TLB-Chapter 39: Oxygenation and Perfusion
A client with a chest tube wishes to ambulate to the bathroom. What is the appropriate nursing response? "The chest tube cannot be moved." "You will need to use a bedpan while the chest tube is in position." "Let me get the unlicensed assistive personnel (UAP) for you." "I can assist you to the bathroom and back to bed."
"I can assist you to the bathroom and back to bed." Explanation: The client can move in bed, and ambulate while carrying the drainage system, as long as he or she has orders to do so. The nurse should supervise ambulation to the bathroom and back to bed while the client has the drain inserted to make sure it stays intact and to monitor for safety. Other answers are incorrect.
The pediatric nurse is caring for four clients. Which client will receive the greatest benefit from the use of an oxygen analyzer to assure that the client is receiving the prescribed amount of oxygen? 3-year old in croup tent 7-year old with nasal cannula 10-year old with simple mask 13-year old with nonrebreather mask
3-year old in croup tent Explanation: An oxygen analyzer is used most commonly when caring for newborns in isolettes, children in croup tents, and clients who are mechanically ventilated. Other answers are incorrect.
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
A. Checking the amount of oxygen in the cylinder before using it RATIONALE 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.
The nurse is caring for a client receiving oxygen therapy via nasal cannula. The client suddenly becomes cyanotic with a pulse oximetry reading of 91%. What is the next most appropriate action the nurse should take? Assess lung sounds Reposition client Elevate head of the bed Assess oxygen tubing connection
Assess oxygen tubing connection Explanation: If the client suddenly becomes cyanotic, the nurse should assess the oxygen tubing to make sure it is still connected. Assessing lung sounds, repositioning the client, and elevating the head of the bed will not correct the problem if the tubing is disconnected.
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
B. The size of the endotracheal tube RATIONALE 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 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.
C. Remove the tape, adjust the depth to ordered depth and reapply the tape. RATIONALE 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 client suffering from chronic obstructive pulmonary disease (COPD) reports that it is hard to cough up secretions and the secretions are thick and sticky. Which intervention will the nurse use to promote respiratory hygiene in this situation? Coughing and deep-breathing exercises Range-of-motion exercises as tolerated Assisted ambulation four times daily Increased oral fluid intake
Increased oral fluid intake Explanation: When a cough is productive, it is important to establish the source of the sputum and assess its color, volume, consistency, and other noteworthy characteristics. The nurse should instruct the client to increase fluid intake to help thin secretions. Encouraging coughing and deep breathing should be done; however, the problem is thick secretions and increasing oral fluids will address the problem directly. Range-of-motion exercises and assisted ambulation help with mobility concerns but will not help to thin out the secretions.
The health care provider has prescribed an oropharyngeal airway for a client with a decreased level of consciousness. The health care provider has noted gurgling respirations and the client's tongue is in the posterior pharynx. The client vomits as the airway is inserted. Which actions should the nurse take? Select all that apply. Position client onto the side immediately. Remove oropharyngeal airway. Provide oral suctioning and mouth care. Raise the head of the bed to 90 degrees. Assess for bleeding in the mouth.
Position client onto the side immediately. Remove oropharyngeal airway. Provide oral suctioning and mouth care. Explanation: The nurse should quickly position client into a lateral position to prevent aspiration, remove the oropharyngeal airway, and then suction or provide oral hygiene as needed. Raising the head of bed to 90 degrees is unnecessary, because the client should be positioned on one side. There is no indication that trauma to the mouth has occurred, so the nurse would not need to assess for bleeding.
Which is a major organ of the upper respiratory tract? trachea bronchi lungs pharynx
pharynx Explanation: The pharynx, mouth, and nose are major organs of the upper respiratory tract. The trachea, bronchi, and lungs are major organs of the lower respiratory tract.
The home care nurse is visiting a client who is totally oxygen dependent and using home oxygen. Upon noticing a gas stove in the kitchen, what teaching will the nurse provide? "It is important to eat at least five servings of vegetables daily." "Remove your oxygen before cooking near the gas stove." "An electric stove may be a safer choice for you." "Be careful not to trip over your oxygen tubing while cooking."
"An electric stove may be a safer choice for you." Explanation: For safety purposes, oxygen tanks should be kept at least 10 feet away from gas stoves, fires, and other flammable devices. If the client removes the oxygen while cooking at a gas stove, hypoxia may occur and the client may become confused and sustain burns.
