Chapter 21 Prep U Questions

The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse will notify the primary provider if drainage is _____ or greater.

50 mL/hr

Which of the following is a potential complication of a low pressure in the ET cuff?

Aspiration pneumonia

A nurse provides care for a client receiving oxygen from a nonrebreather mask. Which nursing intervention has the highest priority?

Assessing the client's respiratory status, orientation, and skin color

Which of the following ventilator modes provides full ventilatory support by delivering a present tidal volume and respiratory rate?

Assist control

The nurse assesses an adult client and observes that the client's breathing pattern is very labored and noisy, with occasional coughing. The nurse should refer the client to a physician for possible

Chronic bronchitis.

A nurse is caring for a client who has a tracheostomy and temperature of 103° F (39.4° C). Which intervention will most likely lower the client's arterial blood oxygen saturation? a) Use of a cooling blanket b) Encouragement of coughing c) Incentive spirometry d) Endotracheal suctioning

Endotracheal suctioning Endotracheal suctioning removes secretions as well as gases from the airway and lowers the arterial oxygen saturation (SaO2) level. Coughing and using an incentive spirometer improve oxygenation and should raise or maintain oxygen saturation. Because of superficial vasoconstriction, using a cooling blanket can lower peripheral oxygen saturation readings, but SaO2 levels wouldn't be affected.

What would the nurse expect to hear when auscultating the lungs of a client with pleuritis?

Friction rub.

The nurse should monitor a client receiving mechanical ventilation for which of the following complications?

Gastrointestinal hemorrhage

Which ventilator mode provides a combination of mechanically assisted breaths and spontaneous breaths? a) Assist-control b) Synchronized intermittent mandatory ventilation (SIMV) c) Pressure support d) Intermittent mandatory ventilation (IMV)

Intermittent mandatory ventilation (IMV) Intermittent mandatory ventilation (IMV) provides a combination of mechanically assisted breaths and spontaneous breaths. Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths. Pressure support ventilation assists SIMV by applying a pressure plateau to the airway throughout the patient-triggered inspiration to decrease resistance within the tracheal tube and ventilator tubing.

For a client who has a chest tube connected to a closed water-seal drainage system, the nurse should include which action in the care plan? a) Measuring and documenting the drainage in the collection chamber b) Maintaining continuous bubbling in the water-seal chamber c) Keeping the collection chamber at chest level d) Stripping the chest tube every hour

Measuring and documenting the drainage in the collection chamber The nurse should regularly measure and document the amount of chest tube drainage to detect abnormal drainage patterns, such as may occur with a hemorrhage (if excessive) or a blockage (if decreased). Continuous bubbling in the water-seal chamber indicates a leak in the closed chest drainage system, which must be corrected. The nurse should keep the collection chamber below chest level to allow fluids to drain into it. The nurse shouldn't strip chest tubes because doing so may traumatize the tissue or dislodge the tube.

A client abruptly sits up in bed, reports having difficulty breathing and has an arterial oxygen saturation of 88%. Which mode of oxygen delivery is most likely to reverse these manifestations? a) Nasal cannula b) Face tent c) Simple mask d) Nonrebreather mask

Nonrebreather mask A nonrebreather mask can deliver levels of the fraction of inspired oxygen (FIO2) as high as 100%. Other modes — simple mask, face tent, and nasal cannula — deliver lower levels of FIO2.

A patient has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the patient complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect?

Oxygen toxicity

A client reports sharp and stabbing chest pain that worsens with deep breathing and coughing. A cardiac cause to this pain is ruled out. The description of the pain is consistent with what respiratory condition?

Pleurisy.

n general, chest drainage tubes are not indicated for a patient undergoing which of the following procedures?

Pneumonectomy

While assessing the thoracic area of an adult client, the nurse plans to auscultate for voice sounds. To assess bronchophony, the nurse should ask the client to

Repeat the phrase "ninety-nine."

When percussing the posterior lung fields, which of the following findings is expected?

Resonance over all lung fields.

The home care nurse is visiting a patient newly discharged home after a lobectomy. What would be most important for the home care nurse to assess? a) The family's willingness to care for the patient b) Resumption of the patient's ADLs c) Signs and symptoms of respiratory complications d) Nutritional status and fluid balance

Signs and symptoms of respiratory complications The nurse assesses the patient's adherence to the postoperative treatment plan and identifies acute or late postoperative complications. All options presented need assessment, but respiratory complications are the highest priority because they affect the patient's airway and breathing.

Which of the following occurs in respiratory distress?

Skin between the ribs moves inward with inspiration.

When preparing to examine a client's thoracic cage, the nurse would locate which landmark as most helpful in determining where to start?

Sternal angle.

A client with myasthenia gravis is receiving continuous mechanical ventilation. When the high-pressure alarm on the ventilator sounds, what should the nurse do?

Suction the client's artificial airway.

A client is prescribed postural drainage because secretions are accumulating in the upper lobes of the lungs. The nurse instructs the client to:

Take prescribed albuterol (Ventolin) before performing postural drainage.

The staff educator from the hospital's respiratory unit is providing a public educational event. The educator is talking about health promotion activities for people with respiratory diseases or those who are at high risk for respiratory complications. What would the educator include in the presentation?

Teaching strategies to reduce complications of existing diagnoses.

An adult client visits the clinic and tells the nurse that he has been "spitting up rust-colored sputum." The nurse should refer the client to the physician for possible

Tuberculosis.

Which of the following is the most reliable and accurate method for delivering precise concentrations of oxygen through noninvasive means

Venturi mask

The nurse is caring for a patient in the ICU who is receiving mechanical ventilation. Which of the following nursing measures are implemented in an effort to reduce the patient's risk of developing ventilator-associated pneumonia (VAP)?

cleaning the pts mouth with chlorhexidine daily

Which of the following would indicate a decrease in pressure with mechanical ventilation?

increase in compliance

In general, chest drainage tubes are not used for the patient undergoing

pneumonectomy

In general, chest drainage tubes are not used for the patient undergoing

pneumonectomy.

The nurse is caring for a patient following a wedge resection. While the nurse is assessing the patient's chest tube drainage system, constant bubbling is noted in the water seal chamber. This finding indicates which of the following problems? a) Tension pneumothorax b) Tidaling c) Increased drainage d) Air leak

Air leak The nurse needs to observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. Tidaling is fluctuation of the water level in the water seal that shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent.

The nurse is preparing to auscultate the posterior thorax of an adult female client. The nurse should

Ask the client to breathe deeply through her nose.

A 62-year-old construction worker presents to the clinic reporting almost a chronic cough and occasional shortness of breath that have lasted for almost 1 year. Although symptoms have occasionally worsened with a cold, they have stayed about the same. The cough has occasional mucus drainage but never any blood. He denies any chest pain. He has had no weight gain, weight loss, fever, or night sweats. His past medical history is significant for high blood pressure and arthritis. He has smoked two packs a day for the past 45 years. He drinks occasionally but denies any illegal drug use. He is married with two children. He denies any foreign travel. His father died of a heart attack and his mother died of Alzheimer's disease. Examination reveals a man looking slightly older than his stated age. His blood pressure is 130/80 and his pulse is 88. He is breathing comfortably with respirations of 12. His head, eyes, ears, nose, and throat examinations are unremarkable. His cardiac examination is normal. On examination of his chest, the diameter seems enlarged. Breath sounds are decreased throughout all lobes. Rhonchi are heard over all lung fields. There is no area of dullness and no increased or decreased fremitus. What thorax or lung disorder is most likely causing his symptoms?

Chronic obstructive pulmonary disease (COPD).

Upon inspection of a client's chest, a nurse observes an increase in the anterior posterior diameter. The nurse recognizes this as a finding in which disease process?

Chronic obstructive pulmonary disease.

The nurse is assessing a patient 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 patient's respirations. How should the nurse best respond to this assessment finding? a) Document that the chest drainage system is operating as it is intended. b) Gently reinsert the chest tube 1 to 2 cm and observe if the water level stabilizes. c) Inform the physician promptly that there is in imminent leak in the drainage system. d) Encourage the patient to do deep breathing and coughing exercises.

