Oxygenation Chapter 35 Flashcards
1
Q
What happens to inhaled air in the airways? How does this occur?
A
Answer:
The airway structures moisten, warm, and filter inhaled air. This is accomplished in three ways:
● A moist mucous-membrane lining adds water to inhaled air.
● Blood flowing through the vessels of airway walls transfer body heat to the inhaled air.
● Tiny hairlike projections from the wall of the airways (cilia) move rhythmically to carry trapped debris up and out of the airway.
2
Q
Pulmonary System
A
Airways and Lungs
3
Q
Ventilation
A
Movement of air into/out of the lungs
4
Q
Respiration
A
Exchange of oxygen/carbon dioxide
5
Q
Which diagnostic test/exam would best measure a client’s level of hypoxemia?
a. chest x-ray
b. pulse oximeter reading
c. ABG
d. peak expiratory flow rate
A
c. ABG
6
Q
Cardiovascular System
A
Heart, blood vessels, red blood cells
Hemoglobin: carries oxygen
Arteries
• Oxygenated blood to tissues
Veins
• Deoxygenated blood back to heart/lungs
7
Q
Tissue Paper My Assets
A
From the Body flows to the
Tricuspid
Then to the
Pulmonic
Out to the lungs, back in from the lungs to the
Mitral
Then to the
Aortic
and out to the body
8
Q
Factors That Influence Oxygenation
A
Lifespan and development (e.g., respiratory distress syndrome, upper respiratory infections (URIs), adolescent smoking, cardiac insufficiency)
Environment (e.g., stress, allergies)
Lifestyle (e.g., nutrition, exercise, substance abuse)
Medications
Pathophysiological Conditions
Neuromuscular abnormalities
Cardiovascular abnormalities
• Heart disease
• Vessel disease
Oxygen transport problems
Metabolic problems
9
Q
Pathophysiological Conditions
A
Alterations in O2 and CO2 levels
Alterations in
Pulmonary system: structure, airways, tissue
Pulmonary circulation
10
Q
Assessing Oxygenation Status
Physical Examination
A
Breathing pattern
Respiratory effort
Pulse oximetry
Cardiac functioning
Using inspection, palpation, percussion, and auscultation
11
Q
The term “Kussmaul” refers to a high-pitched, harsh, crowing inspiratory sound that occurs due to partial obstruction of the larynx.
a. true
b. false
A
Correct answer: B, false
The term for this sound of respiratory distress is “stridor.”
12
Q
Assessing Oxygenation Status
Diagnostic Testing
A
Arterial blood gases (ABGs)
PO2, PCO2
Peak flow monitoring
Cardiac monitoring: electrocardiogram
13
Q
Normal Range for Hemoglobin
A
12-18
14
Q
Hematocrit Levels
A
Men = 40-54%
Women 36-46%
Newborn = 44-64%
Normally 3x the hemoglobin
Measures the % of RBC in whole blood
15
Q
Interventions for Optimal Oxygenation
A
Use of a mechanical ventilator
Use of chest tube drainage
systems
Promoting circulation
Administering respiratory medications
16
Q
Promoting Respiratory Function
A
Immunizations/prevent URIs
Positioning: maximum lung excursion
Incentive spirometry
Aspiration precautions
Mobilizing secretions
• Deep breathing and coughing
• Hydration
• Chest physiotherapy
Oxygen therapy
• Cannula
• Mask
• Transtracheal catheter
Using artificial airways
- Oropharyngeal
- Nasopharyngeal
- Endotracheal tubes
- Tracheostomy tube Artificial airway patency
• Suctioning
•
•
17
Q
ClickerCheck
In caring for a client with a tracheostomy, the nurse would give priority to the nursing diagnosis of
a. Risk for ineffective airway clearance
b. Anxiety related to suctioning
c. Social isolation related to altered body image
d. Impaired tissue integrity
A
Correct answer: A
While other diagnoses may be applicable, maintaining a patent airway by tending to excessive secretions is a priority.
18
Q
A
19
Q
A
20
Q
In which structures of the lung does gas exchange take place?
A
Answer:
Gas exchange takes place in the type I alveolar cells.
21
Q
What does surfactant do for alveoli?
A
Answer:
Surfactant is the substance that lowers the surface tension inside alveoli and prevents their walls from being drawn together. Adequate surfactant levels are key to preventing alveolar collapse and allowing alveolar expansion during breathing.
22
Q
What is the difference between ventilation and respiration?
A
Answer:
Ventilation and respiration have the following differences:
● Ventilation is the movement of air into and out of the lungs through the act of breathing.
● Respiration is gas (carbon dioxide and oxygen) exchange.
