Oxygenation & Perfusion Flashcards
A nurse is assessing a patient with COPD who is experiencing dyspnea. What action will the nurse take first?
a. Place the patient in Fowler position.
b. Encourage diaphragmatic breathing.
c. Ask the patient to cough.
d. Initiate oral suctioning of secretions.
a
Patients with COPD experience dyspnea related to problems with ventilation and/or hypoxemia. One of the most common symptoms of hypoxia is dyspnea (difficulty breathing). Elevating the head of the bed will improve respiratory expansion and oxygenation. Coughing to facilitate secretion removal, pursed-lip breathing, and/or diaphragmatic breathing may be indicated, after sitting the patient up. Suction is indicated for patients demonstrating the presence of secretions, such as adventitious breath sounds or moist cough with phlegm; there is no indication this patient requires suctioning at this time.
A nurse is maintaining airway patency in an unconscious patient by providing frequent nasopharyngeal suction. When would the nurse anticipate inserting a nasopharyngeal airway (nasal trumpet)?
a. Vomiting during suctioning occurs.
b. Secretions appear to contain stomach contents.
c. The suction catheter touches an unsterile surface.
d. Epistaxis is noted with continued suctioning.
d
Repeated suctioning may injure or traumatize the nares, resulting in nosebleed (epistaxis). The nurse would recommend insertion of a nasal trumpet, which will facilitate suction while protecting the nasal mucosa from further trauma.
A nurse in the PACU is performing oral suctioning for a patient with an oropharyngeal airway, when the patient begins to vomit. What is the nurse’s priority nursing action at this time?
a. Removing the suction catheter and elevating the head of the bed
b. Notifying the primary health care provider
c. Confirming the size of the oral airway is correct
d. Placing the patient in the supine position
a
The nurse discontinues suctioning, elevates the head of the bed, and turns the patients to the side to prevent aspiration. Airway protection takes priority; after positioning the patient, the nurse continues to suction the airway and oropharynx. Once airway patency has been established, the nurse will notify the provider of vomiting. There is no indication the oral airway is too large. Placing the patient supine while vomiting is inappropriate, as that could promote aspiration.
A nurse plans to suction a patient’s endotracheal tube using the open suction technique. Which intervention is appropriate for this technique?
a. Using a suction catheter that is the diameter of the endotracheal tube
b. Maintaining the patient in the supine position
c. Administering oxygen prior to suctioning
d. Changing the inline suction device every 24 hours
c
To prevent hypoxemia, prior to endotracheal suctioning, the nurse provides 100% oxygen for a minimum of 30 seconds. This is referred to as hyperoxygenation. The nurse limits the application of suction to no more than 10 to 15 seconds (AARC, 2010; Burns & Delgado, 2019; Hess et al., 2021; Pasrija & Hall, 2020). The external diameter of the suction catheter should not exceed half of the internal diameter of the endotracheal tube. An inline suction device is considered a closed, self-contained system used for a “closed technique” for suction; these are changed every 24 hours.
A nurse is caring for a patient admitted for an acute asthma exacerbation. The patient reports extreme dyspnea, stating, “Turn up the oxygen, I’m not getting enough air.” Which actions would the nurse take first?
a. Suction the airway.
b. Assess the pulse oximetry reading.
c. Obtain a peak flow meter reading.
d. Assess for cyanosis of the lips.
b
Using the nursing process, the nurse first assesses the oxygen saturation via pulse oximetry before changing the oxygen flow rate. Suctioning is provided to remove respiratory secretions; the nurse would note adventitious breath sounds or phlegm with cough indicating a need for suction. A peak flow meter is used to assess the point of highest flow during forced expiration. It is routinely used for patients with moderate or severe asthma to measure the severity of the disease and degree of disease management. While cyanosis of the lips is a late sign of hypoxemia, the nurse can quickly begin to alleviate or lessen dyspnea by simply repositioning the patient.
