Respiratory PassPoint Quiz
A nurse is providing discharge teaching for a client who had a laryngectomy. What should the nurse include in the teaching?
Cover the stoma with a loose plastic cloth whenever you shower or bathe.
A client with DVT suddenly develops dyspnea, tachypnea, and chest discomfort. What should the nurse do first? 1. Elevate the HOB 30 to 45 degrees. 2. Encourage the client to cough and deep breath 3. Auscultate lungs to detect abnormal breath sounds 4. Contact the HCP
Elevate the HOB 30-45 degrees.
A client has had a left chest tube in place for several days. The nurse assesses the client and notes that there is no bubbling in the water seal chamber. Auscultation of the left lower lung reveals vesicular breath sounds. What is the most appropriate action by the nurse?
Further assess the client for reinflation of the lung
For each potential intervention, click to specify whether the intervention is priority, nonessential, or contraindicated for the next 24 hours.
Having the client perform coughing and deep breathing exercises: Priority Initiate intubation and mechanical ventilation: contraindicated Begin smoking cessation education: Nonessential Encourage the use of IS: Priority Have the client change position: Priority Withhold narcotic analgesic meds: contraindicated
A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when they say:
I should become involved in a weight loss program
A nurse instructs a client with allergic rhinitis about the correct technique for using an intranasal inhaler. Which statement indicates that the client understands the instructions?
I should hold one nostril closed while I insert the spray into the other nostril.
A nurse is teaching a client with COPD who is being discharged after traetment for an acute exacerbation. Which statement by the patient demonstrates proper understanding of the instructions?
I should try to eat several small meals during the day.
A client who has started therapy for drug-resistant TB demonstrates understanding of TB transmission by saying:
I'll stop being contagious when I have a negative acid-fast bacilli test
Which intervention is most appropriate for a client with an arterial blood gas of pH 7.5, PaCO2 26, O2 96%, HCO3 24, and PaO2 of 94?
Instruct the client to breathe into a paper bag
A client with lung cancer has developed an intractable, nonproductive cough that is not treated with nonopioid antitussive agents. The health care provider orders codeine, 10 mgPO every 4 hours. Which statement accurately describes codeine?
It's a centrally acting antitussive and can cause dependence
A client is scheduled to undergo a bronchoscopy. Which nursing interventions would be included on the care plan?
Keep suction equipment available Assess cough and gag reflexes after the procedures Report hemoptysis, stridor, or dyspnea immediately
After a bronchoscopy with biopsy, the nurse assesses the client. The nurse should report which finding to the provider?
Laryngeal stridor
The nurse is assessing a client who has a chest tube connected to a water-seal chest tube drainage system. According to the illustration show, what should the nurse do?
Lower the drainage system to maintain gravity flow
For each assessment finding, click to specify if the finding indicates that the client's condition has improved, has not changed, or has declined.
Lungs are clear in all lobes: Improved O2 Sat is 97% On room air: Improved Client is passing flatus: Improved The dressing has 3x5 cm yellow drainage: Declined The abdomen is firm: No change Pain is rated as a 1 on a scale of 0-10: Improved The client is ambulating without assistance: Improved
A client has a tracheostomy. Which nursing action would prevent complications of suctioning?
Maintain sterility of the suction catheter
A client with suspected inhalation anthrax is admitted to the emergency department. Which action by the nurse takes the highest priority?
Monitor vital signs and O2 sat every 15-30 minutes.
The nurse is assessing the client who has recently returned from a 2 month mission to Africa. What type of respiratory protection is appropriate for staff?
N95 particulate respirator
A client with asthma who has wheezing and shortness of breath asks the nurse if it is all right to use the salmeterol inhaler during exercise. What is the nurse's best response?
No, this drug is a maintenance drug, not a rescue inhaler.
The nurse auscultates the lungs of a client who has been diagnosed with a tumor in the lung and notes wheezing over one lung. What additional assessment should the nurse make?
Obstruction of the airway
A client who underwent a left lower lobectomy has been out of surgery for 48 hours. The client is receiving morphine sulfate via a PCA system and reports having pain in the left thorax that worsens when coughing. After checking the PCA system, what should the nurse do next?
Obtain a more detailed assessment of the client's pain using a pain scale
A client with heart failure develops pink, frothy sputum and restlessness. Which actions are priority for the nurse?
