NCLEX Prep - Respiratory Disorders

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?

"After maximal inspiration, I will hold my breath for 10 seconds and then exhale."

A nursing student prepares to instruct a client to expectorate a sample of sputum that will be sent to the laboratory for Gram stain, culture, and sensitivity and describes the procedure to the licensed practical nurse (LPN), who is the primary nurse. The LPN corrects the student if which incorrect description is provided?

"I will have the client take a shallow breath before coughing."

Flail Chest A form of blunt chest trauma, associated with certain types of accidents, in which a loose segment of the chest wall impedes expansion and contraction of the rest of the chest wall. Flail chest may result in hemothorax. Assessment findings include:

--paradoxical respirations (inward movement of the free segment of thorax during inspiration, with outward movement during expiration), --severe chest pain --diminished breath sounds.

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.

-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

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. -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.

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.

-Dyspnea on exertion -Presence of a productive cough -Difficulty breathing while talking

The nurse is preparing to assist a health care provider 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 4 × 4 gauze pads -Povidone-iodine gauze -Petrolatum (Vaseline) gauze

COPD

-Emphysema- 2 major changes, loss of lung elasticity & hyper inflation of lung (air hunger) -Chronic Bronchitis-inflammation of the bronchi & bronchioles by chronic exposure to irritants, especially to tobacco smoke >decrease airflow & gas exchange bc of mucasplugs & infection narrowing the airways >the PaO2 decrease (hypoxemia) & the PaCO2 increases (resp acidosis) >smoking RIsk Factor

The nurse is assessing the puncture site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?

1. 15-mm induration

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is likely to include which nursing diagnosis?

1. Anxiety

The nurse is caring for a client who is scheduled for a bronchoscopy. Which interventions should the nurse perform to prepare the client for this procedure?

1. Explain the procedure., 4. Confirm that a signed informed consent form has been obtained., 5. Ask the client to remove his dentures., 6. Administer atropine and a sedative.

A 48-year-old client is admitted for suspected pulmonary emboli. Upon arrival in the intensive care unit, the client is alert and oriented. He insists on anxiously walking around the room. Which nursing actions take priority for this client?

1. Initiate bed rest with the head of the bed elevated at least 45 degrees, administer supplemental oxygen, and monitor the client's respiratory status.

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should a nurse take first?A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should a nurse take first?

1. Initiate oxygen therapy.

A client has hypoxemia of pulmonary origin. What portion of arterial blood gas results is most useful in distinguishing acute respiratory distress syndrome from acute respiratory failure?

1. Partial pressure of arterial oxygen (PaO2)

The nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do?

1. Place the end of the chest tube in a container of sterile saline.

The nurse administers albuterol (Proventil), as prescribed, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

1. Respiratory rate of 22 breaths/minute

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

1. Wear gloves when handling tissues containing sputum., 2. Wear a face mask at all times., 6. Wash hands after direct contact with the client or contaminated articles.

A client is to receive I.V. vancomycin (Vancocin). When preparing to administer this drug, the nurse should keep in mind that vancomycin:

1. should be infused over 60 to 90 minutes in a large volume of fluid.

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

1. tidal volume

Simple Mask

10-12 L/min

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?

2

The nurse should plan to fill which chamber of the chest drainage unit to prevent atmospheric air from re-entering the pleural space? Refer to figure.

2

A client undergoes a total laryngectomy and tracheostomy formation. On discharge, the nurse should give which instruction to the client and family?

2. "Family members should continue to talk to the client."

A home health care nurse visits a client with chronic obstructive pulmonary disease who requires oxygen. Which statement by the client indicates the need for additional teaching about home oxygen use?

2. "I make sure my oxygen mask is on tightly, so it won't fall off while I nap."

The nurse is administering a purified protein derivative (PPD) test to a homeless client. Which statement concerning PPD testing is true?

2. A positive reaction indicates that the client has been exposed to the disease.

On auscultation, which finding suggests a right pneumothorax?

2. Absence of breath sounds in the right thorax

A client has a sucking stab wound to the chest. Which action should the nurse take first?

2. Apply a dressing over the wound and tape it on three sides.

An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Prescribed respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure?

