Chapter 39: Oxygenation Prep U

The home health nurse is visiting a new client who has recently started using an oxygen concentrator. After assessing the home environment, which comment should the nurse prioritize? "Have you noticed an improvement in how you are feeling?" "Have you discussed a back-up system with your health care provider in case your electricity goes out?" "Are you sleeping better now that you are using the concentrator?" "Does your family help you with the concentrator?"

"Have you discussed a back-up system with your health care provider in case your electricity goes out?"

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." "Take in a large volume of air over 5 seconds and hold your breath as long as you can before exhaling." "Take in a little air over 10 seconds, hold your breath 15 seconds, and exhale slowly." "Take in a small amount of air very quickly and then exhale as quickly as possible."

"Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly."

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." "Oxygen is a flammable gas." "An occasional cigarette will not hurt you." "I understand; I used to be a smoker also."

"You should never smoke when oxygen is in use."

Which normal conditions would a nurse expect to find when performing a physical assessment of a client's respiratory system? Select all that apply. barrel chest appearance in older adults bronchial, vesicular, and bronchovesicular breath sounds anteroposterior diameter of the chest less than the transverse diameter quiet and nonlabored respiration occurring at a rate of 18 to 30 bpm crackles heard on inspiration. slightly contoured chest with no sternal depression

-Bronchial, vesicular, and bronchovesticular breath sounds -Anteroposterior diameter of the chest less than the transverse diameter -Slightly contoured chest with no sternal depression

A nurse is suctioning fluids from a male client via tracheostomy tube. When suctioning, the nurse must limit the suctioning to a maximum of: 5 Seconds 15 Seconds 20 Seconds 30 Seconds

15 Seconds

The nurse is caring for the following clients. Which client is at highest risk for a depressed respiratory system? a client taking methocarbamol for low back spasms a client taking amlodipine for hypertension a client taking an opioid for cancer pain a client taking methimazole for hyperthyroidism

A client taking an opioid for cancer pain

Which outcome best reflects achievement of the goal, "The patient will expectorate lung secretions with no signs of respiratory complications?" Absence of adventitious breath sounds Deep breathing and coughing nonproductively Drinking 3000 mL of fluid in the last 24 hours Expectorating sputum three times between 3 PM and 11 PM

Absence of adventitious breath sounds

A client admitted with angina complains of severe chest pain and suddenly becomes unresponsive. After establishing unresponsiveness, which of the following actions should the nurse take first? Activate the resuscitation team Open the airway Check for chest rise Check the carotid pulse

Activate the resuscitation team

The nurse understands that the most serious complication associated with thrombophlebitis caused by immobility is: Postural hypotension Blanchable erythema Dependent edema Acute chest pain

Acute chest pain

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: heart failure. diminished stroke volume. high cardiac output. adequate tissue perfusion.

Adequate tissue perfusion

Which of the following terms describes the force against which the ventricle must expel blood? Blood pressure Preload Afterload Cardiac output

Afterload

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 Oxygen tent Nasal cannula Oxygen mask

Ambu bag

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention? Explain the use of a BiPAP mask instead of a CPAP mask. Ask the client what factors contribute to nonadherence. Document outcomes of modifications in care. Contact the health care provider to report the client's current status.

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 instruction will the nurse include in the teaching? Inhale through the nose instead of the mouth. Inhale the medication rapidly. Inhale two sprays with one breath for faster action. Be sure to shake the canister before using it.

Be sure to shake the canister before using it

Which of the following classes of medications protects the ischemic myocardium by blocking catecholamines and sympathetic nerve stimulation? Beta-adrenergic blockers Calcium channel blockers Narcotics Nitrates

Beta-adrenergic blockers

To increase both the respiratory and the circulatory functions of a patient in a coma, what is the most important thing the nurse should do? Encourage the patient to cough Massage the patient's body areas Assist the patient with breathing exercises Change the patient's position every 2 hours

Change the patient's position every 2 hours

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? Diabetes mellitus Hypothyroidism Hypoxemia Chronic anemia

Chronic anemia

When attempting to apply a pulse oximetry probe, the nurse identifies that a patient's hands are edematous. The priority action should be to: Attach the probe to one of the patient's toes Connect the probe to one of the patient's earlobes Wash the patient's hand before attaching the probe to the finger Encourage the patient to perform active range-of-motion exercises of the hand.

