RESP
A client is scheduled to undergo a bronchoscopy. Which nursing interventions would be included on the care plan? Select all that apply. Feed the client immediately after the procedure. Keep suction equipment available. Instruct that the client will be awake during the procedure. Assess cough and gag reflexes after the procedure. Explain to the client that a tube will be inserted through the nose and into the stomach. Report hemoptysis, stridor, or dyspnea immediately.
Correct response: Keep suction equipment available. Assess cough and gag reflexes after the procedure. Report hemoptysis, stridor, or dyspnea immediately. Explanation: Suctioning equipment should be kept available to clear the airway and prevent aspiration. Preoperative sedation and local anesthesia depress the gag and cough reflexes, so the nurse must assess for the return of these reflexes after bronchoscopy. Hemoptysis, stridor, or dyspnea should be reported immediately, because these findings indicate respiratory distress possibly caused by a pneumothorax, a complication of bronchoscopy. The client should not eat immediately after the procedure. Food and fluid are withheld until the gag reflex returns. The client is sedated for the procedure. A bronchoscopy involves inserting a fiberoptic endoscope into the bronchi, not the stomach.
A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions? They help prevent subcutaneous emphysema. They help prevent pneumothorax. They help prevent cardiac arrhythmias. They help prevent pulmonary edema.
Correct response: They help prevent cardiac arrhythmias. Explanation: ET suctioning removes oxygen, lowering the partial pressure of arterial oxygen; this, in turn, may induce a cardiac arrhythmia. Hyperventilating and hyperoxygenating the client before and during (or after) suctioning helps prevent this complication. Subcutaneous emphysema occurs when air from the pleural cavity leaks into subcutaneous tissue; it isn't a complication associated with suctioning. Hyperventilation and hyperoxygenation can't prevent a pneumothorax because this condition itself indicates air in the pleural space. Pulmonary edema is associated with cardiac dysfunction, not ET suctioning.
A client has just undergone a bronchoscopy. Which nursing interventions are appropriate after this procedure? Select all that apply. Keep the client flat for at least 2 hours. Provide sips of water to moisten the client's mouth. Withhold food and fluids until the client's gag reflex returns. Assess for hemoptysis and frank bleeding. Alert the client to resume food and fluids when the client's voice returns. Monitor the client's vital signs.
Correct response: Withhold food and fluids until the client's gag reflex returns. Assess for hemoptysis and frank bleeding. Monitor the client's vital signs. Explanation: To prevent aspiration, the client should not receive food or fluids until the gag reflex returns. Although a small amount of blood in the sputum is expected if a biopsy was performed, frank bleeding indicates hemorrhage and should be reported to the physician immediately. Vital signs should be monitored after the procedure, because a vasovagal response may cause bradycardia, laryngospasm can affect respirations, and fever may develop within 24 hours of the procedure. To reduce the risk of aspiration, the client should be placed in a semi-Fowler's or side-lying position after the procedure until the gag reflex returns. The client does not lose the voice after a bronchoscopy, so voice should not be used as a gauge for resuming food and fluid intake.
A client comes to the emergency department complaining of sudden onset of diarrhea, anorexia, malaise, cough, headache, and recurrent chills. Based on the client's history and physical findings, the physician suspects legionnaires' disease. While awaiting diagnostic test results, the client is admitted to the facility and started on antibiotic therapy. What's the drug of choice for treating legionnaires' disease? azithromycin rifampin amantadine amphotericin B
Correct response: azithromycin Explanation: Azithromycin is the drug of choice for treating legionnaires' disease. Rifampin is used to treat tuberculosis. Amantadine, an antiviral agent, and amphotericin B, an antifungal agent, are ineffective against legionnaires' disease, which is caused by bacterial infection.
An adult with a history of chronic obstructive pulmonary disease (COPD) and metastatic carcinoma of the lung has not responded to radiation therapy and is being admitted to the hospice program. The nurse should conduct a focused assessment for which symptom? ascites pleural friction rub dyspnea peripheral edema
Correct response: dyspnea Explanation: Dyspnea is a distressing symptom in clients with advanced cancer including metastatic carcinoma of the lung, previous radiation therapy, and coexisting COPD. Ascites does occur in clients with metastatic carcinoma; however, in the client with COPD and lung cancer, dyspnea is a more common finding. A pleural friction rub is usually associated with pneumonia, pleurisy, or pulmonary infarct.