23
Q
Describe how the diaphragm, accessory muscles, and pressure changes within the lungs create inhalation and exhalation.
A
Answer:
The diaphragm is the major muscle of breathing. Inhalation begins when the diaphragm contracts and the chest cavity is pulled downward. The lung bases descend with the chest cavity, significantly enlarging the lungs. Intercostal muscles, the small muscles around the ribs, also contract and pull the ribs slightly outward, expanding the chest cavity and lungs. The overall effect is to enlarge the chest cavity and subsequently the lungs. The negative pressure created in the lungs draws air in through the only opening to the outside, the trachea. Exhalation occurs when the diaphragm and intercostals muscles relax, allowing the chest and lungs to return to their normal resting size. The reduction in size causes a rise in pressure inside the chest and lungs to above atmospheric pressure, which causes air to flow out of the lungs. Exhalation requires no energy or effort.
24
Q
How does hypoventilation affect risk for hypoxemia and hypoxia?
A
Answer:
Hypoventilation occurs when a small amount of air is moved into and out of the lungs, which is caused by a decreased rate and/or depth of breathing. Hypoventilation increases the risk for problems with oxygenation (hypoxemia) and perfusion (hypoxia).
25
Describe two ways in which breathing is controlled.
Answer:
● Chemoreceptors located in the medulla of the brainstem, the carotid arteries, and the aorta detect changes in blood pH, O2, and CO2 levels, and they send messages back to the central respiratory center in the brain stem. In response, the respiratory center increases or decreases ventilation to maintain normal blood levels of pH, O2 (pO2), and CO2 (pCO2). Normally the blood CO2 level provides the primary stimulus to breathe. 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.
● In addition, lung receptors, located in the lung and chest wall, are sensitive to breathing patterns, lung expansion, lung compliance, airway resistance, and respiratory irritants. The respiratory center uses feedback from the lung receptors to adjust ventilation.
● Voluntary control from the motor cortex can override the involuntary respiratory centers, but only temporarily.
26
The level of which gas (oxygen or carbon dioxide) is the primary stimulant for breathing?
Answer:
Carbon dioxide
27
What are the major risks to oxygenation related to developmental factors?
Answer:
Children and adults have the following major risks factors related to oxygenation:
● Children. Incomplete development of the lungs and immune system place infants and young children at increased risk for problems with oxygenation. Increasing motor skills that are not accompanied by knowledge of risks also place young children at risk for aspiration and drowning.
● Older adults. The effects of aging also influence oxygenation. Costal cartilage begins to calcify, making the chest wall gradually less mobile and more rigid, reducing chest wall movement during breathing. The lungs have less recoil ability, and the alveoli lose elasticity. These changes result in reduced lung expansion and less alveolar inflation, especially in the bases of the lungs. The cough reflex is less effective, and the number of cilia in the airways decline with aging, making it more difficult to expel mucus or foreign material. Exhalation becomes less efficient, causing progressive air trapping, which decreases the ability to increase ventilation when oxygenation demands increase (as with exercise). The immune response declines with aging, especially cell-mediated immunity, T-cell activity, and the inflammatory response. All of these changes put elders at risk for respiratory infections.
28
What environmental and lifestyle factors that influence ventilation and circulation can be avoided or minimized?
Answer:
The following environmental and lifestyle factors that influence ventilation can be avoided:
● Poor nutrition
● Obesity
● Sedentary lifestyle
● Smoking
● Substance abuse
To a lesser extent, exposure to poor air quality, altitude, temperature extremes, and stress can be minimized.
29
What are some indirect indicators of tissue oxygenation?
Answer:
Adequacy of tissue oxygenation can be indirectly assessed by determining whether organs are functioning normally. For example, hypoxic central nervous system tissue causes abnormal brain functioning (e.g., altered level of consciousness), whereas hypoxic renal tissue causes abnormal kidney functioning (e.g., poor urine output), and hypoxic limb tissue results in abnormal muscle functioning (e.g., muscle weakness and pain with exercise).
30
How are hyperventilation and hypoventilation related to carbon dioxide levels?
Answer:
Ventilation relates to carbon dioxide levels in the following ways:
● Hypoventilation causes an excess of dissolved carbon dioxide in the blood, called hypercarbia (also called hypercapnia).
● Hyperventilation causes a low level of dissolved carbon dioxide in the blood, called hypocarbia (also called hypocapnia).
31
What are the effects of carbon dioxide levels on the nervous system?
Answer:
Carbon dioxide levels affect the nervous system in the following ways:
● Very high blood levels of carbon dioxide have an anesthetic effect on the nervous system and can lead to somnolence progressing to coma and death, a syndrome known as carbon dioxide narcosis.
