Saunders NCLEX Respiratory

A client who is intubated and receiving mechanical ventilation is at risk for infection. The nurse would include which measures in the care of this client? Select all that apply. 1. Monitor the client's temperature. 2. Use sterile technique when suctioning. 3. Use the closed-system method of suctioning. 4. Monitor sputum characteristics and amounts. 5. Drain water from the ventilator tubing into the humidifier bottle

1. Monitor the client's temperature. 2. Use sterile technique when suctioning. 3. Use the closed-system method of suctioning. 4. Monitor sputum characteristics and amounts. Rationale:Monitoring temperature and sputum production is indicated in the care of the client. A closed-system method of suctioning and sterile technique decrease the risk of infection associated with suctioning. Water in the ventilator tubing would be emptied, not drained back into the humidifier bottle. This puts the client at risk of acquiring infection, especially Pseudomonas.

The nurse is caring for a client at risk for acute respiratory distress syndrome (ARDS). As part of the plan, the nurse will assess for which sign or symptom for early detection of this disorder? 1. Edema 2. Dyspnea 3. Frothy Sputum 4. Diminished breath sounds

2. Dyspnea Rationale:In most cases of ARDS, tachypnea and dyspnea are the first clinical manifestations. Blood-tinged frothy sputum would be a later sign after the development of pulmonary edema. Breath sounds in the early stages of ARDS usually are clear. Edema is not directly associated with ARDS.

The nurse has assisted the primary health care provider and the anesthesiologist with placement of an endotracheal (ET) tube for a client in respiratory distress. What is the initial nursing action to evaluate proper ET tube placement? 1 Tape the ET tube in place, and note the centimeter marking at the lip line. 2 Ask the radiology department to obtain a stat portable radiograph at the client's bedside. 3 Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. 4 Attach the ET tube to the ventilator and determine whether the client is able to tolerate the tidal volume prescribed.

3 Use an Ambu (resuscitation) bag to ventilate the client and assess for bilateral breath sounds. Rationale:The nurse verifies the placement of an ET tube immediately by ventilating the client using an Ambu bag and by auscultating for breath sounds bilaterally, which ensures ventilation of both lungs. After this initial assessment, placement is checked radiographically. The nurse marks the ET tube at the point where it enters the nose or mouth for ongoing monitoring of correct placement, but this will not determine initial adequate placement of the ET tube. Noting the tidal volume and the client's toleration of the tidal volume prescribed is not a measure of appropriate ET tube placement.

The nurse is caring for a client with a tracheostomy tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the tracheostomy and suspects tracheoesophageal fistula when which occurs? 1. Suctioning is required frequently. 2. The client's skin and mucous membranes are light pink. 3. Aspiration of gastric contents occurs during suctioning. 4. Excessive secretions are suctioned from the tube and stoma.

3. Aspiration of gastric contents occur during suctioning. Rationale:Necrosis of the tracheal wall can lead to formation of an abnormal opening between the posterior trachea and the esophagus. The opening, called a tracheoesophageal fistula, allows air to escape into the stomach, causing abdominal distention. It also causes aspiration of gastric contents. Options 1, 2, and 4 are not signs of this complication.

The nurse is caring for a client on a mechanical ventilator. The low-pressure alarm sounds. The nurse suspects that the most likely cause of the alarm is which finding? 1. A tubing obstruction or kink 2. The accumulation of secretions 3. Disconnection of the ventilator tubing 4. Condensation of water in the ventilator tubing

3. Disconnection of the ventilator tubing Rationale: The low-pressure alarm sounds when little or no pressure is generated during the delivery of the machine breaths. Alarm triggers include disconnection of the ventilator tubing at any point in the circuit, a cuff leak, and exaggerated client respiratory effort generating extreme negative pressure. The remaining options identify causes for triggering the high-pressure alarm.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse would assess for which earliest sign of acute respiratory distress syndrome? 1 Bilateral wheezing 2 Inspiratory crackles 3 Intercostal retractions 4 Increased respiratory rate

4 Increased respiratory rate Rationale:The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which finding? 1. Slow, deep respirations 2. Rapid, deep respirations 3. Paradoxical respirations 4. Pain, especially with inspiration

4. Pain, especially with inspiration Rationale:Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.

The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism? 1A 25-year-old client with diabetic ketoacidosis 2A 65-year-old client out of bed 1 day after prostate resection 3A 73-year-old client who has just had pinning of a hip fracture 4A 38-year-old client with pulmonary contusion sustained in an automobile crash

A: A 73-year-old client who has just had pinning of a hip fracture Rationale: Clients frequently at risk for pulmonary embolism include those who are immobilized. This is especially true in the immobilized postoperative client. Other causes include those with conditions that are characterized by hypercoagulability, endothelial disease, or advancing age.

