NCLEX PN Review - RESPIRATORY

the nurse is assisting with monitoring the functioning of a chest-tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. which findings should the nurse expect to note? select all that apply excessive bubbling in the water-seal chamber vigorous bubbling in the suction-control chamber 50 mL of drainage in the drainage-collection chamber the drainage system is maintained below the client's chest an occlusive dressing is in place over the chest tube insertion site fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation

50 mL of drainage in the drainage-collection chamber // the drainage system is maintained below the client's chest // an occlusive dressing is in place over the chest-tube insertion site // fluctuation of water in the tube of the water-seal chamber during inhalation and exhalation rationale the bubbling of water in the water-seal chamber indicates air drainage from the client. this is usually seen when intrathoracic pressure is greater than atmospheric pressure, and it may occur during exhalation, coughing, or sneezing. excessive bubbling in the water-seal chamber may indicate an air leak, which is an unexpected finding. the fluctuation of water in the tube in the water-seal chamber during inhalation and exhalation is expected. an absence of fluctuation may indicate that the chest tube is obstructed, the lung has reexpanded, or no more air is leaking into the pleural space. gentle (not vigorous) bubbling should be noted in the suction-control chamber. a total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room; however, drainage of more than 70 to 100 mL/hour is considered excessive and requires RN and HCP notification. the chest-tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. positioning the drainage system below the client's chest allows gravity to drain the pleural space.

the nurse is collecting data on a client with chronic airflow limitation (CAL) and notes that the client has a "barrel chest" the nurse interprets that this chest has which forms of CAL a) emphysema b) bronchial asthma c) chronic obstructive bronchitis d) both bronchial asthma and bronchitis

a) emphysema rationale the client with emphysema has hyperinflation of the alveoli and has flattening of the diaphragm. these lead to increased anteroposterior diameter, which is referred to as "barrel chest." the client also has dyspnea with prolonged expiration and has hyperresonant lungs to percussion.

the nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. the nurse should provide the client with which information about this type of tube? a) enables the client to speak b) prevents the client from speaking c) is necessary for mechanical ventilation d) prevents air from being inhaled through the tracheostomy opening

a) enables the client to speak rationale a fenestrated tube has a small opening in the outer cannula that allows some air to escape through the larynx; this type of tube enables the client to speak. the other options are incorrect with regard to this type of tube.

the nurse is planning to suction a client through a tracheostomy tube. which is the amount of time for application of suction during withdrawal of the catheter? a) 10 seconds b) 25 seconds c) 30 seconds d) 35 seconds

a) 10 seconds rationale during suctioning, the nurse should apply suction during the withdrawal of the catheter for a period of 5 to 10 seconds. suction applied longer than this can cause hypoxia in the client.

the nurse is caring for a client at home who has had a tracheostomy tube for several months. the nurse monitors the client for complications associated with the long-term tracheostomy and suspects tracheoesophageal fistula if which observation is noted for the client? a) abdominal distention b) purulent drainage around the tracheotomy site c) excessive secretions from the tracheotomy site d) inability to pass a suction catheter through the tracheotomy

a) abdominal distention rationale necrosis of the tracheal wall can lead to an artificial opening between the posterior trachea and the esophagus. this problem is called tracheoesophageal fistula. the fistula allows air to escape into the stomach, causing abdominal distention. it also can cause aspiration of gastric contents. option B may indicate an infection. option C may indicate the need for more frequent suctioning. the last option may indicate an obstruction of some sort or the presence of bronchoconstriction

a clinical nurse is reinforcing instructions to a client with a diagnosis of pharyngitis. which intervention should the client be encouraged to perform? a) avoid foods that are highly seasoned b) restrict fluid intake to 1000mL daily c) drink warm herbal tea throughout the day d) substitute hot chocolate in place of coffee

a) avoid foods that are highly seasoned rationale the client with pharyngitis should be instructed to consume cool clear fluids, ice chips, or ice pops to soothe the painful throat. milk and milk products are avoided because they tend to increase mucous production. food that are highly seasoned are irritating to the throat and should be avoided, and the client should be instructed to drink 2000 to 3000 mL of fluid daily, unless contraindicated.

a client with active TB demonstrates less-than-expected interest in learning about the prescribed medication therapy. which technique would the nurse ultimately need to employ in order to encourage participation? a) directly observed therapy b) more medication instructions c) involvement of the family in teaching d) reinforcement by the HCP

a) directly observed therapy rationale TB is a highly communicable disease, which is reportable to local public health departments. each of these agencies has regulations that may be enforced to ensure compliance with TB therapy. the client may be required to have directly observed therapy to reduce the risk to the general public. this involves having a responsible person actually observe the client taking the medication each day.

a client with AIDS has become infected with histoplasmosis. the nurse monitors the client for which signs and symptoms? a) dyspnea b) headache c) weight gain d) hypothermia

a) dyspnea rationale histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. the infection begins as a respiratory infection and can progress to disseminated infection. typical signs and symptoms include fever, dyspnea, cough, and weight loss. there also may be enlargement of the client's lymph nodes, liver and spleen.

a client with AIDS has histoplasmosis. which signs/symptoms should the nurse expect the client to experience? a) dyspnea b) headache c) weight gain d) hypothermia

a) dyspnea rationale histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. the infection begins as a respiratory infection and can progress to disseminated infection. typical signs and symptoms include fever, dyspnea, cough, and weight loss. there may be an enlargement of the clients lymph nodes, liver and spleen as well.

the nurse is assisting in caring for a postoperative client who had a pneumonectomy. the nurse monitors the client for which adverse signs and symptoms indicating acute pulmonary edema? a) frothy sputum b) pain with deep breathing c) increased chest tube drainage d) respiratory rate of 20 breaths per minute

a) frothy sputum rationale the client developing pulmonary edema after pneumonectomy demonstrates dyspnea, cough, frothy sputum, crackles, and possibly cyanosis. a respiratory rate of 20 breaths per minute is within normal limits. pain with deep breathing is expected and managed with analgesics. the client with pneumonectomy usually does not have a chest tube.

the nurse is preparing to obtain a sputum specimen from the client. which nursing action is essential in obtaining a proper specimen? a) have the client take three deep breaths b) limit fluids before obtaining the specimen c) ask the client to obtain the specimen after eating d) ask the client to spit into the collection container

a) have the client take three deep breaths rationale to obtain a sputum specimen, the client should brush his or her teeth to reduce mouth contamination. the client should then take three deep breaths and cough into a sputum specimen container. the client should be encouraged to cough and not spit so that sputum can be obtained. sputum can be thinned by fluids or by a respiratory treatment, such as inhalation of nebulized saline or water. the optimal time to obtain a specimen is on arising in the morning

the nurse is assigned to care for a client after a left pneumonectomy. which position is contraindicated for this client? a) lateral position b) low-fowlers position c) semi-fowlers position d) head of the bed elevation at 40 degrees

a) lateral position rationale complete lateral positioning is contraindicated for client following pneumonectomy. because the mediastinum is no longer held in place on both sides by lung tissue, lateral positioning may cause mediastinal shift and compression of the remaining lung. the head of the bed should be elevated.

the nurse is taking the nursing history of a client with silicosis. the nurse checks whether the client wears which item during periods of exposure to silica particles? a) mask b) gown c) gloves d) eye protection

a) mask rationale silicosis results from chronic, excessive inhalation of particles of free crystalline silica dust. the client should wear a mask to limit inhalation of this substance, which can cause restrictive lung disease after years of exposure. the other options are not necessary.

a client begins to drain small amounts of red blood from a tracheostomy tube 36 hours after a supraglottic laryngectomy. the LPN should perform which action? a) notify the RN b) increase the frequency of suctioning c) add moisture to the oxygen delivery system d) document the character and amount of drainage

a) notify the RN rationale immediately following laryngectomy, there is a small amount of bleeding from the tracheostomy, which resolves within the first few hours. bleeding 24 hours after the surgery may be a sign of impending rupture of a vessel. the bleeding in this instance represents a potentially life-threatening situation, and the RN needs to be notified, who will then contact the HCP. although the other options may be appropriate, they do not address the urgency of the problem. failure to notify the HCP in a timely fashion places the client at risk

the nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. which equipment should the nurse plan to have at the bedside when the client returns from surgery? a) obturator b) oral airway c) epinephrine d) tracheostomy tube with the next larger size

a) obturator rationale a replacement tracheostomy tube of the same size and an obturator is kept at the bedside at all times, in case the tracheostomy tube is dislodged. in addition, a curved hemostat that could be used to hold the trachea open, if dislodgment occurs, should also be kept at the bedside. an oral airway and epinephrine would not be needed.

