(skills/fundamentals) Lippincott Ch 39: Oxygenation & Perfusion
flow meter
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?
d
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: a) pulmonary embolism. b) myocardial infarction. c) lung cancer. d) congestive heart failure.
c (a manual resuscitation bag (Ambu bag) may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube.)
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? a. Oxygen mask b. Nasal cannula c. Ambu bag d. Oxygen tent
b (Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis. Stiffer lungs tend to collapse, and their alveoli also collapse. Consequently, the amount of space available for gas exchange in the lungs decreases. Croup, asthma, and alcohol use do not lead to atelectasis.)
A nurse is assigned to care for a client admitted to the health care facility with the diagnosis of atelectasis. When interviewing the client, the nurse would anticipate a history of: a) croup b) pneumonia c) alcohol use d) asthma
c (Chest physiotherapy may help loosen and mobilize secretions, increasing mucus clearance. This is especially helpful for patients with large amounts of secretions or an ineffective cough, such as patients with cystic fibrosis. Chest physiotherapy has limited evidence for its effectiveness and is not recommended for use in numerous patient populations, including children with pneumonia, adults with COPD, and postoperative adults)
A nurse is assisting a respiratory therapist with chest physiotherapy for patients with ineffective cough. For which patient might this therapy be recommended? a) A postoperative adult b) An adult with COPD c) A teenager with cystic fibrosis d) A child with pneumonia
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 method might the nurse use to measure the patient's oxygen saturation? a) Thoracentesis b) Pulse oximetry c) Diffusion capacity d) Maximal respiratory pressure
a (If a problem exists in ventilation, respiration, or perfusion, hypoxia may occur. Hypoxia is a condition in which an inadequate amount of oxygen is available to cells. The most common symptoms of hypoxia are dyspnea (difficulty breathing), an elevated blood pressure with a small pulse pressure, increased respiratory and pulse rates, pallor, and cyanosis.)
A nurse is caring for a patient with COPD. What would be an expected finding upon assessment of this patient? a. Dyspnea b. Hypotension c. Decreased respiratory rate d. Decreased pulse rate
c (The nurse should encourage the patient to breathe through the nose with the mouth closed. The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient's nostrils. The nurse should adjust the fit of the cannula so it is snug but not tight against the skin. The nurse should adjust the flow rate as ordered.)
A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? a) The nurse assures that the oxygen is flowing into the prongs. b) The nurse adjusts the fit of the cannula so it fits snug and tight against the skin. c) The nurse encourages the patient to breathe through the nose with the mouth closed. d) The nurse adjusts the flow rate to 6 L/min or more.
b (The nurse would base the size of the suctioning catheter on the size of the endotracheal tube. The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. Larger catheters can contribute to trauma and hypoxemia.)
A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the chosen catheter? a) The age of the patient b) The size of the endotracheal tube c) The type of secretions to be suctioned d) The height and weight of the patient
c (The tube depth should be maintained at the same level unless otherwise ordered by the health care provider. If the depth changes, the nurse should remove the tape, adjust the tube to ordered depth, and reapply the tape.)
A nurse is securing a patient's endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident? a) Instruct the assistant to notify the primary care provider. b) Assess the patient's vital signs. c) Remove the tape, adjust the depth to ordered depth and reapply the tape. d) No action is required as depth will adjust automatically.
a (When a patient vomits upon suctioning of an oropharyngeal airway, the nurse should remove the catheter; it has probably entered the esophagus inadvertently. If the patient needs to be suctioned again, the nurse should change the catheter, because it is probably contaminated. The nurse should also turn the patient to the side and elevate the head of the bed to prevent aspiration.)
A nurse is suctioning an oropharyngeal airway for a patient who vomits when it is inserted. Which priority nursing action should be performed by the nurse related to this occurrence? a) Remove the catheter. b)Notify the primary care provider. c) Check that the airway is the appropriate size for the patient. d)Place the patient on his or her back.
d (When nosebleed (epistaxis) is noted with continued suctioning, the nurse should notify the health care provider and anticipate the need for a nasal trumpet. The nasal trumpet will protect the nasal mucosa from further trauma related to suctioning.)