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage would the nurse expect? 1 Serous 2 Bloody 3 Serosanguineous 4 Bloody, with frequent small clots

2 Bloody Rationale:In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client would not experience frequent clotting. Proper chest tube function would allow for drainage of blood before it has the chance to clot in the chest or the tubing.

A primary health care provider (PHCP) tells the nurse that a client's chest tube is to be removed since pneumothorax is resolved. The nurse would bring which dressing materials to the bedside for the PHCP's use? 1. Telfa dressing and Neosporin ointment 2. Petrolatum gauze and sterile 4 × 4 gauze 3. Benzoin spray and a hydrocolloid dressing 4. Sterile 4 × 4 gauze, Neosporin ointment, and tape

2. Petrolatum gauze and sterile 4 x 4 gauze Rationale: On removal of the chest tube, sterile petrolatum gauze and sterile 4 × 4 gauze is placed at the insertion site. The entire dressing is securely taped to make sure it is occlusive. The use of Telfa dressing, Neosporin ointment, hydrocolloid dressing, or benzoin spray is not indicated. Elastoplast tape may be used at the discretion of the PHCP as the tape of choice to make the dressing occlusive.

A client has experienced pulmonary embolism. The nurse would assess for which symptom, which is most commonly reported? 1 Hot, flushed feeling 2 Sudden chills and fever 3 Chest pain that occurs suddenly 4 Dyspnea when deep breaths are taken

3 Chest pain that occurs suddenly Rationale:The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1 Cyanosis 2 Hypotension 3 Paradoxical chest movement 4 Dyspnea, especially on exhalation

3 Paradoxical chest movement Rationale:Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position would the nurse instruct the client to assume? 1 Sitting up in bed 2 Side-lying in bed 3 Sitting in a recliner chair 4 Sitting up and leaning on an overbed table

4 Sitting up and leaning on an overbed table Rationale:Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.

A client is diagnosed with a rib fracture and asks the nurse why strapping of the ribs is not being done. Which response by the nurse is most appropriate? 1 "Strapping is useful only if the ribs are fractured in several places at once." 2 "That's a good idea. I'll ask the doctor for a prescription for the needed supplies." 3 "That isn't done because people often would develop pneumonia from the constricting effect on the lungs." 4 "That might help you to breathe better, but this facility does not carry the necessary supplies in the stockroom. When you get home, you can purchase them at the medical supply store."

3 "That isn't done because people often would develop pneumonia from the constricting effect on the lungs." Rationale: Strapping of the ribs has a constricting effect on the ribs and on deep breathing and can actually increase the risk of atelectasis and pneumonia. Therefore, options 1, 2, and 4 are incorrect.

The nurse is monitoring the respiratory status of a client with laryngeal cancer after creation of a tracheostomy. Which coexisting condition in the client may cause an inaccurate pulse oximetry reading? 1 Fever 2 Epilepsy 3 Hypotension 4 Respiratory failure

3 Hypotension Rationale:Hypotension, shock, or the use of peripheral vasoconstricting medications may result in inaccurate pulse oximetry readings as a result of impaired peripheral perfusion. Fever and epilepsy would not affect the accuracy of measurement. Respiratory failure also would not affect the accuracy of measurement, although the readings may be abnormally low.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection to remove a cancerous tumor. Which are the expected assessment findings? Select all that apply. 1. Excessive bubbling in the water seal chamber 2. Vigorous bubbling in the suction control chamber 3. Drainage system maintained below the client's chest 4. 50 mL of drainage in the drainage collection chamber 5. Occlusive dressing in place over the chest tube insertion site 6. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

3 Drainage system maintained below the client's chest 4 50 mL of drainage in the drainage collection chamber 5 Occlusive dressing in place over the chest tube insertion site 6 Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation Rationale:The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling would be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires notification of the primary health care provider. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. Which item(s) would the nurse place at the client's bedside? 1Code cart 2Intubation tray 3Thoracentesis tray 4Chest tube and drainage system

A: Intubation tray Rationale: The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures that an intubation tray is readily available. The other items are not needed at the client's bedside.

