Saunders NCLEX Respiratory

The nurse is providing home education for a client diagnosed with acute bronchitis. The nurse would tell the client to return to the clinic if which symptoms were present? Select all that apply. 1Bloody sputum 2Difficulty breathing 3Temperature of 99.0° F (37.2° C) 4Symptoms lasting more than 4 weeks 5Heart rate of 74 beats per minute (bpm)

A: Bloody sputum Difficulty breathing Symptoms lasting more than 4 weeks Rationale: Acute bronchitis is a condition of acute inflammation of the bronchi due to a viral or bacterial infection. The condition is self-limiting, and treatment is supportive to aid in relieving symptoms and client discomfort. The client with acute bronchitis would be educated to return to the clinic if certain symptoms develop, such as difficulty breathing, bloody sputum, temperature of 100.4° F (38° C) or higher, or if symptoms last longer than 4 weeks. Therefore, options 1, 2, and 4 are correct. The temperature in option 3 is not high enough to be concerning. Option 5 describes a normal heart rate.

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse how to manage the amount of oxygen given. How would the nurse instruct the client? 1Do not exceed 1 L/min. 2Do not exceed 2 L/min. 3Adjust the oxygen depending on SpO2. 4Adjust the oxygen depending on respiratory rate.

A: Adjust the oxygen depending on SpO2. Rationale: The client with COPD is often dependent on oxygen. The oxygen would be adjusted depending on the SpO2, which needs to be 88% to 92%. All other options are incorrect.

The nurse is providing education to a group of adolescents diagnosed with asthma. The nurse informs the group that which can be triggers for an asthma attack? Select all that apply. 1Dry air 2Clean air 3Exercise 4Rest and sleep 5An upper respiratory infection (URI) 6Nonsteroidal anti-inflammatory drugs (NSAIDs)

A: Dry air Exercise An upper respiratory infection (URI) Nonsteroidal anti-inflammatory drugs (NSAIDs) Rationale: Triggers for asthma include response to the presence of specific allergens; general irritants such as cold air, dry air, or fine airborne particles; microorganisms; and aspirin and other NSAIDs. Increased airway sensitivity (hyperresponsiveness) can occur with exercise, with an upper respiratory illness, and for unknown reasons. Clean air and adequate rest and sleep help to promote lung function.

A client with chronic obstructive pulmonary disease (COPD) is being evaluated for lung transplantation. The nurse performs the initial physical assessment. Which findings would the nurse anticipate in this client? Select all that apply. 1Dyspnea at rest 2Clubbed fingers 3Muscle retractions 4Decreased respiratory rate 5Increased body temperature 6Prolonged expiratory breathing phase Submit

A: Dyspnea at rest Clubbed fingers Muscle retractions Prolonged expiratory breathing phase Rationale: The client with COPD who is eligible for a lung transplantation has end-stage COPD and will have clinical manifestations of hypoxemia, dyspnea at rest, use of accessory muscle with retractions, clubbing, and prolonged expiratory breathing phase caused by retention of carbon dioxide. Option 4 is incorrect because the client with COPD has an increased respiratory rate, not a decreased one. Option 5 is incorrect because an elevated temperature would not be present unless the client has an infection.

The nurse is doing volunteer work in a homeless shelter. The nurse would monitor the individuals for which initial signs and symptoms of tuberculosis? Select all that apply. 1Fatigue 2Lethargy 3Chest pain 4Morning cough 5Low-grade fever 6Labored breathing

A: Fatigue Lethargy Morning cough Low-grade fever Rationale: The symptoms of tuberculosis include a slight morning cough, fatigue, lethargy, and low-grade fever. The other symptoms listed are advanced (not initial) signs and symptoms.

The nurse would provide which home care instructions to a client with laryngeal cancer who had a laryngectomy and has a stoma? Select all that apply. 1Increase the humidity in the home. 2Obtain and wear a MedicAlert bracelet. 3Wear clothing that does not cover the stoma. 4Stay away from people who have a respiratory infection. 5Be careful with showering to avoid water entering the stoma. 6Decrease fluid intake to prevent excessive secretions from the stoma.

A: Increase the humidity in the home. Obtain and wear a MedicAlert bracelet. Stay away from people who have a respiratory infection. Be careful with showering to avoid water entering the stoma. Rationale: The nurse would teach the client how to care for the stoma, depending on the type of laryngectomy performed. Most interventions focus on protection of the stoma and the prevention of infection. Interventions include obtaining a MedicAlert bracelet, avoiding exposure to people with infections, avoiding swimming, using care when showering, and preventing debris from entering the stoma. Additional interventions include wearing a stoma guard or high-collared clothing to cover the stoma, increasing the humidity in the home, and increasing fluid intake to 3000 mL/day to keep the secretions thin.

Which nursing interventions are appropriate in caring for a client with emphysema? Select all that apply. 1Reduce fluid intake to less than 1500 mL/day. 2Teach diaphragmatic and pursed-lip breathing. 3Encourage alternating activity with rest periods. 4Teach the client techniques of chest physiotherapy. 5Keep the client in a supine position as much as possible.

A: Teach diaphragmatic and pursed-lip breathing. Encourage alternating activity with rest periods. Teach the client techniques of chest physiotherapy. Rationale: Fluids are encouraged, not reduced, to liquefy secretions for easier expectoration. Diaphragmatic and pursed-lip breathing assists in opening alveoli and eases dyspnea. The client needs to be encouraged to perform activities and exercise, such as dressing and walking, as tolerated with rest periods in between. Chest physiotherapy consists of percussion, vibration, and postural drainage. These techniques are helpful in removing secretions. Elevating the head of the bed assists with breathing.

The nurse caring for a client with chronic obstructive pulmonary disease (COPD) anticipates which arterial blood gas (ABG) findings? 1. pH, 7.40; PaO2, 90 mm Hg; CO2, 39 mEq/L; HCO3, 23 mEq/L 2. pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L 3. pH, 7.47; PaO2, 82 mm Hg; CO2, 30 mEq/L; HCO3, 31 mEq/L 4. pH, 7.31; PaO2, 95 mm Hg; CO2, 22 mEq/L; HCO3, 19 mEq/L

A: 2. pH, 7.32; PaO2, 85 mm Hg; CO2, 57 mEq/L; HCO3, 26 mEq/L Rationale: A client with COPD will exist in a state of respiratory acidosis. Options 2 and 4 reflect an acidotic pH. However, option 2 demonstrates increased CO2; a decreased pH and an increased CO2 indicate respiratory acidosis. Increased CO2 acts as an acid in the body, and CO2 is elevated in the client with COPD because of an inability to exhale well and eliminate CO2. Therefore, with a rise in CO2, there is a corresponding fall in pH. The other options are incorrect.

The nurse working on a medical-surgical unit is reviewing the day's client assignment. Which client(s) in the day's assignment would the nurse determine is at risk for the development of pneumonia? Select all that apply. 1An ambulatory client with a left-sided nephrolithiasis 2A client who had a total open hysterectomy 2 days ago 3A client with a fractured hip scheduled for a hip arthroplasty the following day 4A client with chronic obstructive pulmonary disease (COPD) with a tracheostomy 5A client who is nothing-by-mouth (NPO) receiving tube feeding via a nasogastric (NG) tube

A: A client who had a total open hysterectomy 2 days ago A client with a fractured hip scheduled for a hip arthroplasty the following day A client with chronic obstructive pulmonary disease (COPD) with a tracheostomy A client who is nothing-by-mouth (NPO) receiving tube feeding via a nasogastric (NG) tube Rationale: There are several risk factors associated with the development of pneumonia. These include abdominal or chest surgery, a client on strict bed rest or an immobile client, artificial airways that bypass the protective mechanisms of the upper airway, chronic diseases (including chronic lung disease, liver disease, diabetes, and heart conditions) and NG or nasointestinal tubes, which increase the risk of aspiration. The client in option 2 underwent an invasive surgery with large abdominal incisions, which increases this client's risk for an ineffective breathing pattern related to pain with deep breathing and an increased risk for pneumonia due to alveolar collapse. The client in option 3 requires strict bed rest to prevent further injury to the hip and is also at an increased risk for an ineffective breathing pattern related to immobility and pain. The client in option 4 is at an increased risk for pneumonia due to the client's medical history of COPD and the presence of a tracheostomy, which increases the risk of infection. The client in option 5 has an NG tube, which increases the client's risk of aspiration pneumonia. The client in option 1 is not at an increased risk for pneumonia. Therefore, options 2, 3, 4, and 5 are correct.

Which are risk factors for chronic obstructive pulmonary disease (COPD)? Select all that apply. 1Purified air 2Cigarette smoking 3Genetic risk factor 4Environmental factors 5Eating plenty of fruits and vegetables 6Alpha-1 antitrypsin (AAT) deficiency

A: Cigarette smoking Genetic risk factor Environmental factors Alpha-1 antitrypsin (AAT) deficiency Rationale: Risk factors for COPD include cigarette smoking, environmental factors, genetics, and AAT deficiency. Purified air and consumption of fruits and vegetables promote health.

The nurse is caring for a client diagnosed with tuberculosis (TB). Which assessments, if made by the nurse, are consistent with the usual clinical presentation of TB? Select all that apply. 1Cough 2Dyspnea 3Weight gain 4High-grade fever 5Chills and night sweats

A: Cough Dyspnea Chills and night sweats Rationale: The client with TB usually experiences cough (productive or nonproductive), fatigue, anorexia, weight loss, dyspnea, hemoptysis, chest discomfort or pain, chills and sweats (which may occur at night), and a low-grade fever.

The nurse is reviewing the pathophysiology of pleural effusion. The nurse knows that pleural fluid balance is managed by several mechanisms and correctly identifies which of the following as a cause for the development of pleural effusion? Select all that apply. 1Decreased oncotic pressure 2Lymphatic fluid outflow obstruction 3Increased pulmonary capillary pressure 4Decreased pulmonary capillary pressure 5Increased pleural membrane permeability

A: Decreased oncotic pressure Lymphatic fluid outflow obstruction Increased pulmonary capillary pressure Increased pleural membrane permeability Rationale: The lungs are covered by a two-layered pleural membrane that contains a small amount of pleural fluid between the parietal and visceral pleura to lubricate lung movement. The fluid volume in the pleural space is managed by a balance between hydrostatic pressure, oncotic pressure, capillary permeability and lymphatic fluid outflow. Pleural effusion occurs when one of the previously mentioned mechanisms is disturbed and excessive fluid accumulates in the pleural space. Decreased oncotic pressure, lymphatic fluid outflow obstruction, increased capillary pressure (not decreased capillary pressure), and increased pleural membrane permeability can lead to the development of pleural effusion. Therefore, options 1, 2, 3, and 5 are correct.

