Assessment of the Respiratory System Chapter 29 – Flashcards
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a. "When did the cough start?"
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The patient comes to the physician's office for an annual physical. The patient reports having a persistent nagging cough. Which question does the nurse ask first about this symptom? a. "When did the cough start?" b. "Do you have a family history of lung cancer?" c. "Have you been running a fever?" d. "Do you have sneezing and congestion?"
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b. 69 years
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The patient reports smoking a pack of cigarettes a day for 9 years. He then quit for 2 years, then smoked 2 packs a day for the last 30 years. Whar are the pack-years for this patient? a. 39 years b. 69 years c. 19.5 years d. 41 years
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c. The patient will breathe through the mouth and wear a nose clip during the test.
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Pulmonary function tests are scheduled for a patient with a history of smoking who reports dyspnea and chronic cough. What will patient teaching information about this procedure include? a. Do not smoke for at least 2 weeks before the test. b. Bronchodilator drugs may be withheld 2 days before the test. c. The patient will breathe through the mouth and wear a nose clip during the test. d. The patient will be expected to walk on a treadmill during the test.
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a. Age, gener, race, height, weight, and smoking status
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The patient is scheduled to have a pulmonary function test (PFT). Which type of information does the nurse include in the nursing history so that PFT results can be appropriately determined? a. Age, gender, race, height, weight, and smoking status b. Occupational status, activity tolerance for activities of daily living c. Medication history and history of allergies to contrast media d. History of chronic medical conditions and surgical procedures
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b. Encourage the patient to turn, cough, and deep breathe
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The nurse is caring for the older adult who is temporarily confined to bed. Which intervention is important in promoting pulmonary hygiene related to age and decreased mobility? a. Obtain an order for PRN oxygen via nasal cannula b. Encourage the patient to turn, cough, and deep breathe. c. Reassure the patient that immobility is temporary d. Monitor the respiratory rate and check pulse oximetry readings.
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b. "When did you first notice these symptoms?"
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The nurse is assessing an older adult patient who reports a decreased tolerance for exercise and that she must work harder to breathe. Which question assists the nurse in determining if these are normal changes related to aging? a. "How old are you?" b. "When did you first notice these symptoms?" c. "Do you or have you ever smoked cigarettes?" d. "How often do you exercise?"
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c. Check for a gag reflex before allowing the patient to eat
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The patient has had a bronchoscopy and was NPO for several hours before the test. Now a few hours after the test, the patient is hungry and would like to eat a meal. What will the nurse do? a. Order a meal because the patient is now alert and oriented. b. Check pulse oximetry to be sure oxygen saturation has returned to normal c. Check for a gag reflex before allowing the patient to eat. d. Assess for nausea from the medications given for the test
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a. Assess vital signs and respiratory staus and notify the physician of the findings.
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After a bronchoscopy procedure, the patient coughs up sputum which contains blood. What is the best nursing intervention for this patient? a. Assess vital signs and respiratory status and notify the physician of the findings. b. Monitor the patient for 24 hours to see if blood continues in the sputum c. Send the sputum to the lab for cytology for possible lung cancer d. Reassure the patient this is a normal response after a bronchoscopy
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b. The patient does not respond to supplemental oxygen
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Before a bronchoscopy procedure, the patient received benzocaine spray as a topical anesthetic to numb the oropharynx. The nurse is assessing the patient after the procedure. Which finding suggests that the patient is developing methemoglobinemia? a. The patient has a decreased hematocrit level b. The patient does not respond to supplemental oxygen c. The blood sample is a bright cherry red color d. The patient experiences sedation and amnesia
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d. Percutaneous lung biopsy
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The nurse is caring for several patients who had diagnostic testing for respiratory disorders. Which diagnostic test has the highest risk for the postprocedure complication of pneumothorax? a. Bronchoscopy b. Laryngoscopy c. Computed tomography of lungs d. Percutaneous lung biopsy
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c. Assess the patient for respiratory distress and recheck the oximeter reading
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The patient's pulse oximetry reading is 89%. What is the nurse's priority action? a. Recheck the reading with a different oximeter b. Apply supplemental oxygen and recheck the oximeter reading in 15 minutes c. Assess the patient for respiratory distress and recheck the oximeter reading d. Place the patient in the recovery position and monitor frequently
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b. Start oxygen via nasal cannula at 2L/min
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The patient demonstrates labored shallow respirations and a respiratory rate of 32/min with a pulse oximetry reading of 85%. What is the priority nursing intervention? a. Notify respiratory therapy to give the patient a breathing treatment b. Start oxygen via nasal cannula at 2L/min c. Obtain an order for a stat arterial blood gas (ABG) d. Encourage coughing and deep-breathing exercises
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b. Coughing and deep breathing
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The older patient is confined to bed and is therefore prone to decreased alveolar surface and elastic recoil. Which intervention is best to address these physiologic changes? a. Adequate nutritional intake b. Coughing and deep breathing c. Fluids to thin secretions d. Periods of rest and sleep
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b. Normal pH, decreased PaO2, normal PaCO2
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The nurse is reviewing ABG results from an 86-year-old patient. Which results would be considered normal findings for a patient of this age? a. Normal pH, normal PaO2, normal PaCO2 b. Normal pH, decreased PaO2, normal PaCO2 c. Decreased pH, decreased PaO2, normal PaCO2 d. Decreased pH, decreased PaO2, decreased PaCO2
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a. Decreased muscle strength and cough
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The nurse is caring for an older patient and identifies a nursing diagnosis of Ineffective Airway Clearance. Which etiology for this diagnosis is related to the normal aging process? a. Decreased muscle strength and cough b. Increased carbon dioxide exchange b. Decreased residual volume d. Increased elastic recoil of the lungs
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d. Sitting upright
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The nurse is performing a physical assessment of the respiratory system. Although the patient is currently confined to bed, he has the strength and mobility to move and reposition himself. The nurse instructs him to assume which position for the assessment? a. Side-lying b. Semi-Fowlers c. Supine d. Sitting upright
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b. Primary bronchi
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Upon performing a lung sound assessment of the anterior chest, the nurse hears moderatley loud sounds on inspiration that are equal in length with expiration. In what area is this lung sound considered normal? a. Trachea b. Primary bronchi c. Lung fields d. Larynx
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c. Soft, low rustling; like the wind in the trees
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Which sounds in the smaller bronchioles and the alveoli indicate normal lung sounds? a. Harsh, hollow, and tubular blowing b. Nothing; normally no sounds are heard c. Soft, low rustling; like wind in the trees d. Flat and dull tones with a moderate pitch
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b. Soft sound, long inspiration, short quiet expiration
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What is the characteristic of normal lung sounds that should be heard throughout the lung fields? a. Short inspiration, long expiration, loud, harsh b. Soft sound, long inspiration, short quiet expiration c. Mixed sounds of harsh and soft, long inspiration and long expiration d. Loud, long inspiration and short, loud expiration
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c. Fine crackles
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Upon assessing the lungs, the nurse hears short, discrete popping sounds "like hair being rolled between fingers near the ear" in te bilateral lower lobes. How is this assessment documented? a. Rhonchi b. Wheezes c. Fine crackles d. Coarse crackles
