NCLEX 10000 Respiratory

The nurse is reflecting on the evaluation step of the nursing process. Which documentation would indicate nursing actions were effective in reducing breathing problems for a client? Select all that apply.

• Lung sounds clear bilaterally with non-labored respirations noted • Anxiety decreased, oxygen saturation levels at 94%, nonproductive cough, respirations at 22 breaths/min Explanation: A decrease in anxiety with an increase in oxygen saturation and clear lung sounds with non-labored respirations show documentation that breathing has improved. The other answers indicate abnormal data of the respiratory status.

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

Hypoxia Explanation: As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation

A nurse is reviewing orders for a client having an acute asthma attack. Which of the following medications should the nurse administer?

Albuterol 2.5 mg per nebulizer Explanation: Albuterol is a rapidly acting bronchodilator and is the first-line medication to reverse airway narrowing in acute asthma attacks. The other medications are used for long-term control of asthma and are not considered "rescue" inhalers since they are not immediate acting bronchodilators

Having had only one prenatal visit, a 16-year-old primigravida at 37 weeks' gestation is admitted to the hospital in active labor. Her cervix is 7 cm dilated with the presenting part at +1 station. Soon after admission, the nurse observes that the client is hyperventilating. Which action would be most appropriate?

Give the client a paper bag and have her breathe into it. Explanation: Hyperventilation results in excess carbon dioxide being eliminated from the body. Rebreathing into a paper bag or cupping the hands is beneficial because it increases the carbon dioxide remaining in the lungs during breathing. Although taking whiffs of oxygen via nasal cannula may increase oxygen intake with breathing, it will not replace the lost carbon dioxide, the major problem with hyperventilation. Having the client hold her breath has no effect on minimizing the excess carbon dioxide being eliminated. However, doing so can lead to increased intracranial pressure. Breathing with forceful inspirations will not resolve the hyperventilation nor will it replace the carbon dioxide deficiency.

A client has a central venous catheter inserted into the subclavian vein. The nurse assesses the client immediately following the insertion of the catheter and notes a sudden onset of chest pain and shortness of breath. Which of the following complications should the nurse be prepared to treat?

Pneumothorax Explanation: Pneumothorax can occur from inadvertent puncture of the pleura, causing sudden chest pain and shortness of breath. Bronchopneumonia would not occur as a result of catheter contamination. Bronchopneumonia is an infection in the lung tissue. The central line is inserted in the venous system, namely the subclavian vein in this situation. The other answers are incorrect because they are not complications from central line insertions. The nurse must assess the client carefully for these complications to ensure that the parenteral nutrition is being administered safely

A client is admitted to the postsurgical unit after wiring of a fractured jaw. When the nurse completes an assessment, noisy, shallow breathing is noted and the oxygen saturation level is now 90%. What is the appropriate action by the nurse?

Position in Sims position with head to the side, administer oxygen as ordered, and suction if needed. Explanation: Sims position is indicated for clients in the initial postoperative period. Sims position helps ensure patency of the airway by allowing secretions and blood to pool in the cheek and drain out the side of the mouth. If secretions are accumulating too quickly, suctioning may be required. Oxygen is given to improve oxygen saturation levels. If positioned in Fowlers, there will be more likelihood of swallowing the bloody secretions and becoming nauseated. The client's jaw is wired, so the airway cannot be inserted. If the client is positioned supine, he/she could aspirate. If positioned prone, there is more compression on the chest cage that could contribute to more shallow breathing

The nurse should use which type of precautions for a client being admitted to the hospital with suspected tuberculosis?

airborne precautions Explanation: Airborne precautions prevent transmission of infectious agents that remain infectious over long distances when suspended in the air (e.g., mycobacterium tuberculosis, measles, varicella virus [chickenpox], and possibly SARS-CoV). The preferred placement is in an isolation single-client room that is equipped with special air handling and ventilation. A negative pressure room, or an area that exhausts room air directly outside or through HEPA filters, should be used if recirculation is unavoidable. While hand hygiene is important, it is not sufficient to prevent transmission of tuberculosis.. Contact precautions are for clients with known or suspected infections or evidence of syndromes that represent an increased risk for contact transmission. Droplet precautions are intended to prevent transmission of pathogens spread through close respiratory or mucous membrane contact with respiratory secretions. Because these pathogens do not remain infectious over long distances in a health care facility, special air handling and ventilation are not required to prevent droplet transmission.

A nurse recognizes that a client with tuberculosis needs further teaching when the client states:

"It will be necessary for the people I work with to take medication." Explanation: The client requires additional teaching if he states that coworkers will need to take medication. If exposed and testing positive, medications would be required for coworkers. Contacts need to be tested for tuberculosis. However, a person in close contact with a person who's infectious is at greatest risk and should be definitely be checked. The client demonstrates effective teaching if he states that he'll take his medications for 9 to 12 months and that he requires laboratory tests while on medication.

While reviewing the arterial blood gas values of a client with emphysema, the nurse should identify which PaCO2 values as indicating the need for immediate intervention?

80 mm Hg Correct Explanation: Although normal PaCO2 values range from 35 to 45 mm Hg, the client with long-standing emphysema has chronic carbon dioxide retention, leading to elevated PaCO2 levels. A PaCO2 level of 80 mm Hg is life threatening and always requires immediate intervention, possibly mechanical ventilation, to reduce the PaCO2 level. The client with emphysema and a PaCO2 level of 60 mm Hg may not be in immediate danger, but the nurse should further evaluate the client with this level.

The nurse is caring for a client who has experienced severe multiple trauma. The client's arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. This finding is an indicator of the development of which of the following conditions?

Acute respiratory distress syndrome (ARDS). Explanation: ARDS frequently develops after a major insult to the body. The major diagnostic indicator is low arterial oxygen levels that are not responsive to the administration of high concentrations of oxygen. Early recognition of ARDS is important to increase the client's chances of recovery. The oxygen levels of clients with hospital-acquired pneumonia, hypovolemic shock, or asthma would be expected to improve with oxygen administration.