Document that the chest drainage system is operating as it is intended. Fluctuation of the water level in the water seal shows effective connection between the pleural cavity and the drainage chamber and indicates that the drainage system remains patent. No further action is needed.

A client is postoperative and prescribed an incentive spirometer (IS). The nurse instructs the client to:

Expect coughing when using the spirometer properly.

A client comes to the clinic and states, "I have a bad cold and am having trouble breathing." The nurse checks the client's breath sounds and hears bilateral fine crackles at the base. Of what is this finding indicative?

Fluid in the alveoli.

A nurse asks a client to say "ninety-nine" as the nurse palpates the posterior thorax. The nurse is assessing which of the following?

Fremitus.

A client has a history of emphysema. The nurse percusses the chest, expecting to find which of the following?

Hyperresonance.

A nurse is attempting to wean a client after 2 days on the mechanical ventilator. The client has an endotracheal tube present with the cuff inflated to 15 mm Hg. The nurse has suctioned the client with return of small amounts of thin white mucus. Lung sounds are clear. Oxygen saturation levels are 91%. What is the priority nursing diagnosis for this client?

Impaired gas exchange related to ventilator setting adjustments

Auscultation of a 23-year-old client's lungs reveals an audible wheeze. What pathological phenomenon underlies wheezing?

Narrowing or partial obstruction of an airway passage.

A young male client has muscular dystrophy. His PaO2 is 42 mm Hg with a FiO2 of 80%. Which of the following treatments would be least invasive and most appropriate for this client?

Negative-pressure ventilator

A client with end-stage chronic obstructive pulmonary disease (COPD) requires bi-level positive airway pressure (BiPAP). While caring for the client, the nurse determines that bilateral wrist restraints are required to prevent compromised care. Which client care outcome is associated with restraint use in the client who requires BiPAP?

The client will maintain adequate oxygenation.

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? a) The patient is in a hypermetabolic state. b) The patient is hypoxic from suctioning. c) The patient is having a myocardial infarction. d) The patient is having a stress reaction.

The patient is hypoxic from suctioning. Apply suction while withdrawing and gently rotating the catheter 360 degrees (no longer than 10-15 seconds). Prolonged suctioning may result in hypoxia and dysrhythmias, leading to cardiac arrest.

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:

a compromised skin graft.

Fluctuations in the ______ are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respiration

water-seal compartment

The nurse is caring for a patient in the ICU who required emergent endotracheal (ET) intubation with mechanical ventilation. The nurse receives an order to obtain arterial blood gases (ABGs) following the procedure. The nurse recognizes that ABGs should be obtained at which timeframe following the initiation of mechanical ventilation?

20 minutes

A client in acute respiratory distress is brought to the emergency department. After endotracheal (ET) intubation and initiation of mechanical ventilation, the client is transferred to the intensive care unit. Before suctioning the ET tube, the nurse hyperventilates and hyperoxygenates the client. What is the rationale for these interventions?

They help prevent cardiac arrhythmias.

A nurse is assigned to care for a client with a tracheostomy tube. How can the nurse communicate with this client? a) By suctioning the client frequently b) By placing the call button under the client's pillow c) By supplying a magic slate or similar device d) By providing a tracheostomy plug to use for verbal communication

By supplying a magic slate or similar device The nurse should use a nonverbal communication method, such as a magic slate, note pad and pencil, and picture boards (if the client can't write or speak English). The physician orders a tracheostomy plug when a client is being weaned off a tracheostomy; it doesn't enable the client to communicate. The call button, which should be within reach at all times for all clients, can summon attention but doesn't communicate additional information. Suctioning clears the airway but doesn't enable the client to communicate.

The nurse assesses a patient with a heart rate of 42 and a blood pressure of 70/46. What type of hypoxia does the nurse determine this patient is displaying? a) Hypoxic hypoxia b) Histotoxic hypoxia c) Circulatory hypoxia d) Anemic hypoxia

Circulatory hypoxia Given this patient's vital signs, he appears to be in shock. Circulatory hypoxia is hypoxia resulting from inadequate capillary circulation. It may be caused by decreased cardiac output, local vascular obstruction, low-flow states such as shock, or cardiac arrest. Although tissue partial pressure of oxygen (PO2) is reduced, arterial oxygen (PaO2) remains normal. Circulatory hypoxia is corrected by identifying and treating the underlying cause.

During the lung assessment for a client with pneumonia, the nurse auscultates low-pitched, bubbling, moist sounds that persist from early inspiration to early expiration. How should the nurse document these sounds?

Coarse crackles.

A client is on a positive-pressure ventilator with a synchronized intermittent mandatory ventilation (SIMV) setting. The ventilator is set for 8 breaths per minute. The client is taking 6 breaths per minute independently. The nurse a) Consults with the physician about removing the client from the ventilator b) Continues assessing the client's respiratory status frequently c) Changes the setting on the ventilator to increase breaths to 14 per minute d) Contacts the respiratory therapy department to report the ventilator is malfunctioning

Continues assessing the client's respiratory status frequently The SIMV setting on a ventilator allows the client to breathe spontaneously with no assistance from the ventilator for those extra breaths. Data in the stem suggest that the ventilator is working correctly. The nurse would continue making frequent respiratory assessments of the client. There are not sufficient data to suggest the client could be removed from the ventilator. There is no reason to increase the ventilator's setting to 14 breaths per minute or to contact respiratory therapy to report the machine is not working properly.

While caring for a patient with an endotracheal tube, the nurses recognizes that suctioning is required how often? a) When the nurse needs to stimulate the cough reflex b) Every 2 hours when the patient is awake c) When there is a need to prevent the patient from coughing d) When adventitious breath sounds are auscultated

When adventitious breath sounds are auscultated It is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are present. Unnecessary suctioning, such as scheduling every 2 hours, can initiate bronchospasm and cause trauma to the tracheal mucosa.

Which of the following is a correct endotracheal tube cuff pressure?

17mmhg

Arterial blood gases should be obtained at which timeframe following the initiation of continuous mechanical ventilation?

20 minutes

A hospitalized client experiences respiratory distress. The nurse should include which most appropriate client outcome in the plan of care?

Airway patent, breathing quiet, denies dyspnea.

Which of the following statements relating to assessment of the lungs and thorax is most accurate?

Bronchitis is characterized by excess mucus production and chronic cough.

A patient is diagnosed with mild obstructive sleep apnea after having a sleep study performed. What treatment modality will be the most effective for this patient?

Continuous positive airway pressure

Which type of oxygen therapy includes the administration of oxygen at pressure greater than 1 atmosphere?

Hyperbaric

A nurse is auscultating a client's chest for breath sounds. The nurse recognizes that which of the following is the strongest stimulus to breathe?

Hypercapnia.

A nurse observes a client sitting in the tripod position. What is an appropriate action by the nurse in response to this observation?

Observe for the use of accessory muscles.

What is the best guide to make vertical locations on the chest?

Sternal angle.

A high-pitched crowing sound from the upper airway results from tracheal or laryngeal spasm and is called what?

Stridor.

A nurse is caring for a client who was intubated because of respiratory failure. The client is now receiving mechanical ventilation with a preset tidal volume and number of breaths each minute. The client has the ability to breathe spontaneously between the ventilator breaths with no ventilator assistance. The nurse should document the ventilator setting as:

synchronized intermittent mandatory ventilation (SIMV).

Which of the following are indicators that a client is ready to be weaned from a ventilator? Select all that apply. a) Tidal volume of 8.5 mL/kg b) Rapid/shallow breathing index of 112 breaths/min c) Vital capacity of 13 mL/kg d) FiO2 45% e) PaO2 of 64 mm Hg

• PaO2 of 64 mm Hg • Tidal volume of 8.5 mL/kg • Vital capacity of 13 mL/kg Weaning criteria for clients are as follows: Vital capacity 10 to 15 mL/kg; Maximum inspiratory pressure at least -20 cm H2; Tidal volume: 7 to 9 mL/kg; Minute ventilation: 6 L/min; Rapid/shallow breathing index below 100 breaths/min; PaO2 > 60 mm Hg; FiO2 < 40%

A client presents to the health care clinic and reports a recent onset of a persistent cough. The client denies any shortness of breath, change in activity level, or other findings of an acute upper respiratory tract illness. What question by the nurse is most appropriate to further assess the cause for the cough?

