Nurse 202: Quiz #8 Chapter 38: Oxygenation and Perfusion

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 Explanation: This much negative pressure is excessive and may cause excessive trauma, hypoxemia, and atelectasis.

The nurse is instructing the client with a pulmonary disorder on deep breathing. The client asks, "Why is it important to start by breathing through my nose, then exhaling through my mouth?" Which appropriate response would the nurse give this client?

a) "Breathing through your nose first will warm, filter, and humidify the air you are breathing." b) "If you breathe through the mouth first, you will swallow germs into your stomach." c) "We are concerned about you developing a snoring habit, so we encourage nasal breathing first." d) "Breathing through your nose first encourages you to sit up straighter to increase expansion of the lungs during inhalation." --> "Breathing through your nose first will warm, filter, and humidify the air you are breathing." Explanation: Nasal breathing allows the air to be warmed, filtered, and humidified. Nose breathing does not encourage the client to sit up straight. The purpose of nasal breathing is not to prevent germs from entering the stomach or to discourage snoring.

The nurse is preparing discharge teaching for a client with a history of recurrent pneumonia. What deep breathing techniques will the nurse plan to teach?

a) "Take in a little air, hold your breath 15 seconds, and exhale slowly." b) "Take in a small amount of air and exhale quickly." c) "Take in a large volume of air and hold your breath as long as you can." d) "Take in as much air as possible, hold your breath briefly, and exhale slowly." --> "Take in as much air as possible, hold your breath briefly, and exhale slowly." Explanation: This technique maximizes ventilation taking in a large volume of air fills alveoli to a greater capacity, which improves gas exchange. Deep breathing is useful for client's who has been inactive or in pain as associated with pneumonia. The other techniques do not promote improved gas exchange.

The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the oxygen analyzer?

a) "The oxygen analyzer prescribes the concentration of oxygen." b) "Small water droplets come from this, thus preventing dry mucous membranes." c) "This is a gauge used to regulate the amount of oxygen that a client receives." d) "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." --> "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." Explanation: 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 healthcare provider prescribed the concentration of oxygen.

The nurse is demonstrating oxygen administration to a client. What teaching will the nurse include about the flowmeter?

a) "This is a gauge used to regulate the amount of oxygen that a client receives." b) "It measures the percentage of delivered oxygen to determine whether the client is getting the amount prescribed." c) "The flowmeter prescribes the concentration of oxygen." d) "Small water droplets come from this, thus preventing dry mucous membranes." --> "This is a gauge used to regulate the amount of oxygen that a client receives." Explanation: The flowmeter is a gauge used to regulate the amount of oxygen that a client receives. The healthcare provider prescribed the concentration of oxygen. The oxygen analyzer measures the percentage of delivered oxygen to determine whether the client is receiving the prescribed amount.

A client's spouse reports that the client snores loudly and incessantly every night. What is the appropriate nursing response when the client's spouse asks about nasal breathing strips?

a) "Those do not work for snoring." b) "Nasal strips may reduce or eliminate snoring." c) "You will need a prescription for nasal strips." d) "The nasal diameter is decreased by nasal strips." --> "Nasal strips may reduce or eliminate snoring." Explanation: Nasal strips are available over the counter and are used to widen the nasal passageways. A common use for nasal strips is to reduce or eliminate snoring. The other responses are inappropriate

The nurse is caring for a client with a nonhealing wound who has been prescribed hyperbaric oxygen therapy (HBOT). When the client asks, "How will this help me?" what is the appropriate nursing response?

a) "Wounds heal because HBOT helps to regenerate new tissue quickly." b) "It will help you breathe much easier, and feel better." c) "HBOT treats aerobic infections." d) "You will be treated for decompression sickness." --> "Wounds heal because HBOT helps to regenerate new tissue quickly." Explanation: Although HBOT treats a multitude of conditions, the reason for using HBOT for a nonhealing wound is to help regenerate new tissue quickly. HBOT is used to treat anaerobic infections. The other responses are inappropriate.