A client with emphysema is at a greater risk for developing what acid-base imbalance?

Chronic respiratory acidosis Explanation: Respiratory acidosis, which may be either acute or chronic, is caused by excess carbonic acid, which causes the blood pH to drop below 7.35. Chronic respiratory acidosis is associated with disorders such as emphysema, bronchiectasis, bronchial asthma, and cystic fibrosis

A client is 2 hours postoperative after an appendectomy. The nurse recognizes a priority is to teach the client potential pulmonary post-operative complications. What action by the client demonstrates understanding of the teaching?

Diaphragmatic breathing and use of incentive spirometry 4-8 times an hour while awake Explanation: Diaphragmatic breathing helps promote alveolar expansion and facilitates exchange of oxygen and carbon dioxide. Incisional splinting will not assist in preventing pulmonary risk; it will only address pain. Bed rest and passive range of motion are not correct

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

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 pressure ulcers but wouldn't help with the 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.

Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate to observe in a client with these arterial blood gas results?

Increase in rate and depth of respirations Explanation: The medulla in the brainstem is the respiratory center. The medulla is stimulated by an increased concentration of carbon dioxide and hydrogen ions and, to a lesser degree, by the decreased amount of oxygen in the arterial blood. Stimulation of the medulla increases the rate and depth of ventilation to blow off carbon dioxide and hydrogen and increase oxygen levels. This compensatory mechanism causes the patient to breathe faster and more deeply.

A nurse is caring for a client with bronchogenic carcinoma. Which nursing intervention takes highest priority?

Removing pulmonary secretions Explanation: Maintaining a patent airway is the first concern in a client with a condition that may compromise the airway. Therefore, adequate removal of pulmonary secretions is a priority. Although clients may exhibit fatigue, anxiety, or appetite loss, these need to be addressed, but are not the priority

While assessing a child experiencing respiratory distress, the nurse notes subcostal retractions. Which graphic highlights the area where subcostal retractions are seen?

Subcostal retractions are retractions seen below the lower costal margin of the rib cage. Option B highlights the area where subcostal retractions are seen. Option A shows the areas where intercostal retractions would be seen. Option C shows the area for suprasternal retraction. Option D shows the areas for clavicular retractions

A nurse is caring for a client who recently underwent a tracheostomy. What is the nurses first priority when caring for this client?

Suctioning to keep the airway patent Explanation: Maintaining a patent airway is the most basic and critical human need. Helping the client communicate, encouraging the client to cough and breathe deeply, and turning the client are important actions, but are not the priority

A nurse notes crackles on a client diagnosed with right-lower-lobe atelectasis. In which area would the nurse place the stethoscope to assess the adventitious breath sounds?

To auscultate the right lower lobe from the anterior chest, the nurse should place the stethoscope between the fifth and sixth intercostal spaces to the left of the anterior axillary line

A competent client requiring long-term mechanical ventilation privately tells a nurse that he/she wants the ventilator withdrawn. Which response by the nurse is best?

You selected: "Tell me how you are feeling." Explanation: Asking the client how he/she is feeling uses an open-ended question that encourages the client to express his/her feelings. Asking the client to consider his/her family is judgmental and is an inappropriate statement. Ventilation can be withdrawn according to the client's wishes. Telling the client he/she is doing well is judgmental and dismisses the client's concerns.

A client has a positive reaction to the Mantoux test. The nurse interprets this reaction to mean that the client has:

bad exposed to Mycobacterium tuberculosis. Explanation: A positive Mantoux skin test indicates that the client has been exposed to tubercle bacilli. Exposure does not necessarily mean that active disease exists. A positive Mantoux test does not mean that the client has developed resistance. Unless involved in treatment, the client may still develop active disease at any time. Immunity to tuberculosis is not possible.

A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine. Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because it:

may induce bronchospasm. Explanation: Acetylcysteine must be used cautiously in a client with asthma because it may induce bronchospasm. The drug isn't a respiratory depressant or stimulant. It's a mucolytic agent that decreases the viscosity of respiratory secretions by altering the molecular composition of mucus. Acetylcysteine doesn't inhibit the cough reflex

The nurse makes a home visit to a primiparous client and her neonate at 1 week after a vaginal birth. Which finding should be reported to the health care provider (HCP)?

neonatal central cyanosis Explanation: Although acrocyanosis may be present for 24 to 48 hours after birth, central cyanosis of the trunk indicates decreased oxygenation from respiratory distress or another disease state (e.g., cardiac anomalies). This should be reported to the HCP and evaluated further. Maternal lochia serosa in scant amount is a normal finding 1 week postpartum, as is a nonpalpable maternal fundus. Presence of a neonatal tonic neck reflex is a normal finding in a 1-week-old neonate.

A preschool child immobilized in a hip spica cast has trouble breathing after meals. Which action would be best?

offer the child small feedings several times a day. Explanation: A hip spica cast extends up over the abdomen. Because the abdomen is in a fixed space, abdominal distention secondary to eating pushes the abdominal contents against the diaphragm, resulting in decreased chest expansion and subsequent possible respiratory distress. The child's problems are associated with meals, so offering small, frequent meals provides nutritional support while minimizing distention. Encouraging increased drinking would increase abdominal distention, thus increasing the child's respiratory distress. Pursed-lip breathing would prevent air trapping, not decreased chest expansion. .Administering a laxative with meals would not relieve the decreased chest expansion.

A nurse instructs a client with allergic rhinitis about the correct technique for using an intranasal inhaler. Which statement indicates that the client understands the instructions?

"I should hold one nostril closed while I insert the spray into the other nostril." Explanation: When using an intranasal inhaler, it is important to close off one nostril while inhaling the spray into the other nostril to ensure the best inhalation of the spray. Use of the inhaler is not limited to mornings and bedtime. The canister should be shaken immediately before use. The inhaler tip should be inserted into the nostril and pointed toward the outside nostril wall to maximize inhalation of the medication

The nurse is assessing a client's respiratory status. Which assessment data indicate a problem?