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a. Orthopnea
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The nurse is taking a history on a patient who reports sleeping in a recliner chair at night because lying on the bed causes shortness of breath. How is this documented? a. Orthopnea b. Paroxysmal nocturnal dyspnea c. Orthostatic nocturnal dyspnea d. Tachypnea
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a. 45-year-old man who breeds and raises racing pigeons
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Which patient has an increased risk for problems of the respiratory system? a. 45-year-old man who breeds and raises racing pigeons b. 25-year-old woman who enjoys body surfing in the ocean c. 68-year-old woman who does needlework for relaxation d. 56-year-old man who ties flies for trout fishing
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a. Symmetry of chest movement b. Rate, rhythm, and depth of respirations c. Use of accessory muscles for breathing d. Comparison of the anteroposterior diameter with the lateral diameter
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What observations does the nurse make when performing a general assessment of the patient's lungs and thorax? (Select all that apply) a. Symmetry of chest movement b. Rate, rhythm, and depth of respirations c. Use of accessory muscles for breathing d. Comparison of the anteroposterior diameter with the lateral diameter e. Measurement of the length of the chest f. Assessment of chest expansion and respiratory excursion
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d. Clubbing of fingernails and a barrel-shaped chest
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Which assessment finding is an objective sign of chronic oxygen deprivation? a. Continuous cough productive of clear sputum b. Audible inspiratory and expiratory wheeze c. Chest pain that increases with deep inspiration d. Clubbing of fingernails and a barrel-shaped chest
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c. Observe the patient for other findings assoiated with a pneumothorax
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The nurse is palpating the patient's chest and identifies an increased tactile fremitus or vibration of the chest wall produced when the patient speaks. What does the nurse do next? a. Observe for other findings associated with subcutaneous emphysema b. Document the observation as an expected normal finding c. Observe the patient for other findings associated with a pneumothorax. d. Document the observation as a pleural friction rub
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a. Increased red blood cell
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The nurse reviews the complete blood count results for the patient who has chronic obstructive pulmonary disease (COPD) and lives in a high mountain area. What lab results does the nurse expect to see for this patient? a. Increased red blood cells b. Decreased neutrophils c. Decreased eosinophils d. Increased lymphocytes
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c. In older adult patients
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The nurse is inspecting the patient's cest and observes an increase in anteroposterior diameter of the chest. When is this an expected finding? a. With pulmonary mass b. Upon deep inhalation c. In older adult patients d. ith chest trauma
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c. Assess the patient for air hunger or pain at the end of inhalation and exhalation
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While percussing the patient's chest and lung fields, the nurse notes a high, loud, musical, drumlike sound similar to tapping a cheek that is puffed out with air. What is the nurse's priority action? a. Document this expected finding using words like, "high", "loud", and "hollow. b. Immediately notify the physician because the patient has an airway obstruction c. Assess the patient for air hunger or pain at the end of inhalation and exhalation d. Palpate for crackling sensation underneath the skin or for localized tenderness
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c. Sitting up, leaning forward on the overbed table
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What is the best position for the patient to assume fo a thoracentesis? a. Side-lying, affected side exposed, head slightly raised b. Lying flat with arm on affected side across the chest c. Sitting up, leaning forward on the overbed table d. Prone position with arms above the head
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Thoracentesis
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Which procedure has a risk for the complication of pnemothorax? a. Thoracentesis b. Bronchoscopy c. PFT d. Ventilation-perfusion scan
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b. Ventilation-perfusion scanning
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The patient is admitted for a deep vein thrombosis (DVT) and later becomes short of breath. A pulmonary embolus is suspected. The nurse should prepare the patient for which type of diagnostic testing? a. computed tomography b. Ventilation-perfusion scanning c. Magnetic resonance imging d. Digital chest radiography
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c. Pink and frothy
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The respiratory therapist consults with and reports to the nurse on the sputum production of several respiratory patients. The patient producing which kind of sputum needs priority attention? a. Thick and yellow b. Watery mucoid c. Pink and frothy d. Rust-colored
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b. Ineffective tissue perfusion
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The patient with chronic respiratory disease presents with a decreased level of consciousness, dusky skin, pale mucous membranes, decreased capillary refill, and an increased respiratory rate. What is the priority nursing diagnosis? a. Ineffective airway clearance b. Ineffective tissue perfusion c. Decreased cardiac output d. Acute confusion
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b. Unexplained restlessness
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While caring for a patient who had a routine surgical procedure, he nurse suspects that the patient may be having decreased tissue perfusion. Which assessment finding is considered the earliest sign of decreased oxygenation? a. Cyanosis b. Unexplained restlessness c. Cool, clammy skin d. Paleness, shortness of breath
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b. Have patient perform coughing and deep-breathing exercises, then reassess
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The nurse has just received a patient from the recovery room who is somewhat drowsy, but is capable of following instructions. Pulse oximetry has dropped from 95% to 90%. What is the priority nursing intervention? a. Administer oxygen at 2L/min by nasal cannula, then reassess b. Have the patient perform coughing and deep-breathing exercises, then reassess c. Administer Narcan to reverse narcotic sedation effect d. Withhold narcotic pain medication to reduce sedation effect
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c. The procedure is painless and the radioactive substance leaves the body in about 8 hours
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The patient is scheduled or a ventilation perfusion scan. What does the nurse explain to the patient about the procedure? a. Being NPO before the examination is necessary to prevent aspiration of the dye b. After the test, isolation is necessary for 8 hours because of the radioactive dye c. The procedure is painless and the radioactive substance leaves the body in about 8 hours d. The test screens for pulmonary embolus; a CT scan will follow if needed
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d. Oxygen saturation in the red blood cells
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What is a pulse oximeter used to mesure? a. Oxygen perfusion in the extremities b. Pulse and perfusion in the extremities c. Generalized tissue perfusion d. Oxygen saturation in the red blood cells
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b. Decline in forced expiraory volume in 1 second
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Which aspect of PFTs would be considered a normal result in the older adult? a. Increased forced vital capacity b. Decline in forced expiratory volume in 1 second c. Decrease in diffusion capacity of carbon monoxide d. Increased functional residual capacity
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c. There is an increase in anteroposterior ratio
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In the older adult, there is a loss of elastic recoiling of the lung and decreased chest wall compliance. What is the result of this occurrence? a. The thoracic area becomes shorter b. The patient has an increased activity tolerance c. There is an increase in anteroposterior ratio d. The patient has severe shortness of breath
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a. Encourage the patient to ambulate and change positions
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In the older adult, there is a decreased number of functional alveoli. To assist the patient to compensate for this change related to aging, what does the nurse do? a. Encourage the patient to ambulate and change positions b. Allow the patient to rest and sleep frequently c. Have face-to-face conversations when possible d. Obtain an order for supplemental oxygen
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a. "Smoking increases my susceptibility to respiratory infections."
