Respiratory Disorders
The nurse should place a client being admitted to the hospital with suspected tuberculosis on what type of isolation? a) Contact precautions. b) Airborne precautions. c) Standard (routine) precautions. d) Droplet precautions.
B
When caring for a client with a chest tube and water-seal drainage system, the nurse should: a) Strip the chest drainage tubes at least every 4 hours if excessive bleeding occurs. b) Verify that the air vent on the water-seal drainage system is capped when the suction is off. c) Make sure that the drainage apparatus is always below the client's chest level. d) Ensure that the chest tube is clamped when moving the client out of the bed.
C
A black client with asthma seeks emergency care for acute respiratory distress. Because of this client's dark skin, the nurse should assess for cyanosis by inspecting the: a) nail beds. b) lips. c) earlobes. d) mucous membranes.
D
A client has undergone a left hemicolectomy for bowel cancer. Which activities prevent the occurrence of postoperative pneumonia in this client? a) Coughing, breathing deeply, frequent repositioning, and using an incentive spirometer b) Administering oxygen, coughing, breathing deeply, and maintaining bed rest c) Coughing, breathing deeply, maintaining bed rest, and using an incentive spirometer d) Administering pain medications, frequent repositioning, and limiting fluid intake
A
A client with lung cancer has developed an intractable, nonproductive cough that is unrelieved by nonopioid antitussive agents. The physician orders codeine, 10 mg P.O. every 4 hours. Which statement accurately describes codeine? a) It's a centrally-acting antitussive and can cause dependence. b) It's a peripherally-acting antitussive and doesn't cause dependence. c) It's a peripherally-acting antitussive and can cause dependence. d) It's a centrally-acting antitussive and doesn't cause dependence.
A
An anxious client is brought to the walk-in clinic following a bee sting. Physical assessment reveals blood pressure (BP) 160/78, heart rate (HR) 102 beats per minute, and respiration rate 32 breaths per minute with audible wheezing. Which of the following is the nurse's priority action? a) Assess the client's airway b) Administer 100% oxygen via mask c) Assist the client to lie down d) Assess the site to remove the stinger
A
As status asthmaticus worsens, the nurse would expect the client to experience which acid-base imbalance? a) Respiratory acidosis b) Respiratory alkalosis c) Metabolic alkalosis d) Metabolic acidosis
A
Which of the following should be readily available at the bedside of a client with a chest tube in place? a) A bottle of sterile water. b) Another sterile chest tube. c) A tracheostomy tray. d) A spirometer.
A A bottle of sterile water should be readily available and in view when a client has a chest tube so that the tube can be immediately submersed in the water if the chest tube system becomes disconnected. The chest tube should be reconnected to the water-seal system as soon as a sterile functioning system can be re-established. There is no need for a tracheostomy tray, another chest tube, or a spirometer to be placed at the bedside for emergency use
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? a) Pneumothorax b) Myocardial infarction (MI) c) Heart failure d) Pulmonary embolism
A Pneumothorax (air in the pleural space) is a potential complication of all central venous access devices. Signs and symptoms include chest pain, dyspnea, shoulder or neck pain, irritability, palpitations, light-headedness, hypotension, cyanosis, and unequal breath sounds
Outcome criteria for evaluating the effectiveness of airway suctioning should include which of the following? a) Breath sounds clear on auscultation. b) Respirations unlabored. c) Decreased mucus production. d) Hollow sound on chest percussion.
A - should be done whether or not client needs suctioning.
The nurse is teaching a client who has been diagnosed with tuberculosis how to avoid spreading the disease to family members. Which statement(s) by the client indicate(s) that he has understood the nurse's instructions? Select all that apply. a) "It is important that I isolate myself from family when possible." b) "I can use regular plates and utensils whenever I eat." c) "I should use paper tissues to cough in and dispose of them promptly." d) "I should always cover my mouth and nose when sneezing." e) "I will need to dispose of my old clothing when I return home."
B, C, D
The nurse is involved in preoperative teaching with a client who will be undergoing a lung resection. The client is told that two chest tubes will be placed during surgery. The nurse explains that the purpose of the lower chest tube is to A) Remove fluid B) Facilitate "milking" of the tubes C) Prevent clots D) Remove air
A) Fluid accumulates in the base of the pleura postop. The lower chest tube will drain serous and serosanguineous fluid that accumulates as a result of the surgery. A larger-diameter tube is usually used for the lower tube to ensure drainage of clots. Air rises, and the anterior or upper tube is used to remove air from the pleural space. The practice of "milking" the tubes prevents clots is becoming less common.
