Respiratory
Arterial blood gas analysis would reveal which value related to acute respiratory failure?
pH 7.28
decrease in arterial oxygen tension (PaO2) to less than 60 mm Hg
Hypoxemia
Which is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means?
Venturi mask
A pneumothorax is a possible complication of COPD. Symptoms will depend on the suddenness of the attack and the size of the air leak. The most common, immediate symptom that should be assessed is:
Sharp, stabbing chest pain
The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation?
Tension pneumothorax
A nurse would question the accuracy of a pulse oximetry evaluation in which of the following conditions?
A client experiencing hypothermia
Which type of lung cancer is the most prevalent among both men and women?
Adenocarcinoma
A nurse should include what instruction for the client during postural drainage?
Change positions frequently and cough up secretions.
The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema?
Crackles in the lung bases
High or increased compliance occurs in which condition?
Emphysema
A patient prescribed a medication for hypertension started taking it 3 days ago and arrives in the emergency department with an edematous face and tongue and having a difficult time speaking. What medication is the nurse aware of that may produce this type of side effect?
Enalapril (Vasotec)
an increase in arterial carbon dioxide tension (PaCO2) to greater than 50 mm Hg
Hypercapnia
Which clinical manifestation of hemorrhage is related to carotid artery rupture?
Increased pulse rate
A pediatrician diagnosed a child with swollen and inflamed adenoids. The nurse practitioner confirmed the diagnosis by:
Inspecting the roof of the nasopharynx.
Which respiratory volume is the maximum volume of air that can be inhaled after maximal expiration?
Inspiratory reserve volume
The nursing instructor is teaching students about types of lung cancer. Which type of lung cancer is characterized as fast growing and can arise peripherally?
Large cell carcinoma
A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do?
Place the end of the chest tube in a container of sterile saline.
Which of the following alveolar cells secrete surfactant?
Type II
Most cases of acute pharyngitis are caused by which of the following?
Viral infection
A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to:
cough as the cuff is being deflated.
The nurse is caring for a client who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on the client
returning to the nursing unit with two chest tubes.
Which statement indicates a client understands teaching about the purified protein derivative (PPD) test for tuberculosis?
"Because I had a previous reaction to the test, this time I need to get a chest X-ray."
An obese male is being evaluated for OSA. The nurse asks the patient's wife to document the number and frequency of incidences of apnea while her husband is asleep. The nurse tells the wife that a characteristic indicator of OSA is a breathing cycle characterized by periods of breathing cessation for:
10 seconds with 5 episodes/hour.
The herpes simplex virus type 1 (HSV-1), which produces a cold sore (fever blister), has an incubation period of
2 to 12 days
Normally, approximately what percentage of the blood pumped by the right ventricle does not perfuse the alveolar capillaries?
2%
A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for:
5 to 20 minutes.
A patient with COPD requires oxygen administration. What method of delivery does the nurse know would be best for this patient?
A Venturi mask
A nurse is reviewing a client's X-ray. The X-ray shows an endotracheal (ET) tube placed 3/4" (2 cm) above the carina and reveals nodular lesions and patchy infiltrates in the upper lobe. Which interpretation of the X-ray is accurate?
A disease process is present.
The nurse is caring for a respiratory client who uses a noninvasive positive pressure device. Which medical equipment does the nurse anticipate to find in the client's room?
A face mask
What is the reason for chest tubes after thoracic surgery?
Draining secretions, air, and blood from the thoracic cavity is necessary.
A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention?
Encourage coughing to mobilize secretions.
A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation?
Endotracheal suctioning
Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction?
Ensure mouth breathing
A 76-year-old client presents to the ED reporting "laryngitis." The triage nurse should ask whether the client has a medical history that includes
Gastroesophageal reflux disease (GERD)
A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?
Group A, beta-hemolytic streptococci
Which oxygen administration device has the advantage of providing a high oxygen concentration?
