ch 41 oxygenation

Question 1

layers of heart

Answer 1

epicardium

• thin layer of elastic connective tissue and fat that serves as an additional layer of protection from trauma or friction for the heart under the pericardium.
• This layer contains the coronary blood vessels, which oxygenate the tissues of the heart with a blood supply from the coronary arteries.

myocardium

• Middle layer of the heart
• Composed of cardiac muscle
• Contracts to propel blood into the next heart chamber or out into the blood vessels of the body

Endocardium

• Innermost layer of the heart
• Protective lining of the chambers and valves of the heart

Question 2

chambers heart

Answer 2

2 chambers - upper right and left atria and lower right and left ventricles

• Deoxygenated blood Returns to the heart into the Right atrium, flows into the Right ventricle, and is then pumped to the Respiratory system (lungs).
  Oxygenated blood Leaves the lungs to flow into the Left atrium, moves into the Left ventricle, and is then pumped to all parts of the body.

Question 3

cardiac cycle and blood flow

Answer 3

diastole (relaxation)
systole (contraction)

Cardiac output - amount blood pumped out heart in 1 min determined by HR and stroke volume (SV).. CO = HR x SV

HR- freq cardiac cycle, beats per min
SV - volume blood pumped l ventricle each beat

Question 4

Which blood vessel returns oxygenated blood to the heart?

Answer 4

Pulmonary vein

Oxygenated blood moves from the lungs back to the heart through the pulmonary vein.

Question 5

Match the layers of heart with their positions.

Answer 5

Middle layer of muscle tissue in the heart
----Myocardium
Outermost layer of the heart
---Epicardium
Innermost layer of the heart
---Endocardium

Question 6

respiratory system

Answer 6

The upper respiratory tract includes the nose, nasal cavity, sinuses, and pharynx.

The lower respiratory tract includes the larynx, where the vocal cords are located, the trachea, and the branches of the respiratory tree. The trachea branches into the right and left main bronchi. The bronchi divide repeatedly into smaller bronchioles and alveolar ducts. The bronchioles and ducts terminate in the alveoli.

Question 7

components respiratory system

Answer 7

Sinuses
- Air-filled chambers within the skull

Nasal Cavity
- Space posterior to the nose that is divided by the nasal septum

Pharynx
- Passageway through which air flows from the nose to the larynx

Trachea
- Flexible tube about 2.5 cm in diameter and 12.5 cm long that transports air from the pharynx and larynx to the lungs

Bronchi
- The trachea branches into the right and left mainstem bronchi, which are large air passages in the lungs that subdivide to form the bronchial tree and alveolar ducts

Alveoli
- Small sacs surrounded by pulmonary capillaries are the site for O2 and CO2 gas exchange

Question 8

respiration

Answer 8

2 processes:
ventilation (inhalation and exhilation)

oxygenation (O2 blood perfusion)

Question 9

ventilation - movement of gas

Answer 9

It starts with inspiration (inhalation) triggered by impulses generated in the respiratory center of the brain.
The impulses travel through the phrenic nerve, stimulating the diaphragm to move downward, and the intercostal nerve, stimulating the intercostal muscles along the ribs to contract.
These movements cause the chest cavity to expand, thus decreasing pressure within the alveoli of the lungs during inspiration (intraalveolar pressure). The atmospheric pressure is then higher than the intraalveolar pressure. This creates a type of vacuum effect inside the alveoli causing air to move into the respiratory tract and the lungs to fill with air.
The reversal of air movement is called expiration. During expiration (exhalation), the diaphragm relaxes, the chest and lung tissues recoil, and intraalveolar pressure increases, causing air to be forced out of the lungs.

Question 10

oxygenation

Answer 10

Oxygenation involves intake of air and gas exchange in the lungs. O2 is transported via the blood and utilized by the body’s tissues. In the lungs, O2 diffuses across the alveolar walls into the pulmonary capillaries. This gas exchange between the lungs and blood is called external respiration. This O2 then dissolves in the blood plasma or binds itself to the hemoglobin in red blood cells. The O2-enriched blood then travels to the body’s tissues, where tissue perfusion occurs. The exchange of gases between the blood and tissues is called internal respiration. Cellular respiration occurs when the cells use the O2 for metabolism, releasing CO2 in the process.

