NCLEX respiratory
An adult is about to have a tracheostomy performed. Which action is of highest priority for the nurse before the procedure is done? 1. Establishing means of postoperative communication. 2. Drawing blood for serum electrolytes and blood gases. 3. Inserting an indwelling catheter and attaching it to dependent drainage. 4. Doing a surgical prep of the neck and upper chest wall.
(1) A tracheostomy makes a client unable to speak. Other means of communication will be necessary.
A lower left lobectomy was performed on an adult client. He was returned to his room following an uneventful stay in the recovery room. It is most important for the nurse to 1. Encourage him to perform deep breathing and coughing exercises. 2. Assist him with arm exercises to prevent shoulder ankylosis. 3. Help him perform leg exercises to prevent thrombophlebitis. 4. Position him in semi-Fowler's position on his left side.
(1) Deep breathing and coughing assume highest priority after a thoracotomy. Arm and leg exercises are also important. He would be positioned in semi-Fowler's position on his right side (nonoperative).
An adult client had a left thoracotomy. He has portable water seal chest drainage. On the first postoperative day the fluid in the water seal chamber stops fluctuating. What does this most likely indicate? 1. The chest tube is clogged by fibrin or a clot. 2. There is an air leak in the system. 3. Pulmonary edema has occurred due to increased blood volumes in remaining lung tissue. 4. The client's left lung has reexpanded.
(1) Fibrin and clots will obstruct the outflow of air from the patient's thoracic cavity. It is too soon for the lung to have re-expanded. An air leak in the system would cause an absence of bubbling in the suction control chamber not the water seal chamber.
An adult has been diagnosed as having pulmonary tuberculosis. Which test(s) would the nurse expect to be ordered before the client is started on Isoniazid (INH) therapy? 1. LDH, SGOT (AST) 2. BUN, serum creatinine 3. Skin test for allergy 4. Chest X-ray
(1) Liver function tests, SGOT (AST) and LDH would be performed to serve as baseline. Liver toxicity can occur with INH. Renal function tests, BUN and serum creatinine are essential in persons who are receiving streptomycin therapy. There is not a skin test for allergy to INH. A chest X-ray will have been done as part of the diagnostic process but is not necessary again before starting INH therapy.
An adult male has had a hacking cough and shortness of breath for several months. He now has chest pain. His family has pressured him into seeking medical consultation. He continues to say, "It is just a smoker's cough." The physician examines the client and arranges for hospital admission for a diagnostic work-up. The nurse is explaining several types of tests that are ordered. Which of these tests is most definitive in the process of ruling out a malignancy? 1. Needle biopsy. 2. Thoracentesis. 3. Bronchogram. 4. Sputum analysis.
(1) Needle biopsy of the lungs detects peripherally located tumors. It provides a firm diagnosis in 80% of cases.
Which of the following nursing interventions should be instituted the day after surgery for the client who has had a pneumonectomy? 1. Provide range of motion exercises to affected arm. 2. Strip chest tubes every hour. 3. Force fluids to 3500 cc / day. 4. Monitor intermittent positive pressure breathing therapy.
(1) Range of motion exercises should be started within 4 hours of surgery to prevent adhesion formation. Intermittent positive pressure breathing therapy will not be used as the pressure could interrupt the suture line. Most physicians do not insert chest tubes in these clients, as the fluid is allowed to accumulate and eventually consolidate in the space. An increased fluid load could lead to respiratory compromise.
A client with asbestosis must see his doctor regularly for a check up. What is the primary reason for him to have frequent checkups? 1. Patients with asbestosis are at high risk for developing bronchogenic cancer. 2. His doctor is monitoring him closely to look for signs of improvement. 3. Patients who use low flow oxygen for long periods are at high risk for developing neurological symptoms. 4. Periodic sputum samples are needed to follow the progress of the disease.
(1) This is true. The doctor is looking for a change in cough, hemoptysis, weight loss, etc. #2. The asbestos fibers in the lungs cannot be removed and the fibrosis is not reversible. Improvement is not expected. #3. is not correct. #4, sputum production is not a characteristic of this disorder. Also, sputum does not give information about the progress of the fibrosis.
