Tingnan ang lahat ng mga set ng pag-aaral

(1) Respiratory

Pataasin ang iyong marka sa homework at exams ngayon gamit ang Quizwiz!

"The nurse observes air bubbles in a patient's chest tube water seal chamber. How should the nurse interpret this finding? 1. normal 2. an emergency 3. an indication that the pneumothorax is worsening 4. an indication to remove the chest tube"

"1. Global Rationale: Periodic air bubbles in the water-seal chamber are normal and indicate that trapped air is being removed from the chest. This is not an emergency situation, or one that indicates a worsening condition. The nurse would need a physician's order to remove a chest tube. The patient still needs the chest tube in place."

"When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first? a. Monitor the patient every 10 to 15 minutes. b. Notify the patient's health care provider immediately. c. Attempt to calm and reassure the patient. d. Assess vital signs and pulse oximetry."

"D Rationale: The nurse needs to collect additional clinical data to share with the health care provider and to start interventions quickly if appropriate (e.g., increased oxygen flow if hypoxic). The change in the patient's neurologic status may indicate deterioration in respiratory function, and the health care provider should be notified immediately but only after some additional information is obtained. Monitoring the patient and attempting to calm the patient are appropriate actions, but they will not prevent further deterioration of the patient's clinical status and may delay care. Cognitive Level: Application Text Reference: pp. 1804-1805 Nursing Process: Assessment NCLEX: Physiological Integrity"

The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the physician is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? 1. Gather the needed supplies for the procedure. 2. Obtain a signed informed consent form. 3. Assist the client into a side-lying position. 4. Discuss the procedure with the client.

"1. The nurse should gather a thoracotomy tray and the chest tube drainage system and take it to the client's bedside, but it is not the first intervention. ***2. The insertion of a chest tube is an invasive procedure and so requires informed con- sent. Without a consent form, this procedure cannot be done on an alert and oriented client. 3. This is a correct position to place the client for a chest tube insertion, but it is not the first intervention. 4. The physician will discuss the procedure with the client, then informed consent must be obtained, and then the nurse can do further teaching. TEST-TAKING HINT: The test taker must know that invasive procedures require informed consent and legally it must be obtained first before anyone can touch the client."

"The student nurse is learning how to care for patients who had thoracic surgery following a diagnosis of lung cancer. The intensive care unit nurse is assessing the student's understanding. Which statements by the student indicate the need for further education? Standard Text: Select all that apply. 1. ""I should assess the patient's respiratory system at least every four hours."" 2. ""I really shouldn't even offer narcotic pain medications to this patient because it will result in severe respi

"2, 3, 4, 5 Global Rationale: Narcotic pain medications should be offered after thoracic surgery to ensure that the patient can perform pulmonary rehabilitation exercises such as coughing, deep breathing, and incentive spirometry. The patient who is using narcotic pain medications to achieve pain control must be monitored for respiratory depression so that it can be treated. This patient should be encouraged to conserve energy. Items that are used frequently should be kept within the patient's reach. The nurse should elevate the head of the bed to 60 degrees, because elevating the head of the bed reduces pressure on the diaphragm and permits optimal lung expansion. The area between the visceral and parietal pleura must be filled with negative pressure to work appropriately. The chest tube is used to achieve negative pressure within this space. The nurse should perform a respiratory assessment at least every four hours."

A 20-year-old patient who is asking questions about smoking cessation tells the nurse about an upcoming class on scuba diving. The nurse recognizes that this patient might be at risk for developing what health problem? 1. pleural effusion 2. pleurisy 3. pneumothorax 4. hemothorax

"3. Global Rationale: Primary pneumothorax affects previously healthy people, usually tall, slender men between ages 16 and 24. The cause of primary pneumothorax is unknown. Risk factors include smoking. Certain activities also increase the risk of spontaneous pneumothorax, such as high-altitude flying and rapid decompression during scuba diving. The patient's age, smoking status, and scuba diving interest do not increase the risk for developing a pleural effusion, pleurisy, or a hemothorax."

"When admitting a patient in possible respiratory failure with a high PaCO2, which assessment information will be of most concern to the nurse? a. The patient is somnolent. b. The patient's SpO2 is 90%. c. The patient complains of weakness. d. The patient's blood pressure is 162/94."

"A Rationale: Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest. Cognitive Level: Application Text Reference: p. 1804 Nursing Process: Assessment NCLEX: Physiological Integrity"

"13. When the nurse is caring for an obese patient with left lower-lobe pneumonia, gas exchange will be best when the patient is positioned a. on the left side. b. on the right side. c. in the high-Fowler's position. d. in the tripod position."

"B Rationale: The patient should be positioned with the ""good"" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions. Cognitive Level: Comprehension Text Reference: pp. 1809-1810 Nursing Process: Implementation NCLEX: Physiological Integrity"

"The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? a. Notify the health care provider of the patient's vital signs. b. Obtain oxygen saturation using pulse oximetry. c. Document the vital signs and continue to monitor. d. Administer PRN acetaminophen (Tylenol) 650 mg."

"B Rationale: The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing; the nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Documentation and continued monitoring of the vital signs are needed but do not constitute an adequate response to the patient situation. Tylenol administration is appropriate but not the highest priority for this patient. Cognitive Level: Application Text Reference: pp. 1813-1814 Nursing Process: Implementation NCLEX: Physiological Integrity"

A patient with hypercapnic respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. Which collaborative intervention will the nurse anticipate? a. Administration of 100% oxygen by non-rebreather mask b. Endotracheal intubation and positive pressure ventilation c. Insertion of a mini-tracheostomy with frequent suctioning d. Initiation of bilevel positive pressure ventilation (BiPAP)

"B Rationale: The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. BiPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchange. Cognitive Level: Application Text Reference: pp. 1807-1808, 1810 Nursing Process: Planning NCLEX: Physiological Integrit"

"When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The skin on the patient's back is intact and without redness. b. Sputum and blood cultures show no growth after 24 hours. c. The patient's PaO2 is 90 mm Hg, and the SaO2 is 92%. d. Endotracheal suctioning results in minimal mucous return."

"C Rationale: The purpose of prone positioning is to improve the patient's oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective. Cognitive Level: Application Text Reference: pp. 1817-1818 Nursing Process: Evaluation NCLEX: Physiological Integrity"

"A patient in acute respiratory failure has a PaCO2 of 65 mm Hg, rhonchi audible in the right lung, and marked fatigue with a weak cough. The nurse will plan to a. allow the patient to rest to help conserve energy. b. arrange for a humidifier to be placed in the patient's room. c. position the patient on the right side with the head of the bed elevated. d. assist the patient with augmented coughing to remove respiratory secretions."

"D Rationale: The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve PaCO2 and will also help to correct fatigue. If the patient is allowed to rest, the PaCO2 will increase. Humidification may help loosen secretions, but the weak cough effort will prevent the secretions from being cleared. The patient should be positioned with the good lung down to improve gas exchange. Cognitive Level: Application Text Reference: p. 1809 Nursing Process: Planning NCLEX: Physiological Integrity"

"The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider? a. The patient has a cough that is productive of blood-tinged sputum. b. The patient has scattered crackles throughout the posterior lung bases. c. The patient's temperature is 101.5° F after 2 days of IV antibiotic therapy. d. The patient's SpO2 has dropped to 90%, although the O2 flow rate has been increase

"D Rationale: The patient's dropping SpO2 despite having an increase in FIO2 indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow rate. Cognitive Level: Application Text Reference: p. 1815 Nursing Process: Assessment NCLEX: Physiological Integrity"

A patient who is attached to a chest tube drainage unit is being transported from the emergency department to the respiratory care unit. Which of these actions should be performed by the healthcare provider in preparation for the transport?

"Secure the chest tube unit on the gurney. The chest tube drainage unit must always be kept below the patient's chest level to facilitate drainage and avoid backward flow of pleural drainage."

ANS: A Increasing oxygen flow rate usually will improve oxygen saturation in patients with ventilation-perfusion mismatch, as occurs with pulmonary embolism. Because the problem is with perfusion, actions that improve ventilation, such as deep-breathing and coughing, sitting upright, and suctioning, are not likely to improve oxygenation. DIF: Cognitive Level: Application REF: 1747-1749 | 1754 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

"While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation (SpO2) from 94% to 88%. The nurse will a. increase the oxygen flow rate. b. suction the patient's oropharynx. c. assist the patient to cough and deep breathe. d. help the patient to sit in a more upright position."

"A nurse is providing discharge teaching to a pt who has a temp tracheostomy. Which of the following statements by the pt indicates an understanding of the teaching? a. ""I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma"" b. ""I should cut a 4"" gauze dressing and place it around my trach tube to absorb drainage"" c. ""I should remove the old twill ties after the new ties are in place"" d. ""I should apply suction while inserting the cathete

"c. ""I should remove the old twill ties after the new ties are in place"""

"A nurse is providing teaching to a pt who has asthma and a new prescription to montelukast. Which of the following client statements indicates an understanding of the teaching? a. ""I will monitor my HR every day"" b. ""I will make sure I have this medication with me at all times"" c. ""I will need to carefully rinse my mouth after I take this medication"" d. ""I will take this medication every night even if I don't have symptoms"""

"d. ""I will take this medication every night even if I don't have symptoms"" * prophylactic treatment and is taken on a daily basis in the evening"

Which action does the nurse take to prevent hypoxia in a client during nasotracheal suctioning? a. Measuring the pulse oximetry throughout the procedure b. Inserting the suction catheter through the vocal cords only when the client exhales c. Administering 100% oxygen by manual resuscitation bag before initiating suctioning d. Removing the suction tube from the nasopharynx as soon as the client coughs

"e. Administering 100% oxygen by manual resuscitation bag before initiating suctioning * pre oxygenate the patient with 100% oxygen for 30 seconds to 3 minutes (at least 3 hyper-inflations) to prevent hypoxemia. Keep hyper-inflations synchronized with inhalation. If the patient can take deep breaths, instruct them to do so 3-4 times before suctioning a. while you do want to measure pulse oximetry if possible, it isn't critical to do so and doesn't prevent hypoxia... it identifies it. If the oxygen saturation falls below 90%, hypoxia is indicated. b. insert the suction catheter through the vocal cords on INHALATION d. the client may cough once the catheter enters the larynx. wait for them to inhale, then advance the catheter through the vocal cords and into the trachea. do NOT remove the suction tube!"

