Oxygenation!

A nurse is reviewing the laboratory findings for a client who developed fat embolism syndrome (FES) following a fracture. Which of the following laboratory findings should the nurse expect? A. Decreased serum calcium level B. Decreased level of serum lipids C. Decreased ESR. D. Increased PLT.

A. Decreased serum calcium level

A nurse in the post-anesthesia care unit is caring for a client who is postoperative following a thoracotomy and lobectomy. Which of the following postoperative assessments should the nurse give highest priority to? A. Arterial blood gases B. Urinary output C. Chest tube drainage D. Pain level

A. ABG's

A nurse in the emergency department is caring for a client who has pulmonary edema, reports dyspnea, and appears anxious. The client's blood pressure is 108/79 and his apical pulse is 112. Which of the following interventions is the nurse's priority? A. Administer high-flow oxygen at 5 L/min by facemask to the client. B. Place the client in high-Fowler's position with legs dependent. C. Give the client sublingual nitroglycerin. D. Reassure the client.

A. Administer high-flow oxygen at 5 L/min by facemask to the client. Rationale: A client who has pulmonary edema is critically ill and is hypoxic. The first action the nurse should take when using the airway, breathing, circulation approach to client care is to administer high-flow oxygen at 5 L/min by facemask to the client.

A nurse caring for a client who has hypertension and asks the nurse about a prescription for propranolol. The nurse should inform the client that this medication is contraindicated in clients who have a history of which of the following conditions? A. Asthma B. Glaucoma C. Depression D. Migraines

A. Asthma

A nurse is caring for a client who is postoperative following surgical repair of a mandibular fracture with fixed occlusion of the jaws in a closed position. Which of the following statements is the priority for the nurse to make? A. "We can teach you some relaxation techniques to minimize your pain." B. "Keep wire cutters with you at all times." C. "Use a water pick device to keep your teeth clean." D. "Consume a high-protein, liquid diet."

B. "Keep wire cutters with you at all times."

A nurse is caring for a client who is receiving mechanical ventilation and has an ideal weight of 60 kg. The nurse should expect the tidal volume to be set at which of the following? A. 300 mL B. 480 mL C. 800 mL D. 950 mL

B. 480 mL Rationale: The average tidal volume is 7 to 9 mL/kg. 60 kg x 8 mL/kg = 480. Therefore, this setting is within the average range.

A nurse is preparing to measure a client's level of oxygen saturation and observes edema of both hands and thickened toe nails. The nurse should apply the pulse oximeter probe to which of the following locations? A. Finger B. Earlobe C. Toe D. Skin fold

B. Earlobe

A nurse is caring for a client who has acute respiratory distress syndrome (ARDS), and requires mechanical ventilation. The client receives a prescription for pancuronium. The nurse recognizes that this medication is for which of the following purposes? A. Decrease chest wall compliance. B. Suppress respiratory effort. C. Induce sedation. D. Decrease respiratory efforts

B. Suppress respiratory effort.

A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect? A. Nausea B. Dysphagia C. Agitation D. Hypotension

C. Agitation

A nurse is teaching a client who is obese and has obstructive sleep apnea how to decrease the number of nightly apneic episodes. Which of the following client statements indicates an understanding of the teaching? A. "It might help if I tried sleeping only on my back." B. "I'll sleep better if I take a sleeping pill at night." C. "I'll get a humidifier to run at my bedside at night." D. "If I could lose about 50 pounds, I might stop having so many apneic episodes."

D. "If I could lose about 50 pounds, I might stop having so many apneic episodes." Sleep apnea is a disorder in which breathing stops during sleep for at least 10 seconds at least five times per hour. Excessive weight is one of the three major risk factors associated with sleep apnea and is the only one the client can modify (gender and age are the other two). Weight loss and maintenance are the primary interventions for the treatment of sleep apnea

A nurse is performing chest physiotherapy on a client who has a respiratory infection. To increase the velocity and turbulence of the air the client exhales, which of the following techniques should the nurse use? A. Postural drainage B. Nebulization C. Percussion D. Vibration

D. Vibration. Rationale: Vibration after percussion, or alternately with percussion, increases the velocity and turbulence of the air the client exhales, while loosening secretions and triggering coughing.