A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet? a) The patient vomits during suctioning. b) The secretions appear to be stomach contents. c) The catheter touches an unsterile surface. d) A nosebleed is noted with continued suctioning.
d, e, f (Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, and inhaling two sprays with one breath.)
A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply. a) "I will be careful not to shake up the canister before using it." b) "I will hold the canister upside down when using it." c) "I will inhale the medication through my nose." d) "I will continue to inhale when the cold propellant is in my throat." e) "I will only inhale one spray with one breath." f) "I will activate the device while continuing to inhale."
d (When a chest tube becomes separated from the drainage device, the nurse should submerge the end in water, creating a water seal, but allowing air to escape, until a new drainage unit can be attached. This is done instead of clamping to prevent another pneumothorax. Then the nurse should assess vital signs and notify the health care provider.)
A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation? a) Notify the health care provider. b) Apply an occlusive dressing on the site. c) Assess the patient for signs of respiratory distress. d) Put on gloves and insert the chest tube in a bottle of sterile saline.
d (A range of 95% to 100% is considered normal oxygen saturation. As such, there is no need to change the client's position, encourage deep-breathing exercises and coughing, or to review the client's medication history.)
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? a) Encourage the client to do deep-breathing exercises. b) Raise the head of the client's bed slightly, if tolerated. c) Review the medications that the client has taken in the past 90 minutes. d) Document this expected assessment finding.
b, d, e (When caring for patients with COPD, it is important to create an environment that is likely to reduce anxiety and ensure that they eat a high-protein/high-calorie diet. People with dyspnea and orthopnea are most comfortable in a high-Fowler's position because accessory muscles can easily be used to promote respiration. Patients with COPD should pace physical activities and schedule frequent rest periods to conserve energy. Meals should be eaten 1 to 2 hours after breathing treatments and exercises, and drinking 2 to 3 quarts (1.9 to 2.9 L) of clear fluids daily is recommended.)
A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply. a) Refrain from exercise. b) Reduce anxiety. c) Eat meals 1 to 2 hours prior to breathing treatments. d) Eat a high-protein/high-calorie diet. e) Maintain a high-Fowler's position when possible. d) Drink 2 to 3 pints of clear fluids daily.
d (For a patient who is too fatigued to complete daily hygiene on his or her own, the nurse should group personal care activities into smaller steps and allow rest periods between the activities. The nurse should assist with bathing and hygiene tasks as needed and only when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits, and teach the patient to coordinate diaphragmatic breathing with the activity.)
A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient? A) Assist with bathing and hygiene tasks even if the patient feels capable of performing them alone. B) Teach the patient not to talk about the procedure, just to perform it at the best of his or her ability. C) Teach the patient to take short shallow breaths when performing hygiene measures. D) Group personal care activities into smaller steps, allowing rest periods between activities.
electrocardiogram
A recording of the electrical activity of the heart
bronchodilators
A substance that dilates the bronchi in the lungs decreasing resistance in the respiratory airways -allows air to get into lungs -works on nervous system -can be used as rescue inhaler
oxygen tent
An ___________ _________ is commonly used with children who need a cool and highly humidified airflow. It is also more effective for children because they often do not like to keep oxygen administration devices in place.
