adult health prep U Exam 2
Which diagnostic imaging modality is more accurate than computed tomography in detecting malignancies?
PET
A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension?
Type II
A patient in the emergency department who presented with shortness of breath has been informed by her health care provider that her chest X-ray is suggestive of a pleural effusion. The health care provider recently outlined the proposed course of treatment, but the patient has just asked the nurse, "Can you tell me exactly what's wrong with me?" What response would be most accurate?
"Fluid has built up between your lungs and the lining that surrounds your lungs."
Which vitamin is usually administered with isoniazid (INH) to prevent INH-associated peripheral neuropathy
Vitamin B6
A nurse is assessing the injection site of a client who has received a purified protein derivative test. Which finding indicates a need for further evaluation?
15-mm induration
A 73-year-old client is admitted to the pulmonology unit of the hospital. She was admitted with pleural effusion and was "tapped" to drain the fluid to reduce her mediastinal pressure. How much fluid is typically present between the pleurae, which surround the lungs, to prevent friction rub?
20 ml or less
The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the client's needs?
Nasal cannula
The nurse assesses a patient for a possible pulmonary embolism. What frequent sign of pulmonary embolus does the nurse anticipate finding on assessment?
Tachypnea
A mediastinal shift occurs in which type of chest disorder?
Tension pneumothorax
The nurse is creating a plan of care for a client diagnosed with acute laryngitis. What intervention should be included in the client's plan of care?
encourage the client to limit speech whenever possible
Class 1 with regard to TB indicates
exposure and no evidence of infection
The occupational health nurse is obtaining a client history during a pre-employment physical. During the history, the client states that he has hereditary angioedema. The nurse should identify what implication of this health condition?
it can cause a airway obstruction
While caring for a client with an endotracheal tube, the nurse should normally provide suctioning how often?
when adventitious breath sounds are auscultated
The nurse is caring for a client with recurrent hemoptysis who has undergone a bronchoscopy. Immediately following the procedure, the nurse should complete which action?
assess the client for a cough reflex.
The nurse is caring for a client who is postoperative day 2 following a total laryngectomy for supraglottic cancer. The nurse should prioritize what assessment?
assessment of swallowing ability
what are the primary functions of the lungs?
gas exchange ventilation
A nurse is caring for a client with COPD who needs teaching on pursed-lip breathing. Place the steps in order in which the nurse will instruct the client.
"Inhale through your nose." "Slowly count to 3." "Exhale slowly through pursed lips." "Slowly count to 7."
The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk?
A temperature >100.4°F Swollen lymphoid follicles Red pharyngeal membranes White-purple exudates on the back of the throat
The public health nurse is administering Mantoux tests to children who are being registered for kindergarten in the community. How should the nurse administer this test?
Administer intradermal injections into each child's inner forearm
The nurse is interviewing a patient who says he has a dry, irritating cough that is not "bringing anything up." What medication should the nurse question the patient about taking?
Angiotensin converting enzyme (ACE) inhibitors
A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?
Auscultate the lung for adventitious sounds.
The nurse inspects the thorax of a patient with advanced emphysema. What does the nurse expect the chest configuration to be for this patient?
Barrel Chest
After a tonsillectomy, a client is being prepared for discharge. The nurse should instruct the client to report which sign or symptom immediately?
Bleeding "its always bleeding with the tonsillectomy"
A client is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this client?
Continuous positive airway pressure (CPAP)
The nurse is preparing to discharge a client after thoracotomy. The client is going home on oxygen therapy and requires wound care. As a result, he will receive home care nursing. What should the nurse include in discharge teaching for this client?
Correct and safe use of oxygen therapy equipment.
A client is being admitted to the preoperative holding area for a thoracotomy. Preoperative teaching includes what?
Correct use of incentive spirometry
The nurse is caring for a client with extensive respiratory disease. Which is a late sign of hypoxia the client may experience?
