Respiratory

The nurse must be alert for signs of respiratory acidosis in the client with emphysema, because this individual has a long-term problem with oxygen maintenance and: a. An inability to fully exhale retained CO2 b. There is a loss of carbon dioxide from the body's buffer pool c. Hyperventilation occurs, even if the cause is not physiologic d. Localized tissue necrosis occurs as a result of poor oxygen supply

A. An inability to fully exhale retained CO2

A client is returned to the nursing unit after thoracic surgery with chest tubes in place. During the first few hours postoperatively, what type of drainage should the nurse expect? a. Serous b. Serosanguineous c. Bloody, with frequent small clots d. Bloody

D. Bloody Rationale: In the first few hours after surgery, the drainage from the chest tube is bloody. After several hours, it becomes serosanguineous. The client should not experience frequent clotting. Proper chest tube function should allow for drainage of blood before it has the chance to clot in the chest or the tubing. Test-Taking Strategy: Focus on the subject, expected findings after thoracic surgery. Recall that after thoracic surgery, there may be considerable capillary oozing for hours in the postoperative period. This will lead you to choose the bloody drainage option over the serous or serosanguineous drainage options. Knowing that patent chest tubes do not allow blood to collect in the pleural space eliminates the option of blood with clots.

A patient with the diagnosis of chronic obstructive pulmonary disease (COPD) becomes increasingly short of breath. Which nursing intervention is most appropriate? a. Administer O2 using a Venturi mask at 24% b. Use nasal cannula to administer high flow oxygen c. Do not administer O2 due to history of COPD d. Begin oxygen therapy using a simple face mask at 8L

A. Administer O2 using a Venturi mask at 24%

The nurse is providing education to a group of adolescents diagnosed with asthma. The nurse informs the group that which can be triggers for an asthma attack? Select all that apply. a. An upper respiratory infection (URI) b. Exercise c. Hot air d. Non-steroidal anti-inflammatories e. Cold air

A. An upper respiratory infection (URI) B. Exercise D. Non-steroidal anti-inflammatories E. Cold air Rationale: Triggers for asthma include response to the presence of specific allergens; general irritants such as cold air, dry air, or fine airborne particles; microorganisms; and aspirin and other NSAIDs. Increased airway sensitivity (hyperresponsiveness) can occur with exercise, with an upper respiratory illness, and for unknown reasons. Clean air and adequate rest and sleep help to promote lung function.

The nurse is making morning rounds to assess assigned patients. Of the following patients with history of asthma, which patient is of highest priority to assess first? a. A 35-year-old patient who has a longer expiratory phase than inspiratory phase b. A 25-year-old patient with a heart rate of 110 beats/min c. A 42-year-old patient with an oxygen saturation level of 91% at rest d. A 66-year-old patient with a barrel chest and clubbed fingernails

A. A 35-year-old patient who has a longer expiratory phase than inspiratory phase

You are providing discharge teaching to a patient with newly diagnosed asthma. What would be the priority goal to established as part of the teaching plan prior to being discharged from the hospital? The patient will: a. Is able to obtain pulse oximeter readings b. Has identified a pharmacy for prescription medications c. Demonstrates correct use of prescribed inhalers d. Knows the primary care provider's office hours

C. Demonstrates correct use of prescribed inhalers

The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the client to take which action to lessen chance of repeat pneumothorax? a. Exhale very quickly. b. Inhale and exhale quickly. c. Perform the Valsalva maneuver. d. Stay very still.

C. Perform the Valsalva maneuver Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an airtight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.

The nurse instructs a client to use the pursed-lip method of breathing and evaluates the teaching by asking the client about the purpose of this type of breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? a. Strengthen the intercostal muscles. b. Promote carbon dioxide elimination. c. Strengthen the diaphragm. d. Promote oxygen intake.

B. Promote carbon dioxide elimination Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing airway pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.