Question 11

respiratory process

Answer 11

External Respiration

• Occurs in the LUNGS
• O2 moves out of the lungs and into the blood.
• CO2 moves out of the blood and into the alveoli.

Internal Respiration

• Occurs in the TISSUES
• O2 moves out of the blood and into the tissues.
• CO2 moves out of the tissues and into the blood

Cellular Respiration

• Occurs in the CELLS
• Cells use O2 for energy, which produces CO2.

Question 12

Which structures would the nurse recognize as parts of the upper respiratory tract?

Answer 12

Nose, nasal cavity

The nose, nasal cavity, sinuses, and pharynx are parts of the upper respiratory tract.

Sinuses, pharynx

The nose, nasal cavity, sinuses, and pharynx are parts of the upper respiratory tract.

Question 13

Through which parts of the respiratory tract does air flow after moving through the trachea?

Answer 13

Bronchioles

The trachea is the tube that transports air from the pharynx and the larynx to the lungs via the bronchi. Air moves through the trachea into the left and right bronchi, bronchioles, and alveoli.

Alveoli

The trachea is the flexible tube located below the larynx that connects the upper airway to the lower airway. Air moves through the trachea into the left and right bronchi, bronchioles, and alveoli.

Question 14

Which term reflects the process of oxygen diffusing across alveolar walls into pulmonary capillaries?

Answer 14

External respiration

In the lungs, oxygen diffuses across alveolar walls into pulmonary capillaries. This exchange of gases between the lungs and blood is called external respiration.

Question 15

Which description represents the process of exhalation?

Answer 15

Intraalveolar pressure rising above atmospheric pressure

As intraalveolar pressure rises above atmospheric pressure, the pressure gradient changes, causing air to leave the lungs.

Question 16

oxygenation overview

Answer 16

attached

Question 17

cardiovascular factors affecting oxygenation and perfusion - the heart

Answer 17

Heart failure can increase pulmonary vascular congestion, leading to decreased oxygenation. Heart failure is also often associated with decreased cardiac output, which leads to decreased systemic perfusion.

Valvular heart disease can limit blood flow to different parts of the heart and the systemic circuit and can also lead to heart failure.

Cardiac dysrhythmias can also lead to decreased cardiac function and perfusion. For instance, a patient who is bradycardic will have a decreased cardiac output.

Cyanotic congenital heart diseases decrease the delivery of deoxygenated blood to the lungs and lead to deoxygenated blood entering the systemic circuit.

Infections, autoimmune diseases, and cancers of the heart are less common conditions that can decrease cardiac output and perfusion.

Question 18

cardiovascular factors affecting oxygenation and perfusion - blood vessels

Answer 18

Perfusion is directly linked to blood vessel diameter. This is controlled by the nervous system and is influenced by chemical mediators (prostaglandins, neurotransmitters, hormones, nitrous oxide) and the levels of O2 and CO2 in the circulation.

Coronary artery disease decreases the amount of oxygenated blood reaching the heart and therefore the O2 available to the myocardium. Similarly, peripheral vascular disease limits the amount of oxygenated blood delivered to the tissues. The specific blood vessel affected determines which part of the body is affected.

Question 19

respiratory affects perfusion and oxygenation

Answer 19

Respiratory rate is controlled by the respiratory centers found in the brain, and both hypoventilation and hyperventilation can affect oxygenation.

Pulmonary function and lung compliance are general factors that are also tied to oxygenation.

Acute infections of the respiratory system such as pneumonia and bronchitis can decrease oxygenation. Pulmonary emboli cause decreased oxygenation, and the larger the vessel affected, the larger the deficit.

Chronic lung conditions including asthma, cystic fibrosis, chronic obstructive pulmonary disease (COPD), and sarcoidosis also commonly affect perfusion. Other chronic conditions that affect the musculoskeletal system such as muscular dystrophy, kyphosis, and scoliosis decrease the ability of the patient to inhale and exhale. Nervous system disorders, such as myasthenia gravis and Guillain-Barré syndrome, and spinal cord or CNS injuries can decrease respiration either completely or partially.