28 breaths/min and audible Explanation: Twenty-eight breaths are outside the normal range of 14 to 20 breaths/min. Breathing should be without effort or adventitious sounds. Based on these abnormal assessment findings, this client may be experiencing respiratory distress. The rest of the choices are all within normal parameters of respiratory status.

A nurse is caring for a client with a chest tube connected to a three-chamber drainage system without suction. On the illustration below, identify which chamber that the nurse will mark to record the current drainage level.

A chest tube drains blood, fluid, and air from around the lungs. The drainage system, which the nurse measures each shift, is on the right. It has three calibrated chambers that show the amount of drainage collected. When the first chamber fills, drainage empties into the second; when the second chamber fills, drainage flows into the third. The water seal chamber is located in the center. The suction control chamber is on the lef

A client is admitted to the emergency department with a headache, weakness, and slight confusion. The health care provider (HCP) diagnoses carbon monoxide poisoning. What should the nurse do first?

Administer 100% oxygen by mask. Explanation: Carbon monoxide poisoning develops when carbon monoxide combines with hemoglobin. Because carbon monoxide combines more readily with hemoglobin than oxygen does, tissue anoxia results. The nurse should administer 100% oxygen by mask to reduce the half-life of carboxyhemoglobin. Gastric lavage is used for ingested poisons. With tissue anoxia, metabolism is diminished, with a subsequent lowering of the body's temperature; thus, steps to increase body temperature would be required. Unless the carbon monoxide poisoning is intentional, a psychiatric referral would be inappropriate. (

Which assessment finding puts a client at increased risk for epistaxis?

Cocaine use Explanation: Using nasally inhaled illicit drugs, such as cocaine, increases the risk of epistaxis (nosebleed) because of the increased vascularity of the nasal passages. A dry environment (not a humidified one) increases the risk of epistaxis. Hypertension, not hypotension, increases the risk of epistaxis. A history of nasal surgery doesn't increase the risk of epistaxis

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?

Baseline arterial blood gas (ABG) levels Explanation: Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.

When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, then a couple of small breaths, then 10 to 20 seconds of no breaths. The nurse should record the breathing pattern as:

Cheyne-Stokes respiration. Explanation: Cheyne-Stokes respiration is defined as a regular cycle that starts with normal breaths, which increase and then decrease followed by a period of apnea. It can be related to heart failure or a dysfunction of the respiratory center of the brain. Hyperventilation is associated with an increased rate and depth of respirations. Obstructive sleep apnea is recurring episodes of upper airway obstruction and reduced ventilation. Biot's respiration, also known as "cluster breathing," is periods of normal respirations followed by varying periods of apnea

Before seeing a newly assigned client with respiratory alkalosis, a nurse quickly reviews the client's medical history. Which condition is a predisposing factor for respiratory alkalosis?

Extreme anxiety Explanation: Extreme anxiety may lead to respiratory alkalosis by causing hyperventilation, which results in excessive carbon dioxide (CO2) loss. Other conditions that may set the stage for respiratory alkalosis include fever, heart failure, injury to the brain's respiratory center, overventilation with a mechanical ventilator, pulmonary embolism, and early salicylate intoxication. Type 1 diabetes may lead to diabetic ketoacidosis; the deep, rapid respirations occurring in this disorder (Kussmaul's respirations) don't cause excessive CO2 loss. Myasthenia gravis and opioid overdose suppress the respiratory drive, causing CO2 retention, not CO2 loss; this may lead to respiratory acidosis, not alkalosis.

A client with acute asthma is prescribed short-term corticosteroid therapy. Which is the expected outcome for the use of steroids in clients with asthma?

Have an anti-inflammatory effect. Explanation: Corticosteroids have an anti-inflammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion. Corticosteroids do not have a bronchodilator effect, act as expectorants, or prevent respiratory infections.

For a client with chronic obstructive pulmonary disease who has trouble raising respiratory secretions, which ointervention would help reduce the tenacity of secretions?

Help the client maintain a high fluid intake. Explanation: A fluid intake of 2 to 3 L/day, providing that the client does not have cardiovascular or renal disease, helps liquefy bronchial secretions. A low-salt diet, continuous oxygen therapy, and maintaining a semi-sitting position do not help reduce the viscosity of mucus

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?

High-protein Explanation: Breathing is more difficult for clients with COPD, and increased metabolic demand puts them at risk for nutritional deficiencies. These clients must have a high intake of protein for increased calorie consumption. Full liquids, 1,800-calorie ADA, and low-fat diets aren't appropriate for a client with COPD.

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?

Institute isolation precautions. Explanation: SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens

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 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 client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

Partial pressure of arterial oxygen (PaO2) Correct 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 aware that frequent repositioning in bed will assist in the prevention of which of the following for a client?

Pneumonia Explanation: By frequently changing positions in bed, the client can prevent the development of pneumonia, urinary stasis, and deep vein thrombosis. These movements promote blood, oxygen, and fluid circulation throughout the body systems and prevent stasis. Postural hypotension can often be associated with medications and no information is given about this in the question. Arterial thrombosis is incorrect because decreased movement would more likely result in a venous thrombosis

A client with a suspected overdose of an unknown drug is admitted to the emergency department. Arterial blood gas values indicate respiratory acidosis. What should the nurse do first?

Prepare to assist with ventilation. Explanation: Respiratory acidosis is associated with hypoventilation; in this client, hypoventilation suggests intake of a drug that has suppressed the brain's respiratory center. Therefore, the nurse should assume the client has respiratory depression and should prepare to assist with ventilation. After the client's respiratory function has been stabilized, the nurse can safely monitor the heart rhythm, prepare for gastric lavage, and obtain a urine specimen for drug screening.

