concepts 4 exam 3
Which patient statement indicates the need for additional education regarding the use of sodium bicarbonate to treat acidosis? -"I need to purchase antacids without salt" -"I should use the antacid for at least 2 months" -"I should contact the doctor if I have any gastric discomfort with chest pain" -"I should call the doctor if I get short of breath or start to sweat with this medication"
-"I should use the antacid for at least 2 months"
The nurse is providing care to a patient who will need a bronchoscopy. Which patient statement indicates appropriate understanding of the information presented? -"I will be awake and aware during the procedure" -"I will require mechanical ventilation after the procedure" -"I will need to have my prothrombin time drawn after the test" -"I will abstain from eating or drinking for eight hours prior to the procedure"
-"I will abstain from eating or drinking for eight hours prior to the procedure"
The nurse is caring for a patient following a thoracentesis. Which of the following indicates the patient needs additional teaching regarding his discharge instructions? -"I will be short of breath following the procedure, and my symptoms should resolve by the morning" -"there may be a small amount of drainage noted on the dressing" -"I will come back to the hospital if I experience chest pain" -"I can eat my normal diet following discharge"
-"I will be short of breath following the procedure, and my symptoms should resolve by the morning"
The nurse teaches a patient how to implement pursed-lip breathing. Which patient statement indicates a need for additional instruction? -"I will sit up with my shoulders relaxed" -"I will be sure to exhale twice as long as I inhale" -"I will inhale through my mouth while slowly counting" -"I will exhale through my mouth as if I was blowing out candles"
-"I will inhale through my mouth while slowly counting"
The nurse completes discharge teaching for a patient with an anxiety disorder. Which patient statement indicates correct understanding of information related to respiratory alkalosis? -"I will eat more bananas at breakfast" -"I will see my counselor on a regular basis" -"I will not take antacids when I have heartburn" -"I will breathe faster when I am feeling anxious"
-"I will see my counselor on a regular basis"
Which statement by the nurse when explaining the purpose of positive end-expiratory pressure (PEEP) to the patient's caregiver is accurate? -"PEEP will push more air into the lungs during inhalation" -"PEEP prevents the lung sacs from collapsing during exhalation" -"PEEP will prevent lung damage while the patient is on the ventilator" -"PEEP allows the breathing machine to deliver 100% O2 to the lungs"
-"PEEP prevents the lung sacs from collapsing during exhalation"
The nurse working with a student nurse is providing care for a patient requiring mechanical ventilation. The student nurse asks the meaning of assist control. Which response by the nurse is the most appropriate? -"assist control is a means of delivering ventilation that delivers a preset volume and/or pressure each time the patient begins an inspiration" -"assist control allows the patient to breathe independently, but supplies a breath if the patient does not begin an inhalation in a specified period of time" -"assist control is used when weaning a patient from the ventilator because the patient must exercise the muscles of respiration in order to get a full breath" -"assist control is often used when a patient is receiving a paralytic agent"
-"assist control is a means of delivering ventilation that delivers a preset volume and/or pressure each time the patient begins an inspiration"
The nurse is conducting a health history interview for a patient who is diagnosed with COPD. Which question is appropriate when assessing the patient's nutrition-metabolic pattern? -"have you lost any weight recently?" -"do you have trouble getting to the toilet?" -"does your breathing wake you up in the night?" -"do you have any pain associated with breathing?"
-"have you lost any weight recently?"
A new nurse asks for an explanation of "refractory hypoxemia." What answer by the nurse is best? -"it is chronic hypoxemia that accompanies restrictive airway disease" -"it is hypoxemia from lung damage due to mechanical ventilation" -"it is hypoxemia that continues even after the client is weaned from oxygen" -"it is hypoxia that persists even with 100% oxygen administration"
-"it is hypoxia that persists even with 100% oxygen administration"
A client is on mechanical ventilation and the client's spouse wonders why ranitidine is needed since the client "only has lung problems." What response by the nurse is best? -"it will increase the mobility of the gastrointestinal tract" -"it will keep the gastrointestinal tract functioning normally" -"it will prepare the gastrointestinal tract for enteral feedings" -"it will prevent ulcers from the stress of mechanical ventilation"
-"it will prevent ulcers from the stress of mechanical ventilation"
The patient is undergoing an open lung biopsy in the morning and the nurse is educating them regarding the postoperative period. Which of the following statements should be included in the education? -"you will be discharged home immediately following the procedure" -"you most likely will have a chest tube inserted to allow your lungs to re-expand" -"you will need to collect a sputum specimen" -"you will not need any supplemental oxygen"
-"you most likely will have a chest tube inserted to allow your lungs to re-expand"
The nurse is caring for a patient in a community clinic who wishes to quit smoking. The patient asks the nurse "if I quit smoking, will my risk of lung cancer be the same as a nonsmoker?" Which response is best by the nurse? -"no one knows for sure what the risk is for someone who quits smoking" -"your risk of lung cancer will be equal to that of a nonsmoker" -"your risk of lung cancer will decline if you quit, but it will remain higher than a nonsmoker" -"your risk of lung cancer will never drop because the damage has already been done"
-"your risk of lung cancer will decline if you quit, but it will remain higher than a nonsmoker"
The nurse is providing care to a patient diagnosed with COPD who requires supplemental oxygen. Which is the anticipated flow rate range by nasal cannula (NC) when providing care for this patient? -1-2 L/min -2-3 L/min -3-4 L/min -4-5 L/min
-1-2 L/min
When conducting in-line suctioning, which is the maximum amount of time for each suctioning event? -10 seconds -30 seconds -45 seconds -60 seconds
-10 seconds
What fraction of inspired air (FiO2) should the nurse expect the primary health care provider to prescribe for a client who is extremely hypoxic? -100% -90% -60% -21%
-100%
A client arrives at the ER following a burn injury that occurred in the basement at home, and an inhalation injury is suspected. What would the nurse anticipate to be prescribed for the client? -100% oxygen via an aerosol mask -oxygen via nasal cannula at 6 L/min -oxygen via nasal cannula at 15 L/min -100% oxygen via a tight-fitting nonrebreather face mask
-100% oxygen via a tight-fitting nonrebreather face mask
The nurse monitors a patient in the emergency department after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed? -a large air leak in the water-seal chamber -400 mL of blood in the collection chamber -complaint of pain with each deep inspiration -subcutaneous emphysema at the insertion site
-400 mL of blood in the collection chamber
