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chapter 38 respiratory - circulation
Terms in this set (33)
When a person takes a breath in, what is the primary muscle of respiration?
The diaphragm is the primary muscle of respiration. When it contracts, the intrathoracic is increased, forcing atmospheric air into the airways.
The exchange of oxygen and carbon dioxide occurs in the alveoli. How is oxygen carried in the blood?
The hemoglobin:Oxygen is carried on the hemoglobin to the tissues where some is released.
The finding of a barrel chest configuration in a patient may be related to which of the following disorders?
The air trapping that occurs in chronic obstructive pulmonary disease over time causes the chest to expand, leaving a ratio of 1:1 from side to front ratio instead of the normal 1:2 ratio.
Chronic obstructive pulmonary disease
Which of the following patients may need a pharyngeal airway?
A patient with decreased level of consciousness
Which of the following is a recommended immunization for adults yearly?
Which of the following artificial airways would the nurse anticipate to have a cuff at the end?
An endotracheal tube
An endotracheal tube enters the patient's trachea and has a cuff to prevent gastric contents from emptying into the lungs from the gastrointestinal tract.
Which of the following oxygen masks has holes at the side that allow air to enter the mask?
Simple face mask:The holes in the mask allow the CO2 to escape on expiration, and if the oxygen is turned off, room air can be breathed through the holes.
Which of the following conditions would be associated with a wheezing sound on inspiration in a patient's lower posterior chest?
Asthma causes a narrowing of small airways that results in a wheezing sound.
During assessment a patient states, "It's hard for me to breathe and I feel short-winded all the time." What is the most appropriate terminology to be applied in documenting this assessment by the nurse?
Dyspnea is a subjective description reflective of the patient's statement indicating difficulty breathing. Apnea refers to absence of breathing. Tachypnea refers to an increased rate of breathing, usually greater than 20 breaths per minute. Respiratory fatigue is a subjective description. It usually refers to the patient exhibiting signs and symptoms associated with a comprehensive respiratory assessment. The respiratory assessment includes laborious breathing, use of accessory muscles, and slowing of respirations.
STUDY TIP: Be sure to review medical terminology so that you recall the meanings of the Latin and Greek word parts, such as dys-, which means difficult, and -pnea, which means breathing.
The nurse goes to assess a new patient and finds him lying supine in bed. The patient tells the nurse that he feels short of breath. Which nursing action should the nurse perform first?
Raising the head of the bed brings the diaphragm down and allows for better chest expansion, thus improving ventilation.
While caring for a patient with respiratory disease, the nurse observes that the oxygen saturation drops from 94% to 85% when the patient ambulates. What is the most appropriate nursing action?
Oxygen saturation lower than 90% indicates inadequate oxygenation. If the drop is related to activity of some type, supplemental oxygen is indicated. ABG measurements will not be helpful. Even though it is not necessarily a response to activity, the patient should continue to be monitored. Only an earlobe probe should be used on the earlobe to determine oximetry readings. However, the earlobe is very susceptible to vasoconstriction, and may give false readings.
A patient who started smoking in adolescence and continues to smoke 40 years later comes to the clinic. The nurse understands that this patient has an increased risk for being diagnosed with which disorder?
On reviewing the diagnostic reports of a patient with difficulty in breathing, the nurse finds that the patient has decreased diaphragmatic movement, collapsed lung tissue, and airway obstruction. What does the nurse interpret from these findings?
pg. 953Atelectasis is a pulmonary disorder that is caused by the collapse or closure of a lung tissue. It is associated with decreased movement of the diaphragm and obstruction of the airways due to the retention of pulmonary secretions. This results in hypoventilation and difficulty breathing. Pneumonia is a pulmonary infection associated with fever, cough, and increased secretions. Hypercapnia is a condition caused by the presence of high carbon dioxide levels in the blood. Hemoptysis is a condition associated with blood-tinged sputum. It is caused by damage to the tiny blood vessels in the lungs and bronchioles. As the patient does not have high carbon dioxide levels in the blood or blood-tinged sputum, the nurse does not anticipate that the patient has hypercapnia or hemoptysis.