Cyanosis
The nurse is conducting a presurgical interview for a client with laryngeal cancer. The client states that he drinks approximately 20 oz (600 mL) of vodka per day. It is imperative that the nurse inform the surgical team so the client can be assessed for what?
Delirium tremens
The nurse hears the patient's ventilator alarm sound and attempts to find the cause. What is the priority action of the nurse when the cause of the alarm is not able to be determined?
Disconnect the patient from the ventilator and manually ventilate the patient with a manual resuscitation bag until the problem is resolved.
A 68-year-old male patient has been admitted to the surgical unit from the PACU after surgical repair of an inguinal hernia. When performing the patient's admission assessment, the nurse notes that the patient has a barrel chest. This assessment finding should suggest to the nurse that the patient may have a history of what health problem?
Emphysema
A patient comes to the clinic with complaints of a sore throat and is diagnosed with acute pharyngitis. What does the nurse understand is the cause of acute pharyngitis?
Group A, beta-hemolytic streptocci
A patient comes to the clinic and is diagnosed with tonsillitis and adenoiditis. What bacterial pathogen does the nurse know is commonly associated with tonsillitis and adenoiditis?
Group A, beta-hemolytic streptococcus
A client is scheduled for vocal cord stripping to treat a vocal cord lesion. Which statement indicates that the client has realistic postoperative expectations for this surgery?
I know that my voice will sound hoarse
A nurse is caring for a client who has a history of sleep apnea. The client understands the disease process when he says:
I should become involved in a weight loss program
A client is recovering from a tonsillectomy in the postanesthesia care unit. After an overnight stay in the hospital due to increased secretions and vomiting, the nurse delivers client education and accompanying paperwork. Which comment indicates that the client requires additional education?
If I'm vomiting I'll drink lemon lime soda to keep myself hydrated
A client is scheduled to have excess pleural fluid aspirated with a needle in order to relieve her dyspnea. The client inquires about the normal function of pleural fluid. What should the nurse describe?
It lubricates the movement of the thorax and lungs.
Following thoracic surgery, what should the nurse include in the care plan for a client at risk for impaired gas exchange? Select all that apply
Monitor vital signs frequently. Reinforce preoperative breathing exercises. Elevate head of bed 30 to 40 degrees as tolerated. Administer pain medications.
A client with chronic bronchitis is admitted to the health facility. Auscultation of the lungs reveals low-pitched, rumbling sounds. What breath sound should the nurse document?
Rhonchi
The nurse caring for a client recently diagnosed with lung disease encourages the client not to smoke. What is the primary rationale behind this nursing action?
Smoking damages the ciliary cleansing mechanism.
The home care nurse is assessing a client who requires home oxygen therapy. What criterion indicates that an oxygen concentrator will best meet the needs of the client in the home environment?
The client desires a portable oxygen delivery system that can deliver 2 L/min
While assessing the patient, the nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude?
The system has an air leak.
What would the critical care nurse recognize as a condition that may indicate a client's need to have a tracheostomy?
a client requires permanent ventilation.
A client is being treated for bacterial pharyngitis. Which of the following should the nurse recommend when promoting the client's nutrition during treatment?
a liquid or soft diet
A surgeon completes a total laryngectomy. Postoperatively, the nurse explains to the patient's family that:
a permanent tracheal stoma would be necessary
A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP?
administration of pneumococcal vaccine to vulnerable individuals
A first-line antibiotic used to treat acute bacterial rhinosinusitis (ABRS) is
amoxicillin clavulanic
A patient has herpes simplex infection that developed after having the common cold. What medication does the nurse anticipate will be administered for this infection?
an antiviral agent such as acyclovir
A patient is brought into the emergency department with carbon monoxide poisoning after escaping a house fire. What should the nurse monitor this patient for?
