40 Questions
What is the purpose of pursed-lip breathing?
To prevent alveolar collapse
Which of the following is NOT a basic breathing exercise technique mentioned in the text?
Costal breathing
What is the main function of an ABG test among the diagnostic tests for cardiopulmonary functioning mentioned?
To measure oxygen and carbon dioxide levels in the blood
In sputum specimen collection, why is it important for the patient to rinse their mouth before collection?
To remove food particles that may contaminate the specimen
Which action best describes diaphragmatic breathing?
Engaging the diaphragm and abdominal muscles fully
What is the goal of ventilation?
To maintain normal PaCO2 and PaO2 levels
What does hyperventilation often lead to based on arterial blood gas analysis?
Decreased carbon dioxide retention
What does a nurse monitor using a noninvasive oxygen saturation monitor pulse oximeter?
Arterial oxygen saturation
Which condition occurs when alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate sufficient carbon dioxide?
Hypoventilation
What occurs as alveolar ventilation decreases?
Decreased carbon dioxide retention
What is the purpose of sputum specimen collection mentioned in the text?
To identify acid-fast bacilli (AFB) for tuberculosis diagnosis
When should specimens for AFB testing be obtained?
1 to 2 hours after the client eats
Why is it important to use a sterile container for routine cultures and AFB testing?
To prevent contamination of the specimen
What nursing action is recommended prior to obtaining a sputum sample?
Offering mouth care and rinsing with water
Which nursing diagnosis is associated with disturbed sleep patterns due to dyspnea during sleep and sleep apnea?
Disturbed sleep pattern
What is the purpose of pursed-lip breathing during oxygen therapy?
To decrease respiratory rate and improve gas exchange
Which nursing action is essential when using a non-rebreather (NRB) mask for oxygen delivery?
Ensuring the reservoir bag remains fully inflated during both inspiration and expiration
Why is it important for patients to rinse their mouth before sputum specimen collection?
To prevent contamination of the sample with oral bacteria
During specimen collection, why should a nurse ensure a tracheostomy collar is well-fitted?
To avoid skin breakdown around the tracheostomy site
What is a critical nursing action related to diaphragmatic breathing exercises?
Placing hands on the abdomen to assess proper movement during breathing
What is the purpose of purged-lip breathing?
To improve chest expansion
Which diagnostic test is commonly used to evaluate cardiopulmonary functioning?
Electrocardiogram (ECG)
Why is it important for a patient to rinse their mouth before sputum specimen collection?
To prevent contamination of the sample
Which nursing action is appropriate when collecting a sputum specimen for analysis?
Use a sterile container for specimen collection
What best describes diaphragmatic breathing?
Breathing technique involving movement of the abdomen
What is the main difference between open suctioning and closed suctioning?
The type of suction catheter used
Why is closed suctioning preferred for patients on invasive mechanical ventilation?
To reduce the risk of oxygen desaturation
What is the purpose of hyperoxygenating the client prior to tracheal suctioning?
To reduce the risk of oxygen desaturation
What is the recommended suction pressure range during tracheal suctioning?
100-120 mm Hg
How does rotating the catheter help in tracheal suctioning?
Facilitates removal of adhered secretions
What is the purpose of pursed-lip breathing?
To decrease airway resistance and improve oxygen delivery
Which of the following diagnostic tests is crucial for assessing cardiopulmonary functioning?
Pulmonary Function Test
Why is rinsing the mouth before sputum specimen collection important?
To prevent contamination of the sputum sample with bacteria from the mouth
What nursing action is important during sputum specimen collection?
Assessing the sputum color, consistency, and odor before sending it for analysis
How would you describe diaphragmatic breathing?
Inhaling deeply through the nose and expanding the abdomen
What is one of the key benefits of pursed-lip breathing in patients with lung conditions?
Enhancing lung expansion and preventing atelectasis
During diaphragmatic breathing, what should the nurse instruct the patient to focus on?
Expanding the abdomen with each inhalation
What is a common misconception about sputum specimen collection?
Sputum should be collected immediately upon waking up in the morning.
What common mistake should be avoided during diaphragmatic breathing exercises?
Focusing on expanding the chest instead of the abdomen.
