Immersion first test

When developing a discharge plan to manage the care of a client with chronic obstructive pulmonary disease (COPD), the nurse should advise the the client to expect to: ■ 1. Develop respiratory infections easily. ■ 2. Maintain current status. ■ 3. Require less supplemental oxygen. ■ 4. Show permanent improvement.

1 A client with COPD is at high risk for development of respiratory infections. COPD is slowly progressive; therefore, maintaining current status and establishing a goal that the client will require less supplemental oxygen are unrealistic expectations. Treatment may slow progression of the disease, but permanent improvement is highly unlikely.

Which of the following is a priority goal for the client with chronic obstructive pulmonary disease (COPD)? ■ 1. Maintaining functional ability. ■ 2. Minimizing chest pain. ■ 3. Increasing carbon dioxide levels in the blood. ■ 4. Treating infectious agents.

1 A priority goal for the client with COPD is to manage the signs and symptoms of the disease process so as to maintain the client's functional ability. Chest pain is not a typical symptom of COPD. The carbon dioxide concentration in the blood is increased to an abnormal level in clients with COPD; it would not be a goal to increase the level further. Preventing infection would be a goal of care for the client with COPD.

The nurse caring for a client with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate? 1. Do nothing, because this is an expected finding. 2. Check for an air leak because the bubbling should be intermittent. 3. Increase the suction pressure so that the bubbling becomes vigorous. 4. Immediately clamp the chest tube and notify the health care provider.

1 Continuous gentle bubbling should be noted in the suction control chamber. Bubbling should be continuous in the suction control chamber and not intermittent. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system; in addition, increasing the suction can be harmful and is not done without a specific prescription to do so. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy).

A nurse is preparing to administer oxygen to a client who has chronic obstructive pulmonary disease (COPD) and is at risk for carbon dioxide narcosis. The nurse checks to see that the oxygen flow rate is prescribed at: 1 2 to 3 liters per minute 2 4 to 5 liters per minute 3 6 to 8 liters per minute 4 8 to 10 liters per minute

1 In carbon dioxide narcosis, the central chemoreceptors lose their sensitivity to increased levels of carbon dioxide and no longer respond by increasing the rate and depth of respiration. For these clients, the stimulus to breathe is a decreased arterial oxygen concentration. In the client with COPD, a low arterial oxygen level is the client's primary drive for breathing. If high levels of oxygen are administered, the client loses the respiratory drive, and respiratory failure results. Thus the nurse checks the flow of oxygen to see that it does not exceed 2 to 3 liters per minute.

hich intervention should a nurse plan to incorporate in the care of a surgical client to decrease the risk of deep venous thrombosis (DVT) and pulmonary embolism (PE)? 1. Use of intermittent compression devices on the lower extremities 2. Administration of heparin intravenously 3. Coughing and deep breathing exercises 4. Isometric leg exercises

1 Recommendations to prevent DVT and PE address the need to improve circulation and counter any states of hypercoagulopathy. Intermittent compression devices improve circulation. While administration of heparin will achieve anticoagulation, a low dose of unfractionated or low-molecular-weight heparin is usually ordered subcutaneous, and not intravenous, administration. Coughing and deep breathing exercises and isometric leg exercises are positive actions but do not decrease the risk for DVT and PE.

Which of the following physical assessment fi ndings are normal for a client with advanced chronic obstructive pulmonary disease (COPD)? ■ 1. Increased anteroposterior chest diameter. ■ 2. Underdeveloped neck muscles. ■ 3. Collapsed neck veins. ■ 4. Increased chest excursions with respiration

1 Increased anteroposterior chest diameter is characteristic of advanced COPD. Air is trapped in the overextended alveoli, and the ribs are fi xed in an inspiratory position. The result is the typical barrel-chested appearance. Overly developed, not underdeveloped, neck muscles are associated with COPD because of their increased use in the work of breathing. Distended, not collapsed, neck veins are associated with COPD as a symptom of the heart failure that the client may experience secondary to the increased workload on the heart to pump blood into the pulmonary vasculature. Diminished, not increased, chest excursion is associated with COPD

Which of the following interventions should the nurse implement for pulmonary emboli prophylaxis? ■ 1. Have the client perform leg exercises every hour while awake. ■ 2. Encourage the client to cough and deepbreathe. ■ 3. Massage the calves of the client's legs. ■ 4. Have the client wear antiembolism stockings when out of bed.

1 Performing leg exercises, including ankle pumping, ankle rotation, and quadriceps setting exercises, will help prevent stasis of blood in the lower extremities, which can lead to blood clot formation. Encouraging the client to cough and deep-breathe is an important postoperative intervention; however, it is directed at preventing pneumonia, not pulmonary emboli. The nurse should not massage the calves because a deep vein thrombus could dislodge and travel to the pulmonary vasculature. Antiembolism stockings should be worn continuously during the postoperative period.

A client with pleural effusion had a thoracentesis, and a sample of fluid was sent to the laboratory. Analysis of the fluid reveals a high red blood cell count. The nurse interprets that this result is most consistent with: 1 Trauma 2 Infection 3 Liver failure 4 Heart failure

1 Pleural fluid from an effusion that has a high red blood cell count may result from trauma and may be treated with placement of a chest tube for drainage. Other causes of pleural effusion include infection, heart failure, liver or renal failure, malignancy, or inflammatory processes. Infection would be accompanied by white blood cells. The fluid portion of the serum would accumulate with liver failure and heart failure.

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 highpressure 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? 1. Right pneumothorax 2. Pulmonary embolism 3. Displaced endotracheal tube 4. Acute respiratory distress syndrome

1 Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi.

A nurse is preparing to implement emergency care measures for the client who has just experienced pulmonary embolism. The nurse implements which of the following physician prescriptions first? 1 Apply oxygen. 2 Administer morphine sulfate. 3 Start an intravenous (IV) line. 4 Obtain an electrocardiogram (ECG).

1 The client needs oxygen immediately because of hypoxemia, which is most often accompanied by respiratory distress and cyanosis. The client should also have an IV line for the administration of emergency medications such as morphine sulfate. An ECG is useful in determining the presence of possible right ventricular hypertrophy. All of the interventions listed are appropriate, but the client needs the oxygen first.

A client with a history of diabetes mellitus and chronic obstructive pulmonary disease should have which of the following immunizations? ■ 1. Infl uenza. ■ 2. Hepatitis A. ■ 3. Measles-mumps-rubella. ■ 4. Varicella.

1 The client with diabetes and a chronic respiratory condition is most at risk for infl uenza and should receive the vaccine yearly. Diabetes and chronic respiratory conditions do not increase the risk of hepatitis A. An adult client is not as likely to need the measles-mumps-rubella or varicella immunizations, but titers can be checked if the client has not had childhood immunizations or the disease

The nurse is planning to teach a client with chronic obstructive pulmonary disease how to cough effectively. Which of the following instructions should be included? ■ 1. Take a deep abdominal breath, bend forward, and cough three or four times on exhalation. ■ 2. Lie fl at on the back, splint the thorax, take two deep breaths, and cough. ■ 3. Take several rapid, shallow breaths and then cough forcefully. ■ 4. Assume a side-lying position, extend the arm over the head, and alternate deep breathing with coughing.

1 The goal of effective coughing is to conserve energy, facilitate removal of secretions, and minimize airway collapse. The client should assume a sitting position with feet on the fl oor if possible. The client should bend forward slightly and, using pursed-lip breathing, exhale. After resuming an upright position, the client should use abdominal breathing to slowly and deeply inhale. After repeating this process three or four times, the client should take a deep abdominal breath, bend forward, and cough three or four times upon exhalation ("huff" cough). Lying fl at does not enhance lung expansion; sitting upright promotes full expansion of the thorax. Shallow breathing does not facilitate removal of secretions, and forceful coughing promotes collapse of airways. A side-lying position does not allow for adequate chest expansion to promote deep breathing.

During the physical assessment of a client diagnosed with a right tension pneumothorax, a nurse would expect to find: Select all that apply. 1. Tracheal shift to the left. 2. Tracheal shift to the right. 3. Decreased breath sounds on the right side. 4. Subcutaneous emphysema on the left chest. 5. Increased breath sounds on the left side. 6. Point of Maximum Impulse (PMI) shifted further to the left of midline.

1, 3, 6. Answer 1 is correct because, during a tension pneumothorax, thoracic structures are pushed toward the opposite side. Answer 2 is incorrect because thoracic structures are pushed toward the opposite side of the problem. Since Answer 1 is correct, this answer is wrong. Answer 3 is correct because pneumothorax causes partial or total collapse of the lung; therefore, breath sounds would be diminished or absent. Answer 4 is incorrect because, if present, the subcutaneous emphysema would be in the affected side (i.e., right side). Answer 5 is incorrect because the pressure on the nonaffected side might result in a decrease, or no change, in breath sounds. Answer 6 is correct because thoracic structures, including the heart, would shift to the left.

The nurse is performing a respiratory assessment on a client who has a pleural effusion. The nurse should determine if the client has: ■ 1. Decreased chest movement on the affected side. ■ 2. Normal bronchial breath sounds. ■ 3. Hyperresonance on percussion. ■ 4. Fever.

1. A pleural effusion is a collection of fl uid between the pleural layers of the lung. The effusion decreases chest wall movement on the affected side. The nurse should expect the breath sounds to be decreased or diminished over the affected area. Because of the presence of fl uid, percussion would elicit dullness, not hyperresonance. Fever may be present if empyema (purulent pleural fl uid with bacterial infection) has developed, but not in the case of a nonpurulent pleural effusion.

For a client with rib fractures and a pneumothorax, the physician prescribes morphine sulfate, 1 to 2 mg/hour, given I.V. as needed for pain. The nursing care goal is to provide adequate pain control so that the client can breathe effectively. Which of the following outcomes would indicate successful achievement of this goal? ■ 1. Pain rating of 0 on a scale of 0 to 10 by the client. ■ 2. Decreased client anxiety. ■ 3. Respiratory rate of 26 breaths/minute. ■ 4. PaO2 of 70 mm Hg.

1. If the client reports no pain, then the objective of adequate pain relief has been met. Decreased anxiety is not related only to pain control; it could also be related to other factors. A respiratory rate of 26 breaths/minute is not within normal limits. A PaO2of 70 mm Hg is not within normal limits.

A client has been in an automobile accident and the nurse is assessing the client for possible pneumothorax. The nurse should assess the client for: ■ 1. Sudden, sharp chest pain. ■ 2. Wheezing breath sounds over affected side. ■ 3. Hemoptysis. ■ 4. Cyanosis.

1. Pneumothorax signs and symptoms include sudden, sharp chest pain; tachypnea; and tachycardia. Other signs and symptoms include diminished or absent breath sounds over the affected lung, anxiety, and restlessness. Breath sounds are diminished or absent over the affected side. Hemoptysis and cyanosis are not typically present with a moderate pneumothorax.

The nurse is teaching a client who has deep vein thrombosis from limited mobility that caused a pulmonary embolus, which has resolved. Which of the following instructions should nurse give to this client? ■ 1. "Report such signs as leg swelling, discomfort, redness, or warmth." ■ 2. "Sit with your legs lower than the rest of your body." ■ 3. "Walk at least every other day." ■ 4. "Limit your fl uids to 1 liter each day."

1. Prevention of another pulmonary embolus is important; the nurse should teach the client to observe for signs of clot formation to prevent a potentially fatal episode and maintain cardiopulmonary integrity and adequate ventilation and perfusion. Elevation of the lower extremities, not lowering them, promotes venous return to the heart. Ambulation must be done several times each day. Limiting fl uid intake increases blood viscosity, promoting clot formation.

A client experienced a pneumothorax after the placement of a central venous pressure line. Which of the following assessments supports a medical diagnosis of pneumothorax? ■ 1. Sudden, sharp pain on the affected side. ■ 2. Tracheal deviation toward the affected side. ■ 3. Bradypnea and elevated blood pressure. ■ 4. Presence of crackles and wheezes.

1. Signs and symptoms of a pneumothorax include sudden, sharp pain with breathing or coughing on the affected side, tachypnea, dyspnea, diminished or absent breath sounds on the affected side, tachycardia, anxiety, and restlessness. Tracheal deviation away from the affected side indicates a tension pneumothorax, which is a medical emergency.

A client is admitted to the hospital with a diagnosis of suspected pulmonary embolism. Physician orders include the following: oxygen 2 to 4 L/minute per nasal cannula, oximetry at all times, and I.V. administration of 5% dextrose in water at 100 mL/hour. The client has increasing dyspnea and has a respiratory rate of 32 breaths/minute. The nurse should: ■ 1. Increase the oxygen fl ow rate from 2 to 4 L/minute. ■ 2. Call the physician immediately. ■ 3. Provide reassurance to the client. ■ 4. Obtain a sample for arterial blood gas analysis

1. The fi rst action is to increase the oxygen fl ow rate from 2 to 4 L/minute to help ensure adequate oxygenation for the client. Although it is important to notify the physician for additional orders and to obtain further assessment data, such as arterial blood gas measurements, it is a priority to support the client's cardiopulmonary system. It would be appropriate to reassure the client while these other interventions are occurring.

The nurse is planning care for a client with a chest tube attached to a chest drainage system. The nurse plans which action(s) as part of routine chest tube care? Select all that apply. r 1 Encouraging the client to cough and deep breathe r 2 Adding water to the suction chamber as it evaporates r 3 Keeping the collection chamber below the client's waist r 4 Clamping the chest tube when the client gets out of bed r 5 Taping the connection between the chest tube and the drainage system

1235 To avoid causing tension pneumothorax, the nurse avoids clamping the chest tube for any reason unless specifically prescribed. In most instances, clamping of the chest tube is contraindicated by agency policy. The client is encouraged to cough and deep breathe to assist in lung expansion. Water is added to the suction control chamber as needed to maintain the full suction level prescribed. The nurse keeps the drainage collection system below the level of the client's waist to prevent fluid or air from reentering the pleural space. Connections between the chest tube and system are taped to prevent accidental disconnection.

A client without history of respiratory disease has experienced sudden onset of chest pain and dyspnea and is diagnosed with pulmonary embolus. The nurse immediately implements which expected prescription for this client? 1 Semi-Fowler's position, oxygen, and morphine sulfate intravenously (IV) 2 Supine position, oxygen, andmeperidine hydrochloride (Demerol) intramuscularly (IM) 3 High Fowler's position, oxygen, and meperidine hydrochloride (Demerol) intravenously (IV) 4 High Fowler's position, oxygen, and two tablets of acetaminophen with codeine (Tylenol #3)

1Standard therapeutic intervention for the client with pulmonary embolus includes proper positioning, oxygen, and intravenous analgesics. The head of the bed is placed in semi-Fowler's position. High Fowler's is avoided because extreme hip flexure slows venous return from the legs and increases the risk of new thrombi. The supine position will increase the dyspnea that occurs with pulmonary embolism. The usual analgesic of choice is morphine sulfate administered IV. This medication reduces pain, alleviates anxiety, and can diminish congestion of blood in the pulmonary vessels because it causes peripheral venous dilation.

A client with chronic obstructive pulmonary disease is bedridden at home and gets little exercise. The nurse should assess the client for which of the following? ■ 1. Increased sodium retention. ■ 2. Increased calcium excretion. ■ 3. Increased insulin use. ■ 4. Increased red blood cell production.

2 2. Prolonged inactivity causes the body to excrete excessive calcium. This leads to breakdown of bone tissue; as a result, the bones become brittle and fracture easily, a condition known as osteoporosis. The excessive calcium excretion that occurs during bed rest also predisposes the client to formation of renal calculi. Prolonged bed rest does not increase sodium retention, insulin use, or red blood cell production.

