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A client comes to the clinic because of signs and symptoms of a respiratory infection. The client says to the nurse, "How can I prevent my roommate from getting my cold?" What is the nurse's best response? "Cover your cough with your forearm." "Dispose of used paper tissues in a paper bag." "Encourage your roommate to get the flu vaccine." "Move out of your apartment until you are over the cold."

A client develops subcutaneous emphysema after the surgical creation of a tracheostomy. What assessment by the nurse most readily detects this complication? Palpating the neck or face Evaluating the blood gases Auscultating the lung fields Reviewing the chest x-ray film

A client has a closed chest drainage system in place. What should the nurse do to determine the amount of chest tube drainage? Refer to the date and time markings on the outside of the collection chamber. Aspirate the drainage from the collection chamber. Replace the existing system with a new one to access the drainage in the existing system. Clamp the chest tube and empty the fluid from the collection chamber.

A client has been admitted for chronic obstructive pulmonary disease (COPD) exacerbation secondary to an upper respiratory tract infection. The nurse should expect which findings when auscultating the client's breath sounds? Coarse crackles Prolonged inspiration Short, rapid inspiration Normal breath sounds

A client has chronic obstructive pulmonary disease (COPD) and cor pulmonale. When teaching about nutrition, what does the nurse instruct the client? Eat small meals six times a day to limit oxygen needs. Drink large amounts of fluid to help liquefy secretions. Lie down after eating to conserve energy needed for digestion. Increase the intake of protein to decrease intravascular hydrostatic pressure.

A client is admitted with multiple injuries as a result of an accident. A tracheostomy was performed. While the nurse is caring for this client, the client coughs, expelling the tracheostomy tube onto the bed. What should the nurse's first action be? Hold the tracheostomy open with a tracheal dilator and call for assistance Insert an obturator into the tracheostomy and gently reinsert the tracheostomy tube Pick up the tracheostomy tube from the bed and replace it until a new tube is available Obtain a new tracheostomy tube, prepare the new holder, and insert the tube using the obturator

A client is shot in the chest during a holdup and is transported to the hospital via ambulance. In the emergency department, chest tubes are inserted, one in the second intercostal space and one at the base of the lung. What does the nurse expect the tube in the second intercostal space to accomplish? Remove the air that is present in the intrapleural space Drain serosanguineous fluid from the intrapleural compartment Permit the development of positive pressure between the layers of the pleura Provide access for the instillation of medication into the pleural space

A client returns to the unit fully awake after a bronchoscopy and biopsy. Which action is priority? Assess the presence of a gag reflex Provide ice chips as a comfort measure Encourage the client to cough frequently Advise the client to stay flat for several hours

A client sustains a stab wound to the chest, and a chest tube is inserted. Later the client's chest tube appears to be obstructed. Which is the most appropriate nursing action? Instruct the client to cough Clamp the tube immediately Prepare for chest tube removal Arrange for a stat chest x-ray film

A client who has a history of emphysema is transported back to the nursing unit after a radical neck dissection for cancer of the tongue. The client is receiving oxygen and an intravenous infusion. Within the first hour, the client has 50 mL of sanguineous drainage in the portable wound drainage system. Which initial action should the nurse take? Inspect the dressing Increase the oxygen flow rate Notify the healthcare provider Place the client in the supine position

A client who is receiving peritoneal dialysis reports severe respiratory difficulty. What immediate action should the nurse implement? Auscultate the lungs. Obtain arterial blood gases. Notify the healthcare provider. Apply pressure to the abdomen.

A client who just returned from surgery reports shortness of breath and chest pain. Which should the nurse initially administer? Supplemental oxygen Intravenous morphine Endotracheal intubation Sublingual nitroglycerin

A client with a history of hemoptysis and cough for the last six months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. What is the nurse's priority? Immediately contact the primary healthcare provider Document the amount of sputum Monitor vital signs every hour Increase the frequency of coughing and deep breathing

A client with laryngeal cancer has a partial laryngectomy and tracheostomy. To best facilitate communication postoperatively, what should the nurse do? Provide a means for the client to write Allow the client more time for articulation Use visual clues, such as gestures and objects Face the client and speak slowly and distinctly

A client with terminal cancer says to the nurse, "If I could just be free of pain for a few days, I might be able to eat more and regain strength." Which stage of grieving does the nurse concludes the client is experiencing? Bargaining Frustration Depression Rationalization

A healthcare provider prescribes oropharyngeal suctioning as needed for a client in a coma. Which assessment made by the nurse indicates the need for suctioning? Gurgling sounds with each breath Fine crackles at the base of the lungs Cyanosis in the nail beds of the fingers Dry cough at increasingly frequent intervals

A nurse is a preceptor for an orientee (newly hired nurse). The orientee is providing postoperative care to a client who recently returned from a laryngoscopy. The orientee reminds the client not to eat or drink anything until instructed to do so. How does the preceptor evaluate the suitability of the instructions given to the client by the orientee? Appropriate; oral intake after the procedure may result in aspiration Appropriate; it is important to limit painful swallowing Inappropriate; the client is too groggy after general anesthesia to comprehend information Inappropriate; fluid replacement should begin immediately after the procedure

A nurse is administering oxygen to a client with chest pain who is restless. What method of oxygen administration will most likely prevent a further increase in the client's anxiety level? Cannula Catheter Venturi mask Rebreather mask

A nurse is caring for a client who experienced a crushing chest injury. A chest tube is inserted. Which observation indicates a desired response to this treatment? Increased breath sounds Increased respiratory rate Crepitus detected on palpation of the chest Constant bubbling in the drainage collection chamber

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are associated most commonly with COPD? Cardiac problems Joint inflammation Kidney dysfunction Peripheral neuropathy

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD). Which clinical finding supports the nurse's suspicion that the client is developing cor pulmonale? Peripheral edema Productive coughing Twitching of the extremities Lethargy progressing to coma

A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism? An obese client with leg trauma A pregnant client with acute asthma A client with diabetes who has cholecystitis A client with pneumonia who is immunocompromised

A nurse is caring for a variety of clients. In which client is it most essential for the nurse to implement measures to prevent pulmonary embolism? A 59-year-old who had a knee replacement A 60-year-old who has bacterial pneumonia A 68-year-old who had emergency dental surgery A 76-year-old who has a history of thrombocytopenia

A nurse is suctioning a client's airway. Which nursing action will limit hypoxia? Apply suction only after catheter is inserted Limit suctioning with catheter to half a minute Lubricate the catheter with saline before insertion Use a sterile suction catheter for each suctioning episode

A nurse is teaching breathing exercises to a client with emphysema. What is the reason the nurse should include in the teaching as to why these exercises are necessary to promote effective use of the diaphragm? The residual capacity of the lungs has been increased. Inspiration has been markedly prolonged and difficult. The client has an increase in the vital capacity of the lungs. Abdominal breathing is an effective compensatory mechanism and is spontaneously initiated.

A postoperative client is being weaned from mechanical ventilation. What is the most important factor for the nurse to consider when organizing activities? Remain with the client to assess responses. Allow family members to participate in the process. Permit the client more extended times alone for independence. Observe monitoring devices at the control panel of the ventilator.