the nurse notes that a hospitalized client has experienced a positive reaction to the Mantoux tuberculin skin test. which action by the nurse is the priority? a) report the findings b) document the finding in the client's record c) call the employee health department d) call the radiology department for a chest x-ray

a) report the findings rationale the nurse who interprets a Mantoux tuberculin skin test as positive notifies the HCP immediately. the HCP would prescribe a chest x-ray to determine whether the client has clinically active TB or old, healed lesions. a sputum culture would be done to confirm the diagnosis of active TB. the client is placed on TB precautions prophylactically until a final diagnosis is made. the findings are documented in the client's record, but this action is not the highest priority. calling employee health would be of no benefit to the client.

the nurse is assigned to assist in caring for a client with a chest tube drainage system. in planning for the client, the nurse makes certain that what equipment is available, in the event that the drainage system needs to be changed? a) rubber-shod clamps b) wall suction catheter c) vaseline gauze dressing d) a sterile 40-mL syringe

a) rubber-shod clamps rationale if the drainage system needs to be changed, the RN will use rubber-shod clamps to clamp the tube near the client's chest while the drainage system is changed. this procedure is done quickly and with the assistance of another nurse. the clamps are removed immediately after reconnection of the new drainage system. agency procedure regarding clamping chest tubes is always followed, and a HCP's prescription for clamping the tube may be required. if clamps must be used, the best time to apply them is after expiration. an occlusive dressing such as a petrolatum (vaseline) gauze dressing is used when a chest tube is removed. the other options are not needed for changing a drainage system

the nurse is monitoring the respiratory status of a client who has suffered a fractured rib. the nurse monitors the client and understands that which sign/symptom is unrelated to the rib fracture? a) slow, deep respirations b) splinting or guarding the chest c) bruising over the fracture area d) pain, especially with inspiration

a) slow, deep respirations rationale rib fracture is a common injury, especially in the older client, and results from a blunt injury or a fall. typical signs and symptoms include pain and tenderness that are localized at the fracture site and are exacerbated by inspiration and palpation; shallow respirations; splinting or guarding the chest protectively to minimize chest movement; and possible bruising at the fracture site.

the nurse is caring for a client with an endotracheal tube attached to a ventilator. the high-pressure alarm sounds on the ventilator. the nurse prepares to perform which priority nursing intervention? a) suction the client b) check for a disconnection c) notify the respiratory therapist d) evaluate the tube cuff for a leak

a) suction the client rationale when the high-pressure alarm sounds on a ventilator, it is most likely caused by an obstruction. the obstruction can be caused by the client biting on the tube, kinking of the tubing, or mucous plugging requiring suctioning. it is also important to check the tubing for the presence of any water and determine whether the client is out of rhythm with breathing with the ventilator. a disconnection or a cuff leak can result in the sounding of the low-pressure alarm. the respiratory therapist should be notified if the nurse could not determine the cause of the alarm.

a client with TB asks the nurse about precautions to take after discharge from the hospital to prevent transmitting infection to others. the nurse develops a response to the clients question, based on which understanding? a) the disease is transmitted by droplet nuclei b) the client should maintain enteric precautions only c) deep pile carpet should be removed from the home d) clothing and sheets should be bleached after each use

a) the disease is transmitted by droplet nuclei rationale TB is spread by droplet nuclei or by an airborne route. the disease is not carried on objects such as clothing, eating utensils, linens, or furniture. bleaching of clothing and linens is unnecessary, although the client and family members should use good hand-washing technique. it is unnecessary to remove carpeting from the home.

the nurse is preparing to perform chest physiotherapy (CPT) on a client. before determining the correct position in which to place the client, which information should the nurse ascertain? a) the lung areas involved b) the proximity of the oxygen tank c) the client's capability for lung expansion d) the client's procedure for performing deep breathing techniques

a) the lung areas involved rationale the goal of chest physiotherapy is to mobilize secretions for improved respiratory function. the nurse must determine which areas of the lungs should be targeted for this technique. the client's capability for lung expansion is secondary to the lung assessment. deep breathing routines and oxygen use do not specifically relate to client positioning.

the nurse is caring for a client following segmental resection of the upper lobe of the left lung. the nurse notes 700 mL of grossly bloody drainage in the chest tube drainage system during the first hour following surgery. which statement represents the nurse's accurate interpretation of this finding? a) this finding requires further data collection b) this finding indicates the need for autotransfusion c) this finding is expected following this type of surgery d) this finding indicates a malfunction of the chest tube drainage system

a) this finding requires further data collection rationale within the first 2 hours following surgery, 100 to 300 mL of drainage is expected. an amount of 700 mL is excessive and indicates that hemorrhage may be occurring, and the client requires further data collection. the HCP should be notified. the other options are incorrect.

a client experiencing a pleural effusion had a thoracentesis. analysis of the extracted fluid revealed a high red blood cell count. the nurse interprets that this result is consistent with which diagnosis? a) trauma b) infection c) liver failure d) heart failure

a) trauma rationale pleural effusion that has a high red blood cell count may result from trauma and may be treated with placement of a chest tube for drainage. other causes of pleural effusion include infection, HF, liver or renal failure, malignancy, or inflammation processes

a client with arthritis of the hands and fingers is having difficulty using a metered-dose inhaler (MDI). the nurse suggests asking the HCP for which prescription? a) use of a spacer b) use of a nebulizer c) use of an oral (pill) form of the medication d) use of an IV form of the medication

a) use of a spacer rationale for a client with arthritis or other conditions that limit the use of the hands, the use of a spacer may prove beneficial. a spacer allows the medication to be delivered deep into pulmonary tissues, even if the client has difficulty with coordination. MDIs may be difficult to use because they require coordination and adequate hand motion to hold the canister at the proper distance (1 1/2 to 2 inches from the mouth), depress the canister, and inhale. a spacer is especially useful for clients who are older or who have difficulty using an MDI. the other options are incorrect.

the nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for tuberculosis. which instructions should the nurse reinforce? select all that apply activities should be resumed gradually avoid contact with other individuals, except family members, for at least 6 months a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated respiratory isolation is not necessary because family members have already been exposed cover the mouth and nose when coughing or sneezing and confine used tissues to a plastic bag when one sputum culture is negative, the client is no longer considered infectious and can usually return to his or her former employment

activities should be resumed gradually // a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated // respiratory isolation is not necessary because family members have already been exposed // cover the mouth and nose when coughing or sneezing and confine used tissues to plastic bags rationale the nurse should provide the client and family with information about tuberculosis and allay concerns about the contagious aspect of the infection. the client is reassured that after 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. the client is also informed that activities should be resumed gradually. the client and family are informed that respiratory isolation is not necessary, because family members have already been exposed. the client is instructed about thorough hand washing and to cover the mouth and nose when coughing and sneezing and confine used tissues to plastic bags. the client is informed that a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated and that when the results of three sputum cultures are negative, the client is no longer considered infectious and can usually return to his or her former employment.