A nurse administers albuterol, as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

Respiratory rate of 22 breaths/minute Explanation: In a client with emphysema, albuterol is used as a bronchodilator. A respiratory rate of 22 breaths/minute indicates that the drug has achieved its therapeutic effect because fewer respirations are required to achieve oxygenation. Albuterol has no effect on pupil reaction or urine output. It may cause a change in the heart rate, but this is an adverse, not therapeutic, effect

The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which instruction should be included?

Take a deep abdominal breath, bend forward, and cough three or four times on exhalation. Explanation: The goal of effective coughing is to conserve energy, facilitate removal of secretions, and minimize airway collapse. The client should assume a sitting position with feet on the floor if possible. The client should bend forward slightly and, using pursed-lip breathing, exhale. After resuming an upright position, the client should use abdominal breathing to slowly and deeply inhale. After repeating this process three or four times, the client should take a deep abdominal breath, bend forward, and cough three or four times upon exhalation ("huff" cough). Lying flat does not enhance lung expansion; sitting upright promotes full expansion of the thorax. Shallow breathing does not facilitate removal of secretions, and forceful coughing promotes collapse of airways. A side-lying position does not allow for adequate chest expansion to promote deep breathing.

tidal volume. Explanation: Tidal volume is the amount of air inspired and expired with each breath. Residual volume is the amount of air remaining in the lungs after forcibly exhaling. Vital capacity is the maximum amount of air that can be moved out of the lungs after maximal inspiration and expiration. Dead-space volume is the amount of air remaining in the upper airways that never reaches the alveoli. In pathologic conditions, dead space may also exist in the lower airways

The amount of air inspired and expired with each breath is called:

A nurse is conducting an initial assessment on a client with possible tuberculosis. Which assessment finding indicates a risk factor for tuberculosis?

The client had a liver transplant 2 years ago. Explanation: A history of immunocompromised status, such as that which occurs with liver transplantation, places the client at a higher risk for contracting tuberculosis. Other risk factors include inadequate health care, traveling to countries with high rates of tuberculosis (such as southeastern Asia, Africa, and Latin America), being a health care worker who performs procedures in which exposure to respiratory secretions is likely, and being institutionalized

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. 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

A client has the following arterial blood gas values: pH, 7.52; PaO2, 50 mm Hg (6.7 kPa); PaCO2, 28 mm Hg (3.72 kPa); HCO3-, 24 mEq/L (24 mmol/L). Based upon the client's PaO2, which conclusion would be accurate?

The client is severely hypoxic. Explanation: Normal PaO2 level ranges from 80 to 100 mm Hg (10.6 to 13.3 kPa). When the PaO2 value falls to 50 mm Hg (6.7 kPa), the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a severe risk for respiratory failure. The PaO2 is not within normal range. The client will require oxygenation at a concentration that maintains the PaO2 at 55 to 60 mm Hg or more (7.3 to 8 kPa).

Which action will be most helpful to the nurse when determining the need for oxygen therapy in a client with chronic obstructive pulmonary disease?

Use a pulse oximeter to determine oxygen saturation. Explanation: A pulse oximeter, which measures oxygen saturation, is the most effective noninvasive way to determine a client's need for oxygen therapy. Although the client may feel the need for oxygen during periods of dyspnea, this is not a reliable way of determining the client's need. Fatigue may be due to other factors besides oxygenation levels. Evaluating the client's hemoglobin level can provide an indication that the client may have less oxygen-carrying capacity but is not a reliable indicator of oxygen need.

A client with chest pain doesn't respond to nitroglycerin. When he's admitted to the emergency department, the health care team obtains an electrocardiogram and administers I.V. morphine. The physician also considers administering alteplase. This thrombolytic agent must be administered how soon after onset of myocardial infarction (MI) symptoms?

Within 6 hours for the best chance of salvaging the client's myocardium, a thrombolytic agent must be administered within 6 hours after onset of chest pain or other signs or symptoms of MI. Sudden death is most likely to occur within the first 24 hours after an MI. Physicians initiate I.V. heparin therapy after administration of a thrombolytic agent; it usually continues for 5 to 7 day

Which client should the nurse most encourage to receive the pneumococcal and influenza vaccination?

a 75-year-old client with diabetes Explanation: Clients who have a chronic illness, have experienced a serious illness, reside in long-term care facilities, or are 65 years of age or older are encouraged to obtain pneumococcal and influenza vaccinations. Having angina or benign prostatic hypertrophy would not predispose a client to pneumonia or influenza. Pregnancy is not a contraindication, but this woman is not at high risk for these diseases.

A client experiencing a severe asthma attack has the following arterial blood gas results: pH 7.33; PCO2 48 (6.4 kPa); PO2 58 (7.7 kPa); HCO3 26 (26 mmol/L). Which prescriptions should the nurse implement first?

albuterol nebulizer Explanation: The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the client is stable

When performing the Heimlich maneuver on a conscious adult victim, the rescuer delivers inward and upward thrusts specifically:

below the xiphoid process and above the umbilicus. Explanation: The thrusts should be delivered below the xiphoid process, but above the umbilicus, to minimize the risk of internal injuries.

Which finding requires immediate intervention when planning care for an adolescent with cystic fibrosis (CF)?

chest pain with dyspnea Explanation: Chest pain and dyspnea are signs of a pneumothorax and should be treated immediately. Delayed puberty is common in adolescents with CF and is caused by poor nutrition. Poor weight gain is common in children with CF because so little is absorbed in the small intestine. Large, foul-smelling stools indicate noncompliance with taking enzymes and should be addressed, but respiratory complications are the greatest concern.

A Spanish-speaking client admitted with tuberculosis notes, through an interpreter, concerns about paying for needed medications. The nurse should:

collaborate with the social worker to investigate possible availability of funds. Explanation: The nurse should collaborate with the social worker about the client's financial concerns. This collaboration can be done independently without a physician's order. The physician must notify the public health department of the client's diagnosis, but a public health worker does not get involved with the client's financial concerns. The physician and home health nurse are not typically involved with the client's financial concerns until after the client is discharged.

