A nurse caring for a patient with chronic obstructive pulmonary disease (COPD) knows that hypoxia may occur in patients with respiratory problems. What are signs of this serious condition?
Dyspnea
Hypotension
Small pulse pressure
Decreased respiratory rate
Pallor
Increased pulse rate
A nurse is suctioning the nasopharyngeal airway of a patient to maintain a patent airway. For which condition would the nurse anticipate the need for a nasal trumpet?
The patient vomits during suctioning
The secretions appear to be stomach contents
The catheter touches an unsterile surface
Epistaxis is noted with continued suctioning.
The will protect the nasal mucosa from further trauma related to suctioning.
A nurse is choosing a catheter to use to suction a patient's endotracheal tube via an open system. On which variable would the nurse base the size of the catheter to use?
The age of the patient
The size of the endotracheal tube
The type of secretions to be suctioned
The height and weight of the patient
A nurse is caring for a 16 year old male patient who has been hospitalized for an acute asthma exacerbation. Which testing methods might the nurse use to measure the patient's oxygen saturation?
Thoracentesis
Spirometry
Pulse oximetry
Peak expiratory flow rate
Diffusion capacity
Maximal respiratory pressure
are used to monitor the health status of patients with respiratory disorders, such as asthma. is used to obtain baseline information about the patient's oxygen saturation level and is also performed for patients with asthma, along with to monitor airflow. These 3 tests may be administered by the nurse.
estimates the patient's ability to absorb alveolar gases and determines if a gas exchange problem exists. help evaluate neuromuscular causes of respiratory dysfunction. Both tests are usually performed by a respiratory therapist.
The physician or other advanced practice professional can perform a at the bedside with the nurse assisting, or in the radiology department.
is a procedure in which a needle is inserted into the pleural space between the lungs and the chest wall. This procedure is done to remove excess fluid, known as a pleural effusion, from the pleural space to help you breathe easier.
A patient with COPD is unable to perform activities of daily living (ADLs) wihtout becoming exhausted. Which nursing diagnosis best describes this alteration to oxygenation as the etiology?
Decreased Cardiac Output related to difficulty breathing
Impaired Gas Exchange related to use of bronchodialators
Fatigue related to impaired oxygen transport system
Ineffective Airway Clearance related to fatigue
A nurse working in a long-term care facility is providing teaching to patients with altered oxygenation due to conditions such as asthma and COPD. Which measures would the nurse recommend?
Refrain from exercise
Reduce anxiety
Eat meals 1 to 2 hours prior to breathing treatments
Eat a high-protein/high calorie diet
Maintain a high Fowler's position when possible
Drink 2 to 3 pints of clear fluids daily
A nurse is providing postural drainage for a patient with cystic fibrosis. In which position should the nurse place the patient to drain the right lobe of the lung?
High Fowler's position
Left side with pillow under chest wall
Lying position/half on abdomen and half on side
Trendelenberg position
A nurse is teaching a patient how to use a meter-dosed inhaler for her asthma. Which comments from the patient assure the nurse that the teaching has been effective?
I will be careful not to shake up the canister before using it
I will hold the canister upside down when using it
I will inhale the medication through my nose
I will continue to inhale when the cold propellant is in my throat
I will only inhale one spray with one breath
I will activate the device while continuing to inhale
When planning care for a patient with chronic lung disease who is receiving oxygen through a nasal cannula, what does the nurse expect?
The oxygen must be humidified
The rate will be no more than 2 to 3 L/min or less
Arterial blood gases will be drawn every 4 hours to assess flow rate
The rate will be 6 L/min or more
A rate higher than L/min may destroy the hypoxic drive that stimulates respirations in the medulla in a patient with chronic lung disease.
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?
Instruct assistant to notify the primary care provider
Assess the patient's vital signs
Remove the tape, adjust the depth to ordered depth and reapply the tape
No action is required as depth will adjust automatically
What action does the nurse perform to follow the safe technique when using a portable oxygen cylinder?
Checking the amount of oxygen in the cylinder before using it
Using a cylinder for a patient transfer that indicates available oxygen is 500 psi
Placing the oxygen cylinder on the stretcher next to the patient
Discontinuing oxygen flow by turning cylinder key counterclockwise until tight
A nurse providing care of a patient's chest drainage system observes that the chest tube has become separated from the drainage device. What would be the first action that should be taken by the nurse in this situation?