What action is essential because the client had a pneumonectomy? 1. Observe the tracheal position. 2. Auscultate bilateral breath sounds. 3. Assess for hypertension. 4. Assess for blood streaked sputum.
(1) Tracheal shift can occur following pneumonectomy. Tracheal shift would compromise the client's unaffected lung. There will be no breath sounds on the operative sounds. He has only one lung after a pneumonectomy. Hypotension, not hypertension, is a major sign of hemorrhage. The sputum will probably not be bloody, as the remaining lung was not operated on. A small amount of blood streaked sputum could be the result of intubation during surgery.
An adult client is admitted to the acute care hospital with bacterial pneumonia. On admission she was pale to dusky in color. Her respirations were 32, temperature 1030F and pulse 110. Auscultation revealed decreased or absent lung sounds in both bases and rhonchi in both upper lung fields. She was oriented to person, time and place, but her responses were brief. Oxygen per nasal cannula is started at 7 l / minute. IV antibiotics were started. While checking the client one hour after admission the nurse notes that she is less responsive, answering only yes or no questions. Her respirations are somewhat more shallow and have decreased to 27 per minute. What is the best INITIAL action for the nurse to take? 1. Increase the IV infusion rate to increase the amount of circulating antibiotics. 2. Notify the physician of the client's changed mental status and await further orders. 3. Increase the oxygen flow rate to 10 liters / minute. 4. Continue to stimulate her until she responds appropriately.
(2) Changes in mental status are always significant. Since her respirations are decreasing it is doubtful if oxygen would be effective.
A patient is admitted with histoplasmosis. Which item in the patient's history is most likely related to the onset of the disease? 1. He works in a factory. 2. He likes to explore caves. 3. He has three cats. 4. He smokes four packs of cigarettes a week.
(2) Histoplasmosis is caused by a fungus that grows in chicken and bat manure. Bats live in caves. Exploring caves is a likely source of exposure to the fungus. Choice 1, working in a factory, might be related to COPD if the factory had emissions. Choice 3 would be a possible source of toxoplasmosis, not histoplasmosis. Choice 4 is not related to histoplasmosis although it could be related to other respiratory diseases.
An adult is admitted to the hospital with progressive dyspnea on exertion, which has become increasingly severe during the last six months. Physical examination reveals crackles at the base of the lung and clubbing of fingers. The client has asbestosis that has caused fibrosis in the alveoli. Soon after admission, the nurse helps the client to the bathroom. Before he returns to bed, he is very short of breath. Considering the severity of his symptoms, it is essential for the nurse to include which of the following in the plan of care. 1. Give continuous oxygen via nasal catheter. 2. Allow the client to move at his own pace. 3. Give bronchodilators to increase his ability to breathe. 4. Keep the client in bed to prevent further episodes of dyspnea.
(2) The client is best able to evaluate his symptom of dyspnea. When he wants to rest, he should be allowed to rest. #1 is not correct. Oxygen may be ordered, but is often ordered PRN. A nasal cannula is usually ordered. #3 is not an independent nursing action. #4 is not correct. The client will be allowed to do as much as he is able to prevent complications of bedrest. The day should be planned so that periods of exertion are followed by periods of rest.
An adult client had a left lower lobectomy. Passive exercises are started on his left arm after surgery. The exercises are designed to prevent 1. Hyperflexion of the wrist. 2. Ankylosis of the shoulder. 3. Flexion contractures of the elbow. 4. Spasticity of the intercostal muscle
(2) The muscles have been cut during surgery. Range of motion exercises will help to prevent ankylosis of the shoulder or frozen shoulder. Patients also tend to splint incisional discomfort by limiting movement on the affected side.
Preoperative teaching for the client who is to have a pneumonectomy should include all of the following. Which is of highest priority? 1. Management of postoperative pain. 2. Turning, coughing and deep breathing exercises. 3. How to move with the least pain. 4. Leg exercises.