An arterial blood gas report indicates the client's pH is 7.30, PCO2 is 55 mm Hg and HCO3 is 20 mEq/L. These results are consistent with: a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis

B. Respiratory acidosis

The nurse is instructing a hospitalized client with a diagnosis of emphysema about measures that will enhance the effectiveness of breathing during dyspneic periods. Which position should the nurse instruct the client to assume? a. Sitting up in bed b. Sitting up and leaning on an overbed table c. Side-lying in bed d. Sitting in a recliner chair

B. Sitting up and leaning on an overbed table Rationale: Positions that will assist the client with emphysema with breathing include sitting up and leaning on an overbed table, sitting up and resting the elbows on the knees, and standing and leaning against the wall.

A client has just returned from the cardiac catheterization laboratory. The left-sided femoral vessel was used as the access site. How should the nurse position the client? Select one: a. Supine, with the head of the bed elevated 45 to 90 degrees b. Supine, with the head of the bed elevated about 15 degrees c. Knee chest, with the foot of the bed elevated d. Semi Fowler's, with the knees placed on top of 1 pillow

B. Supine, with the head of the bed elevated about 15 degrees Rationale: Following cardiac catheterization, the extremity used for catheter insertion is kept straight for 4 to 6 hours. If the femoral artery was used, strict bed rest is necessary for 6 to 12 hours. The client may turn from side to side. The head of the bed is not elevated more than 15 degrees (unless otherwise prescribed) to prevent kinking of the blood vessel at the groin and possible arterial occlusion.

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD) and reviewing specific instructional points about COPD. What comment by the client indicates that further teaching is needed? a. "I need to avoid alcohol and sedative medications." b. "Besides smoking, I can't be around second- or thirdhand smoke." c. "I have to keep my nasal cannula oxygen levels between 4 and 6 L/minute." d. "I have to cut down on the percentage of carbohydrates in my diet."

C. "I have to keep my nasal cannula oxygen levels between 4 and 6 L/minute." Rationale: Clients with COPD have adapted to a high carbon dioxide level, so their carbon dioxide-sensitive chemoreceptors are essentially not functioning. Their stimulus to breathe is a decreased arterial oxygen (PaO2) level, so administration of oxygen greater than 24% to 28% (1 to 3 L/min) prevents the PaO2 from falling to a level (60 mm Hg) that stimulates the peripheral receptors, thus destroying the stimulus to breathe. The resulting hypoventilation causes excessive retention of carbon dioxide, which can lead to respiratory acidosis and respiratory arrest. Therefore, oxygen administration levels for clients with COPD should be kept within the range of 1 to 3 L/min (per health care provider prescription). Also, nutrition for the client with COPD requires a reduction in the percentage of carbohydrates in the diet. Excessive carbohydrate loads increase carbon dioxide production, which the client with COPD may be unable to exhale. In addition to avoiding alcohol and sedative medications, the increased risk for COPD from active smoking, passive smoking (or secondhand smoke), and smoke that clings to hair and clothing (sometimes called "thirdhand" smoke), contributes to upper and lower respiratory problems. Test-Taking Strategy: Note the strategic words, further teaching is needed. These words indicate a negative event query and ask you to select a statement that is inaccurate. Recall the pathophysiology of breathing for clients with COPD. With these clients, the administration of excessive oxygen results in hypoventilation.

The nurse is caring for a dyspneic client with decreased breath sounds. The nurse should carry out which intervention to decrease the client's work of breathing? a. Administer the prescribed bronchodilator. b. Instruct the client to limit fluid intake. c. Place a continuous pulse oximeter on the client. d. Place the client in low Fowler's position.

A. Administer the prescribed bronchodilator. Rationale: Administering the prescribed bronchodilator will help to decrease airway resistance, which decreases the work of breathing and should ease the client's dyspnea. The client should be placed in high Fowler's position to maximize chest expansion. Clients with increased mucus production have increased airway resistance, which increases the work of breathing. Thus, fluids should be increased to help liquefy secretions. Placing a continuous pulse oximeter will assist with monitoring the client's condition but will have no effect on the client's work of breathing.