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client that which positions alleviate dyspnea? Select all that apply. 1 Sitting up and leaning on a table 2 Standing and leaning against a wall 3 Lying supine with the feet elevated 4 Sitting up with the elbows resting on knees 5 Lying on the back in a low-Fowler's position

1 Sitting up and leaning on a table 2 Standing and leaning against a wall 4 Sitting up with elbows resting on knees Rationale: The client would use the positions outlined in options 1, 2, and 4. These allow for maximal chest expansion. The client would not lie on the back because this reduces movement of a large area of the client's chest wall. Sitting is better than standing, whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not posture control.

Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply. 1Reduce fluid intake to less than 1500 mL/day. 2Teach diaphragmatic and pursed-lip breathing. 3Encourage alternating activity with rest periods. 4Teach the client techniques of chest physiotherapy. 5Keep the client in a supine position as much as possible.

A: 2Teach diaphragmatic and pursed-lip breathing. 3Encourage alternating activity with rest periods. 4Teach the client techniques of chest physiotherapy. Rationale: Fluids are encouraged, not reduced, to liquefy secretions for easier expectoration. Diaphragmatic and pursed-lip breathing assists in opening alveoli and eases dyspnea. The client needs to be encouraged to perform activities and exercise, such as dressing and walking, as tolerated with rest periods in between. Chest physiotherapy consists of percussion, vibration, and postural drainage. These techniques are helpful in removing secretions. Elevating the head of the bed assists with breathing.

The nurse is providing preoperative teaching to the client about the use of an incentive spirometer in the postoperative period. Which instructions would the nurse include? Select all that apply. 1Sit upright in the bed or in a chair. 2Inhale as deeply and quickly as possible. 3Hold the device in a downward position. 4Place the mouthpiece in your mouth and seal your lips tightly around it. 5After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

A: 1Sit upright in the bed or in a chair. 4Place the mouthpiece in your mouth and seal your lips tightly around it. 5After maximum inspiration, hold the breath for 2 to 3 seconds and exhale. Rationale: For optimal lung expansion with an incentive spirometer, the client would assume a semi-Fowler's or high-Fowler's position while holding the incentive spirometer in an upright position. The mouthpiece needs to be covered completely with the lips while the client inhales slowly, with a constant flow through the unit. The breath needs to be held for 2 to 3 seconds before exhaling slowly.

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings? 1. pH, 7.40; PaO2, 90 mm Hg; CO2, 39 mEq/L; HCO3, 23 mEq/L 2. pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L 3. pH, 7.47; PaO2, 82 mm Hg; CO2, 30 mEq/L; HCO3, 31 mEq/L 4. pH, 7.31; PaO2, 95 mm Hg; CO2, 22 mEq/L; HCO3, 19 mEq/L

A: 2. pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L Rationale: A client with COPD will exist in a state of respiratory acidosis. Options 2 and 4 reflect an acidotic pH. However, option 2 demonstrates increased CO2; a decreased pH and an increased CO2 indicate respiratory acidosis. Increased CO2 acts as an acid in the body, and CO2 is elevated in the client with COPD because of an inability to exhale well and eliminate CO2. Therefore, with a rise in CO2, there is a corresponding fall in pH. The other options are incorrect.