● Very low blood levels of carbon dioxide have a stimulating effect on the nervous system and lead to muscle twitching or spasm (especially in the hands and feet) and numbness and tingling in the face and lips.
32
How are hyperventilation and hypoventilation related to carbon dioxide levels?
Answer:
Ventilation relates to carbon dioxide levels in the following ways:
● Hypoventilation causes an excess of dissolved carbon dioxide in the blood, called hypercarbia (also called hypercapnia).
● Hyperventilation causes a low level of dissolved carbon dioxide in the blood, called hypocarbia (also called hypocapnia).
33
What are the effects of carbon dioxide levels on the nervous system?
Answer:
Carbon dioxide levels affect the nervous system in the following ways:
● Very high blood levels of carbon dioxide have an anesthetic effect on the nervous system and can lead to somnolence progressing to coma and death, a syndrome known as carbon dioxide narcosis.
● Very low blood levels of carbon dioxide have a stimulating effect on the nervous system and lead to muscle twitching or spasm (especially in the hands and feet) and numbness and tingling in the face and lips.
34
Identify four pathophysiological conditions that affect pulmonary function. How are they similar? How are they different?
Answer:
The following types of conditions affect ventilation and oxygenation.
● Pulmonary system abnormalities, such as structural alterations, inflammation, obstruction, infection, alveolar–capillary membrane disorders, or collapse of alveoli, affect ventilation and gas exchange.
● Pulmonary circulation abnormalities, such as pulmonary embolus and pulmonary hypertension, can disrupt gas exchange.
● Neuromuscular abnormalities can affect gas exchange by interfering with the regulation of breathing or limiting movement of the muscles involved with breathing. Any condition that causes injury to the CNS or alters CNS function can interfere with the regulation of breathing.
These conditions are similar in that each of these conditions affects oxygenation.
They differ as to whether they affect ventilation, gas exchange, or gas transport.
They also differ in that some affect structure of the pulmonary or cardiovascular systems, and others affect function of these systems.
35
What types of injuries are most likely to cause oxygenation problems?
Answer:
Three types of injuries are most likely to be associated with oxygenation problems:
● Injuries to the chest wall
● Injuries to the CNS that may affect regulation of breathing
● Injuries that may be associated with embolus formation
36
What areas should you include in a nursing history for a patient with oxygenation concerns who is undergoing a comprehensive assessment?
Answer:
For a patient with oxygenation concerns, six areas need to be assessed:
● Demographic data
● Health history
● Respiratory history
● Cardiovascular history
● Environmental history
● Lifestyle
37
When is a cough significant? What aspects of a cough should be assessed?
Answer:
A cough generally becomes significant when it persists, is recurring, or is productive. A persistent or recurring cough is indicative of ongoing or recurring airway irritation. A cough that lasts more than 3 weeks and cannot be explained should be medically evaluated. The following aspects of a cough should be evaluated:
● Type of cough (e.g., dry, productive, hacking)
● Duration of cough
● Timing of cough
● Appearance of sputum (if any)
● Exacerbating factors
● Alleviating factors
● Types of treatments used to date and their effects
● Associated symptoms
● Type, amount, and timing of sputum produced
38
Identify at least five signs that you may observe in a patient experiencing dyspnea.
Answer:
Answers may include any five of the following signs of dyspnea:
● Nasal flaring
● Head bobbing
● Retractions
● Use of accessory muscles during inspiration
● Grunting
● Orthopnea
● Inability to speak complete sentences without stopping to breathe (conversational dyspnea)
● Paroxysmal nocturnal dyspnea
● Stridor
● Wheezing
39
A patient has a respiratory rate of 30 that is rhythmic and moderate in depth. What term would you use to describe this breathing pattern?
40
What does a pulse oximetry reading tell you?
Answer:
Pulse oximetry is a noninvasive estimate of arterial blood oxygen saturation (SaO2). SaO2 reflects the percentage of hemoglobin molecules carrying oxygen. The normal value is 95% to 100%.
41
What is the relationship between arterial PO2 and SaO2 levels?
Answer:
Small changes in SaO2 are associated with large changes in PO2. However, the levels rise and fall together.
42
Identify normal PO2, SaO2, and PCO2 levels.
Answer:
Normal levels are as follows:
● PO2, 80 to 100 mm Hg
● SaO2, 95% to 100%
● PCO2, 35 to 45 mm Hg
43
What effect does ventilation have on arterial PCO2?
