CH 28 Assisting with Respiration and Oxygen Delivery

The nurse uses a diagram to show that when the diaphragm moves:

1. up, the increased negative pressure in the thoracic space forces air into the lungs.

2. down, the intercostal muscles retract, forcing air out of the lungs.

3. down, the negative pressure in the thoracic space pulls air into the lungs.

4. up, the decreased negative pressure allows air to enter the lungs.

ANS: C

When the diaphragm moves down, increasing the size of the thoracic space, air is pulled into the lungs. The respiratory action is controlled by the spinal cord.

DIF: Cognitive Level: Knowledge

REF: p. 509

OBJ: Theory #1

TOP: Respiratory Action

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

The nurse clarifies that the condition in which there is a decreased amount of oxygen in the blood is:

1. hypoxia.

2. hypercapnia.

3. dyspnea.

4. hypoxemia.

ANS: D

Hypoxemia is a condition in which there is a decreased amount of oxygen in the blood, hypoxia is inadequate oxygen to meet cellular needs, hypercapnia is increased level of carbon dioxide in the blood, and dyspnea is difficulty breathing.

DIF: Cognitive Level: Comprehension REF: p. 510

OBJ: Theory #1

TOP: Oxygen Levels

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

The nurse monitoring patients eating in the dining room of a skilled nursing facility notes that a patient begins choking. As the nurse prepares to deliver the Heimlich maneuver, the fist should be positioned:

1. halfway between the xiphoid process and the umbilicus.

2. directly over the sternum.

3. between the umbilicus and the symphysis pubis.

4. directly over the umbilicus.

ANS: A

Proper placement of the fist is halfway between the xiphoid process and the umbilicus.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #1

REF: p. 514|Skill 28-2

TOP: Heimlich Maneuver

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A patient has collapsed and cannot be aroused by asking loudly, "Are you okay?" The next action should be to:

a position the fingers over the carotid artery to feel for a pulse.

1. tilt the head by placing one hand on the forehead and lift the chin.

2. call for help or, if there is assistance, have that person get help.

3. deliver two quick short breaths into the patient's airway.

ANS: C

The sequence for resuscitative interventions is to check for responsiveness; if no response, activate emergency medical services, check for pulse at carotid, begin compressions, then open the airway and check for breathing.

DIF: Cognitive Level: Application

REF: p. 515|Skill 28-3

OBJ: Theory #3

TOP: Basic Life Support

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

The nurse instructing the patient to perform forceful exhalation coughing would instruct the patient to take in:

1. one deep breath and quickly exhale.

2. two breaths and force the air out quickly.

3. two deep breaths, then inhale deeply again and force out the air quickly.

4. one breath, hold it for 3 seconds, then forcefully exhale three times with mouth

ANS: C

Proper coughing procedure is to take in two deep breaths, inhale deeply again and to forcibly exhale (cough) at the end of the third breath. This technique is very effective in moving secretions up the bronchial tree.

DIF: Cognitive Level: Knowledge

REF: p. 513

OBJ: Clinical Practice #1

TOP: Effective Coughing

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The nurse is aware that the best time to schedule a postural drainage treatment is:

1. shortly after the patient arises in the morning, before breakfast.

2. in the morning immediately after breakfast.

3. 30 minutes after lunch.

4. 1 hour after supper.

ANS: A

Postural drainage is best accomplished in the morning prior to eating, because more secretions accumulate while the patient is asleep.

DIF: Cognitive Level: Comprehension

REF: p. 518

OBJ: Clinical Practice #1

TOP: Postural Drainage

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A patient who will begin oxygen therapy has a history of sinus disorders. This patient would benefit most from which oxygen setup?

1. High oxygen flow rate

2. A humidifier

3. A Venturi mask

4. A nasal cannula

ANS: B

If a patient suffers from sinus problems, it is best to add a humidifier to the oxygen setup.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #2

REF: p. 520|Skill 28-4

TOP: Oxygen Therapy

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A patient has a history of chronic obstructive pulmonary disease. The patient's oxygen flow rate should be set to no more than:

1. 5 to 10 L/min.

2. 4 to 5 L/min.

3. 2 to 3 L/min.

4. 1 to 2 L/min.

ANS: C

Patients with obstructive lung diseases should be given only 2 to 3 L/min because higher concentrations of oxygen reduce the respiratory rate. This is because their incentive to breathe comes from lower oxygen levels rather than higher carbon dioxide levels in the blood (they usually have a continuous high level of carbon dioxide).

