Foundations -- Module 14: Oxygenation

A, B, D, E Monitor for restlessness, which is an early manifestation of hypoxia, along with tachycardia, elevated BP, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds. Monitor for tachypnea, which is an early manifestation of hypoxia. Bradycardia is a late manifestation of hypoxia, along with stupor, cyanotic skin and mucous membranes, bradypnea, hypotension, and cardiac dysrhythmias. Monitor for confusion, which is an early manifestation of hypoxia.

A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? Select all that apply. a. restlessness b. tachypnea c. bradycardia d. confusion e. hypertension

A, B, C Provide supplemental oxygen in response to any decline in oxygen saturation while performing tracheostomy care. Use a sterile disposable tracheostomy cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure. Cleanse the exposed surfaces of the outer cannula and the area around and under the faceplate in a circular motion from the stoma site outward. Cleansing in this manner helps move mucus and contaminated material away from the stoma for easy removal.

A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? Select all that apply. a. Apply the oxygen source loosely if the SpO2 decreases during the procedure. b. Use surgical asepsis to remove and clean the inner cannula. c. Clean the outer cannula surfaces in a circular motion from the stoma site outward. d. Replace the tracheostomy ties with new ties. e. Cut a slit in gauze squares to place beneath the tube holders.

B -- The priority action to be taken when using airway, breathing, circulation (ABC) approach to care delivery is to relieve dyspnea. Fowler's position facilitates maximal lung expansion and thus optimizes breathing.

A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? a. increase the oxygen flow b. assist the client to Fowler's position c. promote removal of pulmonary secretions d. obtain a specimen for arterial blood gases

C -- During inspiration, the diaphragm contracts and descends, lengthening the thoracic cavity. This movement is facilitated by a high-Fowler's position in which the abdominal contents move downward, providing more room for the descent of the diaphragm and greater lung expansion.

A nurse is caring for a client who suddenly begins to have respiratory difficulty. In what position would the nurse place the client to facilitate respirations? a. supine b. prone c. high-fowlers d. dorsal recumbent

B -- Pulse oximetry is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma. Diffusion capacity estimates the patient's ability to absorb alveolar gases and determines if a gas exchange problem exists. Maximal respiratory pressures help evaluate neuromuscular causes of respiratory dysfunction. Both tests are usually performed by a respiratory therapist. The physician or other advanced practice professional can perform a thoracentesis at the bedside with the nurse assisting, or in the radiology department.

A nurse is caring for a patient who has been hospitalized for an acute asthma exacerbation. Which testing might the nurse use to measure the patient's oxygen saturation? a. thoracentesis b. pulse oximetry c. maximal respiratory pressure d. vital capacity

B -- The nursing diagnosis Ineffective Airway Clearance indicates the child is unable to clear secretions or obstructions from the respiratory tract to maintain a clear airway. Although the child is anxious, this is not the priority of care. The other two diagnoses are not supported by the data.

A nurse is caring for a toddler who is having an acute asthmatic attack with copious mucus and difficulty breathing. The child's skin is cyanotic, respirations are labored and rapid, and pulse is rapid. What nursing diagnosis would have priority for care of this child? a. Anxiety b. Ineffective Airway Clearance c. Excess Fluid Volume d. Disturbed Sensory Perception

D -- Pursed-lip breathing can help clients with dyspnea and feelings of panic gain control of their respirations. This exercise trains the muscles to prolong expiration, increasing airway pressure during expiration, and reducing the amount of airway trapping and resistance.

A nurse is educating a home care client on how to do pursed-lip breathing. What is the therapeutic effect of this procedure? a. using upper chest muscles more effectively b. replacing the use of incentive spirometry c. reducing the need for p.r.n pain medications d. prolonging expiration to reduce airway resistance

A -- Instruct the client to make each breath deep enough to move the bottom ribs. Start with deep breaths by inhaling through the nose and exhaling through the mouth. Deep breathing should be done hourly when awake, or four times a day.

A nurse is educating a preoperative client on how to effectively deep breathe. Which of the following would be included? a. "Make each breath deep enough to move the bottom ribs." b. "Breathe through the mouth when you inhale and exhale." c. "Breathe in through the mouth and out through the nose." d. "Practice deep breathing at least once a week."

pleural effusion

build-up of excess fluid between the layers of the pleura outside the lungs

21%

Room air (RA) is ____% fraction of inspired air.

