Med surg: Prep u's Management of Patients with Chest and Lower Respiratory Tract Disorder
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at greatest risk for developing pneumonia?
A client with a nasogastric tube
A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for
A kink in the ventilator tubing
The ICU nurse caring for a 2-year-old near drowning victim monitors for what possible complication?
Acute respiratory distress syndrome
The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?
Acute respiratory distress syndrome
Which of the following is a potential complication of a low pressure in the endotracheal cuff?
Aspiration pneumonia
How should the nurse best assess whether a client receiving oxygen therapy is hypoxemic?
Assess the client using pulse oximetry
A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?
Auscultate the lung for adventitious sounds
For a client with an endotracheal (ET) tube, which nursing action is the most important?
Auscultating the lungs for bilateral breath sounds
A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?
Blood-tinged sputum
The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined?
Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?
Dyspnea and wheezing
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
Hypercapnia, hypoventilation, and hypoxemia
A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first?
Initiate oxygen therapy
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily?
Intubate the client and control breathing with mechanical ventilation
The critical care nurse is precepting a new nurse on the unit. Together they are caring for a client who has a tracheostomy tube and is receiving mechanical ventilation. What action should the critical care nurse recommend when caring for the cuff?
Monitor the pressure in the cuff at least every 8 hours
The nurse is caring for a client who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning, the nurse should anticipate that the weaning of the client will progress in what order?
Removal from the ventilator, tube, and then oxygen
A nurse is weaning a client from mechanical ventilation. Which nursing assessment finding indicates the weaning process should be stopped?
Runs of ventricular tachycardia
The home care nurse is visiting a client newly discharged home after a lobectomy. What would be most important for the home care nurse to assess?
Signs and symptoms of respiratory complications
A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?
To remove air from the pleural space
The nurse caring for a client with tuberculosis anticipates administering which vitamin with isoniazid (INH) to prevent INH-associated peripheral neuropathy?
Vitamin B6
