Hinkle Ch. 19: Management of Patients with Chest and Lower Respiratory Tract Disorders

What assessment method would the nurse use to determine the areas of the lungs that need draining? - Inspection - Chest X-ray - Arterial blood gas (ABG) levels - Auscultation

- Auscultation Explanation: The nurse should assess breath sounds before doing postural drainage to determine the areas that need draining. Inspection, chest X-rays, and ABG levels are all assessment parameters that give good information about respiratory function but aren't necessary to determine lung areas requiring postural drainage.

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? - Aspiration - Drug ingestion - Chemical irritation - Direct lung damage

- Chemical irritation Explanation: Chemical irritation from noxious fumes, gases, and air contaminants can induce acute tracheobronchitis. Aspiration related to near drowning or vomiting, drug ingestion or overdose, and direct damage to the lungs are factors associated with the development of acute respiratory distress syndrome.

The nurse is having an information session with a women's group at the YMCA about lung cancer. What frequent and commonly experienced symptom should the nurse be sure to include in the session? - Copious sputum production - Coughing - Dyspnea - Severe pain

- Coughing Explanation: The most frequent symptom of lung cancer is cough or change in a chronic cough. People frequently ignore this symptom and attribute it to smoking or a respiratory infection. The cough may start as a dry, persistent cough, without sputum production. When obstruction of airways occurs, the cough may become productive due to infection.

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? - Give antibiotics as ordered. - Place client on bed rest. - Encourage increased fluid intake. - Offer nutritious snacks 2 times a day.

- Encourage increased fluid intake. Explanation: The nurse places the client in semi-Fowler's position to aid breathing and increase the amount of air taken with each breath. Increased fluid intake is important to encourage because it helps to loosen secretions and replace fluids lost through fever and increased respiratory rate. The nurse monitors fluid intake and output, skin turgor, vital signs, and serum electrolytes. He or she administers antipyretics as indicated and ordered. Antibiotics are not given for viral pneumonia. The client's activity level is ordered by the physician, not decided by the nurse.

The nurse knows the mortality rate is high in lung cancer clients due to which factor? - Increase in women smokers - Increased incidence among the elderly - Increased exposure to industrial pollutants - Few early symptoms

- Few early symptoms Explanation: Because lung cancer produces few early symptoms, its mortality rate is high. Lung cancer has increased in incidence due to an increase in the number of women smokers, a growing aging population, and exposure to pollutants but these are not directly related to the incidence of mortality rates.

The nurse is assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis? - Pain in the feet - Coolness to lower extremities - Decreased urinary output - Localized calf tenderness

- Localized calf tenderness Explanation: If the client were to complain of localized calf tenderness, the nurse would know this is a possible indication of a deep vein thrombosis. The area of tenderness could also be warm to touch. The client's urine output should not be impacted. Pain in the feet is not an indication of possible deep vein thrombosis.

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? - Keeping the head of the bed at 15 degrees or less - Turning the client every 4 hours to prevent fatigue - Using strict hand hygiene - Providing oral hygiene daily

- Using strict hand hygiene Explanation: The nurse should use strict hand hygiene to help minimize the client's exposure to infection, which could lead to pneumonia. The head of the bed should be kept at a minimum of 30 degrees. The client should be turned and repositioned at least every 2 hours to help promote secretion drainage. Oral hygiene should be performed every 4 hours to help decrease the number of organisms in the client's mouth that could lead to pneumonia.

Which type of ventilator has a preset volume of air to be delivered with each inspiration? - Negative pressure - Volume cycled - Time cycled - Pressure cycled

- Volume cycled Explanation: With volume-cycled ventilation, the volume of air to be delivered with each inspiration is preset. Negative-pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a preset pressure, and then cycles off, and expiration occurs passively.

A nurse is teaching a client how to perform flow type incentive spirometry prior to his scheduled thoracic surgery. What instruction should the nurse provide to the client? - "Hold the spirometer at your lips and breathe in and out like you normally would." - "When you're ready, blow hard into the spirometer for as long as you can." - "Take a deep breath and then blow short, forceful breaths into the spirometer." - "Breathe in deeply through the spirometer, hold your breath briefly, and then exhale."

- "Breathe in deeply through the spirometer, hold your breath briefly, and then exhale." Explanation: The client should be taught to lace the mouthpiece of the spirometer firmly in the mouth, breathe air in through the mouth, and hold the breath at the end of inspiration for about 3 seconds. The client should then exhale slowly through the mouthpiece.

The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse? - "The tube will allow air to be restored to the lung." - "The tube will drain secretions from the lung." - "The tube will provide a route for medication instillation to the lung." - "The tube will drain air from the space around the lung."

- "The tube will drain air from the space around the lung." Explanation: Negative pressure must be maintained in the pleural cavity for the lungs to be inflated. An injury that allows air into the pleural space will result in a collapse of the lung. The chest tube can be used to drain fluid and blood from the pleural cavity and to instill medication, such as talc, to the cavity.