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? Pulse oximetry High-Fowler's position 4 L/minute O2 (66 mL/second) nasal cannula Increase fluid intake to 3 L/day (3000 mL/day)
4 L/minute O2 (66 mL/second) 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 or 66 mL/second), the stimulus to breathe is removed. Clients with emphysema are most comfortable in high Fowler's position because it aids in the use of the accessory muscles to promote respirations. Increasing fluid intake helps keep the client's secretions thin. Pulse oximetry monitors the client's arterial oxyhemoglobin saturation while receiving oxygen therapy.
Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply. A. Closely assess the patient before, during, and after the procedure. B. Hyperoxygenate the patient before and after suctioning. C. Limit the application of suction to 20 to 30 seconds. D. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. E. Use an appropriate suction pressure (80 to 150 mm Hg). F. Insert the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube.
A. Closely assess the patient before, during, and after the procedure. B. Hyperoxygenate the patient before and after suctioning. D. Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. E. Use an appropriate suction pressure (80 to 150 mm Hg). RATIONALE Close assessment of the patient before, during, and after the procedure is necessary to limit negative effects. Risks include hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. The nurse should also take the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis related to the use of high negative pressure. Research suggests that insertion of the suction catheter should be limited to a predetermined length (no further than 1 cm past the length of the tracheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis.
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
A. Dyspnea RATIONALE 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 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.
A. Remove the catheter. RATIONALE 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.
An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure? A. Tilt the patient's head forward. B. Hold the mask tightly over the patient's nose and mouth. C. Pull the patient's jaw backward. D. Compress the bag twice the normal respiratory rate for the patient.
B. Hold the mask tightly over the patient's nose and mouth. RATIONALE With the patient's head tilted back, jaw pulled forward, and airway cleared, the mask is held tightly over the patient's nose and mouth. The bag also fits easily over tracheostomy and endotracheal tubes. The operator's other hand compresses the bag at a rate that approximates normal respiratory rate (e.g., 16 to 20 breaths/min in adults).
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
B. Pulse oximetry RATIONALE 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 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. F. Drink 2 to 3 pints of clear fluids daily.
B. Reduce anxiety. D. Eat a high-protein/high-calorie diet. E. Maintain a high-Fowler's position when possible. RATIONALE 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.
The nurse is educating an adolescent with asthma on how to use a metered-dose inhaler. Which education point follows recommended guidelines? Inhale through the nose instead of the mouth. Be sure to shake the canister before using it. Inhale the medication rapidly. Inhale two sprays with one breath for faster action.
Be sure to shake the canister before using it. Explanation: A metered-dose inhaler (MDI) delivers a controlled dose of medication with each compression of the canister. The canister must be shaken to mix the medication properly. MDIs are inhaled through the mouth, into the lungs. The medication should be inhaled slowly to ensure a sufficient dose enters the lungs. If the order is for two sprays, these sprays are administered with one spray for each breath. The inhaled breath should be held briefly after each spray in order to prevent immediately exhaling the medication.
Upon auscultation of the client's lungs, the nurse hears loud, high-pitched sounds over the larynx. What term will the nurse use in documentation to describe this breath sound? Bronchial Vesicular Bronchovesicular Adventitious
Bronchial Explanation: Bronchial breath sounds are loud, high-pitched sounds heard primarily over the trachea and larynx. Vesicular breath sounds are low-pitched, soft sounds heard over the peripheral lung fields. Bronchovesicular breath sounds are medium-pitched blowing sounds heard over the major bronchi. Vesicular, bronchial, and bronchovesicular breath sounds are normal breath sounds. Adventitious breath sounds are abnormal lung sounds.
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
C. A teenager with cystic fibrosis RATIONALE 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 (Andrews et al., 2013; Lisy, 2014; Strickland et al., 2013).
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.
C. The nurse encourages the patient to breathe through the nose with the mouth closed. RATIONALE 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 providing home care instructions for a client who is being discharged to his home with a tracheostomy in place. Which statement accurately describes a guideline for care that should be included in the teaching plan? All the client's immediate family members should be taught how to perform tracheostomy care for the client. Clean, rather than sterile, technique can be used in the home setting. Sterile saline can be made at home using ¼ cup of salt in 1 quart of water and boiling it for 15 minutes. The client should avoid humid locations whenever possible.