Place the client in high Fowler's position Notify the physician of the client's change in status Auscultate bilateral lung sounds for crackles
A client has a central venous catheter inserted into the subclavian vein. The nurse assesses the client immediately follwoing the insertion of the catheter and notes a sudden onset of chest pain and SOB. WHich complication should the nurse be prepared to treat?
Pneumothorax
The nurse observes that a client admitted with asthma is anxious, has audible wheezing, and is using the neck muscles when breathing. What actions would be appropriate?
Position in high fowlers position and administer an albuterol sulfate inhaler
A client diagnosed with an empysema is scheduled for a thoracentesis. The nurse should prepare the client for this procedure with which action?
Position the client sitting upright on the edge of the bed and leaning forward
The nurse is preparing to suction a trach for a client with MRSA. What should the nurse do next?
Proceed to suction the client's trach
The nurse is instructing a client with COPD how to do pursed lip breathing. In which order from first to last should the nurse explain the steps to the clients? All options must be used.
Relax your neck and shoulder muscles Breathe in normally through your nose for two counts. Pucker your lips as if you were going to whistle Breathe out slowly through pursed lips for four counts.
A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?
Suction the client's artificial airway
The nurse teaches thhe client how to instill nose drops. Which technique is correct?
THe client blows the nose gently before instilling drops
A nurse is conducting an initial assessment on a client with possible TB. Which assessment finding indicates a risk factor for TB?
THe client had a liver transplant 2 years ago
A nurse notices that a client admitted for exacerbation of COPD is short of breath. The client has a signed advanced directive indicating that they don't want to be resuscitated. The nurse should
check the clients oxygen saturation
The nurse observes a constant gentle bubbling in the water seal column of a water seal chest drainage system. What should the nurse do nect?
check the connectors between the chest and drainage tubes and where the drainage tube enters the chest drainage system
A client is undergoing a complete physical examination as a requirement for college. When checking the client's respiratory status, the nurse observes respiratory excursion to help assess: a) lung vibrations b) vocal sounds c) breath sounds d) chest movements
chest movements
A client with emphysema is at greater risk for developing what acid-base imbalance?
chronic respiratory acidosis
What is the best way for the nurse to position a chest tube for a client to prevent dislocation?
coiled flat on the bed and secured without putting tension on the tube
A client admitted with tuberculosis reports concerns about payinf for needed medications. THe nurse should:
collaborate with the social worker to investigate possibility of funds
Which performance improvement strategy helps prevent adverse reactions to blood products?
confirming client identification with two qualified health professionals
For a client with a sucking stab wound in the chest wall, the nurse should first:
cover the wound with a petroleum-impregnated dressing
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's teenage daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? a) 3 to 5 days b) 1 to 3 weeks c) 2 to 4 months d) 6 to 12 months
d
The nurse is planning to teach a client with COPD how to cough effectively. WHich instruction should be included?
Take a deep abdominal breath, bend forward, and cough three or four times on exhalation.
For a client with asthma, the health care provider prescribed albuterol, two puffs a day via a metered-dose inhaler (MDI), and beclomethasone, two puffs a day via MDI. How should the nurse instruct the client to administer these drugs?
Take the albuterol first and follow with beclomethasone two times a day
A competent client requiring long-term mechanical ventilation privately tells a nurse that the want the ventilator withdrawn. Which response by the nurse is best?
Tell me more about how you are feeling
The nurse has placed the intubated client with ARDS in the prone position for 30 minutes. Which factors would require the nurse to discontinue prone positioning and return the client to supine position?
The Spo2 and Po2 have decreased THe client is tachycardiac with a drop in BP the face has increased skin breakdown and edema
A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition?
The client has a partial pressure of arterial oxygen value of 90 mm Hg or higher
When attempting to check the pupils of a client scheduled to receive general anesthesia the nurse notices that the client has trouble tilting the head back. What is the primary concern about this finding?
The client is at risk for difficult intubation
Oxygen at the rate of 2 liters per minute through nasal cannula is prescribed for a client with chronic obstructive pulmonary disease (COPD). Which of the following statements best describes why the oxygen therapy is maintained at a relatively low concentration?
The client's respiratory center is so used to high carbon dioxide and low oxygen that changing these levels may eliminate his stimulus for breathing.