Question 20

Hematological Factors Affecting Oxygenation and Perfusion

Answer 20

The binding of O2 to hemoglobin found in blood is related to pH; CO2; 2,3-bisphosphoglyceric acid; and temperature.

Anemias lower the O2-carrying capacity of the blood. These can include:

Common chronic conditions such as iron deficiency anemia or sickle cell anemia
Acute conditions caused by blood loss such as an acute gastrointestinal bleed or trauma
These conditions that lower the amount of red blood cells or hemoglobin make less O2 available for cellular respiration.

Question 21

Which systems are major factors in oxygenation and perfusion?

Answer 21

Respiratory

The respiratory system conveys oxygen from the external environment to the blood and is a major factor in oxygenation and perfusion.

Hematologic

The hematologic system receives oxygen at the level of the alveoli and transports it throughout the body and is a major factor in oxygenation and perfusion.

Cardiovascular

The cardiovascular system is responsible for the circulation of oxygenated blood and is a major factor in oxygenation and perfusion.

Question 22

Which chronic respiratory disorder may decrease oxygenation?

Answer 22

Asthma

Asthma is a chronic respiratory disorder that can decrease oxygenation.

Question 23

Which location of the respiratory centers would the nurse identify when explaining respiratory failure to a patient’s family?

Answer 23

Brain

The respiratory centers are located in the brain and control the rate of respiration.

Question 24

Which heart wall changes would the nurse expect in a patient with damage to the epicardium?

Answer 24

Impaired secretion of serous fluid
– Secretion of serous fluid is a function of the epicardium.

Increased friction during heart contractions
—The epicardium secretes serous fluid, which decreases friction during heart contractions.

Question 25

Which factors influence the binding of oxygen to hemoglobin?

Answer 25

pH
—The binding of oxygen to hemoglobin is influenced by pH, carbon dioxide, 2,3 BPG, and temperature.

2,3 BPG
—The binding of oxygen to hemoglobin is influenced by pH, carbon dioxide, 2,3 BPG, and temperature.

Temperature
—The binding of oxygen to hemoglobin is influenced by pH, carbon dioxide, 2,3 BPG, and temperature.

Carbon dioxide
—The binding of oxygen to hemoglobin is influenced by pH, carbon dioxide, 2,3 BPG, and temperature.

Question 26

Which factors that control blood vessel diameter would the nurse include when teaching about factors affecting oxygenation and perfusion?

Answer 26

Oxygen
—Blood vessel diameter is controlled by chemical mediators (prostaglandins, neurotransmitters, hormones, nitrous oxide) and the levels of oxygen and carbon dioxide in the circulation.

Hormones
—Blood vessel diameter is controlled by chemical mediators (prostaglandins, neurotransmitters, hormones, nitrous oxide) and the levels of oxygen and carbon dioxide in the circulation.

Nitrous oxide
—Blood vessel diameter is controlled by chemical mediators (prostaglandins, neurotransmitters, hormones, nitrous oxide) and the levels of oxygen and carbon dioxide in the circulation. Nitrous oxide causes vasodilation.

Prostaglandins
—Blood vessel diameter is controlled by chemical mediators (prostaglandins, neurotransmitters, hormones, nitrous oxide) and the levels of oxygen and carbon dioxide in the circulation.

Question 27

In which order does blood flow through the heart?

Answer 27

• Deoxygenated blood enters the right atrium via the superior vena cava, inferior vena cava, and coronary sinus.
• Blood passes through the tricuspid valve to the right ventricle.
• Blood enters the lungs via the pulmonary arteries, and gas exchange occurs through the pulmonary capillary system.
• Blood flows through pulmonary veins to the left atrium.
• Blood moves through the mitral valve to the left ventricle.
• Blood moves through the aortic valve into the aorta.

Question 28

Which response would the nurse give to a patient with weak right ventricular systole who asks “What is wrong with my heart?”

Answer 28

“The right side of your heart is not pumping with enough force to propel an adequate amount of blood to the lungs.”