anemic hypoxia
A 13-year-old boy has been brought to the emergency department by his mother after he took a powerful blow to his nose during a volleyball game. Preliminary examination suggests a nasal fracture, which should prompt the nurse to:
apply ice and tell the patient to keep head elevated
A patient playing softball was hit in the nose by the ball and has been determined to have an uncomplicated fractured nose with epistaxis. The nurse should prepare to assist the physician with what tasks?
applying nasal packing
An adult client with cystic fibrosis is admitted to an acute care facility with an acute respiratory infection. The ordered respiratory treatment includes chest physiotherapy. When should the nurse perform this procedure? Select all that apply.
at bedtime before meals
An 87-year-old client has been hospitalized with pneumonia. Which nursing action would be a priority in this client's plan of care?
cautious hydration
Which of the following nursing interventions should a nurse perform when caring for a patient with an endotracheal tube?
clean teeth with applicators
What finding by the nurse may indicate that the client has chronic hypoxia?
clubbing of the fingers
Which assessment finding puts a client at increased risk for epistaxis?
cocaine use
The nurse is caring for an elderly client in the PACU. The client has had a bronchoscopy, and the nurse is monitoring for complications related to the administration of lidocaine. For what complication related to the administration of large doses of lidocaine in the elderly should the nurse assess?
confusion and lethargy
A client has been diagnosed with heart failure that has not yet responded to treatment. What breath sound should the nurse expect to assess on auscultation?
crackles
The nurse is caring for a patient with a pulmonary disorder. What observation by the nurse is indicative of a very late symptom of hypoxia?
cyanosis
For air to enter the lungs (process of ventilation), the intrapulmonary pressure must be less than atmospheric pressure so air can be pulled inward. Select the movement of respiratory muscles that makes this happen during inspiration.
diaphragm contracts and elongates the chest cavity
The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding?
document that the chest drainage is operating as it is intended
The nurse is assessing a client who has a chest tube in place for the treatment of a pneumothorax. The nurse observes that the water level in the water seal rises and falls in rhythm with the client's respirations. How should the nurse best respond to this assessment finding?
document that the chest drainage system is operating as it is intended
A client with unresolved hemothorax is febrile, with chills and sweating. He has a nonproductive cough and chest pain. His chest tube drainage is turbid. A possible explanation for these findings is:
empyema
A 60-year-old man has been diagnosed with obstructive sleep apnea (OSA) based on his clinical symptoms and polysomnographic findings. What intervention should the nurse perform to assist this patient in the management of his health problem?
encouraging the patient to avoid alcohol and hypnotic medications
Which is a priority nursing intervention that the nurse should perform for a client who has undergone surgery for a nasal obstruction?
ensure mouth breathing
A homeless client with streptococcal pharyngitis is being seen in a clinic. The nurse is concerned that the client will not continue treatment after leaving the clinic. Which of the following measures is the highest priority?
give that dirty homeless man a shot of penicillin
The nurse in a long-term-care facility is aware of the importance of preventing upper respiratory infections (URIs) among the residents of the facility. How is this best accomplished?
handwashing by staff and residents
The perioperative nurse has admitted a client who has just underwent a tonsillectomy. The nurse's postoperative assessment should prioritize which of the following potential complications of this surgery?
hemorrhage
A client is being assessed for acute laryngitis. The nurse knows that clinical manifestations of acute laryngitis include
hoarseness
The nurse is caring for a patient in the outpatient clinic with suspicion of cancer due to recent weight loss for unidentifiable reasons. The patient has a 25-year history of smoking. The nurse performs an assessment and asks the patient about symptoms related to laryngeal cancer. What is an early symptom associated with laryngeal cancer?
hoarseness "always with laryngeal cancer"
The nurse is performing client education for a client who is being discharged on mini-nebulizer treatments. What information should the nurse prioritize in the client's discharge teaching?
how to preform diaphragmatic breathing
The nurse is caring for a client who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the client?
how to splint the incision when coughing
The nurse is caring for a client in the ED for epistaxis. What information should the nurse include in client discharge teaching as a way to prevent epistaxis?
