ATI MedSurg - Respiratory
a nurse is reinforcing teaching about pursed-lip breathing for a client who has COPD and emphysema. the nurse should explain that this breathing technique does which of the following?
keeps the airways open on exhalation - the client who has COPD with emphysema should use pursed-lip breathing when experiencing dyspnea. this is one of the simplest ways to control dyspnea. it slows the client's pace of breathing and keeps the airway open on exhalation, making each breath more effective. pursed-lip breathing releases trapped air in the lungs and prolongs exhalation to slow the breathing rate. this improved breathing pattern moves carbon dioxide out of the lungs more efficiently - the client who uses pursed-lip breathing prolongs exhalation, rather than increasing oxygen intake on inhalation. increase oxygen cautiously because the client depends on low oxygen to stimulate breathing - the client should use pursed-lip breathing breathes in through the nares and out through pursed lips, rather than concentrating on using chest-wall muscles - the client who uses pursed-lip breathing breathes in through the nares and out through the pursed lips, rather than concentrating on using the diaphragm
a nurse is reinforcing preoperative teaching with a client who is to undergo a pneumonectomy. the client states, "I am afraid it will hurt to cough after the surgery." which of the following statements should the nurse make?
"I will show you how to splint your incision while coughing." - the client who has a pneumonectomy must cough to clear secretions from the remaining lung. the nurse should show the client how to splint her incision to reduce pain when coughing - the client who had a pneumonectomy must cough to clear secretions from the remaining lung - pain medication reduces pain to a tolerable level. however, it does not necessarily keep the client pain-free. additionally, telling the client not to worry is a barrier to communication and provides false reassurance
a nurse is assisting with discharge teaching for a client who is postoperative following a rhinoplasty. which of the following instructions should the nurse include?
"Lie on your back with your head elevated 30 degrees when resting." - the nurse should instruct the client to rest in the semi-Fowler's position to prevent aspiration of nasal secretions - the client should apply cold compresses to his face to decrease swelling - the client should avoid taking aspirin, because it increases the risk of bleeding by decreasing platelet aggregation - the client should open his mouth when sneezing to reduce straining of the incisional site
a nurse in a clinic is reinforcing teaching with a client who is to have tuberculin skin test. which of the following information should the nurse include?
"You must return to the clinic to have the test read in 2 or 3 days." - the client should have the skin test read in 2 to 3 days. an area of induration after 48 to 72 hr indicates exposure to the tubercle bacillus. if the client does not return to have a test read within 72 hr, another skin test is necessary - a positive test means that the client has been exposed to tubercle bacillus, but it does not mean that the client has an active case of TB. the client should have a chest x-ray to rule-out active TB - the client who has a positive tuberculin skin test should have a chest x-ray to rule-out active TB. when a client has a positive skin test, subsequent skin test will always be positive - the nurse will inject 0.1 ml of purified protein derivative (PPD) intradermally to the dorsal aspect of the client's forearm
a nurse on a medical unit is assisting with the care of a client who aspirated gastric contents prior to admission. the provider prescribed 100% oxygen by nonrebreather mask after the client reported severe dyspnea. which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)?
PaO2 50 mmHg - the client who has manifestations of ARDS has a low PaO2 level eve with the administration of oxygen. hypoxemia after treatment with oxygen is a manifestation of ARDS - although this client's temperature is not within the expected reference range, it is not a clinical manifestation of ARDS - the client who has ARDS will have clear breath sounds because edema occurs in the interstitial spaces and not in the airway - the client who has ARDS will manifest hyperpnea, which is an increased rate and depth of breathing, and indicates the presence of an increase in the work of breathing
a nurse on a medical unit is assisting with the care of a client who has a possible closed pneumothorax and significant bruising on the left chest following a motor-vehicle crash. the client reports severe left chest pain on inspiration. the nurse should hear which of the following findings when auscultating the client's lung sounds?
absence of breath sounds - a client who has pneumothorax experiences severely diminished or absent breath sounds on the affected side - a client who has asthma experiences an expiratory wheezing during an acute asthma attack - a client who has an airway obstruction experiences inspiratory stridor, which is a loud crowing-like sound often heard without a stethoscope - a client who has thick sputum production or obstruction from a foreign body has rhonchi, which are dry, low-pitched, snore-like noises produced in the throat
a nurse is preparing to assist a provider to withdraw arterial blood from a client's radial artery for measurement of ABG. which of the following actions should the nurse plan to take?