endotracheal
An ________________ tube is a polyvinyl chloride airway that is inserted through the nose or mouth into the trachea, using a laryngoscope as a guide. It is used to administer oxygen by mechanical ventilator, to suction secretions easily, or to bypass upper airway obstructions
a
An older adult client is visibly pale with a respiratory rate of 30 breaths per minute. Upon questioning, the client states to the nurse, "I can't seem to catch my breath." The nurse has responded by repositioning the client and measuring the client's oxygen saturation using pulse oximetry, yielding a reading of 90%. The nurse should interpret this oxygen saturation reading in light of the client's: a) hemoglobin level b) age c) blood pH d) sodium and potassium level
concentrator
An oxygen _________________ removes nitrogen from the room air and concentrates the oxygen left in the air. -needs a power source such as an electrical outlet, battery pack, or car charger, but never runs out (of oxygen) and does not need to be refilled. -used instead of cylinders -portable and cost effective
physiotherapy
Chest ___________________ may help loosen and mobilize secretions, increasing mucus clearance. -This is especially helpful for patients with large amounts of secretions or an ineffective cough. -Includes percussion, vibration, and postural drainage and is generally performed by respiratory therapists and physical therapists, or nurses with specialized skills, in acute care environments for select patients
carbon dioxide
Hyperventilation can lead to a lowered level of arterial ___________________
active, passive
Inspiration, the ____________- phase, involves movement of muscles and the thorax to bring air into the lungs. Expiration, the _____________ phase, is the movement of air out of the lungs.
compliance
Lung ________________ refers to the ease with which the lungs can be inflated.
pursed lip
Patients who experience dyspnea and feelings of panic can often reduce these symptoms by using ___________ _______ breathing. -creates a smaller opening for air movement, effectively slowing and prolonging expiration.
simple
The ________ face mask is connected to oxygen tubing, a humidifier, and a flow meter, just like the nasal cannula. -has vents on its sides that allow room air to leak in the vents also allow exhaled carbon dioxide to escape. -Often used when an increased delivery of oxygen is needed for short periods (e.g., less than 12 hours). -eating and talking are difficult, a tight seal is required, and there is the potential for skin breakdown. -low flow
partial rebreather
The __________ ______________ mask is similar to a simple face mask, but is equipped with a reservoir bag for the collection of the first part of the patient's exhaled air. (The remaining exhaled air exits through vents.) -The air in the reservoir is mixed with 100% oxygen for the next inhalation. -eating and talking are difficult, a tight seal is required, and there is the potential for skin breakdown. -conserves oxygen -low flow
lower
The __________ airway, known as the tracheobronchial tree, includes the trachea, main stem bronchi, segmental bronchi, and terminal bronchioles. Its major functions are conduction of air, mucociliary clearance, and production of pulmonary surfactant.
upper
The ______________ airway is composed of the nose, pharynx, larynx, and epiglottis. Its main function is to warm, filter, and humidify inspired air.
nonrebreather
The _______________ mask delivers the highest concentration of oxygen via a mask to a spontaneously breathing patient. -It is similar to the partial rebreather mask except that two one-way valves prevent the patient from rebreathing exhaled air. -eating and talking are difficult, a tight seal is required, and there is the potential for skin breakdown. -low flow
retraction
The accessory muscles of the abdomen, neck, and back are used to maintain respiratory movements at times when breathing is difficult. These muscles are used to facilitate breathing; the movement is called ___________________.
a (The infant's normal respiratory rate is 20 to 40 breaths per minute. The normal range for a child age 1 to 5 years is 20 to 32 breaths per minute. For a child 6 to 12 years of age the normal respiratory rate is 18 to 26 breaths per minute. The normal respiratory rate for an adult 65 years and older is 16 to 24 breaths per minute.)
The nurse is assessing the vital signs of clients in a community health care facility. Which client respiratory results should the nurse report to the health care provider? a) An infant with a respiratory rate of 16 bpm b) A 4-year-old with a respiratory rate of 32 bpm c) A 12-year-old with a respiratory rate of 20 bpm d) A 70-year-old with a respiratory rate of 18 bpm
distilled water
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?
medulla
The respiratory center is located in the ______________ in the brainstem, immediately above the spinal cord.
sputum
The respiratory secretion expelled by coughing or clearing the throat is called _______________.
creatine kinase, troponin
These biomarkers are used to monitor cardiac injury and myocardial infarction. Measuring the levels of these enzymes can help determine the extent and timing of the damage.
a (The cylinder must always be checked before use to ensure that enough oxygen is available for the patient. It is unsafe to use a cylinder that reads 500 psi or less because not enough oxygen remains for a patient transfer. A cylinder that is not secured properly may result in injury to the patient. Oxygen flow is discontinued by turning the valve clockwise until it is tight.)
