Decreased cardiac output Show
(Conditions such as fever, sepsis, heart failure, poisoning, and poor hemoglobin quality alter the body's oxygen and delivery system balance by increasing oxygen demand, decreasing cardiac output, and decreasing the oxygen-carrying capacity of the blood. These conditions typically do not decrease the utilization of the oxygen in the body. The entry of organisms into the bloodstream is related to barrier breakdown.)
Terms in this set (30)When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to help maintain good skin integrity? C. Assessing the patient's external ears, nares, and nasal mucosa for breakdown at least once per shift. Rationale: Frequent assessment is a priority and will help the nurse identify early signs of skin breakdown. Although applying lotion is appropriate, this option is not the best way to maintain good skin integrity. It may not be appropriate to remove the cannula in a patient for whom oxygen therapy has been ordered. The patient may be unaware of facial skin areas that are dry or cracking. When caring for a patient who is receiving oxygen by simple face mask, which action ensures that the rate of oxygen being delivered is appropriate? D. Assessing for proper placement of the mask on the patient's face. Rationale: Monitoring placement of the cannula tips helps ensure that the patient receives the oxygen prescribed. Asking the patient if he or she is having trouble breathing does not address oxygen delivery. Oxygen tubing should not be pulled tight. There should be enough slack in the tubing to allow the patient to turn his or her head comfortably. Securing the oxygen tubing to keep the patient from pulling out the cannula does not address oxygen delivery. When caring for a patient for whom oxygen by nonrebreathing mask has been ordered, which action ensures appropriate oxygen delivery? D. Assessing that the reservoir bag stays inflated Rationale: A mask that fits properly will deliver the prescribed amount of oxygen. The oxygen tubing should not be looped around the side rail of the bed. Assessing breath sounds does not ensure that the oxygen is being delivered appropriately. The tubing should have some slack so that the patient can move his or her head. When caring for a patient who is receiving supplemental oxygen by face tent, which action ensures that the oxygen is flowing? C. Ensuring that a mist is always present Rationale: It is appropriate to ensure that a mist is always present when oxygen is delivered by face tent. Testing the closing capacity of the mask's valves is appropriate only for a nonrebreathing mask. Monitoring the seal over the patient's mouth and nose is appropriate only for a nonrebreathing mask. Such an assessment is appropriate, but correct positioning of the mask does not indicate that oxygen is flowing from it. What would the nurse do when receiving an order to increase the delivery rate of a patient's oxygen per nasal cannula from 1 L/min to 3 L/min? D. Adjust the float ball on the flow meter to 3 L/min Rationale: The nurse would increase the flow rate by moving the ball on the oxygen delivery system from 1 L/min to 3 L/min. Taking deeper breaths will not change the flow rate from 1 L/min to 3 L/min. There is no need to change the delivery device. The provider has ordered oxygen to be administered per nasal cannula, not per simple face mask. If the flow rate of oxygen is 4 L/min or higher, humidification is added. Oxygen delivered at the rate of 3 L/min need not be humidified. Why might the collection of a sputum specimen be delayed up to 2 hours? B. The patient has just finished eating lunch. Rationale: Specimen collection must be postponed for 1 to 2 hours after eating or the administration of a tube feeding, so the procedure would have to be delayed if the patient has just finished having lunch. The patient could be awakened to obtain the specimen. The administration of pain medication would not necessitate a delay in the collection of a sputum specimen. The presence of visitors would not necessitate a delay in the collection of a sputum specimen. They could be asked to step out of the room during the procedure. Which
criterion makes it appropriate for the nurse to delegate to nursing assistive personnel (NAP) the skill of collecting a sputum specimen? C. The patient can produce the specimen by coughing. Rationale: The skill of collecting a sputum specimen may be delegated only if the specimen is produced by the noninvasive means of expectoration (the patient's coughing). The amount of time it takes to complete the skill of collecting a sputum specimen, the likelihood of infection, and the availability of training at the agency are not criterion used to determine whether the skill may be delegated. What is the role of nursing assistive personnel (NAP) when a sputum specimen is collected by means of