An older adult's daughter is asking about the follow-up evaluation for her father after his pneumonectomy for primary lung cancer. What should the nurse tell the daughter?
The follow up for your father will be a chest x-ray every 6 months
A client has a chest tube attached to a water seal drainage system, and the nurse notes that the fluid in the tube and in the water seal column has stopped fluctuating. How should the nurse interpret this finding?
The lung has fully expanded.
A nurse is helping a suspected choking victim. When should the nurse perform the Hiemlich maneuver?
The victim cannot speak due to an airway obstruction.
A 56-year-old client on the surgical unit had a large bowel resection to resolve complications of diverticulitis. Assessment findings that require Follow-up
* Decreased breath sounds in lung bases RR 24 bpm O2 Sat 92% Shallowing respirations Smoking hx
A nurse is assessing a client using a trach tube. The client has bilateral rhonchi in the upper lobes of the lungs and is unsuccessful in coughing up secretions. Which action should the nurse take?
Use a sterile suction kit to suction the client
A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than :
0.5
A client with COPD and cor pulmonale is being prepared for discharge. The nurse should provide which instruction?
Weigh yourself daily and report a gain of 2 lb in 1 day.
A client's undergone a bronchoscopy. Which nursing interventions are appropriate for this procedure?
Withhold food and fluids until the client's gag reflex returns. Assess for hemoptysis and frank bleeding Monitor the client's vital signs
Which client should the nurse most encourage to receive the pneumococcal and influenza vaccination?
a 75-year-old woman with diabetes
Which resgistered nurse should be assigned to the client who had a chest tube inserted yesterday?
a RN who use to work on the cardiovascular unit
A nurse is caring for a group of clients on a medical-surgical floor. Which client is at the most risk for developing pneumonia?
a client with an NG tube
A client with a clamped chest tube in place has become increasingly short of breath throughout the shift and reports pain to the right chest wall. The nurse understands that the most likely cause is:
a tension pneumothorax
The nurse is suctioning a client who had a laryngectomy. What is the maximum amount of time the nurse should suction the client?
10 seconds
A client with a nasotracheal tube needs to be suctioned. What is the length of time the nurse should apply the suction for each pass of the catheter?
10-15 seconds.
The client is to receive theophylline 500 mg IV in 500 mL of normal saline solution to run over 4 hours. The tubing delivers 60 gtt/mL. The nurse should set the infusion pump to administer the solution at how many milliliters per hour?
125
A nurse is assessing the injection site of a client who has had a PPD test. Which finding indicates a need for further evaluation?
15-mm induration
For a client with acute pulmonary embolism, the physician orders heparin 25,000 units in 500 mL of dectrase 5% in water at 1,100 units/hour. The nurse should administer how many ml/hour?
22
A physician orders prednisone to control inflammation in a client with interestitial lung disease. During client teaching, the nurse stresses the importance of taking prednisone exactly as ordered and cautions against discontinuing the drug abruptly. A client who discontinues it abruptly may experience:
acute adrenocorticla insufficiency
A client admitted with multiple traumatic injuries receives massive fluid resuscitation. Later the physician suspects that the client has aspirated stomach contents. The nurse should monitor closely for complications that include which of the following?
acute respiratory distress syndrome (ARDS)
A client experiencing a severe asthma attach has the following ABGs, ph 7.33, PCO2 48, PO2 58, HCO3 26. Which prescription should the nurse first implement?
albuterol nebulizer
A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?
an inhaled beta2-adrenergic agonist
A 6-year-old child is admitted to a pediatric unit for the traetment of osteomyelitis. What medication classificiation would the nurse anticipate as documented on the medication report?
antibiotic
After nasal surgery, the client expresses concern about how to decrease facial pain and swelling while recovering at home. Which instruction would be most effective for decreasing pain and edema?
apply cold compresses to the area
An adolescent with cystic fibrosis has been hospitalized several times. On the latest admission the client has labored respirations, fatigue, malnutrition, and failure to thrive. What nursing actions are most importnat?
applying an oximeter and initiating respiratory therapy
The nurse caring for a client diagnosed with COPD is experiencing respiratory acidosis. The decrease in pH exists because the client's lungs:
are unable to blow off carbon dioxide
The nurse is caring for a client that is experiencing increasing shortness of breath. The client is pale and slight circumoral cyanosis is developing. Which laboratory test best measures adequacy of tissue oxygenation?