A nurse is assessing a client who is 1 day postoperative following a lobectomy and has a chest tube drainage system in place. Which of the following findings by the nurse indicates a need for intervention? A. Chest tube eyelets not visible. B. Continuous bubbling in the suction control chamber. C. Presence of tidal fluctuation in the water seal chamber. D. Development of subcutaneous emphysema.

Rationale: Subcutaneous emphysema is an indication that air is trapped in and under the skin, which be the result of a pneumothorax and should be reported to the provider.

A nurse in the emergency department is caring for a client who was injured in a motor-vehicle crash. The client reports dyspnea and severe pain. The nurse notes that the client's chest moves inward during inspiration and bulges out during expiration. The nurse should identify this finding as which of the following? A. Atelectasis B. Flail chest C. Hemothorax D. Pneumothorax

A. Atelectasis Rationale: Atelectasis is a collapse of the alveoli. With atelectasis, the exchange of oxygen and carbon dioxide is diminished. Crackles, fever and productive cough are manifestations of atelectasis

A nurse is caring for a client who has a central venous catheter and develops acute shortness of breath. Which of the following actions should the nurse take first? A. Clamp the catheter. B. Position the client in left lateral trendelenburg. C. Initiate oxygen therapy. D. Auscultate breath sounds.

A. Clamp the catheter. The greatest risk to this client is injury from further air entering the central venous catheter; therefore, the first action the nurse should take is to clamp the catheter.

A nurse is assessing a client who has a fracture of the femur. The nurse obtains vital signs on admission and again in 2 hours. Which of the following changes in assessment should indicate to the nurse that the client could be developing a serious complication? A. Increased respiratory rate from 18 to 44/min B. Increased oral temperature from 36.6° C (97.8° F) to 37° C (98.6° F) C. Increased blood pressure from 112/68 to 120/72 mm Hg D. Increased heart rate from 68 to 72/min.

A. Increased respiratory rate from 18 to 44/min. Rationale: This change in respiratory rate is significant, as the first value is within the expected reference range, but the second value is very elevated for an adult client. Increased respiratory rate could be a manifestation of a possible fat embolism, a serious complication that may follow the type of fracture sustained by the client. Fat emboli can be trapped in lung tissue, leading to respiratory symptoms and mental disturbances.

A nurse is auscultating the lungs of a client who has pleurisy. Which of the following adventitious breath sounds should the nurse expect to hear? A. Loud, scratchy sounds. B. Squeaky, musical sounds. C. Popping sounds. D. Snoring sounds.

A. Loud, scratchy sounds. Rationale: Loud, scratchy sounds caused by inflammation of the pleura are a manifestation of pleurisy

A nurse is caring for a client who is postoperative and whose respirations are shallow and 9/min. Which of the following acid-based imbalances should the nurse identify the client as being at risk for developing initially? A. Respiratory acidosis B. Respiratory alkalosis. C. Metabolic acidosis. D. Metabolic alkalosis.

A. Respiratory acidosis

A nurse is teaching a client about taking diphenhydramine. The nurse should explain to the client that which of the following is an adverse effect of this medication? A. Sedation B. Constipation C. HTN D. Bradycardia

A. Sedation

A nurse is caring for a client who has an acute respiratory failure (ARF). The nurse should monitor the client for which of the following manifestations of this condition? (Select all that apply.) A. Severe dyspnea B. Nausea C. Decreased level of consciousness D. Headache E. Hypotension

A. Severe dyspnea C. Decreased level of consciousness D. Headache E. Hypotension

A nurse is reviewing the arterial blood gas results for a client in the ICU who has kidney failure and determines the client has respiratory acidosis. Which of the following findings should the nurse expect? A. Widened QRS complexes. B. Hyperactive deep tendon reflexes. C. Bounding peripheral pulses. D. Warm, flushed skin.

