Acute Upper & Lower Resp Disorder Unit

A nurse is caring for a client who develops a PE. Which of the following interventions is the priority for the nurse to take? a. Administer IV morphine. b. Begin oxygen therapy. c. Start an IV infusion of lactated Ringer's. d. Initiate cardiac monitoring.

b. Begin oxygen therapy. rational: When using the airway, breathing, circulation approach to client care, the nurse determines that the priority is administering oxygen therapy to the client to alleviate difficulty breathing and treat hypoxia.

A nurse is caring for a client who is 1 day post op following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The client's SiO2 is 89%. ABG results are pH 7.31, PaO2 93 mmHg, PCO2 50 mmHg, HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse? a. ​Switch oxygen to a nonrebreather mask. b. Increase oxygen to 70%. c. Place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing. d. Position the client prone and have the respiratory therapist perform postural drainage.

c. Place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing. rational: Positioning the client to improve gas exchange by deep-breathing, coughing, and removal of secretions may resolve the problem and is an appropriate action by the nurse.

A nurse is collecting data from a client who has respiratory disorder and displays manifestations of hypoxia. Which of the following findings should the nurse expect? a. ​Bradycardia ​b. Bradypnea ​c. Pallor ​d. Cyanosis

d. Cyanosis rational: A client who is hypoxic will eventually develop cyanosis due to insufficient oxygen in the body, known as hypoxia.

A nurse is caring for a client who has a chest tube inserted for a pneumothroax. Which of the following actions should the nurse take? a. Empty the collection chamber on the client's chest tube every 4 hr. b. Strip the client's chest tube every 2 hr. c. Pin the chest tube to the client's gown. d. Tape the connections on the client's chest tube.

d. Tape the connections on the client's chest tube. rational: The nurse should securely tape all connections on the client's chest tube to maintain a closed system and prevent a break in the connection.

A nurse is monitoring a child who is postoperative following a tonsillectomy for signs of hemorrhage. Which of the following findings is a sign of this postoperative complication? a. ​Mouth breathing ​b. Frequent swallowing c. ​Reports of thirst d. ​Reports of pain

​b. Frequent swallowing rational: ​Frequent swallowing and throat clearing are signs of hemorrhage after a tonsillectomy.

A nurse is reinforcing teaching with a newly licensed nurse about the manifestations of hypoxia. Which of the following findings should the nurse include in the teaching? a. ​Nausea ​b. Dysphagia ​c. Agitation d. Warm, dry skin

​c. Agitation rational: Manifestations of hypoxia include agitation and restlessness due to neurological changes from poor oxygen exchange.

A nurse is reinforcing teaching with a client who has pleurisy. Which of the following statement by the client indicates an understanding of the teaching? a. "I should lie on the affected side." b. "This condition is chronic." c. "I should take shallow breaths while I have pleurisy." d. "I should expect to develop a fever and a productive cough."

a. "I should lie on the affected side." rational: Lying on the affected side may provide relief of discomfort. (Power point says the splint the affected side when coughing to relieve some of the pain during the cough)

A nurse is collecting data from a client who has a new chest tube that is attached to closed chest water-seal drainage and suction. The nurse should report which of the following findings to the charge nurse? a. Continuous bubbling in the water-seal chamber b. Occasional bubbling in the water-seal chamber c. Constant bubbling in the suction-control chamber d. Fluctuations in the fluid level in the water-seal chamber

a. Continuous bubbling in the water-seal chamber rational: Excessive and continuous bubbling in the water-seal chamber indicates an air leak in the drainage system. The nurse should report this finding to the provider or charge nurse.

A nurse is contributing to the care plan of an older adult client who has pneumonia. Which of the following interventions should the nurse include in the plan? a. Encourage fluid intake of 2.5 L per day. b. Assist the client to cough and deep breathe every 4 hr. c. Encourage independence in completing ADLs. d. Use an N-95 respirator when providing client care.

a. Encourage fluid intake of 2.5 L per day. rational: Increasing fluid intake for the client who has pneumonia will assist in breaking up the consolidation in the lungs by thinning the mucous, allowing the client to cough more effectively.