What action does the nurse perform to follow safe technique when using a portable oxygen cylinder? a) Checking the amount of oxygen in the cylinder before using it b) Using a cylinder for a patient transfer that indicates available oxygen is 500 psi c) Placing the oxygen cylinder on the stretcher next to the patient d) Discontinuing oxygen flow by turning the cylinder key counterclockwise until tight
d (The adult chest contour is slightly convex, with no sternal depression. The skin of the thorax should be warm and dry, and the anteroposterior diameter of the chest should be less than the transverse diameter. The contour of the intercostal spaces should be flat or depressed.)
When inspecting a client's chest to assess respiratory status, the nurse should be aware of which normal finding? a) The contour of the intercostal spaces should be rounded. b) The skin at the thorax should be cool and moist. c) The anteroposterior diameter should be greater than the transverse diameter. d) The chest should be slightly convex with no sternal depression.
a (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 client with decreased cardiac output would gain weight, have decreased urine output, and display mental confusion.)
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) weight loss c) increased urine output d) mental alertness
d (Pulmonary function testing is used to measure lung size and airway patency. Chest x-rays are used to detect pathologic lung changes. Bronchoscopy allows the visualization of the airways directly. Skin tests are used to detect allergies.)
Which diagnostic procedure measures lung size and airway patency, producing graphic representations of lung volumes and flows? a) Chest x-ray b) Bronchoscopy c) Skin tests d) Pulmonary function tests
b
Which guideline is recommended for determining suction catheter depth when suctioning an endotracheal tube? a) Combine the length of the endotracheal tube and any adapter being used, and add an additional 2 cm. b) 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. c) 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. d) For a closed system, combine the length of the endotracheal or tracheostomy tube and any adapter being used, and add an additional 3 cm.
peak expiratory flow rate
___________ __________ ________ ____________ refers to the point of highest flow during forced expiration. -patient forcibly exhales into the peak flow meter, this is repeated 3x and highest number is recorded
cough suppressants
_____________ ______________ are recommended in patients with a dry, nonproductive cough. It is not usually recommended for a productive cough unless used during sleep because retaining secretions could lead to pulmonary infection.
incentive spirometry
_____________ ______________ provides visual reinforcement for deep breathing by the patient. An incentive spirometer assists the patient to breathe slowly and deeply and to sustain maximal inspiration. The gauge on the spirometer allows the patient to measure one's own progress, providing immediate positive reinforcement.
sympathetic
_____________ nerves stimulate the SA and AV nodes to increase HR and the force of contraction.
mucolytic
______________ agents liquefy or loosen thick secretions
capnography
_______________ is a method to monitor ventilation and, indirectly, blood flow through the lungs. Exhaled air passes through a sensor that measures the amount of carbon dioxide (CO2) exhaled with each breath.
spirometry
________________ measures the volume of air in liters exhaled or inhaled by a patient over time. -The patient inhales deeply and exhales forcefully
parasympathetic
_________________ nerves (vagus) stimulate the SA and AV nodes to decrease HR.
Proprioceptors
__________________ in the muscles and joints respond to body movements, such as exercise, and cause an increase in ventilation.
thoracocentesis
__________________ is the procedure of puncturing the chest wall and aspirating pleural fluid. -may be performed to obtain a specimen for diagnostic purposes or to remove fluid that has accumulated in the pleural cavity and is causing respiratory difficulty and discomfort
Expectorants
____________________ are drugs that facilitate the removal of respiratory tract secretions by reducing the viscosity of the secretions.
chemoreceptors
______________________ in the aortic arch and carotid bodies are sensitive to the same arterial blood gas (ABG) levels and blood pressure and can activate the medulla.