What misconception might a patient have about pursed-lip breathing technique?
It increases carbon dioxide elimination.
Study Notes
Cardiopulmonary Resuscitation (CPR)
- CPR is necessary to restore circulation when oxygen is not delivered to tissues and carbon dioxide is not transported from tissues, leading to tissue metabolism becoming anaerobic and metabolic and respiratory acidosis.
- Permanent heart, brain, and other tissue damage occur within 4 to 6 minutes.
- CPR involves chest compressions, airway opening, breathing, and defibrillation with an automatic external defibrillator (AED).
Respiratory Functioning
- The goal of ventilation is to produce a normal arterial carbon dioxide tension (PaCO2) between 35 and 45 mm Hg and a normal arterial oxygen tension (PaO2) between 80- and 100-mm Hg.
- Hypoventilation and hyperventilation are determined by arterial blood gas analysis.
- Hypoxemia refers to a decrease in the amount of arterial oxygen.
- Nurses monitor arterial oxygen saturation (SpO2) using a noninvasive oxygen saturation monitor pulse oximeter, with a normal value of ≥ 95%.
- Hypoventilation occurs when alveolar ventilation is inadequate to meet the oxygen demand of the body or eliminate sufficient carbon dioxide.
Suctioning
- Open suctioning involves using a new sterile catheter for each suction session, with sterile gloves and following Standard Precautions.
- Closed suctioning involves using a reusable sterile suction catheter encased in a plastic sheath, with nonsterile gloves recommended to prevent contact with splashes from body fluids.
- Prior to suctioning, hyperoxygenate the client using a bag-valve-mask (BVM) or specialized ventilator function with an FiO2 of 100%.
- The nurse suction a small amount of water through the catheter to ensure that the catheter's suction is functioning properly.
- In tracheal suctioning, use suction pressure between 100 and 120 mm Hg as you withdraw, applying suction intermittently only while withdrawing the catheter.
Breathing Exercises
- The three basic techniques are deep-breathing and coughing exercises, pursed-lip breathing, and diaphragmatic breathing.
- Deep-breathing and coughing exercises are routine interventions used by postoperative patients.
- Pursed-lip breathing involves deep inspiration and prolonged expiration through pursed lips to prevent alveolar collapse.
- Diaphragmatic breathing is a deep breathing exercise that fully engages the diaphragm and increases the efficiency of the lungs, improving ventilation and oxygenation.
Diagnostic Tests
- Tests used for cardiopulmonary functioning include blood specimens (ABGs), X-rays of the organs, and TB skin testing.
- Airway Management involves maintaining a patent airway, mobilizing secretions, suctioning the airway, and managing artificial airways (mechanical or assisted ventilation) to promote adequate gas exchange and lung expansion.
Oxygen Therapy
- The goal of oxygen therapy is to prevent or relieve hypoxia by delivering oxygen at concentrations greater than ambient air (21%).
- Supplemental oxygen therapy offers many benefits to patients with chronic cardiopulmonary diseases.
- Oxygen is supplied to a patient's bedside either by oxygen tanks or through a permanent wall-piped system.
- FiO2 is the fraction (0.21) or percentage (21%) of inspired oxygen, with supplementation oxygen raising FiO2 above 21%.
Oxygen Delivery Methods
- Oxygen delivery methods include nasal cannula, simple face mask, partial rebreather mask, non-rebreather (NRB) mask, Venturi mask, and tracheostomy collar.
- Each method has a specific FiO2 delivery range and flow rates.
- Nursing actions involve monitoring the patient for signs of changes in cardiopulmonary functioning, such as sudden shortness of breath, pain, oxygen desaturation, and anxiety.
Respiratory Function Nursing Diagnoses
- Nursing diagnoses include Ineffective airway clearance, Ineffective breathing patterns, Impaired gas exchange, Decreased cardiac output, Ineffective tissue perfusion, and other associated diagnoses.
- Nursing actions involve sputum specimen collection, offering mouth care, and rinsing with water prior to obtaining the sample.
Learn about the nursing actions required for sputum specimen collection to diagnose tuberculosis, including offering mouth care, obtaining specimens early in the morning, and timing sample collection in relation to client meals.
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