Respiratory
A client has been admitted with chest trauma after a motor vehicle crash and has undergone subsequent intubation. The nurse checks the client when the high-pressure alarm on the ventilator sounds, and notes that the client has absence of breath sounds in the right upper lobe of the lung . The nurse immediately assess for other signs of which condition. A.) right pneumothorax B.) pulomary embolism C.) displaced endotrachel tube D.) acute respiratory distress syndrome
A.) pneumothorax is characterized by restless, tachycardia, dyspnea, pain with respiration, asymmetrical chest expansion, and diminished or absent breath sounds on the affected side. Pneumothorax can cause increased airway pressure because of resistance to lung inflation. Acute respiratory distress syndrome and pulmonary embolism are not characterized by absent breath sounds. An endortracheal tube that is inserted too far can cause absent breath sounds, but the lack of breath sounds most likely would be on the left side because of the degree of curvature of the right and left mainstem bronchi.
A client who is human immunodeficiency virus (HIV) - positive has had a tuberculin skin test (TST). The nurse notes a 7mm area of induration at the site of the skin test and interprets the results as which finding? A.) positive B.) negative C.) inconclusive D.) need for repeat testing
A.) the client with HIV infection is considered to have positive test results on tuberculin skin testing with an area of induration larger than 5mm. The client without HIV is positive with an induration larger than 10mm. The client with HIV is immunosuppressed, making a smaller area of induration positive for this type of client. It is possible for the client infected with HIV to have false-negative readings because of the immunosuppression factor. Options 2, 3, and 4 are incorrect interpretations.
The nurse is suctioning a client via an endotracheal tube. During the suctioning procedure, the nurse notes on the monitor that the heart rate is decreasing. Which nursing intervention is appropriate A.) continue to suction. B.) Notify the health care provider immediately C.) stop the procedure and reoxygenate the client. D.) Ensure that the suction is limited to 15 seconds.
C.) During suctioning, the nurse should monitor the client closely for adverse effects, including hypoxemia, cardiac irregularities such as decrease in heart rate resulting from vagal stimulation, mucosal trauma, hypotension, and paroxysmal coughing. If adverse effects develop, especially cardiac irregularities, the procedure is stopped and the client is reoxygenated.
A client with a chest injury has suffered flail chest. The nurse assesses the client for which most distinctive sign of flail chest? A.) Cyanosis B.) Hypotension C.) Paradoxical chest movement D.) Dyspnea, especially on exhalation
C.) Flail chest results from multiple rib fractures. This results in a "floating" section of ribs. Because this section is unattached to the rest of the bony rib cage, this segment results in paradoxical chest movement. This means that the force of inspiration pulls the fractured segment inward, while the rest of the chest expands. Similarly, during exhalation, the segment balloons outward while the rest of the chest moves inward. This is a characteristic sign of fail chest.
A client has experienced pulmonary embolism. The nurse should assess for which symptom, which is most commonly reported? A.) hot, flushed feeling B.) sudden chills and fever C.) chest pain that occurs suddenly D.) dyspnea when deep breaths are taken.
C.) The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accomplished by an increase respiratory rate. Other typical symptoms of pulmonary embolism include apprehension and restlessness, tachycardia, cough and cyanosis
The nurse is assessing a client with multiple trauma who is at risk for developing acute respiratory distress syndrome. The nurse should assess for which earliest sign of acute respiratory distress syndrome? A.) bilateral wheezing B.) inspiratory crackles C.)intercoastal retractions D.) increased respiratory rate
D.) The earliest detectable sign of acute respiratory distress syndrome is an increased respiratory rate, which can begin from 1 to 96 hours after the initial insult to the body. This is followed by increasing dyspnea, air hunger, retraction of accessory muscles, and cyanosis. Breath sounds may be clear or consist of fine inspiratory crackles or diffuse coarse crackles.
A client with acquired immunodificiency virus (AIDS) has histoplasmosis. The nurse should assess the client for which expected finding? A.) dyspnea B.) headache C.) weight gain D.) hypothermia
A.) Histoplasmosis is an opportunistic fungal infection that can occur in the client with AIDS. The infection begins as a respiratory infection and can progress to disseminated infection. Typical signs and symptoms include fever, dyspnea, cough, and weight loss. Enlargement of the clients lymph nodes, liver and spleen may occur as well.
The nurse is preparing a list of home care instructions for a client who has been hospitalized and treated for tuberculosis. Which instructions should the nurse include on the list? SATA A.) activities should be resumed gradually. B.) avoid contact with other individuals, except family members, for at least six months. C.) a sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. D.) Respiratory isolation is not necessary because family members have already been exposed. E.) Cover the mouth and nose when coughing or sneezing and put used tissues in plastic bags F.) when 1 sputum culture is negative, the client is no longer considered infectious and usually can return to former employment
A, C, D and E.) The nurse should provide the client and family with information about tuberculosis allay concerns about the contagious aspect of the infection. The client needs to follow the medication regimen exactly as prescribed and always have a supply of the medication on hand. Side effects and adverse effects of the medication and ways of minimizing them to ensure compliance should be explained. After 2 to 3 weeks of medication therapy, it is unlikely that the client will infect anyone. Activity should be resumed gradually and a well-balanced diet that is rich in iron, protein, and vitamin C to promote healing and prevent recurrence of infection should be consumed. Respiratory isolation is not necessary because family members already have been exposed. Instruct the client about thorough hand washing, to cover mouth and nose when coughing and sneezing and to put used tissue into plastic bags. A sputum culture is needed every 2 to 4 weeks once medication therapy is initiated. When the results of 3 sputum culture are negative, the client is no longer considered infectious and can usually return to former employment.
The nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease. Which findings would the nurse expect to note on assessment of this client? SATA A.) a low arterial PCO2 level B.) a hyperinflated chest noted on the chest x-ray C.) decreased oxygen saturation with mild exercise D.) a widened diaphragm noted on the on the chest x-ray E.) pulmonary function tests that demonstrate increased vital capacity
B and C.) clinical manifestation of chronic obstructive pulmonary disease (COPD) include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest X-rays reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced. Pulmonary function tests will demonstrate decreased vital capacity.
The nurse is discussing the techniques of chest physiotherapy and postural drainage (respiratory treatments) to a client having expectoration problems because of chronic thick, tenacious mucus production in the lower airway. The nurse explains that after the client is position for postural drainage the nurse will perform which action to help loosen secretions? A.) palpation and clubbing B.) percussion and vibration C.) hyperoxygenation and suctioning D.) administer a bronchodilator and monitor peak flow
B.) Chest physiotherapy of percussion and vibration helps to loosen secretions in the smaller lower airways. Postural drainage positions the client so that gravtiy can help mucus move from smaller airways to larger ones to support expectoration of the mucus. Options 1,3, and 4 are not actions that help loosen secretions.
The nurse is preparing to give a bed bath to an immobilized client with tuberculosis. The nurse should wear which items when performing this care? A.) surgical mask and gloves B.) particulate respirator, gown, and gloves C.) particulate respirator and protective eye wear D.) surgical mask, gown, and protective eye wear
B.) The nurse who is in contact with a client with tuberculosis should wear an individually fitted particulate respirator. The nurse should also wear gloves as per standard precautions. the nurse wears a gown when the possibility exists that the clothing could become contaminated, such as when giving a bath.
The emergency department nurse is assessing a client who has sustained a blunt injury to the chest wall. Which finding indicates the presence of a pneumothorax in this client? A.) a low respiratory rate B.) diminished breath sounds C.) the presence of a barrel chest D.) a sucking sound at the site of injury
B.) diminished breath sounds. The client has sustained a blunt or closed-chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A large pneumothorax may cause tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. Hyper-resonance also may occur on the affected side. A sucking sound at the site of injury would be noted with an open chest injury
The nurse is preparing to suction a client via a tracheostomy tube. The nurse should plan to limit the suctioning time to a maximum of which time period? A.) 5 sec B.) 10 sec C.) 30sec D.) 60sec
B.) hypoxemia can be caused by prolonged suctioning which stimulates the pacemaker cells in the heart. A vasovagal response may occur causing bradycardia. The nurse must preoxygenate the client before suctioning and limit the suctioning pass to 10 seconds.
The nurse is caring for a client after a bronchoscopy and biopsy. Which finding, if noted in the client, should be reported immediately to the health care provider? A.) dry cough B.) hematuria C.) bronchospasm D.) blood-streaked sputum
C.) If a biopsy was performed during a bronchoscopy, blood-streaked sputum is expected for several hours. Frank blood indicates hemorrhage. A dry cough may be expected. The client should be assessed for signs of complications, which would indicate cyanosis, dyspnea, stridor, bronchospasm, hemoptysis, hypotension, tachycardia, and dysrhythmias. Hematuria is unrelated to his procedure.
The nurse instructs a client to to use the pursed lip method of breathing and evaluates the teaching by asking the client about the purpose of this type if breathing. The nurse determines that the client understands if the client states that the primary purpose of pursed-lip breathing is to promote which outcome? A.) promote oxygen intake. B.) strengthen the diaphragm C.) strengthen the intercostal muscles D.) Promote carbon dioxide elimination
D.) Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. This type of breathing allows better expiration by increasing air pressure that keeps air passages open during exhalation. Options 1, 2, and 3 are not the purposes of this type of breathing.
The nurse is assessing the respiratory status of a client who has suffered a fractured rib. The nurse should expect to note which finding? A.) slow, deep respirations B.) rapid, deep respirations C.) paradoxical respirations D.) Pain, especially with inspiration
D.) Rib fractures result from a blunt injury or a fall. Typical signs and symptoms include pain and tenderness localized at the fracture site that is exacerbated by inspiration and palpation, shallow respirations, splinting or guarding the chest protectively to minimize chest movement, and possible bruising at the fracture site. Paradoxical respirations are seen with flail chest.
The nurse has conducted discharge teaching with a client diagnosed with tuberculosis who has been receiving medication for 2 weeks. The nurse determines that the client has understood the information if the client makes which statement. A.) "I need to continue medication therapy for 1 month" B.) "I can't shop at the mall for the next 6 months" C.) "I can return to work if a sputum culture comes back negative" D.) "I should not be contagious after 2 to 3 weeks of medication therapy"
D.) The client is continued on medication therapy for up to 12 months, depending on the situation. The client generally is considered noncontagious after 2 to 3 weeks of medication therapy. The client is instructed to wear a mask if there will be exposure to crowds until the medication is effective in preventing transmission. The client is allowed to return to work when the results of 3 sputum cultures are negative.