Term
| A client with chronic pulmonary disease has a bluish tinge around the lips. The nurse charts which term to most accurately describe the client’s condition? |
|
Definition
| A bluish tinge to mucous membranes is called cyanosis. This is most accurate because it is what the nurse observes. |
|
|
Term
| To prevent postoperative complications, the nurse assists the client with coughing and deep-breathing exercises. This is best accomplished by implementing which of the following? |
|
Definition
Huff coughing every 2 hours or as needed.
Rationale: Huff coughing helps keep the airways open and secretions mobilized. Huff coughing is an alternative for clients who are unable to perform a normal forceful cough (e.g., postoperatively). Deep breathing and coughing should be performed at the same time. |
|
|
Term
| The nurse is preparing to perform tracheostomy care. Prior to beginning the procedure the nurse performs which action? |
|
Definition
Tells the client to raise two fingers to indicate pain or distress.
Rationale: Prior to starting the procedure, it is important to develop a means of communication by which the client can express pain or discomfort. |
|
|
Term
| Which action by the nurse represents proper nasopharyngeal/nasotracheal suction technique? |
|
Definition
Rotate the catheter while applying suction.
Rationale: Rotating the catheter prevents pulling of tissue into the opening on the catheter tip and side. |
|
|
Term
| Which client statement informs the nurse that his teaching about the proper use of an incentive spirometer was effective? |
|
Definition
“I should inhale slowly and steadily to keep the balls up.”
Rationale: Proper use of an SMI requires the client to take slow, steady inhalations, every hour or two, 5 to 10 breaths each time. |
|
|
Term
| While a client with chest tubes is ambulating, the connection between the tube and the water seal dislodges. Which action by the nurse is most appropriate? |
|
Definition
Reconnect the tube to the water seal
.
Rationale: The tube should be reconnected to the water seal as quickly as possible |
|
|
Term
| The nurse makes the assessment that which client has the greatest risk for a problem with the transport of oxygen from the lungs to the tissues? A client who has |
|
Definition
Anemia.
Rationale: Anemia is a condition of decreased red blood cells and decreased hemoglobin. Hemoglobin is how the oxygen molecules are transported to the tissues. |
|
|
Term
| Which term does the nurse document to best describe a client experiencing shortness of breath when lying down who must assume an upright or sitting position to breathe more comfortably and effectively? |
|
Definition
Orthopnea
Rationale: Respiratory difficulty related to a reclining position without other physical alterations is defined as orthopnea. |
|
|
Term
| A client with emphysema is prescribed corticosteroid therapy on a short-term basis for acute bronchitis. The client asks the nurse how the steroids will help him. The nurse responds by saying that the corticosteroids will do which of the following? |
|
Definition
Decrease inflammation in the airways.
Rationale: Glucocorticoids are prescribed because of their anti-inflammatory effect. |
|
|
Term
| The nurse is planning to perform percussion and postural drainage. Which is an important aspect of planning the client’s care? |
|
Definition
Percussion and postural drainage should be done before lunch.
