Oxygenation & Perfusion

The nurse is planning care for a client who is prescribed a simple mask for oxygen delivery. What intervention will the nurse include in the plan of care?

Assess the client for anxiety due to claustrophobia

The home care nurse visits a client with compromised lung function. The client has greenish-yellow sputum with a musty odor. Which assessment is the priority for the client?

Auscultate bilateral breath sounds

The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines?

Be sure to shake the canister before using

Patients receiving drugs that affect the _____ need to be monitored carefully for resp. complications.

CNS

Cough is most effective in what position?

Sitting upright with feet flat on floor

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

A nurse is volunteering at a day camp. A child is stung by a bee and develops wheezing in the upper airways. The child is experiencing:

bronchospasm

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?

chronic anemia

The nurse is assessing a client with lung cancer. What manifestations may suggest that the client has chronic hypoxia?

clubbing

The nurse is implementing an order for oxygen for a client with facial burns. Which delivery device will the nurse gather?

face tent

Conditions in which a patient might require a chest tube

pleural effusion hemothorax pneumothorax

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?

residual volume

Nursing Interventions: decreased gas exchange or increased work of breathing

rest periods quit smoking breathing exercise avoid pollutants avoid opiods/sleeping pills avoid infection

Considerations for infants

short airways rapid RR rapid pulse

Considerations for older adults

tissues and airways less elastic muscles less powerful; less efficient breathing airways collapse more easily

After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding. (T/F?)

true

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

The nurse is teaching the client with a pulmonary disorder about 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?

"Breathing through your nose first will warm, filter, and humidify the air you are breathing."

Cardiopulmonary assessment - 4 techniques and order used

1. inspection 2. palpation 3. percussion 4. auscultation

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:

Adequate tissue perfusion

The nurse provides care for the client with asthma reporting shortness of breath. Which action(s) does the nurse take to promote client comfort and decrease anxiety? Select all that apply.

Plan for periods of rest between activities Instruct on effective breathing as needed Assess the client's level of anxiety and possible causes Assess the relationship of inspiration to expiration Encourage relaxation activities such as music and reading

When caring for a client with a tracheostomy, the nurse would perform which recommended action?

Suction the tracheostomy tube using sterile technique.

When inspecting a client'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.

The nurse performs assessments of cardiopulmonary functioning and oxygenation during regular physical assessments. Based on developmental variations, which findings would the nurse consider normal? Select all that apply.

The power of the respiratory and abdominal muscles is reduced in older adults, and therefore the diaphragm moves less efficiently. The normal infant's chest is small and the airways are short, making aspiration a potential problem. Alterations in respiratory function due to aging in older adults increase the risk for disease, especially pneumonia and other chest infections. The respiratory rate is more rapid in infants until the alveoli increase in number and size to produce adequate oxygenation at lower respiratory rates.

Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube?

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.

A nurse assessing a client's respiratory status gets a weak signal from the pulse oximeter. The client's other vital signs are within reference ranges. What is the nurse's best action?

Warm the clients hands and try again

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

pursed lip breathing

a technique of exhaling against pursed lips to prolong exhalation, preventing bronchiolar collapse and air trapping; done to increase expiratory airway pressure, improve oxygenation of the blood, and help prevent early airway closure.

A client has edema of the feet and ankles, along with crackles in the lower lobes and a frothy, productive cough. The client is suffering from:

congestive heart failure

What kind of fluid should be used with a humidifier?

distilled water

Nursing interventions: decreased CO and ability to respond to stress

encourage physical activity low fat low salt diet quit smoking weight control regular check ups medication compliance stress reduction

t/f - sedentary activity patterns encourage expansion of alveoli

false

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?

hypoxia

Nursing interventions: decreased ventilation and ineffective cough

increase fluid intake cool mist humidifier avoid OTC meds teach effective cough instruct use of supplemental oxygen

Nursing diagnoses that can be treated with independent nursing interventions.

ineffective airway clearance ineffective breathing pattern impaired gas exchange

While auscultating a client's chest, the nurse auscultates crackles in the lower lung bases. What condition does the nurse identify the client is experiencing?

fluid in the lungs

A client with chronic obstructive pulmonary disease (COPD) requires low flow oxygen. How will the oxygen be administered?

nasal cannula

The nurse is caring for a client admitted for a mild exacerbation of asthma who has been prescribed portable oxygen at 2 L/min. What delivery device will the nurse select to apply oxygen to the client?

nasal cannula

Which is a sign of dyspnea specific to infants?

nasal flaring retractions of the ribs during inspiration