39 Prep Part 2
expectorant
a drug that breaks up mucus and promotes coughing
bronchodilator
a medication that expands the opening of the passages into the lungs
Corticosteroids
anti-inflammatory agents
Cardiac output equation
heart rate (bpm) x stroke volume (ml)= L/m
atelectasis
partial or complete collapse of the lung. Bed rest can result in the incomplete lung expansion and collapse of alveoli
What does the medulla control
respiration, cardiac, vomiting, swallowing
A client is reporting slight shortness of breath and lung auscultation reveals the presence of bilateral coarse crackles. The client's SaO2 is 90% on pulse oximetry. The nurse has applied supplementary oxygen by nasal cannula, recognizing that the flow rate by this method should not exceed:
6 L/minute.
The pediatric nurse is caring for four clients. Which client will receive the greatest benefit from the use of an oxygen analyzer to assure that the client is receiving the prescribed amount of oxygen? 3-year old in croup tent 7-year old with nasal cannula 10-year old with simple mask 13-year old with nonrebreather mask
An oxygen analyzer is used most commonly when caring for newborns in isolettes, children in croup tents, and clients who are mechanically ventilated. Other answers are incorrect.
A nurse is delivering 3 L/min oxygen to a client via nasal cannula. What percentage of delivered oxygen is the client receiving?
32% A nasal cannula is used to deliver from 1 L/minute to 6 L/minute of oxygen. 1 L/minute = 24%, 2 L/minute = 28%, 3 L/minute = 32%, 4 L/minute = 36%, 5 L/minute = 40%, and 6 L/minute = 44%
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: pulmonary embolism. myocardial infarction. lung cancer. congestive heart failure.
A client who has edema and a cough that is productive with frothy sputum is manifesting heart failure.
The nurse is caring for a client who has a compromised cardiopulmonary system and needs to assess the client's tissue oxygenation. The nurse would use which appropriate method to assess this client's oxygenation? Hematocrit values Hemoglobin levels Pulmonary function Arterial blood gas
Arterial blood gases include the levels of oxygen, carbon dioxide, bicarbonate, and pH. Blood gases determine the adequacy of alveolar gas exchange and the ability of the lungs and kidneys to maintain the acid-base balance of body fluids.
A nurse is reading a journal article about pollutants and their effect on an individual's respiratory function. Which problem would the nurse most likely identify as an effect of exposure to automobile pollutants? -Croup -Atelectasis -Bronchitis -Bronchiectasis
Bronchitis refers to a condition in which the airways become inflamed, commonly due to respiratory irritants such as air pollution and high humidity. Exposure to such irritants leads to the release of inflammatory mediators, which in turn, lead to inflammation and narrowing of the airways and increased mucus production. Atelectasis refers to the partial or complete collapse of the small air sacs in the lungs, common after surgery or with obstruction or compression of the airways or lungs. Bronchiectasis results from chronic inflammation or infection causing an excess accumulation of mucus. Croup is an infection of the airways, most commonly viral in origin.
The nurse is assessing a client with a chest tube that has been inserted after experiencing blunt trauma that resulted in a pneumothorax. What nursing action is appropriate when constant bubbling is noted in the suction control chamber? Remove the chest tube. Document the finding. Contact the Rapid Response Team. Remind the client to remain stationary in bed to stop the bubbling.
Constant bubbling in the suction control chamber is normal and should be documented. Other actions are inappropriate.
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? -Apple bright light to device to get a better read. -Warm the clients hands and try again. -Add a blood pressure cuff to help with blood flow. -Use the clients earlobe.
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.
A nurse assessing a client's respiratory effort notes that the client is breathing 8 shallow breaths/min. Which action best meets this client's immediate oxygenation needs? Suction the client's upper airway. Apply nasal cannula at 6 L/min Use a bag and mask. Establish an oxygen hood.
If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a bag and mask may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Suction is unnecessary unless there is an obvious obstruction. Nasal cannula is insufficient and an oxygen hood is not used in urgent situations.
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: -asthma -pneumonia -croup -alcohol
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.
An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's: -blood pH level -Age -electrolyte levels -hemoglobin level
Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.
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? -Discard the first sputum sample. -Instruct the client to inhale deeply and then cough. -Place client in dorsal lateralis position. -Have patient gargle with salt water solution
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 working in the intensive care unit is preparing to admit a client from the emergency department who had a stroke located in the medulla. What equipment should the nurse have present in the room upon the client's arrival into the unit? Select all that apply. -Thermometer -Ventilator -Pulse oximeter -Communication board -Drainage system
The medulla houses the respiratory center, which regulates respirations. If damaged, the client will need monitoring of oxygenation (pulse oximeter) and a mechanism for breathing, getting oxygen, and clearing secretions from the airway (endotracheal tube). There is no indication that the client's lungs have collapsed, so a chest drainage system is not needed. A communication board would be used if the client could not be understood. It is important to record temperature, but the most important items are pulse oximeter and endotracheal tube.