A. Widened QRS complexes. Rationale: A client who has respiratory acidosis is likely to cardiac changes from delayed electrical conduction through the heart, such as widened QRS complexes, tall T waves, prolonged PR intervals, and a heart rate that ranges from bradycardia to heart block

A. nurse is caring for a client who develops a pulmonary embolism. Which of the following interventions should the nurse implement first? A. Give morphine IV B. Administer oxygen therapy C. Start an IV infusion of LR. D. Initiate cardiac monitoring.

B. Administer oxygen therapy Rationale: The greatest risk to the safety of a client who has a pulmonary embolism is hypoxemia with respiratory distress and cyanosis. Oxygen therapy should be applied by the nurse using a nasal cannula or mask. Pulse oximetry should be initiated to monitor oxygen saturation.

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. The client pulls out his endotracheal tube. Which of the following actions should the nurse take first? A. Prepare the client for reintubation B. Assess the client's airway. C. Suction the client's mouth. D. Elevate the client's HOB.

B. Assess the client's airway.

A nurse is caring for a client who is 12 hr postoperative and has a chest tube to a disposable water-seal drainage system with suction. The nurse should intervene for which of the following observations? A. Constant bubbling in the suction-control chamber. B. Continuous bubbling in the water-seal chamber. C. Bloody drainage in the collection chamber. D. Fluid-level fluctuations in the water-seal chamber.

B. Continuous bubbling in the water-seal chamber.

A nurse is assessing a client who has developed atelectasis postoperatively. Which of the following findings should the nurse expect? A. Facial flushing. B. Increased dyspnea. C. Decreasing respiratory rate. D. Friction rub.

B. Increased dyspnea. Rationale: The postoperative client is at increased risk for developing atelectasis because of a blunted cough reflex or shallow breathing due to anesthesia, opioids or pain medication. Common manifestations include shortness of breath and pleural pain.

A nurse is providing teaching to a client who is postoperative following coronary artery bypass graft (CABG) surgery and is receiving opioid medications to manage discomfort. Aside from managing pain, which of the following desired effects of medications should the nurse identify as most important for the client's recovery? A. It decreases the client's level of anxiety. B. It facilitates the client's deep breathing. C. It enhances the clients ability to sleep. D. It reduces the client's blood pressure.

B. It facilitates the client's deep breathing.

A nurse is caring for a client who has a chest tube in place to a closed chest drainage system. Which of the following findings should indicate to the nurse that the client's lung has re-expanded? A. Oxygen saturation of 95% B. No fluctuations in the water seal chamber. C. No reports of pleuritic chest pain. D. Occasional bubbling in the water-seal chamber.

B. No fluctuations in the water seal chamber. Rationale: Fluctuation stops when the lung has re-expanded, but the nurse should check for other indications of re-expansion, such as equal breath sounds bilaterally, because fluctuation can also stop when the tubing is obstructed, a dependent loop hangs below the rest of the tubing, or the suction source is not functioning.

A nurse is reviewing the laboratory values of a client who has respiratory acidosis. Which of the following findings should the nurse expect? A. HCO3- 30 mEq/L B. PaCO2 50 mm Hg C. pH 7.45 D. Potassium 3.3 mEq/L

B. PaCO2 50 mm Hg

nurse in the intensive care unit is providing teaching for a client prior to removal of an endotracheal tube. Which of the following instructions should the nurse include in the teaching? A. "Rest in a side-lying position after the tube is removed." B. "Use the incentive spirometer every 4 hr after the tube is removed. C. "Avoid speaking for long periods." D. "A nurse will monitor your vital signs every 15 minutes in the first hour after the tube is removed."

C. "Avoid speaking for long periods." Rationale: The client should avoid speaking for long periods to promote gas exchange

A nurse is caring for a client who experienced a lacerated spleen and has been on bedrest for several days. The nurse auscultates decreased breath sounds in the lower lobes of both lungs. The nurse should realize that this finding is most likely an indication of which of the following conditions? A. An upper respiratory infection. B. Pulmonary edema. C. Atelectasis. D. Delayed gastric emptying.