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings should the nurse anticipate in this client? Select all that apply. a. Clubbed fingers b. Muscle retractions c. Increased body temperature d. Prolonged expiratory breathing phase e. Dyspnea at rest f. Decreased respiratory rate

A. Clubbed fingers B. Muscle retractions D. Prolonged expiratory breathing phase E. Dyspnea at rest Rationale: The client with COPD who is eligible for a lung transplantation has end-stage COPD and will have clinical manifestations of hypoxemia, dyspnea at rest, use of accessory muscle with retractions, clubbing, and prolonged expiratory breathing phase caused by retention of carbon dioxide. Option 4 is not correct because the client with COPD has an increased respiratory rate, not a decreased one. Option 5 is not correct because an elevated temperature would not be present unless the client has an infection. Test-Taking Strategy: Focus on the subject, manifestations in COPD for a client with disease advanced enough to be eligible for a lung transplantation. Think about the pathophysiology associated with COPD. Remember that fever is not present with COPD unless there is an infection and that the respiratory rate is normally increased.

The nurse is monitoring the chest tube drainage system in a client with a chest tube. The nurse notes intermittent bubbling in the water seal chamber. Which is the most appropriate nursing action? a. Document the findings. b. Check for an air leak. c. Notify the health care provider. d. Change the chest tube drainage system

A. Document the findings Rationale: Bubbling in the water seal chamber is caused by air passing out of the pleural space into the fluid in the chamber. Intermittent (not constant) bubbling is normal. It indicates that the system is accomplishing one of its purposes, removing air from the pleural space. Continuous bubbling during inspiration and expiration indicates that an air leak exists. If this occurs, it must be corrected. Notifying the health care provider and changing the chest tube drainage system are not indicated at this time. Test-Taking Strategy: Note the strategic words, most appropriate. Note the subject, chest tube drainage systems, and focus on the words intermittent bubbling and water seal chamber. Recalling that intermittent (not constant) bubbling is normal in this chamber will direct you to the correct option.

Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply. a. Encourage alternating activity with rest periods. b. Reduce fluid intake to less than 1500 mL/day. c. Teach the client techniques of chest physiotherapy. d. Teach diaphragmatic and pursed-lip breathing. e. Keep the client in a supine position as much as possible.

A. Encourage alternating activity with rest periods. C. Teach the client techniques of chest physiotherapy. D. Teach diaphragmatic and pursed-lip breathing. Rationale: Fluids are encouraged, not reduced, to liquefy secretions for easier expectoration. Diaphragmatic and pursed-lip breathing assists in opening alveoli and eases dyspnea. The client should be encouraged to perform activities and exercise, such as dressing and walking, as tolerated with rest periods in between. Chest physiotherapy consists of percussion, vibration, and postural drainage. These techniques are helpful in removing secretions. Elevating the head of the bed assists with breathing.

The nurse is caring for a client who is on strict bed rest and creates a plan of care with goals related to the prevention of deep vein thrombosis and pulmonary emboli. Which nursing action is most helpful in preventing these disorders from developing? a. Encouraging active range-of-motion exercises b. Restricting fluids c. Applying a heating pad to the lower extremities d. Placing a pillow under the knees

A. Encouraging active range-of-motion exercises Rationale: Clients at greatest risk for deep vein thrombosis and pulmonary emboli are immobilized clients. Basic preventive measures include early ambulation, leg elevation, active leg exercises, elastic stockings, and intermittent pneumatic calf compression. Keeping the client well hydrated is essential because dehydration predisposes to clotting. A pillow under the knees may cause venous stasis. Heat should not be applied without a health care provider's prescription.

A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse should determine that which finding documented in the client's record is an expected finding with this client? a. Hyperinflation of lungs documented by chest x-ray b. Increased oxygen saturation with ambulation c. A shortened expiratory phase of the respiratory cycle d. A widened diaphragm documented by chest x-ray

A. Hyperinflation of lungs documented by chest x-ray Rationale: The clinical manifestations of COPD are several, including hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory respiratory muscles, and prolonged exhalation. Chest x-ray results indicate a hyperinflated chest and may indicate a flattened diaphragm if the disease is advanced. Test-Taking Strategy: Focus on the subject, expected finding in COPD. Eliminate option 1 because the reverse is true, even in the client with no respiratory disorder. Eliminate option 2 because it is the opposite of what happens with exacerbation. Eliminate option 4 because the client with COPD has a prolonged expiratory phase.

