Resp medsurg

A nurse cares for a client who is mechanically ventilated with an FiO2 setting of 80%. The nurse consults with the health care team about reducing the client's ventilator-related complication risk. The nurse advocates for which FiO2 setting? A) 50% B) 30% C) 21% D) 75%

50% 50% FiO2 represents the goal of oxygen therapy, because it both supplements the client's need for supplemental oxygen and reduces the risk of oxygen toxicity, which may occur with increased FiO2.

The nurse cares for a client immediately following the placement of a left chest tube for a pneumothorax. Which assessment finding is mostconcerning to the nurse? A. There is an absence of lung sounds on the left chest. B. The client reports chest pain at 4/10 after the procedure. C. The client has a respiratory rate of 22 breaths/min. D. The client has serous drainage of 150 mL from the procedure.

A

A nurse cares for a client with suspected tuberculosis. Which test confirms this diagnosis? A. Sputum culture B. Mantoux skin test C. Blood culture D. Chest x-ray

A A positive sputum culture indicating the presence of acid-fast bacilli is used to diagnose tuberculosis.

A nurse cares for a client with silicosis after occupational exposure to silica. The client tells the nurse, "My breathing seemed to get bad just since my last birthday." Which type of silicosis does the nurse suspect the client is suffering from? A. Acute B. Simple C. Complicated D. Accelerated

A Acute silicosis is characterized by rapid onset of symptoms such as coughing, weight loss, and shortness of breath after exposure to silica dust.

The nurse assesses a client with a left pneumothorax. The client has a chest tube to traditional water-seal. Which finding on the chest tube system requires intervention by the nurse? A. The suction chamber is empty. B. There is intermittent bubbling in the water chamber. C. The water chamber is filled to the 2 cm mark. D. The suction chamber is set to 20 cm H2O.

A An empty suction chamber is not an expected finding with a traditional water-seal chest tube. Empty suction chambers are indicated for dry-suction water seal systems.

A nurse working in a correctional facility provides care for a client experiencing a decline in health condition, as evidenced by a decrease in oxygen saturation. Which action does the nurse implement first? A. Apply oxygen and remain with the client until vital signs stabilize. B. Leave the room to get additional help. C. Notify the healthcare provider of the client's status. D. Call for the Correctional Emergency Response Team (CERT).

A Applying supplemental oxygen and remaining with the client until the client is stable is the first step the nurse should implement.

A client with chronic obstructive pulmonary disease (COPD) is admitted with heart failure. The nurse assesses a weak, nonproductive cough and mild dyspnea. Which complication does the nurse recognize as most likely to occur? A. Atelectasis B. Pulmonary embolism C. Pulmonary hypertension D. Pleural effusion

A Atelectasis Atelectasis is most likely to occur because the client has a weak cough. Deep breathing and coughing helps to prevent atelectasis (collapse of the alveoli) and if the client is unable to cough correctly, atelectasis may occur.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). The client experiences activity intolerance related to alterations in oxygen transport. Which goal does the nurse plan for the client? A. By discharge, the client uses two strategies to conserve energy. B. By discharge, the client's skin will remain dry and intact. C. The client verbalizes consistent relief of pain. D. The client remains free from pulmonary infection.

A By discharge, the client uses two strategies to conserve energy. This goal uses all aspects of SMART goal setting: Specific, Measurable, Achievable, Relevant, and Time-specific. This is the goal the nurse will plan for this client because it best supports the client's nursing diagnosis of activity intolerance.

Prior to in-line suctioning a client who is mechanically ventilated, the nurse hyper-oxygenates the client. What complication does the nurse's action help to prevent? A. Cardiac arrhythmia B. Severe coughing C. Pulmonary hypertension D. Subcutaneous emphysema

A Cardiac arrhythmia Hyperoxygenation prior to suctioning increases the client's blood oxygen level to prevent hypoxemia (decreased blood oxygen levels). Hypoxemia may lead to cardiac arrhythmia due to lack of perfusion to the heart, and hyperoxygenation helps to prevent this complication.

A nurse cares for a client who is recovering from a bronchoscopy. Which action does the nurse perform? A. Confirm the return of the client's gag reflex. B. Assist with early ambulation. C. Encourage rapid and deep breaths. D. Position the client in the lateral recumbent position.

A Confirm the return of the client's gag reflex. The nurse must confirm the return of the client's gag reflex prior to providing any liquid hydration. If the nurse does not confirm this and the client attempts to drink fluid, the client may aspirate the liquid.

While observing a client performing a pulmonary function test (PFT), the nurse notes the client forcibly exhales after a full inspiration. Which aspect of the PFT does the nurse recognize the client is performing? A. Forced vital capacity B. Static lung capacity C. Functional residual capacity D. Tidal volume

A Forced vital capacity Forced vital capacity is the volume of air that can be forcibly exhaled after full inspiration.

A client is suspected of having acute respiratory distress syndrome (ARDS). Which findings does the nurse report to the healthcare provider (HCP) as best supporting ARDS? A. Hypoxemia despite high fraction of inspired oxygen (FiO2) B. Reports of dyspnea C. Circumoral cyanosis D. Respiratory rate of 26 breaths/min

A Hypoxemia despite high fraction of inspired oxygen (FiO2) The diagnosis of ARDS is determined by the finding of low partial pressure of arterial oxygen (PaO2) or hypoxemia despite supplemental oxygen delivery to increase the FiO2.

The nurse receives report on a group of surgical clients. The nurse assesses which client first? A. The client experiencing increased agitation B. The client with scant bleeding on the abdominal dressing C. The client whose respiratory rate is 14 breaths/min D. The client reporting 6 out of 10 aching joint pain

A Increased agitation, tremors, and tachycardia need immediateassessment. Obtain additional assessment, such as vital signs, assessing the level of consciousness and for the presence of hallucinations. Notify the healthcare provider (HCP) of the change in the client's condition for additional orders.

A nurse is assessing a client with a femur fracture. Upon assessment, the client is restless and verbalizes chest pain upon inspiration. The nurse notes petechia over the chest and axillary area. Vital signs are as follows: respiratory rate of 24 breaths/min, heart rate of 115 beats/min, temperature 38 °C (100.4 °F), SpO₂ of 90% on room air. After placing the client on supplement oxygen, which action does the nurse perform next? A. Notify the rapid response team. B. Place the client on a cardiac monitor. C. Initiate intravenous access. D. Take the client's blood pressure.

A Notify the rapid response team. The client's signs and symptoms are indicative of a fat embolism. Fat embolism syndrome is a medical emergency. After securing oxygenation, the nurse should call a rapid response for immediate medical management.