C. Atelectasis.

A nurse is caring for a client who is unconscious and has a breathing pattern characterized by alternating periods of hyperventilation and apnea. The nurse should document that the client has which of the following respiratory alterations? A. Kussmaul Respirations B. Apneustic Respirations C. Cheyne-Stokes Respirations D. Stridor

C. Cheyne-Stokes Respirations Cheyne-Stokes respirations (CSR) are characterized by a rhythmic increase (to the point of hyperventilation) and decrease (to the point of apnea) in the rate and depth of respiration. CSR are common respiratory alterations seen in clients who are unconscious, comatose, or moribund (approaching death). Kussmaul respirations are deep, rapid, regular respirations and are commonly seen in clients who are experiencing metabolic acidosis. Stridor is a continuous, high-pitched sound heard on inspiration in clients who have partial airway obstruction of the larynx or trachea

A nurse is monitoring an older adult client immediately following a bronchoscopy. The nurse's priority is to monitor the client for which of the following? A. Observing for confusion. B. Auscultating breath sounds. C. Confirming the gag reflex. D. Measuring blood pressure.

C. Confirming the gag reflex. Rationale: When using the airway, breathing, circulation approach to client care, the nurse should first assess the client's gag reflex to ensure that the client has an open airway.

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to promote thinning of respiratory secretions? A. Encourage the client to ambulate frequently. B. Encourage coughing and deep breathing. C. Encourage the client to increase fluid intake. D. Encourage regular use of incentive spirometer.

C. Encourage the client to increase fluid intake. Rationale: Increasing fluid intake to1,500 to 2,500 mL/day promotes liquefaction and thinning of pulmonary secretions, which improves the client's ability to cough and remove the secretions.

A nurse is developing a plan of care for a client who is postoperative. Which of the following interventions should the nurse include in the plan to prevent pulmonary complications? A. Perform range-of-motion exercises. B. Place suction equipment at the bedside. C. Encourage the use of incentive spirometer. D. Administer an expectorant.

C. Encourage the use of incentive spirometer.

A nurse is caring for a client who has just developed a pulmonary embolism. Which of the following medications should the nurse anticipate administering? A. Furosemide. B. Dexamethasone. C. Heparin D. Atropine.

C. Heparin Rationale: A pulmonary emboli is a condition in which the pulmonary blood flow is obstructed, resulting in hypoxia and possible death. Most often caused by a blood clot, treatment such as heparin, an anticoagulant, is used to prevent the enlargement of the existing clot or formation of new clots.

A nurse is monitoring a client following a thoracentesis. The nurse should identify which of the following manifestations as a complication and contact the provider immediately? A. Serosanguineous drainage from the puncture site. B. Discomfort at the puncture. C. Increased heart rate. D. Decreased temperature.

C. Increased heart rate. Rationale: Clients are at risk for developing pulmonary edema or cardiovascular distress due mediastinal content shift after the aspiration of a large amount of fluid from the client's pleural space. Therefore, the client may experience an increase in heart and respiratory rate, along with coughing with blood-tinged frothy sputum, and tightness in the chest. These findings require notification of the provider immediately.

A nurse in the PACU is assessing a client who has an endotracheal tube (ET) tube in place and observes the absence of left-sided chest wall expansion upon respiration. Which of the following complications should the nurse suspect? A. Blockage of the ET tube by the client's tongue. B. Passage of the ET tube into the esophagus. C. Movement of the ET tube into the right main bronchus. D. Infection of the vocal cords.

C. Movement of the ET tube into the right main bronchus. Rationale: During intubation, the staff can misplace the ET tube in the right mainstem bronchus. The nurse should identify absence of chest wall movement or breath sounds on a single side as indicating ET tube displacement, and should notify appropriate personnel to reposition the tube.

A nurse is caring for a client whose arterial blood gas results show a pH of 7.3 and a PaCO2 of 50 mm Hg. The nurse should identify that the client is experiencing which of the following acid-base imbalances? A. Metabolic acidosis. B. Metabolic alkalosis. C. Respiratory acidosis. D. Respiratory alkalosis.

C. Respiratory acidosis

A nurse is caring for a client who has an endotracheal tube and is receiving mechanical ventilation. Which of the following interventions should the nurse take to reduce the risk for ventilator-associated pneumonia? A. Position the HOB in flat position. B. Turn the client every 4 hr. C. Rinse the client's mouth with an antimicrobial solution every 4 hr. D. Perform hand hygiene prior to suctioning the client ETT.

