chapter 40

Question 1

what is oxygen in relationship to the body?

Answer 1

21 % of the air we breath.
necessary for proper functioning of the living cells
its absence leads to cellular tissue and organism death.

Question 2

what is respiration?

Answer 2

the processes of gas exchange between the individual and the environment

Question 3

what are the 3 components of respiration?

Answer 3

Ventilation or breathing
gas exchange (Oxygen and Carbon dioxide)
transports of oxygen by the blood from the lungs to the tissue

Question 4

hypoxia

Answer 4

low oxygen at the cellular level

Question 5

altered breathing patterns

Answer 5

hypoventilation- poor gas exchange

hyperventilation- increased movement of air into and out of the lungs.

Question 6

clinical manifestations of hypoxia?

Answer 6

Increased rapid rate
rapid, shallow respirations and dyspnea(difficulty breathing)
increased restlessness of lightheadedness
flaring of the nares
sub-sternal or intercostal retractions
cyanosis
agitation

Question 7

cyanosis

Answer 7

Bluish discoloration of the skin and mucous membranes caused by an excess of deoxygenated hemoglobin in the blood or a structural defect in the hemoglobin molecule.

Question 8

hypoxic conditions

Answer 8

trauma, stroke, respiratory disease, unstable angina,

multiple organ failure, cancer, congestive heart failure, heart attack, hemorrhagic stroke, peripheral arterial disease.

Question 9

hyperventilation

Answer 9

rate and depth of respirations increase.

Question 10

what are the common causes of hypoventilation?

Answer 10

lung disease
drugs
anesthesia

Question 11

what are the symptoms of hypoventilation

Answer 11

Dizziness,
headache upon awakening  
lethargy 
cardiac dysrhythmias
cardiac arrest 
convulsions and coma
electrolyte imbalances (K, Na, C)

Question 12

what are some of the therapeutic measures to promote respiration function?

Answer 12

medications and Vaccination (flu and pneumonia)
nebulization and humidification 
incentive and spirometry (deep breathing)
chest physiotherapy 
oxygen therapy
artificial airways 
airway suctioning 
chest tubes (chest collapse)

Question 13

oxygen therapy

Answer 13

PRESCRIBED BY A PHYSCIAN. for clients who have difficulty ventilation
collaboratively done with therapist
Goal: to prevent or relieve hypoxia

Question 14

Nasal Cannula (1-6 L/minute)

Answer 14

24-45% concentration of oxygen

Question 15

Simple Face mask (5-8 L/minute)

Answer 15

30-60 % concentration of oxygen

Question 16

Nonrebreather mask (6-10 L/minute)
highest concentration of oxygen

Answer 16

60-95 % concentration of oxygen

Question 17

Venturi mask (4-12 L/minute)

Answer 17

24-60 % concentration of oxygen

Question 18

Airway suctioning

Answer 18

• Oropharyngeal and nasopharyngeal
• Orotracheal and nasotracheal
• Tracheal

Question 19

Oropharyngeal and nasopharyngeal

Answer 19

used when the client can cough effectively but is not able to clear secretions by expectorating

Question 20

-Orotracheal and nasotracheal

Answer 20

used when the client is unable to manage secretions by coughing

Question 21

tracheal

Answer 21

used with an artificial airway e.g. ET tube or tracheostomy

Question 22

what are some of the indications a client might need suction?

Answer 22

signs of respiration distress or evidence that client is unable to cough up and expectorate secretions.
Dyspnea, bubbling, or rattling breath sounds
poor skin color/ cyanosis
decrease in O2 saturation

Question 23

chest tube

Answer 23

a catheter placed through the thorax to remove air and fluids from the pleural space or to prevent air from reentering or to reestablish intrapleural and intrapulmonic pressures.

Question 24

what are the basic nursing interventions that promote oxygenation?

Answer 24

• Position the client to allow for maximal chest expansion.
• encourage or assist client with frequent changes in position every 2 hours.
• Encourage deep breathing and coughing
• promote comfort so client can tolerate the above activities.

Question 25

What are the desired outcomes?

Answer 25

• Maintain a patent airway
• improve comfort and ease of breathing
• maintain or improve pulmonary ventilation and oxygenation.
• improve ability to participate in physical activities
• prevent risk associated with oxygenation problems.

Question 26

Artificial airway

Answer 26

oral airway
endotracheal airway
tracheostomy

Question 27

Ventilation

Answer 27

The process of moving gases in and out of the lungs

Question 28

Perfusion

Answer 28

relates to the ability of the cardiovascular system to pump oxygenated blood to the tissues and return deoxygenated blood to the lungs

Question 29

Patients with sudden changes in their vital signs, level of consciousness, or behavior are possibly experiencing profound___________.(low Oxygen)

Answer 29

Hypoxia

Question 30

A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder:

1 Alcoholism and hypertension

2 Obesity and diabetes

3 Stress-related illnesses

4 Cardiopulmonary disease and lung cancer

Answer 30

4.-Cardiopulmonary disease and lung cancer

Question 31

A patient has been diagnosed with severe iron deficiency anemia. During physical assessment for which of the following symptoms would the nurse assess to determine the patient’s oxygen status?

1 Increased breathlessness but increased activity tolerance

2 Decreased breathlessness and decreased activity tolerance

3 Increased activity tolerance and decreased breathlessness

4 Decreased activity tolerance and increased breathlessness

Answer 31

4.-Decreased activity tolerance and increased breathlessness

Question 32

A patient is admitted to the emergency department with suspected carbon monoxide poisoning. Even though the patient’s color is ruddy, not cyanotic, the nurse understands that the patient is at a risk for decreased oxygen-carrying capacity of blood because carbon monoxide does which of the following:

1 Stimulates hyperventilation, causing respiratory alkalosis

2 Forms a strong bond with hemoglobin, creating a functional anemia.

3 Stimulates hypoventilation, causing respiratory acidosis

4 Causes alveoli to overinflate, leading to atelectasis

Answer 32

2.-Forms a strong bond with hemoglobin, creating a functional anemia.

Question 33

A 6-year-old boy is admitted to the pediatric unit with chills and a fever of 104° F (40° C). What physiological process explains why the child is at risk for developing dyspnea?

1 Fever increases metabolic demands, requiring increased oxygen need.

2 Blood glucose stores are depleted, and the cells do not have energy to use oxygen.

3 Carbon dioxide production increases as result of hyperventilation.

4 Carbon dioxide production decreases as a result of hypoventilation.

Answer 33

1.-Fever increases metabolic demands, requiring increased oxygen need.

Question 34

A patient was admitted after a motor vehicle accident with multiple fractured ribs. Respiratory assessment includes signs/symptoms of secondary pneumothorax, which includes which of the following?

1 Sharp pleuritic pain that worsens on inspiration

2 Crackles over lung bases of affected lung

3 Tracheal deviation toward the affected lung

4 Increased diaphragmatic excursion on side of rib fractures

Answer 34

1 Sharp pleuritic pain that worsens on inspiration

Question 35

The nurse needs to apply oxygen to a patient who has a precise oxygen level prescribed. Which of the following oxygen-delivery systems should the nurse select to administer the oxygen to the patient?

1 Nasal cannula

2 Venturi mask

3 Simple face mask without inflated reservoir bag

4 Plastic face mask with inflated reservoir bag

Answer 35

Nasal Cannula