arterial blood gases
A client, diagnosed with acute pancreatitis 5 days ago, is experiencing respiratory distress. Which finding should the nurse report to the HCP?
arterial oxygen level of 46 mm Hg
An anxious client is brought to the walk-in clinic following a bee sting. Physical assessment reveals BP 160/78, HR 102, and respiratory rate 32 bpm with audible wheezing. What is the nurses priority action?
assess airway
A client with chronic renal failure is being admitted with pulmonary edema. which is a priority nursing intervention?
assess lung sounds and O2 sat level
A client with emphysema is receiving continuous oxygen therapy. Depressed ventilation is likely to occur unless the nurse ensures that the oxygen is administered in which way?
at a low flow rate
Following the 1400 assessment, which potential complication would the nurse continue to monitor for?
atelectasis paralytic ileus surgical site infection
For a client with an endotrachael tube, which nursing action is the most appropriate?
auscultating the lungs for bilateral breath sounds
Whats the drug of choice for legionnares disease?
azithromycin
A client with rib fractures and a pneumothorax has a chest tube inserted that is connected to a water-seal chest tube drainage system. The nurse notes that the fluid in the water-seal column is fluctuating with each breath that the client takes. What is the significance of this fluctuation? ■ 1. An obstruction is present in the chest tube. ■ 2. The client is developing subcutaneous emphysema. ■ 3. The chest tube system is functioning properly. ■ 4. There is a leak in the chest tube system.
3. The chest tube system is functioning properly
The nurse is performing a respiratory assessment on a client who has a pleural effusion. Which breath sound is expected for this client?
decreased breath sounds on the affected side
A home health nurse sees a client with end stage COPD. An outcome identified for this client is preventing infection. Which finding indicates this outcome has been met?
decreased oxygen requirements
A recent immigrant is diagnosed with TB. Which intervention is most importnat for the nurse to implement with this client?
developing a list of people with whom the client has had contact
The nurse should teach clients that the most common route of transmitting tuberle bacilli from person-to-person is through contaminated:
droplet nuclei
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia
dyspnea and wheezing
A client undergoes surgery to repair lung injuries. Postoperative orders include the transfusion of one unit of packed red blood cells at a rate of 60ml/hour. How long will this transfusion take to infuse?
4 hours
A client has a positive reaction to the Mantoux test. How should the nurse interpret this reaction? The client has:
been exposed to Mycobacterium tuberculosis.
The nurse is instructing the client with COPD to do lip-pursed breathing. What is the expected outcome of this exercise?
better elimination of carbon dioxide
The nurse is instructing the client with COPD to do pursed lip breathing. What is the expected outcome?
better elimination of carbon dioxide
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?
bleeding
When evaluating the effectiveness of airway suctioning, the nurse should use which criterion?
breath sounds clear on auscultation
A nurse is caring for a client diagnosed with pneumonia, a UTI, dehydration, a temp of 101.4 F. The HCP orders 1,000 ml of D5W to infuse over 8 hours. The available drop factor is 20 gtt/mL. The nurse would regulate the intravenous flow rate to deliver how many drops per minute.
42
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's teenage daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy? a) 3 to 5 days b) 1 to 3 weeks c) 2 to 4 months d) 6 to 12 months
6-12 months
The nurse monitors a client following the insertion of a chest tube for a hemopneumothorax. Which observation should the nurse report to the healthcare provider?
600 mL of blood in the collection chamber in 1 hour.
A client with bronchitis is ordered 300 mg of liquid guaifenesin (Robitussin) every 4 hours. The container indicates that there is 200 mg/5 ml. How many milliliters should the nurse administer per dose?
7.5
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 chest tube will be inserted into the left pleural space and attached to a pleural evacuation
A nurse is administering a PPD test to a client. Which is true concerning PPD testing?
A positive reaction indicates that the client has been exposed to the disease
A client with a hx of asthma is admitted to the emergency department. The nurse notes that the client is dyspneic, with a respiratory rate of 35 bpm, nasal flaring, and use of accessory muscles. Auscultation of the lung fields reveals greatly diminished breath sounds. What should the nurse do first?
