NR - 324: Respiratory ATI

A nurse receives prescriptions from the provider for performing nasopharyngeal suctioning on four clients. For which of the following clients should the nurse clarify the provider's prescription? A.) pt w/ epistaxis B.) pt w/ amyotrophic lateral sclerosis C.) pt w/ pneumonia D.) pt w/ emphysema

A client who has epistaxis The nurse should avoid providing nasopharyngeal suctioning for a client who has nasal bleeding because this intervention might cause an increase in bleeding.

A nurse is caring for a client who has a pulmonary embolism. Which of the following interventions is the priority? A.) Provide a quiet environment B.) Encourage use of incentive spirometer every 1-2 hrs C.) Obtain blood sample for electrolyte study D.) Administer heparin via continuous IV infusion

Administer heparin via continuous IV infusion. When using the airway, breathing, circulation approach to client care, the nurse should place priority on stabilizing circulation to the lungs by administering heparin to prevent further clot formation. Therefore, this is the priority intervention.

A nurse in the emergency department is caring for a client who is experiencing a pulmonary embolism. Which of the following actions should the nurse take first? Apply supplemental oxygen. Increase the rate of IV fluids. Administer pain medication. Initiate cardiac monitoring.

Apply supplemental oxygen. When using the airway, breathing, circulation approach to client care, the greatest risk to the client is severe hypoxemia. Therefore, the first action the nurse should take is to apply supplemental oxygen.

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method for the nurse to use to determine the effectiveness of the current treatment regimen? A.) BP B.) Cap refill C.) ABGs D.) HR

Arterial blood gases When using the airway, breathing, circulation approach to client care, the nurse should place priority on evaluating arterial blood gases to determine serum oxygen saturation and acid-base balance.

A nurse is caring for a client who is receiving mechanical ventilation when the low-pressure alarm sounds. Which of the following situations should the nurse recognize as a possible cause of the alarm? Excess secretions Kinks in the tubing Artificial airway cuff leak Biting on the endotracheal tube

Artificial airway cuff leak An artificial airway cuff leak interferes with oxygenation and causes the low-pressure alarm to sound

A nurse is assessing a client who has lung cancer. Which of the following clinical manifestations should the nurse expect? Blood-tinged sputum Decreased tactile fremitus Resonance with percussion Peripheral edema

Blood-tinged sputum The nurse should expect blood-tinged sputum secondary to bleeding from the tumor.

A nurse is caring for a client who has a chest tube following a lobectomy. Which of the following items should the nurse keep easily accessible for the client? A.) Extra drainage system B.) Suture removal kit C.) Container of sterile water D.) Non adherent pads

Container of sterile water The nurse should have a container of sterile water in a location that is easily accessible for this client. The nurse should plan to place the open end of the tubing into the sterile water if the tubing becomes disconnected to prevent a pneumothorax.

A nurse is assessing a client who has a chest tube in place following thoracic surgery. For which of the following findings should the nurse notify the provider?

Continuous bubbling in the water seal chamber

a nurse is assessing a client who's 4 hr postoperative following a total laryngectomy. which of the following findings is the priority for the nurse to report to the provider? A.) Bleeding at the surgical site B.) Decreased oxygen saturation C.) Urinary retention D.) Increased pain level

Decreased oxygen saturation When using the airway, breathing, circulation approach to client care, the nurse should identify decreased oxygen saturation as the priority finding to address and report to the provider. A client who is postoperative following a total laryngectomy is at higher risk for hypoxia because of airway obstruction.

A nurse is assessing a client who has emphysema. Which of the following findings should the nurse report to the provider? A.) Rhonchi on inspiration B.) Elevated temperature C.) Barrel-shaped chest D.) Diminished breath sounds

Elevated temperature The nurse should report an elevated temperature to the provider because it can indicate a possible respiratory infection. Clients who have emphysema are at risk for the development of pneumonia and other respiratory infections.

