care of the patient with a respiratory disorder

2) guaifenesin is an expectorant. it needs to be taken with a full glass of water to decrease the viscosity of secretions. sustained-release preparations are not to be broken open, crushed, or chewed. the medication may occasionally cause dizziness, headache, and drowsiness. the client needs to contact the primary health care provider if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache.

a client has a prescription to take sustained-released guaifenesin every 4 hours, as needed. the nurse determines that the client understands how to most effectively use this medication if the client makes which statement? 1) "i will watch for irritability as a side effect." 2) "i will take the tablet with a full glass of water." 3) "i will need an extra dose if the cough is accompanied by fever." 4) "i will crush the sustained-release tablet if immediate relief is needed."

4) acetylcysteine can be given orally or by nasogastric tube to treat acetaminophen overdose, or it may be given by inhalation for use as a mucolytic. the nurse administering this medication as a mucolytic needs to have suction equipment available in case the client cannot manage to clear the increased volume of liquefied secretions.

a client is receiving acetylcysteine, 20% solution diluted in 0.9% normal saline by nebulizer. the nurse needs to have which item available for a possible adverse event after giving this medication? 1) ambu bag 2) intubation tray 3) nasogastric tube 4) suction equipment

a) the nurse should identify irritability as a finding associated with respiratory failure, as it results from a lack of oxygen. c) the nurse should expect the client to experience difficulty breathing while lying flat when experiencing respiratory failure. the client will likely be restless and want to sit up to relieve the work of breathing. e) the nurse should expect the client to exhibit dyspnea, or shortness of breath, when experiencing respiratory failure.

a nurse at a long-term care facility is collecting data from a client who has a history of asthma and has developed pneumonia. which of the following findings indicate the client is developing respiratory failure? (select all that apply.) a) irritability b) flushed skin c) orthopnea d) heart rate 55/min e) dyspnea

c) respiratory acidosis is always due to inadequate excretion of CO2 with inadequate ventilation, resulting in elevated plasma CO2. any condition that causes hypoventilation is associated with an elevated PaCO2. hyperventilation, causes a decrease in CO2 and is associated with respiratory alkalosis.

a nurse is analyzing her patient's ABG values. which result is inconsistent with the diagnosis of respiratory acidosis? a) pH 7.3 b) PaCO2 50 c) hyperventilation d) hypoventilation

d) the nurse should instruct the client to take a deep breath, exhale, and bear down as the chest tube is being removed. this increases intrathoracic pressure and reduces the risk of an air embolism.

a nurse is assisting a provider with the removal of a chest tube. which of the following actions should the nurse instruct the client to do? a) lie on his left side. b) use the incentive spirometer. c) cough at regular intervals. d) perform the valsalva maneuver.

c) the first action the nurse should take when using the airway, breathing, and circulation approach to client care is to administer oxygen via high-flow mask to provide the client oxygen to restore optimal breathing.

a nurse is assisting in the care of a client who has ARDS with absent breath sounds in the lower lobes and dyspnea. which of the following actions should the nurse take first? a) obtain a chest x-ray. b) prepare for chest tube insertion. c) administer oxygen via a high-flow mask. d) ensure IV access.

b) the nurse should provide emotional support to decrease anxiety. c) the nurse should encourage the client to cough to promote airway clearance. d) the nurse should perform oral suctioning as necessary to promote airway clearance.

a nurse is assisting with the plan of care for a client who has respiratory distress. which of the following interventions should the nurse include in the plan? (select all that apply.) a) position the client on his left side. b) provide emotional support to the client. c) encourage the client to cough. d) perform oral suctioning as needed. e) have the client take short, shallow breaths.

b) providing supplemental oxygen should be included in the plan of care for SARS. oxygen reverses severe hypoxemia. d) administration of bronchodilators should be included in the plan of care for SARS. bronchodilators vasodilate the airway. e) maintaining ventilatory support should be included in the plan of care for SARS. the client can require intubation to maintain a patent airway.

a nurse is assisting with the plan of care for a client who has severe acute respiratory distress system. which of the following interventions should the nurse recommend? (select all that apply.) a) administer antibiotics. b) provide supplemental oxygen. c) administer antiviral medications. d) administer bronchodilators. e) maintain ventilatory support.