Administer bronchodilators as prescribed
A nurse is assisting a client with chronic respiratory disease to walk in the hallway. The nurse observes as the clients Spo2 drops from 94% to 88% during ambulation. Which nursing action is most appropriate?
Administer low flow supplemental O2
After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: a) report fluctuations in the water-seal chamber. b) clamp the chest tube once every shift. c) encourage coughing and deep breathing. d) milk the chest tube every 2 hours.
encourage coughing and deep breathing
When teaching a client with COPD to conserve energy, what instruction should the nurse give the client about breathing when lifting heavy objects? Lift the object by:
exhaling through pursed lips
The nurse should teach the client with asthma to avoid which of the most common precipitating factors of an acute asthma attack?
exposure to cigarette smoke
A client with chronic sinusitis comes to the outpatient department complaining of headache, malaise, and a nonproductive cough. When examining the client's paranasal sinuses, the nurse detects tenderness. To evaluate this finding further, the nurse should transilluminate the:
frontal and maxillary sinuses
An elected official has asked the nurse for information on anthrax and the risk it could pose to residents of the community. What information would they provide?
Anthrax can infect the integumentary, GI, and respiratory systems.
A client has a sucking stab wound to the chest. Which action should the nurse take first?
Apply a dressing over the wound and tape it on three sides
A homeless client comes to the clinic coughing up blood and is diagnosed with TB. Which intervention by the nurse will be most effective in ensuring adherence with the pharmacological treatment regimen?
Arrange for the client ot come to a community center each day to receive a meal and medication
The nurse is instructing a client with acute asthma who is taking short-term corticosteroid therapy. The nurse should tell the client that steroids will have which expected outcomes. Steroids will:
have an anti-inflammatory effect
A client is receiving streptomycin to treat TB. What should the nurse evaluate to determine an adverse effect of the drug?
hearing loss
Which diet would be the most appropriate for a client with COPD?
high-calorie, high-protein diet
A nurse is caring for a client diagnosed with DVT. The client begins to experience symptoms of chest pain, dyspnea, and restlessness. Physical assessment reveals a heart rate of 140 bpm, BP of 100/60, and respiratory rate of 40 bpm. What is the nurse's priority action?
Assess the clients O2 sat level
Upon creating the plan of care for the client, the nurse would include which interventions?
Assist the client with turning while in bed Encourage the use of an IS Splint the abdomen Administer prescribed narcotic analgesic medication as needed
The client is ready for discharge after surgery for a deviated septum. Which instructions are appropriate?
Avoid activities that elicit Valsalva's maneuver.
A HCP has just inserted nasal packing for a client with epistaxis. The client is taking ramipril for HTN. What should the nurse instruct the client to do?
Avoid rigorous aerobic exercise
When performing the Heimlich maneuver on a conscious adult victim, where should the nurse deliver the rescuer and upward thrusts?
Below the xiphoid process and above the umbilicus
A nurse is caring for a client experiencing an acute asthma attack. The client stops wheezing, and breath sounds aren't audible. What is the likely cause of these assessment findings?
Bronchial edema and constriction have worsened.
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?
impaired gas exchange
On admission, the client's ABG values were: pH 7.20, PaO2 64, PaCO2 60 and HCO3 22. A chest tube is inserted and o2 at 4L/min is started. 30 minutes later values are: pH 7.3, PaO2 76, PaCO2 50, and HCO3 22. This would indicate:
improving respiratory status
When assessing a client with chest trauma, the nurse notes that the client is taking small breaths at first, then bigger breaths, and then a couple of small breaths, then 10 to 20 seconds of no breaths. How should the nurse record the breathing pattern?
Cheyne-Stokes respiration
Click to specify if the finding is consistent with the process of hypoventilation, hypopharyngeal obstruction, or asthma.
Choking: hypopharyngeal Decreased O2 sat: hypoventilation, hypopharyngeal obstruction, asthma Shallow respirations: hypoventilation Increased respiratory rate: hypoventilation, asthma Wheezing: asthma
A client in severe respiratory distress is admitted to the hospital. When assessing the client, the nurse should: a) Delay assessment until client's respiratory distress is resolved. b) Focus assessment on the respiratory system and distress. c) Complete a comprehensive physical examination. d) Conduct a complete health history.