A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine? - "Getting the flu can complicate pneumonia." - "Influenza vaccine will prevent typical pneumonias." - "Influenza is the major cause of death in the United States." - "Viruses like influenza are the most common cause of pneumonia."

- "Viruses like influenza are the most common cause of pneumonia." Explanation: Influenza type A is a common cause of pneumonia. Therefore, preventing influenza lowers the risk of pneumonia. Viral URIs can make the client more susceptible to secondary infections, but getting the flu is not a preventable action. Bacterial pneumonia is a typical pneumonia and cannot be prevented with a vaccine that is used to prevent a viral infection. Influenza is not the major cause of death in the United States. Combined influenza with pneumonia is the major cause of death in the United States.

A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation? - 5-mm induration - Reddened area - 15-mm induration - A blister

- 15-mm induration Explanation: A 10-mm induration strongly suggests a positive response in this tuberculosis screening test; a 15-mm induration clearly requires further evaluation. A reddened area, 5-mm induration, and a blister aren't positive reactions to the test and require no further evaluation.

The nurse is administering anticoagulant therapy with heparin. What International Normalized Ratio (INR) would the nurse know is within therapeutic range? - 0.5 to 1.0 - 1.5 to 2.5 - 2.0 to 2.5 - 3.0 to 3.5

- 2.0 to 2.5 Explanation: Low-molecular- weight heparin and fondaparinux (Arixtra) are the cornerstones of therapy, but IV unfractionated heparin may be used during the initial phase (ACCP, 2012). The early maintenance phase of anticoagulation typically consists of overlapping regimens of heparins or fondaparinux for at least 5 days with an oral vitamin K antagonist (e.g., warfarin [Coumadin]). A 3- to 6-month regimen of long-term maintenance with warfarin is typical but depends on the risks of recurrence and bleeding (ACCP, 2012). Heparin must be continued until the INR is within a therapeutic range, typically 2.0 to 3 (Kearon, Kahn, Agnelli, et al., 2008).

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? - 3 months - 3 to 5 months - 6 to 12 months - 13 to 18 months

- 6 to 12 months Explanation: Pulmonary tuberculosis (TB) is treated primarily with anti-TB agents for 6 to 12 months. A prolonged treatment duration is necessary to ensure eradication of the organisms and to prevent relapse.

Acute respiratory failure (ARF) occurs when oxygen tension (PaO2) falls to less than __________ mm Hg (hypoxemia) and carbon dioxide tension (PaCO2) rises to greater than __________ mm Hg (hypercapnia). - 60; 50 - 60; 40 - 75; 50 - 75; 40

- 60; 50 Explanation: Acute respiratory failure (ARF) is classified as hypoxemic (decrease in arterial oxygen tension [PaO2] to less than 60 mm Hg on room air) and hypercapnic (increase in arterial carbon dioxide tension [PaCO2] to greater than 50 mm Hg with an arterial pH of less than 7.35).

What would the critical care nurse recognize as a condition that may indicate a client's need to have a tracheostomy? - A client has a respiratory rate of 10 breaths per minute. - A client requires permanent ventilation. - A client exhibits symptoms of dyspnea. - A client has respiratory acidosis.

- A client requires permanent ventilation. Explanation: A tracheostomy permits long-term use of mechanical ventilation to prevent aspiration of oral and gastric secretions in the unconscious or paralyzed client. Indications for a tracheostomy do not include a respiratory rate of 10 breaths per minute, symptoms of dyspnea, or respiratory acidosis.

Which would be least likely to contribute to a case of hospital-acquired pneumonia? - Host defenses are impaired. - Inoculum of organisms reaches the lower respiratory tract and overwhelms the host's defenses. - A highly virulent organism is present. - A nurse washes her hands before beginning client care.

- A nurse washes her hands before beginning client care. Explanation: HAP occurs when at least one of three conditions exists: host defenses are impaired, inoculums of organisms reach the lower respiratory tract and overwhelm the host's defenses, or a highly virulent organism is present.

The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration? - A resident who suffered a severe stroke several weeks ago - A resident with mid-stage Alzheimer disease - A 92-year-old resident who needs extensive help with ADLs - A resident with severe and deforming rheumatoid arthritis

- A resident who suffered a severe stroke several weeks ago Explanation: Aspiration may occur if the client cannot adequately coordinate protective glottic, laryngeal, and cough reflexes. These reflexes are often affected by stroke. A client with mid-stage Alzheimer disease does not likely have the voluntary muscle problems that occur later in the disease. Clients that need help with ADLs or have arthritis should not have difficulty swallowing unless it exists secondary to another problem.

On auscultation, which finding suggests a right pneumothorax? - Bilateral inspiratory and expiratory crackles - Absence of breath sounds in the right thorax - Inspiratory wheezes in the right thorax - Bilateral pleural friction rub

- Absence of breath sounds in the right thorax Explanation: In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.

The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test? - Administer intradermal injections into each child's inner forearm. - Administer intramuscular injections into each child's vastus lateralis. - Administer a subcutaneous injection into each child's umbilical area. - Administer a subcutaneous injection at a 45-degree angle into each child's deltoid.