"Are you taking any medications on a regular basis?"

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? a) "Don't use the incentive spirometer more than 5 times every hour." b) "You need to start using the incentive spirometer 2 days after surgery." c) "Breathe in and out quickly." d) "Before you do the exercise, I'll give you pain medication if you need it."

"Before you do the exercise, I'll give you pain medication if you need it." The nurse should assess the client's pain level before the client does incentive spirometry exercises and administer pain medication as needed. Doing so helps the client take deeper breaths and help prevents atelectasis. The client should breathe in slowly and steadily, and hold his breath for 3 seconds after inhalation. The client should start doing incentive spirometry immediately after surgery and aim to do 10 incentive spirometry breaths every hour.

The nurse is preparing to perform chest physiotherapy (CPT) on a patient. Which of the following patient statements would indicate the procedure is contraindicated. a) "I received my pain medication 10 minutes ago, let's do my CPT now." b) "I just finished eating my lunch, I'm ready for my CPT now." c) "I just changed into my running suit; we can do my CPT now." d) "I have been coughing all morning and am barely bringing anything up."

"I just finished eating my lunch, I'm ready for my CPT now." When performing CPT, the nurse ensures that the patient is comfortable, is not wearing restrictive clothing, and has not just eaten. The nurse gives medication for pain, as prescribed, before percussion and vibration and splints any incision and provides pillows for support, as needed. A goal of CPT is for the patient to be able to mobilize secretions; the patient who is having an unproductive cough is a candidate for CPT.

A client has been placed on a ventilator, and the spouse is visiting for the first time. The spouse begins to cry. The best statement by the nurse is

"Tell me what you are feeling."

The nurse is preparing to assist the health care provider with the removal of a patient's chest tube. Which of the following instructions will the nurse correctly give the patient? a) "Exhale forcefully while the chest tube is being removed." b) "During the removal of the chest tube, do not move because it will make the removal more painful." c) "When the tube is being removed, take a deep breath, exhale, and bear down." d) "While the chest tube is being removed, raise your arms above your head."

"When the tube is being removed, take a deep breath, exhale, and bear down." When assisting in the chest tube's removal, instruct the patient to perform a gentle Valsalva maneuver or to breathe quietly. The chest tube is then clamped and quickly removed. Simultaneously, a small bandage is applied and made airtight with petrolatum gauze covered by a 4 × 4-inch gauze pad and thoroughly covered and sealed with nonporous tape. The other options are incorrect instructions for the patient.

During a health history of the respiratory system, a patient reports experiencing a cough for several months. Which questions would the nurse ask for more information about the duration of this symptom? (Select all that apply.)

-"Does this occur at a particular time of day?" -"Is it continuous or intermittent?" -"Does it occur at rest or with exercise?" -"Does it wake you at night?"

The thoracic cavity contains which of the following organs? Select all that apply.

-Heart. -Most of the esophagus. -Lungs.

A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mm Hg. The nurse is aware of what complications that can be caused by this pressure? (Select all that apply.)

-tracheal ischemia -tracheal bleeding -tracheal necrosis

A client with pneumonia develops respiratory failure and has a partial pressure of arterial oxygen of 55 mm Hg. He's placed on mechanical ventilation with a fraction of inspired oxygen (FIO2) of 0.9. The nursing goal should be to reduce the FIO2 to no greater than:

0.5.

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 30 to 35 seconds b) 20 to 25 seconds c) 0 to 5 seconds d) 10 to 15 seconds

10 to 15 seconds In general, the nurse should apply suction no longer than 10 to 15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest. Applying suction for 30 to 35 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 20 to 25 seconds is hazardous and may result in the patient's developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest. Applying suction for 0 to 5 seconds would provide too little time for effective suctioning of secretions.

Which of the following ranges of water pressure identifies the amount of pressure within the endotracheal tube cuff that is believed to prevent both injury and aspiration?

15 to 20 mm Hg (Even though everything says 20-25) Usually the pressure is maintained at less than 25 cm water pressure to prevent injury and at more than 20 cm water pressure to prevent aspiration. High cuff pressure can cause tracheal bleeding, ischemia, and pressure necrosis, whereas low cuff pressure can increase the risk of aspiration pneumonia. A measure of 0 to 5 mm Hg or 10 to 15 mm Hg of water pressure would indicate that the cuff is underinflated. A measure of 30 to 35 mm Hg of water pressure would indicate that the cuff is overinflated.

The OR nurse is setting up a water-seal chest drainage system for a patient who has just had a thoracotomy. The nurse knows that the amount of suction in the system is determined by the water level. At what suction level should the nurse set the system? a) 20 cm H2O b) 5 cm H2O c) 15 cm H2O d) 10 cm H2O

20 cm H2O The amount of suction is determined by the water level. It is usually set at 20 cm H2O; adding more fluid results in more suction.

A client has a tracheostomy but doesn't require continuous mechanical ventilation. When weaning the client from the tracheostomy tube, the nurse initially should plug the opening in the tube for: a) 30 to 40 minutes. b) 5 to 20 minutes. c) 15 to 60 seconds. d) 45 to 60 minutes.

5 to 20 minutes. Initially, the nurse should plug the opening in the tracheostomy tube for 5 to 20 minutes, then gradually lengthen this interval according to the client's respiratory status. A client who doesn't require continuous mechanical ventilation already is breathing without assistance, at least for short periods; therefore, plugging the opening of the tube for only 15 to 60 seconds wouldn't be long enough to reveal the client's true tolerance to the procedure. Plugging the opening for more than 20 minutes would increase the risk of acute respiratory distress because the client requires an adjustment period to start breathing normally.

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? a) 84 mm Hg b) 120 mm Hg c) 45 mm Hg d) 58 mm Hg

84 mm Hg : In general, clients with respiratory conditions are given oxygen therapy only to increase the arterial oxygen pressure (PaO2) back to the client's normal baseline, which may vary from 60 to 95 mm Hg.

A young man incurred a spontaneous pneumothorax. The physician has just inserted a chest tube and has prescribed suction set at 20 cm of water. The nurse instills the fluid to this level in the appropriate chamber. Mark the level of fluid on the appropriate chamber of the closed drainage system.

A (below the 2002 date number on picture)

A patient with COPD requires oxygen administration. What method of delivery does the nurse know would be best for this patient?

A Venturi mask

The nurse is assigned the care of a patient with a chest tube. The nurse should ensure that which of the following items is kept at the patient's bedside? a) An incentive spirometer b) A bottle of sterile water c) A set of hemostats d) An Ambu bag

A bottle of sterile water It is essential that the nurse ensure that a bottle of sterile water is readily available at the patient's bedside. If the chest tube and drainage system become disconnected, air can enter the pleural space, producing a pneumothorax. To prevent the development of a pneumothorax, a temporary water seal can be established by immersing the chest tube's open end in a bottle of sterile water. There is no need to have an Ambu bag, incentive spirometer, or a set of hemostats at the bedside.

A young toddler is brought to the emergency room by his parents. The mother states that the child was playing on the floor with toys and suddenly began to wheeze. The mother reports no recent illnesses. The nurse suspects that the most likely cause of the wheezing is

A foreign body obstruction.

A client is on a ventilator. Alarms are sounding, indicating an increase in peak airway pressure. The nurse assesses first for

A kink in the ventilator tubing

A patient with emphysema informs the nurse, "The surgeon will be removing about 30% of my lung so that I will not be so short of breath and will have an improved quality of life." What surgery does the nurse understand the surgeon will perform?