Answer:
Ventilation has the following effects on arterial levels of carbon dioxide:
● In hyperventilation, large amounts of carbon dioxide diffuse into the alveoli and are exhaled into the air, causing arterial PCO2 values to fall.
● In hypoventilation, less carbon dioxide diffuses into the alveoli for exhalation, leaving more carbon dioxide in the arterial blood, which causes PCO2 values to rise.
44
How is PCO2 related to oxygenation?
Answer:
Hypoventilation severe enough to cause hypercarbia is usually associated with hypoxemia because inadequate amounts of oxygen are inhaled. Hyperventilation may or may not be associated with adequate oxygen levels.
45
Identify at least three nursing interventions to promote optimal respiratory function in a hospitalized patient with chronic lung disease.
answer:
Answers may include any three of the following nursing interventions that promote optimal respiratory function:
● Annual influenza vaccination
● Annual pneumonia vaccination
● Frequent position changes to keep all areas of lungs well ventilated
● Incentive spirometry 10 to 20 times per hour
● Positioning upright for meals
46
Why is oxygen humidified?
Answer:
Oxygen is humidified to prevent drying of the airway mucosa and to keep secretions thin.
47
Which oxygen delivery method is appropriate for the following patients?
A patient ordered to receive 2 L/min of oxygen
Answer:
Nasal cannula
48
Which oxygen delivery method is appropriate for the following patients?
A patient who complains of being claustrophobic and requires low-flow humidified oxygen
Answer:
Face tent
49
Which oxygen delivery method is appropriate for the following patients?
A patient with chronic obstructive pulmonary disease (COPD) with an order for oxygen at an FIO2 of 24%
Answer:
Venturi mask
50
Which oxygen delivery method is appropriate for the following patients?
A patient who wants to avoid intubation but requires an FIO2 of 100%
Answer:
Nonrebreather mask
51
In what circumstances would you use an oropharyngeal airway? A nasopharyngeal airway?
Answer:
The airways should be used in the following circumstances:
● Oropharyngeal airways should be used only in unconscious patients because they are likely to trigger gagging, vomiting, or laryngospasm when airway reflexes are intact.
● Nasopharyngeal airways should be used on patients who are semiconscious; they can tolerate nasal airways because they do not stimulate the gag reflex.
52
What facts should be recorded if a patient is intubated?
Answer:
Whenever an airway is inserted, the following facts should be recorded:
● The type and size inserted
● The patient’s response to the insertion
● Once the airway is in place, that breath sounds were heard (to establish that both lungs are ventilated)
● Periodic reassessment of breath sounds, as part of airway maintenance
53
Describe seven interventions associated with caring for a patient with an endotracheal tube.
Answers may include any seven of the following interventions associated with the care of all types of
endotracheal airways:
● Secure the endotracheal tube with ties, tapes, or a commercial holder to prevent accidental displacement.
● Inspect skin around tube or tracheal stoma for redness, drainage, or irritation at least every 8 hours.
● Provide skin care around the tube and tape or holder at least daily.
● Change the endotracheal or tracheostomy ties every 24 hours. Secure the orotracheal tube to the opposite side of the mouth with each change of tape or ties to prevent skin erosion and breakdown.
● Inflate the cuff of the tube with a minimal occlusive volume and monitor cuff pressures to prevent pressure necrosis inside the trachea. (This is a joint responsibility with respiratory therapy.)
● Note the centimeter reference marking on the endotracheal tube to monitor for possible displacement.
● Minimize pulling and traction on the artificial airway by supporting all tubing connected to the airway and using flexible catheter mounts and swivels. If the patient is conscious, remind him not to pull on the airway.
● Use a bite block between the teeth to prevent the patient from occluding an orotracheal tube.
● Have emergency equipment immediately available for reintubation if the tube should become dislodged.
● Provide 100% humidification of inspired air.
● Suction the airway when secretions collect.
54
Describe the difference between pharyngeal and tracheal suctioning.
Pharyngeal and tracheal suctioning have the following differences:
● Pharyngeal suctioning clears secretions that have collected in the back of the throat.
● Tracheal suctioning clears secretions that have entered the lower airways.
55
How can you ensure that the suction catheter enters the trachea and not the esophagus?
Answer:
The following actions can ensure proper placement of the suction catheter into the trachea:
● Insert the catheter into the pharynx.
● Advance it into the trachea during inspiration.
● Once the suction catheter enters the trachea, it will stimulate coughing. If the catheter is not advanced on inspiration, it will enter the esophagus and may trigger gagging or vomiting.
56
What is the purpose of mechanical ventilation?
Answer:
Mechanical ventilation assists a patient to breathe. It can merely assist breathing or breathe entirely for the patient.
