Respiratory system level 2

A client who was recently diagnosed with emphysema develops a malignancy in the right lower lobe of the lung, and a lobectomy is performed. After surgery, the client is receiving oxygen by nasal cannula at 2 L per minute. Blood gas results demonstrate respiratory acidosis. What should be the initial nursing intervention?

Encourage deep breathing

Surgery is performed on a client with a parotid tumor. The postoperative arterial blood gas values are pH 7.32, Pco2 53 mm Hg, and HCO3 25 mEq/L. What action should the nurse take?

Encourage the client to take deep, cleansing breaths

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."

The nurse is caring for a client whose arterial blood gases (ABGs) values are: Po2 89 mm Hg, Pco2 35 mm Hg, and pH of 7.37. These findings indicate that the client is experiencing:

Acid-base balance

What nursing action will most help a client obtain maximum benefits after postural drainage?

Encourage coughing deeply.

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. The nurse's priority is to:

Immediately contact the primary healthcare provider

The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. What is the priority nursing intervention?

Place client in a high-Fowler position

A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and should begin with which aspect of care?

The disease process and breathing exercises

After resection of a lower lobe of the lung, a client has excessive respiratory secretions. Which independent nursing action should the nurse implement?

Turning and positioning

On admission to the intensive care unit, a client is diagnosed with compensated metabolic acidosis. During the assessment, the nurse most likely will identify:

Deep and rapid respirations

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. What is the most appropriate nursing action?

Instruct the client to cough.

During a client's immediate postoperative period after a laryngectomy, a nursing priority is to:

Keep the trachea free of secretions

A client with acquired immunodeficiency syndrome (AIDS) and Cryptococcus pneumonia frequently is incontinent of feces and urine and produces copious sputum. When providing care for this client, the nurse's priority is to:

Use gown, mask, and gloves when bathing the client

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

Vesicular breath sounds

When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. The nurse should document:

Vesicular breath sounds

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 Hemoptysis Night sweats

What is the most effective way for the nurse to loosen respiratory secretions for a client with an endotracheal tube?

Humidify the prescribed oxygen.

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

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?

Inhale completely and then blow out as hard and as fast as possible through the mouthpiece

A tracheostomy is performed on a client in respiratory distress. How should the nurse position the patient following the procedure?

Semi-Fowler

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?

Semi-Fowler position

A nurse is caring for a client who had a bronchoscopy one hour ago. What nursing action is most appropriate to assess the return of the client's gag reflex?

Touch the client's pharynx with a tongue depressor.

A nurse uses abdominal-thoracic thrusts (Heimlich maneuver) when an older adult in a senior center chokes on a piece of meat. Which volume of air is the basis for the efficacy of the abdominal thrusts to expel a foreign object in the larynx?

Residual

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?

Respiratory acidosis

A nurse is caring for a variety of clients. For which client is it most essential for the nurse to implement measures to prevent pulmonary embolism?

59-year-old who had a knee replacement

A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, the nurse expects to identify:

Altered mental status

What nursing action will limit hypoxia when suctioning a client's airway?

Apply suction only after catheter is inserted.

After receiving streptomycin sulfate for 2 weeks as part of the medical regimen for tuberculosis, the client states, "I feel like I am walking like a drunken seaman." The nurse withholds the drug and promptly reports the problem to the health care provider. Which part of the body does the nurse determine is being affected as indicated by the symptom reported by the client?

Eighth cranial nerve's vestibular branch

Nursing intervention for a client who is hyperventilating should focus on providing reassurance and:

Having the client breathe into a paper bag

The nurse provides instructions to a client who will be using an incentive spirometer postoperatively. During the client's return demonstration, the nurse concludes that the teaching has been effective when the client:

Inhales deeply through the mouthpiece, holds the breath for two seconds, and then exhales

A health care provider prescribes metaproterenol (Allupent) for a client who was recently admitted to the hospital. For what therapeutic effect should the nurse monitor the client?

Relaxed bronchial spasm

A client with a spontaneous pneumothorax asks, "Why did they put this tube into my chest?" The nurse explains that the purpose of the chest tube is to:

Remove air from the pleural space

To evaluate the effectiveness of a chest tube inserted in a client with a pneumothorax, the nurse assesses for:

Return of breath sounds

The client with emphysema complains of increased shortness of breath and becomes anxious. The health care provider prescribes oxygen at 1 L/minute via nasal cannula. The nurse understands that this prescription is appropriate because:

High concentrations of oxygen eliminate the respiratory drive.

