NUR 203 Respiratory

A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question should the nurse ask the client in response to this finding?

"Do you have any chronic breathing problems?"

A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements should the nurse include in communications with the respiratory therapist prior to the tests?

"I held the client's morning bronchodilator medication." "I advised the client not to smoke for 6 hours prior to the test." "The client is alert and can follow your commands."

After teaching a client who is prescribed a long-acting beta2 agonist medication, a nurse assesses the client's understanding. Which statement indicates the client comprehends the teaching?

"I will take this medication every morning to help prevent an acute attack."

After teaching a client who is prescribed salmeterol (Serevent), the nurse assesses the client's understanding. Which statement by the client indicates a need for additional teaching?

"I will use the drug when I have an asthma attack." Salmeterol is designed to prevent an asthma attack; it does not relieve or reverse symptoms. Salmeterol has a slow onset of action; therefore, it should not be used as a rescue drug.

The nurse is caring for a client with lung cancer who states, "I don't want any pain medication because I am afraid I'll become addicted." How should the nurse respond?

"It is unlikely you will become addicted when taking medicine for pain."

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this client's teaching?

"Make sure you clean the humidifier to prevent infection."

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond?

"This is normal after surgery. What types of food do you like to eat?"

While obtaining a client's health history, the client states, "I am allergic to avocados." Which responses by the nurse are best?

"What response do you have when you eat avocados?" "I will document this in your record so all of your providers will know." "Have you ever been treated for this allergic reaction?"

A nurse assesses a 66-year-old client who is attempting to quit smoking. The client states, "I started smoking at age 16, and smoked one pack each day until 10 years ago. Then I decreased to a half of a pack per day." How many pack-years should the nurse document for this client? (Record your answer using a whole number.) ___ pack-years

45 pack-years 66 (current age) - 16 (year started smoking) = 50 years of smoking. (40 years 1 pack per day) + (10 years 0.5 pack per day) = 45 pack-years. I don't agree with this answer, I thought the years would be 50 n0t 40 in this calculation, that would make the answer 55 pack years

A nurse administers medications to a client who has asthma. Which medication classification is paired correctly with its physiologic response to the medication?

Cholinergic antagonist - Causes bronchodilation by inhibiting the parasympathetic nervous system

A nurse assesses a client after an open lung biopsy

Client has reduced breath sounds. - Nurse calls physician immediately

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery?

Assist the client to choose a communication method.

A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention should the nurse include in this client's plan of care?

Assistance with activities of daily living

The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur? 1. "Take as deep a breath as possible." 2. "Stand up (unless you have a physical disability)." 3. "Place the meter in your mouth, and close your lips around the mouthpiece." 4. "Make sure the device reads zero or is at base level." 5. "Blow out as hard and as fast as possible for 1 to 2 seconds." 6. "Write down the value obtained." 7. "Repeat the process two additional times, and record the highest number in your chart."

4, 2, 1, 3, 5, 6, 7

A registered nurse (RN) cares for clients on a surgical unit. Which clients should the RN delegate to a licensed practical nurse (LPN)?

A 43-year-old diagnosed with cancer after a lung biopsy 2 days ago An 88-year-old with esophageal cancer who is awaiting gastric tube placement

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions?

A 58-year-old at risk for aspiration following radiation therapy A 66-year-old who is a quadriplegic and has a sacral ulcer An 80-year-old who is aphasic after a cerebral vascular accident A 24-year-old with a traumatic brain injury

A nurse is assessing a client who is recovering from a lung biopsy. Which assessment finding requires immediate action?

Absent breath sounds

A nurse cares for a client who had a chest tube placed 6 hours ago and refuses to take deep breaths because of the pain. Which action should the nurse take?

Administer pain medication and encourage the client to take deep breaths.

A student is practicing suctioning a tracheostomy in the skills laboratory. What action by the student demonstrates that more teaching is needed?

Applying suction while inserting the catheter

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)?

Applying water-soluble lip balm to the client's lips Reminding the client to cough and deep breathe often

A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first?

Ask the client to gargle with mouthwash containing lidocaine.

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. Which action should the nurse take next?

Assess the client's gag reflex before giving any food or water.

A nurse is caring for an older adult client who has a pulmonary infection. Which action should the nurse take first?

Assess the client's level of consciousness.

An unlicensed assistive personnel (UAP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse takes priority?

Assess the client's lung sounds.

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes the client's face is puffy and the eyelids are swollen. What action by the nurse takes priority?

Assess the client's oxygen saturation.

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client?

Cognition Dexterity Range of motion Vision

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first?

Contact the provider and prepare for intubation.

While assessing a client who is 12 hours postoperative after a thoracotomy for lung cancer, a nurse notices that the lower chest tube is dislodged. Which action should the nurse take first?

Cover the insertion site with sterile gauze.

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem?