DIF: Cognitive Level: Comprehension

REF: p. 519

OBJ: Theory #5

TOP: Oxygen Therapy

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

The nurse loosens mucus plugs by using percussion on a patient over the area of the:

1. sternum.

2. thorax.

3. spine between the scapulae.

4. midaxillary line on the rib cage.

ANS: B

Percussion, a rhythmic clapping with cupped hands over the thoracic area, will loosen mucus plugs. This technique is both useless and painful when applied over bony areas.

DIF: Cognitive Level: Knowledge

REF: p. 518

OBJ: Clinical Practice #1

TOP: Oxygen Therapy: Percussion

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

A patient requires a precise concentration of 40% oxygen. Which of the following devices would best allow for this?

1. A simple face mask

2. A nonrebreather mask

3. A partial rebreathing mask

4. A Venturi mask

ANS: D

A Venturi mask is useful when accuracy of delivery is essential.

DIF: Cognitive Level: Comprehension REF: p. 523|Table 28-3

OBJ: Clinical Practice #2

TOP: Oxygen Therapy: Venturi Mask

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The nurse recognizes that a postoperative patient who can breathe independently but has trouble maintaining an airway because of the tongue falling back into the throat would be best benefitted by a(n):

1. pharyngeal airway.

2. endotracheal tube.

3. tracheostomy.

4. partial rebreather oxygen mask.

ANS: A

A pharyngeal airway such as a nasopharyngeal or an oropharyngeal airway is useful for patients who can breathe on their own but tend to occlude the airway with the tongue.

DIF: Cognitive Level: Analysis

REF: p. 522

OBJ: Theory #4

TOP: Airway

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

A nurse performing oral suctioning on an adult patient should set the wall suction machine so that the suction pressure is between:

1. 25 and 50 mm Hg.

2. 50 and 75 mm Hg.

3. 80 and 120 mm Hg.

4. 120 and 180 mm Hg.

ANS: C

The range of suction pressure for an adult patient is between 80 and 120 mm Hg.

DIF: Cognitive Level: Application

REF: p. 524

TOP: Suctioning

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

OBJ: Clinical Practice #1

A nurse caring for a patient with a tracheostomy should determine whether the patient needs suctioning by:

1. monitoring the rate of respirations.

2. determining the last time the patient was suctioned.

3. examining the character of the sputum.

4. auscultating the breath sounds.

ANS: D

Auscultating the patient's breath sounds helps the nurse assesses for retained secretions and verifies the need for suctioning. The respiratory rate may rise when suctioning is needed, but it could also rise for other reasons.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #1

REF: p. 527|Skill 28-6

TOP: Suctioning

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A patient requires suctioning via the nasotracheal route. In order to perform this procedure safely, the nurse should:

1. apply suction while advancing the catheter into the airway.

2. suction the nasotracheal passage after suctioning the mouth.

3. hold the catheter with the dominant hand after donning sterile gloves.

4. insert the nonlubricated catheter into the nasal passage.

ANS: C

The suction catheter should be held with the dominant hand after donning sterile gloves, because sterile technique must be adhered to when suctioning both the nasopharyngeal and tracheal areas.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #1

REF: p. 525|Skill 28-5

TOP: Suctioning

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

The nurse recognizes that, immediately before a tracheotomy cuff deflation, the patient should:

1. be administered extra oxygen.

2. have the pharynx suctioned.

3. have the cuff pressure checked.

4. be monitored for respiratory rate.

ANS: B

Immediately before deflating a cuff on a tracheotomy tube, the pharynx should be suctioned to prevent accumulated oral secretions from entering the bronchial tree once the cuff is deflated.

DIF: Cognitive Level: Application

REF: p. 529

OBJ: Clinical Practice #3

TOP: Tracheostomy

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

The nurse takes into consideration that while caring for a patient on oxygen therapy, safety precautions should be observed, which include:

1. using clothing of synthetic cloth for the patient.

2. removing any adhesive from the patient's skin with acetone.

3. assessing equipment in room for frayed cords.

4. reducing humidification on the oxygen delivery device.

ANS: C

All equipment in a room where oxygen is being administered should be in good working order without frayed or loose connections because of the possibility of fire.