A client is receive enoxaparin (Lovenox) 6 hours before the scheduled time of her laparoscopic vaginal assisted hysterectomy. Which of the following effects does the nurse recognize as an intended therapeutic action of the enoxaparin? ■ 1. Increase in red blood cell production. ■ 2. Reduction of postoperative thrombi. ■ 3. Decrease in postoperative bleeding. ■ 4. Promotion of tissue healing.

2 2. Research fi ndings have shown that enoxaparin and low-dose heparin given 6 to 12 hours preoperatively reduce the incidence of deep vein thrombosis and pulmonary emboli by 60% in clients who are at risk for deep vein thrombosis, such as those who are placed in the lithotomy position. Lovenox has no effect on red blood cell production, postoperative bleeding, or tissue healing. CN: Pharmacological and parenteral

When performing postural drainage, which of the following factors promotes the movement of secretions from the lower to the upper respiratory tract? ■ 1. Friction between the cilia. ■ 2. Force of gravity. ■ 3. Sweeping motion of cilia. ■ 4. Involuntary muscle contractions

2 The principle behind using postural drainage is that gravity will help move secretions from smaller to larger airways. Postural drainage is best used after percussion has loosened secretions. Coughing or suctioning is then used to remove secretions. Movement of cilia is not suffi cient to move secretions. Muscle contractions do not move secretions within the lungs.

A client who experiences repeated pleural effusions from inoperable lung cancer is to undergo pleurodesis. The nurse plans to assist with which of the following after the physician injects the sclerosing agent through the chest tube? 1 Ambulate the client. 2 Clamp the chest tube. 3 Ask the client to cough and deep breathe. 4 Ask the client to remain in one position only.

2 After injection of the sclerosing agent, the chest tube is clamped to prevent the agent from draining back out of the pleural space. Depending on physician preference, a repositioning schedule is used to disperse the substance. Ambulation, coughing, and deep breathing have no specific purpose in the immediate period after injection.

A client with chronic obstructive pulmonary disease (COPD) is experiencing dyspnea and has a low PaO2 level. The nurse plans to administer oxygen as ordered. Which of the following statements is true concerning oxygen administration to a client with COPD? ■ 1. High oxygen concentrations will cause coughing and dyspnea. ■ 2. High oxygen concentrations may inhibit the hypoxic stimulus to breathe. ■ 3. Increased oxygen use will cause the client to become dependent on the oxygen. ■ 4. Administration of oxygen is contraindicated in clients who are using bronchodilators

2 Clients who have a long history of COPD may retain carbon dioxide (CO2). Gradually the body adjusts to the higher CO2 concentration, and the high levels of CO2 no longer stimulate the respiratory center. The major respiratory stimulant then becomes hypoxemia. Administration of high concentrations of oxygen eliminates this respiratory stimulus and leads to hypoventilation. Oxygen can be drying if it is not humidifi ed, but it does not cause coughing and dyspnea. Increased oxygen use will not create an oxygen dependency; clients should receive oxygen as needed. Oxygen is not contraindicated with the use of bronchodilators.

The nurse reviews an arterial blood gas report for a client with chronic obstructive pulmonary disease (COPD). pH 7.35; PC02 62; PO2 70; HCO3 34 The nurse should: ■ 1. Apply a 100% non-rebreather mask. ■ 2. Assess the vital signs. ■ 3. Reposition the client. ■ 4. Prepare for intubation.

2 Clients with chronic COPD have CO2 retention and the respiratory drive is stimulated when the PO2 decreases. The heart rate, respiratory rate, and blood pressure should be evaluated to determine if the client is hemodynamically stable. Symptoms, such as dyspnea, should also be assessed. Oxygen supplementation, if indicated, should be titrated upward in small increments. There is no indication that the client is experiencing respiratory distress requiring intubation

In reviewing a physician's orders for a postoperative client who underwent gynecological surgery, which order should a nurse determine is specifically written with the intent to prevent postoperative thrombophlebitis and pulmonary embolism? 1. Have the client dangle the legs the evening of surgery 2. Administer enoxaparin (Lovenox®) 40 mg subcutaneously daily 3. Administer hydromorphone (Dilaudid®) 1 to 4 mg IV every 3 to 4 hours as needed (prn) 4. Encourage coughing and deep breathing (C&DB) every hour while awake

2 Enoxaparin is an anticoagulant that potentiates the inhibitory effect of antithrombin on factor Xa and thrombin. Early postoperative ambulation instead of dangling is a major preventive technique for thrombophlebitis. Hydromorphone is a narcotic analgesic for pain control. Coughing and deep breathing promote lung expansion and prevent atelectasis and pneumonia.

When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift objects: ■ 1. While inhaling through an open mouth. ■ 2. While exhaling through pursed lips. ■ 3. After exhaling but before inhaling. ■ 4. While taking a deep breath and holding it.

2 Exhaling requires less energy than inhaling. Therefore, lifting while exhaling saves energy and reduces perceived dyspnea. Pursing the lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhaling but before inhaling is similar to lifting with the breath held. This should not be recommended because it is similar to the Valsalva maneuver, which can stimulate cardiac arrhythmias.

A client with chronic obstructive pulmonary disease is admitted to the hospital with an exacerbation and has a nursing diagnosis of Ineffective Airway Clearance. The nurse assesses the client and determines that which factor contributed most to this nursing diagnosis? 1 Fat intake 2 Fluid intake 3 Anxiety level 4 Amount of sleep

2 The client with Ineffective Airway Clearance has ineffective coughing and excess sputum in the airways. The nurse assesses the client for contributing factors such as dehydration and a lack of knowledge of proper coughing techniques. The reduction of these factors helps to limit exacerbations of the disease. Options 1, 3, and 4 are not directly associated with this nursing diagnosis.

A nurse is caring for multiple clients on a medical unit. Which client, who has been diagnosed with a lower extremity deep venous thrombosis (DVT), should the nurse plan for possible placement of a filter in the inferior vena cava to protect against pulmonary embolism? 1. A 22-year-old female who has been taking oral contraceptives 2. A 65-year-old client admitted with a bleeding gastric ulcer 3. A 55-year-old client who had a total knee joint replacement 4. A 52-year-old female who had a vaginal hysterectomy 6 weeks earlier

2 The client with the bleeding gastric ulcer is not a candidate for anticoagulant therapy and, therefore, needs the inferior vena cava filter to prevent an embolus from the DVT reaching the pulmonary circulation. The other clients have no contraindications listed for anticoagulant therapy.

A client's arterial blood gas values are as follows: pH, 7.31; PaO2, 80 mm Hg; PaCO2, 65 mm Hg; HCO3 −, 36 mEq/L. The nurse should assess the client for? ■ 1. Cyanosis. ■ 2. Flushed skin. ■ 3. Irritability. ■ 4. Anxiety.

2 The high PaCO2 level causes fl ushing due to vasodilation. The client also becomes drowsy and lethargic because carbon dioxide has a depressant effect on the central nervous system. Cyanosis is a sign of hypoxia. Irritability and anxiety are not common with a PaCO2 level of 65 mm Hg but are associated with hypoxia.

The emergency department 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? 1. A low respiratory rate 2. Diminished breath sounds 3. The presence of a barrel chest 4. A sucking sound at the site of injury

2 This client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyperresonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury.

In assisting a physician to perform a thoracentesis, how should the nurse position a client with pleural effusion of the left lung? 1. Supine with the left arm extended over the head. 2. Sitting at the side of the bed with both arms resting on a locked over-the-bed table. 3. High Fowler's position with both arms resting on pillows. 4. Semi-Fowler's position tilted on the right side

2. Answer 1 is incorrect because, although this position will promote separation of the ribs, it will not promote maximal access to the fluid. Answer 2 is correct because having the client's pleural cavity in a good vertical, yet safe, comfortable position will achieve maximum access to the pleural fluid. The fluid will gravitate to the lowest point for maximal aspiration. Answer 3 is incorrect because there is inadequate exposure for a midaxillary or posterior aspiration of the pleura

A client with a suspected diagnosis of lung cancer has a bronchoscopy with biopsy. Following the procedure the nurse should: ■ 1. Encourage the client to gargle with oral lidocaine to decrease throat irritation. ■ 2. Monitor the client for signs of pneumothorax. ■ 3. Administer pain medication as needed to relieve mediastinal discomfort. ■ 4. Advise the client not to talk until the gag refl ex returns.

2. After a bronchoscopy with a biopsy, the nurse should monitor the client for signs of pneumothorax as well as hemorrhage. The client should not gargle with oral lidocaine; this will not allow the gag refl ex to return. The client should not have any mediastinal discomfort after a bronchoscopy; if pain does occur it should be reported promptly to the physician. It is not necessary to tell the client not to talk until the gag refl ex returns.

A nurse should interpret which of the following as an early sign of a tension pneumothorax in a client with chest trauma? ■ 1. Diminished bilateral breath sounds. ■ 2. Muffl ed heart sounds. ■ 3. Respiratory distress. ■ 4. Tracheal deviation.

3 Respiratory distress or arrest is a universal fi nding of a tension pneumothorax. Unilateral, diminished, or absent breath sounds is a common fi nding. Tracheal deviation is an inconsistent and late fi nding. Muffl ed heart sounds are suggestive of pericardial tamponade.

To promote comfort and optimal respiratory expansion for a client with chronic obstructive pulmonary disease during sexual intimacy, the nurse can suggest that the couple: ■ 1. Use a waterbed. ■ 2. Use pillows to raise the affected partner's head and upper torso. ■ 3. Have the affected partner assume a dependent position. ■ 4. Limit the duration of the sexual activity

2. Raising the upper torso for the affected partner facilitates respiratory function. The use of a waterbed may be helpful for the sensation of movement but it does not promote respiratory expansion. A dependent position may compromise respiratory expansion, even though energy may be conserved. Duration of sexual activity is not necessarily related to exertion.

A 12-year-old with asthma wants to exercise. Which of the following activities should the nurse suggest to improve her breathing? ■ 1. Soccer. ■ 2. Swimming. ■ 3. Track. ■ 4. Gymnastics

2. Swimming is appropriate for this child because it requires controlled breathing, assists in maintaining cardiac health, enhances skeletal muscle strength, and promotes ventilation and perfusion. Stop-and-start activities, such as soccer, track, and gymnastics, commonly trigger symptoms in asthmatic clients.

A 58-year-old client with pancreatic cancer, who has been bed-bound for 3 weeks, has just returned from having a left subclavian, long-term, tunneled catheter inserted for administration of analgesics. The nurse has not yet received radiographic results for confi rmation of placement. The client becomes restless and dyspneic and complains of chest pain radiating to the middle of his back. Physical assessment reveals tachycardia and absent breath sounds in the left lung. The nurse should further assess the client for: ■ 1. An air embolus. ■ 2. A pneumothorax. ■ 3. A pulmonary embolus. ■ 4. A myocardial infarction.

2. The client is exhibiting signs and symptoms of a pneumothorax from the insertion of the subclavian venous catheter. Although it is possible that the client suffered an air embolus during the procedure, and the client is at risk for pulmonary emboli because of his immobility, absent breath sounds immediately after insertion of a subclavian line are strongly suggestive of a pneumothorax. Unilateral absent breath sounds are not associated with a myocardial infarction.

A client with malignant pleural effusions is complaining of dyspnea and chest pain. Place the following interventions that the nurse should perform in the correct order of priority. 1. administer morphine sulfate 2 mg IV 2. Apply oxygen at 2 L via nasal cannula. 3. Educate the client in anticipation of a thoracentesis. 4. Coach the client on deep breathing exercise

2143 The client is short of breath. The head of the bed should be elevated to enable breathing and oxygen should be applied. Morphine should be administered for pain prior to initiating deep breathing exercises. Deep breathing exercises improve lung expansion and decrease dyspnea. Education can be provided on the thoracentesis that is anticipated once the symptoms are managed.

A nurse is planning care for a client with a chest tube attached to a Pleur-Evac drainage system. The nurse includes which interventions in the plan? Select all that apply. r 1 Clamping the chest tube intermittently r 2 Changing the client's position frequently r 3 Maintaining the collection chamber below the client's waist r 4 Adding water to the suction control chamber as it evaporates r 5 Taping the connection between the chest tube and the drainage system

2345 To prevent a tension pneumothorax, the nurse avoids clamping the chest tube, unless specifically prescribed. In many facilities, clamping of the chest tube is contraindicated by agency policy. Changing the client's position frequently is necessary to promote drainage and ventilation. Maintaining the system below waist level is indicated to prevent fluid from reentering the pleural space. Adding water to the suction control chamber is an appropriate nursing action and is done as needed to maintain the full suction level prescribed. Taping the connection between the chest tube and system is also indicated to prevent accidental disconnection.

The nurse plans care for a client with chronic obstructive pulmonary disease (COPD), understanding that the client is most likely to experience what type of acid-base imbalance? 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis 4. Respiratory alkalosis

3

A nurse checks on a client following lower lobectomy for lung cancer. The nurse finds that the client is dyspneic with respirations in the 40s, is hypotensive, has a SaO2 at 86% on 10 L close-fitting oxygen mask, has a trachea that is deviated slightly to the left, and notes that the right side of chest is not expanding. Which action should be taken by the nurse first? 1. Notify the physician 2. Give the client whatever medication was ordered to decrease anxiety 3. Check the chest tube to make sure it is not obstructed 4. Turn up the oxygen liter flow

3 The scenario presented implies that the client is suffering from a tension pneumothorax as a result of a kinking of the tubing or other blockage in the chest tube system. Although notifying the physician would be warranted, unkinking tubing would give some immediate relief and would be the best initial action. Neither turning up the oxygen flow nor treating the client for anxiety would correct this problem.

A client with a suspected pulmonary embolus receives a ventilation and quantification nuclear medicine (VQ) scan to evaluate regional lung ventilation of airflow and regional lung blood flow. In consulting with a physician, a nurse learns that there is a VQ mismatch. Based on this information, which action should be taken by the nurse? 1. Tell the client that tuberculosis treatment will be needed 2. Reassure the client that he/she does not have a pulmonary embolus 3. Explain to the client that further testing will be needed 4. Inform the client that the test was normal

3 An imbalanced or mismatched VQ scan indicates some type of problem with either ventilation or perfusion. Further testing is required, especially in the case of suspected pulmonary embolus. A chest x-ray, sputum culture, and Gram stain are used to diagnose tuberculosis; treatment should not be initiated. A VQ mismatch is highly suspicious, but not diagnostic of multiple lung diseases, including pulmonary embolus. A VQ mismatch is not a normal finding.

The nurse is planning to obtain an arterial blood gas (ABG) from the radial artery of a client with chronic obstructive pulmonary disease (COPD). To prevent bleeding after the procedure, the nurse should plan time for which activity after the arterial blood is drawn? 1 Holding a warm compress over the puncture site for 5 minutes 2 Encouraging the client to open and close the hand rapidly for 2 minutes 3 Applying pressure to the puncture site by applying a 2 2 gauze for 5 minutes 4 Having the client keep the radial pulse puncture site in a dependent position for 5 minutes

3 Applying pressure over the puncture site for 5 to 10 minutes reduces the risk of hematoma formation and damage to the artery. A cold compress would aid in limiting blood flow; a warm compress would increase blood flow. Keeping the extremity still and out of a dependent position will aid in the formation of a clot at the puncture site.

The nurse is caring for a client who is on strict bed rest and develops a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? 1. Restricting fluids 2. Placing a pillow under the knees 3. Encouraging active range-of-motion exercises 4. Applying a heating pad to the lower extremities

3 Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a health care provider's prescription.

A client is admitted from a nursing home with an acute onset of shortness of breath. A diagnosis of pulmonary embolism is made. One common cause of pulmonary embolism is: ■ 1. Arteriosclerosis. ■ 2. Aneurysm formation. ■ 3. Deep vein thrombosis (DVT). ■ 4. Varicose veins.

