Need for air

Question 1

1.Describe the assessment of the cardiopulmonary system.

Answer 1

Take temperature, blood pressure, pulse and O2 sta.
Observe for s/s – dyspnea, chest pain, cough, wheezing, sputum production and hemoptysis.
Observe the patients general appearance – skin color, clubbing of nails, cyanosis, check circulation with the blanch test.
Examine mouth, nose, and throat; auscultate lungs and heart.
Thoracic inspection: are they using other muscle to breathe with such as abdominal muscles.
Thoracic percussion: to determine if lungs are filled with air, fluid or solid.
Review reports/procedures related to respiratory system and heart – O2 sat, chest x-ray, EKG report.
Environmental exposures
Risk factors in work
Medications
Lifestyle factors: Nutrition, exercise, cigarette smoking, substance abuse.

Question 2

2.Define normal for blood pressure, pulse, capillary refill, heart rate?

Answer 2

Normal blood pressure for adult 120/80
Pulse 60-100 beats per minute Pulsation is easily felt, takes moderate pressure to cause it to disappear.
Heart rate 60-100 beats per minute
Respiration 12-20 breaths per minute
Capillary refill 2-3 seconds

Question 3

3.Describe the impact of a client’s level of health, age, lifestyle and environment on tissue oxygenation?

Answer 3

Poor health or illness patient is not breathing as efficiently as they should so tissues are not getting as much oxygen.
Older adults have a decrease in lung function
Living an unhealthy live style, smoking, drinking, abusing drugs, decreases amount of lung function.
Environment pollution decreases the amount of oxygen inhaled so less is available for the tissues.

Question 4

4.Identify normal and abnormal cardiopulmonary assessment findings.

Answer 4

Normal breath sounds: vesicular, bronchovesicular, bronchial, tracheal; clear, patient is not having difficulty breathing. Abnormal sounds: crackles (rales), wheeze (rhonchi), friction rubs.
Atelectasis – collapsed lung, Dyspnea- SOB, cough, sputum production and hemoptysis (blood from lungs). Orthopnea (only able to breath in an upright position), Cyanosis, clubbing of the fingers.
Normal lung sound when percussion is resonance, relative intensity is loud.
Abnormal lung percussion is flat, dull, hyperresonance, and tympany.
Using muscles other than the diaphragm to breathe.
Normal capillary refill is within 2-3 seconds nail should be pink. Abnormal: failure to regain color quickly, over 3 seconds, suggest impaired blood flow.

Question 5

5.Describe respiratory changes associated with aging.

Answer 5

This system is most able to compensate with changes due to aging. Healthy, nonsmoking adults generally show very little decline in respiratory function. Stress of illness may increase the older persons demand for O2 and affect the overall function of other systems. Some calcification and weakening of the chest wall muscles may also occur.

Question 6

6.Distinguish between normal and adventitious breath sounds.

Answer 6

Normal breath sounds:
Vesicular- inspiratory sounds last longer than expiratory.
Bronchovesicular- inspiratory and expiratory sounds almost equal.
Bronchial-expiratory longer than inspiratory.
Tracheal-inspiratory and expiratory sounds about equal.
Adventitious breath sounds:
Crackles (rales) – soft high-pitched discontinuous popping sounds that occur during inspiration.
Wheezes(rhonchi)-caused by air moving through narrowed passages.
Friction rubs-harsh, cracking sound, like two pieces of leather being rubbed together; may subside when client holds breath.

Question 7

7.Identify the locations of various pulses.

Answer 7

Temporal – temple
Carotid – on each side of neck
Brachial – inside bend of elbow cubital
Radial – wrist, side thumb is located on.
Femoral – is in groin
Popliteal – is behind knee
Dorsalis pedis - is located on the top of foot close to ankle.
Posterior tibial – is located back of foot above heel.

Question 8

8.Recognize nursing interventions that promote oxygenation.

Answer 8

Make sure the air way is open and not obstructed. Assist the patient in different positions that will allow for easier breathing. If oxygen is ordered make sure the patient is using it and the rate is correctly set.

Question 9

9.Discuss the cardiopulmonary assessment of observation, auscultation, palpation, and percussion.