The nurse is reviewing the pathophysiology of pleural effusion. The nurse knows that pleural fluid balance is managed by several mechanisms and correctly identifies which of the following as a cause for the development of pleural effusion? Select all that apply. 1Decreased oncotic pressure 2Lymphatic fluid outflow obstruction 3Increased pulmonary capillary pressure 4Decreased pulmonary capillary pressure 5Increased pleural membrane permeability

A: Decreased oncotic pressure Lymphatic fluid outflow obstruction Increased pulmonary capillary pressure Increased pleural membrane permeability Rationale: The lungs are covered by a two-layered pleural membrane that contains a small amount of pleural fluid between the parietal and visceral pleura to lubricate lung movement. The fluid volume in the pleural space is managed by a balance between hydrostatic pressure, oncotic pressure, capillary permeability and lymphatic fluid outflow. Pleural effusion occurs when one of the previously mentioned mechanisms is disturbed and excessive fluid accumulates in the pleural space. Decreased oncotic pressure, lymphatic fluid outflow obstruction, increased capillary pressure (not decreased capillary pressure), and increased pleural membrane permeability can lead to the development of pleural effusion. Therefore, options 1, 2, 3, and 5 are correct.

The nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client with this goal. Which client statement indicates that further instruction is needed? 1"I will lie on the affected side for an hour." 2"I can expect a chest x-ray exam to be done shortly." 3"I will let you know at once if I have trouble breathing." 4"I will notify you if I feel a crackling sensation in my chest."

A: "I will lie on the affected side for an hour." Rationale: After the procedure the client usually is turned onto the unaffected side for 1 hour to facilitate lung expansion. Tachypnea, dyspnea, cyanosis, retractions, or diminished breath sounds, which may indicate pneumothorax, need to be reported to the primary health care provider. A chest x-ray may be performed to evaluate the degree of lung reexpansion or pneumothorax. Subcutaneous emphysema (crepitus) may follow this procedure because air in the pleural cavity leaks into subcutaneous tissues. The involved tissues feel like lumpy paper and crackle when palpated (crepitus). Usually subcutaneous emphysema causes no problems unless it is increasing and constricting vital organs, such as the trachea.

A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the primary health care provider (PHCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation? 1"It will enter the left main bronchus if inserted too far." 2"It will enter the right main bronchus if inserted too far." 3"It may enter the left main bronchus if not inserted far enough." 4"It may enter the right main bronchus if not inserted far enough."

A: "It will enter the right main bronchus if inserted too far." Rationale:If the endotracheal tube is inserted too far into the client's trachea, the tube will enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at all will occur. The other options are incorrect.

The nurse is providing instructions to a client with chronic obstructive pulmonary disease about using an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. What statement by the client indicates successful teaching? 1"It will open up the major airways." 2"It will keep the small airways open." 3"It will increase lubrication for the lungs." 4"The lungs can better rid themselves of secretions."

A: "It will keep the small airways open." Rationale: Sustained inhalation helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. The remaining options are not reasons for sustaining inflation.

The experienced nurse is teaching a new graduate nurse about tracheostomy care. The experienced nurse would determine teaching has been effective if the new graduate nurse states that which client has an immature tracheostomy? 1A client who underwent a tracheotomy 2 days ago 2A client who underwent a tracheotomy 8 days ago 3A client who underwent a tracheotomy 10 days ago 4A client who underwent a tracheotomy 1 month ago

A: A client who underwent a tracheotomy 2 days ago Rationale: After a tracheotomy, the tracheostomy tract becomes more established and matured over time. Tube dislodgment within 72 hours after a tracheotomy is considered an emergency because replacement of the tube is difficult due to the immaturity of the tract. This factor makes it more likely the tube will enter subcutaneous tissue instead of the trachea during attempted replacement. Since the client in option 1 has had the tracheotomy most recently compared with the other clients and the tracheostomy is considered immature, this client would be more likely to have complications if tube dislodgment occurs. Therefore, option 1 is the correct answer.

The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. How does the nurse correctly interpret this documentation? 1A shunt unit exists. 2Anatomical dead space is present. 3Physiological dead space is present. 4Ventilation-perfusion matching is occurring.

A: A shunt unit exists. Rationale: When there is no ventilation to an alveolar unit but perfusion continues, a shunt unit exists. As a result, no gas exchange occurs, and unoxgenated blood continues to circulate. Anatomical dead space normally is present in the conducting airways, where pulmonary capillaries are absent. Physiological dead space occurs with conditions such as emphysema and pulmonary embolism. Ventilation-perfusion matching refers to a matching distribution of blood flow in the pulmonary capillaries and air exchange in the alveolar units of the lungs.