3 DVT is commonly associated with venous stasis in the legs when there is a lack of the skeletal muscle pump that enhances venous return to the heart. When a client is confi ned to bed rest, venous compression occurs because of the position of the lower extremities. This increased pressure causes damage to the intima lining of the veins and causes platelets to adhere to the damaged site. DVT increases the risk that a displaced plaque will become a pulmonary embolus. Arteriosclerosis is hardening of the arteries; aneurysm is the abnormal dilation of a vessel; and varicose veins are swollen, tortuous veins. These are not generally considered causes of pulmonary embolism.

The nurse develops a plan of care for a client with deep vein thrombosis. Which client position or activity in the plan should be included? 1. Out-of-bed activities as desired 2. Bed rest with the affected extremity kept flat 3. Bed rest with elevation of the affected extremity 4. Bed rest with the affected extremity in a dependent position

3 For the client with deep vein thrombosis, elevation of the affected leg facilitates blood flow by the force of gravity and also decreases venous pressure, which in turn relieves edema and pain. Bed rest is indicated to prevent emboli and to prevent pressure fluctuations in the venous system that occur with walking. Test-Taking Strategy: Focus on the subject, the safe position or activity for the client with deep vein thrombosis. Think about the pathophysiology associated with this disorder and the principles related to gravity flow and edema to answer the question.

The nurse teaches a client with chronic obstructive pulmonary disease (COPD) to assess for signs and symptoms of right-sided heart failure. Which of the following signs and symptoms should be included in the teaching plan? ■ 1. Clubbing of nail beds. ■ 2. Hypertension. ■ 3. Peripheral edema. ■ 4. Increased appetite.

3 Right-sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs and symptoms of right-sided heart failure include peripheral edema, jugular venous distention, hepatomegaly, and weight gain due to increased fl uid volume. Clubbing of nail beds is associated with conditions of chronic hypoxemia. Hypertension is associated with left-sided heart failure. Clients with heart failure have decreased appetites.

A client has a left pleural effusion that has not yet been treated. The nurse plans to have which of the following items available for immediate use? 1 Intubation tray 2 Paracentesis tray 3 Thoracentesis tray 4 Central venous line insertion tray

3 The client with a significant pleural effusion is usually treated by thoracentesis. This procedure allows drainage of the fluid, which may then be analyzed to determine the precise cause of the effusion. The nurse ensures that a thoracentesis tray is readily available in case the client's symptoms should rapidly become more severe. A paracentesis tray is needed for the removal of abdominal effusion. Options 1 and 4 are not specifically indicated for this procedure.

A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? 1. Hot, flushed feeling 2. Sudden chills and fever 3. Chest pain that occurs suddenly 4. Dyspnea when deep breaths are taken

3 The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough, and cyanosis.

The nurse has conducted teaching with a client who experienced pulmonary embolism about methods to prevent recurrence after discharge from the hospital. Evaluation of learning is evident if the client states the intention to do which of the following? 1 Limit the intake of fluids. 2 Sit down whenever possible. 3 Continue to wear supportive hose. 4 Cross the legs only at the ankle and not at the knees.

3 The recurrence of pulmonary embolism can be minimized with the wearing of elastic or supportive hose, because these hose enhance venous return. The client also enhances venous return by avoiding crossing the legs at the knees or ankles, interspersing periods of sitting with walking, and doing active foot and ankle exercises. The client should also take in sufficient fluids to prevent hemoconcentration and hypercoagulability.

The nurse administers theophylline (Theo- Dur) to a client. To evaluate the effectiveness of this medication, which of the following drug actions should the nurse anticipate? ■ 1. Suppression of the client's respiratory infection. ■ 2. Decrease in bronchial secretions. ■ 3. Relaxation of bronchial smooth muscle. ■ 4. Thinning of tenacious, purulent sputum.

3 Theophylline (Theo-Dur) is a bronchodilator that is administered to relax airways and decrease dyspnea. Theophylline is not used to treat infections and does not decrease or thin secretions

The nurse should report which assessment finding to the health care provider (HCP) before initiating thrombolytic therapy in a client with pulmonary embolism? 1. Adventitious breath sounds 2. Temperature of 99.4 ° F orally 3. Blood pressure of 198/110 mm Hg 4. Respiratory rate of 28 breaths/minute

3 Thrombolytic therapy is contraindicated in a number of preexisting conditions in which there is a risk of uncontrolled bleeding, similar to the case in anticoagulant therapy. Thrombolytic therapy also is contraindicated in severe uncontrolled hypertension because of the risk of cerebral hemorrhage. Therefore the nurse would report the results of the blood pressure to the HCP before initiating therapy.

The nurse is interviewing a client with chronic obstructive pulmonary disease (COPD) who has a respiratory rate of 35 breaths per minute and who is experiencing extreme dyspnea. On the basis of the nurse's observations, which nursing diagnosis would be appropriate for the client? 1 Deficient Knowledge related to COPD 2 Disturbed Body Image related to a neurological deficit 3 Impaired Verbal Communication related to a physical barrier 4 Ineffective Coping related to an inability to handle a situational crisis

3 client with COPD may suffer physical or psychological alterations that impair communication. To speak spontaneously and clearly, a person must have an intact respiratory system. Extreme dyspnea is a physical alteration that affects speech. There are no data in the question that support options 1, 2, and 4.

A client is admitted to the emergency department with crushing chest injuries sustained in a car accident. Which of the following signs indicates a possible pneumothorax? ■ 1. Cheyne-Stokes respirations. ■ 2. Increased fremitus. ■ 3. Diminished or absent breath sounds on the affected side. ■ 4. Decreased sensation on the affected side.

3. Accumulation of air in the pleural cavity after a crushing chest injury may be assessed by unilateral diminished or absent breath sounds. Cheyne- Stokes respirations with periods of apnea commonly precede death. They indicate heart failure or brain death. Fremitus is increased with lung consolidation and decreased with pleural effusion or pneumothorax. Pain occurs at the injury site and increases with inspiration

A client presents to an emergency department complaining of pain on the left side and shortness of breath. Vital signs are: BP 140/80 mm Hg; P 110, and R 44. The client's ABG results are: pH 7.5, PaCO2 30 mm Hg; and HCO3 22 mEq/L, SaO2 86%, PaO2 64 mm Hg. A nurse should recognize that these symptoms are consistent with: 1. Possible trauma to the chest wall. 2. Possible pneumonia. 3. Possible pulmonary embolism. 4. Possible acute pulmonary edema.

3. Answer 1 is incorrect because chest trauma would likely result in respiratory acidosis (pH below 7.35 and CO2 above 45), not alkalosis. Answer 2 is incorrect because pneumonia would likely result in respiratory acidosis (pH below 7.35 and CO2 above 45), not alkalosis. Answer 3 is correct because the ABGs show respiratory alkalosis (pH above 7. 45 and CO2 below 35) and a problem with hypoxemia (O2 Sat below 96%) from rapid respirations. The vital signs and symptoms are consistent with a pulmonary embolism, which interferes with exchange of O2. Client hyperventilates, blowing off CO2. Answer 4 is incorrect because pulmonary edema would likely result in respiratory acidosis (pH below 7.35 and CO2 above 45), not alkalosis.

A nurse should anticipate that the chest tube for a client recovering from a pneumothorax will be removed when: 1. Chest drainage decreases to 50 mL in 24 hours. 2. Chest x-ray shows atelectasis has resolved. 3. Water-seal chamber no longer fluctuates with breathing. 4. Breath sounds are present bilaterally in apical lobes.

3. Answer 1 is incorrect because there may have been little drainage if the chest drainage system was removing air, not blood. There should be minimal drainage before removal also. Answer 2 is incorrect because a pneumothorax is a collapse of the lung, partial or complete, not a collapse of alveoli. Answer 3 is correct because the cessation of fluctuation in the water-seal chamber when the chest drainage system is no longer attached to suction is an indication of re-expansion. A chest x-ray would also be indicated. Answer 4 is incorrect because presence of breath sounds would need to be in all lobes, and particularly in the area of lung collapse.

A 7-year-old child with a history of asthma controlled without medications is referred to the school nurse by the teacher because of persistent coughing. Which of the following should the nurse do fi rst? ■ 1. Obtain the child's heart rate. ■ 2. Give the child a nebulizer treatment. ■ 3. Call a parent to obtain more information. ■ 4. Have a parent come and pick up the child.

3. Because persistent coughing may indicate an asthma attack and a 7-year-old child would be able to provide only minimal history information, it would be important to obtain information from the parent. Although determining the child's heart rate is an important part of the assessment, it would be done after the history is obtained. More information needs to be obtained before giving the child a nebulizer treatment. Although it may be necessary for the parent to come and pick up the child, a thorough assessment including history information should be obtained fi rst.

58-year-old male has just had a sclerosing agent instilled after chest tube drainage of a pleural effusion. The nurse should instruct the client to: ■ 1. Lie still to prevent a pneumothorax. ■ 2. Sit upright with arms on an overhead table to promote lung expansion. ■ 3. Change position frequently to distribute the agent. ■ 4. Lie on the side where the thoracentesis was done to hold pressure on the chest tube site.

3. Changing positions frequently aids in distributing the agent to the pleura for sealing. The majority of the pleural fl uid is drained, and the lung should already be reexpanded before instillation of the sclerosing agent. A pressure dressing is applied to the chest tube exit site, and it is not necessary to lie on that side to hold pressure on the area

A 58-year-old male has just had a sclerosing agent instilled after chest tube drainage of a pleural effusion. The nurse should instruct the client to: ■ 1. Lie still to prevent a pneumothorax. ■ 2. Sit upright with arms on an overhead table to promote lung expansion. ■ 3. Change position frequently to distribute the agent. ■ 4. Lie on the side where the thoracentesis was done to hold pressure on the chest tube site.

3. Changing positions frequently aids in distributing the agent to the pleura for sealing. The majority of the pleural fl uid is drained, and the lung should already be reexpanded before instillation of the sclerosing agent. A pressure dressing is applied to the chest tube exit site, and it is not necessary to lie on that side to hold pressure on the area.

client with acute asthma is prescribed short-term corticosteroid therapy. Which is the expected outcome for the use of steroids in clients with asthma? ■ 1. Promote bronchodilation. ■ 2. Act as an expectorant. ■ 3. Have an anti-infl ammatory effect. ■ 4. Prevent development of respiratory infections.

3. Corticosteroids have an anti-infl ammatory effect and act to decrease edema in the bronchial airways and decrease mucus secretion. Corticosteroids do not have a bronchodilator effect, act as expectorants, or prevent respiratory infections.

119. The nurse is caring for a client who is having an acute asthma attack. The nurse should notify the physician of which of the following? ■ 1. Loud wheezing. ■ 2. Tenacious, thick sputum. ■ 3. Decreased breath sounds. ■ 4. Persistent cough.

3. Diminished breath sounds during an acute asthma attack are a serious sign of airway obstruction, fatigue, and impending respiratory failure. Wheezing, coughing, and the production of sputum indicate the presence of airfl ow through the lungs and are less ominous symptoms.

An 11-year-old is admitted for treatment of an asthma attack. Which of the following indicates immediate intervention is needed? ■ 1. Thin, copious mucous secretions. ■ 2. Productive cough. ■ 3. Intercostal retractions. ■ 4. Respiratory rate of 20 breaths/minute.

3. Intercostal retractions indicate an increase in respiratory effort, which is a sign of respiratory distress. During an asthma attack, secretions are thick, the cough is tight, and respiration is diffi cult (and shortness of breath may occur). If mucous secretions are copious but thin, the client can expectorate them, which indicates an improvement in the condition. If the cough is productive it means the bronchospasms and the infl ammation have been resolved to the extent that the mucus can be expectorated. A respiratory rate of 20 breaths/minute would be considered normal and no intervention would be needed.

When instructing clients on how to decrease the risk of chronic obstructive pulmonary disease (COPD), the nurse should emphasize which of the following? ■ 1. Participate regularly in aerobic exercises. ■ 2. Maintain a high-protein diet. ■ 3. Avoid exposure to people with known respiratory infections. ■ 4. Abstain from cigarette smoking.

4 Cigarette smoking is the primary cause of COPD. Other risk factors include exposure to environmental pollutants and chronic asthma. Participating in an aerobic exercise program, although benefi cial, will not decrease the risk of COPD. Insuffi cient protein intake and exposure to people with respiratory infections do not increase the risk of COPD.

A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fl uid in the water-seal column is fl uctuating with each breath that the client takes. What is the signifi cance of this fl uctuation? ■ 1. An obstruction is present in the chest tube. ■ 2. The client is developing subcutaneous emphysema. ■ 3. The chest tube system is functioning properly. ■ 4. There is a leak in the chest tube system.

33. Fluctuation of fl uid in the water-seal column with respirations indicates that the system is functioning properly. If an obstruction were present in the chest tube, fl uid fl uctuation would be absent. Subcutaneous emphysema occurs when air pockets can be palpated beneath the client's skin around the chest tube insertion site. A leak in the system is indicated when continuous bubbling occurs in the water-seal column.

A client is suspected of having a pleural effusion. The nurse assesses the client for which typical manifestations of this respiratory problem? 1 Dyspnea at rest and moist, productive cough 2 Dyspnea at rest and dry, nonproductive cough 3 Dyspnea on exertion and moist, productive cough 4 Dyspnea on exertion and dry, nonproductive cough

4 A pleural effusion is the collection of fluid in the pleural space. Typical assessment findings in the client with a pleural effusion include dyspnea, which usually occurs with exertion, and a dry, nonproductive cough. The cough is caused by bronchial irritation and possible mediastinal shift.

The nurse prepares a client who has a right pleural effusion for a thoracentesis; however, the client experiences severe dizziness when sitting upright. Into which alternate position does the nurse assist the client to maintain safety during the procedure? 1 Right side-lying with the head of the bed flat 2 Prone with the head turned toward the affected side 3 Sims' position with the head of the bed elevated 45 degrees 4 Left side-lying with the head of the bed elevated 45 degrees

4 A thoracentesis is a procedure in which fluid or air is removed from the pleural space via a transthoracic aspiration. Positioning can help isolate the fluid in a pleural effusion; generally, the client sits at the edge of the bed, leaning over the bedside table, allowing the fluid to collect in a dependent body area. If the client is unable to sit up, the nurse turns the client to the unaffected side and elevates the head of the bed 30 to 45 degrees. Turning to the affected side, the prone, and the Sims' positions are unsuitable positions for this procedure because these do not facilitate fluid removal.

A hospitalized client is dyspneic and has been diagnosed with left tension pneumothorax by chest x-ray after insertion of a central venous catheter. Which of the following observed by the nurse indicates that the pneumothorax is rapidly worsening? 1 Hypertension 2 Flat neck veins 3 Pain with respiration 4 Tracheal deviation to the right

4 A tension pneumothorax is characterized by distended neck veins, displaced point of maximal impulse (PMI), tracheal deviation to the unaffected side, asymmetry of the thorax, decreased to absent breath sounds on the affected side, and worsening cyanosis. The increased intrathoracic pressure causes the blood pressure to fall, not rise. The client could have pain with respiration.

A client is scheduled to have a chest x-ray and a pulmonary function test (PFT). The client tires easily. Which action should be taken by the nurse to coordinate the client's care? 1. Have the PFT rescheduled for tomorrow 2. Have the chest x-ray changed to a portable x-ray 3. Accompany the client to both tests so the client can be returned to the unit if excessively tired 4. Contact the radiology department and request the chest x-ray be done right before the PFT

4 Coordinating care and advocating for the client may include ensuring that two departments work together to provide for the best and most convenient care for the client. It is possible that the radiology department is not aware that the PFT is scheduled on the same day or that the client tires easily. The nurse is responsible for acting as a liaison between the client and other health-care team members. Rescheduling the PFT may not be consistent with the physician's treatment plan and should not be decided by the nurse. A portable chest x-ray may not produce that same quality as a standing chest x-ray in the radiology department. It is the physician's decision to change to a portable view. It is unrealistic for the nurse to accompany the client to both of these tests as other clients will need nursing care during this time.