2) signs of allergic reaction to the contrast medium include localized itching and edema, respiratory distress, stridor, and decreased blood pressure. hypothermia is an unrelated event. hematoma formation is a complication of the procedure, but does not indicate an allergic reaction. discomfort is expected.

a nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. the nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which? 1) hypothermia 2) respiratory distress 3) hematoma in the left groin 4) discomfort in the left groin

a) dyspnea can indicate a pneumothorax or a reaccumulation of fluid. thee nurse should notify the provider immediately. c) fever can indicate an infection. the nurse should notify the provider immediately. d) hypotension can indicate intrathoracic bleeding. the nurse should notify the provider immediately.

a nurse is caring for a client following a thoracentesis. which of the following manifestations should the nurse recognize as risks for complications? (select all that apply.) a) dyspnea b) localized bloody drainage on the dressing c) fever d) hypotension e) report of pain at the puncture site

a) humidification should be provided for flow rates of 3 L/min or greater.

a nurse is caring for a client who has a new prescription for oxygen therapy of 4 L/min using a nasal cannula. which of the following actions should the nurse take? a) provide humidification. b) remove the cannula during meal times,. c) establish an alternative means of communication. d) lubricate the nares with 0.9% sodium chloride.

b) the greatest risk to the client is the possibility of bleeding from a peptic ulcer. the priority intervention is to notify the provider of the finding.

a nurse is caring for a client who has a pulmonary embolism and a new prescription for heparin therapy. which of the following statements by the client should indicate an immediate concern for the nurse? a) "i am allergic to morphine." b) "i take antacids several times a day for a stomach ulcer." c) "i had a blood clot in my leg several years ago." d) "it hurts to take a deep breath."

c) an aspirin overdose would result in ABG results that indicate metabolic acidosis.

a nurse is caring for a client who has confusion and lethargy. the client was unresponsive at home, with an empty bottle of aspirin lying next to her bed. vital signs are blood pressure 104/72 mm Hg, heart rate 116/min and regular, and respiratory rate 42/min with deep respirations. which of the following arterial blood gas results should the nurse expect? a) pH 7.68 PaCO2 38 mm Hg HCO3- 28 mEq/L b) pH 7.48 PaCO2 28 mm Hg HCO3- 23 mEq/L c) pH 7.16 PaCO2 38 mm Hg HCO3- 18 mEq/L d) pH 7.58 PaCO2 38 mm Hg HCO3- 29 mEq/L

b) a venturi mask incorporates an adapter that allows a precise amount of oxygen to be delivered.

a nurse is caring for a client who has dyspnea and will receive oxygen continuously. which of the following oxygen devices should the nurse use to deliver a precise amount of oxygen to the client? a) nonrebreather mask b) venturi mask c) nasal cannula d) simple face mask

a) metabolic acidosis results from an excess production of hydrogen ions, which occurs with diabetic ketoacidosis.

a nurse is caring for a client who has metabolic acidosis. which of the following components of the client's medical history should the nurse identify as a risk factor for this acid-base imbalance? a) diabetic ketoacidosis b) sleep apnea c) asthma d) pulmonary edema

b) pale skin is an early manifestation of hypoxemia. e) elevated blood pressure is an early manifestation of hypoxemia.

a nurse is caring for a client who is experiencing respiratory distress. which of the following early manifestations of hypoxemia should the nurse recognize? (select all that apply.) a) confusion b) pale skin c) bradycardia d) hypotension e) elevated blood pressure

a) oxygen equipment is necessary to have in the client's room if the client becomes short of breath following the procedure. c) pulse oximetry is necessary to monitor oxygen saturation level during the procedure. d) a sterile dressing is necessary to apply to the puncture site following the procedure.

a nurse is caring for a client who is scheduled for a thoracentesis. which of the following supplies should the nurse ensure are in the client's room? (select all that apply.) a) oxygen equipment b) incentive spirometer c) pulse oximeter d) sterile dressing e) suture removal kit

a) the client who has undergone a major surgical procedure within the last 3 weeks should not receive thrombolytic therapy because of the risk of hemorrhage from the surgical site.

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? a) hip arthroplasty 2 weeks ago b) elevated sedimentation rate c) incident of exercise-induced asthma 1 week ago d) elevated platelet count

a) a pneumothorax can cause hypoventilation and increased carbon dioxide levels, resulting in respiratory acidosis.

a nurse is caring for a client who was in a motor-vehicle crash. the client reports chest pain and difficulty breathing. a chest x-ray indicates that the client has a pneumothorax. which of the following ABG results should the nurse expect? a) pH 7.06 PaCO2 52 mm Hg HCO3- 24 mEq/L b) pH 7.42 PacO2 38 mm Hg HCO3- 23 mEq/L c) pH 7.20 PaCO2 39 mm Hg HCO3- 18 mEq/L d) pH 7.58 PaCO2 38 mm Hg HCO3- 29 mEq/L

a) the client who has a BMI of 30 is considered obese and is at increased risk for a blood clot. c) a fractured bone, particularly in a long bone such as the femur, increases the risk of fat emboli. e) the client who has turbulent blood flow in the heart, such as with atrial defibrillation, is at an increased risk of a blood clot.