(2) Turning coughing and deep breathing help to prevent the most frequent, most life threatening complication likely to occur after thoracic surgery. The others are important and should be done.
The nurse is performing tracheal suctioning. Which action is essential to prevent hypoxemia during suctioning? 1. Removal of oral and nasal secretions. 2. Encouraging the client to deep breathe and cough. 3. Administer 100% oxygen before suctioning. 4. Auscultate the lungs.
(3) 100% oxygen is given before and after suctioning to prevent hypoxemia.
An adult client has just arrived in the recovery room following a pneumonectomy. What is the most appropriate initial action for the nurse? 1. Take his vital signs for baseline data. 2. Check the IV solution for rate and correct solution. 3. Administer oxygen through an appropriate device. 4. Auscultate for the presence of breath sounds.
(3) An oxygen source is of highest priority as the client is likely to be hypoventilating due to the effects of anesthesia. Oxygen will prevent hypoxia. After starting oxygen the nurse will make all of the other assessments.
An adult client is admitted for diagnosis and treatment of a left lung lesion. A bronchoscopy was performed under local anesthesia. What nursing action is of highest priority when he returns following the bronchoscopy? 1. Collect all sputum for examination. 2. Assess level of consciousness frequently. 3. Withhold food and fluids until gag reflex has returned. 4. Monitor blood pressure and pulse at 10 minute intervals.
(3) Food and fluids should be withheld to prevent aspiration. The client will have received a local anesthetic to block the gag reflex during the bronchoscopy. The nurse should observe sputum for color but it is not necessary to collect it. Bronchoscopy is usually done under a local anesthetic so level of consciousness is not a priority. Vital signs may be monitored but preventing aspiration is of highest priority.
An order is written for oxygen by nasal cannula at 2 liters per minute. In assessing the adequacy of the oxygen therapy, which of the following is most effective? 1. Checking the respiratory rate. 2. Checking the color of mucous membranes. 3. Measurement of pulmonary functions. 4. Measurement of arterial blood gasses.
(4) Arterial blood gasses give the most specific information of the adequacy of the oxygen therapy. #1. The respiratory rate is a good measure but is not the best measure. #2. Color changes in the mucous membranes are a late sign of hypoxemia. #3. Pulmonary function tests are used to evaluate pulmonary function.
A client who has had a lobectomy returns to the nursing unit. He has a chest tube attached to portable water seal drainage system and oxygen per nasal cannula. The first nursing measure concerning the water seal drainage is to 1. Milk the tubing to prevent accumulation of fibrin and clots. 2. Raise the drainage apparatus to bed height to accurately assess the meniscus level. 3. Attach the chest tubes to the bed linen to assure that airflow and drainage are unhindered by kinks. 4. Mark the time and level of drainage in the collection chamber.
(4) It is important to monitor the amount of chest drainage. Chest tubes are milked only if there is an obstruction in the tubing and only with a physician's order. The chest drainage system should not be raised above chest level. It should remain low. Chest tubes should not be attached to the linens.
The nurse is positioning an adult who has just returned to the surgical nursing care unit following a pneumonectomy. What is the most appropriate position in which to place the client? 1. Semi-Fowler's on the unaffected side. 2. Semi-Fowler's on the affected side. 3. Sims position on the unaffected side. 4. Semi-Fowler's on his back.
(4) Semi-Fowler's on the back will neither cause mediastinal shift nor cause hemorrhage at the pulmonary artery stump site. Positioning the client on his affected side could cause hemorrhage at the pulmonary artery stump site. Positioning the client on his unaffected side could cause mediastinal shift.
A tracheostomy tube is inserted in a patient who is in respiratory distress as a result of pneumonia. The family asks why the tube is inserted. What should the nurse include when explaining to the patient and family? The purpose of a tracheostomy tube is to 1. Decrease the client's anxiety by increasing the size of the airway. 2. Provide increased cerebral oxygenation thereby preventing further respiratory depression. 3. Facilitate nursing care since tracheal tubes have fewer side effects than nasotracheal tubes. 4. Provide more controlled ventilation and ease removal of secretions the client is unable to handle.