The nurse has been preparing a client with chronic obstructive pulmonary disease for discharge. Which statement by the client indicates the need for further teaching about nutrition? 1 "I will rest a few minutes before I eat." 2 "I will not eat as much cabbage as I once did." 3 "I will certainly try to drink 3 L of fluid every day." 4 "It's best to eat three large meals a day so that I will get all my nutrients."

4 Large meals distend the abdomen and elevate the diaphragm, which may interfere with breathing for the client with chronic obstructive pulmonary disease. Resting before eating may decrease the fatigue that is often associated with chronic obstructive pulmonary disease. Gas-forming foods may cause bloating, which interferes with normal diaphragmatic breathing. Adequate fluid intake helps to liquefy pulmonary secretions.

A client is newly diagnosed with chronic obstructive pulmonary disease (COPD). The client returns home after a short hospitalization. The home care nurse visits the client and most importantly plans teaching strategies that are designed to: 1 Promote membership in support groups. 2 Encourage the client to become a more active person. 3 Identify irritants in the home that interfere with breathing. 4 Improve oxygenation and minimize carbon dioxide retention.

4 Chronic obstructive pulmonary disease (COPD) is a disease state characterized by airflow obstruction. Improving oxygenation and minimizing carbon dioxide retention are the primary goals. The other options are interventions that will help with the achievement of this primary goal.

The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) how to do pursed-lip breathing. Evaluation of understanding is evident if the client demonstrates which of the following? 1 Breathes in and then holds the breath for 30 seconds 2 Loosens the abdominal muscles while breathing out 3 Inhales with pursed lips and exhales with the mouth open wide 4 Breathes so that expiration is two to three times as long as inspiration

4 Chronic obstructive pulmonary disease is a disease state characterized by airflow obstruction. Prolonging expiration time reduces air trapping caused by airway narrowing that occurs in COPD. Tightening (not loosening) the abdominal muscles aids in expelling air. Exhaling through pursed lips (not with the mouth wide open) increases the intraluminal pressure and prevents the airways from collapsing. The client is not instructed to breathe in and hold the breath for 30 seconds; this action has no useful purpose for the client with COPD.

The home care nurse visits a client with chronic obstructive pulmonary disease (COPD) who is on home oxygen at 2 L per minute. The client's respiratory rate is 22 breaths per minute, and the client is complaining of increased dyspnea. The nurse should take which initial action? 1. Determine the need to increase the oxygen. 2. Call emergency services to come to the home. 3. Reassure the client that there is no need to worry. 4. Collectmore information about the client's respiratory status.

4 Completing the assessment and collecting additional information regarding the client's respiratory status is the initial nursing action. The oxygen is not increased without validation of the need for further oxygen and the approval of the physician, especially because clients with COPD can retain carbon dioxide. Calling emergency services is a premature action. Reassuring the client is appropriate, but it is inappropriate to tell the client not to worry

A client with empyema is to have a thoracentesis performed at the bedside. The nurse plans to have which of the following available in the event the procedure is not effective? 1 Code cart 2 A small-bore needle 3 Extra-large drainage bottle 4 Chest tube and drainage system

4 Empyema is the collection of pus within the pleural cavity. If the exudate is too thick for drainage via thoracentesis, the client may require placement of a chest tube to adequately drain the purulent effusion. A small-bore needle would not effectively allow exudate to drain. Options 1 and 3 are also unnecessary. Priority Nursing Tip: Empyema is usually caused by pulmonary infection and lung abscess after thoracic surgery or chest trauma in which bacteria is introduced directly into the pleural space.

The nurse assesses the respiratory status of a client who is experiencing an exacerbation of chronic obstructive pulmonary disease (COPD) secondary to an upper respiratory tract infection. Which of the following fi ndings would be expected? ■ 1. Normal breath sounds. ■ 2. Prolonged inspiration. ■ 3. Normal chest movement. ■ 4. Coarse crackles and rhonchi.

4 Exacerbations of COPD are commonly caused by respiratory infections. Coarse crackles and rhonchi would be auscultated as air moves through airways obstructed with secretions. In COPD, breath sounds are diminished because of an enlarged anteroposterior diameter of the chest. Expiration, not inspiration, becomes prolonged. Chest movement is decreased as lungs become overdistended.

A client in a postpartum unit complains of sudden sharp chest pain and dyspnea. The nurse notes that the client is tachycardic and the respiratory rate is elevated. The nurse suspects a pulmonary embolism. Which should be the initial nursing action? 1. Initiate an intravenous line. 2. Assess the client's blood pressure. 3. Prepare to administer morphine sulfate. 4. Administer oxygen, 8 to 10 L/minute, by face mask.

4 If pulmonary embolism is suspected, oxygen should be administered, 8 to 10 L/minute, by face mask. Oxygen is used to decrease hypoxia. The client also is kept on bed rest with the head of the bed slightly elevated to reduce dyspnea. Morphine sulfate may be prescribed for the client, but this would not be the initial nursing action. An intravenous line also will be required, and vital signs need to be monitored, but these actions would follow the administration of oxygen.

Which of the following indicates that the client with chronic obstructive pulmonary disease (COPD) who has been discharged to home understands his care plan? ■ 1. The client promises to do pursed-lip breathing at home. ■ 2. The client states actions to reduce pain. ■ 3. The client says that he will use oxygen via a nasal cannula at 5 L/minute. ■ 4. The client agrees to call the physician if dyspnea on exertion increases.

4 Increasing dyspnea on exertion indicates that the client may be experiencing complications of COPD. Therefore, the nurse should notify the physician. Extracting promises from clients is not an outcome criterion. Pain is not a common symptom of COPD. Clients with COPD use low-fl ow oxygen supplementation (1 to 2 L/minute) to avoid suppressing the respiratory drive, which, for these clients, is stimulated by hypoxia

A client with chronic obstructive pulmonary disease (COPD) has a knowledge deficit related to the positions used to breathe more easily. The nurse teaches the client to assume which of the following positions? 1 Sit bolt upright in bed with the arms crossed over the chest. 2 Lie on the side with the head of the bed at a 45-degree angle. 3 Sit in a reclining chair tilted slightly back with the feet elevated. 4 Sit on the edge of the bed with the arms leaning on an overbed table.

4 Proper positioning can decrease episodes of dyspnea in a client with COPD. Appropriate positions include sitting upright while leaning on an overbed table, sitting upright in a chair with the arms resting on the knees, and leaning against a wall while standing. Option 1 restricts the movement of the anterior and posterior walls of the lung, and option 2 restricts the expansion of the lateral wall of the lung. Option 3 restricts posterior lung expansion.

Which of the following is an expected outcome of pursed-lip breathing for clients with emphysema? ■ 1. To promote oxygen intake. ■ 2. To strengthen the diaphragm. ■ 3. To strengthen the intercostal muscles. ■ 4. To promote carbon dioxide elimination.

4 Pursed-lip breathing prolongs exhalation and prevents air trapping in the alveoli, thereby promoting carbon dioxide elimination. By prolonging exhalation and helping the client relax, pursedlip breathing helps the client learn to control the rate and depth of respiration. Pursed-lip breathing does not promote the intake of oxygen, strengthen the diaphragm, or strengthen intercostal muscles.

Which of the following diets would be most appropriate for a client with chronic obstructive pulmonary disease (COPD)? ■ 1. Low-fat, low-cholesterol diet. ■ 2. Bland, soft diet. ■ 3. Low-sodium diet. ■ 4. High-calorie, high-protein diet.

4 The client should eat high-calorie, highprotein meals to maintain nutritional status and prevent weight loss that results from the increased work of breathing. The client should be encouraged to eat small, frequent meals. A low-fat, low- cholesterol diet is indicated for clients with coronary artery disease. The client with COPD does not necessarily need to follow a sodium-restricted diet, unless otherwise medically indicated. There is no need for the client to eat bland, soft foods

A client with empyema is to undergo decortication to remove inflamed tissue, pus, and debris. The nurse offers emotional support to the client on the basis of the understanding that: 1 This problem may decrease the client's life expectancy. 2 The client is likely to be in excruciating pain after surgery. 3 The client will probably have chronic dyspnea after the surgery. 4 Chest tubes will be in place after surgery for some time, and the healing process is slow.

4 The client undergoing decortication to treat empyema needs ongoing support from the nurse. This is especially true because the client will have chest tubes in place after surgery, and these must remain until the former pus-filled space is completely obliterated. This may take some time, and it may be discouraging to the client. Progress is monitored by chest x-ray. Options 1, 2, and 3 are not accurate.

A client is receiving a continuous intravenous infusion of heparin sodium to treat deep vein thrombosis. The client's activated partial thromboplastin (aPTT) time is 65 seconds. The nurse anticipates that which action is needed? 1. Discontinuing the heparin infusion 2. Increasing the rate of the heparin infusion 3. Decreasing the rate of the heparin infusion 4. Leaving the rate of the heparin infusion as is

4 The normal aPTT varies between 20 and 36 seconds, depending on the type of activator used in testing. The therapeutic dose of heparin for treatment of deep vein thrombosis is to keep the aPTT between 1.5 and 2.5 times normal. This means that the client's value should not be less than 30 seconds or greater than 90 seconds. Thus the client's aPTT is within the therapeutic range and the dose should remain unchanged.

A nurse is caring for a postpartum client with thromboembolytic disease. When planning care to prevent the complication of pulmonary embolism, the nurse plans specifically to: 1 Enforce bedrest. 2 Monitor the vital signs frequently. 3 Assess the breath sounds frequently. 4 Administer and monitor anticoagulant therapy as prescribed.

4 The purposes of anticoagulant therapy for the treatment of thromboembolytic disease are to prevent the formation of a clot and to prevent a clot from moving to another area, thus preventing pulmonary embolism. Although options 1, 2, and 3 may be implemented for a client with thromboembolytic disease, option 4 will specifically assist in the prevention of pulmonary embolism.

client has malignant pleural effusions. The nurse should conduct a focused assessment to determine if the client has which of the following? Select all that apply. ■ 1. Hiccups. ■ 2. Weight gain. ■ 3. Peripheral edema, ■ 4. Chest pain. ■ 5. Dyspnea. ■ 6. Cough.

4, 5. A malignant pleural effusion is an accumulation of excessive fl uid within the pleural space that occurs when cancer cells irritate the pleural membrane. Dyspnea can result from the increased pressure that may contribute to increased anxiety and fear of suffocation. Pain is a consequence of the pleural irritation. Cough is related to the atelectasis of the bronchi and inability to clear the airways. Hiccups are usually associated with pericardial effusions. Weight gain and peripheral edema may occur with peritoneal effusion.

The cyanosis that accompanies bacterial pneumonia is primarily caused by which of the following? ■ 1. Decreased cardiac output. ■ 2. Pleural effusion. ■ 3. Inadequate peripheral circulation. ■ 4. Decreased oxygenation of the blood.

4. A client with pneumonia has less lung surface available for the diffusion of gases because of the infl ammatory pulmonary response that creates lung exudate and results in reduced oxygenation of the blood. The client becomes cyanotic because blood is not adequately oxygenated in the lungs before it enters the peripheral circulation. Decreased cardiac output may be a comorbid condition in some clients with pneumonia; however, it is not the cause of cyanosis. Pleural effusions are a potential complication of pneumonia but are not the primary cause of decreased oxygenation. Inadequate peripheral circulation is also not the cause of the cyanosis that develops with bacterial pneumonia.

A client is admitted to the hospital with a diagnosis of a pulmonary embolism. Which of the following problems should the nurse address fi rst? ■ 1. Nonproductive cough. ■ 2. Activity intolerance. ■ 3. Ineffective breathing pattern. ■ 4. Impaired gas exchange.

4. Emboli obstruct blood fl ow, leading to a decreased perfusion of the lung tissue. Because of the decreased perfusion, a ventilation-perfusion mismatch occurs, causing hypoxemia to develop. Arterial blood gas analysis typically will indicate hypoxemia and hypocapnia. A priority objective in the treatment of pulmonary emboli is maintaining adequate oxygenation. A nonproductive cough and activity intolerance do not indicate impaired gas exchange. The client does not demonstrate an ineffective breathing pattern; rather, the problem of impaired gas exchange is caused by the inability of blood to fl ow through the lung tissue.

Which of the following fi ndings would suggest pneumothorax in a trauma victim? ■ 1. Pronounced crackles. ■ 2. Inspiratory wheezing. ■ 3. Dullness on percussion. ■ 4. Absent breath sounds.

4. Pneumothorax means that the lung has collapsed and is not functioning. The nurse will hear no sounds of air movement on auscultation. Movement of air through mucus produces crackles. Wheezing occurs when airways become obstructed. Dullness on percussion indicates increased density of lung tissue, usually caused by accumulation of fl uid.

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 highpressure 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? 1. Right pneumothorax 2. Pulmonary embolism 3. Displaced endotracheal tube 4. Acute respiratory distress syndrome

1 Pneumothorax is characterized by restlessness, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endotracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi

A child is admitted with acute exacerbation of asthma. A physician orders 100% oxygen via mask. Which physician order should be a nurse's next priority? 1. Continuous inhaled albuterol. 2. IV Solu-Medrol 2 mg/kg loading dose. 3. IV fluids at maintenance rate. 4. Chest x-ray.

1 Answer 1 is correct because the nurse's priority is to alleviate airway inflammation, and administration of a beta agonist such as albuterol is recommended. Answer 2 is incorrect because the loading dose of Solu-Medrol (methylprednisolone) should be administered after starting albuterol treatments. Answer 3 is incorrect because IV fluids can be given after starting albuterol treatments. Answer 4 is incorrect because a chest x-ray can be obtained after starting albuterol treatments.

A physician orders arterial blood gases (ABGs) on a 5-year-old client admitted with severe asthma. Which signs and symptoms noted during a nurse's assessment of the child are consistent with the blood gas findings of pH = 7.30, PaCO2 = 49 mm Hg, and HCO3 = 24 mEq/L? 1. Diaphoresis, headache, tachycardia, confusion, restlessness, apprehension, and flushed face 2. Rapid and deep respirations, paresthesia, lightheadedness, twitching, anxiety, and fear 3. Rapid and deep breathing, fruity breath, fatigue, headache, lethargy, drowsiness, nausea, vomiting, and abdominal pain 4. Slow and shallow breathing, hypertonic muscles, restlessness, twitching, confusion, irritability, apathy, tetany, and seizures

1 Diaphoresis, headache, tachycardia, confusion, restlessness, apprehension, and flushed face are all signs and symptoms of respiratory acidosis without compensation. These occur because of the lack of oxygen and trapping of carbon dioxide in the lower airway from the narrowed airway passages. Rapid and deep respirations, paresthesia, light-headedness, twitching, anxiety, and fear are signs and symptoms of respiratory alkalosis. Respiratory alkalosis may occur in asthma if excess artificial ventilation is used in treatment. Rapid and deep breathing, fruity breath, fatigue, headache, lethargy, drowsiness, nausea, vomiting, and abdominal pain are signs and symptoms of metabolic acidosis. Slow and shallow breathing, hypertonic muscles, restlessness, twitching, confusion, irritability, apathy, tetany, and seizures are signs and symptoms of metabolic alkalosis. Metabolic acidosis and alkalosis are not associated with asthma but may occur from other complications.

Which of the following should lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus? ■ 1. Acute respiratory distress syndrome. ■ 2. Migraine-like headaches. ■ 3. Numbness in the right leg. ■ 4. Muscle spasms in the right thigh.