The nurse is providing preoperative teaching with the client about the use of an incentive spirometer in the postoperative period. Which instructions should the nurse NOT include? a. Inhale as deeply and quickly as possible. b. Place the mouthpiece in your mouth and seal your lips tightly around it. c. After maximum inspiration, hold the breath for 2 to 3 seconds and exhale. d. Sit upright in the bed or in a chair.

A. Inhale as deeply and quickly as possible

The nurse is reinforcing instructions to a client about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit? a. Maintain inflation of the alveoli. b. Enhance ciliary action in the tracheobronchial tree. c. Increase surfactant production d. Dilate the major bronchi.

A. Maintain inflation of the alveoli Rationale: Sustained inhalation when using an incentive spirometer helps maintain inflation of the terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. The remaining options are not benefits for sustained inhalation. Test-Taking Strategy: Focus on the subject, the benefit of sustaining the inhaled breath. Also, note the strategic word, primary, indicating that all of the options may be correct but one option is the best benefit. Use knowledge of anatomy and physiology. Recalling that the alveoli are the most distal part of the respiratory tree will direct you to the correct option.

A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? a. Paradoxical chest movement b. Hypotension c. Dyspnea, especially on exhalation d. Cyanosis

A. Paradoxical chest movement Rationale: Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of flail chest. Test-Taking Strategy: Note the strategic word, most. Cyanosis and hypotension occur with many different disorders, so eliminate options 1 and 2 first. From the remaining options, choose paradoxical chest movement over dyspnea on exhalation by remembering that a flail chest has broken rib segments that move independently of the rest of the rib cage

The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate? a. Provide nasotracheal suctioning as needed to remove secretions. b. Plan activities with rest periods to conserve oxygen needs. c. Monitor oxygenation (the oxygen saturation [SaO2]) during activity. d. Initiate and maintain supplemental oxygen as prescribed.

A. Provide nasotracheal suctioning as needed to remove secretions Rationale: Note that the patient is "unresponsive", therefor unable to cough and deep breath to clear secretions on own. Ineffective airway clearance reflects the client's inability to expectorate secretions. The intervention specifically addressing retained secretions is in the correct option. Options 1 and 4 are interventions addressing impaired problem with gas exchange. Option 2 is an intervention aimed at addressing a problem with activity intolerance. Test-Taking Strategy: Note the subject, care of the client with pneumonia. Also, note the strategic words, most appropriate. Focus on the data in the question. Note the relationship between the words inability to clear the airway related to retained secretions in the question and the correct option.

The nurse instructs a client on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly? a. The client breathes out slowly through the mouth. b. The client breathes in through the mouth. c. The client avoids using the abdominal muscles to breathe out. d. The client puffs out the cheeks when breathing out through the mouth

A. The client breathes out slowly through the mouth Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. The client should close the mouth and breathe in through the nose. The client then purses the lips and breathes out slowly through the mouth, without puffing the cheeks. The client should spend at least twice the amount of time breathing out that it took to breathe in. The client should use the abdominal muscles to assist in squeezing out all of the air. The client also is instructed to use this technique during any physical activity, inhale before beginning the activity, and exhale while performing the activity. The client is also instructed that he or she should never hold the breath.

The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? Select all that apply. a. A widened diaphragm noted on the chest x-ray b. A hyperinflated chest noted on the chest x-ray c. Decreased oxygen saturation with mild exercise d. Pulmonary function tests that demonstrate increased vital capacity e. A low arterial PCo2 level

B. A hyperinflated chest noted on the chest x-ray C. Decreased oxygen saturation with mild exercise Rationale: Clinical manifestations of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity. Test-Taking Strategy: Focus on the subject, manifestations of COPD. Think about the pathophysiology associated with this disorder. Remember that hypercapnia, a hyperinflated chest, a flat diaphragm, oxygen desaturation on exercise, and decreased vital capacity are manifestations.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How should the nurse instruct the client? a. Adjust the oxygen depending on respiratory rate. b. Adjust the oxygen depending on SpO2. c. Do not exceed 2 L/min. d. Do not exceed 1 L/min.