a client with a diagnosis of lung cancer returns to the nursing unit after a left pneumonectomy. which nursing actions should be done? select all that apply turn completely on the side administer humidified oxygen instruct on the use of the incentive spirometer monitor vital signs and pulse oximetry frequently place in respiratory isolation to prevent isolation

administer humidified oxygen // instruct on the use of the incentive spirometer // monitor vital signs and pulse oximetry frequently rationale a client with a pneumonectomy can be turned slightly and supported with a pillow but complete lateral positioning is contraindicated because of pressure on the bronchial stump of shifting of mediastinal contents. in addition, the surgeon's prescription for positioning is always checked and followed. the client needs to receive oxygen and use an incentive spirometer to prevent atelectasis in the remaining lung. vital signs and pulse oximetry need ot be monitored frequently. the client should not be placed in respiratory isolation to prevent infection; this is unnecessary

the nurse is preparing to suction an adult client through the client's tracheostomy tube. which interventions should the nurse perform for this procedure? select all that apply. apply suction for up to 10 to 15 seconds hyperoxygenate the client before suctioning set the wall suction unit pressure at 160 mm Hg apply suction while gently inserting the catheter apply intermittent suction while rotating and withdrawing the catheter advance the catheter until resistance is met and then pull the catheter back 1 cm

apply suction for up to 10 to 15 seconds // hyperoxygenate the client before suctioning // apply intermittent suction while rotating and withdrawing the catheter // advance the catheter until resistance is met and then pull the catheter back 1 cm. rationale intermittent suction is applied while rotating the catheter for 10 to 15 seconds. the nurse should hyperoxygenate the client with a resuscitator bag/ Ambu-bag connected to an oxygen source before suctioning because suction depletes the client's oxygen supply. the catheter should be inserted gently until resistance is met or the client coughs, then pulled back 1 cm or 1/2 inch. intermittent suction is applied while rotating and withdrawing the catheter. setting the wall suction unit pressure at 160 mmHg is incorrect because wall suction should be set to 80 to 12 mm Hg. pressure set a higher level can cause trauma to respiratory tract issues. strict asepsis needs to be maintained, and the nurse would wear sterile gloves to perform the procedure. suction is never applied when inserting the catheter because it will deplete oxygen and can traumatize tissues.

the nurse is assisting in preparing a list of instruction for an adult client who is being discharged following a tonsillectomy. which instructions should the nurse include in the list? select all that apply avoid hot fluids avoid rough foods consume milk products rest for the next 24 hours consume carbonated beverages eat ice cream to soothe the throat

avoid hot fluids // avoid rough foods // rest for the next 24 hours rationale following tonsillectomy, the client is instructed to advance the diet from cool clear liquids to full liquids. hot fluids and carbonated beverages should be avoided because they may be irritating to the throat. milk and milk products are avoided because they may cause the client to cough, which can hurt the surgical site. rough foods and snacks such as raw fruits or vegetables should be avoided for 10 days to protect the scab that forms over the operative site and to prevent bleeding. the client should be instructed to rest in bed or on a couch for 24 hours after the surgical procedure and gradually resume full activity

the nurse is caring for a client with emphysema receiving oxygen. the nurse should check the oxygen flow rate to ensure the client does not exceed how many L / min of oxygen a) 1 b) 2 c) 6 d) 10

b) 2 rationale between 1 and 3 L/min of oxygen by nasal cannula may be required to raise the PaO2 level to 60 to 80 mm Hg. however, oxygen is used cautiously in the client with emphysema and should not exceed 2 L /min. because of the long-standing hypercapnia that occurs in this disorder, the respiratory drive is triggered by low oxygen levels rather than by increased carbon dioxide levels, which is the case in a normal respiratory system

the nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. the nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs? a) suctioning is required frequently b) aspiration of gastric contents occurs when suctioning c) the client's skin and mucous membranes are light pink d) excessive secretions are suctioned from a tracheostomy

b) aspiration of gastric contents occurs when suctioning rationale necrosis of the tracheal wall in a client with a tracheostomy can lead to an artificial opening between the posterior trachea and esophagus. this problem is called tracheoesophageal fistula. the fistula allows air to escape into the stomach, causing abdominal distention. it also causes aspiration of gastric contents. the other options are not signs of this complication

a cardiac monitor alarm sounds and the nurse notes a straight line on the monitor screen. what is the nurse's immediate nursing action? a) call a code b) assess the client c) confirm the rhythm d) check the cardiac leads and wires

b) assess the client rationale if a monitor alarm sounds, the nurse should first assess the clinical status of the client to see whether the problem is an actual dysrhythmia or a malfunction of the monitoring system. asystole should be mistaken for an unattached electrocardiogram wire. the other options would be appropriate once the nurse has assessed the client.

the nurse is performing nasopharyngeal suctioning on a client and suddenly notes the presence of bloody secretions. which action should the nurse implement? a) continue suctioning to remove the blood b) check the amount of suction pressure being applied c) encourage the client to cough out the bloody secretions d) remove the suction catheter from the nose and begin vigorous suctioning through the mouth

b) check the amount of pressure being applied rationale the return of bloody secretions is an unexpected outcome related to suctioning. if this occurs, the nurse should first assess the client and then determine the amount of suction pressure being applied. the amount of suction pressure may need to be decreased. the nurse also needs to be sure that intermittent suction and catheter rotation are being done during suctioning. continuing with the suctioning or vigorous suctioning through the mouth will cause increased trauma and thus increased bleeding. suctioning is normally performed on clients who are unable to expectorate secretions. therefore, it is unlikely that the client will be able to cough out the bloody secretions.

the nurse is caring for a client hospitalized with acute exacerbation of COPD. which should the nurse expect the client to experience? a) hypocapnia b) hyperinflated lungs on chest x-ray c) increased oxygen saturation with exercise d) a widened diaphragm noted on chest x-ray

b) hyperinflated lungs on chest x-ray rationale signs/symptoms of COPD include hypoxema, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.

which statement by the client indicates a need for further teaching regarding the reinforced home care instructions for acute sinusitis? a) i should drink large amounts of fluids b) i will need surgery to drain my sinuses c) i should apply a wet, warm heat pack over my sinuses d) i will need to sleep with the head of the bed elevated

b) i will need surgery to drain my sinuses rationale the nurse provides instructions to the client regarding measures to promote sinus drainage, comfort, and resolution of the infection. the nurse instructs the client to apply heat in the form of hot wet packs over the affected sinuses to promote comfort and help resolve the infection. large amounts of fluids are important to help liquefy secretions. sleeping with the head of the bed elevated to a 45-degree angle will assist in promoting drainage. surgery may be performed to improve drainage in chronic conditions if other measures are not helpful, but it is not usually a treatment for acute sinusitis

the nurse is reading the results of a Mantoux tuberculin skin test on a client with no documented health problems. the site has no induration and a 1-mm area of ecchymosis. which interpretation should the nurse make of these results? a) positive b) negative c) uncertain d) borderline

b) negative rationale a positive Mantoux tuberculin skin test reading has an induration measuring 10 mm or more in diameter and indicates exposure to tuberculosis. a small area of ecchymosis is insignificant and is probably related to injection technique. therefore, the remaining options are incorrect.

the nurse is caring for a restless client who keeps biting down on an orotracheal tube. the nurse uses which intervention to prevent the client from obstructing the airway with the teeth? a) bite stick b) oral airway c) nasal airway d) padded tongue blade

b) oral airway rationale an oral airway may be used to keep the client from biting down, occluding an orotracheal tube. a nasal airway is not used in conjunction with an oral endotracheal tube. a padded tongue blade or a bite stick may be used initially to open the mouth for easier insertion of an oral airway.

a client who has been taking isoniazid for 1 1/2 months complains to the nurse about numbness, paresthesia, and tingling in the extremities. the nurse interprets that the client is experiencing which adverse effect? a) hypercalcemia b) peripheral neuritis c) small blood vessel spasm d) impaired peripheral circulation

b) peripheral neuritis rationale an adverse effect of isoniazid is peripheral neuritis. this is manifested by numbness, tingling, and paresthesias in the extremities. this adverse effect can be minimized with pyridoxine (vitamin B6) intake.

the nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. the nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which? a) hypothermia b) respiratory distress c) hematoma in the left groin d) discomfort in the left groin

b) respiratory distress rationale signs of allergic reaction to the contrast medium include localized itching and edema, respiratory distress, stridor, and decreased blood pressure. hypothermia is an unrelated event. hematoma formation is a complication of the procedure but does not indicate an allergic reaction. discomfort is expected

the emergency department nurse is caring for a client who sustained a blunt injury to the chest wall. which sign noted in the client indicates the presence of a pneumothorax? a) bradypnea b) shortness of breath c) a low respiratory rate d) the presence of a barrel chest

b) shortness of breath rationale the client has sustained a blunt or a closed chest injury. this type of injury can result in a closed pneumothorax. basic symptoms of a closed pneumothorax are shortness of breath and chest pain. a larger pneumothorax may present with tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. there may also be hyperresonance on the affected side. the presence of a barrel chest is characteristic of chronic obstructive pulmonary disease or emphysema.

