Oxygenation part 2
A client is being considered for bariatric surgery. Which client health problem does the nurse identify as a consistent with morbid obesity? Dumping syndrome compartment syndrome hypoventilation syndrome syndrome of inappropriate anti-diuretic hormone secretion
Hypoventilation syndrome then elation insufficiency occurs in response to adequate chest wall expansion during caused by weight of adipose tissue on the rib cage and the bodies need for oxygen to all body cells
The nurse is preparing to preform endotracheal suctioning on a client. Before beginning the procedure, which intervention with the nurse do? Ask the client to take several deep breath's. Instructed client to cough before suctioning. Administer 100% oxygen to the client. Change the suctioning equipment to ensure sterility
Administer 100% oxygen to the client. Before suctioning, regardless of the means, oxygen should be administered, because the suctioning procedure depletes oxygen from the respiratory tract, causing a potential drop in oxygen saturation levels.
Which finding during a home health visit would prompt the nurse to provide a client with home safety instructions? Select all that apply. Area rugs on the floor clogged, dirty fireplace multiple electrical cords multiple prescribed medications wheeled walker with uneven legs
All
Which clinical manifestation with the nurse expect when assessing a client with atelectasis? Hyper renaissance to percussion rhonchi and wheezes sudden onset of shortness of breath crackles at the bases
Crackles at the bases atelectasis involves collapsing of the alveoli distal to the bronchioles, and find crackles at the lung bases are typically heard as the Alveoli expand with deep breathing. Dullness to percussion may occur without atelectasis because the alveoli are collapsed. Rhonchi and wheezes are associated with narrowing or obstruction of the larger airways, not with collapse of the alveoli
The nurse determines that a newborn is suffering from respiratory distress. Which visible signs confirm this assessment? Select all that apply. Crackles cyanosis wheezing tachypnea retractions
Cyanosis, tachypnea, retractions Cyanosis occurs because of an adequate oxygenation. Tachypnea is a compensatory mechanism necessary to increase oxygenation. Retractions occur in an effort to increase lung capacity.
Which nursing assessment supports a diagnosis of atelectasis in a postop patient? productive cough clubbing of the fingertips low pitched expiratory rhonchi diminished breath sounds on auscultation
Diminished breath sounds are auscultation Atelectasis refers to the collapse of the alveoli: breath sounds over the area are diminished. A productive cough most often is associated with the inflammation or infection, not atelectasis. Clubbing of the fingertips is a late sign of chronic hypoxia related to prolong obstructive lung disease. Rhonchi are most commonly heard in clients with infectious or inflammatory diagnosis such as pneumonia or chronic bronchitis.
Which skin color change with the nurse expect to see if a client with dark skin develop cyanosis? Gray purple dark red purple to brownish
Gray In a dark colored skin, cyanosis can be identified by a gray color, which is most seen in the conjunctiva of the eye. A purple skin color is an indication of errythmia. In a light-skinned client, a dark red color is an indicator of ecchymosis. A purple to brownish color identifies a ecchymosis
The clinic nurse is taking the sexual health history of an adolescent when the adolescent begins to perspire and hyperventilate. The client reports feeling dizzy and shortness of breath. Which condition but the nurse identify? Metabolic alkalosis respiratory acidosis pulmonary hypertension hypoventilation syndrome
Hypoventilation syndrome hyperventilation syndrome is a respiratory alkalosis that occurs with deep rapid breathing the clinical findings are related to an increased pH and lowered bicarbonate and oxygen levels. Metabolic alkalosis and manifested by adaptation such as hypotension, tachycardia, confusion, hyperreflexia, and dysrhythmias. Respiratory acidosis is manifested by adaptation such as tachycardia, headache, altered mental status, muscle twitching, and warm, flushed skin. Pulmonary hypertension occurs when the pulmonary arterial pressure is increased chronic pulmonary disorders are associated with pulmonary hypertension