The nurse is caring for a 75-year-old client who had radical head and neck surgery. Thirty minutes after awakening from anesthesia, the client becomes agitated, disoriented, and confused. The nurse should:

Administer the prescribed oxygen

The nurse is monitoring a client who is receiving peritoneal dialysis. After the dialysate has infused, the client reports severe respiratory difficulty. What immediate action should the nurse implement?

Auscultate breath sounds.

A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. The nurse should:

Discontinue or decrease the oxygen flow rate

What is the major factor a nurse considers when anticipating the method of oxygen administration to be prescribed by the health care provider for a client?

Pathologic condition

The nurse observes a client with chronic obstructive pulmonary disease (COPD) breathing rapidly and using accessory muscles of respiration. The nurse auscultates the lungs and hears crackles and wheezes. What action should the nurse take?

Raise the head of the bed to a high-Fowler position and administer 2 L/min oxygen per nasal cannula

Tuberculosis is confirmed and isoniazid (INH), rifampin (Rifadin), and pyridoxine (vitamin B6) are prescribed for a client. The client says, "I've never had to take so many medicines for an infection before." What is the nurse's best reply?

This type of organism is difficult to destroy."

A client with chronic obstructive pulmonary disease (COPD) reports a five-pound weight gain in one week. The nurse recalls that the complication that may have precipitated this weight gain is:

Cor pulmonale

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?

Crackles are located in the smaller air passages.

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?

Decreased sounds

A client has chronic obstructive pulmonary disease (COPD) and cor pulmonale. When teaching about nutrition, the nurse instructs the client to:

Eat small meals six times a day to limit oxygen needs

Polycythemia frequently is associated with chronic obstructive pulmonary disease (COPD). When assessing for this complication, the nurse should monitor for:

Elevated hemoglobin

A client has a left pneumonectomy. Which nursing intervention is critical when the client regains consciousness in the postanesthesia care unit?

Encouraging deep breathing

What should the nurse expect when assessing a client with pleural effusion?

Reduced or absent breath sounds at the base of the lung

A client with acquired immunodeficiency syndrome (AIDS) is to receive aerosolized pentamidine (Pentam). Before administration, the nurse auscultates bilateral wheezes. The nurse should:

Withhold the medication and contact the healthcare provider to prescribe a bronchodilator.

A client with a diagnosis of tuberculosis is receiving isoniazid (INH) as part of a chemotherapy protocol. The nurse assesses the client for adverse responses to the medication. The nurse determines that prompt intervention is needed for which client response?

Yellow sclera

While a client with a fractured femur is being prepared for surgery, the client exhibits cyanosis, tachycardia, dyspnea, and restlessness. The nurse's first action should be to:

Administer oxygen by mask

A client with a tentative diagnosis of lung cancer is scheduled for a mediastinoscopy with biopsy. What is a priority nursing action?

Advise the client to avoid eating or drinking anything for several hours before the test.

A client is admitted to the hospital for medical treatment of bronchopneumonia. What test result should the nurse examine to help determine the effectiveness of the client's therapy?

Culture and sensitivity tests of sputum

During a mass disaster drill simulating a terrorist attack, the nurse must triage numerous severely ill individuals. The client who should receive care first is the client that is:

Gasping for breath and conscious

A health care 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

A nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. What information is most significant to include?

Importance of meticulous oral hygiene

After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client says:

"I get a sharp, stabbing pain when I take a deep breath."

A client is to continue oxygen therapy at home when discharged. Which client statement indicates the need for further instruction by the nurse?

"I have a new woolen blanket to keep me warm."

A client with the diagnosis of osteogenic sarcoma has metastasis to the lung. Which client statement about the concept of metastasis indicates a need for further instruction?

"I'm upset to know that the tumor may metastasize to my bones."

A client with tuberculosis asks the nurse why vitamin B6 (pyridoxine) is given with isoniazid (INH). What explanation should the nurse provide?

"Isoniazid interferes with the synthesis of this vitamin."

A client with chronic bronchitis smokes one or two cigarettes a day and has not been performing the prescribed pulmonary physiotherapy exercises because they are too tiring. What is the best response by the nurse?

"Tell me about your typical day before the exercises were prescribed."

A client has a persistent productive cough that becomes blood tinged. A needle biopsy is scheduled. The client tells the nurse, "During the procedure, a needle will be inserted into my back to collapse my lung." Which is the most appropriate response by the nurse?

"Tell me more about the conversation you had with your health care provider."

