ATI MedSurg Respiratory

A nurse is assisting with discharge teaching for a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include?

"Lie on your back with your head elevated 30° when resting The nurse should instruct the client to rest in the semi-Fowler's position to prevent aspiration of nasal secretions.

A nurse in a clinic is reinforcing teaching with a client who is to have a tuberculin skin test. Which of the following information should the nurse include?

"You must return to the clinic to have the test read in 2 or 3 days. The client should have the skin test read in 2 to 3 days. An area of induration after 48 to 72 hr indicates exposure to the tubercle bacilus. If the client does not return to have the test read within 72 hr, another skin test is necessary.

A nurse on a medical unit is assisting with the care of a client who has a possible closed pneumothorax and significant bruising of the left chest following a motor-vehicle crash. The client reports severe left chest pain on inspiration. The nurse should hear which of the following findings when auscultating the client's lung sounds?

Absence of breath sounds A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side.

A nurse is preparing to assist a provider to withdraw arterial blood from a client's radial artery for measurement of ABG. Which of the following actions should the nurse plan to take?

Check the circulation in the client's ulnar artery prior to obtaining the specimen. The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery.

A nurse is assisting with the care for a client who hada chest tube inserted 12 hr ago. The nurse notes a crackling sensation upon palpation of the skin on the right side of the client's chest. The nurse should notify the charge nurse that the client demonstrating a clinical manifestation of which of the following complications?

Crepitus Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissue, which is often a clinical manifestation of a pneumothorax.

A nurse is assisting with the development of a teaching plan about how to prevent an acute asthma attack for a young adult client. Which of the following points should the nurse plan to discuss first?

Determine the client's perception of the disease process and what might have triggered the current attack. The nurse should apply the nursing process priority-setting framework. The nurse can use the nursing process to plan client care and prioritize nursing actions. Each step of the nursing process builds on the previous step, beginning with assessment or data collection. Before the nurse can formulate a plan of action, implement a nursing intervention, or notifya provider of a change in the client's status, she must first collect adequate data from the client. Assessing or collecting additional data will provide the nurse with knowledge to make an appropriate decision. Therefore, the first step the nurse should take is to assess the client's current knowledge.

A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax?

Dry cough The client who has a dry cough has a clinical manifestation found in the prodromal stage of inhalation anthrax. During this stage, it is difficult to distinguish from influenza or pneumonia because there is no sore throat or rhinitis.

A nurse is reinforcing preoperative teaching with a client who is to undergo a pneumonectomy. The client states, "I am afraid it will hurt to cough after the surgery." Which of the following statements should the nurse make?

I will show you how to splint your incision while coughing. The client who had a pneumonectomy must cough to clear secretions from the remaining lung The nurse should show the client how to splint her incision to reduce pain when coughing.

A nurse is reinforcing teaching about pursed-lip breathing for a client who has chronic obstructive pulmonary disease and emphysema. The nurse should explain that this breathing technique does which of the following?

Keeps the airways open on exhalation The client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea, This is one of the simplest ways to control dyspnea. It slows the clients pate of breathing and keeps the airway open on exhalation, making each breath more effective. Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently.

A nurse in a provider's office is collecting data from a client who is states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis?

Night sweats Night sweats and fevers are clinical manifestations of tuberculosis.

A nurse is assisting with the plan of care for a client who has chronic obstructive pulmonary disease and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan?

O Eat high-calorie foods first The client who has COPD often experiences early satiety. Therefore, the client should eat calorie-dense foods first.

A nurse on a medical unit is assisting with the care of a client who aspirated gastric contents prior to admission. The provider prescribed 100% oxygen by nonrebreather mask after the client reported severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)?

Pao, 50 mm Hg The client who has manifestations of ARDS has a low Pao, level even with the administration of oxygen. Hypoxemia after treatrment with oxygen is a manifestation of ARDS.

A nurse is caring for an older adult client who has chronic obstructive pulmonary disease and pneumonia. The nurse should monitor the client for which of the following acid-base imbalances?

Respiratory acidosis Respiratory acidosis is a common complication of COPD. This complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs.

A nurse is assisting the provider to prepare a client for a thoracentesis. The nurse should instruct the client that which of the following positions will be used for this procedure?

Sitting while leaning forward over the bedside table When preparing a client for a thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table because this position maximízes the space between the client's ribs and allows for aspiration of accumulated fluid and air.

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. The nurse collects additional data from the client. Which of the following findings is an indication of pulmonary embolism?

Sudden onset of dyspnea Clinical manifestations of pulmonary embolism have a rapid onset. Dyspnea occurs due to reduced blood flow to the lungs.

A nurse is assisting with the plan of care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care?

Tape all connections between the chest tube and drainage system. The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing fram accidently disconnecting.

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions?

The client has coarse crackles in the lung fields. The nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction client's airway secretions.

A nurse is collecting data from a client who has a prescription for cisplatin IV to treat lung cancer. Which of the following client findings is an adverse effect of this medication?

Tinnitus An adverse effect of cisplatin is ototoxicity, which can cause tinnitus.

A nurse is reinforcing teaching with a client who has cystic fibrosis and a prescription for daily chest physiotherapy. The nurse should instruct the client that which of the following is the purpose of these treatments?

To mobilize secretions in the airways The purpose of chest physiotherapy is to loosen the client's secretions and promote drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity

A nurse is reinforcing teaching with a client about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation?

Total lung capacity Pulmonary function tests are used to examine the effectiveness of the lungs and identify lung problems. Total lung capacity measures the amount of air the lungs can hold after maximum inhalation.