Oxygenation (50) Flashcards
A client with chronic pulmonary disease has a bluish tinge around the lips. The nurse charts which term to most accurately describe the client’s condition?
- Hypoxia
- Hypoxemia
- Dyspnea
- Cyanosis
4. Cyanosis
A bluish tinge to mucous membranes is called cyanosis. This is most accurate because it is what the nurse observes.
The nurse can only observe signs/symptoms of hypoxia (option 1). More information is needed to validate this conclusion.
Hypoxemia requires blood oxygen saturation data to be confirmed (option 2), and dyspnea is difficult breathing (option 3).
To prevent postoperative complications, the nurse assists the client with coughing and deep-breathing exercises. This is best accomplished by implementing which of the following?
- Coughing exercises 1 hour before meals and deep breathing 1 hour after meals
- Forceful coughing as many times as tolerated
- Huff coughing every 2 hours or as needed
- Diaphragmatic and pursed-lip breathing 5 to 10 times, four times a day
- Huff coughing every 2 hours or as needed
Huff coughing helps keep the airways open and secretions mobilized. Huff coughing is an alternative for clients who are unable to perform a normal forceful cough (e.g., postoperatively).
Deep breathing and coughing should be performed at the same time.
Only at mealtimes is not sufficient (option 1). Extended forceful coughing fatigues the client, especially postoperatively (option 2).
Diaphragmatic and pursed-lip breathing are techniques used for clients with obstructive airway disease (option 4).
The nurse is preparing to perform tracheostomy care. Prior to beginning the procedure the nurse performs which action?
- Tells the client to raise two fingers to indicate pain or distress.
- Changes the twill tape holding the tracheostomy in place.
- Cleans the incision site.
- Checks the tightness of the ties and knot.
1. Tells the client to raise two fingers to indicate pain or distress.
Prior to starting the procedure, it is important to develop a means of communication by which the client can express pain or discomfort.
The twill tape is not changed until after performing tracheostomy care (option 2).
Cleaning the incision should be done after cleaning the inner cannula (option 3).
Checking the tightness of the ties and knot is done after applying new twill tape (option 4).
Which action by the nurse represents proper nasopharyngeal/ nasotracheal suction technique?
- Lubricate the suction catheter with petroleum jelly before and between insertions.
- Apply suction intermittently while inserting the suction catheter.
- Rotate the catheter while applying suction.
- Hyperoxygenate with 100% oxygen for 30 minutes before and after suctioning.
3. Rotate the catheter while applying suction.
Rotating the catheter prevents pulling of tissue into the opening on the catheter tip and side.
Suction catheters may only be lubricated with water or water-soluble lubricant (petroleum jelly, e.g., Vaseline, has an oil base) (option 1).
No suction should ever be applied while the catheter is being inserted because this can traumatize tissues (option 2).
The client should be hyperoxygenated for only a few minutes before and after suctioning and this is generally limited to clients who are intubated or have a tracheostomy (option 4).
Which client statement informs the nurse that his teaching about the proper use of an incentive spirometer was effective?
- “I should breathe out as fast and hard as possible into the device.”
- “I should inhale slowly and steadily to keep the balls up.”
- “I should use the device three times a day, after meals.”
- “The entire device should be washed thoroughly in sudsy water once a week.”
2. “I should inhale slowly and steadily to keep the balls up.”
Proper use of an SMI requires the client to take slow, steady inhalations, every hour or two, 5 to 10 breaths each time.
Only the mouthpiece can be successfully rinsed or wiped clean. The device should not be submerged in water (option 4).
While a client with chest tubes is ambulating, the connection between the tube and the water seal dislodges. Which action by the nurse is most appropriate?
- Assist the client to ambulate back to bed.
- Reconnect the tube to the water seal.
- Assess the client’s lung sounds with a stethoscope.
- Have the client cough forcibly several times.
2. Reconnect the tube to the water seal.
The tube should be reconnected to the water seal as quickly as possible.
Assisting the client back to bed (option 1) and assessing the client’s lung (option 3) are possible actions after
the system is reconnected.
The nurse makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has
- Anemia.
- An infection.
- A fractured rib.
- A tumor of the medulla.
1. Anemia.
Anemia is a condition of decreased red blood cells and decreased hemoglobin. Hemoglobin is how the oxygen molecules are transported to the tissues.
Option 2 would depend on where the infection is located.
Option 3: A fractured rib would interrupt transport of oxygen from the atmosphere to the airways.
Option 4: Damage to the medulla would interfere with neural stimulation of the respiratory system.
Which term does the nurse document to best describe a client experiencing shortness of breath when lying down who must assume an upright or sitting position to breathe more comfortably and effectively?
- Dyspnea
- Hyperpnea
- Orthopnea
- Acapnea
3. Orthopnea
Respiratory difficulty related to a reclining position without other physical alterations is defined as orthopnea.
A client with emphysema is prescribed corticosteroid therapy on a short-term basis for acute bronchitis. The client asks the nurse how the steroids will help him. The nurse responds by saying that the corticosteroids will do which of the following?
- Promote bronchodilation.
- Help the client to cough.
- Prevent respiratory infection.
- Decrease inflammation in the airways.
4. Decrease inflammation in the airways.
Glucocorticoids are prescribed because of their anti-inflammatory effect.
Options 1, 2, and 3 are not achieved with glucocorticoids.
The nurse is planning to perform percussion and postural drainage. Which is an important aspect of planning the client’s care?
- Percussion and postural drainage should be done before lunch.
- The order should be coughing, percussion, positioning, and then suctioning.
- A good time to perform percussion and postural drainage is in the morning after breakfast when the client is well rested.
- Percussion and postural drainage should always be preceded by 3 minutes of 100% oxygen.
1. Percussion and postural drainage should be done before lunch.
Postural drainage results in expectoration of large amounts of mucus. Clients sometimes ingest part of the secretions.
The secretions may also produce an unpleasant taste in the
oral cavity, which could result in nausea/vomiting.
This procedure should be done on an empty stomach to decrease client discomfort.