A client with silicosis is being monitored yearly at the health care clinic. On assessment, the nurse would ask the client about which manifestations of the disorder? Select all that apply. 1Fatigue 2Malaise 3Anorexia 4Weight gain 5Dyspnea at rest

A: Fatigue Malaise Anorexia Rationale: Silicosis is a chronic lung fibrosis that results from the long-term inhalation of silica dust. It is characterized by nodule formation between alveoli, leading to fibrosis. Malaise, extreme fatigue, anorexia, weight loss, and dyspnea on exertion (not at rest) would occur in a client with silicosis. Additional manifestations include reduced lung volume and upper lobe fibrosis.

The nurse is providing preoperative teaching to the client about the use of an incentive spirometer in the postoperative period. Which instructions would the nurse include? Select all that apply. 1Sit upright in the bed or in a chair. 2Inhale as deeply and quickly as possible. 3Hold the device in a downward position. 4Place the mouthpiece in your mouth and seal your lips tightly around it. 5After maximum inspiration, hold the breath for 2 to 3 seconds and exhale.

A: Sit upright in the bed or in a chair. Place the mouthpiece in your mouth and seal your lips tightly around it. After maximum inspiration, hold the breath for 2 to 3 seconds and exhale. Rationale: For optimal lung expansion with an incentive spirometer, the client would assume a semi-Fowler's or high-Fowler's position while holding the incentive spirometer in an upright position. The mouthpiece needs to be covered completely with the lips while the client inhales slowly, with a constant flow through the unit. The breath needs to be held for 2 to 3 seconds before exhaling slowly.

The nurse is reviewing the clinical manifestations of foreign body airway obstruction. Which of the following would the nurse identify as signs or symptoms of this condition? Select all that apply. 1Stridor 2Cyanosis 3Wheezing 4Bradycardia 5Intercostal retractions

A: Stridor Cyanosis Wheezing Intercostal retractions Rationale: Acute airway obstruction is a medical emergency that needs to be recognized quickly with interventions begun early. The clinical manifestations of acute airway obstruction include choking, stridor, accessory muscle use, suprasternal or intercostal retractions, nasal flaring, wheezing, restlessness, tachycardia, cyanosis, and altered level of consciousness. Tachycardia, not bradycardia, is a clinical manifestation of acute airway obstruction. Therefore, option 4 is incorrect and options 1, 2, 3 and 5 are correct.

A client who experiences frequent upper respiratory infections (URIs) asks the nurse why food does not seem to have any taste during illness. Which response by the nurse is most appropriate? 1"You lack the energy to cook wholesome meals." 2"Blocked nasal passages impair the sense of smell." 3"Loss of appetite is triggered by the infectious organism." 4"Infection blocks sensation in the taste buds of the tongue."

A: "Blocked nasal passages impair the sense of smell." Rationale: When nasal passages become blocked as a result of a URI, the client has an impaired sense of taste and smell. This occurs because one of the normal functions of the nose is to stimulate appetite through the sense of smell. The other options are incorrect and unrelated to this symptom.

The client is admitted to the hospital with a diagnosis of Legionnaires' disease. The nurse is providing information on the disease and treatment expectations. Which statement by the client indicates an understanding of the disease and treatments? 1"I would avoid all contact with my family." 2"I would avoid large crowds for at least 3 weeks." 3"I cannot give Legionnaires' disease to other people." 4"I will have to take antibiotics until my symptoms disappear."

A: "I cannot give Legionnaires' disease to other people." Rationale: Legionnaires' disease is spread through infected aerosolized water. The mode of transmission is not person to person. Antibiotics must be given for the entire duration of the prescription; therefore, the remaining options are incorrect.

The nurse is discharging a client with chronic obstructive pulmonary disease (COPD) and reviewing specific instructional points about COPD. What comment by the client indicates that further teaching is needed? 1"I need to avoid alcohol and sedative medications." 2"I have to cut down on the percentage of carbohydrates in my diet." 3"Besides smoking, I can't be around second- or thirdhand smoke." 4"I have to keep my nasal cannula oxygen levels between 4 and 6 L/min."

A: "I have to keep my nasal cannula oxygen levels between 4 and 6 L/min." Rationale: Clients with COPD have adapted to a high carbon dioxide level, so their carbon dioxide-sensitive chemoreceptors are essentially not functioning. Their stimulus to breathe is a decreased arterial oxygen (Pao2) level, so administration of oxygen greater than 24% to 28% (1 to 3 L/min) prevents the Pao2 from falling to a level (60 mm Hg) that stimulates the peripheral receptors, thus destroying the stimulus to breathe. The resulting hypoventilation causes excessive retention of carbon dioxide, which can lead to respiratory acidosis and respiratory arrest. Therefore, oxygen administration levels for clients with COPD need to be kept within the range of 1 to 3 L/min (per primary health care provider prescription). Also, nutrition for the client with COPD requires a reduction in the percentage of carbohydrates in the diet. Excessive carbohydrate loads increase carbon dioxide production, which the client with COPD may be unable to exhale. Alcohol and sedative medications need to be avoided. Active smoking, passive smoking (or secondhand smoke), and smoke that clings to hair and clothing (sometimes called "thirdhand" smoke) contribute to upper and lower respiratory problems, particularly for clients with COPD.

The nurse is providing education to a client diagnosed with valley fever (coccidioidomycosis). Which statement from the client would require a need for further teaching? 1"Valley fever is fungal in origin." 2"I may need to take an antifungal medication to get better." 3"This condition is more common in certain parts of the world." 4"I need to isolate myself at home, as this condition is highly contagious."

A: "I need to isolate myself at home, as this condition is highly contagious." Rationale: Valley fever (coccidioidomycosis) is a fungal infection caused by Coccidiodes that is more common in certain areas of the world, including the southwestern United States, Central America, and South America. The microscopic fungal spores are inhaled via dust, and the condition is not contagious or transmissible from person-to-person. The condition may need to be treated with antifungal medication. Therefore, option 4 is the client statement that requires further teaching as this condition is not contagious.

The nurse has provided a client with tuberculosis (TB) instructions on proper handling and disposal of respiratory secretions. The nurse determines that the client demonstrates understanding of the instructions when the client makes which statement? 1"I will discard used tissues in a plastic bag." 2"I need to wash my hands at least 4 times a day." 3"I will brush my teeth and rinse my mouth once a day." 4"I will turn my head to the side if I need to cough or sneeze."

A: "I will discard used tissues in a plastic bag." Rationale:Used tissues are discarded in a plastic bag. The client with TB needs to wash the hands carefully after each contact with respiratory secretions. Oral care needs to be done more frequently than once a day. The client would not only turn the head but also cover the mouth and nose when laughing, sneezing, or coughing.

The nurse is providing immediate postprocedure care to a client who had a thoracentesis to relieve a tension pneumothorax that resulted from rib fractures. The goal is that the client will exhibit normal respiratory functioning, and the nurse provides instructions to assist the client with this goal. Which client statement indicates that further instruction is needed? 1"I will lie on the affected side for an hour." 2"I can expect a chest x-ray exam to be done shortly." 3"I will let you know at once if I have trouble breathing." 4"I will notify you if I feel a crackling sensation in my chest."

A: "I will lie on the affected side for an hour." Rationale: After the procedure the client usually is turned onto the unaffected side for 1 hour to facilitate lung expansion. Tachypnea, dyspnea, cyanosis, retractions, or diminished breath sounds, which may indicate pneumothorax, need to be reported to the primary health care provider. A chest x-ray may be performed to evaluate the degree of lung reexpansion or pneumothorax. Subcutaneous emphysema (crepitus) may follow this procedure because air in the pleural cavity leaks into subcutaneous tissues. The involved tissues feel like lumpy paper and crackle when palpated (crepitus). Usually subcutaneous emphysema causes no problems unless it is increasing and constricting vital organs, such as the trachea.

The nurse is providing care for a client recently admitted with new-onset pleurisy. Upon auscultation of the client's lungs, the nurse notes an absence of the pleural friction rub that was documented on previous assessments. What is the most likely indication for this change in the client's lung sounds? 1Effectiveness of medication therapy 2The deep breaths that the client is taking 3Decreased inflammatory reaction at the site 4Accumulation of pleural fluid in the inflamed area

A: Accumulation of pleural fluid in the inflamed area Rationale: Pleural friction rub is auscultated early in the course of pleurisy before pleural fluid accumulates. Once fluid accumulates in the inflamed area, friction between the visceral and parietal lung surfaces decreases, and the pleural friction rub disappears. The remaining options are incorrect interpretations.

The nurse is providing education to a client diagnosed with acute laryngitis. Which client statement indicates a need for further teaching? 1"I would only whisper to talk." 2"I will run my humidifier at home." 3"I can take acetaminophen as needed for pain." 4"I will drink more fluids and will avoid caffeine and alcohol."

A: "I would only whisper to talk." Rationale: Acute laryngitis refers to swelling and inflammation of the larynx that can result from a viral or bacterial infection, voice overuse, or exposure to inhalant chemicals. The treatment for acute laryngitis is supportive in nature; antibiotics are prescribed if the condition is caused by bacteria. Supportive measures include acetaminophen as needed for pain, humidifier use, throat lozenges, increased fluid intake, and avoidance of caffeine and alcohol. The client needs to be educated to limit the use of the voice to rest the larynx. Whispering needs to be avoided, as this causes more strain on the larynx. Therefore, option 1 is the client statement that would require further teaching from the nurse, as whispering would be avoided.

The nurse is teaching a client diagnosed with acute bacterial rhinosinusitis about supportive measures to increase client comfort. Which client statement would indicate a need for further teaching? 1"I would increase my fluid intake." 2"I can apply hot, wet packs to my face to help with the pain." 3"Sleeping with my head elevated will help drain my sinuses." 4"I would run a dehumidifier in my bedroom at night while I'm sleeping."

A: "I would run a dehumidifier in my bedroom at night while I'm sleeping." Rationale: Supportive therapy for rhinosinusitis includes humidification; nasal irrigation with saline solution; application of hot, wet packs; increasing fluid intake to at least 2 liters (L) per day, unless contraindicated; sleeping with the head elevated; and avoiding irritating agents, such as cigarette smoke or other allergens. Therefore, options 1, 2, and 3 indicate the client understands the appropriate supportive measures for rhinosinusitis. Option 4 indicates a need for further teaching, as humidification of air, not dehumidification of air, assists with the discomfort of rhinosinusitis.