DIF: Cognitive Level: Comprehension REF: p. 518

OBJ: Clinical Practice #5

TOP: Safety Precautions with Oxygen

KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

A nurse caring for a patient with a water seal type chest drainage that is on low suction assesses that there is constant bubbling in the suction container. The nurse should:

1. immediately turn the patient to the side of the insertion site.

2. check for air leaks in drainage system.

3. document findings.

4. clamp the chest tube and place the patient in high Fowler's position.

ANS: C

Document findings. Constant bubbling in the suction chamber indicates that suction is on.

DIF: Cognitive Level: Analysis

REF: p. 521

OBJ: Clinical Practice #4

TOP: Coughing and Deep Breathing

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

A nurse is aware that adequate hydration is necessary to mobilize respiratory secretions. To thin respiratory secretions for easier expectoration, the patient should consume at least:

1. 500 to 1000 mL/day.

2. 1000 to 1500 mL/day.

3. 1500 to 2000 mL/day.

4. 2500 to 3000 mL/day.

ANS: C

A fluid intake of at least 1500 to 2000 mL/day is needed to thin respiratory secretions for easier removal by coughing.

DIF: Cognitive Level: Comprehension REF: p. 533

OBJ: Clinical Practice #1

TOP: Mobilizing Secretions KEY:

Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The nurse would determine that this patient is aware of how to use the incentive spirometer device properly when the patient:

1. took 10 slow, deep breaths every hour.

2. took five quick "huffs" and then coughed vigorously.

3. exhaled deeply and then inhaled quickly and forcefully three times.

4. took five deep breaths slowly every 4 hours.

ANS: A

Proper technique for use of an incentive spirometer is to take 10 slow, deep breaths every hour and to hold each breath for 3 seconds to enhance gas exchange.

DIF: Cognitive Level: Knowledge

REF: p. 534

OBJ: Clinical Practice #1

TOP: Incentive Spirometer

KEY: Nursing Process Step: Evaluation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The nurse assists the patient with emphysema into the most beneficial position to facilitate respiration, which is:

1. semi-Fowler's position with a single pillow behind the head.

2. high Fowler's position without a pillow behind the head.

3. right lateral with the head of the bed elevated 45 degrees.

4. sitting upright and forward with arms supported on an over the bed table.

ANS: D

Sitting upright and leaning forward with arms supported on an over the bed table is best for this patient, because it allows for expansion of the thoracic cage in all four directions (front, back, and two sides).

DIF: Cognitive Level: Application

TOP: Positioning

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

OBJ: Clinical Practice #1

REF: p. 534

The nurse performing tracheotomy care will:

1. raise the head of the bed to high Fowler's position.

2. remove the inner cannula with the ungloved hand.

3. suction tracheotomy before beginning care.

4. clean cannula with gauze and replace and lock.

ANS: C

Proper procedure includes suctioning the tracheostomy before beginning care.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #3

REF: p. 535 Sk1ll 28-7

TOP: Tracheotomy Care

KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control

The nurse caring for a patient with a disposable chest drainage system can promote effective tube function and patient safety by:

1. taping all connections within the system.

2. keeping the system at the level of the patient's chest.

3. turning on suction to 35 cm.

4. looping the tubing between the mattress and the bed rail to minimize length.

ANS: A

All connections in the system should be taped. Suction should be set at 20 cm unless ordered otherwise. Looping the tubing encourages plugs in the tubing.

DIF: Cognitive Level: Application

OBJ: Clinical Practice #4

REF: p. 530 Step 28-1

TOP: Chest Tube Care

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk

The nurse takes into consideration that a pulse oximeter may not give an accurate reading if the patient is:

1. dark skinned

2. jaundiced.

3. obese.

4. febrile.

ANS: B

An accurate reading is dependent on light passing through the vascular bed. Jaundice may cause an inaccurate reading.

DIF: Cognitive Level: Knowledge

REF: p. 512|Skill 28-1

OBJ: Theory #1

TOP: Pulse Oximetry

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

The nurse clarifies that the cough mechanism is stimulated when:

1. foreign substances are propelled by the cilia toward the respiratory tract.

2. dehumidified air enters the upper airway passages.

3. more than 250 mL of air moves in and out of the lungs with each breath.

4. the blood transports carbon dioxide to the lungs.

ANS: A

Cilia work to propel foreign substances toward the entrance of the respiratory tract, and the cough reflex works to expel the secretions.

