Respiratory

What amount of chest tube drainage needs to be reported to the provider?

>100mL/hr

A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus? A. A client who has a chest tube following a pneumothorax B. A client who has an acute exacerbation of Crohn's disease C. A client who is postoperative following a laparoscopic appendectomy D. A client who is recovering from thyroid storm

A. A client who has a chest tube following a pneumothorax RATIONALE: Crepitus, a crackling sound resulting from air trapped under the skin can be palpated following a pneumothorax

A nurse in the ED is assessing a client for closed pneumothorax and significant bruising of the left chest following a MVA. The client reports severe left chest pain on inspiration. The nurse should assess the client for which of the following manifestations of pneumothorax? A. Absence of breath sounds B. Expiratory wheezing C. Inspiratory stridor D. Rhonchi

A. Absence of breath sounds RATIONALE: on the affected side B- asthma C- d/t obstruction D- thick sputum or foreign body will produce rhonchi, which are dry, low pitched snoring like noises produced in the throat

A nurse in a medical-surgical unit is assessing a client. The nurse should identify that which of the following findings is a manifestation of a pulmonary embolism? A. Stabbing chest pain B. Calf tenderness C. Elevated temperature D. Bradycardia

A. Stabbing chest pain RATIONALE: also dyspnea, coughing, hemoptysis, tachypnea, tachycardia, diaphoresis, and feeling of impending doom

A nurse is providing discharge teaching about improving gas exchange for a client who has emphysema. Which of the following instructions should the nurse include in the teaching? A. Use pursed-lip breathing during periods of dyspnea B. Limit fluid intake to 1500mL/day C. Practice chest breathing each day D. Wear home oxygen to maintain an SaO2 of at least 94%

A. Use pursed-lip breathing during periods of dyspnea

What is happening in a tension pneumothorax?

Air is entering on inspiration, but can't escape on expiration (one way valve)

What does CONTINUOUS bubbling indicate in a water seal chamber?

Air leak

A nurse is caring for a client who is experiencing acute opioid toxicity. Which of the following actions should the nurse identify as the priority? A. Insert a large-bore IV catheter B. Ensure an adequate airway C. Obtain an accurate medication history D. Prepare to administer an antagonist

B. Ensure an adequate airway

A nurse is providing teaching to a client who has a chronic cough and is scheduled for a bronchoscopy. Which of the following statements indicates an understanding of the teaching? A. I can keep my dentures in during the procedure B. I am allowed only clear liquids prior to the procedure C. A tissue sample might be obtained during the procedure D. A signed consent form is not required for this procedure

C. A tissue sample might be obtained during the procedure

A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? A. Instruct the client to cough B. Administer oxygen via facemask C. Evaluate the client for stridor D. Keep the client in a semi-to-high Fowler's position

C. Evaluate the client for stridor RATIONALE: stridor= high pitched sound that indicates laryngospasm or swelling around the glottis (the other actions are relevant, but not priority)

A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? A. Pericardial friction rub B. Weight gain C. Night sweats D. Cyanosis of the fingertips

C. Night sweats

A nurse is caring for a client who is extremely anxious and is hyperventilating. The client's ABG results are pH 7.50, PaCO2 27, and HCO3 25. The nurse should identify that the client has which of the following acid base imbalances? A. Respiratory acidosis B. Metabolic acidosis C. Respiratory alkalosis D. Metabolic alkalosis

C. Respiratory alkalosis

A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? A. Wheezing B. Bradypnea C. Tachycardia D. Diaphoresis

C. Tachycardia RATIONALE: tachycardia, dyspnea, restlessness, HA and increased BP are indications of impending respiratory failure

A nurse is teaching breathing techniques to a client who has emphysema. Which of the following statements indicates that the client understands the mechanics of pursed-lip breathing? A. I'll inhale slowly through pursed lips to help me breathe better B. When I do my pursed-lip breathing, I'll lie down first C. When I breathe out through pursed lips, my airways don't collapse between breaths D. I'll relax my stomach muscles when I am doing my pursed-lip breathing exercises