A registered nurse who is orienting a new nursing graduate to the hospital emergency department instructs the new graduate to monitor a client for one-sided chest movement on the right side while the client is being intubated by the primary health care provider (PHCP). Which statement made by the new nursing graduate indicates understanding of the importance of this observation? 1"It will enter the left main bronchus if inserted too far." 2"It will enter the right main bronchus if inserted too far." 3"It may enter the left main bronchus if not inserted far enough." 4"It may enter the right main bronchus if not inserted far enough."

A: "It will enter the right main bronchus if inserted too far." Rationale:If the endotracheal tube is inserted too far into the client's trachea, the tube will enter the right main bronchus. This occurs because the right bronchus is shorter and wider than the left and extends downward in a more vertical plane. If the tube is not inserted far enough, no chest expansion at all will occur. The other options are incorrect.

The nurse is providing instructions to a client with chronic obstructive pulmonary disease about using an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. What statement by the client indicates successful teaching? 1"It will open up the major airways." 2"It will keep the small airways open." 3"It will increase lubrication for the lungs." 4"The lungs can better rid themselves of secretions."

A: "It will keep the small airways open." Rationale: Sustained inhalation helps maintain inflation of terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. The remaining options are not reasons for sustaining inflation.

The nurse working in a primary care provider's (PHCP's) office receives a call from a client last seen 4 weeks ago who was diagnosed with acute bronchitis. The client states adherence to the supportive measures that were prescribed, yet the symptoms have not improved and the dyspnea has worsened. Which is the most appropriate response from the nurse? 1"Remember to use your prescribed inhaler before strenuous activities." 2"Please come into the office as soon as possible for further evaluation and treatment." 3"Take a hot shower and run a humidifier in your home, which will help to open your airways." 4"This is expected with bronchitis. You can expect the symptoms to resolve within the next couple of weeks."

A: "Please come into the office as soon as possible for further evaluation and treatment." Rationale: Acute bronchitis may be viral or bacterial in nature and is usually a self-limiting condition. Treatment is usually supportive with antitussives, bronchodilators, and air humidification. If influenza is the cause of the bronchitis, antivirals may be appropriate. If symptoms do not improve or are worsening after 4 weeks, such as increasing dyspnea or fever, the client needs to be reevaluated for potential complications of bronchitis that require further treatment, such as pneumonia. Therefore, option 2 is correct. Options 1, 3, and 4 do not address the client's concern; these options tell the client to continue the supportive measures despite worsening symptoms.

The nurse is teaching a client with a recurrent history of rhinosinusitis about the condition. Which statement from the client indicates a need for further teaching? 1"Viruses are usually the cause of rhinosinusitis." 2"Rhinosinusitis is caused only by an infectious organism." 3"The frontal and maxillary sinuses are most commonly affected." 4"Since I have a deviated septum, that increases my risk of rhinosinusitis."

A: "Rhinosinusitis is caused only by an infectious organism." Rationale: Rhinosinusitis is inflammation of the mucous membranes of the sinuses. The etiology of rhinosinusitis can be infectious or noninfectious in nature. The most common cause of rhinosinusitis is viral infection, but bacterial infection can also cause this condition. The frontal and maxillary sinuses are more likely to be affected. Certain predisposing factors include conditions that impede sinus drainage, such as a deviated nasal septum, nasal polyps or masses, inhaled pollutants, allergies, intranasal illicit drug use, facial trauma, or dental infection. Seasonal allergies increase the risk of rhinosinusitis due to nasal mucosa edema impeding drainage of secretions. Therefore, since rhinosinusitis can occur due to a noninfectious etiology, option 2 is the client statement that requires a need for further teaching and is the correct answer.

The nurse is assisting the primary health care provider (PHCP) in assessment of a 67-year-old client with suspected pneumonia using the Expanded CURB-65 scale. The client is alert and oriented. Vital signs are respiratory rate 32 breaths per minute and blood pressure 102/70 mm Hg. Laboratory results demonstrate a blood urea nitrogen (BUN) of 12 mg/dL (4.3 mmol/L), lactate dehydrogenase (LDH) level of 200 μ/L (200 μ/L), albumin 4.0 g/dL (40 g/L) and platelet count of 200,000/mm3 (200 × 109/L). Which score reflects the client's Expanded CURB-65 scale? 1. 2 2. 4 3. 5 4. 7

A: 2 Rationale: The Expanded CURB-65 scale uses several criteria to calculate a score that helps determine the perceived severity of the client's pneumonia; it can assist the PHCP in determining the treatment plan. These criteria include confusion, BUN, respiratory rate, blood pressure, age, LDH, albumin, and platelet count. The client scores 1 point for each abnormal parameter, including confusion compared to baseline, BUN greater than 20 mg/dL (7.2 mmol/L), respiratory rate greater than 30 breaths per minute, systolic blood pressure (SBP) less than 90 mm Hg or diastolic blood pressure (DBP) less than 60 mm Hg, age greater than 65 years, LDH greater than 230 μ/L, albumin less than 3.5 g/dL (35 g/L), and platelet count less than 100,000/mm3 (100 × 109). The scores range from 0-2 (low perceived risk), 3-4 (intermediate perceived risk), and 5-8 (high perceived risk). This client scores 1 point for age greater than 65 years and scores another point for respiratory rate. Therefore, option 1 is the correct answer and the total score is 2.

The nurse is caring for a client who underwent a pleurodesis procedure to treat a recurrent pleural effusion. The medication was instilled into the chest tube at 1600 and subsequently clamped. At what time will the nurse unclamp the chest tube? 1. 1800 2. 2000 3. 2200 4. 2400

A: 2400 Rationale: During a pleurodesis procedure, a chemical irritant, such as doxycycline or bleomycin, is instilled into the pleural cavity via a chest tube. The medication needs to stay in place for at least 8 hours to be effective. Options 1, 2, and 3 are too early to unclamp the chest tube as the medication would be in place for only 2, 4, and 6 hours, respectively. Therefore, option 4 is correct.

The nurse is assisting a pulmonologist with a pleurodesis to treat a client with recurrent pleural effusions. After the pulmonologist instills the medication into the pleural space, for how long would the nurse anticipate the chest tube drainage system will need to be clamped? 1. 2 hours 2. 4 hours 3. 6 hours 4. 8 hours

A: 8 hours Rationale: Pleurodesis is a procedure in which a medication, such as doxycycline or bleomycin, is instilled into the pleural space via an existing chest tube. The medication triggers an inflammatory reaction that destroys the pleural space, thereby preventing future fluid accumulation. The chest tube drainage system needs to be clamped for a period of 8 hours after the procedure, after which it is unclamped and the medication is allowed to drain out of the lungs. Options 1, 2 and 3 are inadequate amounts of time for the medication to exert its therapeutic effect after this procedure. Therefore, option 4 is correct.

The nurse is caring for a group of clients on the clinical nursing unit. The nurse interprets that which of these clients is at most risk for the development of pulmonary embolism? 1A 25-year-old client with diabetic ketoacidosis 2A 65-year-old client out of bed 1 day after prostate resection 3A 73-year-old client who has just had pinning of a hip fracture 4A 38-year-old client with pulmonary contusion sustained in an automobile crash

A: A 73-year-old client who has just had pinning of a hip fracture Rationale: Clients frequently at risk for pulmonary embolism include those who are immobilized. This is especially true in the immobilized postoperative client. Other causes include those with conditions that are characterized by hypercoagulability, endothelial disease, or advancing age.

The experienced nurse is teaching a new graduate nurse about tracheostomy care. The experienced nurse would determine teaching has been effective if the new graduate nurse states that which client has an immature tracheostomy? 1A client who underwent a tracheotomy 2 days ago 2A client who underwent a tracheotomy 8 days ago 3A client who underwent a tracheotomy 10 days ago 4A client who underwent a tracheotomy 1 month ago

A: A client who underwent a tracheotomy 2 days ago Rationale: After a tracheotomy, the tracheostomy tract becomes more established and matured over time. Tube dislodgment within 72 hours after a tracheotomy is considered an emergency because replacement of the tube is difficult due to the immaturity of the tract. This factor makes it more likely the tube will enter subcutaneous tissue instead of the trachea during attempted replacement. Since the client in option 1 has had the tracheotomy most recently compared with the other clients and the tracheostomy is considered immature, this client would be more likely to have complications if tube dislodgment occurs. Therefore, option 1 is the correct answer.

The nurse working on a medical respiratory nursing unit is caring for several clients with respiratory disorders. The nurse would determine that which client on the nursing unit is at the lowest risk for infection with tuberculosis? 1An uninsured person who is homeless 2A newly immigrated person from Asia 3A person who is an inspector for the U.S. Postal Service 4An older adult admitted from a long-term care facility

A: A person who is an inspector for the U.S. Postal Service Rationale: Clients at high risk for acquiring tuberculosis include immigrants from Asia, Africa, Latin America, and Oceania; medically underserved populations (ethnic minorities, homeless); those with human immunodeficiency virus infection or other immunosuppressive disorders; residents in group settings (long-term care, correctional facilities); and health care workers.

The nurse reads in the progress notes for a client with pneumonia that areas of the client's lungs are being perfused but are not being ventilated. How does the nurse correctly interpret this documentation? 1A shunt unit exists. 2Anatomical dead space is present. 3Physiological dead space is present. 4Ventilation-perfusion matching is occurring.

A: A shunt unit exists. Rationale: When there is no ventilation to an alveolar unit but perfusion continues, a shunt unit exists. As a result, no gas exchange occurs, and unoxgenated blood continues to circulate. Anatomical dead space normally is present in the conducting airways, where pulmonary capillaries are absent. Physiological dead space occurs with conditions such as emphysema and pulmonary embolism. Ventilation-perfusion matching refers to a matching distribution of blood flow in the pulmonary capillaries and air exchange in the alveolar units of the lungs.

A client has been treated for pleural effusion with a thoracentesis. The nurse determines that this procedure has been effective if the nurse notes which assessment finding? 1Absence of dyspnea 2Increased severity of cough 3Dull percussion notes over lung tissue 4Decreased tactile fremitus over lung tissue

A: Absence of dyspnea Rationale: The client who has undergone thoracentesis would experience relief of the signs and symptoms experienced before the procedure. Typical signs and symptoms of pleural effusion include dry, nonproductive cough; dyspnea (usually on exertion); decreased or absent tactile fremitus; and dull or flat percussion notes on respiratory assessment.