The nurse is caring for a patient in respiratory distress whose pulse oximetry reading is 95%. What should the nurse anticipate the PaO2 level is on the arterial blood gases? -60 mmHg -80 mmHg -95 mmHg -100 mmHg
-80 mmHg
After oxygen has been administered, the next priority intervention the nurse would initiate for a patient with a pulmonary embolus is the administration of which of these therapies? -normal saline IV fluid -IV heparin -platelet administration -antibiotics for inflammatory fever
-IV heparin
A nurse is caring for a patient with acute respiratory distress syndrome who is receiving mechanical ventilation using synchronized intermittent mandatory ventilation. The settings include a fraction of inspired oxygen of 80%, tidal volume of 450, rate of 16, and positive end-expiratory pressure of 5 cm. Which assessment finding is most important for the nurse to report to the health care provider? -O2 saturation of 99% -heart rate of 106 -crackles audible at lung bases -respiratory rate of 22
-O2 saturation of 99%
A client who is diagnosed with ARDS requires mechanical ventilation. Which ventilator mode should the nurse expect to implement to promote pressure throughout the respiratory cycle? -PEEP -sensitivity -flow rate -tidal volume
-PEEP
A nurse is teaching about partial pressure of CO2 in arterial blood (PaCO2). Which statement indicates a need for further teaching? -PaCO2 level indicates the partial pressure of CO2 in arterial blood -PaCO2 level is used to evaluate the respiratory component of acid-base balance -PaCO2 level when higher than 45 mmHg indicates alkalosis -PaCO2 level when lower than 35 mmHg indicates alkalosis
-PaCO2 level when higher than 45 mmHg indicates alkalosis
The nurse is caring for a patient with ARDS who is on pressure support ventilation, FiO2 at 80% and PEEP at 15 cm H2O. The patient weighs 72 kg. What finding would indicate that treatment is effective? -PaO2 of 60 mmHg -tidal volume of 700 mL -cardiac output of 2.7 L/min -inspiration to expiration ratio of 1:2
-PaO2 of 60 mmHg
Which of the following would be an abnormal finding for an older adult? -kyphosis -AP to lateral diameter of 1:1 -PaCO2 of 47 on an arterial blood gas -PaO2 of 60 on an arterial blood gas
-PaO2 of 60 on an arterial blood gas
A nurse is scheduled to take care of these 4 patients in a trauma step down unit. Which one should the nurse assess first? -a 19 year old 2 days post-motor vehicle crash, rib fractures and on CPAP for oxygenation issues, complaining of increasing chest pain -a 40 year old 1 day postoperative for a ruptured spleen following a motor vehicle accident, slightly confused about how he got to the unit -a 21 year old still comatose following a fall and flail chest, remains stable on a ventilator and drug therapy for low blood pressure -a 60 year old with a left femur fracture following a farming accident who is experiencing new onset of slight shortness of breath
-a 21 year old still comatose following a fall and flail chest, remains stable on a ventilator and drug therapy for low blood pressure
A pulmonary nurse cares for clients who have COPD. Which client would the nurse assess first? -a 46 year old with a 30 pack year history of smoking -a 52 year old in a tripod position using accessory muscles to breathe -a 68 year old who has dependant edema and clubbed fingers -a 74 year old with a chronic cough and thick tenacious secretions
-a 52 year old in a tripod position using accessory muscles to breathe
The nurse is providing care to a patient who is being weaned from mechanical ventilation. Which finding would necessitate the continuation of mechanical ventilation if noted during the assessment? -an FiO2 less than or equal to 0.430.5 -a PEEP less than or equal to 538 cm H2O -a pH greater than 7.25 during spontaneous ventilation -a drop in blood pressure indicating a hypotensive state
-a drop in blood pressure indicating a hypotensive state
The nurse correlates which data from a patient's history to a diagnosis of bronchitis? -a history of rhinitis -a history of eczema -a history of allergies -a history of progressive dyspnea
-a history of progressive dyspnea
After the nurse has received change of shift report, which patient should the nurse assess first? -a patient with pneumonia who has crackles in the right lung base -a patient with possible lung cancer who has just returned after bronchoscopy -a patient with hemoptysis and a 16 mm induration with TB skin testing -a patient with COPD and pulmonary function testing that indicates low forced vital capacity
-a patient with possible lung cancer who has just returned after bronchoscopy
Which of the following findings would suggest pneumothorax in a trauma victim? -pronounced crackles -inspiratory wheezing -dullness on percussion -absent breath sounds
-absent breath sounds
A patient has been on a 100% nonrebreather mask for hypoxia for the last 3 days. Which complication should the nurse monitor for? -hypoxemia -bronchospasm -pneumothorax -absorption atelectasis
-absorption atelectasis
The nurse is providing care to a patient who is intubated and receiving mechanical ventilation after a motor vehicle crash. The patient is fighting the ventilator and attempting to remove the endotracheal tube. Which nursing action decreases the patient's risk for developing respiratory alkalosis? -apply wrist restraints -administer a prescribed sedative -teach the patient to take slow, deep breaths -discuss removing the endotracheal tube with the health care provider
-administer a prescribed sedative
An hour after a thoracotomy, a patient complains of incisional pain at a level 7 and has decreased left-sided breath sounds. The pleural drainage system has 100 mL of bloody drainage and a large air leak. Which action should the nurse take? -clamp the chest tube in two places -administer the prescribed morphine -milk the chest tube to remove any clots -assist the patient with incentive spirometry
-administer the prescribed morphine
this mode of ventilation is used for spontaneously breathing patient's who requite a high level of pressure to effectively recruit alveoli. the high level of pressure forces the alveoli open and contributes to gas exchange. the inflation period is long and breaths may be initiated spontaneously and by the vent. this mode allows for spontaneous breathing at a preset CPAP that is interrupted by pressure to release a lower pressure. this mode decreases the risk of barotrauma
-airway pressure-release ventilation
A client has been diagnosed with a very large pulmonary embolism and has a dropping blood pressure. What medication would be most beneficial? -alteplase -enoxaparin -unfractionated heparin -warfarin sodium
-alteplase
Which description best explains residual volume (RV)? -amount of air in the lungs at the end of maximal inhalation -amount of air remaining in the lungs at the end of full forced exhalation -amount of air remaining in the lungs after normal exhalation -maximal amount of forced air that can be exhaled after maximal inspiration
-amount of air remaining in the lungs at the end of full forced exhalation
Which diagnostic test should the nurse anticipate when providing care to a patient diagnosed with chronic obstructive pulmonary disease (COPD) to monitor acid-base balance? -pulse oximetry -bronchoscopy -sputum studies -arterial blood gases
-arterial blood gases
The nurse is providing care for a patient admitted to the unit with respiratory failure and respiratory acidosis. Which data from the nursing history is the probable cause for the patient's current diagnosis? -aspiration pneumonia -a recent trip to South Africa -recent recovery from a cold virus -use of ibuprofen for the control of pain