2. At least 2 hours after a meal

When a client's ventilation is impaired, the body retains which substance?

2. Carbon dioxide

After undergoing a right lower lobectomy for treatment of lung cancer, a 75-year-old client returns to his room with a chest tube in place. Several hours later a nurse finds the client out of bed barely able to speak, with the chest tube removed. Which action should the nurse take immediately?

2. Cover the insertion site with an occlusive dressing, call for assistance, and remain with the client.

During inspiration, which of the following occurs?

2. Diaphragm descends.

A client is admitted with chronic obstructive pulmonary disease (COPD). Which of the following signs and symptoms are characteristic of COPD

2. Dyspnea on exertion, 3. Barrel chest, 5. Clubbed fingers and toes

While receiving heparin to treat a pulmonary embolus, a client passes bright red urine. What should the nurse do first?

2. Expect protamine sulfate to be ordered.

The nurse is caring for a client with pneumonia. The nurse should expect to observe which signs and symptoms?

2. Fever, 5. Use of accessory muscles during respiration, 6. Crackles or rhonchi.

For a client with impaired gas exchange, which position is best?

2. High Fowler's

Which of the following would be appropriate for a client with arterial blood gas (ABG) values of pH 7.5, PaCO2 26 mm Hg, O2 saturation 96%, HCO3- 24 mEq/L, and PaO2 94 mm Hg?

2. Instruct the client to breathe into a paper bag.

A client is scheduled to undergo a bronchoscopy. Which nursing interventions would be included on the care plan?

2. Keep suction equipment available., 4. Assess cough and gag reflexes after the procedure., 6. Report hemoptysis, stridor, or dyspnea immediately.

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery would most likely reverse the manifestations?

2. Nonrebreather mask

An elderly client is admitted to an acute care facility with influenza. The nurse monitors the client closely for complications. What is the most common complication of influenza?

2. Pneumonia

A client admitted to the health care facility with acute bronchitis is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the likely cause of this sound?

2. The oxygen tubing is pinched.

A client with a pneumothorax receives a chest tube attached to a Pleur-evac. The nurse notices that the fluid of the second chamber of the Pleur-evac is bubbling continuously. Which nursing assumptions would be valid?

2. There is a leak somewhere in the tubing system.

A nurse detects bilateral crackles when auscultating a client's lungs. Which statement about crackles is true?

2. They're usually heard on inspiration and don't clear with a cough.

The nurse assesses a client's respiratory status. Which observation indicates that the client is experiencing difficulty breathing?

2. Use of accessory muscles

A 47-year-old male client with an unresolved hemothorax is febrile, with chills and diaphoresis. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:

2. empyema.

A positive Mantoux test indicates that the client:

2. has produced an immune response.

The nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. The reason for this change is that:

2. the airways are so swollen that no air can get through.

client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?

3. "Weigh yourself daily and report a gain of 2 lb in 1 day."

The oxygen saturation level of a 48-year-old client admitted to the hospital with bronchial pneumonia decreases, and his breathing is shallow. He refuses to perform coughing and deep-breathing exercises, or use an incentive spirometer. Which measures can the nurse take to help improve the client's respiratory status?

3. Elevate the head of the bed, and demonstrate and reinforce the importance of incentive spirometry, turning, coughing, and deep breathing.

A client is prescribed rifampin (Rifadin), 600 mg by mouth daily. Which statement about rifampin is true?

3. It's tuberculocidal, destroying the offending bacteria.

The nurse is teaching a client about theophylline toxicity. Which of the following is a sign or symptom of theophylline toxicity?

3. Nausea

A 69-year-old client comes to the emergency department with a history of productive cough, night sweats, and a 30-lb weight loss over the past 8 months. A diagnosis of tuberculosis is suspected. Which intervention is necessary for this client?

3. Place the client in a private room with negative air pressure, and implement airborne precautions.

Which of the following is the hallmark of adult respiratory distress syndrome (ARDS)?

3. Progressive hypoxemia despite oxygen therapy

For a client with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway?

3. Teaching the client how to perform controlled coughing

The nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

3. The system has an air leak.

A client is brought to the emergency department in acute respiratory distress. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?