The nurse is assessing the vital signs of a newborn. The nurse documents which respiratory rate as normal?

a) 30 to 55 breaths per minute b) 12 to 15 breaths per minute c) 20 to 30 breaths per minute d) 12 to 20 breaths per minute --> 30 to 55 breaths per minute Explanation: The nurse should expect the newborn to have a respiratory rate of 30 to 55 breaths per minute. Toddlers and preschoolers have a respiratory rate of 20 to 30 per minute. School-age children and adolescents have a respiratory rate of 12 to 20 breaths per minute

The nurse is reviewing the chart of a client receiving oxygen therapy. The nurse would question which supplemental oxygen prescription if written by the health care practitioner?

a) 8 L/min oxygen via nasal cannula b) 8 L/min oxygen via partial rebreather mask c) 10 L/min oxygen via Venturi mask d) 12 L/min oxygen via nonrebreather mask --> 8 L/min oxygen via nasal cannula Explanation: The correct amount delivered FiO2 for a nonrebreather mask is 12 L/min; 8-11 L/min for partial rebreather mask; 4-10 L/min for Venturi mask; and 1-6 L/min for nasal cannula. However, per nasal cannula it may be no more than 2-3 L/min to patient with chronic lung disease.

The nurse caring for a client who will have a chest tube removed within the next hour includes which of the following nursing interventions on the client's plan of care? (Select all that apply)

a) Ask the client to bear down, then slowly withdraw the chest tube b) Apply a semipermeable dressing to the insertion site immediately after the chest tube is removed c) Administer prescribed pain medication 15 to 30 minutes before chest tube removal d) Teach the client about relaxation exercises to be used during chest tube removal --> Administer prescribed pain medication 15 to 30 minutes before chest tube removal • Teach the client about relaxation exercises to be used during chest tube removal Explanation: After the chest tube is removed, the plan of care should include the following nursing interventions: administration of prescribed pain medication 15 to 30 minutes before chest tube removal and teaching the client relaxation exercises to utilize during the procedure. Occlusive dressing versus a semipermeable dressing should be utilized.

During data collection, the nurse auscultates low-pitched, soft sounds over the lungs' peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?

a) Bronchial b) Vesicular c) Bronchovesicular d) Crackles --> Vesicular Explanation: Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields. Crackles are soft, high-pitched, discontinuous popping sounds heard on inspiration. Medium-pitched blowing sounds heard over the major bronchi describe bronchovesicular breath sounds, whereas bronchial breath sounds are loud, high-pitched sounds heard over the trachea and larynx.

A client who was prescribed CPAP reports nonadherence to treatment. What is the priority nursing intervention?

a) Contact the healthcare provider to report the client's current status. b) Ask the client what factors contribute to nonadherence. c) Document outcomes of modifications in care. d) Explain the use of a BiPAP mask instead of a CPAP mask. --> Ask the client what factors contribute to nonadherence. Explanation: The nurse must first assess the reasons that contribute to nonadherence; interventions cannot be determined without a thorough assessment. Then, the nurse can work with the healthcare provider to find alternate treatment options if necessary, and then document the care.

During oxygen administration to the client, which pieces of equipment would enable the nurse to regulate the amount of oxygen delivered?

a) Flow meter b) Oxygen analyzer c) Humidifier d) Nasal cannula --> Flow meter Explanation: In order to regulate the amount of oxygen delivered to the client, the nurse should use a flow meter. A flow meter is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine if the client is receiving the amount prescribed by the physician.

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?

a) Hypercapnia b) Eupnea c) Cyanosis d) Hypoxemia --> Cyanosis Explanation: Cyanosis around the lips indicates serious hypoxemia. Cyanosis is caused by a desaturation of oxygen on the hemoglobin in the blood. Hypercapnia is caused by an abnormally high carbon dioxide level in the blood. Hypoxemia is caused by low oxygen levels in the blood. Eupnea is easy, free respiration.