D -- A nebulizer is used to adminster medications in the form of an inhaled mist. Bronchodilators are medications that may be administered by nebulizer or metered-dose inhaler to open narrowed airways. Antihistamines are not administered via nebulizer; they are prescribed to manage allergy-related symptoms. Narcotics are not administered via nebulizer; they are used to manage complaints of pain.

What category of medications may be administered by nebulizer or metered-dose inhaler to open narrowed airways? a. bronchoconstrictors b. antihistamines c. narcotics d. bronchodilators

C -- Pulse oximetry is a noninvasive technique that measures the oxygen saturation of arterial blood. The normal range is 95% to 100%. It does not measure cardiac output, peripheral blood flow, or venous oxygen saturation.

What does pulse oximetry measure? a. cardiac output b. peripheral blood flow c. arterial oxygen saturation d. venous oxygen saturation

pH, carbon dioxide, bicarbonate, pO2, SaO2

What findings are on an ABG?

thoracostomy

What is a chest tube insertion called?

increase in troponin levels

What is an indicator of MI?

0-0.4 ng/mL

What is the normal range for troponin?

22-198 U/L

What is the normal range of creatine kinase?

to keep tongue clear of airway

What is the purpose of the oropharyngeal airway?

C

Which nursing intervention is most appropriate for preventing atelectasis in the postoperative patient? a. postural drainage b. chest percussion c. incentive spirometer d. suctioning

A -- If a chest tube becomes disconnected from the drainage unit, the nurse should submerge the end of the tube in a bottle of sterile water, thus preventing a pneumothorax but still allowing air to escape.

While the nurse is providing morning hygiene for a client who has a chest tube, the client has rolled over quickly and the chest tube has become disconnected from the drainage unit. How should the nurse first respond to this event? a. submerge the end of the tube in sterile water b. clamp the tube near the end and also near the insertion point c. place the end of the tube on a sterile surface and seek help promptly d. clean the end of the tube with an alcohol swab and reconnect it to the drainage unit

hypoxia

a condition in which an inadequate amount of oxygen is available to cells

oropharyngeal/nasopharyngeal airway

a semicircular tube of plastic or rubber inserted into the back of the pharynx through the mouth or nose in a patient who is breathing spontaneously

trach tube

an artificial opening made into the trachea, usually at the level of the second or third cartilaginous ring

wheezes

continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors

vesicular

low-pitched, soft sound during expiration heard over most of the lungs

Passy Muir Valve

one way valve attached to a trachestomy tube that allows for vocalization

endotracheal tube

polyvinyl-chloride airway that is inserted through the nose or the mouth into the trachea, using a laryngoscope as a guide

fraction of inspired oxygen (FiO2)

the percentage of oxygen the client receives

pleura

thin membranes the line the lungs and the inside of the chest cavity and act to lubricate and facilitate breathing

B -- The preschool-age child's eustachian tubes, bronchi, and bronchioles are elongated and less angular. Thus, the average number of routine colds and infections increases when the child enters daycare or school and is exposed more frequently to pathogens.

A father of a preschool-age child tells the nurse that his child "has had a constant cold since going to daycare." How would the nurse respond? a. "Your child must have a health problem that needs medical care." b. "Children in daycare have more exposures to colds." c. "Are you washing your hands before you touch the child?" d. "Be sure and have your child wear a protective mask at school."

D -- In individuals with chronic obstructive pulmonary disease and similar lung problems, the clinical features of oxygen toxicity are due to high carbon dioxide content in the blood (hypercapnia). This leads to drowsiness (narcosis), deranged acid-base balance due to respiratory acidosis, and death.

A patient has been newly diagnosed with COPD. In discussing his condition with the nurse, which of his statements would indicate a need for further education? a. "I'll make sure that I rest between activities so I do not get so short of breath." b. "I will rest for 30 minutes before I eat my meal." c. "If I have trouble breathing at night, I will use 2-3 pillows to prop up." d. "If I get short of breath, I will turn up my oxygen level to 6 L/min."

B -- The client using an incentive spirometer should exhale normally and place the lips around the mouthpiece. He or she should inhale slowly and deeply without using the nose, and when the client cannot inhale anymore, hold the breath and count to 3 before exhaling normally. This should be performed 5 to 10 times every one to two hours, if possible.