A client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the nurse notes which assessment finding? 1Absence of dyspnea 2Increased severity of cough 3Dull percussion notes over lung tissue 4Decreased tactile fremitus over lung tissue

A: Absence of dyspnea Rationale: The client who has undergone thoracentesis would experience relief of the signs and symptoms experienced before the procedure. Typical signs and symptoms of pleural effusion include dry, nonproductive cough; dyspnea (usually on exertion); decreased or absent tactile fremitus; and dull or flat percussion notes on respiratory assessment.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How would the nurse instruct the client? 1Do not exceed 1 L/min. 2Do not exceed 2 L/min. 3Adjust the oxygen depending on SpO2. 4Adjust the oxygen depending on respiratory rate.

A: Adjust the oxygen depending on SpO2. Rationale: The client with COPD is often dependent on oxygen. The oxygen would be adjusted depending on the SpO2, which needs to be 88% to 92%. All other options are incorrect.

The nurse is caring for a client with chronic obstructive pulmonary disease who is dyspneic and has decreased breath sounds. The nurse would carry out which intervention to decrease the client's work of breathing? 1Instruct the client to limit fluid intake. 2Place the client in low-Fowler's position. 3Administer the prescribed bronchodilator. 4Place a continuous pulse oximeter on the client.

A: Administer the prescribed bronchodilator. Rationale:Administering the prescribed bronchodilator will help to decrease airway resistance, which decreases the work of breathing and would ease the client's dyspnea. The client needs to be placed in high-Fowler's position to maximize chest expansion. Clients with increased production of mucus have increased airway resistance, which increases the work of breathing. Thus, fluids would be increased to help liquefy secretions. Placing a continuous pulse oximeter will assist with monitoring the client's condition but will have no effect on the client's work of breathing.

The nurse is caring for a client with a tracheostomy receiving supplemental oxygen via a tracheostomy mask and is preparing to perform tracheostomy care. While preparing the supplies, the nurse notes the tracheostomy tube is pulsing, there is bleeding from the stoma, and the client is increasingly restless. The nurse calls for a rapid response team (RRT) and removes the tracheostomy tube. Which action would the nurse take next? 1Obtain blood type and crossmatch 2Ensure intravenous (IV) access patency 3Apply direct pressure to the source of bleeding 4Assist the primary health care provider (PHCP) with endotracheal intubation

A: Assist the primary health care provider (PHCP) with endotracheal intubation Rationale: Bleeding from a tracheostomy can indicate a serious medical emergency known as trachea-innominate artery fistula. The tracheostomy tube will pulse simultaneously with the heartbeat, and heavy bleeding will be noted from the stoma. The tracheostomy tube needs to be removed immediately and an alternative airway will need to be secured. After calling for help, the nurse would first prepare for endotracheal intubation. Therefore, option 4 is correct. Options 1, 2, and 3 are appropriate actions by the nurse, but a patent airway is the priority. Furthermore, those nursing interventions can be carried out simultaneously with assistance from the RRT.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse would assess for which earliest sign of acute respiratory distress syndrome? 1Bilateral wheezing 2Inspiratory crackles 3Intercostal retractions 4Increased respiratory rate

A: Increased respiratory rate Rationale: The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

The nurse is preparing a client diagnosed with a partial foreign body airway obstruction for a procedure to facilitate foreign body removal. The nurse would prepare the client for which of the following procedures? 1Lung biopsy 2Paracentesis 3Thoracentesis 4Bronchoscopy

A: Bronchoscopy Rationale: Bronchoscopy is a procedure in which a fiberoptic scope is introduced into the bronchi. This procedure is used for several purposes, including to suction mucous plugs, lavage the lungs, or remove foreign objects. Paracentesis is a procedure in which fluid is removed from the peritoneal space via a needle or catheter. Thoracentesis is a procedure in which pleural fluid is removed from the pleural space via a needle or catheter. A lung biopsy is a procedure in which lung tissue is obtained via several routes, including transbronchial or percutaneous biopsy, transthoracic needle aspiration, video-assisted thoracoscopic surgery (VATS), or open lung biopsy. Therefore, since bronchoscopy is a procedure to remove a foreign object from the lungs, option 4 is correct.

