Chapter 39: Oxygenation and Perfusion
Transtracheal oxygen delivery
A small catheter is inserted into the trachea under local anesthesia and the catheter is attached to the oxygen source
The nurse is caring for patient who complains of difficulty breathing. In what position would the nurse place this patient?
Fowler's position
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 suctioning
A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this?
Dyspnea
nasal cannula
Most commonly used respiratory aid, consist of a disposable, plastic device with two protruding prongs for insertion into nostrils. Connects to an O2 source with a humidifier and a flow meter
A nurse working in a long-term care facility is providing teaching to a patient with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? (SATA)
Reduce anxiety, eat high-protein/high-calorie diet, maintain a high-fowler's position when possible
When inspecting a patient'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
Partial rebreather mask
This mask is equipped with a reservoir bag for the collection of the first part of the patient's exhaled air. The air is mixed with 100% oxygen for the next inhalation
The nurse is assessing the respiratory rates of patients in a community health care facility. which patient exhibits an abnormal value? a) infant with respiratory rate of 20 bpm b) a 4y/o with a respiratory rate of 40 bpm c) a 12 year old with a respiratory rate of 20 bpm d) a 70 y/o with a respiratory rate of 18 bpm
a
The nurse sets up an oxygen tent for a patient. Which patient is the best candidate for this oxygen delivery system?
a child who has pneumonia
The nurse is preparing a patient for a complete blood count test. Which actions would the nurse perform? (SATA) a) emphasize that there is no discomfort during the venipuncture b)inform the patient that this test can assist in evaluating the body's response to illness c) inform the patient that specimen collection takes approximately 5-10 minutes d) administer an analgestic to the patient prior to the test e)explain that, based on results, additional testing may be performed.
a, c, e
What assessments would a nurse make when auscultating the lungs?
cardiovascular function
What action does the nurse perform to follow safe techniques when using a portable oxygen cylinder?
check the amount of oxygen in the cylinder before using it
Mr. Parks has chronic obstructive pulmonary disease. His nurse has taught him pursed lip breathing, which helps him in which of the following ways?
decreases the amount of air trapping and resistance
An ED nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure?
hold the mask tightly over the patient;s nose and mouth
The nurse assesses a patient and detects the following findings: difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis. What consideration would the nurse suspect as causing these respiratory alterations?
hypoxia
nonrebreather mask
produces the highest concentration of oxygen with a mask; contains two one-way valves that prevent conservation of exhaled air, which escapes through side vents
When caring for a patient with a tracheostomy, the nurse would perform which recommended action?
suction the tracheostomy tube using sterile technique
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 chosen catheter?
the size of the endotracheal tube
The nurse is auscultating the lungs of a patient 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
A nurse auscultates the lungs of a patient with asthma. Which lung sound is characteristic of this condition?
wheezes
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
A nurse is performing CPR on a patient who is in cardiac arrest. What action would the nurse perform second?
Activate the emergency response system
which assessments and interventions should the nurse consider when performing tracheal suctioning? (SATA) a)closely assess the patient before, during, and after the procedure b)Hyperoxygenate the patient before and after suctioning c)limited the application of suction to 20-30 seconds d)monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of vagus nerve e) use appropriate suction pressure (80-150 mmHg)
a, b, d, e
The nurse is reviewing the results of a patient's arterial blood gas and pH analysis. Normal findings include (SATA): a) pH 7.45 b) PCO2 40 mmHg c) PO2 70 mmHg d) HCO3 30 mEq/L e) base excess or deficit +2 mmol/L
a, b, e
simple facemask
connects to oxygen tubing, a humidifier and flow meter and uses a delivery flow rate greater than 5 L/min; should be comfortably snug over face but not tight; has vents in sides to allow room air to leak in room air, diluting the source oxygen
venturi mask
delivers the most precise concentration of oxygen and has a large tube with an oxygen inlet. As the tube narrows, pressure drops, causing air to be sucked in through the side ports
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 o2 saturation?
pulse oximetry
A nurse providing care for a patients chest drainage system observes that the chest tube has become separate 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
The 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. What action would be appropriate related to this incident?
remove the tape, adjust the depth to ordered depth and reapply the tape
A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient?
teach the patient to take short shallow breaths when performing hygiene measures
A nurse suctioning a patient through a tracheostomy tube should be careful not to occlude the Y-port when inserting the suction catheter because it would cause what to occur?
trauma to the tracheal mucosa
The nurse schedules a pulmonary function to measure the amount of air left in the patient's lungs at maximum expiration. what test does the nurse order?
Residual volume (RV)
When percussing a normal lung, which sound would the nurse hear?
Resonance
The nurse performs assessments of cardiopulmonary functioning and oxygenation during regular physical assessments. Based on developmental variations, which findings would the nurse consider normal(SATA)? a)the power of the respiratory and abdominal muscles is reduced in older adults, and therefore the diaphragm moves less efficiently b)the normal infant's chest is small and the airways are short, making aspiration a potential problem. c) alterations in respiratory function due to aging in older adults increases the risk for disease, especially pneumonia and other chest infections. d) the respiratory rate is more rapid in infants until the alveoli increases in number and size to produce adequate oxygenation at lower respiratory rates e) the chest in the older adult is unable to stretch as much, resulting in an increase in maximum inspiration and expiration
a, b, c, d
Which normal conditions would a nurse expect to find when performing a physical assessment of a patient's respiratory system? (SATA) a) slightly contoured chest with no sternal depression b)anteroposterior diameter of the chest less than the transverse diameter c) quiet and nonlabored respiration occurring at a rate of 18-30 bpm d) barrel chest appearance in older adults e) bronchial, vesicular, and bronchovesicular breath sounds
a, b, e
The nurse is teaching a patient the proper use of inhaled medications. which are appropriate teaching points to include? (SATA) a) bronchodilators are used to liquefy of loosen thick secretions or reduce inflammation in airways b)nebulizers are used to deliver a controlled dose of medication with each compression of the canister c) DPIs are actuated by the patient inspiration, so there is no need to coordinate the delivery of puff with inhalation d) metered-dose inhalers deliver a controlled dose of medications with each compression of the canister
a, c, d
When preparing a patient for a cardiac catheterization, what are the responsibilities of the nurse? (SATA) a) verify that an informed consent was obtained b) inform the patient that bedrest is required for 24 hours after the procedure c) tell the patient to avoid heavy lifting, sports, and strenuous housework for 1 week d) make sure patient is NPO after midnight before the procedure e) inform the patient that when dye is given, a feeling of warmth or flushing, or a metallic taste may occur
a, d, e
which actions should a nurse perform when inserting an oropharyngeal airway? (SATA) a)use an airway that reaches from the nose to the back angle of the jaw b)wash hands and put on PPE, as indicated c) position patient flat on his or her back with the head turned to one side d)insert the airway with the curved tip pointing down toward the base of the mouth e) rotate the airway 180 degrees as it passes the uvula f)remove airway for a brief period every 4 hours or according to facility policy
b, e, f
The nurse is teaching an adolescent with asthma how to use a metered-dose inhaler. Which teaching follows recommended guidelines?
be sure to shake the canister before using it
A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? a) the nurse assures that the oxygen is flowing into the prongs b)the nurse adjusts the fit of the cannula so it fits snug and tight against the skin c)the nurse encourages the patient to breathe through the bose with the mouth closed d) the nurse adjusts the flow rate to 6 L/min or more
c