A lung volume reduction

A patient is to receive an oxygen concentration of 70%. What is the best way for the nurse to deliver this concentration? a) A Venturi mask b) An oropharyngeal catheter c) A partial rebreathing mask d) A nasal cannula

A partial rebreathing mask Partial rebreathing masks have a reservoir bag that must remain inflated during both inspiration and expiration. The nurse adjusts the oxygen flow to ensure that the bag does not collapse during inhalation. A high concentration of oxygen (50% to 75%) can be delivered because both the mask and the bag serve as reservoirs for oxygen. The other devices listed cannot deliver oxygen at such a high concentration.

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 Anemic hypoxia is a result of decreased effective hemoglobin concentration, which causes a decrease in the oxygen-carrying capacity of the blood. It is rarely accompanied by hypoxemia. Carbon monoxide poisoning, because it reduces the oxygen-carrying capacity of hemoglobin, produces similar effects but is not strictly anemic hypoxia, because hemoglobin levels may be normal.

While inspecting the thorax, the nurse views it from posterior and lateral positions to assess which of the following?

Anteroposterior to lateral diameter.

A client has a sucking stab wound to the chest. Which action should the nurse take first? a) Prepare to start an I.V. line. b) Apply a dressing over the wound and tape it on three sides. c) Prepare a chest tube insertion tray. d) Draw blood for a hematocrit and hemoglobin level.

Apply a dressing over the wound and tape it on three sides. The nurse should immediately apply a dressing over the stab wound and tape it on three sides to allow air to escape and to prevent tension pneumothorax (which is more life-threatening than an open chest wound). Only after covering and taping the wound should the nurse draw blood for laboratory tests, assist with chest tube insertion, and start an I.V. line.

The apex of each lung is located at the

Area slightly above the clavicle.

A client on long-term mechanical ventilation becomes very frustrated when he tries to communicate. Which intervention should the nurse perform to assist the client?

Ask the client to write, use a picture board, or spell words with an alphabet board.

The nurse received a client from the post-anesthesia care unit (PACU) who has a chest tube to a closed drainage system. Report from the PACU nurse included drainage in the chest tube at 80 mL of bloody fluid. Fifteen minutes after transfer from the PACU, the chest tube indicates drainage as pictured. The client is reporting pain at "8" on a scale of 0 to 10. The first action of the nurse is to: a) Administer prescribed pain medication. b) Notify the physician. c) Assess pulse and blood pressure. d) Lay the client's head to a flat position.

Assess pulse and blood pressure. The client has bled 120 mL of bloody drainage in the chest drainage system within 15 minutes. It is most important for the nurse to assess for signs and symptoms of hemorrhage, which may be indicated by a rapid pulse and decreasing blood pressure. The nurse may then lay the client in a flat position and notify the physician.

A client in the intensive care unit has a tracheostomy with humidified oxygen being instilled through it. The client is expectorating thick yellow mucus through the tracheostomy tube frequently. The nurse

Assesses the client's tracheostomy and lung sounds every 15 minutes

Which ventilator mode provides full ventilatory support by delivering a present tidal volume and respiratory rate?

Assist-control Assist-control ventilation provides full ventilator support by delivering a preset tidal volume and respiratory rate. Intermittent mandatory ventilation (IMV) provides a combination of mechanically assisted breaths and spontaneous breaths. SIMV delivers a preset tidal volume and number of breaths per minute. Between ventilator-delivered breaths, the patient can breathe spontaneously with no assistance from the ventilator for those extra breaths.

A 21-year-old college senior presents to the clinic reporting shortness of breath and a nonproductive nocturnal cough. She states she used to feel this way only with extreme exercise, but lately she has felt this way continuously. She denies any other upper respiratory, gastrointestinal, and urinary symptoms and says she has no chest pain. Her past medical history is significant only for seasonal allergies, for which she takes a nasal steroid spray; she takes no other medications. She has had no surgeries. Her mother has allergies and eczema; her father has high blood pressure. She is an only child. She denies smoking and illegal drug use but drinks three to four alcoholic beverages per weekend. She is a junior in finance at a local university and has recently started a job as a bartender in town. On examination she is in no acute distress. Temperature is 98.6, blood pressure is 120/80, pulse is 80, and respirations are 20. Head, eyes, ears, nose, and throat examinations are essentially normal. Inspection of her anterior and posterior chest shows no abnormalities. On auscultation of her chest, there is decreased air movement and a high-pitched whistling on expiration in all lobes. Percussion reveals resonant lungs. Which disorder of the thorax or lung does this presentation best describe?

Asthma.

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.

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? a) Have the patient cough. b) Have the patient inform the nurse of the need to be suctioned. c) Auscultate the lung for adventitious sounds. d) Assess the CO2 level to determine if the patient requires suctioning.

Auscultate the lung for adventitious sounds. When a tracheostomy or endotracheal tube is in place, it is usually necessary to suction the patient's secretions because of the decreased effectiveness of the cough mechanism. Tracheal suctioning is performed when adventitious breath sounds are detected or whenever secretions are obviously present. Unnecessary suctioning can initiate bronchospasm and cause mechanical trauma to the tracheal mucosa.

For a client with an endotracheal (ET) tube, which nursing action is the most important? a) Monitoring serial blood gas values every 4 hours b) Turning the client from side to side every 2 hours c) Providing frequent oral hygiene d) Auscultating the lungs for bilateral breath sounds

Auscultating the lungs for bilateral breath sounds For the client with an ET tube, the most important nursing action is auscultating the lungs regularly for bilateral breath sounds to ensure proper tube placement and effective oxygen delivery. Although turning the client from side to side every 2 hours, monitoring serial blood gas values every 4 hours, and providing frequent oral hygiene are appropriate actions for this client, they're secondary to ensuring adequate oxygenation.

A nurse prepares to perform postural drainage. How should the nurse ascertain the best position to facilitate clearing the lungs?

Auscultation

Before weaning a client from a ventilator, which assessment parameter is the most important for the nurse to obtain?

Baseline arterial blood gas (ABG) levels

The nurse is preparing to percuss a patient's anterior chest area. Which approach will the nurse use for this assessment?

Begin above the right clavicle and percuss each section comparing the right chest with the left chest.

Which of the following is an adverse reaction that would require termination of the weaning process from the ventilator?

Blood pressure increase of 20 mm Hg

The nurse is caring for a patient being weaned from the mechanical ventilator. Which of the following patient findings would require the termination of the weaning process?

Blood pressure increase of 20 mm Hg from baseline

A nurse performs a respiratory assessment on a client and notes the respiratory rate to be 10 breaths per minute. The nurse knows the proper term for this rate is what?

Bradypnea.

The nurse is performing the technique shown. What is the nurse assessing?

Chest expansion.

The nurse is caring for a patient following a thoracotomy. Which of the following findings requires immediate intervention by the nurse? a) Pain of 5 on a 1 to 10 pain scale b) Heart rate: 112 bpm c) Moderate amounts of colorless sputum d) Chest tube drainage of 190 mL/hr

Chest tube drainage of 190 mL/hr The nurse should monitor and document the amount and character of drainage every 2 hours. The nurse will notify the primary provider if drainage is 150 mL/hr or greater. The other findings are normal following a thoracotomy; no intervention is required.

The nurse is transporting a patient with chest tubes to a treatment room. The chest tube becomes disconnected and falls between the bed rail. What is the priority action by the nurse? a) Clamp the chest tube close to the connection site. b) Call the physician. c) Cut the contaminated tip of the tube and insert a sterile connector and reattach. d) Immediately reconnect the chest tube to the drainage apparatus.

Cut the contaminated tip of the tube and insert a sterile connector and reattach. If the patient is lying on a stretcher and must be transported to another area, place the drainage system below the chest level. If the tubing disconnects, cut off the contaminated tips of the chest tube and tubing, insert a sterile connector in the cut ends, and reattach to the drainage system. Do not clamp the chest tube during transport.

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

DELETE

The nurse is caring for a patient with an endotracheal tube (ET). Which of the following nursing interventions is contraindicated? a) Checking the cuff pressure every 6 to 8 hours b) Ensuring that humidified oxygen is always introduced through the tube c) Deflating the cuff prior to tube removal d) Deflating the cuff routinely

Deflating the cuff routinely Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the ET is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.