1 Fat emboli usually result in symptoms of acute respiratory distress syndrome, such as apprehension, chest pain, cyanosis, dyspnea, tachypnea, tachycardia, and decreased partial pressure of arterial oxygen resulting from poor oxygen exchange. Migraine-like headaches are not a symptom of a fat embolism, but mental confusion, memory loss, and a headache from poor oxygen exchange may be seen with central nervous system involvement. Numbness in the right leg is a peripheral neurovascular response that most likely is related to the femoral fracture. Muscle spasms in the right thigh are a symptom of a neuromuscular response affecting the local muscle around the femoral fracture site.

A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress? 1. Restlessness 2. Bradycardia 3. Constricted pupils 4. Clubbing of the fingers

1 Inadequate oxygenation of the brain may produce restlessness or behavioral changes. 2 The pulse increases with cerebral hypoxia. 3 The pupils dilate with cerebral hypoxia. 4 This is the result of increased vascularization and reflects a response to prolonged hypoxia.

A nurse is working with a client to update the client's asthma action plan. The nurse knows that this action plan should include information on: 1. medication adjustments that should be made if peak flow is less than 50% normal. 2. timeline for allergy skin testing. 3. the most direct route when the client drives to the hospital. 4. the best methods for chest physiotherapy (CPT).

1 The asthma action plan is intended to help clients determine how and when to adjust care if their asthma worsens; primarily through adjustment of medication regimen. The plan also identifies the best ways to access and alert emergency personnel if an acute attack occurs but the client should not be driving him- or herself to the hospital. Allergy skin testing would be done in the early phases of diagnosis. CPT is not usually a part of asthma therapy.

A client with acute respiratory distress syndrome (ARDS) is on a ventilator. The client's peak inspiratory pressures and spontaneous respiratory rate are increasing, and the PO2 is not improving. Using the SBAR (Situation-Background-Assessment- Recommendation) technique for communication, the nurse calls the physician with the recommendation for: ■ 1. Initiating I.V. sedation. ■ 2. Starting a high-protein diet. ■ 3. Providing pain medication. ■ 4. Increasing the ventilator rate.

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

A child with a history of asthma presents to an emergency room and is treated with epinephrine. The child is agitated, sweating profusely while sitting up, and has an oxygen saturation of less than 91% and a respiratory rate of less than 30 breaths per minute. Breath sounds are diminished, and wheezing is absent. Based on this information, which acid-base imbalance should a nurse anticipate? 1. Respiratory acidosis 2. Respiratory alkalosis 3. Metabolic alkalosis 4. Metabolic acidosis

1 The nurse should anticipate respiratory acidosis. This child is most likely in status asthmaticus with continued respiratory distress despite treatment. Even though the child has a high respiratory rate, there is hypoventilation as a result of bronchoconstriction, which results in carbon dioxide retention. High PaCO2 (greater than 42 mm Hg) will result in a lowering of pH or an acidotic state, resulting from primary changes to the respiratory system. Respiratory alkalosis would occur if excess carbon dioxide is blown off with hyperventilation. The client's symptoms are associated with a respiratory and not a metabolic problem; thus, metabolic alkalosis and acidosis are incorrect.

Which of the following conditions can place a client at risk for acute respiratory distress syndrome (ARDS)? ■ 1. Septic shock. ■ 2. Chronic obstructive pulmonary disease. ■ 3. Asthma. ■ 4. Heart failure.

1 The two risk factors most commonly associated with the development of ARDS are gramnegative septic shock and gastric content aspiration. Nurses should be particularly vigilant in assessing a client for onset of ARDS if the client has experienced direct lung trauma or a systemic infl ammatory response syndrome (which can be caused by any physiologic insult that leads to widespread infl ammation). Chronic obstructive pulmonary disease, asthma, and heart failure are not direct causes of ARDS.

client uses a metered-dose inhaler (MDI) to aid in management of his asthma. Which action by the client indicates to the nurse that he needs further instruction regarding its use? Select all that apply. ■ 1. Activation of the MDI is not coordinated with inspiration. ■ 2. The client inspires rapidly when using the MDI. ■ 3. The client holds his breath for 3 seconds after inhaling with the MDI. ■ 4. The client shakes the MDI after use. ■ 5. The client performs puffs in rapid succession.

1, 2, 3, 4, 5. Utilization of an MDI requires coordination between activation and inspiration; deep breaths to ensure that medication is distributed into the lungs, holding the breath for 10 seconds or as long as possible to disperse the medication into the lungs, shaking up the medication in the MDI before use, and a suffi cient amount of time between puffs to provide an adequate amount of inhalation medication.

Which assessment fi ndings should lead the nurse to suspect that a toddler is experiencing respiratory distress? Select all that apply. ■ 1. Coughing. ■ 2. Respiratory rate of 35 breaths/minute. ■ 3. Heart rate of 95 beats/minute. ■ 4. Restlessness. ■ 5. Malaise. ■ 6. Diaphoresis.

1, 2, 4, 6. Coughing, especially at night and in the absence of an infection, is a common symptom of asthma. Early signs of respiratory distress include restlessness, tachypnea, tachycardia, and diaphoresis. Other signs also include hypertension, nasal fl aring, grunting, wheezing, and intercostal retractions. A heart rate of 95 bpm is normal for a toddler. Malaise typically does not indicate respiratory distress.

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse anticipate to be prescribed? 1. Face tent 2. Venturi mask 3. Aerosol mask 4. Tracheostomy collar

2 The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.

The nurse is teaching the client how to use a metered-dose inhaler (MDI) to administer a corticosteroid. Which of the following client actions indicates that he is using the MDI correctly? Select all that apply. ■ 1. The inhaler is held upright. ■ 2. The head is tilted down while inhaling the medicine. ■ 3. The client waits 5 minutes between puffs. ■ 4. The mouth is rinsed with water following administration. ■ 5. The client lies supine for 15 minutes following administration.

1, 4. The client should shake the inhaler and hold it upright when administering the drug. The head should be tilted back slightly. The client should wait about 1 to 2 minutes between puffs. The mouth should be rinsed following the use of a corticosteroid MDI to decrease the likelihood of developing an oral infection. The client does not need to lie supine; instead, the client will likely to be able to breathe more freely if sitting upright.

The care plan for an older adult with asthma, chronic obstructive pulmonary disease (COPD), and chronic anxiety should include: Select all that apply. 1. Inhalation therapy and instruction about methods of conserving energy. 2. An exercise program to increase the vital capacity of the lungs. 3. Respiratory exercises with emphasis on forced inhalation. 4. Oxygen therapy at 4 L/min as needed, and deep breathing for relaxation. 5. Teaching the use of the diaphragm to improve breathing.

1, 5. Answer 1 is correct because the actions are appropriate for the older adult and will improve ventilation. Answer 2 is incorrect because lung capacity diminishes with age and this is not reversible. Answer 3 is incorrect because COPD traps air, so the client should learn pursed-lip breathing, not forced inhalation. Answer 4 is incorrect because the oxygen level is higher than recommended for COPD. The stimulus to breathe is hypoxia. Answer 5 is correct because the diaphragm should be used to facilitate inspiration and expiration rather than the accessory muscles of breathing

The nurse is planning to teach the client how to properly use a metered-dose inhaler to treat asthma. Which of the following instructions should the nurse include in the teaching plan? ■ 1. Rinse the mouth after each use of a steroid inhaler. ■ 2. Inhale quickly when administering the medication. ■ 3. Inhale the medication and then exhale through the nose. ■ 4. Cough and deep-breathe before inhaling the medication.

1. Clients should be instructed to rinse their mouths after using a steroid inhaler to avoid developing thrush. Clients should also be instructed to inhale slowly through the mouth and then hold the breath as they count to 10 slowly. It is not necessary for the client to cough and deep-breathe before using the inhaler.

Which of the following fi ndings would most likely indicate the presence of a respiratory infection in a client with asthma? ■ 1. Cough productive of yellow sputum. ■ 2. Bilateral expiratory wheezing. ■ 3. Chest tightness. ■ 4. Respiratory rate of 30 breaths/minute.

1. A cough productive of yellow sputum is the most likely indicator of a respiratory infection. The other signs and symptoms-wheezing, chest tightness, and increased respiratory rate-are all fi ndings associated with an asthma attack and do not necessarily mean an infection is present.

client is prescribed metaproterenol (Alupent) via a metered-dose inhaler, two puffs every 4 hours. The nurse instructs the client to report adverse effects. Which of the following are potential adverse effects of metaproterenol? ■ 1. Irregular heartbeat. ■ 2. Constipation. ■ 3. Pedal edema. ■ 4. Decreased pulse rate.

1. Irregular heartbeats should be reported promptly to the care provider. Metaproterenol (Alupent) may cause irregular heartbeat, tachycardia, or anginal pain because of its adrenergic effect on beta-adrenergic receptors in the heart. It is not recommended for use in clients with known cardiac disorders. Metaproterenol does not cause constipation, pedal edema, or bradycardia.

92. Which of the following health promotion activities should the nurse include in the discharge teaching plan for a client with asthma? ■ 1. Incorporate physical exercise as tolerated into the daily routine. ■ 2. Monitor peak fl ow numbers after meals and at bedtime. ■ 3. Eliminate stressors in the work and home environment. ■ 4. Use sedatives to ensure uninterrupted sleep at night.

1. Physical exercise is benefi cial and should be incorporated as tolerated into the client's schedule. Peak fl ow numbers should be monitored daily, usually in the morning (before taking medication). Peak fl ow does not need to be monitored after each meal. Stressors in the client's life should be modifi ed but cannot be totally eliminated. Although adequate sleep is important, it is not recommended that sedatives be routinely taken to induce sleep

A client experiencing a severe asthma attack has the following arterial blood gas: pH 7.33; PCO2 48; PO2 58; HCO3 26. Which of the following orders should the nurse perform fi rst? ■ 1. Albuterol (Proventil) nebulizer. ■ 2. Chest x-ray. ■ 3. Ipratropium (Atrovent) inhaler. ■ 4. Sputum culture.

1. The arterial blood gas reveals a respiratory acidosis with hypoxia. A quick-acting bronchodilator, albuterol, should be administered via nebulizer to improve gas exchange. Ipratropium is a maintenance treatment for bronchospasm that can be used with albuterol. A chest x-ray and sputum sample can be obtained once the client is stable.

When developing a teaching plan for the mother of an asthmatic child concerning measures to reduce allergic triggers, which of the following suggestions should the nurse include: ■ 1. Keep the humidity in the home between 50% and 60%. ■ 2. Have the child sleep in the bottom bunk bed. ■ 3. Use a scented room deodorizer to keep the room fresh. ■ 4. Vacuum the carpet once or twice a week

1. To help reduce allergic triggers in the home, the nurse should recommend that the humidity level be kept between 50% and 60%. Doing so keeps the air moist and comfortable for breathing. When air is dry, the risk for respiratory infections increase. Too high a level of humidity increases the risk for mold growth. Typically, the child with asthma should sleep in the top bunk bed to minimize the risk of exposure to dust mites. The risk of exposure to dust mites increases when the child sleeps in the bottom bunk bed because dust mites fall from the top bed, settling in the bottom bed. Scented sprays should be avoided because they may trigger an asthmatic episode. Ideally, carpeting should be avoided in the home if the child has asthma. However, if it is present, carpeting in the child's room should be vacuumed often, possibly daily, to remove dust mites and dust particles.

A nurse is caring for a newly admitted 4-year-old client diagnosed with asthma who is pale, and has dry mucous membranes, cracked lips, and nasal flaring with inspiration. Which actions should the nurse perform? SELECT ALL THAT APPLY 1. Obtain a pulse oximetry 2. Obtain vital signs 3. Assess lung sounds 4. Administer a nebulizer treatment 5. Offer oral fluids 6. Elevate the head of the bed

1236 Obtaining a pulse oximetry and assessing vital signs and lung sounds provide important information to assess the respiratory status and can safely be performed within the scope of nursing practice. Elevating the head of the bed promotes oxygenation. Before administering any medication or treatment, such as a nebulizer treatment, a nurse should determine if the treatment or medication has been ordered by a physician or other care provider. Before offering oral fluids, a nurse should check to see if oral fluids can be give

Which assessment findings should indicate to a nurse that an adult client experiencing an acute asthma attack warrants urgent medical intervention with an inhaled beta-2 agonist? SELECT ALL THAT APPLY. 1. Respiratory rate (RR) of 32 breaths per minute 2. Pulsus paradoxus 3. Wheezes heard on chest auscultation 4. Client speaking in short sentences to indicate need for oxygen 5. Oxygen saturation 94% 6. Heart rate (HR) 122 beats per minute

1236 The increased RR is the body's attempt to increase oxygen intake. Pulsus paradoxus is a greater than 10 mm Hg drop in systolic blood pressure (BP) or weakening of the pulse during inspiration. It occurs in asthma because of the high negative intrathoracic pressure that increases venous return and right ventricular filling. Consequently, the interventricular septum bulges slightly into the left ventricular outflow tract, decreasing cardiac output and thus BP. Wheezes are expiratory sounds from forced airflow through abnormally collapsed airways with residual air trapping. HR increases to compensate for the decreased oxygenation and pulsus paradoxus. Dyspneic persons speak in words not sentences. An oxygen saturation of 94% correlates with a PaO2 of 70% (normal PaO2 is 70%-100%).

A client is hospitalized with a diagnosis of emphysema. Which dietary modifications should a nurse expect to be prescribed for this client, who has no other underlying medical conditions? SELECT ALL THAT APPLY. 1. Mechanical soft 2. Low calorie 3. High protein 4. Restricted potassium 5. Increased calcium

13 Mechanical soft decreases the chewing effort. Eating, chewing, and digestion increase oxygen demand. Carbohydrate (CHO) metabolism increases CO2 levels. A high-protein, low-CHO diet is prescribed to provide calories for energy but prevent increased CO2 levels. A highcalorie diet is prescribed because of the increased energy consumption with eating. Potassium is restricted with renal failure, not emphysema. Calcium is increased with diseases such as tuberculosis or osteoporosis.

The nurse is assessing a client recovering from anesthesia. Which of the following is an early indicator of hypoxemia? ■ 1. Somnolence. ■ 2. Restlessness. ■ 3. Chills. ■ 4. Urgency.

2 One of the earliest signs of hypoxia is restlessness and agitation. Decreased level of consciousness and somnolence are later signs of hypoxia. Chills can be related to the anesthetic agent used but are not indicative of hypoxia. Urgency is not related to hypoxia.

A client with a diagnosis of chronic obstructive pulmonary disease (COPD) has developed polycythemia vera, and a nurse has completed teaching on measures to prevent complications. During a home health visit, the nurse evaluates that the client is correctly following the teaching when the client: SELECT ALL THAT APPLY. 1. tells the nurse about discontinuing iron supplements. 2. relays increasing alcohol intake to decrease blood viscosity. 3. records the amount consumed after drinking a glass of water. 4. discusses yesterday's phlebotomy treatment to remove blood. 5. shows the nurse a menu plan for eating three large meals daily. 6. reclines in a recliner chair with legs uncrossed, wearing antiembolic stockings (TEDS®).

1346 Iron supplements, including those in multivitamins, should be avoided because the iron stimulates red blood cell production. Increasing fluid intake to 3,000 mL daily will help decrease blood viscosity. Phlebotomy is performed on a routine or intermittent basis to diminish blood viscosity, deplete iron stores, and decrease the client's ability to manufacture excess erythrocytes. Elevating the legs, avoiding constriction or crossing the legs, and wearing antiembolic socks help prevent deep vein thrombosis. Alcohol increases the risk of bleeding. Frequent, small meals are better tolerated, especially if the liver is involved.