Nonrebreathing mask
An experienced nurse is assisting and notes air movement over the trachea to the upper lungs. The air movement is noted equally on inspiration as expiration. Which breath sounds would the nurse document?
Normal bronchovesicular sounds
The nurse is caring for a client with an endotracheal tube. Which client data does the nurse interpret as a life-threatening situation?
Sudden restlessness
A client is visiting the emergency department because of massive bleeding from the nose that will not stop. Blood is on the client's shirt, and bleeding from the nose continues. The nurse intervenes by
Telling the client to sit upright with the head tilted forward
You are studying for a physiology test about the respiratory system. What should you know about central chemoreceptors in the medulla?
They respond to changes in CO2 levels and hydrogen ion concentrations (pH) in the cerebrospinal fluid.
Understanding pulmonary physiology, what characteristic would the nurse expect to result in decreased gas exchange in older adults?
alveolar walls containing fewer capillaries
A first-line antibiotic used to treat acute rhinosinusitis is
ampicillin
Class 1 with regard to TB indicates
exposure and no evidence of infection.
A victim of a motor vehicle accident has been brought to the emergency room. The patient is exhibiting paradoxical chest expansion and respiratory distress. Which of the following chest disorders should be suspected?
flail chest
A late complication of radiation therapy is
laryngeal necrosis.
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder?
pH 7.28, PaO2 50 mm Hg
The client is to receive cephalexin (Ancef) 500 mg in 50 mL of normal saline intravenous piggyback. The medication is to infuse over 30 minutes. How many mL/hr would the nurse set the intravenous pump? Enter the correct number ONLY.
100
The nurse is assigned to care for a client with a chest tube. The nurse should ensure that which item is kept at the client's bedside?
A bottle of sterile water
The nurse is caring for a client who has recurrent sinusitis. Which consideration could the nurse suggest to best decrease the frequency of infections?
Administer an over-the-counter decongestant.
Which is a potential complication of a low pressure in the endotracheal tube cuff?
Aspiration pneumonia
Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate?
Assist control
For a client with an endotracheal (ET) tube, which nursing action is the most important?
Auscultating the lungs for bilateral breath sounds
A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?
Dyspnea and wheezing
The nurse is assessing a patient who has been admitted with possible ARDS. What findings would distinguish ARDS from cardiogenic pulmonary edema?
Elevated B-type natriuretic peptide (BNP) levels
A nursing student understands the importance of the psychosocial aspects of disease processes. When working with a patient with COPD, the student would rank which of the following nursing diagnoses as the MOST important when analyzing the psychosocial effects?
Ineffective coping related to anxiety
The nurse is caring for a client diagnosed with enlarged adenoids. What condition is produced by enlarged adenoids?
Noisy breathing
A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important?
Partial pressure of arterial oxygen (PaO2)
A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect?
Pneumothorax
A client suspected of developing acute respiratory distress syndrome (ARDS) is experiencing anxiety and agitation due to increasing hypoxemia and dyspnea. A nurse would implement which intervention to improve oxygenation and provide comfort for the client?
Position the client in the prone position
The nurse is caring for a client whose respiratory status has declined since shift report. The client has tachypnea, is restless, and displays cyanosis. Which diagnostic test should be assessed first?
Pulse oximetry
Bleeding from the drains at the surgical site or with tracheal suctioning may signal the occurrence of hemorrhage. Which of the following is a clinical manifestations associated with hemorrhage?
Rapid, deep respirations
The nurse assesses a patient for possible acute pharyngitis. Which of the following clinical manifestations are consistent with this diagnosis? Select all that apply.
Red pharyngeal membranes Swollen lymphoid follicles White-purple exudates on the back of the throat A temperature >100.4°F
A student nurse is working with a client who is diagnosed with head trauma. The nurse has documented Cheyne-Stokes respirations. The student would expect to see which of the following?
Regular breathing where the rate and depth increase, then decrease
Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:
a compromised skin graft.
A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?