C. Rinse the client's mouth with an antimicrobial solution every 4 hr. Rationale: The nurse should brush the client's teeth every 8 hr and rinse the client's mouth with an antimicrobial rinse every 2 hr to reduce the growth of bacteria.

A nurse is prioritizing client care after receiving change-of-shift report. Which of the following clients should the nurse plan to see first? A. A client who is scheduled for an abdominal x-ray and is awaiting transport. B. A client who has a prescription for discharge. C. A client who received oral pain medication 30 minutes ago. D. A client who to an assistive personnel he is short of breath.

D. A client who to an assistive personnel he is short of breath.

A nurse in an emergency department is caring for a client who has a sucking chest wound resulting from a gunshot. The client has a blood pressure of 100/60 mm Hg, a weak pulse rate of 118/min, and a respiratory rate of 40/min. Which of the following actions should the nurse take? A. Raise the foot of the bed to a 90 degree angle. B. Remove the dressing to inspect the wound. C. Prepare to insert a central Line. D. Administer oxygen via nasal cannula.

D. Administer oxygen via nasal cannula. The client has an increased respiratory rate and heart rate, indicating that she is having respiratory difficulty. The sucking chest wound indicates the client has a pneumothorax and/or a hemothorax. Administering oxygen will increase the oxygen exchange in the lungs and the oxygen available to the tissue.

A nurse is caring for a client who has active pulmonary tuberculosis (TB) and is to be started on intravenous rifampin therapy. The nurse should instruct the client that this medication can cause which of the following adverse effects? A. Constipation B. Black colored stools C. Staining of teeth D. Body secretions turning a red-orange color

D. Body secretions turning a red-orange color

A nurse in the emergency department is assessing an older adult client who has community- acquired pneumonia. Which of the following findings should the nurse expect? A. Unequal pupils B. HTN C. Tympany upon chest percussion. D. Confusion

D. Confusion Rationale: Confusion due to hypoxemia is an expected finding for an older-adult who has pneumonia.

A nurse is caring for a child who is experiencing status asthmaticus. Which of the following interventions is the priority for the nurse to take? A. Administer a short-acting ß2 -agonist (SABA) B. Obtain a peak flow reading. C. Administer an inhaled glucocorticoid. D. Determine the cause of the acute exacerbation

D. Determine the cause of the acute exacerbation Rationale: Determining the cause of the acute exacerbation is non-urgent while the client is in distress. Although the nurse should determine the trigger for the asthma exacerbation to prevent future attacks, there is another action that is the priority.

A nurse is assessing a client who has postoperative atelectasis and is hypoxic. Which of the following manifestations should the nurse expect? A. Bradycardia B. Bradypnea C. Lethargy D. Intercostal retractions.

D. Intercostal retractions. Rationale: Hypoxia is a condition in which the tissues of the body are oxygen-starved. It follows hypoxemia (low oxygen in the blood) and is manifested as substernal or intercostal retractions as the body works harder to draw more oxygen into the lungs.

A charge nurse is reviewing guidelines for initiating airborne precautions. Which of the following clients should the nurse identify as requiring airborne precautions? A. A client who has scabies B. Perussis C. Streptococcal pharyngitis D. Measles.

D. Measles. Rationale: A client who has measles requires airborne precautions as well as a negative pressure room

A nurse is suctioning the endotracheal tube of a client who is on a ventilator. The client's heart rate increases from 86/min to 110/min and becomes irregular. Which of the following actions should the nurse take? A. Obtain a cardiology consult. B. Suction the client less frequently. C. Administer an anti-dysrhythmic medication. D. Perform pre-oxygenation prior to suctioning.

D. Perform pre-oxygenation prior to suctioning. Rationale: Suctioning should be performed on the endotracheal tube of a client who is mechanically ventilated to remove accumulated secretions from the airways. Possible complications of the procedure include hypoxemia, manifested by tachycardia and arrhythmia, and tissue injury. . In preparation for suctioning, and to prevent hypoxemia, the client should be pre-oxygenated using a manual resuscitator bag set at 100% oxygen.