Connect the probe to one of the patient's earlobes

The physician orders bed rest for a patient. The nurse understands that bed rest primarily is used to: Conserve energy Maintain strength Reduce peristalsis Enhance protein synthesis

Conserve energy

What should the nurse do first when caring of an infant, a toddler, or a nonverbal patient who is restless, agitated, and irritable? Administer oxygen Suction the oropharynx Reduce environmental stimuli Determine patency of the airway

Determine patency of the airway

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? Encourage the client to do deep-breathing exercises. Document this expected assessment finding. Review the medications that the client has taken in the past 90 minutes. Raise the head of the client's bed slightly, if tolerated.

Document this expected assessment finding

Which are the most effective leg exercises the nurse should encourage a patient to perform to prevent circulatory complications during the postoperative period? Flexing the knees Isometric exercises Dorsiflexion exercises Passive range of motion

Dorsiflexion exercises

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? Contact the physician for nutrition shake. Snack on high-carbohydrate foods frequently. Eat smaller meals that are high in protein. Eat one large meal at noon.

Eat smaller meals that are high in protein.

Which of the following diagnostic tools is most used to determine the location of myocardial damage? Cardiac catheterization Cardiac enzymes Echocardiogram Electrocardiogram

Electrocardiogram

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? oxygen analyzer flow meter nasal strip nasal cannula

Flow meter

A physician orders chest physiotherapy with percussion and vibration for a patient. After the physician leaves, the patient says, "I still don't understand the purpose of this therapy." The nurse's best reply is, "It : Eliminates the need to cough." Limits the production of bronchial mucus." Helps clear the airways of excessive secretions." Promotes the flow of secretions to the base of the lungs."

Helps clear the airways of excessive secretions."

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? low blood pressure high respiratory rate low pulse rate high temperature

High respiratory rate

The nurse is assessing a postoperative patient. Which complication has most likely occurred when the patient experiences purulent sputum, dyspnea, and chest pain? Hypostatic pneumonia Hypovolemic shock Thrombophlebitis Pneumothorax

Hypostatic pneumonia

The nurse assesses a client and detects the following findings: Difficulty breathing, increased respiratory and heart rates, and pale skin with lip cyanosis. What condition would the nurse suspect as causing these respiratory alterations? Unstable angina Hypoxia Atelectasis Hyperventilation

Hypoxia

The physician has ordered O2 at 2 liters/minute via nasal cannula. O2 amounts greater than 2 liters/minute are contraindicated in the client with COPD because: Higher concentrations result in severe headache Hypercapnic drive is necessary for breathing in COPD As the disease progresses, higher O2 flow rates will be required Hypoxic drive is needed for breathing

Hypoxic drive is needed for breathing.

The nurse teaches a patient how to use an incentive spirometer. The nurse understands that the most appropriate expected outcome associated with the use of an incentive spirometer is: Coughing will be stimulated Sputum will be expectorated Inspiratory volume will be increased Supplemental oxygen use will be reduced

Inspiratory volume will be increased

The nurse is caring for a client who is wearing oxygen via nasal cannula. The client asks about the bubbling water attached to the oxygen. Which response by the nurse is appropriate? It regulates the amount of oxygen received. It determines whether you are getting enough oxygen. It decreases dry mucous membranes by delivering small water droplets. It prescribes oxygen concentration.

It decreases dry mucous membranes by delivering small water droplets.

Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen? It determines whether the client is getting enough oxygen. It decreases dry mucous membranes via delivering small water droplets. It regulates the amount of oxygen received. It prescribes oxygen concentration.

It determines whether the client is getting enough oxygen.

The nurse in charge is teaching a client with emphysema how to perform pursed-lip breathing. The client asks the nurse to explain the purpose of this breathing technique. Which explanation should the nurse provide? It helps prevent airway collapse during expiration. It increases inspiratory muscle strength. It decreases use of accessory breathing muscles. It prolongs the inspiratory phase of respiration.

It helps prevent airway collapse during expiration.

Toxicity from which of the following medications may cause a client to see a green-yellow halo around lights? A) Lanoxin (Digoxin) B) Furosemide (Lasix) C) Metoprolol (Lopressor) D) Enalapril (Vasotec)

Lanoxin (Digoxin)

An unconscious patient who had oral surgery is admitted to the post-anesthesia care unit. In what position should the nurse place the patient? Prone position Supine position Lateral position Fowler's position

Lateral position

Which of the following landmarks is correct for obtaining an apical pulse? Left intercostal space, midaxillary line Left fifth intercostal space, midclavicular line Left second intercostal space, midclavicular line Left seventh intercostal space, midclavicular line

Left fifth intercostal space , midclavicular line.