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:

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

Bed rest is prescribed for a client with pneumonia during the acute phase of the illness. The nurse should determine the effectiveness of bed rest by assessing the client's:

decreased cellular demand for oxygen. Correct Explanation: Exudate in the alveoli interferes with ventilation and the diffusion of gases in clients with pneumonia. During the acute phase of the illness, it is essential to reduce the body's need for oxygen at the cellular level; bed rest is the most effective method for doing so. Bed rest does not decrease coughing or promote clearance of secretions, and it does not reduce pain when taking deep breaths.

Which physical sensation will the client who has had an abdominal hysterectomy most likely experience if she hyperventilates while performing deep-breathing exercises?

dizziness Explanation: Hyperventilation occurs when the client breathes so rapidly and deeply that she exhales excessive amounts of carbon dioxide. A characteristic symptom of hyperventilation is dizziness. To avoid hyperventilation, the nurse should assist the client in the practice of slow, deep breathing in a regular breathing pattern. Dyspnea, blurred vision, and mental confusion are not associated with hyperventilation

A client is receiving streptomycin in the treatment regimen of tuberculosis. The nurse should assess for:

hearing loss. Explanation: Streptomycin can cause toxicity to the eighth cranial nerve, which is responsible for hearing, balance, and body position sense. Nephrotoxicity is a side effect that would be indicated with an increase in creatinine. Streptomycin does not cause difficulty in swallowing. Streptomycin is given via intramuscular injection

When assessing a client with advanced chronic obstructive pulmonary disease (COPD) which are expected findings?

increased anteroposterior chest diameter Explanation: Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump blood into the pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD

The client is taking triamcinolone acetonide inhalant to treat bronchial asthma. The nurse should assess the client for:

oral candidiasis. Explanation: Acetonide inhalant is a corticosteroid. Use of a steroid inhaler can cause the client to develop oral candidiasis (thrush). It is important that the client rinse his or her mouth after using the inhaler. Acetonide inhalant does not lead to the development of systemic complications such as hyperglycemia, ulcers, or fluid retention.

The nurse is caring for a client with end-stage kidney disease. What arterial blood gas results are most closely associated with this disorder?

pH 7.20, PaCO2 36, HCO3 14- Explanation: Metabolic acidosis occurs in ESKD because the kidneys are unable to excrete increased loads of acid. Decreased acid secretion results from the inability of the kidney tubules to excrete ammonia (NH3-) and to reabsorb sodium bicarbonate (HCO3-). There is also decreased excretion of phosphates and other organic acids.

To help control pain during coughing for a client who has had a pulmonary lobectomy, the nurse should:

raise the bed to semi-Fowler's position and position the client's hands so that the incision is supported anteriorly and posteriorly. Explanation: Semi-Fowler's position allows for downward displacement of the diaphragm and relaxation of the abdominal muscles, which are needed for good ventilatory excursion. The hand placement supports the operative area and splints it without causing pain from pressure. Trendelenburg's position is contraindicated because abdominal contents pushing against the diaphragm will decrease effective lung volume. Keeping the bed flat does not allow the diaphragm to descend. Positioning the client on the operative side prevents maximum inflation of the lung

A client appears flushed and has shallow respiration. The arterial blood gas report shows the following: pH, 7.24; partial pressure of arterial carbon dioxide (PaCO2), 49 mm Hg (6.5 kPa); bicarbonate (HCO3-), 24 mEq/L (24 mmol/L). These findings are indicative of which acid-base imbalance?

respiratory acidosis Explanation: The pH of 7.24 indicates that the client is acidotic. The PaCO2 value of 49 mm Hg is elevated. The HCO3- value of 24 mEq/L is normal. The client is in uncompensated respiratory acidosis. Hypoventilation and a flushed appearance are additional clinical manifestations of respiratory acidosis

When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift objects:

while exhaling through pursed lips. Explanation: Exhaling requires less energy than inhaling. Therefore, lifting while exhaling saves energy and reduces perceived dyspnea. Pursing the lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhaling but before inhaling is similar to lifting with the breath held. This should not be recommended because it is similar to the Valsalva maneuver, which can stimulate cardiac arrhythmias

A client is breathing 40 breaths/minute. He is diaphoretic and confused. Which nursing diagnosis should be the priority for the client at this time?

Impaired gas exchange Explanation: Impaired gas exchange is the priority nursing diagnosis for this client. Insomnia, Anxiety, and Risk for injury due to confusion are also appropriate nursing diagnoses, but they are less important at this time

A client has just returned from the postanesthesia care unit after undergoing a laryngectomy. Which intervention should the nurse include in the plan of care?

Maintain the head of the bed at 30 to 40 degrees. Correct Explanation: Immediately after surgery, the client should be maintained in a position with the head of the bed elevated 30 to 40 degrees (semi-Fowler's position) to decrease tissue edema, facilitate breathing, and decrease pain related to edema formation. Immediately postoperatively, the client should be provided alternative means of communicating, such as a communication board. As healing progresses and edema subsides, a speech therapist should work with the client to explore various voice restoration options, such as the use of a voice prosthesis, electrolarynx, artificial larynx, or esophageal speech. Food is not initiated in the immediate postoperative phase; enteral feedings are usually used to meet nutritional needs until edema subsides. Irrigation of the drainage tubes is an inappropriate action

While assessing a thoracotomy incisional area from which a chest tube exits, the nurse feels a crackling sensation under the fingertips along the entire incision. What should the nurse do next?