B. Adjust the oxygen depending on SpO2 Rationale: The client with COPD is often dependent on oxygen, and has compensated for chronically lower O2 levels and higher CO2 levels. The oxygen should be adjusted depending on the SpO2, which should be 88% to 92%. Increasing the O2 too much, resulting too high of SpO2 should be avoided in COPD patients. All other options are incorrect. Test-Taking Strategy: Focus on the subject, oxygen delivery rate for the client with COPD. Use knowledge of basic respiratory physiology and note that the SpO2 is acceptable between 88% and 92% with this disorder.

The nurse assesses a patient who reports waking up feeling very tired, even after 9 hours of undisturbed sleep. What action would the nurse take first? a. Request a prescription for a sleep aid from the prescriber b. Ask the patient if he or she has ever been evaluated for sleep apnea. c. Advise the patient to avoid beverages with caffeine before bed. d. Educate the patient regarding benefits of sleeping upright in a reclining chair.

B. Ask the patient if he or she has ever been evaluated for sleep apnea.

An oxygen delivery system is prescribed for a client with chronic obstructive pulmonary disease to deliver a precise oxygen concentration. Which oxygen delivery system would the nurse prepare for the client? a. Aerosol mask b. Venturi mask c. Face tent d. Tracheostomy collar

B. Venturi mask Rationale: The Venturi mask delivers the most accurate oxygen concentration. It is the best oxygen delivery system for the client with chronic airflow limitation such as chronic obstructive pulmonary disease, because it delivers a precise oxygen concentration. The face tent, aerosol mask, and tracheostomy collar are also high-flow oxygen delivery systems but most often are used to administer high humidity.

The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's SpO2 level is 86%. Based on this assessment, which action is appropriate? a. Place the client on a nonrebreather mask on 100% FiO2. b. Maintain at 2 L/min and call respiratory therapy for a breathing treatment. c. Increase to 3 L/min and titrate until the SpO2 is 92%. d. Increase to 3 L/min and titrate until the SpO2 is 95%.

C. Increase to 3 L/min and titrate until the SpO2 is 92% Rationale: Oxygen is used cautiously and should be titrated to the lowest amount needed. The current recommendation is that hypoxia should be treated with oxygen and that oxygen should be titrated to keep the SpO2 level between 88% and 92%. An SpO2 of 95% is the recommended level for a healthy individual and may not be achieved in a patient with long-standing emphysema; therefore, option 1 is incorrect. A nonrebreather mask is not necessary at this point, and increasing oxygen via nasal cannula should be attempted first; therefore, option 3 is incorrect. It may be necessary to call respiratory therapy for a breathing treatment; however, the oxygen needs to be titrated, making option 4 incorrect. Test-Taking Strategy: Focus on the subject, oxygen therapy for a client who has emphysema and the potential for hypoxia. Note the word appropriate. Note that there are two parts to each option and that both parts need to be correct. Recall that in the client with emphysema, and all other respiratory conditions, hypoxia needs to be treated. Therefore option 4 can be deleted. Focus on the data in the question to eliminate 3 because a nonrebreather is unnecessary. For the remaining options, focus on the client's diagnosis and recall that a SpO2 of 95% is the recommended level for a healthy individual.

The nurse assesses a patient with chronic obstructive pulmonary disease (COPD). Which questions would the nurse ask to determine the patient's activity tolerance? (Select all that apply) a. "Have you lost any weight lately?" b. "How long does it take to perform your morning routine?" c. "Do you walk upstairs every day?" d. "Do you have any difficulty sleeping?"

B. "How long does it take to perform your morning routine?" C. "Do you walk upstairs every day?"

A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority? a. Gas exchange alteration related to ventilation-perfusion mismatch b. Altered breathing pattern secondary to increased work of breathing c. Low cardiac output secondary to cor pulmonale (right-sided heart failure) d. Inability to clear the airway related to inability to expectorate sputum