a nurse is caring for a group of clients. which of the following clients are at risk for a pulmonary embolism? (select all that apply.) a) a client who has a BMI of 30 b) a client who is postmenopausal c) a client who has a fractured femur d) a client who is a marathon runner e) a client who has chronic atrial fibrillation

d) intermittent bubbling in the water-seal chamber is normal, but continuous bubbling can indicate an air leak. fluctuation of the water level in the water-seal is called tidaling. bubbling and tidaling do not occur when the tube is placed in the mediastinal space.

a nurse is caring for a patient diagnosed with lung cancer who has a chest tube. the chest tube has continuous bubbling in the water-seal chamber. what does the nurse understand this indicates? a) tidaling b) the in the mediastinum c) a properly functioning system d) an air leak in the system

d) excessive vomiting causes a loss of gastric acids and an accumulation of bicarbonate in the blood, resulting in metabolic alkalosis.

a nurse is checking ABG results for a client who has vomited repeatedly during the past 24 hr. which of the following acid-base imbalances should the nurse expect? a) respiratory acidosis b) respiratory alkalosis c) metabolic acidosis d) metabolic alkalosis

b) gentle bubbling in the suction control chamber is an expected finding as air is being removed. c) a rise and fall of the fluid level in the water seal chamber upon inspiration and expiration indicates that the drainage system is functioning properly.

a nurse is collecting data from a client who has a chest tube and drainage system in place. which of the following findings should the nurse expect? (select all that apply.) a) continuous bubbling in the water seal chamber b) gentle constant bubbling in the suction control chamber c) rise and fall in the level of water in the water seal chamber with inspiration and expiration d) exposed sutures without dressing e) drainage system upright at chest level

a) tachycardia is an expected finding of metabolic and respiratory acidosis. e) dysrhythmias are an expected finding of metabolic and respiratory acidosis. f) tachypnea is an expected finding of pancreatitis, metabolic acidosis, and respiratory acidosis.

a nurse is collecting data from a client who has pancreatitis. the client's ABGs indicate metabolic acidosis. which of the following findings should the nurse expect? (select all that apply.) a) tachycardia b) hypertension c) bounding pulses d) insomnia e) dysrhythmias f) tachypnea

c) a change in color of sputum can be a manifestation of an infection.

a nurse is collecting data from a client who is receiving mechanical ventilation. which of the following findings indicates that the client might have developed an infection? a) decrease in blood pressure b) increase in abdominal girth c) change in sputum color d) absent breath sounds over one lung area

d) laryngospasms can indicate the client is having difficulty maintaining a patent airway. the nurse should notify the provider immediately.

a nurse is collecting data on a client following a bronchoscopy. which of the following findings should the nurse report to the provider? a) blood-tinged sputum b) dry, nonproductive cough c) sore throat d) laryngospasm

a) the client who has a pneumothorax can experience tachypnea related to respiratory distress caused by the injury. b) the client who has a pneumothorax can experience deviation of the trachea as tension increases within the chest. e) the client who has a pneumothorax can experience pleuritic pain related to the inflammation of the pleura of the lung caused by the injury.

a nurse is collecting data on 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.) a) tachypnea b) deviation of the trachea c) bradycardia d) decreased use of accessory muscles e) pleuritic pain

b) the nurse should expect the client to have a pleural friction rub. d) the nurse should expect the client to have petechiae. e) the nurse should expect the client to have tachycardia.

a nurse is collecting data on a client who has a pulmonary embolism. which of the following manifestations should the nurse expect to find? (select all that apply.) a) bradypnea b) pleural friction rub c) hypertension d) petechiae e) tachycardia

b) the client can have cyanosis as a manifestation indicative of flail chest due to inadequate oxygenation. c) the client can have hypotension as a manifestation indicative of flail chest. d) the client can have dyspnea as a manifestation indicative of flail chest. this is due to injury and the client's inability to effectively inhale and exhale. e) the client can have paradoxic chest movement as a manifestation indicative of flail chest. this is due to injury to the chest and the inability to inhale and exhale.

a nurse is collecting data on a client who has a suspected flail chest. which of the following findings should the nurse expect? (select all that apply.) a) bradycardia b) cyanosis c) hypotension d) dyspnea e) paradoxic chest movement

d) the client should notify the provider of a productive or persistent cough. this can indicate need for treatment of a respiratory infection.