Complete a focused assessment on the respiratory system
The nursing staff is divided over withdrawing care from a competent, chronically ill client. THe nurse-manager would take which step to meet the needs of the staff>
Contact the institutional ethics committee for strategies
Upon analysis of a client's arterial blood gas results, the nurse determines that the concentration of carbon dioxide and hydrogen ions are elevated and the oxygen in the arterial blood is decreased. What respiratory assessment findings would the nurse anticipate to observe in a client with these arterial blood gas results?
increase in rate and depth of respirations
A physician orders palliative care consult for a client with end stage chronic obstructive pulmonary disease who wishes no further medical intervention. Which step should the nurse anticipate based on the nurse's knowledge of palliative care?
increasing the need for antianxiety agents
A client who sustained a pulmonary contusion in a motor vehicle accident develops a pulmonary embolism. Which nursing diagnosis takes priority with this client? a) Excess fluid volume related to excess sodium intake b) Acute pain related to tissue trauma c) Ineffective breathing pattern related to tissue trauma d) Activity intolerance related to insufficient energy to carry out activities of daily living
ineffective breathing pattern related to tissue trauma
A client is transported to the ER with an acute respiratory infection. Vital signs are T 102, P 110 bpm, R 32 bpm. Circumoral cyanosis is noted, and the O2 sat is 86%. What should be the immediate actions by the nurse caring for this patient?
initiate oxygen at 6 L/min via nasal cannula. Place the client in high Fowler's position
The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect:
inspiratory and expiratory wheezing
A client requires long-term ventilator therapy. The client has a trach in place that requires frequent suctioning. Which technique should the nurse use?
intermittent suction while withdrawing the catheter
A nurse is administering moderate sedation to a client with COPD. The nurse's next action is based on the principle that:
it may be necessary to raise the head of this client's bed
The nurse administers theophylline to a client. When evaluating the effectiveness of this medication, what is an expected outcome?
less difficulty breathing
The nurse is caring for a child with history of strep throat. Upon current assessment, the child reports abdominal pain and joint ashiness. Which lab data would the nurse communicate to the HCP immediate;y?
leukocytosis
A client hospitalized for treatment of a pulmonary embolism develops respiratory alkalosis. Which clinical findings commonly accompany respiratory alkalosis?
light headedness or paresthesia
The nurse instructs the UAP on how to care for a client with chest tubes that are connected to water-seal drainage. The nurse should instruct the UAP to:
mark the time and amount of drainage on the collection chamber
A client with cystic fibrosis develops pneumonia. To decrease the viscosity of respiratory secretions, the physician orders acetylcysteine. 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
For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan?
measuring and documenting the drainage in the collection chamber
A client has the following ABG values: pH 7.12, PaCO2 40, HCO3 15. These ABG values suggest which disorder?
metabolic acidosis
The nurse is assessing a client with a darker-skin tone in need of emergency care for acute respiratory distress. Which area would the nurse inspect when assessing for cyanosis in this client?
mucous membranes
A physician orders albuterol for a client with newly diagnosed asthma. When traching about this drug, the nurse should explain that it may cause:
nervousness
A HCP has entered orders for a client witth COPD. Which order should the nurse question?
oxygen increased to 3L/min if O2 sat is less than 94% on room air
The nurse is analyzing the ABG results of client diagnosed with severe pneumonia. What ABG results are most consistent with this diagnosis?
pH 7.20, PaCO2 65, HCO3 26
Arterial blood gas analysis would reveal which finding related to acute respiratory failure?
pH 7.24
The nurse has received lab reports for several clients undergoing care. Which set of ABG results will the nurse investigate first?
pH 7.49, PaCO2 30, PaO2 75, HCO3 22
The nurse is caring for a client with ARDS. What portion of arterial blood gas results does the nurse find most concerning, requiring intervention?
partial pressure of PaO2 of 69
The nurse is preparing to assist with the removal of a chest tube. Which dressing is appropriate at the site from which the chest tube is removed?
petrolatum gauze
A nurse is interpreting blood gases for a client with acute respiratory distress syndrome. Which set of ABGs does the nurse expect for this client?
ph 7.25, PaCO2 48. HCO3 24
A client with Guillain-Barre syndrome develops respiratory acidosis as a result of reduced aveolar ventilation. Which combination of ABG values confirms respiratory acidosis?
ph 7.25, PaCO2 50 mm hg
The nurse is aware that frequent repositioning in bed will assist in the prevention of what condition for a client?