check the circulation in the client's ulnar artery prior to obtaining the specimen - the nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. the most common site for withdrawal of arterial blood gases is the radial artery - the nurse should not administer oxygen prior to the blood draw, because the test measures the client's blood gases when breathing room air - the nurse should use ice to preserve the arterial blood gas specimen during transport to the laboratory. if the sample is not placed on ice, the pH and PO2 values can be inaccurate. it is not necessary to place ice to the withdrawal site - the nurse should apply pressure to the puncture site for 5 to 10 min after the needle is withdrawn. high pressure of the blood in the arteries places the client at risk for hemorrhage from the withdrawal site
a nurse is assisting with the care for a client who has a chest tube inserted 12 hr ago. the nurse notes a crackling sensation upon palpation of the skin on the right side of the client's chest. the nurse should notify the charge nurse that the client is demonstrating a clinical manifestation of which of the following complications?
crepitus - crepitus, also called subq emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. crepitus indicates an air leak into the subq tissue, which is often a clinical manifestation of a pneumothorax - friction rub is a scratching or squeaking sound the nurse can hear when auscultating the client's lungs. this condition occurs due to the pleural surfaces rubbing together. a friction rub is a clinical manifestation of pleurisy - crackles, which are sometimes called rales, are wet popping sounds the nurse can hear when auscultating the client's lungs. this condition occurs when there is fluid in the client's airways or alveoli. crackles are a clinical manifestation of pneumonia - tactile fremitus is a vibration of the chest wall that the nurse can feel when palpating the client's chest as the client repeats a syllable such as "nine-nine." increased tactile fremitus is a clinical manifestation of pneumonia
a nurse is assisting with the development of a teaching plan about how to prevent an acute asthma attack for a young adult client. which of the following points should the nurse plan to discuss first?
determine the client's perception of the disease process and what might have triggered the current attack - the first step the nurse should take is to assess the client's current knowledge, by applying the nursing process priority-setting framework - although it is important for the nurse to discuss how to eliminate environmental triggers that precipitate asthma attacks, there is another point the nurse should discuss first - it is important for the nurse to discuss the client's medication regimen to ensure understanding of how to use each medication, there is another point the nurse should discuss first - it is important for the nurse to review manifestations of respiratory infections with the client, there is another point the nurse should discuss first
a nurse is an urgent care clinic is collecting data from a client who reports exposure to anthrax. which of the following findings is an indication of the prodromal stage of inhalation anthrax?
dry cough - the client who has a dry cough has a clinical manifestation found in the prodromal stage of inhalation anthrax. during this stage, it is difficult to distinguish from influenza or pneumonia because there is no sore throat or rhinitis - the client who has rhinitis is not manifesting findings of anthrax, however, rhinitis is typically seen with colds and influenza - the client who has a sore throat is not manifesting findings of inhalation anthrax, however, a sore throat is typically seen with colds and influenza - swollen lymph nodes with a swollen edematous lesion can be a clinical manifestation of cutaneous anthrax
a nurse is assisting with the plan of care for a client who has COPD and is malnourished. which of the following recommendations to promote nutritional intake should the nurse include in the plan?
eat high-calorie foods first - clients with COPD often experiences early satiety. therefore, the client should eat calorie-dense foods first - although it is important for a client who has COPD to maintain adequate fluid intake to prevent dehydration and inhibit the production of tenacious secretions, the client should limit intake of water at meal times to reduce the feeling of early fullness - the client should rest before meals to decrease dyspnea while eating - although the client should keep foods on hand for snacking, she should avoid dry and salty foods, which can place her at risk for aspiration and make her mouth dry
a nurse in a provider's office is collecting data from a client who states he was recently exposed to TB. which of the following findings is a clinical manifestation of pulmonary TB?
night sweats - night sweats and fevers are clinical manifestations of TB - pericardial friction rub is a manifestation of rheumatic carditis - anorexia and weight loss are manifestations of TB, not weight gain - cyanosis of the fingertips are manifestation of Raynaud's disease
a nurse is caring for an older client who has COPD and pneumonia. the nurse should monitor the client for which of the following acid-base imbalances?