oropharyngeal airway
a curved device inserted through the patient's mouth into the pharynx to help maintain an open airway
surfactant
a detergent-like phospholipid, reduces the surface tension between the moist membranes of the alveoli, preventing their collapse.
nasopharyngeal airway
a flexible breathing tube inserted through the patient's nostril into the pharynx to help maintain an open airway
nasal cannula
also called nasal prongs, is the most commonly used oxygen delivery device. -The cannula is a disposable plastic device with two protruding prongs that are inserted into the nostrils. -The cannula is connected to an oxygen source with a flow meter and, many times, a humidifier. -does not impede eating or speaking and is used easily in the home -can be dislodged easily and low-flow rates can cause dryness of the nasal mucosa. -can be high or low flow
tracheostomy
an artificial opening made into the trachea, usually at the level of the second or third cartilaginous ring. -can be temporary or permanent -inserted for a variety of reasons (replace endotracheal tube, provide a method for mechanical ventilation of the patient, to bypass an upper airway obstruction, or to remove tracheobronchial secretions.) -may result in the inability to speak, depending on the type of tube in use.
diaphragmatic breathing
breathing with the use of the diaphragm to achieve maximum inhalation and slow respiratory rate. -he patient places one hand on the stomach and the other on the middle of the chest. The patient breathes in slowly through the nose, letting the abdomen protrude as far as it will go, then breathes out through pursed lips while contracting the abdominal muscles, with one hand pressing inward and upward on the abdomen. -helpful for COPD
oxygen
considerations for __________ therapy: -avoid excessive static electricity -no smoking within 10 feet of source
rhonchi
continuous low pitched, rattling lung sounds that often resemble snoring -heard in patients with chronic obstructive pulmonary disease (COPD), pneumonia, or cystic fibrosis
wheezes
continuous musical sounds, produced as air passes through airways constricted by swelling, narrowing, secretions, or tumors. -heard in patients with asthma, tumors, or a buildup of secretions.
crackles
fine, intermittent crackling sounds made as air moves through fluid in the airways or alveoli and opening of deflated small airways and alveoli. -occur due to inflammation or congestion and are associated with pneumonia, heart failure, bronchitis, and COPD -also called rales
respiration
gas exchange between the atmospheric air in the alveoli and blood in the capillaries
bronchial
loud, high-pitched sounds heard primarily over the trachea and larynx
vesicular
low-pitched, soft sounds heard over peripheral lung fields
bronchovesicular
medium-pitched blowing sounds heard over the major bronchi
pulse oximetry
noninvasive technique that measures the arterial oxyhemoglobin saturation (SpO2) of arterial blood. -reported result is a ratio, expressed as a percentage, between the actual oxygen content of the hemoglobin and the potential maximum oxygen-carrying capacity of the hemoglobin -SaO2 can be measured by ABG, not this technique
heart failure
occurs when the heart is unable to pump a sufficient blood supply, resulting in inadequate perfusion and oxygenation of tissues.
echocardiogram
record of the heart using sound
corticosteroids
substance that lowers swelling in the breathing passages and lungs. -not a rescue inhaler, takes longer to work -works on inflammatory cells in airway
venturi
the ___________ mask delivers the most precise concentrations of oxygen. -eating and talking are difficult, a tight seal is required, and there is the potential for skin breakdown. -high flow
pulmonary ventilation
the movement of air into and out of the lungs
perfusion
the process by which oxygenated capillary blood passes through body tissue
carbon dioxide, hydrogen ions
the respiratory center (medulla and pons) is stimulated by an increase in what two things?
arterial blood gas
this test examines arterial blood to determine the pressure exerted by oxygen and carbon dioxide in the blood and blood pH. -measures the adequacy of oxygenation, ventilation, and perfusion.
6
when providing supplementary oxygen to a client through a nasal cannula, the volume should not exceed ________L/min. If more oxygen than this is needed, a mask should be used.