The nurse cares for a client diagnosed with pleural effusion. Which symptom is likely to be present upon physical assessment? A. Orthopnea B. Lower back pain C. Productive cough D. Eupnea

A Orthopnea (difficulty breathing when lying down) is a common symptom of pleural effusion. This symptom is likely to be present upon physical assessment. Orthopnea is a common symptom in pleural effusion, causing difficulty breathing when lying down. Explanation What is Pleural Effusion? Pleural effusion: buildup of excess fluid between the layers of the pleura outside the lungs Pleura: thin membranes lining the lungs and chest cavity, lubricating and facilitating breathing

A client with emphysema receives discharge instructions regarding home oxygen use via nasal cannula. Which statement does the nurse include? A. "Do not be around those who are smoking cigarettes. " B. "Ensure the nasal cannula is applied tightly around the ears." C. "Inhale through the mouth when using the oxygen." D. "Adjust the flow rate to comfort during meals."

A Oxygen is an oxidizer and will cause fire to burn faster if ignited. Smoking near oxygen equipment is dangerous due to the risk of fire.

A nurse provides oral care for a client who is mechanically ventilated. What is the best rationale for providing this care? A. Routine oral care may reduce the risk of pneumonia. B. The client's oral cavity requires regular moisture. C. The client is fully dependent on the nurse's actions. D. Routine oral care may reduce the risk of tooth decay.

A Routine oral care may reduce the risk of pneumonia. Routine oral care does reduce the risk of pneumonia. Specifically, it reduces the risk of ventilator-associated pneumonia, a serious complication of mechanical ventilation.

Which intervention does the nurse implement when caring for a client recently diagnosed with emphysema? A. Teach the client postural drainage. B. Reduce the client's fluid intake. C. Keep the client in a supine position. D. Advise the client to get an annual pneumonia vaccine.

A Teaching the client postural drainage is appropriate, because this provides the client with techniques of airway clearance. This is the appropriate nursing action for this client. Nursing Interventions for Emphysema Postural drainage Position client in specific positions for 5-10 minutes each Helps clear different lung fields of secretions Chest physiotherapy Low-flow oxygen High Fowler position Improves ventilation Increased fluid intake Liquefies secretions for easier clearance

A nurse provides teaching to a client recently diagnosed with sarcoidosis. When explaining the disease, which cause does the nurse include? A. Is not known B. Smoking C. Bacterial infection D. Exposure to asbestos

A The cause of sarcoidosis remains unknown. It is thought that an altered immune response in some genetically susceptible individuals is a causative factor for the development of the disease.

A nurse cares for a client with a GI bleed. The client is short of breath, exhibits clear lung sounds, and has an oxygen saturation of 98%. The nurse evaluates which laboratory results? A. Hemoglobin and hematocrit B. Brain natriuretic peptide C. Arterial PaO2 and PaCO2 D. WBC count

A The client likely has anemia due to blood loss from the GI bleed. Anemia is a decrease in the red blood cell count of the blood, a hematologic condition. This may cause shortness of breath in the client and explains the clear breath sounds and adequate oxygenation.

A nurse cares for an immunocompromised client who has developed histoplasmosis. Which condition does the nurse recognize has similar signs and symptoms to histoplasmosis? A. Pneumonia B. Pulmonary fibrosis C. Tuberculosis D. Pulmonary hypertension

A The signs and symptoms of histoplasmosis are similar to pneumonia and include cough, flu-like symptoms, dyspnea, and fever. Histoplasmosis: An opportunistic fungal infection Affects immunocompromised patients Treatment and Recovery Majority of cases resolve without treatment Severe cases require antifungal medication

A client in hospice for end-stage lung cancer is brought unconscious, mottled, and breathing rapidly to the emergency department (ED) by the power of attorney for health care (POA). The nurse knows that what statement to the POA is appropriate? A) "Tell me about what is happening." B) "We cannot treat hospice clients." C) "We must prepare for intubation." D) "We should notify the funeral home."

A This is an open line of questioning and may clarify the power of attorney's reasons behind bringing the client to the emergency department (ED). This helps direct further client care and nursing actions.

A client with emphysema is short of breath. The nurse assists the client into which position? A. sitting upright and leaning forward B. supine with pillows under the legs C. leaning back in a recliner D. lying to the left side

A This is the tripod position. Instructing the client to sit upright and lean forward, usually onto a bedside table, assists the dyspneic (short of air) client to maximize lung volume. High-Fowler position (sitting at a 90-degree angle) is often effective, too.

A post-anesthesia care (PACU) nurse provides care to a client after gastric bypass surgery. Which nursing action is most important? A. Position the client in a semi-Fowler's position. B. Assess for adequate pain control. C. Measure and record intake and output. D. Monitor the amount and type of incision drainage.

A This position helps to prevent serious complications such as airway obstruction and aspiration.

A nurse admits a client with tuberculosis (TB). What does the nurse include in the client teaching? Select All That Apply A) "Your tuberculosis skin test will always be positive." B) "You will have to take multiple drugs to treat tuberculosis." C) "You must stay in isolation for two weeks." D) "You may have to take medication for up to five months." E) "Once treated, the disease never comes back."

A, B, C Clients with TB are treated with multiple drugs for 6-9 months and are isolated for the first 2 weeks of treatment. They will always have a positive skin test.

A client with chronic obstructive pulmonary disease (COPD) receives discharge instructions from the nurse. Which instructions does the nurse include? Select All That Apply A. Limit time in cold air. B. Avoid chores that involve aerosols or dust. C. Avoid cigarette smoke. D. Get an influenza vaccine every year. E. Running is a good exercise.

A, B, C, D Cigarette smoke, cold air, chemicals, and dust exposure can cause exacerbations. An annual influenza vaccine is recommended for all COPD clients.

A client is admitted with pneumonia. Which nursing intervention does the nurse start to assist with airway clearance? Select All That Apply A. Position the client in semi-Fowler. B. Encourage client to turn side-to-side frequently. C. Provide adequate hydration. D. Encourage the use of incentive spirometry. E. Encourage deep breathing and coughing exercises.

A, B, C, D, E Nursing interventions that open up the alveoli, mobilize and thin secretions, and promote ventilation assist with airway clearance.