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia? nonproductive cough and normal temperature sore throat and abdominal pain hemoptysis and dysuria dyspnea and wheezing
Correct response: dyspnea and wheezing Explanation: In a client with bacterial pneumonia, retained secretions cause dyspnea, and respiratory tract inflammation causes wheezing. Bacterial pneumonia also produces a productive cough and fever, rather than a nonproductive cough and normal temperature. Sore throat occurs in pharyngitis, not bacterial pneumonia. Abdominal pain is characteristic of a GI disorder, unlike chest pain, which can reflect a respiratory infection such as pneumonia. Hemoptysis and dysuria aren't associated with pneumonia.
A client reports difficulty breathing and a sharp pain in the right side of the chest. The respiratory rate measures 40 breaths/minute. The nurse should assign highest priority to which care goal? maintaining an adequate circulatory volume maintaining effective respirations reducing anxiety relieving pain
Correct response: maintaining effective respirations Explanation: As suggested by the ABCs of cardiopulmonary resuscitation — airway, breathing, and circulation — the most important goal is to maintain a patent airway and effective respirations, regardless of the client's diagnosis or clinical presentation. Although maintaining an adequate circulatory volume, reducing anxiety, and relieving pain are pertinent for this client, they're secondary to maintaining effective respirations.
After undergoing a thoracotomy, a client is receiving epidural analgesia. Which assessment finding indicates that the client has developed the most serious complication of epidural analgesia? heightened alertness increased heart rate numbness and tingling of the extremities respiratory depression
Correct response: respiratory depression Explanation: Respiratory depression is the most serious complication of epidural analgesia. Other potential complications include hypotension, decreased sensation and movement of the extremities, allergic reactions, and urine retention. Typically, epidural analgesia causes central nervous system depression (indicated by drowsiness) as well as a decreased heart rate and blood pressure.
A client reports having a dry, hacking cough that disturbs sleep at night. Which antitussive agent and intervention are most appropriate for this client? decreasing the room temperature and administering a benzonatate increasing fluids to liquefy secretions and administering codeine using a cooling mist humidifer and administering dextromethorphan providing a heat vaporizer and administering hydrocodone
Correct response: using a cooling mist humidifer and administering dextromethorphan Explanation: Dextromethorphan is the most widely used antitussive in Canada because it produces few adverse reactions while effectively suppressing a cough. A cool mist humidifier will help open nasal passages. Benzonatate is used for cough associated with respiratory conditions and chronic pulmonary diseases. Opioid antitussives, such as codeine and hydrocodone, are reserved for treating unruly coughs usually associated with lung cancer.
A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan? keeping the head of the bed at 15 degrees or less turning the client every 4 hours to prevent fatigue using strict hand hygiene providing oral hygiene daily
Correct response: using strict hand hygiene Explanation: The nurse should use strict hand hygiene to help minimize the client's exposure to infection, which could lead to pneumonia. The head of the bed should be kept at a minimum of 30 degrees. The client should be turned and repositioned at least every 2 hours to help promote secretion drainage. Oral hygiene should be performed every 4 hours to help decrease the number of organisms in the client's mouth that could lead to pneumonia.
A client with chronic obstructive pulmonary disease (COPD) and cor pulmonale is being prepared for discharge. The nurse should provide which instruction? "Limit yourself to smoking only 2 cigarettes per day." "Eat a high-sodium diet." "Weigh yourself daily and report a gain of 2 lb (0.91 kg) in 1 day." "Maintain bed rest."
Correct response: "Weigh yourself daily and report a gain of 2 lb (0.91 kg) in 1 day." Explanation: The nurse should instruct the client to weigh themselves daily and report a gain of 2 lb (0.91 kg) in 1 day. COPD causes pulmonary hypertension, leading to right-sided heart failure or cor pulmonale. The resultant venous congestion causes dependent edema. A weight gain may further stress the respiratory system and worsen the client's condition. The nurse should also instruct the client to eat a low-sodium diet to avoid fluid retention and engage in moderate exercise to avoid muscle atrophy.The client shouldn't smoke at all.