A client who is recovering from chest trauma is to be discharged home with a chest tube drainage system intact. The nurse should instruct the client to call the physician for which of the following? a) Continuous bubbling in the water-seal chamber. b) Fluid in the chest tube. c) Respiratory rate greater than 16 breaths/minute. d) Fluctuation of fluid in the water-seal chamber
A) indicates a leak in the system!
A client with acute asthma is prescribed short-term corticosteroid therapy. Which is the expected outcome for the use of steroids in clients with asthma? a) Promote bronchodilation. b) Have an anti-inflammatory effect. c) Act as an expectorant. d) Prevent development of respiratory infections.
B
A nurse is caring for a client who recently underwent a tracheostomy. What is the nurses first priority when caring for this client? a) Turning from side to side to mobilize secretions b) Suctioning to keep the airway patent c) Using a letter board for communication d) Encouraging coughing and deep breathing
B
A nurse is helping a suspected choking victim. The nurse should perform the Heimlich maneuver when the victim: a) Can make only minimal vocal noises. b) Cannot speak due to airway obstruction. c) Starts to become cyanotic. d) Is coughing vigorously.
B
An older adult has asthma and asks the nurse about taking the pneumonia vaccine. The nurse should tell the client: a) "You do not need the vaccine unless you are exposed to pneumonia." b) "You should receive the vaccine." c) "You should not have the vaccine because it is contraindicated in asthma." d) "You will need the vaccine only if you have frequent asthma attacks."
B
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? a) Oxygen analyzer b) Manual resuscitation bag c) Water-seal chest drainage set-up d) Tracheostomy cleaning kit
B 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
A client has a sucking stab wound to the chest. Which action should the nurse take first? a) Prepare a chest tube insertion tray. b) Prepare to start an I.V. line. c) Apply a dressing over the wound and tape it on three sides. d) Draw blood for a hematocrit and hemoglobin level.
C
A client with a longstanding diagnosis of generalized anxiety disorder presents to the emergency room. The triage nurse notes upon assessment that the patient is hyperventilating. The triage nurse is aware that hyperventilation is the most common cause of: a) acute CNS disturbances b) increased PaCO2 c) respiratory alkalosis d) metabolic acidosis
C
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 daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? a) 2 to 4 months b) 3 to 5 days c) 6 to 12 months d) 1 to 3 weeks
C
After teaching a client how to instill nose drops, the nurse evaluates that the client's technique is correct when the client does which of the following? a) Blows the nose gently after instilling the medicine. b) Uses sterile technique when handling the dropper. c) Lies supine for several minutes after instilling the drops. d) Uses a new dropper for each medication instillation.
C
To promote comfort and optimal respiratory expansion for a client with chronic obstructive pulmonary disease during sexual intimacy, the nurse can suggest that the couple: a) Have the affected partner assume a dependent position. b) Limit the duration of the sexual activity. c) Use pillows to raise the affected partner's head and upper torso. d) Use a waterbed.
C
When teaching a client with chronic obstructive pulmonary disease to conserve energy, the nurse should teach the client to lift objects: a) While taking a deep breath and holding it. b) After exhaling but before inhaling. c) While exhaling through pursed lips. d) While inhaling through an open mouth.
C Exhaling requires less energy than inhaling. Therefore, lifting while exhaling saves energy and reduces perceived dyspnea. Pursing the lips prolongs exhalation and provides the client with more control over breathing. Lifting after exhaling but before inhaling is similar to lifting with the breath held. This should not be recommended because it is similar to the Valsalva maneuver, which can stimulate cardiac arrhythmias.
Which intervention is most appropriate for a client with an arterial blood gas (ABG) of pH 7.5, a partial pressure of arterial carbon dioxide (PaCO2) of 26 mm Hg, oxygen (O2) saturation of 96%, bicarbonate (HCO3-) of 24 mEq/L, and a PaO2 of 94 mm Hg? a) Administer ordered supplemental oxygen. b) Administer an ordered decongestant. c) Instruct the client to breathe into a paper bag. d) Offer the client fluids frequently.
