Nurs.241 Resp. exam

the priority collaborative problems for patients with PE include:

1. Hypoxemia 2. hypotension 3. excessive bleeding 4. anxiety

The priority collaborative problems for patients with head and neck cancer include:

1. potential for *airway obstruction* due to edema and presence of tumor 2. potential for *aspiration* due to edema, anatomic changes, or altered protective reflexes 3. *anxiety* due to threat of death, change in role status, or change in economic status 4. *decreased self esteem* due to cancer and cancer treatment side effects

HCO3-

21-28 the age you wanna be

PaCO2

35-45

A nurse assesses a 66-year-old client who is attempting to quit smoking. The client states, "I started smoking at age 16, and smoked one pack each day until 10 years ago. Then I decreased to a half of a pack per day." How many pack-years should the nurse document for this client? (Record your answer using a whole number.) ___ pack-years

45 pack-years66 (current age) - 16 (year started smoking) = 50 years of smoking.(40 years ´ 1 pack per day) + (10 years ´ 0.5 pack per day) = 45 pack-years.

notify the surgeon if more than

70 ml/hr of drainage occurs

PaO2

80-100

SpO2

95-100%

Other TB Diagnostics

Acid-Fast Smear of sputum "Sputum for AFB" X 3 ◦AFB Precautions Bacterial culture of sputum (takes 1-4 weeks to confirm) QuantiFERON-TB Gold Test

Influenza Prevention

Annual flu vaccine - 0.5 mL IM ◦Assess for allergies to eggs Population at highest risk ◦People over 50 ◦Residents of nursing homes ◦Pregnant women ◦Chronic diseases ◦Health care workers ◦Family of at risk patients

Non-infectious Respiratory Problems

COPD Emphysema Chronic Bronchitis

Lung Biopsy

Follow-up care: ◦Assess vital signs and breath sounds at least every 4 hrfor 24 hr. ◦Assess for respiratory distress. ◦Report reduced or absent breath sounds immediately. ◦Monitor for hemoptysis. (blood in sputum)

is it a cold or the flu

Influenza-Active viral disease Transmitted by droplets - coughing, sneezing, etc.

Diagnostic Assessment

Laboratory assessment ◦RBC ◦ABG ◦Sputum Imaging assessment ◦x-rays ◦CT Other noninvasive diagnostic assessments ◦Pulse oximetry ◦Capnometryand capnography ◦PFTs ◦Exercise testing

TB clinical manifestations

Low grade fever/chills Cough - may or may not be productive Night sweats Fatigue Weight loss Hemoptysis SOB

Pneumonia in the ImmunocomprisedPatient

Occurs in those who are immunocompromised from illness or treatment Types ◦Pneumocystiscarinnipneumonia (PCP) ◦Fungal

antidote for warfarin

Vitamin K

excessive / continous bubbling in the water seal chamber indicates

an air leak

A pulmonary nurse cares for clients who have chronic obstructive pulmonary disease (COPD). Which client should the nurse assess first? a. A 46-year-old with a 30-pack-year history of smoking b. A 52-year-old in a tripod position using accessory muscles to breathe c. A 68-year-old who has dependent edema and clubbed fingers d. A 74-year-old with a chronic cough and thick, tenacious secretions

b. A 52-year-old in a tripod position using accessory muscles to breathe The client who is in a tripod position and using accessory muscles is working to breathe. This client must be assessed first to establish how well the client is breathing and provide interventions to minimize respiratory failure. The other clients are not in acute distress.

COPD

chronic obstructive pulmonary disease

A client is being discharged on long-term therapy for tuberculosis (TB). What referral by the nurse is most appropriate? a.Community social worker for Meals on Wheels b.Occupational therapy for job retraining c.Physical therapy for homebound therapy services d.Visiting Nurses for directly observed therapy

d.Visiting Nurses for directly observed therapy Directly observed therapy is often utilized for managing clients with TB in the community. Meals on Wheels, job retraining, and home therapy may or may not be appropriate.

use a manual resuscitation bag to ventilate the patient if the tracheostomy tube has been

dislodged or been decannulated

Low pressure alarm

indicates a low exhaled volume due to a disconnection, cuff leak, and/or tube displacement

High pressure alarm

indicates excess secretions, patient biting the tubing, kinks in tubing, patient coughing, pulmonary edema, bronchospasm, pneumothorax

TB

is a highly communicable disease caused by mycobacterium tuberculosis. Airborne **NIGHT SWEATS**

after chest tube insertion

monitor drainage hourly during 1st 24 hours after 24 hours every 8 hours

Umbrella Filter

works well, prevents from having PE, check pedal pulses afterwards

COPD risk factors=

· CIGARETTE SMOKING #1 · Passive smoking · Recurrent respiratory infections · Occupational exposure · Air pollution · Genetic-abnormalities · Asthma - COPD is 12X greater · AAT deficiency - causes COPD to develop at fairly young age

Preventing aspiration during swallowing

1) avoid serving meals when pt is fatigued 2) provide smaller more frequent meals 3) provide adequate time for eating. do not rush patient 4) close supervision if pt is self feeding 5) emergency suction equipment close by at hand & turned on 6) avoid water and thin liquids 7) thicken all liquids even water 8) avoid foods that generate liquids, like fruits 9) *when possible deflate the tube cuff during meals* or at least partially 10) suction after initial cuff deflation to clear the airway and allow maximum comfort during meal 11) feed each bite, take bite slowly 12) encourage dry swallow after each bite to clear residue from throat 13) avoid consecutive swallows of liquids 14) small volumes of liquids 15) encourage pt to tuck his or her chin down and move the forehead forward while swallowing. 16) pt indicate when they are ready for next bite 17) if pt coughs stop the feeding, until she indicates airway has been cleared. 18) monitor tolerance to oral food intake by assessing RR, ease, pulse

tension pneumothorax

A life-threatening complication of pneumothorax in which air continues to enter the pleural space during inspiration and does not exit during expiration, leads to collapse of lung and compressing blood vessels which limits blood return=decreased cardiac output. If not promptly treated it is quickly fatal.

The nurse is providing education on preventing pulmonary disorders at a community health fair. Which of these groups does the nurse target? Select all that apply. Bakers Coal miners Electricians Furniture refinishers Plumbers Potters

Bakers Coal miners Furniture refinishers Potters The groups the nurse targets as people at risk for pulmonary disorders include bakers, coal miners, furniture refinishers, and potters. Being exposed to flour as a baker for prolonged periods of time may cause a condition called occupational asthma. Coal miners are at risk for developing pneumoconiosis as the result of inhalation of coal dust. Owing to the chemicals used to refinish furniture (paint strippers, solvents, etc.), masks and adequate ventilation are essential for furniture refinishers. One of the main solvents involved will metabolize in the body to carbon monoxide and will impair the ability of the tissue to extract oxygen. Silicosis or inhalation of silica dust is a hazard for professional and recreational potters.Except in unique situations, electricians and plumbers do not need to wear masks or utilize special ventilation for their jobs.

Which assessment finding in the client with exacerbation of emphysema requires intervention by the nurse? Barrel-shaped chest Bronchial breath sounds heard at the bases Hyperresonance to percussion of the chest Ribs lying horizontal

Bronchial breath sounds heard at the bases The client with bronchial breath sounds needs intervention by the nurse. These sounds are not normally heard in the periphery and may indicate atelectasis or increased lung density, as might present with a tumor or an infectious process such as pneumonia.The anteroposterior diameter is the same as the lateral-to-lateral or side-to-side diameter in a client with emphysema, so the client will generally have a barrel-shaped chest. Air-filled cavities, such as the lung, are hyperresonant to percussion. Air trapping causes the ribs in a client with emphysema to lie in a more horizontal direction.

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy and the eyelids are swollen. What action by the nurse takes priority? a. Assess the client's oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.

a. Assess the client's oxygen saturation. This client may have subcutaneous emphysema, which is air that leaks into the tissues surrounding the tracheostomy. The nurse should first assess the client's oxygen saturation and other indicators of oxygenation. If the client is stable, the nurse can palpate the skin of the upper chest to feel for the air. If the client is unstable, the nurse calls the Rapid Response Team. Using a bag-valve-mask device may or may not be appropriate for the unstable client.

A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action? a. Increased temperature b. Absent breath sounds c. Productive cough d. Incisional discomfort

b. Absent breath sounds Absent breath sounds may indicate that the client has a pneumothorax, a serious complication after a needle biopsy or open lung biopsy. The other manifestations are not life threatening.

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor? a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing

c. Tying a square knot at the back of the neck To prevent pressure ulcers and for client safety, when ties are used that must be knotted, the knot should be placed at the side of the client's neck, not in back. The other actions are appropriate.

notify rapid response team

of patient with posterior nose bleed

A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What primary assessment will the nurse make while preparing the client for a computed tomography (CT) scan? "Do you have any metal anywhere in your body?" "Do you have diabetes?" "Are you allergic to iodine or shellfish?" "Do you drink alcohol regularly?"

"Are you allergic to iodine or shellfish?" While preparing the client for a CT scan, the nurse's primary assessment would be to determine whether the client has any sensitivity to the contrast material by asking if the client has a known allergy to contrast, iodine or shellfish. CT scans, especially spiral or helical CT scans, with injected contrast can detect pulmonary emboli.Assessing for any metal in the body is done when clients undergo MRI. Diabetes is not a contraindication for CT with contrast. However, if the client receives metformin, the drug is stopped at least 24 hours before contrast dye is used and withheld until adequate kidney function is confirmed. Assessing regular alcohol intake is important, but is not the primary assessment.

The nurse is preparing a client with possible pulmonary embolism for a CT scan with contrast. Prior to the scan, which of these assessment questions is essential for the nurse to ask? "Do you take supplements containing vitamin K?" "Did you take metformin today?" "Are you allergic to peanuts?" "Have you had shortness of breath recently?"

"Did you take metformin today?" The assessment question that is essential for the nurse to ask is, "Did you take metformin today?" IV contrast material can be nephrotoxic. Metformin is stopped at least 24 hours before contrast dye is used and is not restarted until adequate kidney function is confirmed.If pulmonary embolism is confirmed, warfarin may be prescribed. If so, vitamin K-containing foods and vitamins will need to be limited. Peanut allergy does not pose a risk with contrast. Shortness of breath is a typical finding when a PE is present, and is not the priority assessment prior to CT.

mycoplasma

"walking pneumonia" Most often seen in school-age children, teens and young adults Spread by respiratory droplets Bacterial cultures often negative Sore throat,nasalcongestion Treated with erythromycin

Nursing Management of COPD

**Activity Intolerance** Provide rest periods Progressive exercise routine Avoid fatigue **Alteration in Nutrition** Monitor weight Supplements or small meals Assess for S/S PUD, GERD **Potential for Infection** Avoid respiratory infections Teach S/S of respiratory infection Aggressive early treatment of respiratory infection **Knowledge Deficit** Educate patient and family ◦Pulmonary rehab ◦Smoking cessation Home meds Oxygen use **Imblanaced nutrition** Interventions to achieve and maintain body weight: ◦Prevent protein-calorie malnutrition through dietary consultation ◦Monitor weight, skin condition, and serum prealbuminlevels ◦Dyspnea management ◦Food selection to prevent weight loss **Anxiety** Interventions for increased anxiety: ◦Important to have patient understand that anxiety will worsen symptoms ◦Plan ways to deal with anxiety

Assess the patient hourly for the first several days after head and neck surgery to recognize a carotid artery leak. If you suspect a leak, respond by calling the rapid response team and

*DO NOT TOUCH THE AREA BECAUSE ADDITIONAL PRESSURE COULD CAUSE AN IMMEDIATE RUPTURE*. if it ruptures place constant pressure over the site and secure the airway. Maintain direct manual, continuous pressure on the carotid artery and immediately transport the patient to the operating room for resection. Do not leave the patient. Carotid artery rupture has a high risk for stroke and death.

COPD Expected outcomes-

*Expected to attain & maintain gas exchange at baseline level, indicators include:* 1. Maintain SpO2 of at least 88% 2. Remains free of cyanosis 3. Maintains cognitive orientation 4. Coughs & clears secretions effectively 5. Maintains RR & rhythm appropriate to their activity level

PneumoniaNursing Care

*Ineffective airway clearance* ◦Assess respiratory status q shift & prn ◦Hydration ◦Humidification ◦Turn, cough, & deep breathe q 2 hr ◦IS q 1 hrWA ◦Chest physiotherapy ◦Pulse oximetry, ◦ABGs *Activity intolerance* ◦Monitor VS before, during, & after activity ◦Assess ADL ability & assist when needed ◦Alternate rest & activity ◦Turn q 2 hrwhile in bed ◦Positive reinforcement *Risk for deficient fluid volume* ◦Monitor VS ◦Monitor skin turgor ◦Monitor intake & output ◦Hydration ◦Oral ◦IV -I&O's bc risk for shock *Imbalanced nutrition less than body requirements* ◦Monitor intake ◦Calorie count ◦Electrolytes ◦Shakes ◦IVF *Deficient knowledge* ◦Educate of cause, complications, management, & follow-up ◦Smoking cessation ◦Vaccinations

After thoracentesis teach patient symptoms of pneumothorax (partial or complete collapse of lung) which can occur w/I 24 hours after. Symptoms include:

*Pain on affected side that is worse at the end of inhalation and the end of exhalation *rapid HR *Rapid, shallow RR *a feeling of air hunger * prominence of the effected side that does not move in and out with respiratory effort * trachea slanted more to the unaffected side instead of being in the center of the neck * new onset of "nagging" cough *cyanosis -->Instruct the pt to go to closest ER immediately if any of these symptoms occur following a thoracentesis

tracheostomy care chart 28-3

*assemble the necessary equipment *wash hands. Maintain standard precautions *suction if necessary *remove old dressing and excess secretions * set up sterile field * remove and clean inner cannula. *Use half strength hydrogen peroxide to clean the cannula and sterile saline to rinse it *, if inner cannula disposable dispose and replace w/ a new one *clean the stoma site and then the trash plate with half strength hydrogen peroxide followed by sterile saline. Ensure no solutions enter the tracheostomy * change ties if soiled. *Secure new ties in place before removing soiled ones* to prevent accidental decannulation. If a knot is needed, tie a square knot that is visible on the side of the neck. *Only 1 finger should be able to be placed b/n the tape and the neck.* *wash hands *document the type and amount of secretions and the general condition of the stoma and surrounding skin tissue integrity. Document pts response to procedure and any teaching or learning occurred.

