coughing. Keeping the client NPO is not necessary; unless contraindicated, the client with pneumonia is usually offered his or her regular diet as tolerated.
The nurse develops a plan of care related to a coughing and deep breathing regimen for a client who has had a pneumonectomy. The plan should include that, postoperatively, the client should cough and deep breathe: Every 15 minutes for the first 24 hours and then every 2 hours Every 30 minutes for the first 24 hours and then every 2 hours Every hour for the first 24 hours and then every 2 hours Every 2 hours for the first 24 hours and then every 3 hours
Every hour for the first 24 hours and then every 2 hours Excessive endotracheal secretions after a pneumonectomy require coughing routines that are effective but not exhausting. Every 15 minutes for the first 24 hours and then every 2 hours, and every 30 minutes for the first 24 hours and then every 2 hours are too exhausting. Every 2 hours for the first 24 hours and then every 3 hours is not specific for a client who has had a pneumonectomy.
A 7-year-old child survives a near-drowning episode in a cold pond. What factor does the nurse identify that will have the greatest effect on the child's prognosis? Hypoxia Hyperthermia Emotional trauma Aspiration pneumonia
Hypoxia The degree of hypoxia experienced by the child will determine the extent of neurological, liver, and renal damage. The child was hypothermic, not hyperthermic. Although emotional trauma can be overwhelming, it usually does not influence the ultimate physical prognosis as the extent of the hypoxia does. Although aspiration pneumonia may be severe initially, it does not result in long-term sequelae as hypoxia can.
A client is returned to the surgical unit after an abdominal cholecystectomy. What is the main reason why the nurse should assess for clinical indicators of respiratory complications? Length of time required for surgery is prolonged. Incision is in close proximity to the client's diaphragm. Client's resistance is lowered because of bile in the blood. Bloodstream is invaded by microorganisms from the biliary tract.
Incision is in close proximity to the client's diaphragm. The location of the incision results in pain on inspiration or coughing. The subsequent reluctance to cough and deep breathe facilitates respiratory complications from retained secretions. Length of time required for surgery does not take a prolonged period. Bile does not impair inflammatory or immune responses. Cholelithiasis and cholecystitis generally are inflammatory, not infectious, processes.
The nurse reinforces instructions about how to use a nebulizer to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that additional teaching is needed when the client: Places the tip of the mouthpiece an inch beyond the lips Holds the inspired breath for at least three seconds Exhales slowly through the mouth with lips pursed slightly Inhales with the lips tightly sealed around the mouthpiece of the nebulizer
Inhales with the lips tightly sealed around the mouthpiece of the nebulizer Inhaling with the lips tightly sealed around the mouthpiece of the nebulizer results in nasal breathing, which negates the effects of aerosol medication. The mouthpiece should be gently held in the mouth just past the lips. The nebulizer tip should be past the lips to deliver the medication. Holding the inspired breath for at least three seconds promotes contact of the medication with the bronchial mucosa. Exhaling slowly through the mouth with lips pursed slightly prolongs and improves delivery of the medication to the respiratory mucosa.
Immediately after being placed in the supine position, an adolescent child experiences shortness of breath and must sit up to breathe. What term should the nurse use to document this clinical phenomenon? Apnea Dyspnea Orthopnea Hyperpnea
Orthopnea Orthopnea is shortness of breath in any position except the erect, sitting, or standing position. Apnea is a temporary cessation of breathing. Dyspnea is labored or difficult breathing regardless of the position. Hyperpnea is an increased respiratory rate, not shortness of breath.
What should the nurse expect when assessing a client with pleural effusion? Crackles or rhonchi at the posterior of the lungs Deviation of the trachea toward the affected side Increased resonance on percussion of the affected area Reduced or absent breath sounds at the base of the lung
Reduced or absent breath sounds at the base of the lung Compression of the lung by fluid that accumulates at its base reduces expansion and air exchange. Crackles or rhonchi at the posterior of the lungs are not associated with pleural effusion. If tracheal deviation occurs, it is away from the affected side. Dullness is produced on percussion of the affected area.