3. They help prevent cardiac arrhythmias.

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?

3. Tidal volume

Which phrase is used to describe the volume of air inspired and expired with a normal breath?

3. Tidal volume

The nurse is teaching a client with chronic bronchitis about breathing exercises. Which of the following should the nurse include in the teaching?

3. Use diaphragmatic breathing.

For a client with advanced chronic obstructive pulmonary disease (COPD), which nursing action promotes adequate gas exchange?

3. Using a high-flow Venturi mask to deliver oxygen as prescribed

A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure?

3. Withhold food and fluids until the client's gag reflex returns., 4. Assess for hemoptysis and frank bleeding., 6. Monitor the client's vital signs.

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for:

3. adult respiratory distress syndrome (ARDS).

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse should:

3. encourage coughing and deep breathing.

A client's chest X-ray reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from: .

3. increased pulmonary capillary permeability

A 21-year-old client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician prescribes acetylcysteine (Mucomyst). 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:

3. it may induce bronchospasm.

A client with asthma is receiving a theophylline preparation to promote bronchodilation. Because of the risk of drug toxicity, the nurse must monitor the client's serum theophylline level closely. The nurse knows that the therapeutic theophylline concentration falls within which range?

4. 10 to 20 mcg/ml

After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's teenage daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? The amount of air inspired and expired with each breath is called: 1. tidal volume. A nurse detects bilateral crackles when auscultating a client's lungs. Which statement about crackles is true? 2. They're usually heard on inspiration and don't clear with a cough. When a client's ventilation is impaired, the body retains which substance? 2. Carbon dioxide The nurse is caring for a client who has a chest tube connected to a three-chamber drainage system without suction. Identify the chamber that collects drainage from the client. The drainage chamber is on the right. It has three calibrated columns that show the amount of drainage collected. When the first column fills, drainage empties into the second; when the second column fills, drainage flows into the third. The water-seal chamber is located in the center. The suction-control chamber is on the left. A client admitted to the health care facility with acute bronchitis is receiving supplemental oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the likely cause of this sound? 2. The oxygen tubing is pinched. The nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

4. 6 to 12 months

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which findings suggest pulmonary embolism?

4. Chest pain and dyspnea

The nurse is collecting data on a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

4. Dyspnea and wheezing

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which of the following problems?

4. Hypercapnia, hypoventilation, and hypoxemia

A client is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this client?

4. Impaired gas exchange related to airflow obstruction

A client with a nursing diagnosis of Impaired spontaneous ventilation undergoes a tracheostomy after many failed attempts at weaning from a mechanical ventilator. The nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?

4. Withdraw residual air from the cuff and then reinflate it.

A woman whose husband was recently diagnosed with active pulmonary tuberculosis (TB) is a tuberculin skin test converter but doesn't show signs of active tuberculosis. Management of her care would include:

4. advising her to begin prophylactic therapy with isoniazid (INH).

At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) by I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer:

4. albuterol (Proventil).

A client has allergy-induced asthma. During assessment of breath sounds the nurse would expect:

4. wheezing and shortness of breath

A client with pneumonia has just finished dinner. The nurse must calculate the client's fluid intake before taking the tray from his room. The client had 6 ounces of soup, 4 ounces of milk, and 8 ounces of juice. How many milliliters of fluid should the nurse record on the client's intake record?

540

Partial Rebreather

70-90%, 6-15 L/min

Non-rebreather

90-100%, 15 L/min Used in trauma/ emergencies

The nurse determines that which client is at greatest risk for development of acute respiratory distress syndrome (ARDS)?

A client with pancreatitis and gram-negative sepsis

The nurse is caring for several clients with respiratory disorders. Which client is at least risk for developing a tuberculosis infection?

A man who is an inspector for the U.S. Postal Service

A client has undergone fluoroscopy-assisted aspiration biopsy of a lung lesion. The nurse determines that the client is experiencing complications from the procedure if the nurse makes which observation?

Absence of breath sounds in the right upper lobe

The nurse is assisting in caring for a client with a tracheal tube attached to a ventilator when the high-pressure alarm sounds. The nurse checks the client and system for which most likely cause?