A nurse is educating a postoperative client on how to use an incentive spirometer. Which of the following is an accurate step that should be included in the teaching plan? a. Instruct the client to inhale normally and then place the lips securely around the mouthpiece. b. Instruct the client to inhale slowly and as deeply as possible through the mouthpiece, without using the nose c. When the client cannot inhale anymore, the patient should hold his breath and count to 10 d. encourage the patient to perform incentive spirometry 2-3 times every 1-2 hours, if possible

A -- A chest tube is a firm plastic tube with drainage holes in the proximal end that is inserted into the pleural space, thus allowing compressed lung tissue to re-expand.

A nurse is explaining a chest tube to family members who do not understand where it is placed. What would the nurse tell them? a. "It is inserted into the space between the lining of the lungs and the ribs." b. "I do not know exactly. I will make sure the doctor comes to explain." c. "It is inserted directly into the lung itself, connecting to a lung airway." d. "It is inserted into the peritoneal space and drains into the lungs."

A -- When using a nasal cannula to deliver oxygen to a client, the nurse should remember that the nasal cannula can cause the nasal mucosa to dry in case of high oxygen flow. A simple mask can cause anxiety in clients who are claustrophobic. Clients using a partial rebreather mask are at risk of suffocation. A face tent may deliver an inconsistent amount of oxygen, depending on environmental loss.

A nurse uses a nasal cannula to deliver oxygen to a client who is extremely hypoxic and has been diagnosed with chronic lung disease. What is the most important thing to remember when using a nasal cannula? a. it can cause the nasal mucosa to dry in case of high flow b. it can cause anxiety in clients who are claustrophobic c. it can create a risk of suffocation d. it can result in an inconsistent amount of O2

Venturi mask

mask which delievers the most precise concentrations of oxygen

vital capacity

maximum amount of air exhaled after maximum inspiration

bronchovesicular

medium pitch and sound during expiration, heard over the upper anterior chest and intercostal area

heart failure

occurs when the heart is unable to pump a sufficient blood supply, resulting in adequate perfusion and oxygenation of tissues

thoracentesis

procedure in which a needle is inserted into the pleural space between the lungs and the chest wall in order to remove excess fluid, known as pleural effusion

CPAP (continuous positive airway pressure)

provides continuous mild air pressure to keep airways open

surfactant

reduces the surface tension between the moist membranes of the alveoli, preventing their collapse

cardiac output

the amount of blood pumped per minute

alveoli

the endpoint of the respiratory system

atelectasis

the incomplete lung expansion or the collapse of alveoli; prevents pressure changes and the exchange of gas by diffusion in the lungs

pulmonary ventilation

the movement of air into and out of the lungs

diffusion

the movement of gas or particles from areas of higher pressure or concentration to areas of lower pressure or concentration

perfusion

the process by which oxygenated capillary blood passes through body tissues

stroke volume

the quantity of blood forced out of the left ventricle with each contraction

C -- The effects of both active and passive cigarette smoke increase airway resistance, reduce ciliary action, increase mucus production, and thicken alveolar-capillary membranes and bronchial walls. Cigarette smoke is the most important risk factor in pulmonary disease.

Of all factors, what is the most important risk factor in pulmonary disease? a. air pollution from vehicles b. dangerous chemicals in the workplace c. active and passive cigarette smoke d. loss of the ozone layer of the atmosphere

A -- Lung compliance refers to the stretchability of the lungs, or the ease with which lungs can be inflated. Emphysema, a chronic lung disease, and the normal changes associated with aging are examples of conditions that result in decreased elasticity of lung tissue, which in turn decreases lung compliance.

Which of the following diseases may result in decreased lung compliance? a. emphysema b. appendicitis c. acne d. chronic diarrhea

A -- • Interventions appropriate for the nursing diagnosis of excess fluid volume include assessing respiratory status and lung sounds every 4 hours and prn. Assessment of the respiratory status is the priority; The other interventions are appropriate but not #1 priority.

Which of the following interventions would be a top priority for a patient with the nursing diagnosis of excess fluid volume? a. assess respiratory status and breath sounds every 4 hours and PRN b. provide oxygen as prescribed c. monitor strict intake and output d. provide information about activity upon discharge

C -- At the end of the terminal bronchioles, there are clusters of alveoli that are the site of gas exchange. The wall of each alveolus is made of a single-cell layer of squamous epithelium. This thin wall allows for exchange of gases within the capillaries covering the alveoli.