(4) This is the purpose of a tracheostomy. The client may become less anxious when she is no longer hypoxic. However, relief of anxiety is not the purpose of a tracheostomy tube.
A female patient suffers adult respiratory distress syndrome as a consequence of shock. The patient's condition deteriorates rapidly, and endotracheal intubation and mechanical ventilation are initiated. When the high pressure alarm on the mechanical ventilator, alarm sounds, the nurse starts to check for the cause. Which condition triggers the high pressure alarm? a. Kinking of the ventilator tubing b. A disconnected ventilator tube c. An endotracheal cuff leak d. A change in the oxygen concentration without resetting the oxygen level alarm
Answer A. Conditions that trigger the high pressure alarm include kinking of the ventilator tubing, bronchospasm or pulmonary embolus, mucus plugging, water in the tube, coughing or biting on endotracheal tube, and the patient's being out of breathing rhythm with the ventilator. A disconnected ventilator tube or an endotracheal cuff leak would trigger the low pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would tigger the oxygen alarm.
Nurse Lei caring for a client with a pneumothorax and who has had a chest tube inserted notes continues gentle bubbling in the suction control chamber. What action is appropriate? a. Do nothing, because this is an expected finding b. Immediately clamp the chest tube and notify the physician c. Check for an air leak because the bubbling should be intermittent d. Increase the suction pressure so that the bubbling becomes vigorous
Answer A. Continuous gentle bubbling should be noted in the suction control chamber. Option b is incorrect. Chest tubes should only be clamped to check for an air leak or when changing drainage devices (according to agency policy). Option c is incorrect. Bubbling should be continuous and not intermittent. Option d is incorrect because bubbling should be gentle. Increasing the suction pressure only increases the rate of evaporation of water in the drainage system.
Nurse Oliver is caring for a client immediately after removal of the endotracheal tube. The nurse reports which of the following signs immediately if experienced by the client? a. Stridor b. Occasional pink-tinged sputum c. A few basilar lung crackles on the right d. Respiratory rate 24 breaths/min
Answer A. The nurse reports stridor to the physician immediately. This is a high-pitched, coarse sound that is heard with the stethoscope over the trachea. Stridor indicates airway edema and places the client at risk for airway obstruction. Options B, C, and D are not signs that require immediate notification of the physician
Rhea, confused and short breath, is brought to the emergency department by a family member. The medical history reveals chronic bronchitis and hypertension. To learn more about the current respiratory problem, the doctor orders a chest x-ray and arterial blood gas (ABG) analysis. When reviewing the ABG report, the nurses sees many abbreviations. What does a lowercase "a" in ABG value present? a. Acid-base balance b. Arterial Blood c. Arterial oxygen saturation d. Alveoli
Answer B. A lowercase "a" in an ABG value represents arterial blood. For instance, the abbreviation PaO2 refers to the partial pressure of oxygen in arterial blood. The pH value reflects the acid base balance in arterial blood. Sa02 indicates arterial oxygen saturation. An uppercase "A" represents alveolar conditions: for example, PA02 indicates the partial pressure of oxygen in the alveoli.
When caring for a male patient who has just had a total laryngectomy, the nurse should plan to: a. Encourage oral feeding as soon as possible b. Develop an alternative communication method c. Keep the tracheostomy cuff fully inflated d. Keep the patient flat in bed
Answer B. A patient with a laryngectomy cannot speak, yet still needs to communicate. Therefore, the nurse should plan to develop an alternative communication method. After a laryngectomy, edema interferes with the ability to swallow and necessitates tube (enteral) feedings. To prevent injury to the tracheal mucosa, the nurse should deflate the tracheostomy cuff or use the minimal leak technique. To decrease edema, the nurse should place the patient in semi-fowler's position.
Dr. Jones prescribes albuterol sulfate (Proventil) for a patient with newly diagnose asthma. When teaching the patient about this drug, the nurse should explain that it may cause: a. Nasal congestion b. Nervousness c. Lethargy d. Hyperkalemia
Answer B. Albuterol may cause nervousness. The inhaled form of the drug may cause dryness and irritation of the nose and throat, not nasal congestion; insomnia, not lethargy; and hypokalemia (with high doses), not hyperkalemia. Other adverse effects of albuterol include tremor, dizziness, headache, tachycardia, palpitations,hypertension, heartburn, nausea, vomiting and muscle cramps.