A child survives near drowning episode of a cold pond. Which factor with the nurse identified that will have the greatest effect on the child's prognosis? Hypoxia hyperthermia emotional trauma aspiration pneumonia
Hypoxia the degree of hypoxia experienced by the child will determine the extent of neurological, liver, and renal damage. The child was hypothermic, not hyperthermic. Although emotional trauma can be overwhelming, it usually does not influence the ultimate physical prognosis as the extent of the hypoxia does. Although aspiration pneumonia may be severe initially, it does not result in long-term symptoms as hypoxia can
A child is admitted with a fever of 103°F, stiffness of the neck, general malaise. Which is the priority nursing intervention for this child? Increasing fluids administering oxygen giving a sponge bath instituting droplet precautions
Instituting droplet precautions droplet precautions prevent the spread of infection to others: isolation is a priority and should be implemented immediately. There is no indication that the child is dehydrated, fluid maintenance is a continuing goal. There is no indication that the child needs oxygen. Oxygen is not given routinely: it is given if a child has decreased oxygen saturation level. A sponge bath is not given because the child is sensitive to stimuli, and movement causes increased discomfort
A client shows an increase in respiratory rate that is abnormally deep and regular. Which condition with the nurse expect? Hypoventilation biot respiration Kussmaul respiration Cheyenne Stokes respiration
Kussmaul respiration Kussmaul respiration is an alteration of the breathing process characterized by an increase in abnormal deep and regular rate of respiration. A client suffering from hypoventilation would have abnormally low respiratory rate and the depth of ventilation is depressed. In Biot respiration, respirations are abnormally shallow for 2 to 3 breaths, followed by irregular periods of apnea. And irregular respiratory rate and depth characterized by alternating periods of apnea and hyperventilation would be observed in a client with Cheyenne Stokes respiration
The nurse is caring for a toddler in an acute respiratory distress precipitated by laryngotracheobronchitis. The child has a temperature of 103°F. Which is the priority nursing intervention? delivering humidified oxygen initiating measures to reduce fever monitoring respiratory status continuously providing support to diminish apprehension
Monitoring respiratory status continuously laryngeal spasms can occur abruptly: patency of the airway is determined through continuous monitoring for the signs of respiratory distress. Providing oxygen is important, but the maintenance of respiration is a priority. The fever should be treated, but it is not critical at 103°F: maintenance of the respiration is the priority. Offering support is important, but maintenance of the respiration is the priority
Which finding for a client who has just arrived in the emergency department and has a history of heart failure requires the most rapid action by the nurse? Irregular apical pulse oxygen saturation 86% crackles at both lung bases atrial fib on cardiac monitor
Oxygen saturation 86% because oxygen saturation less than 90% indicates of your hypoxemia, the nurse would notify the healthcare provider about the low saturation and start oxygen, typically using a nonrebreather mask.
A client presents with hemoptysis. The nurse recalls that the clinical manifestation associated with which disease? Anemia pneumonia tuberculosis leukocytosis
Tuberculosis Hemoptysis is an Expectoration of blood stained sputum derived from the lungs, bronchi, or trachea: this is a clinical manifestation of tissue erosion caused by tuberculosis. Anemia does not cause bleeding, but may be caused by bleeding. Pneumonia causes sputum as a result of information, but the sputum is usually yellow, not bloody. Leukocytosis is increased by blood cells: it does not cause hemoptysis
Which action with the nurse plan to take to prevent aspiration and a client who has just returned to the nursing unit after a bronchoscopy? Administer oxygen through a nasal cannula have the client rest and supine position suction oral secretions at frequent intervals with hold food until gag reflex returns
Withhold food until gag reflex returns because monitoring anesthesia care and a local anesthetic to decrease pharyngeal discomfort are used during a bronchoscopy, ensuring nothing is taken by mouth until the gag reflex returns prevent aspiration.
