EAQ Respiratory System

A client's respiratory status may be affected after abdominal surgery. The nurse documents the behavioral objective for this client. What statement is a behavioral objective?

Correct1 Demonstrates the technique of coughing and deep breathing Demonstrating the technique of coughing and deep breathing is an objective that includes observable client behavior, which is specified by amount and time and therefore is measurable. The statement that respirations will improve with coughing and deep breathing is an objective not stated in measurable terms. The statement that coughing and deep breathing will facilitate output of secretions is not stated in measurable terms. Telling the client to cough and deep breathe five or six times every hour while awake is a statement, not an objective.

The primary responsibility of a nurse when caring for a client with a chest tube attached to a three-chamber underwater-seal drainage system is to:

Correct1 Ensure maintenance of the closed system An airtight system is needed to reestablish negative pressure and reinflate the lung. Drainage can be maintained without mechanical suction. Encouraging coughing and deep breathing is important, but not the priority. Any position is acceptable as long as the tube is not compressed or pulled.

After a laryngectomy is scheduled, the most important factor for the nurse to include in the preoperative teaching plan is:

Correct1 Establishing a means for communicating postoperatively Communication is a priority; it facilitates interaction, limits anxiety, and promotes safety. A nasogastric tube can cause trauma to the suture lines; total parenteral nutrition may be used. Demonstrating how to care for a permanent laryngeal stoma is done postoperatively as the client begins to accept the laryngectomy. After a laryngectomy the client cannot cough; expectoration occurs through the stoma.

A nurse is teaching Hands Only Basic Life Support for adults in the community. What should the rescuer do first after determining that the person is not responding and the emergency medical system has been activated?

Correct1 Identify the absence of pulse. Once it is verified that the person is unresponsive and the emergency medical system has been activated, then whether the client is breathing should be established. Rescue breaths are not given with the hands-only basic life support method of CPR. Chest compressions are initiated as soon as it is identified that the person is not breathing; they are given at a rate of 100/min, to a depth of 2 inches each for 2 minutes, allowing full recoil between compressions. This quickly circulates the blood.

The nurse is caring for a client two days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for sputum that is:

Correct1 Sooty The mucous membranes of the respiratory tract may be charred after inhalation burns; this is evidenced by the production of sooty sputum. Frothy sputum usually is indicative of pulmonary edema. Yellow sputum usually is indicative of a respiratory infection. Tenacious sputum usually is indicative of respiratory infection.

A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and should begin with which aspect of care?

Correct1 The disease process and breathing exercises Clients need to understand the disease process and how interventions, such as breathing exercises, can improve ventilation. Learning to control or prevent respiratory infections is important, but it should be taught later. Although it is helpful to know about aerosol therapy and nebulizers, knowing how to use aerosol therapy, especially nebulizers, should be taught later. Although it is important to teach the client how to set priorities in carrying out everyday activities, this should be taught later.

A client with chronic obstructive pulmonary disease (COPD) reports chest congestion, especially upon wakening in the morning. The nurse should suggest that the client:

Correct1 Use a humidifier in the bedroom A humidifier will help liquefy secretions and promote their expectoration. Sleeping on pillows facilitates breathing; it does not relieve chest congestion. Nonproductive coughing should be avoided because it is irritating and exhausting. Deep breathing and coughing at night will not help relieve early morning congestion.

A client is admitted for dehydration, and an intravenous (IV) infusion of normal saline is started at 125 mL/hour. One hour later, the client begins screaming, "I can't breathe!" How should the nurse respond?

Correct2 Elevate the head of the client's bed and obtain vital signs Verbalization indicates that the client is breathing; elevating the head of the bed facilitates breathing by decreasing pressure against the diaphragm. Vital signs reflect the current status of the client. Auscultation of breath sounds should be done also. Discontinuing the IV access line is unsafe and may cause unnecessary discomfort if it must be restarted; more information is needed before calling the health care provider. No information is available to support changing the IV to an intermittent lock; assessment for allergies should be done on admission. Not enough information is available to support requesting a prescription for a sedative; further assessment is required.

A client is admitted for a rhinoplasty. To monitor for hemorrhage after the surgery, the nurse should assess specifically for the presence of:

Correct2 Excessive swallowing Internal bleeding after nasal surgery may flow by gravity to the posterior oropharynx, where it is swallowed. Facial edema is expected after the trauma of surgery. The edema that results from the trauma of surgery may be perceived as pressure around the eye; although it is expected, it is not a priority. Pink-tinged drainage on the nasal packing and nasal drip dressing is expected for 24 to 48 hours after surgery.

A client has a persistent productive cough that becomes blood tinged. A needle biopsy is scheduled. The client tells the nurse, "During the procedure, a needle will be inserted into my back to collapse my lung." Which is the most appropriate response by the nurse?

Correct3 "Tell me more about the conversation you had with your health care provider." Exploration and collection of data are important parts of the therapeutic process; anxiety, fear, and depression can influence understanding. The response "Your perception of the diagnostic test is incorrect" will put the client on the defensive. Instructing the client to ask the health care provider to clarify the procedure is not the priority; at this point, the nurse should collect more data. The response "The procedure will be fast so that you will experience minimal discomfort" is false reassurance.