After surgery, a client reports sudden severe chest pain and begins coughing. The nurse suspects the client has a thromboembolism. What characteristic of the sputum supports the nurse's suspicion that the client has a pulmonary embolus? Pink Clear Green Yellow

The nurse is caring for a client two days after the client was admitted with burn injury. When performing the respiratory assessment, the nurse observes for which type of sputum? Sooty Frothy Yellow Tenacious

The nurse is teaching the client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing (PLB). What is the rationale for the nurse's teaching? Prolonged exhalation to decrease air trapping Shortened inhalation to reduce bronchial swelling Increased respiratory rate to improve arterial oxygenation Decreased use of diaphragm to increase amount of inspired air

The nurse places a pulse oximetry probe on the finger and toe of a client with a respiratory disorder to determine the oxygen saturation of hemoglobin (SpO 2) . Which other parameter can be determined using this technique? Arterial oxygen saturation Partial pressure of oxygen in arterial blood Partial pressure of arterial carbon dioxide Partial pressure of oxygen in venous blood

The nurse provides discharge instructions to a client who had a rhinoplasty. Which instructions should the nurse share with the client? Avoid items that may trigger sneezing Consume fluids at a tepid temperature Brush the teeth thoroughly after each food intake Sleep on the back using one pillow under the head

What is the normal value of functional residual capacity? 2.5 L 3.5 L 4.5 L 6.0 L

Which condition can cause a client's partial pressure of end-tidal carbon dioxide (PETCO 2) to be 50 mmHg? Hypoventilation Tracheal extubation Pulmonary embolism Total airway obstruction

Which statement appropriately describes tidal volume? It is the volume of air inhaled and exhaled with each breath. It is the amount of air remaining in the lungs after forced expiration. It is the additional air that can be forcefully inhaled after normal inhalation. It is the additional air that can be forcefully exhaled after normal exhalation

Which surgical procedure is appropriate for the removal of a vocal cord due to laryngeal cancer? Cordectomy Tracheotomy Total laryngectomy Oropharyngeal resections

While a nurse is conducting an initial assessment on a client, which classic sign would alert the nurse that the client has chronic obstructive pulmonary disease (COPD)? Barrel chest Cyanosis Hyperventilation Lordosis

While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse? Initiate oxygen via a nasal cannula Administer the prescribed morphine Prepare the client for endotracheal intubation Place a nitroglycerin tablet under the client's tongue

A client who is a pipe smoker is diagnosed with cancer of the tongue. A hemiglossectomy and right radical neck dissection are performed. To ensure airway patency while the client is in the postanesthesia care unit, what should the nurse do? Suction as needed Apply an ice collar Maintain a high-Fowler position Encourage expectoration of secretions

A After a hemiglossectomy a client will have difficulty swallowing and expectorating oral secretions because of the trauma of surgery. Although the application of an ice collar may limit edema or pain, it will not maintain patency of an airway that is compromised by secretions. A side-lying position will facilitate better drainage from the mouth. The client may not be reactive or have energy to cough or expectorate; the priority is to prevent secretions from entering the respiratory tract.

A client is admitted to the hospital with chronic asthma. Which complication should the nurse monitor in this client? Atelectasis Pneumothorax Pulmonary edema Respiratory alkalosis

A As a result of narrowed airways, adequate ventilation of lung tissue is compromised, and alveoli may collapse. Pneumothorax is not a common complication of asthma; a collapsed lung is referred to as a pneumothorax. Pulmonary edema is not a common complication of asthma; pulmonary edema is caused by left-sided heart failure. Respiratory alkalosis is not a common complication of asthma; with narrowed air passages, the client with asthma is at risk for hypoxia and respiratory acidosis.

While assessing the medical reports of a client with upper respiratory tract infections, the nurse notices that there are alterations in the platelet count. The client has a history of recent nasal surgery. Which clinical condition does the nurse suspect? Epistaxis Rhinosinusitis Allergic rhinitis Acute pharyngitis

A Epistaxis or nosebleeds may alterplatelet counts. Epistaxis may be observed in clients with upper respiratory tract infections, overuse of decongestant nasal sprays, or nasal surgery. Rhinosinusitis is the concurrent inflammation of the nasal mucosa. Allergic rhinitis is the reaction of the nasal mucosa to a specific allergen. Acute pharyngitis is an acute inflammation of the pharyngeal walls caused by viral or bacterial infections.

The client has just had a chest tube inserted. How should the nurse monitor for the complication of subcutaneous emphysema? Palpate around the tube insertion sites for crepitus Auscultate the breath sounds for crackles and atelectasis Observe the client for the presence of a barrel-shaped chest Compare the length of inspiration with the length of expiration

A Subcutaneous emphysema occurs when air leaks from the intrapleural space through the thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sound heard when tissues containing gas are palpated. Crackles and atelectasis are unrelated to crepitus. They occur within the lung; subcutaneous emphysema occurs in the soft tissues. Observing the client for the presence of a barrel-shaped chest is related to prolonged trapping of air in the alveoli associated with emphysema, a chronic obstructive pulmonary disease. Comparing the length of inspiration with the length of expiration is unrelated to subcutaneous emphysema, which involves gas in the soft tissues from a pleural leak.

A client presents to the emergency room with coughing and sudden wheezing. The nurse notes the client is progressing quickly into respiratory distress. The nurse identifies that the client is experiencing what problem? An acute asthma attack Acute bronchitis Left-sided heart failure Cor pulmonale

A Symptoms for an acute asthma attack often are wheezing, coughing, dyspnea, and chest tightness. Cough, fever, and fatigue are often symptoms exhibited with acute bronchitis. Fatigue, breathlessness, weakness, shortness of breath, and fluid accumulation in the lungs are often signs of left-sided heart failure. Tiring easily, shortness of breath with exertion, lower leg edema, chest pain, and heart palpitations often are exhibited with cor pulmonale.

A client sustains a crushing injury to the lower left leg, and a below-the-knee amputation is performed. For which common clinical manifestations of a pulmonary embolus should the nurse assess this client? Select all that apply. Sharp chest pain Acute onset of dyspnea Pain in the residual limb Absence of the popliteal pulse Blanching of the affected extremity

A client is admitted to the hospital with a diagnosis of restrictive airway disease. The nurse expects the client to exhibit which early signs of respiratory acidosis? Select all that apply. Headache Irritability Restlessness Hypertension Lightheadedness

ABC

What points should be considered when a client with a respiratory disorder undergoes a spiral-computed tomography (CT) scan to diagnose a pulmonary embolism? Select all that apply. The test involves the administration of a contrast medium. Clients should have their hydration levels assessed. Clients are instructed to lie still on a hard table. Clients are served shellfish before the test. A client's serum creatinine level is evaluated after the test.

ABC

Which physical assessment findings of a client suspected of having a respiratory disorder would be considered normal? Select all that apply. A midline trachea Pink nasal mucosa Deviated nasal septum Nonlabored respirations of 14 breaths/min Anteroposterior to lateral chest diameter (2:1)

ABD

A nurse assesses a newly admitted client with a diagnosis of pulmonary tuberculosis (TB). Which clinical findings support this diagnosis? Select all that apply. Fatigue Polyphagia Hemoptysis Night sweats Black tongue

ACD

A 65-year old client is found to have dilatation of the bronchioles and alveolar ducts. Which suggestions of the nurse would help the client overcome this situation? Select all that apply. Suggest the use of incentive spirometry. Suggest that the client takes an adequate amount of calcium daily. Suggest that the client perform vigorous pulmonary hygiene activities. Suggest that the client maintain an upright position as much as possible. Suggest that the client talk face-to face with others as much as possible.

ACD Dilatation of the bronchioles and alveolar ducts is a respiratory system change related to aging. Using incentive spirometry may help clients improve functioning of the lungs. This action may help the client take breaths more easily and more comfortably.

A client appears anxious, exhibiting 40 shallow respirations per minute. The client complains of feeling dizzy and lightheaded and of having tingling sensations of the fingertips and around the lips. What does the nurse conclude that the client's complaints probably are related to? Eupnea Hyperventilation Kussmaul respirations Carbon dioxide intoxication

A client has a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason identified by the nurse for suctioning the client? Humidified oxygen is saturated with fluid. The tracheostomy tube interferes with effective coughing. The inner cannula of the tracheostomy tube irritates the mucosa. The weaning process increases the amount of respiratory secretions.

A client is admitted for a rhinoplasty. To monitor for hemorrhage after the surgery, the nurse should assess specifically for the presence of which response? Facial edema Excessive swallowing Pressure around the eyes Serosanguineous drainage on the dressing

A client is admitted to the emergency department with a stab wound of the chest. What is the priority when the nurse performs a focused assessment of the client's response to this injury? Level of pain Quality and depth of respirations Amount of serosanguineous drainage Blood pressure and pupillary response

A client is admitted to the hospital with a diagnosis of cancer of the larynx, and a laryngectomy is scheduled. What is the most important piece of equipment that the nurse should place at the client's bedside postoperatively? Tracheostomy set Suction equipment Humidified oxygen Cold-steam vaporizer

A client is admitted to the hospital with a diagnosis of emphysema. What should the nurse include when teaching the client breathing exercises? Spend more time inhaling than exhaling to blow off carbon dioxide Perform diaphragmatic exercises to improve contraction of the diaphragm Perform sit-ups to strengthen abdominal muscles to improve breathing Use abdominal exercises to limit the use of accessory muscles of respiration

A client is brought to the emergency department after a bee sting. The client has a history of allergies to bees and is having difficulty breathing. What client reaction should cause a nurse the most concern? Ischemia Asphyxia Lactic acidosis Increased blood pressure

A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? Bradycardia Restlessness Constricted pupils Clubbing of the fingers

A client tells the nurse that the client's chest tube is scheduled to be removed soon. Before it is removed, what is the nurse aware of? The drainage system will be disconnected from the chest tube. A chest x-ray will be performed to determine lung re-expansion. An arterial blood gas will be obtained to determine oxygenation status. The client will be sedated 30 minutes before the procedure.