The nurse has assessed the respiratory pattern of an adult client. The nurse determines that the client is exhibiting Kussmaul respirations with hyperventilation. The nurse should contact the client's physician because this type of respiratory pattern usually indicates

Diabetic ketoacidosis.

Which of the following muscles is primarily responsible for thoracic cavity enlargement?

Diaphragm.

The nurse percusses the lungs of a patient with pneumonia. What percussion note would the nurse expect to document?

Dullness.

What replaces resonance when fluid or solid tissue replaces air-containing lung or occupies the pleural space?

Dullness.

After suctioning a tracheostomy tube, the nurse assesses the client to determine the effectiveness of the suctioning. Which findings indicate that the airway is now patent? a) Effective breathing at a rate of 16 breaths/minute through the established airway b) Increased pulse rate, rapid respirations, and cyanosis of the skin and nail beds c) Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds d) A respiratory rate of 28 breaths/minute with accessory muscle use

Effective breathing at a rate of 16 breaths/minute through the established airway Proper suctioning should produce a patent airway, as demonstrated by effective breathing through the airway at a normal respiratory rate of 12 to 20 breaths/minute. The other options suggest ineffective suctioning. A respiratory rate of 28 breaths/minute and accessory muscle use may indicate mild respiratory distress. Increased pulse rate, rapid respirations, and cyanosis are signs of hypoxia. Restlessness, pallor, increased pulse and respiratory rates, and bubbling breath sounds indicate respiratory secretion accumulation.

A client is recovering from thoracic surgery needed to perform a right lower lobectomy. Which of the following is the most likely postoperative nursing intervention? a) Make sure that a thoracotomy tube is linked to open chest drainage. b) Restrict intravenous fluids for at least 24 hours. c) Assist with positioning the client on the right side. d) Encourage coughing to mobilize secretions.

Encourage coughing to mobilize secretions. The client is encouraged to cough frequently to mobilize secretions. The client will be placed in the semi-Fowler's position. Thoracotomy tubes are always attached to closed, sealed drainage to re-expand lung tissue and prevent pneumothorax. Restricting IV fluids in a client who is NPO while recovering from surgery would lead to dehydration. (less)

A nurse is planning care for a client after a tracheostomy. One of the client's goals is to overcome verbal communication impairment. Which intervention should the nurse include in the care plan? a) Answer questions for the client to reduce his frustration. b) Make an effort to read the client's lips to foster communication. c) Encourage the client's communication attempts by allowing him time to select or write words. d) Avoid using a tracheostomy plug because it blocks the airway.

Encourage the client's communication attempts by allowing him time to select or write words. The nurse should allow ample time for the client to respond and shouldn't speak for him. She should use as many aids as possible to assist the client with communicating and encourage the client when he attempts to communicate. When the client is ready, the nurse can use a tracheostomy plug to facilitate speech. Making an effort to read the client's lips and answering questions for the client are inappropriate.

A patient is being educated in the use of incentive spirometry prior to having a surgical procedure. What should the nurse be sure to include in the education?

Encourage the patient to take approximately 10 breaths per hour, while awake.

Which characteristic feature of the sternum should the nurse observe in a client with the diagnosis of pectus carinatum?

Forward protrusion.

A grandmother brings her 13-year-old grandson for evaluation. She noticed last week when he took off his shirt that his breastbone seemed collapsed. He seems embarrassed and says that it has been that way for awhile. He states he has no symptoms from it and that he just tries not to take off his shirt in front of anyone. He denies any shortness of breath, chest pain, or lightheadedness on exertion. His past medical history is unremarkable. He is in sixth grade and just moved in with his grandmother after his father was transferred for a work contract. His mother died several years ago in a car accident. He states that he does not smoke and has never touched alcohol. Examination shows a teenage boy appearing his stated age. Visual examination of his chest reveals that the lower portion of the sternum is depressed. Auscultation of the lungs and heart is unremarkable. What disorder of the thorax best describes these findings?

Funnel chest (pectus excavatum).

The nurse is reviewing the client's health history and notes he has pectus excavatum. The nurse would assess the client for what?

Funnel chest.

During a health history, a client tells the nurse that "I cannot breathe well" at night when the client is lying down. The client also has trouble sleeping because of waking up with trouble breathing. The nurse would assess this client further for which of the following?

Heart failure.

The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply.)

Hold the breath at the end of inspiration for a few seconds. Cough frequently. Frequently evaluate progress.

The nurse is caring for a patient who is scheduled to have a thoracotomy. When planning preoperative teaching, what information should the nurse communicate to the patient? a) How to splint the incision when coughing b) How to take prophylactic antibiotics correctly c) How to milk the chest tubing d) How to manage the need for fluid restriction

How to splint the incision when coughing Prior to thoracotomy, the nurse educates the patient about how to splint the incision with the hands, a pillow, or a folded towel. The patient is not taught how to milk the chest tubing because this is performed by the nurse. Prophylactic antibiotics are not normally used and fluid restriction is not indicated following thoracotomy.

A nurse assesses the respiration pattern on a client who arrives in the emergency department due to an overdose of narcotics. The nurse notes the respirations are decreased in rate and depth, and have an irregular pattern. How should the nurse document this finding?

Hypoventilation.

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

Hypoxia

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition? a) Hypoxia b) Semiconsciousness c) Delirium d) Hyperventilation

Hypoxia As the respiratory center in the brain becomes depressed, hypoxia occurs, producing wheezing, bradycardia, and a decreased respiratory rate. Delirium is a state of mental confusion characterized by disorientation to time and place. Hyperventilation (respiratory rate greater than that metabolically necessary for gas exchange) is marked by an increased respiratory rate or tidal volume, or both. Semiconsciousness is a state of impaired consciousness characterized by limited motor and verbal responses and decreased orientation.

A nurse is caring for a client after a thoracotomy for a lung mass. Which nursing diagnosis should be the first priority? a) Anxiety b) Deficient knowledge: Home care c) Impaired physical mobility d) Impaired gas exchange

Impaired gas exchange Impaired gas exchange should be the nurse's first priority. After ensuring that the client has adequate gas exchange, she can address the other diagnoses of Anxiety, Impaired physical mobility, and Deficient knowledge: Home Care.

The nurse has instructed a patient on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which of the following?

Improve oxygen transport, induce a slow, deep breathing pattern, and assist the patient to control breathing

A nurse auscultates a client's lungs and hears fine crackles. What is an appropriate action by the nurse?

Instruct the client to cough forcefully.

The nurse is assisting a client with postural drainage. Which of the following demonstrates correct implementation of this technique? a) Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. b) Administer bronchodilators and mucolytic agents following the sequence. c) Use aerosol sprays to deodorize the client's environment after postural drainage. d) Perform this measure with the client once a day.

Instruct the client to remain in each position of the postural drainage sequence for 10 to 15 minutes. Postural drainage is usually performed two to four times daily, before meals (to prevent nausea, vomiting, and aspiration) and at bedtime. Prescribed bronchodilators, water, or saline may be nebulized and inhaled before postural drainage to dilate the bronchioles, reduce bronchospasm, decrease the thickness of mucus and sputum, and combat edema of the bronchial walls. The nurse instructs the client to remain in each position for 10 to 15 minutes and to breathe in slowly through the nose and out slowly through pursed lips to help keep the airways open so that secretions can drain while in each position. If the sputum is foul-smelling, it is important to perform postural drainage in a room away from other patients or family members. (Deodorizers may be used to counteract the odor. Because aerosol sprays can cause bronchospasm and irritation, they should be used sparingly and with caution.)

Which of the following ventilator modes provides a combination of mechanically assisted breaths and spontaneous breaths?