The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's Spo2 level is 86%. Based on this assessment, which action would the nurse take first? 1Increase to 3 L/min and titrate until the SpO2 is 100%. 2Check the client's record to determine the client's baseline SpO2. 3Place the client on a nonrebreather mask on 100% FiO2. 4Maintain oxygen flow at 2 L/min and call respiratory therapy for a breathing treatment.

A: Check the client's record to determine the client's baseline SpO2. Rationale: The nurse would first assess the client for signs of respiratory compromise and would check the client's record to determine the client's baseline value. The nurse would not increase the client's oxygen flow and titrate until the level is 100%. Oxygen flow rates are determined based on the client's normal baseline and would be titrated to the lowest amount needed; usually between 88% and 92% for a client with obstructive lung disease. Therefore, option 1 is incorrect. A nonrebreather mask is not necessary at this point, and oxygen via nasal cannula would be attempted first; therefore, option 3 is incorrect. It may be necessary to call respiratory therapy for a breathing treatment; however, client assessment is done first, making option 4 incorrect.

A client has experienced pulmonary embolism. The nurse would assess for which symptom, which is most commonly reported? 1Hot, flushed feeling 2Sudden chills and fever 3Chest pain that occurs suddenly 4Dyspnea when deep breaths are taken

A: Chest pain that occurs suddenly Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.

The nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The primary health care provider (PHCP) states that as a result of fluid in the alveoli, surfactant production is falling. What does the nurse anticipate as a physiological consequence? 1Atelectasis and viral infection 2Bronchoconstriction and stridor 3Collapse of alveoli and decreased compliance 4Decreased ciliary action and retained secretions

A: Collapse of alveoli and decreased compliance Rationale: Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become "stiff" because of decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis. The remaining options are incorrect.

The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? 1A low respiratory rate 2Diminished breath sounds 3The presence of a barrel chest 4A sucking sound at the site of injury

A: Diminished breath sounds Rationale: This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

A client is suspected of having a pulmonary embolus. The nurse assesses the client, knowing that which is a common clinical manifestation of pulmonary embolism? 1Dyspnea 2Bradypnea 3Bradycardia 4Decreased respirations

A: Dyspnea Rationale: The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain.

A client is on continuous mechanical ventilation (CMV) and the high-pressure alarm sounds. Which action would the nurse take to eliminate the problem? 1Silence the alarm to avoid disturbing the client. 2Check the ventilator circuit for any disconnections. 3Inflate the cuff of the endotracheal tube to a pressure of 25 mm Hg. 4Empty excess accumulated water from the ventilatory circuit tubing.

A: Empty excess accumulated water from the ventilatory circuit tubing. Rationale: High-pressure alarms can be triggered by increased airway resistance caused by excess secretions in the airway, biting the tube, coughing, bronchospasm, a kinked ventilatory circuit, or excess condensation of water in the ventilator tubing. Excess water needs to be emptied from the tubing. Alarms would never be silenced until the cause has been identified and corrected. In addition, this will not eliminate the problem. The low-pressure alarm would sound with a disconnection. Filling the cuff to 25 mm Hg can result in impaired circulation to the tracheal mucosa.

A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse would determine that which finding documented in the client's record is an expected finding with this client? 1 Increased oxygen saturation with ambulation 2 A widened diaphragm documented by chest x-ray 3 Hyperinflation of lungs documented by chest x-ray 4 A shortened expiratory phase of the respiratory cycle

A: Hyperinflation of lungs documented by chest x-ray Rationale: The clinical manifestations of COPD are several, including hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory respiratory muscles, and prolonged exhalation. Chest x-ray results indicate a hyper-inflated chest and may indicate a flattened diaphragm if the disease is advanced.

A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope in which location? 1Just under the left clavicle 2Midsternum, 1 inch to the left 3Over the fifth intercostal space 4Midsternum, 1 inch to the right

A: Just under the left clavicle Rationale: The apex of the lung is the rounded, uppermost part of the lung. Therefore, the nurse would place the stethoscope just under the left clavicle. All of the other options are incorrect locations for assessing the left apex.