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The nurse teaches the patient about the impact of cigarette smoking on the lower respiratory tract. Which statement by the patient indicates an understanding of the information? a. "Smoking increases my susceptibility to respiratory infections." b. "If I stop smoking the damage to my lungs will be reversed." c. "Cigarette smoke affects my ability to cough out secretions from the lungs." d. "Smoking makes the large and small airways get bigger."
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c. Hemoglobin of 9g/dL
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The patient reports fatigue and shortness of breath when getting up to walk to the bathroom; however, the pulse oximetry reading is 99%. The nurse identifies a diagnosis of activity intolerance. Which laboratory value is consistent with the patient's subjective symptoms? a. BUN of 15 mg/dL b. WBC count of 8000/mm3 c. Hemoglobin of 9g/dL d. Glucose 160 mg/dL
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d. Visualize airway structures and obtaining tissue samples
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The patient who had neck surgery for removal of a tumor reports, "not being able to breathe very well." The nurse observes that the patient has decreased chest movement and an elevated pulse. A bronchoscopy is ordered. For what reason did the physician order a bronchoscopy for this patient? a. Reverse and relieve any obstruction caused during the neck surgery b. Assess the function of vocal cords or remove foreign bodies from the larynx c. Aspirate pleural fluid or air from the pleural space d. Visualize airway structures and obtaining tissue samples
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d. Presence or absence of gag reflex
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The patient returns to the unit after bronchoscopy. In addition to respiratory staus assessment, which assessment does the nurse make in order to prevent aspiration? a. Presence of pain or soreness in throat b. Time and amount of last oral fluid intake c. Type and location of chest pain d. Presence or absence of gag reflex
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b. Encourage coughing and deep breathing
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The nurse hears fine crackles during a lung assessment of the patient who is in the initial postoperative period. Which nursing intervention helps relieve this respiratory problem? a. Monitor the patient with a pulse oximeter b. Encourage coughing and deep breathing c. Obtain an order for a chest x-ray d. Obtain an order for high-flow oxygen
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b. Continuous cough
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In performing a respiratory assessment, which finding is considered the principal or main sign of respiratory disease? a. Sputum production b. Continuous cough c. Fever with congestion d. Increased respiratory rate
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d. Sudden onet of sharp pain after sneezing with lung sounds diminished over the left upper lobe
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The patient is admitted for a pneumothorax. Which clinical assessment findings are most likely to be documented in the patient's admission record? a. Progressive fatigue and shortness of breath that has been increasing over a period of years b. Cough, high fever, rusty-colored sputum production with decreased breath sounds, particularly in lower lobes c. Frequent cough and copious sputum poduction, and wheezing and coarse crackles heard throughout the lung fields d. Sudden onset of sharp pain after sneezing with lung sounds diminished over the left upper lobe
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c. 12 to 20
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For a healthy adult, what is the expected normal range for the respiratory rate per minute? a. 10 to 12 b. 12 to 15 c. 12 to 20 d. 20 or more
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d. 50-year-old man with a PaO2 of 84
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The nurse is reviewing partial pressure of arterial oxygen (PaO2) levels for several adult patients. Which patient has a PaO2 that is lower than expected for his age? a. 40-year-old man with a PaO2 of 96 b. 85-year-old man with a PaO2 of 83.5 c. 65-year-old man with a PaO2 of 92 d. 50-year-old man with a PaO2 of 84
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d. "When was the last time you were hospitalized?"
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The nurse is performing a respiratory assessment on the older adult patient. Which question is not appropriate to ask when using the Gordon's Functional Health Pattern Assessment approach? a. "How has your general health been?" b. "Have you had any colds this past year?" c. "Do you have sufficient energy to do what you like to do?" d. "When was the last time you were hospitalized?"
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a. ACE inhibitor
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The patient has previously reported several chronic health conditions including hypertension and heart problems, and has stated a new drug was recently added to his drug regimen. Today the patient reports a new onset of cough. Which drug does the nurse suspect the patient has recently been prescribed? a. ACE inhibitor b. Vasodilator c. Diuretic d. Calcium channel blocker
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b. Limited to bed or chair and experiences shortness of breath at rest
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The nurse makes observations about several respiratory patients' abilities to perform activities of daily living in order to quantigy the level of dyspnea. Which patient is considered to have Class V dyspnea? a. Experiences subjective shortness of breath when walking up a flight of stairs b. Limited to bed or chair and experiences shortness of breath at rest c. Can independently shower and dress, but cannot keep pace with similarly aged people d. Experience shortness of breath during aerobic exercise such as jogging
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a. Respiratory acidosis
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The nurse is reviewing the arterial blood gas results for a 25-year-old trauma patient who has new onset of shortness of breath and demonstrates shallow and irregular respirations. The pH is 7.26. What imbalances does the nurse suspect this patient has? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis
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a. Tuberculosis
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The patient is HIV positive and reports feeling tired with shortness of breath, weight loss, and occasionally coughing up blood-tinged sputum. After considering these symptoms in conjunction with the patient's HIV status, what disorder does the nurse suspect this patient has? a. Tuberculosis b. Bronchitis c. Pneumococcal pneumonia d. Lung abscess
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b. Diminished breath sounds Rationale: The patient has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury. The word blunt eliminates "d". Respiratory injuries increase respirations so that eliminates "a". A barrel chest is a characteristic finding in a client with COPD so that eliminates "c"
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An emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? a. A low respiratory rate b. Diminished breath sounds c. The presence of a barrel chest d. A sucking sound at the site of injury
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b. Hyperinflated chest noted on the chest x-ray Rationale: Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Eliminate "a" because hypercapnia would be noted in a person with COPD. Eliminate "c" because oxygen desaturation would occur. Eliminate "d" because it would be a flattened diaphragm that would be noted.
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A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which of the ollowing would the nurse expect to note on assessment of this client? a. Hypocapnia b. A hyperinflated chest noted on the chest x-ray c. Increased oxygen saturation with exercise d. A widened diaphragm noted n the chest x-ray
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d. Promote carbon dioxide elimination Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options a,b, & c are not the purpose for this type of breathing.
