Chapter 39: Oxygenation and Perfusion
The nurse is conducting a respiratory assessment of a client age 71 years who has been recently admitted to the hospital unit. Which assessment finding should the nurse interpret as abnormal?
fine crackles to the bases of the lungs bilaterally
Except in the case of infants, fine crackles always constitute an abnormal assessment finding.
A client's primary care provider has informed the nurse that the client will require thoracentesis. The nurse should suspect that the client has developed which disorder of lung function?
pleural effusion. Thoracentesis involves the removal of fluid from the pleural space, either for diagnostic purposes or to remove an accumulation of fluid in this space (pleural effusion).
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?
flow meter. A flow meter is a gauge used to regulate the amount of oxygen delivered to the client and is attached to the source of oxygen.
What structural changes to the respiratory system should a nurse observe when caring for older adults?
respiratory muscles become weaker. 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.
Oxygen and carbon dioxide move between the alveoli and the blood by:
diffusion. One of the structural changes affecting the respiratory system that a nurse should observe in an older adult is respiratory muscles becoming weaker.
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:
a bronchospasm. When allergic responses take place in the lungs, breathing difficulties are far more severe. Small airways become edematous, mucus production increases, and inflammatory chemical mediators cause bronchospasm.
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 nurse is calculating the cardiac output of an adult with a stroke volume of 75 mL (75 × 109/L) and a pulse of 78 beats/min. What number would the nurse document for this assessment?
5,850 mL (5,850 × 109/L)
Cardiac output is determined by multiplying the stroke volume by the heart rate/min, which equals 5,850 mL (5,850 × 109/L). Cardiac output and peripheral resistance determine both systolic and diastolic pressures.
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. Pulse oximetry is often used as a measure of tissue perfusion. An oxygen saturation of greater than 94% is typically indicative of good tissue perfusion.
The nurse is demonstrating oxygen administration to a client. Which teaching will the nurse include about the humidifier?
“Small water droplets come from this, thus preventing dry mucous membranes.” The humidifier produces small water droplets which are delivered during oxygen administration to prevent or decrease dry mucous membranes.
The nurse is caring for a client who has had a percutaneous tracheostomy (PCT) following a motor vehicle accident and has been prescribed oxygen. What delivery device will the nurse select that is most appropriate for this client?
A tracheostomy collar delivers oxygen near an artificial opening in the neck. This is appropriate for a client who has had a PCT
The nurse is preparing discharge teaching for a client who has chronic obstructive pulmonary disease (COPD). Which teaching about deep breathing will the nurse include?
“Inhale slowly over three seconds, purse your lips, contract abdominal muscles, and exhale slowly.” Pursed-lip breathing is a form of controlled ventilation that is effective for clients with COPD.
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?
A nasal cannula is ideal for administering low concentrations of oxygen to clients who are not extremely hypoxic or have chronic lung disease
The nurse is caring for a client who has a percutaneous tracheostomy (PCT) following a skydiving accident. Which oxygen delivery device will the nurse select?
Distilled water is used when humidification is desired. Other answers are incorrect.
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?
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.
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
A client vomits as a nurse is inserting his oropharyngeal airway. What would be the mostappropriate intervention in this situation?
Remove the airway, turn the client to the side, and provide mouth suction, if necessary.
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.
- 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.
A client is diagnosed with hypoxia related to emphysema. The client’s adult child will be assisting the client with daily hygiene. How will the nurse explain positioning of the client to the caregiver?
An upright, sitting position is the best for daily hygiene so a lightweight chair that can be used in and out of the shower works best to help your parent breathe easier and allow you to assist.”
The nurse performs a respiratory assessment on a healthy client. While listening to the client’s lungs, the nurse hears them fill with air and then return to a resting position. The nurse deems the findings normal. Which is the best way to document this respiratory assessment and lung sounds?
“Respiratory rate 14, even, regular, and easy; depth with acceptable parameters; lung sounds clear all lobes bilaterally; absence of adventitious lung sounds; absence of spontaneous cough; oxygen saturation 98%."
A client returns to the telemetry unit after an operative procedure. Which diagnostic test will the nurse perform to monitor the effectiveness of the oxygen therapy ordered for the client?