After surgery to create an ileal conduit, a client is admitted to the postanesthesia care unit. Which clinical finding during the first hour of the postoperative period should the nurse report to the health care provider?

Correct3 Absence of urinary output Urine should drain continually from the conduit because there is no sphincter control, unless a continent conduit is created. The stoma may be edematous for several weeks after surgery. Vomiting is a common occurrence after anesthesia. Diminished bowel sounds are expected; peristalsis is decreased because of anesthesia and the stress of intestinal manipulation during surgery.

A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), the nurse should:

Correct3 Administer oxygen at a low concentration to maintain respiratory drive With chronically high levels of carbon dioxide it is believed that decreased oxygen levels become the stimulus to breathe; high oxygen administration negates this mechanism. However, the results of one recent study of clients with stable COPD indicate that the hypercarbic drive is preserved. More research is needed before this theory is applied clinically. Initiating pulmonary hygiene to clear air passages of trapped mucus is an appropriate intervention, but is not directly related to CO2 intoxication (CO2 narcosis). Encouraging continuous rapid panting to promote respiratory exchange will not bring oxygen into the alveoli for exchange nor will it adequately remove carbon dioxide because it will increase bronchiolar obstruction. Inhalation should be of regular depth, and expiration should be prolonged to prevent carbon dioxide trapping (air trapping).

Following a right pneumonectomy, a patient returns to the nursing unit. The priority nursing intervention is:

Correct3 Encourage deep breathing Encouraging deep breathing helps to keep the airway patent and prevents atelectasis of the remaining lung by raising intrapleural pressure. Although important, assessing for pain is not the priority. Removing the airway is done in the post anesthesia unit after the gag reflex returns. Placing the client on the left side will restrict left lung expansion.

The nurse is caring for a client that has a lesion in the right upper lobe. A diagnosis of tuberculosis (TB) has been made. What are the clinical manifestations of tuberculosis?

Correct3 Night sweats and blood-tinged sputum Blood-tinged sputum, in the absence of pronounced coughing, often is the presenting sign of TB; diaphoresis at night is a later sign. Recurrent fever is present; frothy sputum occurs with pulmonary edema. A productive cough occurs with TB. A productive cough occurs with TB, but engorged neck veins occur with heart failure.

A client is admitted to the hospital with a diagnosis of emphysema and dyspnea. The nurse should encourage the client to assume what position?

Correct3 Orthopneic The orthopneic position lowers the diaphragm and provides for maximum thoracic expansion. The supine position will not facilitate thoracic expansion because it permits abdominal organs to press against the diaphragm. The contour position will not facilitate thoracic expansion because it permits abdominal organs to press against the diaphragm. Although the semi-Fowler position can help, it is not as beneficial as the orthopneic position.

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. What is the priority nursing intervention?

Correct3 Place client in a high-Fowler position Placing the client in a high-Fowler position promotes lung expansion and gas exchange; it also decreases venous return and cardiac workload. Initiating oxygen therapy may be done, but positioning should be done first because it will have an immediate effect. Time is needed to set up the system for the delivery of oxygen. Maintaining adequate oxygen exchange is the priority; an x-ray film can be obtained, but after breathing is supported. A friction rub is related to inflammation of the pleura, not to heart failure.

The nurse is reviewing the client's health history. With which diagnosis is a client most likely to exhibit hemoptysis?

Correct3 Tuberculosis Hemoptysis is expectoration of blood-stained sputum derived from the lungs, bronchi, or trachea; this is a clinical manifestation of tissue erosion caused by tuberculosis. Anemia does not cause bleeding, but it may be caused by bleeding. Pneumonia causes sputum as a result of inflammation, but the sputum usually is yellow, not bloody. Leukocytosis is increased white blood cells; it does not cause hemoptysis.

What breathing exercises should the nurse teach a client with the diagnosis of emphysema?

Correct4 Diaphragmatic exercises to improve contraction of the diaphragm. With emphysema the diaphragm is flattened and weakened; strengthening the diaphragm is desirable to maximize exhalation. Prolonged exhalations are more desirable; clients with emphysema have an increased residual volume, which eventually causes a barrel chest. Abdominal exercises enhance, not limit, the accessory muscles of respiration which are needed as a compensatory mechanism for clients with emphysema. Sit-ups are too strenuous for clients with emphysema.

Immediately after a storm has passed, the nurse is working with a rescue team that is searching for injured people. The nurse finds a victim lying next to a broken natural gas main. The victim is not breathing and is bleeding heavily from a wound on the foot. What should be the nurse's first intervention?

Correct4 Safely remove the victim from the immediate vicinity. The first action should be to safely remove the victim from the source of further injury. Treating the victim for shock is not the priority. Breathing is the priority once further injury is avoided. Applying surface pressure to the foot wound should be the last concern. The guidelines for CPR should be followed.

A client has a total hip replacement for long-standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is:

Correct4 Pulmonary embolism A pulmonary embolism is the most common complication of hip surgery because of high vascularity and the release of fat cells from the bone marrow. The occurrence of pneumonia is rare because of early activity after surgery. In addition, the operative area is not in proximity to the diaphragm and lungs; therefore, it does not impede deep breathing. Postoperative hemorrhage with hip surgery is rare because bleeding at the operative site is not covert. The incidence of wound infection is no greater than with other postoperative clients.