NUR 203 Respiratory

A client is receiving mechanical ventilation. How frequently should the nurse auscultate the client's lungs to check for secretions?

2-4 h

Arterial blood gases should be obtained at which timeframe following the initiation of continuous mechanical ventilation?

20 minutes

The nursing instructor is discussing pulmonary arterial hypertension with the nursing students. What would the instructor describe as the pathophysiology of secondary pulmonary arterial hypertension?

Alveolar destruction causes increased resistance and pressure in the pulmonary vascular bed.

A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse

Assesses the client's tracheostomy and lung sounds every 15 minutes

A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?

Auscultation

The nurse is caring for a patient being weaned from the mechanical ventilator. Which of the following patient findings would require the termination of the weaning process?

BP increase of 20mmHg from baseline

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse

Continues assessing the client's respiratory status frequently

Which of the following is a correct endotracheal tube cuff pressure?

Cuff pressures should be checked with a calibrated aneroid manometer device every 6 to 8 hours to maintain cuff pressures between 15 and 20 mm Hg.

An emergency room nurse is assessing a patient who is complaining of dyspnea. Which of these signs would indicate the presence of a pleural effusion?

Decreased chest wall excursion upon palpation

What is the reason for chest tubes after thoracic surgery?

Draining secretions, air, and blood from the thoracic cavity is necessary.

Which of the following interventions does a nurse implement for patients with empyema?

Encourage breathing exercises

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?

Encourage increased fluid intake.

The nurse has instructed a patient on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which of the following?

Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?

In general, clients with respiratory conditions are given oxygen therapy only to increase the arterial oxygen pressure (PaO2) back to the client's normal baseline, which may vary from 60 to 95 mm Hg.

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique?

Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. usually performed two to four times daily, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime.

Which of the following is a true statement regarding severe acute respiratory syndrome (SARS)?

It is the most contagious during the second week of illness

Which of the following is a potential complication of a low pressure in the endotracheal tube (ET) cuff?

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

A client is admitted to the health care facility with active tuberculosis (TB). The nurse should include which intervention in the care plan?

Putting on an individually fitted mask when entering the client's room

A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?

Suction the client, withdraw residual air from the cuff, and reinflate it.

A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan?

Using strict hand hygiene

Which type of ventilator has a present volume of air to be delivered with each inspiration?

With volume-controlled ventilation, the volume of air to be delivered with each inspiration is present.

Constant bubbling in the water seal of a chest drainage system indicates which of the following problems?

air leak

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

ambu

A client is admitted to the emergency department with a stab wound and is now presenting dyspnea, tachypnea, and sucking noise heard on inspiration and expiration. The nurse should care for the wound in which manner?

apply airtight dressing

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:

ards

The nurse caring for a patient with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?

b6

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

baseline ABGs

A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by:

using the minimal-leak technique with cuff pressure less than 25 cm H2O.

Which of the following should a nurse encourage in patients who are at the risk of pneumococcal and influenza infections?

vaccines

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 daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?

6-12 mo

The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated.

"I just finished eating my lunch, I'm ready for my CPT now." When performing CPT, the nurse ensures that the patient is comfortable, is not wearing restrictive clothing, and has not just eaten.

The nurse is preparing to assist the health care provider with the removal of a patient's chest tube. Which of the following instructions will the nurse correctly give the patient?

"When the tube is being removed, take a deep breath, exhale, and bear down."

A client admitted with pneumonia has a history of lung cancer and heart failure. A nurse caring for this client recognizes that he should maintain adequate fluid intake to keep secretions thin for ease in expectoration. The amount of fluid intake this client should maintain is:

1.4 L. Clients need to keep their secretions thin by drinking 2 to 3 L of clear liquids per day. In clients with heart failure, fluid intake shouldn't exceed 1.5 L daily.

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for

A kink in the ventilator tubing

The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication?

Acute respiratory distress syndrome

Which of the following types of lung cancer is the most prevalent carcinoma of the lung for both men and women?

Adenocarcinoma

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

Airborne and contact precautions SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact.

A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?

Blood-tinged sputum

You are an occupational nurse completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?

Fibrotic changes in lungs

The nurse should monitor a client receiving mechanical ventilation for which of the following complications?

GI hemorrhage

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

Hypercapnia, hypoventilation, and hypoxemia

Which of the following ventilator modes provides a combination of mechanically assisted breaths and spontaneous breaths?

Intermittent mandatory ventilation (IMV)

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

Kinking of the ventilator tubing

A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?

Nasogastric, orogastric, and endotracheal tubes increase the risk of pneumonia because of the risk of aspiration from improperly placed tubes.

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

Partial pressure of arterial oxygen (PaO2)

A 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?

Place the end of the chest tube in a container of sterile saline to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. The nurse should apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected. The nurse shouldn't clamp the chest tube because clamping increases the risk of tension pneumothorax.

In general, chest drainage tubes are not indicated for a patient undergoing which of the following procedures?

Pneumonectomy

A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?

Pneumothorax

Resistance to one of the first-line antituberculotic agents in people who have not had previous treatment is

Primary drug resistance to one of the first-line antituberculotic agents is people who have not had previous treatment. Secondary or acquired drug resistance is resistance to one or more antituberculotic agents in patients undergoing therapy. Multidrug resistance is resistance to two agents, isoniazid (INH) and rifampin.

A 67-year-old female client is being discharged postoperative following pelvic surgery. The patient care instructions to prevent the development of a pulmonary embolus would include which of the following?

Tense and relax muscles in lower extremities.

A Class 1 with regards to TB indicates

exposure and no evidence of infection.

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?

no longer than 10 to 15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest.

Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration?

non rebreather

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 the nurse take first?

o2

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

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

Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?

venturi

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

water seal chamber