Respiratory

The nurse is planning to suction a client through a trach tube. Which Amt of time for application of suction during withdrawal of the catheter

10 seconds

The nurse is caring for a client with emphysema receiving o2. The nurse should check the o2 flow rate to ensure give client doesn't exceed how many L/min of o2

2

The nurse is told that an assigned client will have the chest tubes removed. The nurse plans to do which in prep for the procedure

Administer pain meds 15-30 mins prior to the procedure

The nurse is preparing a list of home care instructions for the client who has been hospitalized and treated for TB. Which instructions should the nurse reinforce

Activities should resume gradually A sputum culture is needed every 2-4weeks once meds are started Resp isolation is not necessary Cover the mouth and nose when coughing or sneezing and confine tissues to plastic bags

The nurse is assisting w monitoring the functioning of a chest tube drainage system in a client who just returned from the recovery room after a thoracotomy with wedge resection. What should the nurse expect to find

50 ml of drainage Drainage below pts chest Occlusive dressing Fluctuation of water in the tube of the water seal chamber

The nurse is caring for several clients with resp disorders. Which client is least at risk for TB

A man who is an inspector for the us postal service

The nurse provides instruction to a client about the use of an incentive spirometer. The nurse determines that the client needs further teaching about its use of the client states

After maximal inspiration, I will hold my breath for 10 seconds and then exhale

The nurse is preparing to suction an adult client through the clients trach. Which intervention should the nurse preform for this procedure

Apply suction for up to 10-15 sec Hyperoxygenate before suction Apply intermittent suction while withdrawing Advance catheter until resistance

A client has a script for continuous monitoring of o2 saturation by pulse ox. The nurse performs which can best action to ensure accurate readings on the oximeter

Ask the client to limit motion in the hand attached to the pulse ox

The nurse is caring for a client with a trach tube who is receiving mechanical ventilation. The nurse is monitoring for complications related to the trach and suspects tracheoesophageal fistula when which occurs

Aspiration of the gastric contents occurs when suctioning

The nurse is assisting in planning care for a client with a chest tube. The nurse should suggest to include which interventions in the plan?

Be sure all connections remain air tight Be sure connections are taped and secure Monitor closely for tubing that is kinked or obstructed

The nurse is caring for an older client who is in bed rest. The nurse plans which intervention to prevent resp complications

Changing clients position every 2 hours

The nurse is assisting with collecting a subjective and objective data from a client admitted to the hospital with TB. The nurse should expect to note which finding

Complaints of night sweats

The nurse is assigned to assist with caring for a client who has a chest tube. The nurse notes fluctuations of the fluid level in the water seal chamber. Based on the observation which action is appropriate

Continue to monitor because this is an expected finding

The nurse is performing nasotrachael suctioning of a client. The nurse interprets that the client is adequately tolerating the procedure if which observation is made

Cough occurs with suctioning

The nurse is providing endotracheal suctioning to a client who is mechanically ventilated when the client becomes restless and tachycardic. Which action should the nurse take

Discontinue suctioning until the client is stabilized and monitor vital signs

A client with AIDS has histoplasmosis . Which sign/symptom should the nurse expect the client to experience

Dyspnea

The nurse is caring for a client hospitalized with acute exacerbation of copd. Which should the nurse expect to note in this client

Dyspnea on exertion Presence of productive cough Difficulty breathing while talking

The nurse is told that an assigned client will have a fenestrated tracheostomy tube inserted. The nurse should provide the client with which info about this type of tube

Enables client to speak

The nurse is preparing to obtain a sputum specimen from the client. Which nursing action is essential in obtaining proper specimen

Have the client take 3 deep breaths

The nurse is caring for a client hospitalized with acute exacerbation of copd. Which should the nurse expect the client to experience

Hyperinflated lungs on chest x ray

The nurse is reinforcing d/c teaching with a client diagnosed with TB and has been on meds for 1 1/2 weeks. The nurse knows that the client understood the info if which statement is made