Isoniazid

*avoid antacids & take on empty stomach 1-2 hours before meals* take multivitamin with B-complex vitamins b/c can deplete them in body dont drink alcohol report signs of liver failure/toxicity

Ethambutol

*report any changes in vision* immediately, can lead to blindness avoid alcohol ask if ever had GOUT b/c increases uric acid production report signs of liver failure/toxicity instruct to drink at least 8 ounces of water

patients with chest tubes immediately notify physician or rapid response team if:

*tracheal deviation * sudden onset or increased intensity of dyspnea * O2 less than 90% *drainage greater than 70ml/hr *visible eyelets on chest tube *chest tube falls out, 1st cover the area with dry sterile gauze *chest tube disconnects from the drainage system, 1st put the end of tube in a container of sterile water and keep below the level of the patients chest *drainage in tube stops within 1st 24 hrs

Rifampin

*warn patients to expect orange reddish staining of the skin and urine, and all other secretions, contact lenses will become stained* dont drink alcohol use contraceptives while using and 1 month after report signs of liver failure/toxicity

A nurse answers a call light and finds a client anxious, short of breath, reporting chest pain, and having a blood pressure of 88/52 mm Hg on the cardiac monitor. What action by the nurse takes priority? a.Assess the client's lung sounds .b.Notify the Rapid Response Team. c.Provide reassurance to the client. d.Take a full set of vital signs.

.b.Notify the Rapid Response Team. This client has manifestations of a pulmonary embolism, and the most critical action is to notify the Rapid Response Team for speedy diagnosis and treatment. The other actions are appropriate also but are not the priority.

A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention? a. Hollow sounds are heard over the trachea. - The nurse increases the oxygen flow rate. b. Crackles are heard in bases. - The nurse encourages the client to cough forcefully .c. Wheezes are heard in central areas. - The nurse administers an inhaled bronchodilator. d. Vesicular sounds are heard over the periphery. - The nurse has the client breathe deeply.

.c. Wheezes are heard in central areas. - The nurse administers an inhaled bronchodilator. Wheezes are indicative of narrowed airways, and bronchodilators help to open the air passages. Hollow sounds are typically heard over the trachea, and no intervention is necessary. If crackles are heard, the client may need a diuretic. Crackles represent a deep interstitial process, and coughing forcefully will not help the client expectorate secretions. Vesicular sounds heard in the periphery are normal and require no intervention.

A nurse is assisting the health care provider who is intubating a client. The provider has been attempting to intubate for 40 seconds. What action by the nurse takes priority? a.Ensure the client has adequate sedation. b.Find another provider to intubate .c.Interrupt the procedure to give oxygen. d.Monitor the client's oxygen saturation.

.c.Interrupt the procedure to give oxygen. Each intubation attempt should not exceed 30 seconds (15 is preferable) as it causes hypoxia. The nurse should interrupt the intubation attempt and give the client oxygen. The nurse should also have adequate sedation during the procedure and monitor the client's oxygen saturation, but these do not take priority. Finding another provider is not appropriate at this time.

Priority problems for patients with COPD:

1. Decreased gas exchange due to alveolar-capillary membrane changes, reduced air way size, ventilator muscle fatigue, excessive mucus production, airway obstruction, diaphragm flattening, fatigue, decreased energy 2. WEIGHT LOSS due to dyspnea, excessive secretions, anorexia, and fatigue 3. ANXIETY due to a change in health status, and situational crisis 4. DECREASED INDURANCE due to fatigue dyspnea, and imbalance between oxygen supply and demand 5. POTENTIAL FOR PNEOMNIA or other RESPIRATORY INFECTIONS due to presence of thick secretions and the immunosuppressive effects of some drugs

The cdc recommends that older adults than 65 be vaccinated with both pneomonia vaccines

1st Prevnar 13 followed by Pneumovax 6 to 12 months later

Nursing Management of Patients on Mechanical Ventilation

Assess patient first then equipment Respiratory assessment and VS Cardiovascular status and fluid balance

Nursing Management of COPDAlteration in Respiratory Function

Avoid irritants Drug therapy - bronchodilators, corticosteroids, annual flu vaccine, pneumococcal vaccine (see medication handout) Hydration - 3L/day Breathing retraining Pulmonary hygiene Chest physiotherapy Home O2 therapy

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision

a. Cognition b. Dexterity d. Range of motion e. Vision The older adult is at risk for having impairments in cognition, dexterity, range of motion, and vision that could limit the ability to perform tracheostomy care and should be assessed. Hydration is not directly related to the ability to perform self-care.

Diagnostic Testing

Blood tests Sputum tests (1st thing in morning) Radiographic examinations including standard chest x-rays, digital chest radiography, CT Ventilation and perfusion scanning Pulse oximetry

The nurse is assessing a client with chronic bronchitis who smoked 3 packs of cigarettes daily for 32 years. How does the nurse document pack-year history of smoking in the medical record? Client has a 32 pack-year history Client has a 96 pack-year history Client smoked 3 packs for years Client was a passive smoker for 32 years

Client has a 96 pack-year history This client has a 96-year pack history. Pack-year history refers to the number of packs per day multiplied by the number of years the client smoked.Pack-year history refers to the number of packs per day multiplied by the number of years the client smoked.

Which client does the charge nurse on the medical-surgical unit assign to an RN who has floated from the postanesthesia care unit (PACU)? Client with possible ulcer who just returned from an endoscopy Client with emphysema who needs teaching about pulmonary function testing Client with pancreatitis who needs a preoperative chest x-ray Client who had 1200 mL of pleural fluid removed by thoracentesis

Client who had 1200 mL of pleural fluid removed by thoracentesis A nurse working in the PACU would be most familiar with assessing vital signs and respiratory status for a postoperative client after an invasive procedure such as thoracentesis. When a large volume of fluid has been removed, there is a greater risk for instability. This client is within this nurse's skill set.Endoscopy is typically performed with sedation, not general anesthesia, which will not require the critical rescue skills of the PACU nurse. Pulmonary function testing is not a procedure the PACU nurse would typically encounter nor will it require the skill level of the PACU nurse. Although a client with pancreatitis is seriously ill and would require a chest x-ray before undergoing operative procedures, a nurse with a PACU monitoring skill set would not be required.

The nurse is working in an urgent care clinic where four clients are waiting to be seen. Which client needs to be evaluated first by the nurse? Client who is short of breath after walking up two flights of stairs Client with a 10 mm area of redness on the arm after receiving purified protein derivative (Mantoux) skin test Client with sore throat and fever of 102.2°F (39°C) oral Client who is speaking in three-word sentences and has an SpO2 of 90%

Client who is speaking in three-word sentences and has an SpO2 of 90% The client that requires first and immediate evaluation by the nurse is the client who is speaking in three-word sentences and displaying dyspnea. This, coupled with an SpO2 of 90%, indicates hypoxemia.The client displaying shortness of breath after walking up two flights of stairs may be displaying signs/symptoms of underlying cardiopulmonary disease. This is not an emergency as there is no indication of dyspnea at rest. Induration, not redness, reflects a positive Mantoux test with possible TB. This develops slowly and will not take priority over airway and breathing. Sore throat and fever are symptoms of infection that require further evaluation, but not emergently.

The RN has received report about four clients. Which client needs the most immediate assessment? Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry Client admitted 3 hours ago for a scheduled thoracentesis in 30 minutes Client with bronchogenic lung cancer who returned from bronchoscopy 3 hours ago Client with pleural effusion who has decreased breath sounds at the right base

Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry The client in need of the most immediate assessment is the one with acute asthma with an oxygen saturation of 89% by pulse oximetry. *An oxygen saturation level less than 91% *indicates hypoxemia and instability requiring immediate assessment and intervention to improve blood and tissue oxygenation.The client who is scheduled for a thoracentesis will be able to receive teaching and will have the opportunity to ask questions and have them answered before the procedure is performed. There is no evidence the client who had a bronchoscopy 3 hours ago is unstable and therefore does not require attention at this moment. It would not be unusual to have diminished breath sounds at the base of the lung of the client with pleural effusion.

The home health nurse is assigned to visit these clients when a change in agency staffing requires that one of the clients be rescheduled for a visit on the following day. Which client will be best to reschedule? Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% Client with history of a cough, weight loss, and night sweats who has just had a positive Mantoux test Client with newly diagnosed pleural effusion who needs an admission visit and an initial intake assessment Client with percutaneous lung biopsy yesterday who called in to report increased dyspnea

Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% The best client for the nurse to reschedule for a home visit is the client with chronic emphysema who is on home oxygen and who has an appropriate SpO2 level. A SpO2 level of between 89% and 92% is appropriate and satisfactory.The client with a positive Mantoux test, in addition to a history of cough, weight loss, and night sweats, is highly suspicious for tuberculosis and needs to be seen that day. The nurse needs to perform follow-up assessment and coordinate follow up testing. The nurse may need to provide reporting to the public health department and to develop a plan for close personal contacts. A client with a newly diagnosed pleural effusion needs a complete and thorough admission and intake assessment to ensure that oxygenation and underlying needs are addressed. A percutaneous lung biopsy may be performed as an outpatient procedure. The client who had a percutaneous lung biopsy and is experiencing increased dyspnea needs to be assessed that day to determine whether a life-threatening pneumothorax or hemothorax has developed.

The nurse is caring for a client who just returned from an open lung biopsy and has a prescription for morphine by client controlled analgesia (PCA). Which of these actions to detect early opioid induced respiratory depression does the nurse recommend? Continuous pulse oximetry Serial arterial blood gas measurements Continuous capnography Apnea monitoring

Continuous capnography For early detection of opioid-induced respiratory depression, the nurse recommends continuous capnography. Capnography detects exhaled carbon dioxide which increases during opioid-induced respiratory depression.Capnography, to detect opioid-induced respiratory depression, has been proven to be superior for early detection of respiratory changes and is a more sensitive indicator of respiratory depression than pulse oximetry. Arterial blood gas measurement is painful and expensive, and is not practical to use this methodology on a continuous basis. Apnea monitoring will detect a lack of breathing, but capnography will alert the nurse to respiratory depression prior to that time.

The nurse is caring for a client with heart failure and acute kidney injury. For which of these breath sounds will the nurse assess? Crackles Rhonchi Pleural friction rub Wheeze

Crackles When caring for a client with heart failure and acute kidney disease, the nurse would assess for crackles. Crackles are described as a popping, discontinuous sound caused by air moving into previously deflated airways or areas of fluid.Rhonchi are low-pitched, coarse snoring sounds caused by thick secretions in larger airways. A pleural friction rub sounds grating, loud, or scratchy as inflamed surfaces of the pleura rub together. Wheezes are frequently referred to as musical or squeaky sounds caused by bronchospasm. They may occur on inspiration or on expiration as air rushes through narrowed airways.

A client is admitted to the medical floor with a new diagnosis of lung cancer. How will the nurse initially assist the client in managing the anxiety associated with the new diagnosis? Encourage the client to ask questions and verbalize concerns. Provide privacy for the client to be alone to deal with his or her own feelings. Medicate the client with diazepam for anxiety every 8 hours. Provide journals about cancer treatment.

Encourage the client to ask questions and verbalize concerns. The best way for the nurse to initially assist the client in managing anxiety related to a new diagnosis of cancer is to encourage the client to ask questions and voice concerns. The availability of the nurse to answer questions and listen to the client's concerns will help to decrease anxiety.The client may choose to be alone, although this may be a maladaptive coping behavior. Diazepam every 8 hours will reduce the client's anxiety but not help to manage its cause such as fear of the unknown or fear of death. It is more important to work with the client to assist him or her in dealing with those issues first. Knowledge about cancer diagnosis and treatment may help relieve anxiety but the nurse must first assess the client's needs as well as the plan of care.

The nurse in the outpatient clinic is scheduling a client for pulmonary function tests. When teaching the client about pulmonary function testing (PFT), which point is essential for the nurse to emphasize? Administer bronchodilator medication on call. Encourage clear fluid intake 12 hours before the procedure. Ensure the client does not smoke for 6 hours before the test. Provide supplemental oxygen.

Ensure the client does not smoke for 6 hours before the test. The essential nursing intervention for a client being prepared for a PFT is to make sure that the client does not smoke for 6 hours before the test. Smoking can alter parts of the PFT (diffusing capacity [DLCO]), yielding inaccurate results.Administering bronchodilators is not indicated for PFT, but they may be withheld for 4 to 6 hours before the test. Encouraging fluid intake does not have an effect on PFT testing. Supplemental oxygen is not required and will alter the results of PFT. However, oxygen may be given if the client develops distress during testing.

The nurse is preparing the client for a diagnostic bronchoscopy. Which nursing intervention is essential for the nurse to perform prior to the procedure? Obtain informed consent. Ensure the client has had nothing by mouth. Review dietary and medication allergies. Perform aggressive chest physiotherapy.