A client is admitted for respiratory distress and suspected pneumonia. Which assessment findings consistent with this diagnosis require continued monitoring? Select All That Apply A. Chest pain with inspiration B. Temperature 101.4 °F (38.56 °C) C. Dyspnea with ambulation D. Blood pressure 109/78 mmHg E. Respiratory crackles and wheezes

A, B, C, E Signs and symptoms of pneumonia include fever, productive cough, dyspnea, pleuritic chest pain, increased respiratory rate, and chills.

A nurse cares for a client with a pulmonary embolism. Which assessment findings does the nurse associate with this condition? Select All That Apply A. Hemoptysis B. Sudden chest pain C. Sudden headache D. Anxiety E. New-onset dyspnea

A, B, D, E Pulmonary embolism symptoms include sudden onset chest pain, hemoptysis, new-onset dyspnea, and anxiety.

A health care provider (HCP) plans to wean a client off a ventilator and asks the nurse for data regarding the client's readiness to wean. Which data does the nurse provide to the HCP? Select All That Apply A. Oxygen requirements B. ABG results C. WBC count D. Echocardiogram report E. Level of consciousness

A, B, E Assessing ventilation status (ABGs), oxygen requirements, and level of consciousness are important indicators of the client's readiness to wean.

The nurse cares for a client suspected of having a pulmonary embolism. The nurse assesses for which findings to support pulmonary embolism? Select All That Apply A. Restlessness B. Headache C. Blood-tinged sputum D. Bradypnea E. Tachycardia

A, C, D Evidence of PE includes signs of sympathetic nervous system activation and acute respiratory symptoms.

The nurse is preparing to teach a client's caregiver how to perform tracheostomy tube care at home. How will the nurse teach the procedure? Place each step in order, from first to last. All options must be used. A. Place the client in a semi-Fowler position. B. Clean the stoma. C. Suction the tracheostomy tube. D. Replace the inner cannula. E. Change the tracheostomy holder.

A, C, D, B, E The order is: semi-Fowler position, suction the trach tube, replace inner cannula, clean stoma, and change the tracheostomy holder.

A nurse cares for a client at risk for pneumonia. Which interventions does the nurse implement to reduce the risk of pneumonia? Select All That Apply A. Promoting incentive spirometry B. Recommending bed rest C. Encouraging deep breathing D. Encouraging oral hydration E. Assisting in frequent repositioning

A, C, D, E Frequent repositioning, incentive spirometry, deep breathing, and oral hydration promote secretion mobilization and inflation of alveoli.

A nurse cares for a client who is intubated and mechanically ventilated. Which assessment findings lead the nurse to perform endotracheal (ET) suction? Select All That Apply A. High peak inspiratory pressure B. Pulse of 62 beats/min. C. Increased incidence of coughing D. Increased oxygen requirements E. Coarse rhonchi bilaterally

A, C, D, E Retained secretions occlude the airway and may result in bilateral rhonchi, high peak inspiratory pressure, higher O2 requirements, and increased coughing. Explanation Indications for Endotracheal (ET) Suctioning Suctioning is necessary when certain signs are observed in patients. These include: Wet respirations: Audible moist breathing sounds. Rhonchi: Snoring-like sounds in the lungs. Increased peak inspiratory pressure: Higher peak pressure during inhalation. Bubbling in the ET tube: Presence of bubbles in the endotracheal tube. Restlessness: Patient discomfort or agitation. Vital sign changes: Faster respirations, increased heart rate, or decreased O2 sats

A nurse cares for a client with a hemothorax. The nurse reports what findings as evidence of empyema? Select All That Apply A. Fever B. Hyper-resonance on percussion C. Diminished breath sounds D. Decreased respiratory rate E. Night sweats

A, C, E A nurse cares for a client with a hemothorax. The nurse reports what findings as evidence of empyema? Select All That Apply Fever Hyper-resonance on percussion Diminished breath sounds Decreased respiratory rate Night sweats

A client is admitted with a diagnosis of acute exacerbation of chronic obstructive pulmonary disease (AECOPD). The nurse assesses for what findings directly related to the pathological changes of AECOPD? Select All That Apply A) Expiratory wheezes B) Anemia of chronic disease C) Elevated serum bicarbonate D) Bilateral coarse crackles E) Productive cough

A, C, E Chronic inflammation leads to elevated bicarbonate levels (compensation), productive cough, and expiratory wheezes.

A nurse cares for a client suspected of having acute respiratory distress syndrome (ARDS). Which assessment data supports the suspected diagnosis? Select All That Apply A. Crackles B. Slow onset C. Confusion D. Metabolic alkalosis E. Tachypnea

A, C, E In ARDS, confusion, tachypnea, and crackles are key symptoms due to impaired oxygenation and pulmonary edema. Pulmonary edema and decreased surfactant production increase the thickness of the alveolar capillary space, making it harder for oxygen to reach the blood. Results in hypoxemia and respiratory acidosis, not metabolic alkalosis. Symptoms Confusion (due to hypercapnia and impaired ventilation) Tachypnea Crackles (due to pulmonary edema and interstitial fluid accumulation) Increased work of breathing Nasal flaring or use of accessory muscles

A nurse cares for a patient diagnosed with pleurisy. Which assessment findings does the nurse expect? Select All That Apply A. Sharp pain on inspiration B. Crackles on auscultation C. Dull pain on expiration D. Friction rub on auscultation E. Tachypnea with rest

A, D Pleurisy causes sharp pain on inspiration and a friction rub on auscultation, indicating inflammation of the pleural membrane.

A client with cor pulmonale secondary to chronic obstructive pulmonary disease (COPD) is being discharged home on oxygen therapy at 2 L nasal cannula via portable oxygen tank. What information does the nurse include when teaching about home oxygen use? Select All That Apply A. "Ensure you have a regular delivery schedule and a spare source of oxygen available." B. "Replace the nasal cannula and tubing every week or more often if soiled." C. "Even if your dyspnea is worse, never allow the administration of oxygen above three liters." D. "If you are not experiencing any dyspnea, remove the oxygen to reduce dependence." E. "Do not allow open flame or smoking in the room where

A, E Always have a spare oxygen source and avoid open flames or smoking during therapy.

A client with chronic obstructive pulmonary disease (COPD) has a moderate increase in dyspnea. The nurse performs interventions in what order? (Place each option in order, from first task to last.) All options must be used. A. Place the client in an upright position. B. Auscultate the client's breath sounds. C. Encourage pursed lip breathing. D. Administer prescribed albuterol inhaler. E. Measure oxygen saturation level.