The nurse is responding to an adult client who aspirated while eating in a restaurant; the client is choking and becomes unresponsive. The client has a pulse with agonal breathing. The nurse has already called for an automatic external defibrillator (AED) and activated the emergency response system. Which of the following nursing interventions is appropriate in the care of this client? 1Initiate chest compressions immediately 2Reassess the carotid pulse every 5 minutes 3Administer rescue breaths at a rate of 6 to 8 breaths per minute 4Administer rescue breaths at a rate of 10 to 12 breaths per minute

A: Administer rescue breaths at a rate of 10 to 12 breaths per minute Rationale: Foreign body airway obstruction can result in a partial or complete obstruction of the airway. The initial response would be to check the client's mouth for the cause of the obstruction and to manually relieve the obstruction if possible. Abdominal thrusts or the Heimlich maneuver should be attempted to relieve the obstruction. If the client loses consciousness or becomes unresponsive, the nurse would lower the client to the floor and check for a pulse and respirations. If no pulse is present, the nurse would initiate cardiopulmonary resuscitation. However, in this case, remember that the client has a pulse and agonal breathing, which is not adequate for oxygenation. Rescue breaths need to be initiated immediately just as if the client were not breathing at all. The nurse would deliver rescue breaths every 5 to 6 seconds or at a rate of 10 to 12 breaths per minute and recheck the carotid pulse every 2 minutes until further help arrives. Option 1 is incorrect because the nurse would assess the client further and gather more information before initiating chest compressions. Also, the client has a pulse, so unless the client becomes pulseless, it is an inappropriate action to take. Option 2 is incorrect because every 5 minutes is too infrequent and the carotid pulse needs to be reassessed every 2 minutes while delivering rescue breaths. Option 3 is incorrect because it is an inappropriate rate; rescue breaths need to be administered at a rate of 10 to 12 breaths per minute.

The nurse is caring for a client with chronic obstructive pulmonary disease who is dyspneic and has decreased breath sounds. The nurse would carry out which intervention to decrease the client's work of breathing? 1Instruct the client to limit fluid intake. 2Place the client in low-Fowler's position. 3Administer the prescribed bronchodilator. 4Place a continuous pulse oximeter on the client.

A: Administer the prescribed bronchodilator. Rationale:Administering the prescribed bronchodilator will help to decrease airway resistance, which decreases the work of breathing and would ease the client's dyspnea. The client needs to be placed in high-Fowler's position to maximize chest expansion. Clients with increased production of mucus have increased airway resistance, which increases the work of breathing. Thus, fluids would be increased to help liquefy secretions. Placing a continuous pulse oximeter will assist with monitoring the client's condition but will have no effect on the client's work of breathing.

An ambulatory care nurse is assessing a client with chronic sinusitis. The nurse would expect to note which assessment findings in this client? Select all that apply. 1Anosmia 2Chronic cough 3Purulent nasal discharge 4Intolerance to hot weather 5Intolerance to strong aromas

A: Anosmia Chronic cough Purulent nasal discharge Rationale: Chronic sinusitis is characterized by persistent purulent nasal discharge, a chronic cough due to nasal discharge, anosmia (loss of smell), nasal stuffiness, and headache that is worse on arising after sleep. Intolerance to hot weather and intolerance to strong aromas are not characteristics.

The nurse in the emergency department is preparing for the arrival of a client with suspected carbon monoxide poisoning. Which primary health care provider (PHCP) order would the nurse perform first upon the client's arrival? 1Insert an intravenous (IV) catheter. 2Draw a serum carboxyhemoglobin level. 3Apply 100% oxygen via nonrebreather mask. 4Apply a continuous oxygen saturation monitor.

A: Apply 100% oxygen via nonrebreather mask. Rationale: Carbon monoxide poisoning results in the displacement of oxygen from hemoglobin in the blood, resulting in tissue hypoxia. Although options 1, 2 and 4 are appropriate interventions in the care of a client with carbon monoxide poisoning, the first action the nurse would take to assist the client's airway and breathing would be to apply high-flow oxygen via a nonrebreather mask. Therefore, option 3 is correct.

The nurse is reviewing the interventions for relieving an airway obstruction. Which initial action would be taken in this situation? 1Initiate abdominal thrusts 2Insert a nasal or oral airway 3Extend the client's head and neck 4Assess for the cause of the obstruction

A: Assess for the cause of the obstruction Rationale: Airway obstruction can be related to a variety of causes. The first step when intervening in this situation is to assess the cause of the obstruction in order to determine the appropriate interventions to relieve the obstruction. Therefore, option 4 is the correct answer. If the obstruction is due to the tongue blocking the airway or a buildup of excessive secretions, the client's head and neck would be extended and a nasal or oral airway would be inserted for suctioning. If the airway is blocked due to a foreign body, abdominal thrusts would be initiated.

The nurse is caring for a client with dysphagia who is diagnosed with pneumonia and prescribed a honey-thick diet. The nurse is preparing to assist the client with eating. Which is the priority nursing action? 1Assess the client's gag reflex 2Provide oral care after the meal 3Place the client in semi-Fowler's position 4Allow the client frequent rest breaks during the meal

A: Assess the client's gag reflex Rationale: The priority nursing action for a client with dysphagia is to assess for an intact gag reflex before attempting to feed the client in order to prevent aspiration. While options 2, 3, and 4 are all appropriate nursing interventions in the care of this client, these interventions would be done after assessing for a gag reflex and are not the highest priority. Therefore, option 1 is correct.

The nurse is caring for a client with a tracheostomy receiving supplemental oxygen via a tracheostomy mask and is preparing to perform tracheostomy care. While preparing the supplies, the nurse notes the tracheostomy tube is pulsing, there is bleeding from the stoma, and the client is increasingly restless. The nurse calls for a rapid response team (RRT) and removes the tracheostomy tube. Which action would the nurse take next? 1Obtain blood type and crossmatch 2Ensure intravenous (IV) access patency 3Apply direct pressure to the source of bleeding 4Assist the primary health care provider (PHCP) with endotracheal intubation

A: Assist the primary health care provider (PHCP) with endotracheal intubation Rationale: Bleeding from a tracheostomy can indicate a serious medical emergency known as trachea-innominate artery fistula. The tracheostomy tube will pulse simultaneously with the heartbeat, and heavy bleeding will be noted from the stoma. The tracheostomy tube needs to be removed immediately and an alternative airway will need to be secured. After calling for help, the nurse would first prepare for endotracheal intubation. Therefore, option 4 is correct. Options 1, 2, and 3 are appropriate actions by the nurse, but a patent airway is the priority. Furthermore, those nursing interventions can be carried out simultaneously with assistance from the RRT.

The nurse is assessing a client complaining of fatigue and facial pain. Upon assessment, the nurse notes tenderness to percussion above the bilateral eyebrows and bilateral cheeks. The client also complains of facial pressure that is worse when bending forward; thick, greenish-yellow nasal discharge; sore throat; and fever at home. Which condition would the nurse suspect? 1Laryngitis 2Pharyngitis 3Nasal polyp 4Bacterial rhinosinusitis

A: Bacterial rhinosinusitis Rationale: The client's signs and symptoms are consistent with bacterial rhinosinusitis. Rhinosinusitis is characterized by pain with percussion over the frontal and maxillary sinuses, fever, sore throat, sinus pressure or pain that is exacerbated by bending forward, purulent nasal discharge or postnasal drip, fatigue, and ear pressure. Therefore, option 4 is correct. The assessment data collected by the nurse are not characteristic of laryngitis, pharyngitis, or a nasal polyp. However, a nasal polyp is a risk factor for the development of rhinosinusitis. Therefore, options 1, 2 and 3 are incorrect.

The nurse is performing a respiratory assessment on a client with a left lower lobe cancerous lung mass. Chest auscultation over the posterior left lower lobe reveals these breath sounds. The nurse would interpret this as which sound? Refer to audio. 1Pleural friction rub 2Vesicular breath sounds 3Bronchial breath sounds 4Bronchovesicular breath sounds

A: Bronchial breath sounds Rationale: The sounds that the nurse hears are bronchial breath sounds. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. The expiration phase is louder and longer than the inspiration phase, and a distinct pause can be heard between the inspiration and expiration phases. Bronchial breath sounds normally are heard only over the trachea and immediately above the manubrium. Bronchial breath sounds are abnormal anywhere over the posterior or lateral chest. When heard in these areas, they indicate abnormal sound transmission because of consolidation of lung tissue, as in a lung mass, atelectasis, or pneumonia. A pleural friction rub is a superficial, low-pitched, coarse rubbing or grating sound that sounds like two rough surfaces rubbing together and is heard in the client with pleurisy. Vesicular breath sounds normally are heard over the lesser bronchi, bronchioles, and lobes (peripheral lung fields). These sounds are soft and low pitched and resemble a sighing or gentle rustling. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at the T4 level medial to the scapula posteriorly. These sounds are a mixture of bronchial and vesicular breath sounds and are of moderate pitch with a medium intensity.

The nurse is preparing a client diagnosed with a partial foreign body airway obstruction for a procedure to facilitate foreign body removal. The nurse would prepare the client for which of the following procedures? 1Lung biopsy 2Paracentesis 3Thoracentesis 4Bronchoscopy

A: Bronchoscopy Rationale: Bronchoscopy is a procedure in which a fiberoptic scope is introduced into the bronchi. This procedure is used for several purposes, including to suction mucous plugs, lavage the lungs, or remove foreign objects. Paracentesis is a procedure in which fluid is removed from the peritoneal space via a needle or catheter. Thoracentesis is a procedure in which pleural fluid is removed from the pleural space via a needle or catheter. A lung biopsy is a procedure in which lung tissue is obtained via several routes, including transbronchial or percutaneous biopsy, transthoracic needle aspiration, video-assisted thoracoscopic surgery (VATS), or open lung biopsy. Therefore, since bronchoscopy is a procedure to remove a foreign object from the lungs, option 4 is correct.

The nurse is performing an admission assessment on a client with tuberculosis (TB) and is collecting subjective and objective data. Which finding would the nurse expect to note? 1High fever 2Flushed skin 3Complaints of weight gain 4Complaints of night sweats

A: Complaints of night sweats Rationale: The client with TB usually experiences a low-grade fever, weight loss, pallor, chills, and night sweats. The client also will complain of anorexia and fatigue. Pulmonary symptoms include a cough that is productive of a scant amount of mucoid sputum. Purulent, blood-stained sputum is present if cavitation occurs. Dyspnea and chest pain occur late in the disease.