Which respiratory structure is the site of gas exchange? a. mediastinum b. parietal pleura c. alveoli d. diaphragm

stable angina

a temporary imbalance between the amount of oxygen needed by the heart and the amount delivered to the heart muscles

C -- The medulla in the brain stem, immediately above the spinal cord, is the respiratory center. Stretch receptors are located in muscles. Chemoreceptors that affect respirations are located in the aortic arch and the carotid bodies.

A client has had a head injury affecting the brain stem. What is located in the brain stem that may affect respiratory function? a. chemoreceptors b. stretch receptors c. respiratory center d. oxygen center

A -- Clients who are hypoxic commonly experience anxiety and restlessness related to feelings of suffocation.

A client is experiencing hypoxia. Which of the following nursing diagnoses would be appropriate? a. anxiety b. nausea c. pain d. hypothermia

A -- Any change in the surface area of the lungs hinders diffusion of gas exchange. Any disease or condition that results in changes in the alveolar-capillary membrane, such as pneumonia or pulmonary edema, makes diffusion more difficult, assessed by decreased oxygen saturation measurement.

A nurse is caring for a client with pneumonia. The client's oxygen saturation is below normal. What abnormal respiratory process does this demonstrate? a. changes in the alveolar capillary membrane and diffusion b. alterations in the structures of the ribs and diaphragm c. rapid decreases in atmospheric and intrapulmonic pressures d. lower than normal concentrations of environmental oxygen

A, B, D -- would typically not see hypotension, but hypertension

A nurse is caring for a patient with chronic obstructive pulmonary disease (COPD) knows that hypoxia may occur in patients with respiratory problems. What are signs of this serious condition? Select all that apply. a. dyspnea b. tachycardia c. hypotension d. pallor

A, D, E Tracheal deviation typically occurs away from affected side in pneumothorax.

A patient was admitted following a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of pneumothorax. Which are the most common assessment findings associated with a pneumothorax? (Select all that apply). a. sharp pleuritic pain that worsens on inspiration b. crackles over lung bases of affected lung c. tracheal deviation toward affected lung d. worsening dyspnea e. absent lung sounds to auscultation on affected side

low flow oxygen, typically 5-8 L

What kind of oxygen does a simple face mask provide?

10-15 L

What kind of oxygen does non-rebreather masks provide?

8-11 L

What kind of oxygen does partial rebreather masks provide?

- patients after surgery - COPD patients - any patients with respiratory issues

What patients will benefit from using an incentive spirometer?

C -- After insertion, the chest tube is secured with a suture and tape, covered with an airtight dressing, and usually attached to a closed water-seal drainage system that prevents air from reentering the pleural space

What prevents air from re-entering the pleural space when chest tubes are inserted? a. the location of the tube insertion b. the sutures that hold in the tube c. a closed water-seal drainage system d. respiratory inspiration and expiration

hemoglobin and hematocrit

Which labs show how much O2 the patient's blood is getting?

rhonchi

adventitous breath sound heard in patients with COPD, pneumonia, chronic bronchitis, or cystic fibrosis

myocardial ischemia

decreased oxygen supply to the heart caused by insufficient blood supply

hypventilation

decreased rate or depth of air movement into the lungs

CPAP (continuous positive airway pressure)

deliver a steady, continuous stream of pressurized air to patient's airway to prevent them from collapsing and causing apnea events

nebulizers

disperse fine particles of liquid medication into the deeper passages of thee respiratory tract, where absorption occurs

cough suppressants

drugs that depress the cough reflex

corticosteroids

drugs that reduce inflammation in the structures of the lung

nasal cannula

tubing with two small prongs for insertion into the nares

pursed lip breathing

type of breathing great for patients who are anxious about having difficulty breathing (especially COPD/chronic lung patients)

dry powder inhaler (DPI)

types of breath-activated delivery methods for inhaled medications

rhonchi

continuous low pitched, rattling lung sounds that often resemble snoring

trachea, right and left mainstem bronchi, segmental bronchi, terminal bronchioles

What are the components of the lower airway?

nose, pharynx, larynx, epiglottis

What are the components of the upper airway?

respiration

involves gas exchange between the atmospheric air in the alveoli and blood in the capillaries

A, D, E Apply suction pressure only while withdrawing the catheter to prevent damaging the tracheal tissue. Suction the client's airway only as needed, because suctioning is not without risk. It can cause mucosal damage, bleeding, and bronchospasm. Use surgical asepsis when performing endotracheal suctioning to prevent contamination with microorganisms that can cause an infection. Use a new suction catheter, unless an in-line suctioning system is in place, to prevent contamination with microorganisms that can cause an infection. To prevent hypoxemia, apply suction for only 10-15 seconds and allow 2-3 minutes between passes for ventilation and oxygenation.