A client who is homeless is hospitalized for alcohol withdrawal. When considering the type of personal protective equipment that is needed for the client's care, what condition does the nurse recall that homeless persons are at risk for? Prostatitis Tuberculosis Osteoarthritis Diverticulosis

A client with a puncture wound of the chest wall is brought to the emergency department. What should be the nurse's first action? Prepare for a thoracentesis. Apply a wound dressing. Obtain baseline vital signs. Suction fluid from the wound.

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? Deflate the cuff on the endotracheal tube for a few minutes every one to two hours. Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. Adjust the temperature of fluid in the humidification chamber depending on the volume of gas delivered. Regulate the positive end-expiratory pressure (PEEP) according to the rate and depth of the client's respirations.

A graduate nurse reminds a client who just had a laryngoscopy not to take anything by mouth until instructed to do so. Which conclusion should be made about this intervention by the nurse preceptor who is evaluating the performance of the graduate nurse? Appropriate, because such clients usually experience painful swallowing for several days Appropriate, because early eating or drinking after such a procedure may cause aspiration Inappropriate, because the client is likely to be anxious, and it is easier to remove the water pitcher Inappropriate, because the client is conscious and may be thirsty after not being allowed to drink fluids

A nurse auscultates a client's lungs and hears a fine crackling sound in the left lower lung during respiration. The nurse charts, "crackles and rhonchi in the left lower lung." What does this documentation represent? A nursing diagnosis An inaccurate interpretation A correct nursing assessment An accurate conclusion if crepitus was ruled out

A nurse is caring for a client experiencing an acute episode of bronchial asthma. What should nursing interventions achieve? Curing the condition permanently Raising mucous secretions from the chest Limiting pulmonary secretions by decreasing fluid intake Convincing the client that the condition is emotionally based

A nurse is caring for a client who was admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease and is receiving oxygen at 2 L/min via nasal cannula. What is the primary focus of therapy when caring for this client? Limiting hydration Improving ventilation Decreasing exogenous oxygen Correcting the bicarbonate deficit

A nurse is caring for a client with the diagnosis of emphysema, a chronic obstructive pulmonary disease (COPD). The client is hypoxemic and also has chronic hypercarbia. Which statement reflects the oxygen needs of this client? The client may need up to 60% oxygen flow via Venturi mask. The client requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal cannula. The client should receive humidified oxygen delivered by a face mask. The client's respiratory treatment plan should have oxygen eliminated from it.

A nurse provides smoking-cessation education to a client with chronic obstructive pulmonary disease (COPD). The nurse concludes that the client is ready to quit smoking when the client makes which statement? "I'll just finish the carton that I have at home." "I'll cut back to a half pack a day." "I find that smoking is the only way I can relax." "I should find this easy because I don't smoke when I drink."

A nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange? Supine Orthopneic Low-Fowler Semi-Fowler

A nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. What information is most significant to include? Purpose of bronchodilators Importance of meticulous oral hygiene Technique used in pursed-lip breathing Methods used to maintain a dust-free environment

After resection of a lower lobe of the lung, a client has excessive respiratory secretions. Which independent nursing action should the nurse implement? Postural drainage Turning and positioning Administration of an expectorant Percussion and vibration techniques

Oxygen therapy is prescribed for a client being cared for in the coronary care unit. The nurse implements safety precautions. Which information should the nurse consider when planning care for this client? Oxygen is flammable. Oxygen supports combustion. Oxygen has unstable properties. Oxygen converts to an alternate form of matter.

The nurse is caring for a client with a pneumothorax and chest tube. To evaluate the effectiveness of a chest tube, the nurse assesses for which finding? Productive coughing Return of breath sounds Increased pleural drainage in the chamber Constant bubbling in the water-seal chamber

Which condition may lead to collapse of the walls of the bronchioles and alveolar air sacs? Asthma Emphysema Chronic bronchitis Centrilobular emphysema

Which part of the respiratory system is referred to as Angle of Louis? Hilum Carina Alveoli Epiglottis

While assessing a client, the nurse finds increased vibrations over the chest wall. What condition can be inferred from this finding? Atelectasis Pneumonia Orthopnea Pneumothorax

While caring for a client with asthma, the nurse auscultates a bilateral high-pitched, continuous whistling sound in the anterior lung fields. What finding does the nurse document in the medical record? Crackles Wheezes Rhonchus Pleural friction rub

While preparing the client for a diagnostic procedure, the nurse positions the client upright with elbows on an overbed table and the feet supported. The nurse also instructs the client not to talk or cough during the procedure. Which diagnostic test is the client undergoing? Lung biopsy Thoracentesis Mediastinoscopy Ventilation-perfusion scan

A client is discharged from the hospital after receiving a lung transplant. Which medical device should the client use to monitor his or her lung function at home? Oximetry Spirometry Capnography Ventilation-perfusion

B A spirometer is a hand-held device that can be used at home. A client blows forcefully and quickly into the device after taking a deep breath. This device is used to diagnose early lung transplant rejections or infections and helps to monitor lung function. Oximetry is used for the intermittent monitoring of arterial or venous oxygen saturation. Capnography helps to assess the level of CO 2 in exhaled air; this device graphically displays the amount of partial pressure of CO 2. Ventilation-perfusion is used to assess the ventilation and perfusion of the lungs.

A client with chronic obstructive pulmonary disease (COPD) reports a 5-pound (2.3 kg) weight gain in one week. What does the nurse recall is the complication that may have precipitated this weight gain? Polycythemia Cor pulmonale Compensated acidosis Left ventricular failure

B A sudden weight gain is an initial sign of right ventricular failure caused by COPD. Polycythemia is associated with polycythemia vera, not COPD. A sudden weight gain is not associated with compensated acidosis. Right, not left, ventricular failure[1][2] occurs with COPD.

A client with chronic obstructive pulmonary disease is admitted to the hospital with a tentative diagnosis of pleuritis. When caring for this client, what should the nurse do? Administer opioids frequently Assess for signs of pneumonia Give medication to suppress coughing Limit fluid intake to prevent pulmonary edema

B Clients with pleuritic disease are prone to developing pneumonia because of impaired lung expansion, air exchange, and drainage. Opioids are contraindicated because opioids depress respirations. Coughing should not be suppressed; it enhances lung expansion, air exchange, and lung drainage. Oral fluids should be encouraged; pulmonary edema does not develop unless the client has severe cardiovascular disease.

A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, which response does the nurse expect? Hypokalemia Metabolic acidosis Respiratory alkalosis Decreased carbon dioxide level

B Decreased oxygen promotes the conversion of pyruvic acid to lactic acid, resulting in metabolic acidosis. Arterial blood gases do not assess serum potassium levels. Hyperkalemia will occur with shock because of renal shutdown. Respiratory alkalosis may occur in early shock because of rapid, shallow breathing, but in late shock metabolic or respiratory acidosis occurs. The carbon dioxide level will be increased in profound shock.

A client with late-stage dementia of the Alzheimer type aspirates gastric contents and develops acute respiratory distress syndrome (ARDS). Which phase characterized by signs of pulmonary edema and atelectasis should the nurse consider when planning care? Fibrotic Exudative Reparative Proliferative

B Exudative (injury) phase of ARDS is the early phase. Alveoli become fluid-filled with pulmonary shunting and atelectasis. Fibrotic phase of ARDS leads to pulmonary hypertension and fibrosis. Reparative (resolution) phase starts about two weeks after injury; it is characterized by recovery. If this phase persists for a prolonged time, extensive fibrosis, death, or chronic disease may result.