"The nurse is caring for a client with a right-sided chest tube secondary to a pneu- mothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. 1. Place the client in a low-Fowler's position. 2. Assess chest tube drainage system frequently. 3. Maintain strict bed rest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema."

***2. The system must be patent and intact to function properly. ***4. Looping the tubing prevents direct pressure on the chest tube itself and keeps tubing off the floor, addressing both a safety and an infection control issue. ***5. Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site.

Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube and there is excessive bubbling in the water-seal compartment? 1. Check the amount of wall suction being applied. 2. Assess the tubing for any blood clots. 3. Milk the tubing proximal to distal. 4. Encourage the client to cough forcefully.

1. Checking to see if someone has increased the suction rate is the simplest action for the nurse to implement; if it is not on high, then the nurse must check to see if the problem is with the client or the system.

Which action should the nurse implement for the client with a hemothorax who has a right-sided chest tube with excessive bubbling in the water-seal compartment? 1. Check the amount of wall suction being applied. 2. Assess the tubing for any blood clots. 3. Milk the tubing proximal to distal. 4. Encourage the client to cough forcefully

1. Checking to see if someone has increased the suction rate is the simplest and a noninvasive action for the nurse to implement; if it is not on high, then the nurse must check to see if the problem is with the client or the system.

The nurse is caring for a patient on mechanical ventilation with positive end expiratory pressure (PEEP). When assessing the patient, which finding would indicate the possibility of tension pneumothorax? 1. new onset of absent breath sounds over the right lung 2. blood pressure of 170/80 3. pulse oximetry readings ranging from 94% to 96% 4. crackles and wheezing heard in both lungs

1. Global Rationale: In a tension pneumothorax, air enters the pleural space with each breath but does not exit. Progressive accumulation of air in the pleural space leads to collapse of the lung on the affected side and hypoxia. As a result, the patient would have absent breath sounds on the affected side rather than adventitious sounds (crackles and wheezes). As the pressure in the thorax increases, cardiac output declines and the patient becomes hypotensive. A pulse oximetry reading of 94% demonstrates adequate oxygenation.

The nurse is assessing a patient recovering from a motor vehicle crash. Which assessment finding indicates that the patient is experiencing a pneumothorax? 1. hyperresonance to percussion at the apex of the left lung 2. dullness to percussion at the base of the left lung 3. crackles throughout the left lung 4. shallow breathing

1. Global Rationale: In pneumothorax, the percussion tone is hyperresonant due to the trapped air in the pleural space. Dullness to percussion is suggestive of fluid accumulation, such as in hemothorax. Crackles in the left lung suggest fluid accumulation in the alveoli. Shallow breathing can occur but is not specific to pneumothorax. It would also be seen in rib fractures and flail chest.

"During the assessment of a patient's respiratory status, the nurse notes paradoxical lung movements. This finding is consistent with what health problem? 1. flail chest 2. pleurisy 3. pneumothorax 4. pneumonia"

1. Global Rationale: Physiologic function of the chest wall is impaired as the flail segment is sucked inward during inhalation and moves outward with exhalation. This is known as paradoxic movement. This movement is not associated with pleurisy, pneumothorax, or pneumonia.

A patient has a chest tube inserted for a pneumothorax. What should the nurse expect when assessing the drainage system? 1. periodic bubbling in the water seal chamber immediately after insertion 2. no evidence of tidaling 3. vigorous bubbling in the suction control chamber 4. large amount of bloody drainage in the drainage collection chamber

1. Global Rationale: When a chest tube is inserted in the pleural space for a pneumothorax, the trapped air is allowed to escape and periodic bubbling is observed in the water seal as the lung reexpands. The water column in the water seal should rise with inspiration and fall with expiration (tidaling). There should be gentle bubbling in the suction control chamber to avoid rapid evaporation of the fluid in the chamber. Large amounts of bloody drainage would be anticipated after chest tube insertion for hemothorax.

"Which intervention should the nurse implement for a male client who has had a left- sided chest tube for six (6) hours and refuses to take deep breaths because it hurts too much? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain that deep breaths do not have to be taken at this time. 4. Tell the client that if he doesn't take deep breaths, he could die."

"Which intervention should the nurse implement for a male client who has had a left-sided chest tube for six (6) hours and who refuses to take deep breaths because of the pain? 1. Medicate the client and have the client take deep breaths. 2. Encourage the client to take shallow breaths to help with the pain. 3. Explain deep breaths do not have to be taken at this time. 4. Tell the client if he doesn't take deep breaths, he could die."

1. The client must take deep breaths to help push the air out of the pleural space into the water-seal drainage, and deep breaths will help prevent the client from developing pneumonia or atelectasis.

The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the LPN? 1. The client with pneumonia who has a pulse oximeter reading of 91%. 2. The client with a hemothorax who has Hgb of 9 mg/dL and Hct of 20%. 3. The client with chest tubes who has jugular vein distention and BP of 96/60. 4. The client who is two (2) hours post-bronchoscopy procedure.

1. This pulse oximeter reading indicates the client is hypoxic and therefore is not stable and should be assigned to an RN. 2. This H&H are very low; therefore the client is not stable and should be assigned to an RN. 3. Jugular vein distention and hypotension are signs of a tension pneumothorax, which is a medical emergency, and the client should be assigned to an RN. ***4. A client that is two (2) hours post- bronchoscopy procedure could safely be assigned to an LPN. TEST-TAKING HINT: The test taker must under- stand that the LPN should be assigned the least critical client or the client that is stable and not exhibiting any complications second- ary to the admitting disease or condition.

The client is admitted to the emergency department with chest trauma. When assess- ing the client, which signs/symptoms would the nurse expect to find that support the diagnosis of pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy bloody sputum and consolidation. 4. Barrel chest and polycythemia.

Which assessment data indicate to the nurse the chest tubes inserted three (3) days ago have been effective in treating the client with a hemothorax? 1. Gentle bubbling in the suction compartment. 2. No fluctuation (tidaling) in the water-seal compartment. 3. The drainage compartment has 250 mL of blood 4. The client is able to deep breathe without any pain.

2. At three (3) days postinsertion, no fluctuation (tidaling) indicates the lung has reexpanded, which indicates the treatment has been effective.

A patient is diagnosed with a tension pneumothorax. What should the nurse expect to assess in this patient? Standard Text: Select all that apply. 1. hypertension 2. distended neck veins 3. bradycardia 4. absent breath sounds on the affected side 5. tracheal deviation toward unaffected side

2, 4, 5 Global Rationale: Manifestations of a tension pneumothorax include hypotension, shock, distended neck veins, severe dyspnea, tachypnea, tachycardia, decreased respiratory excursion, absent breath sounds on affected side, and tracheal deviation toward unaffected side.

"The unlicensed nursing assistant is assisting the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? 1. The client's chest tube is below the level of the chest. 2. The nursing assistant has the chest tube attached to suction. 3. The nursing assistant allowed the client out of the bed. 4. The nursing assistant uses a bedside commode for the client."

The unlicensed assistive personnel (UAP) assists the client with a chest tube to ambulate to the bathroom. Which situation warrants immediate intervention from the nurse? 1. The UAP keeps the chest tube below chest level. 2. The UAP has the chest tube attached to suction. 3. The UAP allowed the client out of the bed. 4. The UAP uses a bedside commode for the client.

2. The chest tube system can function as a result of gravity and does not have to be attached to suction. Keeping it attached to suction could cause the client to trip and fall. Therefore, this is a safety issue and the nurse should intervene and explain this to the UAP.

The alert and oriented client is diagnosed with a spontaneous pneumothorax, and the healthcare provider is preparing to insert a left-sided chest tube. Which intervention should the nurse implement first? 1. Gather the needed supplies for the procedure. 2. Obtain a signed informed consent form. 3. Assist the client into a side-lying position. 4. Discuss the procedure with the client.

2. The insertion of a chest tube is an invasive procedure and requires informed consent. Without a consent form, this procedure should not be done on an alert and oriented client.

"The nurse is caring for a client with a right-sided chest tube secondary to a pneumothorax. Which interventions should the nurse implement when caring for this client? Select all that apply. 1. Place the client in the low Fowler's position. 2. Assess chest tube drainage system frequently. 3. Maintain strict bedrest for the client. 4. Secure a loop of drainage tubing to the sheet. 5. Observe the site for subcutaneous emphysema."

2. The system must be patent and intact to function properly. 4. Looping the tubing prevents direct pressure on the chest tube itself and keeps tubing off the floor, addressing both a safety and a potential clogging of the tube. 5. Subcutaneous emphysema is air under the skin, which is a common occurrence at the chest tube insertion site.

The client is admitted to the emergency department with chest trauma. Which signs/symptoms indicate to the nurse the diagnosis of pneumothorax? 1. Bronchovesicular lung sounds and bradypnea. 2. Unequal lung expansion and dyspnea. 3. Frothy, bloody sputum and consolidation. 4. Barrel chest and polycythemia.

2. Unequal lung expansion and dyspnea indicate a pneumothorax.

"The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse take if there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a stat chest x-ray. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client's pulse oximeter reading."

The nurse is presenting a class on chest tubes. Which statement describes a tension pneumothorax? 1. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during a central line placement.

Which assessment data indicate that the chest tubes have been effective in treating the client with a hemothorax who has a right-sided chest tube? 1. There is gentle bubbling in the suction compartment. 2. There is no fluctuation (tidaling) in the water-seal compartment. 3. There is 250 mL of blood in the drainage compartment 4. The client is able to deep breathe without any pain.

3. At three (3) days post-insertion, no fluctuation (tidaling) indicates the lung has reexpanded, which indicates the treatment has been effective.

The nurse is presenting a class on chest tubes. Which statement best describes a tension pneumothorax? 1. A tension pneumothorax develops when an air-filled bleb on the surface of the lung ruptures. 2. When a tension pneumothorax occurs, the air moves freely between the pleural space and the atmosphere. 3. The injury allows air into the pleural space but prevents it from escaping from the pleural space. 4. A tension pneumothorax results from a puncture of the pleura during a central line placeme

3. This describes a tension pneumothorax. It is a medical emergency requiring immediate intervention to preserve life.

A patient is brought to the emergency department unconscious following a barbiturate overdose. Which potential complication will the nurse include when developing the plan of care? a. Hypercapnic respiratory failure related to decreased ventilatory effort b. Hypoxemic respiratory failure related to diffusion limitations c. Hypoxemic respiratory failure related to shunting of blood d. Hypercapnic respiratory failure related to increased airway resistance

A Rationale: The patient with an opioid overdose develops hypercapnic respiratory failure as a result of the decrease in respiratory rate and depth. Diffusion limitations, blood shunting, and increased airway resistance are not the primary pathophysiology causing the respiratory failure. Cognitive Level: Application Text Reference: p. 1800 Nursing Process: Diagnosis NCLEX: Physiological Integrity

"The client has a right-sided chest tube. As the client is getting out of the bed it is acci- dentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion sit

The charge nurse is making client assignments on a medical floor. Which client should the charge nurse assign to the licensed practical nurse (LPN)? 1. The client with pneumonia who has a pulse oximeter reading of 91%. 2. The client with a hemothorax who has Hb of 9 g/dL and Hct of 20%. 3. The client with chest tubes who has jugular vein distention and BP of 96/60. 4. The client who is two (2) hours post-bronchoscopy procedure.