A patient with COPD is unable to perform personal hygiene without becoming exhausted. What nursing intervention would be appropriate for this patient?
a. Assisting with all bathing and hygiene
b. Telling the patient to avoid speaking during hygiene
c. Teaching the patient to take short shallow breaths during activity
d. Taking rest periods between activities
d
To prevent fatigue during activities including hygiene, the nurse should group (personal care) activities into smaller steps and encourage rest periods between activities. The nurse promotes and maintains dignity, independence, and strength by assisting with activities when the patient has difficulty. The nurse should encourage the patient to voice feelings and concerns about self-care deficits and teach the patient to coordinate pursed-lip or diaphragmatic breathing with the activity.
A nurse working in the pulmonary clinic is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend? Select all that apply.
a. Avoid exercise.
b. Take steps to manage or reduce anxiety.
c. Eat meals 1 to 2 hours prior to breathing treatments.
d. Eat a high-protein/high-calorie diet.
e. Maintain a high-Fowler position when possible.
f. Drink 2 to 3 pints of clear fluids daily.
b, d, e
When caring for patients with COPD, it is important to help create an environment that is likely to reduce anxiety, which increases oxygen demand. A high-protein/high-calorie diet is recommended to meet increased energy needs due to the work of breathing. People with dyspnea and orthopnea are most comfortable in a high-Fowler (upright) position because accessory muscles can easily be used to facilitate respiration and lung expansion. Meals should be eaten 1 to 2 hours after breathing treatments; exercises and drinking 2 to 3 quarts (1.9 to 2.9 L) of clear fluids daily is recommended, rather than 2 to 3 pints.
A student with a history of asthma visits the school nurse reporting difficulty breathing and wheezing. Which tool would the nurse use to assess the severity of airway resistance?
a. Peak flow meter
b. End-tidal CO2 monitor
c. Chest tube
d. Arterial blood gas
a
A peak flow meter is used to assess the point of highest flow during forced expiration. It is routinely used by and for patients with moderate or severe asthma to measure the severity of the disease and degree of disease management. Capnography or end-tidal CO2 monitoring is used for assessing and monitoring ventilation and placement of artificial airways, predicting patients who are at risk for respiratory compromise, are experiencing partial or complete airway obstruction, or are experiencing hypoventilation (Burns & Delgado, 2019; Seckel, 2018). A chest tube is used to remove air or fluid from the pleural space. The arterial blood gas (ABG) is used to assess oxygenation, ventilation, and acid–base status; it is invasive and not performed in the school setting.
A nurse is teaching a patient how to use a metered-dose inhaler for asthma. Which comments from the patient assure the nurse that the teaching has been effective? Select all that apply.
a. “I’ll be careful not to shake the canister before using it.”
b. “It’s important to hold the canister upside down when using it.”
c. “I have to remember to inhale the medication through my nose.”
d. “I will continue to inhale when the cold propellant is in my throat.”
e. “I won’t inhale more than one spray with one breath.”
f. “I will activate the device while continuing to inhale.”
d, e, f
Common mistakes that patients make when using MDIs include failing to shake the canister, holding the inhaler upside down, inhaling through the nose rather than the mouth, inhaling too rapidly, stopping the inhalation when the cold propellant is felt in the throat, failing to hold their breath after inhalation, inhaling two sprays with one breath, and not activating the device while inhaling.
A nurse is caring for a patient with chronic lung disease who is receiving oxygen through a nasal cannula. What nursing action is performed correctly? Select all that apply.
a. Making sure the oxygen is flowing into the prongs
b. Maintaining oxygen saturation between 94% and 98%
c. Encouraging the patient to breathe through their nose with their mouth closed
d. Initiating the oxygen flow rate at 6 L/min or more
e. Protecting the patient’s skin from irritation by the oxygen tubing
a, c, e
The nurse should assure that the oxygen is flowing out of the prongs prior to inserting them into the patient’s nostrils. The nurse should encourage the patient to breathe through their nose with the mouth closed. The nurse should adjust the flow rate and maintain the patient’s oxygen saturation as prescribed. The nurse should implement pressure injury prevention strategies; pressure from the tubing could result in medical device–related alterations in skin integrity.