An older client complains of confusion, dry mouth, and constipation. The client was treated for rhinitis a week ago and is taking chlorpheniramine. Which information provided by the nurse would be beneficial to the client? Chlorpheniramine needs to be stopped immediately. These are common side effects of chlorpheniramine. Hydroxyzine needs to be taken with chlorpheniramine. The chlorpheniramine prescription needs to be changed.

B First-generation antihistamines such as chlorpheniramine have side effects such of confusion, dry mouth, and constipation in older adults. Making the older client aware of the adverse effects may be beneficial for the client. The nurse does not need to order the client to stop the prescribed drug treatment immediately. Hydroxyzine also has the same side effects, so suggesting this drug will not be beneficial. A nurse should first consult the primary healthcare provider before recommending changing the medication.

A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained secretions. To decrease the amount of secretions retained, what should the nurse do? Administer continuous oxygen Increase fluid intake to at least 2 L a day Place the client in a high-Fowler position Instruct the client to gargle deep in the throat using warmed normal saline

B Increased fluid intake helps to liquefy respiratory secretions, which promotes expectoration. Oxygen may dry the mucous membranes, which may thicken secretions; oxygen should be administered only when necessary. Placing the client in a high-Fowler position promotes retention of secretions; supine, prone, and Trendelenburg positions promote removal of secretions via gravity. Retained secretions are in the bronchi and trachea; gargling lubricates only the oropharynx.

A nurse is caring for a client with a pneumothorax who has a chest tube attached to a closed chest drainage system. If the chest tube and closed chest drainage system are effective, what type of pressure will be reestablished? Neutral pressure in the pleural space Negative pressure in the pleural space Atmospheric pressure in the thoracic cavity Intrapulmonic pressure in the thoracic cavity

B Removal of air and fluid from the pleural space reestablishes negative pressure, resulting in lung expansion. Neutral pressure in the pleural space will cause collapse of the lung. Atmospheric pressure in the thoracic cavity will cause collapse of the lung. Intrapulmonic pressure refers to pressure within the lung itself, not the pressure within the thoracic cavity.

The nurse is providing postoperative care to a client with lung cancer who had a partial pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels spongy and crackles can be felt. How does the nurse describe this assessment finding? Respiratory stridor Subcutaneous emphysema Bilateral 2+ pitting edema Chest distention

B There is air in the tissues and palpation results in a crackling sound referred to as subcutaneous emphysema. Respiratory stridor is a harsh, high-pitched sound usually produced on inspiration because of airway obstruction. Bilateral 2+ pitting edema is excessive accumulation of fluid in tissue spaces. The size of the chest is determined by the bony structure; a barrel chest with an increase in the anteroposterior (AP) diameter is associated with chronic obstructive pulmonary disease (COPD), not cancer of the lung.

A client who has acquired human immunodeficiency syndrome (HIV) develops bacterial pneumonia. On admission to the emergency department, the client's PaO 2 is 80 mm Hg. When the arterial blood gases are drawn again, the level is determined to be 65 mm Hg. What should the nurse do first? Prepare to intubate the client. Increase the oxygen flow rate per facility protocol. Decrease the tension of oxygen in the plasma. Have the arterial blood gases redone to verify accuracy.

B This decrease in PaO 2 indicates respiratory failure; it warrants immediate medical evaluation. Most facilities have a protocol to increase the oxygen flow rate to keep oxygen saturation greater than 92%. The client PaO 2 of 65 mm Hg is not severe enough to intubate the client without first increasing flow rate to determine if the client improves. Decreasing the tension of oxygen in the plasma is inappropriate and will compound the problem. The PaO 2 is a measure of the pressure (tension) of oxygen in the plasma; this level is decreased in individuals who have perfusion difficulties, such as those with pneumonia. Having the arterial blood gases redone to verify accuracy is negligent and dangerous; a falling PaO 2 level is a serious indication of worsening pulmonary status and must be addressed immediately. Drawing another blood sample and waiting for results will take too long.

A 67-year-old client has tested positive for influenza A. The client also has asthma. Which drug would the nurse recommend be avoided in this client? Ribavirin Zanamivir Oseltamivir Amantadine

B Zanamivir is used with caution in clients who have asthma or chronic obstructive pulmonary disease (COPD) and in older adults. Ribavirin is used for the treatment of severe influenza B. Oseltamivir may be used in treating both influenza A and B. Amantadine may be used for the treatment of influenza A.

What should the nurse assess when inspecting the mouth and pharynx of a client suspected of having a pulmonary disorder? Select all that apply. Polyps Gag reflex Shotty nodes Poor dentition Gum retraction

BCD

Which findings should the nurse expect to see in a client with chronic obstructive pulmonary disease? Select all that apply. Elevated levels of partial arterial oxygen Elevated levels of eosinophils Elevated levels of neutrophils Elevated levels of red blood cells Elevated levels of peripheral capillary oxygen saturation

BCD Elevated levels of eosinophils, neutrophils, and red blood cells are often related to the excessive production of erythropoietin in response to a chronic hypoxic state and indicates possible chronic obstructive pulmonary disease. Elevated levels of partial arterial oxygen and peripheral capillary oxygen saturation are not associated with chronic obstructive pulmonary disease. However, elevated levels of partial arterial oxygen indicate possible excessive oxygen administration. Decreased levels of peripheral capillary oxygen saturation indicate possible impaired ability of hemoglobin to release oxygen to tissues.

A nurse is caring for a client who underwent surgery for laryngeal cancer. Which nursing action may help to communicate effectively with the client? Select all that apply. Asking the client open-ended questions Providing the client with praise and encouragement Collaborating with a speech and language pathologist Using a high-pitched tone of voice to speak with the client Asking the client to make noise when immediate attention is required

BCE

A nurse is caring for a client with a nosebleed originating from the anterior aspect of the nose. Which nursing interventions would help the client? Select all that apply. Positioning the client horizontally without a pillow Applying direct lateral pressure to the nose for 10 minutes Reducing anxiety and blood pressure by reassuring the client Instructing the client to blow his or her nose to remove the blood Loosely packing the client's nares with gauze or nasal tampons

BCE

What are the uses of pulmonary function tests (PFT)? Select all that apply. Pulmonary function tests (PFT) can detect lung cancer. Pulmonary function tests (PFT) can measure lung volume. Pulmonary function tests (PFT) can assess responses to bronchodilators. Pulmonary function tests (PFT) are performed on the pulmonary nodules. Pulmonary function tests (PFT) can diagnose pulmonary disease.

BCE

The nurse is collecting the health history of a client suspected to have a pulmonary disorder. Which questions should the nurse ask the client related to health perception and health management? Select all that apply. "Do you experience a morning headache?" "Have you ever smoked elicit street drugs?" "What do you do when you get short of breath?" "Are you able to maintain a typical activity pattern?" "What equipment helps you manage your respiratory problems?"