57
Why is a chest tube inserted?
Answer:
A chest tube is inserted to remove air or fluid from the pleural space so that the lungs can fully expand.
58
What is the advantage of a three-chamber system (compared to a one-chamber or two-chamber system)?
Answer:
A three-chamber system provides controlled negative pressure, a place for fluid collection, and a water seal. It does not increase the work of breathing. The three-chamber system also allows for drainage of larger amounts of fluid than does a one- or two-chamber system
59
How does a portable chest drainage system compare to a water-seal drainage system?
Answer:
A portable chest drainage system is smaller and lighter, so it makes ambulation easier than with a water-seal system. A portable system is a single chamber, whereas a water-seal system can be one, two, or three chambers. The portable system is dry seal and drains by gravity (although it can be connected to wall suction). However, it holds a maximum of 500 mL, so it is not practical for those with large amounts of drainage.
60
Describe oxygenation and perfusion
Answer:
Getting oxygen into blood as it flows through the lungs is only the first step in tissue oxygenation. The oxygenated blood must be transported to the tissues so that oxygen is available to them.
● Oxygenation refers to how well cells, tissues, and organs are supplied with oxygen.
● Perfusion refers to the circulation of blood to all body regions.
61
Trace the path of normal electrical impulses in the heart.
Answer:
Normal electrical impulses in the heart follow this path:
● The sinoatrial (SA) node initiates impulses that trigger each heart beat.
● Each impulse travels rapidly down the atrial conduction system so that both atria contract as a unit.
● There is a slight delay at the atrioventricular node (AV) node.
● From the AV node, impulses pass into the left and right bundles of His and into the Purkinje fibers.
62
How do the walls of arteries, veins, and capillaries differ?
Answer:
The walls have the following differences:
● Arteries have thick, elastic walls that allow them to stretch during cardiac contraction (systole) and to recoil when the heart relaxes (diastole).
● Veins and venules have thin, muscular but inelastic walls that easily collapse. Blood flows from the capillaries into venules and then into veins, which return deoxygenated blood to the heart. The muscular wall of veins contract or relax in response to feedback from the sympathetic nervous system.
● Capillaries are tiny microscopic vessels that are only one cell thick to facilitate the passage of gases, nutrients, and wastes through them. Billions of capillaries provide blood flow to every cell in the body. Capillaries lie between the arterial and venous systems.
63
What is the importance of diastole to perfusion of the heart?
Answer:
During diastole, the coronary arteries are the only arteries in the body that fill.
64
How are oxygen and carbon dioxide transported in the blood?
Answer:
The gases are transported in the blood as follows:
● Oxygen (O2) is carried in the blood bound to hemoglobin (97%) or in a dissolved state (3%). At the tissue level, oxygen leaves the hemoglobin, becomes dissolved in the blood, and passes through the capillary membrane. Only the dissolved form of oxygen can pass through capillary membranes. Oxygen bound to hemoglobin serves as a reservoir, holding oxygen until it is needed in the dissolved state.
● Carbon dioxide (CO2) can be carried in the blood in three ways: a dissolved state, bound to hemoglobin, or as a bicarbonate ion. It leaves the cells by passing through the cellular–capillary membrane in the dissolved state. In the blood, about 7% remains dissolved in plasma, 23% attaches to hemoglobin, and 70% is converted into bicarbonate ions. At the alveolar–capillary membrane, dissolved carbon dioxide diffuses into the alveoli for exhalation from the lungs
65
How is the cardiovascular system regulated?
Answer:
The cardiovascular system is regulated by the autonomic nervous system through its influence on heart rate, cardiac muscle contractility, and vascular tone.
● Sympathetic fibers, through branches at the thoracic level of the spinal cord, stimulate the heart, resulting in an increased heart rate and increased myocardial contractility. Parasympathetic fibers innervate the heart through the vagus nerve.
● Parasympathetic stimulation of the heart results in a slowed heart rate with no influence on myocardial contractility.
● All blood vessels are innervated by sympathetic fibers that maintain them in a baseline state of partial contraction, even during rest. This baseline state maintains blood pressure and blood flow even when a person is resting or asleep. Sympathetic stimulation above and beyond this baseline varies in response to body needs. Increasing sympathetic stimulation causes constriction of some vessels (e.g., skin, gastrointestinal tract, and kidneys) and dilation of other vessels (skeletal muscle). This serves to shunt blood flow to the skeletal muscles for a “fight or flight” response. The parasympathetic nervous system has no significant control over blood vessels.