A, E, C, B, D

A client arrives in the emergency department after being rescued from a house fire. Pulse oximetry is 95% and the client is alert. Which interventions does the nurse do first? A) Administer oxygen and obtain a mechanical ventilator. B) Assess the client for singed nasal hair, stridor, and chest tightness. C) Begin a peripheral intravenous line and administer fluids at a rapid rate. D) Obtain vital signs and begin cardiac monitori

Assess the client for singed nasal hair, stridor, and chest tightness. A primary ABC survey, or assessment, is a priority. Interventions that follow: prevent shock address respiratory distress provide injury care (A-Airway, B-Breathing, C-Circulation)

A nurse assists a health care provider with the removal of a chest tube. How does the nurse instruct the client prior to the procedure? A. "Bear down while inhaling forcefully through your nose with your mouth held closed." B> "Bear down by attempting to exhale through the mouth and nose with your lips held closed." C. "Place your hands on your abdomen and breathe deeply through your nose while pushing against your abdomen." D. "Use your hands to hold a pillow against your abdomen while inhaling slowly."

B "Bear down by attempting to exhale through the mouth and nose with your lips held closed." The client should be instructed to perform the Valsalva maneuver upon removal of the chest tube. This is best accomplished by instructing the client to bear down by attempting to exhale through the mouth and nose with closed lips.

A nurse teaches a client about the insertion of a chest tube prior to the procedure. Which statement shows that the client requires further teaching? A. "The procedure will help improve my breathing." B. "I will avoid moving in bed to prevent dislodging the tube." C. "The procedure can be performed in my room." D. "I will be given medication to decrease pain from the procedure."

B "I will avoid moving in bed to prevent dislodging the tube." The client should be encouraged to reposition in bed and to practice deep-breathing and coughing in order to re-expand the lungs and facilitate gas exchange. The nurse teaches the client how to comfortably reposition without dislodging the chest tube.

A nurse instructs a client with asthma about the proper use of a metered-dose inhaler (MDI) spacer device. Which statement by the client indicates the need for further instruction? A. "It will make it easier for me to use my inhaler." B. '"can use my medication less often.'' C. "It will disperse my medication evenly." D. "It will reduce the risk of a yeast infection."

B ''I can use my medication less often.'' Although the use of the spacer helps to deposit the medication better, it does not impact how frequently the dose of the medication should be taken. This is altered by the health care provider only. This client statement requires further instruction.

A client's chest x-ray indicates acute respiratory distress syndrome (ARDS). Which pathophysiological process does the nurse recognize is the underlying cause of this condition? A. Decreased blood flow in the pulmonary vessels B. Increased permeability of pulmonary capillaries C. Decreased compliance of the lungs D. Increased retention of serum carbon dioxide

B ARDS occurs from inflammation or injury to the lung from various processes. It ultimately leads to increased permeability of the pulmonary capillaries and subsequent leakage of fluid in the interstitial space of the lungs.

A nurse assesses a client suspected of having a pleural effusion. While assessing the client, which finding does the nurse associate with the client's condition? A. Localized crackles B. Diminished breath sounds C. Bradycardia D. Productive cough

B Diminished breath sounds Diminished breath sounds occur due to the accumulation of fluid in the pleural space. This also causes impaired gas exchange, hypoxemia, dyspnea, and a dry, nonproductive cough.

A nurse cares for a client with a chest tube who is postoperative from a thoracotomy. Which nurse action does the nurse perform? A. Clamp the tube once per day. B. Encourage deep breathing and coughing. C. Milk the chest tube to facilitate draining. D. Notify the health care provider for water seal chamber fluctuations.

B Encourage deep breathing and coughing to prevent pneumonia and facilitate drainage.

A nurse cares for a client with pleurisy and a friction rub present with auscultation. What does the nurse recognize is the cause of the auscultation finding? A. Retained secretions B. Inflammation C. Allergic reaction D. Parenchymal consolidation

B Inflammation Pleurisy results from inflammation of the pleura, the layers surrounding the lung. This condition is very painful and causes sharp pain with breathing, especially with inspiration. A pleural friction rub is a classic finding with pleurisy and results from the inflammation of the pleural lining.

A nurse administers a tuberculosis (TB) skin test to a client at high risk for TB. Which statement does the nurse include when teaching the client about the procedure? A. "Tuberculosis may need confirmation by chest x-ray." B. "It does not differentiate between latent and active TB." C. "It does not work if there is a history of TB." D. "Hives around the injection site indicate active TB."

B It does not differentiate between latent and active TB." The TB skin test does not differentiate between dormant and active TB; it only tests for the presence of TB infection.

A client with simple chronic silicosis has had no significant changes since diagnosis six months ago. Which characteristic of simple silicosis does the nurse include when teaching the client about the disease? A. Cavitation on chest x-ray B. Opacification on chest x-ray C. Rapidly progressing symptoms D. Nonspecific symptoms

B Opacification on chest x-ray Opacification, or a "ground glass" appearance, is a characteristic of simple chronic silicosis. The nurse teaches the client about these terms in a way the client can understand.

A client receives naloxone after being overmedicated with an opioid. Which laboratory result does the nurse expect with opioid overdose? A. Arterial blood pH 7.39 (7.35-7.45) B. Partial pressure of carbon dioxide (PaCO2) 50 mm Hg (35 -45 mm Hg) C. Partial pressure of oxygen (PaO2) 85 mm Hg (80-100 ) D. Bicarbonate (HCO3) 25 mEq/L (21-28 mEq/L)

B Partial pressure of carbon dioxide (PaCO2) 50 mm Hg (35 -45 mm Hg) Respiratory acidosis will demonstrate high PaCO2 because respiratory depression causes PaCO2 buildup.

A client with pneumonia experiences ineffective airway clearance related to increased sputum production. The nurse plans a goal that the client will improve airway clearance. What outcome best demonstrates this goal? A. The nurse observes a normal respiratory rate each time vital signs are obtained. B. The client increases the incentive spirometer value by 500 mL by end of shift. C. The client is observed coughing and deeply breathing frequently throughout the shift. D. The client exhibits decreased shortness of breath and increased oxygen saturation.

B The client increases the incentive spirometer value by 500 mL by end of shift. This outcome uses all aspects of SMART requirements: Specific, Measurable, Achievable, Relevant, and Time-specific. This is the outcome the nurse will plan for this client because it best supports the client's nursing diagnosis of ineffective airway clearance and the overall goal of an improved airway. By increasing volume of air the client is demonstrating that the airway is effectively clearing.

The nurse cares for an adult client reporting difficulty breathing. Which action does the nurse take first? (Listen to the audio clip.) STRIDOR is noted. A. Administer cool, humidified air via a high-flow delivery device. B. Prepare to assist in the placement of an advanced airway. C. Administer prescribed bronchodilator via a nebulizer. D. Obtain the client's vital signs and oxygen saturation level.