a client with pneumonia is admitted to the hospital and the HCP writes prescriptions for the client. which prescription should the nurse complete first? a) increase the intake of oral fluids b) administer a prescribed antibiotic c) obtain a culture and sensitivity of sputum d) encourage the use of an incentive spirometer

c) obtain a culture and sensitivity of sputum rationale a culture and sensitivity should be obtained before any antibiotic therapy is begun to avoid masking the microorganisms identified in the culture. the other options are standard parts of therapy for pneumonia, but sputum is collected first.

the nurse is monitoring a client with a closed chest tube drainage system and notes fluctuation of the fluid level in the water-seal chamber during inspiration and expiration. on the basis of this finding, which conclusion should the nurse make? a) there is a leak in the system b) the chest tube is functioning as expected c) the amount of suction needs to be decreased d) the occlusive dressing at the insertion site needs reinforcement

b) the chest tube is functioning as expected rationale the presence of fluctuation of the fluid level in the water-seal chamber indicates a patent drainage system. with normal breathing, the water level rises with inspiration and falls with expiration. fluctuation stops if the tube is obstructed, if the suction is not working properly, or if the lung has reexpanded. the remaining options are incorrect interpretations of the finding

the nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. which observation by the nurse indicates that the client is performing the technique correctly? a) the client breathes in through the mouth b) the client breathes out slowly through the mouth c) the client avoids using the abdominal muscles to breathe out d) the client puffs out the cheeks when breathing out through the mouth

b) the client breathes out slowly through the mouth rationale pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. the client should close the mouth and breathe in through the nose. the client then purses the lips and breathes out slowly through the mouth, without puffing the cheeks. the client should spend at least twice the amount of time breathing out that it took to breathe in. the client should use the abdominal muscles to assist in squeezing out all of the air. the client also is instructed to use this technique during any physical activity, and to exhale while performing the activity. the client should never hold his or her breath.

the nurse reinforces instructing a client how to use an incentive spirometer. which observation would indicate the ineffective use of this equipment by the client? a) the client inhales slowly b) the client is breathing through the nose c) the client removes the mouthpiece from the mouth to exhale d) the client forms a tight seal around the mouthpiece with the lips

b) the client is breathing through the nose rationale incentive spirometer is not effective if the client breathes through the nose. the client should exhale, form a tight seal around the mouthpiece, inhale slowly, hold to the count of 3, and remove the mouthpiece to exhale. the client should repeat the exercise approximately 10 times every hour for best results

the nurse is observing a client with COPD performing the pursed-lip breathing technique. which observation by the nurse would indicate accurate performance of this breathing technique? a) the client's inhalation is twice as long as exhalation b) the client's exhalation is twice as long as inhalation c) the client loosens the abdominal muscles while breathing out d) the client inhales with pursed lips and exhales with the mouth open wide

b) the clients exhalation is twice as long as inhalation rationale prolonging the time for exhaling reduces air trapping because of airway narrowing or collapse in COPD. tightening the abdominal muscles aids in expelling air. exhaling through pursed lips increased the intraluminal pressure and prevents the airway from collapsing

the nursing student and clinical instructor are performing tracheotomy suction at the bedside of an adult client with a tracheostomy. which action by the nursing student is incorrect, causing the clinical instructor to intervene? a) the student uses wall suction unit pressure of 100 mmHg b) the student suctions the client's tracheotomy tube for 15 seconds c) the student places the client in semi-Fowler's position before suctioning d) the student inserts the catheter into the tracheostomy without applying suction

b) the student suctions the client's tracheotomy tube for 15 seconds rationale applying suction longer than 10 seconds can cause oxygen deprivation. the client should be placed into semi-Fowlers position to optimize breathing. wall suction pressure of 100 mmHg is usually recommended to prevent tissue disruption. the student is expected to insert the catheter without suction applied, to maintain oxygen deliveyr and to prevent damage to the mucosa.

a client with a tracheostomy gets easily frustrated when trying to communicate personal needs to the nurse. the nurse determines that which method for communication may be the easiest for the client? a) use a pad and paper b) use a picture or word board c) have the family interpret needs d) devise a system of hand signals

b) use a picture or word board rationale the client with a tracheostomy in place cannot speak. the nurse devises an alternative communication system with the client. use of a picture or word board is the simplest method of communication because it requires only pointing at the word or object. a pad and pencil is an acceptable alternative but requires more client effort and more time. the use of hand signals may not be a reliable method because it may not meet all needs and is subject to misinterpretation. the family does not need to bear the burden of communicating the client's needs, and they may not understand them either.

the low-pressure alarm sounds on the ventilator. the nurse checks the client and then attempts to determine the cause of the alarm but is unsuccessful. which initial action should the nurse take? a) administer oxygen b) ventilate the client manually c) check the client's vital signs d) start CPR

b) ventilate the client manually rationale if an alarm is sounding at any time and the nurse cannot quickly ascertain the problem, the client is disconnected from the ventilator and a manual resuscitation device is used to support respirations until the problem can be corrected. although oxygen is helpful, it will not provide ventilation to the client. checking vital signs is not the initial action. there is no reason to begin CPR

the low-exhaled volume (low-pressure) alarm sounds on a ventilator. the nurse rushes to the client's room and checks the client to determine the cause of the alarm but is unable to do so. which would be the next immediate nursing action? a) call the rapid response team overhead b) ventilate the client with a resuscitation bag c) call the respiratory therapist to the bedside d) call the client's HCP to the bedside

b) ventilate the client with a resuscitation bag rationale mechanical ventilators have alarm systems that warn the nurse of a problem with either the client or the ventilator. alarm systems must be activated and functional at all times. the nurse must be recognize an emergency and intervene promptly so that complications are prevented. if the cause of an alarm cannot be determined, the nurse ventilates the client manually with a resuscitation bag until the problem is corrected by a second nurse, the respiratory therapist or HCP. the nurse also notifies the RN of the occurrence and obtains assistance from the RN.

the nurse is assisting in planning care for a client with a chest tube. the nurse should suggest to include which interventions in the plan? select all that apply pin the tubing to the bed linens be sure all connections remain airtight be sure all connections are taped and secure empty the drainage from the drainage collection chamber daily monitor closely for tubing that is kinked or obstructed by the weight of the client

be sure all connections remain airtight // be sure all connections are taped and secure // monitor closely for tubing that is kinked or obstructed by the weight of the client rationale chest-tube tubing is never pinned to the bed linens because this presents the risk for accidental dislodgment of the tube when the client moves. the chest tube system is not opened and emptied because a closed system must be maintained; if the system is opened, lung collapse can occur. the other options are inappropriate interventions for the plan of care for a client with a chest tube.

a client with no history of respiratory disease is admitted to the hospital with respiratory failure. the nurse reviews the ABG reports for which results that are consistent with this disorder? a) Pao2 58 mmHg PaC02 32 mmHg b) Pa02 60 mmHg PaCo2 45mmHg c) Pa02 49mmHg PaCo2 52mmHg d) Pao2 73mmHg PaCo2 62mmHg

c) Pao2 49mmHg PaCo2 52mmHg rationale respiratory failure is described as a Pa02 of 50mmHg or less, and a PaCo2 of 50 mmHg or greater in a client with no history of respiratory disease. in a client with a history of respiratory disorder with hypercapnia, PaCo2 elevations of 5mmHg or more from the client's baseline is considered diagnostic.