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?

a) Hyperventilation b) Atelectasis c) Hypoxia d) Perfusion --> Hypoxia Explanation: Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. Difficulty breathing, increased respiratory and pulse rates, and pale skin with regions of cyanosis are all signs of hypoxia. Hyperventilation is an increased rate and depth of ventilation, above the body's normal metabolic requirements. Perfusion refers to the process by which oxygenated capillary blood passes through body tissues. Atelectasis refers to collapsed alveoli.

To determine the quality of oxygenation, the nurse performs the physical assessment, the arterial blood gas test, and pulse oximetry. What is the purpose of the pulse oximetry test?

a) Monitor the pressure of oxygen dissolved in plasma. b) Measure the volume of air exhaled or inhaled over time. c) Calculate the pressure of carbon dioxide dissolved in plasma. d) Monitor the amount of oxygen saturation in the blood. --> Monitor the amount of oxygen saturation in the blood. Explanation: The pulse oximetry test is a noninvasive transcutaneous technique for periodically or continuously monitoring the oxygen saturation of blood. The arterial blood gases test the client's blood for the partial pressure of oxygen dissolved in plasma, the percentage of hemoglobin saturated with oxygen, and the partial pressure of carbon dioxide dissolved in plasma.

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?

a) Nasal cannula b) Flow meter c) Nasal strip d) Oxygen analyzer --> Flow meter Explanation: The nurse should use a flow meter to regulate the amount of oxygen delivered to the client. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen.

A nurse assessing a patient's respiratory effort notes that the client's breaths are shallow and 8 per minute. Shortly after, the client's respirations cease. Which of the following should the nurse use for this patient?

a) Oxygen mask b) Ambu bag c) Nasal cannula d) Oxygen tent --> Ambu bag Explanation: If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag)may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube

A patient's primary care provider has informed the nurse that the patient will require thoracentesis. The nurse should suspect that the patient has developed which of the following disorders of lung function?

a) Pneumonia b) Tachypnea c) Wheezes d) Pleural effusion --> Pleural effusion Explanation: 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 and pneumonia would necessitate the procedure only if the infection resulted in pleural effusion.

The nurse is caring for a client with emphysema. A review of the client's chart reveals pH 7.36, paO2 73 mm Hg, PaCO2 64 mm Hg, and HCO3 35 mEq/L. The nurse would question which prescription, if prescribed by the health care practitioner?

a) Pulse oximetry b) 4 L/minute O2 nasal cannula c) Increase fluid intake to 3 L/day d) High-Fowler's position --> 4 L/minute O2 nasal cannula Explanation: The client with chronic lung disease, such as emphysema, becomes insensitive to carbon dioxide and responds to hypoxia to stimulate breathing. If given excessive oxygen (4 L/minute), the stimulus to breathe is removed.

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

a) Rapid respirations b) Mental alertness c) Increased urine output d) Weight loss --> Rapid respirations Explanation: Normal cardiac output averages from 3.5 L/minute to 8.0 L/minute. With decreased cardiac output, there is a reduction in the amount of circulating blood that is available to deliver oxygen to the tissues. The body compensates by increasing respiratory rate to increase oxygen delivery to the tissues.

The nurse is observing the unlicensed assistive personnel (UAP) perform oropharyngeal suctioning on a client. Which action, performed by the UAP, would indicate to the nurse that suctioning is being properly performed?

a) The UAP applies lubricant to the first 2 to 3" of the catheter. b) The UAP allows 30-second to 1-minute intervals between suctioning passes. c) The UAP advances the catheter approximately 5" to 6" to reach the pharynx. d) The UAP advances the catheter approximately 3" to 4" to reach the pharynx. --> The UAP advances the catheter approximately 3" to 4" to reach the pharynx. Explanation: When performing oropharyngeal suctioning, the catheter should be placed along the side of the mouth toward the trachea and advanced 3" to 4" to reach the pharynx. In nasopharyngeal suctioning, the catheter should be inserted through the naris and along the floor of the nostril toward the trachea