Nurse Reese is caring for a client hospitalized with acute exacerbation ofchronic obstructive pulmonary disease. Which of the following would the nurse expect to note on assessment of this client? a. Hypocapnia b. A hyperinflated chest noted on the chest x-ray c. Increased oxygen saturation with exercise d. A widened diaphragm noted on the chest x-ray
Answer B. 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.
Nurse Ryan caring for a client with a chest tube turns the client to the side, and the chest tube accidentally disconnects. The initial nursing action is to: a. Call the physician b. Place the tube in bottle of sterile water c. Immediately replace the chest tube system d. Place a sterile dressing over the disconnection site
Answer B. If the chest drainage system is disconnected, the end of the tube is placed in a bottle of sterile water held below the level of the chest. The system is replaced if it breaks or cracks or if the collection chamber is full. Placing a sterile dressing over the disconnection site will not prevent complications resulting from the disconnection. The physician may need to be notified, but this is not the initial action.
While changing the tapes on a tracheostomy tube, the male client coughs and tube is dislodged. The initial nursing action is to: a. Call the physician to reinsert the tube b. Grasp the retention sutures to spread the opening c. Call the respiratory therapy department to reinsert the tracheotomy d. Cover the tracheostomy site with a sterile dressing to prevent infection
Answer B. If the tube is dislodged accidentally, the initial nursing action is to grasp the retention sutures and spread the opening. If agency policy permits, the nurse then attempts immediately to replace the tube. Covering the tracheostomy site will block the airway. Options A and C will delay treatment in this emergency situation.
On auscultation, which finding suggests a right pneumothorax? a. Bilateral inspiratory and expiratory crackles b. Absence of breaths sound in the right thorax c. Inspiratory wheezes in the right thorax d. Bilateral pleural friction rub.
Answer B. In pneumothorax, the alveoli are deflated and no air exchange occurs in the lungs. Therefore, breath sounds in the affected lung field are absent. None of the other options are associated with pneumothorax. Bilateral crackles may result from pulmonary congestion, inspiratory wheezes may signal asthma, and a pleural friction rub may indicate pleural inflammation.
A nurse is caring for a male client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate to ensure that it does not exceed: a. 1 L/min b. 2 L/min c. 6 L/min d. 10 L/min
Answer B. Oxygen is used cautiously and should not exceed 2 L/min. Because of the long-standing hypercapnia that occurs in emphysema, the respiratory drive is triggered by low oxygen levels rather than increased carbon dioxide levels, as is the case in a normal respiratory system.
An oxygen delivery system is prescribed for a male client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which of the following types of oxygen delivery systems would the nurse anticipate to be prescribed? a. Face tent b. Venturi mask c. Aerosol mask d. Tracheostomy collar
Answer B. 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.
A nurse is caring for a male client with acute respiratory distress syndrome. Which of the following would the nurse expect to note in the client? a. Pallor b. Low arterial PaO2 c. Elevated arterial PaO2 d. Decreased respiratory rate
Answer B. The earliest clinical sign of acute respiratory distress syndrome is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a PaO2 lower than 60 mm Hg.
A male patient has a sucking stab wound to the chest. Which action should the nurse take first? a. Drawing blood for a hematocrit and hemoglobin level b. Applying a dressing over the wound and taping it on three sides c. Preparing a chest tube insertion tray d. Preparing to start an I.V. line
Answer B. The nurse immediately should apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.
Nurse Maureen has assisted a physician with the insertion of a chest tube. The nurse monitors the client and notes fluctuation of the fluid level in the water seal chamber after the tube is inserted. Based on this assessment, which action would be appropriate? a. Inform the physician b. Continue to monitor the client c. Reinforce the occlusive dressing d. Encourage the client to deep-breathe
Answer B. The presence of fluctuation of the fluid level in the water seal chamber indicates a patent drainage system. With normal breathing, the water level rises with inspiration and falls with expiration. Fluctuation stops if the tube is obstructed, if a dependent loop exists, if the suction is not working properly, or if the lung has reexpanded. Options A, C, and D are incorrect.