Ensure the client has had nothing by mouth. When preparing a client for a diagnostic bronchoscopy, it is essential for the nurse to make sure the client is NPO for 4 to 8 hours before the procedure to reduce the risk for aspiration.It is important to verify allergies, however ensuring NPO status is maintained is essential to prevent aspiration, which can be life threatening. The nurse will verify that consent for the procedure was obtained. Until the client has a gag reflex and is fully alert, he or she should be maintained on NPO status to prevent aspiration. Aggressive chest physiotherapy is not indicated in a client who has had a bronchoscopy and may cause bleeding if biopsies have been obtained.

A client with asthma reports shortness of breath. Which of these findings does the nurse anticipate when assessing this client's chest? Expiratory wheezing not cleared by coughing Bronchial breath sounds over the trachea Crackles throughout the lung fields Bronchovesicular breath sounds in the lung bases

Expiratory wheezing not cleared by coughing In a client with asthma and shortness of breath, the nurse expects to hear expiratory wheezing not cleared by coughing. Wheezes are squeaky, musical, continuous sounds associated with bronchospasm, typical with asthma. They may be heard without a stethoscope and usually do not clear with coughing.Bronchial breath sounds are normal breath sounds, heard over the trachea and larynx. Crackles, an adventitious breath sound, will sound like popping, discontinuous sounds caused by air moving into previously deflated airways or coarse rattling sounds caused by fluid. Bronchovesicular breath sounds are normal breath sounds heard over major bronchi where fewer alveoli are located. They are best heard between the scapula and anterior chest.

because pneumonia is a frequent cause of sepsis, use a sepsis screening tool to monitor patients who have pneumonia.

For patients with pneumonia always check O2 with VS

COPD affects

GAS EXCHANGE and the oxygenation of all tissues. COPD interferes with airflow and gas exchange. COPD disorders include emphysema and chronic bronchitis. Many patients with emphysema also have chronic bronchitis.

Fungal

Greatest in immunocompromised Not contagious Cough, hemoptysis, fungus ball Very difficult to treat *Amphotericin B often used** give test dose 1st*-can cause allergic reactions, check BUN, creatinine ◦Given IV every other day ◦May continue 4 - 10 weeks ◦Nursing Interventions and precautions?

Penetrating Chest Trauma

Hemothorax- blood in pleural space Pneumothorax - air in pleural space ◦Spontaneous pneumothorax Traumatic/Open Pneumothorax - opening between atmosphere and pleural space Tension pneumothorax - affected lung collapses and compresses heart, great vessels and opposite lung

Anticoagulation Therapy

Heparin ◦What lab test? ptt ◦Normal range 30-40 secs. ◦Weight based therapy check ptt everyday Warfarin sodium (Coumadin) ◦Lab test? pt, INR ◦Normal range? 11-12.5 secs. takes longer

TuberculosisHigh Risk Groups

Homeless Alcoholics Elderly Institutionalized Immunosuppressed Low SES Immigrants from countries with high TB Previously active TB

The nurse in the medical clinic is performing an assessment on an older adult client. Which finding requires further assessment by the nurse? Inability to state name and date of birth Slight kyphoscoliosis Soft speaking voice Need to rest after activity

Inability to state name and date of birth The nurse would further assess the client who is unable to state name and date of birth. The older adult has a higher risk for hypoxemia than a younger client. The older adult can become confused during acute respiratory conditions, which requires additional investigation.Progressive Kyphoscoliosis occurs with aging because the thorax becomes shorter. With aging, laryngeal muscles lose elasticity, and airways lose cartilage causing the client's voice to become soft and difficult to understand. This is due to age-related changes in chest wall compliance and elasticity. Increased need for rest periods during exercise may occur.

TB test

Mantoux test 0.1 mL PPD given intradermally- should see a wheal develop Read in 48 - 72 hours 0 - 4 mm induration not significant 5 mm or greater significant in certain people (HIV) 10 mm or greater induration significant for all people. *always document in mL *3-10 wks after exposure to have + test Positive reaction does not mean that active disease is present but does indicate exposure to TB or dormant disease

A client has returned to the medical surgical unit after a bronchoscopy. Which nursing task is best for the charge nurse to delegate to the experienced unlicensed assistive personnel (UAP)? Assess breath sounds. Offer clear liquids when gag reflex returns. Determine level of consciousness. Monitor blood pressure and pulse.

Monitor blood pressure and pulse. The best nursing task for the charge nurse to delegate to the experienced unlicensed assistive personnel (UAP) is monitoring blood pressure and pulse. An experienced UAP would have experience in taking client vital signs after procedures requiring conscious sedation or anesthesia.Evaluating breath sounds, gag reflex, and determining level of consciousness are considered nursing assessments and require the skill and knowledge of a higher-level provider or professional nurse.

Ventilator Acquired Pneumonia Management

Most common and lethal form of hospital acquired pneumonia HOB elevated 30-45 degrees Sedation vacation Oral care at least every 12 hrs. with disinfecting rinse Continuously removing subglottic secretions Handwashing Not wearing hand jewelry Changing vent circuit no more frequently than every 48 hrs.

Pseudomonas hospital acquired

Nosocomial origin Greater in those with existing illnesses May lead to empyema or lung abscess Death occurs in 40-60% of population Chills, fever, productive cough Treatment - aminoglycosisdes(gentamicin, piperacillin) --really hard to get rid of -smells very bad -watch for kidney function before starting antibiotics

Nursing Management of PE

Oxygen therapy and possible ventilator Hydration and vasodilation Heparin and coumadin Increase cardiac contractility Lyse clot - thrombolytics Pulmonary embolectomy- surgical procedure Prevention for high-risk patients Pain management Maintain oxygen therapy, anxiety and monitor for complications

Upper Respiratory Infections

Persons at greatest risk for URI Infants and young children Elderly, chronically ill, immunosuppressed, malnourished, dehydrated, decreased LOC Allergies, smokers environmental irritants, ETOH & drug abuse Immobilized and hospitalized patients

A client has been diagnosed with a very large pulmonary embolism (PE) and has a dropping blood pressure. What medication should the nurse anticipate the client will need as the priority? a.Alteplase (Activase) b.Enoxaparin (Lovenox) c.Unfractionated heparin d.Warfarin sodium (Coumadin)

a.Alteplase (Activase) Activase is a "clot-busting" agent indicated in large PEs in the setting of hemodynamic instability. The nurse knows this drug is the priority, although heparin may be started initially. Enoxaparin and warfarin are not indicated in this setting.

The RN and the LPN/LVN are working together to provide care for a group of clients on a medical surgical unit. Which of these actions is most appropriate for the RN to perform? Administer purified protein derivative (PPD) for tuberculosis testing. Assess vital signs and the puncture site one day post thoracentesis. Monitor oxygen saturation using pulse oximetry every 4 hours. Plan client and family teaching regarding upcoming pulmonary function testing.

Plan client and family teaching regarding upcoming pulmonary function testing. The most appropriate action for the RN to perform is developing the teaching plan for upcoming pulmonary function test. These skills are complex, requiring use of the nursing process, and are not in the scope of practice of the LPN/LVN.Medication administration and monitoring of vital signs and client status after procedures can be accomplished by the LPN/LVN. Monitoring of oxygen saturation by pulse oximetry can also be included in the vital signs assessment.

Planning and Implementation: Responding

Promote airway clearance Decrease drug resistance and infection spread ◦Combination drug therapy with strict adherence ◦Isoniazid ◦Rifampin ◦Pyrazinamide ◦Ethambutol ◦Negative sputum culture = No longer infectious Manage anxiety Improve nutrition Manage fatigue

TB drugs

Remember RIPE All RIPE 1st line defense drugs for TB can damage the liver. Warn the patient not to drink any alcoholic beverages for entire duration of TB therapy.

QSEN: NCLEX Review

Safe Effective Care ◦Safety (check respiratory status every 15 minutes after for 2 hours post endoscopy) Health Promotion and Maintenance ◦Teach older patients effect of aging Psychosocial Integrity ◦Allow ptto express feelings Physiological Integrity ◦Assess the airway and breathing issues

When caring for a client who has just undergone thoracentesis, which of these interventions does the nurse perform first? Encourage coughing and deep breathing. Schedule an immediate chest x-ray. Document the volume of removed fluid in the medical record. Set up a water seal drainage unit.

Schedule an immediate chest x-ray. After thoracentesis, the nurse first makes sure a chest x-ray is performed to rule out possible pneumothorax and mediastinal shift (shift of central thoracic structures toward one side).Coughing and deep breathing is done to promote lung expansion as part of the treatment for the underlying disorder. This can wait until a chest x-ray is completed. The volume of fluid will be recorded in the medical record, after the nurse schedules the x-ray to ensure a pneumothorax did not occur. Pigtail drain catheters may be left in place to a waterseal drainage system, rather than performing thoracentesis aspiration on a recurring basis, but this action is not standard.

Pneumonia Complications

Shock & respiratory failure ◦Occurs in those receiving no treatment, inadequate, delayed, or resistant to therapy ◦Ventilator support, vasopressors, & corticosteroids Atelectasis & pleural effusion ◦Lung collapse ◦Thoracentesis or chest tube Superinfection ◦Follows large doses of ABX

common causes of ARDS

Shock. Severe trauma. Burns. Sepsis. drugs. Pancreatitis. Results from shock, shock-like state, or direct lung injury Damage to alveolar capillary membrane Severe ventilation-perfusion mismatch and gas exchange impairment Destruction of surfactant producing cells and decreased lung compliance

Blunt Chest Trauma

Sternal and Rib Fractures ◦Fx of first 3 ribs can lacerate subclavian artery or vein ◦Fxof ribs 5 - 9 can lacerate liver and/or spleen ◦Nursing management - pain control, breathing exercises, splint chest Flail chest - multiple rib fractures ◦Paradoxical respirations ◦Nursing management - TCDB, Suction, pulmonary hygiene, intubation/ventilation Pulmonary contusion

PE

Sudden onset dyspnea Sharp pleuritic pain Respiratory distress Crackles or friction rub Anxiety Cough - hemoptysis DX - VQ scan and pulmonary angiography

Mechanical VentilationIndications for Use

Surgical procedures Decreased LOC Post-op Neuromuscular diseases Spinal cord injury (SCI) or head injury (HI) Drug overdose Respiratory Failure Multiple trauma or shock - ARDS

The nurse is caring for four clients who came to the emergency department with a productive cough. Which of these clients requires immediate intervention by the nurse? The client with blood in the sputum The client with mucoid sputum The client with pink, frothy sputum The client with yellow sputum

The client with pink, frothy sputum The nurse would immediately assess and interview the client with a productive cough and pink, frothy sputum. Pink, frothy sputum is common with pulmonary edema, a life-threatening exacerbation of heart failure. This client requires immediate assessment and intervention.Blood in the sputum may occur with chronic bronchitis or lung cancer. These conditions develop over time and therefore do not require immediate attention. Mucoid sputum may be related to smoking and does not require immediate attention. Although yellow sputum may indicate an infection that requires treatment, the condition is not life threatening.

The emergency department nurse is assessing a client who believes he has sustained a pneumothorax after an outpatient thoracentesis earlier today. For which of these symptoms will the nurse assess? Select all that apply. Slowing heart rate Sensation of air hunger Tracheal deviation Pain on the unaffected side Blue discoloration of the lips

Tracheal deviation Sensation of air hunger Blue discoloration of the lips The nurse would assess for a pneumothorax if the client has a sensation of air hunger, tracheal deviation, and blue discoloration of the lips. All clients need to be taught to go to the ED for symptoms of a pneumothorax after a thoracentesis. Symptoms include pain on the affected side, rapid heart rate, rapid, shallow respirations, sensation of air hunger, prominence of the affected side that does not move in and out with respiratory effort, tracheal deviation to the unaffected, new onset of "nagging" cough and cyanosis.Tachycardia, rather than bradycardia, is consistent with a pneumothorax. Pain occurs on the affected side, not the unaffected side.

ARDS

Ventilator care ◦PEEP - Positive end expiratory pressure-best thing going to help patient if too high can rupture alveoli ◦Anti-anxiety meds ◦Neuromuscular blockers PRN ◦Complete sedation (Propofol(diprivan) ◦What nursing care should be included? VS 1-2 hrs when adding peep can cause decreased B/P

Staphlococcal

Very damaging to lung tissue - lead to severe hypoexmia Greater in immunocompromised, chronically ill & IV drug users Increased resistance to antibiotics Death occurs in 25-60% of population Treatment - gentamicin,

The nurse in a life care community for geriatric clients is providing education to a group of residents on expected changes during aging. Which of these activities does the nurse encourage the older adult to perform to maintain respiratory function? Stay in bed to prevent fatigue. Walk as tolerated each day. Consume adequate calcium. Perform oral hygiene twice daily.

Walk as tolerated each day. The best activity for the older adult to perform in order to maintain respiratory function is to try and walk each day. Ambulation to the client's ability is easily performed in an older adult facility as it does not require special equipment. Health and fitness help keep losses in respiratory functioning to a minimum.Older clients have less tolerance for exercise and may need increased rest periods during exercise. However, bedrest is not necessary or desirable. Encouraging adequate calcium intake to prevent osteoporosis is more helpful prior to menopause, and is less helpful with elderly clients. Oral hygiene aids in the removal of secretions when present, but is not the best intervention to maintain respiratory function.