Answer 9

Observe the patient for the following: dyspnea, cough, sputum production, chest pain, wheezing, hemoptysis, orthopnea, cyanosis, and clubbing of the fingers.
Auscultation: listen to the lungs for crackles, wheezes, friction rubs. Lungs should be clear. Listen to heart for irregular beating.
Palpation: check peripheral pulse rate for signs of circulation. Should be strong and regular.
Percussion: percuss the lungs to make sure they are clear. If not assess the sound to determine if fluid or mass maybe present.

Question 10

Oxygenation

Answer 10

occurs when O2 molecules enter the tissue

Question 11

Diffusion

Answer 11

the spread of particles through random motion from regions of higher concentration to regions of lower concentration

Question 12

Ventilation

Answer 12

is the process of moving gases into and out of the lungs.

Question 13

Ventilation requires coordination of the muscles of the__________and__________ as well as intact innervation

Answer 13

lungs and thorax

Question 14

The major inspiratory muscle of respiration is the

Answer 14

diaphragm

Question 15

Hypoventilation

Answer 15

reduced rate and depth of breathing that causes an increase in carbon dioxide

Question 16

Hyperventilation

Answer 16

increased volume ventilation which results in a lowered carbon dioxide level. It is frequently seen in many disease states – asthma, pulmonary embolism, and anxiety.

Question 17

Respiration

Answer 17

gas exchange; oxygenation of blood & elimination of carbon dioxide: one inhalation and one exhalation

Question 18

Inhalation

Answer 18

drawing air into the airways

Question 19

Exhalation

Answer 19

relaxation of the chest and lungs; requires no energy expenditure

Question 20

Hemoptysis

Answer 20

Expectoration of blood from the respiratory tract; a symptom of both pulmonary and cardiac disorders

Question 21

Cyanosis

Answer 21

A late sign of hypoxia

A blue discoloration of the skin and mucous membranes caused by the presence of desaturated hgb in the capillaries.

Question 22

Atelectasis

Answer 22

a collapsed or airless condition of the lung.
May be caused by obstruction of one or more airways with mucus plugs, or by hypoventilation secondary to pain (such as pain seen with fractured ribs). It may be a complication of abdominal or thoracic surgery.

Question 23

Conditions Affecting Chest Wall Movements

Answer 23

Pregnancy
Obesity
Musculoskeletal Abnormalities
Trauma
Neuromuscular Disease
CNS Alterations
Chronic Disease

Question 24

Crackles (rales)

Answer 24

soft, high-pitched discontinuous popping sounds that occur during inspiration

Question 25

Wheezes (rhonchi)-

Answer 25

caused by air moving through narrowed passages

Question 26

Friction rubs

Answer 26

harsh, cracking sound, like two pieces of leather being rubbed together; may subside when client holds breath

Question 27

List adventitious breath sounds

Answer 27

Crackles (rales), Wheezes (rhonchi), Friction rubs

Question 28

List “normal” breath sounds

Answer 28

Vesicular, Bronchovesicular, Bronchial, Tracheal

Question 29

Vesicular

Answer 29

Inspiratory sound last longer than expiratory. Heard over most of both lungs.

Question 30

Bronchovesicular

Answer 30

Inspiratory and expiratory sounds almost equal. Heard in the 1st and 2nd interspaces anteriorly between the scalpulae.

Question 31

Bronchial

Answer 31

Expiratory longer than inspiratory. Heard over the upper part of the sternal area

Question 32

Tracheal

Answer 32

Inspiratory and expiratory sounds are about equal. Heard over the trachea in the neck.

Question 33

Capillary Refill (Blanch Test)

Answer 33

A test of the integrity of the circulation performed by applying and then quickly releasing pressure to a fingernail or toenail. After losing color, the blanched nail normally regains a pink appearance within 2-3 seconds or less. Failure to regain color quickly suggests impaired blood flow to the extremity.