4. A client two (2) hours post-bronchoscopy procedure could safely be assigned to an LPN.

"The nurse is caring for a client with a right-sided chest tube that is accidentally pulled out of the pleural space. Which action should the nurse implement first? 1. Notify the health-care provider to have chest tubes reinserted STAT. 2. Instruct the client to take slow shallow breaths until the tube is reinserted. 3. Take no action and assess the client's respiratory status every 15 minutes. 4. Tape a petroleum jelly occlusive dressing on three (3) sides to the insertion site."

4. Taping on three sides prevents the development of a tension pneumothorax by inhibiting air from entering the wound during inhalation but allowing it to escape during exhalation.

Which of these individuals is at risk for a primary spontaneous pneumothorax?

6 ft. 138 lb pt. who smokes A primary spontaneous pneumothorax occurs most commonly in young males who are tall and thin.

"An 8-year-old client with cystic fibrosis is admitted to the hospital and will undergo a chest physiotherapy treatment. The therapy should be properly coordinated by the nurse with the respiratory therapy department so that treatments occur during: A) Between meals B) After meals C) After medication D) Around the child's play schedule"

A 2-year-old client with cystic fibrosis is confined to bed and is not allowed to go to the playroom. Which of the following is an appropriate toy would the nurse select for the child: A) Pounding board and hammer B) Arranging stickers in the album C) Musical automobile D) Puzzle

A nurse is assisting the provider who is performing a thoracentesis at the bedside of a pt. Which of the following actions should the nurse take? Select all that apply a. Wear goggles and mask during the procedure b. Cleanse the procedure area with an antiseptic solution c. Instruct the client to take deep breaths through the procedure d. Position the client laterally on the affected side before the procedure e. Apply pressure to the site after the procedure

A B E a. Wear goggles and mask during the procedure * reduces the risk of exposure to pleural fluid b. Cleanse the procedure area with an antiseptic solution * antiseptics are antimicrobial substances that are applied to living skin/tissue to reduce risk of infection e. Apply pressure to the site after the procedure * decreases risk of bleeding at procedure site The nurse should instruct the pt to remain as still as possible during to reduce the risk of puncturing the pleura or lung. The pt should be positioned in a sitting position leaning over the bedside table or laterally on the UNAFFECTED side to promote access to the site and encourage draining of pleural fluid

To evaluate both oxygenation and ventilation in a patient with acute respiratory failure, the nurse uses the findings revealed with a. arterial blood gas (ABG) analysis. b. hemodynamic monitoring. c. chest x-rays. d. pulse oximetry.

A Rationale: ABG analysis is useful because it provides information about both oxygenation and ventilation and assists with determining possible etiologies and appropriate treatment. The other tests may also provide useful information about patient status but will not indicate whether the patient has hypoxemia, hypercapnia, or both. Cognitive Level: Comprehension Text Reference: p. 1805 Nursing Process: Assessment NCLEX: Physiological Integrity

"Which information obtained by the nurse when assessing a patient with acute respiratory distress syndrome (ARDS) who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates a complication of ventilator therapy is occurring? a. The patient has subcutaneous emphysema. b. The patient has a sinus bradycardia, rate 52. c. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. d. The patient has bronchial breath sounds in both the lung fields."

A Rationale: Complications of positive-pressure ventilation (PPV) and PEEP include subcutaneous emphysema. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns, but they are not caused by PPV and PEEP. Cognitive Level: Application Text Reference: p. 1816 Nursing Process: Assessment NCLEX: Physiological Integrity

The nurse will monitor for clinical manifestations of hypercapnia when a patient in the emergency department has a. chest trauma and multiple rib fractures. b. carbon monoxide poisoning after a house fire. c. left-sided ventricular failure and acute pulmonary edema. d. tachypnea and acute respiratory distress syndrome (ARDS).

A Rationale: Hypercapnia is caused by poor ventilatory effort, which occurs in chest trauma when rib fractures (or flail chest) decrease lung ventilation. Carbon monoxide poisoning, acute pulmonary edema, and ARDS are more commonly associated with hypoxemia. Cognitive Level: Application Text Reference: p. 1800 Nursing Process: Assessment NCLEX: Physiological Integrity

"A patient with acute respiratory distress syndrome (ARDS) has progressed to the fibrotic phase. The patient's family members are anxious about the patient's condition and are continuously present at the hospital. In addressing the family's concerns, it is important for the nurse to a. support the family and help them understand the realistic expectation that the patient's chance for survival is poor. b. inform the family that home health nurses will be able to help them maintain the mechanical

A Rationale: The chance for survival is poor when the patient progresses to the fibrotic stage because permanent damage to the alveoli has occurred. Because of continued severe hypoxemia, the patient is not a candidate for home health or long-term care. The fibrotic stage indicates a poor patient prognosis, not the resolution of the ARDS process. Cognitive Level: Application Text Reference: p. 1814 Nursing Process: Implementation NCLEX: Psychosocial Integrity

When receiving report during the transfer of a patient who has a pneumothorax, the healthcare provider is told that the patient has subcutaneous emphysema. Which assessment finding will validate this statement?

A crackling sensation when the chest is palpated If air leaks into the subcutaneous tissue, a crackling or popping sensation can be felt on palpation.

The healthcare provider is caring for a patient who has a pneumothorax. When assessing the patient and the chest tube drainage system, a large fibrin clot is noted in the tubing. Which additional assessment finding requires immediate action by the healthcare provider?

A downward trend in blood pressure Clots in the system can cause occlusion and lead to a tension pneumothorax, which may be evidenced by a downward trend in blood pressure as increased pressure on the heart and great vessels impair cardiac output.

The nurse is caring for a patient admitted to the hospital with pneumonia. Upon assessment, the nurse notes a temperature of 101.4° F, a productive cough with yellow sputum and a respiratory rate of 20. Which of the following nursing diagnosis is most appropriate based upon this assessment? A. Hyperthermia related to infectious illness B. Ineffective thermoregulation related to chilling C. Ineffective breathing pattern related to pneumonia D. Ineffective airway clearance related to thick secret

A. Hyperthermia related to infectious illness Because the patient has spiked a temperature and has a diagnosis of pneumonia, the logical nursing diagnosis is hyperthermia related to infectious illness. There is no evidence of a chill, and her breathing pattern is within normal limits at 20 breaths per minute. There is no evidence of ineffective airway clearance from the information given because the patient is expectorating sputum.

At what age is this disease diagnosed? A) Childhood years [5-12] B) Teenage years [12-17] C) Early years [0-5] D) Adult years [18-50]

A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery systems should the nurse use to provide the client with the highest level of oxygen? a. Nasal cannula b. Non-rebreather mask c. Simple face mask d. Partial rebreather mask

B b. Non-rebreather mask * Made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This delivers greater than 90% FiO2!

A patient who has a diagnosis of pneumonia reports a sudden onset of sharp pain on one side of the chest. The patient is dyspneic and oxygen saturation falls to 89%, percent. After administering oxygen to the patient, which of these actions should the healthcare provider perform next?

Auscultate the lungs bilaterally If breath sounds are distant or absent on one side, the healthcare provider will suspect a pneumothorax.

A 6-year-old with cystic fibrosis has an order for Creon. The nurse knows that the medication will be given: A) At bedtime B) With meals and snacks C) Twice daily D) Daily in the morning

Cystic fibrosis is caused by: A) A defective gene that causes abnormalities in the brain B) A defective gene that leads to the making of an abnormal protein C) It is not known what the cause is D) Someone who eats too much salt

The recommended diet for someone with cystic fibrosis is: A) High fat diet B) High calorie and high protein diet C) Low fat diet D) High calorie diet

Which of the following clients is at high risk for developmental problem? A) A preschooler with tonsillitis B) A 2 1/2 -year old boy with cystic fibrosis C) A 5-year-old with asthma on cromolyn sodium D) A toddler with acute Glomerulonephritis on antihypertensive and antibiotics

A finding indicating to the nurse that a 22-year-old patient with respiratory distress is in acute respiratory failure includes a a. shallow breathing pattern. b. partial pressure of arterial oxygen (PaO2) of 45 mm Hg. c. partial pressure of carbon dioxide in arterial gas (PaCO2) of 34 mm Hg. d. respiratory rate of 32/min.

B Rationale: The PaO2 indicates severe hypoxemia and that the nurse should take immediate action to correct this problem. Shallow breathing, rapid respiratory rate, and low PaCO2 can be caused by other factors, such as anxiety or pain. Cognitive Level: Application Text Reference: p. 1806 Nursing Process: Assessment NCLEX: Physiological Integrity

Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) is most appropriate for the RN to delegate to an experienced LPN/LVN working in the intensive care unit? a. Placing the patient in the prone position b. Assessment of patient breath sounds c. Administration of enteral tube feedings d. Obtaining the pulmonary artery pressures

C Rationale: Administration of tube feedings is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff and should be supervised by an RN. Assessment of breath sounds and obtaining pulmonary artery pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient. Cognitive Level: Application Text Reference: pp. 1816-1818 Nursing Process: Implementation NCLEX: Safe and Effective Care Environment

All the following medications are ordered for a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) and acute renal failure. Which medication should the nurse discuss with the health care provider before administration? a. IV ranitidine (Zantac) 50 mg IV b. sucralfate (Carafate) 1 g per nasogastric tube c. IV gentamicin (Garamycin) 60 mg d. IV methylprednisolone (Solu-Medrol) 40 mg

C Rationale: Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS. Cognitive Level: Application Text Reference: p. 1816 Nursing Process: Implementation NCLEX: Physiological Integrity

It will be most important for the nurse to check pulse oximetry for which of these patients? a. A patient with emphysema and a respiratory rate of 16 b. A patient with massive obesity who is refusing to get out of bed c. A patient with pneumonia who has just been admitted to the unit d. A patient who has just received morphine sulfate for postoperative pain

C Rationale: Hypoxemia and hypoxemic respiratory failure are caused by disorders that interfere with the transfer of oxygen into the blood, such as pneumonia. The other listed disorders are more likely to cause problems with hypercapnia because of ventilatory failure. Cognitive Level: Application Text Reference: pp. 1799-1800 Nursing Process: Assessment NCLEX: Physiological Integrity

When a patient is diagnosed with pulmonary fibrosis, the nurse will teach the patient about the risk for poor oxygenation because of a. too-rapid movement of blood flow through the pulmonary blood vessels. b. incomplete filling of the alveoli with air because of reduced respiratory ability. c. decreased transfer of oxygen into the blood because of thickening of the alveoli. d. mismatch between lung ventilation and blood flow through the blood vessels of the lung.