Create a communication system. Try loose-fitting shirts with collars. Wear fashionable scarves.

A nurse evaluates the following arterial blood gas and vital sign results for a client with chronic obstructive pulmonary disease (COPD): Arterial Blood Gas Results Vital Signs pH = 7.32 PaCO2 = 62 mm Hg PaO2 = 46 mm Hg HCO3- = 28 mEq/L Heart rate = 110 beats/min Respiratory rate = 12 breaths/min Blood pressure = 145/65 mm Hg Oxygen saturation = 76% Which action should the nurse take first?

Document the findings as normal for a client with COPD. Oxygen should be administered to a client who is hypoxic even if the client has COPD and is a carbon dioxide retainer

A nurse auscultates a harsh hollow sound over a client's trachea and larynx. Which action should the nurse take first?

Document the findings.

A nurse plans care for a client who is at high risk for a pulmonary infection. Which interventions should the nurse include in this client's plan of care?

Encourage deep breathing and coughing. Ambulate the client three times each day. Provide a diet high in protein and vitamins.

A nurse assesses a client who is prescribed fluticasone (Flovent) and notes oral lesions. Which action should the nurse take?

Encourage oral rinsing after fluticasone administration.

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority?

Ensure informed consent is on the chart.

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention should the nurse complete prior to the procedure?

Explain the procedure in detail to the client and the family.

A nurse cares for a client with a 40-year smoking history who is experiencing distended neck veins and dependent edema. Which physiologic process should the nurse correlate with this client's history and clinical manifestations?

Increased pulmonary pressure creating a higher workload on the right side of the heart

A nurse cares for a client who is experiencing epistaxis. Which action should the nurse take first?

Initiate Standard Precautions.

A nurse cares for a client who is prescribed an intravenous prostacyclin agent. Which actions should the nurse take to ensure the client's safety while on this medication?

Keep an intravenous line dedicated strictly to the infusion. Ensure that there is always a backup drug cassette available. Use strict aseptic technique when using the drug delivery system. Intravenous prostacyclin agents should be administered in a central venous catheter with a dedicated intravenous line for this medication. Death has been reported when the drug delivery system is interrupted; therefore, a backup drug cassette should also be available. The nurse should use strict aseptic technique when using the drug delivery system. The nurse should teach the client that this medication decreases pulmonary pressures and increases lung blood flow.

A nurse cares for a client who has a pleural chest tube. Which action should the nurse take to ensure safe use of this equipment?

Keep padded clamps at the bedside for use if the drainage system is interrupted.

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best?

Measure and compare cuff pressures.

The nurse is caring for a child with carbon monoxide poisoning associated with smoke inhalation. Which is essential in this child's care?

Monitor arterial blood gases.

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. Which action should the nurse take next?

Notify the Rapid Response Team.

A nurse cares for a client who has developed esophagitis after undergoing radiation therapy for lung cancer. Which diet selection should the nurse provide for this client?

Omelet, soft whole wheat bread Side effects of radiation therapy may include inflammation of the esophagus. Clients should be taught that bland, soft, high-calorie foods are best, along with liquid nutritional supplements.

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client's pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate?

Stay with the client and have someone else call the provider immediately.

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met?

The client has joined a book club that meets at the library.

After teaching a client how to perform diaphragmatic breathing, the nurse assesses the client's understanding. Which action demonstrates that the client correctly understands the teaching?

The client places his or her hands on his or her abdomen.

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action?

The trachea is deviated toward the opposite side of the neck.

A nurse assesses a client who has a chest tube. For which manifestations should the nurse immediately intervene?

Tracheal deviation Sudden onset of shortness of breath

A nurse assesses a client who has a mediastinal chest tube. Which symptoms require the nurse's immediate intervention?

Tracheal deviation Sudden onset of shortness of breath Drainage greater than 70 mL/hr Disconnection at Y site

A nurse teaches a client who has open vocal cord paralysis. Which technique should the nurse teach the client to prevent aspiration?

Tuck the chin down when swallowing.

A student nurse is providing tracheostomy care. What action by the student requires intervention by the instructor?

Tying a square knot at the back of the neck

A nurse assesses a client who is prescribed varenicline (Chantix) for smoking cessation. Which manifestations should the nurse identify as adverse effects of this medication?

Visual hallucinations Impaired judgment Varenicline (Chantix) has a black box warning stating that the drug can cause manic behavior and hallucinations.

A nurse is providing care after auscultating clients' breath sounds. Which assessment finding is correctly matched to the nurse's primary intervention?

Wheezes are heard in central areas. - The nurse administers an inhaled bronchodilator.

A nurse cares for a client who has a chest tube. When would this client be at highest risk for developing a pneumothorax?

When the tube becomes disconnected from the drainage system

The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated with sepsis. Nursing actions should include:

monitoring pulse oximetry.