Question 34

Laboratory and diagnostic tests

Answer 34

ABG’s
Chest x-ray
O2 saturation
Sputum culture
FOB
PFT’s
EKG
Holter Monitor

Question 35

List S/S of respiratory infection

Answer 35

Dyspnea – difficult or labored breathing, shortness of breath
Orthopnea – inability to breathe except in an upright position
Cough
Hemoptysis – bloody sputum
Sputum production
Chest pain
Wheezing
Clubbing of the fingers
Cyanosis

Question 36

Cough Assessment

Answer 36

Onset
Duration
Type:; dry, hacking moist, barking, brassy, or paroxysmal (a sudden attack, outburst, or intensification of S & S)
Progress; better, worse, unchanged, persistent
Pattern: daytime, nighttime, different intensity with time or activity

Question 37

Significance of Sputum Characteristics

Answer 37

White / clear – usually viral
Yellow or green – S & S of infection
Black – inhalation of coal, smoke, or soot
Rust – associated with the presence of blood
Pink and frothy – associated with pulmonary edema

Question 38

Thoracic percussion

Answer 38

Sets the chest wall and underlying structures in motion, producing vibrations.
Used to determine if tissues are filled with air, fluid, or solid material.

Question 39

Characteristics of percussion sounds

Answer 39

Flatness
Dullness
Resonance 
Hyperresonance
Tympany

Question 40

Importance of pulse oximetry

Answer 40

A noninvasive method of continuously monitoring the O2 saturation of hgb (SaO2).

Question 41

Normal ABG’s

Answer 41

pH: 7.35 – 7.45
PaCO2: 35 – 45 mm/hg
PaO2: 80 – 100 mm/hg
O2 sat: 95 – 100%
Base excess or deficit: + or – 2
HCO3: 22 – 26 mEq/L

Question 42

What are the purposes for bronchoscopy?

Answer 42

The direct inspection and examination of the larynx, trachea, and bronchi.

Question 43

What is the significance of clubbing of the nail beds?

Answer 43

This is a sign of lung disease found in patients with chronic hypoxic conditions, chronic lung infection, and malignancies of the lung/lungs.

Question 44

Collection of a sputum specimen, Expectoration

Answer 44

Instruct patient to clear the nose and throat and rinse the mouth to decrease contamination of the sputum. After a few deep breaths, the patient coughs (vs. spits) into a sterile container.
Best obtained in early morning.

Question 45

List oxygen safety measures

Answer 45

O2 should be set at the prescribed rate. Smoking is not permitted.
Store O2 cylinders in an upright position.
Check O2 available in portable cylinders before transporting or ambulating patients. Post O2 caution signs on doors.

Question 46

Hypoxia

Answer 46

is a deficiency of oxygen in body tissues; can also be a decreased concentration of oxygen in inspired air.

Question 47

Hypoxemia

Answer 47

is a decreased oxygen concentration of arterial blood, measured by PaO2 values.

Question 48

Methods used for continued hypoxia

Answer 48

Monitor ABG’s
Monitor pulse oximetry
Perform a complete respiratory assessment
Notify MD
Identify methods to decrease O2 demands

Question 49

S/S of airway obstruction

Answer 49

Shortness of breath
Wheezing
Use of accessory muscles
Pallor
Cyanosis
Nasal flaring

Question 50

Nursing History

Answer 50

Fatigue
Dyspnea
Cough
Wheezing
Pain
Environmental or Geographical Exposures
Respiratory Infections
Risk Factors
Medications

Question 51

Lifestyle Factors Affecting Cardiopulmonary Function

Answer 51

Nutrition – obesity, malnourished, anemia
Exercise – increases the body’s metabolic activity and oxygen demand
Cigarette smoking – vasoconstriction of vessels, heart and lung disease
Substance abuse – poor nutritional intake, inhaled fumes

Question 52

Respiratory Changes Associated with Aging

Answer 52

This system is most able to compensate with changes due to aging.
Healthy, nonsmoking adults generally show very little decline in respiratory function.
Stress or illness may increase the older persons demand for O2 and affect the overall function of other systems.
Some calcification and weakening of the chest wall muscles may also occur.