A client develops a deep vein thrombosis after surgery. Which alteration in the client's condition may indicate that the client is experiencing a pulmonary embolus? Bradycardia Flushed face Unilateral chest pain Decreased blood pressure

A client develops respiratory alkalosis. When the nurse is reviewing the laboratory results, which finding is consistent with respiratory alkalosis? An elevated pH, elevated PCO 2 A decreased pH, elevated PCO 2 An elevated pH, decreased PCO 2 A decreased pH, decreased PCO 2

A client has a history of falling while playing football and now reports pain in the nose and difficulty breathing. What condition may the client have? Crepitus Sinusitis Fracture of the nose Upper respiratory tract infection

A client has a left pneumonectomy. Which nursing intervention is critical when the client regains consciousness in the postanesthesia care unit? Assessing for pain Removing the airway Encouraging deep breathing Positioning on the right side

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. Which clinical finding should the nurse expect when assessing this client? Hypertension Tenacious sputum Altered mental status Slowed rate of breathing

A client is admitted to the postanesthesia care unit after a segmental resection of the right lower lobe of the lung. A chest tube drainage system is in place. When caring for this tube, what should the nurse do? Raise the drainage system to bed level and check its patency Clamp the tube when moving the client from the bed to a chair Mark the time and fluid level on the side of the drainage chamber Secure the chest catheter to the wound dressing with a sterile safety pin

A client on a mechanical ventilator is receiving positive end-expiratory pressure (PEEP). The nurse understands that this treatment improves oxygenation primarily by doing what? Providing more oxygen to lung tissue Forcing pressure into lung tissue, which improves gas exchange Opening collapsed alveoli and keeping them open Opening collapsed bronchioles, which allows more oxygen to reach lung tissue

A client sustains fractured ribs as a result of a motor vehicle collision. Which clinical indicator identified by the nurse suggests the client may be experiencing a complication of fractured ribs? Report of pain when taking deep breaths Client is observed splinting the fracture site Diminished breath sounds on the affected side Bowel sounds are auscultated in the lower chest

A client who experienced smoke inhalation has a negative chest x-ray and arterial blood gases that demonstrate PaO 2 of 75 mm Hg, PaCO 2 of 45 mm Hg, and pH of 7.35. Which intervention should the nurse anticipate will be prescribed by the healthcare provider? Deep suctioning Bronchodilators Breathing exercises Mechanical ventilation

A client who had surgery for a laryngectomy is returned to the surgical unit from the postanesthesia care unit. In which position is it most appropriate for the nurse to place the client at this time? Prone with the head turned to one side Supine with the knees flexed at 10 degrees Lateral with the head slightly elevated and flexed Supine with the head in a hyperextended position

A client with a coronary occlusion is experiencing chest pain and distress. Why does the nurse administer oxygen? To prevent dyspnea To prevent cyanosis To increase oxygen concentration to heart cells To increase oxygen tension in the circulating blood

A client with a malignant parotid tumor is treated aggressively with radiation therapy and surgery. Postsurgical arterial blood gas results are as follows: pH 7.32, PCO 2 53 mm Hg, and HCO 3 25 mEq (25 mmol/L). The nurse should take which action? Obtain a prescription and administer a diuretic. Instruct the client to breathe into a rebreather bag at a slow rate. Ask the client to cough forcefully and take deep breaths. Obtain a prescription for sodium bicarbonate.

A client with a pneumothorax has a chest tube inserted and attached to a closed chest drainage system. The client asks, "Why is the tube in my chest hooked up to a contraption with water in it?" How does the nurse explain the function of the water? Promotes pleural drainage via gravity Measures the pressures in the chest wall Prevents reflux of air back into the chest Ensures bubbling in the water-seal chamber

A client with asthma is being taught how to use a peak flow meter to monitor how well the asthma is being controlled. What should the nurse instruct the client to do? Perform the procedure once in the morning and once at night. Move the trunk to an upright position and then exhale while bending over. Inhale completely and then blow out as hard and as fast as possible through the mouthpiece. Place the mouthpiece between the lips and in front of the teeth before starting the procedure.

A client with emphysema experiences a sudden episode of shortness of breath and is diagnosed with a spontaneous pneumothorax. The client asks, "How could this have happened?" The nurse's response is based on what likely cause of the spontaneous pneumothorax? Pleural friction rub Tracheoesophageal fistula Rupture of a subpleural bleb Puncture wound of the chest wall

A client with emphysema is admitted to the hospital with pneumonia. On the third hospital day, the client complains of a sharp pain on the right side of the chest. The nurse suspects a pneumothorax. What breath sound is most likely to be present when the nurse assesses the client's right side? Crackling Wheezing Decreased sounds Adventitious sounds

A client with pneumonia now requires use of a nonrebreathing mask to maintain adequate oxygen saturation levels. How does the nurse interpret this information? The client's pneumonia is continually improving. Oxygen concentrations up to 44% can be obtained. Mechanical ventilation may be required next. Nasal cannula may be used while the client is eating.

A client's respiratory status deteriorates, and endotracheal intubation and positive pressure ventilation are instituted. What is the nurse's most immediate intervention at this time? Prepare the client for emergency surgery. Facilitate the client's verbal communication. Assess the client's response to the interventions. Maintain sterility of the ventilation system that is being used.

A nurse administers oxygen at 2 L/min via nasal cannula to a client with chronic obstructive pulmonary disease (COPD). By administering a low concentration of oxygen to this client, the nurse is preventing which physiologic response? Decrease in red cell formation Rupture of emphysematous bullae Depression in the respiratory center Excessive drying of the respiratory mucosa

A nurse is caring for a client after abdominal surgery and encourages the client to turn from side to side and to engage in deep-breathing exercises. What complication is the nurse trying to prevent? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

A nurse is caring for a client with pulmonary tuberculosis. What must the nurse determine before discontinuing airborne precautions? Client no longer is infected. Tuberculin skin test is negative. Sputum is free of acid-fast bacteria. Client's temperature has returned to normal.

A nurse is teaching a community health class about the risk factors for cancer. Which factor has the least influence in predisposing an individual to cancer of the larynx? Air pollution Heavy alcohol ingestion Inadequate dental hygiene Chronic respiratory infection

A nurse teaches a client how to perform diaphragmatic breathing. Which instruction should the nurse provide? Take rapid, deep breaths Breathe with hands on the hips Expand the abdomen on inhalation Perform exercises leaning forward while in a sitting position

After abdominal surgery, a goal is to have the client achieve alveolar expansion. The nurse determines that this goal is most effectively achieved by what method? Postural drainage Pursed-lip breathing Incentive spirometry Sustained exhalation

An older adult client who complains of difficulty breathing after a surgery is found to have decreased vital capacity on spirometry. Which nursing intervention should be performed in this situation? Assess the client's mobility. Monitor respirations and breathing effort. Teach coughing and deep-breathing exercises. Determine normal activity levels and note when the client tires.

During a client's immediate postoperative period after a laryngectomy, what is a nursing priority? Provide emotional support Observe for signs of infection Keep the trachea free of secretions Promote a means of communication

During a follow-up visit three weeks after a laryngectomy, a client exhibits concern that the laryngectomy tube may become dislodged. What should the nurse teach the client to do if the tube becomes dislodged? Reinsert another tube immediately. Notify the healthcare provider at once. Keep calm because this is no immediate emergency. Quickly take action to prevent the tracheal stoma from closing.

During data collection, the nurse inspects the client's nose and concludes that the client has an infection. Which finding supports the nurse's conclusion? Bloody discharge Watery discharge Thick mucosal discharge Purulent and malodorous discharge

Polycythemia is frequently associated with chronic obstructive pulmonary disease (COPD). Which should the nurse monitor for when assessing for this complication? Pallor and cyanosis Dyspnea on exertion Elevated hemoglobin Decreased hematocrit

The healthcare provider prescribes theophylline to be given intravenously for the client experiencing an acute asthma attack. What does the nurse teach the client is the function of this medication? Antibiotic Antihistamine Bronchodilator Expectorant

The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which would be appropriate to include? They are indicative of pleural rubbing. They are signs of bronchial constriction. Crackles are located in the smaller air passages. Crackles are heard during respiratory expiration.

The nurse is caring for a client who has a tracheostomy tube with a high-volume, low-pressure cuff. What does the cuff prevent? Leakage of air Lung infection Mucosal necrosis Tracheal secretion

The nurse is providing postoperative care to a client with cancer of the lung who had a lobectomy. The client has a chest tube attached to suction. Which assessment finding includes a complication? Clots in the tubing during the first postoperative day Bloody fluid in the drainage-collection chamber on the first postoperative day Subcutaneous emphysema on the second postoperative day Decreased bubbling in the water-seal chamber on the third postoperative day

The nurse is reviewing the client's health history. With which diagnosis is a client most likely to exhibit hemoptysis? Anemia Pneumonia Tuberculosis Leukocytosis

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. Which is the priority nursing intervention? Initiate oxygen therapy Obtain chest x-ray film immediately Place client in a high-Fowler position Assess the client for a pleural friction rub

When providing discharge teaching for a young female client who had a pneumothorax, it is important that the nurse include the signs and symptoms of a recurring pneumothorax. What is the most important symptom that the nurse should teach the client to report to the healthcare provider? Substernal chest pain Episodes of palpitation Severe shortness of breath Dizziness when standing up

Which assessment finding is considered the earliest sign of decreased tissue oxygenation? Cyanosis Cool, clammy skin Unexplained restlessness Retraction of interspaces on inspiration

Which cartilage is also known as the Adam's apple? Costal Cricoid Thyroid Arytenoid

Which criteria should the primary healthcare provider use for the prescription of long-term continuous oxygen therapy? PaO 2-72, SpO 2- 96 PaO 2-60, SpO 2- 90 PaO 2-55, SpO 2- 88 PaO 2-40, SpO 2- 75

Which sounds are described as abnormal extra breath sounds to include crackles, rhonchi, wheezes, and pleural friction rubs? Vesicular Bronchial Adventitious Bronchovesicular

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO 2 of 60 mm Hg. These blood gases require nursing attention because they indicate which condition? Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

C The normal blood pH range is 7.35 to 7.45; therefore, a blood pH of 7.25 indicates acidosis. The parameter for respiratory function is CO 2 and the acceptable range of arterial PCO 2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated, resulting in respiratory acidosis. HCO 3 is the parameter for metabolic functions. A pH of 7.25 is acidic, indicating acidosis and not alkalosis.