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). What would the nurse expect to note in the client? 1Pallor 2Low arterial Pao2 3Elevated arterial Pao2 4Decreased respiratory rate

A: Low arterial Pao2 Rationale: The earliest clinical sign of ARDS is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a Pao2 lower than 60 mm Hg.

The nurse is caring for a client who is anxious and is experiencing dyspnea and restlessness from hypoxemia associated with pulmonary edema. Auscultation of the lungs reveals these breath sounds. The nurse determines that these breath sounds are usually caused by which condition? Refer to audio. 1Obstruction of the bronchus 2Inflammation of the pleural surfaces 3Passage of air through a narrowed airway 4Opening of small airways that contain fluid

A: Opening of small airways that contain fluid Rationale: The sounds that the nurse hears are high-pitched crackles. Crackles are audible when there is a sudden opening of small airways that contain fluid, are usually heard during inspiration, and do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema. High-pitched crackles are characteristically fine and are high-pitched, discontinuous popping noises (nonmusical sounds) heard during the end of inspiration. Medium-pitched crackles produce a moist sound about halfway through inspiration. Coarse crackles are low-pitched bubbling sounds that start early in inspiration and extend into the first part of expiration. Rhonchi (low-pitched, coarse, loud, low-snoring, or moaning sounds) are heard in conditions causing obstruction of the bronchus or trachea. A pleural friction rub (a superficial, low-pitched, coarse rubbing or grating sound) is heard when the pleural surfaces are inflamed. Passage of air through a narrowed airway is associated with wheezes (a high-pitched musical sound similar to a squeak).

The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse would expect to note which finding? 1Slow, deep respirations 2Rapid, deep respirations 3Paradoxical respirations 4Pain, especially with inspiration

A: Pain, especially with inspiration Rationale: Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include shallow respirations, splinting or guarding the chest protectively to minimize chest movement, pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.

The nurse is assessing a client's tracheostomy and notes that the skin around the stoma appears swollen with no redness or drainage present. Which action would the nurse take next? 1Palpate the skin around the stoma. 2Notify the primary health care provider (PHCP). 3Document the finding with no further intervention. 4Instruct the client to perform deep breathing exercises.

A: Palpate the skin around the stoma. Rationale: A complication of a tracheostomy is subcutaneous emphysema, in which air leaks into the subcutaneous tissue due to a misplaced tracheostomy tube. An important nursing assessment for the client with a tracheostomy is to examine the neck for swelling and then to palpate the swollen area. If subcutaneous emphysema is present, the nurse will feel a popping or crackling sensation when pressing on the skin. The nurse would then contact the PHCP for further interventions after collecting more assessment data. Therefore, option 1 is correct. Option 2 is appropriate after further assessing the area. Options 3 and 4 are inappropriate interventions for subcutaneous emphysema.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? 1Cyanosis 2Hypotension 3Paradoxical chest movement 4Dyspnea, especially on exhalation

A: Paradoxical chest movement Rationale: Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest.

A client did not seek medical treatment for a previous respiratory infection, and subsequently an empyema developed in the left lung. The nurse would assess the client for which signs and symptoms associated with this problem? 1Pleural pain and fever 2Decreased respiratory rate 3Diaphoresis during the day 4Hyperresonant breath sounds over the left thorax

A: Pleural pain and fever Rationale: The client with empyema usually experiences dyspnea, increased respiratory rate, pleural pain, night sweats, fever, anorexia, and weight loss. There is a decrease in breath sounds over the affected area, a flat sound to percussion, and decreased tactile fremitus.

The nurse is assisting a radiologist to facilitate a thoracentesis for a client with pleural effusion. The nurse assists the client to a position that widens the spaces between the ribs to help drain which area? 1Alveoli 2Trachea 3Pleural space 4Main bronchi

A: Pleural space Rationale: Thoracentesis is the needle aspiration of fluid or air from the pleural space for diagnostic or management purposes. Thoracentesis may be done at the bedside and is often done with imaging for guidance. The other options are incorrect.

