oxygenation

Question 1

respiratory system includes

Answer 1

upper airways, lungs, lower airways, and alveolar air sacs (base of lungs)

Question 2

the lungs aid the body

Answer 2

in oxygenation and tissue perfusion

Question 3

noninvasive procesures

Answer 3

• chest x-ray (CXR): use lead sheild for adults who are childbearing age
• pulse oximetry
• pulmonary function tests
• sputum culture
• ct scan
• mri

Question 4

hypoxemia

Answer 4

when there is a limited amount of oxyegen in the blood

Question 5

retractions

Answer 5

• when the muscles are pulled inward and occur between the ribs when inspiration occurs
• intercostal retractions are a sign that the airway is blocked

Question 6

Hypoxia

Answer 6

lack of oxygen at the cellular level

Question 7

clinical manifestation of hypoxia and hypoemia

Answer 7

tachypnea
tachycardia
restlessness
pale skin and mucous membranes 
elevated blood pressure
use of accessory muscles, nasal flaring, adventitious lung sounds

Question 8

nursing actions for hypoxia and hypoxemia

Answer 8

• monitor respiratory rate and pattern, level of consciousness
• provide oxygen therapy at the lowest liter flow that will correct hypoxia
• make sure the mask creates a secure seal over the nose and mouth
• assess/monitor restlessness, hypertension, and headache
• wheezing because of inflammation on inhaling or exhale
• auscultate the lungs for breath sounds and adventitious sounds (crackles and wheezes)
• assess/ monitor oxygenation status with pulse oximetry
• promote oral hygiene
• encourage turning, coughing, deep breathing, and the use of incentive spirometry and suctioning
• promote rest and decrease environmental stimuli

Question 9

oxygen therapy

Answer 9

• a therapeutic gas that treats hypoxemia (low levels of arterial oxygen)
• administering and adjusting oxygen requires a prescription

Question 10

oxygen delivery devices

Answer 10

• nasal cannula
• simple face mask
• partial rebreather mask
• non-rebreather mask
• venturi mask
• aerosol mask, face tent
• t-piece

Question 11

nasal cannula

Answer 11

tubing with two small prongs for insertion into the nares

- fraction of inspired oxygen: delivers an Fio2 of 24% to 44% at a flow rate of 1-6 l/min

Question 12

nasal cannula advantages

Answer 12

• safe, simple, easy to apply method
• cannula is comfortable and well tolerates
• client is able to eat, talk, and ambulate

Question 13

nasal cannula disadvantages

Answer 13

• FiO2 varies with flow rate, and the rate and depth of the clients breathing
• extended use can lead to skin breakdown and dry mucous membranes
• tuning is easily dislodged

Question 14

nasal cannula nursing actions

Answer 14

• assess the patency of the nares
• ensure that the prongs fit in the nares properly
• use water-soluble gel to prevent dry nares
• provider humidication for flow rates of 4l/min and greater **

Question 15

simple face mask

Answer 15

• covers the client’s nose and mouth
• delivers an Fi02 of 35% to 50% at flow rates of 6 to 12 l/min
• minimum flow rate is 6l/min to ensure flushing of CO2 from the mask

Question 16

simple face mask advantages

Answer 16

• face mask is easy to apply and can be more comfortable than a nsal cannula
• provides humidified oxygen

Question 17

simple face mask disadvantages

Answer 17

• flow rates less than 6L/min can result in rebreathing of co2
• clients who have anixety or claustrophobia do not tolerate it well
• eating, drinking, and talking are impaires. mositure and pressure can collect under mask and cause skin breakdown
• face mask pose a greater risk of aspiration

Question 18

simple face mask nursing actions

Answer 18

• assess proper fit to ensure a secure seal over the nose and mouth
• make sure the client wears a nasal cannula during meals
• use with caution for clients who have a high risk of aspiration or airway obsutrction
• monitor for skin breakdown

Question 19

non-rebreather mask fraction of inspired oxygen

Answer 19

• delivers an FiO2 of 80% to 95% at flow rates of 10-15 l/min to keep the reservoir bag 2/3 full during inspiration and expiration

Question 20

non-rebreather mask advantages

Answer 20

• it delivers the highest 02 concentration possible
• a one-way valve situated between the mask and reservoir allows the client to inhale maximum 02 from the reservoir bag
• the two exhalation ports have flaps covering them that prevent room air from entering the mask

Question 21

non-rebreather mask disadvantage

Answer 21

• the valve and flap on the mask must be intact and functional during each breath
• it is poorly tolerated by clients who have anxiety or claustrophobia
• eating drinking and talking are impaired
• use with caution for clients who have high risk of aspiration or airway obstruction

Question 22

non-rebreather mask nursing actions

Answer 22

• perform and hourly assessment of the valve and flap
• assess proper fit to ensure a secure seal over the nose and mouth
• assess for skin breakdown beneath the edges of the mask and bride of the nose. make sure the client uses a nasal cannula during meals

Question 23

oxygen complications

Answer 23

• oxygen toxicity can result from high concentrations of oxygen (typically greater than 50%)
• long duration of oxygen therapy (typically more than 24 to 48 hours) and the severity of lung disease

Question 24

oxygen toxicity manifsations

Answer 24

• nonproductive cough
• substernal pain
• nausea
• vomiting
• fatigue
• dyspnea
• restlessness
• paresthesias

Question 25

oxygen toxicity nursing actions

Answer 25

- use the lowest level of oxygen necessay to maintain an adequate spo2 - monitor abg and notify the provider if sp02 levels are outside the expected reference range - decrease the fio2 as the clients spo2 imrpoves

Question 26

combustion nursing actions

Answer 26

- post "no smoking" or "oxygen in use" signs to alert others of the fire hazard. known where to find the closest fire extinguisher - educate about the fire hazard of smoking with oxygen use - have clients wear a cotton gown because synthetic or wool fabrics can generate static electricity

Question 27

combustion

Answer 27

- ensure that all electric devices (razors, hearing aids, radios) are working well - make sure all electric machinery (monitors, suction machines is grounded - do not sure volatile, flammable materials (alcohol, acetone) near clients receiving oxygen

Question 28

specimen collection and airway clearance

Answer 28

- mucoasl secretion buildup or aspiration of emeis can obstruct a clients airway - adequate hydration and coughing help the client maintain airway patency - these interventions promote adequate gas exchange and lung expansion

Question 29

specimen collection and airway clearance nursing actions that mobilize secretions and maintain airway patency include:

Answer 29

- assistance with coughing - hydration - positioning - humidification - nebulizer therapy - chest phsiotherapy - suctioning

Question 30

suctioning

Answer 30

don the required personal protective equitment - assist the client to high-fowelers or fowlers position for suctioning if possible - encourage the client to breathe deeply and cough in a an attempt to clear secretions without artifical suction

Question 31

suctioning nursing actions

Answer 31

- obtain baseline breath sounds and vital signs, including sao2 by a pulse oximeter - can monitor sao2 continually during the procedure - oropharyngeal suctioning use a yankauer or tonsil tipped rigid suction catheter and move the catheter around the mouth, gum line, and pharynx