- Administer intradermal injections into each child's inner forearm. Explanation: The purified protein derivative (PPD) is always injected into the intradermal layer of the inner aspect of the forearm. The subcutaneous and intramuscular routes are not utilized.

A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute? - Droplet precautions - Airborne and contact precautions - Contact and droplet precautions - Contact precautions

- Airborne and contact precautions Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. The client should be placed on airborne and contact precautions to prevent the spread of infection. Droplet precautions don't require a negative air pressure room and wouldn't protect the nurse who touches contaminated items in the client's room. Contact precautions alone don't provide adequate protection from airborne particles.

Which is a potential complication of a low pressure in the endotracheal tube cuff? - Tracheal bleeding - Aspiration pneumonia - Tracheal ischemia - Pressure necrosis

- Aspiration pneumonia Explanation: Low pressure in the cuff can increase the risk for aspiration pneumonia. High pressure in the cuff can cause tracheal bleeding, ischemia, and pressure necrosis.

For a client with an endotracheal (ET) tube, which nursing action is the most important? - Auscultating the lungs for bilateral breath sounds - Turning the client from side to side every 2 hours - Monitoring serial blood gas values every 4 hours - Providing frequent oral hygiene

- Auscultating the lungs for bilateral breath sounds Explanation: - Auscultating the lungs for bilateral breath sounds

A nurse should include what instruction for the client during postural drainage? - Lie supine to rest the lungs. - Sit upright to promote ventilation. - Remain in each position for 30 to 45 minutes for best results. - Change positions frequently and cough up secretions.

- Change positions frequently and cough up secretions. Explanation: Clients who lie supine will have secretions accumulate in the posterior lung sections, whereas upright patients will pool secretions in their lower lobes. By changing positions, secretions can drain from the affected bronchioles into the bronchi and trachea and then be removed by coughing or suctioning.

The nurse is caring for a client following a thoracotomy. Which finding requires immediate intervention by the nurse? - Heart rate, 112 bpm - Moderate amounts of colorless sputum - Pain of 5 on a 1-to-10 scale - Chest tube drainage, 190 mL/hr

- Chest tube drainage, 190 mL/hr Explanation: The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse must notify the primary provider if drainage is ≥150 mL/hr. The other findings are normal following a thoracotomy and no intervention would be required.

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse... - Consults with the physician about removing the client from the ventilator - Changes the setting on the ventilator to increase breaths to 14 per minute - Continues assessing the client's respiratory status frequently - Contacts the respiratory therapy department to report the ventilator is malfunctioning

- Continues assessing the client's respiratory status frequently Explanation: The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client. There are not sufficient data to suggest the client could be removed from the ventilator. There is no reason to increase the ventilator's setting to 14 breaths per minute or to contact respiratory therapy to report the machine is not working properly.

A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client? - Surgery to remove the tonsils and adenoids - Medications to assist the patient with sleep at night - Continuous positive airway pressure (CPAP) - Bi-level positive airway pressure (BiPAP)

- Continuous positive airway pressure (CPAP) Explanation: CPAP provides positive pressure to the airways throughout the respiratory cycle. Although it can be used as an adjunct to mechanical ventilation with a cuffed endotracheal tube or tracheostomy tube to open the alveoli, it is also used with a leak-proof mask to keep alveoli open, thereby preventing respiratory failure. CPAP is the most effective treatment for obstructive sleep apnea because the positive pressure acts as a splint, keeping the upper airway and trachea open during sleep. CPAP is used for clients who can breathe independently. BiPAP is most often used for clients who require ventilatory assistance at night, such as those with severe COPD or sleep apnea.

A client is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what? - Correct use of a ventilator - Correct use of incentive spirometry - Correct use of a mini-nebulizer - Correct technique for rhythmic breathing

- Correct use of incentive spirometry Explanation: Instruction in the use of incentive spirometry begins before surgery to familiarize the client with its correct use. You do not teach a client the use of a ventilator; you explain that he may be on a ventilator to help him breathe. Rhythmic breathing and mini-nebulizers are unnecessary.

A nurse is caring for a client who has just been diagnosed with lung cancer. What is a cardinal sign of lung cancer? - Cough or change in chronic cough - Pain on inspiration - Obvious trauma - Shortness of breath

- Cough or change in chronic cough Explanation: A cough or change in chronic cough is the most frequent symptom of lung cancer. Symptoms of fractured ribs consist primarily of severe pain on inspiration and expiration, obvious trauma, and shortness of breath. These symptoms may also be caused by other disorders, but they are not considered to be indicative of lung cancer.

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client? - Client teaching about the cause of TB - Reviewing the risk factors for TB - Developing a list of people with whom the client has had contact - Client teaching about the importance of TB testing

- Developing a list of people with whom the client has had contact Explanation: To lessen the spread of TB, everyone who had contact with the client must undergo a chest X-ray and TB skin test. Testing will help determine if the client infected anyone else. Teaching about the cause of TB, reviewing the risk factors, and the importance of testing are important areas to address when educating high-risk populations about TB before its development.