A nurse is caring for a client who has returned to the unit following a surgical procedure. The client's oxygen saturation is 85%. Which of the following actions should the nurse take first? A. Administer oxygen at 2 L/min B. Administer prescribed analgesic medication. C. Encourage coughing and deep breathing. D. Raise the head of the bed.

D. Raise the head of the bed.

A nurse is monitoring a client who has a chest tube in place connected to wall suction due to a right-sided pneumothorax. The client complains of chest burning. Which of the following actions should the nurse take? A. Increase the client's wall suction. B. Strip the client's chest tube. C. Clamp the client's chest tube. D. Reposition the client.

D. Reposition the client. Rationale: The nurse repositioning the client is an appropriate action to relieve chest burning from the chest tube.

A nurse is caring for four hospitalized clients. Which of the following clients should the nurse identify as being at risk for fluid volume deficit? A. The client who has been NPO since midnight for endoscopy. B. The client who has left-sided heart failure and has a brain natriuretic peptide (BNP) level of 600 pg/mL. C. The client who has end-stage renal failure and is scheduled for dialysis today. D. The client who has gastroenteritis and is febrile.

D. The client who has gastroenteritis and is febrile. This client has two risk factors for the development of fluid volume deficit, or dehydration. Gastroenteritis is characterized by diarrhea and may also be associated with vomiting, so it can be a significant source of fluid loss. The client who has a fever can also lose fluid via diaphoresis, and fever raises the metabolic rate, further putting the client at increased risk for dehydration. Consequently, this is the client at greatest risk for fluid volume deficit.

A nurse is caring for a female client in the emergency department who reports shortness of breath and pain in the lung area. She states that she started taking birth control pills 3 weeks ago and that she smokes. Her heart rate is 110/min, respiratory rate 40/min, and blood pressure 140/80 mm Hg. Her arterial blood gases are pH 7.50, PaCO2 29 mm Hg, PaO2 60 mm Hg, HCO3 20 mEq/L, and SaO2 86%. Which of the following is the priority nursing intervention? A. Prepare for mechanical ventilation. B. Administer oxygen via face mask. C. Prepare to administer a sedative. D. Assess for indication of pulmonary embolism.

B. Administer oxygen via face mask. The pH reflects alkalosis, and the low PaCO2 indicates that the lungs are involved, so the client has respiratory alkalosis. The client's oxygen saturation is low, so one priority is to administer oxygen via mask attempting to achieve an oxygen saturation of at least 95%. The greatest risk to this client is hypoxia, thus the priority is to restore oxygenation.

A nurse is caring for a client who has a three-chamber closed chest tube system. Which of the following actions should the nurse take after noticing a rise in the water seal chamber with client inspiration? A. Continue to monitor the client. B. Immediately notify the provider. C. Reposition the client toward the left side. D. Clamp the chest tube near the water seal.

A. Continue to monitor the client. Rationale: The fluid in the water seal chamber rises 2 to 4 inches during inhalation and falls during exhalation. This is a process called tidaling. An absence of tidaling might indicate a fully expanded lung or an obstruction in the chest tube.

A nurse is caring for a client who has a disposable three-chamber chest tube in place. Which of the following findings should indicate to the nurse that the client is experiencing a complication? A. Continuous bubbling in the water seal chamber. B. Occasional bubbling in the water seal chamber. C. Constant bubbling in the suction control chamber. D. Fluctuations in the fluid level in the water seal chamber.

A. Continuous bubbling in the water seal chamber. Rationale: Excessive and continuous bubbling in the water-seal chamber indicates an air leak in the drainage system.

A nurse is caring for a client who is receiving positive-pressure mechanical ventilation. Which of the following interventions should the nurse implement to prevent complications? (Select all that apply.) A. Elevate the head of the bed to at least 30&deg. B. Verify the prescribed ventilator settings daily. C. Apply restraints if the client becomes agitated. D. Administer pantoprazole as prescribed. E. Reposition the endotracheal tube to the opposite side of the mouth daily.