The nurse in the emergency department is caring for a client brought in from a house fire. The client is exhibiting dyspnea with clear breath sounds bilaterally and is complaining of a severe headache. The client is exhibiting signs of confusion and is oriented to self. The client's vital signs are as follows: temperature 98.2℉ (36.7℃), oxygen saturation 91%, respiratory rate 26 breaths per minute, heart rate 112 beats per minute, and blood pressure 100/62. Which of the following conditions would the nurse suspect? 1Pneumonia 2Pneumothorax 3Pleural effusion 4Carbon monoxide poisoning

A: Carbon monoxide poisoning Rationale: Carbon monoxide is present in many noxious substances, including cigarette smoke and fire smoke. Carbon monoxide has a higher affinity for hemoglobin than oxygen and displaces oxygen from hemoglobin, thereby inhibiting the body's ability to oxygenate tissues. Clinical manifestations include severe headache, dyspnea, tachypnea, confusion, tachycardia, cyanosis, and respiratory depression. Carbon monoxide poisoning results from inhaling combustion fumes, such as from a fire, and carbon monoxide displaces oxygen on the red blood cells, inhibiting the body's ability to carry and deliver oxygen to tissues. Since the client has been in a house fire, which is a risk factor for this condition, and is exhibiting signs and symptoms consistent with carbon monoxide poisoning, option 4 is correct.

The nurse is caring for a client with emphysema who is receiving oxygen. The nurse assesses the oxygen flow rate and notes that the client is receiving 2 L/min. The client's Spo2 level is 86%. Based on this assessment, which action would the nurse take first? 1Increase to 3 L/min and titrate until the SpO2 is 100%. 2Check the client's record to determine the client's baseline SpO2. 3Place the client on a nonrebreather mask on 100% FiO2. 4Maintain oxygen flow at 2 L/min and call respiratory therapy for a breathing treatment.

A: Check the client's record to determine the client's baseline SpO2. Rationale: The nurse would first assess the client for signs of respiratory compromise and would check the client's record to determine the client's baseline value. The nurse would not increase the client's oxygen flow and titrate until the level is 100%. Oxygen flow rates are determined based on the client's normal baseline and would be titrated to the lowest amount needed; usually between 88% and 92% for a client with obstructive lung disease. Therefore, option 1 is incorrect. A nonrebreather mask is not necessary at this point, and oxygen via nasal cannula would be attempted first; therefore, option 3 is incorrect. It may be necessary to call respiratory therapy for a breathing treatment; however, client assessment is done first, making option 4 incorrect.

The nurse who is participating in a client care conference with other members of the health care team is discussing the condition of a client with acute respiratory distress syndrome (ARDS). The primary health care provider (PHCP) states that as a result of fluid in the alveoli, surfactant production is falling. What does the nurse anticipate as a physiological consequence? 1Atelectasis and viral infection 2Bronchoconstriction and stridor 3Collapse of alveoli and decreased compliance 4Decreased ciliary action and retained secretions

A: Collapse of alveoli and decreased compliance Rationale: Surfactant is a phospholipid produced in the lungs that decreases surface tension in the lungs. This prevents the alveoli from sticking together and collapsing at the end of exhalation. When alveoli collapse, the lungs become "stiff" because of decreased compliance. Common causes of decreased surfactant production are ARDS and atelectasis. The remaining options are incorrect.

The nurse is reviewing the pleural fluid cytology report for a client with pleural effusion. The report describes the fluid as clear and pale yellow with no red blood cells (RBCs) or white blood cells (WBCs) detected. Based on these results, which underlying condition would the nurse suspect? 1Malignancy 2Pneumonia 3Tuberculosis 4Congestive heart failure

A: Congestive heart failure Rationale: There are various types of pleural fluid, including transudative fluid or exudative fluid, depending on the underlying cause. Exudate is typically cloudy and yellow and is cell-rich, including WBCs. Generally, exudate indicates an underlying infectious, inflammatory, or malignant process. Transudate is clear or pale yellow with few cells present. Transudate can be related to congestive heart failure due to fluid overload; cirrhosis due to decreased albumin production and subsequent decreased oncotic pressure; or renal disease, which contributes to fluid overload and increased capillary pressure. Options 1, 2 and 3 are either malignant or infectious processes and would likely cause an exudative pleural effusion. Since the client's pleural fluid is clear and pale yellow with no RBCs or WBCs, the transudate is present. Therefore, option 4 is correct as congestive heart failure is associated with transudative pleural effusion.

The nurse is caring for a client with a suspected lower airway infection. The nurse determines that the client is experiencing a productive cough with clear sputum, voice hoarseness, and myalgia. The client's chest x-ray (CXR) demonstrates consolidation in the right and left lower lung lobes, and laboratory results indicate leukocytosis. Based on these data, which client finding would rule out bronchitis? 1Leukocytosis 2Voice hoarseness 3Productive cough with clear sputum 4Consolidation of the right and left lower lung lobes on CXR

A: Consolidation of the right and left lower lung lobes on CXR Rationale: Acute bronchitis is inflammation of the lower respiratory tract bronchi that is usually caused by a virus, but can also be bacterial in nature. Signs and symptoms include a cough, which is often productive with clear or purulent sputum, headache, fever, malaise, myalgia, dyspnea, and chest pain. Client assessment may reveal normal breath sounds or adventitious sounds, such as crackles or wheezes on expiration. However, with bronchitis, consolidation would be negative on the CXR and instead pneumonia would be suspected. Furthermore, leukocytosis, which is an elevated white blood cell (WBC) count, would be expected for an infectious or inflammatory process such as bronchitis. Therefore, option 4 is the correct answer; when consolidation is present on the client's CXR, a diagnosis other than bronchitis, such as pneumonia, would be suspected.

The nurse is caring for a client who had tuberculin skin testing 48 hours ago on admission to the nursing unit. The nurse reads the test result as positive. Which action by the nurse has the highest priority? 1Document the finding in the client's record. 2Call the employee health service department. 3Contact the primary health care provider (PHCP). 4Call the radiology department for a chest radiographic study to be done.

A: Contact the primary health care provider (PHCP). Rationale: The nurse who obtains a positive test reading would call the PHCP immediately. The PHCP will prescribe a chest x-ray study to determine whether the client has clinically active tuberculosis (TB) or old, healed lesions. A sputum culture would be obtained to confirm the diagnosis of active TB. The client can be placed on prophylactic TB precautions until a final diagnosis is made. Although the results of the test would be documented and the employee health service department would be notified, these are not the actions of highest priority among the options provided.

A client with chronic obstructive pulmonary disease (COPD) is experiencing exacerbation of the disease. The nurse would determine that which finding documented in the client's record is an expected finding with this client? 1 Increased oxygen saturation with ambulation 2 A widened diaphragm documented by chest x-ray 3 Hyperinflation of lungs documented by chest x-ray 4 A shortened expiratory phase of the respiratory cycle

A: Hyperinflation of lungs documented by chest x-ray Rationale: The clinical manifestations of COPD are several, including hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory respiratory muscles, and prolonged exhalation. Chest x-ray results indicate a hyper-inflated chest and may indicate a flattened diaphragm if the disease is advanced.

The nurse is reviewing the pathophysiology of pneumonia. The nurse would correctly identify which infection source as an example of hematogenous spread in the pathogenesis of pneumonia? 1Inhalation of pathogens in the air 2Aspiration of microbes from the oropharynx 3Aspiration of microbes from the nasopharynx 4Develops from a primary infection at a different site in the body

A: Develops from a primary infection at a different site in the body Rationale: Pneumonia is an acute infection of the lung tissue. Several defense mechanisms protect the lung from infection; however, there are three identified methods by which pathogens reach the lung—aspiration, inhalation, or hematogenous spread. Options 2 and 3 both describe the aspiration route of the pathogenesis of pneumonia, in which normal inhabitants of the oropharynx and nasopharynx reach the lung tissue and cause infection. Option 1 describes the inhalation route. Option 4 describes the hematogenous spread route, as this refers to a primary infection elsewhere in the body, such as endocarditis, spreading to the lung tissue and causing a secondary infection. Therefore, option 4 is correct.

The nurse is teaching a client with chronic obstructive pulmonary disease about fundamental concepts of gas exchange. When asked for further details by the client, the nurse plans to explain that gas exchange occurs through which process? 1Osmosis 2Diffusion 3Ionization 4Active transport

A: Diffusion Rationale: Gas exchange occurs by diffusion, which means that oxygen and carbon dioxide move across the alveolar-capillary membrane as a result of a pressure gradient. Osmosis is the process of movement according to a concentration gradient. Ionization refers to the process whereby a molecule gains or loses electrons. Active transport is movement of molecules by carrying them across a cell membrane.

The nurse is preparing a room for a client diagnosed with pertussis. Which type of precautions would the nurse plan to implement for the client? 1Droplet precautions 2Contact precautions 3Airborne precautions 4Standard precautions

A: Droplet precautions Rationale: Pertussis is an extremely contagious bacterial infection of the lower respiratory tract caused by the organism Bordetella pertussis (B. pertussis). The condition is characterized by a whooping-like cough. Although the clinical presentation may be more severe in infants and children, pertussis also can affect adults. Pertussis is transmitted via respiratory droplets, and droplet precautions are appropriate when treating a client with this condition. Therefore, option 1 is correct.

A client is suspected of having a pulmonary embolus. The nurse assesses the client, knowing that which is a common clinical manifestation of pulmonary embolism? 1Dyspnea 2Bradypnea 3Bradycardia 4Decreased respirations

A: Dyspnea Rationale: The common clinical manifestations of pulmonary embolism are tachypnea, tachycardia, dyspnea, and chest pain.

The nurse is instructing a client in diaphragmatic breathing. To reinforce the need for this technique, the nurse teaches the client that in normal respiration, which is an action of the diaphragm? 1Aids in exhalation as it contracts 2Moves up and inward as it contracts 3Moves downward and out as it contracts 4Makes the thoracic cage smaller as it contracts

A: Moves downward and out as it contracts Rationale: As the diaphragm contracts, it moves downward and out, becoming flatter and expanding the thoracic cage. This process occurs during the inspiratory phase of the respiratory cycle. Therefore, the remaining options are incorrect.

A client is on continuous mechanical ventilation (CMV) and the high-pressure alarm sounds. Which action would the nurse take to eliminate the problem? 1Silence the alarm to avoid disturbing the client. 2Check the ventilator circuit for any disconnections. 3Inflate the cuff of the endotracheal tube to a pressure of 25 mm Hg. 4Empty excess accumulated water from the ventilatory circuit tubing.

A: Empty excess accumulated water from the ventilatory circuit tubing. Rationale: High-pressure alarms can be triggered by increased airway resistance caused by excess secretions in the airway, biting the tube, coughing, bronchospasm, a kinked ventilatory circuit, or excess condensation of water in the ventilator tubing. Excess water needs to be emptied from the tubing. Alarms would never be silenced until the cause has been identified and corrected. In addition, this will not eliminate the problem. The low-pressure alarm would sound with a disconnection. Filling the cuff to 25 mm Hg can result in impaired circulation to the tracheal mucosa.