Accumulation of secretions in the client's lungs

The nurse is told that an assigned client will have the chest tubes removed. The nurse plans to do which in preparation for the procedure?

Administer pain medication 15 to 30 minutes before the procedure.

Lung Sound-Wheeze

Adventious, continuous with a musical quality. (Asthma)

Cystic Fibrosis

An autosomal recessive disease that causes dysfunction of the exocrine glands. Tenacious mucus production obstructs vital structures Multiple problems result from the exocrine dysfunction-lung insufficiency (most critical problem), pancreatic insufficiency, increased loss of sodium and chloride in sweat.

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 Apply intermittent suction while rotating and withdrawing the catheter Advance the catheter until resistance is met and then pull the catheter back 1 cm

The nurse is reviewing the record of a client with acute respiratory distress syndrome (ARDS). The nurse determines that which finding documented in the client's record is consistent with the most expected characteristic of this disorder?

Arterial Pao2 of 48

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?

Arterial blood gases indicate a pH of 7.4, Po2 of 80 mm Hg, and Pco2 of 40 mm Hg.

A client has a prescription for continuous monitoring of oxygen saturation by pulse oximetry. The nurse performs which best action to ensure accurate readings on the oximeter?

Ask the client to limit motion in the hand attached to the pulse oximeter.

The nurse is assisting in preparing a list of instructions 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. Rest for the next 24 hours.

The nurse has finished suctioning a client. The nurse should use which parameters to best determine the effectiveness of suctioning?

Breath sounds are clear

The nurse is performing tracheal suctioning on an assigned client. The nurse uses which parameter as the accurate indicator of the effectiveness of suctioning?

Breath sounds are now clear.

A client who underwent a bronchoscopy was returned to the nursing unit 1 hour ago. The nurse determines that the client is experiencing complications of the procedure if the nurse notes which sign/symptom?

Breath sounds greater on the right than the left

Lung Sound-Stridor

Caused by upper airway narrowing or obstruction. Ofter heard without a stethospcope, occurs with in 20% of extubated pt's, loud, high pitched crowing Causes-pertussis, croup, epiglottitis, aspiration.

The nurse is caring for an older client who is on bed rest. The nurse plans which intervention to prevent respiratory complications?

Changing the client's position every 2 hours

A client attached to mechanical ventilation suddenly becomes restless and pulls out the tracheostomy tube. Which is the nurse's priority intervention?

Check the client for spontaneous breathing.

The nurse is caring for a hospitalized client with a suspected diagnosis of tuberculosis (TB). Which finding does the nurse expect to note during data collection?

Chills and night sweats

Hypoxia

Condition in whihc the body or a region of the bodyis deprived of adequate oxygen supply (can be generalized or local).

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?

Continue to monitor, because this an expected finding

Lung Sound-Rhonchi

Continuous both inspiratory and expiratory, low pitched similar to wheezes. Often have a snoring , gurgling or rattle like quality.

The nurse is caring for a client who is suspected of having lung cancer. The nurse monitors the client for which most frequent early sign of lung cancer?

Cough

The nurse is performing nasotracheal suctioning of a client. The nurse determines that the client is adequately tolerating the procedure if which observation is made?

Coughing occurs with suctioning.

A client with active tuberculosis (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?

Directly observed therapy

Lung Sound-Crackles

Discontinuous breief, popping sounds. (Pneumonia, CHF, mositure)

The nurse is assisting a health care provider with the insertion of a wet-suction chest tube. The nurse notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this observation, the nurse plans to take which appropriate action?

Document the accurate functioning of the tube.

A client with acquired immunodeficiency syndrome (AIDS) has become infected with histoplasmosis. The nurse monitors the client for which signs and symptoms?

Dyspnea

A client with acquired immunodeficiency syndrome (AIDS) has histoplasmosis. Which sign/symptom should the nurse expect the client to experience?

Dyspnea

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

Dyspnea on exertion Presence of a productive cough Difficulty breathing while talking

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 client has which forms of CAL?

Emphysema

A client who is experiencing severe respiratory acidosis has a potassium level of 6.2 mEq/L. The nurse determines this result is best characterized by which interpretation?