Which diagnostic test is performed under general anesthesia to detect non-Hodgkin lymphoma and requires the client to sign an informed consent form? A thoracentesis A bronchoscopy A mediastinoscopy Computed tomography (CT)

C A mediastinoscopy is a surgical procedure that requires the client to sign an informed consent form. This procedure is performed under general anesthesia and is used to detect non-Hodgkin lymphoma. A thoracentesis is a diagnostic procedure used to obtain a specimen of pleural fluid for diagnosis, to remove pleural fluid, or to instill medication. A bronchoscopy is used to diagnose a condition, to biopsy, to collect a specimen, or to suction mucous plugs, and remove foreign objects. Computed tomography (CT) is performed to diagnose lesions difficult to assess via conventional X-ray studies.

A nurse is caring for a client with an endotracheal tube. Which is the most effective way for the nurse to loosen respiratory secretions? Increase oral fluid intake Provide chest physiotherapy Humidify the prescribed oxygen Instill a saturated solution of potassium iodide

C Because the client has an endotracheal tube in place, secretions can be loosened by administration of humidified oxygen and by frequent turning. A client with an endotracheal tube in place is not permitted fluids by mouth. Providing chest physiotherapy is too vigorous for a client with an endotracheal tube. Potassium is never instilled into the lungs.

On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, what is the nurse most likely to identify? Muscle twitching Mental instability Deep and rapid respirations Tachycardia and cardiac dysrhythmias

C Deep, rapid respirations are an adaptation to a decreased serum pH. Carbonic acid dissociates in the lungs to hydrogen ions and carbon dioxide, which helps increase the serum pH. Muscle twitching results from low serum calcium (hypocalcemia), not compensated metabolic acidosis. Mental confusion does not occur in compensated acidosis; confusion can occur in uncompensated metabolic acidosis. Tachycardia and cardiac dysrhythmias are associated with hyperthyroidism, not compensated metabolic acidosis.

What data about the fluid in the water-seal chamber of a closed chest drainage system provide support for the nurse's conclusion that the system is functioning correctly? Contains many small air bubbles Bubbles vigorously on inspiration Rises with inspiration and falls with expiration Remains at a consistent level during the respiratory cycle

C During inspiration, negative pressure in the pleural space increases, causing fluid to rise in the chamber; during expiration, negative pressure in the pleural space decreases, causing fluid to drop in the chamber. If the system is closed to the atmosphere, as it should be, bubbles will not be present. Changes in intrapleural pressure cause fluid to rise on inspiration and fall on expiration (tidaling).

After a laryngectomy a client is concerned about improving the ability to communicate. Which topic should the nurse include in a teaching plan for the client? Sign language Body language Esophageal speech Computer-generated speech

C Esophageal speech[1][2] is one method for the client to communicate after a laryngectomy; speech is produced by expelling swallowed air across constricted tissue in the pharyngoesophageal segment. Although sign language may be an adjunct to verbal speech, it should not be the primary means of communication. Body language is used for individuals who wish to communicate with someone who is deaf. Computer-generated speech does not allow for the spontaneous communication possible with a tracheoesophageal puncture, esophageal speech, or an electrolarynx.

The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. What type of respirations does the nurse expect the client to exhibit? Dyspnea Hyperpnea Kussmaul breathing Cheyne-Stokes breathing

C Kussmaul breathing is an abnormally deep, very rapid, sighing type of respiratory pattern that develops as a compensatory response to metabolic acidosis and attempts to raise the pH of the blood by blowing off carbon dioxide. Dyspnea is difficult breathing associated with subjective or objective distress in response to oxygen problems. Hyperpnea is a deep, rapid rate of breathing without a subjective sense of extra effort, usually as a response to strenuous effort. Cheyne-Stokes respirations are characterized by a waxing and waning of breathing that is usually associated with pathology of the respiratory center in the brain.

A nurse gave a client naloxone. To evaluate the effectiveness of the medication, what should the nurse assess for? Change in level of consciousness Increased pain Increased respiration Decreased heart rate

C Naloxone is given for decreased respirations caused by opioid overdose[1][2]. The amount given is determined by the respiratory status, not the level of consciousness. Undesirable side effects of naloxone are pain and rapid heart rate with dysrhythmias.

In which positions should the nurse place a client who has just had a right pneumonectomy? Right or left side-lying High-Fowler or supine Supine or right side-lying Left side-lying or low-Fowler

C Supine or right side-lying permits ventilation of the remaining lung and prevents fluid from draining into the sutured bronchial stump.

The nurse is assessing a client's arterial blood gases and determines that the client is in compensated respiratory acidosis. The pH value is 7.34; which other result helped the nurse reach this conclusion? PO 2 value is 80 mm Hg. PCO 2 value is 60 mm Hg. HCO 3 value is 50 mEq/L (50 mmol/L). Serum potassium value is 4 mEq/L (4 mmol/L).

C The HCO 3 value is elevated. The urinary system compensates by retaining H + ions, which become part of the bicarbonate ions; the bicarbonate level becomes elevated and increases the pH level to near the expected range. The expected HCO 3 value is 21 to 28 mEq/L (21 to 28 mmol/L), and the expected pH value is 7.35 to 7.45. The body's usual PO 2 value is 80 to 100 mm Hg; 80 mm Hg is within the expected range. The body's PCO 2 value is 35 to 45 mm Hg; although in compensated respiratory acidosis[1][2] the PCO 2 level may be increased, it is the increased HCO 3 level that indicates compensation. A K + level of 4 mEq/L (4 mmol/L) is within the expected range of 3.5 to 5 mEq/L (3.5 to 5 mmol/L); the serum potassium level is not significant in identifying compensated respiratory acidosis.

When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How should the nurse document this finding? Adventitious sounds Fine crackling sounds Vesicular breath sounds Diminished breath sounds

C Vesicular are normal respiratory sounds heard on auscultation as inspired air enters and leaves the alveoli. Adventitious is the general term for all abnormal breath sounds. Crackles heard at the end of an inspiration are associated with fluid in the alveoli. Diminished breath sounds are evidence of a reduction in the amount of air entering the alveoli; this usually is caused by obstruction or consolidation.

Soft swishing sounds of breathing are heard when the nurse auscultates a client's chest. What term should be used when documenting this assessment? Fine crackles Adventitious sounds Vesicular breath sounds Diminished breath sounds

C Vesicular breath sounds[1][2] are expected respiratory sounds heard on auscultation as inspired air enters and leaves alveoli. Fine crackles are faint crackling sounds heard at the end of inspiration; they are associated with pulmonary edema. Adventitious sounds is a general term for all abnormal breath sounds. Diminished breath sounds are evidence of a decreased amount of air entering the alveoli; this usually is caused by obstruction or consolidation.

A client is experiencing dyspnea. In which position should the nurse place the client? Sims Supine Orthopneic Trendelenburg

C he orthopneic position refers to sitting up and leaning slightly forward, which lowers the diaphragm, allowing the lungs more room for expansion. Horizontal positions, such as Sims and supine, do not allow the gravitational effect on the diaphragm and thus do not maximize air exchange. The Trendelenburg position forces the diaphragm up toward the lungs, thereby interfering with lung expansion.

