EAQ N4510 Respiratory Summer 2020
A nurse is caring for several clients in the intensive care unit. Which is the greatest risk factor for a client to develop acute respiratory distress syndrome (ARDS)? A.)Aspirating gastric contents B.)Getting an opioid overdose C.)Experiencing an anaphylactic reaction D.)Receiving multiple blood transfusions
A Aspirating gastric contents is a common cause of ARDS. Gastric enzymes injure alveolar-capillary membranes, which release inflammatory mediators; the process progresses to pulmonary edema, vascular narrowing and obstruction, pulmonary hypertension, and impaired gas exchange. Getting an opioid overdose is not as common a cause of ARDS as is aspiration pneumonia; this more likely will cause depressed respirations. Although anaphylaxis may cause ARDS, it is not a common cause. Although multiple blood transfusions have been known to precipitate ARDS, they are not a common cause.
A client with late-stage dementia of the Alzheimer type aspirates gastric contents and develops acute respiratory distress syndrome (ARDS). Which phase characterized by signs of pulmonary edema and atelectasis should the nurse consider when planning care? A.)Fibrotic B.)Exudative C.)Reparative D.)Proliferative
B Exudative (injury) phase of ARDS is the early phase. Alveoli become fluid-filled with pulmonary shunting and atelectasis. Fibrotic phase of ARDS leads to pulmonary hypertension and fibrosis. Reparative (resolution) phase starts about two weeks after injury; it is characterized by recovery. If this phase persists for a prolonged time, extensive fibrosis, death, or chronic disease may result.
What finding would be consistent with long-standing hypoxemia in a client who reports shortness of breath? A.) Scoliosis B.)Kyphosis C.)Clubbing D.)Kyphoscoliosis
C Clubbing, a sign of long-standing hypoxemia, involves an increase in the angle between the base of the nail and the fingernail to 180 degrees or more. It is usually accompanied by an increase in the depth, bulk, and sponginess of the end of the finger. Scoliosis, kyphosis, and kyphoscoliosis are the spinal curvatures that affect breathing.
The arterial blood gases of a client with chronic obstructive pulmonary disease (COPD) deteriorate, and respiratory failure is impending. Which clinical indicator should the nurse assess first? A.)Cyanosis B.)Bradycardia C.)Mental confusion D.)Distended neck veins
C Decreased oxygen to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase oxygen to body cells. Distended neck veins occur with fluid volume excess (e.g., pulmonary edema).
The nurse is caring for different clients in a healthcare setting who are diagnosed with respiratory disorders. Which client may have the anteroposterior chest diameter equal to the lateral chest and the slope of the ribs more horizontal to the spine? A.)Client 1 B.)Client 2 C.)Client 3 D.)Client 4
A Client 1 with cystic fibrosis may have increased anteroposterior diameter; that is, the anteroposterior chest diameter is equal to the lateral chest measurement and the slope of the ribs are more horizontal to the spine. Client 2 with bronchiectasis may have finger clubbing with increased depth, bulk, and sponginess of the distal portion of the finger. Client 3 with metabolic acidosis may have Kussmaul respirations that are regular, rapid, and deep. Client 4 with pulmonary edema may sit in a tripod position, which involves leaning forward with arms and elbows supported on an overbed table.
What clinical indicators should a nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply. A.)Crackles B.)Atelectasis C.)Hypoxemia D.)Severe dyspnea E.)Increased pulmonary wedge pressure
A,B,C,D Crackles occur as fluid leaks into the alveolar interstitial space. The alveoli collapse from surfactant dysfunction and infiltrate from inflammation. Arterial hypoxemia that does not respond to supplemental oxygen is a characteristic sign of ARDS. Severe dyspnea can occur 12 to 48 hours after the initial onset of ARDS, which usually is an inflammatory trigger. Pulmonary wedge pressure is unaffected in ARDS; pulmonary wedge pressure is elevated in problems with cardiogenic origin.
The registered nurse is teaching a group of nursing students about the characteristics of the five percussion notes. Which statements made by a student nurse indicate effective learning? Select all that apply. A.)"Resonance indicates the presence of trapped air." B.)"Dullness can be percussed over a consolidated lung." C.)"Hyperresonance is characteristic of normal lung tissue." D.)"Tympanic notes over the lung usually indicate a large pneumothorax." E.)"Flatness percussed over the lung fields indicates massive pleural effusion."