Which clinical finding in a patient's laboratory reports indicates hyperlipidemia?
pg. 955The lipoprotein profile consists of four tests (cholesterol, LDL, HDL, and triglycerides) and helps to diagnose hyperlipidemia. The normal value of triglycerides is less than 150 mg/dL. Therefore, a triglyceride value of 170 mg/dL indicates hyperlipidemia. A total cholesterol value of less than 200 mg/dL is a normal finding. An LDL value of 90 mg/dL is a normal value. LDL above 100 mg/dL indicates hyperlipidemia. An HDL value greater than 60 mg/dL is a normal value.
The nurse is evaluating a coworker who is monitoring a chest tube in a patient with a pneumothorax. Which action of the coworker indicates the need for correction?
Fluid may reenter the lungs if the drainage collection device is raised above chest level. Therefore, the nurse does not raise the drainage collection device above chest level. Water seals are created and maintained by adding 2 cm of sterile fluid to a chamber. This water seal can be maintained only by placing the collection device in an upright position. Draining the tube every 15 minutes by lifting it ensures that the tubes are maintained without any obstruction. Semi-Fowler's position promotes optimal drainage of air for a pneumothorax.
Test-Taking Tip: Think of the phrase "indicates the need for correction" as meaning, "All of the following are correct EXCEPT..." This phrasing in the question is asking you to identify the incorrect action.
A patient with chronic obstructive pulmonary disease (COPD) is receiving oxygen at 2 L/min. While in the supine position for a bath, the patient complains of shortness of breath. Which is the most appropriate first nursing action?
Breathing is easier in semi-Fowler's position because it permits greater expansion of the chest cavity. If repositioning does not improve the situation, then oxygenation and contacting the healthcare provider might be appropriate. The patient would not benefit from tracheal suctioning.
Test-Taking Tip: If the question asks for an immediate action or response, all of the answers may be correct, so base your selection on identified priorities for action.
Which statement made by a student nurse indicates the need for further teaching about suctioning a patient with a tracheostomy?
Saline has been found to cause more side effects when suctioning and does not increase the amount of secretions removed.
What parameters does a nurse monitor in a patient who has developed hypoxemia? Select all that apply.
Hypoxemia is a low level of oxygen in the blood. Hypoxemia may be manifested by a high respiratory or heart rate. Other indications may be cyanosis, a bluish discoloration of the skin related to deoxygenation of hemoglobin, a decreasing oxygen saturation, and a feeling of distress. Blood urea is a renal parameter, so it is less significant when monitoring a patient with hypoxia. Serum bilirubin indicates liver function, so it is less significant when monitoring a patient with hypoxia.
STUDY TIP: Make note cards with disorders on one side, and signs and symptoms on the other. Carry them with you to quiz yourself when you have a few minutes. For this question, your note card would have "hypoxemia" on one side; on the reverse side, "increased pulse rate," "increased respiratory rate," and "cyanosis" would be some of the listings.
A family of four approaches the community nurse for a pneumococcal vaccine. The family's ages are grandfather, 70; mother, 46; daughter, 22; and son, 18. The son is a smoker. None of the family has asthma or other chronic illnesses. Who should be given pneumococcal vaccine in this family? Select all that apply.
The pneumococcal vaccine is recommended for all adults older than 65 years; therefore, the grandfather should receive the vaccine. It is also indicated for patients with a history of asthma, smokers, and patients having any chronic illnesses irrespective of their age. Therefore, the son should also receive the pneumococcal vaccine. The mother and daughter do not need the vaccine as they are younger than 65 years and do not have asthma or any other chronic illness.
The nurse is caring for patients with cardiopulmonary disorders in a health care facility. What is the initial nursing intervention when assessing these patients?
What is the reason for heart failure after myocardial infarction (MI)?
pg 951Impairment of the contractile function of the ventricle. Heart failure is a physiologic state in which the heart cannot pump enough blood to meet the metabolic needs of the body. It results from changes in systolic or diastolic function of the left ventricle. After an MI, some of the heart muscle is replaced by noncontracting scar tissue, and the ventricles pump less efficiently. Chronic pulmonary disease and volume overload can precipitate heart failure because they increase the workload of the heart. Oxygen demands are increased with stress, dysrhythmias, infections, and certain other disorders. Inability of the heart chambers to fill adequately results from disorders such as valvular stenosis or constrictive pericarditis.
The nurse performs nasotracheal suctioning of a patient. The nurse finds that the patient gags and becomes nauseated upon insertion of the catheter into the trachea. What should the nurse's response be?