C. When I breathe out through pursed lips, my airways don't collapse between breaths

A nurse in a clinic is providing teaching for a client who is scheduled to have a tuberculin skin test. Which of the following pieces of information should the nurse include? A. If the test is positive, it means you have an active case of TB B. If the test is positive, you should have another TB skin test in 3 weeks C. You must return to the clinic to have the test read in 2-3 days D. A nurse will use a small lancet to scratch the skin of your forearm before applying the tuberculin substance

C. You must return to the clinic to have the test read in 2-3 days RATIONALE: A- needs chest x-ray B- needs chest x-ray next D- 0.1mL PPD intradermally to the dorsal aspect of the client's forearm

What is expected with suction control of ~20cm H2O?

Continuous bubbling with suction expected

A client comes to the ED in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? A. Tracheostomy placement B. Thoracentesis C. CT scan of the chest D. Chest tube insertion

D. Chest tube insertion RATIONALE: insert chest tube and connect to a water seal drainage

A nurse is preparing a client for discharge following a bronchoscopy. Which of the following assessments is the nurse's monitoring priority? A. Measuring HR B. Palpating peripheral pulses C. Observing sputum for blood D. Confirming the gag reflex

D. Confirming the gag reflex

A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reasom for having 2 chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? A. Removing air from the pleural space B. Creating access for irrigating the chest cavity C. Evacuating secretions from the bronchioles and alveoli D. Draining blood and fluid from the pleural space

D. Draining blood and fluid from the pleural space

A nurse is auscultating the lungs of a client who is having an acute asthma attack. Which of the following sounds should the nurse expect to hear? A. Soft blowing B. Loud bubbling C. Dry grating D. Noisy wheezing

D. Noisy wheezing

A nurse in the PACU is assessing a newly admitted client and observes intercostal retractions and a high-pitched inspiratory sound. The nurse should identify these findings as manifestations of which of the following complications? A. Pulmonary edema B. Tension pneumothorax C. Flail chest D. Respiratory obstruction

D. Respiratory obstruction RATIONALE: high pitched inspiratory noise (stridor)

A nurse is preparing a client for thoracentesis. In which of the following positions should the nurse place the client? A. Lying flat on the affected side B. Prone with the arms raised over the head C. Supine with the head of the bed D. Sitting while leaning forward over the bedside table

D. Sitting while leaning forward over the bedside table

A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication? A. Hallucinations B. Pruritus C. Hand and food syndrome D. Tinnitus

D. Tinnitus RATIONALE: An adverse effect of Cisplatin is ototoxicity, manifesting as tinnitus

What needs to be kept at the bedside for mechanical ventilation?

Manual resuscitation bag (bag-valve mask) and reintubation equipment of 2 different sizes

What are the s/s of Cystic Fibrosis in the GI system?

Steatorrhea (fatty, malodorous stools) -Delayed growth -Fat soluble vitamin deficiency (A, D, E, K)

When should antivirals be taken after the onset of symptoms for influenza?

Take within 48hr

How should a water seal drainage system be set up?

-Add sterile fluid to the 2cm line, check every 2hr -Chamber must be kept UPRIGHT & below chest insertion site

What is the nursing care for a patient with Cystic Fibrosis?