A nurse is caring for a newly-admitted client who has emphysema. The nurse should place the client in which of the following positions to promote effective breathing? Lateral position with a pillow at the back and over the chest to support the arm High-Fowler's position with the arms supported on the overbed table Semi-Fowler's position with pillows supporting both arms Supine position with the head of the bed elevated to 15°

High-Fowler's position with the arms support on the over-bed table. The nurse should place the client in a position that allows for greater expansion of the chest, such as sitting upright and leaning slightly forward while supporting both arms with pillows for comfort on the overbed table.

A nurse is caring for a client who is in respiratory distress. Which of the following low-flow delivery devices should the nurse use to provide the client with the highest level of oxygen? A.) Nasal cannula B.) Nonrebreather mask C.) Simple face mask D.) Partial rebreather mask

Nonrebreather mask The nurse should use a nonrebreather mask for a client who is in respiratory distress to provide the highest oxygen level. A nonrebreather mask is made up of a reservoir bag from which the client obtains the oxygen, a one-way valve to prevent exhaled air from entering the reservoir bag, and exhalation ports with flaps that prevent room air from entering the mask. This device delivers greater than 90% FiO2.

A nurse in the emergency department is caring for a client who is experiencing acute respiratory failure. Which of the following laboratory findings should the nurse expect? Arterial pH 7.50 PaCO2 25 mm Hg SaO2 92% PaO2 58 mm Hg

PaO2 58 mm Hg The nurse should expect the client to have lower partial pressures of oxygen.

A nurse is preparing a client for discharge following a bronchoscopy with the use of moderate sedation. The nurse should place the priority on which of the following assessments? Presence of gag reflex Pain level rating using a 0 to 10 scale Hydration status Appearance of the IV insertion site

Presence of gag reflex The greatest risk to the client is aspiration due to a depressed gag reflex. Therefore, the priority assessment by the nurse is to determine the return of the gag reflex.

A nurse is caring for a client who has asthma and is receiving albuterol. For which of the following adverse effects should the nurse monitor the client? Hyperkalemia Dyspnea Tachycardia Candidiasis

Tachycardia The nurse should monitor the client for tachycardia, which is a common adverse effect of this medication, especially if the client uses albuterol on a regular basis. The nurse should monitor a client who is taking an inhaled glucocorticoid, such as beclomethasone, for candidiasis

A nurse is working in the emergency department is caring for a client following an acute chest trauma. Which of the following findings indicates to the nurse the client is possibly experiencing a tension pneumothorax? Collapsed neck veins on the affected side Collapsed neck veins on the affected side Tracheal deviation to the affected side Tracheal deviation to the unaffected side

Tracheal deviation to the unaffected side The nurse should recognize that deviation of the trachea to the unaffected side is a possible indicator that the client is experiencing a tension pneumothorax. A tension pneumothorax results from free air filling the chest cavity, causing the lung to collapse and forcing the trachea to deviate to the unaffected side.

A nurse is caring for a client who is in respiratory distress and requires endotracheal suction. Which of the following actions should the nurse take?

Use a rotating motion when removing the suction catheter.

A nurse is caring for a client who is post operative and has a respiratory rate of 9/min secondary to general anesthesia effects and incisional pain. Which of the following ABG values indicates the client is experiencing respiratory acidosis? A.) pH 7.50, PO2 95 mm Hg, PaCO2 25 mm Hg, HCO3- 22 mEq/L B.) pH 7.50, PO2 87 mm Hg, PaCO2 35 mm Hg, HCO3- 30 mEq/L C.) pH 7.30, PO2 90 mm Hg, PaCO2 35 mm Hg, HCO3- 20 mEq/L D.) pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L

pH 7.30, PO2 80 mm Hg, PaCO2 55 mm Hg, HCO3- 22 mEq/L These ABG values indicate respiratory acidosis. The pH is less than 7.35 and the PaCO2 is greater than 45 mm Hg, which indicates respiratory acidosis.