Which client with the nurse assessed first after her first shift report? A six month old with a cough and inspiratory strider with exertion a two-year-old with asthma who required a PRN albuterol treatment two hours ago a three-year-old with cystic fibrosis and pneumonia who required 22% oxygen all night a 20-month-old with Bronchiolitis and bilateral crackles who is receiving 23% oxygen
A six month old with a cough and inspiratory straighter with exertion this patient is demonstrating respiratory distress and needs to be evaluated first. Albuterol is a commonly used as needed treatment, but the treatment was two hours ago, lessening the need for this child to be evaluated first. Clients with cystic fibrosis are often admitted with pneumonia requiring oxygen therapy. Crackles are an expected symptom with bronchitis, and 23% is a minimal amount of oxygen
Client reports left-sided chest pain after playing racquetball the client is hospitalized and diagnosed with left pneumothorax. When assessing the clients left chest area, the nurse expect to find which Finding? Dull sound on percussion vocal fremitus palpation rails with rhonchi on auscultation absence of breath sounds on auscultation
Absence of breath sounds on auscultation the left lung is collapsed, therefore there are no breath sounds. A tympanic, not a dull, sound will be hard with a pneumothorax. There is no vocal fremitus because there is no airflow into the left long as a result of the pneumothorax. Rails with rhonchi will not be heard because there is no airflow into the left lung as a result of a pneumothorax
Which goal is the priority for a client with asthma who has a prescription for inhaled bronchodilator? Is able to obtain pulse oximeter readings demonstrates use of meter dose inhaler knows the healthcare providers office hours can identify triggers that may cause wheezing
Demonstrates use of a metered dose inhaler clients with asthma use meter does in Hailer's to administer medications prophylactically or during times of an asthma attack: this is an important skill to have. Home management typically includes self monitoring of the peak expiratory flow rate rather than pulse oximetry. Although knowing a healthcare providers office hours is important, it is not a priority, during a asthma attack that does not respond to a plan intervention, the client should go to the emergency department of the local hospital or call 911 for assistance. Although it is important to identify triggers that may cause wheezing, knowing this cannot prevent all wheezing, therefore, being able to abort wheezing with a bronchodilator is the greater priority
During the evening after her thoracentesis, the client reports anxiety. Which action with the nurse take first? Administer the prescribed analgesic listen to the clients breath sounds give the client the prescribed as needed lorazepam ask the client about specific concerns or worries
Listen to the clients breath sounds because anxiety is a frequently an early manifestation of hypoxemia, the nurses initial action will be to assess for complications of thoracentesis such as pneumothorax by listening for lung sounds
The nurse instructs a client to breathe deeply to open collapsed Alviola which explanation because the nurse offered to explain the relationship between alveoli and improved oxygenation? The alveoli need oxygen to live the alveoli have no direct effect on oxygenation collapse alveoli increase oxygen demand oxygen is exchanged for carbon dioxide in the alveolar membrane
Oxygen is exchanged for carbon dioxide in the alveolar membrane the exchange of oxygen and carbon dioxide occurs in the alveolar membrane. If the Alveoli collapse, this is this exchange cannot occur because the pulmonary ventilation is reduced. Explaining this process in simple terms to a client may increase compliance with the recommended breathing exercises aimed at improving oxygenation. Alveoli do not have a direct effect on oxygenation. The statements at the alveoli need oxygen to live and that collapse alveoli increase oxygen demand are not specific regarding the pathophysiology of the alveolar membrane
Which condition in a client in an emergency department would require immediate care based on priority? Bronchiolitis severe skin inflammation bruises and superficial laceration 20% carbon monoxide poisoning
Bronchiolitis clients with respiratory disorder should be provided immediate care because they are life-threatening conditions. Treatment can be delay for clients with skin information because the condition of the client is not severe. Clients with bruises and superficial lacerations can be cared for after a few minutes or hours depending on the situation. A client with 20% carbon monoxide poisoning as likely to present with a headache and decrease visual acquity and does not require immediate attention
When performing a focus respiratory assessment, which action with the nurse take first? Examine for any abnormal respiratory patterns inspect for changes and skin color or temperature check for any evidence of respiratory distress determine the shape and symmetry of the chest
Check for any evidence of respiratory distress the initial action of respiratory assessment is to observe for any signs of respiratory distress. The other actions are also part of a focus respiratory assessment and will be done once the nurse is assured that no acute respiratory distress as present. A respiratory pattern would be assessed to determine whether it's respirations are regular end of consistent depth, but this would only be done after the nurse to determine that the client was not in respiratory distress. Changes in skin color such a cyanosis would be monitored after the nurse checked for acute respiratory distress. The shape and symmetry of the chest would be checked but is not as important as assuring that the client is not in respiratory distress
Which nursing interventions would provide safe oxygen therapy select all that apply check tubing for kinks. Run wires under carpeting post no smoking signs in clients room place oxygen tanks flat in the carts when not in use make sure the client is using oil based product to lubricate the nose
Check tubing for kinks post no smoking signs in clients room
A client is hospitalized for an exaggeration of emphysema. The client is experiencing a fever, chills, and difficulty breathing on exertion. What is an important nursing action? Checking for capillary refill encouraging increase fluid intake suctioning secretions from the airway administering a high concentration of oxygen
Encouraging increase fluid intake fluids or replace fluid loss from a fever and decreased be viscosity of secretions. Capillary refill relates to peripheral to tissue perfusion. There are no data to suggest that secretions are black in the air way, there's no support that suction suctioning is needed. High concentration of oxygen generally are not administer to clients with chronic obstructive pulmonary disease. Traditionally, the reason given for this was that clients with COPD become desensitized to carbon dioxide as a respiratory stimulus so that reduce oxygen levels act as the stimulus and high concentrations of oxygen levels may be actually depressing respirations.