-aspiration pneumonia
The nurse is caring for a patient who has just been orally intubated. Which action should the nurse take first? -assess for symmetrical chest rise and fall with ventilation -provide mouth care to ensure a clean oral cavity -assess the need for nutritional support by an oral nasogastric tube -provide a communication board for the patient and family
-assess for symmetrical chest rise and fall with ventilation
The client with a chronic obstructive respiratory disease is receiving oxygen via nasal cannula. Which of the following interventions does the nurse plan to include in the client's care? -assess nares for skin breakdown every 6 hours -check patency of the cannula every 2 hours -inspect the mouth every 6 hours -check oxygen flow every 24 hours
-assess nares for skin breakdown every 6 hours
Your postoperative client's ABG's are pH 7.22, HCO3 21 mEq/L, PCO2 65 mmHg, and PO2 58 mmHg. What is your best first action? -notify the physician -assess the client's airway -increase the oxygen flow rate -document the finding as the only action
-assess the client's airway
The nurse is performing pulmonary function testing on a patient. Which action is beneficial to the patient? -assessing for respiratory distress -scheduling the test after a meal -providing rest before the procedure -administering an inhaled bronchodilator six hours before the procedure
-assessing for respiratory distress
Which nursing action determines the accuracy of the detected waveform when monitoring a patient's oxygen saturation via oximetry? -using a site with adequate perfusion -ensuring that any nail polish is removed -leaving the sensor in place for a minimum of ten seconds -assessing the heart rate and comparing it with the displayed pulse
-assessing the heart rate and comparing it with the displayed pulse
A patient with COPD is given a high dose of oxygen in response to low SpO2. What is the priority intervention for this patient? -cardiovascular assessment -assessment of respiratory rate -medication administration -respiratory therapy referral
-assessment of respiratory rate
What ventilation setting delivers a preset tidal volume whenever the patient exerts inspiration, and still ensures that the patient receives a breath if they do not spontaneously trigger the ventilator? -controlled mandatory ventilation -assist control ventilation -synchronized intermittent mandatory ventilation -continuous positive airway pressure
-assist control ventilation
Which of the following modes of ventilation increases the risk of developing respiratory alkalosis? -controlled mandatory ventilation -synchronized intermittent mandatory ventilation -assist control ventilation -pressure control ventilation
-assist control ventilation
this mode of ventilation is used for patient's who have weak respiratory muscles and may be unable to maintain adequate ventilation. the respiratory rate and volume of breaths are preset. if the patient does not initiate a breath, the vent delivers the breaths at the preset rate and volume. if the patient does initiate a breath, the vent delivers the preset volume (assisted breath), allowing the patient to control the rate of breaths. a disadvantage of this mode is that hyperventilation can occur, resulting in respiratory alkalosis
-assist control ventilation
The nurse is caring for a client diagnosed with flail chest who has had a chest tube for 3 days. The nurse notes there is no tidaling in the water-seal compartment. Which initial action should be taken by the nurse? -check the tubing for any dependant loops -auscultate the client's posterior breath sounds -prepare to remove the client's chest tubes -notify the HCP that the lungs have re-expanded
-auscultate the client's posterior breath sounds
Following a thoracotomy to remove a lung tumor, a nurse is preparing a client to be discharged home. Which are appropriate teaching points for the client? SATA: -avoid lifting greater than 20 pounds -build up exercise endurance -continue to build endurance even when dyspneic -expect return to normal activity level and strength within 1 month -make time for frequent rest periods with activity
-avoid lifting greater than 20 pounds -build up exercise endurance -make time for frequent rest periods with activity
which complication is associated with excessively high levels of PEEP
-barotrauma and pneumothorax
The nurse is providing care to a patient diagnosed with emphysema. Which clinical manifestation does the nurse correlate with this diagnosis? -tachycardia -cough -barrel chest -wheezing
-barrel chest
The nurse is reviewing the chest x-ray report of a ventilated patient requiring an FiO2 of 70%. Which finding is most concerning? -atelectasis -bilateral infiltrates -5% pneumothorax -endotracheal tube 4 cm above the carina
-bilateral infiltrates
When conducting a respiratory assessment, the nurse notes a low-pitched sound that is continuous throughout inspiration. Which does this lung sound indicate to the nurse? -narrow bronchi -narrow trachea passages -inflamed pleural surfaces -blocked large airway passages
-blocked large airway passages
The nurse is providing care to a patient admitted with a respiratory disorder. Which laboratory finding would be most significant? -blood pH 7.32 -oxygen saturation 96% -serum sodium 140 mg/dL -hemoglobin level 12 mg/dL
-blood pH 7.32
A patient is on mechanical ventilation with positive end expiratory pressure (PEEP). Which finding indicates the patient is developing a complication related to therapy and requires immediate intervention? -HCO3 26 mmHg -blood pressure 70/45 -PaO2 80 mmHg -PaCO2 38 mmHg
-blood pressure 70/45
The nurse is caring for a patient suspected of having ARDS. What is the most likely diagnostic test ordered in the early stages of the disease to differentiate the patient's symptoms from those of cardiac etiology? -carboxyhemoglobin level -brain natriuretic peptide (BNP) level -c reactive protein level -complete blood count
-brain natriuretic peptide (BNP) level
A nurse is caring for a patient who has developed postoperative respiratory acidosis. What is the most likely cause of respiratory acidosis? -hepatic failure -bronchial obstruction -salicylate intoxication -increased levels of aldosterone
-bronchial obstruction
The client with a right-sided pneumothorax had chest tubes inserted 2 hours ago. There is no fluctuation in the water-seal chamber of the Pleurovac. Which intervention should the nurse implement first? -assess the client's lung sounds -check for any kinks in the tubing -ask the client to take deep breaths -turn the client from side to side
-check for any kinks in the tubing
A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? -hot, flushed feeling -sudden chills and fever -chest pain that occurs suddenly -dyspnea when deep breaths are taken
-chest pain that occurs suddenly
While auscultating a patient's chest, the nurse notes wheezing. Based on this data, which diagnosis does the nurse anticipate? -bronchiectasis -pleural effusion -pulmonary edema -chronic obstructive pulmonary disease
-chronic obstructive pulmonary disease
The results of a patient's arterial blood gas sample indicate an oxygen level of 72 mmHg. Which should nurse closely assess when providing care to this patient? -perfusion -cognition -communication -fluid and electrolytes
-cognition
In what ventilation setting does the ventilator deliver tidal volume at a preset rate because the patient is not breathing spontaneously? -controlled mandatory ventilation -assist control ventilation -synchronized intermittent mandatory ventilation -continuous positive airway pressure