Clean, rather than sterile, technique can be used in the home setting. Explanation: Clean, rather than sterile technique, can be used in the home setting. The client and home caregiver should be instructed on how to perform tracheostomy care. Sterile saline can be made by mixing 1 teaspoon of table salt in 1 quart of water and boiling for 15 minutes. There is no need for the client to avoid humid locations.
A nurse is assessing the breath sounds of a newborn. Which sound is an expected finding for this developmental level? Clear sounds Crackles Bruits Wheezes TAKE ANOTHER QUIZ
Crackles Explanation: Normal breath sounds of an infant are harsh crackles at the end of deep inspiration. Wheezing is a whistling sound made while breathing. Clear sounds are usually not heard in an infant. A bruit is an audible vascular sound and not a pulmonary sound associated with turbulent blood flow.
The pediatric nurse is instructing parents on safety when caring for toddlers and preschoolers. Which of the following teaching interventions is appropriate for this age group? Normal breathing is 30 to 60 breaths per minute Cut a hot dog in half, then pieces Provide toys with small pieces Sleep supine, not prone
Cut a hot dog in half, then pieces Explanation: During the toddler and preschool years, children place things in their mouths, and caregivers must protect them against aspirating foreign objects that can obstruct small air passages. Providing safe toys and avoiding hard candy or small hard pieces of food are important ways to ensure normal respiratory function for children in this age group.
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. "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." RATIONALE 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 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. A nosebleed is noted with continued suctioning. RATIONALE 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 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.
D. Group personal care activities into smaller steps, allowing rest periods between activities. RATIONALE 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 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. Put on gloves and insert the chest tube in a bottle of sterile saline. RATIONALE 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.
The nurse is administering oxygen to an older adult client who has been assessed to have increased work of breathing. If the intervention has been effective, what finding(s) will the nurse expect on evaluation of the client? Select all that apply. Respiratory rate is 33 breaths/min at rest. Heart rate is 64 beats/min. Oxygen saturation reads 88% on 5L of oxygen. Mucous membranes are pink and moist. Client is able to state the date, time and location.
Heart rate is 64 beats/min. Mucous membranes are pink and moist. Client is able to state the date, time and location. Explanation: A normal resting heart rate indicates a tolerable work of breathing. When in respiratory distress, clients will also experience tachycardia or a heart rate higher than 100 beats/min. Skin color and mucous membranes are another indicator of the client's oxygenation status. When hypoxic, a client will present as pale skinned, sometimes with bluish-ness around the mouth called cyanosis. Mucous membranes can also appear pale or blanched due to poor circulation. A client with normal work of breathing will have pink and moist mucous membranes. Level of consciousness is another indicators or normal oxygenation. If the client is oriented to day, time and place, the client has an intact level of consciousness, a sign of normal oxygenation. A respiratory rate of 33 breaths/min indicates tachypnea related to increased work of breathing. This is a sign of hypoxia. The nurse will oxygenate the client with an aim to bring the client's oxygen saturation above 90%, to ease the work of breathing. An oxygen saturation of 88% with oxygen supplementation is too low and the nurse will need to re-evaluate the effectiveness of the intervention.
A nurse on a cardiac care unit oversees the care of diverse clients' cardiac health problems. Which action can be most appropriately delegated to a licensed practical nurse (LPN)? Application of a client's cardiac monitor Initiation of manual external defibrillation Initiation of CPR for a client who is found unresponsive Collecting an arterial blood sample
Initiation of CPR for a client who is found unresponsive Explanation: The initiation and provision of cardiopulmonary resuscitation is appropriate for all health care providers. Depending on the state's nurse practice act and the organization's policies and procedures, an LPN may or may not be able to perform the other listed actions. Reference:
The nurse prepares the client for a 12-lead electrocardiogram (ECG). Which actions should the nurse provide? Select all that apply. Instruct the client to relax arms away from waist and legs not touching the footboard. Prepare skin, removing excess oil and clip areas of excessive hair. Lead cables should be taut to improve the quality and accuracy of the ECG. Place self-stick electrodes and place according to anatomical locations. Explain that the client needs to lie still and not talk during the ECG recording.