B The most immediate need is to be ready to place an artificial airway if the patient's airway fails. Then, the team can treat the cause and other symptoms.

A nurse cares for a client with a right pleural effusion requiring treatment. Which item does the nurse have available for immediate use by the health care provider? A. Central line catheter tray B. Thoracentesis tray C. Arterial blood gas kit D. Respiratory intubation kit

B Thoracentesis tray Thoracentesis is a procedure that drains the accumulated fluid in the pleural space of the lungs. This is the treatment of choice for pleural effusions large enough to require treatment.

A nurse is assessing a client admitted for blunt trauma to the chest. The nurse notifies the healthcare provider that the client may have a tension pneumothorax, based on which assessment finding? A. Paradoxical chest movement B. Tracheal deviation C. Dullness upon percussion D. Crackles heard on auscultation

B Tracheal deviation is indicative of a tension pneumothorax. As air and pressure build in the pleural space, it causes a mediastinal shift, resulting in deviation of the trachea toward the unaffected side.

An adult client on the surgical floor has tachycardia, tachypnea, and a slight temperature elevation. The client is sitting at a 90-degree angle and reports severe shortness of air. Which assessment does the nurse perform first? A. pupil reactivity B. breath sounds C. heart sounds D. peripheral circulation

B breath sounds Changes with breath sounds help the nurse determine the next assessments or interventions.

A client admits to the hospital for complications due to chronic emphysema. What characteristics of this condition does the nurse identify? Select All That Apply A. Manifestation of bradypnea B. Loss of lung elasticity C. Hyperinflation of the lungs D. Hypoxemia E. An excess of the protease enzyme

B, C, D, E Emphysema causes loss of lung elasticity, low PaO2, excess protease, and hyperinflation, which increases respiratory effort.

A client is diagnosed with a right-sided tension pneumothorax. Which finding makes the nurse suspect the client's condition is worsening? Select All That Apply A. Heart rate of 58 beats/min. B. Left deviation of the trachea C. Agitation and restlessness D. Point of maximal impulse displacement E. Respiratory rate of 28 breaths/min.

B, C, D, E Worsening tension pneumothorax displaces the heart, increases respiratory rate, results in tracheal deviation, and causes agitation as oxygenation declines. Explanation What is Tension Pneumothorax? A serious condition that happens when air enters the space around the lungs (pleural space) and cannot escape. Often occurs due to trauma, like a stab wound, creating a one-way valve effect.

A nurse cares for a client who is post-pneumonectomy. The nurse forms a plan of care to treat ineffective airway clearance related to increased secretions and decreased coughing effectiveness due to pain. Which nursing interventions does the nurse include in the client's care? Select All That Apply A. Position the client in the side-lying position on the non-operated side. B. Offer the client sips of water frequently. C. Assist the client to perform deep breathing exercises which assist with coughing. D. Milk or strip the client's chest tubes to improve pleural suction. E. Plan chest physiotherapy sessions based on client pain level.

B, C, E Nursing interventions that open up the alveoli, mobilize & thin secretions, and promote ventilation assist with airway clearance.

A nurse cares for a client with a right tension pneumothorax. Which observation does the nurse associate with worsening of the client's condition? Select All That Apply A. Hypertension B. Left deviation of the trachea C. Right-sided weakness D. Displacement of the point of maximal impulse E. Bilateral crackles

B, D Manifestations of tension pneumothorax result from pressure changes and the shifting of organs and structures in the thoracic cavity.

A nurse cares for a client who is orally intubated and mechanically ventilated. Which interventions does the nurse perform in order to reduce the client's risk of pneumonia? Select All That Apply A. Restricting the client's fluids B. Performing oral care every four hours C. Administering prophylactic antibiotics D. Repositioning the client every two hours E. Elevating the head of the bed

B, D, E To prevent pneumonia in ventilated clients, perform oral care, reposition regularly, and elevate the head of the bed.

A nurse cares for a client with chronic obstructive pulmonary disease (COPD). Which instruction does the nurse use when teaching the client about breathing techniques for COPD? A. "Inhale longer than you exhale." B. "Exhale through your nose." C. "Use your abdomen when breathing." D. "Use deep, rapid breathing."

C "Use your abdomen when breathing." The nurse should instruct the client on diaphragmatic breathing, or using the muscle of the diaphragm in the abdomen to aid in breathing.

A nurse teaches a client with emphysema about oxygen use at home via nasal cannula. Which flow rate does the nurse tell the client not to exceed? A. 4 L/min. B. 6 L/min. C. 2 L/min. D. 10 L/min.

C 2 L/min. provides the client with supplemental oxygen and places the client at the lowest risk for developing complications related to oxygen therapy.

The nurse cares for a client with a tracheostomy tube. Which suctioning technique by the nurse demonstrates proper technique? A. Insert the suction catheter until resistance is met while suctioning consistently. B. Apply sterile gloves, open the suction kit, and fill the basin with normal saline. C. Apply intermittent suctioning for 10 seconds while withdrawing the catheter. D. Connect tubing to the suction device, and set the suction pressure to 185 mm Hg.

C Apply intermittent suctioning for 10 seconds while withdrawing the catheter. Intermittent suctioning for no more than 5 to 10 seconds while withdrawing the catheter from the airway is proper technique.

A client is orally intubated and mechanically ventilated due to respiratory failure. Which item does the nurse ensure is kept next to the client's bed at all times? A. Tracheostomy kit B. An endotracheal tube C. Bag valve mask device D. Arterial blood gas kit

C Bag valve mask device A manual resuscitation bag (BVM or Ambu bag) is required to be kept at the client's bedside at all times to ensure ventilation, should the client be disconnected from the ventilator, or if the ventilator requires troubleshooting.

A nurse cares for a client who undergoes a bronchoscopy with biopsy. Which immediate post-procedure finding does the nurse report to the health care provider? A. Cough B. Drowsiness C. Bronchospasm D. Dark red sputum

C Bronchospasm Bronchospasm is an unexpected finding post-bronchoscopy and requires immediate attention from the nurse. This can manifest as reports of chest tightness, auscultated wheezing, decreased oxygenation with continual coughing, or audible stridor.

The nurse assesses a client with obesity and finds the breath sounds to be diminished throughout all fields. The oxygen saturation is at the client's baseline, and no other respiratory symptoms are present. What action does the nurse take? A. Have the client lean forward and assess all lung fields in this position. B. Request a chest x-ray to rule out atelectasis or pneumothorax. C. Consult the medical record for past documentation of breath sounds. D. Encourage the client to breathe deeply and cough and then reauscultate.

