questions for med surg test

A college student presents to the health clinical with signs and symptoms of viral rhinitis (common cold). The patient states, "I've felt terrible all week; what can I do to feel better?" Which of the following is the best response the nurse can give?

"You should rest, increase your fluids, and take Ibuprofen."

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than:

0.5 an FIO2 greater than 0.5 for as little as 16 to 24 hours can be toxic and can lead to decreased gas diffusion and surfactant activity. The ideal oxygen source is room air FIO2 0.18 to 0.21.

The goal for oxygen therapy in COPD is to support tissue oxygenation, decrease the work of the cardiopulmonary system, and maintain the resting partial arterial pressure of oxygen (PaO2) of at least ______ mm Hg and an arterial oxygen saturation (SaO2) of at least ___%.

60 mm Hg; 90%

The nurse is assigned the care of a patient with a chest tube. The nurse should ensure that which of the following items is kept at the patient's bedside?

A bottle of sterile water It is essential that the nurse ensure that a bottle of sterile water is readily available at the patient's bedside. If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent the development of a pneumothorax, a temporary water seal can be established by immersing the chest tube's open end in a bottle of sterile water. There is no need to have an Ambu bag, incentive spirometer, or a set of hemostats at the bedside.

the emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. which finding would indicate the presence of a pneumothorax in this client? A. a low respiratory rate B. diminished breath sounds C. the presence of barrel chest D. a sucking sound at the site of injury

B. diminished breath sounds -if it was an open chest injury than it would be the sucking sound at the site of injury

The nurse is caring for a patient in the ICU who is receiving mechanical ventilation. Which of the following nursing measures are implemented in an effort to reduce the patient's risk of developing ventilator-associated pneumonia (VAP)?

Cleaning the patient's mouth with chlorhexidine daily The five key elements of the VAP bundle include the following: elevation of the head of the bed (30 to 45 degrees: semi-Fowler's position), daily "sedation vacations," and assessment of readiness to extubate (see below); peptic ulcer disease prophylaxis (with histamine-2 receptor antagonists, such as ranitidine [Zantac]); deep venous thrombosis (DVT) prophylaxis; and daily oral care with chlorhexidine (0.12% oral rinses). The patient should be turned and repositioned every 2 hours to prevent complications of immobility and atelectasis and to optimize lung expansion.

What client would be most in need of an endotracheal tube?

Comatose clients

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?

Encourage the patient to take approximately 10 breaths per hour, while awake.

Which of the following exposures accounts for the majority of cases with regard to risk factors for chronic obstructive pulmonary disease (COPD)?

Exposure to tobacco smoke

A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client?

Impaired gas exchange related to ventilator setting adjustments

Which of the following is the key underlying feature of asthma?

Inflammation

A client is being seen in the emergency department for exacerbation of chronic obstructive pulmonary disease (COPD). The first action of the nurse is to administer which of the following prescribed treatments?

Oxygen through nasal cannula at 2 L/minute

You are assessing a client's potential for pulmonary emboli. What finding indicates possible deep vein thrombosis?

Pain in the calf

In general, chest drainage tubes are not indicated for a patient undergoing which of the following procedures?

Pneumonectomy Usually, no drains are used for the patient having a pneumonectomy because the accumulation of fluid in the empty hemothorax prevents mediastinal shift. With lobectomy, two chest tubes are usually inserted for drainage, the upper tube for air and the lower tube for fluid. With wedge resection, the pleural cavity usually is drained because of the possibility of an air or blood leak. With segmentectomy, drains are usually used because of the possibility of an air or blood leak.

The client is prescribed albuterol (Ventolin) 2 puffs as a metered-dose inhaler. The nurse evaluates client learning as satisfactory when the client

Positions the inhaler 1 to 2 inches away from his open mouth To administer a metered-dose inhaler, the client holds the inhaler upright and shakes the inhaler. The inhaler is positioned 1 to 2 inches away from the client's open mouth. After administering the medication, the client holds the breath for as long as possible, at least 10 seconds. The client may administer the next puff in 15 to 30 seconds.

A patient with asthma is prescribed a short acting beta-adrenergic (SABA) for quick relief. Which of the following is the most likely drug to be prescribed?

Proventil

The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to

Purse the lips when exhaling air from the lungs.

The nurse is providing discharge instructions for a patient following laryngeal surgery. The nurse instructs the patient to avoid which of the following?