Rationale: Postural drainage results in expectoration of large amounts of mucus. Clients sometimes ingest part of the secretions. The secretions may also produce an unpleasant taste in the oral cavity, which could result in nausea/vomiting. This procedure should be done on an empty stomach to decrease client discomfort. |
|
|
Term
| Adventitious breath sounds |
|
Definition
| abnormal breath sounds that occur when air passes through narrowed airways or airways filled with fluid or mucus, or when pleural linings are inflamed |
|
|
Term
|
Definition
| a complete absence of respirations |
|
|
Term
|
Definition
|
|
Term
|
Definition
| shallow breaths interrupted by apnea |
|
|
Term
|
Definition
| abnormally slow respiratory rate, usually less than 10 respirations per minute |
|
|
Term
| Cheyne-Stokes respirations |
|
Definition
| rhythmic waxing and waning of respirations from very deep breathing to very shallow breathing with periods of temporary apnea, often associated with cardiac failure, increased intracranial pressure, or brain damage |
|
|
Term
|
Definition
| a method for suctioning an endotracheal tube or tracheostomy in which the suction catheter, enclosed in a plastic sheath, attaches to the ventilator tubing, and the client does not need to be disconnected from the ventilator |
|
|
Term
|
Definition
| a bluish tinge of skin color |
|
|
Term
|
Definition
| the mixing of molecules or ions of two or more substances as a result of random motion |
|
|
Term
|
Definition
| difficult or labored breathing |
|
|
Term
|
Definition
| a chronic pulmonary condition in which the alveoli are dilated and distended |
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
|
|
Term
|
Definition
| the proportion of red blood cells (erythrocytes) to the total blood volume |
|
|
Term
|
Definition
| the accumulation of blood in the pleural cavity |
|
|
Term
|
Definition
| a device that adds water vapor to inspired air |
|
|
Term
|
Definition
| a condition in which carbon dioxide accumulates in the blood |
|
|
Term
| Hypercarbia (hypercapnia) |
|
Definition
| accumulation of carbon dioxide in the blood |
|
|
Term
|
Definition
| giving the client breaths that are greater than the client's normal tidal volume set on the ventilator through the ventilator circuit or via a manual resuscitation bag |
|
|
Term
|
Definition
| increasing the oxygen flow before suctioning and between suction attempts to avoid suction-related hypoxemia |
|
|
Term
|
Definition
| very deep, rapid respirations |
|
|
Term
|
Definition
| low partial pressure of oxygen or low saturation of oxyhemoglobin in the arterial blood |
|
|
Term
|
Definition
| insufficient oxygen anywhere in the body |
|
|
Term
| Incentive spirometer (sustained maximal inspiration device, SMI) |
|
Definition
| a device that measures the flow of air inhaled through a mouthpiece |
|
|
Term
|
Definition
| pressure in the pleural cavity surrounding the lungs |
|
|
Term
|
Definition
| pressure within the lungs |
|
|
Term
|
Definition
| hyperventilation that accompanies metabolic acidosis in which the body attempts to compensate (give off excess body acids) by blowing off carbon dioxide through deep and rapid breathing |
|
|
Term
|
Definition
| expansibility of the lung |
|
|
Term
|
Definition
| the tendency of lungs to collapse away from the chest wall |
|
|
Term
|
Definition
| ability to breathe only when in an upright position (sitting or standing) |
|
|
Term
|
Definition
| the compound of oxygen and hemoglobin |
|
|
Term
|
Definition
| the pressure exerted by each individual gas in a mixture according to its percentage concentration in the mixture |
|
|
Term
|
Definition
| accumulation of air in the pleural space |
|
|
Term
|
Definition
| positioning of a client to allow the drainage, by gravity, of secretions from the lungs |
|
|
Term
|
Definition
| where gas exchange occurs between the air on the alveolar side and the blood on the capillary side; the alveolar and capillary walls form the respiratory membrane |
|
|
Term
|
Definition
| the mucous secretion from the lungs, bronchi, and trachea |
|
|
Term
|
Definition
| a harsh, crowing sound made on inhalation caused by constriction of the upper airway |
|
|
Term
|
Definition
| the aspiration of secretions through a catheter connected to a suction machine or wall suction outlet |
|
|
Term
|
Definition
| a surface-active agent (e.g., soap or a synthetic detergent); in pulmonary physiology, a mixture of phospholipids secreted by alveolar cells into the alveoli and respiratory air passages that reduces the surface tension of pulmonary fluids and thus contributes to the elastic properties of pulmonary tissue |