Administer oxygen by nasal cannula as ordered: most significant ABG value is the PaO2 value of 60 mm Hg, which indicates hypoxemia
A physician orders triamcinolone and salmeterol for a client with a history of asthma. What action should the nurse take when administering these drugs?
Administer the salmeterol and then administer the triamcinolone.
What finding by the nurse may indicate that the client has chronic hypoxia?
Clubbing of the fingers
A patient comes to the clinic and is diagnosed with tonsillitis and adenoiditis. What bacterial pathogen does the nurse know is commonly associated with tonsillitis and adenoiditis?
Group A, beta-hemolytic streptococcus
Which is the priority nursing diagnosis for a client undergoing a laryngectomy?
Ineffective airway clearance
A client is 2 hours post-op tracheostomy. The nurse assesses the client and finds the client's breathing is shallow at a respiratory rate 30. The nurse notes increased mucus production around the tracheostomy and on the dressing. What are the priority nursing concerns? Select all that apply.
Ineffective airway clearance Impaired gas exchange
Which of the following medications are classified as leukotriene modifiers (inhibitors)? Select all that apply.
Montelukast Zafirlukast Zileuton
A client is receiving moderate sedation while undergoing bronchoscopy. Which assessment finding should the nurse attend to immediately?
Oxygen saturation of 90%
A client with thrombocytopenia, secondary to leukemia, develops epistaxis. The nurse should instruct the client to:
sit upright, leaning slightly forward.
The nurse should advise the patient who has nasal packing for epistaxis that the packing can be left in place?
Anywhere from 2 to 6 days.
While assessing for tactile fremitus, the nurse palpates almost no vibration. Which of the following conditions in this client's history will account for this finding?
Emphysema
The nurse is reviewing the blood gas results for a patient with pneumonia. What arterial blood gas measurement best reflects the adequacy of alveolar ventilation?
PaCO2
A young adult visited a clinic because he was injured during a softball game. He told the nurse that the ball struck him in his "Adam's apple." To assess the initial impact of injury, the nurse:
Palpates the thyroid cartilage.
A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?
Partial laryngectomy
A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan?
Using strict hand hygiene
What is histamine, a mediator that supports the inflammatory process in asthma, secreted by?
Mast cells
A client finished a course of antibiotics for laryngitis but continues to experience persistent hoarseness. Which symptom would cause the nurse to suspect laryngeal cancer?
a feeling of swelling at the back of the throat
The nurse at an employee wellness clinic is meeting with a client who reports voice hoarseness for more than 2 weeks. To determine if the client may have symptoms of early laryngeal cancer, the next question the nurse should ask is, "Do you have
a persistent cough or sore throat"
A nurse is caring for a client with status asthmaticus. Which medication should the nurse prepare to administer?
An inhaled beta2-adrenergic agonist
A client admitted to the facility for treatment for tuberculosis receives instructions about the disease. Which statement made by the client indicates the need for further instruction?
"I'll stay in isolation for 6 weeks."
A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct?
"Before you do the exercise, I'll give you pain medication if you need it."
A client with chronic obstructive pulmonary disease (COPD) reports increased shortness of breath and fatigue for 1 hour after awakening in the morning. Which of the following statements by the nurse would best help with the client's shortness of breath and fatigue?
"Delay self-care activities for 1 hour."
A physician orders metaproterenol by metered-dose inhalation four times daily for a client with acute bronchitis. Which statement by the client indicates effective teaching about this medication?
"I need to hold my breath as long as possible after I take a deep inhalation."
The nurse is caring for a client with an exacerbation of COPD and scheduled for pulmonary function studies using a spirometer. Which client statement would the nurse clarify?
"I will breathe in through my mouth and out through my nose."
A client who has started therapy for drug-resistant tuberculosis demonstrates understanding of tuberculosis transmission when he says:
"I'll stop being contagious when I have a negative acid-fast bacilli test."