C Rationale: Pulmonary fibrosis causes the alveolar-capillary interface to become thicker, which increases the amount of time it takes for gas to diffuse across the membrane. Too-rapid pulmonary blood flow is another cause of shunt but does not describe the pathology of pulmonary fibrosis. Decrease in alveolar ventilation will cause hypercapnia. Ventilation and perfusion are matched in pulmonary fibrosis; the problem is with diffusion. Cognitive Level: Application Text Reference: p. 1802 Nursing Process: Implementation NCLEX: Physiological Integrity

"When caring for a patient who developed acute respiratory distress syndrome (ARDS) as a result of a urinary tract infection (UTI), the nurse is asked by the patient's family how a urinary tract infection could cause lung damage. Which response by the nurse is appropriate? a. ""The infection spread through the circulation from the urinary tract to the lungs."" b. ""The urinary tract infection produced toxins that damaged the lungs."" c. ""The infection caused generalized inflammation that damage

C Rationale: The pathophysiologic changes that occur in ARDS are thought to be caused by inflammatory and immune reactions that lead to changes at the alveolar-capillary membrane. ARDS is not directly caused by infection, toxins, or fever. Cognitive Level: Application Text Reference: p. 1813 Nursing Process: Implementation NCLEX: Physiological Integrity

The nurse is describing the effects of smoking. Which effect should be included? (Select all that apply.) Constriction of smooth muscle Destruction of airways Inhibited function of alveolar macrophages Atrophy of mucus-secreting glands Enhanced ciliary movement

Constriction of smooth muscle Destruction of airways Inhibited function of alveolar macrophages

The nurse is completing a health history of a client who has an exacerbation of chronic obstructive pulmonary disease. Which should the nurse obtain? Peripheral pulses Current medications Breath sounds Percussion tone

Current medications

How is CF diagnosed? A. Sweat test B. Blood test C. Lung volume test D. A and B

"When caring for a patient who has a pneumothorax, which of these actions should the healthcare provider include in the patient's plan of care?"

Encourage the patient to breathe deeply and cough regularly. Regular deep breathing and coughing will help re-expand the collapsed lung.

"20. Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct? a. ""PEEP will prevent fibrosis of the lung from occurring."" b. ""PEEP will push more air into the lungs during inhalation."" c. ""PEEP allows the ventilator to deliver 100% oxygen to the lungs."" d. ""PEEP prevents the lung air sacs from collapsing during exhalation."""

D Rationale: By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient. Cognitive Level: Comprehension Text Reference: p. 1817 Nursing Process: Planning NCLEX: Physiological Integrity

After prolonged cardiopulmonary bypass, a patient develops increasing shortness of breath and hypoxemia. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with a. positioning the patient for a chest radiograph. b. drawing blood for arterial blood gases. c. obtaining a ventilation-perfusion scan. d. inserting a pulmonary artery catheter.

D Rationale: Pulmonary artery wedge pressure will remain at normal levels in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema. Cognitive Level: Application Text Reference: p. 1815 Nursing Process: Implementation NCLEX: Physiological Integrity

The nurse is assessing a client who has chronic bronchitis. Which symptom should the nurse expect to find? (Select all that apply.) Distended neck veins Barrel chest Wheezing Diminished breath sounds Cough with sputum production

Distended neck veins Wheezing Cough with sputum production

The client with chronic obstructive pulmonary disease has severe hypercapnia, hypoxemia, lethargy, and cyanotic nail beds. Which treatment should the nurse expect to be ordered? Percussion and postural drainage Endotracheal intubation Respiratory treatment with bronchodilators High flow oxygen administration

Endotracheal intubation

During assessment of a client with acute respiratory distress syndrome (ARDS), the nurse notes an oxygen saturation of 78% and a respiratory rate of 28 breaths/min. The nurse notifies the healthcare provider and should prepare for intubation using which type of airway? Tracheostomy Endotracheal tube Oropharyngeal airway Nasopharyngeal airway

Endotracheal tube An endotracheal tube is the most common type of airway placed, especially in emergency situations in which mechanical ventilation is required. This client would not initially need a tracheostomy, because it is an airway used for long-term support. Oropharyngeal and nasopharyngeal airways are only used when the upper air passages are at risk of becoming obstructed by secretions or the tongue.

The nurse is discussing dietary changes for a client with chronic obstructive pulmonary disease. Which advice should the nurse include? Follow a high-carbohydrate diet. Restrict fluids. Increase dairy products. Follow a low-salt diet.

Follow a low-salt diet.

The nurse reviews the arterial blood gas (ABG) results of a client with end-stage chronic obstructive pulmonary disease (COPD). Which finding should the nurse expect? Hypercapnia with hypoxia Hypercapnia with normal oxygenation Low CO2 with hypoxia Normal CO2 with hypoxia

Hypercapnia with hypoxia

The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about the purpose of using a bronchodilator. Which explanation should the nurse include? Has long duration of affect Exhibits anti-inflammatory properties Strengthens the bronchial muscle contraction Improves airflow and reduces air trapping

Improves airflow and reduces air trapping

"A 6-year-old child is diagnosed with chronic obstructive pulmonary disease (COPD). Which risk factor should the nurse expect to find in the child's history? Secondhand cigarette smoke Exposure to air pollution Inherited genetic abnormality Repeated bouts of colds and flu"

Inherited genetic abnormality

Which condition should the nurse understand occurs in the pathophysiology of emphysema? (Select all that apply.) Excessive mucus produced Decrease in cilia function Fluid buildup in the lungs Loss of elastic recoil of the lungs Enlargement of the alveoli

Loss of elastic recoil of the lungs Enlargement of the alveoli

A nurse is caring for a pt who is receiving mechanical ventilation when the low pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm? a. Excess secretions b. Kinks in the tubing c. Artificial airway cuff leak d. Biting on the endotracheal tube

c. Artificial airway cuff leak * Interferes with oxygenation and causes low pressure alarm to sound The others cause the high pressure alarm to sound

The nurse is providing care to a client with acute respiratory distress syndrome (ARDS). Which independent intervention should the nurse prepare to perform for this client? (Select all that apply.) Maintain the head of the bed at 30 degrees. Recommend a prone position to facilitate oxygenation. Prescribe analgesia for pain. Order a Foley catheter to monitor urine output. Auscultate heart and lung sounds.

Maintain the head of the bed at 30 degrees. Recommend a prone position to facilitate oxygenation. Auscultate heart and lung sounds. The nurse can independently auscultate heart and lung sounds, maintain the head of the bed at 30 degrees, and recommend prone positioning to facilitate oxygenation. It is outside the scope of nursing practice for the nurse to prescribe analgesics for pain or order a Foley catheter to monitor urine output.

The nurse is caring for a client with acute respiratory distress syndrome (ARDS) who needs an artificial airway to assist in maintaining an open airway. Which airway will the nurse plan to reposition every 8 hours while providing care? Endotracheal Nasopharyngeal Oropharyngeal Tracheostomy

Nasopharyngeal The nasopharyngeal airway must be repositioned every 8 hours to prevent necrosis of the mucosa. The other airways will not require this intervention from the nurse.

The nurse is planning a collaborative care conference for a client recently diagnosed with chronic obstructive pulmonary disease. Which team member should the nurse invite? (Select all that apply.) Nutritionist Physical therapist Respiratory therapist Billing specialist Occupational therapist

Nutritionist Physical therapist Respiratory therapist Occupational therapist

The healthcare provider enters the room of a patient with a diagnosis of tuberculosis and finds the patient dyspneic. The neck veins are also visibly distended. Which of these additional assessments should the healthcare provider perform immediately?

Palpate for tracheal deviation Pressure will eventually build up causing a shift of the mediastinal structures from midline.

The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about types of irritants that should be avoided. Which irritant should the nurse include? (Select all that apply.) Pets Air pollution Warm, humid air Smoke Dust

Pets Air pollution Smoke Dust

The healthcare provider is caring for four patients. Which patient should be assessed first?

RR 28 asymmetrical chest movement Tachypnea and asymmetric chest wall movement are signs of a pneumothorax, so this patient needs prompt assessment and intervention.

4321

TEST

The healthcare provider is assisting during the insertion of a pulmonary artery catheter. Which of these, if assessed in the patient, would indicate the patient is experiencing a complication from the catheter insertion?

Tracheal deviation from midline

"A client reaches for the salmeterol (Serevent) inhaler with the onset of an asthma attack. What is the nurse's best action? a. Instruct the client to use the albuterol (Proventil) inhaler instead b. Assist the client to use oxygen for 3 breaths between the two puffs of the inhaled drug c. Instruct the client to attach the space to the inhaler before using it and inhale as rapidly as possible d. Remind the client to take a deep breath, hold it for 15 seconds, and then exhale before using the inh

a. Instruct the client to use the albuterol (Proventil) inhaler instead * salmeterol (Serevent) is a LABA, so it needs time to build up an effect. The patient needs to use a SABA (albuterol) during an attack.