Gently remove the catheter and wait until the patient breathes normally, A nurse should analyze the reason for the patient's response to insertion of a suction catheter. Gag reflex and nausea during insertion of the tracheal tube indicate that the catheter has gone into the esophagus. Therefore, the nurse should gently remove the catheter and wait until the patient is stabilized. Once the patient is breathing normally, the catheter is reinserted into the naris. This helps the epiglottis to open and allows the catheter go into the trachea. If the patient is asked to swallow the catheter, it will enter into the esophagus. To suction the left main bronchus, the patient's head should be turned to the right and vice versa once the catheter has entered the trachea. Suction should never be applied during insertion as it may traumatize the mucosal membrane.
Test-Taking Tip: Look for choices that support safety! As the rationale explains, suction should never be applied during insertion, and swallowing will move the catheter into the esophagus, so those choices are eliminated. You will need to know to turn the head away from the main bronchus you wish to suction; then your answer is clear for this question. Even if you did not remember which way to turn the patient's head, by knowing the safety precautions, you would have a good chance of picking the correct answer.
A patient with a right lung abscess is admitted to the hospital. The nurse is instructed to position the patient appropriately to promote lung expansion. What is the most appropriate position for this patient?
45-degree semi-Fowler's position with right lung down
A semi-Fowler's position with the patient at 45 degrees is the best position to be used to promote lung expansion. It also helps to relieve the pressure from the abdomen on the chest. Supine position does not help in lung expansion. In patients with pulmonary abscess, the affected lung should be positioned down to prevent the flow of secretions to the healthy lung. In cases of bilateral lung diseases, the position should be determined by the severity of the disease.
Test-Taking Tip: After reading the choices individually, if you are unsure of the correct response, compare the answers to each other. For this question, there are two choices of supine position and two choices of 45-degree semi-Fowler's position. Let's suppose you know to eliminate the supine choices, then you compare the two 45-degree semi-Fowler's position options. You now have a 50-50 chance of guessing the correct one—but then you recall that an abscess is a type of infection, so it is best to have the affected lung down to avoid transferring the infection. You did it!
The nurse assesses a patient who is short of breath and fatigued. The nurse finds that the oxygen saturation of the blood is reduced. The lab report indicates that the patient's red blood cell count is increased. What do these findings suggest?
The patient has decreased oxygen saturation, which is indicative of hypoxemia. In anemia, red blood cell count is reduced. Based on the assessment findings, the nurse cannot conclude that the patient has hypoventilation. In acute infections, the white blood cell count is altered, but the RBC count is not affected.
A nurse is teaching a patient about lifestyle practices to promote heart health. Which instructions should the nurse include in this teaching? Select all that apply.
A high-fiber and low-fat diet is recommended for patients with a risk for developing cardiopulmonary disease. Cardiac health may be related to diet. The patient is advised to avoid meats that are high in fat and eat lean cuts of meat, such as chicken breasts and the white meat of turkey. Eating fruits and vegetables is encouraged. Weight management and a high-fiber diet may help to lower cholesterol. Exercising for 30-60 minutes will help in promoting circulation of the blood and a healthy heart. Diets high in fats and proteins will lead to cardiac disorders. A calorie intake of 3000 calories may lead to weight gain and obesity, and have an adverse effect on the heart.
A patient is admitted to the hospital with a pneumothorax following a blunt injury to the chest. Which signs and symptoms should a nurse expect to find in this patient? Select all that apply.
Pneumothorax is the accumulation of air between the parietal and visceral pleura. It causes sharp pain in the chest as atmospheric air irritates the pleura. The pain makes it difficult for the patient to breathe normally. The pain increases on inspiration of air. There is no external wound or oozing. There is no overproduction of mucus or radiating arm pain in pneumothorax.
The nurse is caring for a patient who has a chest tube to drain a pneumothorax. What nursing actions should the nurse perform? Select all that apply.