-Administer O2 -Encourage increased fluids, protein/high cal diet -Give A, D, E, K supplements (can't absorb)

A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume

A. Total lung capacity RATIONALE: B- measures the amount of air the client can exhale after maximum inhalation C- measures the amount of air in the lungs after normal expiration D- Amount of air in the lungs after forced expiration

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? SATA A. Tracheal deviation to the left B. Temperature of 102F C. Absent breath sounds on the right side D. Neck vein distention E. Bradypnea

A. Tracheal deviation to the left C. Absent breath sounds on the right side D. Neck vein distention

A nurse is providing preoperative teaching to a client who has lung cancer and will undergo a pneumonectomy. Which of the following statements should the nurse include? SATA A. You will have a chest tube in place after surgery B. We'll frequently help you turn, cough, and breathe deeply after surgery C. You will have to remain in bed for about 2 days after the surgery D. We'll give you oxygen to support your breathing if you need it E. You should expect pain for the first few days after surgery

A. You will have a chest tube in place after surgery B. We'll frequently help you turn, cough, and breathe deeply after surgery D. We'll give you oxygen to support your breathing if you need it

A nurse is teaching a client with cystic fibrosis about daily chest physiotherapy. Which of the following is the purpose of these treatments? A. To encourage deep breaths B. To mobilize secretions in the airways C. To dilate the bronchioles D. To stimulate the cough reflex

B. To mobilize secretions in the airways

A nurse is providing discharge teaching to a client who has emphysema. Which of the following instructions should the nurse include? A. Be sure to take cough medicine to avoid coughing B. Try to drink at least 3 liters of fluid per day C. Try to reduce your smoking to 2 cigarettes per day D. Be sure to eat 3 full meals each day

B. Try to drink at least 3 liters of fluid per day

A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse take first? A. Provide chest physiotherapy B. Perform oropharyngeal suction C. Encourage deep breathing and coughing D. Assist the client with ambulation

C. Encourage deep breathing and coughing

What are the medications used for patients with Cystic Fibrosis?

-Bronchodilators -Anticholinergics -Dornase alfa -Abx for pulmonary infections -PANCREATIC ENZYMES (TAKE WITH MEALS AND SNACKS)

What procedures can be done for Cystic Fibrosis?

-Chest physiotherapy (percussion, vibration, postural drainage, breathing exercises to loosen respiratory secretions) -SCHEDULE TREATMENTS BEFORE MEALS OR 1-2HR AFTER TO AVOID VOMITING -Use bronchodilator 30min-1hr before tx

What is the treatment for a tension pnemothorax?

-IMMEDIATE large bore needle into pleural space to remove air & re-expand the lung -INSERT CHEST TUBE

What is the nursing management of chest tubes?

-Keep occlusive dressing on chest tube insertion site -Assess insertion site for subcutaneous emphysema (edema, crepitus) and infection -Only clamp when ordered; do not "strip" the tue -Encourage patient to cough, deep breathe, use IS

What needs to be kept at the bedside for a patient with a chest tube?

-Padded clamps, sterile water, sterile gauze

What does the high pressure alarm with mechanical ventilation indicate?

-Pulmonary edema -Pneumothorax -Bronchospasm -Biting -Secretions -Cough -Kink

What type of teaching is needed for patients with COPD?

-Smoking cessation -Abdominal & pursed lip breathing -Effective coughing -Use incentive spirometer -Small frequent meals with high cal/protein diet

What are the S/S of a tension pneumothorax?

-Tracheal deviation to the UNAFFECTED side -ABSENT breath sounds on AFFECTED side -Respiratory distress -Asymmetry of thorax -Hypotension -Tachycardia -Tachypnea -JVD -Pallor -Anxiety

A nurse is providing discharge instructions to a client who has a new laryngectomy. The nurse should tell the client to be careful while bathing to prevent which of the following complications? A. Aspiration of water B. Infection of the stoma C. Bleeding around the stoma D. Skin breakdown around the stoma

A. Aspiration of water RATIONALE: The client should use a shower shield over the stoma when bathing or showering to keep water out of the airway

A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia and weight loss. Which of the following actions should the nurse take? SATA A. Assign the client to a private room with negative-pressure airflow B. Add contact precautions to the client's plan of care C. Wear a N95 respirator when entering the client's room D. Ensure the clients environment provides 4 exchanges of fresh air per minute E. Institute protective environment precautions as soon as the client arrives on the unit

