Med/Surg: Respiratory
1 Keep suction apparatus readily available in case excessive respiratory secretions occur. Initial attempts at oral feeding may cause a choking feeling that may produce severe coughing that raises secretions. Effective coughing is difficult because with a laryngectomy there is no glottis to close to assist with an expulsive cough. Excessive secretions may block the airway and must be removed by suctioning. Swallowing does not have an adverse effect on the suture line; a nasogastric tube is not used because it can traumatize the suture line. A progressive diet is started with liquids, not pureed foods. Airway patency is the priority, not administering medication for pain.
Several days after a client had a total laryngectomy, the health care provider prescribes a progressive diet as tolerated. What should the nurse do? 1 Keep suction apparatus readily available in case excessive respiratory secretions occur. 2 Administer the diet through a nasogastric tube until the suture line heals. 3 Encourage intake of pureed foods to help promote the swallowing reflex. 4 Administer the prescribed pain medication before meals to limit discomfort.
3 "Tell me more about the conversation you had with your health care provider. Exploration and collection of data are important parts of the therapeutic process; anxiety, fear, and depression can influence understanding. The response "Your perception of the diagnostic test is incorrect" will put the client on the defensive. Instructing the client to ask the health care provider to clarify the procedure is not the priority; at this point, the nurse should collect more data. The response "The procedure will be fast so that you will experience minimal discomfort" is false reassurance. Test-Taking Tip: Avoid selecting answers that state hospital rules or regulations as a reason or rationale for action.
A client has a persistent productive cough that becomes blood tinged. A needle biopsy is scheduled. The client tells the nurse, "During the procedure, a needle will be inserted into my back to collapse my lung." Which is the most appropriate response by the nurse? 1 "Your perception of the diagnostic test is incorrect." 2 "I will ask the primary health care provider to clarify the diagnostic procedure." 3 "Tell me more about the conversation you had with your health care provider." 4 "The procedure will be fast so that you will experience minimal discomfort."
4 A sore throat." A general anesthetic is delivered via an endotracheal tube that irritates the posterior pharynx and larynx. Side effects of general anesthesia do not include transient headaches or an elevated temperature. Hiccoughs, headaches, and an elevated temperature are systemic effects, not local effects, and are not side effects of general anesthesia Test-Taking Tip: Identify option components as correct or incorrect. This may help you identify a wrong answer. Example: If you are being asked to identify a diet that is specific to a certain condition, your knowledge about that condition would help you choose the correct response (e.g., cholecystectomy = low fat, high protein, low-calorie diet ).
A client is scheduled to receive general anesthesia during an upcoming surgery. The nurse provides education about common side effects of general anesthesia. The nurse concludes that the teaching has been effective when the client states, "Immediately after surgery I may experience: 1 Transient headaches." 2 An elevated temperature." 3 Paroxysmal hiccoughs." 4 A sore throat."
4 Right side-lying Lying on the affected right side increases drainage from the pleural space and allows the unaffected lung to expand to the fullest extent. The supine position is undesirable because this may not allow the unaffected lung to fully expand and provide maximum oxygenation. The left Sims position is undesirable because this may not allow the unaffected lung to fully expand and provide maximum oxygenation. Immobilization promotes stasis of respiratory secretions. The client should be encouraged to perform deep breathing and coughing exercises and periodically move around in bed.
A client has a chest tube inserted to treat a right hemopneumothorax. In which position should the nurse place the client to facilitate chest drainage? 1 Supine 2 Left Sims 3 Immobilized 4 Right side-lying
4 Tachycardia The heart rate increases in an attempt to compensate for the lack of oxygen to body cells. Tremors are not associated with respiratory distress; tremors are associated with neurological problems. Severe generalized edema (anasarca) is not associated with respiratory distress; anasarca is associated with renal failure. An increased respiratory rate (tachypnea), not a decreased respiratory rate (bradypnea), is associated with respiratory distress. STUDY TIP: Regular exercise, even if only a 10-minute brisk walk each day, aids in reducing stress. Although you may have been able to enjoy regular sessions at the health club or at an exercise class several times a week, you now may have to cut down on that time without giving up a set schedule for an exercise routine. Using an exercise bicycle that has a book rack on it at home, the YMCA, or a health club can help you accomplish two goals at once. You can exercise while beginning a reading assignment or while studying notes for an exam. Listening to lecture recordings while doing floor exercises is another option. At least a couple of times a week, however, the exercise routine should be done without the mental connection to school; time for the mind to unwind is necessary, too.