The nurse is teaching pursed lip breathing to a client with COPD. The client ask about the benefit of this exercise. Which explanation with the nurse give? prevents complications that are associated with COPD Relieve shortness of breath by increasing the breath rate increases the amount of air that the client can inhale with each breath keeps the airway open longer to decrease the work that goes into breathing
Keeps the airway open longer to decrease the work that goes into breathing purse lip breathing keeps the airway open longer to decrease the work that goes into breathing clients with COPD are taught to breathe out through pursed lips to help keep the air passages open until exhalation is complete. Pursed lip breathing does not prevent COPD complications. Pursed lip breathing may relieve shortness of breath by decreasing the breath rate. Pursed lip breathing does not increase the amount of air taken in during inspiration
Which of the following oxygen delivery would the nurse anticipate will be prescribe for a client with a pulse oximetry reading of 65% Face tent Venturi mask nasal cannula nonrebreather mask
Nonrebreather mask the expected value of a pulse ox symmetry reading is 95% to 100%. Nonrebreather mask will deliver high oxygen concentration is up to 90% at a liter flow of 10 to 15 L per minute when using a nonrebreather mask the client breaths only the oxygen source from the bag. A face tentdelivers 30% to 50% oxygen when set at a flow rate of 4 to 8 L per minute. Eventually mask delivers 24 to 50% oxygen one set to have flow rate of 4 to 10 L per minute and nasal cannula delivers 24% to 45% oxygen one side at a flow rate of 2 to 6 L per minute
The nurse is teaching hands only basic life support for adults in the community. After determining that the victim is not responding an emergency medical system has been activated, which action should the rescuer take? Identify the absence of a pulse give two rescue breaths with a CPR mask perform the head tilt chin lift maneuver perform chest compression at a rate of 100 per minute
Perform chest compressions at a rate of 100 per minute once the community rescuer verifies that the person is unresponsive and has activated the emergency medical response system, the rescue or should immediately begin chest compressions at the rate of 100 per minute to a depth of 2 inches, allowing full chest recoil between compressions. Performing the head tilt chin left maneuver, giving rescue breaths, and check in for a pulse are not part of the hands only basic life support method of cardio pulmonary resuscitation. This method was designed to make it easier for community people to perform CPR it quickly circulates the blood until trained assistance arrives
Soft swishing sound of breathing or heard when the nurse auscultate a clients chest. Which term would be used when documenting this finding? Find crackles Adventitious sounds vesicular breath sounds diminished breath sounds
Vesicular breath sounds Vesicular breath sounds are expected respiratory sounds heard on auscultation as inspired air enters and leaves the Alveoli. Fine crackles are faint cracking noises heard at the end of inspiration: they are associated with pulmonary Edema. Adventitious sounds as a general term for all abnormal breath sounds. Diminished breath sounds are evidence of a decreased amount of air entering the alveoli: that's usually is caused by obstruction or consolidation
The nurse performs a respiratory assessment and auscultates breath sounds that are high pitch creaking and accentuated on expiration. Which term correctly describes the findings? Rhonchi wheezes plural friction rub broncovesicular
Wheezes wheezes are one of the most common breath sounds assessed and auscultated and clients with asthma and COPD. Wheezes are produced as air flows through the narrow passage ways. Rhonchi are of course, rattling sound similar to the snoring and are usually caused by secretions in the bronchial airways. A pleural friction rub is an abrasive sound made by two acutely inflamed Serous surfaces rubbing together during the respiratory cycle. Bronco vestibular sounds are intermediate between bronchial upper and vestibular lower breath sounds: they are normal when heard between the first and second intercostal space is anteriorly and posteriorly between the scapula