I should not be contagious after 2-3 weeks of therapy

The client has a chest tube that is attached to a chest drainage system. The client asks the nurse can the tube come out faster if you turn the wall suction up higher. The nurse response is based on which fact with regard to turning up the wall suction

It would not increase the actual suction in the system but would cause more air to be pulled through the air vent and suction chamber to the suction source

The nurse is assigned to care for a client after a left pneumonectomy. Which position is contraindicated for this client

Lateral position

A client is being prepared for a thoracentesis. What position for procedure

Lying on unaffected side with head of bed elevated 45 degrees

The nurse is taking nursing history from a client with silicosis. The nurse checks whether the client wears which item during periods of exposure to silica particles

Mask

The nurse is reading the results of a PPD on a client with no documented health problems. The site has no induration and a 1mm area of ecchymosis. Which interpretation should the nurse make of the results

Negative

The nurse is providing morning care to a client who has a closed chest tube drainage system to treat a pneumothorax. When the nurse turns the client to the side, the chest tube is accidentally dislodged from the chest. After immediately applying sterile gauze over the chest tube insertion site which should the nurse do next

Notify the RN

The nurse is assisting in planning care for a client scheduled for insertion of a trach. Which equipment should the nurse plan to have at the bedside when the client returns from surgery

Obturator

The nurse is gathering data on a client with a diagnosis of TB. The nurse should review the results of which diagnostic test to confirm the diagnosis

Sputum culture

The nurse assigned to care for a client who has a chest tube. The nurse is told to monitor the client for crepitus. Which method should be used to monitor for crepitus

Palpating for the leakage of air into the subcutaneous tissues

A client who has been taking isoniazid for 1 1/2 months complains to the nurse about numbness, paresthesia and tingling in extremities. The nurse interprets that the client is experiencing which adverse affect

Peripheral neuritis

The nurse is assigned to assist the healthcare provider with the removal of a chest tube. The nurse should reinforce instructing the client to do which process

Preform valsalvas maneuver

The nurse is instructing a client about pursed lip breathing and the client asks about its purpose. The nurse should tell the client that the primary purpose of pursed lip breathing

Promote co2 elimination

The nurse notes that a hospitalized client has experienced a positive reaction to a PPD. Which action by the nurse is a priority

Report the findings

The nurse is caring for a client after pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by observing for the presence of which?

Respiratory distress

The ER nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign noted in the client indicates the presence of pneumothorax

Shortness of breath

The nurse is reinforcing discharge instructions to the client with pulmonary sarcoidosis. The nurse knows that the client understands the information if the client verbalized which early sign of exacerbation

Shortness of breath

The nurse is reinforcing instructions to a hospitalized client w a diagnosis of emphysema about positions that will enhance the effectiveness of breathing during dyspneic episodes. Which position should the nurse advise to use

Sitting on the side of the bed, leaning on an over bed table

The nurse is caring for a client with a endotracheal tube attatched to a vent. The high pressure alarm sounds on the vent. The nurse prepares to preform which nursing action

Suction the client

The nurse is monitoring a client with a closed chest tube drainage system and notes fluctuations of the fluid level in the water seal chamber during inspiration and expiration. On the basis of this finding which conclusion should the nurse make

The chest tube is functioning as to be expected

The nurse instructs the client on pursed lip breathing and asks the client to demonstrate the breathing technique. Which observation indicates that the client is profound for this correctly

The client breathes out slowly through the mouth

A client with TB asks the nurse about precautions to take after d/c from the hosp to prevent transmitting infection to others. The nurse develops a response to the clients question based on what

The disease is transmitted by droplet nuclei

A client is being d/c from the hospital to home with a diagnosis of TB is worried about the possibility of infecting family. Which info should assure the client that contaminating family is not likely

The family will receive prophylactic therapy. The client will not be contagious after 2-3 consecutive weeks of med therapy

The low pressure alarm sounds on the vent. The nurse checks the client and then attempts to determine the cause of the alarm but was unsuccessful. Which initial action should the nurse take

Vent client manually