-controlled mandatory ventilation
Which chronic lung condition noted in the patient's health history supports the current diagnosis of respiratory acidosis? -aspiration -pneumonia -cystic fibrosis -hyperthyroidism
-cystic fibrosis
Which clinical manifestation supports the nurse's plan of care focusing on chronic respiratory acidosis? -irritability -blurred vision -daytime sleepiness -warm, flushed skin
-daytime sleepiness
A patient reporting chest tightness arrives at the hospital. On assessment, the nurse notes wheezing, cough, elevated blood pressure, and pulse rate. The primary health care provider prescribes corticosteroids. Which is most likely the outcome of the prescribed therapy? -increases the hydration of the airway -decreases the inflammation of the airway -aids in bronchial smooth muscle relaxation -aids in muscle relaxation around the alveoli
-decreases the inflammation of the airway
The patient with acute respiratory distress syndrome would exhibit which of the following symptoms? -decreasing PaO2 levels despite increased FiO2 administration -elevated alveolar surfactant levels -increased lung compliance with increased FiO2 administration -respiratory acidosis associated with hyperventilation
-decreasing PaO2 levels despite increased FiO2 administration
The nurse is caring for a comatose patient with respiratory acidosis. For which intervention will the nurse need to collaborate when caring for this patient? -monitoring vital signs -measuring intake and output -determining recent eating behaviors -identifying current oxygen saturation level
-determining recent eating behaviors
The ER nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding would indicate the presence of a pneumothorax in this client? -a low respiratory rate -diminished breath sounds -the presence of a barrel chest -a sucking sound at the site of injury
-diminished breath sounds
The nurse is performing in-line suctioning when the patient experiences a drop in oxygen saturation and bradycardia. Which nursing action is appropriate? -continue suctioning and administer 50% oxygen -discontinue suctioning and prepare for resuscitation -discontinue suctioning and administer 100% oxygen -continue suctioning and administer prescribed epinephrine
-discontinue suctioning and administer 100% oxygen
a client in severe respiratory distress is prescribed continuous albuterol nebulizers. which side effect does the nurse monitor the client? SATA: -dizziness -excessive salivation -hyperkalemia -tremors -wheezing
-dizziness -tremors
The nurse is assessing a patient 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 patient's respirations. How should the nurse best respond to this assessment finding? -gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes -inform the physician promptly that there is imminent leak in the drainage system -encourage the patient to do deep breathing and coughing exercises -document that the chest drainage system is operating as intended
-document that the chest drainage system is operating as intended
The nurse is reviewing the health care provider orders for a patient who is diagnosed with respiratory alkalosis. Which prescription is appropriate for this patient's care needs? -draw arterial blood gas analysis -administer oxygen via face mask -restrict fluid to 2 liters per day -infuse one ampule of sodium bicarbonate
-draw arterial blood gas analysis
Which assessment data would cause the nurse to document the patient is experiencing early respiratory distress? SATA: -dyspnea -restlessness -tachycardia -confusion -cyanosis
-dyspnea -restlessness -tachycardia
The nurse is caring for a patient with COPD. The patient has been receiving high-flow oxygen therapy for an extended time. What symptoms should the nurse anticipate if the patient were experiencing oxygen toxicity? -bradycardia and frontal headache -dyspnea and substernal pain -peripheral cyanosis and restlessness -hypotension and tachycardia
-dyspnea and substernal pain
The nurse is conducting a respiratory assessment. Which respiratory manifestation indicates inadequate oxygenation? -mild hypertension -cool clammy skin -dyspnea on exertion -unexplained apprehension
-dyspnea on exertion
The nurse is providing care to a patient who is mechanically ventilated. In order to decrease the risk for aspiration, which action by the nurse is appropriate? -elevate the head of the bed between 30 to 45 degrees -limit each suctioning event to no more than 10 seconds -perform chest physiotherapy as prescribed by the practitioner -ensure an NPO status is maintained for the length of the prescribed treatment
-elevate the head of the bed between 30 to 45 degrees
A patient with a possible pulmonary embolism complains of chest pain and difficulty breathing. The nurse finds a heart rate of 142 beats per minute, blood pressure of 100/60 mmHg, and respirations of 42. Which action should the nurse take first? -administer anticoagulant drug therapy -notify the patient's health care provider -prepare the patient for a spiral computed tomography -elevate the head of the bed to a semi-fowler's position
-elevate the head of the bed to a semi-fowler's position
What is the primary difference between emphysema and chronic bronchitis? -chronic bronchitis predominantly affects the large airways -emphysema predominantly affects the large airways -emphysema predominantly affects the alveoli -chronic bronchitis predominantly affects the alveoli
-emphysema predominantly affects the alveoli
The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm beeps and the nurse notes a collection of moisture in the ventilator tubing. Which action by the nurse is appropriate? -empty the water -suction as needed -insert an oral airway -assess for asymmetric chest rise
-empty the water
A patient with respiratory failure has a respiratory rate of 6 breaths per minute and an oxygen saturation of 88%. The patient is increasingly lethargic. Which intervention will the nurse anticipate? -administration of 100% oxygen by non-rebreather mask -endotracheal intubation and positive pressure ventilation -insertion of a mini-tracheostomy with frequent suctioning -initiation of continuous positive pressure ventilation
-endotracheal intubation and positive pressure ventilation
A nurse is preparing to admit a client on mechanical ventilation for acute respiratory failure from the ER. What action does the nurse take first? -assessing that the ventilator settings are correct -ensuring that there is a bag-valve mask in the room -obtaining personal protective equipment -planning to suction the client upon arrival to the room
-ensuring that there is a bag-valve mask in the room
The nurse is providing care to a patient who is recovering from facial trauma who requires high-flow oxygen therapy. Which method of oxygen delivery should the nurse plan for when providing care? -face tent -nasal cannula -venturi mask -nonrebreather mask
-face tent
this PFT is the amount of air an individual can forcefully exhale after maximum inspiration
-forced vital capacity
A patient with a diagnosis of COPD requires supplemental oxygen therapy because of hypoxemia. Which statement is true concerning oxygen therapy with a patient diagnosed with COPD? -high oxygen concentrations have no effect on patients with COPD -the patient will become dependant on oxygen -there is no indication for supplemental oxygen for a patient with COPD -high oxygen concentrations may decrease the hypoxic drive to breathe