humidify the indoor environment
Which nursing diagnosis is most likely for a client who has just undergone a total laryngectomy?
impaired verbal communication
A client visiting the clinic is diagnosed with acute sinusitis. To promote sinus drainage, the nurse should instruct the client to perform what action?
increase fluid intake
The nurse is caring for a client who needs education on his medication therapy for allergic rhinitis. The client is to take cromolyn daily. In providing education for this client, how should the nurse describe the action of the medication?
it inhibits the of histamine and other chemicals
A patient taking isoniazid (INH) therapy for tuberculosis demonstrates understanding when making which statement?
its all right if I have a grilled cheese
The nurse recognizes that aspiration is a potential complication of a laryngectomy. How should the nurse best manage this risk?
keep a complete suction at the bedside
A client who has been diagnosed with an early glottis cancer would likely undergo which type of surgery?
laser microsurgery
The medical nurse is creating the care plan of an adult client requiring mechanical ventilation. What nursing action is most appropriate?
monitor cuff pressure every 8 hours
Computed tomography of a patient's chest is suggestive of a malignancy, but these results are not conclusive. As a result, the patient has been scheduled for a bronchoscopy. What patient education should the nurse provide for this patient regarding this diagnostic procedure?
monitor patient closely until gag reflex returns
The nurse is caring for a client who is experiencing mild shortness of breath during the immediate postoperative period, with oxygen saturation readings between 89% and 91%. What method of oxygen delivery is most appropriate for the client's needs?
nasal cannula
A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspects?
oxygen toxicity
A nurse assesses arterial blood gas results for a patient in acute respiratory failure (ARF). Which results are consistent with this disorder?
pH 7.28, PaO2 50 mm Hg
A patient has had a laryngectomy and was able to retain his airway, with no difficulty swallowing. There is no split of thyroid cartilage. The nurse would record this type of laryngectomy as which of the following?
partial laryngectomy
A patient is diagnosed as being in the early stage of laryngeal cancer of the glottis with only 1 vocal cord involved. For what type of surgical intervention will the nurse plan to provide education?
partial laryngectomy
A physician stated to the nurse that the client has fluid in the pleural space and will need a thoracentesis. The nurse expects the physician to document this fluid as
pleural effusion
Which type of pneumonia has the highest incidence in clients with AIDS and clients receiving immunosuppressive therapy for cancer?
pneumocystis
The nurse is assessing a client for obstructive sleep apnea (OSA). Which are signs and symptoms of OSA? Select all that apply
polycythemia loud snoring insomnia
What does a positive Mantoux test indicate?
production of an immune response
The nurse is performing preoperative teaching with a client who has cancer of the larynx. After explaining the most important information, what is the nurse's best action?
provide the client with audiovisual materials about the surgery
The nurse is teaching a client with allergic rhinitis about the safe and effective use of his medications. What would be the most essential information to give this client about preventing possible drug interactions?
read the drug label before taking the medication.
The home care nurse is monitoring a client discharged home after resolution of a pulmonary embolus. For what potential complication should the home care nurse be most closely monitoring this client?
residual effect of compromised oxygenation
A nurse has pharyngitis and will be providing self care at home. It is most important for the nurse to
seek medical help if he experiences inability to swallow
The nurse is admitting a client who just had a bronchoscopy. Which assessment should be the nurse's priority?
shallow reflex
The nurse is caring for a client who is to undergo a thoracentesis. In preparation for the procedure, the nurse places the client in which position?
sitting on the edge of the bed
A client asks a nurse a question about the Mantoux test for tuberculosis. The nurse should base her response on the fact that the
skin test doesn't differentiate between active and dormant tuberculosis infection.