Instruct the client to relax arms away from waist and legs not touching the footboard. Prepare skin, removing excess oil and clip areas of excessive hair. Place self-stick electrodes and place according to anatomical locations. Explain that the client needs to lie still and not talk during the ECG recording. Explanation: The client needs to be in a relaxed position without limbs, or electrode lead wires touching each other to provide the best ECG recording. The nurse needs to prepare the skin removing excess oil, moisture, trim excessive amounts of hair, and slightly abrade the skin surface so the electrode pads will make proper contact. The lead wires should not be taut because that will cause electrical interference providing a poor ECG recording. Electrodes and ECG cables must be placed in anatomical correct positions to provide an accurate ECG tracing.
A nursing instructor is teaching a class on the mechanics of respiration and the process of ventilation. The instructor determines that the education was successful when the students identify which activity as occurring during inspiration? Intercostal muscles contract. Chest pressure increases. Thorax size reduces. Air flows out of the lungs.
Intercostal muscles contract. Explanation: During inspiration, the diaphragm and external intercostal muscles contract. Their contraction enlarges the thorax volume and decreases intrathoracic pressure. The expanding chest wall pulls the lungs outward. As the lungs expand, pressure drops within the airways. During exhalation, the diaphragm and intercostal muscles relax, causing the thorax to return to its smaller resting size. During exhalation, the pressure in the chest increases, allowing air to flow out of the lungs.
A nurse is overseeing the care of a client who is receiving oxygen via nasal cannula. Which aspects of the client's care can the nurse safely delegate to unlicensed assistive personnel (UAP)? Select all that apply. Auscultating the client's lungs to determine the effectiveness of treatment Measuring the client's respiratory rate Inserting the client's nasal cannula after it has become dislodged Increasing the flow rate of the client's oxygen when the client is short of breath Reapplying the client's nasal cannula after a bath
Measuring the client's respiratory rate Inserting the client's nasal cannula after it has become dislodged Reapplying the client's nasal cannula after a bath Explanation: Reapplication of the nasal cannula during nursing care activities, such as during bathing, may be performed by UAP. UAP may measure a client's respiratory rate in the context of measuring the client's vital signs. Chest auscultation and changes to oxygen delivery are beyond the scope of UAP.
A client with a diagnosis of advanced Alzheimer disease is unable to follow directions required to use an inhaled bronchodilator. Which medication delivery system is most appropriate for this client? Nebulizer Dry powder inhaler Metered-dose inhaler with spacer Metered-dose inhaler without spacer
Nebulizer Explanation: Inhalers differ in the amount of dexterity required in order to deliver an accurate dose, but each requires some degree of coordinated activity and the ability to follow directions on the part of the client. For a client with decreased cognition, a nebulizer may be more appropriate because the client passively inhales the entire dose. A dry powder inhaler is initiated by inhalation and requires an ability to follow directions and keep the mouth around the port. If the client cannot follow directions then only the nebulizer is appropriate.
The nurse is obtaining a pulse oximetry reading for a client admitted with exacerbation of chronic obstructive pulmonary disease (COPD). When observing a reading of 89%, what action should the nurse perform? No action is required, because this may be normal for the client The nurse should prepare intubation equipment for the health care provider Administer oxygen at 6 L/m by nasal cannula Have the client breath into a paper bag
No action is required, because this may be normal for the client Explanation: For clients with chronic lung disease, a level of 88%-92% may be considered within normal limits and there is no further action for the nurse to take. There is no indication that intubation is needed. Administering oxygen at levels too high may diminish the client's stimulus to breathe, because a higher CO2 level is tolerated. Breathing into a paper bag would elevate the level of carbon dioxide and would be dangerous for this client.
The nurse observes that the client's pulse oximetry is 89%. What is the priority nursing action? Document hypoxemia. Report pulse oximetry to the health care provider. Perform respiratory assessment. Check the placement of the pulse oximeter.
Perform respiratory assessment. Explanation: As the nurse enters the room, the respiratory assessment immediately begins by visualizing the client's skin color, observing chest symmetry, vocalization, and auditory adventitious lung sounds. The nurse can then proceed to check the placement of the pulse oximeter, report findings to the health care provider, and document.