The nurse is discussing tests to evaluate the extent of chronic obstructive pulmonary disease (COPD). Which test should the nurse include? (Select all that apply.) Ventilation-perfusion testing Pulmonary function tests Lung biopsy Bronchoscopy Arterial blood gas analysis

Ventilation-perfusion testing Pulmonary function tests Arterial blood gas analysis

The nurse gave discharge instructions to a client who has chronic obstructive pulmonary disease (COPD). Which action by the client indicates that the teaching was effective? Maintains adequate fluid intake by taking at least 5 quarts of fluid daily Eats a least two large meals per day Maintains oxygen saturation of at least 95% Wears an identification band and carries a list of medications

Wears an identification band and carries a list of medications

"ANS: D Since agitation and confusion are frequently the initial indicators of hypoxemia, the nurse's initial action should be to assess oxygen saturation. The other actions also are appropriate, but assessment of oxygenation takes priority over other assessments and notification of the health care provider. DIF: Cognitive Level: Application REF: 1750-1751 OBJ: Special Questions: Prioritization TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity"

When assessing a patient with chronic lung disease, the nurse finds a sudden onset of agitation and confusion. Which action should the nurse take first? a. Check pupil reaction to light. b. Notify the health care provider. c. Attempt to calm and reassure the patient. d. Assess oxygenation using pulse oximetry.

"A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four pts. For which of the following puts should the nurse clarify the provider's prescription? a. Client who has epistaxis b. Client who has amyotrophic lateral sclerosis c. Client who has pneumonia d. Client who has emphysema"

a. Client who has epistaxis May cause an increase in bleeding!

A nurse is assessing a client who has acute respiratory distress syndrome. Which of the following findings should the nurse report to the provider? a. Decreased bowel sounds b. O2 sat 92% c. CO2 24 d. Intercostal retractions

d. Intercostal retractions Indicates increasing respiratory compromise

"A nurse is caring for a pt who is in respiratory distress and requires endotracheal suctioning. Which of the following actions should the nurse take? a. Use clean technique when suctioning the pt's ET tube b. Use a rotating motions when removing the suction catheter c. Suction the oropharyngeal cavity prior to suctioning the ET tube d. Suction the client's ET tube every 2 hours"

b. Use a rotating motions when removing the suction catheter * reduces risk of tissue trauma * suction ET tube prior to the non-sterile oropharyngeal cavity to prevent cross-contamination * only suction as needed because routing suctioning can result in hypoxia, tissue damage, bleeding, and bronchospasms

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen? a. BP b. Capillary refill c. ABGs d. HR

c. ABGs

A nurse is caring for a pt who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client? a. Hyperkalemia b. Dyspnea c. Tachycardia d. Candidiasis

c. Tachycardia * Albuterol can cause HYPOkalemia * Candidiasis is r/t inhaled glucocorticoids, such as beclomethasone

A nurse is assessing a client who has bacterial pneumonia. Which of the following clinical manifestations should the nurse expect? a. Decreased fremitus b. SaO2 95% on room air c. Temp 101.8 F d. Bradypnea

c. Temp 101.8 F * Pt would have INCREASED fremitus & tachypnea

In performing a chest assessment, the nurse observes or determines all of the following findings on a 70 yo client. Which finding indicates to the nurse that the client may have an increased residual lung volume? a. Exhalation is twice as long as inhalation b. Breath sounds are absent at the lung edges c. The intercostal spaces measure 4 cm d. Vibrations can be felt on the chest wall when the client speaks

c. The intercostal spaces measure 4 cm Normally should be ~2 cm apart. Increases with air-trapping.

A nurse working in the ED is caring for a pt following an acute chest trauma. Which of the following findings indicates to the nurse the client is possible experiencing a tension pneumothorax? a. Collapsed neck veins on the affected side b. Collapsed neck veins on the unaffected side c. Tracheal deviation to the affected side d. Tracheal deviation to the unaffected side

d. Tracheal deviation to the unaffected side * A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side * DISTENDED neck veins are an expected finding of a tension pneumothorax

A patient has undergone open heart surgery for a congenital heart defect and has a chest tube drainage system in place. If there is damage to the thoracic duct during the procedure, what type of fluid will the healthcare provider observe in the collection chamber?

milky white The thoracic duct is a major lymphatic vessel.

Nurse Oliver observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

there is an air leak. Constant bubbling in the chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the nurse should notice that the fluid has stopped fluctuating in the water-seal chamber.

"A pregnant woman presents with worsening dyspnea and tachypnea since being diagnosed with pneumonia last week. The client is currently at 28 weeks of gestation and asks the nurse if she will need to deliver early. Which is the best reply by the nurse? ""Yes, we will need to delivery your baby as soon as possible."" ""It's hard to know right now."" ""There's no need to deliver your baby early. The baby is safer in your womb."" ""We'll monitor the baby very closely and pla

"""We'll monitor the baby very closely and plan for delivery if needed for the baby's safety."""

"Which intervention should the nurse implement first for the client diagnosed with a hemothorax who has had a right-sided chest tube for three (3) days and has no fluctuation (tidaling) in the water compartment? 1. Assess the client's bilateral lung sounds. 2. Obtain an order for a STAT chest x-ray. 3. Notify the health-care provider as soon as possible. 4. Document the findings in the client's chart."

"1. Assessment of the lung sounds could indicate the client's lung has reexpanded because it has been three (3) days since the chest tube has been inserted."

"The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse implement if there is no fluctuation (tidaling) in the water-seal compartment? 1. Obtain an order for a STAT chest x-ray. 2. Increase the amount of wall suction. 3. Check the tubing for kinks or clots. 4. Monitor the client's pulse oximeter reading."

"3. The key to the answer is ""2 hours."" The air from the pleural space is not able to get to the water-seal compartment, and the nurse should try to determine why. Usually the client is lying on the tube, it is kinked, or there is a dependent loop."

"A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR technique for communication, the nurse calls the healthcare provider with the recommendation for: A. initiating IV sedation B. starting a high-protein diet C. providing pain medication D. increasing the ventilator rate"

"A The client may be fighting the ventilator breaths. Sedation is indicated to improve compliance with the ventilator in an attempt to lower peak inspiratory pressures. The workload of breathing does indicate the need for increase protein calories; however, this will not correct the respiratory rate. There is no indication that the client is experiencing pain. Increasing the rate on the ventilator is not indicated with the client's increased spontaneous rate."

ANS: C A decrease in respiratory rate in a patient with respiratory distress suggests the onset of fatigue and a high risk for respiratory arrest. Therefore immediate action such as positive pressure ventilation is needed. Patients who are experiencing respiratory distress frequently sit in the tripod position because it decreases the work of breathing. Crackles in the lung bases may be the baseline for a patient with COPD. An oxygen saturation of 91% is common in patients with COPD and will pro

"A patient with chronic obstructive pulmonary disease (COPD) arrives in the emergency department complaining of shortness of breath and dyspnea. Which assessment finding by the nurse is most important to report to the health care provider? a. The patient has bibasilar lung crackles. b. The patient is sitting in the tripod position. c. The patient's respiratory rate has decreased from 30 to 10 breaths/min. d. The patient's pulse oximetry indicates an O2 saturation of 91%."

A client with acute respiratory distress syndrome (ARDS) has fine crackles at lung bases, and the respirations are shallow at a rate of 28 breaths/ min. The client is restless and anxious. In addition to monitoring the arterial blood gas results, what should the nurse do? Select all that apply. A. monitor serum creatinine and blood urea nitrogen levels. B. administer a sedative. C. Keep the head of the bed flat. D. Administer humidified oxygen. E. Auscultate the lungs.

"A, D, E Acute respiratory distress syndrome (ARDS) may cause renal failure and superinfection, so the nurse should monitor urine output and urine chemistries. Treatment of hypoxemia can be complicated because changes in lung tissue leave less pulmonary tissue available for gas exchange, thereby causing inadequate perfusion. Humidified oxygen may be one means of promoting oxygenation. The client has crackles in the lung bases, so the nurse should continue to assess breath sounds. Sedatives should be used with caution in clients with ARDS. The nurse should try other measures to relieve the client's restlessness and anxiety. The head of the bed should be elevated to 30 degrees to promote chest expansion and prevent atelectasis"

The nurse interprets which finding as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? A. elevated carbon dioxide level B. hypoxia not responsive to oxygen therapy C. metabolic acidosis D. sever, unexplained electrolyte imbalance

"B A hallmark of early ARDS is refractory hypoxemia. The client's PaO2 level continues to fall, despite higher concentrations of administered oxygen. Elevated carbon dioxide and metabolic acidosis occur late in the disorder. Severe electrolyte imbalances are not indicators of ARDS."

A client with acute respiratory distress syndrome (ARDS) is showing sings of increased dyspnea. The nurse reviews a report of blood gas values that recently arrived (See report). pH 7.35 PaCO2 25 mm Hg (3.3 kPa) Hco3 22 mEq/L (22mmol/L) PaO2 95 mm Hg (12.6 kPa) Which finding is abnormal? A. pH B. PaCO2 C. HCO3 D. PaO2

"B The normal range for PaCO2 is 35-45. Thus, this client's PaCO2 level is low. The client is experience respiratory alkalosis (carbonic acid deficit) due to hyperventilation. The nurse should report this finding to the HCP because it requires intervention. The increase in ventilation decrease the PaCO2 level, which leads to decreased carbonic acid and alkalosis. The bicarbonate level is normal in uncompensated respiratory alkalosis along with the normal PaO2 level. Normal serum pH is 7.35-7.45; in uncompensated respiratory alkalosis, the serum pH is >7.45"

The nurse has placed the intubated client with Acute Respiratory Distress Syndrome (ARDS) in prone position for 30 minutes. Which factors would require the nurse to discontinue prone positioning and return the client to the supine position? Select all that apply. A. The family is coming to visit. B. The client has increased secretions requiring frequent suctioning C. The SpO2 and Po2 have decreased. D. The client is tachycardic with drop in blood pressure. E. The face has increased skin breakdow

"C, D, E The prone position is used to improve oxygenation, ventilation and perfusion. The importance of placing clients with ARDS in prone positioning allows for mobilization of secretions, and the nurse can provide suctioning. Clinical judgement must be used to determine the length of time in prone position. If the client's hemodynamic status, oxygenation or kin is compromised, the client should be returned to the supine position for evaluation. Facial edema is expected with the prone position, but the skin breakdown is of concern."

The nurse is developing a plan of care for an older adult client who presents with hypoxemia and agitation. What nursing diagnosis is the priority for this client? Confusion, Risk for Acute Coping, Ineffective Anxiety Pain, Acute

"Confusion, Risk for Acute Older adults are more likely to suffer from confusion and agitation during states of hypoxemia. The client's priority diagnosis is Confusion, Risk for Acute due to the potential for safety issues. The client may be suffering from anxiety, acute pain, or ineffective coping, but these are not the priorities"

The nurse is caring for a client who had an episode of near-drowning 5 days ago. This morning, the nurse noted rhonchi in the lower lung lobes on auscultation. Which action by the nurse is best? Documenting the findings as normal Preparing for intubation Notifying the healthcare provider Monitoring vital signs and oxygen saturation every 2 hours

"Notifying the healthcare provider Changes in lung sounds after a pulmonary injury, like near-drowning, can indicate that the client is developing acute respiratory distress syndrome (ARDS). The nurse should notify the healthcare provider of the change in the client's condition. Intubation is not necessary unless the client is in respiratory distress. Rhonchi on auscultation are not a normal finding and require the nurse to take action. It is not appropriate for the nurse to simply monitor the client without taking action to prevent a worsening of the client's condition."