An emergency room nurse is assessing a male client who has sustained a blunt injury to the chest wall. Which of these signs would indicate the presence of a pneumothorax in this client? a. A low respiratory rate b. Diminished breath sounds c. The presence of a barrel chest d. A sucking sound at the site of injury
Answer B. This client has sustained a blunt or a 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.
A nurse performs an admission assessment on a female client with a diagnosis of tuberculosis. The nurse reviews the result of which diagnosis test that will confirm this diagnosis? a. Bronchoscopy b. Sputum culture c. Chest x-ray d. Tuberculin skin test
Answer B. Tuberculosis is definitively diagnosed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made based on a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histological evidence of granulomatous disease on biopsy.
A male patient's X-ray result reveals bilateral white-outs, indicating adult respiratory distress syndrome (ARDS). This syndrome results from: a. Cardiogenic pulmonary edema b. Respiratory alkalosis c. Increased pulmonary capillary permeability d. Renal failure
Answer C. ARDS results from increased pulmonary capillary permeability, which leads to noncardiogenic pulmonary edema. In cardiogenic pulmonary edema, pulmonary congestion occurs secondary to heart failure. In the initial stage of ARDS, respiratory alkalosis may arise secondary to hyperventilation; however, it does not cause ARDS. Renal failure does not cause ARDS, either.
For a female patient with chronic obstructive pulmonary disease, which nursing intervention would help maintain a patent airway? a. Restricting fluid intake to 1,000 ml per day b. Enforcing absolute bed rest c. Teaching the patient how to perform controlled coughing d. Administering prescribe sedatives regularly and in large amounts
Answer C. Controlled coughing helps maintain a patent airway by helping to mobilize and remove secretions. A moderate fluid intake (usually 2 L or more daily) and moderate activity help liquefy and mobilize secretions. Bed rest and sedatives may limit the patient's ability to maintain a patent airway, causing a high risk for infection from pooled secretions.
Miriam, a college student with acute rhinitis sees the campus nurse because of excessive nasal drainage. The nurse asks the patient about the color of the drainage. In a acute rhinitis, nasal drainage normally is: a. Yellow b. Green c. Clear d. Gray
Answer C. Normally, nasal drainage in acute rhinitis is clear. Yellow or green drainage indicates spread of the infection to the sinuses. Gray drainage may indicate a secondary infection.
For a patient with advance chronic obstructive pulmonary disease (COPD), which nursing action best promotes adequate gas exchange? a. Encouraging the patient to drink three glasses of fluid daily b. Keeping the patient in semi-fowler's position c. Using a high-flow venture mask to deliver oxygen as prescribe d. Administering a sedative, as prescribe
Answer C. The patient with COPD retains carbon dioxide, which inhibits stimulation of breathing by the medullary center in the brain. As a result, low oxygen levels in the blood stimulate respiration, and administering unspecified, unmonitored amounts of oxygen may depress ventilation. To promote adequate gas exchange, the nurse should use a Venturi mask to deliver a specified, controlled amount of oxygen consistently and accurately. Drinking three glasses of fluid daily would not affect gas exchange or be sufficient to liquefy secretions, which are common in COPD. Patients with COPD and respiratory distress should be places in high-Fowler's position and should not receive sedatives or other drugs that may further depress the respiratory center.
After undergoing a left pneumonectomy, a female patient has a chest tube in place for drainage. When caring for this patient, the nurse must: a. Monitor fluctuations in the water-seal chamber b. Clamp the chest tube once every shift c. Encourage coughing and deep breathing d. Milk the chest tube every 2 hours
Answer C. When caring for a patient who is recovering from a pneumonectomy, the nurse should encourage coughing and deep breathing to prevent pneumoniain the unaffected lung. Because the lung has been removed, the water-seal chamber should display no fluctuations. Reinflation is not the purpose of chest tube. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.