D. Inability to clear the airway related to inability to expectorate sputum Rationale: COPD is a term that represents the pathology and symptoms that occur with clients experiencing both emphysema and chronic bronchitis. All of the problems listed are potentially appropriate for a client with COPD. For the nurse prioritizing this client's problems, it is important first to maintain circulation, airway, and breathing. At present, the client demonstrates problems with ventilation because of ineffective coughing, so the correct option would be the priority problem. The bilateral crackles would suggest fluid or sputum in the alveoli or airways; however, the client is unable to expectorate this sputum. The client's respiratory rate is only slightly elevated, so option 3, altered breathing pattern, is not as important as airway. The client is cyanotic, but this probably is because of the ineffective clearance of the sputum, causing poor gas exchange. The data in the question do not support low cardiac output as being most important at this time. Test-Taking Strategy: Note the strategic word, priority. Focus on the data in the question, and note that the client is unable to expectorate sputum. Use the ABCs-airway, breathing, and circulation. This will direct you to the correct option.

The nurse is assessing the functioning of a chest tube drainage system in a client who has just returned from the recovery room following a thoracotomy with wedge resection. Which are the expected assessment findings? Select all that apply. a. 50 mL of drainage in the drainage collection chamber b. Excessive bubbling in the water seal chamber c. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation d. Drainage system maintained below the client's chest e. Occlusive dressing in place over the chest tube insertion site f. Vigorous bubbling in the suction control chamber

A. 50 mL of drainage in the drainage collection chamber C. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation D. Drainage system maintained below the client's chest E. Occlusive dressing in place over the chest tube insertion site Rationale: The bubbling of water in the water seal chamber indicates air drainage from the client and usually is seen when intrathoracic pressure is higher than atmospheric pressure, and may occur during exhalation, coughing, or sneezing. Excessive bubbling in the water seal chamber may indicate an air leak, an unexpected finding. Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation is expected. An absence of fluctuation may indicate that the chest tube is obstructed or that the lung has reexpanded and that no more air is leaking into the pleural space. Gentle (not vigorous) bubbling should be noted in the suction control chamber. A total of 50 mL of drainage is not excessive in a client returning to the nursing unit from the recovery room. Drainage that is more than 70 to 100 mL/hour is considered excessive and requires notification of the health care provider. The chest tube insertion site is covered with an occlusive (airtight) dressing to prevent air from entering the pleural space. Positioning the drainage system below the client's chest allows gravity to drain the pleural space.

The nurse is caring for a hospitalized client who is retaining carbon dioxide (CO2) because of respiratory disease. The nurse anticipates which physical response will initially occur? a. The client's arterial blood gas results will reflect acidosis. b. The client's sodium and chloride levels will rise. c. The client will complain of facial numbness and tingling. d. The client will lose consciousness.

A. The client's arterial blood gas results will reflect acidosis Rationale: When the client with respiratory disease retains CO2, a rise in CO2 will occur. This results in a corresponding fall in pH, thus respiratory acidosis. This concept forms the basis for key aspects of acid-base balance. The other options are incorrect and are not associated with this initial physical response. Test-Taking Strategy: Note the strategic word, initially. Note the words retaining carbon dioxide, and focus on the subject, the client's diagnosis of respiratory disease. Recalling the inverse relationship between pH and CO2 in the body will direct you to the correct option. As CO2 rises, pH falls, and as CO2 falls, pH rises.

A client who is experiencing respiratory difficulty asks the nurse, "Why it is so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses? a. Air is flowing against a pressure gradient. b. The respiratory muscles relax. c. The respiratory muscles contract. d. Air flows by gravity.

B. The respiratory muscles relax Rationale: Exhalation is less taxing for the client because it is a passive process in which the respiratory muscles relax. This allows air to flow upward out of the lungs. Air flows according to a pressure gradient from higher pressure to lower pressure. It does not flow by gravity or against a pressure gradient. Test-Taking Strategy: Knowledge that respiratory muscles tighten or contract with inspiration and relax with expiration will lead you to the correct option.

A patient who had a chest tube placed 8 hours ago and refuses to take deep breaths because of the pain. What action is of highest priority? a. Ambulate the patient in the hallway to promote deep breathing. b. Contact the prescriber and request a STAT chest X-ray c. Auscultate the patient's anterior and posterior lung fields. d. Administer pain medication and encourage the patient to take deep breaths.

D. Administer pain medication and encourage the patient to take deep breaths.