The nurse provides care for the client admitted to the emergency department with pneumonia that was unresponsive to single antibiotic therapy. The nurse administers multiple antibiotics, mucolytics, expectorants, and bronchodilators. For which factor(s) does the nurse monitor the client? Select all that apply. Tachypnea Hydration status Coughing effectiveness Asymmetric chest movements Sputum color, viscosity, and odor Bradycardia
Tachypnea Hydration status Coughing effectiveness Asymmetric chest movements Sputum color, viscosity, and odor Explanation: The nurse assesses the rate, rhythm, and depth of respiration for tachypnea, which is frequently present because of discomfort of moving chest wall and/or fluid in the lung due to a compensatory response to airway obstruction. In addition, the nurse assesses the client's hydration status because airway clearance is hindered by inadequate hydration and thickening of secretions. Assessing the client's cough effectiveness and productivity is crucial because coughing is the most effective way to remove secretions caused by pneumonia. The nurse assesses the chest movement and use of accessory muscles looking for shallow respirations and asymmetric chest movement, which are frequently present because of discomfort of moving chest wall and/or fluid in lung due to a compensatory response to airway obstruction. The nurse observes the sputum color, viscosity, and odor in order to report changes in sputum characteristics that may indicate further infection as well as sputum that is discolored, tenacious, or has an odor that may increase airway resistance and may warrant further intervention. Bradycardia is not a factor that the nurse assesses in the client with pneumonia; instead tachycardia related to the shortness of breath, increased respiratory effort and thickened secretions of pneumonia are more likely for the nurse to assess.
A new graduate nurse is performing a focused respiratory assessment. The nurse preceptor will intervene if which action by the graduate nurse is noted? The graduate nurse explains the assessment procedure before performing it. The graduate nurse palpates the point of maximal impulse (PMI). The graduate nurse auscultates breath sounds as the client breathes through the nose. The graduate nurse attaches a pulse oximeter to the client's index finger.
The graduate 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 oximeter are included in the respiratory assessment.
The nurse is caring for a client who is receiving continuous oxygen at 3 L/minute via nasal cannula. The client's oxygen saturation has consistently been 94% to 96%, but suddenly drops to 86% as the nurse palpates the client's abdomen. The client denies respiratory difficulty or other distress. What is a likely reason for the client's decreasing oxygen saturation? The nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen. The client is holding his or her breath. The client's appendix has ruptured. The client has developed a pulmonary embolism and has a ventilation-perfusion mismatch
The nurse has inadvertently stepped on the client's oxygen tubing, occluding the flow of oxygen. Explanation: A sudden drop in oxygen saturation without clinical signs or symptoms may be caused by disruption of oxygen flow. The information in the question does not support a pulmonary embolism, the client holding his or her breath, or an appendix rupturing.
The nurse educator would intervene with client teaching if which action by the staff nurse occurs when teaching voluntary coughing? The nurse has the client lying in bed in semi-Fowler's position. The nurse develops a specific schedule for coughing. The nurse encourages the client to cough before meals. The nurse reminds the client to combine coughing and deep breathing.
The nurse has the client lying in bed in semi-Fowler's position. Explanation: The client should be sitting upright with feet flat on the floor to be most effective. As part of the client's plan of care, the nurse should develop a specific schedule for coughing. Coughing before meals improves the taste of food and oxygenation. When combined with deep breathing, coughing is most effective.
A nurse assessing a client's respiratory effort notes that the client is breathing 8 shallow breaths/min. Which action best meets this client's immediate oxygenation needs? Suction the client's upper airway. Apply nasal cannula at 6 L/min Use a bag and mask. Establish an oxygen hood.
Use a bag and mask. Explanation: If the client is not breathing with an adequate rate and depth, or if the client has lost the respiratory drive, a bag and mask may be used to deliver oxygen until the client is resuscitated or can be intubated with an endotracheal tube. Suction is unnecessary unless there is an obvious obstruction. Nasal cannula is insufficient and an oxygen hood is not used in urgent situations.
Which scenario describes how carbon dioxide levels determine the frequency and depth of ventilation? Breathing increases when carbon dioxide levels decrease. An increase in circulating carbon dioxide causes an increase in the release of hydrogen ions, stimulating chemoreceptors in the aortic arch and carotid arteries, causing deeper and more rapid breathing. A decrease in the partial pressure of oxygen in arterial blood causes an increase in carbon dioxide levels, which in turn causes breathing to be slowed and more shallow. When carbon dioxide levels in the blood increase, chemoreceptors are stimulated, causing deeper and more rapid breathing.
