Chapter 19 ( MEDSURG)

A 68-year-old male patient has been admitted to the surgical unit from the PACU after surgical repair of an inguinal hernia. When performing the patient's admission assessment, the nurse notes that the patient has a barrel chest. This assessment finding should suggest to the nurse that the patient may have a history of what health problem?

Emphysema

A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?

Auscultate the lung for adventitious sounds.

Postural drainage has been ordered for a client who is having difficulty mobilizing bronchial secretions. Before repositioning the client and beginning treatment, the nurse should perform what health assessment?

Chest auscultation

A nurse is educating a client in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the client and the family that this drainage system is used for?

Removing excess air and fluid

The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?

Swallow reflex

The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action?

Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax

The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding?

Document that the chest drainage system is operating as it is intended.

A nurse is discussing squamous epithelial cells lining each alveolus, which consist of different types of cells. Which type of alveolar cells produce surfactant?

Type II cells

The nurse is assessing a patient in respiratory failure. What finding is a late indicator of hypoxia?

Cyanosis

The nurse is caring for a patient with a pulmonary disorder. What observation by the nurse is indicative of a very late symptom of hypoxia?

Cyanosis

Which is a late sign of hypoxia?

Cyanosis

The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the client's needs?

Nasal cannula

The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the client has what diagnosis?

COPD

A thoracentesis is performed to obtain a sample of pleural fluid or a biopsy specimen from the pleural wall for diagnostic purposes. What does serous fluid indicate? Cancer

Cancer

The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying?

Circulatory hypoxia

The nurse is assessing the lungs of a patient diagnosed with pulmonary edema. Which of the following would be expected upon auscultation?

Crackles at lung bases

A nurse understands that a safe but low level of oxygen saturation provides for adequate tissue saturation while allowing no reserve for situations that threaten ventilation. What is a safe but low oxygen saturation level for a patient?

95%

A client is being treated for a pulmonary embolism and the medical nurse is aware that the client suffered an acute disturbance in pulmonary perfusion. This involved an alteration in what aspect of normal physiology?

Adequate flow of blood through the pulmonary circulation.

A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client?

Continuous positive airway pressure (CPAP)

A client who is post-thoracotomy is retaining secretions. What is the nurse's initial intervention?

Encourage the client to cough

Which respiratory volume is the maximum volume of air that can be inhaled after a normal exhalation?

inspiratory reserve volume

A client is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The client inquires about the normal function of pleural fluid. What should the nurse describe?

it lubricates the movement of the thorax and lungs.

The nurse auscultates the lung sounds of a client during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as

pleural friction rub.

What are the primary functions of the lungs? Select all that apply.

ventilation gas exchange

Computed tomography of a patient's chest is suggestive of a malignancy, but these results are not conclusive. As a result, the patient has been scheduled for a bronchoscopy. What patient education should the nurse provide for this patient regarding this diagnostic procedure?

"We'll monitor you closely after the procedure, especially until your gag reflex returns."

A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client.

"Inhale through your nose." "Slowly count to 3." "Exhale slowly through pursed lips." "Slowly count to 7."

Following a chest X-ray, a patient has been diagnosed with a pleural effusion. The care team has concluded that the quantity of fluid in the patient's intrapleural space necessitates thoracentesis. What patient education should the nurse provide in anticipation of this procedure?

"It's very important that you remain still while the doctor is performing the procedure

The OR nurse is setting up a water-seal chest drainage system for a client who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system?

20 cm H2O

What would the critical care nurse recognize as a condition that may indicate a client's need to have a tracheostomy?

A client requires permanent ventilation.

The nurse has assessed a client's family history for three generations. The presence of which respiratory disease would justify this type of assessment?

Asthma

An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. The ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? Select all that apply.

Before meals At bedtime

What finding by the nurse may indicate that the client has chronic hypoxia?

Clubbing of the fingers

A client is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what?

Correct use of incentive spirometry

Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium?

Difficulty in breathing

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?

Encourage the patient to take approximately 10 breaths per hour, while awake.

A client recovering from thoracic surgery is on long-term mechanical ventilation and becomes very frustrated when he tries to communicate. What intervention should the nurse perform to assist the client?

Express empathy and then encourage the client to write, use a picture board, or spell words with an alphabet board.

The nurse is caring for a client who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the client?

How to splint the incision when coughing

A client is undergoing testing to see if he has a pleural effusion. Which of the nurse's respiratory assessment findings would be most consistent with this diagnosis?

Lung fields dull to percussion, absent breath sounds, and a pleural friction rub

A nurse has performed tracheal suctioning on a client who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention?

Measure the client's oxygen saturation.

A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse?

Measure the client's oxygen saturation.

The nurse is performing an assessment for a patient with congestive heart failure. The nurse asks if the patient has difficulty breathing in any position other than upright. What is the nurse referring to?

Orthopnea

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?

PaO2

The nurse is assessing a client who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding?

Perform a swallowing assessment.

What is the primary function of the larynx?

Producing sound

A client has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the client discouraged and saddened. The client states, "I am recovering so slowly. I really thought I would be better by now." What nursing action should the nurse prioritize?

Provide emotional support to the client and family

The nurse is caring for a client who is to undergo a thoracentesis. In preparation for the procedure, the nurse places the client in which position?

Sitting on the edge of the bed

The critical care nurse and the other members of the care team are assessing the client to see if he is ready to be weaned from the ventilator. What are the most important predictors of successful weaning that the nurse should identify?

Stable vital signs and ABGs

While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. What should the nurse conclude?

The system has an air leak.

A client is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The client inquires about the normal function of pleural fluid. What should the nurse describe? It allows for full expansion of the lungs withi

t lubricates the movement of the thorax and lungs.