-high oxygen concentrations may decrease the hypoxic drive to breathe
The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient? -how to milk the chest tubing -how to splint the incision when coughing -how to take prophylactic antibiotics -how to manage the need for fluid restriction
-how to splint the incision when coughing
headache, confusion, decreased LOC, somnolence, tachycardia, flushed, dizziness, and pink color to the skin are signs of what type of acute respiratory failure
-hypercapnia
A patient who is receiving mechanical ventilation is at risk for which complications? -hypotension, infection, and barotrauma -anxiety, hypertension, and fatigue -VAP, atelectasis, and hypothermia -dyspnea, hypoxia, and normothermia
-hypotension, infection, and barotrauma
The nurse notes on the arterial blood gas record that the patient's PO2 is low. How should the nurse document this finding? -hypoxemia -hypoxia -acidosis -alkalosis
-hypoxemia
increased HR, increased RR, increased BP, restlessness, agitation, confusion, and anxiety are signs of what type of acute respiratory failure
-hypoxemia
The nurse understands oxygen therapy for a patient with COPD requires close monitoring because of which of the following? -hypoxic respiratory drive -hypercapnic respiratory drive -acidotic respiratory drive -alkalotic respiratory drive
-hypoxic respiratory drive
The nurse is teaching a client with 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
While caring for a patient who has been admitted with a pulmonary embolism, the nurse notes a change in the patient's oxygen saturation from 94% to 88%. Which action should the nurse take? -suction the patient's oropharynx -increase the prescribed O2 flow rate -instruct the patient to cough and deep breathe -help the patient to sit in a more upright position
-increase the prescribed O2 flow rate
The pulmonary edema associated with ARDS is caused by: -increased permeability of the ACM -right ventricular failure with pulmonary hypertension -left ventricular failure due to poor oxygenation -fluid overload related to resuscitation in the first phase
-increased permeability of the ACM
The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm beeps and the nurse notes the patient is biting down on the endotracheal tube. Which action by the nurse is appropriate? -suction as needed -insert an oral airway -assess for asymmetric chest rise -empty water from the ventilator tubing
-insert an oral airway
Which mode of mechanical ventilation helps to reduce the risk of barotrauma? -assist control ventilation -intermittent mandatory ventilation -negative pressure ventilation -synchronized intermittent mandatory ventilation
-intermittent mandatory ventilation
this mode of ventilation is used for patients who can breathe spontaneously but at a volume or rate that does not meet adequate oxygenation. it provides a combination of ventilator-assisted breaths and spontaneous breaths of the patient. this mode makes sure that a preset volume and rate of breaths are given per minute regardless of the patient's efforts. this mode decreases the risk of barotrauma but increases the risk of the patient fighting the vent ("bucking the vent")
-intermittent mandatory ventilation
Which mode of mechanical ventilation provides a combination of ventilator-assisted breathes and spontaneous breaths of the client? -synchronized intermittent mandatory ventilation (SIMV) -airway pressure release ventilation (APRV) -intermittent mandatory ventilation (IMV) -pressure support ventilation (PSV)
-intermittent mandatory ventilation (IMV)
Which is true regarding emphysema? -it is caused by inflammation of bronchioles -it is associated with blood-tinged sputum -it is associated with chronic respiratory acidosis -it is associated with chronic dilation of bronchioles
-it is associated with chronic respiratory acidosis
The nurse is caring for a patient in acute respiratory failure whose oxygenation continues to decrease. The patient is currently on a nonrebreather mask with 100% FiO2. The nurse requests an order for noninvasive positive-pressure ventilation. How will this benefit the patient? -it provides a higher level of oxygen -it breathes for the patient so they don't have to -it provides pressure with each of the patient's own breaths -it pushes air into the lungs
-it provides pressure with each of the patient's own breaths
An intubated client's oxygen saturation has dropped to 88%. What action by the nurse takes priority? -determine if the tube is kinked -ensure that all connections are patent -listen to the client's lung sounds -suction the endotracheal tube
-listen to the client's lung sounds
The nurse is caring for a patient with shortness of breath and respiratory rate of 28. Which is the most preferred method to auscultate the chest of the patient with this condition? -listening at the apices -listening at the lung bases -listening by comparing opposite areas of the chest -listening to each cycle of inspiratory and expiratory cycle
-listening at the lung bases
A patient with acute respiratory distress syndrome who is intubated and receiving mechanical ventilation develops a right pneumothorax. Which collaborative action will the nurse anticipate next? -increase the tidal volume and respiratory rate -decrease the fraction of inspired oxygen -perform endotracheal suctioning more frequently -lower the positive-end expiratory pressure
-lower the positive-end expiratory pressure
The nurse is planning care for an older adult patient with respiratory acidosis. Which intervention should the nurse include in this patient's plan of care? -maintain adequate hydration -reduce environmental stimuli -administer intravenous sodium bicarbonate -administer prescribed intravenous fluid carefully
-maintain adequate hydration
A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. Which action by the nurse is best? -elevate the head of the client's bed -measure and compare cuff pressures -place the client on NPO status -request that the client have a swallow study
-measure and compare cuff pressures
The nurse is creating a care plan for an adult requiring mechanical ventilation. What nursing action is most appropriate? -keep the patient in a low fowler's position -perform tracheostomy care at least once per day -maintain continuous bedrest -monitor cuff pressure every 8 hours
-monitor cuff pressure every 8 hours
Which of the following indicates an abnormal assessment finding of the respiratory system? -symmetrical chest expansion -muscle retractions with inhalation -the sound of resonance with percussion of lung tissue -pink mucosa of the mouth and nares
-muscle retractions with inhalation
The nurse is reviewing orders on the patient who is to receive supplemental oxygen. It is a priority for the nurse to follow up with the provider about which order? -nasal cannula at 2 L/min -venturi mask at 24% concentration -nasal cannula at 8 L/min -venturi mask at 50% concentration
-nasal cannula at 8 L/min
Which information about a patient who is receiving cisatracurium (nimbex) to prevent asynchronous breathing with the positive pressure ventilator requires action by the nurse? -no sedative has been ordered for the patient -the patient does not respond to verbal stimulation -there is no cough or gag reflex when the patient is suctioned -the patient's oxygen saturation remains between 90%-93%
-no sedative has been ordered for the patient