Mark the area with a skin pencil at the outer periphery of the crackling. Explanation: This crackling sensation is subcutaneous emphysema. Subcutaneous emphysema is not an unusual finding and is not dangerous if confined, and the nurse should mark the area to detect if the area is expanding. Progression can be serious, especially if the neck is involved; a tracheotomy may be needed at that point. If emphysema progresses noticeably in 1 hour, the HCP should be notified. Lowering the head of the bed will not arrest the progress or provide any further information. A tracheotomy tray would be useful if subcutaneous emphysema progresses to the neck. Subcutaneous emphysema may progress if the chest drainage system does not adequately remove air and fluid; therefore, the system should not be turned off

To more easily remove thick, tenacious secretions when suctioning a tracheostomy, the nurse should liquefy the secretions before suctioning by instilling the tracheostomy tube with 1 to 2 mL of sterile:

Normal saline normal saline solution. Correct Explanation: Sterile normal saline is the solution of choice for instillation into a tracheostomy tube cannula to help liquefy sticky secretions. Normal saline solution is less irritating to mucous membranes than plain water, bacteriostatic water, or a dextrose solution

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 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 on the medical-surgical unit just received report on her client care assignment. Which client should she assess first?

The client with unilateral leg swelling who's complaining of anxiety and shortness of breath Explanation: The client who is complaining of anxiety and shortness of breath and has unilateral leg swelling should be seen first. This client is exhibiting signs and symptoms of pulmonary embolism, which is a life-threatening condition. Crackles, fever, and pleuritic pain are signs and symptoms of pneumonia. Anorexia, weight loss, and night sweats are signs and symptoms of tuberculosis. Difficulty sleeping, daytime fatigue, and morning headache are symptoms of sleep apnea. Pneumonia, sleep apnea, and tuberculosis aren't medical emergencies. Clients with these disorders don't take priority over the client with a pulmonary embolis

A client with a suspected pulmonary disorder undergoes pulmonary function tests. To interpret test results accurately, the nurse must be familiar with the terminology used to describe pulmonary functions. Which term refers to the volume of air inhaled or exhaled during each respiratory cycle?

Tidal volume Correct Explanation: Tidal volume refers to the volume of air inhaled or exhaled during each respiratory cycle when breathing normally. Normal tidal volume ranges from 400 to 700 ml. Vital capacity refers to the total volume of air that can be exhaled during a slow, maximal expiration after maximal inspiration. Functional residual capacity refers to the volume of air remaining in the lungs after a normal expiration. Maximal voluntary ventilation is the greatest volume of air expired in 1 minute with maximal voluntary effort.

After suctioning a client, a nurse should expect to find:

clear breath sounds. Explanation: Clear breath sounds, which indicate that secretions have been removed, indicate effective suctioning. An above-normal respiratory rate, such as a rate of 28 breaths/minute, may indicate that the airway isn't clear of secretions and the client's respiratory rate has increased to compensate. A slightly increased heart rate, such as a rate of 104 beats/minute, may indicate health concerns unrelated to suctioning. Brisk capillary refill indicates adequate cardiovascular function and is unrelated to suctioning.

A nurse is caring for an adolescent involved in a motor vehicle crash. The adolescent has a chest tube in place. If the chest tube is accidentally removed, the nurse should immediately:

cover the opening with petroleum gauze. Explanation: If a chest tube is accidentally removed, the nurse should cover the insertion site with sterile petroleum gauze. The nurse should then observe the client for respiratory distress because tension pneumothorax may develop. If tension pneumothorax does develop, the nurse should remove the gauze to allow air to escape. The nurse shouldn't reintroduce the tube. Rather, the nurse should have another staff member call a physician so another tube can be introduced by the physician under sterile conditions

An adult with a history of chronic obstructive pulmonary disease (COPD) and metastatic carcinoma of the lung has not responded to radiation therapy and is being admitted to the hospice program. The nurse should conduct a focused client assessment for:

dyspnea. Explanation: Dyspnea is a distressing symptom in clients with advanced cancer including metastatic carcinoma of the lung, previous radiation therapy, and coexisting COPD. Ascites does occur in clients with metastatic carcinoma; however, in the client with COPD and lung cancer, dyspnea is a more common finding. A pleural friction rub is usually associated with pneumonia, pleurisy, or pulmonary infarct.

A nurse assesses arterial blood gas results for a client in acute respiratory failure (ARF). Which of the following results are consistent with this disorder?

pH 7.28, PaO2 50 mm Hg Explanation: ARF is defined as a decrease in the arterial oxygen tension (PaO2) to less than 50 mm Hg (hypoxemia) and an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg (hypercapnia), with an arterial pH of less than 7.35.

What type of diet should the nurse teach the parents to give an older infant with cystic fibrosis (CF)?

high-calorie diet Explanation: CF affects the exocrine glands. Mucus is thick and tenacious, sticking to the walls of the pancreatic and bile ducts and eventually causing obstruction. Because of the difficulty with digestion and absorption, a high-calorie, high-protein, high-carbohydrate, moderate-fat diet is indicated

Which diet would be most appropriate for a client with chronic obstructive pulmonary disease (COPD)?

high-calorie, high-protein diet Explanation: The client should eat high-calorie, high-protein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing. The client should be encouraged to eat small, frequent meals. A low-fat, low-cholesterol diet is indicated for clients with coronary artery disease. The client with COPD does not necessarily need to follow a sodium-restricted diet, unless otherwise medically indicated. There is no need for the client to eat bland, soft foods.

The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk?

hypoxia not responsive to oxygen therapy Explanation: A hallmark of early ARDS is refractory hypoxemia. The client's PaO2 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS.

When assessing a client with advanced chronic obstructive pulmonary disease (COPD) which are expected findings?

increased anteroposterior chest diameter Explanation: Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fixed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump blood into the pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD.

The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect:

inspiratory and expiratory wheezing. Explanation: The hallmark signs of asthma are chest tightness, audible wheezing, and coughing. Inspiratory and expiratory wheezing is the result of bronchoconstriction. Even between exacerbations there may be some soft wheezing, so a finding of normal breath sounds would be expected in the absence of asthma. The expected finding is decreased forced expiratory volume (forced expiratory flow [FEF] is the flow [or speed] of air coming out of the lung during the middle portion of a forced expiration) due to bronchial constriction. Morning headaches are found in more advanced cases of COPD and signal nocturnal hypercapnia or hypoxemia.