a nurse is reinforcing discharge instructions for a client who experienced a pneumothorax which of the following statements should the nurse use when teaching the client? a) "notify your provider if you experience weakness." b) "you should be able to return to work in 1 week." c) "you need to wear a mask when in crowded areas." d) "notify your provider if you experience a productive cough."

b) vecuronium is a neuromuscular blocking agent given to facilitate ventilation, especially with ventilator settings that could be painful. it also helps decrease oxygen consumption.

a nurse is reinforcing teaching with the family of a client who has acute respiratory distress syndrome and is receiving vecuronium. which of the following statements by a family member should the nurse identify as understanding of the teaching? a) "this medication is given to treat infection." b) "this medication is given to facilitate ventilation." c) "this medication is given to decrease inflammation." d) "this medication is given to reduce anxiety."

c) when using the airway, breathing, circulation priority approach to care, the priority finding is related to the respiratory status. meeting oxygenation needs by administering oxygen therapy is the priority action.

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 38.4 degrees C, and blood pressure 100/54 mm Hg. which of the following nursing actions is the priority? a) notify the provider. b) ensure access to heparin via IV infusion. c) administer oxygen therapy. d) obtain a spiral CT scan.

a) a client who experienced a near-drowning incident is at risk for developing ARDS due to trauma to the lungs and cerebral edema. b) a client following coronary artery bypass graft surgery is at risk for developing ARDS due to trauma to the chest. d) a client who has dysphagia is at risk for developing ARDS due to difficulty swallowing and risk for aspiration. e) a client who experienced a drug overdose is at risk for developing ARDS due to damage to the central nervous system.

a nurse is reviewing the health records of five clients. which of the following clients are at risk for developing acute respiratory distress syndrome? (select all that apply.) a) a client who experienced a near-drowning incident b) a client following coronary artery bypass graft surgery c) a client who has a hemoglobin of 15.1 mg/dL d) a client who has dysphagia e) a client who experienced a drug overdose

b) the priority action the nurse should take when using the airway, breathing, circulation approach to client care is to establish and maintain the client's respiratory function. obtaining a large-bore IV needle for decompression is the priority action.

a nurse is reviewing the prescriptions for a client who has a pneumothorax. which of the following actions should the nurse perform first? a) check the client's pain. b) obtain a large-bore IV needle for decompression. c) administer lorazepam. d) prepare for chest tube insertion.

c) dyspnea, the main symptom of both types of PAH, first occurs with exertion and eventually at rest. other signs and symptoms include chest pain, weakness, fatigue, syncope, occasional hemoptysis, and signs of right-sided heart failure.

a nurse working on a general medical-surgical floor is discussing the clinical manifestations of pulmonary arterial hypertension with a recent nursing graduate. what is the main symptom of PAH that the nurse would explain? a) chest pain b) fatigue c) dyspnea d) hemoptysis

c) normal saline is used with blood transfusions and to replace large sodium losses, as in burn injuries. it is not used for heart failure, pulmonary edema, renal impairment, or sodium retention.

a nurse working on a trauma unit is initiating IV fluids for a patient. for what condition would the nurse administer normal saline? a) renal impairment b) pulmonary edema c) burns d) heart failure

b) the basic physiologic disturbances in SIADH are excessive ADH activity, with water retention and dilutional hyponatremia, and inappropriate urinary excretion of sodium in the presence of hyponatremia. serum sodium levels are decreased. urine osmolarity is increased in SIADH.

a patient is diagnosed with SIADH. what disturbance should the nurse be aware of related to this diagnosis? a) excess water loss b) dilutional hyponatremia c) serum sodium level of 148 mg/dL d) decreased urine osmolarity

d) thrombolytic therapy dissolves the thrombi or emboli more quickly and restores more normal hemodynamic functioning of the pulmonary circulation, thereby reducing pulmonary hypertension and improving perfusion, oxygenation, and cardiac output. however, bleeding is a significant side effect. chest pain, a rash, and elevated temperature are not therapy-specific side effects associated with the use of thrombolytics.

a patient is receiving thrombolytic therapy for treatment of a pulmonary emboli. for what side effect should the nurse monitor the patient? a) chest pain b) rash c) hyperthermia d) bleeding

3) naloxone hydrochloride is an antidote to opioids and may also be given to the postoperative client to treat respiratory depression. when given to the postoperative client for respiratory depression, it may also reverse the effects of analgesics. therefore, the nurse needs to check the client for a sudden increase in the level of pain experienced. options 1, 2, and 4 are not associated with this medication.

a postoperative client has received a dose of naloxone hydrochloride for respiratory depression shortly after transfer to the nursing unit from the postanesthesia care unit. after administration of the medication, the nurse needs to check the client for which sign/symptom? 1) pupillary changes 2) scattered lung wheezes 3) sudden increase in pain 4) sudden episodes of diarrhea