Swimming

When caring for a client who has just had a total laryngectomy, the nurse should plan to:

develop an alternative communication method.

A nurse is assisting with a subclavian vein central line insertion when the client's oxygen saturation drops rapidly. He complains of shortness of breath and becomes tachypneic. The nurse suspects the client has developed a pneumothorax. Further assessment findings supporting the presence of a pneumothorax include:

diminished or absent breath sounds on the affected side.

Which of the following is an adverse reaction that would require termination of the weaning process from the ventilator?

Blood pressure increase of 20 mm Hg

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

Kinking of the ventilator tubing

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?

84 mm Hg

Instructions for TB treatment: A.Instructions should be resumed gradually B.Avoid contact w other individuals, except family members, for at least 6 months C.A sputum culture is needed every 2-4 weeks once medication is started D.Respiratory isolation is not necessary because family has already been exposed E.Cover the mouth and nose when coughing or sneezing and put tissues in plastic bags F.When one sputum culture is negative, the client is no longer considered infectious and can usually return to former employment - FALSE because you need 3 sputum cultures

A. Instructions should be resumed gradually C. A sputum culture is needed every 2-4 weeks once medication is started D. Respiratory isolation is not necessary because family has already been exposed E. Cover the mouth and nose when coughing or sneezing and put tissues in plastic bags

the nurse is caring for a client who is postoperative and develops an acute onset of severe chest pain that worsens upon inspiration. the client is anxious and tachypneic. which of the following actions should the nurse take first? A.apply supplemental oxygen B.increase the rate of IV fluids C. administer pain medication D. initiate heparin therapy

A.apply supplemental oxygen -when using the airway, breathing, circulation arppoach to client care the greatest risk of the client is every hypoxemia . therefore, the first action the nurse should take is to apply supplemental oxygen.

For a client with an endotracheal (ET) tube, which nursing action is the most important?

Auscultating the lungs for bilateral breath sounds

A nurse consulting with a nutrition specialist knows it's important to consider a special diet for a client with chronic obstructive pulmonary disease (COPD). Which diet is appropriate for this client?

High-protein

After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered:

Significant An induration of 10 mm or greater is usually considered significant and reactive in people who have normal or mildly impaired immunity. Erythema without induration is not considered significant.

A patient comes to the clinic for the third time in 2 months with chronic bronchitis. What clinical symptoms does the nurse anticipate assessing for this patient?

Sputum and a productive cough

The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis?

Stabbing pain during respiratory movement

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

Suction the client's artificial airway.

Which of the following techniques does a nurse suggest to a patient with pleurisy while teaching about splinting the chest wall?

Turn onto affected side. Teach the client to splint their chest wall by turning onto the affected side. The nurse instructs the patient with pleurisy to take analgesic medications as prescribed, but this not a technique related to splinting the chest wall. The patient can splint the chest wall with a pillow when coughing. The nurse instructs the patient to use heat or cold applications to manage pain with inspiration, but this not a technique related to splinting the chest wall.

The nurse is caring for a patient being weaned from the mechanical ventilator. Which of the following patient findings would require the termination of the weaning process?

Blood pressure increase of 20 mm Hg from baseline In collaboration with the primary provider, the nurse would terminate the weaning process if adverse reactions occur, including a heart rate increase of 20 beats/min, systolic BP increase of 20 mm Hg, a decrease in oxygen saturation to less than 90%, respiratory rate less than 8 or greater than 20 breaths/min, ventricular dysrhythmias, fatigue, panic, cyanosis, erratic or labored breathing, and paradoxical chest movement. A vital capacity of 10 to 15 mL/kg, maximum inspiratory pressure (MIP) at least -20 cm H2O, tidal volume: 7 to -9 mL/kg, minute ventilation: 6 L/min, and rapid/shallow breathing index below 100 breaths/min/L; PaO2 greater than 60 mm Hg with FiO2 less than 40% are criteria if met by the patient indicates that the patient is ready to be weaned from the ventilator. A normal vital capacity is 10 to 15 mL/kg.

A victim has sustained a blunt force trauma to the chest. A pulmonary contusion is suspected. Which of the following clinical manifestations correlate with a moderate pulmonary contusion?

Blood-tinged sputum

A client has a red pharyngeal membrane, reddened tonsils, and enlarged cervical lymph nodes. The client also reports malaise and sore throat. The nurse needs to assess first for:

Fever

The nurse should monitor a client receiving mechanical ventilation for which of the following complications?