A nurse is in the cafeteria at work. A fellow worker at another table suddenly stands up, leans forward with hands crossed at the neck, and makes gasping noises. The nurse first
stand behind the person choking
When the nurse gives a client and family instructions after laryngeal surgery, which does the nurse indicate should be avoided?
swimming
A nursing student is discussing a client with viral pharyngitis with the preceptor at the walk-in clinic. What should the preceptor tell the student about nursing care for clients with viral pharyngitis?
symptom management is the main focus of medical nursing care
A 4 year-old client has had recurrent episodes of bronchitis during the winter months. The client spends a significant amount of time outdoors enjoying the snow and breathes primarily through the mouth. What suggestion would the nurse most likely make to the client's mother?
teach the kid to breath through her nose
A client is visiting the emergency department because of massive bleeding from the nose that will not stop. Blood is on the client's shirt, and bleeding from the nose continues. The nurse intervenes by
telling the client to sit upright and tilt the head forward?
The nurse is providing care for a client who has just been admitted to the postsurgical unit following a laryngectomy. What assessment should the nurse prioritize?
the client's airway patency
A female patient with obstructive sleep apnea (OSA) has been recommended a continuous positive airway pressure (CPAP) machine for the treatment of her health problem. The nurse's priority for patient education should be:
the importance of complying with the cpap despite the inconvenience associated with its use
In relation to the structure of the larynx, which describes the cricoid cartilage?
the only complete cartilaginous ring in the larynx
Two months prior to a scheduled tonsillectomy, a client has a peritonsillar abscess related to a severe strep infection. After culturing the area and before receiving the results, the physician immediately prescribes a potent antibiotic. The physician is quick to prescribe a strong antibiotic to prevent:
the spread of microorganisms into the bloodstream
While assessing the client, the nurse observes constant bubbling in the water-seal chamber of the client's closed chest-drainage system. What should the nurse conclude?
the system has a air leak.
A client with chronic lung disease is undergoing lung function testing. What test result denotes the volume of air inspired and expired with a normal breath?
tidal volume
The amount of air inspired and expired with each breath is called:
tidal volume
Which hollow tube transports air from the laryngeal pharynx to the bronchi?
trachea
The nurse is caring for a client with suspected ARDS with a pO2 of 53. The client is placed on oxygen via face mask and the PO2 remains the same. What does the nurse recognize as a key characteristic of ARDS?
unresponsive arterial hypoxemia
Which intervention regarding nutrition is implemented for clients who have undergone laryngectomy?
use enteral feedings after procedure
It is cold season and the school nurse been asked to provide an educational event for the parent teacher organization of the local elementary school. What should the nurse include in teaching about the treatment of pharyngitis?
use of warm saline gargles or throat irrigations can relieve symptoms
A client with a severe exacerbation of COPD requires reliable and precise oxygen delivery. Which mask will the nurse expect the health care provider to prescribe?
venturi mask
The nurse is caring for a patient who had a total laryngectomy and has drains in place. When does the nurse understand that the drains will most likely be removed?
when the patient has less than 30 ml or less for 2 consecutive days
A client in the ICU is status post embolectomy after a pulmonary embolus. What assessment parameter should the nurse monitor most closely on a client who is postoperative following an embolectomy?
Pulmonary arterial pressure
A new influenza vaccine is developed annually from three different strains of "flu" virus expected to arrive in the upcoming flu season. Annual flu vaccines are recommended for healthcare workers, populations at high risk for developing complications, and those exposed to many different people daily. The flu vaccine is not recommended for individuals who:
chemo pt's, diabetic pt's, all of the above
The nurse auscultates crackles in a patient with a respiratory disorder. With what disorder would crackles be commonly heard?
collapsed alveoli
Patient's arterial blood gas analysis reveals a pH of 7.32 and a PCO2 of 60. Which of the following imbalances do these values reveal?
respiratory acidosis
Constant bubbling in the water seal of a chest drainage system indicates:
Air leak
Which of the following would be inconsistent with the respiratory system mechanisms leading to acute respiratory failure (ARF)?
Decreased dead space
The nurse is assessing a client who frequently coughs after eating or drinking. How should the nurse best follow up this assessment finding?