—The right ventricle empties during systole, and the blood is pushed to the lungs via the pulmonary artery.

Question 29

Which information would the nurse include when teaching about the heart?

Answer 29

The heart has two atrial chambers and two ventricular chambers.
–The heart consists of four chambers. The upper two smaller chambers are the right and left atria. The lower two larger chambers are the right and left ventricles.

The heart pumps oxygenated blood to all parts of the body.
—The heart pumps oxygenated blood to all parts of the body.

The heart plays a role in tissue oxygenation.
—The heart works in tandem with the respiratory system to ensure tissue oxygenation.

Question 30

Which trigger of inspiration would the nurse include when teaching a patient with a chronic respiratory disease about the breathing process?

Answer 30

Impulses in the respiratory center of the brain

The movement of air into and out of the lungs is known as ventilation, which starts with inspiration (inhalation) triggered by impulses generated in the respiratory center of the brain.

Question 31

Which statement describes the role of the phrenic nerve during the inspiratory phase of respiration?

Answer 31

Stimulates the diaphragm to move downward

–The phrenic nerve stimulates the diaphragm to move downward, which aids inspiration.

Question 32

In which order does the process of inspiration and expiration occur?

Answer 32

• The respiratory center in the brain sends an impulse to nerves.
• The phrenic nerve stimulates the diaphragm to move downward, and the intercostal nerve causes the intercostal muscles to contract.
• The chest cavity expands, causing decreased intraalveolar pressure. -Atmospheric pressure exceeds intraalveolar pressure, causing air to move into the respiratory tract and the lungs to fill with air.
• The diaphragm relaxes, and intraalveolar pressure increases.
• Air is forced out from the lungs.

Question 33

nurses role incentiv

Question 34

Which acute respiratory disorder may decrease oxygenation?

Answer 34

Pneumonia

Pneumonia is an acute respiratory disorder that can decrease oxygenation.

Question 35

incentive spirometer

Answer 35

good to prevent and treat chronic respiratory illnesses with secretions in lungs i.e COPD

treat or stop atelectasis (collapse alveolar sac and unable to inflate or deflate lung)

Pre-opt and post-opt patients
Patients with breathing disorders: COPD (strengthen lung function)
Patients with respiratory illnesses: Pneumonia (helps keep lungs healthy while sick and move fluid/pus affecting the alveoli sac)
How often should a patient use and incentive spirometer? 10 times every 1 to 2 hours while awake

Question 36

rn role incentive spirometer

Answer 36

• Educate patient how to use it and the importance of using it regularly
• Observing and encouraging patient to use it often
• Monitoring lung sounds for improvement: For example, if the patient has atelectasis the lungs will sound diminished or bronchial breath sounds may be heard in the peripheral lung fields, or crackles. LISTEN TO ABNORMAL LUNG SOUNDS-

Question 37

wrong ways use incentive spirometer

Answer 37

Blowing into the device (most devices will not work if this is done)
Rapidly inhaling and exhaling off of the device
Inhaling too fast or too slow off of the device and not allowing the piston to completely fall to baseline before repeating
Not using it often (less than 2 -3 times per day)
Not using the device in sets of 10

Question 38

how to set up and use incentive spirometer

Answer 38

• Attach the flexible tubing to port
• Set goal for patient with the yellow marker
• Have patient sit-up and exhale completely
• Seal lips around mouthpiece tightly
• Have patient inhale deeply and slowly…making sure to keep yellow indicator within normal range (not too fast or too slow)…Piston will rise
• Patient needs to keep inhaling as deep as possible. …until unable to hold breath any longer and then hold breath for 6 seconds
• Exhale slowly and allow piston to fall before repeating again

Question 39

box 41.2 rn assessment questions

Answer 39

Nature of the Cardiopulmonary Problem
• Describe the problem that you’re having with your heart.
• Does the problem (e.g., chest pain, rapid heart rate) occur at a specific time of the day, during or after exercise, or all the time?
• Do you notice abnormal beats?
• If you have chest pain, what relieves or makes the pain worse?