DIF: Cognitive Level: Knowledge

REF: p. 509

OBJ: Theory #1

TOP: Respiratory Structure Function KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

When assessing the lungs of a patient, the nurse assesses a wheezing sound on inspiration.

This finding is documented as:

1. apnea.

2. dyspnea.

3. stridor.

4. retractions.

ANS: C

Stridor is a wheezing sound that can be heard on auscultation or even with the naked ear and indicates respiratory obstruction.

DIF: Cognitive Level: Knowledge

REF: p. 510

TOP: Stridor

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

OBJ: Theory #1

When a patient with a tracheostomy tube is taken care of at home by family, tracheostomy care instructions from the nurse include: (Select all that apply.)

1. use sterile gloves during suctioning

2. avoid going to crowded theaters and malls.

3. change catheters every 8 hours.

4. keep the home environment free of dust.

5. use bleach to clean suction equipment.

ANS: B, C, D, E

The patient should avoid crowded places to decrease the chance of respiratory infections; use household bleach, hydrogen peroxide, or soap and water to clean equipment; change catheter every 8 hours; and maintain the home environment free of air pollutants to decrease irritation to airway passages.

DIF: Cognitive Level: Comprehension REF: p. 538

TOP: Home Care of Tracheostomy Patient

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

OBJ: Clinical Practice #3

The nurse is aware that changes occur in the respiratory system after the age of 70 that put the older adult more at risk for respiratory problems. These changes include: (Select all that apply.)

1. decreased oxygen saturation.

2. increased elasticity in thorax and respiratory tissues.

3. incomplete expirations.

4. thinning of alveolar membrane.

5. impaired cilia.

ANS: A, C, E

After the age of 70, changes in the respiratory system that put the older adult at risk for respiratory disorders are decreased oxygen saturation and elasticity of the thorax and respiratory tissues, incomplete respirations, thickening of the alveolar membranes, impaired cilia, and a lessened respiratory reserve.

DIF: Cognitive Level: Comprehension REF: p. 510

OBJ: Theory #1

TOP: Age-Related Changes

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

The multiple causes for hypoxia include: (Select all that apply.)

1. extreme fright.

2. aspirated vomit.

3. pulmonary fibrosis.

4. hiccoughs.

5. high altitude.

ANS: B, C, E

Among the many causes of hypoxia are aspirated vomit, pulmonary fibrosis, and high altitude.

DIF: Cognitive Level: Comprehension

REF: p. 510|Box 28-1

OBJ: Theory #2

TOP: Causes for hypoxia

KEY: Nursing Process Step: N/A

MSC: NCLEX: N/A

A sputum specimen is best obtained just after the patient______or after a________treatment because this is when there is more mucus available or when it is easier to cough up.

ANS: awakens; nebulizer

A sputum specimen is best obtained just after the patient awakens or after a nebulizer treatment because this is when there is more mucus available or when it is easier to cough up.

DIF: Cognitive Level: Application

TOP: Specimen Collection

MSC: NCLEX: N/A

REF: p. 518

OBJ: Clinical Practice #1

KEY: Nursing Process Step: N/A

When obtaining a sputum specimen, the nurse should provide the patient with a sterile sputum cup and instruct the patient to rinse her mouth with______________.

ANS: water

When obtaining a sputum specimen, the nurse should provide the patient with a sterile sputum cup and instruct the patient to rinse her mouth with water.

DIF: Cognitive Level: Application

REF: p. 518

OBJ: Clinical Practice #1

TOP: Specimen Collection

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

The nurse explains that the rate of respiration is triggered when the medulla senses a change in the level of_______ions in the blood.

ANS: hydrogen

When there is an increase in hydrogen ions in the blood (pH), the medulla signals the spinal nerves to increase and deepen respirations. A drop in the pH reverses the process causing a slowing of the respirations.

DIF: Cognitive Level: Knowledge

REF: p. 509

OBJ: Theory #1

TOP: pH Effect on Respiration

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

The nurse administering cardiopulmonary resuscitation (CPR) would administer chest compressions at the rate of____________compressions/minute.

ANS:

100

The CPR guidelines require that there be 100 chest compressions/minute.

DIF: Cognitive Level: Knowledge

REF: p. 515|Skill 28-3

OBJ: Theory #3

TOP: CPR

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk