ATI Respiratory Learning System Med-Surg

A nurse is caring for a patient following a throacentesis. Which of the following manifestations should the nurse recognize as risks for complications? (Select all that apply)

1. Dyspnea

A home health nurse is teaching a patient who has active TB. The provider has prescribed the following medication regiment: isoniazid 250 mg PO daily, rifampin 500 mg PO daily, pyrazinamide 750 mg PO daily, and ethambutol 1 mg PO daily. Which of the following patient statements indicate the client understands the teaching? (Select all that apply)

2. "I will wash my hands each time I cough." 3. "I will wear a mask when I am in a public area."

A nurse is reinforcing teaching with a patient on the purpose of taking a bronchodilator. Which of the following patient statements indicates an understanding of the teaching?

2. "I take this medication to prevent asthma attacks."

A nurse is discharging a patient who has COPD. Upon discharge, the patient is concerned that he will never be able to leave his house now that he is on continuous oxygen. Which of the following is an appropriate response by the nurse?

1. "There are portable oxygen delivery systems that you can take with you."

A nurse is reviewing the health records of five clients. Which of the following clients are at risk for developing respiratory distress syndrome? (Select all that apply)

1. A client who experienced a near-drowning incident. 2. A client following coronary artery bypass graft surgery. 4. A client who has dyphagia. 5. A client who experienced a drug overdose.

A nurse is caring for a group of clients. Which of the following clients are at risk for a PE? (Select all that apply)

1. A client who has a BMI of 30 3. A client who has a fractured femur. 5. A client who has chronic atrial fibrillation

A nurse in the emergency department is assessing a patient for a closed pneumothorax and significant bruising of the left chest following a MVA. The client reports severe left chest pain on inspiration. The nurse should assess the patient for which of the following manifestations of a pneumothorax: A. absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi

1. Absence of breath sounds A client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side. Expiratory wheezing = asthma attack Inspiratory stridor = loud crowning like sound, = airway obstruction rhonchi: heard in pts with thick sputum production or obstruction from a foreign body - dry, low-pitched - snore like noises - produced in throat

A nurse in an urgent care clinical is collecting data from a patient who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax: A. Dry cough B. Rhinitis C. Sore throat D. Swollen lymph nodes

1. Dry cough A dry cough is a clinical manifestation found in the prodromal stage of having 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 planning care for a patient who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan: A. Eat high calorie foods first B. increase intake of water at meal times C. Perform active ROM before meals D. Keep saltine crackers nearby for snacking

1. Eat high-calorie foods first The client who has COPD often experiences early satiety. Therefore, the client should eat calorie-dense foods first. Although it is important for a client who has COPD to maintain adequate fluid intake to prevent dehydration and inhibit the production of tenacious secretions, the client should limit intake of water at mealtimes to reduce the feeling of early satiety. Rest before meals to decrease dyspnea during meals The client should keep foods on hand for snacking, but should avoid dry and salty foods, which can place the client at risk for aspiration and make the client's mouth dry.

A nurse is planning care for a patient following the insertion of a chest tube and drainage system. Which of the following should be included in the plan of care? (Select all that apply)

1. Encourage the patient to cough every 2 hours 2. Check for continuous bubbling in the suction chamber 5. Obtain a chest x-ray A chest x-ray is obtained following the procedure to verify chest tube placement.

A nurse is caring for a client who is receiving vecuronium for acute respiratory distress syndrome. Which of the following medications should the nurse anticipate administering with this medication? (Select all that apply)

1. Fentanyl 3. Midazolam

A nurse is caring for a client who is to receive thrombolytic therapy. Which of the following factors should the nurse recognize as a contraindication to the therapy?

1. Hip arthroplasty 2 weeks ago

A nurse is caring for a patient who has acute respiratory distress syndrome. Which of the following assessment findings indicates a decline in the patient's condition:

1. Increase in respiratory rate

A nurse is preparing to care for a patient following chest tube placement. Which of the following items should be available in the patient's room? (Select all that apply)

1. Oxygen 2. Sterile water 5. Occlusive dressing

A nurse is caring for a patient who is scheduled for a throacentesis. Which of the folowing supplies should the nurse ensure are in the patient's room? (Select all that apply)

1. Oxygen equipment 3. Pule oximeter 4. Sterile dressing

A nurse is providing information about TB to a group of patients at a local community center. Which of the following manifestations should the nurse include in the teaching? (Select all that apply)

1. Persistent cough 3. Fatigue 4. Night sweats 5. Purulent sputum

A nurse is caring for a patient who is scheduled for a thoracentesis. Prior to the procedure, which of the following actions should the nurse take:

1. Position the client in an upright position, leaning over the bedside table.

A nurse on a med-surg unit is caring for a patient who is postoperative following a hip replacement surgery. The patient reports feeling apprehensive and restless. Which of the follow findings should the nurse recognize as an indication of a PE: a. sudden onset of dyspnea b. Tracheal deviation c. Bradycardia d. Difficulty swallowing

1. Sudden onset of dyspnea Clinical manifestations of pulmonary embolism have a rapid onset. PE S&S: - Dyspnea - Tachycardia Dyspnea occurs due to reduced blood flow to the lungs. Tracheal deviation is an indication of pneumothorax. Difficulty swallowing is an indication of many conditions, including oral cance

A nurse is assessing a client following a gunshot wound to the chest. For which of the following findings should the nurse monitor to detect a pneumothorax? (Select all that apply)

1. Tachypnea 2. Deviation of the trachea 5. Pleuritic pain

A nurse is providing teaching to a patient about pulmonary function tests. Which of the following tests measures the volume of air the lungs can hold at the end maximum inhalation: A. Total lung capacity B. Vital lung capacity C. Functional Residual capacity D. Residual volume

1. 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.

A nurse is assisting with a thoracentesis. Which of the following actions is appropriate for the nurse to take when assisting with this procedure: (Select all that apply)

1. Wear goggles and mask during the procedure 2. Cleanse the area with an antiseptic solution 5. Apply pressure to the site after the needle is withdrawn

A nurse is caring for a client who has a new prescription for heparin therapy. Which of the following statements by the client should indicate an immediate concern for the nurse?

2. "I take antacids several time a day."

A nurse is orienting a newly licensed nurse on the purpose of administering vecuronium to a client who has ARDS. Which of the following statements by the newly licensed nurse indicates understanding of the teaching?

2. "This medication is given to facilitate ventilation." Vecuronium is a neuromuscular blocking agent given to facilitate ventilation and decrease oxygen consumption.

A nurse is teaching a patient who has TB. Which of the following statements should the nurse include in the teaching?

2. "You will need to provide sputum samples every 4 weeks to monitor the effectiveness of the medication."

A nurse is caring for a patient who has a chest tube and drainage system in place. The nurse observes that the chest tube was accidentally removed. Which of the following actions should the nurse take first?

2. Apply sterile gauze to the insertion site

A nurse is assessing a patient who has a chest tube in place following a thoracic surgery. Which of the following findings indicates a need for intervention:

2. Continuous bubbling in the water seal chamber. Continuous bubbling in the water seal chamber suggests an air leak.

A nurse in the emergency department is assessing a client who has a suspected flail chest. Which of the following findings should the nurse expect? (Select all that apply)

2. Cyanosis 3. Hypotension 4. Dyspnea 5. Paradoxic chest movement

A nurse is assessing a patient who has emphysema. The nurse should report which of the following assessment findings:

2. Elevated temperature Patients who have emphysema are at risk for development of pneumonia and other respiratory infections. A nurse should report an elevated temperature to the provider.

A nurse is assessing a patient who has a history of asthma. Which of the following factors should the nurse identify as a risk for asthma?

2. Environmental allergies

A nurse is assessing a patient who has a chest tube and drainage system in place. Which of the following are expected findings? (Select all that apply)

2. Gentle constant bubbling in the suction control chamber 3. Rise and fall in the level of water in the water seal chamber with inspiration and expiration

A nurse is reviewing the prescriptions for a client who has a pneumothorax. Which of the following actions should the nurse perform first?

2. Obtain a large-bore IV needle for decompression.

A nurse on a medical unit is caring for a patient who apirated gastric contents prior to admission. The nurse administers 100% oxygen by nonbreather mask after the patient reports severe dyspnea. Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS): A. Tympanic temperature 38 C (100.4F) B. PaO2 50mm Hg C. Rhonchi D. Hypopnea

2. PaO2 50 mm Hg The patient who has manifestations of ARDS has a low PaO2 level even with the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS. ARDS s/sx - Hyperpnea - Clear breath sounds because edema occurs in interstitial spaces - Low PaO2 level even with administration of oxygen

A nurse is assessing a client who has a PE. Which of the following manifestations should the nurse expect to find? (Select all that apply)

2. Pleural friction rub 4. Petechiae 5. Tachycardia

A nurse is caring for a patient who has COPD. Which of the following findings should the nurse report to the provider:

2. Productive cough with green sputum -- it indicates an infection

A nurse is planning care for a client who has severe acute respiratory distress system (SARS). Which of the following actions should be included in the plan of care for this client? (Select all that apply)

2. Provide supplemental oxygen 4. Administer of bronchodilators 5. Maintain ventilatory support

A nurse is caring for an elderly patient who suffers from COPD with pneumonia. The nurse should monitor the patient for which of the following acid-base imbalances? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis

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

A nurse is reviewing ABG laboratory results of a patient who is in respiratory distress. The results are pH 7.47, PaCO2 32 mm Hg, HCO3 22 mm Hg. The nurse should recognize that the client is experiencing which of the following acid-base imbalances:

2. Respiratory alkalosis

A nurse is teaching about daily chest physiotherapy with a patient who has cystic fibrosis. The nurse should instruct the patient that which of the following is the purpose of the treatments: A. To encourage deep breaths B. To mobilize secretions in airway C. To dilate the bronchioles D. To stimulate the cough reflex

2. To mobilize secretions in the airways The purpose of chest physiotherapy is to loosen the patient's secretions and promote drainage of secretions from the lungs. Chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity. A positive test means the client has been exposed to tubercle bacillus (TB), but it does not mean that the client has an active case of tuberculosis. The client should have a chest x-ray to rule out active tuberculosis. The nurse will inject 0.1 mL of purified protein derivative intradermally to the dorsal aspect of the client's forearm.

A nurse is caring for a patient who is in respiratory distress and requires endotracheal suctioning. Which of the following actions should the nurse take:

2. Use a rotating motion to remove the suction catheter

A nurse in the emergency department is caring for a patient who is having an acute asthma attack. Which of the following assessments indicates that the respiratory status is declining? (Select all that apply)

2. Wheezing 3. Retraction of sternal muscles 5. PVCs

A nurse is providing discharge teaching to a patient who has COPD and a new prescription for albuterol. Which of the following statements by the patient indicates an understanding of the teaching?

3. "I can have an increase in my heart rate while taking this medication.

A nurse is providing discharge teaching to a patient who has a new prescription for prednisone for asthma. Which of the following patient statements indicates an understanding of the teaching:

3. "I will take my medication with meals."

A nurse is caring for a patient who has a new diagnosis of TB and has been placed on a multimedication regimen. Which of the following instructions should the nurse give the patient related to ethambutol?

3. "Watch for any changes in vision."

A nurse is preparing to administer a new prescription for isoniazid to a patient who has TB. The nurse should instruct the patient to report which of the following findings as an adverse effect of the medication?

3. "You might notice tingling of your hands."

A nurse is reviewing prescriptions for a client who has acute dyspnea and diaphoresis. The client states she is anxious and is unable to get enough air. Vital signs are heart rate 117/min, respirations 38/min, temperature 101.2 F, and blood pressure 100/54 mm Hg. Which of the following nursing actions is the priority?

3. Administer oxygen therapy.

A nurse in the emergency department is assessing a client who was in a MVA. Findings include absent breath sounds in the left lower lobe with dyspnea, blood pressure 118/68 mm Hg, heart rate 124/min, respirations 38/min, temperature 101.4 F, and SaO2 92% on room air. Which of the following actions should the nurse take first?

3. Administer oxygen via a high-flow mask.

A nurse is caring for a patient receiving mechanical ventilation. The low pressure alarm sounds. Which of the following should the nurse recognize as a cause for the alarm:

3. Artificial airway cuff leak

A nurse is caring for a patient following the insertion of a chest tube. The nurse should plan to have which of the following items in the patient's room:

3. Container of sterile water

A patient is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation on the right side of the patient's chest. After notifying the provider, the nurse should document the finding as which of the following: A. Friction rub B. Crackles C. Crepitus D. Tactile Fremitus

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

A nurse is preparing to administer a dose of a new prescription of prednisone to a patient who has COPD. The nurse should monitor for which of the following adverse effects of this medication? (Select all that apply)

3. Fluid retention 5. Black, tarry stools

A nurse in a provider's office is assessing a patient who states he was recently exposed to TB. Which of the following findings is a clinical manifestation of pulmonary TB: A. Pericardial friction rub B. Weight gain C. Night Sweats D. Cyanosis of the fingertips

3. Night sweats Night sweats and fevers are clinical manifestations of TB. pericardial friction rub is a clinical manifestation of rheumatic carditis. Anorexia and weight loss are clinical manifestations of tuberculosis. Cyanosis of the fingertips is a clinical manifestation of Raynaud's disease.

A nurse is preparing to assist a provider to withdraw arterial blood from a patient's radial artery for measurement of ABG. Which of the following actions should the nurse plan to take? A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen. B. Apply ice to site after obtaining the specimen C. Perform an Allen's test prior to obtaining the specimen D. Release pressure applied to puncture site 1 min after needle is withdrawn

3. Perform an Allen's test 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. The nurse should apply pressure to the puncture site for 5 to 10 min after the needle is withdrawn. High pressure of the blood in the arteries places the client at risk for hemorrhage from the withdrawal site. The nurse should use ice to preserve the arterial blood gas specimen during transport to the laboratory. If the sample is not placed on ice, the pH and PO2 values can be inaccurate. It is not necessary to place ice on the withdrawal site. The nurse should not administer oxygen prior to the blood draw, because the test measures the client's arterial blood gases when breathing room air.

A nurse is planning care for a patient who has COPD. Which of the following interventions should the nurse include in the plan of care:

3. Provide a diet high in calories and protein

A nurse is planning to instruct a patient on how to perform pursed-lip breathing. Which of the following should the nurse include in the plan of care?

3. Take a deep breath in through your nose.

A nurse is caring for a patient who has bacterial pneumonia. The nurse should expect which of the following assessment findings:

3. Temperature 38.8 C ( 101.8 F) An elevated temperature is an expected finding for a patient who has bacterial pneumonia.

A nurse is discharging a patient who has pulmonary TB and is to start therapy with rifampin. The nurse should plan to include which of the following in the patient's teaching plan:

3. Urine and other secretions will be orange. Rifampin will turn urine and other secretions orange.

A nurse is instructing a patient on the use of an incentive spirometer. Which of the following statements by the client indicates an understanding of the teaching."

4. "I will take in a deep breath and hold it before exhaling."

A nurse is reviewing discharge instructions for a client who experienced a pneumothorax. Which of the following statements should the nurse use when teaching the client?

4. "Notify your provider if you experience a productive cough."

A nurse is caring for a patient with a PE. Which of the following interventions is the priority:

4. Administer heparin via continuous IV fusion

A nurse is caring for a patient 2 hours after admission. The patient has an SaO2 of 91% exhibits audible wheezes, and is using accessory muscles when breathing. Which of the following classes of medications should the nurse expect to administer?

4. Beta 2 agonist

A nurse is assessing a patient following a bronchoscopy. Which of the following findings should the nurse report to the provider:

4. Bronchospasms

A nurse is caring for a patient who has acute respiratory failure. Which of the following laboratory findings should the nurse expect:

4. PaO2 58 mm Hg

A nurse is assisting a provider with the removal of a chest tube. Which of the following should the nurse instruct the patient to do?