The client asks the nurse to explain the reason for a chest tube insertion in treating a pneumothorax. Which is the best response by the nurse?
"The tube will drain air from the space around the lung."
A client at risk for pneumonia has been ordered an influenza vaccine. Which statement from the nurse best explains the rationale for this vaccine?
"Viruses like influenza are the most common cause of pneumonia."
The nurse is discussing immediate postoperative communication strategies with a client scheduled for a total laryngectomy. What information will the nurse include?
"You can use writing or a communication board to communicate."
Which range of water pressure within the endotracheal tube cuff is believed to prevent both injury and aspiration?
15 to 20 mm Hg
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 daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?
6 to 12 months
The goal for oxygen therapy in COPD is to support tissue oxygenation, decrease the work of the cardiopulmonary system, and maintain the resting partial arterial pressure of oxygen (PaO2) of at least ______ mm Hg and an arterial oxygen saturation (SaO2) of at least ___%.
60 mm Hg; 90%
The nurse is caring for a client who is in respiratory distress. The physician orders arterial blood gases (ABGs) to determine various factors related to blood oxygenation. What site can ABGs be obtained from?
A puncture at the radial artery
Which is a true statement regarding air pressure variances?
Air is drawn through the trachea and bronchi into the alveoli during inspiration.
A client with severe shortness of breath comes to the emergency department. He tells the emergency department staff that he recently traveled to China for business. Based on his travel history and presentation, the staff suspects severe acute respiratory syndrome (SARS). Which isolation precautions should the staff institute?
Airborne and contact precautions
A client has been diagnosed with acute rhinosinusitis caused by a bacterial organism. What antibiotic of choice for treatment of this disorder does the nurse anticipate educating the client about?
Amoxicillin-clavulanic acid
A patient visited a health care clinic for treatment of upper respiratory tract congestion, fatigue, and sputum production that was rust-colored. Which of the following diagnoses is likely based on this history and inspection of the sputum?
An infection with pneumococcal pneumonia
The nurse auscultated a patient's middle lobe of the lungs for abnormal breath sounds. To do this, the nurse placed the stethoscope on the:
Anterior surface of the right side of the chest, between the fourth and fifth rib.
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 client is admitted to the emergency department with a stab wound and is now presenting dyspnea, tachypnea, and sucking noise heard on inspiration and expiration. The nurse should care for the wound in which manner?
Apply airtight dressing
The nurse is caring for a client admitted to the ED with an uncomplicated nasal fracture. Nasal packing has been put in place. Which intervention should the nurse include in the client's care?
Apply an ice pack.
The nurse is caring for a client reporting chest discomfort. The client's diagnosis at admission is left lower lobe pneumonia. Which strategy will the nurse instruct the client to use to help alleviate the discomfort?
Assume a left side-lying position while in bed
The nurse assessed a 28-year-old woman who was experiencing dyspnea severe enough to make her seek medical attention. The history revealed no prior cardiac problems and the presence of symptoms for 6 months' duration. On assessment, the nurse noted the presence of both inspiratory and expiratory wheezing. Based on this data, which of the following diagnoses is likely?
Asthma
An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. Ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure?
At bedtime
A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?
Auscultation
Solu-medrol and prednisone are glucocortico steroids used to prevent or control inflammation in the lungs and airways. As such, which lab value would take priority in the coordination of care for a patient receiving this therapy?
Bedside blood glucose reading of 388 mg/dL
The nurse is obtaining data from a client with a respiratory disorder. Which information would be considered a part of the functional assessment and would assist in the diagnosis of an occupational lung disease?
Black-streaked sputum
Which is an adverse reaction that would require the process of weaning from a ventilator to be terminated?
Blood pressure increase of 20 mm Hg
A client is prescribed two sprays of a nasal medication twice a day. The nurse is teaching the client how to self-administer the medication and instructs the client to
Blow the nose before applying medication into the nares.
The clinic nurse is caring for a client with acute bronchitis. The client asks what may have caused the infection. What may induce acute bronchitis?