Preform a swallowing assessment
The nurse knows that a sputum culture is necessary to identify the causative organism for acute tracheobronchitis. What causative fungal organism would the nurse suspect?
aspergillus
The nurse knows that what condition is associated with increased compliance of the lungs?
emphysema
The nurse suctions a patient through the endotracheal tube for 20 seconds and observes dysrhythmias on the monitor. What does the nurse determine is occurring with the patient?
the patient is hypoxic from suctioning
A client is exhibiting signs of a pneumothorax following tracheostomy. The surgeon inserts a chest tube into the anterior chest wall. What should the nurse tell the family is the primary purpose of this chest tube?
to remove air from the pleural cavity
A nurse is assessing a client's respiratory system. Which alveolar cells secrete surfactant to reduce lung surface tension?
type 11
A patient has a Mantoux skin test prior to being placed on an immunosuppressant for the treatment of Crohn's disease. What results would the nurse determine is not significant for holding the medication?
0 to 4 mm
While planning a client's care, the nurse identifies nursing actions to minimize the client's pleuritic pain. Which intervention should the nurse include in the plan of care?
Avoid actions that will cause the client to breathe deeply.
A patient is admitted to the hospital with pulmonary arterial hypertension. What assessment finding by the nurse is a significant finding for this patient?
Dyspnea
A patient comes to the clinic with fever, cough, and chest discomfort. The nurse auscultates crackles in the left lower base of the lung and suspects that the patient may have pneumonia. What does the nurse know is the most common organism that causes community-acquired pneumonia?
Streptococcus pneumoniae
Postural drainage has been ordered for a client who is having difficulty mobilizing bronchial secretions. Before repositioning the client and beginning treatment, the nurse should perform what health assessment?
chest auscultation
The most diagnostic clinical symptom of pleurisy is
stabbing pain during respiratory movements
The nurse is caring for a client with a lower respiratory tract infection. When planning a focused respiratory assessment, the nurse should know that this type of infection most often causes what?
Impaired gas exchange
The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis?
Stabbing pain during respiratory movement
A nurse is preparing dietary recommendations for a client with a lung abscess. Which statement would be included in the plan of care?
"You must consume a diet rich in protein, such as chicken, fish, and beans.
The nurse is auscultating the patient's lung sounds to determine the presence of pulmonary edema. What adventitious lung sounds are significant for pulmonary edema?
Crackles in the lung bases
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?
increase the fluid intake
Following a chest X-ray, a patient has been diagnosed with a pleural effusion. The care team has concluded that the quantity of fluid in the patient's intrapleural space necessitates thoracentesis. What patient education should the nurse provide in anticipation of this procedure?
it is very important that you sit still.
The nurse is educating a patient with COPD about the technique for performing pursed-lip breathing. What does the nurse inform the patient is the importance of using this technique?
it prolongs exhalation
A 52-year-old mother of three has just been diagnosed with lung cancer. The health care provider discusses treatment options and makes recommendations to this patient. After the health care provider leaves the room, the patient asks the nurse how the treatment is decided on. What would be the nurse's best response?
"The type of treatment depends on the cell type of the cancer, the stage of the cancer, and the patient's health status."
A new employee asks the occupational health nurse about measures to prevent inhalation exposure to toxic substances. What should the nurse recommend?
"Wear protective attire and devices when working with a toxic substance.
After diagnosing a client with pulmonary tuberculosis, the physician tells family members that they must receive isoniazid (INH [Laniazid]) as prophylaxis against tuberculosis. The client's daughter asks the nurse how long the drug must be taken. What is the usual duration of prophylactic isoniazid therapy?
6 to 12 months
A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings?
84 mm Hg
The nurse at a long-term care facility is assessing each of the residents. Which resident most likely faces the greatest risk for aspiration?
A resident who suffered a severe stroke several weeks ago
A client presents to the ED after being in a boating accident about 3 hours ago. Now the client reports headache, fatigue, and the feeling that he "just can't breathe enough." The nurse notes that the client is restless and tachycardic with an elevated blood pressure. This client may be in the early stages of what respiratory problem?
