ATI: Basic Oxygenation – Flashcards
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A nurse is assessing a client who has an acute respiratory Infection that puts her at risk for hypoxemia? (Select all that apply.) A. Restlessness B. Trachypnea C. Bradycardia D. Confusion E. Pallor
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A, B, D, E The nurse should monitor for restlessness, which is an early manifestation of hypoxemia, along with tachycardia, elevated blood pressure, confusion, use of accessory muscles, nasal flaring, tracheal tugging, and adventitious lung sounds. C. Bradycardia is a late manifestation of hypoxemia, along with stupor, cyanotic skin and mucous membranes, bradypnea, hypotension, and cardiac dysrhythmias.
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A provider is discharging a client who has a prescription for home oxygen therapy via nasal cannula. Client and family teaching by the nurse should include which of the following instructions? (select all that apply) A. Apply petroleum jelly around and inside the nares. B. Remove the nasal cannula during mealtimes. C. Check the position of the cannula frequently D. Report any nasal stuffiness, nausea, or fatigue. E. Post "no smoking" signs in a prominent location.
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C, D, E C. The nurse should teach the client that a disadvantage of the nasal cannula is that it dislodges easily. The client should form the habit of checking its position periodically and readjusting it as necessary. D. The nurse should teach the client about oxygen toxicity, which is complication of oxygen therapy, usually from high concentrations or long durations. Manifestations include a nonproductive cough, substernal pain, nasal stuffiness, nausea, vomiting, fatigue, headache, sore throat, and hypoventilation. The client should report any of these promptly. E. The nurse should teach the client that oxygen is combustible and thus increases the risk of fire injuries. No one in the house should smoke or use any device that might generate sparks in the area where the oxygen is in use.
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A nurse is caring for a client who is having difficulty breathing. The client is lying in bed and is already receiving oxygen therapy via nasal cannula. Which of the following interventions is the nurse's priority? A. Increase the oxygen flow. B. Assist the client to Fowler's position. C. Promote removal of pulmonary secretions. D. Obtain a specimen for arterial blood gases.
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B. Assist the client to Fowler's position. The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to care delivery is to relieve dyspnea (difficult breathing). Fowler's position facilitates maximal lung expansionand and thus optimizes breathing. With the client in this position, the nurse can better assess and determine the cause of the client's dyspnea.
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A nurse is prepraring to perform endotracheal suctioning for a client. The nurse should follow which of the following guidelines? (select all that apply.) A. Apply suction while withdrawing the catheter. B. Perform suctioning on a routine basis, every 2 to 3 hr. C. Maintain medical asepsis during suctioning. D. Use a new catheter for each suctioning attempt. E. Limit total suctioning time to 5 minutes.
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A, D, E A. The nurse should apply suction pressure only while withdrawing the catheter to prevent damaging the tracheal tissue. D. The nurse should use a new suction catheter, unless an in-line suctioning system is in place, to prevent contamination with microorganism that can cause an infection. E. To prevent hypoxemia, the nurse should limit total suctioning time to 5 minutes and allow at least 1 min between passes for ventilation and oxygenation.
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A nurse is caring for a client who has a tracheostomy. Which of the following actions should the nurse take when providing tracheostomy care? (select all that apply.) A. Apply the oxygen source loosely if the SpO2 decreases during the procedure B. Use surgical asepsis to remove and clean the inner cannula. C. Clean the outer surfaces in a circular motion from the stoma site outward. D. Replace the tracheostomy ties with new ties. E. Cut a slit in gauze squares to place beneath the tube holder.
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A, B, C A. The nurse should provide supplementl oxygen in response to any decline in oxygen saturation while performing tracheostomy care. B. The nurse should use a sterile disposable tracheostomy cleaning kit or sterile supplies and maintain surgical asepsis throughout this part of the procedure. C. The nurse should cleanse the surface around the stoma in a circular motion from the stoma outward. Cleansing in this manner helps move mucus and contaminated material away from the stoma for easy removal.