Questions to Ask Associated With Breathing
• Describe the breathing problems you are having.
• How has your breathing pattern changed?
• Do you have a cough? Is the coughing increasing? Is it worse at a certain time of day?
• Describe your cough. Is it dry or moist? Do you have sputum with coughing? Is this different in color, volume, or thickness?
• On a scale of 0 to 10, with 10 being the most severe, rate your shortness of breath. What helps your shortness of breath?

Questions to Ask Related to Chest Pain
• If you are having chest pain, what causes the pain and how long does it last? Is this a different type of pain? Can you show me where the pain is located?
• Does the chest pain occur with coughing?
• On a scale of 0 to 10, with 0 being no pain and 10 being the most severe pain, rate your chest pain at its worst. Is the pain different today?

Questions to Ask Regarding Predisposing Factors
• Have you been exposed to a cold or flu or other respiratory illnesses?
• Tell me the medications you are taking. Are you taking over-the-counter medications or supplements? If so, what are they?
• Do you smoke? Have you been exposed to secondhand smoke?
• Have you been doing any unusual exercises?

Questions to Ask Regarding Effect of Symptoms
• Describe for me a typical daily diet.
• Tell me how your symptoms affect daily activities, your appetite, sleeping, and exercise routine.

Question 40

box 41.3

Answer 40

Pulmonary Diseases
The impact of pulmonary diseases on patients and their families varies among cultures. It is important to understand these variations in terms of assessing for and providing care in patients with lung diseases. In 2018, approximately two-thirds of the new cases of TB diagnosed in the United States occurred in people who were not born in the United States. The countries where these patients were most likely to be born were Mexico, the Philippines, India, Vietnam, and China
People of certain ethnic or cultural backgrounds tend to live in the same area, which can affect their exposure to certain environmental pollutants or triggers of respiratory exacerbations. Their location of living can also affect their socioeconomic status and their access to health care, which can also have a great impact on their pulmonary health (Celedon et al., 2017).
While ethnic and cultural differences can contribute to overall health, it should be noted that in today’s globalization, health care providers should look more at acculturation (cultural exchange of beliefs, values, or behaviors as a result of interacting with people of other cultures) as an influence on a person’s or a family’s health. For example, smoking rates are higher in females of Mexican descent who have lived in the United States (Celedon et al., 2017).
The American Thoracic Society and the National Heart, Lung, and Blood Institute recommend looking more at the individual person and less at the person’s race or ethnicity when trying to develop a plan of care. There is discussion about looking at a person’s genetic makeup to develop a plan of care as genetic testing could help determine actual risk of disease and which medications would work best for that particular patient (Celedon et al., 2017).

Implications for Patient-Centered Care
• If your patients are foreign born, ask whether they have had the bacille Calmette-Guérin (BCG) vaccine, which can cause a positive reaction to the TB skin test. Also assess their exposure to people with known TB or other pulmonary infectious diseases (CDC, 2019c).

• Immunization clinics should concentrate on the underserved urban communities, especially those with large numbers of older adults. Provide TB skin testing, flu vaccines, and pneumonia vaccines as needed.
• Community health departments need to target at-risk populations for flu and pneumonia vaccine clinics.
• Public health programs for those at highest risk for pulmonary diseases should focus on pollution prevention, immunizations, and smoking-cessation programs.

Question 41

box 41.5

Answer 41

impaired gas exchange

Question 42

figure 41.6 gas exchange

Answer 42

concept map

Question 43

box 41.7 chest physiotherapy

Answer 43

Nursing and respiratory therapy collaborate with the health care provider to determine whether chest physiotherapy (CPT) is best for a patient. The following guidelines help in physical assessment and subsequent decision making:

• Conduct a complete respiratory assessment to confirm need for CPT, including sputum production, effectiveness of cough, history of pulmonary problems successfully relieved with CPT, abnormal lung sounds, and documented conditions such as atelectasis, complicated pneumonia, vital signs, or changes in oxygenation status (Lewis et al., 2017; Strickland, 2013).
• Know the patient’s medications. Certain medications, particularly diuretics and antihypertensives, cause fluid and hemodynamic changes. These decrease a patient’s tolerance to positional changes and postural drainage. Long-term steroid use increases a patient’s risk of pathological rib fractures and often contraindicates vibration.
• Know the patient’s medical history. Certain conditions such as increased intracranial pressure, spinal cord injuries, and abdominal aneurysm resection contraindicate the positional changes of postural drainage. Thoracic trauma or surgery contraindicates percussion and vibration.
• Know the patient’s level of cognitive function. Participation in controlled coughing techniques requires him or her to follow instructions. Congenital or acquired cognitive limitations alter a patient’s ability to learn and participate in these techniques.
• Be aware of the patient’s exercise tolerance. CPT maneuvers are fatiguing

Question 44

tidal volume

Answer 44

amount of air exhaled following normal respiration

affected by:
health status, activity, pregnancy, exercise, obesity, obstructive/restrive lung disease

Question 45

lung sounds, good

Answer 45

vesicular - low pitch, heard over most of the lung, auscultate below collar bones, armpits and back

broncho-vesicular - medium pitch, heard over mainstream bronchi, auscultate near sternum and spine

broncho (tracheal)- high pitch, heard over trachea, auscultation over trachea

Question 46

abnormal lung sounds (adventitious)

Answer 46

crackles/rales- fine to coarse bubbly sounds, fluid or collapsed smaller airways

wheezes- high pitched whistling, narrow obstructed airways – asthma, allergic rx

rhonchi- loud low pitch rumbling, fluid or mucous, RESOLVE WITH COUGHING

stridor- chocking, croup (children)

pleural friction rub - material rubbing together

Question 47

bradypnea

Answer 47

breathing below 12 /min

Question 48

tachypnea

Answer 48

breathing above 20 / min

Question 49

apnea

Answer 49

respiration cease sev seconds

Question 50

hyperventilation

Answer 50

rate and depth breathing increase,

Hypocarbia (low CO2) can occur from blowing off too much CO2 and not enough O2 consumption

Question 51

hypoventilation

Answer 51

rr low and depth depressed

hypercarbia (excessive CO2) can occur from not blowing off enough CO2

Question 52

work of breathing

Answer 52

resistance, compliance, acc muscle use

inspiration - active
expiration - passive

Compliance - ability lung to distend and expand with interthoracic pressure
—need good lung elasticity and recoil and surfactant for best compliance

Question 53

chest wall movement issues

Answer 53

pregnancy, obesity, musculoskeletal disease, trauma, neuromuscular disease, CNS alterations, abdominal surgery

C3-C5 trauma - phrenic nerve runs through these and controls diaphragm contraction and relaxation

medulla oblongata- controls breathing rate

Question 54

ventilation

Answer 54

goal= normal arterial CO2 tension and normal arterial O2 tension

Labs: 
PaO2 - 80-100
PaCO2- 35-45
SpO2 - greater 95%
EtCO2 - 35-45

Question 55

atelectasis

Answer 55

collapsed alveoli, deflated or filled with fluid
hypoventilation can cause this

conditions:
immobility #1, obesity, sleep apnea, chronic lung disease

Question 56

hyperventilation

Answer 56

remove CO2 faster than produced
anxiety, infection, drugs, pH, aspirin poisoning, amphetamine

rapid rr, sighing breaths, numbness/tingling, loss LOC

Question 57

hypoxia
R- restlessness
A- anxiety
T- tachycardia/tachypnea
Late
B- bradycardia
E- extreme restlessness
D- dyspnea

Answer 57

inadequate tissue oxygenation

causes:
decreased hemoglobin (altitude)
diminished O2 levels 
inability of tissues get O2 from blood - 
             cyanide poisoning
decreased diffusion - pneumonia, 
       -atelectasis, shock

S/S
- apprehension, restlessness, dec LOC
\++ incr BP, HR, RR
later
central cyanosis- tongue, soft palate, 
peripheral cyanosis - extremities, +++vasoconstriction
conjunctiva= hypoxemia
decrease BP, shock

Question 58

dyspnea

Answer 58

difficulty breathing, lack O2, ass w/ hypoxia

subjective: difficulty breathing
obj: access muscle use, nasal flaring, inc rate and depth