Gastrointestinal hemorrhage Gastrointestinal hemorrhage occurs in approximately 25% of clients receiving prolonged mechanical ventilation. Other possible complications include incorrect ventilation, oxygen toxicity, fluid imbalance, decreased cardiac output, pneumothorax, infection, and atelectasis. Immunosuppression and pulmonary emboli are not direct consequences of mechanical ventilation.

A patient with bronchiectasis is admitted to the nursing unit. The primary focus of nursing care for this patient includes which of the following?

Implementing measures to clear pulmonary secretions

The nurse has instructed a patient on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which of the following?

Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods?

10 to 15 seconds

Which of the following ranges of water pressure identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration?

15 to 20 mm Hg

The nurse is educating a patient who will be started on an antituberculosis medication regimen. The patient asks the nurse, "How long will I have to be on these medications?" What should the nurse tell the patient?

6 to 12 months

Blunt injury to chest wall - what finding indicated pneumothorax? A.Low resp rate B.Diminished breath sounds C.Presence of barrel chest D.Rush of air sound at site of injury

B Diminished breath sounds

A nurse is assessing a client two has emphysema. The nurse should report which of the following assessment findings? A. digital clubbing B.elevated temperature C.barrel-shaped chest D.diminished breath sounds

B elevated temperature because this would indicate that the client can now have a respiratory infection such as pneumonia

the nurse understands that the pathophysiology of chronic obstructive pulmonary disease is related to? A.chronic vasodilation and widening of airways B.chornic inflammation and narrowing of airways C.chronic decreased CO2 levels D.chronic vasoconstriction of airways

B. chronic inflammation and narrowing of airways

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?

Baseline arterial blood gas (ABG) levels Before weaning the client from mechanical ventilation, it's most important to have baseline ABG levels. During the weaning process, ABG levels will be checked to assess how the client is tolerating the procedure. Other assessment parameters are less critical. Measuring fluid volume intake and output is always important when a client is being mechanically ventilated. Prior attempts at weaning and ECG results are documented on the client's record, and the nurse can refer to them before the weaning process begins.

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for

A kink in the ventilator tubing

Which of the following is accurate regarding status asthmaticus?

A severe asthma episode that is refractory to initial therapy

the nurse is caring for a client hospitalized with acute exacberation of COPD. which finding would the nurse expect to note on assessment of this client?

A. hyper inflated chest and flattened diaphragm noted on the chest X-ray B. decreased oxygen saturation with mild exercise

On auscultation, which finding suggests a right pneumothorax?

Absence of breath sounds in the right thorax

The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of which of the following?

2 to12 days

The nurse is caring for a patient in the ICU who required emergent endotracheal (ET) intubation with mechanical ventilation. The nurse receives an order to obtain arterial blood gases (ABGs) following the procedure. The nurse recognizes that ABGs should be obtained at which timeframe following the initiation of mechanical ventilation?

20 minutes

The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?

A face mask

Which of the following is true about both lung transplant and bullectomy?

Both are aimed at improving the overall quality of life of a patient with COPD. The treatments for COPD are aimed more at treating the symptoms and preventing complications, thereby improving the overall quality of life of a patient with COPD. In fact, there is no cure for COPD. Lung transplant is aimed at treating end-stage emphysema and bullectomy is used to treat patients with bullous emphysema.

Which of the following is the most effective treatment for obstructive sleep apnea (OSA)?

Continuous positive airway pressure (CPAP)

Which of the following exposures accounts for most of the risk factors for COPD?

Exposure to tobacco smoke

You are an occupational nurse completing routine assessments on the employees where you work. What might be revealed by a chest radiograph for a client with occupational lung diseases?

Fibrotic changes in lungs

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?

Hypercapnia, hypoventilation, and hypoxemia

Which of the following electrolyte imbalances occur with adrenal insufficiency?

Hyperkalemia.

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

Hypoxia As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.

In which stage of COPD is the forced expiratory volume (FEV) less than 30%?

III

As status asthmaticus worsens, the nurse would expect which acid-base imbalance?

Respiratory acidosis

In chronic obstructive pulmonary disease (COPD), decreased carbon dioxide elimination results in increased carbon dioxide tension in arterial blood, leading to which of the following acid-base imbalances?

Respiratory acidosis

A nurse administers albuterol (Proventil), as ordered, to a client with emphysema. Which finding indicates that the drug is producing a therapeutic effect?