Intermittent mandatory ventilation (IMV)

A client suffers acute respiratory distress syndrome as a consequence of shock. The client's condition deteriorates rapidly, and endotracheal (ET) intubation and mechanical ventilation are initiated. When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm? a) A change in the oxygen concentration without resetting the oxygen level alarm b) Kinking of the ventilator tubing c) An ET cuff leak d) A disconnected ventilator tube

Kinking of the ventilator tubing Conditions that trigger the high-pressure alarm include kinking of the ventilator tubing, bronchospasm, pulmonary embolus, mucus plugging, water in the tube, and coughing or biting on the ET tube. The alarm may also be triggered when the client's breathing is out of rhythm with the ventilator. A disconnected ventilator tube or an ET cuff leak would trigger the low-pressure alarm. Changing the oxygen concentration without resetting the oxygen level alarm would trigger the oxygen alarm, not the high-pressure alarm.

A client is coughing copious amounts of purulent mucous. What disease condition is related to this finding?

Lung abscess.

A client is prescribed postural drainage because secretions are building in the superior segment of the lower lobes. Which is the best position to teach the client to use for postural drainage?

Lying prone

A client with chronic obstructive pulmonary disease (COPD) is intubated and placed on continuous mechanical ventilation. Which equipment is most important for the nurse to keep at this client's bedside?

Manual resuscitation bag

The clavicles extend from the acromion of the scapula to the part of the sternum termed the

Manubrium.

A nurse has performed tracheal suctioning on a patient who experienced increasing dyspnea prior to a procedure. When applying the nursing process, how can the nurse best evaluate the outcomes of this intervention? a) Percuss the patient's lungs and thorax. b) Determine whether the patient can now perform forced expiratory technique (FET). c) Measure the patient's oxygen saturation. d) Have the patient perform incentive spirometry.

Measure the patient's oxygen saturation. The patient's response to suctioning is usually determined by performing chest auscultation and by measuring the patient's oxygen saturation. FET, incentive spirometry, and percussion are not normally used as evaluative techniques.

How should a nurse position a client to accurately auscultate the right middle lobe of the lung?

Move the right arm away from the body.

The nurse is caring for a patient 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 patient's needs? a) Simple mask b) Nasal cannula c) Partial-rebreathing mask d) Non-rebreathing mask

Nasal cannula A nasal cannula is used when the patient requires a low to medium concentration of oxygen for which precise accuracy is not essential. The Venturi mask is used primarily for patients with COPD because it can accurately provide an appropriate level of supplemental oxygen, thus avoiding the risk of suppressing the hypoxic drive. The patient's respiratory status does not require a partial- or non-rebreathing mask.

Of the following oxygen administration devices, which has the advantage of providing high oxygen concentration? a) Venturi mask b) Catheter c) Non-rebreather mask d) Face tent

Non-rebreather mask The non-rebreather mask provides high oxygen concentration but it is usually poor fitting. The Venturi mask provides low levels of supplemental oxygen. The catheter is an inexpensive device that provides a variable fraction of inspired oxygen and may cause gastric distention. A face tent provides a fairly accurate fraction of inspired oxygen, but is bulky and uncomfortable. It would not be the device of choice to provide high oxygen concentration.

The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber?

Notify the physician.

The nurse is assessing a patient with chest tubes connected to a drainage system. What should the first action be when the nurse observes excessive bubbling in the water seal chamber? a) Disconnect the system and get another. b) Notify the physician. c) Place the head of the patient's bed flat. d) Milk the chest tube.

Notify the physician. Observe for air leaks in the drainage system; they are indicated by constant bubbling in the water seal chamber, or by the air leak indicator in dry systems with a one-way valve. In addition, assess the chest tube system for correctable external leaks. Notify the primary provider immediately of excessive bubbling in the water seal chamber not due to external leaks.

An elderly client reports a feeling of dyspnea with normal activities of daily living. What is an appropriate action by the nurse?

Observe the client's respiratory rate and pattern.

When auscultating the lungs, the nurse listens over symmetrical lung fields for which of the following?

One deep inspiration and expiration through the open mouth.

A client who just underwent hip replacement surgery reports pain at a 10 on a scale of 0 to 10 and receives 4 mg of morphine. A nurse on the orthopedic unit enters the client's room and finds that the client has a respiratory rate of 7 breaths/min. The client is groggy and hard to arouse. What could be contributing to the client's findings?

Opiates, which may cause hypoventilation.

Identify the location where vesicular, bronchovesicular, bronchial, and tracheal lung sounds are heard (in that order).

Over most of the both lungs. Between the scapulae. Over the manubrium. Over the trachea in the neck.

A patient with emphysema is placed on continuous oxygen at 2 L/min at home. Why is it important for the nurse to educate the patient and family that they must have No Smoking signs placed on the doors?

Oxygen supports combustion

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?

PaO2

Which of the following would be best for a nurse to use when assessing for fremitus in a client?

Palmar base (ulnar surface).

While performing an assessment of a client who sustained a chest injury, which physical examination technique should the nurse use to elicit crepitus?

Palpation.

A client is receiving supplemental oxygen. When determining the effectiveness of oxygen therapy, which arterial blood gas value is most important? a) Partial pressure of arterial carbon dioxide (PaCO2) b) Bicarbonate (HCO3-) c) Partial pressure of arterial oxygen (PaO2) d) pH

Partial pressure of arterial oxygen (PaO2) The most significant and direct indicator of the effectiveness of oxygen therapy is the PaO2 value. Based on the PaO2 value, the nurse may adjust the type of oxygen delivery (cannula, Venturi mask, or mechanical ventilator), flow rate, and oxygen percentage. The other options reflect the client's ventilation status, not oxygenation. The pH, HCO3-, and PaCO2.

The nurse is discussing activity management with a patient who is postoperative following thoracotomy. What instructions should the nurse give to the patient regarding activity immediately following discharge? a) Walk on a treadmill 30 minutes daily. b) Perform shoulder exercises five times daily. c) Walk 1 mile 3 to 4 times a week. d) Use weights daily to increase arm strength.

Perform shoulder exercises five times daily. The nurse emphasizes the importance of progressively increased activity. The nurse also instructs the patient on the importance of performing shoulder exercises five times daily. The patient should ambulate with limits and realize that the return of strength will likely be gradual and likely will not include weight lifting or lengthy walks.

Which action by a nurse demonstrates proper technique for assessment of chest expansion?

Place both hands on the posterior chest at T9, press thumbs together, and then ask client to take a deep breath.

A nurse is caring for a client with a chest tube. If the chest drainage system is accidentally disconnected, what should the nurse plan to do? a) Clamp the chest tube immediately. b) Apply an occlusive dressing and notify the physician. c) Secure the chest tube with tape. d) Place the end of the chest tube in a container of sterile saline.

Place the end of the chest tube in a container of sterile saline. If a chest drainage system is disconnected, the nurse may place the end of the chest tube in a container of sterile saline or water to prevent air from entering the chest tube, thereby preventing negative respiratory pressure. The nurse should apply an occlusive dressing if the chest tube is pulled out — not if the system is disconnected. The nurse shouldn't clamp the chest tube because clamping increases the risk of tension pneumothorax. The nurse should tape the chest tube securely to prevent it from being disconnected, rather than taping it after it has been disconnected.

The nurse is preparing to perform tracheostomy care on a patient with a newly inserted tracheostomy tube. Which of the following actions, if preformed by the nurse, indicates the need for further review of the procedure? a) Dries and reinserts the inner cannula or replaces it with a new disposable inner cannula b) Places clean tracheostomy ties, and removes soiled ties after the new ties are in place c) Puts on clean gloves; removes and discards the soiled dressing in a biohazard container d) Cleans the wound and the plate with a sterile cotton tip moistened with hydrogen peroxide

Places clean tracheostomy ties, and removes soiled ties after the new ties are in place For a new tracheostomy, two people should assist with tie changes. The other actions, if performed by the nurse during tracheostomy care, are correct.

