321 Exam 2- Oxygenation and Perfusion

Which teaching about the humidifier is important for the nurse to provide to a client using oxygen?

It decreases dry mucous membranes via delivering small water droplets.

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.

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)

When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding?

The chest should be slightly convex with no sternal depression.

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.

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

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

diffusion

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

expectorants

drugs that facilitate the removal of respiratory tract secretions by reducing the viscosity of the secretions ****congestion

cough suppressants

drugs that suppress cough reflex -codeine -irritating, nonproductive cough without congestion

T/F: Cough suppressants are drugs that facilitate the removal of respiratory tract secretions by reducing the viscosity of the secretions.

false

T/F: Respiration is the process by which oxygenated capillary blood passes through body tissue.

false

corticosteroid side effects

fluid retention, hypertension, weight gain, hyperglycemia, insomnia

a patient with COPD is unstable to perform personal hygiene without becoming exhausted. what nursing intervention would be appropriate for this patient?

group personal care activities into smaller steps, allowing for rest periods between activities

Which of the following oxygen delivery methods is most likely used to deliver an FiO2 of 24% to 44% with a flow of 1 to 6L/min?

nasal cannula

The __________ oxygen mask delivers the highest concentration of oxygen, via a mask, to a spontaneously breathing patient.

nonrebreather

tracheostomy tube includes

outer cannula (main shaft), inner cannula, obturator

corticosteroids

prednisone, dexamethasone, budesonide, triamcinolone, acetonide

cuffed endotracheal tube

prevents air leakage and bronchial aspiration of foreign material while allowing more precise control of oxygen and mechanical ventilation

The nurse is performing a check with an oxygen analyzer. Which oxygen analyzer assessment finding indicates that the device is working properly?

reads 0.21 when checking oxygen in room air

The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care?

stay indoors as much as possible

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

albuterol side effects

tremors, anxiety, insomnia, headache, palpitations, hypertension, vomiting

An older resident at a long-term care facility has been placed on oxygen via a partial rebreather mask due to COVID-19. While helping the resident prepare for sleep, the nurse notices the mask is no longer fitting properly. Which question should the nurse prioritize?

"Is your mask causing discomfort?"

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."

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."

nonrebreather mask

- highest concentration of oxygen via a mask to spontaneously breathing patient - 6-15 L/min 60-100%

nasal cannula

-1 to 6 L 1-2 L/min = 24-28% 3-5 L/min = 32-40% 6 L/min = 44% -safe and simple -delivers low concentration -allows client to eat, speak -dislodged easily -can cause skin breakdown over ears - can cause drying go mucous membranes so humidify over 4L

Thoracotomy pre-op assessment

-breath sounds -s/s -smoking history -cardiopulmonary history -breathing pattern -sleeping upright? -medical conditions

patients can keep their secretions thin by drinking

1.9 to 2.9 L of fluids daily

room air FiO2

21%

simpleface mask delivers an FiO2 of

40-60%

partial rebreather masks deliver an FiO2 of

50-60%

pH (arterial blood gas)

7.35-7.45

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

Be sure to shake the canister before using it.

ineffective airway clearance dx

"i never feel as though i am getting enough air" -thick, yellow secretion -pale skin with circumoral cyanosis -resp rate 40 breaths/min -shallow resp. -coarse crackles bilaterally -ineffective cough

Which of the following oxygen delivery methods is most likely used to deliver an FiO2 of up to 95% at 8-15L/min?

Non-rebreather mask

albuterol action

bronchodilator

Which of the following mechanisms is the most likely cause of acute respiratory distress syndrome (ARDS)?

damaged alveolar-capillary membrane

a nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient?

dyspnea

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

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

obturator

guides the direction of the outer cannula and is inserted into the tube during placement and removed once the outer cannula of the tube is in place

venturi-mask

have air entrainer that allows oxygen to be mixed with room air -can deliver a precise FiO2 to the patient ranging from 24-60%

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

a nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. what would be the first action that should be taken by the nurse in this situation?

put on gloves and insert the chest tube in a bottle of sterile saline

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

rapid respirations

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

placement of endotracheal tube results in

inability to speak

T/F: Patients who experience dyspnea and feelings of panic can often reduce these symptoms by using pursed-lip breathing.

true

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

impaired gas exchange dx

-using pursed lips breathing -sitting hunched over -altered blood gases show respiratory acidosis -reports shortness of breath for 1 week

simple face mask

-6-10 L -short term therapy -interferes with eating, speaking -4-60%

which assessments and interventions should the nurse consider when performing tracheal suctioning?