"ANS: C The PaO2 indicates severe hypoxemia and respiratory failure. Rapid action is needed to prevent further deterioration of the patient. Although the shallow breathing, rapid respiratory rate, and low PaCO2 also need to be addressed, the most urgent problem is the patient's poor oxygenation. DIF: Cognitive Level: Application REF: 1746-1747 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment"

"The nurse is caring for a 22-year-old patient who came to the emergency department with acute respiratory distress. Which information about the patient requires the most rapid action by the nurse? a. Respiratory rate is 32 breaths/min. b. Pattern of breathing is shallow. c. The patient's PaO2 is 45 mm Hg. d. The patient's PaCO2 is 34 mm Hg."

"ANS: C The patient's increased respiratory rate in combination with the admission diagnosis of gram-negative sepsis indicates that acute respiratory distress syndrome (ARDS) may be developing. The nurse should check for hypoxemia, a hallmark of ARDS. The health care provider should be notified after further assessment of the patient. Administration of the scheduled antibiotic and administration of Tylenol also will be done, but they are not the highest priority for a patient who may be developi

"The nurse obtains the vital signs for a patient admitted 2 days ago with gram-negative sepsis: temperature 101.2° F, blood pressure 90/56 mm Hg, pulse 92, respirations 34. Which action should the nurse take next? a. Administer the scheduled IV antibiotic. b. Give the PRN acetaminophen (Tylenol) 650 mg. c. Obtain oxygen saturation using pulse oximetry. d. Notify the health care provider of the patient's vital signs."

"ANS: C The patient's assessment indicates that assisted coughing is needed to help remove secretions, which will improve oxygenation. A 2-hour rest period at this time may allow the oxygen saturation to drop further. Humidification will not be helpful unless the secretions can be mobilized. Positioning on the right side may cause a further decrease in oxygen saturation because perfusion will be directed more toward the more poorly ventilated lung. DIF: Cognitive Level: Application REF: 1754-175

"The pulse oximetry for a patient with right lower lobe pneumonia indicates an oxygen saturation of 90%. The patient has rhonchi, a weak cough effort, and complains of fatigue. Which action is best for the nurse to take? a. Position the patient on the right side. b. Place a humidifier in the patient's room. c. Assist the patient with staged coughing. d. Schedule a 2-hour rest period for the patient."

"ANS: A Increasing somnolence will decrease the patient's respiratory rate and further increase the PaCO2 and respiratory failure. Rapid action is needed to prevent respiratory arrest. An SpO2 of 90%, weakness, and elevated blood pressure all require ongoing monitoring but are not indicators of possible impending respiratory arrest. DIF: Cognitive Level: Application REF: 1751 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity"

"ANS: A The purpose of prone positioning is to improve the patient's oxygenation as indicated by the PaO2 and SaO2. The other information will be collected but does not indicate whether prone positioning has been effective. DIF: Cognitive Level: Application REF: 1762-1763 TOP: Nursing Process: Evaluation MSC: NCLEX: Physiological Integrity"

"When prone positioning is used in the care of a patient with acute respiratory distress syndrome (ARDS), which information obtained by the nurse indicates that the positioning is effective? a. The patient's PaO2 is 90 mm Hg, and the SaO2 is 92%. b. Endotracheal suctioning results in minimal mucous return. c. Sputum and blood cultures show no growth after 24 hours. d. The skin on the patient's back is intact and without redness."

"ANS: B The patient should be positioned with the ""good"" lung in the dependent position to improve the match between ventilation and perfusion. The obese patient's abdomen will limit respiratory excursion when sitting in the high-Fowler's or tripod positions. DIF: Cognitive Level: Application REF: 1754-1755 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity"

"When the nurse is caring for an obese patient with left lower lobe pneumonia, gas exchange will be best when the patient is positioned a. on the left side. b. on the right side. c. in the tripod position. d. in the high-Fowler's position."

ANS: A The subcutaneous emphysema indicates barotrauma caused by positive pressure ventilation and PEEP. Bradycardia, hypoxemia, and bronchial breath sounds are all concerns and will need to be addressed, but they are not indications that PEEP should be reduced. DIF: Cognitive Level: Application REF: 1760-1761 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity

"Which assessment finding by the nurse when caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP) indicates that the PEEP may need to be decreased? a. The patient has subcutaneous emphysema. b. The patient has a sinus bradycardia with a rate of 52. c. The patient's PaO2 is 50 mm Hg and the SaO2 is 88%. d. The patient has bronchial breath sounds in both the lung fields."

ANS: D By preventing alveolar collapse during expiration, PEEP improves gas exchange and oxygenation. PEEP will not prevent the fibrotic changes that occur with ARDS, push more air into the lungs, or change the fraction of inspired oxygen (FIO2) delivered to the patient. DIF: Cognitive Level: Comprehension REF: 1761-1762 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

"Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the family members of a patient with ARDS is correct? a. ""PEEP will prevent fibrosis of the lung from occurring."" b. ""PEEP will push more air into the lungs during inhalation."" c. ""PEEP allows the ventilator to deliver 100% oxygen to the lungs."" d. ""PEEP prevents the lung air sacs from collapsing during exhalation."""

"A client with end-stage chronic obstructive pulmonary disease (COPD) asks the nurse about lung surgery. Which is the best response by the nurse? ""Lung reduction surgery is experimental but may be an option."" ""No surgery is possible when you have COPD."" ""Because you cannot tolerate high levels of oxygen, surgery is impossible."" ""Lung transplants are only done for children."""

"""Lung reduction surgery is experimental but may be an option."""

"The nurse is caring for an older adult client who may need to be intubated. The family asks about the potential risks. Which is the best reply by the nurse? ""There are no risks to intubation."" ""The doctor feels that intubation is the best option for your family member."" ""Older adults may be more likely to experience injury to the airway during intubation."" ""Intubation and mechanical ventilation are not long-term solutions. They just allow the lungs to rest."

"""Older adults may be more likely to experience injury to the airway during intubation."" Older adults are more prone to injuries occurring during intubation and with mechanical ventilation. It is irresponsible of the nurse to not acknowledge the risks or not discuss them with the family by saying that it is what the doctor recommends. Mechanical ventilation can be a short-term solution but is not always. Next Question"

"A pediatric client is not responding to treatment for acute respiratory distress syndrome (ARDS) and requires intubation. The mother is anxious that the procedure will hurt. Which is the best response by the nurse? ""We will administer medication to help him sleep through the intubation and as needed while he is on the ventilator."" ""Don't worry; intubation and using a ventilator doesn't hurt at all."" ""He may feel a little nervous, but he will get used to the venti

"""We will administer medication to help him sleep through the intubation and as needed while he is on the ventilator."" Pediatric clients have higher sedation needs to limit stress, anxiety, and pain and to minimize the risk that they will pull at the tube. Intubation and mechanical ventilation can produce anxiety and agitation in all clients and require some sedation."

The nurse is caring for a client diagnosed with a pneumothorax who had chest tubes inserted four (4) hours ago. There is no fluctuating (tidaling) in the water-seal compartment of the closed chest drainage system. Which action should the nurse implement first? 1. Milk the chest tube. 2. Check the tubing for kinks. 3. Instruct the client to cough. 4. Assess the insertion site.

2. The nurse should implement the least invasive intervention first. The nurse should check to see if the tubing is kinked, causing a blockage between the pleural space and the water-seal bottle.

One of the most important pulmonary treatments in cystic fibrosis is: A) Chest physiotherapy. B) Inhaled beta agonists. C) Oral enzymes. D) Inhaled corticosteroids.

When administering pancrelipase to child with cystic fibrosis, nurse Faith knows they should be given: A) With meals and snacks B) After each bowel movement and after postural drainage C) On awakening, following meals, and at bedtime D) Every three hours while awake

Which complication is associated with mechanical ventilation? A. gastrointestinal hemorrhage B. immunosuppression C. increased cardiac output D. pulmonary emboli

A Gastrointestinal hemorrhage occurs in about 25% of clients receiving prolonged mechanical ventilation because of the development of stress ulcers. Clients who are receiving steroid therapy and those with a previous hx of ulcers are most likely to be at risk. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection and atelectasis.

A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the healthcare provider? A. Arterial oxygen level of 46 mm Hg (6.1 kPa) B. respirations of 12 breaths/min C. lack of adventitious lung sounds D. Oxygen saturation of 96% on room air

A Manifestations of ARDS secondary to acute pancreatitis include respiratory distress, tachypnea, dyspnea, fever, dry cough, fine crackles heard throughout lung fields, possible confusion and agitation and hypoxemia with arterial oxygen level below 50 mm Hg. The nurse should report the arterial oxygen level of 46 to the HCP. A respiratory rate of 12 is normal and not considered a sign of respiratory distress. Adventitious lung sounds such as crackles, are typically found in clients with ARDS. Oxygen saturation of 96% is satisfactory and does not represent hypoxemia or low arterial oxygen saturation.

"A client has the following arterial blood gas values: pH 7.52 PaO2 50 mm Hg (6.7 kPa) PaCO2 28 mm Hg (3.72 kPa) HCO3 24 mEq/L (24 mmol/L) Based upon the client's PaO2, which conclusion would be accurate? A. The client is severely hypoxic B. The Oxygen level is low but poses no risk for the client C. The client's PaO2 level is within normal range D. The client requires oxygen therapy with very low oxygen concentrations"

A Normal PaO2 level ranges from 80-100 mm Hg. When PaO2 falls to 50 mm Hg, the nurse should be alert for signs of hypoxia and impending respiratory failure. An oxygen level this low poses a sever risk for respiratory failure. The client will require oxygenation at a concentration that maintains the PaO2 at 55-60 mm Hg or more.

Which condition can place a client at risk for acute respiratory distress syndrome (ARDS)? A. septic shock B. chronic obstructive pulmonary disease C. asthma D. heart failure

A The two risk factors most commonly associated with the development of ARDS are gram-negative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or a systemic inflammatory response syndrome. COPD, asthma, and HF are not direct causes of ARDS.