C - Patient is hyperventilating
A nurse is caring for a client who presents to the emergency department following a motor vehicle accident that caused chest trauma, as a result of hitting the steering wheel. Which assessment should most concern the nurse? a) Lung movement inward during expiration and outward during inspiration b) Barrel chest with pleurtic chest pain c) Lung movement outward during expiration and inward during inspiration d) An increased anterior posterior diameter with hemoptysis
C) ICn paradoxical chest expansion, the lungs move outward during expiration and inward during inspiration. This is very common with a flail chest, commonly caused by hitting the steering wheel. The client may exhibit signs of ineffective gas exchange, such as tachypnea (an abnormally fast respiratory rate), secondary to a paradoxical breathing pattern
Which intervention will the nurse expect for a client with a positive tuberculin skin test? a) Obtain a sputum specimen for AFB b) Administer the first dose of rifampin c) Prepare the client for a chest X-ray d) Place to client in airborne precautions
C) Next step would be to check if any chest infiltrates exist Next step (if chest xray is positive) is sputum specimen Also if chest xray is positive: administer Rifampin
A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says: a) "I should sleep on my side all night long." b) "I need to keep my inhaler at the bedside." c) "I should eat a high-protein diet." d) "I should become involved in a weight loss program."
D
The client with tuberculosis is to be discharged home with community health nursing follow-up. Of the following nursing interventions, which should have the highest priority? a) Offering the client emotional support. b) Coordinating various agency services. c) Assessing the client's environment for sanitation. d) Teaching the client about the disease and its treatment.
D
The nurse is assessing a client who has been in a car accident. The client reports sore ribs and painful breathing on the left side of the chest wall. A chest X-ray confirms fracture of two ribs and left-sided hemopneumothorax. What can the nurse anticipate? a) Aspirational thoracentesis will be performed to remove the accumulated bloody fluid. b) Splinting of the affected ribs will be initiated and limitation of upper body activity recommended. c) Oxygen will be initiated and a bronchoscopy will be performed to identify the area of damage. d) A chest tube will be inserted into the left pleural space and attached to a pleural evacuation device.
D
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? a) Hyperoxemia, hypocapnia, and hyperventilation b) Hyperventilation, hypertension, and hypocapnia c) Hypotension, hyperoxemia, and hypercapnia d) Hypercapnia, hypoventilation, and hypoxemia
D
Which of the following is an expected outcome for an elderly client following treatment for bacterial pneumonia? a) A respiratory rate of 25 to 30 breaths/minute. b) A maximum loss of 5 to 10 lb (2.27 to 4.53 kg) of body weight. c) Chest pain that is minimized by splinting the rib cage. d) The ability to perform activities of daily living without dyspnea.
D An expected outcome for a client recovering from pneumonia would be the ability to perform activities of daily living without experiencing dyspnea. A respiratory rate of 25 to 30 breaths/minute indicates the client is experiencing tachypnea, which would not be expected on recovery. A weight loss of 5 to 10 lb (2.27 to 4.53 kg) is undesirable; the expected outcome would be to maintain normal weight. A client who is recovering from pneumonia should experience decreased or no chest pain
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? a) Incentive spirometry b) Encouragement of coughing c) Use of a cooling blanket d) Endotracheal suctioning
D Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected
The nurse is aware that the best position for a client with impaired gas exchange is what? a) Sims b) Side-lying c) Semi-Fowler's d) High Fowler's
D) Allows maximal chest expansion If client can't tolerate high, go to semi-fowler's
While reviewing the arterial blood gas values of a client with emphysema, the nurse should identify which of the following PaCO2 values as indicating the need for immediate intervention? a) 45 mm Hg. b) 60 mm Hg. c) 35 mm Hg. d) 80 mm Hg.
[PaCO2 = 35-45, alk-acid] d) 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 would want to further evaluate the client with this level
When suctioning a tracheostomy tube 3 days following insertion, the nurse should follow which of the following procedures? a) Use a sterile catheter each time the client is suctioned. b) Protect the catheter in sterile packaging between suctioning episodes. c) Clean the catheter in sterile water after each use and reuse for no longer than 8 hours. d) Use a clean catheter with each suctioning, and disinfect it in hydrogen peroxide between uses.
a) The recommended technique is to use a sterile catheter each time the client is suctioned. There is a danger of introducing organisms into the respiratory tract when strict aseptic technique is not used. Reusing a suction catheter is not consistent with aseptic technique. The nurse does not use a clean catheter when suctioning a tracheostomy or a laryngectomy; it is a sterile procedure.