A client has a chest tube for a pneumothorax. The nurse finds the client in respiratory difficulty, with the chest tube separated from the drainage system. What should the nurse do? Obtain a new sterile drainage system. Use two clamps to close the drainage tube. Place the client in the high-Fowler position. Reconnect the client's tube to the drainage system.

A client is admitted to the hospital with a diagnosis of laryngeal cancer. What is a common early sign of laryngeal cancer for which the nurse should assess in this client? Aphasia Dyspnea Dysphagia Hoarseness

A client is admitted to the intensive care unit with pulmonary edema. Which clinical finding does the nurse expect when performing the admission assessment? Weak, rapid pulse Decreased blood pressure Radiating anterior chest pain Crackles at bases of the lungs

A client is admitted with possible tuberculosis. To make a definitive diagnosis, the nurse expects which diagnostic test to be prescribed? Chest x-ray film Tuberculin skin test Pulmonary function test Sputum test for acid-fast bacilli

A client is experiencing severe respiratory distress. Which response should the nurse expect the client to exhibit? Tremors Anasarca Bradypnea Tachycardia

A client is transferred from the postanesthesia care unit to the intensive care unit after a radical neck dissection. In what position should the nurse place the client to facilitate respirations and promote comfort? Sims Lateral Orthopneic Semi-Fowler

A client returns from a radical neck dissection with a tracheotomy and two portable wound drainage systems at the operative site. Inspection of the neck incision reveals moderate edema of the tissues. Which assessment finding is a priority requiring immediate nursing intervention? Cloudy wound drainage Poor gag reflex Decreased urinary output Restlessness with dyspnea

A client returns from surgery after a total laryngectomy with a laryngectomy tube in the permanent stoma. In which position should the nurse place this client to facilitate respirations and promote comfort? Side-lying position Orthopneic position High-Fowler position Semi-Fowler position

A client who is negative for human immunodeficiency virus (HIV) but who has a history of chronic obstructive pulmonary disease (COPD) requests the nurse to read the results of the client's Mantoux test for tuberculosis. The test site has a 10-mm area of induration with 5 mm of erythema. How should the nurse interpret the finding? The erythema does not meet the criterion for a diagnosis of tuberculosis; the results are negative. The clinical manifestations indicate that the client has tuberculosis; the results are positive. The results are indeterminate because of the client's history of COPD. The client has been exposed to the pathogen that causes tuberculosis.

A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's arterial blood studies indicate pH 7.30, PO 2 60 mm Hg, PCO 2 55 mm Hg, and HCO 3 23 mEq/L (23 mmol/L). How should the nurse interpret these findings? Hypocapnia Hyperkalemia Generalized anemia Respiratory acidosis

A client with oat-cell lung cancer is scheduled for a mediastinoscopy and biopsy. What should the nurse include in the client's education? Chest tubes will be in place after the procedure. The procedure will visualize the mainstem bronchus. Some pleural fluid will be removed during the procedure. The procedure is an endoscopic examination of lymph nodes.

A nurse instructs a client to breathe deeply to open collapsed alveoli. What is the best explanation the nurse could offer to explain the relationship between alveoli and improved oxygenation? The alveoli need oxygen to live. The alveoli have no direct effect on oxygenation. Collapsed alveoli increase oxygen demand. Oxygen is exchanged for carbon dioxide in the alveolar membrane.

A nurse is caring for a client with a chest tube. How will complete lung expansion be determined before removal of the chest tube? Return of usual tidal volume Decreased adventitious sounds Absence of additional drainage Comparison of chest radiographs

A nurse is caring for a client with a pneumothorax who has a chest tube in place with a closed drainage system. Which of these actions by the nurse is correct? Strip the chest tube periodically. Administer the prescribed cough suppressant at the scheduled times. Empty and measure the drainage in the collection chamber each shift. Keep the drainage system lower than the level of the client's chest.

A nurse is providing education to a coworker who is caring for a client who is scheduled to have a thoracentesis for a pleural effusion. Which information will be appropriate for the nurse to include? The thoracentesis procedure uses the principle of positive pressure. It is common for a sclerosing agent to be instilled at the end of the procedure. Clients will have temporary increased dyspnea immediately after the procedure. Rapid removal of large amounts of fluid may precipitate cardiovascular collapse.

A nurse is teaching Hands Only Basic Life Support for adults in the community. What should the rescuer do first after determining that the person is not responding and the emergency medical system has been activated? Identify the absence of pulse. Give two rescue breaths with a CPR mask. Perform the head tilt-chin lift maneuver. Perform chest compression at a rate of 100/min.

A nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. What is the most important intervention for the nurse to include in this plan? Ensuring sufficient rest Changing lifestyle routines Breathing clean outdoor air Taking medications as prescribed

A nurse works with a large population of immigrant clients and is concerned about the debilitating effects of influenza. Which action by the nurse is the first line of defense against an emerging influenza pandemic? Complying with quarantine measures Instituting strict international travel restrictions Seeking aid from the international public health community Reporting surveillance findings to appropriate public health officials

A postoperative client is diagnosed as having atelectasis. Which nursing assessment supports this diagnosis? Productive cough Clubbing of the fingertips Crackles at the height of inhalation Diminished breath sounds on auscultation

A registered nurse is examining the medical reports of different clients. Which client may need immediate assessment? A client who is scheduled for a bronchoscopy A client who is scheduled for a thoracentesis A client with pleural effusion and decreased breath sounds A client with acute asthma and 85% oxygen saturation

Before discharge, the nurse is planning to teach the client with emphysema pursed-lip breathing. What should the nurse instruct the client about the purpose of pursed-lip breathing? Decreases chest pain Conserves energy Increases oxygen saturation Promotes elimination of CO 2

During the infusion of dialysate during peritoneal dialysis, the client exhibits symptoms of severe respiratory difficulty. What should the nurse do? Slow the rate of the client's infusion Place the client in a low-Fowler position Auscultate the client's lungs for breath sounds Drain the fluid from the client's peritoneal cavity

Histoplasmosis is suspected in a client. Which risk factor is the nurse likely to find in the history? The client is a chain smoker. The client works in a cement factory. The client has a history of a minor hand fracture. The client has a history of travel to central parts of North America.

On a client's admission to a rehabilitation unit, the nurse gives the client, who is not immunocompromised, a purified protein derivative (PPD) of tuberculin to test for tuberculosis. Which client reaction indicates a positive response? 5-mm erythema with no induration No erythema with 3-mm induration 7-mm erythema with 5-mm induration 5-mm erythema with 10-mm induration

The nurse obtains a laboratory report that shows acid-fast rods in a client's sputum. Which disorder should the nurse consider may be related to these results? Influenza virus Diphtheria bacillus Bordetella pertussis Mycobacterium tuberculosis

What breathing exercises should the nurse teach a client with the diagnosis of emphysema? An inhalation that is prolonged to promote gas exchange. Abdominal exercises to limit the use of accessory muscles. Sit-ups to help strengthen the accessory muscles of respiration. Diaphragmatic exercises to improve contraction of the diaphragm.

What condition would a nurse suspect in a client with abnormal respirations with alternating periods of apnea and rapid breathing? Pectus carinatum Pectus excavatum Kussmaul breathing Cheyne-Stokes respirations

What is the normal value of inspiratory reserve volume? 0.5 L 1.0 L 1.5 L 3.0 L

When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? Administer sedatives around the clock Turn client every four hours Increase ventilator settings as needed Suction as needed

Which chest examination findings can be observed in a client with pneumonia? Absent sounds on auscultation Hyperresonance on percussion Prolonged expiration on inspection Increased fremitus over affected area on palpation

Which client would have relatively smaller tidal volumes due to limited chest wall movement? A client with asthma A client with pneumonia A client with pulmonary fibrosis A client with phrenic nerve paralysis

Which part of the upper respiratory system is involved in equalizing the pressure within the middle ear while swallowing? Glottis Paranasal sinus Palatine tonsils Eustachian tubes

Which physical assessment maneuver is the nurse performing when instructing the client to breathe in slowly and a little more deeply than normal through the mouth? Palpation Inspection Percussion Auscultation

Which pulmonary function test provides a more sensitive index of obstruction in smaller airways? Forced vital capacity Functional residual capacity Forced expiratory volume in 1 second Forced expiratory flow over the 25% to 75% volume of the forced vital capacity

Which respiratory measurement is useful in differentiating between obstructive and restrictive pulmonary dysfunction? Peak expiratory flow rate Forced vital capacity Forced mid-expiratory flow rate Forced expiratory volume/forced vital capacity ratio

What intervention should a nurse perform during a chest examination of a female client with a suspected lung disorder? Perform the test in a dark room Examine only the anterior chest Observe for any evidence of respiratory distress Begin the chest examination on the posterior chest

D A female's chest examination should begin with the posterior chest in order to prevent interference from the breast tissue. A chest examination is best performed in a well-lighted, warm room with measures to ensure the client`s privacy. The nurse should perform the exam on both the anterior and posterior chest of clients. Observing any evidence of respiratory distress should be conducted on both males and females.