After an anterior wall myocardial infarction, which of the following problems is indicated by auscultation of rales? Atrial septal defect Right heart failure Left heart failure Tricuspid valve regurgitation

Left heart failure

The nurse is caring for a patient who has a chest tube after thoracic surgery. The nurse should: Clamp the tube when providing for activities of daily living Position the collection device at the same level as the chest Maintain an airtight dressing over the puncture wound Empty chest tube drainage every eight hours

Maintain an airtight dressing over the puncture wound

Which is the most important action by the nurse after a patient has a thoracotomy? Ensure the patient's intake is at least 3000 mL of fluid per 24 hours. Provide the patient with adequate medication for pain relief. Maintain the integrity of the patient's chest tube. Reposition the patient every 2 hours.

Maintain the integrity of the patient's chest tube.

The nurse is educating a client on the proper use of inhaled medications. What are appropriate education points to include? select all that apply: Metered-dose inhalers deliver a controlled dose of medications with each compression of the canister. Inhaled corticosteroids should be followed by rinsing mouth with water. Nebulizers are used to deliver a controlled dose of medication with each compression of the canister. When using an MDI, the client should shake the device before inhaling.

Metered-dose inhalers deliver a controlled dose of medications with each compression of the canister. Inhaled corticosteroids should be followed by rinsing mouth with water. When using an MDI, the client should shake the device before inhaling.

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? face tent nasal cannula simple mask nonrebreather mask

Nasal cannula

When assessing a patient, which adaptation indicates the presence of respiratory distress? Rate of fourteen breaths per minute Productive cough Sore throat Orthopnea

Orthopnea

A nurse must deliver oxygen at a concentration of 85% to an infant. Which delivery device would be most appropriate for an infant? Nasal cannula Venturi mask Simple mask Oxygen hood

Oxygen hood

An obese patient had limited mobility after an open reduction and internal fixation of a fractured hip. The nurse should monitor this patient for the most serious complication of increased blood coagulability precipitated by immobility which is: Muscle atrophy Pain in the calf Hypotension Bradypnea

Pain in the calf

A patient is admitted with the diagnosis of peripheral arterial disease. Which is a specific desirable outcome for a patient with this diagnosis? Respirations within the expected range Palpable peripheral pulses Prolonged capillary refill

Palpable peripheral pulses

When the head of the bed is elevated to facilitate breathing, the main principle that explains how this action facilitates respiration is based on the science of: 1. Physics 2. Biology 3. Anatomy 4. Chemistry

Physics

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? Tachypnea Wheezes Pneumonia Pleural effusion

Plural effusion

When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing: Malnutrition Anemia Poor tissue perfusion Congestive heart failure

Poor tissue perfusion

A client with pulmonary edema has been on diuretic therapy. The client has an order for additional furosemide (lasix) in the amount of 40 mg IV push. Knowing that the client also will be started on Lanoxin (Digoxin), a nurse check the client's most recent: Digoxin level Sodium level Potassium level Creatine level

Potassium level

Myocardial oxygen consumption increases as which of the following parameters increase? Preload, afterload, and cerebral blood flow Preload, afterload, and heart rate Preload, afterload, and renal blood flow Preload, afterload, and respiratory rate

Preload, afterload, and heart rate

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? thoracentesis peak expiratory flow rate spirometry pulse oximetry

Pulse oximetry

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? thoracentesis pulse oximetry spirometry peak expiratory flow rate

Pulse oximetry

A patient sucking on a hard candy inhales while laughing and develops a total airway obstruction. When the nurse implements abdominal thrusts, the nurse is attempting to: Produce a burp Pump the heart Push the air out of the lungs Put pressure on the stomach

Push air out of the lungs.

The nurse teaches a patient to make a series of short, forceful exhalations just before actually coughing (huffing). The purpose of this action is to: Conserve the patient's energy Liquify the respiratory secretions Limit the pain precipitated by coughing Raise the sputum to a level where it can be expectorated

Raise the sputum to a level where it can be expectorated

The nurse is caring for a patient receiving oxygen via nasal cannula. The nurse should: Reassess the nares, cheeks, and ears for signs of pressure every 2 hours Loop the tubing over the patient's ears and adjust the tubing firmly under the chin Ensure physical hygiene includes applying oil-based lubricant to the patient's nares Alternate the position of the prongs curving upward versus downward every 2 hours.

Reassess the nares, cheeks, and ears for signs of pressure every 2 hours

A client vomits as a nurse is inserting his oropharyngeal airway. What would be the most appropriate intervention in this situation? Leave the airway in place and promptly notify the health care provider for further instructions. Immediately remove the airway, rinse the client's mouth with sterile water, and report this to the health care provider. Suction the client's mouth through the oropharyngeal airway to prevent aspiration. Remove the airway, turn the client to the side, and provide mouth suction, if necessary.