A nurse teaches a client who has chronic obstructive pulmonary disease. Which statements related to nutrition should the nurse include in this client's teaching? (Select all that apply.) a. "Avoid drinking fluids just before and during meals." b. "Rest before meals if you have dyspnea." c. "Have about six small meals a day." d. "Eat high-fiber foods to promote gastric emptying." e. "Increase carbohydrate intake for energy."

a. "Avoid drinking fluids just before and during meals." b. "Rest before meals if you have dyspnea." c. "Have about six small meals a day." Fluids can make a client feel bloated and should be avoided with meals. Resting before the meal will help a client with dyspnea. Six small meals a day also will help to decrease bloating. Fibrous foods can produce gas, which can cause abdominal bloating and can increase shortness of breath. The client should increase calorie and protein intake to prevent malnourishment. The client should not increase carbohydrate intake as this will increase carbon dioxide production and increase the client's risk of for acidosis.

A nurse teaches a client who is interested in smoking cessation. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "Find an activity that you enjoy and will keep your hands busy." b. "Keep snacks like potato chips on hand to nibble on." c. "Identify a punishment for yourself in case you backslide." d. "Drink at least eight glasses of water each day." e. "Make a list of reasons you want to stop smoking."

a. "Find an activity that you enjoy and will keep your hands busy." d. "Drink at least eight glasses of water each day." e. "Make a list of reasons you want to stop smoking." The nurse should teach a client who is interested in smoking cessation to find an activity that keeps the hands busy, to keep healthy snacks on hand to nibble on, to drink at least 8 glasses of water each day, and to make a list of reasons for quitting smoking. The nurse should also encourage the client not to be upset if he or she backslides and has a cigarette.

A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.) a. "I held the client's morning bronchodilator medication." b. "The client is ready to go down to radiology for this examination." c. "Physical therapy states the client can run on a treadmill." d. "I advised the client not to smoke for 6 hours prior to the test." e. "The client is alert and can follow your commands."

a. "I held the client's morning bronchodilator medication." d. "I advised the client not to smoke for 6 hours prior to the test." e. "The client is alert and can follow your commands." To ensure the PFTs are accurate, the therapist needs to know that no bronchodilators have been administered in the past 4 to 6 hours, the client did not smoke within 6 to 8 hours prior to the test, and the client can follow basic commands, including different breathing maneuvers. The respiratory therapist can perform PFTs at the bedside. A treadmill is not used for this test.

While obtaining a client's health history, the client states, "I am allergic to avocados." Which responses by the nurse are best? (Select all that apply.) a. "What response do you have when you eat avocados?" b. "I will remove any avocados that are on your lunch tray." c. "When was the last time you ate foods containing avocados?" d. "I will document this in your record so all of your providers will know." e. "Have you ever been treated for this allergic reaction?"

a. "What response do you have when you eat avocados?" d. "I will document this in your record so all of your providers will know." e. "Have you ever been treated for this allergic reaction?" Nurses should assess clients who have allergies for the specific cause, treatment, and response to treatment. The nurse should also document the allergies in a prominent place in the client's medical record. The nurse should collaborate with food services to ensure no avocados are placed on the client's meal trays. Asking about the last time the client ate avocados does not provide any pertinent information for the client's plan of care.

The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur? 1. "Take as deep a breath as possible." 2. "Stand up (unless you have a physical disability)." 3. "Place the meter in your mouth, and close your lips around the mouthpiece." 4. "Make sure the device reads zero or is at base level." 5. "Blow out as hard and as fast as possible for 1 to 2 seconds." 6. "Write down the value obtained." 7. "Repeat the process two additional times, and record the highest number in your chart." a. 4, 2, 1, 3, 5, 6, 7 b. 3, 4, 1, 2, 5, 7, 6 c. 2, 1, 3, 4, 5, 6, 7 d. 1, 3, 2, 5, 6, 7, 4

a. 4, 2, 1, 3, 5, 6, 7 4. "Make sure the device reads zero or is at base level." 2. "Stand up (unless you have a physical disability)." 1. "Take as deep a breath as possible." 3. "Place the meter in your mouth, and close your lips around the mouthpiece." 5. "Blow out as hard and as fast as possible for 1 to 2 seconds." 6. "Write down the value obtained." 7. "Repeat the process two additional times, and record the highest number in your chart." The proper order for obtaining a peak expiratory flow rate is as follows. Make sure the device reads zero or is at base level. The client should stand up (unless he or she has a physical disability). The client should take as deep a breath as possible, place the meter in the mouth, and close the lips around the mouthpiece. The client should blow out as hard and as fast as possible for 1 to 2 seconds. The value obtained should be written down. The process should be repeated two more times, and the highest of the three numbers should be recorded in the client's chart.

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.) a. A 24-year-old with a traumatic brain injury b. A 36-year-old who fractured his left femur c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident

a. A 24-year-old with a traumatic brain injury c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident Risk for asphyxiation related to inspissated oral and nasopharyngeal secretions is caused by poor oral hygiene. Clients at risk include those with altered mental status and level of consciousness (traumatic brain injury), dehydration, an inability to communicate (aphasic) and cough effectively (quadriplegic), and a risk of aspiration (aspiration precautions). The client with a fractured femur is at risk for a pulmonary embolism.

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.) a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Oxygen-induced hyperventilation e. Toxicity

a. Absorptive atelectasis b. Combustion c. Dried mucous membranes e. Toxicity Complications of oxygen therapy include absorptive atelectasis, combustion, dried mucous membranes, and oxygen toxicity. Oxygen-induced hypoventilation is also a complication.

A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)? a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Remove the tubing from the client's nose. d. Turn the client every 2 hours or as needed.

a. Apply water-soluble ointment to nares and lips. Oxygen can be drying, so the UAP can apply water-soluble lubricant to the client's lips and nares. The UAP should not adjust the oxygen flow rate or remove the tubing. Turning the client is not related to comfort measures for oxygen.

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time

a. Applying suction while inserting the catheter Suction should only be applied while withdrawing the catheter. The other actions are appropriate.

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying water-soluble lip balm to the client's lips b. Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy

a. Applying water-soluble lip balm to the client's lips d. Reminding the client to cough and deep breathe often The UAP can perform hygiene measures such as applying lip balm and reinforce teaching such as reminding the client to perform coughing and deep-breathing exercises. Oral care can be accomplished with normal saline, not products that dry the mouth. Ensuring the humidity is adequate and suctioning through the tracheostomy are nursing functions.

A nurse plans care for a client who has chronic obstructive pulmonary disease and thick, tenacious secretions. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Ask the client to drink 2 liters of fluids daily. b. Add humidity to the prescribed oxygen. c. Suction the client every 2 to 3 hours. d. Use a vibrating positive expiratory pressure device. e. Encourage diaphragmatic breathing.

a. Ask the client to drink 2 liters of fluids daily. b. Add humidity to the prescribed oxygen. d. Use a vibrating positive expiratory pressure device. Interventions to decrease thick tenacious secretions include maintaining adequate hydration and providing humidified oxygen. These actions will help to thin secretions, making them easier to remove by coughing. The use of a vibrating positive expiratory pressure device can also help clients remove thick secretions. Although suctioning may assist with the removal of secretions, frequent suctioning can cause airway trauma and does not support the client's ability to successfully remove secretions through normal coughing. Diaphragmatic breathing is not used to improve the removal of thick secretions.

A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first? a. Ask the client to gargle with mouthwash containing lidocaine. b. Administer prescribed intravenous pain medications. c. Explain that soreness is normal and will improve in a couple days. d. Assess the client's neck for redness and swelling.

a. Ask the client to gargle with mouthwash containing lidocaine. Mouthwashes and throat sprays containing a local anesthetic agent such as lidocaine or diphenhydramine can provide relief from a sore throat after radiation therapy. Intravenous pain medications may be used if local anesthetics are unsuccessful. The nurse should explain to the client that this is normal and assess the client's neck, but these options do not decrease the client's discomfort.

An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority? a. Assess the client's lung sounds. b. Assign a different UAP to the client. c. Report the UAP to the manager. d. Request thicker liquids for meals.

a. Assess the client's lung sounds. The priority is to check the client's oxygenation because he or she may have aspirated. Once the client has been assessed, the nurse can consult with the registered dietitian about appropriately thickened liquids. The UAP should have reported the incident immediately, but addressing that issue is not the immediate priority.

A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this client's plan of care? a. Assistance with activities of daily living b. Physical therapy activities every day c. Oxygen therapy at 2 liters per nasal cannula d. Complete bedrest with frequent repositioning

a. Assistance with activities of daily living A client with dyspnea and difficulty completing activities such as climbing a flight of stairs has class III dyspnea. The nurse should provide assistance with activities of daily living. These clients should be encouraged to participate in activities as tolerated. They should not be on complete bedrest, may not be able to tolerate daily physical therapy, and only need oxygen if hypoxia is present.

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first? a. Contact the provider and prepare for intubation. b. Administer prescribed albuterol nebulizer therapy. c. Place the client in high-Fowler's position. d. Ask the client to perform deep-breathing exercises.

a. Contact the provider and prepare for intubation. Facial and neck tissue edema can occur in clients with facial trauma. Airway patency is the highest priority. Clients who experience stridor and hypoxia, manifested by anxiety and restlessness, should be immediately intubated to ensure airway patency. Albuterol decreases bronchi and bronchiole inflammation, not facial and neck edema. Although putting the client in high-Fowler's position and asking the client to perform breathing exercises may temporarily improve the client's comfort, these actions will not decrease the underlying problem or improve airway patency.

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Don't go out in public alone .c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

a. Create a communication system. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves. The client with a tracheostomy may be shy and hesitant to go out in public. The client should have a sound communication method to ease frustration. The nurse can also suggest ways of enhancing appearance so the client is willing to leave the house. These can include wearing scarves and loose-fitting shirts to hide the stoma. Keeping the client homebound is not good advice.

A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which action should the nurse take first? a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowler's position. d. Administer prescribed albuterol.

a. Document the findings. Bronchial breath sounds, including harsh, hollow, tubular, and blowing sounds, are a normal finding over the trachea and larynx. The nurse should document this finding. There is no need to implement oxygen therapy, administer albuterol, or change the client's position because the finding is normal.

A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this client's plan of care? (Select all that apply.) a. Encourage deep breathing and coughing. b. Implement an air mattress overlay. c. Ambulate the client three times each day. d. Provide a diet high in protein and vitamins. e. Administer acetaminophen (Tylenol) twice daily.

a. Encourage deep breathing and coughing. c. Ambulate the client three times each day. d. Provide a diet high in protein and vitamins. Regular pulmonary hygiene and activities to maintain health and fitness help to maximize functioning of the respiratory system and prevent infection. A client at high risk for a pulmonary infection may need a specialty bed to help with postural drainage or percussion; this would not include an air mattress overlay, which is used to prevent pressure ulcers. Tylenol would not decrease the risk of a pulmonary infection.

A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take? a. Encourage oral rinsing after fluticasone administration. b. Obtain an oral specimen for culture and sensitivity. c. Start the client on a broad-spectrum antibiotic. d. Document the finding as a known side effect.

a. Encourage oral rinsing after fluticasone administration. The drug reduces local immunity and increases the risk for local infection, especially Candida albicans. Rinsing the mouth after using the inhaler will decrease the risk for developing this infection. Use of mouthwash and broad-spectrum antibiotics is not warranted in this situation. The nurse should document the finding, but the best action to take is to have the client start rinsing his or her mouth after using fluticasone. An oral specimen for culture and sensitivity will not provide information necessary to care for this client.

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this client's history and clinical manifestations? a. Increased pulmonary pressure creating a higher workload on the right side of the heart b. Exposure to irritants resulting in increased inflammation of the bronchi and bronchioles c. Increased number and size of mucus glands producing large amounts of thick mucus d. Left ventricular hypertrophy creating a decrease in cardiac output

a. Increased pulmonary pressure creating a higher workload on the right side of the heart Smoking increases pulmonary hypertension, resulting in cor pulmonale, or right-sided heart failure. Increased pressures in the lungs make it more difficult for blood to flow through the lungs. Blood backs up into the right side of the heart and then into the peripheral venous system, creating distended neck veins and dependent edema. Inflammation in bronchi and bronchioles creates an airway obstruction which manifests as wheezes. Thick mucus in the lungs has no impact on distended neck veins and edema. Left ventricular hypertrophy is associated with left heart failure and is not caused by a 40-year smoking history.

A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first? a. Initiate Standard Precautions. b. Apply direct pressure. c. Sit the client upright. d. Loosely pack the nares with gauze.

a. Initiate Standard Precautions. The nurse should implement Standard Precautions and don gloves prior to completing the other actions.

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.) a. The client does not allow smoking in the house. b. Electrical cords are in good working order .c. Flammable liquids are stored in the garage. d. Household light bulbs are the fluorescent type. e. The client does not have pets inside the home.

a. The client does not allow smoking in the house. b. Electrical cords are in good working order .c. Flammable liquids are stored in the garage. Oxygen is an accelerant, which means it enhances combustion, so precautions are needed whenever using it. The nurse should assess if the client allows smoking near the oxygen, whether electrical cords are in good shape or are frayed, and if flammable liquids are stored (and used) in the garage away from the oxygen. Light bulbs and pets are not related to oxygen safety.

A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which manifestations should the nurse identify as adverse effects of this medication? (Select all that apply.) a. Visual hallucinations b. Tachycardia c. Decreased cravings d. Impaired judgment e. Increased thirst

a. Visual hallucinations d. Impaired judgment Varenicline (Chantix) has a black box warning stating that the drug can cause manic behavior and hallucinations. The nurse should assess for changes in behavior and thought processes, including impaired judgment and visual hallucinations. Tachycardia and increased thirst are not adverse effects of this medication. Decreased cravings is a therapeutic response to this medication.