A nurse is teaching a client to use a metereddose inhaler (MDI) to administer his bronchodilator medication. Indicate the correct order of the steps the client should take to use the MDI appropriately. 1. Shake the inhaler immediately before use 2. Hold breath for 5 to 10 seconds and then exhale. 3. Activate the MDI on inhalation. 4. Breathe out through the mouth.

1432 When using inhalers, clients should fi rst shake the inhaler to activate the MDI, and then breathe out through the mouth. Next, the client should activate the MDI while inhaling, hold the breath for 5 to 10 seconds, and then exhale normally.

A client with acute respiratory distress syndrome (ARDS) has fi ne crackles at lung bases and the respirations are shallow at a rate of 28 breaths/minute. The client is restless and anxious. In addition to monitoring the arterial blood gas results, the nurse should do which of the following? Select all that apply. ■ 1. Monitor serum creatinine and blood urea nitrogen levels. ■ 2. Administer a sedative. ■ 3. Keep the head of the bed fl at. ■ 4. Administer humidifi ed oxygen. ■ 5. Auscultate the lungs.

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

The care plan for an older adult with asthma, chronic obstructive pulmonary disease (COPD), and chronic anxiety should include: Select all that apply. 1. Inhalation therapy and instruction about methods of conserving energy. 2. An exercise program to increase the vital capacity of the lungs. 3. Respiratory exercises with emphasis on forced inhalation. 4. Oxygen therapy at 4 L/min as needed, and deep breathing for relaxation. 5. Teaching the use of the diaphragm to improve breathing.

15 Answer 1 is correct because the actions are appropriate for the older adult and will improve ventilation. Answer 2 is incorrect because lung capacity diminishes with age and this is not reversible. Answer 3 is incorrect because COPD traps air, so the client should learn pursed-lip breathing, not forced inhalation. Answer 4 is incorrect because the oxygen level is higher than recommended for COPD. The stimulus to breathe is hypoxia. Answer 5 is correct because the diaphragm should be used to facilitate inspiration and expiration rather than the accessory muscles of breathing.

The nurse interprets which of the following as an early sign of acute respiratory distress syndrome (ARDS) in a client at risk? ■ 1. Elevated carbon dioxide level. ■ 2. Hypoxia not responsive to oxygen therapy. ■ 3. Metabolic acidosis. ■ 4. Severe, unexplained electrolyte imbalance.

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

Which of the following is an indication of a complication of septic shock? ■ 1. Anaphylaxis. ■ 2. Acute respiratory distress syndrome (ARDS). ■ 3. Chronic obstructive pulmonary disease (COPD). ■ 4. Mitral valve prolapse.

2 ARDS is a complication associated with septic shock. ARDS causes respiratory failure and may lead to death, even after the client has recovered from shock. Anaphylaxis is a type of distributive or vasogenic shock. COPD is a functional category of pulmonary disease that consists of persistent obstruction of bronchial airfl ow and involves chronic bronchitis and chronic emphysema. Mitral valve prolapse is a condition in which the mitral valve is pushed back too far during ventricular contraction.

A home health nurse is visiting a client whose chronic bronchitis has recently worsened. Which instruction should the nurse reinforce with this client? 1. Increase amount of bedrest 2. Increase fluid intake 3. Decrease caloric intake 4. Reduce home oxygen use

2 Adequate fluids may help liquefy secretions for easier expectoration. Imposing bedrest on a client with shortness of breath may worsen the situation. Physical activity interspersed with adequate rest can improve respiratory functioning. A diet high in calories can compensate for these client's hypermetabolic state, dyspnea, and poor appetite. Reducing home oxygen use, in this situation, would most likely exacerbate the client's symptoms

The nurse is monitoring a client who is taking propranolol (Inderal LA). Which assessment data indicates a potential serious complication associated with this medication? 1. The development of complaints of insomnia 2. The development of audible expiratory wheezes 3. A baseline blood pressure of 150/80 mm Hg followed by a blood pressure of 138/72 mm Hg after two doses of the medication 4. A baseline resting heart rate of 88 beats/minute followed by a resting heart rate of 72 beats/minute after two doses of the medication

2 Audible expiratory wheezes may indicate a serious adverse reaction, bronchospasm. β-Blockers may induce this reaction, particularly in clients with chronic obstructive pulmonary disease or asthma. Normal decreases in blood pressure and heart rate are expected. Insomnia is a frequent mild side effect and should be monitored.

A client who has asthma is taking albuterol (Ventolin) to treat bronchospasms. The nurse should assess the client for which of the following adverse effects that can occur as a result of taking this drug? Select all that apply. ■ 1. Lethargy. ■ 2. Nausea. ■ 3. Headache. ■ 4. Nervousness. ■ 5. Constipation.

2, 3, 4. Albuterol is a beta-adrenergic agonist. Possible adverse effects include nausea, headache, and nervousness as well as insomnia and vomiting. Constipation is not associated with this drug. The client will not become lethargic; instead, he may experience restlessness.

client with asthma has been prescribed beclomethasone (Beclovent) via metered-dose inhaler. To determine if the client has been rinsing the mouth after each use of the inhaler, the nurse should inspect the client's mouth for: ■ 1. Gingival hyperplasia. ■ 2. Oral candidiasis. ■ 3. Ulceration ■ 4. Dental caries

2. Beclomethasone is an inhaled steroid used for the maintenance treatment of asthma. The steroid can precipitate overgrowth of fungus, such as oral Candida albicans. Rinsing the mouth well after each use decreases the incidence of oral fungal infections. Beclomethasone does not cause gingival hyperplasia, ulceration, or caries.

A client with asthma asks the nurse if she should use her salmeterol (Serevent) inhaler when she exercises and experiences wheezing and shortness of breath. The nurse's best response is which of the following? ■ 1. "Yes, use the inhaler immediately for these symptoms." ■ 2. "No, this drug is a maintenance drug, not a rescue inhaler." ■ 3. "Use the inhaler 5 minutes before you exercise to prevent the wheezing." ■ 4. "This inhaler is for allergic rhinitis, not asthma."

2. Salmeterol (Serevent) is a beta2-agonist, a maintenance drug that the asthmatic client uses twice daily, every 12 hours. Albuterol (Proventil) is used as the "rescue inhaler" for bronchospasms. Serevent can be used to prevent exercise-induced bronchospasms, but it should be taken 30 to 60 minutes before exercise. If the client is taking Serevent twice daily, it should not be used in additional doses before exercise; twice daily is the maximum dosage. Indications for Serevent include only asthma and bronchospasm induced by chronic obstructive pulmonary disease.

The nurse should teach the client with asthma that which of the following is one of the most common precipitating factors of an acute asthma attack? ■ 1. Occupational exposure to toxins. ■ 2. Viral respiratory infections. ■ 3. Exposure to cigarette smoke. ■ 4. Exercising in cold temperatures.

2. The most common precipitator of asthma attacks is viral respiratory infection. Clients with asthma should avoid people who have the fl u or a cold and should get yearly fl u vaccinations. Environmental exposure to toxins or heavy particulate matter can trigger asthma attacks; however, far fewer asthmatics are exposed to such toxins than are exposed to viruses. Cigarette smoke can also trigger asthma attacks, but to a lesser extent than viral respiratory infections. Some asthmatic aattacks are triggered by exercising in cold weather.

A 10-year-old child who is 5′ 4″ (138 cm) tall with a history of asthma uses an inhaled bronchodilator only when needed. He takes no other medications routinely. His best peak expiratory fl ow rate is 270 L/minute. The child's current peak fl ow reading is 180 L/minute. The nurse interprets this reading as indicating which of the following? ■ 1. The child's asthma is under good control, so the routine treatment plan should continue. ■ 2. The child needs to start a short-acting inhaled beta2-agonist medication. ■ 3. This is a medical emergency requiring a trip to the emergency department for treatment. ■ 4. The child needs to begin treatment with inhaled cromolyn sodium (Intal) for asthma control.

2. The peak fl ow of 180 L/minute is in the yellow zone, or 50% to 80% of the child's personal best. This means that the child's asthma is not well controlled, thereby necessitating the use of a shortacting beta2-agonist medication to relieve the bronchospasm. A peak fl ow reading greater than 80% of the child's personal best (in this case, 220 L/minute or better) would indicate that the child's asthma is in the green zone or under good control. A peak fl ow reading in the red zone, or less than 50% of the child's personal best (135 L/minute or less), would require notifi cation of the health care provider or a trip to the emergency department. Cromolyn sodium (Intal) is not used for short-term treatment of acute bronchospasm. It is used as part of a long-term therapy regimen to help desensitize mast cells and thereby help to prevent symptoms.

The nurse is instructing a client with COPD how to do pursed-lip breathing. In which order should the nurse explain the steps to the client? ■ 1. "Breathe in normally through your nose for 2 counts (while counting to yourself, one, two)." ■ 2. "Relax your neck and shoulder muscles." ■ 3. "Pucker your lips as if you were going to whistle." ■ 4. "Breathe out slowly through pursed lips for 4 counts (while counting to yourself, one, two, three, four)."`

2134 The nurse should instruct the client to fi rst relax the neck and shoulders and then take several normal breaths. After taking a breath in, the client should pucker the lips, and fi nally breathe out through pursed lips.

The nurse is teaching an adolescent with asthma how to use an inhaler. In which order should the nurse instruct the client to follow the steps from fi rst to last? 1. inhale through an open mouth 2. Breathe out through the mouth. 3. Hold the breath for 5 to 10 seconds. 4. Press the canister to release the medication.

2143 When dispensing medication from an inhaler, the client should fi rst breathe out through the mouth. Next the client inhales through an open mouth and then presses the canister to dispense the medication while continuing to inhale and holds the breath for 5 to 10 seconds. The client can then exhale and breathe normally. CN: Pharmacological

A client, newly diagnosed with asthma is preparing for discharge. Which point should a nurse emphasize during the client's teaching? 1. Contact care provider only if nighttime wheezing becomes a concern 2. Limit exposure to sources that trigger an attack 3. Use peak flow meter only if symptoms are worsening 4. Use inhaled steroid medication as a rescue inhaler

22 A client newly diagnosed with asthma has a large number of educational concerns that need to be addressed. Of primary importance is knowing ways to prevent an attack, such as avoiding known triggers. A peak flow meter is generally used on a daily basis to help document and identify worsening symptoms over time. Symptoms, such as worsening peak flow meter readings and nighttime wheezing, are one of many health changes that should signal the client to contact his or her care provider. Generally speaking, inhalers with steroid medications are not to be used as a rescue inhaler in the event of an attack.

37 A nurse instructs a 15-year-old client diagnosed with asthma about using a peak expiratory flow meter. Which immediate action should the nurse recommend if the client obtains a reading that falls below 50% of his or her normal personal best reading? 1. Self-administer a nebulizer treatment 2. Use the "as needed" medication for asthma 3. Call the physician 4. Go to the emergency department

22 The appropriate first action to take when the peak flow rate is less than 50% of the personal best is to immediately take the "as needed" medication for asthma, which should be a short-acting bronchodilator. Severe airway narrowing may be occurring. Preparing for a nebulizer treatment will delay intervention. If the peak expiratory flow rate does not return immediately and stays in the yellow range (50% to 79% of personal best), then the physician should be notified or the child should go to the emergency department.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which finding would the nurse expect to note on assessment of this client? Select all that apply. 1. Hypocapnia 2. A hyperinflated chest noted on the chest x-ray 3. Decreased oxygen saturation with mild exercise 4. A widened diaphragm noted on the chest x-ray 5. Pulmonary function tests that demonstrate increased vital capacity

23 Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.

Which actions should be taken by a nurse when caring for a client who is experiencing dyspnea due to heart failure and chronic obstructive pulmonary disease (COPD)? SELECT ALL THAT APPLY. 1. Apply oxygen 6 liters per nasal cannula 2. Elevate the head of the bed 30 to 40 degrees 3. Weigh the client daily in the morning 4. Teach the client pursed-lip breathing techniques 5. Turn and reposition the client every 1 to 2 hours

234 Elevating the head of the bed will promote lung expansion. Daily weights will assess fluid retention. Fluid volume excess can increase dyspnea and cause pulmonary edema. Pursed-lip breathing techniques allow the client to conserve energy and slow the breathing rate. Options 1 and 5 are incorrect actions. Applying greater than 4 liters of oxygen per nasal cannula is contraindicated for COPD. High flow rates can depress the hypoxic drive. Because the client with COPD suffers from chronically high CO2 levels, the stimulus to breathe is the low O2 level (a hypoxic drive). The situation does not warrant turning the client every 1 to 2 hours. This activity could increase the client's energy expenditure and dyspnea.

A 56-year-old female with lung cancer is undergoing a thoracentesis. Which of the following outcomes of the procedure are expected? Select all that apply. ■ 1. Treatment of recurrent malignant effusion. ■ 2. Diagnosis of underlying disease. ■ 3. Palliation of symptoms. ■ 4. Relief of acute respiratory distress. ■ 5. Removal of the cancer cells.

234 Thoracentesis is usually successful for diagnosis of underlying disease, palliation of symptoms, and treating the acute respiratory distress; alleviation of the symptoms and distress is usually short-term. The thoracentesis is not used as a treatment for recurrent pleural effusion because the fl uid accumulates rapidly. Thoracentesis does not remove cancer cells.

A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? 1. Warm, dry skin 2. Decreased wheezing 3. Pulse rate of 90 beats/minute 4. Respirations of 18 breaths/minute

2Asthma is a chronic inflammatory disease of the airways. Decreased wheezing in a child with asthma may be interpreted incorrectly as a positive sign when it may actually signal an inability to move air. A "silent chest" is an ominous sign during an asthma episode. With treatment, increased wheezing actually may signal that the child's condition is improving. Warm, dry skin indicates an improvement in the child's condition because the child is normally diaphoretic during exacerbation. The normal pulse rate in a 10-year-old is 70 to 110 beats/minute. The normal respiratory rate in a 10-year-old is 16 to 20 breaths/minute. Test-

Which nursing diagnosis reflects the basic rationale for symptoms in a client with acute respiratory distress syndrome (ARDS)? 1. Ineffective breathing pattern. 2. High risk for infection. 3. Impaired gas exchange. 4. Activity intolerance.

3

client with asthma has pronounced wheezing upon auscultation. Suspecting an impending asthma attack, a nurse should: 1. have the client cough and deep breathe. 2. prepare to intubate the client. 3. prepare to administer a nebulized beta-2 adrenergic agonist. 4. have the client lay on his or her right side.

3 A client with asthma who is experiencing wheezing and an impending attack is best treated with inhaled beta-2 adrenergic agonist drugs such as albuterol (Ventolin®). Oxygen and corticosteroids may also be used. Neither coughing and deep breathing nor positioning will stop the attack. Intubation is not effective in treating the underlying cause of the attack, which is an inflammatory response and would not be a first-line intervention.

The nurse is caring for a client who has experienced severe multiple trauma. The client's arterial blood gases reveal low arterial oxygen levels that are not responsive to high concentrations of oxygen. The nurse is aware that this fi nding is a major indicator of the development of which of the following conditions? ■ 1. Hospital-acquired pneumonia. ■ 2. Hypovolemic shock. ■ 3. Acute respiratory distress syndrome (ARDS). ■ 4. Asthma.

3 ARDS frequently develops after a major insult to the body. The major diagnostic indicator is low arterial oxygen levels that are not responsive to the administration of high concentrations of oxygen. Early recognition of ARDS is important to increase the client's chances of recovery. The oxygen levels of clients with hospital-acquired pneumonia, hypovolemic shock, or asthma would be expected to improve with oxygen administration

A nurse observes for early manifestations of acute respiratory distress syndrome (ARDS) in a client being treated for smoke inhalation. Which signs indicates the possible onset of ARDS in this client? 1. Cough with blood-tinged sputum and respiratory alkalosis 2. Decrease in both white and red blood cell counts 3. Diaphoresis and low SaO2 unresponsive to increased oxygen administration 4. Hypertension and elevated PaO2

3 ARDS is manifested and similar to an extreme state of respiratory distress that would include diaphoresis, tachypnea, and use of accessory muscles. Because of damage and alterations in lung tissue, the client would not be able to increase his or her oxygenation despite an increase in the flow or amount of oxygen. Blood pressure and acid-base imbalances vary depending on the stage of ARDS.