Question 59

cough

initiate every 2 hrs with resp problems

Answer 59

productive: sputum?
nonproductive: dry

adequate hydration

encourage coughing ++most effective way to move secretions through airways

Question 60

1 Rn defense– turn, cough, deep breath

cough

Answer 60

cascade- progression from huff.. take deep slow breath, hold 1-2 secs, then open mouth and perform series coughs throughout exhilation – cystic fibrosis

quad- manual ass cough for those without abdominal control i.e spinal cord. pt exhales, rn push inward and upward on abs toward diaphram

huff- stimulates nat cough reflex. inhales deeply, holds breath 2-3 secs, then forceful exhale

Question 61

low flow O2 delivery

Answer 61

nasal cannula

• 1-6 L/min - 22-44%
• can lead to skin breakdown
• use humidiication if greater 4 L/min or 24 hrs

Simple face mask

• 6-12 L/min - 33-55%
• short trans, skin breakdown and ASPIRATION

partial rebreather
- 6-11 L/min - 60-75%
SOB, breath 1/3 of exhaled air, keep bag partially inflated

non-breather
- 10-15 L/min - 80-95%
step before intubation, need hourly assessment, aspiration

Question 62

high flow O2

Answer 62

venturi mask
- 4-12 L/min, 24-50%
precise O2 with humid, need highly precise O2 with humid - chronic lung disease

face tent
-24-100%, high humidity, post op

Question 63

too much O2??

Answer 63

dry mucous membranes
O2 toxicity
- chest pain/heaviness, coughing, dyspnea, muscle twitch, nausea, GI upset
skin breakdown

Question 64

1. The nurse is preparing to perform nasotracheal suctioning on a patient. Arrange the steps in order.

Answer 64

7. Perform hand hygiene.
8. Assist patient to semi-Fowler’s or high Fowler’s position, if able.
9. Apply sterile gloves.
10. Have patient take deep breaths.
11. Lubricate catheter with water-soluble lubricant.
12. Advance catheter through nares and into trachea.
13. Apply suction.
14. Withdraw catheter.

Question 65

2. Which skills can the nurse delegate to assistive personnel (AP)? (Select all that apply.)

Answer 65

4. Assist with care of an established tracheostomy tube.

5. Reposition a patient with a chest tube.

Question 66

3. The nurse is caring for a patient with pneumonia. On entering the room, the nurse finds the patient lying in bed, coughing, and unable to clear secretions. What should the nurse do first?

Answer 66

2. Elevate the head of the bed to 45 degrees.

Question 67

4. The nurse is performing discharge teaching for a patient with chronic obstructive pulmonary disease (COPD). What statement, made by the patient, indicates the need for further teaching?

Answer 67

2. “When I am sick, I should limit the amount of fluids I drink so that I don’t produce excess mucus.”

Question 68

5. Which assessment findings indicate that the patient is experiencing an acute disturbance in oxygenation and requires immediate intervention? (Select all that apply.)

Answer 68

2. Retractions
3. Respiratory rate of 28 breaths per minute
4. Nasal flaring

Question 69

6. The nurse is caring for a patient with an artificial airway. What are reasons to suction the patient? (Select all that apply.)

Answer 69

1. The patient has visible secretions in the airway.
2. There is a sawtooth pattern on the patient’s EtCO2 monitor.
3. The patient has excessive coughing.

Question 70

7. The nurse is caring for a patient with a chest tube for treatment of a right pneumothorax. Which assessment finding necessitates immediate notification of the health care provider?

Answer 70

1. New, vigorous bubbling in the water seal chamber

Question 71

8. The nurse has just witnessed her patient go into cardiac arrest. What priority interventions should the nurse perform at this time? (Select all that apply.)

Answer 71

1. Perform chest compressions.

2. Ask someone to bring the defibrillator to the room for immediate defibrillation.

Question 72

9. The nurse is performing tracheostomy care on a patient. What finding would indicate that the tracheostomy tube has become dislodged?

Answer 72

2. Patient speaking to nurse

Question 73

10. Which number corresponds to the spot where you would assess for an air leak in the patient with a chest tube?

Answer 73

A. 1