Eldon Martin is a 75-year-old retired Marine Corps officer. He smoked cigarettes most of his adult life, but quit 10 years ago when he learned he had allergy-induced asthmatic lung disease. He comes to the hospital today with a high fever, productive cough, and pain in his chest. He is diagnosed wi...
Davis- Chapter 36: Oxygenation
Quesstions & Answers
Eldon Martin is a 75-year-old retired Marine Corps officer. He smoked cigarettes most of
his adult life, but quit 10 years ago when he learned he had allergy-induced asthmatic
lung disease. He comes to the hospital today with a high fever, productive cough, and
pain in his chest. He is diagnosed with pneumonia.
What additional assessment findings would be important for the nurse to gather in
relation to oxygenation concerns? Select all that apply.
1. Pulse oximetry reading
2. Arterial blood gas
3. Normal diet
4. Lung sounds
5. Number of years of smoking - ANSWERS1. Pulse oximetry reading
2. Arterial blood gas
4. Lung sounds
5. Number of years of smoking
Findings that can impact oxygenation include risk factors such as tobacco use. Physical
assessment should include inspection, breathing pattern, signs of distress, lung sounds,
and diagnostic tests.
Upon further assessment, the nurse discovers that Mr. Martin has conversational
dyspnea and use of accessory muscles. His sputum is dark yellow-green and thick. He
is having difficulty expectorating. What is the best position for Mr. Martin?
1. Low Fowler's
2. High Fowler's
3. Side-lying
4. Trendelenburg
5. Prone - ANSWERS2. High Fowler's
A high Fowler's position maximizes lung expansion to promote ventilation. Mr. Martin
may even be more comfortable sitting on the side of the bed in a tripod position, leaning
over the overbed table, or resting on pillows.
, To promote mobilization of the pneumonia secretions, which actions should the nurse
include in the plan of care? Select all that apply.
1. Encourage cough and deep breathing.
2. Promote a balanced diet.
Maintain hydration.
3. Ambulate in hallway five times a day.
4. Perform chest physiotherapy. - ANSWERS1. Encourage cough and deep breathing.
Maintain hydration.
4. Perform chest physiotherapy.
To mobilize the secretions of pneumonia the nurse should promote coughing and deep
breathing, hydration, and chest physiotherapy. Additional interventions to consider
include smoking cessation, incentive spirometry, and aspiration precautions. Although
the promotion of a balanced diet is important, it is not likely that Mr. Martin has much of
an appetite and that is not the most important step to improve the pneumonia
symptoms. Ambulating can mobilize secretions but this is not an option with his current
state of poor health.
The nurse performs a routine assessment on Mr. Martin and discovers that his pulse
oximetry reading is 89%. She contacts the healthcare provider and receives an order for
oxygen at 2 L/nasal cannula. What hazards should be considered with the use of
oxygen? Select all that apply.
1. High oxygen concentration can lead to alveolar collapse.
2. Toxicity can develop if too much oxygen is delivered.
3. Oxygen tanks are pressurized and can turn into an unguided missile.
4. Oxygen is highly combustible.
5. Oxygen is not harmful and should be used regularly for sick clients. - ANSWERS1.
High oxygen concentration can lead to alveolar collapse.
2. Toxicity can develop if too much oxygen is delivered.
3. Oxygen tanks are pressurized and can turn into an unguided missile.
4. Oxygen is highly combustible.
Oxygen is often considered "safe" by healthcare personnel and patients because it is so
readily used and available. Nurses must remember that oxygen is a drug and should be
treated with the same level of caution.
As the nurse is placing the oxygen, she reflects on the percentage of oxygen being
delivered via nasal cannula (NC) at 2 L. What would be the correct amount?
1. 21%
2. 24%
3. 28%
4. 32%
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