The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding? - Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. - Inform the physician promptly that there is in imminent leak in the drainage system. - Encourage the client to do deep breathing and coughing exercises. - Document that the chest drainage system is operating as it is intended.

- Document that the chest drainage system is operating as it is intended. Explanation: Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed.

What is the reason for chest tubes after thoracic surgery? - Draining secretions, air, and blood from the thoracic cavity is necessary. - Chest tubes allow air into the pleural space. - Chest tubes indicate when the lungs have re-expanded by ceasing to bubble. - Draining secretions and blood while allowing air to remain in the thoracic cavity is necessary.

- Draining secretions, air, and blood from the thoracic cavity is necessary. Explanation: After thoracic surgery, draining secretions, air, and blood from the thoracic cavity is necessary to allow the lungs to expand.

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? - Nonproductive cough and normal temperature - Sore throat and abdominal pain - Hemoptysis and dysuria - Dyspnea and wheezing

- Dyspnea and wheezing Explanation: In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.

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 white blood count - Elevated troponin levels - Elevated myoglobin levels - Elevated B-type natriuretic peptide (BNP) levels

- Elevated B-type natriuretic peptide (BNP) levels Explanation: Common diagnostic tests performed in patients with potential ARDS include plasma brain natriuretic peptide (BNP) levels, echocardiography, and pulmonary artery catheterization. The BNP level is helpful in distinguishing ARDS from cardiogenic pulmonary edema. Cardiogenic pulmonary edema is an acute event that results from heart failure, in which the cardiac chambers release atrial natriuretic peptide (ANP) and BNP to promote vasodilation and diuresis. BNP levels are not similarly elevated with ARDS.

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care? - Turning the client every 2 hours - Elevating the head of the bed 30 degrees - Encouraging increased fluid intake - Maintaining a cool room temperature

- Encouraging increased fluid intake Explanation: Increasing the client's intake of oral or I.V. fluids helps liquefy thick, tenacious secretions, and ensures adequate hydration. Turning the client every 2 hours would help prevent atelectasis, but will not adequately mobilize thick secretions. Elevating the head of the bed would reduce pressure on the diaphragm and ease breathing, but wouldn't help the client with secretions. Maintaining a cool room temperature wouldn't help the client with secretions.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? - Endotracheal suctioning - Encouragement of coughing - Use of a cooling blanket - Incentive spirometry

- Endotracheal suctioning Explanation: Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

The occupational nurse is completing routine assessments on the employees at a company. What might be revealed by a chest radiograph for a client with occupational lung diseases? - Fibrotic changes in lungs - Hemorrhage - Lung contusion - Damage to surrounding tissues

- Fibrotic changes in lungs Explanation: For a client with occupational lung diseases, a chest radiograph may reveal fibrotic changes in the lungs. Hemorrhage, lung contusion, and damage to surrounding tissues are possibly caused by trauma due to chest injuries.

You are an occupational health nurse in a large ceramic manufacturing company. How would you intervene to prevent occupational lung disease in the employees of the company? - Fit all employees with protective masks. - Insist on adequate breaks for each employee. - Give workshops on disease prevention. - Provide employees with smoking cessation materials.

- Fit all employees with protective masks. Explanation: The primary focus is prevention, with frequent examination of those who work in areas of highly concentrated dust or gases. Laws require work areas to be safe in terms of dust control, ventilation, protective masks, hoods, industrial respirators, and other protection. Workers are encouraged to practice healthy behaviors, such as quitting smoking. Adequate breaks, giving workshops, and providing smoking cessation materials do not prevent occupational lung diseases.

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? - Pneumothorax - Flail chest - ARDS - Tension pneumothorax

- Flail chest Explanation: During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) 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. The mediastinum then shifts back to the affected side (Fig. 23-8). This paradoxical action results in increased dead space, a reduction in alveolar ventilation, and decreased compliance.

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? - Promote more efficient and controlled ventilation and to decrease the work of breathing - Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing - Promote the strengthening of the client's diaphragm - Promote the client's ability to take in oxygen

- Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing Explanation: Pursed-lip breathing, which improves oxygen transport, helps induce a slow, deep breathing pattern and assists the client to control breathing, even during periods of stress. This type of breathing helps prevent airway collapse secondary to loss of lung elasticity in emphysema.

In a client with amyotrophic lateral sclerosis (ALS) and respiratory distress, which finding is the earliest sign of reduced oxygenation? - Decreased heart rate - Increased restlessness - Increased blood pressure - Decreased level of consciousness (LOC)

- Increased restlessness Explanation: In ALS, an early sign of respiratory distress is increased restlessness, which results from inadequate oxygen flow to the brain. As the body tries to compensate for inadequate oxygenation, the heart rate increases and blood pressure drops. A decreased LOC is a later sign of poor tissue oxygenation in a client with respiratory distress.

