PrepU chapter 17- upper respiratory tract
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of
2 to 12 days
The goal for oxygen therapy in COPD is to support tissue oxygenation, decrease the work of the cardiopulmonary system, and maintain the resting partial arterial pressure of oxygen (PaO2) of at least ______ mm Hg and an arterial oxygen saturation (SaO2) of at least ___%.
60 mm Hg; 90%
A patient with COPD requires oxygen administration. What method of delivery does the nurse know would be best for this patient?
A Venturi mask
The nurse is assigned to care for a client with a chest tube. The nurse should ensure that which item is kept at the client's bedside?
A bottle of sterile water
The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?
A puncture at the radial artery
Which type of lung cancer is the most prevalent among both men and women?
Adenocarcinoma
A physician orders triamcinolone and salmeterol for a client with a history of asthma. What action should the nurse take when administering these drugs?
Administer the salmeterol and then administer the triamcinolone.
A client has a sucking stab wound to the chest. Which action should the nurse take first?
Apply a dressing over the wound and tape it on three sides.
Which is a potential complication of a low pressure in the endotracheal tube cuff?
Aspiration pneumonia
Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate?
Assist control
Solu-medrol and prednisone are glucocortico steroids used to prevent or control inflammation in the lungs and airways. As such, which lab value would take priority in the coordination of care for a patient receiving this therapy?
Bedside blood glucose reading of 388 mg/dL
The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema?
Crackles in the lung bases
A patient is prescribed a mast cell stabilizer for the treatment of asthma. Which commonly used medication will the nurse educate the patient about?
Cromolyn sodium
Which ventilation-perfusion ratio is exhibited in a client diagnosed with a pulmonary embolus?
Dead space
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?
Dyspnea and wheezing
Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction?
Ensure mouth breathing
During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?
Hypercapnia
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
Hypercapnia, hypoventilation, and hypoxemia
Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration?
Inspiratory reserve volume
Which of the following medications are classified as leukotriene modifiers (inhibitors)? Select all that apply.
Montelukast Zafirlukast Zileuton
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
Noisy breathing
Which oxygen administration device has the advantage of providing a high oxygen concentration?
Nonrebreathing mask
The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation?
PaCO2
The nurse is assessing a client for obstructive sleep apnea (OSA). Which are signs and symptoms of OSA? Select all that apply.
Polycythemia Loud snoring Insomnia
Bleeding from the drains at the surgical site or with tracheal suctioning may signal the occurrence of hemorrhage. Which of the following is a clinical manifestations associated with hemorrhage?
Rapid, deep respirations
After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered:
Significant
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?
Tension pneumothorax
When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?
Test the nasal drainage for glucose.
Once the patient has been cleared for oral feedings, post laryngectomy, the nurse knows to prepare:
Thick liquids that are easy to swallow.
Most cases of acute pharyngitis are caused by which of the following?
Viral infection
The client is to receive cephalexin (Ancef) 500 mg in 50 mL of normal saline intravenous piggyback. The medication is to infuse over 30 minutes. How many mL/hr would the nurse set the intravenous pump? Enter the correct number ONLY.
100
Which range of water pressure within the endotracheal tube cuff is believed to prevent both injury and aspiration?
15 to 20 mm Hg
The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?
A face mask
Which is a true statement regarding air pressure variances?
Air is drawn through the trachea and bronchi into the alveoli during inspiration.
A patient visited a health care clinic for treatment of upper respiratory tract congestion, fatigue, and sputum production that was rust-colored. Which of the following diagnoses is likely based on this history and inspection of the sputum?
An infection with pneumococcal pneumonia
A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?
An inhaled beta2-adrenergic agonist
The nurse should advise the patient who has nasal packing for epistaxis that the packing can be left in place?
Anywhere from 2 to 6 days.
The nurse is caring for a client reporting chest discomfort. The client's diagnosis at admission is left lower lobe pneumonia. Which strategy will the nurse instruct the client to use to help alleviate the discomfort?
Assume a left side-lying position while in bed
An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure?
At bedtime
For a client with an endotracheal (ET) tube, which nursing action is the most important?
Auscultating the lungs for bilateral breath sounds
A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?
Auscultation
Which is an adverse reaction that would require the process of weaning from a ventilator to be terminated?
Blood pressure increase of 20 mm Hg
A client is prescribed two sprays of a nasal medication twice a day. The nurse is teaching the client how to self-administer the medication and instructs the client to
Blow the nose before applying medication into the nares.
A patient prescribed a medication for hypertension started taking it 3 days ago and arrives in the emergency department with an edematous face and tongue and having a difficult time speaking. What medication is the nurse aware of that may produce this type of side effect?
Enalapril (Vasotec)
A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention?
Encourage coughing to mobilize secretions.
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?
Endotracheal suctioning
A patient with sinus congestion points to a location on the inside of his eye as the area of pain. The nurse documents that the patient is complaining of pain in which sinus?
Ethmoid
A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion?
Fluoroscopy
A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?