Remove the airway, turn the client to the side, and provide mouth suction, if necessary

A meal tray arrives for a patient who is receiving 24% oxygen via a Venturi mask. To meet this patient's needs, the nurse should: Request an order to use a nasal cannula during meals Discontinue the oxygen when the patient is eating meals Obtain an order to change the mask to a non-rebreather mask during meals Arrange for liquid supplements that can be administered via straw through a valve in the mask

Request an order to use a nasal cannula during meals

The practitioner's order reads, "6 L Oxygen Via Face Mask." The patient, who has been extremely confused since being in the unfamiliar environment of the hospital, becomes agitated and repeatedly pulls off the mask. The nurse should: Tighten the trap around the head Reapply the mask every time the patient pulls it off Provide an explanation of why the oxygen is necessary Request that the order for oxygen be changed to a nasal cannula

Request that the order for oxygen be changed to a nasal cannula

Which adaptation is of most concern when the nurse assesses pulmonary changes associated with immobility? Shallow breathing Increased oxygen saturation Decreased chest wall expansion Respirations that sound gurgling

Respirations that sounds gurgling

Which nursing assessment best indicates a patient's ability to tolerate activity? Results of vital signs before and after activity Presence of adventitious breath sounds Flexibility of muscles and joints Complaints of weakness

Results of vital signs before and after activity

The nurse is teaching a patient how to use an incentive spirometer. The nurse should assist the patient to assume which position? Sitting Side-lying Orthopneic Low-Fowler's

Sitting

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. Cut down on smoking. Practice good hand hygiene. Avoid exposure to large crowds.

Stay indoors as much as possible

A new graduate nurse is performing a focused respiratory assessment. The nurse preceptor will intervene if which action by the graduate nurse is noted? The graduate nurse auscultates breath sounds as the client breathes through the nose. The graduate nurse explains the assessment procedure before performing it. The graduate nurse palpates the point of maximal impulse (PMI). The graduate nurse attaches a pulse oximeter to the client's index finger.

The graduate nurse auscultates breath sounds as the client breathes through the nose.

The nurse is caring for a client who is receiving continuous oxygen at 3 L/minute via nasal cannula. The client's oxygen saturation has consistently been 94% to 96%, but suddenly drops to 86% as the nurse palpates the client's abdomen. The client denies respiratory difficulty or other distress. What is a likely reason for the client's decreasing oxygen saturation? The client's appendix has ruptured. The nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen. The client has developed a pulmonary embolism and has a ventilation-perfusion mismatch. The client is holding his or her breath.

The nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen.

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

They are low-pitched, soft sounds heard over peripheral lung fields.

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. They are medium-pitched blowing sounds heard over the major bronchi. They are soft, high-pitched discontinuous (intermittent) popping lung sounds. They are loud, high-pitched sounds heard primarily over the trachea and larynx.

They are low-pitched, soft sounds heard over peripheral lung fields.

Which is used to describe the volume of an air inspired and expired with a normal breath? Vital capacity Tidal volume Total lung capacity Peak expiratory flow rate

Tidal volume

The major difference between pursed-lip breathing and diaphragmatic breathing is with diaphragmatic breathing the patient: Inhales through the mouth Exhales through pursed-lips Raises both shoulders while breathing deeply Tightens the abdominal muscles while exhaling

Tightens the abdominal muscles while exhaling

What is the primary reason for administering morphine to a. client with myocardial infarction? To sedate the client To decrease pain To decrease anxiety To decrease oxygen demand on the heart

To decrease oxygen demand on the heart (MONA)

Which of the following blood tests is most indicative of cardiac damage? Electrolytes Complete blood count Troponin 1 Creatine kinase

Troponin 1

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 False

True

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. Using a spare endotracheal tube of the same size as being used for the client, insert the suction catheter halfway to the end of the tube and note the length of catheter used to reach this point. 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. For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.

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.

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 Stridor Crackles Absent breath sounds in lower lobes

Wheezing

The nurse auscultates a client with soft, high-pitched popping breath sounds on inspiration. The nurse documents the breath sounds heard as: wheezes. crackles. vesicular. bronchovesicular.

crackles

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? mineral oil distilled water tap water normal saline

distilled water

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 Partial rebreather mask Simple mask Nonrebreather mask

nasal cannula

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? nasal cannula simple mask tracheostomy collar face tent

tracheostomy collar

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 face tent simple mask nasal cannula

tracheostomy collar

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 Crackles Absent breath sounds in lower lobes Stridor

wheezing