The chest tube drainage set should be kept below the patient's chest level as it is facilitated by gravity. It is essential to fill the water seal chamber to the level given by the manufacturer. Bubbling in the water seal chamber could indicate an air leak, which may be a sign of new or persistent hemothorax. If the tube disconnects from the drainage collection device, immediately clamp the tube at two places with the covered hemostats. Tubing is only clamped if the collection device is lifted above the level of the chest, when the drainage collection device needs to be changed, or if the device breaks. Do not keep the drainage set above the level of the chest as it will be difficult to drain against gravity. Many nurses were taught to "strip" or "milk" the tubing of a chest tube if there was a lack of drainage or a noted occlusion. However, this practice is outdated and could be dangerous for a practitioner to perform. Evidence reveals that this can result in pleural damage, increased bleeding, trauma, and even impair left ventricular function due to increased intrathoracic pressure.
The nurse is evaluating a coworker who is performing tracheostomy suctioning on a patient. Which nursing action implemented by the coworker indicates the need for further teaching?
Tracheostomy suctioning helps to remove thick mucus and secretions from the trachea. The nurse places the patient in Fowler's or semi-Fowler's position and not in the supine position, because the supine position may increase the risk of aspiration. The nurse suctions for 10-15 seconds, ensuring adequate oxygen levels are maintained. The nurse assesses the patient's cardiac status after the procedure to determine the effectiveness of the procedure. The nurse sets the pressure of the suction device to 80-120 mmHg, which is an optimal range for performing tracheostomy suctioning. Any increase or decrease in pressure may cause damage to the lungs or airways.
Test-Taking Tip: Read every word of each question and option before responding. Glossing over the question just to get to the choices can cause you to misread or misinterpret the real intent of the question.
Two hours after surgery, the nurse assesses a patient who had a chest tube inserted during surgery. There is 200 mL of dark-red drainage in the chest tube at this time. What is the appropriate action for the nurse to perform?
Record the amount and continue to monitor drainage. Dark-red drainage after surgery (50 to 200 mL per hour in first 3 hours) is expected, but be aware of sudden increases greater than 100 mL per hour after the first 3 hours, especially if it becomes bright-red in color.
The nurse is explaining to a new coworker about the various characteristics or types of cough that can be encountered in patients. Which statements are true? Select all that apply.
When assessing any patient with a cough, it is essential to determine whether it is productive or nonproductive and its frequency, as various disorders have various patterns of cough. Hemoptysis is bloody sputum and it will require further evaluation. Patients with chronic bronchitis have excessive production of mucus and this mucus is accumulated in the lungs. The mucus gets accumulated when the patient is lying down and gets coughed out when the patient gets up. Hematemesis is vomiting of blood and not bloody sputum. Patients with sinusitis usually cough in early mornings to clear the airways of the sinus drainage.
The nurse is reviewing the pulmonary function test reports of a group of patients. Which patient's report indicates a respiratory disorder?
RV is the amount of air remaining in the lungs after maximum expiration with a normal RV of 1.2 L. In emphysema, the value may be up to four times the normal finding, or over 4 L. The FVC refers to the volume of air expired forcefully after maximum inspiration, and the normal volume is 4 L. The forced expiratory volume refers to the volume of air expired after 1 second of FVC; the normal volume is 3 L. The functional residual capacity refers to the volume of air remaining in the lungs after normal expiration; the normal volume is 2.3 L.
A patient has bluish discoloration of the skin and increased respirations. Which laboratory test does the nurse expect the primary health care provider to prescribe for this patient?
The nurse expects the primary health care provider to prescribe arterial blood gas analysis to measure the oxygen levels in the blood. Hypoxemia is a condition in which the oxygen levels are decreased in the blood. It is characterized by high respiratory and/or heart rate, bluish discoloration of the skin, and a feeling of distress. The bluish coloration of the skin indicates decreased oxygen levels. Pulmonary function tests are used to diagnose emphysema, a chronic obstructive pulmonary disorder. Blood creatinine levels and blood urea nitrogen levels are evaluated when the patient is suspected to have developed nephrotoxicity. WBC count is used to diagnose an infection.
A patient wants to understand the mechanism of respiration. What should the nurse explain to the patient? Select all that apply.
Normal breathing is a quiet process which requires minimum effort. Ventilation is the process of air moving in and out of lungs. The major muscles in breathing are the diaphragm and the intercostal muscles. Noisy breathing occurs in diseased conditions or in presence of some obstruction. All chest muscles, such as pectorals and sternocleidomastoid, are used in labored breathing. Perfusion is a process by which the cardiovascular system delivers oxygen-rich blood to the tissues and returns deoxygenated blood to the lungs.
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