A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? Select all that apply. a. apply suction while withdrawing the catheter b. perform suctioning on a routine basis every 2-3 hrs c. maintain medical asepsis during suctioning d. use a new catheter for each suctioning attempt e. apply suction for 10-15 seconds

D -- The dry suction or one-way valve system works even if knocked over, making it ideal for clients who are ambulatory.

A physician is choosing a chest drainage system for a client who is ambulating daily. Which of the following systems would be the best choice for this client? a. traditional water seal b. wet suction c. dry suction water seal d. dry suction/one-way valve system

C, D, E Teach the client to apply a water-based lubricant to protect the nares from drying during oxygen therapy. Teach the client to leave the nasal cannula on while eating, because it does not interfere with eating. Teach the client about oxygen toxicity, which is a complication of oxygen therapy, usually from high concentrations or long durations. Manifestations include a nonproductive cough, substernal pain, nausea, and vomiting.

A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? Select all that apply. a. apply petroleum jelly around and inside the nares b. remove the nasal cannula during mealtimes c. check the position of the nasal cannula frequently d. report any nausea or difficulty breathing e. post "no smoking" signs in prominent locations

A, B, C

Appropriate follow-up evaluation of a patient after suctioning includes the following: (Select all that apply). a. assessment of vital signs b. document the appearance of any secretions noted c. compare findings to previous assessment data d. only document abnormal findings; the physician will see the results when rounding

4-6 L

How much oxygen does venturi mask provide?

A

The nurse is explaining the reason for the use of incentive spirometry. The patient verbalizes understanding when he states: a. This device will help me breathe more deeply and expand my lungs. b. This device will help stop my coughing. c. This device will allow me to blow up the ball to 200. d. I won't have to take my cough medication if I use this device.

oxyhemoglobin

Most oxygen (97%) is carried by RBCs in the form of __________.

D -- The normal range for an infant's breath per minute is 30-60.

A nurse assesses the vital signs of a healthy newborn infant. What respiratory rate could be expected based on the developmental level of this client? a. 15-25 breaths/minute b. 16-20 breaths/minute c. 20-44 breaths/minute d. 30-55 breaths/minute

D -- Before beginning the interview for a health history, the nurse should ascertain that the client is not in acute distress. If the client is experiencing any respiratory distress, the nurse immediately initiates interventions to help relieve symptoms.

A nurse is beginning to conduct a health history for a client with respiratory problems. He notes that the client is having respiratory distress. What would the nurse do next? a. continue with the health history, but more slowly b. ask questions of the family instead of the client c. conduct the interview later and let the client rest d. initiate interventions to help relieve the symptoms

A, C, D The nurse should inform the client who has been prescribed the use of a liquid oxygen unit that the unit may leak during warm weather; frozen moisture may occlude the outlet; and the unit is more expensive when compared with other portable sources of oxygen. Emission of a bad smell if filters are not cleaned, increase in the electric bill, and requirement of a secondary source of oxygen in case of failure are disadvantages of using an oxygen concentrator and are not related to the use of a liquid oxygen unit.

A nurse is caring for an older adult client who is to be discharged from the health care facility. The client has been prescribed the use of a liquid oxygen unit at home to continue with oxygen therapy. What should the nurse tell the client regarding the potential problems of using a liquid oxygen unit? Select all that apply. a. liquid oxygen may leak during warm weather b. the unit may give off a bad smell if not cleaned regularly c. the unit's outlet may become occluded because of frozen mixture d. portable liquid oxygen is more expensive e. the unit may require a secondary source of O2

B -- Smoking inhibits mucus removal. By producing more mucus and by slowing the mucous escalator, smoking inhibits mucus removal and can cause airway blockage, promoting bacterial colonization and infection.

A nurse is conducting a health promotion program for adolescents to educate them about the hazards of smoking. When describing the effects on the respiratory system, which of the following would the nurse most likely include? a. decreased production of mucous b. inhibition of mucus removal c. increase in the mucus escalator d. inhibition of bacterial colonization

C -- To apply an oxygen mask, position the facemask over the client's nose and mouth and adjust the elastic strap so that the mask fits snugly, but comfortably, on the face. For a mask with a reservoir, be sure to allow oxygen to fill the bag before proceeding to the next step. Remove the mask and dry the skin every two to three hours if the oxygen is running continuously; do not use powder around the mask.