Question 53

Precautionary Measures for Older Adults

Answer 53

Don’t smoke!
Pneumococcal vaccine – prevents 85-90% of all cases of pneumonia
Influenza vaccine yearly – reduces flu related deaths in the elderly
Wellness activities – regular exercise, appropriate fluid intake, and avoidance of people who are sick

Question 54

Developmental stage

Answer 54

infants (RDS), toddlers (choking), preschool and school age (accidents, childhood illnesses), adolescents (social habits), young and middle age adults (unhealthy lifestyles), older adults (decreased heart and lung function)

Question 55

Lifestyle

Answer 55

pregnancy, job hazards, nutrition, obesity, exercise, smoking, substance abuse,

Question 56

Factors that Influence Oxygenation

Answer 56

Developmental stage
Lifestyle
Medications
Disease processes

Question 57

“1. A patient has a fractured rib and is breathing less often and with less depth because of the pain. The nurse would document this finding using which term?

a. Fremitus
b. Hyperventilation
c. Pleural friction rub
d. Hypoventilation

Answer 57

1. d. Hypoventilation is a decreased rate or depth of air movement into the lungs. Hyperventilation is an increased rate and depth of ventilation. Fremitus is the vibration of the chest wall that can be palpated. A pleu- ral friction rub is a dry grating sound caused by inflam- mation of pleural surface.

Question 58

2. When auscultating Mr. Chang’s breath sounds, the nurse detects a continuous, musical sound heard on expiration. The nurse identifies this sound as which of the following?
   a. Crackles
   b. Wheezes
   c. Bronchial sounds
   d. Pleural friction rub

Answer 58

2. b. Wheezes are a continuous sound heard on expiration. Crackles are not described as squeaky. The pleu- ral friction rub is a dry, grating sound. Bronchial breath sounds are normal sounds heard over the trachea.”

Question 59

3. Air that develops in the pleural space is referred to as:
   a. Pneumothorax
   b. Pleural effusion
   c. Hemothorax
   d. Atelectasis

Answer 59

3. a. Air in the pleural space is termed pneumothorax. Fluid in the pleural space is referred to as a pleural effusion. Blood collection in the pleural space is referred to as a hemothorax. Atelectasis refers to an incomplete expansion or collapse of the alveoli.

Question 60

4. When planning care for a patient with chronic lung dis- ease who is receiving oxygen through a nasal cannula, what does the nurse expect?
   a. The oxygen must be humidified.
   b. The rate will be 2 L/min or less.
   c. Arterial blood gases will be drawn every 4 hours to assess flow rate.
   d. The rate will be 6 L/min or more.”

Answer 60

4. b. A rate higher than 2 L/min may destroy the hypoxic drive that stimulates respirations in the medulla in a patient with chronic lung disease. Oxygen delivered at low rates does not necessarily have to be humidified, and arterial blood gases are not required at regular intervals to determine the flow rate.

Question 61

5. Which oxygen delivery device would the nurse expect to use to provide the highest concentration of oxygen to a patient who is breathing spontaneously?
   a. Partial rebreather mask
   b. Nonrebreather mask
   c. Simple mask
   d. Venturi mask

Answer 61

5. b. The nonrebreather mask provides the highest concen- tration of oxygen to a spontaneously breathing patient. None of the other devices would provide this.

Question 62

6. When teaching a patient about pulse oximetry, which statement would the nurse most likely include in the discussion?
   a. A range of 95% to 100% is considered normal oxygen saturation.
   b. Oximetry measures the oxygen saturation of venous blood.
   c. Fasting is required for 12 hours before the test.
   d. Pulse oximetry is a replacement for arterial blood gas analysis.

Answer 62

6. a. Pulse oximetry measures oxygen saturation levels of arterial blood, which normally range from 95% to 98%. Fasting is not required before the test. Pulse oximetry is an adjunct therapy, not a replacement for arterial blood gas analysis.

Question 63

7. Which action would the nurse include when performing oropharyngeal suctioning on a patient?
   a. Use clean technique.
   b. Apply suction as the catheter is introduced.
   c. Flush the catheter with saline between catheter insertions.
   d. Limit suctioning to 25- to 30-second intervals at one time.