A client is being prepared for a bronchoscopy. The nurse can delegate which task to the unlicensed assistive personnel (UAP)?

placing the client on NPO status Explanation: It would be appropriate for the nurse to instruct the UAP to place the client on NPO status. It is the responsibility of the health care provider performing the procedure to obtain the client's informed consent and have the form signed. It is the responsibility of the registered nurse to teach clients and evaluate their health status. These responsibilities cannot be delegated to a UAP.

The nurse is reading the results of a tuberculin skin test (see figure). The nurse should interpret the results as:

positive. Explanation: The tuberculin test is positive. The test should be interpreted 2 to 3 days after administering the purified protein derivative (PPD) by measuring the size of the firm, raised area (induration). Positive responses indicate that the client may have been exposed to the tuberculosis bacteria. A negative response is indicated by the absence of a firm, raised area, or an area that is less than 5 mm in diameter. Since the test is positive, it is not necessary to redo the test. The test is positive, not false. (

An expected outcome of theophylline ethylenediamine when administered to a client with chronic obstructive pulmonary disease is:

relax bronchial smooth muscle. Explanation: Theophylline ethylenediamine is a xanthine derivative that acts directly on bronchial smooth muscle to relax and dilate the bronchi and relieve bronchial constriction and spasms. When the drug exerts its primary desired effect, dyspnea and shortness of breath decrease. Theophylline ethylenediamine does not reduce bronchial secretions or decrease alveolar elasticity. Theophylline ethylenediamine does increase strength of myocardial contractility, but this is not the action for which it is used.

A client admitted with acute anxiety has the following arterial blood gas (ABG) values: pH, 7.55; partial pressure of arterial oxygen (PaO2), 90 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 27 mm Hg; and bicarbonate (HCO3-), 24 mEq/L. Based on these values, the nurse suspects:

respiratory alkalosis. Explanation: This client's above-normal pH value indicates alkalosis. The below-normal PaCO2 value indicates acid loss via hyperventilation; this type of acid loss occurs only in respiratory alkalosis. These ABG values wouldn't occur in metabolic acidosis, respiratory acidosis, or metabolic alkalosis

The client with tuberculosis is to be discharged home with nursing follow-up. Which aspect of nursing care will have the highest priority?

teaching the client about the disease and its treatment Explanation: Ensuring that the client is well educated about tuberculosis is the highest priority. Education of the client and family is essential to help the client understand the need for completing the prescribed drug therapy to cure the disease. Offering the client emotional support, coordinating various agency services, and assessing the environment may be part of the care for the client with tuberculosis; however, these interventions are of less importance than education about the disease process and its treatmen

A client's chest tube is connected to a drainage system with a water seal. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. The fluctuation means that:

the chest tube system is functioning properly. Fluctuation of fluid with respirations in the water seal column indicates that the system is functioning properly. If an obstruction were present in the chest tube, fluid fluctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client's skin around the chest tube insertion site. A leak in the system is indicated when bubbling occurs in the water seal column.

A client recovering from a pulmonary embolism is receiving warfarin. To counteract a warfarin overdose, the nurse should administer:

vitamin K1 (phytonadione). Explanation: Vitamin K1 is the antidote for a warfarin overdose. Heparin is a parenteral anticoagulant. Vitamin C isn't an antidote. Protamine sulfate is the antidote for heparin.

The nurse is caring for a client with tuberculosis. Which precautions should the nurse take when providing care for this client? Select all that apply.

• Wear gloves when handling tissues containing sputum. • Wear a face mask at all times. • Wash hands after direct contact with the client or contaminated articles. Explanation: The nurse should always wear gloves when handling items contaminated with sputum or body secretions. All staff and visitors must wear face masks when coming in contact with the client in his or her room; masks must be discarded before leaving the client's room. Handwashing is required after direct contact with the client or contaminated articles. Strict isolation is not required if the client adheres to special respiratory precautions. The client, not the people in contact with him or her, must wear a mask when leaving the room for tests. The client should be in a negative-pressure, private room, and the door should remain closed at all times to prevent the spread of infection.

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?

Light-headedness or paresthesia Explanation: The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance. (

A child with tetralogy of Fallot and a history of severe hypoxic episodes is to be admitted to the pediatric unit. What would be most important for the nurse to have at the bedside?

oxygen tubing and flow meter plugged in Explanation: Because the child has a history of severe hypoxic episodes, having oxygen readily available at the bedside is most important. Should the child experience another hypoxic episode, oxygen could be administered easily and quickly. Although morphine causes peripheral dilation, which causes the blood to remain in the periphery, decreasing system volume and oxygen administration is the priority. Typically a child with tetralogy of Fallot with episodes of hypoxia does not require suctioning.

When caring for a client who has undergone a left lung lobectomy, what important postoperative measures related to care of chest tubes should be performed by the nurse? Select all that apply

• Measure drainage at the end of each shift. • Assess chest tube dressing for bleeding. • Ensure all connections are securely taped. Explanation: It is important to ensure that chest tube connections are secure so there are no air leaks. In addition, postoperative considerations include checking the chest tube dressing. The drainage would also be measured at the end of each shift. These are primary considerations postoperatively after a lobectomy. Wall suction must be continuously bubbling to ensure there is active suction in the pleural space. The client needs to be in the Fowler's position to promote effective breathing. Prone or supine would not be appropriate.

Which statement by the mother of a neonate diagnosed with bronchopulmonary dysplasia (BPD) indicates effective teaching?

"My baby may require long-term respiratory support." Explanation: BPD is a chronic illness that may require prolonged hospitalization and permanent assisted ventilation. The disease typically occurs in compromised very-low-birth-weight neonates who require oxygen therapy and assisted ventilation for treatment of respiratory distress syndrome. The cause is multifactorial, and the disease has four stages. The neonate's activities may be limited by the disease. Antibiotics may be prescribed and bronchodilators may be used, but these medications will not cure the chronic disease state. Seizure activity is associated with periventricular-intraventricular hemorrhage, not BPD.