● Brain stem centers regulate cardiovascular function and blood pressure in response to baroreceptors and chemoreceptors. The vasomotor center controls sympathetic heart and vascular stimulation. The cardioinhibitory center controls parasympathetic slowing of the heart rate.
● Chemoreceptors located in the aortic arch and the carotid arteries are sensitive to changes in blood pH, oxygen, and carbon dioxide levels. Their main function is to regulate ventilation, but they can send information to the vasomotor center in response to lack of oxygen. The vasomotor center will respond by activating sympathetic stimulation.
66
Does poor peripheral perfusion increase risk for hypoxemia?
Answer:
No, poor peripheral perfusion increases the risk for tissue hypoxia.
67
What changes occur in the cardiovascular system with aging
Answer:
In general, the number of cells and the efficiency of the organs decline gradually as a person ages. Keep in mind, though, that endurance training and regular exercise slow the rate of these changes. In fact, an older person who is physically conditioned by regular exercise may have better heart and circulatory function than a younger adult who is not well conditioned.
Cardiac efficiency gradually declines as the heart muscle loses contractile strength and heart valves become thicker and more rigid. The peripheral vessels become less elastic, which creates more resistance to ejection of blood from the heart. As a result of these changes, the heart becomes less able to respond to increased oxygen demands, and it needs longer recovery times after responding. For example, in response to exercise, an older adult’s heart rate does not increase as much as a younger person’s, but it will remain elevated longer. Thus, older adults have lower exercise tolerance and need more rest after exercise
68
How does smoking affect the cardiovascular system?
Answer:
Tobacco use is a major risk factor in several chronic cardiovascular conditions: stroke, peripheral arterial disease, aortic aneurysm, and heart disease. Smoking is implicated in atherosclerosis (fatty buildups in the arteries), hypertension, and decreased HDL (good) cholesterol—all of which lead to coronary heart disease and heart attack. Other factors contribute to coronary heart disease (e.g., obesity, diabetes, physical inactivity). However, cigarette smoking is such a significant risk factor that the U.S. Surgeon General has called it the leading preventable cause of disease and deaths in the United States. Cigar and pipe smoking are also implicated, but not to the extent of cigarettes (American Heart Association, 2009).
69
Why would you auscultate the lungs as a part of your assessment of cardiac function?
Answer:
The heart and lungs work together to achieve oxygenation of all body tissues. Loss of function in one system (respiratory or cardiovascular) inevitably affects the other system. Adventitious lung sounds may, for example, be a sign of decreased cardiac output.
70
What does the P wave, QRS complex, and T wave of an ECG complex represent?
Answer:
For an ECG complex,
● The P wave represents the firing of the SA node and conduction of the impulse through the atria.
● The QRS complex represents ventricular depolarization and leads to ventricular contraction.
● The T wave represents the ventricles returning to an electrical resting state so they can be stimulated again (ventricular repolarization).
71
What kind of dysrhythmia would describe a heart rate of 140 beats per minute that originates in the ventricles?
Answer:
This would be a ventricular tachydysrhythmia (often called ventricular tachycardia).
72
Identify three strategies that prevent clot formation.
Answer:
Answers may include any three of the following strategies that prevent clot formation:
● Elevate the legs above the level of the heart
● Apply antiembolism stockings (TED hose) or sequential compression devices (SCD)
● Turn patients frequently to prevent vessel injury from prolonged pressure in one position
● Use scrupulous sterile technique when inserting or handling IV lines
● Provide adequate dilution of IV medications
● Provide adequate hydration to keep the blood from becoming viscous (I&O, teach to drink plenty of fluids)
● Promote smoking cessation
● Anticoagulant therapy
● All measures to promote circulation: elevating the patient’s legs above the level of the heart, frequent ambulation, teaching patients not to sit with legs crossed, range-of-motion exercise, and antiembolism stockings or sequential compression devices
73
How do diuretics affect oxygenation?
Answer:
Diuretics increase removal of sodium and water from the body through increased urine output. By reducing the volume of circulating blood and preventing accumulation of fluid in the pulmonary circulation, gas exchange (carbon dioxide and oxygen) is improved.
74
The structure(s) of the respiratory system most associated with the function of respiration is/are the:
A. trachea.
B. alveoli.
C. bronchi.
D. nose.
Answer:
B. alveoli.
Rationale:
Respiration refers to the exchange of oxygen and carbon dioxide in the lungs. This occurs across the alveolar membrane.