A client is experiencing severe respiratory distress. What response should the nurse expect the client to exhibit? 1 Tremors 2 Anasarca 3 Bradypnea 4 Tachycardia
1 Immediately contact the primary health care provider The observation may be indicative of bleeding and the health care provider should be notified. Overlooking the first signs of hemorrhage may permit the client to go into shock. Continuing only to monitor the client is unsafe. Monitoring vital signs every hour for four hours is a potentially life-threatening situation; the health care provider should be notified immediately. Increasing the coughing and deep breathing regimen can precipitate bleeding because of an increase in intrathoracic pressure.
A client with a history of hemoptysis and cough for the last six months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. The nurse's priority is to: 1 Immediately contact the primary health care provider 2 Document the amount of sputum 3 Monitor vital signs every hour 4 Increase the frequency of coughing and deep breathing
1 Use a humidifier in the bedroom A humidifier will help liquefy secretions and promote their expectoration. Sleeping on pillows facilitates breathing; it does not relieve chest congestion. Nonproductive coughing should be avoided because it is irritating and exhausting. Deep breathing and coughing at night will not help relieve early morning congestion.
A client with chronic obstructive pulmonary disease (COPD) reports chest congestion, especially upon wakening in the morning. The nurse should suggest that the client: 1 Use a humidifier in the bedroom 2 Sleep with two or more pillows 3 Cough regularly even if the cough does not produce sputum 4 Cough and deep breathe each night before going to sleep
1 Policies of the agency establish the status of DNR orders Policies relative to DNR orders vary among hospitals and the nurse must adhere to the policies of the institution. The policies of an institution generally reflect the parameters of DNR orders associated within the state. Age is not the important factor in the decision not to resuscitate; the wish of the client is the deciding factor. The decision regarding a DNR order resides with the client, not the health care provider. Although rules associated with DNR orders may vary from state to state and agency to agency, a client has the right to add or rescind a DNR order.
A client with terminal cancer signs a do-not-resuscitate (DNR) order upon admission to the hospital. When the client goes into respiratory arrest a week later, the client is not resuscitated. Which factor does the nurse determine is most relevant to the legal aspects of a DNR order? 1 Policies of the agency establish the status of DNR orders 2 Age is an important factor in the decision not to resuscitate 3 Decisions regarding resuscitation reside with the client's primary health care provider 4 Once a DNR order is signed, it remains in force for the entire hospitalization
3 On Awakening During sleep, mucous secretions in the respiratory tract move slowly toward the throat. On awakening, increased ciliary motion raises these secretions more vigorously, thus facilitating expectoration and the collection of sputum specimens. Although activity mobilizes secretions, no secretions may be present at the time of activity; sputum is most plentiful upon arising. The sputum may leave an unpleasant taste in the mouth, which may interfere with appetite. Sputum more likely would be collected after, not before, a respiratory treatment, because this mobilizes secretions.
A health care provider prescribes daily sputum specimens to be collected from a client. When is the most appropriate time for the nurse to collect these specimens? 1 After activity 2 Before meals 3 On Awakening 4 Before a respiratory treatment
1 Cardiac problems COPD causes increased pressure in the pulmonary circulation. The right side of the heart hypertrophies (cor pulmonale), causing right ventricular heart failure. The skeletal system is not directly related to the pulmonary system; joint inflammation does not occur because of COPD. Kidney dysfunction is not as closely related to the pulmonary system as is the cardiac system; kidney problems usually do not occur because of COPD. Peripheral nerves are not as closely related to the pulmonary system as to the cardiac system; peripheral neuropathy does not occur because of COPD.
A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are associated most commonly with COPD? 1 Cardiac problems 2 Joint inflammation 3 Kidney dysfunction 4 Peripheral neuropathy
2 Gas exchange P. jiroveci , now believed to be a fungus, causes pneumonia in immunosuppressed hosts; it can cause death in 60% of the clients. The client's respiratory status is the priority. Although skin integrity, social isolation, and nutritional status are a concern, the client's respiratory status is the priority. Test-Taking Tip: Because few things in life are absolute without exceptions, avoid selecting answers that include words such as always, never, all, every, and none. Answers containing these key words are rarely correct.
In addition to Pneumocystis jiroveci, a client with acquired immunodeficiency syndrome (AIDS) also has an ulcer 4 cm in diameter on the leg. Considering the client's total health status, the most critical concern is: 1 Skin integrity 2 Gas exchange 3 Social isolation 4 Nutritional status
3 Crackles are located in the smaller air passages. Fine crackles (sometimes called rales) are the sounds of fluid bubbling within the smaller airways and alveoli, usually attributable to pulmonary edema. Pleural rubbing causes a sound with a grating quality heard over the anterolateral area of the chest; it is attributable to decreased pleural lubrication. Bronchial constriction causes rhonchi or wheezes. Crackles are heard during inspiration.
