Respiratory Disorders

The nurse is caring for a client with pneumonia. As part of prescribed therapy, the client must use a bedside incentive spirometer to promote maximal deep breathing. The nurse checks to make sure the client is using the spirometer properly. During each waking hour, the client should perform a minimum of how many sustained, voluntary inflation maneuvers?

8 to 10

During the insertion of a rigid scope for bronchoscopy, a client experiences a vasovagal response. Which physiological response should the nurse monitor this client for?

A drop in the client's heart rate

A client with a productive cough, chills, and night sweats is suspected of having active tuberculosis (TB). The physician should take which action?

Admit him to the hospital in respiratory isolation

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 likely to include which nursing diagnosis?

Anxiety

A nurse is monitoring the progress of a client with acute respiratory distress syndrome (ARDS). Which data best indicate that the client's condition is improving?

Arterial blood gas (ABG) values are normal

The nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?

Assessing the client's respiratory status, orientation, and skin color

A hospitalized client needs a central venous access device inserted. The physician places the device in the subclavian vein. Shortly afterward, the client develops shortness of breath and appears restless. Which action would the nurse take first?

Auscultate breath sounds

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

Bleeding

A nurse caring for a client with deep vein thrombosis must be especially alert for complications such as pulmonary embolism. Which assessment findings by the nurse suggest pulmonary embolism?

Chest pain and dyspnea

Which treatment would the nurse expect for a client with spontaneous pneumothorax?

Chest tube placement

Which symptom would a nurse most likely observe first in a client with an acute pulmonary embolism?

Dyspnea

The oxygen saturation level of a 48-year-old client admitted to the hospital with bronchial pneumonia decreases, and his breathing is shallow. He refuses to perform coughing and deep-breathing exercises, or use an incentive spirometer. Which measures can the nurse take to help improve the client's respiratory status?

Elevate the head of the bed, and demonstrate and reinforce the importance of incentive spirometry, turning, coughing, and deep breathing

The term "pink puffer" refers to the client with which condition?

Emphysema

Which statement best explains how opening up collapsed alveoli improves oxygenation?

Gaseous exchange occurs in the alveolar membrane.

Teaching for a client with chronic obstructive pulmonary disease should include which topic?

How to recognize the signs of an impending respiratory infection

A client with a history of asthma is placed on pulse oximetry to monitor arterial oxygen saturation (SaO2) noninvasively. Which vital sign abnormality may alter pulse oximetry values?

Hypotension

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

A client who underwent surgery 12 hours ago has difficulty breathing. He has petechiae over his chest and reports acute chest pain. What action should a nurse take first?

Initiate oxygen therapy.

Exercise has which effect on clients with asthma, chronic bronchitis, and emphysema?

It enhances cardiovascular fitness.

Which additional data should immediately be gathered to determine the status of a client with a respiratory rate of 4 breaths/minute?

Level of consciousness and a pulse oximetry value

A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. While monitoring the client, which clinical findings that commonly accompany respiratory alkalosis would the nurse expect to assess?

Light-headedness or paresthesia

Which condition could lead to acute respiratory distress syndrome (ARDS)?

Massive trauma

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

Measuring and documenting the drainage in the collection chamber

A 52-year-old client admitted with a 3-month history of hemoptysis, shortness of breath, weight loss, and chronic productive cough undergoes testing, which reveals bronchial cancer. After being informed of his diagnosis, the client is tearful and nervous. He tells the nurse he has questions about the type of treatment plan an oncologist might offer. Which action should the nurse take?

Offer emotional support and reassure the client that an oncologist is being consulted to devise a treatment plan.

A nurse performing preoperative teaching for a client who will be undergoing surgery should focus primarily on which area?

Providing general information, answering questions, and offering emotional support to the client and family

In the client with terminal lung cancer, the focus of nursing care is on which nursing intervention?

Providing pain control

A client presents with shortness of breath and absent breath sounds on the right side, from the apex to the base. Which condition would best explain this?

Spontaneous pneumothorax

Which best describes pleural effusion?

The accumulation of fluid between the linings of the pleural space

The nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing and breath sounds are not audible. The nurse understands this change occurred for which reason?

The airways are so swollen that no air can get through

After a motor vehicle accident, a client has a tube inserted that begins to drain a large amount of dark red fluid. Which explanation best describes what caused this type of drainage from the chest tube insertion?

The client has experienced a hemothorax instead of a pneumothorax

On entering the room of a client with chronic obstructive pulmonary disease (COPD), the nurse notices that the client is receiving oxygen at 4 L/minute by way of a nasal cannula. The nurse's actions should be based on which statement?

The flow rate is too high

A client is receiving oxygen by way of a nasal cannula at a rate of 2 L/minute. How should the oxygen flow meter be set?

The line marked "2" should cut the ball in half

The 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

A client with a pneumothorax receives a chest tube attached to a Pleur- evac. The nurse notices that the fluid of the second chamber of the Pleur-evac is bubbling continuously. Which nursing assumptions would be valid?

There is a leak somewhere in the tubing system.

A client diagnosed with active tuberculosis (TB) would be hospitalized primarily for which reason?

To prevent spread of the disease

The nurse assesses a client's respiratory status. Which observation indicates that the client is experiencing difficulty breathing?

Use of accessory muscles

Which measure can reduce or prevent the incidence of atelectasis in a postoperative client?

Use of an incentive spirometer

A client with a nursing diagnosis of Impaired spontaneous ventilation undergoes a tracheostomy after many failed attempts at weaning from a mechanical ventilator. The nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?

Withdraw residual air from the cuff and then reinflate it.

A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later, the physician suspects that the client has aspirated stomach contents. The nurse knows that this client is at highest risk for:

adult respiratory distress syndrome (ARDS).

At 11 p.m., a client is admitted to the emergency department. He has a respiratory rate of 44 breaths/minute. He's anxious, and wheezes are audible. The client is immediately given oxygen by face mask and methylprednisolone (Depo-medrol) by I.V. At 11:30 p.m., the client's arterial blood oxygen saturation is 86%, and he's still wheezing. The nurse should plan to administer:

albuterol (Proventil).

A 47-year-old male client with an unresolved hemothorax is febrile, with chills and diaphoresis. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:

empyema

A 21-year-old client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician prescribes acetylcysteine (Mucomyst). Before administering the first dose, the nurse checks the client's history for asthma. Acetylcysteine must be used cautiously in a client with asthma because:

it may induce bronchospasm.

A client is diagnosed with a severe airway obstruction. During data collection, which findings does the nurse expects to find?

• Clutching the neck • Inability to speak • Cyanosis