A nurse is delivering oxygen to a client via an oxygen mask. Which of the following is a recommended guideline for this procedure? a. Adjust the mask so it fits snugly around the face. b. For a mask with a reservoir, fill the reservoir half-full of O2. c. Remove the mask and dry the skin every 2-3 hours if the O2 is running continuously. d. If the client is experiencing redness around the mask, remove and apply powder to the mask.

B -- Clients can keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of clear fluids daily. Fluid intake should be increased to the maximum the client's health state can tolerate.

A nurse is educating a client who has congested lungs how to keep secretions thin, and more easily coughed up and expectorated. What would be one self-care measure to teach? a. limit oral intake of fluids to less than 500 mL per day b. increase oral intake of fluids to 2-3 quarts per day c. maintain bed rest for at least 3 days d. take warm baths every night for a week

B -- When using water-seal chest tube drainage, the nurse should never separate the chest tube from the drainage system unless clamped. Even then, the tube should be clamped only briefly. When using an oxygen concentrator as a source of oxygen, the nurse should clean the filter regularly to avoid an unpleasant taste or smell. A secondary source of oxygen should also be available in case of a power failure. When cleaning a transtracheal catheter, oxygen needs to be administered with a nasal cannula.

A physician prescribes the use of water-seal chest tube drainage for a client at a health care facility. What should the nurse ensure when using the water-seal chest tube drainage? a. filters need to be cleaned regularly to avoid unpleasant taste or smell b. the chest tube should not be separated from the drainage system unless clamped c. a nasal cannula should be used to administer O2 when cleaning the opening d. a secondary source of O2 should be available in case of power failure

A -- The normal changes in the respiratory system associated with aging (such as rigidity of tissues and airways and decreased movement of the diaphragm) coupled with fractured ribs would increase the risk of pneumonia in an older adult.

A woman 90 years of age has been in an automobile crash and sustained four fractured ribs on the left side of her thorax. Based on her age and the injury, she is at risk for what complication? a. pneumonia b. altered thought process c. urinary incontinence d. viral influenza

A -- Wheezes are continuous sounds heard on expiration and sometimes on inspiration. They originate as air passes through airways constricted by swelling (as in asthma), secretions, or tumors.

An emergency room nurse is auscultating the chest of a child who is having an asthmatic attack. Auscultation reveals the presence of wheezes. During what part of respirations do wheezes occur? a. inspiration and expiration b. only on inspiration c. only on expiration d. when coughing

hypoventilation

Hypoxia is often caused by _________________.

D -- The normal infant's chest is small and the airways are short. There are fewer and smaller alveoli in infants. As a result, the respiratory rate is more rapid in infants than any other age group.

In what age group would a nurse expect to assess the most rapid respiratory rate? a. older adults b. middle adults c. adolescents d. infants

A -- People with chronic congestive heart failure often experience shortness of breath because of excess fluid in the lungs and low oxygen levels. Stridor is associated with respiratory infections such as croup. Wheezing may be heard in individuals who use tobacco products.

The home care nurse visits a client who has dyspnea. The nurse notes the client has pitting edema in his feet and ankles. What additional assessment would the nurse expect to observe? a. crackles in the lower lobes b. inspiratory stridor c. expiratory stridor d. wheezing in the upper lobe

D -- Continuous low pitched, rattling lung sounds that often resemble snoring. Obstruction or secretions in larger airways are frequent causes of rhonchi. They can be heard in patients with chronic obstructive pulmonary disease (COPD), bronchiectasis, pneumonia, chronic bronchitis, or cystic fibrosis.

The nurse assesses a patient on the acute care medical unit with a diagnosis of COPD. What common adventitious breath sound will the nurse anticipate to find on auscultation in the COPD patient? a. wheezing b. stridor c. pleural rub d. rhonchi

A -- The nurse should consider providing six small meals distributed over the course of the day instead of three large meals. Meals should be eaten one to two hours after breathing treatments and exercises.