Which of the following interventions should the nurse anticipate in a client who has been diagnosed with acute respiratory distress syndrome (ARDS)? a) Mechanical ventilation. b) Tracheostomy. c) Insertion of a chest tube. d) Use of a nasal cannula.
a) Edotracheal intubation & mechanical ventilation are required in ARDS to maintain adequate respiratory support. Nasal cannula is not enough!
A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as: a) synchronized intermittent mandatory ventilation (SIMV). b) assist-control (AC) ventilation. c) continuous positive airway pressure (CPAP). d) pressure support ventilation (PSV).
a) In SIMV mode, the ventilator delivers a preset # of breaths at a preset tidal volume. The client can breathe on his own in between the breaths delivered by the ventilator. In AC ventilation, the ventilator delivers a preset # of breaths at a preset tidal volume and any breaths that the client takes on his own are assisted by the ventilator so they reach the present tidal volume. In CPAP, the ventilator provides only positive airway pressure; it doesn't provide any breaths to the client. In PSV, a pressure plateau is added to the ventilator to prevent the airway pressure from falling beneath a preset level.
Which nursing action is essential for the hospitalized client with a new tracheostomy? a) Relieve anxiety related to the tracheostomy. b) Maintain a patent airway. c) Decrease secretions. d) Provide client teaching regarding tracheostomy care.
a) The priority for a client with a new tracheostomy is to MAINTAIN A PATENT AIRWAY. A new tracheostomy commonly causes bleeding and excess secretions, and the client may require frequent suctioning to maintain a patent airway.
A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and complains of acute chest pain. What action should the nurse take first? a) Initiate oxygen therapy. b) Administer analgesics as ordered. c) Administer a heparin bolus and begin an infusion at 500 units/hour. d) Perform nasopharyngeal suctioning.
a) signs suggest pulmonary embolism! The physician will most likely order an anticoagulant (like heparin) to dissolve the thrombus.
A client who underwent a left lower lobectomy has been out of surgery for 48 hours. The client is receiving morphine sulfate via a patient-controlled analgesia (PCA) system and reports having pain in the left thorax that worsens when coughing. The nurse should: a) Let the client rest, so the client is not stimulated to cough. b) Obtain a more detailed assessment of the client's pain using a pain scale. c) Check that the PCA device is functioning properly, and then reassure the client that the machine is working and will relieve the pain. d) Encourage the client to take deep breaths to help control the pain.
b
A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest where there was an impact on the steering wheel. He also has a compound fracture of his right tibia and fibula and multiple lacerations and contusions. The primary goal at this point is to: a) Maintain adequate circulating volume. b) Maintain adequate oxygenation. c) Decrease chest pain. d) Reduce the client's anxiety.
b) Blunt chest trauma can lead to respiratory failure.
A nurse is assisting a client with a chronic respiratory disease to walk in the hallway. The nurse observes as the client's SpO2 drops from 94% to 88% during ambulation. Which of the following is the appropriate action of the nurse? a) Notify the healthcare provider b) Administer low flow supplemental O2 c) Encourage the client to continue with walking d) Document the SpO2 and continue to monitor
b) Client is hypoxemic and needs O2
Which of the following assessments is most appropriate for determining the correct placement of an endotracheal tube in a mechanically ventilated client? a) Verifying the amount of cuff inflation. b) Auscultating breath sounds bilaterally. c) Assessing the client's skin color. d) Monitoring the respiratory rate.
b) The nurse should also look for the symmetrical rise & fall of the chest and should note the location of the exit mark on the tube.
A nurse recognizes that a client with tuberculosis needs further teaching when the client states: a) "I'll have to take these medications for 9 to 12 months." b) "The people I have contact with at work should be checked also." c) "It will be necessary for the people I work with to take medication." d) "I'll need to have scheduled laboratory tests while I'm on the medication."
c) If exposed & positive, meds would be required for coworkers.
A client reports difficulty breathing and a sharp pain in the right side of his chest. The respiratory rate measures 40 breaths/minute. The nurse should assign highest priority to which care goal? a) Relieving pain b) Reducing anxiety c) Maintaining an adequate circulatory volume d) Maintaining effective respirations
d