A male patient is admitted to the health care facility for treatment of chronic obstructive pulmonary disease. Which nursing diagnosis is most important for this patient? a. Activity intolerance related to fatigue b. Anxiety related to actual threat to health status c. Risk for infection related to retained secretions d. Impaired gas exchange related to airflow obstruction
Answer D. A patient airway and an adequate breathing pattern are the top priority for any patient, making "impaired gas exchange related to airflow obstruction" the most important nursing diagnosis. The other options also may apply to this patient but less important.
Before administering ephedrine, Nurse Tony assesses the patient's history. Because of ephedrine's central nervous system (CNS) effects, it is not recommended for: a. Patients with an acute asthma attack b. Patients with narcolepsy c. Patients under age 6 d. Elderly patients
Answer D. Ephedrine is not recommended for elderly patients, who are particularly susceptible to CNS reactions (such as confusion and anxiety) and to cardiovascular reactions (such as increased systolic blood pressure, coldness in the extremities, and anginal pain). Ephedrine is used for its bronchodilator effects with acute and chronic asthma and occasionally for its CNS stimulant actions for narcolepsy. It can be administered to children age 2 and older.
Blessy, a community health nurse is conducting an educational session with community members regarding tuberculosis. The nurse tells the group that one of the first symptoms associated with tuberculosis is: a. Dyspnea b. Chest pain c. A bloody, productive cough d. A cough with the expectoration of mucoid sputum
Answer D. One of the first pulmonary symptoms is a slight cough with the expectoration of mucoid sputum. Options A, B, and C are late symptoms and signify cavitation and extensive lung involvement.
A male adult patient on mechanical ventilation is receiving pancuronium bromide (Pavulon), 0.01 mg/kg I.V. as needed. Which assessment finding indicates that the patient needs another pancuronium dose? a. Leg movement b. Finger movement c. Lip movement d. Fighting the ventilator
Answer D. Pancuronium, a nondepolarizing blocking agent, is used for muscle relaxation and paralysis. It assists mechanical ventilation by promoting encdotracheal intubation and paralyzing the patient so that the mechanical ventilator can do its work. Fighting the ventilator is a sign that the patient needs another pancuronium dose. The nurse should administer 0.01 to 0.02 mg/kg I.V. every 20 to 60 minutes. Movement of the legs, or lips has no effect on the ventilator and therefore is not used to determine the need for another dose.
A nurse instructs a female client to use the pursed-lip method of breathing and the client asks the nurse about the purpose of this type of breathing. The nurse responds, knowing that the primary purpose of pursed-lip breathing is to: a. Promote oxygen intake b. Strengthen the diaphragm c. Strengthen the intercostal muscles d. Promote carbon dioxide elimination
Answer D. Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options A, B, and C are not the purposes of this type of breathing.
A male adult patient hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? a. Nausea or vomiting b. Abdominal pain or diarrhea c. Hallucinations or tinnitus d. Lightheadedness or paresthesia
Answer D. The patient with respiratory alkalosis may complain of lightheadedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rare are associated with respiratory alkalosis or any other acid-base imbalance.
Nurse Ruth assessing a patient for tracheal displacement should know that the trachea will deviate toward the: a. Contralateral side in a simple pneumothorax b. Affected side in a hemothorax c. Affected side in a tension pneumothorax d. Contralateral side in hemothorax
Answer D. The trachea will shift according to the pressure gradients within the thoracic cavity. In tension pneumothorax and hemothorax, accumulation of air or fluid causes a shift away from the injured side. If there is no significant air or fluid accumulation, the trachea will not shift. Tracheal deviation toward the contralateral side in simple pneumothorax is seen when the thoracic contents shift in response to the release of normal thoracic pressure gradients on the injured side.
A nurse is assisting a physician with the removal of a chest tube. The nurse should instruct the client to: a. Exhale slowly b. Stay very still c. Inhale and exhale quickly d. Perform the Valsalva maneuver
Answer D. When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed. Options A, B, and C are incorrect client instructions.