The nurse is assessing a client with a chest tube for a pneumothorax. The nurse assesses a crackling sensation beneath the fingertips around the chest tube insertion site. The nurse should take which action? -document the finding -clamp the chest tube -notify the health care provider -apply oxygen via nasal cannula
-notify the health care provider
A patient is admitted to the ER for the treatment of a drug overdose causing acute respiratory acidosis. Which substance noted on the toxicology report is most likely the cause for the current diagnosis? -PCP -cocaine -marijuana -oxycodone
-oxycodone
A patient diagnosed with COPD has a pulse oximetry of 93%, increased RBC and WBC count, temperature of 101 degrees, pulse 100, respirations 35, and a chest xray examination that showed a flattened diaphragm with infiltrates. Based on this data, which prescription does the nurse question for this patient? -antibiotic therapy -nonsteroidal anti-inflammatory agents -oxygen by nasal cannula at 3-4 L/min -bronchodilators such as an adrenergic stimulating drug or anticholinergic agents
-oxygen by nasal cannula at 3-4 L/min
The nurse is providing care for a patient admitted with smoke inhalation injury who is developing acute respiratory distress (ARDS). Which course of action regarding oxygen therapy should the nurse anticipate for this patient? -oxygen via a facial mask -oxygen via a venturi mask -oxygen via a nasal cannula -oxygen via mechanical ventilation
-oxygen via mechanical ventilation
A nurse is checking the arterial blood gas results of an older adult who has developed postsurgical respiratory alkalosis. Which ABG result confirms that the patient has developed respiratory alkalosis? -pH > 7.45, HCO3 > 28 mEq/L, and if compensated, then PCO2 > 45 mmHg -pH > 7.45, PaCO2 < 35 mmHg, and if compensated, then HCO3 < 22 mEq/L -pH < 7.35, HCO3 < 22 mEq/L, and if compensated, then PCO2 < 35 mmHg -pH < 7.35, PaCO2 > 45 mmHg, and if compensated, then HCO3 > 26 mEq/L
-pH > 7.45, PaCO2 < 35 mmHg, and if compensated, then HCO3 < 22 mEq/L
The nurse is caring for a client who experienced a flailed chest injury (multiple rib fractures) as a result of a motorcycle accident. The nurse realizes that pain management for this client will directly impact the effectiveness of his respiratory functioning primarily because: -pain increases metabolic needs, thus increasing oxygen consumption -pain increases emotional distress, which can lead to hyperventilation -pain will decrease the client's motivation to deep breathe, contributing to shallow diminished respirations -pain will decrease the client's ability to both relax and recuperate, thus extending the period of recovery
-pain will decrease the client's motivation to deep breathe, contributing to shallow diminished respirations
A patient with respiratory distress syndrome is being weaned from mechanical ventilation. Which nursing action is appropriate for this patient? -increase percentage of oxygen being provided through the ventilator -place in the fowler position -provide morning care during the weaning procedure -medicate with morphine for pain as needed
-place in the fowler position
A client with a chest tube in place is being transported via stretcher to another room closest to the nurse's station. During the transport the collection unit bangs against the wall and breaks open. The nurse immediately: -clamps the tube -tells the client to hyperventilate -raises the tuning above the client's chest level -places the end of the tube in a container of sterile water
-places the end of the tube in a container of sterile water
The nurse anticipates which of the following in the initial care of a patient with ARDS? -inotropic agents -fresh frozen plasma -anticoagulants -positive-pressure ventilation
-positive-pressure ventilation
A client in the ER has several broken ribs and reports severe pain. What care measure will best promote comfort? -prepare to assist with intercostal nerve block -humidify the supplemental oxygen -splint the chest with a large ACE wrap -provide warmed blankets and warmed IV fluids
-prepare to assist with intercostal nerve block
A patient has been brought to the ER by the paramedics. The patient is suspected of having ARDS. What intervention should the nurse first anticipate? -preparing to assist with intubating the patient -setting up oxygen at 5 L/min via nasal cannula -performing deep suctioning -setting up a nebulizer to administer corticosteroids
-preparing to assist with intubating the patient
this mode of ventilation gives a set positive pressure during spontaneous inspirations. the patient breathes spontaneously with their own volume, rate, and inspiratory time but has continuous positive pressure that is maintained during inspiration. this continuous positive pressure assists in reducing the workload of breathing and keeping the alveoli open. this mode helps the patient overcome the dead space of the ETT
-pressure support ventilation
A patient with exacerbation of COPD has a respiratory rate of 28. Which action should the nurse take? -increase the oxygen -provide comfortable positioning -provide a sedative -encourage slowing of the breathing
-provide comfortable positioning
The nurse is caring for a ventilated patient with respiratory failure who is restless and anxious. The nurse notes that the pulse oximetry saturation is decreasing as the patient becomes more agitated. What action should the nurse take? -increase the FiO2 on the ventilator -suction the lungs -provide sedation -reposition the patient onto their side
-provide sedation
A patient is admitted to the ER with dyspnea. Upon assessment, the nurse notes a bluish discoloration of the patient's lips, fine crackles on auscultation, and dullness upon percussion of the lung fields. Based on this data, which diagnosis does the nurse anticipate? -asthma -pleural effusion -pulmonary edema -pulmonary fibrosis
-pulmonary edema
The nurse is caring for a patient in the emergency department presenting with a sudden onset of shortness of breath. On 4 L NC the patient has an 89% pulse oximeter reading. It is determined that the patient has a ventilation-perfusion mismatch. What is the cause? -pulmonary edema -pulmonary embolism -pulmonary hypertension -pulmonary fibrosis
-pulmonary embolism
What is the predominant test for lower airway disorders? -arterial blood gases -chest xray -pulmonary function tests -oxygen saturation
-pulmonary function tests
The nurse is caring for a patient who is intubated and receiving positive pressure ventilation to treat acute respiratory distress syndrome. Which finding is most important to report to the health care provider? -red-brown drainage from nasogastric tube -BUN level of 32 mg/dL -scattered coarse crackles heard throughout lungs -arterial blood gasses: pH of 7.32, PaCO2 of 50, and PaO2 of 68
-red-brown drainage from nasogastric tube
Which clinical manifestation in the patient with chronic obstructive pulmonary disease (COPD) is more indicative of emphysema? -cyanosis -obese -reddish complexion -non-productive cough
-reddish complexion
The nurse is caring for a patient with acute respiratory distress syndrome whose condition is deteriorating. What ventilatory options may be considered to improve the refractory hypoxemia? SATA: -reduce the tidal volume -increase the PEEP -decrease the FiO2 -high frequency oscillating ventilation -partial liquid ventilation
-reduce the tidal volume -increase the PEEP -high frequency oscillating ventilation -partial liquid ventilation
A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for? -maintaining positive chest-wall pressure -monitoring pleural fluid osmolarity -providing positive intrathoracic pressure -removing excess air and fluid