The nurse is auscultating breath sounds in a hospitalized client with emphysema and hears these sounds. The nurse would document this finding as which sound? Refer to audio. 1Crackles 2High-pitched wheezes 3Bronchial breath sounds 4Bronchovesicular breath sounds

A: High-pitched wheezes Rationale: The sounds that the nurse hears are high-pitched wheezes. These are musical sounds that predominate in expiration but may occur in both expiration and inspiration. They occur in the small airways and are heard in narrowed-airway diseases such as asthma or emphysema. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger. Crackles occur with the sudden opening of small airways that contain fluid, usually are heard during inspiration, and do not clear with a cough. Crackles are heard in conditions such as congestive heart failure or pulmonary edema. Bronchial breath sounds are loud, high-pitched sounds that resemble air blowing through a hollow pipe. Bronchial breath sounds normally are heard only over the trachea and immediately above the manubrium. Bronchial breath sounds are abnormal anywhere over the posterior or lateral chest. When they are heard in these areas, they indicate abnormal sound transmission because of consolidation of lung tissue such as in a lung mass, atelectasis, or pneumonia. Bronchovesicular breath sounds normally are heard over the first and second intercostal spaces at the sternal border anteriorly and at the T4 level medial to the scapula posteriorly (over major bronchi). These sounds are a mixture of bronchial and vesicular breath sounds and are of moderate pitch with a medium intensity.

The nurse is caring for a client with a respiratory disorder who is attempting to stop smoking. The primary health care provider has recommended nicotine gum. When reviewing this treatment with the client, the nurse would provide which instruction? 1Drink water while chewing the gum. 2Only chew the gum for a maximum of 10 minutes. 3Hold the gum between the cheek and teeth periodically. 4Eat a light snack immediately before chewing the gum.

A: Hold the gum between the cheek and teeth periodically. Rationale: Nicotine gum needs to be chewed for 30-minute intervals with periods of holding the gum between the cheek and teeth; food and drink would be avoided 15 minutes before and during use.

The nurse is reading a tuberculin skin test for a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. How would the nurse interpret the result? 1Positive 2Negative 3Uncertain 4Borderline

A: Negative Rationale: A positive reading has an induration measuring 10 mm or larger and is considered abnormal. A small area of ecchymosis is insignificant and probably is related to injection technique. The remaining options are incorrect interpretations.

A client with chronic obstructive pulmonary disease (COPD) has a respiratory rate of 24 breaths per minute, bilateral crackles, and cyanosis and is coughing but unable to expectorate sputum. Which problem is the priority? 1Low cardiac output secondary to cor pulmonale 2Gas exchange alteration related to ventilation-perfusion mismatch 3Altered breathing pattern secondary to increased work of breathing 4Inability to clear the airway related to inability to expectorate sputum

A: Inability to clear the airway related to inability to expectorate sputum Rationale: COPD is a term that represents the pathology and symptoms that occur with clients experiencing both emphysema and chronic bronchitis. All of the problems listed are potentially appropriate for a client with COPD. For the nurse prioritizing this client's problems, it is important first to maintain circulation, airway, and breathing. At present, the client demonstrates problems with ventilation because of ineffective coughing, so the correct option would be the priority problem. The bilateral crackles would suggest fluid or sputum in the alveoli or airways; however, the client is unable to expectorate this sputum. The client's respiratory rate is only slightly elevated, so option 3, altered breathing pattern, is not as important as airway. The client is cyanotic, but this probably is because of the ineffective clearance of the sputum, causing poor gas exchange. The data in the question do not support low cardiac output as being most important at this time.

A client with a history of silicosis is admitted to the hospital with respiratory distress and impending respiratory failure. Which item(s) would the nurse place at the client's bedside? 1Code cart 2Intubation tray 3Thoracentesis tray 4Chest tube and drainage system

A: Intubation tray Rationale: The client with impending respiratory failure may need intubation and mechanical ventilation. The nurse ensures that an intubation tray is readily available. The other items are not needed at the client's bedside.

A chest x-ray report for a client indicates the presence of a left apical pneumothorax. The nurse would assess the status of breath sounds in that area by placing the stethoscope in which location? 1Just under the left clavicle 2Midsternum, 1 inch to the left 3Over the fifth intercostal space 4Midsternum, 1 inch to the right

A: Just under the left clavicle Rationale: The apex of the lung is the rounded, uppermost part of the lung. Therefore, the nurse would place the stethoscope just under the left clavicle. All of the other options are incorrect locations for assessing the left apex.

Which are possible causes of upper airway obstruction? Select all that apply. 1Thin secretions 2Laryngeal edema 3Head and neck cancer 4Foreign body aspiration 5Lymph node enlargement

A: Laryngeal edema Head and neck cancer Foreign body aspiration Lymph node enlargement Rationale: Obstruction of the upper airway can be due to obstruction by edema, a tumor, lymph node enlargement, or foreign body aspiration. Thick, not thin, secretions could obstruct the upper airway.

The nurse and an assistive personnel (AP) are assisting the respiratory therapist to position a client for postural drainage. The AP asks the nurse how the respiratory therapist selects the position to be used for the procedure. The nurse responds that a position is chosen that will use gravity to help drain secretions from which primary areas? 1Lobes 2Alveoli 3Trachea 4Main bronchi

A: Lobes Rationale: Postural drainage uses specific client positions that vary depending on the affected lobe or lobes. The positions usually place the head lower than the affected lung segments to facilitate drainage of secretions. Postural drainage often is done in conjunction with chest percussion for maximum effectiveness. The other options are incorrect.

The nurse is caring for a client with acute respiratory distress syndrome (ARDS). What would the nurse expect to note in the client? 1Pallor 2Low arterial Pao2 3Elevated arterial Pao2 4Decreased respiratory rate

A: Low arterial Pao2 Rationale: The earliest clinical sign of ARDS is an increased respiratory rate. Breathing becomes labored, and the client may exhibit air hunger, retractions, and cyanosis. Arterial blood gas analysis reveals increasing hypoxemia, with a Pao2 lower than 60 mm Hg.

The nurse is teaching a client with chronic obstructive pulmonary disease about positions that help breathing during dyspneic episodes. The nurse instructs the client to avoid which position, which would aggravate breathing? 1Sitting up and leaning on a table 2Standing and leaning against a wall 3Lying on the back in a low-Fowler's position 4Sitting up with the elbows resting on the knees

A: Lying on the back in a low-Fowler's position Rationale: The client would not lie on the back because this reduces movement of a large area of the client's chest wall. The client would use positions that allow for maximal chest expansion. Sitting, if possible, is better than standing. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing and not for posture control.

The nurse is teaching a client with chronic airflow limitation (CAL) about positions that help breathing during dyspneic episodes. Which position, assumed by the client, would indicate that the client needs additional teaching on positioning? 1Sitting up and leaning on a table 2Standing and leaning against a wall 3Sitting up with elbows resting on knees 4Lying on the back in a low-Fowler's position

A: Lying on the back in a low-Fowler's position Rationale: The client would use the positions outlined in options 1, 2, and 3. These allow for maximal chest expansion and decreased use of accessory muscles of respiration. The client would not lie on the back because it reduces movement of a large area of the client's chest wall. Sitting is better than standing, whenever possible. If no chair is available, leaning against a wall while standing allows accessory muscles to be used for breathing rather than posture control.

The nurse is reinforcing instructions to a client with pneumonia about the use of an incentive spirometer. The nurse tells the client to sustain the inhaled breath for 3 seconds. When the client asks the nurse about the rationale for this action, the nurse explains that which is the primary benefit? 1Dilate the major bronchi. 2Increase surfactant production. 3Maintain inflation of the alveoli. 4Enhance ciliary action in the tracheobronchial tree.

A: Maintain inflation of the alveoli. Sustained inhalation when using an incentive spirometer helps maintain inflation of the terminal bronchioles and alveoli, thereby promoting better gas exchange. Routine use of devices such as an incentive spirometer can help prevent atelectasis and pneumonia in clients at risk. The remaining options are not benefits for sustained inhalation.

The nurse is caring for a client who underwent a thoracentesis to treat pleural effusion. The pleural fluid testing results indicate the pleural fluid is cloudy and confirm the presence of white blood cells (WBCs). Which condition would the nurse suspect? 1Cirrhosis 2Malignancy 3Chronic kidney disease 4Congestive heart failure

A: Malignancy Rationale: Pleural effusion is a sign of an underlying disease process and the type of pleural fluid can provide information about what underlying disease is responsible for the effusion. Pleural fluid is described as transudative or exudative. Transudative pleural fluid is typically a clear, pale yellow fluid due to the lack of protein or cells in the fluid. Congestive heart failure, chronic liver disease such as cirrhosis, or renal disease may be the underlying cause of a transudative pleural effusion. Exudative fluid is cloudy due to the presence of WBCs and is a sign of an inflammatory or infectious process, including malignancy. In this situation, the pleural fluid is exudative since it is cloudy and WBCs are present. Since options 1, 3 and 4 are likely related to transudative, clear pleural fluid, option 2 is the correct answer.

The nurse in the emergency department is reviewing laboratory results for a client with carbon monoxide poisoning. The client's carboxyhemoglobin level is 25%. How would the nurse interpret the severity of carbon monoxide poisoning? 1Mild poisoning 2Fatal poisoning 3Severe poisoning 4Moderate poisoning

A: Moderate poisoning Rationale: Carbon monoxide is a colorless, odorless, and tasteless gas that is released into the air due to combustion. Carbon monoxide has a higher affinity for hemoglobin than oxygen, forming carboxyhemoglobin and thereby impeding the body's ability to oxygenate tissues. Laboratory testing to determine the severity of carbon monoxide poisoning is a serum carboxyhemoglobin level. A normal carbon monoxide, or carboxyhemoglobin, level is 1% to 10%. Mild poisoning is indicated by carbon monoxide levels ranging from 11% to 20%. Moderate poisoning is indicated by carbon monoxide levels ranging from 21% to 40%. Severe poisoning is indicated by carbon monoxide levels ranging from 41% to 60%. Lastly, fatal poisoning is indicated by carbon monoxide levels ranging from 61% to 80%. Therefore, a carboxyhemoglobin level of 25% indicates moderate carbon monoxide poisoning. Therefore, option 4 is correct.

The nurse is providing instructions to a client about diaphragmatic breathing. The nurse tells the client that this technique is helpful because in normal respiration, as the diaphragm contracts, it takes which action? 1Aids in exhalation 2Moves up and inward 3Moves downward and out 4Makes the thoracic cage smaller

A: Moves downward and out Rationale: As the diaphragm contracts, it moves downward and out, becoming flatter and expanding the thoracic cage, to promote lung expansion. This process occurs during the inspiratory phase of the respiratory cycle. The incorrect options occur with exhalation and relaxation of the diaphragm.

