NR224 Final Exam Test Map
Distribution of Questions:
Main Focus Topics : Oxygenation, Bowel/Nutrition, Medications
Delegation: For all topics, please know what the nurse can and cannot delegate related to
the patient
...
NR224 Final Exam Test Map
Distribution of Questions:
Main Focus Topics : Oxygenation, Bowel/Nutrition, Medications
Delegation: For all topics, please know what the nurse can and cannot delegate related to
the patient’s care.
Oxygenation
Basic A & P
• Ventilation - the movement of air between the atmosphere and the alveoli of the lungs as we
inhale and exhale
• Diffusion - gas exchange which involves CO2 between the alveoli and the pulmonary capillaries
• Transportation - transport of oxygen from the lungs to the tissues and transport of carbon dioxide
from the tissues to the lungs
Respiratory assessment/Priorities of care/s/s of respiratory abnormalities and
RN Response
• Assessment includes pain, dyspnea, wheezing, respiratory infections, health risks, smoking,
cough, environmental exposures, allergies, and medications used.
• Alterations in Respiratory Functioning
• Hyperventilation - ventilation in excess of that required to eliminate carbon dioxide produced by
cellular metabolism
• Hypoventilaiton - alveolar ventilation inadequate to meet the body’s oxygen demand or to eliminate
sufficient carbon dioxide
• Hypoxia - inadequate tissue oxygenation at the cellular level
• Cyanosis - blue discoloration of the skin and mucous membranes
• Interventions2
• Position the client to allow for maximal chest expansion
• Encourage or assist client with frequent changes in position,every 2 hours
• Encourage deep breathing and coughing
• Encourage ambulation
• Promote comfort so client can tolerate the above activities
• increased fluids
• suctioning3
Delivery systems
• Oxygen is a medication, it must be administered as prescribed.
• The dose or concentration of the oxygen should be continuously monitored
• Humidification is necessary for clients receiving O2 therapy >4L/min
• If you have a client receiving oxygen you must check it when you assess the client
• If client is transported make sure portable tank has enough oxygen in tank
• Initiating the adm of oxygen is considered similar to administering a medication and is not
delegated to UAP
• UAP may reapply the oxygen delivery device
• Nasal Cannula
• Most commonly used oxygen device because of convenience and client comfort
• Delivered oxygen concentration can vary with client breathing pattern
• Nasal passages must be patent for client to receive O2
• Can cause skin breakdown over the ears and i
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