A client was admitted to the hospital 24 hours ago after sustaining blunt chest trauma. The nurse monitors for which earliest clinical manifestation of acute respiratory distress syndrome (ARDS)? 1 Cyanosis and pallor 2 Diffuse crackles and rhonchi on chest auscultation 3 Increase in respiratory rate from 18 to 30 breaths per minute 4 Haziness or "white-out" appearance of lungs on chest radiograph

3 Acute respiratory distress syndrome usually develops within 24 to 48 hours after an initiating event, such as chest trauma. In most cases tachypnea and dyspnea are the earliest clinical manifestations as the body compensates for mild hypoxemia through hyperventilation. Cyanosis and pallor are late findings and are the result of severe hypoxemia. Breath sounds in the early stages of ARDS are usually clear but then progress to diffuse crackles and rhonchi as pulmonary edema occurs. Chest radiographic findings may be normal during the early stages but will show diffuse haziness or "white-out" appearance in the later stages.

A child arrives in an emergency department with a chief complaint of asthma exacerbation. Which assessment information is most important for the nurse to obtain first? 1. Whether the child has been taking asthma medications as prescribed. 2. When the child began having symptoms. 3. Whether the child is able to speak in full sentences. 4. The child's ABG levels.

3 Answer 1 is incorrect because knowing whether the child has been taking medications is not part of the initial physical assessment. Answer 2 is incorrect because knowing when the child began having symptoms is not part of the initial physical assessment. Answer 3 is correct because the nurse should first assess the child's airway to determine the severity of respiratory symptoms. One way to assess shortness of breath is to determine whether the child speaks in full sentences, short phrases, or barely at all. Answer 4 is incorrect because the nurse should first assess the airway. ABGs (arterial blood gases) may be obtained later if ordered by the practitioner.

Oxygen therapy is ordered to assist the client with breathing. Which principle should guide a nurse in managing the delivery of oxygen to an elderly client with emphysema? 1. O2 should be high (6-8 L) since hypoxemia is the stimulus to breathe. 2. O2 should be high since the stimulus to breathe is the high PCO2. 3. O2 should be low (2-3 L) since the stimulus to breathe is the low PO2. 4. O2 should be low since the stimulus to breathe is the high PCO2

3 Answer 1 is incorrect because setting the O2 level above 2 to 3 L will diminish the stimulus to breathe. Answer 2 is incorrect because the stimulus to breathe in a client with COPD is the low PO2. Answer 3 is correct because the client with emphysema (COPD) will stop breathing if O2 is set too high. Answer 4 is incorrect because the stimulus to breathe in the client with COPD is not CO2 but a low PO2.

A client with a diagnosis of asthma is admitted to the hospital with respiratory distress. Which type of adventitious lung sounds should the nurse expect to hear when performing a respiratory assessment on this client? 1. Stridor 2. Crackles 3. Wheezes 4. Diminished

3 Asthma is a respiratory disorder characterized by recurring episodes of dyspnea, constriction of the bronchi, and wheezing. Wheezes are described as high-pitched musical sounds heard when air passes through an obstructed or narrowed lumen of a respiratory passageway. Stridor is a harsh sound noted with an upper airway obstruction and often signals a life-threatening emergency. Crackles are produced by air passing over retained airway secretions or fluid, or the sudden opening of collapsed airways. Diminished lung sounds are heard over lung tissue where poor oxygen exchange is occurring.

Which finding should a nurse expect when completing an assessment on a client with chronic bronchitis? 1. Minimal sputum with cough 2. Pink, frothy sputum 3. Barrel chest 4. Stridor on expiration

3 Barrel chest is indicative of a client with chronic bronchitis because of lung hyperinflation. Pink, frothy sputum is indicative of pulmonary edema. Minimal sputum with cough is more indicative of emphysema than chronic bronchitis, which usually is characterized by copious secretions. Stridor indicates some type of upper respiratory edema that would not be an expected finding in this scenario.

133. Which of the following interventions should the nurse anticipate in a client who has been diagnosed with acute respiratory distress syndrome (ARDS)? ■ 1. Tracheostomy. ■ 2. Use of a nasal cannula. ■ 3. Mechanical ventilation. ■ 4. Insertion of a chest tube.

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

A pediatric nurse is providing discharge instructions to the parents of an infant with a history of hypoxemia. The nurse teaches the parents about the signs and symptoms associated with hypoxemia. Which signs or symptoms should prompt the parents to notify the practitioner immediately? 1. Weight loss or gain 2. Excessive crying 3. Dehydration and respiratory infection 4. Not achieving developmental milestones

3 Hypoxemia is decreased oxygen concentration of arterial blood. Dehydration can increase the risk of stroke in hypoxemic children. Respiratory infection may compromise pulmonary function and increase an infant's hypoxemia. Weight changes, excessive crying, or concerns over developmental milestones should be reported to the practitioner but often are not immediate concerns.

A client learning about chronic obstructive pulmonary disease self-care at a community health class, asks a nurse why the participants are being taught about the "lip-breathing." The nurse should respond by explaining that pursed-lip breathing can help to: 1. reduce upper airway inflammation. 2. reduce anxiety through humor. 3. strengthen respiratory muscles. 4. increase effectiveness of inhaled medications.

3 Pursed-lip breathing increases the strength of respiratory muscles and helps to keep alveoli open. It does not have an affect on upper airway inflammation, provide humor therapy, and is not a part of medication administration.

A client with acute respiratory distress syndrome has a prescription to be placed on a continuous positive airway pressure (CPAP) face mask. The nurse implements which of the following for this procedure to be most effective? 1 Obtains baseline arterial blood gases 2 Obtains baseline pulse oximetry levels 3 Applies the mask to the face with a snug fit 4 Encourages the client to remove the mask frequently for coughing and deep breathing exercises

3 The CPAP face mask must be applied over the nose and mouth with a snug fit, which is necessary to maintain positive pressure in the client's airways. The nurse obtains baseline respiratory assessments and arterial blood gases to evaluate the effectiveness of therapy, but these are not done to increase the effectiveness of the procedure. A disadvantage of the CPAP face mask is that the client must remove it for coughing, eating, or drinking. This removes the benefit of positive pressure in the airway each time it is removed.

A client with acute respiratory distress syndrome is intubated and placed on a ventilator. What should the nurse do when caring for this client and the mechanical ventilator? 1. Regulate the PEEP according to the rate and depth of the client's respirations. 2. Deflate the cuff on the endotracheal tube for a few minutes every one to two hours. 3. Assess the need for suctioning when the high-pressure alarm of the ventilator is activated. 4. Adjust the temperature of fluid in the humidification chamber, depending on the volume of gas delivered.

3 The high-pressure alarm signifies increased pressure in the tubing or the respiratory tract; obstruction usually is caused by excessive secretions. 1 This is a dependent function of the nurse and cannot be implemented without a health care provider 's order. 2 High-volume, low-pressure cuffs make this unnecessary; it will decrease the effectiveness of the ventilator and compromise respiratory status. 4 The temperature can remain constant, usually at about 5° F to 10° F below body temperature.

A client with chronic obstructive pulmonary disease (COPD) is in the third postoperative day following right-sided thoracotomy. During the day shift, the client has required 10 L oxygen by mask to keep his or her oxygen saturations greater than 88%. Based on this information, which action should be taken by the evening shift nurse? 1.Work to wean oxygen down to 3 L by mask 2. Call respiratory therapy for a nebulizer treatment 3. Check respiratory rate and notify the physician 4. Administer dose of ordered pain medications

3 The night shift nurse should check the client's respiratory rate and report abnormal findings to the physician. Although uncommon, clients with COPD on high flow oxygen can lose their respiratory drive. Working to wean down oxygen by mask below 3 L will cause retention of CO2; oxygen by mask generally should be set at 4 L or greater. Although a nebulizer and pain medications may assist the client, the immediate need is to determine if the high flow oxygen is affecting the client's respiratory drive and to further determine the cause of the low oxygen saturations.

Zafirlukast (Accolate) is prescribed for a client with bronchial asthma. Which laboratory test does the nurse expect to be prescribed before the administration of this medication? 1. Platelet count 2. Neutrophil count 3. Liver function tests 4. Complete blood count

3 Zafirlukast (Accolate) is a leukotriene receptor antagonist used in the prophylaxis and long-term treatment of bronchial asthma. Zafirlukast is used with caution in clients with impaired hepatic function. Liver function laboratory tests should be performed to obtain a baseline, and the levels should be monitored during administration of the medication.

An adolescent complains of chest pain and goes to the school nurse. The nurse determines that the teenager has a history of asthma but has had no problems for years. Which of the following should the nurse do next? ■ 1. Call the adolescent's parent. ■ 2. Have the adolescent lie down for 30 minutes. ■ 3. Obtain a peak fl ow reading. ■ 4. Give two puffs of a short-acting bronchodilator

3. Complaints of chest pain in children and adolescents are rarely cardiac. With a history of asthma, the most likely cause of the chest pain is related to the asthma. Therefore, the nurse should check the adolescent's peak fl ow reading to evaluate the status of the air fl ow. Calling the adolescent's parent would be appropriate, but this would be done after the nurse obtains the peak fl ow reading and additional assessment data. Having the adolescent lie down may be an option, but more data need to be collected to help establish a possible cause. Because the adolescent has not experienced any asthma problems for a long time, it would be inappropriate for the nurse to administer a short-acting bronchodilator at this time.

After discussing asthma as a chronic condition, which of the following statements by the father of a child with asthma best refl ects the family's positive adjustment to this aspect of the child's disease? ■ 1. "We try to keep him happy at all costs; otherwise, he has an asthma attack." ■ 2. "We keep our child away from other children to help cut down on infections." ■ 3. "Although our child's disease is serious, we try not to let it be the focus of our family." ■ 4. "I'm afraid that when my child gets older, he won't be able to care for himself like I do."

3. Positive adjustment to a chronic condition requires placing the child's illness in its proper perspective. Children with asthma need to be treated as normally as possible within the scope of the limitations imposed by the illness. They also need to learn how to manage exacerbations and then resume as normal a life as possible. Trying to keep the child happy at all costs is inappropriate and can lead to the child's never learning how to accept responsibility for behavior and get along with others. Although minimizing the child's risk for exposure to infections is important, the child needs to be with his or her peers to ensure appropriate growth and development. Children with a chronic illness need to be involved in their care so that they can learn to manage it. Some parents tend to overprotect their child with a chronic illness. This overprotectiveness may cause a child to have an exaggerated feeling of importance or later, as an adolescent, to rebel against the overprotectiveness and the parents

When preparing the teaching plan for the mother of a child with asthma, which of the following should the nurse include as signs to alert the mother that her child is having an asthma attack? ■ 1. Secretion of thin, copious mucus. ■ 2. Tight, productive cough. ■ 3. Wheezing on expiration. ■ 4. Temperature of 99.4° F (37.4° C).

3. The child who is experiencing an asthma attack typically demonstrates wheezing on expiration initially. This results from air moving through narrowed airways secondary to bronchoconstriction. The child's expiratory phase is normally longer than the inspiratory phase. Expiration is passive as the diaphragm relaxes. During an asthma attack, secretions are thick and are not usually expelled until the bronchioles are more relaxed. At the beginning of an asthma attack the cough will be tight but not productive. Fever is not always present unless there is an infection that may have triggered the attack.

12- year-old client with asthma is receiving I.V. hydrocortisone, ampicillin, and theophylline. The client vomits after breakfast and lunch, is very irritable, and has a heart rate of 120 beats/minute. The nurse should: ■ 1. Offer small amounts of clear liquids. ■ 2. Inform the primary health care provider that the child is having an allergic reaction to the ampicillin. ■ 3. Hold the next dose of theophylline and inform the primary health care provider of the vomiting. ■ 4. Administer oxygen to decrease the heart rate.

3. The therapeutic level of theophylline is 10 to 20 mcg/m. A toxic level of theophylline can cause vomiting, irritability, headache, and tachycardia. Oral rehydration may be helpful if the vomiting had created enough of a fl uid volume defi cit to elevate the heart rate, but this is unlikely since the client has an I.V. Allergic reactions to ampicillin usually include rash, urticaria, respiratory distress, and hypotension, not tachycardia and vomiting. Although the child's heart rate could indicate hypoxia, none of the other signs indicate a need for oxygen.

A client who has been taking fl unisolide (AeroBid), two inhalations a day, for treatment of asthma. has painful, white patches in his mouth. Which response by the nurse would be most appropriate? ■ 1. "This is an anticipated adverse effect of your medication. It should go away in a couple of weeks." ■ 2. "You are using your inhaler too much and it has irritated your mouth." ■ 3. "You have developed a fungal infection from your medication. It will need to be treated with an antifungal agent." ■ 4. "Be sure to brush your teeth and fl oss daily. Good oral hygiene will treat this problem."

3. Use of oral inhalant corticosteroids such as fl unisolide (AeroBid) can lead to the development of oral thrush, a fungal infection. Once developed, thrush must be treated by antifungal therapy; it will not resolve on its own. Fungal infections can develop even without overuse of the corticosteroid inhaler. Although good oral hygiene can help prevent development of a fungal infection, it cannot be used alone to treat the problem.

A nurse is performing a respiratory assessment on a client being treated for an asthma attack. The nurse determines that the client's respiratory status is worsening if which of the following occurs? 1 Loud wheezing 2 Wheezing on expiration 3 Noticeably diminished breath sounds 4 Wheezing during inspiration and expiration

3Noticeably diminished breath sounds are an indication of severe obstruction and impending respiratory failure. Wheezing is not a reliable manifestation to determine the severity of an asthma attack. Clients with minor attacks may experience loud wheezes, whereas others with severe attacks may not wheeze. The client with severe asthma attacks may have no audible wheezing because of the decrease of airflow. For wheezing to occur, the client must be able to move sufficient air to produce breath sounds. Wheezing usually occurs first on expiration. As the asthma attack progresses, the client may wheeze during both inspiration and expiration.

A 4-year-old child is hospitalized and diagnosed with mild intermittent asthma. Oxygen is ordered via simple facemask. A nurse should plan to instruct the parents that which items can be harmful while oxygen is being administered? 1. Plastic blocks and handheld toys 2. Electronic educational toys and books 3. Cotton-filled toys and clothing 4. Synthetic toys and clothing

4 Synthetic toys and clothing are restricted during oxygen use because these items can build up static electricity, create a spark, and start a fire. Plastic blocks, handheld toys, electronic toys, books, cotton-filled toys, and clothing are safe and entertaining toys to provide children while they are receiving oxygen therapy.

Following an unrestrained motor vehicle crash, a client presents to an emergency department with multiple injuries, including chest trauma. A physician notifies the care team that the client has progressed to acute respiratory distress syndrome (ARDS) and requests that the family be updated on the client's condition. The nurse should plan to discuss with the family that: 1. the condition generally stabilizes with positive prognosis. 2. the client can be discharged with home oxygen. 3. the condition is always fatal. 4. the condition is highly life-threatening and that end-of-life concerns should be addressed.

4 ARDS has a reported mortality rate of 50% to 70% and family should be prepared for the possibility that their loved one may not survive the injury or diagnosis. The nurse must be able to discuss the care to be given, the progression of the syndrome, and make appropriate referrals as needed (such as pastoral care). The condition often does not have a positive prognosis and, if the client survives, home oxygen may or may not be needed. ARDS is not always fatal.