The nurse is caring for a client who is anxious and is experiencing dyspnea and restlessness from hypoxemia associated with pulmonary edema. Auscultation of the lungs reveals these breath sounds. The nurse determines that these breath sounds are usually caused by which condition? Refer to audio. 1Obstruction of the bronchus 2Inflammation of the pleural surfaces 3Passage of air through a narrowed airway 4Opening of small airways that contain fluid

A: Opening of small airways that contain fluid Rationale: The sounds that the nurse hears are high-pitched crackles. Crackles are audible when there is a sudden opening of small airways that contain fluid, are usually heard during inspiration, and do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema. High-pitched crackles are characteristically fine and are high-pitched, discontinuous popping noises (nonmusical sounds) heard during the end of inspiration. Medium-pitched crackles produce a moist sound about halfway through inspiration. Coarse crackles are low-pitched bubbling sounds that start early in inspiration and extend into the first part of expiration. Rhonchi (low-pitched, coarse, loud, low-snoring, or moaning sounds) are heard in conditions causing obstruction of the bronchus or trachea. A pleural friction rub (a superficial, low-pitched, coarse rubbing or grating sound) is heard when the pleural surfaces are inflamed. Passage of air through a narrowed airway is associated with wheezes (a high-pitched musical sound similar to a squeak).

The nurse is assessing a client's tracheostomy and notes that the skin around the stoma appears swollen with no redness or drainage present. Which action would the nurse take next? 1Palpate the skin around the stoma. 2Notify the primary health care provider (PHCP). 3Document the finding with no further intervention. 4Instruct the client to perform deep breathing exercises.

A: Palpate the skin around the stoma. Rationale: A complication of a tracheostomy is subcutaneous emphysema, in which air leaks into the subcutaneous tissue due to a misplaced tracheostomy tube. An important nursing assessment for the client with a tracheostomy is to examine the neck for swelling and then to palpate the swollen area. If subcutaneous emphysema is present, the nurse will feel a popping or crackling sensation when pressing on the skin. The nurse would then contact the PHCP for further interventions after collecting more assessment data. Therefore, option 1 is correct. Option 2 is appropriate after further assessing the area. Options 3 and 4 are inappropriate interventions for subcutaneous emphysema.

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 positioned for postural drainage, the nurse will perform which action to help loosen secretions? 1Palpation and clubbing 2Percussion and vibration 3Hyperoxygenation and suctioning 4Administer a bronchodilator and monitor peak flow

A: Percussion and vibration Rationale: Chest physiotherapy of percussion and vibration helps to loosen secretions in the smaller lower airways. Postural drainage positions the client so that gravity 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 will loosen secretions.

The nurse is assessing a client and notes unilateral swelling on the left side of the throat with deviation of the uvula toward the right side, halitosis, left-sided cervical lymphadenopathy, and fever. The client reports throat pain and difficulty swallowing. Which condition would the nurse suspect? 1Laryngitis 2Pharyngitis 3Rhinosinusitis 4Peritonsillar abscess

A: Peritonsillar abscess Rationale: Peritonsillar abscess can occur due to acute tonsillitis when the infection spreads from the tonsil to the surrounding area, resulting in abscess formation. Signs and symptoms include unilateral swelling of the throat due to pus collection in the abscess, which causes the uvula to deviate to the unaffected side; lymphadenopathy on the affected side; halitosis (bad breath); fever; severe throat pain with radiation to the ear or teeth; difficulty swallowing or breathing; and tonic contraction of the chewing muscles. Therefore, option 4 is correct. Based on the client's signs and symptoms, the nurse would suspect peritonsillar abscess rather than laryngitis, pharyngitis, or rhinosinusitis. Options 1, 2, and 3 are incorrect.

A client did not seek medical treatment for a previous respiratory infection, and subsequently an empyema developed in the left lung. The nurse would assess the client for which signs and symptoms associated with this problem? 1Pleural pain and fever 2Decreased respiratory rate 3Diaphoresis during the day 4Hyperresonant breath sounds over the left thorax

A: Pleural pain and fever Rationale: The client with empyema usually experiences dyspnea, increased respiratory rate, pleural pain, night sweats, fever, anorexia, and weight loss. There is a decrease in breath sounds over the affected area, a flat sound to percussion, and decreased tactile fremitus.

The nurse is assisting a radiologist to facilitate a thoracentesis for a client with pleural effusion. The nurse assists the client to a position that widens the spaces between the ribs to help drain which area? 1Alveoli 2Trachea 3Pleural space 4Main bronchi

A: Pleural space Rationale: Thoracentesis is the needle aspiration of fluid or air from the pleural space for diagnostic or management purposes. Thoracentesis may be done at the bedside and is often done with imaging for guidance. The other options are incorrect.

An emergency department nurse is performing a respiratory assessment on a client who is complaining of painful breathing. On palpation the nurse notes a coarse grating sensation during inspiration, and on auscultation the nurse hears this breath sound. The nurse interprets these findings as characteristic of which condition? Refer to audio. 1Asthma 2Pleurisy 3Emphysema 4Pulmonary edema

A: Pleurisy Rationale: The sound that the nurse hears is a pleural friction rub. A pleural friction rub is the result of pleural inflammation, often associated with pleurisy, pneumonia, or pleural infarction. It is a superficial, low-pitched, coarse rubbing or grating sound that sounds like two rough surfaces rubbing together. A pleural friction rub is heard throughout inspiration and expiration and is loudest over the lower anterolateral surface. It is not cleared by a cough. Disorders that cause airflow obstruction, such as emphysema or asthma, would produce high- or low-pitched wheezes (musical sounds similar to a squeak). Crackles occur with the sudden opening of small airways that contain fluid, usually are heard during inspiration, and do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema.

The nurse is assessing a client presenting with a productive cough, fever, chills, dyspnea, tachypnea, and chest pain that is worse with deep inspiration. Lung auscultation reveals bilateral crackles in the lower lobes. The client's chest x-ray (CXR) reveals bilateral pulmonary infiltrates in the lower lobes. Which condition would the nurse suspect? 1Sinusitis 2Laryngitis 3Bronchitis 4Pneumonia

A: Pneumonia Rationale: The nurse would suspect pneumonia, as pneumonia is characterized by a cough (which may or may not be productive), fever, chills, dyspnea, tachypnea, and inspiratory chest pain. Lung auscultation will reveal adventitious sounds, such as crackles. Options 1 and 2 are incorrect as the client data suggest a lower respiratory tract infection, and sinusitis and laryngitis are upper respiratory tract infections. Bronchitis and pneumonia share similar symptoms; however, the CXR for a client with acute bronchitis is normal and will not demonstrate infiltrates. Therefore, option 3 is incorrect. A CXR of a client with pneumonia will demonstrate infiltrates or the fluid buildup that occurs in this disease. Therefore, option 4 is correct.

The nurse is planning care for an 81-year-old unresponsive client admitted to the hospital with a medical diagnosis of pneumonia. The nurse has identified the problem of inability to clear the airway related to retained secretions. Which intervention is most appropriate? 1Initiate and maintain supplemental oxygen as prescribed. 2Plan activities with rest periods to conserve oxygen needs. 3Provide nasotracheal suctioning as needed to remove secretions. 4Monitor oxygenation (the oxygen saturation [SaO2]) during activity.

A: Provide nasotracheal suctioning as needed to remove secretions. Rationale: Ineffective airway clearance reflects the client's inability to expectorate secretions. The intervention specifically addressing retained secretions is the correct option. Options 1 and 4 are interventions addressing impaired problem with gas exchange. Option 2 is an intervention aimed at addressing a problem with activity intolerance.

A client with an endotracheal tube who is being mechanically ventilated is visibly anxious. What is the best nursing action? 1Ask a family member to stay with the client at all times. 2Encourage the client to sleep until arterial blood gas results improve. 3Ask the primary health care provider for a prescription for succinylcholine. 4Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed.

A: Provide reassurance to the client and give small doses of morphine sulfate intravenously as prescribed. Rationale: Morphine sulfate often is prescribed for pain and anxiety in the client receiving mechanical ventilation. The nurse needs to speak to the client calmly and provide reassurance to the anxious client. Family members also are stressed, not just because of the complication but because of the original injury. It is not beneficial to ask the family to take on the burden of remaining with the client at all times. Succinylcholine is a neuromuscular blocker but has no anti-anxiety properties. Encouraging the client to sleep until arterial blood gas results improve does nothing to reassure or help the client.

The nurse monitors the respiratory status of the client being treated for acute exacerbation of chronic obstructive pulmonary disease (COPD). Which assessment finding would indicate deterioration in ventilation? 1Cyanosis 2Hyperinflated chest 3Rapid, shallow respirations 4Coarse crackles auscultated bilaterally

A: Rapid, shallow respirations Rationale: An increase in the rate of respirations and a decrease in the depth of respirations together indicate deterioration in ventilation. Cyanosis is not a good indicator of oxygenation in the client with COPD. Cyanosis may be present in some but not all clients. A hyperinflated chest (barrel chest) and hypertrophy of the accessory muscles of the upper chest and neck are common features of chronic COPD. During an exacerbation, coarse crackles are expected to be heard bilaterally throughout the lungs but do not indicate deterioration in ventilation.

The nurse is assisting a client with a tracheostomy turn in bed when the tube gets caught under the client, causing the tracheostomy tube to be pulled out. The nurse calls a rapid response team (RRT) and attempts to replace the tracheostomy tube with the same size tube as the tube that was pulled out and is unsuccessful. While waiting for the RRT, which action would the nurse take? 1Auscultate bilateral breath sounds. 2Place the client in the low Fowler's position. 3Ventilate the client using a manual resuscitation bag with the stoma unoccluded. 4Reattempt the insertion with a tracheostomy tube that is one size smaller than the original tracheostomy tube.

A: Reattempt the insertion with a tracheostomy tube that is one size smaller than the original tracheostomy tube. Rationale: As part of the nursing care for a client with a tracheostomy, a tracheostomy kit with both a same-sized tube as the tube in place and a tube that is one size smaller than the tube in place, as well as an obturator and a curved Kelly clamp, needs to be kept at the bedside at all times in the event of accidental decannulation. During accidental decannulation and after asking for additional assistance, the nurse would insert an obturator into the same-sized tracheostomy tube and attempt to reinsert the tube into the stoma. If the nurse is unsuccessful, the nurse would attempt to perform the reinsertion procedure with a tracheostomy tube that is one size smaller than the original tube. Therefore, option 4 is correct. Option 1 would be an appropriate nursing assessment once the tracheostomy tube has been replaced to assess whether reinsertion has been successful and the client's airway is patent. Option 2 is incorrect because high Fowler's position, not low Fowler's position, is recommended for clients in respiratory distress. Option 3 is incorrect because manually ventilating the client with the stoma unoccluded would not ventilate the client, as the stoma would need to be occluded for the lungs to be ventilated.