A. Assign the client to a private room with negative-pressure airflow C. Wear a N95 respirator when entering the client's room RATIONALE: B- AIRBORNE precautions D- 6-12/minute E- this is for immunocompromised patients

A nurse is caring for a client who smokes cigarettes and has a new diagnosis of emphysema. How should the nurse assist the client with smoking cessation? A. Discuss ways the client can reduce the number of cigarettes smoked per day B. Suggest the client switch from smoking cigarettes to smoking a pipe C. Inform the client that treatment will be ineffective if smoking continues D. Discourage the use of nicotine gum

A. Discuss ways the client can reduce the number of cigarettes smoked per day RATIONALE: realistic and gradual

A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax? A. Dry cough B. Rhinitis C. Sore throat D. Swollen lymph nodes

A. Dry cough RATIONALE: During the prodromal stage, it is difficult to distinguish the condition from influenza or pneumonia because there is NO sore throat or rhinitis

A nurse is planning care for a client who has COPD and is malnourished. Which of the following recommendations to promote nutritional intake should the nurse include in the plan? A. Eat a high-calorie foods first B. Increase intake of water at meal times C. Perform active ROM exercises before meals D. Keep saltine crackers nearby for snacking

A. Eat a high-calorie foods first

A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? SATA A. Explain that the client will receive sedation and will not remember the procedure B. Verify that the client understands the purpose and nature of the procedure C. Offer the client sips of clear liquids until 1hr before the test D. Obtain a pre-procedural specimen E. Instruct the client to keep his neck in a neutral position

A. Explain that the client will receive sedation and will not remember the procedure B. Verify that the client understands the purpose and nature of the procedure RATIONALE: C- NPO 6-8hrs prior D- the provider can obtain the specimen during the procedure E- neck will be hyperextended

A nurse on a medical-surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and report to the provider? A. Increased coughing B. Diaphragmatic breathing C. Hemoptysis D. Kussmaul respirations

A. Increased coughing

A nurse is caring for a client who is receiving mechanical ventilation and develops acute respiratory distress. Which of the following actions should the nurse take first? A. Initiate bag-valve mask ventilation B. Provide the client with a communication board C. Obtain a blood sample for ABG analysis D. Document the ventilator settings

A. Initiate bag-valve mask ventilation

A nurse is planning postoperative education for a client who will undergo a radical neck dissection for cancer of the larynx. The nurse should include which of the following topics? SATA A. NPO status B. Alternative methods of communication C. Endotracheal intubation D. Changes in body image E. Swallowing exercises

A. NPO status B. Alternative methods of communication D. Changes in body image E. Swallowing exercises RATIONALE: A- the client will receive fluids & nutrition via enteral tube while healing from the surgery E- contact SLP

A nurse is caring for a client immediately following extubation. Which of the following manifestations indicates that the nurse should call the rapid response team? A. Stridor B. Coughing C. Hoarseness D. Extensive oral secretions

A. Stridor RATIONALE: High pitched sound heard during inspiration= laryngeal edema and can indicate impending airway obstruction

A nurse on a medical-surgical unit is caring for a client who is postoperative following a hip replacement surgery. The client reports feeling apprehensive and restless. Which of the following findings should the nurse recognize as an indication of pulmonary embolism? A. Sudden onset of dyspnea B. Tracheal deviation C. Bradycardia D. Difficulty swallowing

A. Sudden onset of dyspnea

A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low pressure alarm on the ventilator sounds, it indicates which of the following to the nurse? A. Excessive airway secretions B. A leak within the ventilators circuitry C. Decreased lung compliance D. The client coughing or attempting to talk

B. A leak within the ventilators circuitry

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following points should the nurse plan to discuss first? A. Eliminating environmental triggers that precipitate attacks B. Addressing the client's perception of the disease and what might have triggered past attacks C. Overviewing the client's medication regimen D. Explaining the manifestations of respiratory infections