A client who is receiving chemotherapy for lung cancer has nausea and vomiting because of the therapy. The client wants to know if it is true that smoking marijuana will help. What is the nurse's best response?

"Tetrahydrocannabinol is an ingredient in marijuana that acts as an antiemetic in some people."

The nurse provides preoperative education to a client with extensive cancer of the upper right lobe of the lung who is scheduled for a lobectomy. The nurse concludes that the teaching was effective when the client states,

"The remaining lung tissue will fill in the empty space. I will have chest tubes to help with drainage after surgery."

Oxygen given to clients during stage 4 of chronic obstructive pulmonary disease (COPD) should be administered in which manner?

1 to 2 L via nasal cannula to keep SaO2 above 90%.

A nurse is caring for a client after a left pneumonectomy for cancer. The nurse palpates the client's trachea routinely. What is the rationale for this nursing intervention?

A mediastinal shift may have occurred.

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?

Absence of breath sounds over the affected area,

Pyridoxine (vitamin B6) and isoniazid (INH) are prescribed as part of the chemotherapy protocol for a client with tuberculosis. Which response indicates to the nurse that vitamin B6 is effective?

Absence of numbness and tingling in extremities

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:

Acute asthma attack

A client has chronic obstructive pulmonary disease (COPD). To decrease the risk of CO2 intoxication (CO2 narcosis), the nurse should:

Administer oxygen at a low concentration to maintain respiratory drive

When clients develop respiratory alkalosis, the nurse expects lab values to reflect:

An elevated pH, decreased Pco2

A client with a malignant parotid tumor is treated aggressively with radiation therapy and surgery. Postsurgical arterial blood gas results are: pH 7.32, Pco2 53 mm Hg,and HCO3 25 mEq. The nurse should take which action?

Ask the client to cough forcefully and take deep breaths

A nurse is caring for several clients in the intensive care unit. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome (ARDS)?

Aspirating gastric contents

The nurse is preparing to discharge a client who presented to the emergency room for an acute asthma attack. The nurse notes that upon discharge the health care provider has prescribed theophylline (Theo-Dur) 300 mg orally to be taken daily at 9:00 AM. The nurse should teach the client to take the medication:

At a specific time prescribed.

An older adult comes for an annual physical and tells the nurse, "I had three respiratory infections last year. How can I prevent this from happening again?" What is the nurse's best response?

Avoid putting your hands near your nose and mouth."

A client with cancer of the lung 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 conclude the client is in?

Bargaining

A client who experienced smoke inhalation has a negative chest x-ray and arterial blood gases that demonstrate PaO2 of 70 mm Hg, PaCO2 of 45 mm Hg, and pH of 7.35. What intervention should the nurse anticipate will be prescribed by the health care provider?

Breathing exercises

A client has been admitted for an upper respiratory tract infection secondary to chronic obstructive pulmonary disease (COPD). The nurse should expect which findings when auscultating the client's breath sounds?

Coarse crackles

A client with a chest tube is to be transported via a stretcher. When transporting the client, the nurse should keep the:

Collection device below the level of the client's chest.

Following surgery in the inguinal area, the client complains of pain on the right side of the chest, becomes dyspneic, and begins to cough violently. The nurse suspects that a pulmonary embolus has occurred. What is the priority nursing action?

Elevate the head of the bed

A client responds well after extensive pulmonary surgery for lung cancer and is discharged. A week after discharge the home care nurse observes the client's downcast eyes and lack of interest in the environment. The client's family states that this behavior started a few days after discharge. The nurse understands that the client's response is:

Expected, but needs to be addressed

During the evening after a paracentesis, the nurse identifies that the client, although denying any discomfort, is very anxious. The best nursing approach is to:

Explore the client's concerns while administering the prescribed anxiolytic

A client with late-stage dementia of the Alzheimer type aspirates gastric contents and develops acute respiratory distress syndrome (ARDS). The pathophysiologic changes associated with ARDS progress through expected phases. What phase is characterized by signs of pulmonary edema and atelectasis?

Exudative

A spontaneous pneumothorax is suspected in a client with a history of emphysema. In addition to calling the health care provider, what action should the nurse take?

Give oxygen at 2 L per minute via nasal cannula.

A client with a coronary occlusion is experiencing chest pain and distress. The nurse administers oxygen to:

Increase oxygen concentration to heart cells.

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. What initial action should the nurse take?

Inspect the dressing.T

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?