When carbon dioxide levels in the blood increase, chemoreceptors are stimulated, causing deeper and more rapid breathing. Explanation: Peripheral and central chemoreceptors in the aortic arch and carotid arteries and the medulla are sensitive to circulating blood levels of carbon dioxide and hydrogen ions. Increased carbon dioxide levels lead to more rapid and deep breathing, whereas decreased carbon dioxide levels lead to slower and shallower respirations. Reference:
Which guideline describes the proper method for measuring the appropriate length to use when inserting a nasopharyngeal airway? When holding the airway on the side of the client's face, it should reach from the tragus of the ear to the tip of the nostril. When holding the airway on the side of the client's face, it should reach from the opening of the mouth to the back angle of the jaw. When holding the airway on the side of the client's face, it should reach from the tip of the ear to the nostril times two. The airways come in standard sizes determined by the height and weight of the client.
When holding the airway on the side of the client's face, it should reach from the tragus of the ear to the tip of the nostril. Explanation: The nasopharyngeal airway length is measured by holding the airway on the side of the client's face. The airway should reach from the tragus of the ear to the tip of the nostril. The diameter should be slightly smaller than the diameter of the nostril. For an oropharyngeal airway, when holding the airway on the side of the client's face, it should reach from the opening of the mouth to the back angle of the jaw.
A client 57 years of age is recovering in a hospital following a bilateral mastectomy and breast reconstruction 2 days earlier. Since her surgery, the client has been unwilling to mobilize despite the nurse's education on the benefits of early mobilization following surgery. The nurse would recognize that the client's prolonged immobility creates a risk for: atelectasis. pneumothorax. hemothorax. tachypnea.
atelectasis. Explanation: Prolonged bed rest can result in the incomplete lung expansion and collapse of alveoli that characterize atelectasis. Immobility is not commonly implicated in cases of pneumothorax or hemothorax. A pneumothorax is a collapsed lung. Hemothorax is a collection of blood in the space between the chest wall and the lung. Tachypnea, if present, would likely be a sign of atelectasis rather than an independent finding.
When the nurse observes a newborn infant demonstrating an irregular abdominal breathing pattern, with a respiratory rate of 50 breaths/minute with occasional pauses in breathing of 5-second durations. What is the most appropriate action by the nurse? begin resuscitation efforts. elevate the head of the crib. continue to assess the infant. position the infant side-lying.
continue to assess the infant. Explanation: Newborns breathe rapidly at 30 to 60 breaths per minute and may have occasional pauses of several seconds between breaths.
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? tap water normal saline distilled water mineral oil
distilled water Explanation: Distilled water is used when humidification is desired. Other answers are incorrect.
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: hemoglobin level. age. blood pH. sodium and potassium levels.
hemoglobin level. Explanation: Pulse oximetry readings are reflective of the number of available oxygen receptors on hemoglobin molecules. Consequently, an acceptable reading in a client with low hemoglobin can be artificially inflated. Age, blood pH, and electrolyte levels do not have a direct bearing on the accuracy and clinical application of pulse oximetry.
The nurse is caring for a client with respiratory alkalosis. Which arterial blood gas data does the nurse anticipate finding? pH less than 7.35; HCO3 low; PaCO2 low pH greater than 7.45; HCO3 high; PaCO2 high pH less than 7.35; HCO3 high; PaCO2 high pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation
pH greater than 7.45; HCO3 low; PaCO2 low; hyperventilation Explanation: In respiratory alkalosis, anticipated arterial blood gas results are anticipated to reflect pH greater than 7.45; HCO3 low; and PaCO2 low. Other answers are incorrect.
The nurse is caring for a client who has excess levels of carbon dioxide in the blood, and chronic hypoxemia. Which intervention will the nurse recommend? deep breathing incentive spirometry pursed-lip breathing diaphragmatic breathing
pursed-lip breathing Explanation: Pursed-lip breathing is most helpful for clients who have excessive levels of carbon dioxide in the blood and chronic hypoxemia. Other choices do not eliminate as much carbon dioxide from the blood.
What structural changes to the respiratory system should a nurse observe when caring for older adults? respiratory muscles become weaker diminished coughing and gag reflexes increased use of accessory muscles for breathing increased mouth breathing and snoring
respiratory muscles become weaker Explanation: One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker. The nurse should also observe other structural changes: the chest wall becomes stiffer as a result of calcification of the intercostals cartilage, kyphoscoliosis, and arthritic changes to costovertebral joints; the ribs and vertebrae lose calcium; the lungs become smaller and less elastic; alveoli enlarge; and alveolar walls become thinner. Diminished coughing and gag reflexes, increased use of accessory muscles for breathing, and increased mouth breathing and snoring are functional changes to the respiratory system in older adults.