ANS: A Pulmonary artery wedge pressures are normal in the patient with ARDS because the fluid in the alveoli is caused by increased permeability of the alveolar-capillary membrane rather than by the backup of fluid from the lungs (as occurs in cardiogenic pulmonary edema). The other tests will not help in differentiating cardiogenic from noncardiogenic pulmonary edema. DIF: Cognitive Level: Application REF: 1753-1754 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient develops increasing dyspnea and hypoxemia 2 days after having cardiac surgery. To determine whether the patient has acute respiratory distress syndrome (ARDS) or pulmonary edema caused by left ventricular failure, the nurse will anticipate assisting with a. inserting a pulmonary artery catheter. b. obtaining a ventilation-perfusion scan. c. drawing blood for arterial blood gases. d. positioning the patient for a chest radiograph.

"ANS: B Since the reason for the poor airway clearance is the thick secretions, the best action will be to encourage the patient to improve oral fluid intake. The use of the incentive spirometer should be more frequent in order to facilitate the clearance of the secretions. The other actions also may be helpful in improving the patient's gas exchange, but they do not address the thick secretions that are causing the poor airway clearance. DIF: Cognitive Level: Application REF: 1755 TOP: Nursing

A patient has a nursing diagnosis of ineffective airway clearance related to thick, secretions. Which action will be best for the nurse to include in the plan of care? a. Encourage use of the incentive spirometer. b. Offer the patient fluids at frequent intervals. c. Teach the patient the importance of coughing. d. Increase oxygen level to keep O2 saturation >95%.

"ANS: A The FIO2 of 80% increases the risk for oxygen toxicity. Since the patient's O2 saturation is 99%, a decrease in FIO2 is indicated to avoid toxicity. The other patient data would be typical for a patient with ARDS and would not need to be urgently reported to the health care provider. DIF: Cognitive Level: Analysis REF: 1760 | 1761-1762 OBJ: Special Questions: Prioritization TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity"

A patient with ARDS who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation (SIMV) has settings of fraction of inspired oxygen (FIO2) 80%, tidal volume 500, rate 18, and positive end-expiratory pressure (PEEP) 5 cm. Which assessment finding is most important for the nurse to report to the health care provider? a. Oxygen saturation 99% b. Patient respiratory rate 22 breaths/min c. Crackles audible at lung bases d. Apical pulse rate 104 beats/min

ANS: B Gentamicin, which is one of the aminoglycoside antibiotics, is potentially nephrotoxic, and the nurse should clarify the drug and dosage with the health care provider before administration. The other medications are appropriate for the patient with ARDS. DIF: Cognitive Level: Application REF: 1761-1762 TOP: Nursing Process: Implementation MSC: NCLEX: Physiological Integrity

A patient with acute respiratory distress syndrome (ARDS) and acute renal failure has the following medications prescribed. Which medication should the nurse discuss with the health care provider before administration? a. ranitidine (Zantac) 50 mg IV b. gentamicin (Garamycin) 60 mg IV c. sucralfate (Carafate) 1 g per nasogastric tube d. methylprednisolone (Solu-Medrol) 40 mg IV

ANS: A Because barotrauma is associated with high airway pressures, the level of PEEP should be decreased. The other actions will not decrease the risk for pneumothorax. DIF: Cognitive Level: Application REF: 1760-1761 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity

A patient with acute respiratory distress syndrome (ARDS) who is intubated and receiving mechanical ventilation develops a pneumothorax. Which action will the nurse anticipate taking? a. Lower the positive end-expiratory pressure (PEEP). b. Increase the fraction of inspired oxygen (FIO2). c. Suction more frequently. d. Increase the tidal volume.

"ANS: B The patient's lethargy, low respiratory rate, and SpO2 indicate the need for mechanical ventilation with ventilator-controlled respiratory rate. Administration of high flow oxygen will not be helpful because the patient's respiratory rate is so low. Insertion of a mini-tracheostomy will facilitate removal of secretions, but it will not improve the patient's respiratory rate or oxygenation. BiPAP requires that the patient initiate an adequate respiratory rate to allow adequate gas exchang

A patient with respiratory failure has a respiratory rate of 8 and an SpO2 of 89%. The patient is increasingly lethargic. The nurse will anticipate assisting with a. administration of 100% oxygen by non-rebreather mask. b. endotracheal intubation and positive pressure ventilation. c. insertion of a mini-tracheostomy with frequent suctioning. d. initiation of bilevel positive pressure ventilation (BiPAP).

The nurse is caring for a client who is in the process of weaning off of mechanical ventilation. Which assessment finding should the nurse report to the healthcare provider? (Select all that apply.) Abdominal breathing Oxygen saturation level of 98% Respiratory rate of 18 beats/min Pallor Agitation

Abdominal breathing Pallor Agitation Assessment findings that may indicate dysfunctional weaning include pallor or cyanosis, agitation or apprehension, presence of abdominal breathing, abnormal vital signs, and decreased level of consciousness. A respiratory rate of 18 beats/min and oxygen saturation level of 98% are both within normal limits and do not need to be reported.

"ANS: D This patient's history of septicemia and labored breathing suggest the onset of ARDS, which will require rapid interventions such as administration of oxygen and use of positive pressure ventilation. The other patients also should be assessed as quickly as possible, but their assessment data are typical of their disease processes and do not suggest deterioration in their status. DIF: Cognitive Level: Analysis REF: 1758-1760 OBJ: Special Questions: Multiple Patients TOP: Nursing Process:

After receiving change-of-shift report, which patient will the nurse assess first? a. A patient with cystic fibrosis who has thick, green-colored sputum b. A patient with pneumonia who has coarse crackles in both lung bases c. A patient with emphysema who has an oxygen saturation of 91% to 92% d. A patient with septicemia who has intercostal and suprasternal retractions

The nurse is assessing an older adult client with acute respiratory distress syndrome (ARDS). Which assessment finding indicates an early sign of hypoxemia for this client? (Select all that apply.) Agitation Tachypnea Confusion Anxiety Dyspnea

Agitation Confusion Anxiety Anxiety, agitation, and confusion are assessment findings that older adult clients experience as early signs of hypoxemia. While dyspnea and tachypnea may indicate hypoxemia, these are not early symptoms the nurse will find during the assessment process.

The nurse is assessing a client diagnosed with emphysema. Which clinical manifestation should the nurse expect to find? (Select all that apply.) Barrel chest Diminished breath sounds Cough with copious amounts of sputum Hypercapnia noted within laboratory results Use of accessory muscles when breathing

Barrel chest Diminished breath sounds Use of accessory muscles when breathing

Which action should the nurse anticipate in a client who has been diagnosed with acute respiratory distress syndrome (ARDS)? A. tracheostomy B. use of a nasal cannula C. mechanical ventilation D. insertion of a chest tube

C Endotracheal intubation and mechanical ventilation are required for ARDS to maintain adequate respiratory support. Endotracheal intubation, not a tracheostomy, is usually the initial method of maintaining an airway. The client requires mechanical ventilation; nasal oxygen will not provide adequate oxygenation. Chest tubes are used to remove air or fluid form intrapleural spaces.

A nurse is teaching a client about chronic obstructive pulmonary disease (COPD). Which information should the nurse include? (Select all that apply.) COPD exacerbations cause shortness of breath and increased sputum production. After a flare-up, the lung tissue returns to normal. COPD is a respiratory disorder that has components of chronic bronchitis and emphysema. COPD is a curable disease. Intermittent flare-ups of the symptoms are expected.

COPD exacerbations cause shortness of breath and increased sputum production. COPD is a respiratory disorder that has components of chronic bronchitis and emphysema. Intermittent flare-ups of the symptoms are expected.

The nurse is teaching coughing techniques to a client with chronic obstructive pulmonary disease. Which technique should the nurse include? Cough twice, the first time to loosen mucus and the second time to expel secretions. Limit fluid intake to decrease pulmonary secretions. Inhale deeply through the mouth prior to huff coughing. Utilize oxygen therapy as needed.

Cough twice, the first time to loosen mucus and the second time to expel secretions.

"The mother of a child with cystic fibrosis tells the nurse that her child makes ""snoring"" sounds when breathing. The nurse is aware that many children with cystic fibrosis have: A) Enlarged adenoids B) Choanal atresia C) Septal deviations D) Nasal polyps"

"The nurse is teaching the mother of a child with cystic fibrosis how to do postural drainage. The nurse should tell the mother to: A) Use the heel of her hand during percussion B) Change the child's position every 20 minutes C) Do percussion after the child eats and at bedtime D) Use cupped hands during percussion"

A child who has recently been diagnosed with cystic fibrosis is in a pediatric clinic where a nurse is performing an assessment. Which later finding of this disease would the nurse not expect to see at this time? A) Bulky greasy stools B) Meconium ileus C) Positive sweat test D) Moist, productive cough

A child with cystic fibrosis is being treated with inhalation therapy with Pulmozyme (dornase alfa). A side effect of the medication is: A) Hair loss B) Brittle nails C) Weight gain D) Sore throat

Cystic fibrosis is diagnosed by: A) Echocardiogram B) Chest X-ray C) Complete blood panel D) Sweat test

"Which assessment is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client? A. assessing the client's skin color B. monitoring the respiratory rate C. verifying the amount of cuff inflation D. auscultating breath sounds bilaterally"

D Auscultation for bilateral breath sounds is the most appropriate method for determining cuff placement. The nurse should also look for the symmetrical rise and fall the the chest and should note the location of the exit mark on the tube. Assessments of skin color, respiratory rate, and the amount of cuff inflation cannot validate the placement of the ET Tube.

Which nursing interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)? A. teaching cigarette smoking cessation B. maintaining adequate serum potassium levels C. monitoring the clients for signs of hypercapnia D. replacing fluids adequately during hypovolemic states

D One of the major risk factors for developing ARDS is hypovolemic shock. Adequate fluid replacement is essential to minimize the risk of ARDS in these clients. Teaching smoking cessation does not prevent ARDS. An abnormal serum potassium level and hypercapnia are not risk factors for ARDS.