The nurse is planning for the care of a client with acute tracheobronchitis. What nursing interventions should be included in the plan of care? Select all that apply. - Increasing fluid intake to remove secretions - Encouraging the client to rest - Using cool-vapor therapy to relieve laryngeal and tracheal irritation - Giving 3 L fluid per day - Administering a narcotic analgesic for pain

- Increasing fluid intake to remove secretions - Encouraging the client to rest - Using cool-vapor therapy to relieve laryngeal and tracheal irritation Explanation: In most cases, treatment of tracheobronchitis is largely symptomatic. Cool vapor therapy or steam inhalations may help relieve laryngeal and tracheal irritation. A primary nursing function is to encourage bronchial hygiene, such as increased fluid intake and directed coughing to remove secretions. Fatigue is a consequence of tracheobronchitis; therefore, the nurse cautions the client against overexertion, which can induce a relapse or exacerbation of the infection. The client is advised to rest.

A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: - Risk for falls. - Ineffective breathing pattern. - Impaired tissue integrity. - Ineffective airway clearance.

- Ineffective airway clearance. Explanation: Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.

Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths? - Intermittent mandatory ventilation (IMV) - Assist control - Synchronized intermittent mandatory ventilation (SIMV) - Pressure support

- Intermittent mandatory ventilation (IMV) Explanation: IMV provides a combination of mechanically assisted breaths and spontaneous breaths. Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the client can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the client-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing.

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 the client and control breathing with mechanical ventilation - Increase oxygen administration - Administer a large dose of furosemide (Lasix) IVP stat - Schedule the client for pulmonary surgery

- Intubate the client and control breathing with mechanical ventilation Explanation: A client with ARDS may need mechanical ventilation to assist with breathing while the underlying cause of the pulmonary edema is corrected. The other options are not appropriate.

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? - Kinking of the ventilator tubing - A disconnected ventilator circuit - An ET cuff leak - A change in the oxygen concentration without resetting the oxygen level alarm

- Kinking of the ventilator tubing Explanation: Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator circuit or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.

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? - Tracheostomy cleaning kit - Water-seal chest drainage set-up - Manual resuscitation bag - Oxygen analyzer

- Manual resuscitation bag Explanation: The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.

A nurse has performed tracheal suctioning on a client who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? - Determine whether the client can now perform forced expiratory technique (FET). - Percuss the client's lungs and thorax. - Measure the client's oxygen saturation. - Have the client perform incentive spirometry.

- Measure the client's oxygen saturation. Explanation: The client's response to suctioning is usually determined by performing chest auscultation and by measuring the client's oxygen saturation. FET, incentive spirometry, and percussion are not normally used as evaluative techniques.

A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply. - Monitor pulmonary status as directed and needed. - Regularly assess the client's vital signs every 2 to 4 hours. - Encourage deep breathing exercises. - Request order for patient-controlled analgesia pump - Monitor and record hourly intake and output.

- Monitor pulmonary status as directed and needed. - Regularly assess the client's vital signs every 2 to 4 hours. - Encourage deep breathing exercises. Explanation: Interventions to improve the client's gas exchange include monitoring pulmonary status as directed and needed, assessing vital signs every 2 to 4 hours, and encouraging deep breathing exercises. The nurse would request an order for patient-controlled analgesia if appropriate for the client, but that would be an intervention related to post-surgical pain, not impaired gas exchange. Monitoring and recording hourly intake and output are essential interventions for ensuring appropriate fluid balance but not directly related to impaired gas exchange.

A patient with emphysema is placed on continuous oxygen at 2 L/min at home. Why is it important for the nurse to educate the patient and family that they must have No Smoking signs placed on the doors? - Oxygen is combustible. - Oxygen is explosive. - Oxygen prevents the dispersion of smoke particles. - Oxygen supports combustion.

- Oxygen supports combustion. Explanation: Because oxygen supports combustion, there is always a danger of fire when it is used. It is important to post "No Smoking" signs when oxygen is in use, particularly in facilities that are not smoke free.

Which is a key characteristic of pleurisy? - Pain - Dyspnea - Anxiety - Blood-tinged secretions

- Pain Explanation: The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain.

A client is brought to the emergency department following a motor vehicle accident. Which of the following nursing assessments is significant in diagnosing this client with flail chest? - Respiratory acidosis - Paradoxical chest movement - Chest pain on inspiration - Clubbing of fingers and toes

- Paradoxical chest movement Explanation: Flail chest occurs when two or more adjacent ribs fracture and results in impairment of chest wall movement. Respiratory acidosis and chest pain are symptoms that can occur with flail chest but is not as significant in the diagnosis as paradoxical chest movement. Clubbing of fingers and toes are sign of prolonged tissue hypoxia.