A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the following snacks should the nurse offer the client? a. Orange ice pop b. Hot tea c. Ice cream d. Cranberry juice

a. Orange ice pop rational: clear, cold fluid helps decrease swelling and pain in the operative area

A client with laryngeal cancer has a partial laryngectomy and tracheostomy. To best facilitate communication postoperatively, the nurse should: a. Provide a means for the client to write. b. Allow the client more time for articulation. c. Use visual clues, such as gestures and objects. d. Face the client and speak slowly and distinctly.

a. Provide a means for the client to write. rational: The client will be unable to speak because a tracheostomy tube is in place to prevent edema.

A nurse is collecting data from a client who has shallow respirations and a respiratory rate of 9/min. Which of the following acid-base imbalances should the nurse expect? a. Respiratory acidosis b. Respiratory alkalosis c. Metabolic acidosis d. Metabolic alkalosis

a. Respiratory acidosis rational: Respiratory acidosis represents an increase in the acid component, carbon dioxide, due to inadequate excretion, and an increase in the hydrogen ion concentration (decreased pH) of the arterial blood. A major cause of this imbalance is hypoventilation.

A nurse is assisting with teaching a client who has a history of smoking about recognizing early manifestations of laryngeal cancer. The nurse should instruct the client to monitor and report which of the following manifestations of laryngeal cancer? a. Aphagia b. Hoarseness c. Tinnitus d. Epistaxis

b. Hoarseness rational: Laryngeal cancer is often caused by chronic exposure to tobacco and alcohol. Persistent hoarseness is an early manifestation of cancer of the larynx because the presences of a tumor can impede the action of the vocal cords during speech.

A nurse is caring for a client who is postoperative and has developed atelectasis. Which of the following findings should the nurse expect? a. Facial flushing b. Increasing dyspnea c. Decreasing respiratory rate d. Dry cough

b. Increasing dyspnea rational: Atelectasis is a closure or collapse of the alveoli due to obstruction or hypoventilation, causing shortness of breath and pleural pain.

The nurse is caring for a client who has pneumothorax and a water seal chest tube drainage system to suction. Which of the following actions should the nurse take? a. Add tap water as needed to the suction control chamber. b. Maintain the drainage container below the level of the client's chest. c. Empty the collection container every shift. d. Clamp the chest tubes if it becomes disconnected

b. Maintain the drainage container below the level of the client's chest. rational: Keeping the drainage collection container below the level of the client's chest prevents the back-flow of fluid into the client's chest.

A nurse is reviewing the laboratory results of a client who is postoperative and has respiratory rate of 7/min. The arterial blood gas (ABG) values include a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis

b. Respiratory acidosis rational: The nurse should identify the client who has respiratory problems such as obstruction or depression of the respiratory system as at risk for the development of respiratory acidosis. The expected pH range is 7.35 to 7.45. The pH of 7.22 indicates that this client is acidotic. The pH is decreased while the PaCO2 is elevated. Therefore, the correct interpretation of the results is that the client is in respiratory acidosis.

A nurse is caring for a client who is scheduled to undergo thoracentesis. In which of the following positions should the nurse place the client for the procedure? a. Prone with arms raised over the head. b. Sitting, leaning forward over the bedside table. c. High Fowler's position d. Side-lying with knees drawn up to the chest.

b. Sitting, leaning forward over the bedside table. rational: Thoracentesis is aspiration of fluid or air from the pleural space. The nurse should place the client in a sitting position and leaning over a bedside table to ensure that the diaphragm is dependent. This facilitates the removal of accumulated fluid, which tends to pool in the bases of the pleural space.