A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client? Slow, deep respirations Normal oral temperature Dry, unproductive cough Diminished breath sounds

D Because atelectasis[1][2] involves collapsing of alveoli distal to the bronchioles, breath sounds are diminished in the lower lobes. The client will have rapid, shallow respirations to compensate for poor gas exchange. Atelectasis results in an elevated temperature. Atelectasis results in a loose, productive cough.

A client with chronic obstructive pulmonary disease has increased hemoglobin and hematocrit levels. How should the nurse interpret these findings? Increased leukocyte development in response to infection Decreased extracellular fluid volume secondary to infection Decreased red blood cell proliferation because of hypercapnia Increased erythrocyte production as a result of chronic hypoxia

D Hypoxia stimulates production of large quantities of erythrocytes in an attempt to compensate for the lack of oxygen. White blood cell production increases with infection; infection is not the cause of the increase in the hemoglobin and hematocrit. There is a loss of extracellular fluid in an acute infection with a fever; however, in a chronic condition, this fluid is replenished and the hematocrit usually is unaffected. Hypercapnia is an increase in PCO 2 in extracellular fluid; this does not have a direct effect on the hemoglobin and hematocrit levels.

A client presenting with an acute asthma attack is being assessed in the emergency room. The client's spouse reports that the client currently is being treated for an upper respiratory infection. The nurse should understand that the client most likely has which type of asthma? Allergic Emotional Extrinsic Intrinsic

D Intrinsic asthma is triggered by an internal factor such as a cold. Intrinsic asthma does not have an identifiable allergen. Asthma related to emotions is considered to be extrinsic asthma. Extrinsic asthma includes allergens such as pet dander, dust mites, mold, dust, etc.

In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? Chest tube insertion Aggressive diuretic therapy Administration of beta-blockers Positive end-expiratory pressure (PEEP)

D Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation. Fluid is not in the pleural space, so chest tube insertion is not indicated. Aggressive diuretic therapy and administration of beta-blockers are contraindicated because of severe hypotension from the fluid shift into the interstitial spaces in the lungs.

Which pulmonary risk may be increased in a postoperative client due to anesthesia? Rhonchi Fremitus Dyspnea Atelectasis

D Postoperative clients are at risk for atelectasis, which involves the collapse of the alveoli. This condition is caused by the effects of anesthesia. Rhonchi are continuous rumbling or snoring sounds caused by the obstruction of the larger airways. Fremitus is the vibration of the chest wall during vocalization. Dyspnea is shortness of breath; this condition is an after effect of atelectasis.

During chest examination in a healthy client, the APN percusses and hears a low-pitched sound over the lungs. Which sound should the nurse document in the medical record? Dull Flat Tympany Resonance

D Resonance is a low-pitched sound heard over the lungs during percussion in healthy individuals. Breathing sounds may be considered dull if sounds are of medium-intensity pitch and duration and are heard over areas of mixed, solid, and lung tissue. Soft high-pitched sounds of short duration heard over very dense tissue where air is not present is described as a flat sound. Sounds with drum-like, loud, or empty quality heard over a gas-filled stomach or intestines are described as tympany.

While caring for a client with a nasal injury, the nurse also suspects a skull fracture. Which manifestation might have led the nurse to conclude this? Positive dipstick test Crackling of the skin on palpation Clearly visible fracture in the X-ray report Clear yellow halo ring structure on a filter paper

D The drainage of cerebrospinal fluid (CSF) from the injured area indicates a skull fracture. The presence of a clear yellow halo ring-shape structure appearing on a piece of filter paper indicates the presence of CSF, an indication of a skull fracture. A positive dipstick test indicates the presence of sugar in the CSF. Crackling of the skin occurs with a normal nose injury. An X-ray may not detect the presence of CSF.

The nurse instructs the client admitted for an acute exacerbation of chronic obstructive pulmonary disease (COPD) about the importance of assessing for right-sided heart failure after discharge. What does the nurse instruct the client to assess for? Increased appetite Clubbing of the nail beds Hypertension Weight gain

D The most common signs and symptoms of right-sided heart failure are hepatomegaly, weight gain, jugular vein distention, and peripheral edema. Clients with right-sided heart failure often have decreased appetites. Clubbing is indicative of hypoxemia. Hypertension is associated with left-sided heart failure.

A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain? Retrospective 24-hour calorie count Elimination pattern during the last 30 days Complete gynecological and sexual history Presence of a cough and pulmonary secretions

D The presence of a cough and pulmonary secretions, in addition to a history of rheumatic fever, requires an assessment for other cardiopulmonary problems and fluid overload. Anorexia and weight gain do not indicate a nutritional problem but a fluid balance problem. Loss of appetite in conjunction with shortness of breath and the history of rheumatic fever makes gastrointestinal (elimination) symptoms secondary in importance. There is no reason to investigate the gynecological and sexual history in relation to the current problem.

A client who works in the leather industry complains of a bloody discharge and persistent pain after the treatment of sinusitis. The client has a history of smoking. The nurse suggests the client consult a primary healthcare provider immediately. Which risk does the nurse suspect in the client? Epistaxis Facial trauma Fracture of the nose Tumor of the nasal cavity

D Tumors of the nasal cavity and sinuses are rare but are a result of a loss of cellular regulation. These tumors commonly develop in people who are regularly exposed to leather dust. Cigarette smoking coupled with leather exposure further increases the risk of tumors. The symptoms of a tumor include persistent nasal obstruction, bloody discharge, and pain that persists even after sinusitis treatment.

A client comes to the emergency department reporting chest pain and difficulty breathing. A chest x-ray reveals a pneumothorax. Which finding should the nurse expect to identify when assessing the client? Distended neck veins Paradoxical respirations Increasing amounts of purulent sputum Absence of breath sounds over the affected area

D When the lung is collapsed, air is not moving into and out of the area, and therefore breath sounds are absent. Distended neck veins are associated with failure of the right side of the heart and can occur with a mediastinal shift, but there is no evidence of either. Paradoxical respirations occur with flail chest, not pneumothorax. Purulent sputum is a sign of infection, not pneumothorax.

A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" Which information should the nurse provide about the purpose of the chest tube? It checks for bleeding in the lung. It monitors the function of the lung. It drains fluid from the pleural space. It removes air from the pleural space.

D With a pneumothorax, a chest tube attached to a closed chest drainage system removes trapped air and helps to reestablish negative pressure within the pleural space; this results in lung reinflation. A closed chest drainage system may be inserted to remove blood related to a hemothorax, not to assess for bleeding. Monitoring the function of the lung is not the purpose of inserting chest tubes; the function of the lungs is monitored through the assessment of vital signs, breath sounds, arterial blood gases, and chest x-ray. Draining fluid from the pleural space is the reason for use of a closed chest drainage system when there is fluid in the pleural space.

After assessing a client's breath sounds, the nurse suspects bronchospasm. Which adventitious breath sound has prompted the nurse's suspicion? Wheezing Rhonchi Pleural friction rub Low-pitched crackles

Wheezing, a high-pitched, musical, continuous sound that does not clear with coughing, is an adventitious breath sound that may indicate bronchospasm. Rhonchi are associated with obstruction by a foreign body. Pleural friction rub can be heard in cases of pleurisy. Pneumonia may be present in a client who exhibits low-pitched crackles.

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