Ch 14 Oxygenation

When an older adult patient with chronic emphysema comes to the emergency department in respiratory distress, at what rate should the nurse begin oxygen per nasal cannula?

• 2 L/min

• 3 L/min

• 4 L/min

• 5 L/min

Answer explanation

Administering O2 at more than 2 L/min to a person with chronic pulmonary disease may cause respiratory failure.

The nurse instructs a patient receiving home O2 therapy to drink plenty of fluids to help keep bronchial secretions liquefied. What is the recommended fluid?

• Milk

• Water

• Tea with artificial sweetener

• Coffee

Answer explanation

Water is the best option. Drinks with caffeine, sugar, or dairy products are not helpful to liquefy secretions.

The wife of a patient with a cuffed tracheostomy asks why the cuff is inflated intermittently. What is the purpose of the inflated cuff?

• Prevent regurgitation after meals.

• Hold the trachea open until it is completely healed.

• Dilate the tracheal opening for passage of secretions.

• Prevent aspiration when eating.

Answer explanation

The cuff is inflated to prevent aspiration while eating or when cleaning the tracheostomy tube.

Which of the following is an appropriate nursing measure when performing tracheostomy care?

• Wear clean gloves.

• Insert the catheter without suction.

• Suction for 1 minute before removing the catheter.

• Place the used catheter in a plastic shield for later use.

Answer explanation

Insertion of the suction catheter without suction reduces the probability of tissue injury. Sterile gloves should be used for tracheostomy care. Suctioning should be done for a maximum of 10 seconds at a time. A used catheter should be disposed of appropriately.

An 80-year-old male patient has been admitted to the acute care facility with the diagnosis of pneumonia. He is receiving oxygen via nasal cannula at 2 L/min. The nurse assesses respirations at 24/min, PaO2 level 88 mm Hg, and pink skin tone. What action should the nurse implement?

• Notify the health care provider.

• Increase oxygen to 4 L/min.

• Record PaO2 level.

• Administer nebulizer treatment.

Answer explanation

The nurse would document PaO2 level. Normal arterial oxygen levels sometimes decrease with age, but not usually low enough to fall outside the normal range. It may be possible for an 80-year-old person to have an arterial partial pressure oxygen (PaO2) level (the amount of oxygen found in the arterial circulation) between 80 and 85 mm Hg (normal range is 80 to 100 mm Hg) without experiencing significant alterations in health.

What is the appropriate value for the venturi mask? (Capitalize Venturi) Oxygen delivery devices with percent of oxygen delivered. Press Image to see closer.

• 1–6 L/min = 24%–44% O2

• 5–8 L/min = 35%–55% O2

• 4–10 L/min = 24%–55% O2

• 6–12 L/min = 60%–90% O2

• 6–15 L/min = 70%–100% O2

A patient has a new health care provider’s order for oxygen administration at 2 L via nasal cannula. Who can initiate implementation of this order? (Select all that apply.)

• RN

• UAP

• Respiratory therapist

• EMT

• Nutritional specialist

Answer explanation

Oxygen therapy may be initiated by a respiratory therapist, a nurse, an emergency medical technician (EMT), or any other licensed health care provider with an appropriate order for the oxygen. In some facilities, there is a respiratory care department, staffed by respiratory therapists who assume the responsibility of administering oxygen and delivering treatments that will improve a patient’s ventilation and oxygenation. Adjustment of the oxygen flow rate is not delegated to UA nor nutritional specialist.

The nurse is caring for a patient with an endotracheal tube. What interventions will the nurse implement? (Select all that apply.)

• Change or clean all respiratory therapy equipment every 24 hours.

• Turn and reposition the patient every 2 hours.

• Provide constant airway humidification.

• Encourage intake of fruits and vegetables.

• Elevate the head of the bed.

Answer explanation

Nursing interventions for the patient with an endotracheal tube include turning and repositioning every 2 hours for maximal ventilation and lung expansion, constant airway humidification and elevation of the head of the bed to assist with ventilation. Equipment should be changed or cleaned at least every 8 hours. Patients with endotracheal tubes are allowed nothing by mouth (NPO). It is necessary to provide parenteral or enteral nourishment.

A _____________ cannula is a device consisting of small tubes inserted into the nares and is the most common way to administer oxygen.

Answer explanation

A nasal cannula is device consisting of small tubes inserted into the nares and is the most common way to administer oxygen.

When suctioning a tracheostomy suction may be applied for a maximum of __ seconds at a time never longer.

Answer explanation

Suctioning should be done for a maximum of 10 seconds at a time. Prolonged suctioning depletes oxygen supply.