The newly hired nurse is caring for a client who had a tracheostomy four hours ago. Which action by the nurse, if noted by the charge nurse, would cause the charge nurse to intervene?

a) The newly hired nurse adjusts the bed to a comfortable working position. b) The newly hired nurse explains what she is doing and the reason to the client, even though the client does not appear to be alert. c) The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). d) The newly hired nurse assesses the client's pain and administers pain medication. --> The newly hired nurse delegates care of the tracheostomy to a licensed practical/vocational nurse (LPN/LVN). Explanation: Care of a tracheostomy tube in a stable situation, such as long-term care and other community-based care settings, may be delegated to licensed practical/vocational nurses (LPN/LVN); not in an acute instance. Adjusting the bed to a comfortable working position prevents back and muscle strain.

A newly hired nurse is performing a focused respiratory assessment. The nurse mentor will intervene if which action by the newly hired nurse is noted?

a) The newly hired nurse explains the assessment procedure before performing it. b) The newly hired nurse attaches a pulse oximetry to the client's index finger. c) The newly hired nurse auscultates breath sounds as the client breathes through the nose. d) The newly hired nurse palpates the point of maximal impulse (PMI). --> The newly hired nurse auscultates breath sounds as the client breathes through the nose. Explanation: Breath sounds should be auscultated while the client breathes slowly through an open mouth; nose breathing may produce false breath sounds. Explanation before procedures helps reduce a client's anxiety. Palpation of the PMI and attaching the pulse oximetry are included in the respiratory assessment.

The nurse is auscultating the lungs of a client and detects normal vesicular breath sounds. What is a characteristic of vesicular breath sounds?

a) They are low-pitched, soft sounds heard over peripheral lung fields. b) They are medium-pitched blowing sounds heard over the major bronchi. c) They are loud, high-pitched sounds heard primarily over the trachea and larynx. d) They are soft, high-pitched discontinuous (intermittent) popping lung sounds. --> They are low-pitched, soft sounds heard over peripheral lung fields. Explanation: Normal breath sounds include vesicular (low-pitched, soft sounds heard over peripheral lung fields), bronchial (loud, high-pitched sounds heard primarily over the trachea and larynx), and bronchovesicular (medium-pitched blowing sounds heard over the major bronchi) sounds. Crackles are soft, high-pitched discontinuous (intermittent) popping sounds.

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?

a) Total lung capacity (TLC) b) Residual Volume (RV) c) Forced Expiratory Volume (FEV) d) Tidal volume (TV) --> Residual Volume (RV) Explanation: During a pulmonary function test the amount of air left in the lungs at the end of maximal expiration is called residual volume. Tidal volume refers to the total amount of air inhaled and exhaled with one breath. Total lung capacity is the amount of air contained within the lungs at maximum inspiration

In which client would the nurse assess for a depressed respiratory system?

a) a client taking opioids for cancer pain b) a client taking amlodipine for hypertension c) a client taking antibiotics for a urinary tract infection d) a client taking insulin for diabetes --> a client taking opioids for cancer pain

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?

a) educating the client on pursed-lip breathing techniques b) administration of inhaled corticosteroids c) oropharyngeal suctioning twice daily d) educating the client on the use of incentive spirometry --> educating the client on the use of incentive spirometry Explanation: Incentive spirometry maximizes lung inflation and can prevent or reduce atelectasis and help mobilize secretions. Pursed-lip breathing primarily addresses dyspnea and anxiety. Suctioning is only indicated when clients are unable to independently mobilize secretions.

The nurse is caring for a 3-year-old client who experienced smoke inhalation during a house fire, and now requires oxygen. What delivery device will the nurse select that is most appropriate for this client?

a) nasal catheter b) venturi mask c) oxygen tent d) non-rebreather mask --> oxygen tent Explanation: An oxygen tent is often used when caring for active toddlers who require oxygen, since they are less likely to keep a mask on. Nasal catheters and masks are inappropriate, as the child will attempt to remove them and not receive the benefit of oxygen therapy.