Oxygenation

Question 1

Ventilation

Answer 1

Process of moving gases in and out of the lungs

Question 2

What is ventilation affected by?

Answer 2

• Rate and depth of breathing
• Condition of the airway
• Condition of the lungs

Question 3

Respiration external

Answer 3

Exchange of respiratory gases at the alveoli

Question 4

External respirations affected by

Answer 4

• Thickness of alveolar membrane

- Lung surface

Question 5

Respiration internal

Answer 5

Exchange of respiratory gases at the capillary level into organs and tissues

Question 6

what alveoli are and what is happening in and around them constantly (in a healthy client).

Answer 6

They are tiny air sacs surrounded by a network of capillaries. Oxygen and carbon dioxide flow back and forth between the two

Question 7

how inhalation occurs.

Answer 7

Expansion of lungs and chest cavity due to the negative pressure in the lungs causes air to be drawn in.

Question 8

Respiration

Answer 8

the exchange of carbon dioxide and oxygen in the lungs

Question 9

chemoreceptors

Answer 9

• HIGH CO2 LEVELS STIMULATE BREATHING TO ELIMINATE THE EXCESS CO2
• A SECONDARY, THOUGH IMPORTANT, DRIVE TO BREATHE IS HYPOXEMIA. LOW BLOOD O2 LEVELS STIMULATE BREATHING TO GET MORE OXYGEN INTO THE LUNGS

Question 10

Eupnea

Answer 10

normal breathing, about 12-20 bpm

Question 11

Tachypnea

Answer 11

fast, shallow breathing, more than 24 bpm. Caused by hypoxemia or increased oxygen demand and can cause hypoventilation

Question 12

Bradypnea

Answer 12

slow respirations, fewer than 10 bpm and may cause poor gas exchange and can be caused by sedative and opioid meds and neuromuscular dysfunction

Question 13

Kussmaul’s

Answer 13

regular but increased rate and abnormally deep respirations and can be caused by fear, anxiety or panic

Question 14

Biot’s

Answer 14

irregular respirations (usually shallow), alternating with periods of apnea and usually associated with brain injury

Question 15

Cheyne-Stokes

Answer 15

gradual increase in depth followed by gradual decrease in depth then a period of apnea. Often associated w brain injury

Question 16

Apnea

Answer 16

absence of breathing. Requires immediate cardiopulmonary resuscitation

Question 17

Paroxysmal nocturnal dyspnea (PND)

Answer 17

sudden awakening caused by shortness of breath during sleep

Question 18

Conversational dyspnea

Answer 18

cant speak complete sentences without pausing to breathe

Question 19

Stridor

Answer 19

high-pitched, harsh, crowing inspiratory sound caused by partial obstruction. Partial can become complete so get immediate care

Question 20

WHITE OR CLEAR sputum means

Answer 20

usually in viral infection (common cold)

Question 21

YELLOW OR GREEN sputum means

Answer 21

sign of infection

Question 22

Black sputum means

Answer 22

caused by coal dust, smoke, or soot

Question 23

Rust colored sputum

Answer 23

usually associated w pneumococcal pneumonia, TB and possibly blood presence

Question 24

HEMOPTYSIS

Answer 24

the coughing up of blood

Question 25

PINK FROTHY SPUTUM

Answer 25

is associated w pulmonary edema

Question 26

FOUL ODOR sputum

Answer 26

bacterial infection (pneumonia or lung abscesses)

Question 27

What are two methods nurses use to collect sputum specimens?

Answer 27

• EXPORATED have patient breathe a few times to stimulate a cough and spit the specimen into a cup
• SUCTIONED

Question 28

What are several ways you can confirm that you are getting accurate pulse ox readings?

Answer 28

Choose a site w proper circulation, free or artificial nails and contains no moisture, make sure site is clean, dim the lights or cover probe w bed covers

Question 29

The nurse assesses that several clients have low oxygen saturation levels. Which client will benefit the most from receiving oxygen via a nasal cannula?

The client who has dry oral mucous membranes from mouth breathing

The client who has a nasogastric tube in place for gastric decompression

The client who has many visitors and spends much time sitting in a chair

The client who has an upper respiratory infection and spends much time sleeping

Answer 29

The client who has many visitors and spends much time sitting in a chair

Question 30

The nurse is caring for a client with severe dyspnea who is receiving oxygen via a Venturi mask. Which action would the nurse take when caring for this client?

Assess frequently for nasal drying.

Keep the mask tight against the face.

Monitor oxygen saturation levels when the client is eating.

Set the oxygen flow at the highest setting that the client can tolerate.

Answer 30

Monitor oxygen saturation levels when the client is eating.

Because the mask cannot be worn when eating, the client may become hypoxic. A nasal cannula may be needed to deliver oxygen while the client is eating. Nasal drying usually is not a problem with the use of a Venturi mask.

Question 31

When the oxygen saturation of a client with pneumonia is at 89% to 90% while using a nonrebreather mask, which collaborative action would the nurse anticipate?

Administration of oxygen using a simple face mask

Use of a Venturi mask for administration of high-flow oxygen

Continued oxygen administration with the nonrebreather mask

Oxygen administration with bi-level positive airway pressure (BiPAP)

Answer 31

Oxygen administration with bi-level positive airway pressure (BiPAP

The client’s oxygen saturation is low even with the fraction of inspired oxygen (FiO2) levels of up to 95% that can be administered with a nonrebreather mask, and another method of oxygen administration is needed. BiPAP adds positive pressure during inspiration to oxygen administration, decreasing some of the work of breathing and improving tidal volumes and gas exchange without some of the risks that are associated with intubation and mechanical ventilation.

Question 32

The nurse is preparing to perform endotracheal suctioning on a client. Before beginning the procedure, which intervention would the nurse do?

Ask the client to take several deep breaths.

Instruct the client to cough before suctioning.

Administer 100% oxygen to the client.

Answer 32

Administer 100% oxygen to the client.

Before suctioning, regardless of the means, oxygen should be administered, because the suctioning procedure depletes oxygen from the respiratory tract, causing a potential drop in oxygen saturation levels. In a client with an endotracheal tube, manually bagging with 100% oxygen will hyperoxygenate the lungs.

Question 33

When suctioning a client with a tracheostomy, which nursing intervention is correct?

Hyperventilate the client with room air before suctioning.

Apply suction only as the catheter is being withdrawn.

Insert the catheter until the cough reflex is stimulated.

Answer 33

Apply suction only as the catheter is being withdrawn.

Question 34

Which nursing action is appropriate when suctioning the secretions of a client with a tracheostomy?

Use a new sterile catheter with each insertion.

Initiate suction as the catheter is being withdrawn.

Insert the catheter until the cough reflex is stimulated

Answer 34

Initiate suction as the catheter is being withdrawn.

Question 35

The nurse is suctioning a client’s airway. Which nursing action will limit hypoxia?

Limit suctioning with catheter to 30 seconds.

Apply suction only after the catheter is inserted.

Lubricate the catheter with saline before insertion.

Answer 35

Apply suction only after the catheter is inserted.

Question 36

The nurse teaches a postoperative client how to use an incentive spirometer. Which client behavior indicates to the nurse that the spirometer is being used correctly?

Inhales deeply through the mouthpiece, relaxes, and then exhales

Inhales deeply, seals the lips around the mouthpiece, and exhales

Uses the incentive spirometer for 10 consecutive breaths per hour

Answer 36

Inhales deeply through the mouthpiece, relaxes, and then exhales