A client has a chest tube inserted to treat a right hemopneumothorax. In which position should the nurse place the client to facilitate chest drainage? Supine Left Sims Immobilized Right side-lying
Right side-lying Lying on the affected right side increases drainage from the pleural space and allows the unaffected lung to expand to the fullest extent. The supine position is undesirable because this may not allow the unaffected lung to fully expand and provide maximum oxygenation. The left Sims position is undesirable because this may not allow the unaffected lung to fully expand and provide maximum oxygenation. Immobilization promotes stasis of respiratory secretions. The client should be encouraged to perform deep breathing and coughing exercises and periodically move around in bed.
A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's blood studies indicate pH 7.30, Po 2 60 mm Hg, Pco 2 55 mm Hg, and HCO 3 23 mEq/L. The nurse concludes that the client is experiencing: Hypocapnia Hyperkalemia Generalized anemia Respiratory acidosis
Respiratory acidosis The pH is less than the norm of 7.35 to 7.45, indicating acidosis. The Po 2 is less than the norm of 80 to 100 mm Hg. The Pco 2 is increased more than the norm of 35 to 45 mm Hg. The HCO 3 is within the norm of 23 to 28 mEq/L. These results indicate a respiratory etiology. The client's carbon dioxide level is increased, not decreased. These values are unrelated to hyperkalemia; a serum potassium level more than 5 mEq/L indicates hyperkalemia. These values are unrelated to anemia; decreased levels of red blood cells (RBCs), Hb, and Hct are related to anemia.
When a preterm newborn requires oxygen, the nurse in the neonatal intensive care unit monitors and adjusts the oxygen concentration. What complication do these adjustments attempt to prevent? Cataracts Strabismus Ophthalmia neonatorum Retinopathy of prematurity
Retinopathy of prematurity Retinopathy of prematurity is caused by the high concentration of oxygen that may have to be used to support some preterm neonates; oxygen must be administered cautiously and, depending on the neonate's blood oxygen level, adjusted accordingly. Cataracts and strabismus (crossed eyes) are not caused by a high oxygen concentration. Ophthalmia neonatorum refers to an inflammation of the eyes caused by a gonorrheal or chlamydial infection contracted as the fetus passes through the birth canal.
A 6-year-old child with acute spasmodic bronchitis who is receiving humidified air removes the mask, and while bathing the child the nurse notes increasing respiratory distress. What is the most appropriate nursing intervention? Stopping the bath and replacing the mask Performing postural drainage and clapping the chest Placing the child in the orthopneic position and calling the practitioner Suctioning the child's nasal passages and waiting for the dyspnea to subside
Stopping the bath and replacing the mask Interrupting the bath and providing humidified air will reduce energy requirements, allow the child to rest, and lessen the demand for oxygen. Although postural drainage loosens secretions in the lungs, it should not be used when the child is in distress. The orthopneic position will not reduce energy and oxygen demands; the health care provider should be called if appropriate nursing measures do not relieve the dyspnea. Suctioning is not performed unless respiratory distress is severe; it increases restlessness and energy demands.
Continuous positive-pressure ventilation therapy by way of an endotracheal tube is started in a newborn with respiratory distress syndrome (RDS). The nurse determines that the infant's breath sounds on the right side are diminished and that the point of maximum impulse (PMI) of the heartbeat is in the left axillary line. How should the nurse interpret these data? These findings are expected because infants with this disorder often have some degree of atelectasis. The inspiratory pressure on the ventilator is probably too low and needs to be increased for adequate ventilation. These findings indicate that the infant may have a pneumothorax, and the health care provider should be contacted immediately. The endotracheal tube needs to be pulled back to ventilate both lungs because it has probably slipped into the left main stem bronchus.
These findings indicate that the infant may have a pneumothorax, and the health care provider should be contacted immediately. Diminution of breath sounds on the right side and detection of PMI in the left axillary line are key signs of a pneumothorax, which can occur when an infant is being given oxygen by means of positive pressure. These findings are not expected in infants with RDS. A problem with the ventilator will not result in these clinical manifestations. These findings do not indicate that the endotracheal tube has moved.
A client has a fractured mandible that is immobilized with wires. For which life-threatening postoperative problem should the nurse monitor this client? Infection Vomiting Osteomyelitis Bronchospasm
Vomiting Vomiting may result in aspiration of vomitus, because it cannot be expelled; this may cause pneumonia or asphyxia. Infection, osteomyelitis, and bronchospasm generally are not life-threatening problems.