The nurse auscultates fine crackles in a client who has been in respiratory distress. When the nurse is providing information to the client about crackles, which would be appropriate to include? 1 They are indicative of pleural rubbing. 2 They are signs of bronchial constriction. 3 Crackles are located in the smaller air passages. 4 Crackles are heard during respiratory expiration.
2 "I will maintain complete bed rest." Although energy should be conserved, it is not necessary to restrict all activity; the client needs further teaching. Smoking should be avoided because it is a respiratory tract irritant and it interferes with gas exchange in the alveoli. Extremes in environmental temperature and humidity place stress on the respiratory system, interfering with gaseous exchange. Meticulous oral care is advisable because of the presence of excessive mucus; also, it reduces the amount of microorganisms that can enter the tracheobronchial tree, which can precipitate infection.
The nurse provides teaching about self-care management to a client who recently was diagnosed with emphysema. The nurse concludes that further teaching is needed when the client states: 1 "I will try to avoid smoking." 2 "I will maintain complete bed rest." 3 "I'll control the temperature in my home." 4 "I'll need to clean my mouth several times a day"
4 Nonrebreather mask The expected value of a pulse oximetry reading is 95% to 100%. Nonrebreather mask will deliver high oxygen concentrations (95% to 100%) at a liter flow of 10 to 15 L/min. When using a nonrebreather mask, the client breathes only the oxygen source from the bag. A face tent delivers 30% to 50% oxygen when set at a flow rate of 4 to 8 L/min. A Venturi mask delivers 24% to 50% oxygen when set at a flow rate of 4 to 10 L/min. A nasal cannula delivers 24% to 45% oxygen when set at a flow rate of 2 to 6 L/min.
Which method of oxygen delivery should a nurse anticipate will be prescribed for a client with a pulse oximetry reading of 65%? 1 Face tent 2 Venturi mask 3 Nasal cannula 4 Nonrebreather mask
2 Excessive swallowing Internal bleeding after nasal surgery may flow by gravity to the posterior oropharynx, where it is swallowed. Facial edema is expected after the trauma of surgery. The edema that results from the trauma of surgery may be perceived as pressure around the eye; although it is expected, it is not a priority. Pink-tinged drainage on the nasal packing and nasal drip dressing is expected for 24 to 48 hours after surgery.
A client is admitted for a rhinoplasty. To monitor for hemorrhage after the surgery, the nurse should assess specifically for the presence of: 1 Facial edema 2 Excessive swallowing 3 Pressure around the eyes 4 Serosanguineous drainage on the dressing
4 Increased erythrocyte production as a result of chronic hypoxia Hypoxia stimulates production of large quantities of erythrocytes in an attempt to compensate for the lack of oxygen. White blood cell production increases with infection; infection is not the cause of the increase in the hemoglobin and hematocrit. There is a loss of extracellular fluid in an acute infection with a fever; however, in a chronic condition, this fluid is replenished and the hematocrit usually is unaffected. Hypercapnia is an increase in PCO2 in extracellular fluid; this does not have a direct effect on the hemoglobin and hematocrit levels.
A client with chronic obstructive pulmonary disease has increased hemoglobin and hematocrit levels. The nurse concludes that the altered blood levels are caused by: 1 Increased leukocyte development in response to infection 2 Decreased extracellular fluid volume secondary to infection 3 Decreased red blood cell proliferation because of hypercapnia 4 Increased erythrocyte production as a result of chronic hypoxia
4 Difficulty in expelling the air trapped in the alveoli Emphysema involves destructive changes in the alveolar walls, leading to dilation of the air sacs; there is subsequent air trapping and difficulty with expiration. Bronchospasm is characteristic of asthma, not emphysema. The vital capacity is decreased because of restriction of the diaphragm and thoracic movement. Expiration is slowed by pursed-lip breathing to keep the airways open so less air is trapped.
A client with emphysema experiences shortness of breath and uses pursed-lip breathing and accessory muscles of respiration. The nurse determines that the cause of the dyspnea is: 1 Spasm of the bronchi that traps the air 2 Increase in the vital capacity of the lungs 3 Too rapid expulsion of the air from the alveoli 4 Difficulty in expelling the air trapped in the alveoli
3 Monitor oxygen saturation levels when eating. Because the mask cannot be worn when eating, the client may become hypoxic. A nasal cannula may be needed to deliver oxygen while the client is eating. Nasal drying usually is not a problem with the use of a Venturi mask. Nasal drying occurs more frequently when a nasal cannula is used. Too tight a fit is uncomfortable and may cause damage to the skin. The mask should fit snugly, but not be too tight. The oxygen should be set at the level prescribed by the health care provider.