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? - pH - Bicarbonate (HCO3-) - Partial pressure of arterial oxygen (PaO2) - Partial pressure of arterial carbon dioxide (PaCO2)

- Partial pressure of arterial oxygen (PaO2) Explanation: The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2

The nurse is preparing to perform tracheostomy care for a client with a newly inserted tracheostomy tube. Which action, if performed by the nurse, indicates the need for further review of the procedure? - Cleans an infected wound and the plate with a sterile cotton tip moistened with hydrogen peroxide - Dries and reinserts the inner cannula or replaces it with a new disposable inner cannula - Puts on clean gloves; removes and discards the soiled dressing in a biohazard container - Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting

- Places clean tracheostomy ties then removes soiled ties after the new ties are in place without a second nurse assisting Explanation: For a new tracheostomy, two people should assist with tie changes to help make sure the new tracheostomy is not dislodged. A dislodged tracheostomy is a medical emergency. The other actions, if performed by the nurse during tracheostomy care, are correct. The wound and plate should be cleaned with sterile cotton-tipped applicators moistened with saline or sterile water or with hydrogen peroxide if infection is present. The inner cannula should be dried before reinsertion or if a disposable is being used, a new disposable cannula should be reinserted. The nurse should put on clean gloves and discard the soiled dressing in a biohazard container.

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? - Pulmonary embolism - Myocardial infarction (MI) - Heart failure - Pneumothorax

- Pneumothorax Explanation: Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds. A chest X-ray reveals the collapse of the affected lung that results from pneumothorax. Triple-lumen catheter insertion through the subclavian vein isn't associated with pulmonary embolism, MI, or heart failure.

A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. - Post thoracotomy - Spontaneous pneumothorax - Need for postural drainage - Chest trauma resulting in pneumothorax - Pleurisy

- Post thoracotomy - Spontaneous pneumothorax - Chest trauma resulting in pneumothorax Explanation: Chest drainage systems are used in treatment of spontaneous pneumothorax and trauma resulting in pneumothorax. Postural drainage and pleurisy are not indications for use of a chest drainage system.

You are caring for a client with chronic respiratory failure. What are the signs and symptoms of chronic respiratory failure? - Progressive loss of lung function associated with chronic disease - Sudden loss of lung function associated with chronic disease - Progressive loss of lung function with history of normal lung function - Sudden loss of lung function with history of normal lung function

- Progressive loss of lung function associated with chronic disease Explanation: In chronic respiratory failure, the loss of lung function is progressive, usually irreversible, and associated with chronic lung disease or other disease. This makes options B, C, and D incorrect.

The nurse is caring for a client who is intubated for mechanical ventilation. Which intervention(s) will the nurse implement to reduce the client's risk of injury? Select all that apply. - Provide oral hygiene. - Assess for a cuff leak. - Reduce pulling on ventilator tubing. - Monitor cuff pressure every 8 hours. - Position with head above the stomach level.

- Provide oral hygiene. - Assess for a cuff leak. - Reduce pulling on ventilator tubing. - Monitor cuff pressure every 8 hours. - Position with head above the stomach level. Explanation: Maintaining the endotracheal or tracheostomy tube is an essential part of airway management. Oral hygiene is provided frequently because the oral cavity is a primary source of lung contamination in the client who is intubated. Assessing for a leak from the cuff of the endotracheal tube needs to be done at the same time as providing other respiratory care. Ventilator tubing should be positioned so that there is minimal pulling or distortion of the tube in the trachea which reduces the risk of trauma to the trachea. Cuff pressure is monitored every 8 hours to maintain the pressure at 20 to 25 mm Hg. The head of the bed should be higher than the stomach to reduce the risk of aspiration.

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 studies - Exercise tolerance tests - Arterial blood gas values - Chest x-ray

- Pulmonary function studies Explanation: Pulmonary function studies are performed to determine whether the planned resection will leave sufficient functioning lung tissue. ABG values are assessed to provide a more complete picture of the functional capacity of the lung. Exercise tolerance tests are useful to determine if the client who is a candidate for pneumonectomy can tolerate removal of one of the lungs. Preoperative studies, such as a chest x-ray, are performed to provide a baseline for comparison during the postoperative period and to detect any unsuspected abnormalities.

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 - Inspiratory crackles - Bilateral wheezing - Cyanosis

- Rapid onset of severe dyspnea Explanation: The acute phase of ARDS is marked by a rapid onset of severe dyspnea that usually occurs less than 72 hours after the precipitating event.

The nurse is caring for a client who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning, the nurse should anticipate that the weaning of the client will progress in what order? - Removal from the ventilator, tube, and then oxygen - Removal from oxygen, ventilator, and then tube - Removal of the tube, oxygen, and then ventilator - Removal from oxygen, tube, and then ventilator

- Removal from the ventilator, tube, and then oxygen Explanation: The process of withdrawing the client from dependence on the ventilator takes place in three stages: the client is gradually removed from the ventilator, then from the tube, and, finally, oxygen.

The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated? - Deflating the cuff before removing the tube - Routinely deflating the cuff - Checking the cuff pressure every 6 to 8 hours - Ensuring that humidified oxygen is always introduced through the tube

- Routinely deflating the cuff Explanation: - Routinely deflating the cuff

A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped? - Respiratory rate of 16 breaths/minute - Oxygen saturation of 93% - Runs of ventricular tachycardia - Blood pressure remains stable

- Runs of ventricular tachycardia Explanation: Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. The client's blood pressure remains stable, so the weaning can continue.

