Chapter 19- Upper Respiratory PrepU Questions

The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient?

6-12 months

The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication?

ARDS

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?

PaO2 level of 90mmHg or higher

Which is a potential complication of a low pressure in the endotracheal tube cuff?

aspiration pneumonia

The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to:

assess pulse and BP

What assessment method would the nurse use to determine the areas of the lungs that need draining?

auscultation

For a client with an endotracheal (ET) tube, which nursing action is the most important?

auscultation of bilateral lung sounds

You are a clinic nurse caring for a client with acute tracheobronchitis. The client asks what may have caused the infection. Which of the following responses from the nurse would be most accurate?

chemical irritation

Which term refers to lung tissue that has become more solid in nature as a result of a collapse of alveoli or an infectious process?

consolidation

A client has a sucking stab wound to the chest. Which action should the nurse take first?

cover sound with dressing and tape on 3 sides

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema?

crackles in the lungs

What is the reason for chest tubes after thoracic surgery?

draining secretions, blood and air away from thoracic cavity as needed

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

dyspnea and wheezing

After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent?

effective breathing at 16 breaths per min through established airwasy

The nurse is assessing a patient who has been admitted with possible ARDS. Which finding would be evidence for a diagnosis of cardiogenic pulmonary edema rather than ARDS?

elevated BNP levels

A client who is post-thoracotomy is retaining secretions. What is the nurse's initial intervention?

encourage coughing

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?

encourage fluid intake

A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?

flail chest

A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?

impaired gas exchange

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result?

improved O2 transportation, induce slow deep breathing patterns, assist client to control breathing patterns

A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily?

intubate to control with mechanical breathing

The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique?

it prolongs exhalation

A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:

keeping airway patent

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

manual resuscitation bag

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which oxygen delivery method would give the greatest level of inspired oxygen?

non-rebreather mask

The nurse is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's:

oxygen saturation levels

A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?

oxygen toxicity

A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?

pneumothorax

A nurse is administering a purified protein derivative (PPD) test to a client. Which statement concerning PPD testing is true?

positive results indicate exposure to the disease

The nurse has admitted a client who is scheduled for a thoracic resection. The nurse is providing preoperative teaching and is discussing several diagnostic studies that will be required prior to surgery. Which study will be performed to determine whether the planned resection will leave sufficient functioning lung tissue?

pulmonary function tests

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS?

rapid onset of severe dyspnea

The most diagnostic clinical symptom of pleurisy is:

stabbing pain during respiratory movement

The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment?

tachypnea

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?

tension pneumothorax

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?

the patient is hypoxic from suctioning

Which type of ventilator has a preset volume of air to be delivered with each inspiration?

volume cycled

A client is admitted to the health care facility with active tuberculosis (TB). What intervention should the nurse include in the client's care plan?

wearing a disposable particulate respirator that fits snuggly around the face