Expected and indicates that acidosis has driven hydrogen ions into the cell, forcing potassium out

A client diagnosed with tuberculosis (TB) is distressed over the loss of physical stamina and fatigue. The nurse should provide which explanation for these symptoms?

Expected and the client should very gradually increase activity as tolerated

Symptoms of TB

Fever with night sweats, anorexia, wt loss, malaise, fatigue, cough, hemoptysis, dyspnea, positive sputum culture.

Chest Tube

Fluntuations-normal Continuous bubbling-leak

A client enters the urgent care center with epistaxis but no obvious facial injury. The nurse should take which action?

Have the client sit down, lean forward, and apply pressure to the nose.

The nurse is assessing a client diagnosed with sinusitis. Which are signs and symptoms of sinusitis? Select all that apply.

Headache especially in the morning Elevated white blood cell (WBC) count Feeling of heaviness over affected areas

The nurse is caring for the client diagnosed with tuberculosis (TB). Which finding made by the nurse would be inconsistent with the usual clinical presentation of tuberculosis?

High-grade fever

Lung Sound-Bronchial

Hollow, tubular, low pitched. Ausculated over the trachea.

The nurse is caring for a client with a wet suction chest tube who accidentally disconnects the tube from the drainage system when trying to get out of bed. The nurse should take which action?

Immerse the end of the tube in sterile saline.

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?

Increased intracranial pressure

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 mm Hg. The nurse reviews the plan of care for the client and determines that which priority problem potentially exists for this client?

Ineffective oxygen and carbon dioxide exchange

Pleurisy

Inflammation of the lining of the lungs & chest (pleura) that leads to chest pain (usually sharp) when you take a breath or cough -knifelike pain on inspiration

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?

Inspect chest tube connections.

The nurse is planning care for a client whose oxygenation is being monitored by a pulse oximeter. Which intervention is important to ensure accurate monitoring of the client's oxygenation status?

Instruct the client not to move the sensor.

A client with chronic obstructive pulmonary disease (COPD) on bed rest is weaned from the ventilator before transferring to a medical unit. To adequately restore client strength before getting the client out of bed, which is the priority client activity for the nurse to incorporate in the plan of care?

Instruct the client to reposition himself.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/min. The nurse responds that this would be harmful because it could cause which difficulty?

It could decrease the client's oxygen-based respiratory drive.

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 nurse's response is based on which fact with regard to turning up the wall suction?

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.

The chest x-ray report for a client states that the client has a left apical pneumothorax. The nurse should monitor the status of breath sounds in that area by placing the stethoscope in which location?

Just under the left clavicle

A client with right pleural effusion by chest x-ray is being prepared for a thoracentesis. The client experiences dizziness when sitting upright. The nurse assists the client to which position for the procedure?

Left side-lying with the head of the bed elevated at 45 degrees

Acute Resp. Distress Syndrome (ARDS)

Life threating lung condition that prevents enough oxygen from geting into the blood. Fluid makes lungs heavy/stiff & decreases ability to expand. >Resp acidosis, sob, high BP, High HR, decrease lung sounds >Do high fowler, diuretics, increase o2, fluid restriciton-steroids

A client with an oral endotracheal tube attached to a mechanical ventilator is about to begin the weaning process. The nurse asks the health care provider whether this process should be delayed temporarily, based on administration of which medication to the client in the last hour?

Lorazepam (Ativan)

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?

Low peak inspiratory pressure on the ventilator

A client is being prepared for a thoracentesis. The nurse should assist the client to which position for the procedure?

Lying in bed on the unaffected side, with the head of the bed elevated 45 degrees

The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position because it will aggravate breathing?

Lying on his or her back in low-Fowler's position

Indications for suctioning

Moist wet respirations, restlessness, rhonchi on ausculation of lungs, visible mucus bubbling in the ETT, increased pulse and resp rate, increased inspritary pressures on the vent.

Process of lungs

Nasal cavity > mouth > epiglottis > larynx > trachea > alveoli (grapes) > bronchioles

A client with a nasal tumor is being admitted to the hospital. The nurse collects data about which primary symptom that the client is expected to exhibit?