A client with an endotracheal tube who is being mechanically ventilated is visibly anxious. What is the best nursing action? 1Ask a family member to stay with the client at all times. 2Encourage the client to sleep until arterial blood gas results improve. 3Ask the primary health care provider for a prescription for succinylcholine. 4Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.

A: Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed. Rationale: Morphine sulfate often is prescribed for pain and anxiety in the client receiving mechanical ventilation. The nurse needs to speak to the client calmly and provide reassurance to the anxious client. Family members also are stressed, not just because of the complication but because of the original injury. It is not beneficial to ask the family to take on the burden of remaining with the client at all times. Succinylcholine is a neuromuscular blocker but has no anti-anxiety properties. Encouraging the client to sleep until arterial blood gas results improve does nothing to reassure or help the client.

The nurse is assisting a client with a tracheostomy turn in bed when the tube gets caught under the client, causing the tracheostomy tube to be pulled out. The nurse calls a rapid response team (RRT) and attempts to replace the tracheostomy tube with the same size tube as the tube that was pulled out and is unsuccessful. While waiting for the RRT, which action would the nurse take? 1Auscultate bilateral breath sounds. 2Place the client in the low Fowler's position. 3Ventilate the client using a manual resuscitation bag with the stoma unoccluded. 4Reattempt the insertion with a tracheostomy tube that is one size smaller than the original tracheostomy tube.

A: Reattempt the insertion with a tracheostomy tube that is one size smaller than the original tracheostomy tube. Rationale: As part of the nursing care for a client with a tracheostomy, a tracheostomy kit with both a same-sized tube as the tube in place and a tube that is one size smaller than the tube in place, as well as an obturator and a curved Kelly clamp, needs to be kept at the bedside at all times in the event of accidental decannulation. During accidental decannulation and after asking for additional assistance, the nurse would insert an obturator into the same-sized tracheostomy tube and attempt to reinsert the tube into the stoma. If the nurse is unsuccessful, the nurse would attempt to perform the reinsertion procedure with a tracheostomy tube that is one size smaller than the original tube. Therefore, option 4 is correct. Option 1 would be an appropriate nursing assessment once the tracheostomy tube has been replaced to assess whether reinsertion has been successful and the client's airway is patent. Option 2 is incorrect because high Fowler's position, not low Fowler's position, is recommended for clients in respiratory distress. Option 3 is incorrect because manually ventilating the client with the stoma unoccluded would not ventilate the client, as the stoma would need to be occluded for the lungs to be ventilated.

A client with long-standing empyema undergoes decortication of the affected lung area. Postoperatively the nurse would place the client in which position? 1Supine 2Left-lateral 3Side-lying 4Semi-Fowler's

A: Semi-Fowler's Rationale: After any procedure involving lung surgery, the nurse would position the client in semi-Fowler's position. This position allows for maximal lung expansion and promotes drainage through the chest tube that may be placed during surgery. The positions identified in the remaining options will limit lung expansion.

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position would the nurse instruct the client to assume? 1Sitting up in bed 2Side-lying in bed 3Sitting in a recliner chair 4Sitting up and leaning on an overbed table

A: Sitting up and leaning on an overbed table Rationale: Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.

The client is returned to the nursing unit following thoracic surgery to treat lung cancer with a chest tube in place. During the first few hours postoperatively, the nurse assesses for drainage and expects to note which characteristics? 1The drainage is serous. 2The drainage is bloody. 3The drainage is serosanguineous. 4The drainage is bloody, with frequent small clots.

A: The drainage is bloody. Rationale: In the first few hours after surgery the drainage from the chest tube is bloody. After several hours it becomes serosanguineous. The client would not experience frequent clotting. Proper chest tube function would allow for drainage of blood before it has the chance to clot in the chest or the tubing.

The nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client's closed chest drainage system. How would the nurse interpret this finding? 1The drainage chamber is full. 2The pneumothorax is resolving. 3The suction chamber system is shut off. 4There is an air leak somewhere in the system.

A: There is an air leak somewhere in the system. Rationale: Continuous bubbling through both inspiration and expiration indicates that there is air leaking into the system. A resolving pneumothorax or a full drainage chamber would not cause bubbling with respiration in the water seal chamber. Shutting off the suction to the system stops bubbling in the suction control chamber but does not affect the water seal chamber.