Chemical irritation
You are a clinic nurse caring for a client with acute tracheobronchitis. The client asks what may have caused the infection. Which of the following responses from the nurse would be most accurate?
Chemical irritation
A patient is prescribed a mast cell stabilizer for the treatment of asthma. Which commonly used medication will the nurse educate the patient about?
Cromolyn sodium
Which ventilation-perfusion ratio is exhibited in a client diagnosed with a pulmonary embolus?
Dead space
An elderly client is diagnosed with pulmonary tuberculosis. Upset and tearful, he asks the nurse how long he must be separated from his family. Which nursing diagnosis is most appropriate for this client?
Deficient knowledge (disease process and treatment regimen)
The nurse is educating a patient diagnosed with acute bacterial rhinosinusitis about interventions that may assist with symptom control. What should the nurse include in this information? (Select all that apply.)
Ensure an adequate fluid intake. Increase the humidity in the home. Apply local heat to promote drainage.
The nurse knows the mortality rate is high in lung cancer clients due to which factor?
Few early symptoms
A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?
Flail chest
A nurse is obtaining a health history from a client who reports hemoptysis for the past 2 months. The client reports occasional dyspnea. Which imaging study, ordered by the physician, will view the thoracic cavity while in motion?
Fluoroscopy
Which type of oxygen therapy includes the administration of oxygen at pressure greater than atmospheric pressure?
Hyperbaric
During assessment of a patient with OSA, the nurse documents which of the following characteristic signs that occurs because of repetitive apneic events?
Hypercapnia
When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems?
Hypercapnia, hypoventilation, and hypoxemia
A nurse notes that the FEV1/FVC ratio is less than 70% and the FEV1 is 40% for a patient with COPD. What stage should the nurse document the patient is in?
III Grade I FEV1 of greater than or equal to 80% Grade II FEV1 of 50%-80% Grade III FEV1 of <30%-50% Grade IV FEV1 of <30%
A nurse is assisting a client with mild chronic obstructive pulmonary disease (COPD) to set a goal related to the condition. Which of the following is an appropriate goal for this client?
Increase walking distance around a city block without shortness of breath. Mild COPD, goals are to increase exercise and prevent further loss of pulmonary function
Which measure may increase complications for a client with COPD?
Increased oxygen supply: Clients with alveolar hypoventilation cannot increase ventilation to adjust for this increased load, and hypercapnia occurs.
A client with suspected severe acute respiratory syndrome (SARS) comes to the emergency department. Which physician order should the nurse implement first?
Institute isolation precautions.
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily?
Intubate the client and control breathing with mechanical ventilation
The nurse is instructing a client who is scheduled for a laryngectomy about methods of laryngeal speech. Which best describes tracheoesophageal puncture (TEP)?
It requires the insertion of a prosthesis into the trachea.
A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?
Kinking of the ventilator tubing
A client presents to the ED reporting severe coughing episodes. The client states that "the episodes are more intense at night." The nurse should suspect which of the following conditions based on the client's primary report?
Left-sided heart failure
A client has a nursing diagnosis of "ineffective airway clearance" as a result of excessive secretions. An appropriate outcome for this client would be which of the following?
Lungs are clear on auscultation.
The nurse is caring for a client with hypoxemia of unknown cause. Which of the following oxygen transport considerations does the nurse identify as crucial to circulate oxygen in the body system? Select all that apply.
Oxygen is dissolved. Oxyhemoglobin circulates to the body tissue. Adequate red blood cells are needed for oxygen transport.
A client is admitted to the facility with a productive cough, night sweats, and a fever. Which action is most important in the initial care plan?
Placing the client in respiratory isolation
The nurse is assessing a client for obstructive sleep apnea (OSA). Which are signs and symptoms of OSA? Select all that apply.