A client with long-standing empyema undergoes decortication of the affected lung area. Postoperatively the nurse would place the client in which position? 1Supine 2Left-lateral 3Side-lying 4Semi-Fowler's

A: Semi-Fowler's Rationale: After any procedure involving lung surgery, the nurse would position the client in semi-Fowler's position. This position allows for maximal lung expansion and promotes drainage through the chest tube that may be placed during surgery. The positions identified in the remaining options will limit lung expansion.

The nursing student is reviewing the pathophysiology of carbon monoxide poisoning. After reviewing the material, how would the nursing student correctly interpret a carboxyhemoglobin level of 56%? 1Mild poisoning 2Fatal poisoning 3Severe poisoning 4Moderate poisoning

A: Severe Rationale: A normal carbon monoxide, or carboxyhemoglobin, level is 1% to 10%. Mild poisoning is indicated by carbon monoxide levels ranging from 11% to 20%. Moderate poisoning is indicated by carbon monoxide levels ranging from 21% to 40%. Severe poisoning is indicated by carbon monoxide levels ranging from 41% to 60%. Lastly, fatal poisoning is indicated by carbon monoxide levels ranging from 61% to 80%. Therefore, a carboxyhemoglobin level of 56% indicates severe carbon monoxide poisoning. Therefore, option 3 is correct.

A client with smoke inhalation is experiencing severe dyspnea, and the nurse listens to the client's breath sounds and hears this sound. The nurse would document this finding as which sound? Refer to audio. 1Stridor 2Crackles 3Rhonchi 4High-pitched wheezes

A: Stridor Rationale: The sound that the nurse hears is stridor. Stridor is a harsh, high-pitched sound associated with breathing and is the major manifestation of airway obstruction. The nurse immediately notifies the primary health care provider (PHCP). The nurse also places the client in a high-Fowler's position to aid in breathing and proper alignment of airway structures. The nurse then monitors the client, including vital signs, and prepares the client for endotracheal intubation or tracheostomy. Rhonchi (low-pitched, coarse, loud, low-snoring or moaning sounds) are heard in conditions causing obstruction of the bronchus or trachea. Crackles are audible when there is a sudden opening of small airways that contain fluid, are usually heard during inspiration, and do not clear with a cough. Crackles resemble the sound of a lock of hair being rubbed between the thumb and forefinger and are heard in conditions such as pulmonary edema. High-pitched crackles are characteristically fine and are high-pitched discontinuous popping noises (nonmusical sounds) heard during the end of inspiration. Medium-pitched crackles produce a moist sound about halfway through inspiration. Coarse crackles are low-pitched bubbling sounds that start early in inspiration and extend into the first part of expiration. High-pitched wheezes are musical sounds that predominate in expiration but may occur in both expiration and inspiration. They occur in the small airways and are heard in narrowed-airway diseases such as asthma or emphysema.

The nurse instructs a client with chronic obstructive pulmonary disease on pursed-lip breathing and asks the client to demonstrate the breathing technique. Which observation by the nurse would indicate that the client is performing the technique correctly? 1The client breathes in through the mouth. 2The client breathes out slowly through the mouth. 3The client avoids using the abdominal muscles to breathe out. 4The client puffs out the cheeks when breathing out through the mouth.

A: The client breathes out slowly through the mouth. Rationale: Pursed-lip breathing facilitates maximal expiration for clients with obstructive lung disease. The client would close the mouth and breathe in through the nose. The client then purses the lips and breathes out slowly through the mouth, without puffing the cheeks. The client would spend at least twice the amount of time breathing out that it took to breathe in. The client needs to use the abdominal muscles to assist in squeezing out all of the air. The client also is instructed to use this technique during any physical activity—to inhale before beginning the activity and exhale while performing the activity. The client is also instructed to never hold the breath.

A client tells the nurse that the primary health care provider (PHCP) has stated a diagnosis of silicosis. The nurse determines that which finding is consistent with this respiratory disorder? 1The client has reduced lung volume and fibrosis on chest x-ray. 2There is evidence of silica in the bloodstream but no clinical symptoms. 3The client has normal pulmonary function studies but has shortness of breath. 4Massive pulmonary fibrosis is visible on chest x-ray, and extrapulmonary symptoms are apparent.

A: The client has reduced lung volume and fibrosis on chest x-ray. Rationale: The client with silicosis has evidence of fibrosis on chest x-ray. Pulmonary function studies reveal some decreases in vital capacity and total lung volume. This disease is restricted to the respiratory system only.

The nurse caring for a client who has a pneumothorax notes continuous bubbling in the water seal chamber of the client's closed chest drainage system. How would the nurse interpret this finding? 1The drainage chamber is full. 2The pneumothorax is resolving. 3The suction chamber system is shut off. 4There is an air leak somewhere in the system.

A: There is an air leak somewhere in the system. Rationale: Continuous bubbling through both inspiration and expiration indicates that there is air leaking into the system. A resolving pneumothorax or a full drainage chamber would not cause bubbling with respiration in the water seal chamber. Shutting off the suction to the system stops bubbling in the suction control chamber but does not affect the water seal chamber.

The nurse in an ambulatory clinic is preparing to administer a tuberculin skin test to a client who may have been exposed to a person with tuberculosis (TB). The client reports having received the bacillus Calmette-Guérin (BCG) vaccine before moving to the United States from a foreign country. Which interpretation would the nurse make? 1The client has no risk of acquiring TB and needs no further workup. 2The client is at increased risk for acquiring TB and needs immediate medication therapy. 3The client's test result will be negative, and a sputum culture will be required for diagnosis. 4The client's test result will be positive, and a chest x-ray study will be required for evaluation.

A: The client's test result will be positive, and a chest x-ray study will be required for evaluation. Rationale: The BCG vaccine is routinely given in many foreign countries to enhance resistance to TB. The vaccine uses attenuated tubercle bacilli, so the results of skin testing in persons who have received the vaccine will always be positive. This client needs to be evaluated for TB with a chest radiographic study. The remaining options are incorrect interpretations.

The client is returned to the nursing unit following thoracic surgery to treat lung cancer with a chest tube in place. During the first few hours postoperatively, the nurse assesses for drainage and expects to note which characteristics? 1The drainage is serous. 2The drainage is bloody. 3The drainage is serosanguineous. 4The drainage is bloody, with frequent small clots.

A: The drainage is bloody. Rationale: In the first few hours after surgery the drainage from the chest tube is bloody. After several hours it becomes serosanguineous. The client would not experience frequent clotting. Proper chest tube function would allow for drainage of blood before it has the chance to clot in the chest or the tubing.

A client who has been diagnosed with pleurisy tells the nurse that it is painful to inhale. The nurse responds that this is an expected finding because of which physical response to this disorder? 1The stretch receptors in the lungs are irritated. 2The diaphragm is weak and is difficult to move. 3This condition causes nerve endings to be especially sensitive. 4The inflamed pleurae cannot glide against each other as they normally do.

A: The inflamed pleurae cannot glide against each other as they normally do. Rationale: Pleurisy is an inflammation of the visceral and parietal pleurae. The inflammation prevents the parietal and visceral pleural surfaces from gliding over each other with respiration. As a result, the client experiences pain, especially with inspiration. The remaining options are incorrect.

A client who is experiencing respiratory difficulty asks the nurse, "Why is it so much easier to breathe out than in?" In providing a response, the nurse explains that breathing is easier on exhalation because of which respiratory responses? 1Air flows by gravity. 2The respiratory muscles relax. 3The respiratory muscles contract. 4Air is flowing against a pressure gradient.

A: The respiratory muscles relax. Rationale: Exhalation is less taxing for the client because it is a passive process in which the respiratory muscles relax. This allows air to flow upward out of the lungs. Air flows according to a pressure gradient from higher pressure to lower pressure. It does not flow by gravity or against a pressure gradient.

The nursing instructor is reviewing the various complications of a tracheostomy. The nursing instructor determines teaching has been effective if the nursing student correctly identifies which of the following conditions as tracheal dilation and cartilage erosion? 1Tracheomalacia 2Tracheal stenosis 3Tracheoesophageal fistula (TEF) 4Trachea-innominate artery fistula

A: Tracheomalacia Rationale: Several complications can arise from the creation of a tracheostomy related to increased cuff pressure or tube positioning that result in impaired tissue integrity. Some of these complications include tracheomalacia, tracheal stenosis, TEF, and trachea-innominate artery fistula. Tracheal stenosis describes narrowing of the tracheal lumen due to growth of scar tissue in response to tissue irritation from the cuff. TEF describes erosion of the posterior tracheal wall from continuous, excessive cuff pressure that creates an opening between the trachea and anterior esophagus. Trachea-innominate artery fistula is a medical emergency that results from lateral malplacement of the tracheostomy tube that causes pressure and subsequent necrosis and erosion of the innominate artery. Tracheomalacia is tracheal dilation and cartilage erosion from continuous cuff pressure. Therefore, option 1 is correct.

Which position would best help the breathing of a client with chronic obstructive pulmonary disease (COPD)? 1Sitting position 2Tripod position 3Supine position 4High-Fowler's position

A: Tripod position Rationale: The tripod position (leaning forward with elbows flexed) helps to decrease the work of breathing in clients who have severe shortness of breath caused by asthma, COPD, or respiratory failure. Positioning the arms in this manner increases the anterior-posterior diameter of the chest, thereby changing the pressures within the chest cavity. The sitting position and high-Fowler's position decrease the anterior-posterior diameter. The supine position will make breathing more difficult.

The nursing instructor is reviewing the risk factors for upper airway obstruction with a group of nursing students. The nursing instructor determines there is a need for further teaching if the nursing student identifies which of the following as a risk factor? 1Neck burns 2Anaphylaxis 3Absent gag reflex 4Thin oral secretions

A:Thin oral secretions Rationale: There are several risk factors for upper airway obstruction. These include burns of the head or neck; anaphylaxis; absent gag reflex; upper airway abscesses; trauma of the face, trachea, or larynx; tongue occlusion; or edema and conditions with neurological sequelae, such as stroke or cerebral edema. Thick secretions that are poorly managed can harden into a crust and block the airway. Therefore, thick secretions, not thin secretions, increase the risk of airway obstruction. Therefore, option 4 is the correct answer, as this response would indicate a need for further teaching.