The nurse caring for a client with emphysema has determined that a priority nursing diagnosis for this client is "Imbalanced Nutrition: Less Than Body Requirements related to difficulty breathing while eating." Based upon this diagnosis, which of the following is an appropriate nursing intervention to include in the client's care plan? a. provide 6 small meals daily b. provide 3 large meals daily c. encourage the client to eat immediately before breathing treatments d. encourage the client to alternate eating and using a nebulizer during meal time

D -- Insufficient arterial blood flow causes decreased nutrition and oxygenation at the cellular level. Decreased tissue perfusion can be temporary, with few or minimal consequences to the health of the patient, or it can be more acute or protracted, with potentially destructive effects on the patient. When diminished tissue perfusion becomes chronic, it can result in tissue or organ damage or death.

The nurse is assessing a patient with a new diagnosis of angina. Which NANDA is most appropriate? a. imbalanced nutrition: less than body requirements b. excess fluid volume c. risk for electrolyte imbalance d. risk for decreased cardiac tissue perfusion

C -- Asthma exacerbation is characterized by constricted (narrowing) airways. Bronchodilators dilate airways in order to assist breathing.

The nurse is caring for a patient in an acute asthma exacerbation. Which category of medications will be most effective to assist the patient? a. antihistamines b. expectorant c. bronchodilator d. opioid pain medication

B

The nurse is caring for a patient who has decreased mobility. Which intervention is a simple and cost-effective method for reducing the risks of pulmonary complications? a. antibiotics b. frequent change of position c. oxygen humidification d. chest physiotherapy

A -- Stiffer lungs tend to collapse and their alveoli also collapse. This condition is called atelectasis.

The nurse is caring for a postoperative adult client who has developed pneumonia. The nurse should assess the client frequently for symptoms of: a. atelectasis b. bronchospasm c. croup d. epiglottitis

A -- Clients can help keep their secretions thin by drinking two to three quarts (1.9 L to 2.9 L) of clear fluids daily. Although it is important to create an environment that is likely to reduce a client's anxiety, doing so will not assist in promoting airway clearance. The nurse should not encourage the client to decrease the number of cigarettes smoked daily, but should encourage the client to stop smoking. Proper positioning to ease respirations includes placing the client in a high- Fowler's position.

The nurse is developing a plan of care for a client admitted with pneumonia. The nurse has determined that a priority nursing diagnosis for this client is "Ineffective Airway Clearance related to copious and tenacious secretions." Based upon this nursing diagnosis, what is an appropriate nursing intervention to include in the client's care plan? a. encouraging the client to consume 2-3 quarts of clear fluids daily b. creating an environment that is likely to reduce anxiety c. positioning the client supine d. encouraging the client to decrease the number of cigarettes smoked daily

B -- Peak expiratory flow rate (PEFR) refers to the volume of air that can be forcibly exhaled. While sitting or standing, the client takes a deep breath and forcibly exhales through a mouthpiece. The client does this three times, and the highest number is recorded. Clients commonly measure PEFR at home to monitor airflow when they have conditions such as asthma.

What information would a home care nurse provide to a client who is measuring peak expiratory flow rate at home? a. "Although the test is uncomfortable, it is not painful." b. "You will be asked to forcefully exhale into a mouthpiece." c. "The test is used to determine how much air you inhale." d. "You will do this each morning while still lying in bed."

1-6 L

What is considered low-flow oxygen?

3.5-8 L/min CO = SV x HR

What is the average cardiac output? How do you find cardiac output?

smoking

What is the most common risk factor and contributor to the development of COPD?

low flow oxygen (1-6 L)

What kind of oxygen does a nasal cannula provide?

B -- Researchers have demonstrated a high correlation between air pollution and lung diseases, including cancer. Air pollution puts people with certain occupations, and those who live in large cities, at a greater risk for these diseases.

Which individual is at greater risk for respiratory illness from environmental causes? a. a farmer on a large farm b. a factory worker in a large city c. a woman living in a small town d. a child living in a rural area

lower airway components

Which lung components function is to conduct air, mucociliary clearance, and production of pulmonary surfactant?

upper airway components

Which lung components function to warm, filter, and humidify inspired air?

expectorants

drugs that facilitate the removal of respiratory tract secretions by reducing the viscosity of the secretions (increases coughing)

antihistamines

drugs that target the H1 receptors to reduce runny nose, sneezing, etc.

crackles

frequently heard on inspiration, are soft, high-pitched discontinuous (intermittent) popping sounds

alveoli

function to exchange oxygen and carbon dioxide in the bloodstream

troponin

group of proteins found in skeletal and heart muscle fibers that regulate muscular contractions

bronchial

high-pitched and longer, heard primarily over the trachea