B. Addressing the client's perception of the disease and what might have triggered past attacks RATIONALE: First assess the client's knowledge

A nurse is assisting a provider with a comprehensive physical examination of a client. When the provider uses transillumination, the nurse should explain to the client that this technique helps evaluate which of the following structures? A. Lymph nodes B. Maxillary sinuses C. Intercostal spaces D. Salivary glands

B. Maxillary sinuses RATIONALE: Clear sinus spaces allow transillumination

A nurse on a medical unit is caring for a client who aspirated gastric contents prior to admission. The nurse administers 100% oxygen by nonrebreather mask after the client reports severe dyspnea. Which of the following findings is a clinical manifestation of ARDS? A. Tympanic temperature of 100.4F B. PaO2 50mmHg C. Rhonchi D. Hypopnea

B. PaO2 50mmHg RATIONALE: ARDS= low PaO2 level, even after the administration of oxygen

A nurse is providing instructions about pursed-lip breathing for a client who has COPD. with emphysema. This breathing technique accomplishes which of the following? A. Increases oxygen intake B. Promotes Co2 elimination C. Uses the intercostal muscles D. Strengthens the diaphragm

B. Promotes Co2 elimination

A nurse is caring for an older adult client who has COPD with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis

B. Respiratory acidosis RATIONALE: Patient with COPD are unable to exhale CO2

A client is admitted to the ED following a MVA. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? A. Friction rub B. Crackles C. Crepitus D. Tactile fremitus

C. Crepitus RATIONALE: crepitus, aka subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel while palpating the skin surface over the clients chest; crepitus indicates an air leak into the subcutaneous tissue, a manifestation of pneumothorax A- friction rub is scratching or squeaking B- aka rales, are wet, popping sounds heard when auscultating the client's lungs when fluid is present in the airways/alveoli D- tactile fremitus is a vibration of the chest wall that the nurse can feel when palpating the client's chest as the client repeats a syllable such as "nine, nine". Increased tactile fremitus is a clinical manifestation of pneumonia

A nurse is providing discharge teaching to a client who had a pulmonary embolism. Which of the following statements indicates that the client understands the information? A. I'll expect a little leg swelling since I won't be active for a while B. I'll see the doctor every week to change my vena cava filter C. I'll call the doctor if I see any blood in my urine or stool D. I'll have to take the blood thinner for a few more days

C. I'll call the doctor if I see any blood in my urine or stool RATIONALE: B- the vena cava filter remains in place either until the provider determines there is not a high risk for clot formation or permanently D- weeks to years

A nurse is caring for a client who has a 20-year history of COPD and is receiving oxygen at 2L/min via nasal cannula. The client is dyspneic and has an oxygen saturation via pulse oximetry of 85%. Which of the following actions should the nurse take? A. Place a nonrebreather mask on the client and increase the oxygen flow to 3L/min B. Prepare the client for possible endotracheal intubation and mechanical ventilation C. Increase the oxygen flow and request an ABG determination D. Position the client supine and administer an anti anxiety medication

C. Increase the oxygen flow and request an ABG determination

A nurse is assessing a client who has pharyngitis. Which of the following findings is the nurse's priority to report to the provider? A. Elevated temperature B. Swollen cervical lymph nodes C. Inspiratory stridor D. Purulent nasal discharge

C. Inspiratory stridor

A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take? A. Cover the insertion site with a hydrocolloid dressing after removal B. Provide pain medication immediately after removal C. Instruct the client to perform the Valsalva maneuver during removal D. Delegate removal of the chest tube to a licensed practical nurse (LPN)

C. Instruct the client to perform the Valsalva maneuver during removal RATIONALE: This is to maintain the appropriate amount of negative pressure in the chest in order to prevent air entry into the pleural space

A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client? A. The client will need intensive smoking-cessation education B. After surgery, the prognosis for the client's with lung cancer is usually good C. Lung cancer usually has metastasized before the client presents with symptoms D. Oxygen therapy is ineffective following a lobectomy

