Respiratory: PP-Pt.2
Q: A young adult is admitted to the emergency department after an automobile accident. The client has severe pain in the right chest from contact with the steering wheel. What should the nurse do first? A: Maintain adequate oxygenation.
Rationale: Blunt chest trauma may lead to respiratory failure, and maintenance of adequate oxygenation is the priority for the client. Decreasing the client's anxiety is related to maintaining effective respirations and oxygenation. Although pain is distressing to the client and can increase anxiety and decrease respiratory effectiveness, pain control is secondary to maintaining oxygenation. Maintaining adequate circulatory volume is also secondary to maintaining adequate oxygenation.
Q: The client with pneumonia develops mild constipation, and the nurse administers docusate sodium as prescribed. This drug works by: A: softening the stool.
Rationale: Docusate sodium is a stool softener that allows fluid and fatty substances to enter the stool and soften it. Docusate sodium does not lubricate the stool, increase stool bulk, or stimulate peristalsis.
Q: The nurse is preparing a client for a thoracentesis. How should the nurse position the client for the procedure? A: Sitting forward with the arms supported on the bedside table.
Rationale: In preparation for a thoracentesis, the client should be asked to sit forward and place his arms on the bedside table for support. This position provides access to the chest wall and intercostal spaces for insertion of the needle. The supine, Sims', or prone position would not provide adequate access to the chest wall or separate the intercostal spaces sufficiently for needle insertion.
Q: Following surgery, to evaluate the effectiveness of the client's use of an incentive spirometer, the nurse should determine if the client: A: can breathe more easily.
Rationale: Incentive spirometry promotes lung expansion and increases respiratory function. When used properly, an incentive spirometer causes sustained maximal inspiration and increased cardiac output.
Q: A nurse is assisting an anesthetist during the intubation of a client. The anesthetist visualizes the vocal cords with the laryngoscope and says to the nurse, "This is an easy one. Why don't you give it a try?" indicating that the nurse should insert the endotracheal tube. What would be the most appropriate response by the nurse? A: "This procedure is not within my scope of practice."
Rationale: Intubating a client is not within the nurse's scope of practice, even with the anesthetist directing the procedure. The nurse should refuse to place the tube into the client. The other options are incorrect because they do not demonstrate that the nurse is aware of his/her scope of practice and if the client were injured during the procedure, the nurse could be accused of malpractice.
Q: A nurse is preparing a staff education program on innovative devices in pulmonary circulation. Beginning with basic concepts, place the following structures in chronological order to trace the pathway of normal pulmonary circulation. All options must be used. A: Right ventricle Pulmonary artery Arterioles Alveoli Pulmonary vein Left atrium
Rationale: Pulmonary circulation is the movement of blood from the heart, to the lungs, and back to the heart again. Deoxygenated blood is ejected from the right ventricle into the pulmonary artery and then into the lungs via the arterioles and alveoli. The pulmonary vein then carries oxygenated blood back to the left atrium for circulation throughout the body.
Q: To more easily remove thick, tenacious secretions when suctioning a tracheostomy, the nurse should liquefy the secretions before suctioning by instilling the tracheostomy tube with 1 to 2 mL of sterile: A: Normal saline normal saline solution.
Rationale: Sterile normal saline is the solution of choice for instillation into a tracheostomy tube cannula to help liquefy sticky secretions. Normal saline solution is less irritating to mucous membranes than plain water, bacteriostatic water, or a dextrose solution.
Q: A client who has undergone outpatient nasal surgery is ready for discharge and has nasal packing in place. The nurse should instruct the client to: A: avoid activities that elicit the Valsalva maneuver.
Rationale: The client should be instructed to avoid any activities that cause Valsalva's maneuver (e.g., constipation, vigorous coughing, exercise) in order to reduce bleeding and stress on suture lines. The client should not take aspirin because of its antiplatelet properties, which may cause bleeding. Oral hygiene is important to rid the mouth of old dried blood and to enhance the client's appetite. Cool compresses, not heat, should be applied to decrease swelling and control discoloration of the area.
Q: The nurse is caring for a client with asthma. The nurse should conduct a focused assessment to detect: A: inspiratory and expiratory wheezing.
Rationale: The hallmark signs of asthma are chest tightness, audible wheezing, and coughing. Inspiratory and expiratory wheezing is the result of bronchoconstriction. Even between exacerbations there may be some soft wheezing, so a finding of normal breath sounds would be expected in the absence of asthma. The expected finding is decreased forced expiratory volume (forced expiratory flow [FEF] is the flow [or speed] of air coming out of the lung during the middle portion of a forced expiration) due to bronchial constriction. Morning headaches are found in more advanced cases of COPD and signal nocturnal hypercapnia or hypoxemia.
Q: The nurse is caring for a group of clients on a pulmonary unit. The nurse can delegate which task to unlicensed assistive personnel (UAP)? A: Assisting a client with adjusting his or her nasal cannula
Rationale: UAP can assist a client with the adjustment of their oxygen delivery device. Making adjustments based on client responses, monitoring for adverse effects, and assessing for the best methods of oxygen delivery are skills that require nursing judgments and can only be performed by a nurse.