A nurse is reinforcing teaching with a client who is obese and has obstructive sleep apnea about how to decrease the number of apneic episodes he has each night. Which of the following statements should the nurse identify as an indication that the client understands the instructions? a. "I'll use a humidifier beside my bed at night." b. "I'll sleep better if I take a sleeping pill at night." c. "I am going to try to lose about 50 pounds." d. "I am going to have a glass of red wine before bedtime."

c. "I am going to try to lose about 50 pounds." rational: Weight loss and maintaining an optimum weight help decrease the number of apneic episodes per night or completely eliminate them.

A nurse is assisting with the care of a client who has multiple injuries following a motor vehicle crash. The nurse should monitor for which of the following manifestations of a pneumothorax? a. Inspiratory stridor b. Expiratory wheeze c. Absence of breath sounds d. Coarse crackles

c. Absence of breath sounds rational: A client who has a pneumothorax will have diminished or absent breath sounds on the affected side due to partial or total collapse of the lung.

A nurse is assisting with monitoring a client following a bronchoscopy. Which of the following actions should the nurse identify as the priority? a. Checking the client's temperature b. Auscultating heart sounds c. Confirming presence of a gag reflex d. Measuring blood pressure

c. Confirming presence of a gag reflex rational: The priority action the nurse should take when using the airway, breathing, circulation approach to client care is to confirm that the client has a gag reflex. Absence of the gag reflex places the client at risk for impaired airway from aspiration.

A nurse is caring for a client who has pneumonia. Which of the following actions should the nurse take to thin the client's respiratory secretions? a. Encourage the client to ambulate more often. b. Encourage coughing and deep breathing. c. Encourage the client to drink more fluids. d. Encourage regular use of the incentive spirometer.

c. Encourage the client to drink more fluids. rational: Fluids help liquefy and thin pulmonary secretions, which facilitates expectoration to clear the airways. The client should drink 1,500 to 2,500 mL/day to keep secretions thin.

A nurse at a provider's office is collecting data from a client who reports taking pseudoephedrine for sinus problems. The nurse should recognize that which of the following conditions from the client's history places the client at risk for harm while taking pseudoephedrine? a. Eczema b. Migraine headaches c. Hypertension d. Overweight

c. Hypertension rational: Sympathomimetic medications, like pseudoephedrine, can cause systemic vasoconstriction, which could be harmful for clients who have cardiovascular disorders. The risk is higher for oral medications than topical formulations. Therefore, the nurse should notify the provider and warn the client of the potential hazard.

A nurse is caring for a client who has HTN and experiences acute epistaxis. What is the sequence of steps the nurse should follow when caring for this client? (Put steps in correct order) a. Apply direct pressure to the client's nares. b. Place ice on the bridge of the client's nose. c. Initiate standard precautions for the client. d. Tilt the client's head forward.

c. Initiate standard precautions for the client. d. Tilt the client's head forward. a. Apply direct pressure to the client's nares. b. Place ice on the bridge of the client's nose.

A client develops a nosebleed (epistaxis) and seeks treatment at a first-aid station. The nurse can help control the bleeding by: a. Tilting the head backward b. Packing the nose with tissue c. Pinching the nostrils together d. Instructing the client to blow the nose gently

c. Pinching the nostrils together rational: Pinching the nostrils together places pressure on the bleeding vessel, which can help control the bleeding.

A nurse is caring for a client after a radical neck dissection. To which of the following should the nurse give priority in the immediate postoperative period? a. Malnourishment related to NPO status and dysphagia b. Impaired verbal communication related to the tracheostomy c. High risk for infection related to surgical incisions d. Ineffective airway clearance related to thick, copious secretions

d. Ineffective airway clearance related to thick, copious secretions rational: According to the airway, breathing, circulation (ABC) priority-setting framework, the priority action is the client's need for adequate oxygenation. A client who has a new tracheostomy requires frequent suctioning in the early postoperative period because of copious secretions and the decreased effectiveness of the cough mechanism.