To promote effective airway clearance in a client with acute respiratory distress, what should the nurse do? A. administer oxygen every 2 hours B. turn the client every 4 hours C. administer sedatives to promote rest D. suction if cough is ineffective

D The nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned q2h to help move secretions; q4h is not often enough. Administering sedatives to promote rest is contraindicated in ARDS because sedatives can depress respirations

"To improve the oxygenation of a client with acute respiratory distress syndrome (ARDS) who is receiving mechanical ventilation, the nurse should place the client in which position? A. supine B. semi-Fowler's C. Lateral side D. prone"

D. Prone positioning is used to improve oxygenation in clients with ARDS who are receiving mechanical ventilation. The positioning allows for recruitment of collapsed alveolar units, improvement in ventilation, reduction in shunting, mobiliation of secretions, and improvement in functional reserve capacity (FRC). When the client is supine, side-to-side repositioning should be done every 2 hours with the head of the bed elevated at least 30 degrees.

The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) about the benefits of an exercise regimen. Which information should the nurse include? (Select all that apply.) Dyspnea and fatigue may improve with exercise. An exercise regimen can improve the ability to perform activities of daily living (ADLs). Exercise can prevent the condition from worsening. Inhale and exhale rapidly to maintain oxygenation while exercising. Regular exercise improves exercise tole

Dyspnea and fatigue may improve with exercise. An exercise regimen can improve the ability to perform activities of daily living (ADLs). Exercise can prevent the condition from worsening. Regular exercise improves exercise tolerance and muscle strength.

The nurse is caring for a client with respiratory acidosis secondary to end-stage acute respiratory distress syndrome (ARDS). Which result should the nurse anticipate on the arterial blood gas? High PaO2 and low PaCO2 Low PaO2 and low PaCO2 Low PaO2 and high PaCO2 High PaO2 and high PaCO2

Low PaO2 and high PaCO2 In end-stage ARDS, physiological changes in the alveoli prevent CO2 from diffusing across the alveolar membranes, causing the PaCO2 to rise and PaO2 to fall. Eventually, respiratory distress and respiratory failure will develop, and without further intervention, death will result.

The nurse is planning care for a client with acute respiratory distress syndrome (ARDS). Which independent nursing intervention should the nurse include in the care of this client? (Select all that apply.) Maintain the head of the bed at less than 30 degrees. Obtain a sputum culture. Prescribe surfactant therapy. Position the client in a prone position for 60 minutes five times a day. Suction the airway as needed.

Obtain a sputum culture Suction the airway as needed Nursing interventions for a client who is suffering from ARDS include suctioning and obtaining sputum cultures. It is outside the scope of nursing practice to prescribe surfactant therapy. The head of the bed should be maintained at greater than 30 degrees. Prone positioning is recommended for 30 minutes three to four times per day.

The nurse is preparing a program about acute respiratory distress syndrome (ARDS) in the older adult and plans to explain why this population is at greater risk for the disease. Which topic should be included in the discussion? (Select all that apply.) Poor muscle strength Lower functional residual capacity Loss of elastic tissue Increased chest diameter Higher sedation requirements

Poor muscle strength Loss of elastic tissue Increased chest diameter Older adults are at greater risk for getting ARDS and are also at higher risk for mortality from the condition. Physiologic changes in the older adult are partially responsible for this increased risk, including loss of elastic tissue, decreased muscle strength, and increased chest diameter. The pediatric population tends to have higher sedation requirements and a lower functional residual capacity.

A client who is diagnosed with acute respiratory distress syndrome (ARDS) requires mechanical ventilation. Which ventilator mode should the nurse expect to implement to promote pressure throughout the respiratory cycle? Sensitivity Positive end-expiratory pressure (PEEP) Flow rate Tidal volume (TV)

Positive end-expiratory pressure (PEEP) Positive end-expiratory pressure can be used with many different ventilator settings and maintains positive pressure in between breaths and during exhalation, preventing collapse of the alveoli. Flow rate, sensitivity, and tidal volume are settings that can be adjusted on the ventilator.

The nurse is caring for a client with chronic obstructive pulmonary disease (COPD) who has shortness of breath, a respiratory rate of 28 breaths/min, and an O2 saturation of 92%. Which intervention is contraindicated in this client? Performing percussion, vibration, and postural drainage Applying oxygen Administering bronchodilators Putting the client in supine recumbent position

Putting the client in supine recumbent position

A client is brought into the emergency department after aspirating on pureed foods at the long-term care facility. The nurse knows that which physiologic change can trigger acute respiratory distress syndrome? Release of chemical mediators Increased surfactant production Destruction of extracellular platelets Intracellular edema

Release of chemical mediators After the initial pulmonary injury, such as aspiration, chemical mediators are released, which damage the alveolar-capillary membrane and trigger other changes associated with ARDS. This damage can cause interstitial (not intracellular) edema and decreased (not increased) surfactant production. Destruction of platelets is not associated with ARDS.

The nurse is leading a support group for clients and families with chronic obstructive pulmonary disease (COPD). Which item should be discussed as a method to prevent COPD exacerbations? (Select all that apply.) Restricting smoking in home environment Use of cough suppressants Use of cool mist humidifiers Yearly flu vaccine Pneumococcal vaccine

Restricting smoking in home environment Use of cool mist humidifiers Yearly flu vaccine Pneumococcal vaccine

The nurse is caring for a client with suspected acute respiratory distress syndrome (ARDS). Which symptom of ARDS should the nurse anticipate will appear within 24 to 48 hours after the initial insult? (Select all that apply.) Shortness of breath Rapid breathing Fluid imbalance Chest x-ray clear of infiltrates Arterial blood gases varying from normal limits

Shortness of breath Rapid breathing Chest x-ray clear of infiltrates Rapid breathing and shortness of breath are two early symptoms of ARDS that manifest in the first day or two after the initial injury. On chest x-ray, no infiltrates will be noted in the early stages and lung sounds will be clear. Fluid imbalance and abnormal arterial blood gas levels will be noted later in the disease process.

The nurse is caring for an adult who is diagnosed with acute respiratory distress syndrome (ARDS) after a near-drowning episode last week. Which type of medication should the nurse anticipate the provider ordering to help open alveoli? Inhaled nitric oxide Surfactant therapy Nonsteroidal anti-inflammatory drugs (NSAIDs) Corticosteroids

Surfactant therapy Surfactant therapy, a mixture of phospholipids, neutral lipids, and proteins, is used to help maintain open alveoli in clients with ARDS. Corticosteroids, inhaled nitric oxide, and NSAIDs are also used to treat ARDS, but they are not used to help maintain open alveoli

The nurse is caring for a client who has been using mechanical ventilation for several months after an episode of sepsis and acute respiratory distress syndrome (ARDS). Which ventilator setting should the nurse anticipate the healthcare provider ordering for weaning? Synchronized intermittent mandatory ventilation (SIMV) Positive end-expiratory pressure (PEEP) Assist-control mode ventilation (ACMV) Bilevel ventilation (BIPAP)

Synchronized intermittent mandatory ventilation (SIMV) SIMV is frequently used for weaning, gradually decreasing the number of mandatory ventilator-assisted breaths as arterial blood gases (ABG), exhaled carbon dioxide (ETCO2), and respiratory rate are monitored. Once the client is able to tolerate four breaths per minute, the CPAP or T-piece weaning is attempted, followed by eventual extubation.

"A client is diagnosed with acute respiratory distress syndrome (ARDS). The client's spouse asks the nurse what caused ARDS. Which etiology of indirect injury to the lungs should the nurse include in the response? (Select all that apply.) Smoke inhalation Systemic sepsis Fat embolism Multiple blood transfusions Pancreatitis"

Systemic sepsis Multiple blood transfusions Pancreatitis Pancreatitis, systemic sepsis, and multiple blood transfusions are causes of indirect injury to the lungs. Smoke inhalation and fat embolisms are causes of direct injury to the lungs.

"ANS: D The patient's low SpO2 despite receiving a high fraction of inspired oxygen (FIO2) indicates the possibility of acute respiratory distress syndrome (ARDS). The patient's blood-tinged sputum and scattered crackles are not unusual in a patient with pneumonia, although they do require continued monitoring. The continued temperature elevation indicates a possible need to change antibiotics, but this is not as urgent a concern as the progression toward hypoxemia despite an increase in O2 flow

The nurse is caring for a patient who was hospitalized 2 days earlier with aspiration pneumonia. Which assessment information is most important to communicate to the health care provider? a. Cough that is productive of blood-tinged sputum b. Scattered crackles throughout the posterior lung bases c. Temperature of 101.5° F (38.6° C) after 2 days of IV antibiotic therapy d. Oxygen saturation (SpO2) has dropped to 90% with administration of 100% O2 by non-rebreather mask.

"ANS: C Elevation of the head decreases the risk for aspiration. PEEP is frequently needed to improve oxygenation in patients receiving mechanical ventilation. Suctioning should be done only when the patient assessment indicates that it is necessary. Enteral feedings should provide adequate calories for the patient's high energy needs. DIF: Cognitive Level: Application REF: 1760-1761 TOP: Nursing Process: Planning MSC: NCLEX: Physiological Integrity"

To decrease the risk for ventilator-associated pneumonia, which action will the nurse include in the plan of care for a patient who requires intubation and mechanical ventilation? a. Avoid use of positive end-expiratory pressure (PEEP). b. Suction every 2 hours. c. Elevate head of bed to 30 to 45 degrees. d. Give enteral feedings at no more than 10 mL/hr.

"ANS: C ABG analysis is most useful in this setting because ventilatory failure causes problems with CO2 retention, and ABGs provide information about the PaCO2 and pH. The other tests also may be done to help in assessing oxygenation or determining the cause of the patient's ventilatory failure. DIF: Cognitive Level: Application REF: 1752-1754 TOP: Nursing Process: Assessment MSC: NCLEX: Physiological Integrity"

To evaluate the effectiveness of prescribed therapies for a patient with ventilatory failure, which diagnostic test will be most useful to the nurse? a. Chest x-rays b. Pulse oximetry c. Arterial blood gas (ABG) analysis d. Pulmonary artery pressure monitoring

ANS: B Insertion of retention catheters is included in LPN/LVN education and scope of practice and can be safely delegated to an LPN/LVN who is experienced in caring for critically ill patients. Placing a patient who is on a ventilator in the prone position requires multiple staff and should be supervised by an RN. Assessment of breath sounds and obtaining pulmonary artery pressures require advanced assessment skills and should be done by the RN caring for a critically ill patient. DIF: Cognitiv

Which of these nursing actions included in the care of a mechanically ventilated patient with acute respiratory distress syndrome (ARDS) can the RN delegate to an experienced LPN/LVN working in the intensive care unit? a. Assess breath sounds b. Insert a retention catheter c. Place patient in the prone position d. Monitor pulmonary artery pressures

(1) Respiratory

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