the nurse is caring for several clients with respiratory disorders. which client is at least risk for developing a tuberculosis infection? a) an uninsured man who is homeless b) a woman newly immigrated from Korea c) a man who is an inspector for the US Postal Service d) an older woman admitted from a long-term care facility

c) a man who is an inspector for the U.S. Postal Service rationale people at high risk for acquiring tuberculosis include children younger than 5 years of age; homeless individuals or those from a lower socioeconomic group, minority groups, or immigrant group; individuals in constant, frequent contact with an untreated or undiagnosed individual; individuals living in crowded areas, such LTACs, prisons, and mental health facilities; older clients; individuals with malnutrition, an infection, or an immune dysfunction or HIV, or individuals who are immunosuppressed as a result of medication therapy and individuals who abuse alcohol or are IV drug users

a client has a prescription for continuous monitoring of oxygen saturation by pulse ox. the nurse performs which best action to ensure accurate readings on the oximeter? a) apply the sensor to a finger that is cool to the touch b) apply the sensor to a finger with very dark nail polish c) ask the client to limit motion in the hand attached to the pulse ox d) place the sensor distal to an IV site with continuous IV infusion

c) ask the client to limit motion in the hand attached to the pulse ox rationale several factors can interfere with the reading of accurate oxygen saturation levels on a pulse oximeter. to ensure accurate readings, the nurse should ask the client to limit motion of the area attached to the sensor. the nurse should apply the device to a warm area because hypotension, hypothermia, and vasoconstriction interfere with blood flow to the area. if possible, the nurse should avoid placing the sensor distal to any invasive arterial or venous catheters, pressure dressings, or blood pressure cuffs. the nurse needs to know that very dark nail polish interferes with accurate measurement.

a client arrives in the emergency department with a bloody nose. which is the initial nursing action? a) place the client in a supine position b) apply an ice collar around the client's neck c) assist the client to a sitting position with the head tilted slightly forward d) instruct the client to swallow the blood until the bleeding can be controlled

c) assist the client to a sitting position with the head tilted slightly forward rationale the initial nursing action to treat the client with a bloody nose is to loosen clothing around the neck to prevent pressure on the carotid artery. the client should be assisted to a sitting position with the head tilted slightly forward, and pressure should be applied to the nares by pinching the nose toward the septum for 10 minutes. ice packs can be applied to the nose and forehead. if these actions are not successful in controlling the bleeding, an ice collar may be applied along with a topical vasoconstrictive medication. the HCP may also prescribe packing to the nostrils. the client should be provided with an emesis basin and should be instructed not to swallow blood to reduce the risk of nausea and vomiting

the nurse is assessing a client who has frequent episodes of asthma. which assessment finding is most closely associated with asthma? a) fine rhonchi b) pink, frothy sputum c) bilateral wheezing d) rhonchi that clear with a cough

c) bilateral wheezing rationale wheezing is the symptom most associated with asthma, a reactive airway disease. fine rhonchi, rhonchi that clear with a cough, pink, frothy, sputum are not associated with asthma.

the nurse is caring for an older client who is on bed rest. the nurse plans which interventions to prevent respiratory complications? a) decreasing oral fluid intake b) monitoring vital signs every shift c) changing the client's position every 2 hours d) instructing the client to bear down every hour and to hold his or her breath

c) changing the client's position every 2 hours rationale frequent position changes help mobilize lung secretions and prevent pooling. this is the only intervention identified in the options that will prevent respiratory complications. the nurse should encourage fluid intake to thin secretions and thus enable the client to expectorate more easily. it is important to encourage coughing and deep breathing to mobilize lung secretions. the nurse should assess the client's vital signs every 4 hours to identify an elevated temperature, which may suggest infection. the client should be instructed to avoid the valsalva maneuver or any activity that involves holding the breath

a client arrives in the emergency department with an episode of status asthmaticus. what is the nurse's priority action? a) obtain a set of vital signs b) administer oxygen at 21% c) place the client in high Fowler's position d) obtain equipment for starting an IV line

c) place the client in high Fowler's position rationale the first nursing action is to place the client in a position that aids in respiration, which would be sitting bolt upright or in high-Fowler's. other nursing actions follow in rapid sequence and include monitoring vital signs and administering bronchodilators and oxygen (but at levels of 2 to 5 L/min or 24% to 28% by Ventimask). insertion of an IV line and ongoing monitoring of respiratory status are also indicated.

the nurse checks a closed chest tube drainage system on a client who had a lobectomy of the left lung 24 hour ago. the nurse notes that there has been no chest tube drainage for the past hour. which should the nurse do first? a) contact the RN b) check the client's BP and heart rate c) check for kinks in the chest drainage system d) connect a new drainage system to the client's chest tube

c) check for kinks in the chest drainage system rationale if the nurse notes that a chest tube is not draining, the nurse would first check for a kink or possible clot in the chest drainage system. the nurse then notifies the RN and observes the client for respiratory distress or mediastinal shift (if this occurs, the HCP is notified). checking the HR and BP is not directly related to the lack of chest tube drainage. connecting a new drainage system to the client's chest tube is done when the fluid drainage chamber is full. there is a specific procedure to follow when a new drainage system is connected to a client's chest tube.

a client is at risk of developing a pulmonary embolism. the nurse monitors for which initial sign/symptom. a) hot, flushed feeling b) sudden chills and fever c) chest pain that occurs suddenly d) dyspnea noted when deep breaths are taken

c) chest pain that occurs suddenly rationale the most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. the next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. other typical symptoms of pulmonary embolism include cough, tachycardia, fever, diaphoresis, anxiety, and possibly syncope.

the nurse is assigned to assist with caring for a client who has a chest tube. the nurse notes fluctuations of the fluid level in the water-seal chamber. based on this observation, which action would be appropriate? a) empty the drainage b) encourage the client to deep breathe c) continue to monitor, because this is an expected finding d) encourage the client to hold his or her breath periodically

c) continue to monitor, because this is an expected finding rationale the presence of fluctuations in the fluid level in the water-seal chamber indicates a patent drainage system. with normal breathing, the water level rises with inspiration and falls with expiration. the apparatus and all connections must remain airtight at all times, and the drainage is never emptied because of the risk of disruption in the closed system, which can result in lung collapse. encouraging the client to deep breathe is unrelated to this observation. the client is not told to hold his or her breath.

the nurse is performing nasotracheal suctioning of a client. the nurse interprets that the client is adequately tolerating the procedure if which observation is made? a) skin color becomes cyanotic b) secretions are becoming bloody c) coughing occurs while suctioning d) heart rate decreases from 78 to 54 beats/minute

c) coughing occurs while suctioning rationale coughing is a normal response to suctioning for the client with an intact cough reflex, and it is not an indication that the client is not tolerating the procedure. the client should be encouraged to cough to help with removal of secretions from the lungs. the nurse should monitor for the adverse effects of suctioning, which include cyanosis (pulse ox falls below 90% or 5% from baseline), excessively rapid or slow heart rate (a 20 beat/minute change), or the sudden development of bloody secretions. if they occur, the nurse stops suctioning, administers oxygen as appropriate, and reports these sgins to the HCP immediately.

the nurse is assisting a client with a closed chest tube drainage system to get out of bed to a chair. during the transfer, the chest tube gets caught in the leg of the chair and accidentally dislodges from the insertion site. which action should the nurse implement? a) change the dressing site on the chest b) reinsert the chest tube using sterile technique c) cover the insertion site with sterile vaseline gauze d) transfer the client back to bed and encourage the client to breath deeply

c) cover the insertion site with sterile vaseline gauze rationale if a chest tube dislodges from the insertion site, the nurse immediately covers the site with sterile vaseline gauze. the nurse would then notify the RN, assist the client back to bed, and perform a respiratory assessment on the client. the RN would then contact the HCP. the nurse does not reinsert a chest tube. the HCP will reinsert the chest tube if necessary.

the nurse is checking the chest tube drainage system of a postoperative client who had a right upper lobectomy. the closed drainage system has 300 mL of bloody drainage, and the nurse notes intermittent bubbling in the water-seal chamber. one hour following the initial data collection, the nurse notes that the bubbling in the water-seal chamber is now constant, and the client appears dyspneic. based on these findings, which action should the nurse do first? a) check the client's lung sounds b) check the client's vital signs c) inspect chest tube connections d) note the amount of drainage

c) inspect chest tube connections rationale the client's dyspnea is most likely related to an air leak caused by a loose connection. other causes might be a tear in the pulmonary pleura, which requires HCP intervention. although the other options are correct, they should be performed after initial attempts to locate and correct the air leak. it only takes a moment to check the connections, and if a leak is found and corrected, the client's symptoms should resolve. the nurse would also notify the RN.