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A nurse instructs a client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: a. Promote oxygen intake b. Strengthen the diaphragm c. Strengthen the intercostal muscles d. Promote carbon dioxide elimination
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c. Ventilates the client manually Rationale: If at any time an alarm is sounding and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and manual resuscitation is used to support respirations until the problem can be corrected. No reason is given to begin cardiopulmonary resuscitation. Checking vital signs is not the initial action. Although oxygen is helpful, it will not provide ventilation to the client.
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The low pressure alarm sounds on a ventilator. A nurse assesses the client and then attempts to determine the cause of the alarm. The nurse is unsuccessful in determining the cause of the alarm and takes what initial action? a. Administers oxygen b. Checks the client's vital signs c. Ventilates the client manually d. Starts cardiopulmonary resuscitation
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c. Bronchospasm Rationale: If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemrrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrealted to this procedure.
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A nurse is caring for a client aftera bronchoscopy and biopsy. Which of the following signs, if noted in the client, should be reported immediately to the physician? a. Dry cough b. Hematuria c. Bronchospasm d. Blood-streaked sputum
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c. 10 seconds Rationale: Hypoxemia can be caused by prolonged suctioning, which stimulates the pacemaker cells in the heart. A vasovagal response may occur, causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
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A nurse is suctioning fluids from a client via a tracheostomy tube. When suctioning, the nurse must limit the suctioning time to a maximum of: a. 1 minute b. 5 seconds c. 10 seconds d. 30 seconds
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c. Stop the procedure and reoxygenate the client Rationale: During suctioning, the nurse should monitor the client closely for side effects, including hypoxemia, cardiac irregularities such as a decrease in heart rate resulting from vgal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If side effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.
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A nurse is suctioning fluids from a client through an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which of the following is the appropriate nursing intervention? a. Continue to suction b. Notify the physician immediately c. Stop the procedure and reoxygenate the client d. Ensure that the suction is limited to 15 seconds
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d. Pain, especially with inspiration Rationale: Rib fractures are a common injury, especially in the older client, and result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site and exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.
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A nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which of the following? a. Slow deep respirations b. Rapid deep respirations c. Paradoxical respirations d. Pain, especially with inspiration
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c. Paradoxical chest movement Rationale: Flail chest results from multiple rib fractures. This results in a "floating" section of the ribs. Because this section is unattached to the rest of the boy rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.
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A client with a chest injury has suffered flail chest. A nurse assesses the client fo which most distinctivesign of flail chest? a. Cyanosis b. Hypotension c. Paradoxical chest movement d. Dyspnea, especially on exhalation
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a. Right pneumothorax Rationale: Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung infaltion. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on theleft side because of the degree of curvature of the right and left main stem bronchi.
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A client has been admitted with chest trauma after a motor vehicle accident and has undergone subsequent intubation. A nurse checks the client when the high-pressure alarm on the ventilator sounds, ad notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assess for other signs of: a. Right pneumothorax b. Pulmonary embolism c. Displaced endotracheal tube d. Acute repiratory distress syndrome
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d. Increased respiratory rate Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rae, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles. a, b, & c would all occur later than an increased respiratory rate.
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A nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse assesses for which earliest sign of acute respiratory distress syndrome? a. Bilateral wheezing b. Inspiratory crackles c. Intercostal retractions d. Increased respiratory rate
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a. Emphysema Rationale: The client with emphysema has hyperinflation of the alveoli and flattening of the diaphragm. These lead to increased anteroposterior diameter, referred to as barrel chest. The client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion.
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A nurse is assessing a client with chronic airflow limitation and notes that the client has a "barrel chest." The nurse interprests that this client has which of the following forms of chronic airflow limitation? a. Emphysema b. Bronchial asthma c. Chronic obstructive bronchitis d. Bronchial asthma and bronchitis
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d. "I should not be contagious after 2 to 3 weeks of medication therapy." Rationale: The client is continued on medication therapy for 6 to 12 months, depending on the situation. The client generally is considered not to be contagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of three sputum cultures are negative.
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A nurse has conducted discharge teaching with a client diagnosed with tuberculosis. The client has been taking medication for 1 1/2 weeks. The nurse evaluates that the client has understood the information if the client makes which of the following statements? a. "I need to continue drug therapy for 2 months." b. "I can't stop at the mall for the next 6 months." c. "I can return to work if a sputum culture comes back negative." d. "I should not be contagious after 2 to 3 weeks of medication therapy."
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b. Particulate respirator, gown, and gloves Rationale: The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse also wears a gown when the possibility exits that the clohing could become contaminated, such as when giving a bed bath.
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A nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which of the following items when performing this care? a. Surgical mask and gloves b. Particulate respirator, gown, and gloves c. Particulate respirator and protective eyewear d. Surgical mask, gown, and protective eyewear
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c. Chest pain that occurs suddenly Rationale: the most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.
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A client has experienced pulmonary embolism. A nurse assesses for which symptom, which is most commonly reported? a. Hot, flushed feeling b. Sudden chills and fever c. Chest pain that occurs suddenly d. Dyspnea when deep breaths are taken
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a. Positive Rationale: The client with human immunodeficiency virus (HIV) infection is considered to have positive results on Mantoux skin testing with an area larger than 5 mm of induration. The client without HIV is positive with an induration larger than 10 mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options b, c, & d are incorrect interpretations.
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A client who is humanimmunodeficiency virus-positive has had a Mantoux skin test. The nurse notes a 7-mm area of induration at the site of the skin test. The nurse interprets the results as: a. Positive b. Negative c. Inconclusive d. Indicating the need for repeat testing
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a. Dyspnea Rationale: Histoplasmosis s an opportunistic fungal infection that can occur in the client with acquired immunodeficiency syndrome (AIDS). The infection begins as a respiratory infection and can progress to diseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the client's lymph nodes, liver, and spleen may occur as well.
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A client with acquired immunodeficiency syndrome has histoplasmosis. A nurse assesses the client for which of the following signs and symptoms? a. Dyspnea b. Headache c. Weight gain d. Hypothermia
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d. Shortnes of breath Rationale: Dry cough and dyspnea are typical signs and symptoms of pulmonary sarcoidosis. Others include night sweats, fever, weight loss, and skin nodules. The shortness of breath appears earlier than other symptoms.
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A nurse is giving discharge instructions to a client with pulmonary sarcoidosis. The nurse concludes that the client understands the information if the client reports which of the following early signs of exacerbation? a. Fever b. Fatigue c. Weight loss d. Shortness of breath
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a. Mask Rationale: Silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. The client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. Options b, c, & d are not necessary.