Group A, beta-hemolytic streptococci
A patient comes to the clinic and is diagnosed with tonsillitis and adenoiditis. What bacterial pathogen does the nurse know is commonly associated with tonsillitis and adenoiditis?
Group A, beta-hemolytic streptococcus
Which type of oxygen therapy includes the administration of oxygen at pressure greater than atmospheric pressure?
Hyperbaric
A client is 2 hours post-op tracheostomy. The nurse assesses the client and finds the client's breathing is shallow at a respiratory rate 30. The nurse notes increased mucus production around the tracheostomy and on the dressing. What are the priority nursing concerns? Select all that apply.
Ineffective airway clearance Impaired gas exchange
A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by:
Inspecting the roof of the nasopharynx.
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily?
Intubate the client and control breathing with mechanical ventilation
A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?
Kinking of the ventilator tubing
The nursing instructor is teaching students about types of lung cancer. Which type of lung cancer is characterized as fast growing and can arise peripherally?
Large cell carcinoma
An experienced nurse is assisting and notes air movement over the trachea to the upper lungs. The air movement is noted equally on inspiration as expiration. Which breath sounds would the nurse document?
Normal bronchovesicular sounds
The nurse is caring for a client with hypoxemia of unknown cause. Which of the following oxygen transport considerations does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply.
Oxygen is dissolved. Oxyhemoglobin circulates to the body tissue. Adequate red blood cells are needed for oxygen transport.
A young adult visited a clinic because he was injured during a softball game. He told the nurse that the ball struck him in his "Adam's apple." To assess the initial impact of injury, the nurse:
Palpates the thyroid cartilage.
A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?
Partial laryngectomy
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?
Partial pressure of arterial oxygen (PaO2)
A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do?
Place the end of the chest tube in a container of sterile saline.
A client suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. A nurse would implement which intervention to improve oxygenation and provide comfort for the client?
Position the client in the prone position
The nurse assesses a patient for possible acute pharyngitis. Which of the following clinical manifestations are consistent with this diagnosis? Select all that apply.
Red pharyngeal membranes Swollen lymphoid follicles White-purple exudates on the back of the throat A temperature >100.4°F
A pneumothorax is a possible complication of COPD. Symptoms will depend on the suddenness of the attack and the size of the air leak. The most common, immediate symptom that should be assessed is:
Sharp, stabbing chest pain
The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:
Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.
A client is visiting the emergency department because of massive bleeding from the nose that will not stop. Blood is on the client's shirt, and bleeding from the nose continues. The nurse intervenes by
Telling the client to sit upright with the head tilted forward
A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?
They help prevent cardiac arrhythmias.
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?
Total laryngectomy
Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?
Venturi mask
What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?
Warm and humidify inspired air
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?
Water-seal chamber
Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:
a compromised skin graft.
The nurse at an employee wellness clinic is meeting with a client who reports voice hoarseness for more than 2 weeks. To determine if the client may have symptoms of early laryngeal cancer, the next question the nurse should ask is, "Do you have
a persistent cough or sore throat"
Understanding pulmonary physiology, what characteristic would the nurse expect to result in decreased gas exchange in older adults?
alveolar walls containing fewer capillaries
A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:
cough as the cuff is being deflated.
A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as:
synchronized intermittent mandatory ventilation (SIMV).
A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer?
a feeling of swelling at the back of the throat
Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?
"Because I had a previous reaction to the test, this time I need to get a chest X-ray."
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?
"Before you do the exercise, I'll give you pain medication if you need it."
A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath and fatigue for 1 hour after awakening in the morning. Which of the following statements by the nurse would best help with the client's shortness of breath and fatigue?
"Delay self-care activities for 1 hour."
Which clinical manifestation of hemorrhage is related to carotid artery rupture?
Increased pulse rate
A client presents to the ED reporting severe coughing episodes. The client states that "the episodes are more intense at night." The nurse should suspect which of the following conditions based on the client's primary report?
Left-sided heart failure
What is histamine, a mediator that supports the inflammatory process in asthma, secreted by?
Mast cells
A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:
5 to 20 minutes.
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?
6 to 12 months
A client has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of this disorder does the nurse anticipate educating the client about?
Amoxicillin-clavulanic acid
The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care?
Apply an ice pack.
The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis?
Chemical irritation
High or increased compliance occurs in which condition?
Emphysema
A first-line antibiotic used to treat acute rhinosinusitis is
ampicillin
Class 1 with regard to TB indicates
exposure and no evidence of infection.
As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that:
laryngeal cancer is one of the most preventable types of cancer.
A late complication of radiation therapy is
laryngeal necrosis.
Arterial blood gas analysis would reveal which value related to acute respiratory failure?
pH 7.28
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder?
pH 7.28, PaO2 50 mm Hg
The nurse is caring for a client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client
returning to the nursing unit with two chest tubes.
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
sit upright, leaning slightly forward.
A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when he:
uses the sternocleidomastoid muscles.
The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify?
"I will breathe in through my mouth and out through my nose."