Nasal obstruction

The nurse is monitoring a client for Biot's respirations. Which condition causes Biot's respirations?

Neurologic disorders

The nurse is caring for the client who is at risk for lung cancer because of an extremely long history of heavy cigarette smoking. The nurse tells the client to report which frequent early symptom of lung cancer?

Nonproductive hacking cough

Lung Sounds-Vesicular

Normal Soft & low pitched with a rustling quality during inspiration and are even softer during expiration

Lung Sound-Bronchiovesicular

Normal sounds in the mid chest area or in the posterior chest between the scapula.

Upper Resp. System

Nose, nasal cavity, ethmoidal air cells, frontal sinus, maxillary sinus, sphenoidal sinus, larynx (voice box)

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?

Notify the registered nurse (RN).

A client who has just suffered a large flail chest is experiencing severe pain and dyspnea. Which would be the appropriate nursing action?

Notify the registered nurse.

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?

Obturator

The nurse is preparing a plan of care for the client who will be returning from surgery following a right lung wedge resection. Included in the plan of care is that in the postoperative period, the nurse should avoid which positioning?

On the right side

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?

Oral airway

The nurse is assigned to assist the health care provider with the removal of a chest tube. The nurse should reinforce instructing the client to do which during this process?

Perform Valsalva's maneuver.

A client arrives in the emergency department with an episode of status asthmaticus. What is the nurse's priority action?

Place the client in high-Fowler's position.

A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD) and has an arterial blood gas test done. Which results would the nurse expect to note?

Po2 of 60 mm Hg and Pco2 of 50 mm Hg

A client is admitted to the hospital with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which arterial blood gas supports this diagnosis?

Po2 of 60 mm Hg and Pco2 of 50 mm Hg

Flail Chest: Nursing Considerations

Prepare for intubation and mechanical ventilation.

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?

Promote carbon dioxide elimination.

The nurse is caring for a client with tuberculosis (TB) who is fearful of the disease and anxious about the prognosis. In planning nursing care, the nurse should incorporate which action as the best strategy to assist the client in coping with the disease?

Provide reassurance that continued compliance with medication therapy is the most proactive way to cope with the disease.

A client with a suspected throat infection with Streptococcus needs to have a throat culture obtained. The nurse should take which action after obtaining the culture if the specimen cannot be delivered to the laboratory for at least an hour?

Refrigerate the specimen.

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?

Report the findings.

The nurse is working in a tuberculosis (TB) screening clinic. The nurse understands that which population is at highest risk for TB?

Residents of a long-term care facility

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.

Rest Local heat Analgesics

A client has undergone a right pneumonectomy. The nurse positioning this client following admission from the postanesthesia care unit avoids placing the client in which harmful position?

Right lateral

The nurse is assisting in caring for a client who has just returned from the postanesthesia care unit after radical neck dissection. The nurse monitors the portable wound suction for which types of drainage expected in the immediate postoperative period?

Serosanguineous

The nurse is collecting data on a client with chronic sinusitis. The nurse interprets that which client sign/symptom is unrelated to this problem?

Severe evening headache

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?

Shortness of breath

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?

Shortness of breath

The nurse is monitoring a client following a motor vehicle crash. Which finding would indicate a need for chest tube placement?

Shortness of breath and tracheal deviation

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?

Sitting on the side of the bed, leaning on an overbed table

The nurse is suctioning a client through a tracheal tube. During the suctioning procedure, the nurse notes on the cardiac monitor that the heart rate has dropped 10 beats. Which should be the nurse's next action?

Stop the procedure and oxygenate the client.

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?

Stop the suctioning procedure.

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?

Suction the client.

The nurse is collecting data on a client admitted to the hospital with suspected carbon monoxide poisoning and notes that the client behaves as if intoxicated. The nurse uses this data to make which interpretation?

The behavior is likely the result of hypoxia.

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?

The chest tube is functioning as expected.

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?

The client breathes out slowly through the mouth.

The nurse reads a client's tuberculin skin test as positive. The nurse notes that previous tests were negative. The client becomes upset and asks the nurse what this means. The nurse's response is based on the understanding that which statement is true for this client?