A client admitted for pneumonia has been tachypneic for several days. When the nurse starts an IV to give fluids, the client questions this action, saying "I have been drinking tons of water. How am I dehydrated?" What response by the nurse is best? a."Breathing so quickly can be dehydrating." b."Everyone with pneumonia is dehydrated." c."This is really just to administer your antibiotics." d."Why do you think you are so dehydrated?"

a."Breathing so quickly can be dehydrating." Tachypnea and mouth breathing, both seen in pneumonia, increase insensible water loss and can lead to a degree of dehydration. The other options do not give the client useful information

A nurse is providing pneumonia vaccinations in a community setting. Due to limited finances, the event organizers must limit giving the vaccination to priority groups. What clients would be considered a priority when administering the pneumonia vaccination? (Select all that apply.) a.22-year-old client with asthma b.Client who had a cholecystectomy last year c.Client with well-controlled diabetes d.Healthy 72-year-old client e.Client who is taking medication for hypertension

a.22-year-old client with asthma c.Client with well-controlled diabetes d.Healthy 72-year-old client e.Client who is taking medication for hypertension Clients over 65 years of age and any client (no matter what age) with a chronic health condition would be considered a priority for a pneumonia vaccination. Having a cholecystectomy a year ago does not qualify as a chronic health condition.

The nurse caring for mechanically ventilated clients uses best practices to prevent ventilator-associated pneumonia. What actions are included in this practice? (Select all that apply.) a.Adherence to proper hand hygiene b.Administering anti-ulcer medication c.Elevating the head of the bed d.Providing oral care per protocol e.Suctioning the client on a regular schedule

a.Adherence to proper hand hygiene b.Administering anti-ulcer medication c.Elevating the head of the bed d.Providing oral care per protocol The "ventilator bundle" is a group of care measures to prevent ventilator-associated pneumonia. Actions in the bundle include using proper hand hygiene, giving anti-ulcer medications, elevating the head of the bed, providing frequent oral care per policy, preventing aspiration, and providing pulmonary hygiene measures. Suctioning is done as needed.

A nurse is caring for a client who is on mechanical ventilation. What actions will promote comfort in this client? (Select all that apply.) a.Allow visitors at the client's bedside. b.Ensure the client can communicate if awake. c.Keep the television tuned to a favorite channel. d.Provide back and hand massages when turning. e.Turn the client every 2 hours or more.

a.Allow visitors at the client's bedside. b.Ensure the client can communicate if awake. d.Provide back and hand massages when turning. e.Turn the client every 2 hours or more. There are many basic care measures that can be employed for the client who is on a ventilator. Allowing visitation, providing a means of communication, massaging the client's skin, and routinely turning and repositioning the client are some of them. Keeping the TV on will interfere with sleep and rest.

The emergency department (ED) manager is reviewing client charts to determine how well the staff performs when treating clients with community-acquired pneumonia. What outcome demonstrates that goals for this client type have been met? a.Antibiotics started before admission b.Blood cultures obtained within 20 minutes c.Chest x-ray obtained within 30 minutes d.Pulse oximetry obtained on all clients

a.Antibiotics started before admission Goals for treatment of community-acquired pneumonia include initiating antibiotics prior to inpatient admission or within 6 hours of presentation to the ED. Timely collection of blood cultures, chest x-ray, and pulse oximetry are important as well but do not coincide with established goals.

A client has been hospitalized with tuberculosis (TB). The client's spouse is fearful of entering the room where the client is in isolation and refuses to visit. What action by the nurse is best? a.Ask the spouse to explain the fear of visiting in further detail. b.Inform the spouse the precautions are meant to keep other clients safe. c.Show the spouse how to follow the isolation precautions to avoid illness. d.Tell the spouse that he or she has already been exposed, so it's safe to visit.

a.Ask the spouse to explain the fear of visiting in further detail. The nurse needs to obtain further information about the spouse's specific fears so they can be addressed. This will decrease stress and permit visitation, which will be beneficial for both client and spouse. Precautions for TB prevent transmission to all who come into contact with the client. Explaining isolation precautions and what to do when entering the room will be helpful, but this is too narrow in scope to be the best answer. Telling the spouse it's safe to visit is demeaning of the spouse's feelings.

A client appears dyspneic, but the oxygen saturation is 97%. What action by the nurse is best? a.Assess for other manifestations of hypoxia. b.Change the sensor on the pulse oximeter. c.Obtain a new oximeter from central supply. d.Tell the client to take slow, deep breaths.

a.Assess for other manifestations of hypoxia. Pulse oximetry is not always the most accurate assessment tool for hypoxia as many factors can interfere, producing normal or near-normal readings in the setting of hypoxia. The nurse should conduct a more thorough assessment. The other actions are not appropriate for a hypoxic client.

A nurse is caring for a client on mechanical ventilation and finds the client agitated and thrashing about. What action by the nurse is most appropriate? a.Assess the cause of the agitation. b.Reassure the client that he or she is safe. c.Restrain the client's hands. d.Sedate the client immediately.

a.Assess the cause of the agitation. The nurse needs to determine the cause of the agitation. The inability to communicate often makes clients anxious, even to the point of panic. Pain and confusion can also cause agitation. Once the nurse determines the cause of the agitation, he or she can implement measures to relieve the underlying cause. Reassurance is also important but may not address the etiology of the agitation. Restraints and more sedation may be necessary, but not as a first step.

A client has been diagnosed with an empyema. What interventions should the nurse anticipate providing to this client? (Select all that apply.) a.Assisting with chest tube insertion b.Facilitating pleural fluid sampling c.Performing frequent respiratory assessment d.Providing antipyretics as needed e.Suctioning deeply every 4 hours

a.Assisting with chest tube insertion b.Facilitating pleural fluid sampling c.Performing frequent respiratory assessment d.Providing antipyretics as needed The client with an empyema is often treated with chest tube insertion, which facilitates obtaining samples of the pleural fluid for analysis and re-expands the lungs. The nurse should perform frequent respiratory system assessments. Antipyretic medications are also used. Suction is only used when needed and is not done deeply to prevent tissue injury.

The nurse caring for mechanically ventilated clients knows that older adults are at higher risk for weaning failure. What age-related changes contribute to this? (Select all that apply.) a.Chest wall stiffness b.Decreased muscle strength c.Inability to cooperate d.Less lung elasticity e.Poor vision and hearing

a.Chest wall stiffness b.Decreased muscle strength d.Less lung elasticity Age-related changes that increase the difficulty of weaning older adults from mechanical ventilation include increased stiffness of the chest wall, decreased muscle strength, and less elasticity of lung tissue. Not all older adults have an inability to cooperate or poor sensory acuity.

A client has been diagnosed with tuberculosis (TB). What action by the nurse takes highest priority? a.Educating the client on adherence to the treatment regimen b.Encouraging the client to eat a well-balanced diet c.Informing the client about follow-up sputum cultures d.Teaching the client ways to balance rest with activity

a.Educating the client on adherence to the treatment regimen The treatment regimen for TB ranges from 6 to 12 months, making adherence problematic for many people. The nurse should stress the absolute importance of following the treatment plan for the entire duration of prescribed therapy. The other options are appropriate topics to educate this client on but do not take priority.

Chronic Bronchitis-

an inflammation of the bronchi and bronchioles caused by exposure to irritants, especially cigarette smoke. Irritant triggers inflammation, vasodilation, mucosal edema, congestion, and bronchospasm. Bronchitisaffects only the *AIRWAYS* not the alveoli. · Thick excess mucus = chronic cough · Increased # of mucus glands · Bronchial walls thicken(INFLAMMATION)=impair flow blocking airways · Increased mucus allows for breeding ground for organisms leading to chronic infection · Impairs AIRFLOW & GAS EXCHANGE=PAO2 decreases (hypoxemia), PACO2 increases = ****RESPIRATORY ACIDOSIS***

any patient with stridor

apply oxygen

Pyrazinamide (PZA)

ask if ever had GOUT b/c increases uric acid production instruct to drink at least 8 ounces of water wear protective clothing, photosensitivity may occur avoid alcohol report signs of liver failure/toxicity

Thorancentesis

aspiration of pleural fluid or air from the pleural space: ◦Patient preparation for stinging sensation and feeling of pressure ◦Correct position ◦Motionless patient ◦Follow-up assessment for complications

A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding? a. "Are you taking any medications or herbal supplements?" b. "Do you have any chronic breathing problems?" c. "How often do you perform aerobic exercise?" d. "What is your occupation and what are your hobbies?"

b. "Do you have any chronic breathing problems?" The normal chest has a lateral diameter that is twice as large as the AP diameter. When the AP diameter approaches or exceeds the lateral diameter, the client is said to have a barrel chest. Most commonly, barrel chest occurs as a result of a long-term chronic airflow limitation problem, such as chronic obstructive pulmonary disease or severe chronic asthma. It can also be seen in people who have lived at a high altitude for many years. Therefore, an AP chest diameter that is the same as the lateral chest diameter should be rechecked but is not as indicative of underlying disease processes as an AP diameter that exceeds the lateral diameter. Medications, herbal supplements, and aerobic exercise are not associated with a barrel chest. Although occupation and hobbies may expose a client to irritants that can cause chronic lung disorders and barrel chest, asking about chronic breathing problems is more direct and should be asked first

A nurse assesses a client with chronic obstructive pulmonary disease. Which questions should the nurse ask to determine the client's activity tolerance? (Select all that apply.) a. "What color is your sputum?" b. "Do you have any difficulty sleeping?" c. "How long does it take to perform your morning routine?" d. "Do you walk upstairs every day?" e. "Have you lost any weight lately?"

b. "Do you have any difficulty sleeping?" c. "How long does it take to perform your morning routine?" e. "Have you lost any weight lately?" Difficulty sleeping could indicate worsening breathlessness, as could taking longer to perform activities of daily living. Weight loss could mean increased dyspnea as the client becomes too fatigued to eat. The color of the client's sputum would not assist in determining activity tolerance. Asking whether the client walks upstairs every day is not as pertinent as determining if the client becomes short of breath on walking upstairs, or if the client goes upstairs less often than previously.

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this client's teaching? a. "Add peppermint oil to the humidifier to relax the airway." b. "Make sure you clean the humidifier to prevent infection." c. "Keep the humidifier filled with water at all times." d. "Use the humidifier when you sleep, even during daytime naps."

b. "Make sure you clean the humidifier to prevent infection." Priority teaching related to the use of a room humidifier focuses on infection control. Clients should be taught to meticulously clean the humidifier to prevent the spread of mold or other sources of infection. Peppermint oil should not be added to a humidifier. The humidifier should be refilled with water as needed and should be used while awake and asleep.

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond? a. "I will consult the speech therapist to ensure you are swallowing properly." b. "This is normal after surgery. What types of food do you like to eat?" c. "I will ask the dietitian to change the consistency of the food in your diet." d. "Replacement of protein, calories, and water is very important after surgery."

b. "This is normal after surgery. What types of food do you like to eat?" Many clients experience changes in taste after surgery. The nurse should identify foods that the client wants to eat to ensure the client maintains necessary nutrition. Although the nurse should collaborate with the speech therapist and dietitian to ensure appropriate replacement of protein, calories, and water, the other responses do not address the client's concerns.

A nursing student caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air? a. 14% b. 21% c. 28% d. 31%

b. 21% Room air is 21% oxygen.

A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)? (Select all that apply.) a. A 32-year-old who had a radical neck dissection 6 hours ago b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago c. A 55-year-old who needs discharge teaching after a laryngectomy d. A 67-year-old who is awaiting preoperative teaching for laryngeal cancer e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement

b. A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago e. An 88-year-old with esophageal cancer who is awaiting gastric tube placement The nurse can delegate stable clients to the LPN. The client who had a biopsy 2 days ago and the client who is awaiting gastric tube placement are stable. The client who is 6 hours post-surgery is not yet stable. The RN is the only one who can perform discharge and preoperative teaching; teaching cannot be delegated.

A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first? a. Encourage the client to increase fluid intake. b. Assess the client's level of consciousness. c. Raise the head of the bed to at least 45 degrees. d. Provide the client with humidified oxygen.

b. Assess the client's level of consciousness. Assessing the client's level of consciousness will be most important because it will show how the client is responding to the presence of the infection. Although it will be important for the nurse to encourage the client to turn, cough, and frequently breathe deeply; raise the head of the bed; increase oral fluid intake; and humidify the oxygen administered, none of these actions will be as important as assessing the level of consciousness. Also, the client who has a pulmonary infection may not be able to cough effectively if an area of abscess is present.

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first? a. Assess for drainage from the site. b. Cover the insertion site with sterile gauze. c. Contact the provider and obtain a suture kit. d. Reinsert the tube using sterile technique.

b. Cover the insertion site with sterile gauze. Immediately covering the insertion site helps prevent air from entering the pleural space and causing a pneumothorax. The area will not reseal quickly enough to prevent air from entering the chest. The nurse should not leave the client to obtain a suture kit. An occlusive dressing may cause a tension pneumothorax. The site should only be assessed after the insertion site is covered. The provider should be called to reinsert the chest tube or prescribe other treatment options.

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? a. Assess the client's oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d. Turn the oxygen off while the client eats the meal and then restart it.

b. Determine if the client can switch to a nasal cannula during the meal. Oxygen is a drug that needs to be delivered constantly. The nurse should determine if the provider has approved switching to a nasal cannula during meals. If not, the nurse should consult with the provider about this issue. The oxygen should not be turned off. Lifting the mask to eat will alter the FiO2 delivered.

