Subtopic Respiratory System
A postoperative client is being weaned from mechanical ventilation. What is the most important factor for the nurse to consider when organizing activities? 1 Remain with the client to assess responses. 2 Allow family members to participate in the process. 3 Permit the client more extended times alone for independence. 4 Observe monitoring devices at the control panel of the ventilator.
1 Remain with the client to assess responses. This is a critical time; the client's response to reduction of ventilator support must be observed closely and evaluated for signs of respiratory distress (e.g., shallow breathing, restlessness, use of accessory respiratory muscles, tachycardia, pallor, and tachypnea). Allowing family members to participate in the process delegates professional responsibility inappropriately. Permitting the client more extended times alone for independence will not ensure the client's safety. Observing monitoring devices at the control panel of the ventilator will not provide the client with support and professional assistance.
A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and should begin with which aspect of care? 1 The disease process and breathing exercises 2 How to control or prevent respiratory infections 3 Using aerosol therapy, especially nebulizers 4 Priorities in carrying out everyday activities
1 The disease process and breathing exercises Clients need to understand the disease process and how interventions, such as breathing exercises, can improve ventilation. Learning to control or prevent respiratory infections is important, but it should be taught later. Although it is helpful to know about aerosol therapy and nebulizers, knowing how to use aerosol therapy, especially nebulizers, should be taught later. Although it is important to teach the client how to set priorities in carrying out everyday activities, this should be taught later.
What order would the nurse follow for the assessment of the pharynx in a client with a respiratory disorder? 1. Palpate the lymph nodes. 2. Inspect the mouth. 3. Inspect the neck symmetry. 4. Assess the symmetry of enlarged tonsils, if present. 5. Observe the rise and fall of the soft palate.
1.Inspect the mouth. 2.Observe the rise and fall of the soft palate. 3.Assess the symmetry of enlarged tonsils, if present. 4.Inspect the neck symmetry. 5.Palpate the lymph nodes. The assessment of the pharynx begins with an inspection of the mouth. By using a tongue depressor, the posterior pharynx and the rise and fall of the soft palate are observed. The next step is to assess for edema or ulceration and the symmetry of the enlarged tonsils. The neck is inspected for symmetry, alignment, masses, swelling, bruises, and the use of accessory neck muscles in breathing. The last step is to palpate the lymph nodes for size, shape, mobility with palpation, consistency, and tenderness.
Which condition may lead to collapse of the walls of the bronchioles and alveolar air sacs? 1 Asthma 2 Emphysema 3 Chronic bronchitis 4 Centrilobular emphysema
2 Emphysema Emphysema is a condition in which a dysregulation of lung proteases may lead to the collapse of the walls of the bronchioles and alveolar air sacs. Asthma is a condition that involves a reversible airflow obstruction in the airways. In chronic bronchitis, infections or bronchial irritants cause increased secretions, edema, bronchospasm, and impaired mucociliary clearance. Centriacinar or centrilobular emphysema affect the respiratory bronchioles most severely.
A nurse is caring for a client who was admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease and is receiving oxygen at 2 L/min via nasal cannula. What is the primary focus of therapy when caring for this client? 1 Limiting hydration 2 Improving ventilation 3 Decreasing exogenous oxygen 4 Correcting the bicarbonate deficit
2 Improving ventilation Improving ventilation provides comfort, maintains existing lung function, and prevents further lung damage. Maintaining, not limiting, hydration thins secretions so that ventilation is improved. Oxygen administration should be maintained at no higher than 2 L per minute; this provides oxygen while preventing the development of CO2 narcosis. Bicarbonate usually is not given because the client probably is in compensated respiratory acidosis.
Which disorder would the nurse state is related to the tonsils? 1 Rhinitis 2 Sinusitis 3 Pharyngitis 4 Pneumonia
3 Pharyngitis Pharyngitis, or sore throat, is a common inflammation of the pharyngeal mucous membranes that often occurs with rhinitis and sinusitis. Rhinitis is an inflammation of the nasal mucosa. It is a common problem of the nose and often involves the sinuses. Sinusitis is an inflammation of the mucous membranes or of one or more of the sinuses and is usually associated with rhinitis. Rhinitis and sinusitis are disorders related to the nose and sinuses. Pneumonia is excess fluid in the lungs resulting from an inflammatory process.