A 47-year-old receptionist comes to the office with fever, shortness of breath, and a productive cough with golden sputum. She says she had a cold last week and her symptoms have only worsened despite using over-the-counter cold remedies. She denies any weight gain, weight loss, or cardiac or gastrointestinal symptoms. Her past medical history includes type 2 diabetes for 5 years and high cholesterol level. She takes an oral medication for both diseases. She has had no surgeries. She denies tobacco, alcohol, or drug use. Her mother has diabetes and high blood pressure. Her father passed away from colon cancer. Examination reveals a middle-aged woman appearing her stated age. She looks ill and her temperature is elevated at 101 degrees Farenheit. Her blood pressure and pulse are unremarkable. Her head, eyes, ears, nose, and throat examination are unremarkable except for edema of the nasal turbinates. On auscultation she has decreased air movement and coarse crackles are heard over the left lower lobe. There is dullness on percussion, increased fremitus during palpation, and egophony and whispered pectoriloquy on auscultation. What disorder of the thorax or lung best describes her symptoms?

Pneumonia.

While assessing an adult client's lungs during the postoperative period, the nurse detects coarse crackles. The nurse should refer the client to a physician for possible

Pneumonia.

The nurse is teaching the client in respiratory distress ways to prolong exhalation to improve respiratory status. The nurse tells the client to

Purse the lips when exhaling air from the lungs.

Positive end-expiratory pressure (PEEP) therapy has which effect on the heart?

Reduced cardiac output

A nurse is educating a patient in anticipation of a procedure that will require a water-sealed chest drainage system. What should the nurse tell the patient and the family that this drainage system is used for? a) Removing excess air and fluid b) Monitoring pleural fluid osmolarity c) Maintaining positive chest-wall pressure d) Providing positive intrathoracic pressure

Removing excess air and fluid Chest tubes and closed drainage systems are used to re-expand the lung involved and to remove excess air, fluid, and blood. They are not used to maintain positive chest-wall pressure, monitor pleural fluid, or provide positive intrathoracic pressure

Which of the following statements would not be considered an appropriate intervention for a patient with an ET tube?

Routine cuff deflation is recommended Routine cuff deflation is not recommended because of the increased risk for aspiration and hypoxia. The cuff is deflated before the endotracheal tube is removed. Cuff pressures should be checked every 6 to 8 hours. Humidified oxygen should always be introduced through the tube.

A nurse is weaning a client from mechanical ventilation. Which assessment finding indicates the weaning process should be stopped? a) Runs of ventricular tachycardia b) Oxygen saturation of 93% c) Respiratory rate of 16 breaths/minute d) Blood pressure increase from 120/74 mm Hg to 134/80 mm Hg

Runs of ventricular tachycardia Ventricular tachycardia indicates that the client isn't tolerating the weaning process. The weaning process should be stopped before lethal ventricular arrhythmias occur. A respiratory rate of 16 breaths/minute and an oxygen saturation of 93% are normal findings. Although the client's blood pressure has increased, it hasn't increased more than 20% over baseline, which would indicate that the client isn't tolerating the weaning process.

The client is postoperative for a total laryngectomy and has recovered from anesthesia. The client's respirations are 32 breaths/minute, blood pressure is 102/58, and pulse rate is 104 beats/minute. Pulse oximetry is 90%. The client is receiving humidified oxygen. To aid in the client's respiratory status, the nurse places the client in which of the following positions.

Semi- Fowler's The client is in respiratory distress. The best position for the client who has a tracheostomy and recovered from anesthesia is semi-Fowler's.

The spinous process termed the vertebra prominens is in which cervical vertebra?

Seventh.

A client from a severe motor vehicle accident arrives in the emergency department. The nurse observes irregular respirations of varying depth and rate followed by periods of apnea. Which of the following would the nurse suspect?

Severe brain damage.

Question: The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order:

Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth.

The nurse is teaching a postoperative client who had a coronary artery bypass graft about using the incentive spirometer. The nurse instructs the client to perform the exercise in the following order: 1 Sit in an upright position. 2 Breathe air in through the mouth. 3 Exhale air slowly through the mouth. 4 Hold breath for about 3 seconds. 5 Place the mouthpiece of the spirometer in the mouth.

Sit in an upright position. Place the mouthpiece of the spirometer in the mouth. Breathe air in through the mouth. Hold breath for about 3 seconds. Exhale air slowly through the mouth. The nurse instructs the client, when using the incentive spirometer, the proper use of it. First, the client is to sit in an upright position. The client is then to place the mouthpiece of the spirometer in the client's mouth. Next, the client breathes air in through the mouth. This causes the incentive spirometer to be activated. The client holds his breath for about 3 seconds. Then, the client exhales slowly through the mouth.

When assessing whispered pectoriloquy, the nurse would instruct a client to do which of the following?

Softly repeat the words "one-two-three".

A client is admitted to the health care facility with a diagnosis of left lower lobe pneumonia. What change in egophony should the nurse expect to find in the left lower lobe?

Sound is louder and sounds like "A".

A client undergoes a tracheostomy after many failed attempts at weaning him from a mechanical ventilator. Two days after tracheostomy, while the client is being weaned, the nurse detects a mild air leak in the tracheostomy tube cuff. What should the nurse do first?

Suction the client, withdraw residual air from the cuff, and reinflate it.

The nurse is assisting a physician with an endotracheal intubation for a client in respiratory failure. It is most important for the nurse to assess for:

Symmetry of the client's chest expansion

A patient in the ICU has been orally intubated and on mechanical ventilation for 2 weeks after having a severe stroke. What action does the nurse anticipate the physician will take now that the patient has been intubated for this length of time?

The patient will have an insertion of a tracheostomy tube.

The nurse is caring for a patient who is scheduled for a lobectomy. Following the procedure, the nurse will plan care based on which of the following? a) The patient will return from surgery with no drainage tubes. b) The patient will return to the nursing unit with two chest tubes. c) The patient will require mechanical ventilation following surgery. d) The patient will require sedation until the chest tube (s) are removed.

The patient will return to the nursing unit with two chest tubes. The nurse should plan for the patient to return to the nursing unit with two chest tubes intact. During a lobectomy, the lobe is removed, and the remaining lobes of the lung are re-expanded. Usually, two chest catheters are inserted for drainage. The upper tube is for air removal; the lower one is for fluid drainage. Sometimes, only one catheter is needed. The chest tube is connected to a chest drainage apparatus for several days.

A nurse observes constant bubbling in the water-seal chamber of a closed chest drainage system. What should the nurse conclude? a) The client has a pneumothorax. b) The system has an air leak. c) The chest tube is obstructed. d) The system is functioning normally.

The system has an air leak. Constant bubbling in the water-seal chamber indicates an air leak and requires immediate intervention. The client with a pneumothorax will have intermittent bubbling in the water-seal chamber. Clients without a pneumothorax should have no evidence of bubbling in the chamber. If the tube is obstructed, the fluid would stop fluctuating in the water-seal chamber. (less)

Which observation confirms to the nurse that the client is experiencing a normal inspiration?

The thoracic cavity enlarges.

A client has sustained a brainstem injury. Which of the following would the nurse need to keep in mind about this client's respiratory effort?

There is a loss of involuntary respiratory control.

A patient is being mechanically ventilated in the ICU. The ventilator alarms begin to sound. The nurse should complete which of the following actions first? a) Notify the respiratory therapist. b) Troubleshoot to identify the malfunction. c) Reposition the endotracheal (ET) tube. d) Manually ventilate the patient.

Troubleshoot to identify the malfunction. The nurse should first immediately attempt to identify and correct the problem and, if the problem cannot be identified and/or corrected, the patient must be manually ventilated with an Ambu bag. The respiratory therapist may be notified, but this is not the first action by the nurse. The nurse should not reposition the ET tube as a first response to an alarm.

Which finding during an assessment of a client should alert the nurse to the presence of a persistent atelectasis?

Unequal expansion of the chest.

Which type of ventilator has a pre-sent volume of air to be delivered with each inspiration?

Volume cycled With volume-cycled ventilation, the volume of air to be delivered with each inspiration is present. Negative pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a present pressure, and then cycles off, and expiration occurs passively.