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A nurse is taking the history of a client with silicosis. The nurse assesses whether the client wears which of the following items during periods of exposure to silica particles? a. Mask b. Gown c. Gloves d. Eye protection
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b. Venturi mask Rationale: The venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems, but most often are used to administer high humidity.
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An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed? a. Face tent b. Venturi mask c. Aerosol Mask d. Tracheostomy collar
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d. Sitting on the side of the bed and leaning on the overbed table Rationale: Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against a wall.
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A nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which of the following positions will the nurse instruct the client to assume? a. Sitting up in bed b. Side-lying in bed c. Sitting in a recliner d. Sitting on the side of the bed and leaning on the overbed table
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d. A cough with the expectoration of mucoid sputum Rationale: One of the first pulmonary symptoms of tuberculosis is a slight cough with the expectoration of mucoid sputum. Options a, b, & c are late symptoms and signify cavitation and extensive lung involvement.
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A community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: a. Dyspnea b. Chest pain c. A bloody, productive cough d. A cough with the expectoration of mucoid sputum
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c. Sputum culture Rationale: Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and istological evidence of granulomatous disease on biopsy.
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A nurse perform an admission assessment on a client with a diagnosis of tuberculosis. The nurse reviews the results of which diagnostic test that will confirm this diagnosis? a. Chest x-ray b. Bronchoscopy c. Sputum culture d. Tuberculin skin test
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a. Activities should be resumed gradually c. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. d. Respiratory isolation is not necessary because family members already have been exposed e. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags. Rationale: The nurse should provide the client and the family with information about tuberculosis and allay concerns about the contagious aspect of the infection. Instruct the client to follow the medication regimen exactly as prescribed and always to have a supply of the medications on hand. Advise the client of the side effects of the medication and ways of mnimizing them to ensure compliance. Reassure the client that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Inform the client that activities should be resumed gradually and about the need for adequate nutrition and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection. Inform the client and family that respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing and to cover the mouth and nose when coughing or sneezing and to put used tissues into plastic bags. Inform the client that a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to former employment.
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The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. Of the following instructions, which will the nurse include on the list? a. Activities should be resumed gradually b. Avoid contact with other individuals, except family members, for at least 6 months c. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. d. Respiratory isolation is not necessary because family members already have been exposed. e. Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags f. When one sputum culture is negative, the client is no longer considered infectious and usually can return to former employement.
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c. Take the talet with a full glass of water Rationale: Guaifenesin (Mucinex) is an expectorant and should be taken with a full glass of water to decrease the viscosity of secretions. Extra doses should not be taken. The client should contact the physician if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache. Fluids are needed to decrease the viscosity of secretions. The medication does not have to be taken with meals.
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A client has a prescription to take guaifenesin (Mucinex). The nurse determines that the client understands the proper administration of this medication if the lent states that he or she will: a. Take an extra dose if fever develops b. Take the medication with meals only c. Take the tablet with a full glass of water d. Decrease the amount of daily fluid intake
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c. Resuscitation equipment Rationale: The nurse administering naloxone for suspected opioid overdose should have resuscitation equipment readily available to support naloxone therapy if it is needed. Other adjuncts that may be needed include oxygen, mechanical ventilator, and vasopressors.
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A nurse is preparing to administer a dose of naloxone hydrochloride (Narcan) intravenously to a client with an intravenous opioid overdose. Which supportive medical equipment would the nurse paln tohave at the client's bedside if needed? a. Nasogastric tube b. Paracentesis tray c. Resuscitation equipment d. Central line insertion tray
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a. Take the medication on an empty stomach Rationale: Diphenhydramine (Benadryl) has several uses, including antihistamine, antitussive, antidyskinetic, and sedative-hypnotic. Instructions for use include taking with food or milk to decrease gastrointestinal upset and using oral rinses or sugarless gum or hard candy to minimize dry mouth. Because the medication causes drowsiness, the client should avoid use of alcohol or central nervous system depressants, operating a car, or engaging in other activities requiring mental awareness during use.
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A nurse teaches a client about the effects of diphenhydramine (Benadryl), which has been prescribed as a cough suppressant. The nurse determines that the client needs further instructions if the client states that he or she will: a. Take the medication on an empty stomach b. Avoid using alcohol while taking this medication c. Use sugarless gum, candy, or oral rinses to decrease dry mouth d. Avoid activities requiring mental alertness while taking this medication
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d. Bronchospasm Rationale: Cromolyn sodium (Intal) is an inhaled nonsteroidal antiallergyagent and a mast cell stabilizer. Undesirable side effects associated with inhalatio therapy of cromolyn sodium are bronchospasm, cough, nasal congestion, throat irritation, and wheezing. Clients receiving this medication orally may experience pruritus, nausea, diarrhea, and myalgia.
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A cromolyn sodium (Intal) inhaler is prescribed for a client with allergic asthma. A nurse provides instructions regarding the side effects of this medication. The nurse tells that client that which undesirable effect is associated with this medication? a. Insomnia b. Constipation c. Hypotension d. Bronchospasm
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c. Diabetes mellitus Rationale: Terbutaline (Brethine) is a bronchodilator and is contraindicated in clients with hypersensitivity to sympathomimetics. It should be used with caution in clients with impaired cardiac function, diabetes mellitus, hypertension, hyperthyroidism, or a history of seizures. The medication may increase blood glucose levels.
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Terbutaline (Brethine) is prescribed fora client with bronchitis. A nurse understands that this medication should be used with caution if which of the following medical conditions is present in the client? a. Osteoarthritis b. Hypothyroidism c. Diabetes mellitus d. Polycystic disease
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c. Liver function test Rationale: Zafirlukast (Accolate) is a leukotriene receptor atagonist used in the prophylaxis and long-term treatment of bronchial asthma.Azfirlukast is used with caution in clients with impaired hepatic function.Liver function laboratory tests should be performed to obtain a baseline, and the levels should be monitored during administration of the medication.
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Zafirlukast (Accolate) is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication? a. Platelet count b. Neutrophil count c. Liver function test d. Complete blood count
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b. Peripheral neuritis Rationale: Isoniazid (INH) is an antitubercular medication. A common side effect of isoniazid is peripheral neuritis, manifested by numbness, tingling, and paresthesias in the extremities. This can be minimized with pyridoxine (vitamin B6) intake. Options a, c, & d are incorrect.