A nurse is caring for a client with severe dyspnea who is receiving oxygen via a Venturi mask. What should the nurse do when caring for this client? 1 Assess frequently for nasal drying. 2 Keep the mask tight against the face. 3 Monitor oxygen saturation levels when eating. 4 Set the oxygen flow at the highest setting possible.
1 Obese client with leg trauma An obese client with leg trauma has two risk factors for the development of pulmonary embolism: obesity and leg trauma. A pregnant client with acute asthma has one risk factor for the development of pulmonary embolism: pregnancy. A client with diabetes who has cholecystitis has one risk factor for the development of pulmonary embolism: diabetes. A client with pneumonia who is immunocompromised has no risk factors for the development of pulmonary embolism.
A nurse is caring for a group of clients on a medical-surgical unit. Which client has the highest risk for developing a pulmonary embolism? 1 Obese client with leg trauma 2 Pregnant client with acute asthma 3 Client with diabetes who has cholecystitis 4 Client with pneumonia who is immunocompromised
4 Reporting surveillance findings to appropriate public health officials Honesty and openness are essential to understanding the extent of the problem so that an appropriate local and global response can be mobilized to limit emerging pandemics . Although complying with quarantine measures helps, it can only be done in response to detection and reporting of the presence of an emerging health problem. In response to the severe acute respiratory syndrome (SARS) epidemic of 2002, the International Air Transport Association began work to standardize procedures that address passenger screening and the accurate and quick tracking of passenger travel.
A nurse works with a large population of immigrant clients and is concerned about the debilitating effects of influenza. Which action is the first line of defense against an emerging influenza pandemic? 1 Complying with quarantine measures 2 Instituting strict international travel restrictions 3 Seeking aid from the international public health community 4 Reporting surveillance findings to appropriate public health officials
3 "I get a sharp, stabbing pain when I take a deep breath." Tension is placed on the pleura at the height of inspiration and causes pain. The response "Lately I can only breathe well if I sit up" is typical of heart failure. The response "During the night I sometimes get the chills" may indicate a pulmonary infection. The response "I'm coughing up larger amounts of thicker mucus for the last several days" may indicate a pulmonary infection.
After a thoracentesis for pleural effusion, a client returns to the outpatient clinic for a follow-up visit. The nurse suspects a recurrence of pleural effusion when the client says: 1 "Lately I can only breathe well if I sit up." 2 "During the night I sometimes get the chills." 3 "I get a sharp, stabbing pain when I take a deep breath." 4 "I'm coughing up larger amounts of thicker mucus for the last several days."
3 Absence of urinary output Urine should drain continually from the conduit because there is no sphincter control, unless a continent conduit is created. The stoma may be edematous for several weeks after surgery. Vomiting is a common occurrence after anesthesia. Diminished bowel sounds are expected; peristalsis is decreased because of anesthesia and the stress of intestinal manipulation during surgery.
After surgery to create an ileal conduit, a client is admitted to the postanesthesia care unit. Which clinical finding during the first hour of the postoperative period should the nurse report to the health care provider? 1 Edematous stoma 2 Episodes of vomiting 3 Absence of urinary output 4 Diminished bowel sounds
3 Kussmaul's breathing Kussmaul's breathing is an abnormally deep, very rapid, sighing type of respiratory pattern that develops as a compensatory response to metabolic acidosis and attempts to raise the pH of the blood by blowing off carbon dioxide. Dyspnea is difficult breathing associated with subjective or objective distress in response to oxygen problems. Hyperpnea is a deep, rapid rate of breathing without a subjective sense of extra effort, usually as a response to strenuous effort. Cheyne-Stokes respirations are characterized by a waxing and waning of breathing that usually is associated with pathology of the respiratory center in the brain.
The nurse is caring for a client who has metabolic acidosis as a result of severe dehydration. The type of respirations that the nurse expects the client to exhibit is: 1 Dyspnea 2 Hyperpnea 3 Kussmaul's breathing 4 Cheyne-Stokes breathing
1 Diminished breath sounds Breath sounds will be decreased in clients with COPD because of reduced airflow, pleural effusion, or lung parenchymal destruction. A pleural friction rub occurs when one layer of the pleural membrane slides over the other during breathing; this is associated with pleurisy. Crackles indicate fluid in the alveoli, which is associated with heart failure or infection; rhonchi signifies airway obstruction, not COPD. Expiratory wheezing and coughing are associated with asthma or bronchitis.