The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis? - Dullness or flatness on percussion over areas of collected fluid - Dyspnea and coughing - Fever and chills - Stabbing pain during respiratory movement

- Stabbing pain during respiratory movement Explanation: When the inflamed pleural membranes rub together during respiration (intensified on inspiration), the result is severe, sharp, knifelike pain. The key characteristic of pleuritic pain is its relationship to respiratory movement. Taking a deep breath, coughing, or sneezing worsens the pain. Pleuritic pain is limited in distribution rather than diffuse; it usually occurs only on one side. The pain may become minimal or absent when the breath is held. It may be localized or radiate to the shoulder or abdomen. Later, as pleural fluid develops, the pain decreases.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do? - Check for an apical pulse. - Suction the client's artificial airway. - Increase the oxygen percentage. - Ventilate the client with a handheld mechanical ventilator.

- Suction the client's artificial airway. Explanation: A high-pressure alarm on a continuous mechanical ventilator indicates an obstruction in the flow of gas from the machine to the client. The nurse should suction the client's artificial airway to remove respiratory secretions that could be causing the obstruction. The sounding of a ventilator alarm has no relationship to the apical pulse. Increasing the oxygen percentage and ventilating with a handheld mechanical ventilator wouldn't correct the airflow blockage.

A nurse admits a new client with acute respiratory failure. What are the clinical findings of a client with acute respiratory failure? - Insidious onset of lung impairment in a client who had normal lung function - Sudden onset of lung impairment in a client who had normal lung function - Insidious onset of lung impairment in a client who had compromised lung function - Sudden onset of lung impairment in a client who had compromised lung function

- Sudden onset of lung impairment in a client who had normal lung function Explanation: In acute respiratory failure, the ventilation or perfusion mechanisms in the lung are impaired. Acute respiratory failure occurs suddenly in a client who previously had normal lung function.

A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to: - Lay in bed with the head on a pillow. - Take prescribed albuterol (Ventolin) before performing postural drainage. - Perform drainage 1 hour after meals. - Hold each position for 5 minutes.

- Take prescribed albuterol (Ventolin) before performing postural drainage. Explanation: When a client is to perform postural drainage, the nurse should instruct the client to use the prescribed bronchodilator (e.g., albuterol) first. This will open airways and promote drainage. The client is to perform postural drainage before meals, not after. This will aid in preventing nausea, vomiting, and aspiration. For secretions accumulated in the upper lobes, the client will sit up or even lean forward while sitting. Head on a pillow is not a sufficient increase in height. The client is also to lay in each position for 10 to 15 minutes.

The nurse has explained to the client that after his thoracotomy, it will be important to adhere to a coughing schedule. The client is concerned about being in too much pain to be able to cough. What would be an appropriate nursing intervention for this client? - Teach him postural drainage. - Teach him how to perform huffing. - Teach him to use a mini-nebulizer. - Teach him how to use a metered dose inhaler.

- Teach him how to perform huffing. Explanation: The technique of "huffing" may be helpful for the client with diminished expiratory flow rates or for the client who refuses to cough because of severe pain. Huffing is the expulsion of air through an open glottis. Inhalers, nebulizers, and postural drainage are not substitutes for performing coughing exercises.

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? - The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. - The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. - The client exhibits restlessness and confusion. - The client exhibits bronchial breath sounds over the affected area.

- The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. Explanation: As the acute phase of bacterial pneumonia subsides, normal lung function returns and the PaO2 typically rises, reaching 85 to 100 mm Hg. A PaCO2 of 65 mm Hg or higher is above normal and indicates CO2 retention — common during the acute phase of pneumonia. Restlessness and confusion indicate hypoxia, not an improvement in the client's condition. Bronchial breath sounds over the affected area occur during the acute phase of pneumonia; later, the affected area should be clear on auscultation.

While caring for a client with a chest tube, which nursing assessment would alert the nurse to a possible complication? - Skin around tube is pink. - Bloody drainage is observed in the collection chamber. - Absence of bloody drainage in the anterior/upper tube - The tissues give a crackling sensation when palpated.

- The tissues give a crackling sensation when palpated. Explanation: Subcutaneous emphysema is the result of air leaking between the subcutaneous layers. It is not a serious complication but is notable and reportable. Pink skin and blood in the collection chamber are normal findings. When two tubes are inserted, the posterior or lower tube drains fluid, whereas the anterior or upper tube is for air removal.

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply. - To provide adequate transport of oxygen in the blood - To decrease the work of breathing - To reduce stress on the myocardium - To clear respiratory secretions - To provide visual feedback to encourage the client to inhale slowly and deeply

- To provide adequate transport of oxygen in the blood - To decrease the work of breathing - To reduce stress on the myocardium Explanation: Oxygen therapy is designed to provide adequate transport of oxygen in the blood while decreasing the work of breathing and reducing stress on the myocardium. Incentive spirometry is a respiratory modality that provides visual feedback to encourage the client to inhale slowly and deeply to maximize lung inflation and prevent or reduce atelectasis. A mini-nebulizer is used to help clear secretions.