a client who has just suffered a large flail chest is experiencing severe pain and dyspnea. which would be the appropriate nursing action? a) reposition the client b) document the findings c) notify the RN d) medicate the client for pain

c) notify the RN rationale the nurse would notify the RN, who would then contact the HCP. the client with severe flail chest will have significant paradoxical chest movement. this causes the mediastinal structures to swing back and forth with respiration. this will lead to severe pain and dyspnea and can affect circulatory hemodynamics

the nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. when the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. after immediately applying sterile gauze over the chest tube insertion site which should the nurse do next? a) replace the chest tube system b) obtain a pulse ox reading c) notify the RN d) place the client in trendelenburg's position

c) notify the RN rationale if the chest drainage system is dislodged from the insertion site, the nurse immediately applies sterile gauze over the site and notifies the RN, who then calls the HCP. the nurse should maintain the client in an upright position. a new chest tube system may be attached if the tube requires insertion, but this would not be the next action. pulse ox readings should assist in determining the client's respiratory status, but the priority action should be to notify the RN, who will then call the HCP.

the nurse is assisting in caring for a client who has just returned from the PACU after radical neck dissection. the nurse monitors the portable wound suction for which types of drainage expected in the immediate postoperative period? a) serous b) grossly bloody c) serosanguineous d) serous with sputum

c) serosanguineous rationale immediately after radical neck dissection, the client will have a wound drain in the neck attached to portable suction, which drains serosanguineous drainage. in the first 24 hours after surgery, the drainage may total 80 to 120 mL. the drainage should not be grossly bloody and would not be serous or serous with sputum at this time.

the nurse is collecting data on a client with chronic sinusitis. the nurse interprets that which client sign/symptom is unrelated to this problem? a) loss of smell b) chronic cough c) severe evening headache d) purulent nasal discharge

c) severe evening headache rationale chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough caused by nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse on arising after sleep

the nurse is gathering data on a client with a diagnosis of tuberculosis (TB). the nurse should review the results of which diagnostic test to confirm this diagnosis? a) chest x-ray b) bronchoscopy c) sputum culture d)tuberculin skin test

c) sputum culture rationale a definitive diagnosis of TB is confirmed through culture and isolation of mycobacterium tuberculosis. a presumptive diagnosis is made on the basis of a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histologic evidence of granulomatous disease on biopsy.

the nurse is suctioning an adult client through a tracheostomy tube. during the procedure, the nurse notes that the client's oxygen saturation by pulse oximetry is 89%. which action should the nurse implement? a) continue suctioning b) call respiratory therapy c) stop the suctioning procedure d) obtain a smaller suction catheter

c) stop the suctioning procedure rationale the nurse should monitor the client's heart rate and pulse oximetry during suctioning to assess the client's tolerance of the procedure. oxygen desaturation below 90% indicates hypoxia. if hypoxia occurs during suctioning, the nurse stops the suctioning procedure. using the 100% oxygen delivery system, the client is reoxygenated until baseline parameters are achieved. the size of the catheter should not exceed half of the size of the tracheal lumen. in adults, the standard catheter size is 12 to 14 french. adequate catheter size facilitates efficient removal of secretions without causing hypoxemia.

a client with pneumonia is experiencing problems with ventilation as a result of accumulated respiratory secretions. the nurse determines that which accurately indicates effectiveness of the treatments prescribed for this problem? a) venous oxygen saturation is 95% b) respiratory rate is 20 breaths per minute c) client demonstrated effective coughing techniques d) ABG indicate a pH of 7.4, Po2 of 80 mmHg and Pco2 of 40 mmHg

d) ABG indicate a pH of 7.4, Po2 of 80 mmHg and Pco2 of 40 mmHg rationale demonstration of adequate ventilation can only be accurately evaluated when both Po2 and Pco2 levels are known. the other options do not indicate adequate gas exchange. remember that oxygen saturation index is a measure of the percent of oxygen attached to the available hemoglobin.

a client is admitted to the hospital with acute exacerbation of COPD. which arterial blood gas supports this diagnosis? a) Po2 of 68 mmHg and Pco2 of 40 mmHg b) Po2 of 55 mmHg and Pco2 of 40 mmHg c) Po2 of 70 mmHg and Pco2 of 50 mmHg d) Po2 of 60 mmHg and Pco2 of 50 mmHg

d) Po2 of 60 mmHg and Pco2 of 50 mmHg rationale during an acute exacerbation, the arterial blood gases deteriorate with decreasing Po2 levels and increasing Pco2 levels. in the early stages of COPD, arterial blood gases demonstrate mild to moderate hypoxemia with the Po2 in the high 60s to high 70s (mmHg) and normal arterial Pco2. as the condition advances, hypoxemia increases and hypercapnia may result.

the nurse is told than an assigned client will have the chest tubes removed. the nurse plans to do which in preparation for the procedure? a) clamp the chest tubes b) empty the drainage system c) disconnect the drainage system d) administer pain medication 15 to 30 minutes before the procedure

d) administer pain medication 15 to 30 minutes before the procedure rationale removal of chest tubes can be uncomfortable for a client. the nurse should medicate the client 15 to 30 minutes before the chest tube is removed. the remaining options are inappropriate actions and would not be performed by the nurse.

the nurse provides instructions to a client about the use of an incentive spirometer. the nurse determines that the client needs further teaching about its use if the client makes which statement? a) i need to sit upright when using the device b) i will inhale slowly, maintaining a constant flow c) i need to place my lips completely over the mouthpiece d) after maximal inspiration, i will hold my breath for 10 seconds and then exhale

d) after maximal inspiration, i will hold my breath for 10 seconds and then exhale rationale for optimal lung expansion with the incentive spirometer, the client should assume a semi-Fowler's or high-Fowler's position. the mouthpiece should be covered completely and tightly while the client inhales slowly, with a constant flow through the unit. when maximal inspiration is reached, the client should hold the breath for 5 seconds and then exhale slowly through pursed lips

a client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. which is the nurse's priority intervention? a) prepare for reintubation b) call the HCP c) call the rapid response team d) check the client for spontaneous breathing

d) check the client for spontaneous breathing rationale if unexpected intubation occurs, the nurse would first check the client for airway patency, spontaneous breathing, and vital signs. the nurse would remain with the client, call for assistance from the RN, and prepare for reintubation. there are no data in question to indicate that a code needs to be called.

the nurse is assisting in collecting subjective and objective data from a client admitted to the hospital with TB. the nurse should expect to note which finding? a) high fever b) flushed skin c) complaints of weight gain d) complaints of night sweats

d) complaints of night sweats rationale the client with TB usually experiences a low-grade fever, weight loss, pallor, chills, and night sweats. the client also will complain of anorexia and fatigue. pulmonary symptoms include a cough that is productive of a scant amount of mucoid sputum. purulent, blood-stained sputum is present if cavitation occurs. dyspnea and chest pain occur late in the disease.

the nurse is suctioning a client through a tracheostomy tube. during the procedure, the client begins to cough, and the nurse notes the presence of an audible wheeze. the nurse attempts to remove the suction catheter from the client's trachea but is unable to do so. what is the nurse's priority response? a) call a code b) administer a bronchodilator c) contact the HCP d) disconnect the suction source from the catheter

d) disconnect the suction source from the catheter rationale the inability to remove a suction catheter is a critical situation. this finding, along with the clients symptoms presented in the questions, indicates the presence of bronchospasm and bronchoconstriction. the nurse would immediately disconnect the suction source from the catheter but leave the catheter in the trachea. the nurse would then connect the oxygen source to the catheter. the nurse also notifies the RN, who then notifies the HCP. the HCP will most likely prescribe an inhaled bronchodilator. the nurse also prepares for emergency resuscitation if this situation occurs during suctioning.

the nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. which action should the nurse take? a) notify the rapid response team b) finish the suctioning as quickly as possible c) contact the respiratory department to suction the client d) discontinue suctioning until the client is stabilized and monitor vital signs

d) discontinue suctioning until the client is stabilized and monitor vital signs rationale if a client becomes cyanotic or restless or develops tachycardia, bradycardia, or another abnormal heart rhythm, the nurse must discontinue suctioning until the client is stabilized. the nurse would also notify the registered nurse. it is also important to monitor the vital signs and the pulse oximetry. if the client's condition continues to deteriorate, then the respiratory department and HCP may need to be notified. there is no data in the question that indicates that the rapid response team needs to be notified.