Pulse oximetry is useful for monitoring clients receiving oxygen therapy, titrating oxygen therapy, monitoring those at risk for hypoxia, and postoperative clients
A client with no prior history of respiratory illness has been admitted to a postoperative unit following foot surgery. What intervention should the nurse prioritize in an effort to prevent postoperative pneumonia and atelectasis during this time of reduced mobility following surgery?
Educating the client on the use of incentive spirometry
Which dietary guideline would be appropriate for the older adult homebound client with advanced respiratory disease who informs the nurse that she has no energy to eat?
Eat smaller meals that are high in protein.
A child is admitted to the pediatric division with an acute asthma attack. The nurse assesses the lung sounds and respiratory rate. The mother asks the nurse, “Why is his chest sucking in above his stomach? The nurse's most accurate response is:
“He is using his chest muscles to help him breathe.”
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.
After insertion of a chest tube, fluctuations in the water-seal chamber that correspond with inspiration and expiration are an expected and normal finding.
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?
If the patient is not breathing with an adequate rate and depth, or if the patient has lost the respiratory drive, a manual rescucitation bag (Ambu bag)may be used to deliver oxygen until the patient is resuscitated or can be intubated with an endotracheal tube.
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.”
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 (RV)
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?
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.
Mr. Parks has chronic obstructive pulmonary disease (COPD). His nurse has taught him pursed-lip breathing, which helps him in which of the following ways?
decreases the amount of air trapping and resistance
Which teaching about the oxygen analyzer is important for the nurse to provide to a client using oxygen?
It determines whether the client is getting enough oxygen.
In which client should the nurse prioritize assessments for respiratory depression?
A client taking opioids for cancer pain
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?
Document this expected assessment finding.
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.
The nurse is suctioning a client's tracheostomy when the tracheostomy becomes dislodged and the nurse is unable to replace it easily. What is the nurse's most appropriate response?
- Maintain the client's oxygenation and alert the health care provider immediately.
A health care provider orders the collection of a sputum specimen from a client with a suspected bacterial infection. Which action best ensures a usable specimen?
Instruct the client to inhale deeply and then cough.
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 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, which would be more pronounced when the client has a respiratory infection. Wheezing is a high-pitched, musical sound heard primarily during expiration but may also be heard on inspiration. Wheezing is caused by air passing through constricted passages caused by swelling or secretions.
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:
Pneumonia, which causes the lungs to swell and stiffen, can lead to atelectasis.
The client has an increased anteroposterior chest diameter, dyspnea, and nasal flaring. The most appropriate nursing diagnosis is:
Ineffective Breathing Pattern related to hyperventilation related to increased anteroposterior diameter.
When a nurse observes that an older client's skin is dry and shiny and his nails are thickened, the nurse determines that the client is most likely experiencing
Poor tissue perfusion
During data collection, the nurse auscultates low-pitched, soft sounds over the lungs’ peripheral fields. Which appropriate terminology would the nurse use to describe these lung sounds when documenting?
Vesicular breath sounds are normal and described as low-pitched, soft sounds over the lungs' peripheral fields.
The nurse sets up an oxygen tent for a client. Which client is the best candidate for this oxygen delivery system?
An oxygen tent 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. Since the tent does not allow the maintenance of a satisfactory or precise oxygen concentration, is difficult to maintain a consistent level of oxygen. The oxygen tent does not adequately deliver oxygen at a rate higher than 30% to 50%; thus, it is rarely used with other clients.
A client is admitted to the hospital with shortness of breath, cyanosis and an oxygen saturation of 82% (0.82) on room air. Which action should the nurse implement first?
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 client's hands and try again.
A nurse is performing CPR on a client who collapsed. Which guidelines should be used for this procedure? Select all that apply.
- Position the client supine on his or her back.
- Use the head tilt–chin lift maneuver to open the airway.
- Rest elbows on the flat surface under the client, grasp the angle of the client's lower jaw, and lift with both hands.
Look, listen, and feel for air exchange, taking at least 5 seconds and no more than 10 seconds.
Which factors indicate that the nurse should stop delivery of breaths via a manual resuscitation bag and mask device? Select all that apply.
- The client has a return of spontaneous breathing at 15 breaths per minute.
- The client has been intubated and is connected to a mechanical ventilator.
- The health care provider has ended the cardiopulmonary resuscitation effort.
The air quality index has rated it a red air quality day in the city. Which information will the nurse share with the client about promoting effective respiratory self-care?
Stay indoors as much as possible.