pneumonia
A client who is intubated on mechanical ventilation develops subcutaneous emphysema. Which ventilator setting should the nurse anticipate being adjusted for this client?
positive end-expiratory pressure (PEEP)
A nurse is brought to the emergency department following an automobile accident. The assessment reveals tachycardia, dyspnea, and absent breath sounds over the right lung. WHich action is the nurses most appropriate action?
preparing the client for a chest tube insertion
After a total laryngetomy, the client has a feeding tube. What is the purpose of the feeding tube?
provides nutrition
An expected outcome of theophylline ethylenediamine when administered to a client with COPD is:
relax bronchial smooth muscle
A young adult is admitted for elective nasal surgery for a deviated septum/ Which sign is an important indicator of bleeding even if the nasal drip pad remained dry and intact?
repeated swallowing
A client appears flushed and has shallow respirations. The ABGs are: ph 7.24, PaCO2 49, HCO3 24. These findings are indicative of which imbalance?
respiratory acidosis
A client's arterial blood gas analysis reveals an excess of carbon dioxide. The nurse should recognize that this is consistent with which condition?
respiratory acidosis
As status asthmaticus worsens, the nurse would expect which acid-base imbalance?
respiratory acidosis
A client with longstanding diagnosis of GAD presents to the ER. The triage nurse notes upon assessment that the patient is hyperventilating. THe nurse is aware that hyperventilation is the most common cause of:
respiratory alkalosis
A client with a diagnosis of respiratory acidosis is experiencing renal compensation. What function does the kidney perform to assist in restoring acid-base balance?
returning bicarbonate to the body's circulation
A client's pulmonary function tests note an increased residual volume and a decreased vital capacity. Which is the best nursing diagnosis?
risk for activity intolerance
A nurse is caring for a client who recently underwent a tracheostomy. What is the nurses priority when caring for this client?
suctioning to keep the airway patent
A client has been in an automobile accident, and the nurse is assessing the client for possible pneumothorax. What finding should the nurse immediately report to the health care provider?
sudden, sharp chest pain
The client with TB is to be discharged home with nursing follow-ups. Which aspect of nursing care will have the highest priority?
teaching the client about the disease and its treatment
For a client with COPD, which nursing intervention helps maintain a patent airway?
teaching the client how to perform controlled coughing
Which is an expected outcome for a client who has been treated for bacterial pneumonia?
the ability to perform activities of daily living without dyspnea
A client has been diagnosed with legionellosis (Legionnaires' disease). The client asks "How did I get this?", Which response by the nurse is most accurate?
the bacteria are inhaled from contaminated water droplets
A client has the following ABG values: pH 7.52, PaO2 50, PaCO2 28, HCO3 24. Based upon the client's PaO2, which clinical judgment should the nurse make?
the client is severely hypoxic
A nurse on the medical-surgical unit just received the client care assignment report. Which client should the nurse assess first?
the client with unilateral leg swelling who reports anxiety and shortness of breath.
A client with acute bronchitis is admitted and is receiving oxygen via nasal cannula. When monitoring this client, the nurse suddenly hears a high-pitched whistling sound. What is the most likely cause of this sound?
the oxygen tubing is pinched
THe nurse instills 5 mL of normal saline before suctioning a client's trach. Which indicates the instillation is effective?
the secretions are thinned
A 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 who had a left thoracoscopy sustained an injury secondary to the surgery position. The nurse should assess the client for which sign?
tingling in the arm
a client receiving furosemide as part of the treatment for heart failure. Which finding indicates that the medication is attaining a therapeutic effect?
trace peripheral edema, previously 2+
What should the nurse do when suctioning a client who has a tracheostomy tube 3 days following insertion?
use a sterile catheter each time the client is suctioned
For a client with advanced COPD, which nursing action best promotes adequate gas exchange?
using a Venturi mask to deliver oxygen as ordered
A healthy client presents to the clinic for a routine examination. When auscultating the client's lower lung lobes, the nurse should expect to hear which type of breath sounds?
vesicular
A client recovering from a PE is receiving warfarin. To counteract a warfarin overdose, the nurse should administer
vitamin K
A nurse is caring for a client with TB. Which infection-control technique is the priority when caring for this client?
wearing an N95 respirator when caring for client