C Consult the medical record for past documentation of breath sounds. The nurse should recognize that diminished breath sounds can occur due to poor transmission of sound through the additional adipose tissue. The lack of symptoms, coupled with the diffuse presentation of diminished breath sounds, supports this as the cause. Past assessments that have found the same degree of diminished sounds and the absence of pathology will help confirm the finding as related to obesity and not a respiratory pathology.

A client recovers from a laryngectomy and is mechanically ventilated. Which action does the nurse take when caring for the client? A. Determine the client's position of comfort. B. Suction the tracheostomy every 30 minutes. C. Determine the tracheostomy minimal leak. D. Initiate the client's clear liquid diet.

C Determine the tracheostomy minimal leak. The client with a cuffed tracheostomy tube should have the cuff inflated using the minimal leak technique. This is achieved by inflating the tracheostomy tube to the minimal amount of pressure needed to achieve a slight leak of air around the tube at the end of inspiration. This allows adequate ventilation and decreases the risk of tissue necrosis of the airway due to an overinflated cuff and subsequent pressure on the tissue of the airway.

A client recovering from total hip arthroplasty performed 6 hours ago has an oxygen saturation of 84%. The nurse performs what action first? A. Auscultate lungs for adventitia. B. Apply oxygen at 3 liters via nasal prongs. C. Elevate the head of bed to 70 degrees. D. Encourage deep breathing and coughing.

C Elevate the head of bed to 70 degrees. Elevating the head of bed lowers the diaphragm and reduces work of breathing. This should be done prior to any other intervention.

A client presents to a clinic with symptoms of chronic sinusitis. Which symptom that the client reports does the nurse recognize as unrelated to sinusitis? A. Loss of smell B. Nagging cough C. End of the day headache D. Purulent nasal discharge

C End of the day headache Headaches are common with chronic sinusitis, but headaches associated with this condition are generally worse upon waking and in the morning.

A nurse cares for a client with a traumatic chest injury causing flail chest. Which distinctive characteristic of flail chest does the nurse find on assessment? A. Widening pulse pressure B. Bloody sputum C. Paradoxical chest motion D. Tracheal deviation

C Flail chest is described as two or more ribs broken in two or more places. The classic manifestation of this is a paradoxical chest motion while breathing: a portion of the chest moves in while the other moves out.

A nurse cares for a client receiving a heparin infusion. The nurse observes bright red urine in the client's catheter drainage system. Which action does the nurse take first? A. Prepare a dose of protamine sulfate. B. Send blood to the laboratory for coagulation studies. C. Notify the health care provider. D. Change the heparin infusion rate.

C Notify the health care provider. The client is showing evidence of bleeding (hematuria), and the health care provider should be notified.

A nurse cares for an older adult client with influenza. Which clinical finding indicates a common complication associated with the client's diagnosis? A) 3+ edema to bilateral extremities B) Jugular vein distention C) Patchy infiltrates on chest radiography D) Positive blood cultures

C Patchy infiltrates on chest radiography suggest pneumonia, which is a common complication of influenza infection.

The telehealth nurse interviews a client with chronic obstructive pulmonary disease (COPD) via a web video call. The client describes an increase in PRN salbutamol use in the past four days due to increased dyspnea and also mentions increased cough and sputum production. The client thinks this may just be a chest cold and has not noticed a fever. What action does the nurse advise the client to take? A) Practice pursed lip breathing when dyspneic and use rescue inhaler PRN. B) Increase fluids, get rest, and if a fever develops, notify the nurse for reassessment. C) Seek immediate assessment for suspected acute exacerbation of COPD. D) Monitor sputum closely, and seek medical attention if it becomes purulent.

C Seek immediate assessment for suspected acute exacerbation of COPD. The client living with COPD may require hospitalization for treatment of acute exacerbations (AECOPD). The guidelines for determining the need for intravenous antibiotics and corticosteroids require assessment by a healthcare provider.

A client is admitted with reports of vague symptoms such as lethargy and loss of appetite. Which lab value does the nurse report to the healthcare provider immediately? A. Serum sodium 132 mEq/L (136-145 mEq/L) B. Serum potassium 3.4 mEq/L (3.5-5.0 mEq/L) C. White blood cell count 25,900/mm³ (5,000- 10,000/mm³) D. Serum albumin 2.8 g/dL (3.5-5.5 g/dL)

C The client's high result and vague presentation support a bacterial infection that could progress to sepsis and should be addressed as soon as possible.

The nurse cares for a client following a thoracotomy to perform a lobectomy for lung cancer. The client has a three-chambered, water-seal, stationary chest tube drainage system. Which action by the nurse demonstrates proper care of the drainage system? A. The nurse turns up the wall suction until rapid bubbling is seen in chamber 3. B. The nurse measures the fluid in chamber 1 every 4 hours for the first 24 hours after surgery. C. The nurse fills chamber 2 with at least 2 cm of sterile water to prevent air from returning to the client. D. The nurse strips the chest tube once every eight hours to maintain tube patency.

C The nurse fills chamber 2 with at least 2 cm of sterile water to prevent air from returning to the client. Chamber 2 is the water-seal chamber. It is maintained with at least 2 cm of water to serve as a one-way valve and prevent air from returning to the client. This action demonstrates proper care of the drainage system.

A client with emphysema requires oxygen therapy. How does the nurse administer oxygen therapy to this client? A. Avoid the use of any high-flow oxygen, maintaining a rate of 3 L/min. or less. B. Administer using nasal cannula for client comfort at the number of liters prescribed. C. Titrate oxygen delivery to a minimum SpO2 of 88% unless otherwise prescribed. D. Administer oxygen via Venturi mask, adjusting based on level of dyspnea.

C Titrate oxygen delivery to a minimum SpO2 of 88% unless otherwise prescribed. Best practice dictates the prescribing of oxygen based on oximeter readings. For a client with emphysema, a saturation of 88% is often acceptable.

A client's ventilator alarm reads "low pressure," but after checking the ventilator and endotracheal (ET) tube, the nurse cannot determine the cause of the alarm. Which action does the nurse perform next? A. Connect the client to pulse oximetry. B. Administer additional oxygen. C. Ventilate the client manually. D. Reset the ventilator.

C Ventilate the client manually. When a low-pressure alarm is sounding and cannot be immediately remedied, the nurse must disconnect the ventilator and manually ventilate the client in order to ensure that the client is adequately ventilated.