nasotracheal suctioning? D. Transporting the specimen to the lab Rationale: The nurse may delegate to NAP the task of transporting the sputum specimen to the lab. The nurse may not delegate to NAP any portion of the skill of collecting a sputum specimen by means of nasotracheal suctioning. Which action would help to ensure that the results of a suctioned sputum specimen culture are reliable? D. Refrigerating the specimen until it can be taken to the lab Rationale: Refrigerating the specimen until it can be transported to the lab will help to ensure reliable results. Placing the specimen in a biohazard bag would ensure that no one comes into contact with the specimen during transport, but would have little bearing on the reliability of the specimen culture. The method of specimen collection has no bearing on the reliability of the specimen culture. In any case, it would be impractical for the nurse to stand by and wait until the patient begins to cough on his or her own. The nurse must wear sterile gloves to suction the patient. Which action by the nurse would most effectively reduce the patient's risk for injury when collecting a sputum specimen by means of nasotracheal suctioning? A. Lubricating the catheter with sterile water Rationale: Lubricating the catheter with sterile water minimizes trauma to the patient's respiratory mucosa during nasotracheal suctioning to obtain a sputum specimen. Using aseptic technique might reduce the risk for infection, but would have no effect on the patient's risk for injury during nasotracheal suctioning to obtain a sputum specimen. The semi- to high-Fowler's position is appropriate, but patient positioning is not as important as catheter lubrication in reducing the risk for injury during nasotracheal suctioning to obtain a sputum specimen. Assessing the patient's anxiety level is appropriate, and addressing the patient's apprehension might make him or her less tense during the procedure, thereby reducing the risk for injury. Assessing anxiety is not as important, however, as catheter lubrication in reducing the patient's risk for injury during nasotracheal suctioning to obtain a sputum specimen. What would the nurse do first when preparing to begin oxygen therapy for a patient? B. Review the medical prescription for delivery method and flow rate. Rationale: The nurse's initial action when preparing to begin oxygen therapy would be to review the delivery method and flow rate specified on the medical order. The NAP is not able to complete oxygen orders. Smoking is not permitted inside hospitals. This sign would need to be put up at the patient's home. Suction equipment is not needed for oxygen therapy. When preparing the patient's environment for safe
oxygen therapy, which intervention is a priority to minimize the patient's risk for injury? C. Inspect all electrical equipment in the patient's room for the presence of safety-check tags. Rationale: Inspecting electrical equipment would take priority among the other interventions in providing environmental safety. Placing appropriate signage to alert others to the presence of oxygen and instructing the NAP to immediately correct or report safety hazards do not take priority regarding environmental safety. Ensuring the patient receives the prescribed amount of oxygen does not pertain to environmental safety. When a patient is receiving oxygen at home, which instruction to the family would help them understand how to use the oxygen safely? C. Place a "No Smoking" sign at the entrance to the house. Rationale: "No Smoking" signs should be placed throughout the house as well as at the entrance. Oxygen may not be increased based on the patient's comfort. Extra cylinders should be stored vertically. Keep oxygen at least 10 feet (about 3 meters) away from anything that could generate a spark. What would the nurse do
first when preparing to educate the patient about safe administration of oxygen therapy at home? D. Assess the patient's emotional readiness and physical ability to provide autonomous care. Rationale: The nurse would first assess the patient's emotional readiness and physical ability to provide self-care, since these attributes are necessary in order to teach a patient effectively about oxygen administration. Information about oxygen's combustibility will be provided during patient education. The nurse might or might not need to arrange for a capable family member to be present during the initial discussion. The patient may be entirely capable of handling the oxygen equipment himself or herself. Although written information is a part of patient education, the nurse must first assess the patient's emotional readiness and physical ability to provide self-care. Which statement by the patient would indicate that he or she understands the safe use of oxygen? C. "I'll alert the nurse immediately if I have any increased difficulty breathing." Rationale: The patient should let the nurse know without delay if he or she has increased difficulty breathing. Oxygen saturation should be 90% or higher in a patient on oxygen, although the level may vary depending on the patient's situation and medical history. Oxygen is considered to be a medication, but the patient may not adjust it himself or herself. A health care provider must write an order for initiation of oxygen therapy and for any change in oxygen administration thereafter. The patient should not experience difficulty breathing for no reason; this complaint would need to be reported to the nurse or to the provider. What would the nurse do first to ease breathing for a patient with mild dyspnea? B. Help the patient into an upright sitting position. Rationale: The nurse would first try to ease the patient's breathing using a noninvasive intervention such as this one. Placing the patient in a sitting position improves lung expansion. The nurse would not provide oxygen first. Monitoring the patient with pulse oximetry would not help the patient's manifestations of dyspnea. Determining if the patient has a history of respiratory pathology would not help the patient's current manifestations of dyspnea. During