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? a. Administer prescribed anxiolytic medication. b. Ensure informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.

b. Ensure informed consent is on the chart. Since this is an operative procedure, the client must sign an informed consent, which must be on the chart. Giving anxiolytics and antibiotics and reinforcing teaching may also be required but do not take priority.

A nurse assesses a client who has developed epistaxis. Which conditions in the client's history should the nurse identify as potential contributors to this problem? (Select all that apply.) a. Diabetes mellitus b. Hypertension c. Leukemia d. Cocaine use e. Migraine f. Elevated platelets

b. Hypertension c. Leukemia d. Cocaine use Frequent causes of nosebleeds include trauma, hypertension, leukemia and other blood dyscrasias, inflammation, tumor, dry air, blowing or picking the nose, cocaine use, and intranasal procedures. Diabetes, migraines, and elevated platelets and cholesterol levels do not cause epistaxis.

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that goals for a priority diagnosis are being met? a. 100% of meals being eaten by the client b. Intact skin behind the ears c. The client understanding the need for oxygen d. Unchanged weight for the past 3 days

b. Intact skin behind the ears Oxygen tubing can cause pressure ulcers, so clients using oxygen have the nursing diagnosis of Risk for Impaired Skin Integrity. Intact skin behind the ears indicates that goals for this diagnosis are being met. Nutrition and weight are not related to using oxygen. Understanding the need for oxygen is important but would not take priority over a physical problem.

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Elevate the head of the client's bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study.

b. Measure and compare cuff pressures. Constant pressure from the tracheostomy tube cuff can cause tracheomalacia, leading to dilation of the tracheal passage. This can be manifested by food particles seen in secretions or by noting that larger and larger amounts of pressure are needed to keep the tracheostomy cuff inflated. The nurse should measure the pressures and compare them to previous ones to detect a trend. Elevating the head of the bed, placing the client on NPO status, and requesting a swallow study will not correct this situation.

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next? a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the client's peripheral pulses. d. Obtain blood and sputum cultures.

b. Notify the Rapid Response Team. Cyanosis unresponsive to oxygen therapy is a manifestation of methemoglobinemia, which is an adverse effect of benzocaine spray. Death can occur if the level of methemoglobin rises and cyanosis occurs. The nurse should notify the Rapid Response Team to provide advanced nursing care. An albuterol treatment would not address the client's oxygenation problem. Assessment of pulses and cultures will not provide data necessary to treat this client.

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met? a. The client demonstrates good understanding of stoma care .b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection.

b. The client has joined a book club that meets at the library. The client joining a book club that meets outside the home and requires him or her to go out in public is the best sign that goals for Impaired Self-Esteem are being met. The other findings are all positive signs but do not relate to this nursing diagnosis.

After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client's understanding. Which action demonstrates that the client correctly understands the teaching? a. The client lays on his or her side with his or her knees bent. b. The client places his or her hands on his or her abdomen. c. The client lays in a prone position with his or her legs straight. d. The client places his or her hands above his or her head.

b. The client places his or her hands on his or her abdomen. To perform diaphragmatic breathing correctly, the client should place his or her hands on his or her abdomen to create resistance. This type of breathing cannot be performed effectively while lying on the side or with hands over the head. This type of breathing would not be as effective lying prone.

A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention? (Select all that apply.) a. Production of pink sputum b. Tracheal deviation c. Pain at insertion site d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hrf. Disconnection at Y site f. Disconnection at Y site

b. Tracheal deviation d. Sudden onset of shortness of breath e. Drainage greater than 70 mL/hrf. Disconnection at Y site f. Disconnection at Y site Immediate intervention is warranted if the client has tracheal deviation because this could indicate a tension pneumothorax. Sudden shortness of breath could indicate dislodgment of the tube, occlusion of the tube, or pneumothorax. Drainage greater than 70 mL/hr could indicate hemorrhage. Disconnection at the Y site could result in air entering the tubing. Production of pink sputum, oxygen saturation less than 95%, and pain at the insertion site are not signs/symptoms that would require immediate intervention.

A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration?a. Tilt the head back as far as possible when swallowing. b. Tuck the chin down when swallowing. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing.

b. Tuck the chin down when swallowing. The client with open vocal cord paralysis may aspirate. The nurse should teach the client to tuck in his or her chin during swallowing to prevent aspiration. Tilting the head back would increase the chance of aspiration. Breathing slowly would not decrease the risk of aspiration, but holding the breath would. Keeping the head still and straight would not decrease the risk for aspiration.

An older adult is brought to the emergency department by a family member, who reports a moderate change in mental status and mild cough. The client is afebrile. The health care provider orders a chest x-ray. The family member questions why this is needed since the manifestations seem so vague. What response by the nurse is best? a."Chest x-rays are always ordered when we suspect pneumonia." b."Older people often have vague symptoms, so an x-ray is essential." c."The x-ray can be done and read before laboratory work is reported." d."We are testing for any possible source of infection in the client."

b."Older people often have vague symptoms, so an x-ray is essential." It is essential to obtain an early chest x-ray in older adults suspected of having pneumonia because symptoms are often vague. Waiting until definitive manifestations are present to obtain the x-ray leads to a costly delay in treatment. Stating that chest x-rays are always ordered does not give the family definitive information. The x-ray can be done while laboratory values are still pending, but this also does not provide specific information about the importance of a chest x-ray in this client. The client has manifestations of pneumonia, so the staff is not testing for any possible source of infection but rather is testing for a suspected disorder.

A student nurse is preparing to administer enoxaparin (Lovenox) to a client. What action by the student requires immediate intervention by the supervising nurse? a.Assessing the client's platelet count b.Choosing an 18-gauge, 2-inch needle c.Not aspirating prior to injection d.Swabbing the injection site with alcohol

b.Choosing an 18-gauge, 2-inch needle Enoxaparin is given subcutaneously, so the 18-gauge, 2-inch needle is too big. The other actions are appropriate.

.A nurse is caring for five clients. For which clients would the nurse assess a high risk for developing a pulmonary embolism (PE)? (Select all that apply.) a.Client who had a reaction to contrast dye yesterday b.Client with a new spinal cord injury on a rotating bed c.Middle-aged man with an exacerbation of asthma d.Older client who is 1-day post hip replacement surgery e.Young obese client with a fractured femur

b.Client with a new spinal cord injury on a rotating bed d.Older client who is 1-day post hip replacement surgery e.Young obese client with a fractured femur Conditions that place clients at higher risk of developing PE include prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism, smoking, pregnancy, estrogen therapy, heart failure, stroke, cancer (particularly lung or prostate), and trauma. A contrast dye reaction and asthma pose no risk for PE.

A nurse is preparing to admit a client on mechanical ventilation from the emergency department. What action by the nurse takes priority? a.Assessing that the ventilator settings are correct b.Ensuring there is a bag-valve-mask in the room c.Obtaining personal protective equipment d.Planning to suction the client upon arrival to the room

b.Ensuring there is a bag-valve-mask in the room Having a bag-valve-mask device is critical in case the client needs manual breathing. The respiratory therapist is usually primarily responsible for setting up the ventilator, although the nurse should know and check the settings. Personal protective equipment is important, but ensuring client safety takes priority. The client may or may not need suctioning on arrival.

A client is on intravenous heparin to treat a pulmonary embolism. The client's most recent partial thromboplastin time (PTT) was 25 seconds. What order should the nurse anticipate? a.Decrease the heparin rate. b.Increase the heparin rate. c.No change to the heparin rate. d.Stop heparin; start warfarin (Coumadin).

b.Increase the heparin rate. For clients on heparin, a PTT of 1.5 to 2.5 times the normal value is needed to demonstrate the heparin is working. A normal PTT is 25 to 35 seconds, so this client's PTT value is too low. The heparin rate needs to be increased. Warfarin is not indicated in this situation.

client in the emergency department is taking rifampin (Rifadin) for tuberculosis. The client reports yellowing of the sclera and skin and bleeding after minor trauma. What laboratory results correlate to this condition? (Select all that apply.) a.Blood urea nitrogen (BUN): 19 mg/dL b.International normalized ratio (INR): 6.3 c.Prothrombin time: 35 seconds d.Serum sodium: 130 mEq/L e.White blood cell (WBC) count: 72,000/mm3

b.International normalized ratio (INR): 6.3 c.Prothrombin time: 35 seconds Rifampin can cause liver damage, evidenced by the client's high INR and prothrombin time. The BUN and WBC count are normal. The sodium level is low, but that is not related to this client's problem.

A client is being discharged soon on warfarin (Coumadin). What menu selection for dinner indicates the client needs more education regarding this medication? a.Hamburger and French fries b.Large chef's salad and muffin c.No selection; spouse brings pizza d.Tuna salad sandwich and chips

b.Large chef's salad and muffin Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. The chef's salad most likely has too many leafy green vegetables, which contain high amounts of vitamin K. The other selections, while not particularly healthy, will not interfere with the medication's mechanism of action.

A client is hospitalized with a second episode of pulmonary embolism (PE). Recent genetic testing reveals the client has an alteration in the gene CYP2C19. What action by the nurse is best? a.Instruct the client to eliminate all vitamin K from the diet. b.Prepare preoperative teaching for an inferior vena cava (IVC) filter. c.Refer the client to a chronic illness support group. d.Teach the client to use a soft-bristled toothbrush.

b.Prepare preoperative teaching for an inferior vena cava (IVC) filter. Often clients are discharged from the hospital on warfarin (Coumadin) after a PE. However, clients with a variation in the CYP2C19 gene do not metabolize warfarin well and have higher blood levels and more side effects. This client is a poor candidate for warfarin therapy, and the prescriber will most likely order an IVC filter device to be implanted. The nurse should prepare to do preoperative teaching on this procedure. It would be impossible to eliminate all vitamin K from the diet. A chronic illness support group may be needed, but this is not the best intervention as it is not as specific to the client as the IVC filter. A soft-bristled toothbrush is a safety measure for clients on anticoagulation therapy.

A nurse is teaching a client about warfarin (Coumadin). What assessment finding by the nurse indicates a possible barrier to self-management? a.Poor visual acuity b.Strict vegetarian c.Refusal to stop smoking d.Wants weight loss surgery

b.Strict vegetarian Warfarin works by inhibiting the synthesis of vitamin K-dependent clotting factors. Foods high in vitamin K thus interfere with its action and need to be eaten in moderate, consistent amounts. A vegetarian may have trouble maintaining this diet. The nurse should explore this possibility with the client. The other options are not related.

PE drug therapy

begins immediately with anticoagulants to prevent PE enlargement & more clotting, Unfractionated heparin, low molecular weight heparin Lovenox, or Arixtra is used unless PE is massive or occurs with hemodynamic instability. when in shock, hemodynamic collapse or instability Activase tPA is used.

Normal lung sounds

bronchial, bronchovesicular, vesicular

A nurse cares for a client with chronic obstructive pulmonary disease (COPD) who appears thin and disheveled. Which question should the nurse ask first? a. "Do you have a strong support system?" b. "What do you understand about your disease?" c. "Do you experience shortness of breath with basic activities?" d. "What medications are you prescribed to take each day?"

c. "Do you experience shortness of breath with basic activities?" Clients with severe COPD may not be able to perform daily activities, including bathing and eating, because of excessive shortness of breath. The nurse should ask the client if shortness of breath is interfering with basic activities. Although the nurse should know about the client's support systems, current knowledge, and medications, these questions do not address the client's appearance.

The nurse is teaching a client with chronic obstructive pulmonary disease who has been prescribed continuous oxygen therapy at home. Which statement indicates the client correctly understands the teaching? a. "I plan to wear my oxygen when I exercise and feel short of breath." b. "I will use my portable oxygen when grilling burgers in the backyard." c. "I plan to use cotton balls to cushion the oxygen tubing on my ears." d. "I will only smoke while I am wearing my oxygen via nasal cannula."

c. "I plan to use cotton balls to cushion the oxygen tubing on my ears." Cotton balls can decrease pressure ulcers from the oxygen tubing. Continuous oxygen orders mean the client should wear the oxygen at all times. Oxygen fuels a fire. Wearing oxygen while grilling and smoking increases the risk for fire.

The nurse is caring for a client with lung cancer who states, "I don't want any pain medication because I am afraid I'll become addicted." How should the nurse respond? a. "I will ask the provider to change your medication to a drug that is less potent." b. "Would you like me to use music therapy to distract you from your pain?" c. "It is unlikely you will become addicted when taking medicine for pain." d. "Would you like me to give you acetaminophen (Tylenol) instead?"

c. "It is unlikely you will become addicted when taking medicine for pain." Clients should be encouraged to take their pain medications; addiction usually is not an issue with a client in pain. The nurse would not request that the pain medication be changed unless it was not effective. Other methods to decrease pain can be used, in addition to pain medication

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client states that he no longer enjoys going out with his friends. How should the nurse respond? a. "There are a variety of support groups for people who have COPD." b. "I will ask your provider to prescribe you with an antianxiety agent." c. "Share any thoughts and feelings that cause you to limit social activities." d. "Friends can be a good support system for clients with chronic disorders."

c. "Share any thoughts and feelings that cause you to limit social activities." Many clients with moderate to severe COPD become socially isolated because they are embarrassed by frequent coughing and mucus production. They also can experience fatigue, which limits their activities. The nurse needs to encourage the client to verbalize thoughts and feelings so that appropriate interventions can be selected. Joining a support group would not decrease feelings of social isolation if the client does not verbalize feelings. Antianxiety agents will not help the client with social isolation. Encouraging a client to participate in activities without verbalizing concerns also would not be an effective strategy for decreasing social isolation.