75
Which of the following explains why high-flow oxygen therapy is contraindicated in patients with chronic obstructive pulmonary disease (COPD)? High levels of oxygen:
A. take away the carbon dioxide drive to breathe.
B. burn out the oxygen receptors in the lungs.
C. prevent hypoxemia.
D. prevent hypercarbia.
Answer:
C. prevent hypoxemia.
Rationale:
Patients with COPD are no longer sensitive to high levels of carbon dioxide, therefore their primary drive to breathe becomes hypoxia. High-flow oxygen therapy “fixes” hypoxemia, thereby taking away the secondary drive to breathe in the client with COPD.
76
The nurse is performing a morning assessment. The patient is curled on her side with the bed flat, and the nurse notes breath sounds are absent at the lung bases. Which of the following would be an appropriate nursing action?
A. Obtain assistance to sit the patient up and reassess her lungs
B. Start oxygen at 4 L per nasal cannula
C. Call the physician and notify him of the findings immediately
D. Call for a STAT respiratory treatment
Answer:
A. Obtain assistance to sit the patient up and reassess her lungs
Rationale:
The patient’s position may be altering her ability to adequately perform deep breathing. Sitting the patient up would enable the nurse to more accurately assess the breath sounds before taking any other action.
77
The nurse is caring for Mrs. Plank, who had abdominal surgery yesterday. Today, the nurse has Mrs. Plank splint her incision to enable a strong cough that will move respiratory secretions. This intervention is meeting the outcomes for which nursing diagnosis?
A. Impaired Gas Exchange
B. Ineffective Breathing Pattern
C. Ineffective Airway Clearance
D. Impaired Spontaneous Ventilation
Answer:
C. Ineffective Airway Clearance
Rationale:
There is no evidence given that oxygen is not diffusing across the alveolar membrane, nor that there is an alteration in the patient’s ventilation. The purpose of coughing is to clear the airway of secretions.
78
Describe the breathing of someone who is anxious and breathing deeply and rapidly. The person is \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
Answer:
hyperventilating
79
Mrs. Jones becomes short of breath when the head of her bed is lower than 15° of elevation. Mrs. Jones is experiencing \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_.
Answer:
orthopnea
80
The brain _______ integrates feedback from body receptors to regulate cardiac function.
Answer:
stem
81
A patient with air in the pleural space whose chest tube becomes kinked or clamped is at risk for a \_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_\_
Answer:
tension pneumothorax
82
Subcutaneous heparin is one method to prevent the development of a pulmonary embolus in an immobile patient.
Answer:
True
Rationale:
Subcutaneous heparin prevents the formation of deep vein thromboses, which can become pulmonary emboli.
83
A person with a PCO2 of 28 may experience facial numbness, tingling, or both.
Answer:
True
84
In what structure of the pulmonary system does inhaled air come in contact with the blood of the pulmonary circulation?
## Footnote
1) Apex of the lungs
2) Alveolar-capillary membrane
3) Cilia in the bronchi
4) Right and left main-stem bronchi
Answer:
2) Alveolar-capillary membrane
Rationale:
The lungs are composed of millions of alveoli. The alveoli are tiny air sacs with thin walls surrounded by a fine network of capillaries. Gases easily pass back and forth between the alveoli and capillaries. It is at the alveolar-capillary membrane that inhaled air comes in contact with the blood of the pulmonary circulation.
85
Respiratory function involves, in addition to the respiratory system, which three body systems?
## Footnote
1) Neurological, endocrine, and cardiovascular
2) Cardiovascular, neurological, and integumentary
3) Cardiovascular, neurological, and musculoskeletal
4) Musculoskeletal, cardiovascular, and endocrine
Answer:
3) Cardiovascular, neurological, and musculoskeletal
Rationale:
The musculoskeletal and neurological systems regulate the movement of air into and out of the respiratory system. The cardiovascular system transports oxygen and carbon dioxide, which are exchanged in the lungs.
86
The nurse is caring for an adolescent with a history of asthma. The patient is currently being treated for acute bronchitis. A thorough nursing assessment of the patient's pulmonary status will include: Select all that apply.
## Footnote
1) Skin color and temperature
2) Auscultation of breath sounds
3) Testing of cough reflex
4) Chest x-ray
Answer:
1) Skin color and temperature
3) Testing of cough reflex
Rationale:
Auscultation of the lungs will detect any adventitious breath sounds (e.g., wheezing) that may be present with asthma and bronchitis. Evaluation of skin color and temperature are indirect methods to assess tissue oxygenation. A chest x-ray requires a physician order and is not a part of the nursing assessment. The cough reflex should be assessed in clients with decreased levels of consciousness.
87
What assessment findings might the nurse expect to see in a patient experiencing hypoxia? Select all that apply.