The client has been exposed to tuberculosis.

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?

The client is breathing through the nose.

A client with a respiratory disorder has anorexia secondary to fatigue and dyspnea while eating. The nurse determines that the client has followed the recommendations to improve intake if which action is taken?

The client plans to eat the largest meal of the day at a time when hungry.

A postoperative client is using an incentive spirometer. The nurse observes the client inhale slowly with the mouthpiece placed between the teeth with the lips closed. The client inhales to the preset inspiratory goal and holds the breath for about 3 seconds, then exhales slowly. The client takes one breath and returns the incentive spirometer to the bedside. Based on this observation, which interpretation should the nurse make?

The client should be repeating the sequence 10 to 20 times in each session.

The nurse is observing a client with chronic obstructive pulmonary disease (COPD) performing the pursed-lip breathing technique. Which observation by the nurse would indicate accurate performance of this breathing technique?

The client's exhalation is twice as long as inhalation.

The nurse is caring for a client who has a chest tube connected to a three-chamber drainage system without suction. Identify the chamber that collects drainage from the client.

The drainage chamber is on the right. It has three calibrated columns that show the amount of drainage collected. When the first column fills, drainage empties into the second; when the second column fills, drainage flows into the third. The water-seal chamber is located in the center. The suction-control chamber is on the left.

A client being discharged from the hospital to home with a diagnosis of tuberculosis (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?

The family will receive prophylactic therapy, and the client will not be contagious after 2 to 3 consecutive weeks of medication therapy.

A client reports the chronic use of nasal sprays. The nurse reinforces instructions to this client about which piece of information related to chronic use of nasal sprays?

The protective mechanism of the nose may be damaged.

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?

The student suctions the client's tracheotomy tube for 15 seconds

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?

The system is functioning as expected.

The nurse checks the water seal chamber of a closed chest drainage system and notes fluctuations in the chamber. The nurse analyzes this finding as indicative of which outcome?

The system is functioning as expected.

A client is admitted to the nursing unit following a lobectomy. The nurse caring for the client notes that, in the first hour after admission, the chest tube drainage was 75 mL. During the second hour, the drainage dropped to 5 mL. Which finding does this indicate?

The tube may be occluded.

A client had thoracic surgery 2 days ago and has a chest tube in place connected to a closed chest tube system. The nurse notes continuous bubbling in the water seal chamber. The nurse determines which?

There is a leak in the system, which requires immediate investigation and correction.

The nurse is assigned to assist in caring for a client who has a pneumothorax. The nurse notes continuous bubbling in the water seal chamber of the client's closed-chest drainage system. The nurse determines that this is indicative of which occurrence?

There is an air leak somewhere in the system.

The nurse is collecting data on a client with left lower lobe atelectasis. Identify the area where she may hear fine crackles associated with this condition.

To auscultate the left lower lobe from the anterior chest, use the landmarks of the left anterior axillary line, between the fifth and sixth intercostal spaces.

A client who is postoperative with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed for which reason?

To expel mucus from the airways

Lower Resp. System

Trachea (windpipe), lungs, airway (bronchi & bronchiols), airsacs (Alveoli), right lung (3 sections), left lung (2 sections)

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?

Trauma

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?

Use a picture or word board.

A client with arthritis of the hands and fingers is having difficulty using a metered-dose inhaler (MDI). The nurse suggests asking the health care provider for which prescription?

Use of a spacer

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?

Ventilate the client with a resuscitation bag.

The nurse is admitting a client to the nursing unit who is suspected of having tuberculosis (TB). The nurse plans to admit the client to which type of room?

Venting to the outside, six air exchanges per hour, and ultraviolet light

The nurse is assisting a health care provider 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?

Verify placement by a chest x-ray.

Asthma

a disorder that causes the airways of the lungs to swell and narrow leading to: wheezing, sob, chest tightness coughing

Nasal Cannula

low flow O2 1-6 L/min

The nurse is reviewing the arterial blood gas results of an assigned client. Which arterial blood gases indicate metabolic alkalosis?

pH of 7.48, Pco2 of 40 mm Hg, HCO3- of 36 mEq/L

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?

sputum culture