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH) as prophylaxis against tuberculosis. The client's family asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? 3 to 5 days 1 to 3 weeks 2 to 4 months 6 to 12 months
Correct response: 6 to 12 months Explanation: Prophylactic isoniazid therapy must continue for 6 to 12 months at a daily dosage of 300 mg. Taking the drug for less than 6 months may not provide adequate protection against tuberculosis.
While reviewing the arterial blood gas values of a client with emphysema, the nurse should identify which PaCO2 values as indicating the need for immediate intervention? 35 mm Hg 45 mm Hg 60 mm Hg 80 mm Hg
Correct response: 80 mm Hg Explanation: Although normal PaCO2 values range from 35 to 45 mm Hg, the client with long-standing emphysema has chronic carbon dioxide retention, leading to elevated PaCO2 levels. A PaCO2 level of 80 mm Hg is life threatening and always requires immediate intervention, possibly mechanical ventilation, to reduce the PaCO2 level.The client with emphysema and a PaCO2 level of 60 mm Hg may not be in immediate danger, but the nurse should further evaluate the client with this level.
A client is admitted with heart failure and pulmonary edema. To help alleviate respiratory distress, the nurse should perform which actions? Select all that apply. Place a pillow under both legs. Elevate head of bed to 90 degrees. Administer diuretics as ordered. Encourage deep breathing and coughing. Prepare for modified postural drainage.
Correct response: Elevate head of bed to 90 degrees. Administer diuretics as ordered. Explanation: Elevating the head of the bed allows maximum lung expansion because gravity reduces the pressure of the abdominal viscera on the diaphragm and lungs. Diuretics are administered to a client with heart failure and pulmonary edema to decrease the fluid buildup in the lungs and decrease the workload of the heart. Placing a pillow under the legs would not correct shortness of breath. The client could not tolerate a position for postural drainage based on the current respiratory status.
Which information should the nurse include in a teaching plan for the client newly diagnosed with chronic obstructive pulmonary disease (COPD)? Select all that apply. Pulmonary rehabilitation programs offer very little benefit. Pneumococcal vaccination is contraindicated for clients with lung disease. High humidity increases the effort of breathing. A bronchodilator with meter-dose inhaler should be readily available. Smoking cessation is important to slow or stop disease progression.
Correct response: High humidity increases the effort of breathing. A bronchodilator with meter-dose inhaler should be readily available. Smoking cessation is important to slow or stop disease progression. Explanation: High humidity has been shown to increase the work of breathing. Carrying a metered-dose inhaler can facilitate early intervention if bronchospasm and shortness of breath should occur. Smoking cessation is difficult to achieve but very important in preventing COPD progression. Pulmonary rehabilitation programs are a great source of support for health promotion and maintenance for clients with COPD. Both the pneumococcal and influenza vaccines can help protect again respiratory infections.
A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority? Impaired airway clearance Impaired gas exchange Impaired physical mobility Ineffective breathing pattern
Correct response: Impaired gas exchange Explanation: Impaired gas exchange should be the nurse's first priority because of the lack of ventilation due to the surgical procedure and pain. The other options as not first priorities.
If a client is receiving rescue breaths, and the chest wall fails to rise during cardiopulmonary resuscitation, what should the rescuer do first? Try using a bag-mask device. Decrease the rate of compressions. Intubate the client. Reposition the airway.
Correct response: Reposition the airway. Explanation: If the chest wall is not rising with rescue breaths, the head should be repositioned first to ensure that the airway is adequately opened. A bag-mask device allows for delivery of 100% oxygen, but is difficult to manage if there is just one rescuer; ideally two persons are used to operate the bag-mask device, one to maintain the seal and the other to provide the ventilations. Compressions should be maintained at 100 per minute.
A client is receiving streptomycin to treat tuberculosis. What should the nurse evaluate to determine an adverse effect of the drug? decreased serum creatinine difficulty swallowing hearing loss IV infiltration
Correct response: hearing loss Explanation: Streptomycin can cause toxicity to the eighth cranial nerve, which is responsible for hearing, balance, and body position sense. Nephrotoxicity is a side effect that would be indicated with an increase in creatinine. Streptomycin does not cause difficulty in swallowing. Streptomycin is given via intramuscular injection.