|
|
Term
|
Definition
| abnormally fast respirations; usually more than 24 respirations per minute |
|
|
Term
|
Definition
| the volume of air that is normally inhaled and exhaled |
|
|
Term
|
Definition
|
|
Term
|
Definition
| a series of vigorous quiverings produced by hands that are placed flat against the chest wall to loosen thick secretions |
|
|
Term
|
Definition
| delivers FiO2 of 24 - 44% with flowrates for 1 - 6 liters per minute via tubing with two small prongs for insertion into the nares |
|
|
Term
|
Definition
| delivers FiO2 of 40 - 60% with liter flows of 5 - 8 LPM for short term oxygen therapy |
|
|
Term
|
Definition
| delivers FiO2 of 80-95% at flow rates of 10-15 LPM to keep the reservoir bad two-thirds full during inspiration and expiration |
|
|
Term
|
Definition
| delivers FiO2 of 24 - 55% at flow rates of 2-10 LPM via different size adaptors |
|
|
Term
|
Definition
| delivers FiO2 of 24-100% at flow rates of at least 10 LPM and requires high humidification of oxygen |
|
|
Term
| what can cause a low oximetry reading? |
|
Definition
-nail polish
-inadequate peripheral circulation
-edema
-hypothermia
-decreased hemoglobin level |
|
|
Term
|
Definition
-tachypnea
-tachycardia
-restlessness
-pale skin and mucous membranes
-elevated blood pressure
-symptoms of respiratory distress of accessory muscles (nasal flaring, tracheal tugging, adventitious lung sounds |
|
|
Term
|
Definition
-confusion and stupor
-cyanotic skin and mucous membranes
-bradypnea
-bradycardia
-hypotension
-cardiac dysrhythmias |
|
|
Term
| a nurse is caring for a client who is having trouble breathing. What position should the nurse place the client in? |
|
Definition
|
|
Term
| which oxygen delivery system should be used when a precise amount of oxygen needs to be delivered? |
|
Definition
|
|
Term
| a nurse is preparing to perform endotracheal suctioning for a client. What are appropriate guidelines to be followed? |
|
Definition
-apply suction while withdrawing the catheter
-only perform suction when indicated NOT on a routine basis
-use a new tube each time suctioning is performed
-limit suctioning to two or three attempts
-maintain surgical asepsis |
|
|
Term
| which intervention is appropriate when caring for a client who has a tracheostomy tube? |
|
Definition
-keep cuff pressure between 14 and 20 mmHg
-use surgical asepsis
-ties are changed only when soiled
-use half-strangth hydrogen peroxide and normal saline solution to clean stoma site |
|
|
Term
|
Definition
| the drainage by gravity of secretions from various lung segments |
|
|
Term
|
Definition
| aspirating secretions through a catheter connected to a suction machine or wall suction outlet |
|
|
Term
| clear odorless gas that makes up 21% of the air we breathe |
|
Definition
|
|
Term
|
Definition
| collapse of a portion of the lung |
|
|
Term
|
Definition
| a series of vigorous quiverings produced by hands that are placed flat against the clients chest wall |
|
|
Term
| what does adequate ventilation depend on? |
|
Definition
-clear airways
-intact nervous system and respiratory center
-intact thoracic cavity capable of expanding and contracting
-adequate pulmonary compliance and recoil |
|
|
Term
|
Definition
| the amount of air remaining in the lungs after maximal exhalation |
|
|
Term
|
Definition
| total volume of lungs at maximal inflation |
|
|
Term
|
Definition
| total amount of air that can exhaled after a maximal inspiration |
|
|
Term
| expiratory reserve volume |
|
Definition
| maximum amount of air that can be exhaled following a normal exhalation |
|
|
Term
| what does the cough reflex consist of? |
|
Definition
-nerve impulses sent through the vagus nerve to the medulla
-a large inspiration of approx. 2.5 L occurs
-the epiglottis and glottis(vocal cords)close
-a strong contraction of abdominal and internal intercostl muscles dramatically raises the pressure in the lungs
-the epiglottis and glottis(vocal cords)open suddenly
-air rushes outward with great velocity
-mucus and any foreign particles are dislodged from the lower respiratory tract and are propelled up and out |
|
|
Term
| what is a risk of giving oxygen to clients with chronic obstructive pulmonary disease? |
|
Definition
| with two much oxygen they stop breathing |
|
|
Term
| what may be present with hypoxemia or hypoxia |
|
Definition
|
|
Term
|
Definition
| combined with hemoglobin and carried as oxyhemoglobin |
|
|
Term
| how long can the cerebral cortex tolerate hypoxia before permanent damage occurs |
|
Definition
|
|
Term