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A client has been taking isoniazid (INH) for 1 1/2 months. The client complains to a nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing: a. Hypercalcemia b. Peripheral neuritis c. Small blood vessel spasm d. Impaired peripheral circulation
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b. Report yellow eyes or skin immediately Rationale: Isniazid (INH) is hepatotoxic, and therefore the client is taught to report signs and symptoms of hepatitis immediately, which include yellow skin and sclera. For the same reason, alcohol should be avoided during therapy. The client should avoid intake of swiss cheese, fish such as tuna, and foods containing tyramine because they may cause a reaction characterized by redness and itching of the skin, flushing, sweating, tachycardia, headache, or lightheadedness. The client can avoid developing peripheral neuritis by increasing the intake of pyridoxine (vitamin B6) during the course of isoniazid therapy.
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A client is to begin a 6-month course of therapy with isoniazid (INH). A nurse plans to teach the client to: a. Use alcohol in small amounts only b. Report yellow eyes or skin immediately c. Increas intak of swiss or aged cheeses d. Avoid vitamin supplements during therapy
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c. Causes orange discoloration of seat, tears, urine, and feces Rationale: Rifampin should be taken exactly as directed. Doses should not be doubled or skipped. The client should not stop therapy until directed to do so by a physician. The medication should be administered on an empty stomach unless it causes gastrointestinal upset, and hen it may be taken with food. Antacids, if prescribed, should be taken at least 1 hour before the medication. Rifampin causes orange-red discoloration of body secretions and will stain soft contact lenses permanently.
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A client has been started on long-term therapy with rifampin (Rifadin). A nurse teaches the client that the medication a. Should always be taken with food or antacids b. Should be double-dosed if one dose is forgotten c. Causes orange discloration of sweat, tears, urine, and feces d. May be discontinued independently if symptms are gone in 3 months
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d. Difficulty in discriminating the color red from green Rationale: Ethambutol causes optic neuritis, which decreases visual acuity and the ability to discriminate between the colors red and green. This poses a potential safety hazard when a client is driving a motor vehicle. The client is taught to report this symptom immediately. The client also is taught to take the medication with food if gastrointestinal upset occurs. Impaired hearing results from antitubercular therapy with streptomycin. Orange-red discoloration of secretions occurs with rifampin (Rifadn).
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A nurse has given a client taking ethambutol (Myambutol) information about the medication. The nurse determines that the client understands the instructions if the client states to report immediately: a. Impaired sense of hearing b. Gastrointestinal side effects c. Orange-red discoloration of body secretions d. Difficulty in discriminating the color red from green
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b. Liver enzyme levels Rationale: Isoniazid (INH) therapy can cause an elevation of hepatic enzyme levels and hepatitis. Therefore, liver enzyme levels are monitored when therapy is initiated and during the first 3 months of therapy.They may be monitored longer in the client who is older than 50 or abuses alcohol. The laboratory tests in a, c, & d are not necessary.
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A client with tuberculosis is being started on antituberculosis therapy with isoniazid (INH). Before giving the client the first dose, a nurse ensures that which of the following baseline studies has been completed? a. Electrolyte levels b. Liver enzyme levels c. Serum creatinine level d. Coagulation times
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b. Salmeterol first and then the beclomethasone Rationale: Salmeterol (Srevent Diskus) is an adrenergic type of bronchodilator and beclomethasone dipropionate is a glucocorticoid. Bronchodilators are always administered before glucocorticoids when both are to be given on the same schedule. This allows for widening of the air passages by the bronchodilator, which then makes the glucocorticoid me effective.
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A nurse has an order to give a client salmeterol (Serevent Diskus), two puffs, and beclomethasone dipropionate (Qvar), two puffs, by metered-dose inhaler. The nurse administers the medication by giving the: a. Beclomethasone first and then the salmeterol b. Salmeterol first and then the beclomethasone c. Alternating a single puff of each, beginning with the salmeterol d. Alternating a single puff of each, beginning with the beclomethasone
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a. "I must take the medication exactly as prescribed." Rationale: Antiviral medications for influenza must be taken exactly as prescribed. These medications do not prevent the spread of influenza and clients are usually contagious for up to 2 days after the initiation of antiviral medications. Secondary bacterial infections may occur despite antiviral treatment. Side effects occur with these medications and may necessitate change in activities, especially when driving or operating machinery if dizziness occurs.
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The nurse is caring for a client with a diagnosis of influenza who first began to experience symptoms yesterday. Antiviral therapy is prescribed and the nurse provides instructions to the client about the therapy. Which statement by the client indicates an understanding of the instructions? a. "I must take the medication exactly as prescribed." b. "Once I start the medication, I will no longer be contagious." c. "I will not get any colds or infections while taking this medication." d. "This medication has minimal side effects and I can return to normal activities."
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a. Coffee,cola, and chocolate Rationale: theophylline (Theo-24) is a methylxanthine bronchodilator. The nurse teaches the client to limit the intake of xanthine-containing foods while taking this medication. These foods include coffee, cola, and chocolate
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A client has begun therapy with theophylline (Theo-24). A nurse plans to teach the client to limit the intake of which of the following while taking this medication? a. Coffee, cola, and chocolate b. Oysters, lobster, and shrimp c. Melons, oranges, and pineapple d. Cottage cheese, cream cheese, and dairy creamers
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d. "My lips and tongue are swollen." Rationale: Omalizumab is an anti-inflammatory used for long-term control of asthma. Anaphylactic reactions can occur with the administration of omalizumab. The nurse administering the medication should monitor for adverse reactions of the medication. Swelling of the lips and tongue are an indication of an adverse reaction.The client statements in options a, b, & c are not indicative of an adverse reaction.
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The nurse has just administered the first dose of omalizumab (Xolair) to a client. Which statement by the client would alert the nurse that the client may be experiencing a life threatening adverse reaction? a. "I have a severe headache." b. "My feet are quite swollen." c. "I am nauseated and may vomit." d. "My lips and tongue are swollen."
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a. Signs of hepatitis b. Flu-like symptoms c. Low neutrophil count e. Ocular pain or blurred vision Rationale: Rifabutin (Mycobutin) may be prescribed for a client with active Myobacterium avium complex (MAC) disease and tuberculosis. It inhibits mycobacterial DNA-dependent RNA polymerase and suppresses protein synthesis. Side effects include rash, gastrointestinal disturbances, neutopenia (Low neutrophil count), red-orange-colored body secretions, uveitis (blurred vision and eye pain), myositis, arthralgia, hepatitis, chest pain with dyspnea, and flu-like syndrome. Vitamin B6 deficiency and numbness and tingling in the extremities is associated with the use of isoniazid (INH). Ethambutol (Myambutol) also causes peripheral neuritis.
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Rifabutin (Mycobutin) is prescribed for a client with active mycobacterium avium complex (MAC) disease and tuberculois. For which of the following side effects of the medication should the nurse monitor? (Select all that apply) a. Signs of hepatitis b. Flu-like symptoms c. Low neutrophil count d. Vitamin B6 deficiency e. Ocular pain or blurred vision f. Tingling and numbness of the fingers
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a. Total hip arthroplasty Rationale: The surgical procedure and decreased mobility of the affected extremity will place the client at risk for development of a pulmonary embolism.
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A nurse should recognize that which of the following factors places a client at risk for a pulmonary embolus? a. Total hip arthroplasty b. Peripheral IV catheter c. Indwelling urinary catheter d. Laparoscopic cholecystectomy
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c. Urine andother secretions will be orange in color Rationale: Rifampin will turn the urine and other secretions orange.
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A client with pulmonary tuberculosis is being discharged with a prescription for rifampin (Rifadin). The nurse should plan to include which of the following in the client's discharge? a. Ringing in the ears is expected b. Purified protein derivative skin test results will improve in 4 months c. Urine and other secretions will be orange in color d. Medication should be taken with meals
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a. Holding at the puncture site for 5 min b. Aspirating the specimen into a heparinized syringe e. Performing the Allen test prior to obtaining the specimen Rationale: Holding pressure at the puncture site for 5 minutes is necessary to ensure adequate clotting and prevent bleeding. Aspirating the specimen into a heparinized syringe is required for an accurate sampling result. Performing the Allen test prior to obtaining the specimen prevents use of an artery that has insufficient blood flow, which can damage the hand. Inserting an air bubble into the syringe is not correct because it will not provide accurate results. Transporting the specimen to the lab within 30 min is not correct because it must be transported immediately.
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A nurse is obtaining a blood sample for ABG determination from a client's radial artery. Which of the following interventions are correct when performing this procedure? (Select all that apply) a. Holding pressure at the puncture site for 5 min. b. Aspirating the specimen into a heparinized syringe c. Inserting an air bubble into the syringe before capping d. Transporting the specimen to the laboratory within 30 min e. Performing the Allen test prior to obtaining the specimen
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a. Assessing gag reflex Rationale: Using the safety and risk reduction priority-setting framework, the greatest risk to the client is aspiration due to a depressed gag reflex.
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A nurse is preparing a client for discharge following a bronchoscopy. Which of the following is the priority assessment? a. Assessing gag reflex b. Percussing lung fields c. Auscultating heart sounds d. Palpating peripheral pulses
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a. Apply supplemental oxygen Rationale: According to the airway, breathing, circulation priority-setting framework, the greatest risk to this client is respiratory compromise. The first action would be to apply supplemental oxygen.
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A client who is postoperative develops an acute onset of severe chest pain that is worse with inspiration. The client is anxious and tachypneic. The nurse should anticipate taking which of the following actions first? a. Apply supplemental oxygen b. Auscultate lung sounds c. Administer pain medication d. Initiate heparin therapy
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b. Albuterol (Proventil) Rationale: Albuterol is a short-acting beta 2 adrenergic agonist, which acts quickly to produce bronchodilation during an acute asthma attack.
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A nurse should plan to administer which of the following medications to a client during an acute asthma attack? a. Cromolyn sodium (Intal) b. Albuterol (Proventil) c. Fluticasone and salmeterol (Advair Discus) d. Prednisone (Deltasone)
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b. Produtive cough with green sputum Rationale: A productive cough with green sputum indicates an infection. This should be reported to the primary care provider.
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A nurse is caring for a client who has COPD. Which of the following findings should the nurse report to the primary care provider? a. An oxygen saturation of 89% b. Productive cough with green sputum c. Clubbing of fingers d. Use of pursed-lip breathing with exertion
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c. Artificial airway cuff leak Rationale: An artificial airway cuff leak interferes with oxygenation and causes the low pressure alarm to sound.
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A nurse is caring for a client receiving mechanical ventilation. The low pressure alarm sounds. Which of the following should the nurse recognize as a cause of the alarm? a. Excess secretions b. Kinks in the tubing c. Artificial airway cuff leak d. Biting on the endotracheal tube
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c. Provide a diet that is high in calories and protein Rationale: Clients with COPD have difficulty obtaining enough calories and protein due to fatigue and early satiety. Therefore, the food that is consumed should be high in calories and protein.
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When planning the care for a client with COPD, the nurse should include which of the following interventions? a. Schedule respiratory treatments following meals. b. Have the client sit in a chair for 2-hr periods three times a day c. Provide a diet that is high in calories and protein. d. Combine activities to allow for longer rest periods between activities
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d. Administer IV heparin at 1,300 units per hr. Rationale: A client with a pulmonary embolism is at greatest risk for respiratory arrest related to extension of the clot. Administration of heparin will prevent further clot formation; therefore this is the highest priority.
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A nurse is caring for a client who was just diagnosed with a pulmonary embolism. Which of the following interventions is the highest priority? a. Provide for a quiet environment b. Encourage use of incentive spirometer every 1 to 2 hr. c. Apply electrodes for continuous cardiac monitoring d. Administer IV heparin at 1,300 units per hr.
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a. Increase in respiratory rate Rationale: An increase in respiratory rate indicates increased work of breathing and the need for improvement in oxygen delivery.
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A nurse is caring for a client with adult respiratory distress syndrome (ARDS). Which of the following assessment findings indicates that the client's work of breathing has worsened? a. Increase in respiratory rate b. Increase in oxygen saturation c. Decrease in carbon dioxide retention d. Decrease in adventitious breath sounds
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c. Decreased breath sounds Rationale: The greatest risk following a throacentesis is development of a pneumothorax. Decreased breath sounds may indicate a pneumothorax and is the priority assessment finding.
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A nurse is caring for a client who has just had a thoracentesis. Which of the following is the priority assessment finding? a. Hemoptysis b. Insertion site pain c. Decreased breath sounds d. Temperature of 37.3 (100 deg F)
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c. Temperature of 38.8 C (101.8 F) Rationale: A temperature elevation is expected with bacterial pneumonia
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A nurse is caring for a client diagnosed with bacterial pneumonia. In this situation, the nurse should expect which of the following assessment findings? a. Nonproductive cough b. SaO2 96% c. Temperature of 38.8 C (101.8 F) d. Bradypnea
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c. Arterial blood gases Rationale: Arterial blood gases will provide important information regarding serum oxygen saturation and the acid-base balance of the client's blood. This information will evaluate if the mechanical ventilator is providing adequate oxygenation to maintain lung function.
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A client in acute respiratory failure is receiving mechanical ventilation. Which of the following is the priority assessment the nurse should use to evaluate the effectiveness of the mechanical ventilation? a. Blood pressure b. Breath sounds c. Arterial blood gases d. Heart rate
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b High-Fowler's poson with pillows supporting both arms Rationale: The client should be encouraged to sit upright leaning slightly forward with both arms supported on the overbed table to allow for better expansion of the chest.