A. Elevate the head of the bed to at least 30&deg. D. Administer pantoprazole as prescribed. E. Reposition the endotracheal tube to the opposite side of the mouth daily.

A nurse is assessing a client who has a pneumothorax with a chest tube in place. For which of the following findings should the nurse notify the provider? A. Movement of the trachea toward the unaffected side. B. Bubbling of the water in the water seal chamber. C. Crepitus in the area above and surrounding the insertion site. D. Eyelets are not visible.

A. Movement of the trachea toward the unaffected side. A chest tube inserted for a spontaneous pneumothorax may result in the development of a tension pneumothorax, a medical emergency. This results from air in the pleural space compressing the blood vessels of the thorax and limiting blood return to the heart. An assessment of tracheal deviation, or movement of the trachea toward the unaffected side, is indicative of tension pneumothorax and should be reported to the provider immediately. The water seal chamber prevents air from re-entering the pleural space. Bubbling in this chamber indicates air is being removed from the client's pleural space, allowing re-expansion of the lung. It should occur during exhalation, coughing, and sneezing. When the air from the pleural space is removed, the bubbling will stop. Excessive bubbling in this chamber may indicate an air leak and should be further investigated by the nurse. Crepitus, or subcutaneous emphysema, sounds like a crackling noise when palpated. It can be an expected finding in the client who has a pneumothorax and will persist for several hours (or longer, depending on how long it takes the air to be reabsorbed) following evacuation of the pneumothorax.

A nurse is caring for a client who has returned from the surgical suite following surgery for a fractured mandible. The client had intermaxillary fixation to repair and stabilize the fracture. Which of the following actions is the priority for the nurse to take? A. Prevent aspiration. B. Ensure adequate nutrition. C. Promote oral hygiene. D. Relieve the client's pain.

A. Prevent aspiration.

nurse is caring for a client who experienced a femur fracture 8 hr ago and now reports sudden onset dyspnea and severe chest pain. Which of the following actions should the nurse take first? A. Provide high-flow oxygen. B. Check the client for a positive Chvostek's sign. C. Administer an IV vasopressor medication. D. Monitor the client for headache

A. Provide high-flow oxygen. he first action the nurse should take when using the airway, breathing, circulation approach to client care is to provide the client with high-flow oxygen. The client is experiencing fat embolism syndrome as a complication of a long bone fracture. The lungs are affected first, causing a drop in the level of arterial oxygen, and the client can require mechanical ventilation.

A nurse is monitoring a client who received epinephrine for angioedema after a first dose of losartan. Which of the following data indicates a therapeutic response to the epinephrine? A. Respirations are unlabored. B. Client reports decreased groin pain of 3 on a 1 to 10 scale. C. The client's BP when arising from resting position is at premedication levels. D. The client tolerated a second dose of medication with no great than 1+ peripheral edema.

A. Respirations are unlabored. Rationale: Losartan is an angiotensin receptor blocker (ARB). Both ARBs and angiotensin converting enzyme (ACE) inhibitors have the adverse effect of angioedema. The primary symptom of angioedema is swelling of the tongue, glottis, and pharynx. This results in limitation or blockage of the airway. Angioedema causes the capillaries to become more permeable, resulting in fluid shifting into the subcutaneous tissues. Although the mouth and throat are most often affected, any area may be involved in the process. Untreated, angioedema can result in death. Improvement of respiratory effort following the administration of epinephrine is the most important therapeutic indicator

A client is admitted to the emergency room with a respiratory rate of 7/min. Arterial blood gases (ABG) reveal the following values. Which of the following is an appropriate analysis of the ABGs? pH 7.22 PaCO2 68 mm Hg Base excess -2 PaO2 78 mm Hg Saturation 80% Bicarbonate 26 mEq/L A. Respiratory acidosis B. Metabolic acidosis C. Metabolic alkalosis D. Respiratory alkalosis

A. Respiratory Acidosis

A nurse is assessing a client immediately after the provider removed the client's endotracheal tube. Which of the following findings should the nurse report to the provider? A. Stridor B. Copious oral secretions. C. Hoarseness. D. Sore throat.