-closely assess the patient before, during, and after the procedure -hyperoxygenate the patient before and after the suctioning -monitor the patient's pulse for potential effects of hypoxia -use appropriate suction pressure (80--150mmHg)

The pediatric nurse is instructing parents on safety when caring for toddlers and preschoolers. Which of the following teaching interventions is appropriate for this age group?

Cut a hot dog in half, then pieces

A nurse is conducting a physical assessment of a client who is being treated for pleural effusion at a health care facility. The nurse needs the client to exhale additional air, which will allow the nurse to check the quality of the client's oxygenation. What instruction should the nurse give the client?

contract the abdominal muscles

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 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

oxygen is considered a medication and must be ordered by health care provider, however......

in emergency situation, absence of prescription should not delay the administration of oxygen to patient

endotracheal tube

inserted through the nose or mouth into the trachea to administer oxygen by mechanical ventilator, to suction secretions easily, or to bypass upper airway obstruction

corticosteroid action

reduce inflammation

a nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. which priority nursing action should be performed by the nurse related to this occurrence?

remove the catheter

a nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. which action would be appropriate?

remove the tape, adjust the depth to ordered depth, and reapply the tape

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

Which of the following oxygen delivery methods is most likely used to deliver an FiO2 of 40% to 60% oxygen with a flow of 6 to 12L/min?

simple face mask -mild respiratory distress

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

T/F: Patients with fluid, blood, or air in the pleural space require a chest tube to drain these substances and allow the compressed lung to reexpand.

true

Which factors indicate that the nurse should stop delivery of breaths via a manual resuscitation bag and mask device? Select all that apply.

-The client has been intubated and is connected to a mechanical ventilator. -The client has a return of spontaneous breathing at 15 breaths per minute. -The health care provider has ended the cardiopulmonary resuscitation effort.

venturi mask

-delivers most precise concentrations -delivers high concentrations of oxygen -4-10 L/min -valve to prevent CO2 from returning to mask

albuterol nursing implcations

-don't increase dosage without consulting car provider -children 2-6 y/o more frequently exhibit CNS stimulation

non-rebreather mask

-has a valve on the exhalation port and between reservoir bag and mask -valves prevent room air from coming in -delivers FiO2 up to 95% at 8-15L/min

ineffective breathing pattern dx

-hyperventilating, tachypneic (40 breaths/min) -"tingling feeling in my fingers" -"cant catch my breath and cant lie down in bed"

When using oxygen, which of the following is the most appropriate recommendation?

-no electrical sparks -home education

HCO3 normal range

22-26

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.

a nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. for which condition would the nurse anticipate the need for a nasal trumpet?

a nosebleed is noted with continued suction

a nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. for which patient might this therapy be recommended?

a teenager with cystic fibrosis

tracheostomy

artificial opening made into the trachea through which a tracheostomy tube is inserted

nasal cannula

at 1L/min delivers 24% -every 1L you can add 4% all the way to 6L/min for an FiO2 of 44%

Incomplete lung expansion or the collapse of alveoli, known as __________, prevents pressure changes and the exchange of gas by diffusion in the lungs.

atelectasis

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

Thoracentesis pre-op

instruct patient not to cough or breathe deeply during procedure

a nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. which testing method might the nurse use to measure the patient's oxygen saturation?

pulse oximetry

A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the catheter to use? a) The age of the patient b) The size of the endotracheal tube c) The type of secretions to be suctioned d) The height and weight of the patient

size of the endotracheal tube -external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube

A detergent-like phospholipid, known as ____________, reduces the surface tension between the moist membranes of the alveoli, preventing their collapse.

surfactant

The client is reporting to the nurse that the continuous positive airway pressure (CPAP) mask is torture. What is the best response from the nurse?

tell me more about why it bothers you

A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. which measures would the nurse recommend?

-reduce anxiety -eat a high protein/high calorie diet -maintain a high-fowler's position when possible

corticosteroid nursing implications

-reduce sodium intake -weight daily in the morning -monitor blood pressure and blood sugar

During your assessment of a patient with suspected acute respiratory distress syndrome (ARDS), which of the following findings is most likely to be seen?

1. diffuse pulmonary infiltrates -appearance of white lungs on xray 2. refractory hypoxemia -lungs are adequately perfused but no gas exchange 3. atelectasis 4. restlessness 5. pulmonary hypertension 6. decrease PaO2 -decrease in arterial oxygen in the blood 7.dyspnea

PCO2 normal range

35-45

A nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment?

5,850 mL (5,850 × 109/L)

PO2 normal range

80-100

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

Which of the following oxygen delivery methods is most likely used to deliver a precise FiO2 to the patient ranging from 24% to 60%?

venturi-mask

Often heard in patients with asthma, ________ are continuous, musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors.

wheezes