A nurse cares for a client who underwent thoracic surgery. The nurse applies what findings as evidence of tension pneumothorax? Select All That Apply A. Peripheral edema B. Crackles on auscultation C. Pain with inspiration D. Tracheal deviation E. Elevated blood pressure

C, D Tension pneumothorax presents with tracheal deviation and worsening pain on inspiration, indicating pressure on lung and surrounding tissues. Explanation Causes Usually results from trauma and damage to pleural lining Decreases negative pressure needed for normal lung movement

A nurse performs a physical assessment on a client with chronic obstructive pulmonary disease (COPD). Which signs and symptoms does the nurse expect to assess? Select All That Apply A. Hyperpyrexia B. Shortened expiratory phase C. Digital clubbing D. Hyperinflation of the lungs E. Dyspnea on exertion

C, D, E Chronic airway obstruction and inflammation cause hypoxemia and air trapping resulting in hyperinflation of the lungs, dyspnea on exertion, and digital clubbing

A client is admitted due to pneumonia associated with influenza. Which nursing interventions promote airway patency? Select All That Apply A. Provide a quiet environment. B. Schedule activities after nebulizer treatments. C. Increase the client's fluid intake. D. Turn the client frequently. E. Apply chest physiotherapy.

C, D, E Nursing interventions that open up the alveoli, mobilize & thin secretions, and promote ventilation assist with airway clearance.

An adult with asthma requires education about using a peak flow meter. What information does the nurse teach the client? Select All That Apply: A. Regular use of the peak flow meter can reduce the number of asthma attacks experienced. B. The peak flow meter estimates lung function by determining how much air is inspired into the lungs. C. Comparing ongoing results with the best, stable result helps determine medication requirements. D. Initially, use the peak flow meter twice a day for at least two weeks when asthma is well-controlled. E. If the peak flow is less than 80% of personal best, administer reliever drug and retest in a few minutes.

C, D, E The peak flow meter is an assessment tool that helps guides the client's asthma treatment regimen.

A nurse cares for a client whose endotracheal tube is being removed after successful weaning off mechanical ventilation. Which immediate post-extubation actions does the nurse perform? Select All That Apply A. Position the client in the side-lying position. B. Encourage the client to take small sips of water. C. Monitor continuous pulse oximetry. D. Administer oxygen at 2 liters per minute (LPM). E. Auscultate breath sounds frequently.

C, E Ensure proper oxygenation and identify potential stridor by assessing breath sounds and monitoring pulse oximetry.

The nurse is assessing an older adult client with advanced Parkinson disease. Which clinical manifestation alerts the nurse that the client is developing aspiration pneumonia? Select All That Apply A. Hypernatremia B. Temperature of 37.5 °C (99.5 °F) C. Weak, frequent cough D. Respiratory rate of 20 breaths/min E. Oxygen saturation of 91% F. Unilateral crackles

C, E, F Aspiration pneumonia in advanced Parkinson's: unilateral crackles, weak cough, and oxygen saturation below 95%

A nurse assesses a client with asthma. Which clinical finding indicates the client has severe persistent asthma? A) Symptoms occur at night occasionally. B) Symptoms occur between two and six times a week. C) Continuous symptoms that limit physical activity. D) Symptoms require daily use of a beta-agonist inhaler.

Continuous symptoms that limit physical activity. With severe persistent asthma, the client's symptoms are continuous and limit the client's physical activity.

A healthy client is concerned about getting histoplasmosis from a friend. What does the nurse teach the client about the risk factors of histoplasmosis? A) "Living in close proximity to others increases the risk of infection." B) "Pulmonary hypertension is associated with the infection." C) "Smoking is correlated to the development of the infection." D) "Deficiency of the immune system may result in the development of the disease."

D "Deficiency of the immune system may result in the development of the disease." Histoplasmosis is an opportunistic fungal infection, primarily impacting those with immunodeficiency.

A nurse teaches a group of clients who live in Chicago and have been recently diagnosed with chronic obstructive pulmonary disease (COPD). Which statement does the nurse include in the teaching? A. "Eat three large meals daily." B. "Sleep in the supine position." C. "Increase exercise activities." D. "Do not shovel snow."

D "Do not shovel snow." Clients with COPD should be advised to conserve energy. Shoveling snow exerts the client's energy and increases oxygen demands, and cold air is a known trigger for COPD exacerbations.

A client receives discharge instructions for going home on oxygen therapy. The nurse knows the instructions were understood when the client makes which statement? A. "I will use a portable oxygen tank when doing my woodworking hobby in the garage." B. "I will store my extra portable oxygen tanks out of the way on their sides under my bed." C. "I will make sure to ask visitors to only smoke in the basement or on the other side of the house." D. "I will place a sign on all of my home entry doors that indicates I am using home oxygen equipment."

D "I will place a sign on all of my home entry doors that indicates I am using home oxygen equipment." The client should place a sign on the door of the home in order to alert EMS that oxygen equipment will be in their home. If there is an emergency or a fire in the home, this will alert the team of the increased risk.

The nurse cares for an older adult client in the urgent care clinic. The client and family are concerned the client may have pneumonia. Available data include the following: The client reports feeling lethargic and fatigued but denies a cough. The family reports confusion and poor appetite. Vital signs: Temperature 98.2° F (36.8° C), pulse 71 beats/min., respiration 18 breaths/min., BP 133/82 mm Hg, O2 saturation 90%. Which response by the nurse is appropriate? A. "The low oxygen level is likely causing the acute onset confusion." B. "Your vital signs are normal, and you don't have a fever." C. "You would have a cough if there was an infection in your lungs." D. "The healthcare provider will probably want a sputum sample."

D "The healthcare provider will probably want a sputum sample." The older adult client with pneumonia often presents with weakness, fatigue, confusion, and poor appetite. Fever and cough may be absent, but hypoxemia is often present. A sputum sample can help to identify infectious organisms in the lungs. This is an appropriate response by the nurse.

A nurse measures a client's oxygenation with a pulse oximeter. Which action does the nurse take to maintain accurate and consistent monitoring? A. Change the oximeter to a different finger each hour. B. Ask the client to take rapid, deep breaths during monitoring. C. Apply a blood pressure cuff above the pulse oximeter site. D. Ask the client to avoid repositioning the oximeter.

D Ask the client to avoid repositioning the oximeter. Asking the client to avoid repositioning the oximeter is the action that helps to maintain accurate and consistent monitoring.