A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement should the nurse include in this client's teaching? a. "Make a list of reasons why smoking is a bad habit." b. "Rise slowly when getting out of bed in the morning." c. "Smoking while taking this medication will increase your risk of a stroke. "d. "Stopping this medication suddenly increases your risk for a heart attack.

c. "Smoking while taking this medication will increase your risk of a stroke. Clients who smoke while using drugs for nicotine replacement therapy increase the risk of stroke and heart attack. Nurses should teach clients not to smoke while taking this drug. The other responses are inappropriate.

A nurse is caring for a client who has sleep apnea and is prescribed modafinil (Provigil). The client asks, "How will this medication help me?" How should the nurse respond? a. "This medication will treat your sleep apnea." b. "This sedative will help you to sleep at night." c. "This medication will promote daytime wakefulness." d. "This analgesic will increase comfort while you sleep."

c. "This medication will promote daytime wakefulness." Modafinil is helpful for clients who have narcolepsy (uncontrollable daytime sleep) related to sleep apnea. This medication promotes daytime wakefulness.

A nurse cares for a client who tests positive for alpha1-antitrypsin (AAT) deficiency. The client asks, "What does this mean?" How should the nurse respond? a. "Your children will be at high risk for the development of chronic obstructive pulmonary disease." b. "I will contact a genetic counselor to discuss your condition." c. "Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke." d. "This is a recessive gene and should have no impact on your health."

c. "Your risk for chronic obstructive pulmonary disease is higher, especially if you smoke." The gene for AAT is a recessive gene. Clients with only one allele produce enough AAT to prevent chronic obstructive pulmonary disease (COPD) unless the client smokes. A client with two alleles is at high risk for COPD even if not exposed to smoke or other irritants. The client is a carrier, and children may or may not be at high risk depending on the partner's AAT levels. Contacting a genetic counselor may be helpful but does not address the client's current question.

The nurse instructs a client on how to correctly use an inhaler with a spacer. In which order should these steps occur? 1. "Press down firmly on the canister to release one dose of medication." 2. "Breathe in slowly and deeply." 3. "Shake the whole unit vigorously three or four times." 4. "Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer." 5. "Place the mouthpiece into your mouth, over the tongue, and seal your lips tightly around the mouthpiece." 6. "Remove the mouthpiece from your mouth, keep your lips closed, and hold your breath for at least 10 seconds." a. 2, 3, 4, 5, 6, 1 b. 3, 4, 5, 1, 6, 2 c. 4, 3, 5, 1, 2, 6 d. 5, 3, 6, 1, 2, 4

c. 4, 3, 5, 1, 2, 6 The proper order for correctly using an inhaler with a spacer is as follows. Insert the mouthpiece of the inhaler into the nonmouthpiece end of the spacer. Shake the whole unit vigorously three or four times. Place the mouthpiece into the mouth, over the tongue, and seal the lips tightly around it. Press down firmly on the canister of the inhaler to release one dose of medication into the spacer. Breathe in slowly and deeply. Remove the mouthpiece from the mouth, and, keeping the lips closed, hold the breath for at least 10 seconds. Then breathe out slowly. Wait at least 1 minute between puffs.

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? a. A 26-year-old woman who is 8 months pregnant b. A 42-year-old man with gastroesophageal reflux disease c. A 55-year-old woman who is 50 pounds overweight d. A 73-year-old man with type 2 diabetes mellitus

c. A 55-year-old woman who is 50 pounds overweight The client at highest risk would be the one who is extremely overweight. None of the other clients have risk factors for sleep apnea.

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next? a. Call the physician and request a prescription for food and water. b. Provide the client with ice chips instead of a drink of water. c. Assess the client's gag reflex before giving any food or water. d. Let the client have a small sip to see whether he or she can swallow.

c. Assess the client's gag reflex before giving any food or water. The topical anesthetic used during the procedure will have affected the client's gag reflex. Before allowing the client anything to eat or drink, the nurse must check for the return of this reflex.

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery? a. Assess airway patency, breathing, and circulation. b. Administer prescribed intravenous pain medication. c. Assist the client to choose a communication method. d. Ambulate the client in the hallway to assess gait.

c. Assist the client to choose a communication method. The client will not be able to speak after surgery. The nurse should assist the client to choose a communication method that he or she would like to use after surgery. Assessing the client's airway and administering IV pain medication are done after the procedure. Although ambulation promotes health and decreases the complications of any surgery, this client's gait should not be impacted by a total laryngectomy and therefore is not a priority.

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client states he is dizzy. - Nurse applies oxygen and pulse oximetry. b. Client's heart rate is 55 beats/min. - Nurse withholds pain medication. c. Client has reduced breath sounds. - Nurse calls physician immediately. d. Client's respiratory rate is 18 breaths/min. - Nurse decreases oxygen flow rate.

c. Client has reduced breath sounds. - Nurse calls physician immediately. A potentially serious complication after biopsy is pneumothorax, which is indicated by decreased or absent breath sounds. The physician needs to be notified immediately. Dizziness after the procedure is not an expected finding. If the client's heart rate is 55 beats/min, no reason is known to withhold pain medication. A respiratory rate of 18 breaths/min is a normal finding and would not warrant changing the oxygen flow rate.

A nurse is caring for several older clients in the hospital that the nurse identifies as being at high risk for healthcare-associated pneumonia. To reduce this risk, what activity should the nurse delegate to the unlicensed assistive personnel (UAP)? a.Encourage between-meal snacks. b.Monitor temperature every 4 hours. c.Provide oral care every 4 hours. d.Report any new onset of cough.

c.Provide oral care every 4 hours. Oral colonization by gram-negative bacteria is a risk factor for healthcare-associated pneumonia. Good, frequent oral care can help prevent this from developing and is a task that can be delegated to the UAP. Encouraging good nutrition is important, but this will not prevent pneumonia. Monitoring temperature and reporting new cough in clients is important to detect the onset of possible pneumonia but do not prevent it.

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60-pack-year smoking history. Which action is most important for the nurse to take when interviewing this client? a. Tell the client that he needs to quit smoking to stop further cancer development. b. Encourage the client to be completely honest about both tobacco and marijuana use. c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. d. Avoid giving the client false hope regarding cancer treatment and prognosis.

c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. Smoking history includes the use of cigarettes, cigars, pipe tobacco, marijuana, and other controlled substances. Because the client may have guilt or denial about this habit, assume a nonjudgmental attitude during the interview. This will encourage the client to be honest about the exposure. Ask the client whether any of these substances are used now or were used in the past. Assess whether the client has passive exposure to smoke in the home or workplace. If the client smokes, ask for how long, how many packs per day, and whether he or she has quit smoking (and how long ago). Document the smoking history in pack-years (number of packs smoked daily multiplied by the number of years the client has smoked). Quitting smoking may not stop further cancer development. This statement would be giving the client false hope, which should be avoided, but is not as important as maintaining a nonjudgmental attitude.

A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this client? a. Spaghetti with meat sauce, ice cream b. Chicken soup, grilled cheese sandwich c. Omelet, soft whole wheat bread d. Pasta salad, custard, orange juice

c. Omelet, soft whole wheat bread Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements. Tomato sauce may prove too spicy for a client with esophagitis. A grilled cheese sandwich is too difficult to swallow with this condition, and orange juice and other foods with citric acid are too caustic.

A nurse has educated a client on isoniazid (INH). What statement by the client indicates teaching has been effective? a."I need to take extra vitamin C while on INH." b."I should take this medicine with milk or juice." c."I will take this medication on an empty stomach." d."My contact lenses will be permanently stained."

c."I will take this medication on an empty stomach." INH needs to be taken on an empty stomach, either 1 hour before or 2 hours after meals. Extra vitamin B needs to be taken while on the drug. Staining of contact lenses commonly occurs while taking rifampin (Rifadin).

A client has a pulmonary embolism and is started on oxygen. The student nurse asks why the client's oxygen saturation has not significantly improved. What response by the nurse is best? a."Breathing so rapidly interferes with oxygenation." b."Maybe the client has respiratory distress syndrome." c."The blood clot interferes with perfusion in the lungs." d."The client needs immediate intubation and mechanical ventilation."

c."The blood clot interferes with perfusion in the lungs." A large blood clot in the lungs will significantly impair gas exchange and oxygenation. Unless the clot is dissolved, this process will continue unabated. Hyperventilation can interfere with oxygenation by shallow breathing, but there is no evidence that the client is hyperventilating, and this is also not the most precise physiologic answer. Respiratory distress syndrome can occur, but this is not as likely. The client may need to be mechanically ventilated, but without concrete data on FiO2 and SaO2, the nurse cannot make that judgment.

A nurse in a family practice clinic is preparing discharge instructions for a client reporting facial pain that is worse when bending over, tenderness across the cheeks, and postnasal discharge. What instruction will be most helpful? a."Ice packs may help with the facial pain." b."Limit fluids to dry out your sinuses." c."Try warm, moist heat packs on your face." d."We will schedule you for a computed tomography scan this week."

c."Try warm, moist heat packs on your face." This client has rhinosinusitis. Comfort measures for this condition include breathing in warm steam, hot packs, nasal saline irrigations, sleeping with the head elevated, increased fluids, and avoiding cigarette smoke. The client does not need a CT scan.

A client has been brought to the emergency department with a life-threatening chest injury. What action by the nurse takes priority? a.Apply oxygen at 100%. b.Assess the respiratory rate. c.Ensure a patent airway. d.Start two large-bore IV lines.

c.Ensure a patent airway. The priority for any chest trauma client is airway, breathing, circulation. The nurse first ensures the client has a patent airway. Assessing respiratory rate and applying oxygen are next, followed by inserting IVs.

nurse working in a geriatric clinic sees clients with "cold" symptoms and rhinitis. Which drug would be appropriate to teach these clients to take for their symptoms? a.Chlorpheniramine (Chlor-Trimeton) b.Diphenhydramine (Benadryl) c.Fexofenadine (Allegra) d.Hydroxyzine (Vistaril)

c.Fexofenadine (Allegra) First-generation antihistamines are not appropriate for use in the older population. These drugs include chlorpheniramine, diphenhydramine, and hydroxyzine. Fexofenadine is a second-generation antihistamine.

An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority? a.Determine if the tube is kinked. b.Ensure all connections are patent. c.Listen to the client's lung sounds. d.Suction the endotracheal tube.

c.Listen to the client's lung sounds. *When an intubated client shows signs of hypoxia, check for *DOPE*: displaced tube (most common cause), obstruction (often by secretions), pneumothorax, and equipment problems.* The nurse listens for equal, bilateral breath sounds first to determine if the endotracheal tube is still correctly placed. If this assessment is normal, the nurse would follow the mnemonic and assess the patency of the tube and connections and perform suction.

A client is on a ventilator and is sedated. What care may the nurse delegate to the unlicensed assistive personnel (UAP)? a.Assess the client for sedation needs. b.Get family permission for restraints. c.Provide frequent oral care per protocol. d.Use nonverbal pain assessment tools.

c.Provide frequent oral care per protocol. The client on mechanical ventilation needs frequent oral care, which can be delegated to the UAP. The other actions fall within the scope of practice of the nurse.

A client is admitted with a pulmonary embolism (PE). The client is young, healthy, and active and has no known risk factors for PE. What action by the nurse is most appropriate? a.Encourage the client to walk 5 minutes each hour. b.Refer the client to smoking cessation classes. c.Teach the client about factor V Leiden testing. d.Tell the client that sometimes no cause for disease is found.

c.Teach the client about factor V Leiden testing. Factor V Leiden is an inherited thrombophilia that can lead to abnormal clotting events, including PE. A client with no known risk factors for this disorder should be referred for testing. Encouraging the client to walk is healthy, but is not related to the development of a PE in this case, nor is smoking. Although there are cases of disease where no cause is ever found, this assumption is premature.

Abnormal (adventitious) breath sounds

crackles (doesn't clear with cough, wheezes, Rhonchus pleural friction rub

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take? a. Ambulate the client in the hallway to promote deep breathing .b. Auscultate the client's anterior and posterior lung fields. c. Encourage the client to take shallow breaths to help with the pain. d. Administer pain medication and encourage the client to take deep breaths.

d. Administer pain medication and encourage the client to take deep breaths. A chest tube is placed in the pleural space and may be uncomfortable for a client. The nurse should provide pain medication to minimize discomfort and encourage the client to take deep breaths. The other responses do not address the client's discomfort and need to take deep breaths to prevent complications.

A nurse assesses a client who reports waking up feeling very tired, even after 8 hours of good sleep. Which action should the nurse take first? a. Contact the provider for a prescription for sleep medication. b. Tell the client not to drink beverages with caffeine before bed. c. Educate the client to sleep upright in a reclining chair. d. Ask the client if he or she has ever been evaluated for sleep apnea.

d. Ask the client if he or she has ever been evaluated for sleep apnea. Clients are usually unaware that they have sleep apnea, but it should be suspected in people who have persistent daytime sleepiness and report waking up tired. Causes of the problem should be assessed before the client is offered suggestions for treatment.

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results Vital Signs pH = 7.32 PaCO2 = 62 mm HgPaO2 = 46 mm HgHCO3- = 28 mEq/L Heart rate = 110 beats/min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm HgOxygen saturation = 76% Which action should the nurse take first? a. Administer a short-acting beta2 agonist inhaler. b. Document the findings as normal for a client with COPD. c. Teach the client diaphragmatic breathing techniques. d. Initiate oxygenation therapy to increase saturation to 92%.

d. Initiate oxygenation therapy to increase saturation to 92%. Oxygen should be administered to a client who is hypoxic even if the client has COPD and is a carbon dioxide retainer. The other interventions do not address the client's hypoxia, which is the priority.