A nurse is providing discharge teaching to a client who has a temporary tracheostomy. Which of the following statements by the client indicates an understanding of the teaching? "I should dip a cotton-tipped applicator into full-strength hydrogen peroxide to cleanse around my stoma" "I should cut a 4-inch gauze dressing and place it around my treacheostomy tube to absorb drainage" "I should remove the old twill ties after the new ties are in place" "I should apply suctioning while inserting the catheter into my tracheostomy tube."

"I should remove the old twill ties after the new ties are in place." As a safety measure, the nurse should teach the client to wait until the new ties are in place to remove the old ties. The practice can prevent accidental decannulation.

A nurse is providing discharge teaching to a client who has pulmonary tuberculosis and a new prescription for rifampin. Which of the following instructions should the nurse include? "Ringing in the ears is an adverse effect of this medication." "Have your skin test repeated in 4 months to show a positive result." "Expect your urine and other secretions to be orange while taking this medication." "Remember to take this medication with a sip of water just before your first bite of each meal."

"Expect your urine and other secretions to be orange while taking this medication." The nurse should inform the client that rifampin will turn urine and other secretions orange. Rifampin is hepatotoxic, so the nurse should also instruct the client to notify the provider if manifestations of hepatitis occur, including jaundice, fatigue, or malaise.

A nurse is providing teaching to a client who has chronic asthma and a new prescription of montelukast. Which of the following client statements indicates an understanding of the teaching? A.) "I will monitor my heart rate every day while taking this medication." B.) "I will make sure I have this medication with me at all times." C.) "I will need to carefully rinse my mouth after I take this medication." D.) "I will take this medication every night even if I don't have symptoms."

"I will take this medication every night even if I don't have symptoms." Montelukast is used for the prophylactic treatment of asthma and is taken on a daily basis in the evening.

A charge nurse is reviewing the care of a client who has a chest tube connected to a water seal drainage system in a place following thoracic surgery w/ newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of when to notify the provider? A.) "I will notify the provider if there is a fluctuation of drainage in the tubing with inspiration." B.) "I will notify the provider if there is continuous bubbling in the water seal chamber." C.) "I will notify the provider if there is drainage of 60 milliliters in the first hour after surgery." D.) "I will notify the provider if there are several small, dark-red blood clots in the tubing."

"I will notify the provider if there is continuous bubbling in the water seal chamber." Continuous bubbling in the water seal chamber suggests an air leak and requires notification of the provider. The nurse should check the system for external, correctable leaks while waiting for instructions from the provider.

A charge nurse is providing an in-service to a group of staff nurses about endotracheal suctioning. Which of the following statements by a staff nurse indicates an understanding of the teaching? A.) "I will use clean technique when suctioning a client's endotracheal tube." B.) "I will use a rotating motion when removing the suction catheter." C.) "I will suction the oropharyngeal cavity prior to suctioning the endotracheal tube." D.) "I will suction a client's endotracheal tube every 2 hours."

"I will use a rotating motion when removing the suction catheter." The nurse should rotate the suction catheter during withdrawal to remove secretions from the sides of the airway.

A nurse is caring for four clients. Which of the following clients is at greatest risk for pulmonary embolism? A client who is 48 hr postoperative following a total hip arthroplasty A client who is 8 hr postoperative following an open surgical appendectomy A client who is 2 hr postoperative following an open reduction external fixation of the right radius A client who is 4 hr postoperative following a laparoscopic cholecystectomy

A client who is 48 hr postoperative following a total hip arthroplasty The nurse should identify that a client who has undergone a total hip arthroplasty surgery is at greatest risk for a pulmonary embolus because of decreased mobility of the affected extremity and an increased amount of blood clots forming in the veins of the thigh following hip surgery. Deep-vein thromboses are most likely to occur 48 to 72 hr following the arthroplasty. The nurse should intervene to reduce the risk by applying sequential compression devices or antiembolic stockings and by administering anticoagulant medications.