Respiratory rate of 22 breaths/minute

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:

Symmetry of the client's chest expansion

A nurse is developing a teaching plan for a client with asthma. Which teaching point has the highest priority?

Take ordered medications as scheduled.

The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?

The patient is hypoxic from suctioning.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?

The system has an air leak.

What dietary recommendations should a nurse provide a patient with a lung abscess?

A diet rich in protein

Emphysema is described by which of the following statements?

A disease of the airways characterized by destruction of the walls of overdistended alveoli

After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?

Bleeding The nurse should instruct the client to report bleeding immediately. Delayed bleeding may occur when the healing membrane separates from the underlying tissue — usually 7 to 10 days postoperatively. Difficulty swallowing and throat pain are expected after a tonsillectomy and typically are present even before the client is discharged. Sudden difficulty talking wouldn't occur after discharge if the client could talk normally at the time of discharge, because swelling doesn't take that long to develop.

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse

Continues assessing the client's respiratory status frequently

The nurse is caring for a client who had a recent laryngectomy. Which of the following is reflected in the nursing plan of care?

Develop an alternate method of communication.

A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention?

Encourage coughing to mobilize secretions.

You are doing preoperative teaching with a client scheduled for laryngeal surgery. What should you teach this client to help prevent atelectasis?

Encourage deep breathing every 2 hours.

You are caring for a client who has been diagnosed with viral pneumonia. You are making a plan of care for this client. What nursing interventions would you put into the plan of care for a client with pneumonia?

Encourage increased fluid intake.

Which of the following is a priority nursing intervention that the nurse should perform for a patient who has undergone surgery for a nasal obstruction?

Ensure mouth breathing

Which of the following would indicate a decrease in pressure with mechanical ventilation?

Increase in compliance A decrease in pressure in the mechanical ventilator may be caused by an increase in compliance. Kinked tubing and decreasing lung compliance, and a plugged airway tube cause an increase in peak airway pressure.

Suctioning via endotracheal tube. HR is decreasing during suctioning, which intervention is most appropriate?

Stop the procedure and re oxygenate the client.

The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema?

Crackles in the lung bases

The nurse is transporting a patient with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse?

Cut the contaminated tip of the tube and insert a sterile connector and reattach.

A nurse is caring for a client who has pulmonary embolism. which of the following interventions is the priority? A.provide a quiet environment B.encourage use of incentive spirometry every 1 to 2 hours C.initiate continuous cardiac monitoring D.administer heparin via continous IV infusions

D. administer heparin via continuous IV infusion is the priority nursing interventions

A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says:

"I'll stop being contagious when I have a negative acid-fast bacilli test."

A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement?

"It is all right if I have a grilled cheese sandwich with American cheese." Patients taking INH should avoid foods that contain tyramine and histamine (tuna, aged cheese, red wine, soy sauce, yeast extracts), because eating them while taking INH may result in headache, flushing, hypotension, lightheadedness, palpitations, and diaphoresis. Patients should also avoid alcohol because of the high potential for hepatotoxic effects.

A patient with an advanced laryngeal tumor is to have radiation therapy. The patient tells the nurse, "If I am going to have radiation, I won't need surgery." What is the best response by the nurse?

"Radiation is used to shrink the tumor size and is an adjunct to surgery."

A 42-year-old female client is scheduled for endotracheal intubation prior to her surgery. Which of the following can the nurse instruct this client?

"The ET tube will maintain your airway while you're under anesthesia."

The nurse is obtaining a health history from a client with laryngitis. Which causative factor, stated by the client, is least likely?

"I was chewing ice chips all day long."

A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?

"Weigh yourself daily and report a gain of 2 lb in 1 day."

A patient with end-stage COPD and heart failure asks the nurse about lung reduction surgery. What is the best response by the nurse?

"You and your physician should discuss the options that are available for treatment."

A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply.

-Monitor pulmonary status as directed and needed. -Encourage deep breathing exercises. -Regularly assess the client's vital signs every 2 to 4 hours.

a nurse is assisting with a thoracentesis. which of the following actions is appropriate for the nurse to take when assisting with this procedure?

-wear goggles and mask -cleanse the area with an antiseptic solution -apply pressure to the site after the needle is withdrawn

A physician orders a beta2 adrenergic-agonist agent (bronchodilator) that is short-acting and administered only by inhaler. The nurse knows this would probably be

Albuterol

Which of the following is the strongest predisposing factor for asthma?