the nurse is assigned to care for a client who has a chest tube. the nurse is told to monitor the client for crepitus (subcutaneous emphysema). which method should be used to monitor the client for crepitus? a) asking the client about pain b) checking the respirations hourly c) checking the blood pressure every 2 hours d) palpating for the leakage of air into the subcutaneous tissues

d) palpating for the leakage of air into the subcutaneous tissues rationale subcutaneous emphysema is also known as crepitus. it presents as a "puffed-up" appearance that is caused by the leakage of air into the subcutaneous tissues. it is monitored by palpating and it feels like bubble wrap when palpated. although the other options may be components of the plan of care for a client with a chest tube, these actions will not identify subcutaneous emphysema.

the nurse is reinforcing discharge teaching with a client diagnosed with TB and has been on medication for 1 1/2 weeks. the nurse knows that the client has understood the information if which statement is made? a) i can't stop at the mall for the next 6 months? b) i need to continue medication therapy for 2 months c) i can return to work if a sputum culture comes back negative d) i should not be contagious after 2 to 3 weeks of medication therapy

d) i should not be contagious after 2 to 3 weeks of medication therapy rationale the client is continued on medication therapy for 6 to 12 moths, depending on the situation. the client is generally considered to be not contagious after 2 to 3 weeks of medication therapy. the client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. the client is allowed to return to employment when the results of three sputum cultures are negative

a client is admitted to the hospital with a diagnosis of carbon dioxide narcosis. in addition to respiratory failure, the nurse plans to monitor the client for which complication of this disorder? a) paralytic ileus b) hypernatremia c) hyperglycemia d) increased intracranial pressure

d) increased intracranial pressure rationale carbon dioxide acts as a vasodilator to cerebral blood vessels. with a sufficient rise in carbon dioxide, the client may suffer increased intracranial pressure, which is reflected initially as papiledema and dilated conjunctival blood vessels. the other options are not complications

the nurse is assisting in caring for a client with pneumonia who suddenly becomes restless. arterial blood gases are drawn, and the results reveal a Pao2 of 60 mmHg. the nurse reviews the plan of care for the client and determines that which priority problem potentially exists for this client? a) fatigue b) aspiration c) airway obstruction d) ineffective oxygen and carbon dioxide exchange

d) ineffective oxygen and carbon dioxide exchange rationale restlessness and low Pao2 are hallmark signs of ineffective oxygen exchange. airway obstruction and aspiration are not problems that are specifically associated with existing pneumonia. although many clients with pneumonia experience fatigue, this is not the priority problem.

a client has a chest tube that is attached to a chest drainage system. the client asks the nurse, "can the tube come out faster if you turn the wall suction up higher?" the nurses response is based on which fact with regard to turning up the wall suction? a) it would increase the actual suction in the system and is a good idea b) it would increase the actual suction in the system but could damage lung tissue c) it would not increase the actual suction in the system but could cause the client to suffer injury d) it would not increase the actual suction in the system but would cause more air to be pulled through the air vent and suction chamber to the suction source

d) it would not increase the actual suction in the system but would cause more air to be pulled through the air vent and suction chamber to the suction source rationale the amount of suction in the chest drainage system is controlled by the amount of sterile water that is poured into the suction control chamber. in a dry suction system, this is accomplished by regulating the suction dial on the chest drainage device. increasing the wall suction will only cause vigorous bubbling in the suction chamber, as more air is pulled through the air vent and suction control chamber to the suction source. the only effect this would have is to increase the rate of water evaporation from the suction control chamber, so sterile water would have to be added to the system more frequently.

while assessing a client who is admitted to the hospital with a diagnosis of pleurisy, the nurse would note which characteristic symptom of this disorder? a) early morning fatigue b) dyspnea that is relieved by lying flat c) pain that worsens when the breath is held d) knifelike pain that worsens on inspiration

d) knifelike pain that worsens on inspiration rationale a typical symptom with pleurisy is a knifelike pain that worsens on inspiration. this is a result of the friction caused by the rubbing together of inflamed pleural surfaces. this pain usually disappears when the breath is held because these surfaces stop moving. the client does not experiences early morning fatigue or dyspnea relieved by lying flat.

the nurse is determining the need for suctioning in a client with an endotracheal tube (ETT) attached to a mechanical ventilator. which observation by the nurse is inconsistent with the need for suctioning? a) restlessness b) gurgling sounds with respiration c) presence of congestion in the lungs d) low peak inspiratory pressure on the ventilator

d) low peak inspiratory pressure on the ventilator rationale indications for suctioning include moist, wet respirations; restlessness; congestion on auscultation of the lungs; visible mucus bubbling in the ETT; increased pulse and respiratory rates; and increased peak inspiratory pressures on the ventilator. a low peak inspiratory pressure would indicate a leak in the mechanical ventilation system.

a client is being prepared for a thoracentesis. the nurse should assist the client to which position for the procedure? a) sims' position, with the head of the bed flat b) prone, with the head turned to the side supported by a pillow c) lying in bed on the affected side, with the head of the bed elevated 45 degrees d) lying in bed on the unaffected side, with the head of the bed elevated 45 degrees

d) lying in bed on the unaffected side, with the head of the bed elevated 45 degrees rationale to facilitate the removal of fluid from the chest, the client is positioned sitting on the edge of the bed, leaning over a bedside table, with the feet supported on a stool or lying in bed elevated 45 degrees (Fowler's position) the otehr options are incorrect

the nurse is reviewing the ABG results of an assigned client. which ABGs indicate metabolic alkalosis? a) pH of 7.35 pC02 of 50 mmHg HCO3 of 32 mEq/L b) pH of 7.45 PCO2 of 35 mmHg HCO3 of 22 mEq/L c) pH of 7.38 PCO2 of 45 mmHg HCO3 of 32 mEq/L d) pH of 7.48 PCO2 of 40 mmHg HCO3 of 36 of mEq/L

d) pH of 7.48 PCO2 of 40 mmHg HCO3 of 36 mEq/L rationale in metabolic alkalosis, the pH is elevated along with the bicarbonate level. this is the only option that reflects these values.

the nurse is assigned to assist the HCP with the removal of a chest tube. the nurse should reinforce instructing the client to do which during this process? a) stay very still b) exhale forcefully c) inhale and exhale quickly d) perform Valsalva's maneuver

d) perform valsalva's maneuver rationale when the chest tube is removed, the client is asked to perform valsalva's maneuver (i.e. take a deep breath, exhale, and bear down), the tube is quickly withdrawn, and an airtight dressing is taped in place. an alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. the other options are incorrect client instructions

the nurse is instructing a client about pursed lip breathing, and the client asks the nurse about its purpose. the nurse should tell the client that the primary purpose of pursed lip breathing is which? a) promote oxygen intake b) strengthen the diaphragm c) strengthen the intercostal muscles d) promote carbon dioxide elimination

d) promote carbon dioxide elimination rationale pursed lip breathing facilitates maximal expiration for clients with obstructive lung disease and promotes carbon dioxide elimination. this type of breathing allows better expiration by increasing airway pressure, which keeps air passages open during exhalation. the other options are not the purposes of this type of breathing

the nurse is caring for a client who is being treated for a pneumothorax with a closed chest tube drainage system. when repositioning the client, the chest tube disconnects. which nursing action would be immediate? a) clamp the chest tube b) instruct the client to inhale c) call the HCP d) reattach the chest tube to the drainage system

d) reattach the chest tube to the drainage system rationale in most situations, clamping chest tubes is contraindicated, and agency policy and procedure must be followed with regard to clamping a chest tube. when the client has a residual air leak or pneumothorax, clamping the chest tube may precipitate a tension pneumothorax because the air has no escape route. if the tube becomes disconnected, it is best to immediately reattach it to the drainage system or to submerge the end in a bottle of sterile water to reestablish a water seal. if sterile water or saline is not readily available, it is preferable to leave the tube open because the risk of tension pneumothorax outweighs the consequences of an open tube. the nurse would also notify the RN of the occurrence. the HCP will need to be notified, but this is not the immediate action. the client would not be instructed to inhale.