B,D,E Dullness can be percussed over an atelectatic lung or a consolidated lung. Tympanic notes over the lung usually indicate a large pneumothorax. Flatness percussed over the lung fields indicates massive pleural effusion. These statements made by the student nurse indicate effective learning. Resonance is characteristic of normal lung tissue. Hyperresonance indicates the presence of trapped air.
The nurse is collecting the health history of a client suspected to have a pulmonary disorder. Which questions should the nurse ask the client related to health perception and health management? Select all that apply. A.)"Do you experience a morning headache?" B.)"Have you ever smoked elicit street drugs?" C.)"What do you do when you get short of breath?" D.)"Are you able to maintain a typical activity pattern?" E.)"What equipment helps you manage your respiratory problems?"
B,E The nurse asks the client questions related to health perception and health management to determine if there is a perceived change in the client's health status within the last several days, months, or years. The questions that fall under this category include smoking of elicit street drugs and using any equipment to manage respiratory problems. To determine the sleep-rest pattern, the nurse asks the client about the occurrence of a morning headache. To determine the activity-exercise pattern, the nurse asks the client about the techniques used if shortness of breath occurs and about the maintenance of a typical activity pattern.
A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. Which clinical finding should the nurse expect when assessing this client? A.)Hypertension B.)Tenacious sputum C.)Altered mental status D.)Slowed rate of breathing
C Altered mental status is secondary to cerebral hypoxia, which accompanies acute respiratory distress syndrome (ARDS); cognition and level of consciousness are reduced. Hypotension occurs because of cardiac hypoxia. The sputum is not tenacious, but it may be frothy if pulmonary edema is present. Breathing is fast and shallow.
A client is admitted to the intensive care unit with a diagnosis of acute respiratory distress syndrome. When assessing the client, what does the nurse expect to identify? A.)Hypertension B.)Tenacious sputum C.)Altered mental status D.)Slow rate of breathing
C Altered mental status is secondary to cerebral hypoxia, which accompanies acute respiratory distress syndrome (ARDS); cognition and level of consciousness are reduced. Hypotension occurs because of hypoxia. The sputum is not tenacious, but it may be frothy if pulmonary edema is present. Breathing will be fast and shallow.
The nurse finds that a client becomes dyspneic during activities of daily living, such as showering and dressing. The client can walk for more than a city block but at his or her own pace and cannot keep up with others. Which class of dyspnea describes this client? A.) Class I B.) Class II C)Class III D.)Class IV
C Dyspnea during activities such as showering and dressing and the ability to walk for more than a city block, but only at their own pace without being able to keep up with others, indicates class III dyspnea. The client belonging to class I shows dyspnea on more-than-normal or strenuous exertion. The client belonging to class II shows dyspnea on climbing stairs or on walking on an incline but not during level walking. The client belonging to class IV dyspnea requires assistance in some essential activities of daily living such as dressing and bathing due to dyspnea. This client is not usually dyspneic at rest.
A client who is admitted with emphysema shows progressive respiratory failure and has a Paco2 of 60. To address the problems, the nurse expects to receive a prescription for: A.)Mucolytics B.)Bronchodilators C.)Mechanical ventilation D.)Intermittent positive-pressure breathing (IPPB)
C Mechanical ventilation indicates progressive respiratory failure; ventilatory support is needed when the Paco2 is more than 50. Mucolytics will liquefy secretions, but will not correct the respiratory failure. Bronchodilators may dilate bronchi, but will not improve respiratory exchange to decrease CO2. IPPB will not correct respiratory failure.
A client admitted in the emergency department has airway obstruction, chest wall trauma, external hemorrhage, and hypoglycemia. Which condition of the client will be given the highest priority? A.)Hypoglycemia B.)Chest wall trauma C.)Airway obstruction D.)External hemorrhage
C The highest priority intervention is to establish a patent airway because inadequate oxygen supply to the brain may cause brain death. Assessing the metabolic conditions is done after the airway is cleared. Once the airway is cleared, then the chest wall of the client is assessed. Hemorrhage is assessed after the airway of the client is cleared.