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis? nausea or vomiting abdominal pain or diarrhea hallucinations or tinnitus light-headedness or paresthesia
Correct response: light-headedness or paresthesia Explanation: The client with respiratory alkalosis may complain of light-headedness or paresthesia (numbness and tingling in the arms and legs). Nausea, vomiting, abdominal pain, and diarrhea may accompany respiratory acidosis. Hallucinations and tinnitus rarely are associated with respiratory alkalosis or any other acid-base imbalance.
The nurse auscultates the lungs of a client who has been diagnosed with a tumor in the lung and notes wheezing over one lung. What additional assessment should the nurse make? the presence of exudate in the airways the client's history of smoking an indication of pleural effusion obstruction of the airway
Correct response: obstruction of the airway Explanation: Wheezing over one lung in the presence of a lung tumor is most likely caused by obstruction of the airway by a tumor. Exudate would be more likely to cause crackles. The client's history of smoking would not cause unilateral wheezing. Pleural effusion would produce diminished or absent breath sounds.
The nurse is teaching a client with chronic obstructive pulmonary disease (COPD) to assess for signs and symptoms of right-sided heart failure. Which sign or symptom should be included in the teaching plan? clubbing of nail beds hypertension peripheral edema increased appetite
Correct response: peripheral edema Explanation: Right-sided heart failure is a complication of COPD that occurs because of pulmonary hypertension. Signs and symptoms of right-sided heart failure include peripheral edema, jugular venous distention, hepatomegaly, and weight gain due to increased fluid volume. Clubbing of nail beds is associated with conditions of chronic hypoxemia. Hypertension is associated with left-sided heart failure. Clients with heart failure have decreased appetites.
A client with respiratory acidosis is admitted to the intensive care unit for close observation. The nurse should stay alert for which complication associated with respiratory acidosis? shock stroke seizures hyperglycemia
Correct response: shock Explanation: Complications of respiratory acidosis include shock and cardiac arrest. Stroke and hyperglycemia aren't associated with respiratory acidosis. Seizures may complicate respiratory alkalosis, not respiratory acidosis.
A home health nurse sees a client with end-stage chronic obstructive pulmonary disease (COPD). An outcome identified for this client is preventing infection. Which finding indicates that this outcome has been met? decreased oxygen requirements increased sputum production decreased activity tolerance increased white blood cell count
Correct response: decreased oxygen requirements Explanation: A client who is free from infection will most likely have decreased oxygen requirements. A client with infection will display increased sputum production, fever, shortness of breath, decreased activity tolerance, and increased oxygen requirements. Elevated white blood cell count may be indicative of infection.
The nurse is assessing a client with chronic obstructive pulmonary disease. Which finding requires immediate intervention? distant heart sounds diminished lung sounds inability to speak pursed lip breathing
Correct response: inability to speak Explanation: Inability to speak could indicate respiratory distress. Pulsed lip breathing, while it is an abnormal finding is not indicative of respiratory distress. Distant heart sounds could indicate heart failure but are not indicative of any distress.
A nurse on the medical-surgical unit just received the client care assignment report. Which client should the nurse assess first? the client with anorexia, weight loss, and night sweats the client with crackles and fever who reports pleuritic pain the client who had difficulty sleeping, daytime fatigue, and morning headache the client with unilateral leg swelling who reports anxiety and shortness of breath
Correct response: the client with unilateral leg swelling who reports anxiety and shortness of breath Explanation: The client who reports anxiety and shortness of breath and has unilateral leg swelling should be seen first. This client is exhibiting signs and symptoms of pulmonary embolism, which is a life-threatening condition. Crackles, fever, and pleuritic pain are signs and symptoms of pneumonia. Anorexia, weight loss, and night sweats are signs and symptoms of tuberculosis. Difficulty sleeping, daytime fatigue, and morning headache are symptoms of sleep apnea. Pneumonia, sleep apnea, and tuberculosis aren't medical emergencies. Clients with these disorders don't take priority over the client with a pulmonary embolism.
A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be Risk for falls. Ineffective breathing pattern. Impaired tissue integrity. Ineffective airway clearance.
Correct response: Ineffective airway clearance. Explanation: Ineffective airway clearance is the priority nursing diagnosis for this client. Pneumonia involves excess secretions in the respiratory tract and inhibits air flow to the capillary bed. A client with pneumonia may not have an Ineffective breathing pattern, such as tachypnea, bradypnea, or Cheyne-Stokes respirations. Risk for falls and Impaired tissue integrity aren't priority diagnoses for this client.