A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube? - To remove air from the pleural space - To drain copious sputum secretions - To monitor bleeding around the lungs - To assist with mechanical ventilation

- To remove air from the pleural space Explanation: Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. The primary purpose of a chest tube is not to drain sputum secretions, monitor bleeding, or assist with mechanical ventilation.

Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall? - Turn onto the affected side. - Use a prescribed analgesic. - Avoid using a pillow while splinting. - Use a heat or cold application.

- Turn onto the affected side. Explanation: Teach the client to splint their chest wall by turning onto the affected side. The nurse instructs the patient with pleurisy to take analgesic medications as prescribed, but this not a technique related to splinting the chest wall. The patient can splint the chest wall with a pillow when coughing. The nurse instructs the patient to use heat or cold applications to manage pain with inspiration, but this not a technique related to splinting the chest wall.

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? - Water-seal chamber - Air-leak chamber - Collection chamber - Suction control chamber

- Water-seal chamber Explanation: Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest.

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 snugly around the face - Instructing the client to wear a mask at all times - Wearing a gown and gloves when providing direct care - Keeping the door to the client's room open to observe the client

- Wearing a disposable particulate respirator that fits snugly around the face Explanation: Because TB is transmitted by droplet nuclei from the respiratory tract, the nurse should put on a disposable particulate respirators that fit snugly around the face when entering the client's room. Occupation Safety and Health Administration standards require an individually fitted mask. Having the client wear a mask at all times would hinder sputum expectoration and respirations would make the mask moist. A nurse who doesn't anticipate contact with the client's blood or body fluids need not wear a gown or gloves when providing direct care. A client with TB should be in a room with laminar airflow, and the room's door should be shut at all times.

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with: - a compromised skin graft. - a malignant tumor. - pneumonia. - hyperthermia.

- a compromised skin graft. Explanation: A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must: - follow up with the physician in 2 weeks. - continue to take antibiotics for the entire 10 days. - turn and reposition himself every 2 hours. - maintain fluid intake of 40 oz (1,200 ml) per day.

- continue to take antibiotics for the entire 10 days. Explanation: The client demonstrates understanding of how to prevent relapse when he states that he must continue taking the antibiotics for the prescribed 10-day course. Although the client should keep the follow-up appointment with the physician and turn and reposition himself frequently, these interventions don't prevent relapse. The client should drink 51 to 101 oz (1,500 to 3,000 ml) per day of clear liquids.

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: - report fluctuations in the water-seal chamber. - clamp the chest tube once every shift. - encourage coughing and deep breathing. - milk the chest tube every 2 hours.

- encourage coughing and deep breathing. Explanation: When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.

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: - level of consciousness (LOC). - extremities for signs of cyanosis. - oxygen saturation level. - hemoglobin, hematocrit, and red blood cell levels.

- oxygen saturation level. Explanation: The effectiveness of the client's oxygen therapy is assessed by the ABG analysis or pulse oximetry. ABG results may not be readily available. Presence or absence of cyanosis is not an accurate indicator of oxygen effectiveness. The client's LOC may be affected by hypoxia, but not every change in LOC is related to oxygenation. Hemoglobin, hematocrit, and red blood cell levels do not directly reflect current oxygenation status.

The nurse is caring for a client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client - returning to the nursing unit with two chest tubes. - returning from surgery with no drainage tubes. - requiring mechanical ventilation following surgery. - requiring sedation until the chest tube(s) are removed.

- returning to the nursing unit with two chest tubes. Explanation: The nurse should plan for the client to return to the nursing unit with two chest tubes intact. During a lobectomy, the lobe is removed, and the remaining lobes of the lung are re-expanded. Usually, two chest catheters are inserted for drainage. The upper tube is for air removal; the lower one is for fluid drainage. Sometimes only one catheter is needed. The chest tube is connected to a chest drainage apparatus for several days.

A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the: - area of redness is measured in 3 days and determines whether tuberculosis is present. - skin test doesn't differentiate between active and dormant tuberculosis infection. - presence of a wheal at the injection site in 2 days indicates active tuberculosis. - test stimulates a reddened response in some clients and requires a second test in 3 months.

- skin test doesn't differentiate between active and dormant tuberculosis infection. Explanation: The Mantoux test doesn't differentiate between active and dormant infections. If a positive reaction occurs, a sputum smear and culture as well as a chest X-ray are necessary to provide more information. Although the area of redness is measured in 3 days, a second test may be needed; neither test indicates that tuberculosis is active. In the Mantoux test, an induration 5 to 9 mm in diameter indicates a borderline reaction; a larger induration indicates a positive reaction. The presence of a wheal within 2 days doesn't indicate active tuberculosis.

A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client. "Exhale slowly through your nose." "Slowly count to 3." "Slowly count to 7." "Inhale trough your nose."

"Inhale through your nose." "Slowly count to 3." "Exhale slowly through pursed lips." "Slowly count to 7."