A client had a Mantoux test result of an 8-mm induration. The test is considered positive when the client:

is immunocompromised. Explanation: An induration (palpable raised hardened area of skin) of more than 5 to 15 mm (depending upon the person's risk factors) to 10 Mantoux units is considered a positive result, indicating TB infection. An induration of greater than 5 mm is found in HIV-positive individuals, those with recent contacts with persons with TB, persons with nodular or fibrotic changes on chest x-ray consistent with old healed TB, or clients with organ transplants or immunosuppressed. An induration of greater than 10 mm is positive, and the client may be a recent arrival (less than 5 years) from high-prevalent countries, injection drug user, resident or an employee of high-risk congregate settings (e.g., prisons, long-term care facilities, hospitals, homeless shelters), or mycobacteriology lab personnel. Persons with clinical conditions that place them at high risk (e.g., diabetes, prolonged corticosteroid therapy, leukemia, end-stage renal disease, chronic malabsorption syndromes, low body weight), a child less than 4 years of age, or a child or adolescents exposed to adults in high-risk categorie

The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest X-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate?

A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device. Explanation: Shortness of breath and decreased breath sounds will be present if there is collapse of the lung because of loss of integrity of the pleural space. The chest tube will need to be inserted because of the rib fractures that have resulted in air and blood in the pleural space. The chest tubes will be removed when the hemopneumothorax has resolved. A thoracentesis will not be enough to resolve the hemopneumothorax; splinting of the ribs will not resolve the hemopneumothorax. Oxygen would be indicated, but a bronchoscopy will not confirm the area of damage if the lung is collapsed

The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustration shown, what should the nurse do?

Lower the drainage system to maintain gravity flow. Explanation: To promote chest tube drainage, the drainage system must be lower than the client's lungs. The amount of drainage is not abnormal; it is not necessary to notify the HCP. The nurse should chart the amount and color of drainage every 4 to 8 hours. The chest tube does not need to be clamped; the tubing connection is intact. There is sufficient water to maintain a water seal

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?

Measuring and documenting the drainage in the collection chamber Explanation: The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

Which nursing goal is a priority for the nurse planning care for a client immediately after a total laryngectomy?

Maintain a patent airway. Explanation: Maintaining a patent airway is the priority nursing goal in the immediate postoperative period. The client's ability to cough and deep breathe is impaired because the glottis has been removed. Providing nutrition, preventing hemorrhage, and reducing strain on suture lines are important nursing goals, but maintaining a patent airway is the priority.

A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the health care provider (HCP)?

arterial oxygen level of 46 mm Hg (6.1 kPa) Explanation: Manifestations of adult respiratory distress syndrome (ARDS) secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation, and hypoxemia with arterial oxygen level below 50 mm Hg. The nurse should report the arterial oxygen level of 46 mm Hg (6.1 kPa) to the HCP. A respiratory rate of 12 is normal and not considered a sign of respiratory distress. Adventitious lung sounds, such as crackles, are typically found in clients with ARDS. Oxygen saturation of 96% is satisfactory and does not represent hypoxemia or low arterial oxygen saturation.

A client is prescribed metaproterenol via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report which adverse effect?

irregular heartbeat Explanation: Irregular heartbeats should be reported promptly to the care provider. Metaproterenol may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia

The health care provider prescribes 0.4 mg of atropine sulfate and 75 mg of meperidine hydrochloride to be given intramuscularly to a client 1 hour before surgery. The stock ampule of atropine contains 0.8 mg/mL, and the stock ampule of meperidine contains 100 mg/mL. The two drugs are compatible and can be drawn up in one syringe. What is the combined volume of medication in the syringe?

1.25 mL Explanation: The correct amount to administer is determined by using ratios, as follows: 0.8 mg/1 mL = 0.4 mg/x mL 0.8/x = 0.4 x = 0.5 mL of atropine sulfate 100 mg/1 mL = 75 mg/x mL 100/x = 75 x = 0.75 mL of meperidine hydrochloride 0.5 mL of atropine + 0.75 mL of meperidine hydrochloride = 1.25 mL total

Which information should the nurse include in a teaching plan for the client newly diagnosed with chronic obstructive pulmonary disease? Select all that apply.

• Smoking cessation is important to slow or stop disease progression. • High humidity may increase your work of breathing. • A bronchodilator with meter-dose inhaler should be readily available. Explanation: High humidity has been shown to increase the work of breathing. Carrying a metered-dose inhaler can facilitate early intervention if bronchospasm and shortness of breath should occur. Smoking cessation is difficult to achieve but very important in preventing COPD progression. Pulmonary rehabilitation programs are a great source of support for health promotion and maintenance for clients with COPD. Both the pneumococcal and influenza vaccines can help protect again respiratory infections.

An adolescent with cystic fibrosis has been hospitalized several times. On the latest admission, the client has labored respirations, fatigue, malnutrition, and failure to thrive. Which initial nursing actions are most important?

applying an oximeter and initiating respiratory therapy Explanation: Clients with cystic fibrosis commonly die from respiratory problems. The mucus in the lungs is tenacious and difficult to expel, leading to lung infections and interference with oxygen and carbon dioxide exchange. The client will likely need supplemental oxygen and respiratory treatments to maintain adequate gas exchange, as identified by the oximeter reading. The child will be on bed rest due to respiratory distress. However, although blood gases will probably be prescribed, the oximeter readings will be used to determine oxygen deficit and are, therefore, more of a priority. A diet high in calories, proteins, and vitamins with pancreatic granules added to all foods ingested will increase nutrient absorption and help the malnutrition; however, this intervention is not the priority at this time. Inserting an IV to administer antibiotics is important, and can be done after ensuring adequate respiratory function.