A nurse is admitting a client who has active tuberculosis. Which of the following isolation precautions should the nurse implement? Airborne Neutropenic Contact Droplet

Airborne The nurse should initiate airborne precautions for a client who has tuberculosis because tuberculosis is a respiratory infection that is spread through the air. The client should be placed in a room with negative airflow pressure that is filtered through a high-efficiency particulate air (HEPA) filter. Members of the health care team should not enter the client's room without wearing an N95 respirator mask.

A nurse is planning care for a client who has asthma. Which of the following medications should the nurse plan to administer during an acute asthma attack? A.) cromolyn sodium B.) prednisone C.) fluticasone/salmeterol D.) albuterol

Albuterol The nurse should administer albuterol because it acts quickly to produce bronchodilation during an acute asthma attack.

A nurse is assessing a client who has acute respiratory distress syndrome (ARDS). Which of the following findings should the nurse report to the provider? A.) Decreased bowel sounds B.) Oxygen saturation 92% C.) CO2 24 mEq/L D.) Intercostal retractions

Intercostal retractions The nurse should report intercostal retractions to the provider because this finding indicates increasing respiratory compromise in a client who has ARDS.

A nurse is caring for a client who is 1 hr postoperative following a thoracentesis. Which of the following is the priority assessment finding? A.) Pallor B.) Insertion site pain C.) Persistent cough D.) Temperature 37.3° C (99.1°F)

Persistent cough When using the airway, breathing, circulation approach to client care, the nurse should determine that the priority finding is a persistent cough because this can indicate a tension pneumothorax, which is a medical emergency.

A nurse in a provider's office is assessing a client who has COPD. Which of the following findings is the priority for the nurse to report to the provider? A.) Increased anterior-posterior chest diameter B.) Productive cough with green sputum C.) Clubbing of the fingers D.) Pursed-lip breathing with exertion

Productive cough with green sputum When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is a productive cough with green sputum. The nurse should report this finding to the provider because it can indicate infection.

A nurse is creating a plan of care for a client who has COPD. Which of the following interventions should the nurse include? A.) Schedule respiratory treatments following meals. B.) Have the client sit up in a chair for 2-hr periods three times per day. C.) Provide a diet that is high in calories and protein. D.) Combine activities to allow for longer rest periods between activities.

Provide a diet that is high in calories and protein. The nurse should provide a client who has COPD with a diet that is high in calories and protein and low in carbohydrates.

A nurse is assessing a client who has bacterial pneumonia. Which of the following clinical manifestations should the nurse expect? A.) decreased fremitus B.) SaO2 95% on room air C.) temperature 38.8° C (101.8° F) D.) bradypnea

Temperature 38.8° C (101.8° F) An elevated temperature is an expected finding for a client who has bacterial pneumonia.

A nurse is assisting The provider who is performing a thoracentesis at the bedside of a client. Which of the following action should the nurse take? (Select all that apply.) a.) Wear goggles and a mask during the procedure. b.) Cleanse the procedure area with an antiseptic solution. c.) Instruct the client to take deep breaths during the procedure. d.) Position the client laterally on the affected side before the procedure. e.) Apply pressure to the site after the procedure.

a.) Wear goggles and a mask during the procedure. b.) Cleanse the procedure area with an antiseptic solution. e.) Apply pressure to the site after the procedure. rationale: a.) Wear goggles and a mask during the procedure is correct. The nurse and provider should both wear goggles and a mask to reduce the risk for exposure to pleural fluid. b.) Cleanse the procedure area with an antiseptic solution is correct. The use of an antiseptic solution decreases the risk for infection, which is increased due to the invasive nature of the procedure. c.) Instruct the client to take deep breaths during the procedure is incorrect. The nurse should instruct the client to remain as still as possible during the procedure to reduce the risk for puncturing the pleura or lung. d.) Position the client laterally on the affected side before the procedure is incorrect. The nurse should position the client in a sitting position leaning over the bedside table or laterally on the unaffected side to promote access to the site and encourage drainage of pleural fluid. e.) Apply pressure to the site after the procedure is correct. The application of pressure decreases the risk for bleeding at the procedure site.