1) 2) 5) pleurisy is inflammation of the pleura. the most characteristic symptom of pleurisy is abrupt and severe pain. the pain almost always occurs on one side of the chest. pleurisy pain is sharp, knife-like, and abrupt in onset and is most evident during inspiration. this causes shallow breathing. and pleural friction rub may be heard.

the client is diagnosed with pleurisy. the nurse would expect to see which signs/symptoms? select all that apply. 1) pleural friction rub 2) sharp, knife-like pain 3) cyanosis of lips and nailbeds 4) pain that occurs on both sides of the chest 5) pain that occurs most often during inspiration

2) if an alarm is sounding at any time and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and a manual resuscitation device is used to support respirations until the problem can be corrected. although oxygen is helpful, it will not provide ventilation to the client. checking vital signs is not the initial action. there is no reason to begin CPR.

the low-pressure alarm sounds on the ventilator. the nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. which initial action would the nurse take? 1) administer oxygen. 2) ventilate the client manually. 3) check the client's vital signs. 4) start cardiopulmonary resuscitation.

c) during inspiration, as the chest expands, the detached part of the rib segment moves in a paradoxical manner in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs. on expiration, because the intrathoracic pressure exceeds atmospheric pressure, the flail segment bulges outward, impairing the patient's ability to exhale. hypotension, inadequate tissue perfusion, and metabolic acidosis often follow as the paradoxical motion of the mediastinum decreases cardiac output. metabolic alkalosis and respiratory alkalosis would not be an assessment finding that correlates with a flail chest.

the nurse is assessing a patient with a blunt chest trauma due to an MVA. what finding would be indicative of a flail chest? a) hypertension b) metabolic alkalosis c) paradoxical chest movement d) respiratory alkalosis

1) complete lateral positioning is contraindicated for a client following pneumonectomy. because the mediastinum is no longer held in place on both sides by lung tissue, lateral positioning may cause mediastinal shift and compression of the remaining lung. the head of the bed needs to be elevated.

the nurse is assigned to care for a client after a left pneumonectomy. which position is contraindicated for this client? 1) lateral position 2) low fowler's position 3) semi-fowler's position 4) head of the bed elevation at 40 degrees

3) if a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. frank blood indicates hemorrhage. a dry cough may be expected. the client needs to be assessed for signs of complications, which would include cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. hematuria is unrelated to this procedure.

the nurse is caring for a client after a bronchoscopy and biopsy. which finding needs to be reported immediately to the primary health care provider? 1) dry cough 2) hematuria 3) bronchospasm 4) blood-tinged sputum

b) the use of PEEP helps increase functional residual capacity and reverse alveolar collapse by keeping the alveoli open, resulting in improved arterial oxygenation and a reduction in the severity of the ventilation-perfusion imbalance. the use of positive-pressure ventilation increases intrathoracic pressure and causes a decrease in preload to the heart.

the nurse is caring for a client diagnosed with ARDS. in evaluating the use of PEEP, what outcome would the nurse expect to find? a) increased ventilation-perfusion mismatch b) increased FRC c) decreased intrathoracic pressure d) decreased FRC

4) pursed lip breathing facilitates maximal expiration for clients with obstructive lung disease and promotes carbon dioxide elimination. this type of breathing allows better expiration by increasing airway pressure, which keeps air passages open during exhalation. options 1, 2, and 3 are not the purposes of this type of breathing.

the nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its purpose. the nurse would tell the client that the primary purpose of pursed lip breathing is which? 1) promote oxygen intake 2) strengthen the diaphragm 3) strengthen the intercostal muscles 4) promote carbon dioxide elimination

4) shortness of breath is an early sign of exacerbation of pulmonary sarcoidosis. others include chest pain, hemoptysis, and pneumothorax. systemic signs/symptoms that occur later include weakness and fatigue, malaise, fever, and weight loss.

the nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. the nurse knows that the client understands the information if the client verbalizes which early sign of exacerbation? 1) fever 2) fatigue 3) weight loss 4) shortness of breath

d)

what does the nurse expect to see in the ECG reading when serum potassium levels rise to greater than 6 mEq/L? a) peaked, widened T waves b) ST-segment elevation c) lengthened QT interval d) ST-segment depression

b)

when entering a patient's room, the nurse notices blood clots in the IV line. what is the most appropriate nursing intervention at this time? a) milk the tubing. b) discontinue the infusion. c) irrigate the tubing and catheter. d) aspirate the clot from the tubing.