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? -Gauge regulating the o2 received in the client. -It determines the amount of concentration in the oxygen. -It determines whether the client is getting enough oxygen. -Provides small droplets of water into the oxygen
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 provider prescribes concentration. The humidifier produces small water droplets that are delivered during oxygen administration to decrease dry mucous membranes.
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? -Wheezing -Tachypnea -Pleural effusion -Pneumonia
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.
Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway?
When holding the airway on the side of the client's face, it should reach from the tragus of the ear to the tip of the nostril.
A nurse is preparing to use a wall unit to suction an endotracheal tube. At what pressure should the suction be set? 60 to 80 mm Hg 80 to 150 mm Hg 100 to 160 mm Hg 120 to 170 mm Hg
When utilizing a wall unit to suction an endotracheal tube, the pressure should be set at 80 to 150 mm Hg. This level will provide enough pressure to suction out secretions from the endotracheal tube.
Viceral Pleura and Parietal Pleura
covers the lungs, lines the thoracic cavity
Which is a sign of dyspnea specific to infants?
nasal flaring In the infant, flaring of the nostrils and retractions of the ribs during inspiration are notable signs of air hunger and extraordinary work of breathing.
thoracentesis
surgical puncture to remove fluid from the pleural space
Pulse oximetry readings indicate what
the number of available oxygen receptors on hemoglobin molecules.
The nurse is caring for a client with respiratory alkalosis. Which arterial blood gas data does the nurse anticipate finding? pH less than 7.35; HCO3 low; PaCO2 low pH greater than 7.45; HCO3 high; PaCO2 high pH less than 7.35; HCO3 high; PaCO2 high pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation
In respiratory alkalosis, anticipated arterial blood gas results are anticipated to reflect pH greater than 7.45; HCO3 low; and PaCO2 low. Other answers are incorrect.
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 thoracentesis spirometry peak expiratory flow rate
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.
A client with closed-angle glaucoma and a cough has a prescription for a cough medicine. The nurse would question which cough medicine if prescribed for this client? Cough medicine with a high sugar content Cough medicine with iodine Cough medicine with an antihistamine Cough medicine with a decongestant
The client with closed-angle glaucoma should avoid cough medicine because of its anticholinergic action. The client with diabetes should avoid cough medicine with a high sugar content. The client with thyroid disorders should avoid cough medicine containing iodine. The client with hypertension should avoid cough medicine with decongestants.
The nurse is monitoring a client who is receiving oxygen via a nonrebreather mask at 12 L/min. What actions by the nurse will promote the best outcomes for this client? Select all that apply. Maintain flow rate so that the reservoir bag collapses only slightly during inspiration. Use petroleum jelly around the nose and mouth to prevent the drying effects from the oxygen. Take the mask off frequently to allow the client to have rest periods. Check that the valves and rubber flaps are functioning properly. Monitor SaO2 with pulse oximeter.
The use of a nonrebreather mask will deliver a low-flow administration of oxygen between 10 to 15 L/min. The flow rate should be maintained so that the reservoir bag only collapses slightly during inspiration. Petroleum jelly products should never be used around oxygen as they may be an accelerant during a spark or fire. The client should wear the mask at all times unless prescribed by the health care provider. Be sure that all valves and rubber flaps are functioning properly so that oxygen delivery will not be interrupted. The oxygen saturation should be monitored with pulse oximetry to be sure that the present therapy is having the desired effect and adjustments may be required in the flow rate or delivery system.
Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways? increases carbon dioxide, which stimulates breathing teaches him to prolong inspiration and shorten expiration helps liquefy his secretions decreases the amount of air trapping and resistance
Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways? increases carbon dioxide, which stimulates breathing teaches him to prolong inspiration and shorten expiration helps liquefy his secretions decreases the amount of air trapping and resistance
The nurse is assessing a client's chest tube which was inserted 48 hours earlier. The nurse notes crackling in the skin around the insertion site. Which action should the nurse prioritize? notify the health care provider apply a new dressing over the tube reinforce adhesive material over insertion site document finding
The health care provider should be notified as feeling or hearing air crackling can indicate a subcutaneous air leak and an internal displacement of the drainage tube. This requires emergent care to prevent the recurrence or further damage to the lung. Applying a new dressing or more tape would be inappropriate. The nurse would document after providing the client care.