C. Lung cancer usually has metastasized before the client presents with symptoms

A nurse is assessing a client who has a positive tuberculin skin test. Which of the following findings indicates that the client has active TB? A. Rhinitis B. Air hunger C. Night sweats D. Weight gain

C. Night sweats

A nurse is preparing to assist a provider with an arterial blood withdrawal from a client's radial artery for ABG measurement. Which of the following actions should the nurse plan to take? A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen B. Apply ice to the site after obtaining the specimen C. Perform an Allen's test prior to obtaining the specimen D. Release the pressure applied to the puncture site 1min after the needle is withdrawn

C. Perform an Allen's test prior to obtaining the specimen RATIONALE: The Allen test is a first-line standard test used to assess the arterial blood supply of the hand; this is used to ensure the circulation to the hand is adequate from the radial artery; the radial artery is the most common site for withdrawal of ABGs

A nurse is planning care for a client following placement of a chest tube 1hr ago. Which of the following actions should the nurse include in the plan of care? A. Clamp the chest tube if there is continuous bubbling in the water seal chamber B. Keep the chest tube drainage system at the level of the right atrium C. Tape all connections between the chest tube and drainage system D. Empty the collection chamber and record the amount of drainage every 8hr

C. Tape all connections between the chest tube and drainage system RATIONALE: this is to ensure airtight seal to prevent the chest tubing from accidentally disconnecting A- bubbling in the water seal chamber on forced exhalation/coughing means the system is working properly; DO NOT clamp the chest tube B- below level of chest at all times D- not until it is almost full

A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks the client why the client has 2 chest tubes, which of the following responses should the nurse make? A. Two tubes were necessary due to excessive bleeding from the area of surgery B. The tubes drain blood from 2 different lung areas C. The lower tube will drain blood, and the higher tube will remove air D. The second tube will take over if blood clots block the first tube

C. The lower tube will drain blood, and the higher tube will remove air

A nurse is caring for a client who is postoperative following a rhinoplasty. Which of the following findings should the nurse report to the surgeon? A. Nasal edema B. Mouth breathing C. Periorbital ecchymosis D. Frequent swallowing

D. Frequent swallowing

A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy. Which of the following statements indicates that the client understands the impact of the surgery? A. I'm not going to be able to cough for a while after the surgery B. After I recover from the anesthesia, I'll be able to eat regular food again C. After the surgery, my voice will gradually return but might be weak D. I understand that I will have a permanent tracheostomy after the surgery

D. I understand that I will have a permanent tracheostomy after the surgery RATIONALE: With a partial laryngectomy, the tracheostomy is temporary; this client is having a total laryngectomy, so the tracheostomy will be permanent

A nurse is providing preoperative teaching to a client who is to undergo a pneumonectomy. The client states, "I am afraid coughing will hurt after surgery". Which of the following statements by the nurse is appropriate? A. After the surgeon removes the lung, you will not need to cough B. I'll make sure you get cough suppressants to keep you from straining the incision when you cough C. Don't worry. You will have a pump that delivers pain medication as needed, so you will have very little pain D. I will show you how to splint your incision while coughing

D. I will show you how to splint your incision while coughing

A nurse is caring for a client who has a chest tube. The nurse notes that the chest tube has become disconnected from the chest drainage system. Which of the following actions should the nurse take? A. Place the drainage system at the head of the client's bed B. Increase the suction to the chest drainage system C. Place the client on low-flow oxygen via nasal cannula D. Immerse the end of the chest tube in a bottle of sterile water

D. Immerse the end of the chest tube in a bottle of sterile water

A nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? A. Apply warm compresses to the face B. Take aspirin 650mg by mouth for mild pain C. Close your mouth when sneezing D. Lie on your back with the HOB elevated 30° when resting

