CH. 15 Altered Ventilation & Diffusion Flashcards
A nurse is assessing a client who has an acute respiratory infection, increasing the risk for hypoxemia. Which of the following findings are early indications that should alert the nurse that the client is developing hypoxia? (Select all that apply.)
A. Restlessness
B. Tachypnea
C. Bradycardia
D. Confusion
E. Hypertension
A. CORRECT: Monitor for restlessness, which is an early manifestation of hypoxia, along with tachycardia, elevated blood pressure, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds.
B. CORRECT: Monitor for tachypnea, which is an early manifestation of hypoxia.
D. CORRECT: Monitor for confusion, which is an early manifestation of hypoxia.
E. CORRECT: Monitor for hypertension, which is an early manifestation of hypoxia
A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (Select all that apply.)
A. Apply petroleum jelly around and inside the nares.
B. Remove the nasal cannula during mealtimes.
C. Check the position of the cannula frequently.
D. Report any nausea or difficulty breathing.
E. Post “No Smoking” signs in prominent locations.
C. CORRECT: Teach the client that a disadvantage of the nasal cannula is that it dislodges easily. The client should form the habit of checking its position periodically and readjusting it as necessary.
D. CORRECT: Teach the client about oxygen toxicity, which is a complication of oxygen therapy, usually from high concentrations or long durations. Manifestations include a nonproductive cough, substernal pain, nausea, and vomiting. The client should report any of these promptly.
E. CORRECT: Teach the client that oxygen is combustible and thus increases the risk of fire injuries. No one in the house should smoke or use any device that might generate sparks in the area where the oxygen is in use.
A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse’s priority?
A. Increase the oxygen flow.
B. Assist the client to Fowler’s position.
C. Promote removal of pulmonary secretions.
D. Obtain a specimen for arterial blood gases.
B. CORRECT: The priority action to be taken when using the airway, breathing, circulation (ABC) approach to care delivery is to relieve dyspnea (difficulty breathing). Fowler’s position facilitates maximal lung expansion and thus optimizes breathing. With the client in this position, the cause of the client’s dyspnea can better assessed and determined.
A nurse is preparing to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (Select all that apply.)
A. Apply suction while withdrawing the catheter.
B. Perform suctioning on a routine basis every 2 to 3 hr.
C. Maintain medical asepsis during suctioning.
D. Use a new catheter for each suctioning attempt.
E. Apply suction for 10 to 15 seconds.
A. CORRECT: Apply suction pressure only while withdrawing the catheter to prevent damaging the tracheal tissue.
D. CORRECT: Use a new suction catheter, unless an in‑line suctioning system is in place, to prevent contamination with micro-organisms that can cause an infection.
E. CORRECT: To prevent hypoxemia, apply suction for only 10 to 15 seconds and allow 2 to 3 min between passes for ventilation and oxygenation.
A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (Select all that apply.)
A. Apply the oxygen source loosely if the SpO2 decreases during the procedure.
B. Use surgical asepsis to remove and clean the inner cannula.
C. Clean the outer cannula surfaces in a circular motion from the stoma site outward.
D. Replace the tracheostomy ties with new ties.
E. Cut a slit in gauze squares to place beneath the tube holder.
A. CORRECT: Provide supplemental oxygen in response to any decline in oxygen saturation while performing tracheostomy care.
B. CORRECT: Use a sterile disposable tracheostomy cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure.
C. CORRECT: Cleanse the exposed surfaces of the outer cannula and the area around and under the faceplate in a circular motion from the stoma site outward. Cleansing in this manner helps move mucus and contaminated material away from the stoma for easy removal.
Which of the following does not affect diffusing capacity?
a. The partial pressure of oxygen and carbon dioxide
b. The alveolar surface area
c. The density of the alveolar membrane
d. The volume of air in the atmosphere
d. The volume of air in the atmosphere
Total obstruction of the airway by aspirated material is manifested by:
a. hoarse cough.
b. rapid loss of consciousness.
c. dyspnea.
d. inflammation of the mucosa.
b. rapid loss of consciousness.
A reduced number of red blood cells (RBCs) in the blood results in the following change in the oxygen saturation (SaO2) of the blood:
a. The SaO2 would increase.
b. The SaO2 would decrease.
c. The number of RBCs will not affect the SaO2.
d. There will be a decrease only if the osmotic pressure of the blood is also decreased.
c. The number of RBCs will not affect the SaO2.
Which is a major cause of respiratory failure?
a. Aspiration.
b. Atelectasis.
c. Sepsis.
d. All of these are causes of respiratory failure.
d. All of these are causes of respiratory failure.
Emphysema differs from chronic bronchitis in that emphysema:
a. Is characterized by mucus production and inflammation.
b. Obstructs the large airways.
c. Obstructs the alveoli.
d. is virtually the same condition as chronic bronchitis.
c. Obstructs the alveoli.
You have admitted a 20-year-old male to the emergency room with a history of asthma. He is having an acute asthma attack and is wheezing, fighting for air, hypoxic, and afraid. What is causing these acute symptoms?
a. Relaxation of bronchial smooth muscle with dry mucous membranes
b. Constriction of the bronchial smooth muscle and air trapping
c. Acute destruction of lung tissue
d. Contraction of the elastic fibers of the lung
b. Constriction of the bronchial smooth muscle and air trapping
Which of the following clinical manifestations are related to hypoxemia?
a. Cyanosis
b. Cough
c. Chest pain
d. Hemoptysis
a. Cyanosis
How would you know you have hypoxemia?
a. Radiograph.
b. Measure the partial pressure of oxygen in blood.
c. Measure the partial pressure of carbon dioxide in blood.
d. All of these detect hypoxemia.
b. Measure the partial pressure of oxygen in blood.
Which of the following can trigger acute respiratory distress syndrome?
a. Severe lung infection.
b. Inhaling toxic fumes.
c. Aspirating stomach contents into the lungs.
d. All of these can trigger acute respiratory distress syndrome.
d. All of these can trigger acute respiratory distress syndrome.
What is the major problem in cystic fibrosis?
a. Formation of cysts in fibrotic tissues
b. Pancreatitis
c. Lung injury
d. Electrolyte and water transport
d. Electrolyte and water transport