Polycythemia Loud snoring Insomnia
A client presents to the ED with a suspected allergic reaction. The client is experiencing laryngeal edema, which is causing obstruction, and is demonstrating retractions in the neck during inspiration. Which is the nurse's priority intervention?
Prepare to administer subcutaneous epinephrine and corticosteroids.
Which diagnostic test is the most accurate in assessing acute airway obstruction?
Pulmonary function studies
A client has a nursing diagnosis of acute pain related to upper airway irritation. The best short-term goal for this client is for the client to
Report relief of pain to level 3 using a pain intensity scale of 1 to 10.
After 48 hours, a Mantoux test is evaluated. At the site, there is a 10 mm induration. This finding would be considered:
Significant
Which diagnostic test is used to confirm the diagnosis of maxillary and frontal sinusitis?
Sinus aspirates
The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:
Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.
The nurse receives an order to obtain a sputum sample from a client with hemoptysis. When advising the client of the physician's order, the client states not being able to produce sputum. Which suggestion, offered by the nurse, is helpful in producing the sputum sample?
Take deep breaths and cough forcefully.
When caring for a client with head trauma, a nurse notes a small amount of clear, watery fluid oozing from the client's nose. What should the nurse do first?
Test the nasal drainage for glucose.
A patient comes to the clinic complaining of a possible upper respiratory infection. What should the nurse inspect that would indicate that an upper respiratory infection may be present?
The nasal mucosa
Perfusion refers to blood supply to the lungs, through which the lungs receive nutrients and oxygen. What are the two methods of perfusion?
The two methods of perfusion are the bronchial and pulmonary circulation.
A commonly prescribed methylxanthine used as a bronchodilator is which of the following?
Theophylline
A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?
They help prevent cardiac arrhythmias.
Once the patient has been cleared for oral feedings, post laryngectomy, the nurse knows to prepare:
Thick liquids that are easy to swallow.
The client you are caring for has just been told they have advanced laryngeal cancer. What is the treatment of choice?
Total laryngectomy
Which technique does a nurse suggest to a patient with pleurisy for splinting the chest wall?
Turn onto the affected side.
A nurse is aware that the diagnostic feature of ARDS is sudden:
Unresponsive arterial hypoxemia
A mechanically ventilated client is receiving a combination of atracurium and the opioid analgesic morphine. The nurse monitors the client for which potential complication?
Venous thromboemboli: Neuromuscular blockers predispose the client to venous thromboemboli (VTE)
The nurse documents breath sounds that are soft, with inspiratory sounds longer than expiratory and found over the periphery of the lungs. Which of the following will the nurse chart?
Vesicular
What is the purpose of the vascular and ciliated mucous lining of the nasal cavities?
Warm and humidify inspired air
After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes?
Water-seal chamber
A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?
dyspnea
As part of a primary cancer prevention program, an oncology nurse answers questions from the public at a health fair. When someone asks about laryngeal cancer, the nurse should explain that:
laryngeal cancer is one of the most preventable types of cancer.
The nurse auscultates the lung sounds of a client during a routine assessment. The sounds produced are harsh and cracking, sounding like two pieces of leather being rubbed together. The nurse would be correct in documenting this finding as
pleural friction rub.
The nurse in the ICU is caring for a client with a nasotracheal tube. Because of the tube placement, the nurse understands that the client is at risk for developing
sinus infection
The nurse in the ICU is caring for a client with a nasotracheal tube. Because of the tube placement, the nurse understands that the client is at risk for developing
sinus infection.
A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as:
synchronized intermittent mandatory ventilation (SIMV).
A client is receiving theophylline for long-term control and prevention of asthma symptoms. Client education related to this medication will include
the importance of blood tests to monitor serum concentrations.
A nurse is caring for a client who is at high risk for developing pneumonia. Which intervention should the nurse include on the client's care plan?
use strict hand hygiene
A nurse is caring for a client admitted with an exacerbation of asthma. The nurse knows the client's condition is worsening when he:
uses the sternocleidomastoid muscles.