an admission interview, a patient who is required to stay in the supine position reports, "I can't breathe well while I'm lying down." What would the nurse do first to help this patient? D. Instruct the patient to use two bed pillows when lying supine. Rationale: Instructing the patient to use two bed pillows when lying supine is an appropriate intervention at this time. Although it is appropriate to notify the patient's health care provider of the patient's complaint, doing so is not the first action the nurse would take. Although it may be appropriate to request that the health care provider prescribe oxygen therapy, doing so is not the first action the nurse would take. Although it may be appropriate to interview the patient concerning the onset of this problem, doing so is not the first action the nurse would take. The nurse is caring for a patient who is recovering from a left partial lobectomy. Which action would be most helpful in reexpanding the affected lung? A. Placing the patient in a right side-lying position Rationale: Placing the patient in a right side-lying position will facilitate reexpansion of the affected lung. The unaffected lung should be next to the bed, and the affected lung should be up. Encouraging the patient to breathe deeply and cough every hour, regularly assessing the patient's ability to breathe comfortably, and providing pain medication may be appropriate, but these would not be the most effective way of reexpanding the affected lung. What is the purpose of splinting the abdomen with a small pillow during controlled coughing? C. To maximize transdiaphragmatic pressure during the expiratory phase of the cough Rationale: Splinting the abdomen will increase transdiaphragmatic pressure. Applying a small pillow to the abdomen will not help to reduce chest discomfort, expand lung capacity during the inspiratory phase or to focus the patient's attention on the abdominal muscles used while coughing. What would the nurse do routinely to monitor oxygenation in a patient receiving BiPAP? B. Monitor the patient's pulse oximetry readings. Rationale: The nurse would routinely monitor the patient's pulse oximetry readings, because these values may reveal gradual changes in oxygenation status. Level of consciousness is subjective and may not adequately reflect the patient's oxygenation level. Verifying inspiratory and expiratory pressure settings is not useful in detecting oxygenation. Unless the patient is in critical condition, ABGs are not drawn routinely. Which of the following is a risk factor for decreased oxygen saturation level in a patient? A. Chest wall injury Rationale: Chest wall injury is a risk factor for decreased oxygen saturation level in a patient. Restlessness is a symptom of altered oxygen saturation, not a risk factor for it. Hypotension will influence measurement of the oxygen saturation level but is not a risk factor for decreased oxygen saturation. Prescribed bronchodilators will influence measurement of the oxygen saturation level, but use of such agents is not a risk factor for decreased oxygen saturation. What should the nurse teach nursing assistive personnel (NAP) about selecting the appropriate site for measuring a patient's oxygen saturation level? B. "I've checked her capillary refill, and it's acceptable in both her hands and feet." Rationale: Checking the capillary refill is the correct option, because it provides NAP with specific direction regarding the appropriate sites for this particular patient. The finger can be used if the patient's nails have been polished; the nail polish will simply need to be removed. Previously documented pulse oximetry readings do not pertain to the selection of an appropriate site for the current measurement of peripheral oxygen saturation. Patient teaching does not pertain to site selection. The nurse
measures a patient's oxygen saturation level as being 83%. What would the nurse do first? D. Ask the patient whether he or she is having trouble breathing. Rationale: Asking the patient whether he or she is having trouble breathing is the appropriate response, because the nurse must assess the patient for respiratory problems. Reassessing the oxygen saturation in a different location is not the priority action, because a deficiency has already been determined. Reporting the assessment data is not the priority action, because the nurse must first assess the patient for respiratory problems. Encouraging the patient to rest quietly is not the appropriate response, because the patient is not receiving enough oxygen. The patient must be assessed for respiratory problems without delay. The nurse is preparing to measure the oxygen saturation level of a patient with obesity. Which action would help ensure an adequate measurement? D. Use a disposable tape-on sensor. Rationale: Use of a disposable tape-on sensor is recommended for patients with obesity. The ear would be an appropriate site for sensor placement in a patient who has tremors. The bridge of the nose would be an appropriate site for sensor placement in a patient with peripheral vascular compromise. A finger is a usual site for sensor placement; however, it may not be adequate for a patient with obesity. A patient is