Which assessment finding is considered the earliest sign of decreased tissue oxygenation? A.)Cyanosis B.)Cool, clammy skin C.)Unexplained restlessness D.)Retraction of interspaces on inspiration
C Unexplained restlessness is considered the earliest sign of decreased oxygenation. The other assessment findings, such as cyanosis, cool, clammy skin, and retraction of interspaces on inspiration, are considered late signs of decreased oxygenation.
The nurse instructed a client with asthma about the use of a peak flow meter at home. The client assesses the peak expiratory flow by using the peak flow meter. Which action performed by the client would be appropriate when the reading is in the yellow zone? A.)Perform the peak expiratory flow again immediately B.)Increase the prescribed drug therapy C.)Use a prescribed reliever drug therapy D.)Reassess the asthma plan and change the controller medication
C Yellow is a range between 50% and 80% of personal best. When the reading is in this range, the client is recommended to use the prescribed reliever drug. After a few minutes of the intake of a prescribed reliever drug, the peak expiratory flow should be determined again to know the effect of the reliever medication. Prescribed drug therapy should not be increased without consulting the primary healthcare advisor. Reassessing the asthma plan and changing the controller medication would be required when there are frequents reading in the yellow zone.
The nurse hears a series of long, discontinuous low-pitched sounds similar to blowing through a straw under water while auscultating the lungs of a client with chronic obstructive pulmonary disease. What should the nurse document in the client's assessment record based on this finding? A.)Rhonchi B.)Wheezes C.)Fine crackles D.)Coarse crackles
D A series of long, discontinuous low-pitched sounds similar to blowing through straw under water indicates coarse crackles. Rhonchi are continuous rumbling, snoring, or rattling sounds that occur as a result of an obstruction of the large airways. Wheezes are continuous high-pitched squeaking or musical sounds that indicate airway obstruction. Fine crackles are short, discontinuous, high-pitched sounds like hair being rolled between fingers just behind the ear, heard just before the end of inspiration.
What does the nurse state is the cause of frequent upper respiratory tract infections in toddlers? A.)Stress B.)Unhealthy diet C.)Lack of exercise D.)Immature immune system
D Infants and toddlers are at risk for upper respiratory tract infections as a result of frequent exposure to other children, an immature immune system, and exposure to second-hand smoke. Stress, unhealthy diet, and lack of exercise predispose young and middle-age adults to multiple cardiopulmonary risk factors.
In addition to treatment of the underlying cause, which medical intervention should the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? A.)Chest tube insertion B.)Aggressive diuretic therapy C.)Administration of beta-blockers D.)Positive end-expiratory pressure (PEEP)
D Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation. Fluid is not in the pleural space, so chest tube insertion is not indicated. Aggressive diuretic therapy and administration of beta-blockers are contraindicated because of severe hypotension from the fluid shift into the interstitial spaces in the lungs.
When caring for a client who has acute respiratory distress syndrome (ARDS), the nurse would implement which measure to promote effective airway clearance? A.)Administer sedatives around the clock B.)Turn client every four hours C.)Increase ventilator settings as needed D.)Suction as needed
D The nurse should observe the client's need for tracheal/oral/nasal suctioning every two hours and provide adequate suctioning as needed. The nurse should not administer sedatives around the clock, but administer sedatives as appropriate. The nurse should turn the client every two hours, not four hours. The nurse should not adjust vent settings as needed; however, the nurse should check ventilation settings at least once a shift.
A client with a history of emphysema is admitted with a diagnosis of acute respiratory failure with respiratory acidosis. Oxygen is being administered at 3 L/min nasal cannula. Four hours after admission, the client has increased restlessness and confusion followed by a decreased respiratory rate and lethargy. What should the nurse do? A.)Question the client about the confusion. B.)Change the method of oxygen delivery. C.)Percuss and vibrate the client's chest wall. D.)Discontinue or decrease the oxygen flow rate.
D With emphysema, it is believed that the respiratory center no longer responds to elevated carbon dioxide as the stimulus to breathe [1] [2] but rather to lowered oxygen levels; therefore, the oxygen being delivered must be lowered to supply enough for oxygenation without being so elevated that it negates the stimulus to breathe. However, the results of one recent study of clients with stable chronic obstructive pulmonary disease (COPD) indicate that the hypercarbic drive is preserved. More research is needed before this theory is applied clinically. A confused client cannot answer questions about the confusion. There are no indications that respiratory secretions have increased.