Acute respiratory failure
A client with a pulmonary embolus has the following arterial blood gas (ABG) values: pH, 7.49; partial pressure of arterial oxygen (PaO2), 60 mm Hg; partial pressure of arterial carbon dioxide (PaCO2), 30 mm Hg; bicarbonate (HCO3-) 25 mEq/L. What should the nurse do first?
Administer oxygen by nasal cannula as ordered.
A hospital has been the site of an increased incidence of hospital-acquired pneumonia (HAP). What is an important measure for the prevention of HAP?
Administration of pneumococcal vaccine to vulnerable individuals
The nurse is caring for a client diagnosed with pneumonia. The nurse assesses the client for tactile fremitus by completing which action?
Asking the client to repeat "ninety-nine" as the nurse's hands move down the client's thorax
The home care nurse is planning to begin breathing retraining exercises with a client newly admitted to the home health service. The home care nurse knows that breathing retraining is especially indicated if the client has what diagnosis?
COPD
The nurse is caring for a client who is scheduled for a lobectomy for lung cancer. While assisting with a subclavian vein central line insertion, the nurse notes the client's oxygen saturation rapidly dropping. The client reports shortness of breath and becomes tachypneic. The nurse suspects a pneumothorax has developed. What further assessment findings support the presence of a pneumothorax?
Diminished or absent breath sounds on the affected side
A nurse on a postsurgical unit is aware of the high incidence of pulmonary embolism (PE) among hospitalized patients. What nursing action has the greatest potential to prevent PE among hospital patients?
Early ambulation and the use of compression stockings
To assist a patient with the use of an incentive spirometer, the nurse should:
Encourage the patient to pause after a deep breath, relax, and exhale
A patient arrives in the emergency department after being involved in a motor vehicle accident. The nurse observes paradoxical chest movement when removing the patient's shirt. What does the nurse know that this finding indicates?
Flail chest- During inspiration, as the chest expands, the detached part of the rib segment (flail segment) moves in a paradoxical manner (pendelluft movement) in that it is pulled inward during inspiration, reducing the amount of air that can be drawn into the lungs.
The nurse is caring for a client who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the client?
How to splint the incision when coughing
A nurse is caring for a client with chest trauma. Which nursing diagnosis takes the highest priority?
Impaired gas exchange
A critical-care nurse is caring for a client diagnosed with pneumonia as a surgical complication. The nurse's assessment reveals that the client has an increased work of breathing due to copious tracheobronchial secretions. What should the nurse encourage the client to do?
Increase oral fluids unless contraindicated
A client diagnosed with acute respiratory distress syndrome (ARDS) is restless and has a low oxygen saturation level. If the client's condition does not improve and the oxygen saturation level continues to decrease, what procedure will the nurse expect to assist with in order to help the client breathe more easily?
Intubate the client and control breathing with mechanical ventilation
A gerontologic nurse is teaching a group of medical nurses about the high incidence and mortality of pneumonia in older adults. What is a contributing factor to this that the nurse should describe?
Older adults often lack the classic signs and symptoms of pneumonia.
When giving oxygen to a hypoxic patient, the nurse must remember that oxygen transport is also dependent on the arterial oxygen content. Which of the following is a blood gas analysis that would indicate the presence of hypoxemia?
PaO2 < 60 mm Hg
The nurse is discussing activity management with a client who is postoperative following thoracotomy. What instructions should the nurse give to the client regarding activity immediately following discharge?
Perform shoulder exercises five times daily.
The nurse is assessing an adult client following a motor vehicle accident. The nurse observes that the client has an increased use of accessory muscles and is reporting chest pain and shortness of breath. The nurse should recognize the possibility of what condition?