D. Lie on your back with the HOB elevated 30° when resting

A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of COPD. Which of the following oxygen-delivery methods should the nurse plan to use for this client? A. Simple face mask B. Nonrebreather C. Bag-valve mask D. Nasal cannula

D. Nasal cannula RATIONALE: provides precise concentrations of oxygen

A nurse is caring for a client who has COPD and is experiencing SOB. Which of the following actions should the nurse perform? A. Monitor the client's ABG results B. Instruct the client to perform controlling coughing C. Teach the client how to use pursed-lip breathing D. Place the client in an upright position

D. Place the client in an upright position

A nurse is caring for a client who has a tracheostomy with an inflated cuff in place. Which of the following findings indicates that the nurse should suction the client's airway secretions? A. The client is unable to speak B. The client's airways secretions were last suctioned 2hr ago C. The client coughs and expectorates a large mucous plug D. The nurse auscultates coarse crackles in the lung fields

D. The nurse auscultates coarse crackles in the lung fields RATIONALE: B- the nurse should assess the need for suctioning every 2 hrs and do so as necessary

A nurse is reviewing the lab results of a client who has metabolic alkalosis. Which of the following laboratory values should the nurse expect? A. pH 7.31, HCO3 22, PaCO2 50 B. pH 7.48, HCO3 23, PaCO2 25 C. pH 7.32, HCO3 18, PaCO2 40 D. pH 7.49, HCO3 32, PaCO2 40

D. pH 7.49, HCO3 32, PaCO2 40

What are the precautions for influenza?

DROPLET (A, B and C types)

Why does a patient with COPD have polycythemia (increased RBCs)?

Due to chronic hypoxia

What will be felt on percussion with a pleural effusion & hemothorax?

Dullness

What is the I:E ratio?

Duration of inspiration to expiration (usually 1:2 to 1:1.5)

How often should the endotracheal tube be repositioned to prevent skin breakdown in a patient on mechanical ventilation?

Every 24hr

What is cystic fibrosis?

Genetic disorder (autosomal recessive) causing obstruction of NaCl transport within cell membranes, producing secretions with low water content (thick, sticky mucus)

What is interstitial lung disease?

Group of restrictive lung disorders that causes stiff & noncompliant lungs; replaces healthy tissue with fibrotic scar tissue -RF: sarcoidosis, environmental inhalants, immune disorders -Meds: Corticosteroids (may need lung transplant)

What are the s/s of Cystic Fibrosis in the skin?

High NaCl content in sweat, saliva and tears

What will be felt on percussion with a pneumothorax?

Hyperresonance

What should the nurse do if the chest tube disconnects from the drainage system?

Immediately place the end of the tube in sterile water to maintain water seal

What does tidaling indicate in a water seal drainage system?

Increased or decreased movement of water WITH BREATHING and is EXPECTED "Seals swim in the tides! Tidaling is expected in the water seal"

What does the low pressure alarm with mechanical ventilation indicate?

Low pressure alarm= Leak

What does lack of tidaling indicate in a water seal chamber?

Lung re-expansion OR obstruction

How is tube positioned verified with a chest tube?

Obtain chest x-ray

What will PaCO2 and PaO2 show in a patient with COPD?

PaCO2 will be increased and PaO2 will be decreased

What should the nurse do if the chest tube is accidentally removed?

Place dry, sterile gauze over site and then notify provider

What is a complication of a chest tube?

Pneumothorax

What chest tube position is used for hemothorax or pleural effusion?

Positioned DOWN

What chest tube position is used for pneumothorax?

Positioned UP

What is PEEP?

Positive End Expiratory Pressure: pressure applied at the end of ventilator expirations to distend alveoli and prevent collapse

What complication do nurses need to monitor for in a patient with COPD?

Right sided HF

What are the s/s of Cystic Fibrosis in the respiratory system?

Wheezing, coughing, dyspnea, mucus plugs, cyanosis, barrel-shaped chest, clubbing, chronic respiratory infections