What is the best way for the nurse to position a chest tube for a client to prevent dislocation? coiled flat on the bed and positioned loosely coiled flat on the bed and secured without putting tension on the tube coiled flat and secured to the bedrail coiled flat and secured in dependent loops along the side of the bed
Correct response: coiled flat on the bed and secured without putting tension on the tube Explanation: Tubing that is coiled flat on the bed and secured without putting tension of the tube maintains a patent, free draining system. This prevents fluid accumulation and decreases the risk of infection, atelectasis, and tension pneumothorax. The other choices all have risks associated with becoming disconnected.
To help control pain during coughing for a client who has had a pulmonary lobectomy, the nurse should: place the bed in slight Trendelenburg's position and help the client turn onto the operative side to splint the incision. raise the bed to semi-Fowler's position and position the client's hands so that the incision is supported anteriorly and posteriorly. keep the bed flat and tell the client to place the hands over the incision before taking a deep breath. raise the bed to complete Fowler's position and help the client turn onto the operative side to splint the incision.
Correct response: raise the bed to semi-Fowler's position and position the client's hands so that the incision is supported anteriorly and posteriorly. Explanation: Semi-Fowler's position allows for downward displacement of the diaphragm and relaxation of the abdominal muscles, which are needed for good ventilatory excursion. The hand placement supports the operative area and splints it without causing pain from pressure.Trendelenburg's position is contraindicated because abdominal contents pushing against the diaphragm will decrease effective lung volume.Keeping the bed flat does not allow the diaphragm to descend.Positioning the client on the operative side prevents maximum inflation of the lung.
The nurse is assessing a client recovering from anesthesia. Which finding is an early indicator of hypoxemia? somnolence restlessness chills urgency
Correct response: restlessness Explanation: One of the earliest signs of hypoxia is restlessness and agitation. Decreased level of consciousness and somnolence are later signs of hypoxia. Chills can be related to the anesthetic agent used but are not indicative of hypoxia. Urgency is not related to hypoxia.
A client admitted with a deep vein thrombosis abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to improve these manifestations? simple mask nonrebreather mask face tent nasal cannula
Correct response: nonrebreather mask Explanation: A nonrebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.
The nurse is analyzing the arterial blood gas (AGB) results of a client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis? pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L pH: 7.50, PaCO2: 30 mm Hg, HCO3-: 24 mEq/L pH: 7.42, PaCO2: 45 mm Hg, HCO3-: 22 mEq /
Correct response: pH: 7.20, PaCO2: 65 mm Hg, HCO3-: 26 mEq/L Explanation: Respiratory acidosis is a clinical disorder in which the pH is less than 7.35 and the PaCO2 is greater than 42 mm Hg and a compensatory increase in the plasma HCO3- occurs. It may be either acute or chronic. The ABG of pH: 7.32, PaCO2: 40 mm Hg, HCO3-: 18 mEq/L indicates metabolic acidosis. The ABGs of pH: 7.50, PaCO2: 30 mm Hg, and HCO3-: 24 mEq/L indicate respiratory alkalosis. The ABGs of pH 7.42, PaCO2: 45 mm Hg, and HCO3-: 22 mEq/L indicate a normal result/no imbalance.
A homeless client comes to the clinic coughing up blood and is diagnosed with active tuberculosis (TB). Which interventions by the nurse will be most effective in ensuring adherence with the pharmacological treatment regimen? Arrange for the client to come to a community center each day to receive a meal and medication. Provide the client with written instructions about the importance of adherence to the treatment plan. Recommend having the client admitted to the hospital until the medication regimen is completed. Arrange for the client to pick up the medication in unit dose packaging at a local pharmacy.
Correct response: Arrange for the client to come to a community center each day to receive a meal and medication. Explanation: Directly observed therapy is the most effective means for ensuring compliance with the treatment regimen for tuberculosis. Providing the client with a daily meal will help ensure the client will come to receive the medication. The client should be provided with a mask to wear to the community center to prevent transmission of TB to others. It is not cost-effective to keep the client hospitalized; the TB medication regimen may last one or more years. A homeless client probably will not have the financial resources to pick up the medication at a pharmacy, so a prescription and/or written instructions will not be an effective way to ensure adherence.