Intrinsic

The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. The type of respirations that the nurse expects the client to exhibit is:

Kussmaul's breathing

The nurse is providing care during the immediate postoperative period for a client that had a radical neck dissection. The best method to assess for stridor is:

Listen with a stethoscope over the trachea

A client is diagnosed with tuberculosis associated with human immunodeficiency virus (HIV) infection. What crucial laboratory test results should the nurse review before antitubercular pharmacotherapy is started?

Liver function studies

A client with pneumonia now requires use of a nonrebreathing mask to maintain adequate oxygen saturation levels. How does the nurse interpret this information?

Mechanical ventilation may be required next.

The arterial blood gases of a client with chronic obstructive pulmonary disease (COPD) deteriorate, and respiratory failure is impending. For which clinical indicator should the nurse assess first?

Mental confusion

A nurse assesses a client who is experiencing profound (late) hypovolemic shock. When monitoring the client's arterial blood gas results, what response does the nurse expect?

Metabolic acidosis

A client is admitted to the hospital for a surgical resection of the lower left lobe of the lung. After surgery the client has a chest tube to a closed-chest drainage system. What should the nurse do to determine if the chest tube is patent?

Observe for fluctuations of the fluid in the water-seal chamber

A chest tube is inserted into a client who was stabbed in the chest and is attached to a closed-drainage system. Which is an important nursing intervention when caring for this client?

Observe for fluid fluctuations in the water-seal chamber

A health care provider prescribes daily sputum specimens to be collected from a client. When is the most appropriate time for the nurse to collect these specimens?

On awakening

A client with pulmonary tuberculosis is being treated at home. To help control the spread of the disease, the nurse instructs the client to:

Open the windows frequently to allow air to circulate throughout the house

A client is admitted to the hospital with a diagnosis of emphysema and dyspnea. The nurse should encourage the client to assume what position?

Orthopneic

A client who sustained trauma to the chest as a result of an injury has chest tubes inserted and is attached to a closed-chest drainage system. When caring for this client, the nurse should:

Palpate the area around the tubes for crepitus

A client has chest tubes attached to a chest tube drainage system. What should the nurse do when caring for this client?

Palpate the surrounding area for crepitus.

A client is admitted to the hospital with a diagnosis of emphysema. What should the nurse include when teaching the client breathing exercises?

Perform diaphragmatic exercises to improve contraction of the diaphragm

A nurse who is caring for a client after head and neck surgery is concerned with the client's anger and depressive episodes about the effects of surgery. The action that indicates the client is reaching acceptance is:

Performing self-care of the tracheal stoma

A client who has experienced a fracture of the femur is experiencing respiratory difficulties, and the nurse suspects a pulmonary embolus. Which of these assessment findings is specific to a fat embolism?

Petechiae

A client arrives at a walk-in clinic complaining of chest pain on inspiration and shortness of breath, and has a temperature of 102° F. What term should the nurse document in the medical record when the following is heard on auscultation of the lateral lung fields of this client?

Pleural friction rub

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)?

Positive end-expiratory pressure (PEEP)

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?

Presence of a cough and pulmonary secretions

A client with a 10-year history of emphysema is admitted in acute respiratory distress. During assessment, the nurse expects to identify:

Prolonged expiration with use of accessory muscles

Before discharge, the nurse is planning to teach the client with emphysema pursed-lip breathing. The nurse should instruct the client that the purpose of pursed-lip breathing is to:

Promote elimination of CO2.

A client is receiving an intravenous infusion after a lobectomy for cancer of the lung. The nurse should monitor the client for which complication of intravenous therapy related specifically to postoperative lobectomy?

Pulmonary edema

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. The priority nursing assessments are:

Quality of respirations and presence of pulses

A nurse is caring for a client experiencing an acute episode of bronchial asthma. What should nursing interventions achieve?

Raising mucous secretions from the chest

A nurse is providing education to a co-worker who is caring for a client who is scheduled to have a thoracentesis for a pleural effusion. Which statement would be appropriate for the nurse to include?

Rapid removal of large amounts of pleural fluid may precipitate cardiovascular collapse.

A client has a chest tube for a pneumothorax. The nurse discovers that the chest tube has become disconnected from the drainage system, and the client is experiencing respiratory difficulty. What initial action should the nurse take?

Reconnect the client's tube to the drainage system

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?

Reconnect the client's tube to the drainage system.

A client's purified protein derivative (PPD) test and chest x-ray film results indicate pulmonary tuberculosis. The nurse provides instructions to the client related to collecting sputum specimens for acid-fast bacilli testing. The nurse determines that additional teaching is necessary when the client states that the sputum specimens must be:

Refrigerated until brought to the laboratory

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?" What likely cause of the spontaneous pneumothorax should the nurse's response take into consideration?