4. Perform the Valsalva maneuver

A nurse is preparing a patient for a thoracentesis. In which of the following positions should the nurse place the patient: A. lying flat on affected side B. Prone with arms raised over head C. Supine with HOB elevated D. Sitting while leaning forward over the bedside table

4. Sitting while leaning forward over the bedside table -- this position maximizes the space between the patient's ribs and allows for aspiration of accumulated fluid and air.

A nurse working in the ED is caring for a patient following a chest trauma. Which of the following findings indicates a tension pneumothorax:

4. Tracheal deviation to the unaffected side A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

A nurse is caring for a patient who is postoperative and is hypoventilating secondary to general anesthesia effects and incisional pain. Which of the following ABG values support the nurse's suspicion of respiratory acidosis:

4. pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3 22 mEq/L

Anthrax

An infection caused by the bacteria Bacillus anthracis. Although it's most commonly found in grazing animals (such as sheep, pigs, cattle, horses, and goats), anthrax can sometimes infect humans. In the environment, anthrax can form spores (a version of the germ in a hard shell) that can live in the soil for years. There are three main types of anthrax: cutaneous (skin) anthrax, which can occur if someone handles contaminated animals or animal products (especially animal hides) while they have a cut, abrasion, or rash on the skin; intestinal anthrax, which can occur if someone eats contaminated meat; and pulmonary (inhaled) anthrax, which is extremely rare but can occur if someone breathes anthrax spores, usually found in the dust kicked up by animals. Symptoms vary depending on the type of anthrax. Pulmonary anthrax usually begins with flu-like symptoms but, if untreated, can rapidly turn into severe pneumonia (an inflammation of the lungs).

A nurse is providing instructions about pursed-lip breathing for a patient who has COPD with emphysema. The nurse should explain that this breathing technique accomplishes which of the following: A. Increases oxygen intake B. Promotes carbon dioxide elimination C. Uses the intercostal muscles D. Strengthens the diaphragm

B. Promotes carbon dioxide elimination 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 client's pace of breathing, 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 is developing a teaching plan for a patient about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first: A. How to eliminate environmental triggers that precipitate attacks B. The client's perception of the disease process and what might have triggered past attacks C. The client's medication regimen D. Manifestations of respiratory infections

B. The patient's perception of the disease process and what might have triggered attacks in the past 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. Before the nurse can formulate a plan of action, implement a nursing intervention, or notify a provider of a change in the client's status, the nurse must first collect adequate data from the client. Assessing the client 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 is planning care for a patient following placement of a chest tube 1 hour ago. Which of the following actions should the nurse include in the plan of care: A. Clamp the chest tube if there is continuous bubbling in the water seal chamber. B. Keep the chest tube drainage system at the level of the right atrium. C. Tape all connections between the chest tube and drainage system. D. Empty the collection chamber and record the amount of drainage every 8 hr.

C. Tape all of the connections between the chest tube and the drainage system. The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidently disconnecting. The nurse should not empty the collection chamber or change the system unless it is almost full. The nurse should ensure the chest tube drainage system is below the level of the chest at all times to facilitate proper drainage by gravity. The nurse should expect bubbling in the water seal chamber on forced expiration or coughing, which is an indication that the system is working properly. Additionally, the nurse should avoid clamping the chest tube unless it becomes necessary to replace the drainage unit or locate an air leak.

A nurse in a clinic is providing teaching for a patient who is to have a tuberculin skin test. Which of the following information should the nurse include: A. "If the test is positive, it means you have an active case of tuberculosis." B. "If the test is positive, you should have another tuberculin skin test in 3 weeks." C. "You must return to the clinic to have the test read in 2 or 3 days." D. "A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance."

C. You must return to the clinic to have the test read in 2 to 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 bacillus. If the client does not return to have the test read within 72 hr, another tuberculin skin test is necessary Repeat TB test in 3 weeks = not necessary, pt will need chest xray

Crackles

Crackles, which are sometimes called rales, are wet, popping sounds the nurse can hear when auscultating the client's lungs. This condition occurs when there is fluid in the client's airways or alveoli. Crackles are a clinical manifestation of pneumonia.

Nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? A. Apply warm compresses to the face B. Take aspirin 650 mg by mouth for mild pain C. Close your mouth when sneezing D. Lie on your back with your head elevated 30 degree when resting

D. Lie on your back with your head elevated 30 degree when resting The nurse should instruct the client to rest in the semi-Fowler's position to prevent aspiration of nasal secretions. The client should open her mouth when sneezing to reduce straining on the incisional site. The client should avoid taking aspirin, because it increases the risk of bleeding by decreasing platelet aggregation. The client should apply cold compresses to his face to decrease swelling

A nurse is providing preoperative teaching to a patient who is to undergo a pneumoectomy. The patient states "I am afraid it will hurt to cough after surgery." Which of the following statements by the nurse is appropriate: A. "after the surgeon removes the lung, you will not need to cough." B. "I'll make sure you get a cough suppressant to keep you from straining the incision when you cough." C. "Don't worry. You will have a pump that delivers pain medication as you need it, so you will have very little pain." D. I will show you how to splint your incision while you cough.

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

Residual volume

Measures amt of air in lungs after forced expiration

Functional Residual Capacity

Measures amt of air in lungs after normal expiration

Vital lung capacity

Measures amt of air the client can exhale after maximum inhalation

Tactile fremitus

Tactile fremitus is a vibration of the chest wall that the nurse can feel when palpating the client's chest as the client repeats a syllable such as 'nine-nine'. Increased tactile fremitus is a clinical manifestation of pneumonia.

Pursed lip breathing

The client who uses pursed-lip breathing breathes in through the nares and out through pursed lips, rather than concentrating on using chest-wall muscles. - uses the intercostal muscles - Strengthens the diaphragm - Prolongs exhalation

A nurse is caring for a patient who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the patient's airway secretions: A. Patient is unable to speak B. Pts airway secretions were last suctioned 2 hours ago C. Pt coughs and expectorates a large mucous plug D. Nurse auscultates coarse crackles in the lung fields

The nurse auscultates course crackles in the lung field. nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions. client who has a tracheostomy with an inflated cuff in place is unable to speak. nurse should assess the need for suctioning every 2 hr and then suction as necessary. The nurse should assess the client's airway after coughing and only suction the client's secretions if the client is not able to cough and expectorate secretions.

A nurse is preparing to administer cisplatin IV to a patient with lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication? A. Hallucinations B. Pruritus C. Hand and foot syndrome D. Tinnitus

Tinnitis An adverse effect of cisplatin is ototoxicity, which can cause tinnitis. Hand and foot syndrome = adverse effect of capecitabine, an antineoplastic - medication used to treat breast and colorectal cancer. Pruritus is an adverse effect of methotrexate, which is used to treat cancer and rheumatoid arthritis. Hallucinations are an adverse effect of asparaginase, which is an antineoplastic medication used to treat acute lymphocytic leukemi

Albuterol

albuterol Administration Consideration Use cautiously in clients with hypertension and cerebral vascular disorders. Adverse Reaction Include tachycardia, tremor, hypertension, bronchospasm, headache and dizziness. Available Forms aerosol inhaler, tablets, injection. Class bronchodilator Contraindications May included drug hypersensitivity and breast-feeding. Indications Bronchospasm and the prevention of asthma triggered by exercise. IV_Facts Dilute before injection. Do not mix with other drugs. Nursing Consideration Assess respiratory status often. Watch for adverse reactions. Therapeutic Actions A beta-2 agonist that is primarily used to prevent or relieve bronchospasm.

Friction rub

described as grating, scratching sound of the heart indicative of pericarditis A friction rub is a scratching or squeaking sound the nurse can hear when auscultating the client's lungs. This condition occurs due to the pleural surfaces rubbing together. A friction rub is a clinical manifestation of pleurisy.

Metabolic alkalosis

high pH, high HCO3 Pt has excessive amount of bicarbonate Clients who use bicarbonate of soda as an antacid are at risk for the development of metabolic alkalosis. Excessive vomiting also places a client at risk for development of metabolic alkalosis.

Respiratory alkalosis

hyperventilation Occurs when pt exhales too much carbon dioxide