-removing excess air and fluid
this PFT is the amount of air remaining in the lungs after maximum expiration, the amount of air that can never voluntarily be exhaled
-residual volume
A nurse checks the arterial blood gas results of an older adult and finds that the patient's pH is 7.34, PaCO2 is 46 mmHg, and if compensated, then the HCO3 is 27 mEq/L. What is the nurse's interpretation of the patient's condition by looking at these values? -metabolic alkalosis -respiratory alkalosis -metabolic acidosis -respiratory acidosis
-respiratory acidosis
The nurse is caring for a client with COPD. The nurse should monitor the client for which acid-base imbalance? -metabolic acidosis -metabolic alkalosis -respiratory acidosis -respiratory alkalosis
-respiratory acidosis
A nurse checks the arterial blood gas results of an older adult and finds that the client's pH is 7.46, PaCO2 is 34 mmHg, and if compensated, then the HCO3 is 21 mEq/L. What should be the nurse's interpretation of the patient's condition by looking at these values? -respiratory alkalosis -metabolic alkalosis -metabolic acidosis -respiratory acidosis
-respiratory alkalosis
A patient's ABG results reveal a pH of 7.47, PaCO2 of 31 mmHg, and an HCO3 of 24 mEq/L. Which acid base imbalance should be suspected? -respiratory acidosis -respiratory alkalosis -metabolic acidosis -metabolic alkalosis
-respiratory alkalosis
During the early stages of acute respiratory distress syndrome (ARDS), the nurse should monitor for which arterial blood gas change? -respiratory acidosis -respiratory alkalosis -metabolic acidosis -metabolic alkalosis
-respiratory alkalosis
A patient who is tachypneic for an extended period of time will demonstrate which of the following arterial blood gas results? -respiratory alkalosis with hypercapnia -respiratory acidosis with a rising pH -respiratory alkalosis with hypocapnia -no changes in the results due to metabolic compensation
-respiratory alkalosis with hypocapnia
Which of the following structures actively participates in gas exchange? -bronchi -visceral pleura -respiratory bronchioles -terminal bronchioles
-respiratory bronchioles
A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung. The nurse immediately assesses for other signs of which condition? -right pneumothorax -pulmonary embolism -displaced endotracheal tube -acute respiratory distress syndrome
-right pneumothorax
Which position should the nurse place a patient prior to performing in-line suctioning? -prone -supine -fowler's -semi-fowler's
-semi-fowler's
The nurse educator prepares to speak to a group of students about direct and indirect insults to the lungs that may lead to the development of acute respiratory distress syndrome. Which conditions will the nurse include in the teaching session? SATA: -septic shock -viral pneumonia -aspirin overdose -head injury -angioplasty
-septic shock -viral pneumonia -aspirin overdose -head injury
Which breath sound indicates airway obstruction due to laryngospasm or edema in a client who is weaning off of mechanical ventilation? -stridor -crackles -wheezes -rhonchi
-stridor
The nurse is providing care to a patient who is mechanically ventilated. The high-pressure alarm beeps and the nurse notes a mucous plug in the endotracheal tube. Which action by the nurse is appropriate? -suction as needed -insert an oral airway -assess for asymmetric chest rise -empty water from the ventilator tubing
-suction as needed
The mode of ventilation which allows the patient to breathe spontaneously at his or her own respiratory rate and depth between the ventilator breaths is: -controlled mandatory ventilation -synchronized intermittent mandatory ventilation -assist control mode -pressure control mode
-synchronized intermittent mandatory ventilation
The nurse is caring for a client who has been using mechanical ventilation for several months after an episode of sepsis and ARDS. Which ventilator setting should the nurse anticipate the health care provider to order for weaning? -PEEP -BIPAP -assist control mode ventilation -synchronized intermittent mandatory ventilation
-synchronized intermittent mandatory ventilation
this mode of ventilation is used for patient's who are being weaned from the vent. if the patient does not take a breath, the vent delivers a preset volume and rate per minute. this mode allows the patient to breathe spontaneously at his or her own volume and rate between breaths given by the vent. this mode synchronizes with the patient's respiratory effort
-synchronized intermittent mandatory ventilation
A nurse caring for a patient with a pulmonary embolism expects to fund which diagnostic result? -patchy infiltrates on chest x-ray -metabolic alkalosis on arterial blood gas -elevated CO2 level found on end-tidal carbon dioxide monitor -tachycardia and nonspecific T-wave changes on EKG
-tachycardia and nonspecific T-wave changes on EKG
The nurse is caring for a patient with septic shock and is aware of the need to assess for the development of acute respiratory distress syndrome. Which early clinical manifestation would indicate the development of ARDS? -intercostal retractions -cyanosis -tachypnea -tachycardia
-tachypnea
A patient is admitted to the ER with an open stab wound to the left chest. What action should the nurse take? -keep the head of the patient's bed positioned flat -cover the wound tightly with an occlusive dressing -position the patient so that the left chest is dependant -tape a nonporous dressing on three sides over the wound
-tape a nonporous dressing on three sides over the wound
A client is admitted with a pulmonary embolism. The client is young, healthy, and active and has no known risk factors for PE. Which action by the nurse is most appropriate? -encourage the client to walk 5 minutes each hour -refer the client to smoking cessation classes -teach the client about factor V Leiden testing -tell the client that sometimes no cause for disease is found
-teach the client about factor V Leiden testing
The nurse caring for a patient with a closed pneumothorax will monitor closely for which of these complications? -tension pneumothorax -flail chest -cardiac tamponade -pulmonary embolus
-tension pneumothorax
The nurse understands tracheal deviation in a newly admitted patient to the ER is typically caused by which of the following? -hemothorax -tension pneumothorax -flail chest -subcutaneous emphysema
-tension pneumothorax
The primary reason a client with chronic obstructive pulmonary disease often experiences fatigue and activity intolerance is related to: -the increased presence of surfactant that results in "sticky" alveoli -the presence of chronic infections in the lungs and bronchial tree -the extra energy that is needed to exhale the air from the damaged lungs -the client's elevated anxiety level related to the air hunger being experienced
-the extra energy that is needed to exhale the air from the damaged lungs
The nurse is providing care to a patient who has a tracheostomy. The loss of which protective mechanism does the nurse plan to monitor this patient for during the respiratory assessment? -the ability to cough -the filtration and humidification of inspired air -a decrease in the oxygen-carrying capacity of the trachea -the sneeze reflex initiated by irritants in the nasal passages
-the filtration and humidification of inspired air