the nurse is collecting data from a client who is experiencing the typical signs/symptoms of TB. the nurse should expect the client to report having symptoms of fatigue and cough that have been present for how long? a) a day or two b) almost a week c) one to two weeks d) several weeks to months

d) several weeks to months rationale the client with TB may report symptoms that have been present for weeks or even months. the symptoms may include fatigue, lethargy, chest pain, anorexia, and weight loss, night sweats, low-grade fever, and cough with mucoid or blood-streaked sputum. it may be the production of blood-tinged sputum that finally forces some clients to seek care.

the nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. the nurse knows that the client understands the information if the client verbalizes which early sign of exacerbation? a) fever b) fatigue c) weight loss d) shortness of breath

d) shortness of breath rationale shortness of breath is an early sign of exacerbation of pulmonary sarcoidosis. others include chest pain, hemoptysis, and pneumothorax. systemic signs and symptoms that occur later include weakness and fatigue, malaise, fever and weight loss

the nurse is reinforcing instructions to a hospitalized client with a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. which position should the nurse instruct the client to assume? a) side-lying position b) sitting in a recliner chair c) sitting up in bed at a 90 degree angle d) sitting on the side of the bed, leaning on an overbed table

d) sitting on the side of the bed, leaning on an overbed table rationale positions that will assist the client with breathing include sitting up and leaning on an overbed table, sitting up and resting with the elbows on the knees, or standing or leaning against the wall. the other options offer positions that will not enhance the effectiveness of breathing.

a client being discharged from the hospital to home with a diagnosis of TB is worried about the possibility of infecting family members and others. which information should reassure the client that contaminating family members and others is not likely a) the family does not need therapy, and the client will not be contagious after 1 month of medication therapy b) the family does not need therapy, and the client will not be contagious after 6 consecutive weeks of medication therapy c) the family will receive prophylactic therapy and the client will not be contagious after 1 continuous week of medication therapy d) the family will receive prophylactic therapy and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy

d) the family will receive prophylactic therapy and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy rationale family members or others who have been in close contact with a client diagnosed with TB are placed on prophylactic therapy with isoniaized for 6 to 12 months. the client is usually not contagious after taking medication for 2 to 3 consecutive weeks. however, the client must take the full course of therapy (for 6 months or longer) to prevent reinfection of drug-resistant TB.

the nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. based on this finding, the nurse makes which determination? a) an air leak is present b) the tubing is kinked c) the lung has re-expanded d) the system is functioning as expected

d) the system is functioning as expected rationale fluctuations in the water seal chamber are normal during inhalation and exhalation until the lung re-expands and the client no longer requires chest drainage. if fluctuations are absent, it could indicate an air leak, kinking, or that the lung has re-expanded.

the nurse is admitting a client to the nursing unit who is suspected of having TB. the nurse plans to admit the client to which type of room? a) venting to the outside and ultraviolet light b) ultraviolet light with three air exchanges per hour c) ten air exchanges per hour and venting to the outside d) venting to the outside, six air exchanges per hour, and ultraviolet light

d) venting to the outside, six air exchanges per hour, and ultraviolet light rationale the client is admitted to a private room that has at least six air exchanges per hour and negative pressure in relation to surrounding areas. the room should be vented to the outside and should have ultraviolet lights installed.

the nurse is assisting a HCP with the insertion of an endotracheal tube (ETT). the nurse should plan to ensure that which is done as a final measure to determine correct tube placement a) hyperoxygenate the client b) tape the tube securely in place c) listen for bilateral breath sounds d) verify placement by a chest x-ray

d) verify placement by a chest x-ray rationale the final measure to determine ETT placement is to verify it by a chest x-ray. the chest x-ray shows the exact placement of the tube in the trachea, which should be above the bifurcation of the right and left mainstream bronchi. the other options are incorrect because they are completed initially after tube placement

the nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). which should the nurse expect to note in this client? select all that apply. hypocapnia dyspnea on exertion presence of a productive cough difficulty breathing while talking increased oxygen saturation with exercise a shortened expiratory phase of respiration

dyspnea on exertion // presence of a productive cough // difficulty breathing while talking rationale clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory muscles of respiration, and a prolonged expiratory phase of respiration. the client may also exhibit difficulty breathing while talking, and may have to take breaths between every one or two words. some clients with COPD, especially those with a history of smoking, often have a productive cough especially on arising in the morning. the chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.

the nurse is admitting a client with a possible diagnosis of chronic bronchitis. the nurse collects data from the client and notes that which signs/symptoms support this diagnosis? select all that apply scant mucus early onset cough marked weight loss purulent mucous production mild episodes of dyspnea

early onset cough // purulent mucous production // mild episodes of dyspnea rationale key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucous production, and marked weight loss. by contrast chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucous production, minimal weight loss, and milder severity of dyspnea.

the nurse is preparing to assist a HCP with the insertion of a chest tube. the nurse anticipates that which supplies will be required for the chest tube insertion site? select all that apply elastoplast tape sterile kerlix dressing sterile 4 x 4 gauze pads povidone-iodine gauze petrolatum (Vaseline) gauze

elastoplast tube // sterile 4 x 4 gauze pads // povidone-iodine gauze // petrolatum (Vaseline) gauze rationale the first layer of the chest tube dressing is petrolatum gauze, which allows for an occlusive seal at the chest tube insertion site. additional layers of sterile 4 x 4 gauze cover this layer, and the dressing is secured with a strong adhesive tape or elastoplast tape. povidone-iodine solution may be used to clean the insertion site before the insertion of the chest tube. kerlix dressing, which is a wrap-type dressing used to wrap and hold dressings in place is not used on the chest; these dressing types are used commonly to wrap dressings placed on the arms or legs

a clinic nurse is assisting in caring for a client whose chief complaint is the presence of flulike symptoms. which recommendation by the nurse is therapeutic? select all that apply get plenty of rest take antipyretics for fever increase intake of liquids get a flu vaccine immediately eat carbohydrates only for energy

get plenty of rest // take antipyretics for fever // increase intake of liquids rationale immunization against influenza is a prophylactic measure and is not used to treat flu symptoms. treatment for the flu includes getting rest, drinking fluids, and taking in nutritious foods and beverages. medications such as antipyretics and analgesics also may be used for symptom management. carbohydrates are not necessarily more important than other elements of a healthy diet.

the nurse assessing a client diagnosed with laryngeal cancer would note which signs and symptoms? select all that apply hemoptysis kussmaul respirations enlarged thyroid gland a sensation of a "lump" in the throat hoarseness lasting more than 3 weeks

hemoptysis // a sensation of a "lump" in the throat // hoarseness lasting more than 3 weeks rationale hemoptysis, a sensation of a lump in the throat, and hoarseness lasting more than 3 weeks are common signs and symptoms of laryngeal cancer

the nurse is reinforcing instructions to a client following a total laryngectomy about caring for the stoma. which instructions should the nurse provide to the client? select all that apply protect the stoma from water soaps should be avoided near the stoma wash the stoma daily using a washcloth use diluted alcohol on the stoma to clean it apply a thin layer of petroleum jelly to the skin surrounding the stoma use soft tissues to clean any secretions that accumulate around the stoma

protect the stoma from water // soaps should be avoided near the stoma // wash the stoma daily using a washcloth // apply a thin layer of petroleum jelly to the skin surrounding the stoma rationale the client with a stoma should be instructed to wash the stoma daily with a washcloth. soaps, cotton swabs, or tissues should be avoided because their particles may enter and obstruct the airway. the client should be instructed to avoid applying alcohol to a stoma because it is both drying and irritating. a thin layer of petroleum jelly applied to the skin around the stoma helps prevent cracking. the client is instructed to protect the stoma from water

the nurse is planning therapeutic interventions for a client who experienced a rib fracture 2 days earlier. the nurse understands that which intervention should be included? select all that apply ice rest local heat analgesics oxygen by nasal cannula

rest // local heat // analgesics rationale common therapies for fractured ribs include rest, analgesics and the local application of heat that speeds the resolution of inflammation. ice is not effective 48 hours after injury, and oxygen may not be necessary. analgesics that cause respiratory depression are avoided