prescribed continuous oxygen saturation monitoring. The nurse would confirm that the alarms have been set to which limits? A. Low of 85% and high of 100% Rationale: A low of 85% and a high of 100% are the alarm limits that are usually preset by the manufacturer of the monitoring device, and these limits must be confirmed. The alarm for the lower limit must be set at 85%, and the alarm for the higher limit should be set at 100%. Why is it important for the nurse to set the correct flow rate for a patient to whom oxygen is prescribed? A. To provide the correct amount of oxygen to the patient Rationale: The role of the flow regulator is to deliver the amount of oxygen indicated on the regulator. Although therapeutic effects are an expected outcome of the therapy, such effects cannot be ensured merely by properly setting the prescribed flow rate. Although adverse effects are not an expected outcome of the therapy, such effects cannot be prevented merely by properly setting the prescribed flow rate. The risk of combustion cannot be averted merely by properly setting the prescribed flow rate. What would be the nurse's priority in order to minimize a patient's risk for injury during oxygen therapy? C. Observing the six rights of medication administration. Rationale: Oxygen is considered a medication and must be administered following the six rights of medication administration. Although a patient should call before getting out of bed, since the oxygen tubing may pose a trip hazard, it is more important for the nurse to ensure that the oxygen is administered correctly. The skill of setting and adjusting the oxygen flow rate may not be delegated to NAP. This option is directed toward evaluating the patient's response to oxygen therapy, not toward minimizing his or her risk for injury. What can the nurse do to evaluate a patient's response to continuous oxygen therapy delivered at 4 L/min by nasal cannula? A. Regularly measure and trend the patient's pulse oximetry (SpO2) values. Rationale: Measuring and analyzing the patient's pulse oximetry values will provide objective information about the patient's response to oxygen therapy. Arterial blood monitors oxygen levels, therefore monitoring venous blood does not evaluate the patient's response to oxygen therapy. ABG levels should not be monitored every hour in a patient who is receiving oxygen at a rate of 4 L/min. Assessing the patient's compliance does not provide data regarding his or her response to oxygen therapy. What should the nurse do when a patient is ordered to receive 4 L/min oxygen by nasal cannula? C. Ensure that humidification is present. Rationale: If the oxygen flow rate is 4 L/min or higher, add humidification and verify that water is bubbling in the humidifier. Fluids need not be encouraged in the patient receiving 4 L/min oxygen by nasal cannula. Fluids need not be restricted in the patient receiving 4 L/min oxygen by nasal cannula. Blood pressure need not be measured every hour in a patient receiving 4 L/min oxygen by nasal cannula. What would the nurse monitor frequently to ensure that the prescribed amount of oxygen is being delivered to a patient? B. Oxygen flow meter setting Rationale: The oxygen flow meter setting is directly related to the rate of oxygen delivery. ABG levels would indicate the patient's response to oxygen therapy. Respiratory rate would indicate the patient's response to oxygen therapy. Oxygen delivery has little effect on body temperature. Students also viewedSetting Oxygen Flow Rates5 terms C1trine2013 Setting Oxygen Flow Rates5 terms brijchavPlus N220: Oxygenation video quizzes25 terms kaleikim Oxygen Safety and Measurement10 terms KaraBulut34 Sets found in the same folderN220: Oxygenation video quizzes25 terms kaleikim I2N Module Practice Questions: Airway Management26 terms JessicaZip Setting Oxygen Flow Rates5 terms C1trine2013 Module 16 Urinary23 terms Susieqtt Other sets by this creatormodule 6-890 terms gbrowning12499 4805 - only module 5 (the biggin)92 terms gbrowning12499 midterm module 428 terms gbrowning12499 midterm74 terms gbrowning12499 Recommended textbook solutions
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What would the nurse monitor frequently to ensure that the prescribed amount of oxygen is being delivered to a client?What would the nurse monitor frequently to ensure that the prescribed amount of oxygen is being delivered to a patient? The oxygen flow meter setting is directly related to the rate of oxygen delivery.
When caring for a patient receiving oxygen by nasal cannula which of the following is a priority to help maintain good skin integrity quizlet?Terms in this set (5) When caring for a patient receiving oxygen by nasal cannula, which of the following is a priority to help maintain good skin integrity? Frequently applying moisturizing lotion to facial areas that come into contact with the cannula.
Which equipment would the nurse use to ensure the prescribed rate of oxygen is delivered?In order to regulate the amount of oxygen delivered to the client, the nurse should use a flowmeter. A flowmeter is attached to the source of oxygen. An oxygen analyzer is a device that measures the percentage of delivered oxygen to determine whether the client is receiving the amount prescribed by the physician.
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Why is it important for the nurse to set the correct flow rate for a patient home oxygen is prescribed quizlet?
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