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A nurse is positioning a client with emphysema to promote effective breathing. The nurse should place the client in which of the following positions? a. Lateral position with a pillow over the chest to support the arm b. High-Fowler's position with arms supported on the overbed table c. Semi-Fowler's position with pillows supporting both arms d. Supine position with the head of the bed elevated 15 degrees
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a. Blood-tinged sputum Rationale: Sputum may be blood-tinged secondary to bleeding from the tumor
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When caring for a client with lung cancer, the nurse should expect which of the following assessment findings? a. Blood-tinged sputum b. Decreased tactile fremitus c. Resonance with percussion d. Peripheral edema
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c. Pair of padded clamps Rationale: The nurse should plan to have a pair of padded clamps in the event that the tubing becomes disconnected.
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A nurse is caring for a client following the insertion of a chest tube. The nurse should plan to have which of the following items in the client's room? a. Extra drainage system b. Suture removal set c. Pair of padded clamps d. Nonadherent pads
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d. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3 -22 mEq/L Rationale: These ABG values indicate respiratory acidosis. The pH is below 7.35, and the PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis.
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A client who is postoperative is hypoventilating secondary to general anesthesia effects and incisional pain. Which of the following ABG values support the nurse's suspicion of respiratory acidosis? a. pH 7.50, PO2 95 mm Hg, PaCO2 25 mm Hg, HCO3 -22 mEq/L b. pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3 -30 mEq/L c. pH 7.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3 -20 mEq/L d. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3 -22 mEq/L
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a. Airway patency Rationale: Using the airway, breathing, and circulation priority-setting framework, the greatest risk to the client is airway obstruction. The priority assessment is to determine airway patency.
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When caring for a client immediately following a total laryngectomy for laryngeal cancer, the nurse should give priority to which of the following assessments? a. Airway patency b. Oxygen saturation c. Breath sounds d. Gag reflex
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b. Nonrebreather mask Rationale: A nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This delivers greater than 90% FIO 2 (Fraction of inspired oxygen), which provides the highest level of oxygen.
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A nurse is caring for a client in respiratory distress. Which of the following devices should the nurse use to provide the highest level of oxygen via a low-flow system? a. Nasal cannula b. Nonrebreather mask c. Simple face mask d. Partial rebreather mask
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b. Continuous bubbling in the water seal chamber Rationale: Continuous bubbling in the water seal chamber suggests an air leak, indicating a need for further action.
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A nurse is assessing a client who has a chest tube in place following thoracic surgery. Which of the following findings indicates a need for further action? a. Fluctuation of drainage in the tubing with inspiration b. Continuous bubbling in the water seal chamber c. Drainage of 75 mL in the first hr after surgery d. Several small, dark-red blood clots in the tubing
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a. A client admitted with a closed-head injury who is lethargic Rationale: Increased intracranial pressure often follows a closed-head injury. Nasopharyngeal suctioning can further increase intracranial pressure and should be avoided.
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A nurse receives an order from the primary care provider to perform nasopharyngeal suctioning for each of the following clients. The nurse should question the provider's order for which of the following clients? a. A client admitted with a closed-head injury who is lethargic b. A client admitted with a fractured femur who is in severe pain c. A client admitted with a ruptured appendix who has a temperature of 39 C (102.2 F) d. A client admitted with emphysema who has a respiratory rate of 36/min
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b. Remove the suction catheter using a rotating motion Rationale: Rotating the suction catheter during withdrawal reduces the risk of tissue trauma.
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A nurse should take which of the following action when providing endotracheal suctioning for a client who is in respiratory distress? a. Suction the client's endotracheal tube using clean technique b. Remove the suction catheter using a rotating motion c. Suction the oropharyngeal cavity prior to suctioning the endotracheal tube d. Suction the client's endotracheal tube every 2 hr.
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a. Airborne Rationale: Tuberculosis is a respiratory infection that is spread through the air and requires airborne isolation.
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A client diagnosed with active tuberculosis is hospitalized. Which of the following isolation precautions should the nurse plan to implement? a. Airborne b. Neutopenic c. Contact d. Droplet
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d. "I will take this medication every evening, even when I do not have symptoms." Rationale: Montelukast is used for prophylaxis of asthma exacerbation and should be taken on a daily basis in the evening.
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A nurse is providing instruction to a client on how to use montelukast (Singulair) to treat chronic asthma. The nurse should recognize that the client understands the teaching when he states, a. "I will take this medication with each meal." b. "I will take this medication during my asthma attacks." c. " I will take this medication up to three times a day when I begin to wheeze." d. " I will take this medication every evening, even when I do not have symptoms."
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c. Tachycardia Rationale: Tachycardia is a common side effect, especially if albuterol is used excessively.
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A nurse should plan to monitor a client receiving albuterol (Proventil) for which of the following side effects? a. Hypokalemia b. Dyspnea c. Tachycardia d. Candidiasis
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d. "I should apply suction while inserting the catheter into my tracheostomy." Rationale: Suction should only be applied on withdrawal of the catheter to prevent tracheal tissue trauma.
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A nurse is providing discharge instructions to a client following a tracheostomy. Which of the following statements by the client indicates a need for further instruction? a. "I need to inspect the stoma for signs of infection of skin irritation." b. "I will clean the cannula with half-strength peroxide and rinse with saline." c. "I can remove the old twill tape once the new tape is in place." d. "I should apply suction while inserting the catheter into my tracheostomy."
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b. Cyanotic lips Rationale: Cyanosis of the lips indicates that the client is not efficiently oxygenating the blood. This finding should be reported to the primary care provider.
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A nurse is assessing a client with emphysema. The nurse should report which of the following client assessment findings? a. Fatigue b. Cyanotic lips c. Barrel-shaped chest d. Crackles in posterior chest
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d. Tracheal deviation to the unaffected side Rationale: A pneumothorax will cause the trachea to deviate to the unaffected side.
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A nurse is caring for a client in the emergency department following chest trauma. Which of the following findings should the nurse recognize as indicating a tension pneumothorax? a. Collapsed neck veins on the affected side b. collapsed neck veins on the unaffected side c. Tracheal deviation to the affected side d. Tracheal deviation to the unaffected side
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d. PaO2 58 mm Hg Rationale: The PaO2 is decreased with acute respiratory failure.
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A client is diagnosed with acute respiratory failure. The nurse should expect which of the following laboratory findings? a. Arterial pH 7.50 b. PaCO2 25 mm Hg c. SaO2 92% d. PaO2 58 mm Hg