A nurse prepares to perform postural drainage for a client with pneumonia. Which action does the nurse perform to determine the client position that best facilitates clearing of the lungs? A) Inspection of the chest B) Review of the chest x-ray C) Percussion of the thorax D) Auscultation of the lungs

D Auscultation of the lungs Auscultation of the lungs allows the nurse to determine the areas of the lungs that require drainage. Auscultation findings such as rhonchi or coarse crackles indicate retained fluid in the lungs, which may benefit from postural drainage.

The nurse cares for a client immediately after a bronchoscopy. Which action will the nurse perform? A. Offer soft foods. B. Administer midazolam. C. Offer water. D. Check the gag reflex.

D Check the gag reflex. Checking the client's gag reflex is the appropriate nursing action and the priority of care. Because of sedative medications, the client may not have a gag reflex and subsequently may have swallowing difficulties. Because this impairs the client's airway, this is the priority action.

A nurse notes a client's respiratory rate is 24 breaths/min. on 3 L/min. of oxygen. The client reports shortness of breath. Which action does the nurse perform first? A. Administer a bronchodilator as prescribed. B. Notify the health care provider. C. Increase the oxygen flow rate. D. Conduct a respiratory assessment.

D Conduct a respiratory assessment. Just as assessment is the first step of the nursing process, assessment is the nursing priority when caring for a client with respiratory distress.

A nurse assesses a client who is recovering from a thoracentesis. Which assessment finding is most concerning to the nurse? A. Heart rate 115 beats/min. B. Expiratory wheezes in the upper and lower lobes C. Respiratory rate of 25 breaths/min. D. Diminished breath sounds on the affected side

D Diminished breath sounds on the affected side may be indicative of a pneumothorax, or collapse of the lung. This is a potentially life-threatening condition and takes priority over non-life-threatening assessment findings.

The nurse is helping remove a chest tube following the resolution of a pneumothorax. What does the nurse instruct the client to do during the removal? A. "Take quick, shallow breaths." B. "Breathe forcefully." C. "Take slow, deep breaths." D. "Hold your breath and bear down."

D During chest tube removal, instruct the client to hold their breath and bear down to prevent air from entering pleural space.

A client with emphysema is short of breath. The nurse instructs the client that which position will help alleviate the shortness of breath? A. Supine with pillows under the legs B. Leaning back in the recliner C. Standing with a walker D. Sitting and leaning forward

D Instructing the client to sit upright and lean forward, usually onto a bedside table, assists the dyspneic client with improved diaphragmatic excursion. This improves ventilation and aids in breathing.

A nurse cares for a client who undergoes a thoracentesis, which reveals leukocytosis. How does the nurse interpret these results? A. A trauma occurred. B. The client is bleeding. C. The client has heart failure. D. An infection is present.

D Leukocytosis is elevated white blood cells. An infection in the pleural fluid manifests with elevated white blood cells in the pleural fluid.

A client with dark skin is experiencing respiratory distress due to an asthma exacerbation. Which is the best location for the nurse to check for cyanosis? A. Palms of the hands B. Sclera of the eyes C. Lips D. Mucous membranes

D Mucous membranes are unaffected by skin color and provide the best indicator of respiratory distress.

A client with chronic obstructive pulmonary disease (COPD) requires high-flow oxygen supplementation with precise delivery of oxygen concentration. The client still has control of their own airway and does not have excessive accessory muscle use. Which device does the nurse recognize as appropriate for this client? A. Bilevel positive airway pressure (BiPAP) mask B. Nasal cannula C. Aerosol mask D. Venturi mask

D The design of the Venturi mask allows precise delivery of FiO2 while still maintaining high-flow oxygen.

The nurse administers a purified protein derivative (PPD) test to a coworker. After what time frame does the nurse read the results of the test? A. 72-96 hours B> 24-48 hours C. 12-24 hours D. 48-72 hours

D The usual time to read the results to the PPD exposure is two to three days (48 to 72 hours).

A nurse assesses a client with pneumonia for bronchophony. The nurse uses what procedure? A. Have the client say a long E sound while auscultating the lungs. B. Have the client say "ninety-nine" while placing the palms on the chest wall. C. Ask the client to whisper a phrase while auscultating the lungs. D. Have the client say "ninety-nine" while auscultating the lungs.

D This is the procedure for assessing bronchophony. Normally, the voice transmission is muffled, but if there is an increase in lung density, the nurse will hear a clear "ninety-nine" in the stethoscope.

The nurse cares for a client admitted with chronic obstructive pulmonary disease (COPD) exacerbation. The nurse reviews results from the ABG. Which result is likely for this client? A. pH 7.48; HCO3 25 mEq/L; PaO2 91 mm Hg; PaCO2 26 mm Hg B. pH 7.31; HCO3 18 mEq/L; PaO2 95 mm Hg; PaCO2 37 mm Hg C. pH 7.50; HCO3 33 mEq/L; PaO2 90 mm Hg; PaCO2 39 mm Hg D. pH 7.28; HCO3 28 mEq/L; PaO2 78 mm Hg; PaCO2 48 mm Hg

D pH 7.28; HCO3 28 mEq/L; PaO2 78 mm Hg; PaCO2 48 mm Hg Respiratory acidosis is reflected by low pH, normal or elevated HCO3, low PaO2, and elevated PaCO2. Respiratory acidosis is expected in a client experiencing a COPD exacerbation.

A client is diagnosed with a terminal illness and the client's family member begins to breathe rapidly, appears anxious, and has a syncopal episode. The client's family member is evaluated after the transient loss of consciousness. What acid-base finding does the nurse expect to find in the family member's results? A. pH 7.22 (7.35-7.45) B. PaCO2 56 (35-45 mmHg) C. HCO3- 45 (21-28 mEq/L) D. pH 7.47 (7.35-7.45)

D pH 7.47 (7.35-7.45) "Blowing off" excessive PaCO2 from hyperventilation results in "blowing off" excess acid, causing respiratory alkalosis. Fast breathing causes carbon dioxide to be released too quickly. This reduces carbonic acid in the body and shifts the pH balance.

A nurse suctions a client's endotracheal tube and observes sinus bradycardia on the client's electrocardiogram (EKG) monitor. What is the nurse's response to the client's condition? A. Elevate the client's head of bed. B. Administer intravenous atropine. C. Continue suctioning until mucus is removed. D. Stop suctioning and administer oxygen.

D. Stop suctioning and administer oxygen. The client's arrhythmia is due to the Valsalva response from prolonged suctioning. The appropriate action by the nurse is to stop suctioning and administer oxygen as needed.