A nurse is securing a patient’s endotracheal tube with tape and observes that the tube depth changed during the retaping. Which action would be appropriate related to this incident?
a. Instructing the assistant to notify the health care team
b. Assessing the patient’s vital signs
c. Removing the tape, adjusting the depth to the ordered depth, and retaping securely
d. Taking no action, as the depth will adjust automatically
c
The tube depth should be maintained at the same level unless otherwise prescribed. If the depth changes, the nurse should remove the tape or securement device, adjust the tube to the ordered depth, and reapply the tape or securement device
A nurse is providing teaching for a patient who will undergo cardiac surgery and return to the intensive care unit with an endotracheal tube. What education is most important for the nurse to provide?
a. “The endotracheal tube will drain out excess secretions from the surgical site.”
b. “This tube is used to facilitate breathing; you will not be able to speak while it is in place.”
c. “This is a surgically placed tube in your neck; we will suction it frequently to remove mucus.”
d. “Your oxygenation will be monitored frequently using pulse oximetry.”
b
Patients with an endotracheal tube are unable to speak. Explaining this to the patient preoperatively, along with information that they will be closely monitored, can help decrease anxiety. The endotracheal tube is used during anesthesia or for mechanical ventilation; it is not a surgical drain. A tracheostomy, located in the neck area, is a surgically placed artificial airway. While pulse oximetry will be used to monitor oxygenation, to prevent undue anxiety, it is most important that the patient understands speech will not be possible.
A nurse is caring for a patient who has a pleural chest tube attached to a disposable chest drainage system. Which nursing actions are indicated for this patient? Select all that apply.
a. Avoiding turning the patient to prevent disconnections in the tubing
b. Maintaining an occlusive dressing on the site
c. Assessing the patient for signs of respiratory distress
d. Keeping the chest drainage device at the level of the patient’s thorax
e. Ensuring there are no dependent loops or kinks in the tubing
f. Observing for bubbles indicating air leak in the water seal chamber
b, c, e, f
The chest drainage collection device must be positioned below the tube’s insertion site. Maintaining an occlusive dressing helps prevent air leak; assess for crepitus around the chest tube site indicating air leak. Avoid dependent loops or kinks in the tubing, which could impede drainage. Assess for bubbling in the water seal, maintaining the water level at the 2-cm mark. When a chest tube becomes separated from the drainage device, the nurse should submerge the tube’s end in water, creating a temporary water seal and allowing air to escape until a new drainage unit can be attached.
A nurse in the emergency department is caring for a patient who was brought in by fire rescue due to a heroin overdose. The nurse notes the patient is not breathing. What action will the nurse take immediately? Select all that apply.
a. Tilt the patient’s head forward.
b. Begin ventilation using a manual resuscitation bag (Ambu bag).
c. Place the mask tightly over the patient’s nose and mouth.
d. Pull the patient’s jaw backward.
e. Compress the bag twice the normal respiratory rate for the patient.
f. Recommend that a sputum culture for cytology is obtained.
b, c
The priority is to establish ventilation using the manual resuscitation bag to provide emergency or rescue breathing. The nurse tilts the head back, pulls the jaw forward, and positions the mask tightly over the patient’s nose and mouth. The bag is compressed at a rate that approximates normal respiratory rate (e.g., 12 to 20 breaths/min in adults). Sputum for cytology is done primarily to detect cells that may be malignant, determine organisms causing infection, and identify blood or pus in the sputum. Note that the bag, with the mask removed, also fits easily over tracheostomy and endotracheal tubes.
Which assessments and interventions should the nurse consider when performing tracheal suctioning? Select all that apply.
a. Closely assessing the patient before, during, and after the procedure
b. Hyperoxygenating the patient before and after suctioning
c. Limiting the application of suction to 20 to 30 seconds
d. Monitoring the pulse to detect effects of hypoxia and stimulation of the vagus nerve
e. Using an appropriate suction pressure (80 to 150 mm Hg)
f. Inserting the suction catheter no further than 1 cm past the length of the tracheal or endotracheal tube
a, b, d, e, f
Close assessment of the patient before, during, and after the procedure is necessary to identify complications such as hypoxia, infection, tracheal tissue damage, dysrhythmias, and atelectasis. The nurse should hyperoxygenate the patient before and after suctioning and limit the application of suction to 10 to 20 seconds. In addition, monitor the patient’s pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve. Using an appropriate suction pressure (80 to 150 mm Hg) will help prevent atelectasis caused by excessive 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 tracheal or endotracheal tube) to avoid tracheal mucosal damage.