Rupture of a subpleural bleb

A client admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD) has received a prescription for a medication that is delivered via a nebulizer. When teaching about use of the nebulizer, the nurse should teach the client to:

Seal the lips around the mouthpiece and breathe in and out taking slow, deep breaths

A client with tuberculosis asks the nurse how long chemotherapy will be continued. The nurse's most accurate reply is:

Six to twelve months

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 sputum that is:

Sooty

What must the nurse determine before discontinuing airborne precautions for a client with pulmonary tuberculosis?

Sputum is free of acid-fast bacteria.

The nurse is providing postoperative care to a client with cancer of the lung that had a lobectomy. The client has a chest tube attached to suction. Which assessment finding includes a complication?

Subcutaneous emphysema on the second postoperative day

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, the nurse should:

Suction as needed

A client is experiencing severe respiratory distress. What response should the nurse expect the client to exhibit?

Tachycardia

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 requires lower levels of oxygen delivery, usually 1 to 3 L/min via nasal cannula.

The nurse provides a teaching session related to the severe acute respiratory syndrome (SARS) virus to a group of nursing students. It is appropriate for the nurse to include that, according to evidence-based research, the condition that is related to the SARS virus is:

The common cold

A client with tuberculosis is to begin Rifater (combination of isoniazid [INH], rifampin [RIF], and pyrazinamide [PZA]), and streptomycin sulfate (streptomycin) therapy. The client says, "I've never had to take so much medication for an infection before." The nurse should explain:

This type of organism is difficult to destroy."

A client is scheduled for a pulmonary function test. The nurse explains that during the test one of the instructions the respiratory therapist will give the client is to breathe normally. What should the nurse teach is being measured when the client follows these directions?

Tidal Volume

Diagnostic studies have been prescribed to assess a client's acid-base status. The nurse concludes that the laboratory value that indicates metabolic acidosis is:

Venous serum pH of 7.28

A nurse is caring for a client who had a pneumonectomy. What is the priority nursing assessment?

Ventilatory exchange

A client has a laryngectomy. The avoidance of which activity identified by the client indicates that the nurse's teaching about activities and the stoma is understood?

water sports

A nurse gave a client naloxone (Narcan). To evaluate the effectiveness of the medication, the nurse should assess for:

Increased respiration.

What is the underlying rationale why a nurse assesses a client with emphysema for clinical indicators of hypoxia?

Loss of aerating surface

When caring for a client on mechanical ventilation, the nurse should monitor for which signs of hyperventilation?

Respiratory alkalosis

A health care provider's prescription for a client in ketoacidosis is 500 units Humulin R insulin in 500 mL lactated Ringers intravenously (IV), and administer 60 units of insulin in the next 30 minutes. At how many milliliters per hour should the nurse set the IV infusion device to administer the correct amount of medication? Record your answer using a whole number. ____ mL/hr

120ml/h

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

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

What response provides evidence that a client with chronic obstructive pulmonary disease (COPD) understands the nurse's instructions about an appropriate breathing technique?

Holds each breath for a second at the end of inspiration.

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 states:

I'll cut back to a half pack a day."

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.

A client with bronchial pneumonia is having difficulty maintaining airway clearance because of retained secretions. To decrease the amount of secretions retained, the nurse plans to:

Increase fluid intake to at least 2 L a day

A nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange?

Orthopneic

A client with a pulmonary embolus is intubated and placed on mechanical ventilation. What nursing action is important when suctioning the endotracheal tube?

Hyperoxygenate with 100% oxygen before and after suctioning.

When caring for an intubated client receiving mechanical ventilation, the nurse hears the high-pressure alarm. Which action is most appropriate?

Remove secretions by suctioning

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?

An inaccurate interpretation

The nurse in the postanesthesia care unit is caring for a client who had a left-sided pneumonectomy. The nurse's primary concern is to maintain:

Ventilatory exchange

A client states that the health care provider said the tidal volume (TV) is slightly diminished and asks the nurse what this means. Which explanation should the nurse provide about the volume of air being measured to determine tidal volume?

Exhaled after there is a normal inspiration

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. The nurse concludes that the client's complaints probably are related to:

Hyperventilation

A client appears anxious, with respirations that are shallow and 40 per minute. The client reports feeling dizzy and light-headed and having tingling sensations of the fingertips and around the lips. What does the nurse determine is the probable cause of these clinical manifestations?