You are caring for a patient who is currently receiving continuous pulse oximetry. Which of the following findings might indicate inaccurate readings? -the patient has a core body temperature of 94 -the heart rate obtained through pulse oximetry correlates with the electrocardiogram heart rate -the patient has the probe attached to her earlobe -the patient's pulse oximetry is 95% and the patient denies shortness of breath
-the patient has a core body temperature of 94
A nurse is caring for a patient with ARDS who is being treated with mechanical ventilation and high levels of positive end-expiratory pressure (PEEP). Which assessment finding by the nurse indicates that the PEEP may need to be reduced? -the patient's PaO2 is 50 mmHg and the SaO2 is 88% -the patient has subcutaneous emphysema on the upper thorax -the patient has bronchial breath sounds in both lung fields -the patient has a first degree AV heart block with a rate of 58 beats per minute
-the patient has subcutaneous emphysema on the upper thorax
The high pressure alarm is sounding in the patient's room. Which of the following is most likely the cause? -the ventilator tubing has become disconnected -the patient is trying to talk to his friend -there is a leak in the cuff -the patient is complaining of 9/10 pain
-the patient is trying to talk to his friend
When admitting a patient with possible respiratory failure and a high PaCO2, which assessment finding should be immediately reported to the health care provider? -the patient is very somnolent -the patient complains of weakness -the patient's blood pressure is 164/98 -the patient's oxygen saturation is 90%
-the patient is very somnolent
Synchronized intermittent mechanical ventilation is best for which patient? -the patient with sleep apnea -the patient trying to wean from mechanical ventilation -the patient who is receiving neuromuscular blocking agents -the patient who has respiratory drive but cannot sustain normal tidal volume
-the patient trying to wean from mechanical ventilation
Assist control ventilation is best for which patient? -the patient with sleep apnea -the patient trying to wean from mechanical ventilation -the patient who is receiving neuromuscular blocking agents -the patient who has respiratory drive but cannot sustain normal tidal volume
-the patient who has respiratory drive but cannot sustain normal tidal volume
The nurse is providing care to several patients on a medical-surgical unit. Which patient is at highest risk for a nonthrombotic pulmonary embolism? -the patient who is receiving intravenous pain medication -the patient who is postoperative from a femur fracture repair -the patient with a primary lung tumor -the patient who uses intravenous illicit drugs
-the patient who is postoperative from a femur fracture repair
The nurse is caring for a patient who arrived in the ER with acute respiratory distress. Which assessment finding by the nurse requires the most rapid action? -the patient's PaO2 is 45 mmHg -the patient's PaCO2 is 33 mmHg -the patient's respirations are shallow -the patient's respiratory rate is 32
-the patient's PaO2 is 45 mmHg
When prone positioning is used for a patient with ARDS, which information obtained by the nurse indicates that the positioning is effective? -the patient's PaO2 is 89 mmHg and the SaO2 is 91% -endotracheal suctioning results in clear mucous return -sputum and blood cultures show no growth after 48 hours -the skin on the patient's back is intact and without redness
-the patient's PaO2 is 89 mmHg and the SaO2 is 91%
You are providing care to a patient who is being treated for aspiration pneumonia. The patient is on a 100% nonrebreather mask. Which finding is a hallmark sign and symptom that the patient is developing acute respiratory distress syndrome? -the patient is experiencing bradypnea -the patient is tired and confused -the patient's PaO2 remains at 45 mmHg -the patient's blood pressure is 180/96
-the patient's PaO2 remains at 45 mmHg
Which assessment finding of a patient receiving mechanical ventilation indicates the need for suctioning? -the respiratory rate is 32 -the pulse oximeter shows a SpO2 of 93% -the patient has not been suctioned for the last 6 hours -the lungs have occasional audible expiratory wheezes
-the respiratory rate is 32
The nurse observes constant bubbling in the water-seal chamber of the patient's closed chest drainage system. What is happening? -the system is functioning normally -the patient has a pneumothorax -the system has an air leak -the chest tube is obstructed
-the system has an air leak
A nurse is caring for a client on mechanical ventilation. When double-checking the ventilator settings with the respiratory therapist, what would the nurse ensure? -the client is able to initiate spontaneous breaths -the inspired oxygen has adequate humidification -the upper peak airway pressure limit alarm is off -the upper peak airway pressure limit alarm is on
-the upper peak airway pressure limit alarm is on
A nurse cares for a client with a right pleural effusion. Which item does the nurse have available for immediate use by the health care provider? -arterial blood gas kit -central line catheter tray -respiratory intubation kit -thoracentesis tray
-thoracentesis tray
this PFT is the amount of air inhaled in one cycle during quiet breathing
-tidal volume
Which of the following is not a function of the respiratory system? -acid-base balance -facilitating speech -fluid balance -tissue perfusion
-tissue perfusion
Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema? -to promote oxygen intake -to strengthen the diaphragm -to strengthen the intercostal muscles -to promote carbon dioxide elimination
-to promote carbon dioxide elimination
this PFT is the maximum amount of air the lungs can contain
-total lung capacity
Which would the nurse assess when using palpation during the respiratory assessment? -tracheal position -bronchovesicular sounds -lung density -adventitious breath sounds
-tracheal postion
The nurse is caring for a mechanically ventilated patient with a cuffed tracheostomy tube. Which action by the nurse would best determine if the cuff has been properly inflated? -use a manometer to ensure cuff pressure is at an appropriate level -check the amount of cuff pressure ordered by the health care provider -suction the patient first with a fenestrated inner cannula to clear secretions -insert the decannulation plug before the nonfenestrated inner cannula is removed
-use a manometer to ensure cuff pressure is at an appropriate level
The low-pressure alarm sounds on a ventilator. The nurse assesses the client and then attempts to determine the cause of the alarm. If unsuccessful in determining the cause, the nurse should take which initial action? -administer oxygen -check the client's vital signs -ventilate the client manually -start CPR
-ventilate the client manually
A patient with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the physician to order? -non-rebreather air mask -tracheostomy collar -venturi mask -face tent
-venturi mask
The nurse is caring for a patient with a chest tube placed for a spontaneous pneumothorax. Which assessment finding is anticipated? -bloody return in the collection chamber -continuous bubbling in the water seal -water level fluctuation in the water seal chamber with respiratory effort -subcutaneous emphysema
-water level fluctuation in the water seal chamber with respiratory effort
A client suspected of having ARDS has been scheduled for a chest x-ray. What finding on the chest x-ray is indicative of ARDS? -infiltrates only on the upper lobes -enlargement of the heart with bilateral lower lobe infiltrates -white out infiltrates bilaterally -normal chest xray
-white out infiltrates bilaterally