respiratory acidosis - respiratory acidosis is a common complication of COPD. this complication occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs - respiratory alkalosis occurs when a client exhales too much carbon dioxide. client who hyperventilate often experiences this complication - metabolic alkalosis occurs when a client has an excess of bicarbonate. clients who use bicarbonate of soda as an antacid are at risk for the development of metabolic alkalosis. excessive vomiting also places a client at risk for development of metabolic alkalosis - metabolic acidosis occurs when a client has a decrease in bicarbonate. clients who have severe diarrhea or kidney failure are at risk for the development of metabolic acidosis
a nurse is assisting the provider to prepare a client for thoracentesis. the nurse should instruct the client that which of the following positions will be used for this procedure?
sitting while leaning forward over the bedside table - when preparing a client for a thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table because this position maximizes the space between the client's ribs and allows for aspiration of accumulated fluid and air - when preparing a client for a thoracentesis, the nurse should not position the client lying flat on the affected side, because it does not allow for draining the accumulated fluid and air - when preparing a client for a thoracentesis, the nurse should not place the client prone, because it does not position the client for appropriate access for draining the accumulated fluid and air - when preparing a client for a thoracentesis, the nurse should not place the client supine, because it does not position the client for appropriate access for draining accumulated fluid and air
a nurse is on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. the client reports feeling apprehensive and restless. the nurse collects additional data from the client. which of the following findings is an indication of pulmonary embolism?
sudden onset of dyspnea - clinical manifestations of pulmonary embolism have a rapid onset. dyspnea occurs due to reduced blood flow to the lungs - tracheal deviation is an indication of tension pneumothorax and is fatal if not promptly treated - tachycardia is a clinical manifestation of pulmonary embolism - difficulty swallowing is an indication of many conditions, including oral cancer
a nurse is assisting with the plan of care for a client following placement of a chest tube 1 hr ago. which of the following actions should the nurse include in the plan of care?
tape all connections between the chest tube and drainage system - the nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidentally disconnecting the nurse should expect bubbling in the water seal chamber on forced expiration or coughing, which is an indication that the system is working properly. additionally, the nurse should avoid clamping the chest tube unless it becomes necessary to replace the drainage unit or locate an air leak - the nurse should ensure the chest tube drainage system is below the level of the chest at all times to facilitate proper drainage by gravity - the nurse should not empty the collection chamber or change the system unless it is almost full
a nurse is caring for a client who has a tracheostomy with an inflated cuff in place. which of the following findings indicate that the nurse should suction the client's airway secretions?
the client has coarse crackles in the lung fields - the nurse should auscultate coarse crackles or rhonchi, identify a moist cough, hear or see secretions in the tracheostomy tube, and then suction the client's airway secretions - the client who has a tracheostomy with an inflated cuff in place is unable to speak - the nurse should assess the need for suctioning every 2 hr and then suction as necessary - the nurse should check the client's airway after coughing and only suction the client's secretions, if the client is able to cough and expectorate secretions
a nurse is collecting data from a client who has a prescription for cisplatin IV to treat lung cancer. which of the following client findings is an adverse effect of this medication?
tinnitus - an adverse effect if cisplatin is ototoxicity, which is tinnitus - hallucinations are an adverse effect of asparaginase, which is an antineoplastic medication used to treat acute lymphocytic leukemia - pruritus is an adverse effect of methotrexate, which is used to treat cancer and rheumatoid arthritis - hand and foot syndrome is an adverse effect of capecitabine, an antineoplastic medication used to treat breast and colorectal cancer
a nurse is reinforcing teaching with a client who has cystic fibrosis and a prescription for daily chest physiotherapy. the nurse should instruct the client that which of the following is the purpose of these treatments?
to mobilize secretions in the airways - the purpose of chest physiotherapy is to loosen the client's secretions and promote drainage of secretions from the lungs. chest physiotherapy includes percussion, vibration, and promotion of drainage by gravity - chest therapy does not encourage deep breaths. however, once airway secretions are mobilized and expectorated, the client might be able to breathe deeper - chest physiotherapy does not dilate the bronchioles, however, aerosol bronchodilators are often administered to the client to facilitate mobilizing secretions from larger airways - chest physiotherapy does not stimulate the cough reflex, however, the mobilization of secretions can increase the client's ability to cough up secretions
a nurse is reinforcing teaching with a client about pulmonary function tests. which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation?
total lung capacity - pulmonary function tests are used to examine the effectiveness of the lungs and identify lung problems. total lung capacity measures the amount of air the lungs can hold after maximum inhalation - vital lung capacity measures the amount of air the client can exhale after maximum inhalation - functional residual capacity measures the amount of air in the lungs after normal expiration - residual volume measures the amount of air in the lungs after forced expiration