Allergy

After reviewing the pharmacological treatment for pulmonary diseases, the nursing student knows that bronchodilators relieve bronchospasm in three ways. Choose the correct three of the following options.

Alter smooth muscle tone Increase oxygen distribution Reduce airway obstruction

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.)

Decreases hypoxemia Decreases patient anxiety Sustains positive end expiratory pressure (PEEP)

A client newly diagnosed with emphysema asks the nurse to explain all about the disease. The nurse would include the following response when defining emphysema:

An abnormal distention of the air spaces with destruction of the alveolar walls

A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection?

An antiviral agent such as acyclovir

A client is diagnosed with a chronic respiratory disorder. After assessing the client's knowledge of the disorder, the nurse prepares a teaching plan. This teaching plan is most likely to include which nursing diagnosis?

Anxiety

A client has a sucking stab wound to the chest. Which action should the nurse take first?

Apply a dressing over the wound and tape it on three sides.

A client comes into the emergency department with epistaxis. What intervention should you perform when caring for a client with epistaxis?

Apply direct continuous pressure.

A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply.

Substernal pain Dyspnea Fatigue

A nursing student knows that there are three most common symptoms of asthma. Choose the three that apply.

Cough Dyspnea Wheezing

A recent immigrant is diagnosed with pulmonary tuberculosis (TB). Which intervention is the most important for the nurse to implement with this client?

Developing a list of people with whom the client has had contact

Malignancy of the larynx can be a devastating diagnosis. What does a client with a diagnosis of laryngeal cancer require?

Emotional support

A junior-level nursing class has just finished learning about the management of clients with chronic pulmonary diseases. They learned that a new definition of COPD leaves only one disorder within its classification. Which of the following is that disorder?

Emphysema

Histamine, a mediator that supports the inflammatory process in asthma, is secreted by

Mast cells

You are caring for a client status post lung resection. When assessing your client you find that the bubbling in the water-seal chamber for the chest tubes is more than you expected. What should you check when bubbling in the water-seal chamber is excessive?

See if there are leaks in the system.

A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to

Seek medical help if he experiences inability to swallow

To evaluate pt for hypoxia, MD is most likely to order:

arterial blood gas analysis

Pulmonary embolism most common symptom

chest pain that occurs suddenly

During discharge teaching, a nurse is instructing a client about pneumonia. The client demonstrates his understanding of relapse when he states that he must:

continue to take antibiotics for the entire 10 days.

Exposure to tobacco smoke

mild COPD.

A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks?

Applying nasal packing

The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to:

Assess pulse and blood pressure.

The nurse should be alert for a complication of bronchiectasis that results from a combination of retained secretions and obstruction that leads to the collapse of alveoli. This complication is known as

Atelectasis Retention of secretions and subsequent obstruction ultimately cause the aveoli distal to the obstruction to collapse (atelectasis).

The nurse is caring for the client in the intensive care unit immediately after removal of the endotracheal tube. Which of the following nursing actions is most important to complete every hour to ensure that the respiratory system is not compromised?

Auscultate lung sounds.

A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?

Auscultation

In a patient with COPD the nurse would expect to observe which of the following clinical manifestations based on the arterial blood gas? pH: 7.33 PaCO2: 55 mmHg HCO3: 22 mEq/L PaO2: 78 mmHg A.mental cloudiness B.likely asymptomatic C.increased blood pressure D.tachypnea

B. likely asymptomatic

Which of the following is a leading cause of chronic obstructive pulmonary disease (COPD) exacerbation?

Bronchitis

Which finding should be immediately reported after bronchoscopy and biopsy?

Bronchospasm. -Biopsy can cause blood in sputum, dry cough is expected.

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client?

By supplying a magic slate or similar device

the nurse understand that, for a patient with chronic obstructive pulmonary disease, chronic hypoxemia and thickening of thee wall of the pulmonary vasculature can lead to which complication? A.atelectasiss B.pneumothorax C.pulmonary hypertension D.penumonia

C.pulmonary hypertension

The nurse is caring for a patient following a thoracotomy. Which of the following findings requires immediate intervention by the nurse?

Chest tube drainage of 190 mL/hr The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse will notify the primary provider if drainage is 150 mL/hr or greater. The other findings are normal following a thoracotomy; no intervention is required.

Following are statements regarding medications taken by a patient diagnosed with COPD. Choose which statements correctly match the drug name to the drug category. Select all that apply.

Ciprofloxacin is an antibiotic. Prednisone is a corticosteroid. Albuterol is a bronchodilator.