The nurse is caring for a client with chronic obstructive pulmonary disease (COPD). During assessment, the nurse expects to auscultate: 1 Diminished breath sounds 2 Pleural friction rub 3 Crackles and gurgles 4 Expiratory wheeze and cough
3 Place client in a high-Fowler position Placing the client in a high-Fowler position promotes lung expansion and gas exchange; it also decreases venous return and cardiac workload. Initiating oxygen therapy may be done, but positioning should be done first because it will have an immediate effect. Time is needed to set up the system for the delivery of oxygen. Maintaining adequate oxygen exchange is the priority; an x-ray film can be obtained, but after breathing is supported. A friction rub is related to inflammation of the pleura, not to heart failure.
The nurse's physical assessment of a client with heart failure reveals tachypnea and bilateral crackles. What is the priority nursing intervention? 1 Initiate oxygen therapy 2 Obtain a chest x-ray film immediately 3 Place client in a high-Fowler position 4 Assess the client for a pleural friction rub
4 Diaphragmatic exercises to improve contraction of the diaphragm. With emphysema the diaphragm is flattened and weakened; strengthening the diaphragm is desirable to maximize exhalation. Prolonged exhalations are more desirable; clients with emphysema have an increased residual volume, which eventually causes a barrel chest. Abdominal exercises enhance, not limit, the accessory muscles of respiration which are needed as a compensatory mechanism for clients with emphysema. Sit-ups are too strenuous for clients with emphysema.
What breathing exercises should the nurse teach a client with the diagnosis of emphysema? 1 An inhalation that is prolonged to promote gas exchange. 2 Abdominal exercises to limit the use of accessory muscles. 3 Sit-ups to help strengthen the accessory muscles of respiration. 4 Diaphragmatic exercises to improve contraction of the diaphragm.
2 Use sterile gloves when touching the inner cannula. The tracheostomy site is a portal of entry for microorganisms. Sterile gloves must be used when touching the inner cannula. The high-Fowler position promotes maximum aeration of lungs. Body temperature is not related to the suctioning procedure. Tracheostomy ties should not be removed at the same time, because this could cause the cannula to dislodge, and endanger the patient's airway.
What must the nurse do when performing tracheostomy care? 1 Place the client in the semi-Fowler position. 2 Use sterile gloves when touching the inner cannula. 3 Monitor body temperature after the procedure is completed. 4 Remove both tracheostomy ties at the same time.
4 Pulmonary embolism A pulmonary embolism is the most common complication of hip surgery because of high vascularity and the release of fat cells from the bone marrow. The occurrence of pneumonia is rare because of early activity after surgery. In addition, the operative area is not in proximity to the diaphragm and lungs; therefore, it does not impede deep breathing. Postoperative hemorrhage with hip surgery is rare because bleeding at the operative site is not covert. The incidence of wound infection is no greater than with other postoperative clients.
A client has a total hip replacement for long-standing degenerative bone disease of the hip. When assessing this client postoperatively, the nurse considers that the most common complication of hip surgery is: 1 Pneumonia 2 Hemorrhage 3 Wound infection 4 Pulmonary embolism
1 Instruct the client to splint the wound with a pillow when coughing Supporting the wound with a pillow when coughing relieves some of the pain because it provides support to the incised chest wall. Pain at the incision site when coughing and deep breathing is expected; it does not indicate a need to place the client in the supine position and to inspect the wound site. Analgesics will not relieve the discomfort associated with coughing unless stress placed on the incision by coughing is relieved. Pain at the incision site just when coughing and deep breathing is expected; it does not indicate a need to call the health care provider and then check for wound dehiscence.
A client who had thoracic surgery complains of pain at the incision site when coughing and deep breathing. What action should the nurse take? 1 Instruct the client to splint the wound with a pillow when coughing 2 Place the client in the supine position and inspect the site of the incision 3 Assess the intensity of the pain and administer the prescribed analgesic 4 Call the health care provider immediately and then check for wound dehiscence
4 Presence of a cough and pulmonary secretions Presence of a cough and pulmonary secretions, in addition to a history of rheumatic fever, require an assessment for other cardiopulmonary problems. Anorexia and weight gain do not indicate a nutritional problem but a fluid balance problem. Loss of appetite in conjunction with shortness of breath and the history of rheumatic fever make gastrointestinal symptoms secondary in importance. There is no reason to investigate the gynecological and sexual history in relation to the current problem.
A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain? 1 Retrospective 24-hour calorie count 2 Elimination pattern during the last 30 days 3 Complete gynecological and sexual history 4 Presence of a cough and pulmonary secretions