Hyperventilation

A client who has acquired human immunodeficiency syndrome (HIV) develops bacterial pneumonia. On admission to the emergency department, the client's PaO2 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?

Increase the oxygen flow rate per facility protocol.

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?

Obese client with leg trauma

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

When caring for clients who receive anesthesia, the nurse observes the loss of physiological functions during the stages of anesthesia induction. The last function the client loses is:

Respiratory movement

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD) who develops a pneumothorax and has a chest tube inserted. What is the primary purpose of the chest tube?

Restores negative pressure in the pleural space

A nurse is caring for clients with various health problems. These problems include scarlet fever, otitis media, bacterial endocarditis, rheumatic fever, and glomerulonephritis. What common factor linking these diseases should the nurse consider?

Result from streptococcal infections that enter via the upper respiratory tract

A client has a chest tube inserted to treat a right hemopneumothorax. In which position should the nurse place the client to facilitate chest drainage?

Right side-lying

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?

Rises with inspiration and falls with expiration.

A firefighter is admitted to the emergency department with severe dermal and inhalation burns. On assessment, a nurse identifies tachycardia, tachypnea, and dyspnea. What term should the nurse document in the medical record when the following is heard on auscultation of the lungs of this client?

Stridor

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?" The nurse explains that the water:

prevents reflux of air back into the chest

The nurse develops a plan of care related to a coughing and deep breathing regimen for a client who has had a pneumonectomy. The plan should include that, postoperatively, the client should cough and deep breathe:

Every hour for the first 24 hours and then every 2 hours

A client is admitted for a rhinoplasty. To monitor for hemorrhage after the surgery, the nurse should assess specifically for the presence of

Excessive swallowing

A nurse teaches a client how to perform diaphragmatic breathing. The nurse advises the client to:

Expand the abdomen on inhalation

The nurse is providing postoperative care to a client on the second day after the client had a coronary artery bypass surgery. When assessing the water-seal chamber of the chest drainage device, the nurse observes that the fluid no longer fluctuates. The nurse should:

Assess for obstructions in the chest tube

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?

Assess the client's response to the interventions.

The nurse is caring for a client with cancer of the lung who is considering the biological therapy (e.g., monoclonal antibodies, interferon) that has been recommended in the client's treatment plan. The nurse recalls that this therapy is:

Used as an adjuvant therapy with other therapies

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

A client who is to be admitted for minor surgery has a chest radiograph as part of the presurgical physical. The nurse is notified that the radiograph reveals that the client has pulmonary tuberculosis. What evidence of tuberculosis is provided by the radiograph?

Cavities caused by caseation

After thoracic surgery a client has a chest tube connected to a water-seal drainage system that is attached to suction. When excessive bubbling is observed in the water-seal chamber, the nurse should:

Check the system for air leaks

A nurse is caring for a client who has chest tubes inserted to treat a hemothorax that resulted from a crushing chest injury. A commonality of the various stationary chest tube drainage systems is that the first chamber is designed to:

Collect drainage

After a laryngectomy a client is concerned about improving the ability to communicate. What topic should the nurse include in a teaching plan for the client?

Esophageal speech

A client is on mechanical ventilation. When condensation collects in the ventilator tubing, the nurse should:

Drain the fluid from the tubing

A nurse is monitoring a client who is receiving an intravenous (IV) infusion of normal saline. What is a serious complication of IV therapy?

Shortness of breath with crackles

A client has an endotracheal tube and is receiving mechanical ventilation. Periodic suctioning is necessary and the nurse follows a specific protocol when performing this procedure. Select in order of priority the nursing actions that should be taken when suctioning.

Assess client's vital signs and lung sounds Administer oxygen via a ventilation bag Insert the catheter without applying suction Rotate the catheter while suction is applied

A terminally ill client in a hospice unit for several weeks is receiving a morphine drip. The dose is now above the typical recommended dosage. The client's spouse tells the nurse that the client is again uncomfortable and needs the morphine increased. The prescription states to titrate the morphine to comfort level. What should the nurse do?

Assess the client's pain before increasing the dose of morphine.

After a laryngectomy is scheduled, the most important factor for the nurse to include in the preoperative teaching plan is:

Establishing a means for communicating postoperatively

A nurse is notified that a victim of a gunshot wound to the right side of the chest is being transported to the emergency department. To prepare for the client, the priority nursing intervention is to:

Obtain equipment for chest tube insertion