Pneumothorax
A client has been discharged home after thoracic surgery. The home care nurse performs the initial visit and finds the client discouraged and saddened. The client states, "I am recovering so slowly. I really thought I would be better by now." What nursing action should the nurse prioritize?
Provide emotional support to the client and family
The nurse is caring for a client who has been in a motor vehicle accident and the care team suspects that the client has developed pleurisy. Which of the nurse's assessment findings would best corroborate this diagnosis?
The client's pain intensifies when he coughs or takes a deep breath
While auscultating the lungs of a client with asthma, the nurse hears a continuous, high-pitched whistling sound on expiration. The nurse will document this sound as which of the following?
Wheezes
A client is brought to the ED after aspirating large amounts of water and nearly drowning. This client is at risk for which complication as a result of this recent trauma?
acute respiratory distress syndrome (ARDS)
Understanding pulmonary physiology, what characteristic would the nurse expect to result in decreased gas exchange in older adults?
alceolarwalls containing fewer capillaries
A new ICU nurse is observed by her preceptor entering a patient's room to suction the tracheostomy after performing the task 15 minutes before. What should the preceptor educate the new nurse to do to ensure that the patient needs to be suctioned?
auscultate the lung for adventitious sounds
While conducting the physical examination during assessment of the respiratory system, which conditions does the nurse assess by inspecting and palpating the trachea?
deviation from the midline
Which of the following clinical manifestations should a nurse monitor for during a pulmonary angiography, which indicates an allergic reaction to the contrast medium?
difficulty in breathing
A client is being seen in the pediatric clinic for a middle ear infection. The client's mother reports that when the client develops an upper respiratory infection, an ear infection seems quick to follow. What contributes to this event?
eustachian tubes
A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?
hypercapnia, hypoventilation, and hypoxemia
The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result?
improve oxygen transport
A client is brought to the ED by ambulance after a motor vehicle accident in which the client received blunt trauma to the chest. The client is in acute respiratory failure, is intubated, and is transferred to the ICU. What assessment parameters should the nurse monitor most closely? Select all that apply.
level of consciousness, VS, Arterial blood gases
A critical care nurse is caring for a client with an endotracheal tube who is on a ventilator. The nurse knows that meticulous airway management of this client is necessary. What is the main rationale for this?
maintaining a patent airway
The nurse is caring for a client who is scheduled for a bronchoscopy. The nurse understands that it is important to provide the required information and appropriate explanations for any diagnostic procedure to a client with a respiratory disorder in a way that
manges decreased energy levels
The nurse is caring for a client who is receiving oxygen therapy for pneumonia. The nurse should best assess whether the client is hypoxemic by monitoring the client's:
o2 level
A nurse practitioner diagnosed a patient with an infection in the maxillary sinuses. Select the area that the nurse palpated to make that diagnosis.
on the cheeks below the eyes
The nurse is performing an assessment for a patient with congestive heart failure. The nurse asks if the patient has difficulty breathing in any position other than upright. What is the nurse referring to?
orthopnea
A patient comes to the emergency department complaining of a knifelike pain when taking a deep breath. What does this type of pain likely indicate to the nurse?
pleurisy
Preventing falls in older adults directly correlates to preventing bone fractures. If an older adult falls and fractures one or more ribs, what is a possible complication that could develop after the fracture?
pneumonia
The clinical finding of pink, frothy sputum may be an indication of which condition?
pulmonary edema
When interpreting the results of a Mantoux test, the nurse explains to the client that a reaction occurs when the intradermal injection site shows
redness and induration.
The nurse is caring for a client who is ready to be weaned from the ventilator. In preparing to assist in the collaborative process of weaning, the nurse should anticipate that the weaning of the client will progress in what order?
removal form the ventilator, tube, and oxygen
The nurse has assessed a client's family history for three generations. The presence of which respiratory disease would justify this type of assessment?
Asthma
Which intervention does a nurse implement for clients with empyema?
Encourage breathing exercises
Which interventions does a nurse implement for clients with empyema?
Encourage breathing exercises
