Dynamic Quizzes: Respiratory

Tachycardia

A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure?

Chest tube insertion

A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client?

Crepitus

A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following?

Stabbing chest pain (A manifestation of a pulmonary embolism is sudden chest pain that is sharp and stabbing. Other manifestations include dyspnea, coughing, hemoptysis (coughing up blood), tachypnea, tachycardia, diaphoresis, and a feeling of impending doom.)

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism?

Respiratory obstruction (Intercostal retractions and a high-pitched inspiratory noise (i.e. stridor) are manifestations of an airway obstruction caused by laryngospasm and edema.)

A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. The nurse should identify these findings as manifestations of which of the following complications?

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

A nurse in the emergency department is assessing a client for 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 assess the client for which of the following manifestations of pneumothorax?

-Tracheal deviation to the left -Absent breath sounds on the right side -Neck vein distention (A trachea that is deviated to the unaffected side instead of being in the center of the neck is a manifestation of a pneumothorax. Absent breath sounds on the affected side and neck vein distention are also manifestations of a pneumothorax. As the client's difficulty breathing increases, the blood flow return compresses, causing the neck veins to distend.)

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? (Select all that apply.)

Evaluate the client for stridor (the nurse should continuously evaluate the client's respiratory status. Stridor is a high-pitched sound during inspiration that indicates laryngospasm)

A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first?

Stridor (a high-pitched crowing sound heard during inspiration)

A nurse is caring for a client immediately following extubation. Which of the following manifestations indicates that the nurse should call the rapid response team?

Lung cancer usually has metastasized before the client presents with symptoms.

A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client?

Increase the oxygen flow and request an arterial blood gas determination (The client requires oxygen therapy at a rate that will keep the oxygen saturation between 88% and 92%. The nurse should increase the client's oxygen flow and evaluate its effectiveness with ABG results and oxygen saturation via pulse oximetry measurements.)

A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2 L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take?

Immerse the end of the chest tube in a bottle of sterile water

A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take?

"The lower tube will drain blood, and the higher tube will remove air."

A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make?

Initiate bag-valve-mask ventilation

A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first?

Instruct the client to perform the Valsalva maneuver during removal (The nurse should instruct the client to perform the Valsalva maneuver during removal to maintain the appropriate amount of negative pressure in the chest in order to prevent air entry into the pleural space.)

A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take?

Addressing the client's perception of the disease process and what might have triggered past attacks

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first?

Tape all connections between the chest tube and drainage system

A nurse is planning 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?

Nasal cannula (A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate device for a client who has COPD and requires a precise percentage of inspired oxygen)

A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of chronic obstructive pulmonary disease (COPD). Which of the following oxygen-delivery methods should the nurse plan to use for this client?

-Explain that the client will receive sedation and will not remember the procedure. -Verify that the client understands the purpose and nature of the procedure.

A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (Select all that apply.)

Confirming the gag reflex

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority?

Sitting while leaning forward over the bedside table

A nurse is preparing a client for thoracentesis. In which of the following positions should the nurse place the client?

"I'll call the doctor if I see any blood in my urine or stool." (Bleeding precautions are essential for clients who had a pulmonary embolism because they take an anticoagulant. They should report any signs of bleeding immediately.)

A nurse is providing discharge teaching to a client who had a pulmonary embolism. Which of the following statements indicates that the client understands the information?

Draining blood and fluid from the pleural space

A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons?

"You will have a chest tube in place after surgery." "We'll frequently help you turn, cough, and breathe deeply after surgery." "We'll give you oxygen to support your breathing if you need it."

A nurse is providing preoperative teaching to a client who has lung cancer and will undergo a pneumonectomy. Which of the following statements should the nurse include? (Select all that apply.)

"I will show you how to splint your incision while coughing."

A nurse is providing preoperative teaching to a client who is to undergo a pneumonectomy. The client states, "I am afraid coughing will hurt after the surgery." Which of the following statements by the nurse is appropriate?

"A tissue sample might be obtained during the procedure."

A nurse is providing teaching to a client who has a chronic cough and is scheduled for a bronchoscopy. Which of the following client statements indicates an understanding of the teaching?

PaO2 50 mmHg (This client who has manifestations of ARDS has a low PaO2 level, even after the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS.)

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

Increased coughing

A nurse on a medical-surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the provider?

A client who has a chest tube following a pneumothorax (Crepitus, a crackling sound resulting from air trapped under the skin, can be palpated following a pneumothorax. The nurse should report this finding to the provider.)

A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus?

Sudden onset of dyspnea (Clinical manifestations of pulmonary embolism have a rapid onset)

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. Which of the following findings should the nurse recognize as an indication of pulmonary embolism?