A. Stridor Rationale: Stridor, or a high-pitched crowing sound heard during inspiration, is a result of laryngeal edema. This finding indicates possible obstruction of the client's airway. Therefore, the nurse should report it to the provider immediately.

A nurse is caring for a client who has a chest tube connected to a closed drainage system and needs to be transported to the x-ray department. Which of the following actions should the nurse take? A. Clamp the chest tube prior to transferring the client to a wheelchair. B. Disconnect the chest tube from the drainage system during transport. C. Keep the drainage system below the level of the client's chest at all times D. Empty the collection chamber prior to transport.

C. Keep the drainage system below the level of the client's chest at all times. During transport, the drainage system should be kept below the level of the client's chest to prevent air and drainage fluid from re-entering the thoracic cavity. The chest tube should not be disconnected from the drainage system Clamping the tube can lead to a tension pneumothorax (collapse of the lung) due to increased intrathoracic pressure from gas and fluid that cannot be drained from the pleural space.

A nurse is conducting a primary survey of a client who has sustained life-threatening injuries due to a motor-vehicle crash. Identify the sequence of actions the nurse should take. (Move the actions into the box on the right, placing them in the selected order of performance. Use all the steps.) E. Remove clothing for a thorough assessment D. Determine effectiveness of ventilator efforts. C. Open the airway using a jaw-thrust maneuver. A. Perform a Glasgow Coma Scale assessment. B. Establish IV access.

C. Open the airway using a jaw-thrust maneuver. D. Determine effectiveness of ventilator efforts. B. Establish IV access. A. Perform a Glasgow Coma Scale assessment. E. Remove clothing for a thorough assessment

A nurse is triaging victims of a multiple motor-vehicle crash. The nurse assesses a client trapped under a car who is apneic and has a weak pulse at 120/min. After repositioning his upper airway, the client remains apneic. Which of the following actions should the nurse take? A. Start CPR. B. Place a red tag on the client's upper body and obtain immediate help from other personnel. C. Place a black tag on the client's upper body and attempt to help the next client in need. D. Reposition the client's upper airway a second time before assessing his respirations

C. Place a black tag on the client's upper body and attempt to help the next client in need. Rationale: When assessing an apneic adult casualty in a disaster situation, a nurse should attempt to reposition the upper airway on time. If the client still does not breathe, a black tag should be placed on the upper body and the nurse should move on to the next client in need.

A nurse is caring for a client who is 1-day postoperative following a left lower lobectomy and has a chest tube in place. When assessing the client's three-chamber drainage system, the nurse notes that there is no bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Continue to monitor the client as this is an expected finding. B. Add more water to the suction control chamber of the drainage system. C. Verify that the suction regulator is on and check the tubing for leaks. D. Milk the chest tube and dislodge any clots in the tubinf the are occluding it.

C. Verify that the suction regulator is on and check the tubing for leaks. Rationale: A lack of bubbling may indicate that either the suction regulator is turned off or that there is a leak in the tubing. The expected finding would be a gentle bubbling of the water in the suction control chamber. Stripping, or milking, can pull too hard on the chest cavity and may cause a tissue injury to the lung. Stripping is only done when specifically indicated.

A nurse is observing the closed chest drainage system of a client who is 24 hr post thoracotomy. The nurse notes slow, steady bubbling in the suction control chamber. Which of the following actions should the nurse take? A. Check the tubing connections for leaks. B. Check the suction control outlet on the wall. C. Clamp the chest tube. D. Continue to monitor the client's respiratory status.

D. Continue to monitor the client's respiratory status. Slow, steady bubbling in the suction control chamber is an expected finding. Therefore, the nurse should continue to monitor the client's respiratory status.

A nurse is planning care for a client who has acute respiratory distress syndrome (ARDS). Which of the following interventions should the nurse include in the plan? A. Administer low-flow oxygen continuously via nasal cannula B. Encourage oral intake of at least 3,000 mL of fluids per day C. Offer high-protein and high-carbohydrate foods frequently. D. Place in a prone position.

D. Place in a prone position.