A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?a. Strip the tubing to minimize clot formation and ensure patency. b. Secure tubing junctions with clamps to prevent accidental disconnections. c. Connect the chest tube to wall suction at the level prescribed by the provider. d. Keep padded clamps at the bedside for use if the drainage system is interrupted.

d. Keep padded clamps at the bedside for use if the drainage system is interrupted. Padded clamps should be kept at the bedside for use if the drainage system becomes dislodged or is interrupted. The nurse should never strip the tubing. Tubing junctions should be taped, not clamped. Wall suction should be set at the level indicated by the device's manufacturer, not the provider

A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first? a. Assess the client's pain level. b. Keep the client's head elevated. c. Teach the client about the causes of nasal bleeding. d. Make sure the string is taped to the client's cheek.

d. Make sure the string is taped to the client's cheek. The string should be attached to the client's cheek to hold the packing in place. The nurse needs to make sure that this does not move because it can occlude the client's airway. The other options are good interventions, but ensuring that the airway is patent is the priority objective.

A nurse assesses a client's respiratory status. Which information is of highest priority for the nurse to obtain? a. Average daily fluid intake b. Neck circumference c. Height and weight d. Occupation and hobbies

d. Occupation and hobbies Many respiratory problems occur as a result of chronic exposure to inhalation irritants used in a client's occupation and hobbies. Although it will be important for the nurse to assess the client's fluid intake, height, and weight, these will not be as important as determining his occupation and hobbies. Determining the client's neck circumference will not be an important part of a respiratory assessment.

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the provider immediately.

d. Stay with the client and have someone else call the provider immediately. This client may have a trachea-innominate artery fistula, which can be a life-threatening emergency if the artery is breached and the client begins to hemorrhage. Since no bleeding is yet present, the nurse stays with the client and asks someone else to notify the provider. If the client begins hemorrhaging, the nurse removes the tracheostomy and applies pressure at the bleeding site. The client will need to be prepared for surgery.

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? a. The client rates pain as a 5/10 at the site of the procedure. b. A small amount of drainage from the site is noted. c. Pulse oximetry is 93% on 2 liters of oxygen. d. The trachea is deviated toward the opposite side of the neck.

d. The trachea is deviated toward the opposite side of the neck. A deviated trachea is a manifestation of a tension pneumothorax, which is a medical emergency. The other findings are normal or near normal.

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure? a. Measure oxygen saturation before and after a 12-minute walk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Validate that informed consent has been given by the client.

d. Validate that informed consent has been given by the client. A thoracentesis is an invasive procedure with many potentially serious complications. Verifying that the client understands complications and explaining the procedure to be performed will be done by the physician or nurse practitioner, not the nurse. Measurement of oxygen saturation before and after a 12-minute walk is not a procedure unique to a thoracentesis.

A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax? a. When the insertion site becomes red and warm to the touch b. When the tube drainage decreases and becomes sanguineous c. When the client experiences pain at the insertion site d. When the tube becomes disconnected from the drainage system

d. When the tube becomes disconnected from the drainage system Intrathoracic pressures are less than atmospheric pressures; therefore, if the chest tube becomes disconnected from the drainage system, air can be sucked into the pleural space and cause a pneumothorax. A red, warm, and painful insertion site does not increase the client's risk for a pneumothorax. Tube drainage should decrease and become serous as the client heals. Sanguineous drainage is a sign of bleeding but does not increase the client's risk for a pneumothorax.

A student nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse instructor is best? a."It is chronic hypoxemia that accompanies restrictive airway disease." b."It is hypoxemia from lung damage due to mechanical ventilation." c."It is hypoxemia that continues even after the client is weaned from oxygen." d."It is hypoxemia that persists even with 100% oxygen administration."

d."It is hypoxemia that persists even with 100% oxygen administration." Refractory hypoxemia is hypoxemia that persists even with the administration of 100% oxygen. It is a cardinal sign of acute respiratory distress syndrome. It does not accompany restrictive airway disease and is not caused by the use of mechanical ventilation or by being weaned from oxygen.

A client is on mechanical ventilation and the client's spouse wonders why ranitidine (Zantac) is needed since the client "only has lung problems." What response by the nurse is best? a."It will increase the motility of the gastrointestinal tract." b."It will keep the gastrointestinal tract functioning normally." c."It will prepare the gastrointestinal tract for enteral feedings." d."It will prevent ulcers from the stress of mechanical ventilation."

d."It will prevent ulcers from the stress of mechanical ventilation." Stress ulcers occur in many clients who are receiving mechanical ventilation, and often prophylactic medications are used to prevent them. Frequently used medications include antacids, histamine blockers, and proton pump inhibitors. Zantac is a histamine blocking agent.

A client is brought to the emergency department after sustaining injuries in a severe car crash. The client's chest wall does not appear to be moving normally with respirations, oxygen saturation is 82%, and the client is cyanotic. What action by the nurse is the priority? a.Administer oxygen and reassess. b.Auscultate the client's lung sounds. c.Facilitate a portable chest x-ray. d.Prepare to assist with intubation.

d.Prepare to assist with intubation. This client has manifestations of flail chest and, with the other signs, needs to be intubated and mechanically ventilated immediately. The nurse does not have time to administer oxygen and wait to reassess, or to listen to lung sounds. A chest x-ray will be taken after the client is intubated.

A client is in the family practice clinic reporting a severe "cold" that started 4 days ago. On examination, the nurse notes the client also has a severe headache and muscle aches. What action by the nurse is best? a.Educate the client on oseltamivir (Tamiflu). b.Facilitate admission to the hospital. c.Instruct the client to have a flu vaccine. d.Teach the client to sneeze in the upper sleeve.

d.Teach the client to sneeze in the upper sleeve. Sneezing and coughing into one's sleeve helps prevent the spread of upper respiratory infections. The client does have manifestations of the flu (influenza), but it is too late to start antiviral medications; to be effective, they must be started within 24 to 48 hours of symptom onset. The client does not need hospital admission. The client should be instructed to have a flu vaccination, but now that he or she has the flu, vaccination will have to wait until next year.

A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what should the nurse ensure as a priority? a.The client is able to initiate spontaneous breaths. b.The inspired oxygen has adequate humidification. c.The upper peak airway pressure limit alarm is off. d.The upper peak airway pressure limit alarm is on.

d.The upper peak airway pressure limit alarm is on. The upper peak airway pressure limit alarm will sound when the airway pressure reaches a preset maximum. This is critical to prevent damage to the lungs. Alarms should never be turned off. Initiating spontaneous breathing is important for some modes of ventilation but not others. Adequate humidification is important but does not take priority over preventing injury.

COPD COMPLICATIONS-

hypoxemia & acidosisoccur because pt with COPD has reduced gas exchange, leading to decreased oxygenation and increased carbon dioxide levels. = reduced cellular function respiratory infection,risk increasesdue to increased mucus and poor gas exchange. cardiac failure (cor pulmonale) R. sided HF caused by pulmonary disease dysrhythmias, respiratory failure. Cor pulmonale Chart 30-9 KEY FEATURES pg. 574

pulmonary embolism (PE)

is a collection of particulate matter (solids, liquids or air) that enters the venous circulation and lodges in the pulmonary vessels. Large emboli obstruct pulmonary blood flow, leading to reduced GAS EXCHANGE, reduced O2, pulmonary tissue hypoxia, decreased perfusion, and potential death. Any substance can cause a PE but a blood clot is the most common

Acute respiratory distress syndrome ARDS

is acute respiratory failure with these features: *Hypoxemia that persists even when 100% oxygen is given (refractory hypoxemia) *decreased pulmonary compliance *dyspnea *non-cardiac associated bilateral pulmonary edema *dense pulmonary infiltrates on X-ray (*ground glass appearance*)

pneumonia

is excess fluid in the lungs from an inflammatory process. It can seriously reduce gas exchange

Lung cancer Diagnosing

is made by examination of cancer cells · -early morning sputum may identify tumor cells; however cancer cells may not be present · -if pleural effusion present then thoracentesis is performed · -Most commonly lung lesions are 1stidentified on chest X-RAY · -CT scans are then used to identify the lesions more clearly and guide biopsy procedures · -Thoracoscopy allows direct view of lung entering the chest wall through a small incision · -mediastinoscopy done to see if spread to mediastinal lymph nodes done through small chest incision · -Other tests: needle biopsy of lymph nodes · Direct surgical biopsy · Thoracentesis with pleural biopsy · MRI w/ radionuclide scans of liver, spleen, brain & bone to help determine metastatic tumors · PFTs & ABG's to determine overall respiratory status · PET becoming most thorough way to determine metastases

Thoracentesis

is the surgical perforation of the chest wall and pleural space with a large-bore needle. Performed to obtain specimens for diagnostic evaluation, instill medicines into the pleural space, and remove fluid (effusion) or air from pleural space for therapeutic relief. -performed under local anesthesia by provider at bedside, procedure room, or in providers office - use of ultrasound guidance decreases the risk of complications Patient presentation-large amounts of fluid in the pleural space compress lung tissue and can cause pain, SOB, cough assessment if the effusion area cab reveal abnormal breath sounds, dull percussion sounds, and decreased chest wall expansion, pain can occur due to inflammatory process

warning signs of head and neck cancer

pain, lump in mouth throat or neck, difficulty swallowing, color changes in the mouth or tongue to red white gray dark brown or black, oral lesions or sores that do not heal in 2 weeks,persistent unexplained oral bleeding, numbness in mouth lips or face, change in denture fit, burning sensation when drinking citrus juice or hot liquids , persistent unilateral ear pain, hoarseness or change in voice quality, persistent or recurrent sore throat, S.O.B., anorexia or weight loss.

TB should be considered for any patient with

persistent cough, unintended weight loss, anorexia, night sweats, hemoptysis, SOB, fever, or chills

check the airway and packing at least every hour for a patient with

posterior nasal packing placed after nasal surgery or posterior epistaxis

major risk factors for VTE leading to PE are

prolonged immobility, central venous catheters, surgery, obesity, advancing age, conditions that increase blood clotting, history of thromboembolism **smoking, pregnancy, estrogen therapy, HF, stroke, cancer (particularly lung, prostate cancers) and trauma increase risks for VTE and PE. **fat, oil, air, tumor cells, amniotic fluid and fetal debris, foreign objects, broken IV catheters, injected particles and infected clots can enter a vein and cause a PE. Fat emboli causes ARDS and do not impede lung blood flow.

antidote for heparin

protamine sulfate

The gold standard for diagnosing a PE is

pulmonary angiography. The nurse should facilitate this test as soon as possible.

Emphysema-

remember PINK PUFFER / BARRELLED CHEST · 2 major changes = LOSS OF LUNG ELASTICITY & HYPERINFLATION of the lung · Retain more CO2 INCREASED RR Proteases damage alveoli and small airways by breaking down elastin · resulting in destroyed alveoli and others flabby with less area for GAS EXCHANGE · Uses accessary muscles in neck, chest wall, and abdomen to inhale and exhale · Increase need for O2= patient having *"AIR HUNGER" * sensation · Increased air trapped in lungs · ABG may not show problems until advanced disease · Leads to chronic respiratory acidosis Late stage=low PAO2

Pneumonectomy

removal of entire lung

water seal on chest tube drainage system

should always have at least 2 cm of water to prevent air from returning to the patient

zanamivir

should be used in caution to patients with COPD, asthma, or older adults antiviral agent for the flu

teach patients who have had radiation therapy to the oral cavity

to have dental examinations every 6 months

Assess the skin around a new tracheostomy

to recognize subcutaneous emphysyma. If it is puffy and you can feel a crackling sensation when pressing on the skin, respond by notifying the physician immediately.

Encourage patients with permanent tracheotomies or laryngectomies to become involved in self care and to look at the wound and

touch the affected area

Lung Cancer Warning signs table 30-5

· Hoarseness · Change in respiratory pattern · Persistent couch or change in cough · Blood streaked sputum · Rust colored or purulent sputum · Frank hemoptysis · Chest pain or chest tightness · Shoulder, arm, or chest wall pain · Recurring episodes of pleural effusion, pneumonia, or bronchitis · Dyspnea · Fever associated with 1 or 2 other signs · Wheezing · Weight loss · Clubbing of the fingers

Health promotion and maintenance COPD:

· Incidence & severity would be greatly reduced by smoking cessation. · Urge adults to quit smoking. Chart 27-2 tips to provide · Teach pt's to avoid exposure to other inhalation irritants COPD seen more often in OLDER MEN Occurs in families with AAT deficiency Many COPD pts sleep in a semi sitting position Sits in FORWARD BENDING POSTURE W/ ARMS HELD FORWARD known as orthopenic or tripod position WHEEZES usually present, crackles aren't Reduced breath sounds especially w/ emphysema

Non-surgical management: Nursing management for COPD patients focuses on

· airway maintenance · monitoring breathing techniques · positioning · effective coughing - * teach pts to cough on arising in the morning* cough before meals and at bedtime · oxygen therapy · exercise conditioning · suctioning · hydration · use of vibratory positive-pressure device o *BEFORE ANY INTERVENTION ASSESS* the breathing rate, rhythm, depth, and use of accessory muscles o **AIRWAY MAINTENANCE** is the MOST IMPORTANT FORCUS OF INTERVENTIONS to improve gas exchange

Pneumonia Clinical Manifestations

◦Flushed cheeks and anxious ◦Chest pain ◦Headache ◦Chills ◦Fever sometimes ◦Cough ◦Tachycardia ◦Dyspnea ◦What other S/S? fatigue, crackles, SOB ◦What about the elderly patient? CONFUSION, FALLS