Notify the physician
Apply an occlusive dressing on the site
Assess the patient for signs of respiratory distress
Put on gloves and insert the chest tube in a bottle of sterile saline
An emergency department nurse is using a manual resuscitation bag (Ambu bag) to assist ventilation in a patient with lung cancer who has stopped breathing on his own. What is an appropriate step in this procedure?
Tilt the patient's head forward
Hold the mask tightly over the patient's nose and mouth
Pull the patient's jaw backward
Compress the bag twice the normal respiratory rate for the patient
Which assessments and interventions should the nurse consider when performing tracheal suctioning?
Closely assess the patient before, during and after the procedure.
Hyperoxigenate the patient before and after suctioning
Limit the application of suction to 20 to 30 seconds
Monitor the patient's pulse frequently to detect potential effects of hypoxia and stimulation of the vagus nerve
Use an appropriate suction measure (80-150 mm Hg)
Insert the suction catheter to further than 1cm past the length of the trachea or endotracheal tube
Risks of tracheal suctioning include: , , , , and .
The airway begins at the and ends at the .
Each lung is divided into two . Each lobe is subdivided into or .
The main branches to each lung from the . It subdivides into , they subdivide again and again becoming smaller and smaller. The smallest of these branches are the , ending at the .
The visceral parietal( visceral, parietal ) pleura covers the lung, and the parietal visceral( parietal, visceral ) pleura lines the thoracic cavity.
Pressure w/in the pleural space ( ) is always (a negative pressure).
Inspiration Expiration( Inspiration, Expiration ) is the active phase, expiration inspiration( expiration, inspiration ) is the passive phase.
During : the contracts and descends, lengthening the throracic cavity; the muscles contract, lifting the ribs upward and outward; and the is pushed forward enlarging the chest. This combination of an increased lung volume and decrease of pressure allows air to move in from an area of greater pressure (outside air) into an area of lesser pressure (w/in the lungs). The relaxation or of these structures then results in . This causes a volume in the lungs and an increased in pressure.
The respiratory center is located in the in the . It is stimulated by an increased concentration of and , and to a lesser degree, by the decreased amount of in the arterial blood. In addition chemoreceptors in the and bodies are also sensitive to the same and can activate the medulla.
Atria receive blood from the veins: superior/inferior and the left/right .
Contractions of the heart start in the , followed by contraction of the , with a subsequent resting of the .
Deoxygenated blood flows from the right left( right, left ) side of the heart to the lungs.
Oxygenated blood is returned to the left right( left, right ) side of the heart and pumped out to all other parts of the body.
% of oxygen is carried by red blood cells as part of in the form of . Hemoglobin also carries in the form of carboxyhemoglobin.
Be alert for the possibility of or when administering any narcotic or sedative.
Generalized has been show to cause enough bronchospasm to produce an episode of bronchial asthma.
Be aware of the patient's level before evaluating oxygen saturation because the test measures only the percentage of oxygen carried by the available hemoglobin. Thus even a patient with a hemoglobin level could appear to have a SpO2, because most of that hemoglobin is saturated. However the patient may not have enough oxygen to meet body needs. A range of % to % is considered normal SpO2; values <= % are abnormal.
The max amt of fluid removed with Thoracentesis is generally mL.
People who work hard at breathing often do not have much energy for . Many of the medications used for treatment can cause and .
Research has demonstrated that, in patients with pulmonary disease who are acutely ill, turning to the position on a regular basis promotes oxygenation. In this position the posterior dependent sections of the lungs are better ventilated and perfused.
Patients can help keep their secretions thin by drinking to quarts ( L - L) of clear fluids daily. However, encourage patients with heart failure and low sodium levels to limit their fluid intake to L / day.
Some health care providers consider adequate intake and air as effective expectorants.
Suctioning irritates the mucosa and removes from the respiratory tract, possibly causing hypoxemia. Thus it is important to the patient before suctioning.
In an situation the absence of a should not delay the administration of oxygen to the patient.
Removal of chest tubes can be a painful and stressful process for patients. Whenever possible, administer prior to the tube removal and apply to the chest.
The airway is used to keep the tongue clear of the airway.
A airway is inserted through the nare and protrudes into the back of the pharynx. The allows for frequent suctioning without trauma to the nasal passageway.
Patients w/tracheostomies frequently have an infective mechanism and copious .
Exercise care when changing the ties to prevent accidental decannulation or of the tube.
During tracheal suctioning: to prevent hypoxia, before/after suctioning and limit the application of suction to seconds. Suction catheter should be limited to no further than past the length of the tracheal/endotrachel tube to avoid damage.