Select the nursing diagnosis that would warrant immediate health care provider notification.

Ineffective airway clearance related to excessive mucus production secondary to retained secretions and inflammation

A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?

Institute isolation precautions. SARS, a highly contagious viral respiratory illness, is spread by close person-to-person contact. Contained in airborne respiratory droplets, the virus is easily transmitted by touching surfaces and objects contaminated with infectious droplets. The nurse should give top priority to instituting infection-control measures to prevent the spread of infection to emergency department staff and clients. After isolation measures are carried out, the nurse can begin an I.V. infusion of dextrose 5% in half-normal saline and obtain nasopharyngeal and sputum specimens.

Which of the following is a true statement regarding severe acute respiratory syndrome (SARS)?

It is the most contagious during the second week of illness

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

Manual resuscitation bag The client with COPD depends on mechanical ventilation for adequate tissue oxygenation. The nurse must keep a manual resuscitation bag at the bedside to ventilate and oxygenate the client in case the mechanical ventilator malfunctions. Because the client doesn't have chest tubes or a tracheostomy, keeping a water-seal chest drainage set-up or a tracheostomy cleaning kit at the bedside isn't necessary. Although the nurse may keep an oxygen analyzer (pulse oximeter) on hand to evaluate the effectiveness of ventilation, this equipment is less important than the manual resuscitation bag.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?

Measuring and documenting the drainage in the collection chamber

A young male client has muscular dystrophy. His PaO2 is 42 mm Hg with a FiO2 of 80%. Which of the following treatments would be least invasive and most appropriate for this client?

Negative-pressure ventilator This client needs ventilatory support. His PaO2 is low despite receiving a high dose of oxygen. The iron lung or drinker respiratory tank is an example of a negative-pressure ventilator. This type of ventilator is used mainly with chronic respiratory failure associated with neurological disorders, such as muscular dystrophy. It does not require intubation of the client. The most common ventilator is the positive-pressure ventilator, but this involves intubation with an endotracheal tube or tracheostomy. CPAP is used for obstructive sleep apnea. Bi-PAP is used for those with severe COPD or sleep apnea who require ventilatory assistance at night.

The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?

Notify the physician.

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?

Partial pressure of arterial oxygen (PaO2)

The nurse is assigned the care of a 30-year-old female patient diagnosed with cystic fibrosis (CF). Which of the following nursing interventions will be included in the patient's plan of care?

Performing chest physiotherapy as ordered

The nurse is preparing to perform tracheostomy care on a patient with a newly inserted tracheostomy tube. Which of the following actions, if preformed by the nurse, indicates the need for further review of the procedure?

Places clean tracheostomy ties, and removes soiled ties after the new ties are in place For a new tracheostomy, two people should assist with tie changes. The other actions, if performed by the nurse during tracheostomy care, are correct.

A physician stated to the nurse that the patient has fluid noted in the pleural space and will need a thoracentesis. The nurse would expect that the physician will document this fluid as which of the following?

Pleural effusion

A child is having an asthma attack and the parent can't remember which inhaler to use for quick relief. The nurse accesses the child's medication information and tells the parent to use which inhalant?

Proventil

Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration?

Volume cycled With volume-cycled ventilation, the volume of air to be delivered with each inspiration is present.

Which type of ventilator has a present volume of air to be delivered with each inspiration?

Volume-controlled

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?

Water-seal chamber

Which of the following would not be considered a primary symptom of COPD?

Weight gain

Upon assessment, the nurse suspects that a patient with COPD may have bronchospasm. What manifestations validate the nurse's concern? (Select all that apply.)

Wheezes Compromised gas exchange Decreased airflow

The nurse at an employee wellness clinic is meeting with a client who reports voice hoarseness for more than 2 weeks. To determine if the client may have symptoms of early laryngeal cancer, the next question the nurse should ask is, "Do you have

a persistent cough or sore throat" Hoarseness longer than 2 weeks with a persistent cough or sore throat are early symptoms of laryngeal cancer. Later symptoms of laryngeal cancer include dysphagia, dyspnea, and foul breath.

Intervention for respiratory alkalosis:

breathe into paper bag.

Correct route of admin for potassium:

oral

Drug overdose and respiratory acidosis priority nursing action:

prepare to assist with ventilation

The classification of Stage III of COPD is defined as

severe COPD.

A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds aren't audible. This change occurred because:

the airways are so swollen that no air can get through.