Which statement is true regarding the Hering-Breuer reflex? 1 Increases tidal volume 2 Decreases respiratory rate 3 Prevents overdistension of the lungs 4 Reduces the number of functional alveoli
3 Prevents overdistension of the lungs The Hering-Breuer reflex prevents overdistention of the lungs. An increase in hydrogen ion concentration will cause an increase in the tidal volume via central chemoreceptors. A decrease in the hydrogen ion concentration will cause a decreased respiratory rate via peripheral chemoreceptors. The Hering-Breuer reflex does not cause a reduction in the number of functional alveoli.
A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and PCO2 of 60 mm Hg. These blood gases require nursing attention because they indicate which condition? 1 Metabolic acidosis 2 Metabolic alkalosis 3 Respiratory acidosis 4 Respiratory alkalosis
3 Respiratory acidosis The normal blood pH range is 7.35 to 7.45; therefore, a blood pH of 7.25 indicates acidosis. The parameter for respiratory function is CO2 and the acceptable range of arterial PCO2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated, resulting in respiratory acidosis. HCO3 is the parameter for metabolic functions. A pH of 7.25 is acidic, indicating acidosis and not alkalosis.
A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. Which precaution should the nurse take? 1 Put on a gown when entering the room 2 Place the client with another client who has TB 3 Wear a particulate respirator when caring for the client 4 Don a surgical mask with a face shield when entering the room
3 Wear a particulate respirator when caring for the client A high-particulate filtration mask that meets Centers for Disease Control (CDC) performance criteria (Canada: Public Health Agency of Canada [2013] Canadian Tuberculosis Standards, 7th edition) for a tuberculosis respirator must be worn to protect healthcare providers from exposure to the Mycobacterium tuberculosis organism. Airborne transmission-based precautions do not require a gown unless contact with respiratory secretions is anticipated. The client should be placed in a private room with negative pressure and multiple full air exchanges per hour vented to the outside environment. A surgical mask with a face shield is inadequate to prevent transmission of the tuberculosis microorganism.
A client is admitted to the hospital with a diagnosis of laryngeal cancer. What is a common early sign of laryngeal cancer for which the nurse should assess in this client? 1 Aphasia 2 Dyspnea 3 Dysphagia 4 Hoarseness
4 Hoarseness Hoarseness is caused by the inability of the vocal cords to move adequately during speech when a tumor exists. Aphasia refers to an expressive or receptive communication deficit as a result of cerebral disease; it is not related to laryngeal cancer. Dyspnea is a late, not early, adaptation that occurs with laryngeal cancer when a tumor is large enough to obstruct air flow. Dysphagia is a late, not early, adaptation that occurs when the tumor is large enough to compress the esophagus.
A client with a history of emphysema develops a respiratory infection and is admitted to the hospital in acute respiratory distress. The client's arterial blood studies indicate pH 7.30, PO2 60 mm Hg, PCO2 55 mm Hg, and HCO3 23 mEq/L (23 mmol/L). How should the nurse interpret these findings? 1 Hypocapnia 2 Hyperkalemia 3 Generalized anemia 4 Respiratory acidosis
4 Respiratory acidosis The client is experiencing respiratory acidosis. The pH is less than the norm of 7.35 to 7.45, indicating acidosis. The PO2 is less than the norm of 80 to 100 mm Hg. The PCO2 is increased more than the norm of 35 to 45 mm Hg. The HCO3 is within the norm of 21 to 28 mEq/L (21 to 28 mmol/L). These results indicate a respiratory etiology. The client's carbon dioxide level is increased (hypercapnia), not decreased. These values are unrelated to hyperkalemia; a serum potassium level of more than 5 mEq/L (5 mmol/L) indicates hyperkalemia. These values are unrelated to anemia; decreased levels of red blood cells (RBCs), hemoglobin, and hematocrit are related to anemia.
Which diagnostic test is being performed in this figure? (A nurse is reading a matching machine that is attached with a cord to a smaller machine clamped to the patient's index finger) 1 Capnometry 2 Capnography 3 Pulse oximetry 4 Pulmonary function test
A pulse oximeter uses a wave of infrared light via a sensor placed on the client's finger, toe, nose, earlobe, or forehead to identify hemoglobin saturation with oxygen. In this figure, the instrument is attached to the client's finger. Capnometry and capnography are methods that measure the amount of carbon dioxide present in exhaled air, an indirect measurement of arterial carbon dioxide levels. Pulmonary function tests (PFTs) assess lung function and breathing problems. In this procedure, the client is asked to breathe only through the mouth, and a nose clip may be used to prevent air from escaping through the nose.