Answer 63

7. c. Flushing the catheter with saline between insertions is important to clear the catheter of secretions. The nurse should use sterile technique and should not apply suction as the catheter is being introduced; suctioning should be limited to 10- to 15-second intervals to avoid causing hypoxia

Question 64

8. Effective use of a metered-dose inhaler requires that the patient accomplish which action?
   a. Breathe in through the nose.
   b. Inhale two sprays with one breath.
   c. Hold the breath for 5 to 10 seconds after inspiration.
   d. Exhale quickly through an open mouth

Answer 64

8. c. Holding one’s breath for 5 to 10 seconds after inspiration of the medication allows the drug to reach the alveoli. Correct technique for using an MDI includes breathing in through the mouth so that all the medication is properly delivered to the lungs, using one spray of medication for each breath to receive the correct dose, and exhaling slowly through pursed lips to mini- mize airway trapping and resistance.

Question 65

9. Mr. Parks has chronic obstructive pulmonary disease (COPD). The nurse has taught him that pursed-lip breathing helps him by:
   a. Increasing carbon dioxide, which stimulates breathing
   b. Prolonging inspiration and shortening expiration
   c. Liquefying his secretions
   d. Decreasing the amount of air trapping and resistance

Answer 65

9. d. Doing pursed-lip breathing correctly diminishes carbon dioxide retention. It also prolongs expiration, increases airway pressure, and lessens the amount of airway trapping and resistance.

Question 66

10. A patient develops sudden cardiac arrest. It is imperative to begin CPR as soon as possible. What is the critical time that the nurse must keep in mind before irreversible brain damage occurs?
    a. 1 to 3 minutes
    b. 2 to 4 minutes
    c. 4 to 6 minutes
    d. 8 to 10 minutes

Answer 66

10. c. After 4 to 6 minutes without oxygen, irreversible brain damage can occur.

Question 67

11. David White is in the hospital with a medical diagnosis of viral pneumonia. He is receiving oxygen through a simple face mask. The nurse ensures that the mask fits snugly over the patient’s face for which reason?
    a. To prevent mask movement and consequent skin breakdown
    b. To help the patient feel secure
    c. To maintain carbon dioxide retention
    d. To aid in maintaining expected oxygen delivery

Answer 67

11. d. A snug-fitting mask is necessary to deliver the expected rate of oxygen. A simple face mask does not trap carbon dioxide or cause retention. Patients often complain that an oxygen mask is uncomfortable. A snug fit may limit but not prevent movement of the mask.

Question 68

12. When suctioning a patient through a tracheostomy tube, the nurse was careful not to occlude the Y port when inserting the suction catheter because this would do which of the following?
    a. Prevent suctioning from occurring
    b. Cause trauma to the tracheal mucosa
    c. Break the sterile technique
    d. Suction out all the carbon dioxide

Answer 68

12. b. Occluding the Y port causes suction and may traumatize the tracheal mucosa if applied when the catheter is inserted. Occluding the Y port does not prevent suction.

Question 69

13. What action does the nurse use 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 cylinder key counterclockwise until tight

Answer 69

13. a. 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

Question 70

14. Which of the following assessments should the nurse consider when performing tracheal suctioning? Select all that apply. a. Close assessment of 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. Using an appropriate suction pressure (80–120 mm Hg).
    f. Insert the suction catheter as far as it will go before applying suction. This will help prevent atelectasis related to the use of high negative pressure.

Answer 70

14. a, b, d, e. Close assessment of the patient before, during, and after the procedure is necessary to limit negative effects. Risks include hypoxia, infection, tra- cheal tissue damage, dysrhythmias, and atelectasis. Hyperoxygenate the patient before and after suctioning. Limit the application of suction to 10 to 20 seconds. These interventions help prevent hypoxia. Monitor the patient’s pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80–120 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 tra- cheal or endotracheal tube) to avoid tracheal mucosal damage, including epithelial denudement, loss of cilia, edema, and fibrosis (Roman, 2005).

Question 71

15. Abdominal breathing at 30 to 60 breaths/minute with an irregular pattern of rate and depth would closely describe the breathing patterns of what age group?
    a. Aged adult
    b. Infant
    c. Early childhood
    d. Late childhood

Answer 71

15. b. Respirations in the infant are more rapid and have not stabilized. As alveoli increase in number and size, the respiratory rate decreases.