A 3-year-old child is brought to an emergency department with acute pulmonary edema. The child was seen in an emergency department 48 hours earlier for a near-drowning incident. Treatment was provided at that time, and the child was monitored and discharged home. Current chest radiography indicates diffuse bilateral infiltrates. There is no history of cardiopulmonary disease. Which pulmonary dysfunctions should a nurse think about when assessing the child? 1. Foreign body aspiration 2. Aspiration pneumonia 3. Bronchopneumonia 4. Acute respiratory distress syndrome

4 Acute respiratory distress syndrome is recognized in children as well as adults and has been associated with clinical conditions and injuries such as sepsis, viral pneumonia, smoke inhalation, and near drowning. It is characterized by respiratory distress and hypoxemia occurring within 72 hours of the injury. Foreign body aspiration occurs when any solid or liquid substance is inhaled into the respiratory tract. It is common in infants and young children and can present in life-threatening acute situations. Aspiration pneumonia is caused by aspiration of meconium or amniotic fluids during the birth process. Bronchopneumonia is often basilar, affects the lower lobes of the lungs, and is often nosocomial or community acquired.

child with asthma is being discharged to home and has an order for a bronchodilator (albuterol) to be administered via a metered dose inhaler (MDI). Which point should a nurse address for appropriate administration of this medication? 1. When administering medication via a MDI, avoid shaking the canister before discharging the medication. 2. Medication is ordered in two "puffs"; press on the canister twice in succession to discharge the medication. 3. There should be a tight seal around the mouthpiece of the inhaler before discharging the medication. 4. There should be a 2- to 3-inch space (or spacer device) between the inhaler and the open mouth of the child.

4 Children often have difficulty learning to depress and inhale their medications at the same time, and holding the MDI 2 to 3 inches away from the mouth or utilizing a "spacer" (an attachable device that provides space and contains the medication in a confined area) improves the effects of the medication. Shaking the MDI canister well before use supplies a better delivery of the aerosolized medication. When using two "puffs" of medication, waiting 1 minute between puffs allows for better absorption of the inhaled medication. When using inhaled medications via an MDI, the client should be instructed that wrapping the lips tightly around the mouthpiece consolidates the medication in the buccal cavity and decreases the effectiveness of inhaled medications.

A nurse is caring for a 5-year-old child diagnosed with bronchial asthma. Which statement is most important for the nurse to make when teaching the parents? 1. "Bronchial asthma is also called hyperactive airway disease." 2. "Frequent occurrences of bronchiolitis before 5 years of age could be a sign of asthma." 3. "Severe respiratory alkalosis can result from respiratory failure in asthma." 4. "Severe bronchoconstriction can occur when exposed to cold air and irritating odors."

4 Children with asthma can have sensitization to inhalant antigens such as pollens, molds, house dust, food, and exposure to cold air or irritating odors, such as turpentine, smog, or cigarette smoke. Although bronchial asthma is also called hyperactive airway disease, this is not the most important statement. Asthma tends to occur initially before 5 years of age, but in the early years it may be diagnosed as bronchiolitis rather than asthma. Severe respiratory acidosis, not alkalosis, can result from respiratory failure in asthma.

A cromolyn sodium inhaler is prescribed for a client with allergic asthma. The nurse provides instructions regarding the side and adverse effects of this medication and should tell the client that which undesirable effect is associated with this medication? 1. Insomnia 2. Constipation 3. Hypotension 4. Bronchospasm

4 Cromolyn sodium is an inhaled nonsteroidal antiallergy agent and a mast cell stabilizer. Undesirable effects associated with inhalation therapy of cromolyn sodium are bronchospasm, cough, nasal congestion, throat irritation, and wheezing. Clients receiving this medication orally may experience pruritus, nausea, diarrhea, and myalgia.

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)? 1. Chest tube insertion 2. Aggressive diuretic therapy 3. Administration of beta blockers 4. Positive end-expiratory pressure

4 Mechanical ventilation with positive end-expiratory pressure (PEEP) will help prevent alveolar collapse and improve oxygenation.

Which of the following interventions would be most likely to prevent the development of acute respiratory distress syndrome (ARDS)? ■ 1. Teaching cigarette smoking cessation. ■ 2. Maintaining adequate serum potassium levels. ■ 3. Monitoring clients for signs of hypercapnia. ■ 4. Replacing fl uids adequately during hypovolemic states.

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

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? 1. Sitting up in bed 2. Side-lying in bed 3. Sitting in a recliner chair 4. Sitting on the side of the bed and leaning on an overbed table

4 Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.

The nurse has calculated a low PaO2/FIO2 (P/F) ratio < 150 for a client with acute respiratory distress syndrome (ARDS). The nurse should place the client in which position to improve oxygenation, ventilation distribution, and drainage of secretions? ■ 1. Supine. ■ 2. Semi-fowlers. ■ 3. Lateral side. ■ 4. Prone.

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

The nurse is teaching a client with emphysema about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position that could aggravate breathing? 1. Sitting up and leaning on a table 2. Standing and leaning against a wall 3. Sitting up with the elbows resting on knees 4. Lying on the back in a low-Fowler's position

4 The client should use the positions outlined in options 1, 2, and 3. These allow for maximal chest expansion. The client should not lie on the back because it reduces movement of a large area of the client's chest wall. Sitting is better than standing, whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not posture control.

The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? 1. Bilateral wheezing 2. Inspiratory crackles 3. Intercostal retractions 4. Increased respiratory rate

4 The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.

A lightweight client, diagnosed with chronic obstructive pulmonary disease and an ulcer on the sole of the foot, slides down in bed. Pressure is being exerted to the client's foot from the bottom bed guard. Due to an emergency on the unit, no one is available to assist a nurse with repositioning the client. Which action by the nurse is best? 1. Wait until sufficient help is available to reposition the client 2. Place pillows over the bed guard and elevate both of the client's legs on the pillows 3. Place the bed in Tredelenburg's position to relieve the pressure and then wait for help 4. Use the slight Trendelenburg's position to pull the client up in bed and place the client in a Fowler's position

4 The force of gravity, created by the slight Trendelenburg's position, increases the ability to move a lightweight client up in bed safely while alone. Waiting for help delays relieving the pressure and can increase pain and tissue damage. Placing pillows over the bed guard and elevating the client's legs increases the risk of the client sliding off of the bed when unattended. Leaving the client in the Trendelenburg's position can compromise the client's respiratory status.

136. Which of the following nursing interventions would promote effective airway clearance in a client with acute respiratory distress? ■ 1. Administering oxygen every 2 hours. ■ 2. Turning the client every 4 hours. ■ 3. Administering sedatives to promote rest. ■ 4. Suctioning if cough is ineffective.

4 The nurse should suction the client if the client is not able to cough up secretions and clear the airway. Administering oxygen will not promote airway clearance. The client should be turned every 2 hours to help move secretions; every 4 hours is not often enough. Administering sedatives is contraindicated in acute respiratory distress

In reviewing the laboratory and x-ray reports of an elderly client, which findings should a nurse identify as being consistent with a diagnosis of emphysema? 1. Increased PCO2, hypoinflated alveoli, and decreased PO2 2. Decreased PCO2, decreased PO2, and decreased hematocrit. 3. Increased PCO2, hyperinflated alveoli, and decreased hematocrit. 4. Increased PCO2, increased hematocrit, and hyperinflated alveol

4. Answer 1 is incorrect because alveoli are hyper-inflated, trapping air. Answer 2 is incorrect because CO2 increases. Hypoxemia causes the body to increase red blood cell (RBC) production and hematocrit (Hct) increases. Answer 3 is incorrect because hematocrit will be increased in response to hypoxemia. Answer 4 is correct because emphysema is an obstructive pulmonary disease that traps air in the alveoli. The gas exchange is impaired as CO2 increases. The body attempts to improve oxygenation by producing more red blood cells. There are immature RBCs that result in a more sluggish circulation.

91. Which of the following is an appropriate expected outcome for an adult client with wellcontrolled asthma? ■ 1. Chest X-ray demonstrates minimal hyperinfl ation. ■ 2. Temperature remains lower than 100° F (37.8° C). ■ 3. Arterial blood gas analysis demonstrates a decrease in PaO2. ■ 4. Breath sounds are clear.

4. Between attacks, breath sounds should be clear on auscultation with good air fl ow present throughout lung fi elds. Chest X-rays should be normal. The client should remain afebrile. Arterial blood gases should be normal.

A 34-year-old female with a history of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 breaths/minute, nasal fl aring, and use of accessory muscles. Auscultation of the lung fi elds reveals greatly diminished breath sounds. Based on these fi ndings, which action should the nurse take to initiate care of the client? ■ 1. Initiate oxygen therapy and reassess the client in 10 minutes. ■ 2. Draw blood for an arterial blood gas analysis and send the client for a chest X-ray. ■ 3. Encourage the client to relax and breathe slowly through the mouth. ■ 4. Administer bronchodilators.

4. In an acute asthma attack, diminished or absent breath sounds can be an ominous sign indicating lack of air movement in the lungs and impending respiratory failure. The client requires immediate intervention with inhaled bronchodilators, I.V. corticosteroids and, possibly, I.V. theophylline (Theo-Dur). Administering oxygen and reassessing the client 10 minutes later would delay needed medical intervention, as would drawing blood for an arterial blood gas analysis and obtaining a chest X-ray. It would be futile to encourage the client to relax and breathe slowly without providing the necessary pharmacologic intervention.

The nurse is instructing the mother of a child with asthma about noting food triggers for asthma attacks. Which of the following foods would most likely be responsible for causing an allergic reaction? ■ 1. Whitefi sh. ■ 2. Tossed salad. ■ 3. Hamburger. ■ 4. Fudge brownies

4. In asthma, the airways react to certain external and internal stimuli, including allergens, infections, exercise, and emotions. Food allergens commonly associated with asthma include wheat, egg white, dairy products, citrus fruits, corn, and chocolate.

An 8-year-old child with asthma states, "I want to play some sports like my friends. What can I do?" The nurse responds to the child based on the understanding of which of the following? ■ 1. Physical activities are inappropriate for children with asthma. ■ 2. Children with asthma must be excluded from team sports. ■ 3. Vigorous physical exercise frequently precipitates an asthmatic episode. ■ 4. Most children with asthma can participate in sports if the asthma is controlled.

4. Physical activities are benefi cial to asthmatic children, physically and psychosocially. Most children with asthma can engage in school and sports activities that are geared to the child's condition and within the limits imposed by the disease. The coach and other team members need to be aware of the child's condition and know what to do in case an attack occurs. Those children who have exercise-induced asthma usually use a short-acting bronchodilator before exercising. CN: Health promotion and

A woman who has had asthma since she was a child and it is under control when the client takes her medication correctly and consistently is now pregnant for the fi rst time. Which of the following client statements concerning asthma during pregnancy indicates the need for further instruction? ■ 1. "I need to continue taking my asthma medication as prescribed." ■ 2. "It is my goal to prevent or limit asthma attacks." ■ 3. "During an asthma attack, oxygen needs continue to be high for mother and fetus." ■ 4. "Bronchodilators should be used only when necessary because of the risk they present to the fetus."

44 Asthma medications and bronchodilators should be continued during pregnancy as prescribed before the pregnancy began. The medications do not cause harm to the mother or fetus. Regular use of asthma medication will usually prevent asthma attacks. Prevention and limitation of an asthma attack is the goal of care for a client who is or is not pregnant and is the appropriate care strategy. During an asthma attack, oxygen needs continue as with any pregnant client but the airways are edematous, decreasing perfusion. Asthma exacerbations during pregnancy may occur as a result of infrequent use of medication rather than as a result of the pregnancy

A client is on the ventilator due to a diagnosis of acute respiratory distress syndrome (ARDS). Which assessment finding is most indicative of a complication? A. Diminished breath sounds on auscultation B. Deviation of the trachea C. Weight gain D. Decreased urine output

B A deviated trachea is indicative of a tension pneumothorax associated with noncompliant lungs (as with ARDS) being ventilated at a higher pressure than the lung can tolerate. This requires immediate intervention by the physician. A is incorrect—Diminished breath sounds are common in the client with ARDS due to decrease lung compliance and collapsed alveoli. C is incorrect—While weight gain may occur in ARDS, it is not the most indicative sign of a complication. D is incorrect—Although decreased urinary output is a problem and needs to be addressed, it is not the most indicative sign of a complication.

A nurse should know that the oxygen flow rate set for clients with emphysema is usually low because: 1. Low flow rates enhance ventilation-perfusion (V/Q) ratios. 2. Higher flow rates can depress the hypoxic drive. 3. Low flow rates are palliative and relieve anxiety. 4. O2 prevents compensatory respiratory alkalosis.

CORRECT ANSWER: 2. Answer 1 is incorrect because the V/Q abnormality is related to the disease process and cannot be corrected with O2. Answer 2 is correct because clients with emphysema suffer from chronically high CO2 levels, so the normal CO2 stimulus is ineffective. The stimulus is the low O2—a hypoxic drive. Answer 3 is incorrect because it does not answer the question. Supplemental O2 is not curative; it does make the client feel better, which may be palliative, but the choice of a flow rate is purposeful. Answer 4 is incorrect because the compensation that occurs in response to respiratory acidosis is a metabolic alkalosis.

Oxygen therapy is ordered to assist the client with breathing. Which principle should guide a nurse in managing the delivery of oxygen to an elderly client with emphysema? 1. O2 should be high (6-8 L) since hypoxemia is the stimulus to breathe. 2. O2 should be high since the stimulus to breathe is the high PCO2. 3. O2 should be low (2-3 L) since the stimulus to breathe is the low PO2. 4. O2 should be low since the stimulus to breathe is the high PCO2

CORRECT ANSWER: 3. Answer 1 is incorrect because setting the O2 level above 2 to 3 L will diminish the stimulus to breathe. Answer 2 is incorrect because the stimulus to breathe in a client with COPD is the low PO2. Answer 3 is correct because the client with emphysema (COPD) will stop breathing if O2 is set too high. Answer 4 is incorrect because the stimulus to breathe in the client with COPD is not CO2 but a low PO2.

client is admitted to the emergency room with a diagnosis of acute respiratory distress syndrome. Which assessment findings would the nurse expect? A. A systolic blood pressure greater than 170 B. Tenacious thick greenish yellow sputum C. An altered level of consciousness D. Slow abdominal breathing

Cognition and level of consciousness are reduced secondary to cerebral hypoxia which accompanies ARDS. Blood pressure may be reduced. Sputum is not tenacious, but may be frothy if pulmonary edema is present. Breathing will be rapid and shallow not slow and abdominal

When assessing a client with fractured ribs, which ABG values would be expected? a. PaO2 89 mm Hg, PaCO2 41 mm Hg b. PaO2 101 mm Hg, PaCO2 50 mm Hg c. PaO2 94 mm Hg, PaCO2 35 mm Hg d. PaO2 76 mm Hg, PaCO2 48 mm Hg

D Hypoxemia and Hypercapnia are expected. Hypoxemia is reflected in the PaO2 (partial pressure of oxygen dissolved in the blood), the normal value of which is 80-100 mmHg. Hypercapnia is reflected in the PaCO2 whose normal range is 35-45 mm Hg.

Which laboratory results are consistent with long term COPD? Mark all that apply. a. Erythrocytosis b. Hypoxemia c. Hypercapnia d. Leukopenia

abc COPD is characterized by a decrease in oxygen and increase in carbon dioxide so hypoxemia and hypercapnia are expected. Erythrocytosis or an increase in RBCs also occurs as a compensatory effort to maintain tissue oxygenation. It is frequently seen as PaO2 levels fall below 55 mm Hg.