## Footnote
1) Altered level of consciousness
2) Peripheral pitting edema
3) Cyanosis of skin and mucous membranes
4) Weak or absent peripheral pulses
Answer:
1) Altered level of consciousness
3) Cyanosis of skin and mucous membranes
Rationale:
Hypoxia leads to decreased oxygenation of organs and tissues. To determine adequacy of tissue oxygenation, you must assess both circulation and tissue/organ function. An altered level of consciousness may result from hypoxic central nervous system tissue. Poor peripheral circulation is characterized by weak or absent pulses; pale, ashen, or cyanotic skin and mucous membranes; and cool skin temperature. Peripheral edema does not result from hypoxia.
88
Which of the following goals is appropriate for a client without underlying cardiopulmonary disease who is being monitored with continuous pulse oximetry?
## Footnote
1) Patient will refrain from movement while monitored in order to ensure accurate readings.
2) Oxygen saturation will remain at 80% to 90% during hospitalization.
3) Patient will report pain as less than 3 on a scale of 1 to 10 during monitoring.
4) Oxygen saturation will remain at 95% to 100% while monitored.
Answer:
4) Oxygen saturation will remain at 95% to 100% while monitored.
Rationale:
Normal oxygen saturation is 95% to 100%. Values of 94% or less are considered abnormal in healthy people and should be investigated to determine the cause. Although movement may affect oximetry monitoring, it is essential that patients move and turn in order to prevent atelectasis. Pulse oximetry is a noninvasive form of monitoring that involves placing a probe on a part of the body where capillary blood flow is near the surface (e.g., a nail bed, earlobe, nose, or forehead). It does not cause pain.
89
A 45-year-old woman presents to the emergency department with complaints of shortness of breath, anxiety, dizziness, and numbness and tingling around her mouth. Her respirations are deep, at a rate of 28 per minute. Her lungs are clear with good aeration throughout. Oxygen saturation is 100%. An arterial blood gas shows a PO2 of 110 and PCO2 of 29. Based on this assessment, an appropriate nursing diagnosis would be:
## Footnote
1) Ineffective Airway Clearance
2) Decreased Cardiac Output
3) Impaired Gas Exchange
4) Hypocarbia
Answer:
3) Impaired Gas Exchange
Rationale:
Hypocarbia (hypocapnia) is a low level of dissolved CO2 in the blood because of hyperventilation. In most cases, blood oxygen levels remain normal. Severe hypocarbia stimulates the nervous system, leading to muscle twitching or spasm (especially in the hands and feet) and numbness and tingling in the face and lips. This patient is experiencing hypocarbia; however, this is a medical diagnosis. A corresponding nursing diagnosis is Impaired Gas Exchange. There is no evidence of difficulty maintaining a clear airway or problems with cardiac pumping; therefore, Ineffective Airway Clearance and Decreased Cardiac Output are not good choices.
90
The nurse is caring for an older adult woman who was admitted 3 days ago following a cerebrovascular accident. She has had trouble swallowing and has been placed on aspiration precautions. Care of this patient will include the following: Select all that apply.
## Footnote
1) Ensure she is sitting upright or with the head of the bed elevated to eat and drink
2) Break or crush her pills (if appropriate) before administration
3) Provide only thin, clear liquids
4) Keep suction setup available at all times
Answer:
1) Ensure she is sitting upright or with the head of the bed elevated to eat and drink
3) Provide only thin, clear liquids
Rationale:
Aspiration is a risk for patients with a decreased level of consciousness, diminished gag or cough reflex, or difficulty with swallowing. You should keep suction setup available for routine and emergency use. Keeping the head of the bed elevated will also help to prevent aspiration. Breaking or crushing pills will make it easier for her to swallow her medications. Thin, clear liquids are more likely to be aspirated than are thickened liquids, and there is no indication for clear liquids.
91
While caring for a young adult on a mechanical ventilator, the ventilator alarms sound. On entering the patient's room, the nurse notes that he is agitated and his skin is ashen and diaphoretic. His pulse oximetry shows an oxygen saturation of 78%. The nurse is unable to identify any obvious mechanical problems with the ventilator. The first step the nurse should take is to:
## Footnote
1) assess his breath sounds.
2) call the respiratory therapist to troubleshoot the problem.
3) manually ventilate him with an Ambu-bag.
4) contact the physician.
Answer:
3) manually ventilate him with an Ambu-bag.
Rationale:
All the actions listed are appropriate and necessary. However, if you cannot quickly identify and correct a problem with the ventilator, you must ensure adequate ventilation until the problem can be identified and corrected. Your immediate response should be to manually ventilate the patient with an Ambu-bag. Your colleagues should assist you by troubleshooting the problem, assessing breath sounds, and notifying the physician.