| what does the nurse assessment of oxygenation status include |
|
Definition
| history, physical examination, and review of relevant diagnostic data |
|
|
Term
| how much air for an adult is usually inspired and expired with each breath |
|
Definition
|
|
Term
| assumes a sitting position, often leaning forward slightly to permit greater expansion of the thoracic cavity is signs of what |
|
Definition
|
|
Term
| lung compliance is necessary for__________ and lung recoil is necessary for_____________ |
|
Definition
|
|
Term
| fingers and toes clubbed would be a sign of |
|
Definition
|
|
Term
| hyperventilation what happens to the CO2 level |
|
Definition
| respirations increase and more CO2 is eliminated than is produced |
|
|
Term
|
Definition
| forced expirations and may impair the body's ability to expel CO2 |
|
|
Term
| name the four processes of the respiratory system |
|
Definition
| pulmonary ventilation, alveolar gas exchange, transport of oxygen and carbon dioxide, and systemic diffusion |
|
|
Term
| hypoventilation may be caused by what |
|
Definition
(inadequate alveolar ventilation)
slow or shallow breathing, or both |
|
|
Term
| anxious, tired, and drawn are all signs of what |
|
Definition
|
|
Term
| what is the purpose for the nose in the respiratory system |
|
Definition
| warm, humidify, and filter |
|
|
Term
| what is the partial pressure of oxygen in the venous blood of the pulmonary arteries |
|
Definition
|
|
Term
| what makes up the lower respiratory system |
|
Definition
| trachea and lungs, with the bronchi, bronchioles, alveoli, pulmonary capillary network, and pleural membranes |
|
|
Term
| what are the accessory muscles of respiration |
|
Definition
| anterior neck muscles, intercostal muscles, and muscles of the abdomen |
|
|
Term
| hypoventilation may lead to what |
|
Definition
increased levels of carbon dioxide
or low leveles of oxygen (hypoxemia) |
|
|
Term
| a client who has been taking drugs such as morphine or sedatives, who have metabolic alkalosis, or who have increased intracranial pressure would have what type of breathing |
|
Definition
|
|
Term
| hypoventilation may occur because |
|
Definition
| diseases of the respiratory muscles, drugs, or anesthesia |
|
|
Term
| signs a client has dyspnea |
|
Definition
| flaring of the nostrils, labored-appearing breathing, increased heart rate, cyanosis, and diaphoresis |
|
|
Term
| what is the normal hematocrit for men and for women |
|
Definition
|
|
Term
| what can affect the rate of oxygen transport from the lungs to the tissues |
|
Definition
cardiac output
number of erythrocytes and blood hematocrit
exercise |
|
|
Term
| hypoxemia may be caused by |
|
Definition
| conditions that impair diffusion at the alveolar-capillary level such as pulmonary edema or atelectasis (collapsed alveoli) or by low hemoglobin levels |
|
|
Term
| excessive increases in the blood hematocrit raises what |
|
Definition
|
|
Term
| what are the three ways carbon dioxide is transported from the cells to the lungs |
|
Definition
1. 65% inside RBCs as bicarbonate
2. 30% combines with hemoglobin as carbhemoglobin
3. 5% in solution in the plasma and as carbonic acid |
|
|
Term
|
Definition
type of hyperventilation that accompanies metabolic acidosis
the body attempts to compensate for increased metabolic acids by blowing off acid in the form of CO2 |
|
|
Term
| what makes up the upper respiratory system |
|
Definition
| mouth, nose, pharynx, and larynx |
|
|
Term
| signs client has chronic hypoxemia |
|
Definition
| client feels fatigued and is lethargic |
|
|
Term
| Cheyne-Stokes respirations |
|
Definition
| marked rhythmic waxing and waning of respirations from very deep to very shallow with short periods of apnea commonly caused by chronic diseases, increased intracranial pressure, and drug overdose |
|
|
Term
| the absense of oxygen can lead to what |
|
Definition
| cellular, tissue, and organism death |
|
|
Term
| insufficient oxygen anywhere in the body is what |
|
Definition
|
|
Term
|
Definition
many
most stem from cardiac or respiratory disorders |
|
|
Term
| what is one risk of a humidity tent? |
|
Definition
|
|
Term
|
Definition
also known as crackles, heard in base of lower lungs
short in duration, crackling sound |
|
|
Term
|
Definition
also known as gurgles, heard over most lung areas
continuous, harsh gurgling sound |
|
|
Term
|
Definition
| heard all over continuous high pitched musical sound , best heard on expiration |
|
|
Term
|
Definition
heard in areas of greatest expansion (lower anterior and lateral chest)
grating or creaking sound |
|
|