Which type of ventilator has a present volume of air to be delivered with each inspiration? a) Pressure-cycled b) Negative-pressure c) Time-cycled d) Volume-controlled

Volume-controlled With volume-controlled ventilation, the volume of air to be delivered with each inspiration is present. Negative pressure ventilators exert a negative pressure on the external chest. Time-cycled ventilators terminate or control inspiration after a preset time. When the pressure-cycled ventilator cycles on, it delivers a flow of air (inspiration) until it reaches a present pressure, and then cycles off, and expiration occurs passively.

After lobectomy for lung cancer, a client receives a chest tube connected to a disposable chest drainage system. The nurse observes that the drainage system is functioning correctly when she notes tidal movements or fluctuations in which compartment of the system as the client breathes? a) Collection chamber b) Air-leak chamber c) Suction control chamber d) Water-seal chamber

Water-seal chamber Fluctuations in the water-seal compartment are called tidal movements and indicate normal function of the system as the pressure in the tubing changes with the client's respirations. The air-leak meter — not chamber — detects air leaking from the pleural space. The collection chamber connects the chest tube from the client to the system. Drainage from the tube drains into and collects in a series of calibrated columns in this chamber. The suction control chamber provides the suction, which can be controlled to provide negative pressure to the chest. (less)

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with:

a compromised skin graft

Hyperbaric oxygen therapy increases the blood's capacity to carry and deliver oxygen to compromised tissues. This therapy may be used for a client with: a) a malignant tumor. b) a compromised skin graft. c) hyperthermia. d) pneumonia.

a compromised skin graft. A client with a compromised skin graft could benefit from hyperbaric oxygen therapy because increasing oxygenation at the wound site promotes wound healing. Hyperbaric oxygen therapy isn't indicated for malignant tumors, pneumonia, or hyperthermia.

Constant bubbling in the water seal of a chest drainage system indicates which of the following problems?

air leak

A client with supraglottic cancer undergoes a partial laryngectomy. Postoperatively, a cuffed tracheostomy tube is in place. When removing secretions that pool above the cuff, the nurse should instruct the client to: a) hold the breath as the cuff is being reinflated. b) take a deep breath as the nurse deflates the cuff. c) cough as the cuff is being deflated. d) exhale deeply as the nurse reinflates the cuff.

cough as the cuff is being deflated. The nurse should instruct the client to cough during cuff deflation. If the client can't cough, the nurse should perform suctioning to prevent aspiration of secretions. Because the cuff should be deflated during expiration, the client shouldn't take a deep breath as the nurse deflates the cuff. Likewise, because the cuff is reinflated during inspiration, the client shouldn't hold the breath or exhale deeply during reinflation.

After undergoing a left thoracotomy, a client has a chest tube in place. When caring for this client, the nurse must: a) report fluctuations in the water-seal chamber. b) milk the chest tube every 2 hours. c) clamp the chest tube once every shift. d) encourage coughing and deep breathing.

encourage coughing and deep breathing. When caring for a client who's recovering from a thoracotomy, the nurse should encourage coughing and deep breathing to prevent pneumonia. Fluctuations in the water-seal chamber are normal. Clamping the chest tube could cause a tension pneumothorax. Chest tube milking is controversial and should be done only to remove blood clots that obstruct the flow of drainage.

A home health nurse is visiting a home care client with advanced lung cancer. Upon assessing the client, the nurse discovers wheezing, bradycardia, and a respiratory rate of 10 breaths/minute. These signs are associated with which condition?

hypoxia

A nurse is caring for a client who recently underwent a tracheostomy. The first priority when caring for a client with a tracheostomy is:

keeping his airway patent.

A young male client has muscular dystrophy. His PaO2 is 42 mm Hg with a FiO2 of 80%. Which of the following treatments would be least invasive and most appropriate for this client?

neg pressure ventilator This client needs ventilatory support. His PaO2 is low despite receiving a high dose of oxygen. The iron lung or drinker respiratory tank is an example of a negative-pressure ventilator. This type of ventilator is used mainly with chronic respiratory failure associated with neurological disorders, such as muscular dystrophy. It does not require intubation of the client. The most common ventilator is the positive-pressure ventilator, but this involves intubation with an endotracheal tube or tracheostomy. CPAP is used for obstructive sleep apnea. Bi-PAP is used for those with severe COPD or sleep apnea who require ventilatory assistance at night.

In general, chest drainage tubes are not used for the patient undergoing a) lobectomy. b) pneumonectomy. c) wedge resection. d) segmentectomy.

pneumonectomy. Usually, no drains are used for the pneumonectomy patient because the accumulation of fluid in the empty hemothorax prevents mediastinal shift. With lobectomy, two chest tubes are usually inserted for drainage, the upper tube for air and the lower tube for fluid. With wedge resection, the pleural cavity usually is drained because of the possibility of an air or blood leak. With segmentectomy, drains are usually used because of the possibility of an air or blood leak.

A nurse is caring for a client who has a tracheostomy tube and who is undergoing mechanical ventilation. The nurse can help prevent tracheal dilation, a complication of tracheostomy tube placement, by:

using the minimal-leak technique with cuff pressure less than 25 cm H2O. To prevent tracheal dilation, a minimal-leak technique should be used and the pressure should be kept at less than 25 cm H2O. Suctioning is vital but won't prevent tracheal dilation. Use of a cuffed tube alone won't prevent tracheal dilation. The tracheostomy shouldn't be plugged to prevent tracheal dilation. This technique is used when weaning the client from tracheal support.

The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply.)

• Cough frequently. • Hold the breath at the end of inspiration for a few seconds. • Frequently evaluate progress.

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.)

• Decreases hypoxemia • Decreases patient anxiety • Sustains positive end expiratory pressure (PEEP)

A client with COPD has been receiving oxygen therapy for an extended period. What symptoms would be indicators that the client is experiencing oxygen toxicity? Select all that apply. a) Substernal pain b) Fatigue c) Dyspnea d) Bradycardia e) Mood swings

• Dyspnea • Substernal pain • Fatigue Oxygen toxicity can occur when clients receive too high a concentration of oxygen for an extended period. Symptoms include dyspnea, substernal pain, restlessness, fatigue, and progressive respiratory difficulty. Bradycardia and mood swings are not symptoms of oxygen toxicity.

The nurse is educating the patient in the use of a mini-nebulizer. What should the nurse encourage the patient to do? (Select all that apply.)

• Hold the breath at the end of inspiration for a few seconds. • Cough frequently. • Frequently evaluate progress.

A client who is undergoing thoracic surgery has a nursing diagnosis of "Impaired gas exchange related to lung impairment and surgery" on the nursing care plan. Which of the following nursing interventions would be appropriately aligned with this nursing diagnosis? Select all that apply. a) Encourage deep breathing exercises. b) Monitor and record hourly intake and output. c) Regularly assess the client's vital signs every 2 to 4 hours. d) Maintain an open airway. e) Monitor pulmonary status as directed and needed.

• Monitor pulmonary status as directed and needed. • Regularly assess the client's vital signs every 2 to 4 hours. • Encourage deep breathing exercises. Interventions to improve the client's gas exchange include monitoring pulmonary status as directed and needed, assessing vital signs every 2 to 4 hours, and encouraging deep breathing exercises. Maintainin an open airway is appropriate for improving the client's airway clearance. Monitoring and recording hourly intake and output are essential interventions for ensuring appropriate fluid balance.

A nurse educator is reviewing the indications for chest drainage systems with a group of medical nurses. What indications should the nurses identify? Select all that apply. a) Chest trauma resulting in pneumothorax b) Need for postural drainage c) Post thoracotomy d) Pleurisy e) Spontaneous pneumothorax

• Post thoracotomy • Spontaneous pneumothorax • Chest trauma resulting in pneumothorax Chest drainage systems are used in treatment of spontaneous pneumothorax and trauma resulting in pneumothorax. Postural drainage and pleurisy are not criteria for use of a chest drainage system.

A patient is being mechanically ventilated with an oral endotracheal tube in place. The nurse observes that the cuff pressure is 25 mm Hg. The nurse is aware of what complications that can be caused by this pressure? (Select all that apply.)

• Pressure necrosis • Tracheal bleeding • Tracheal ischemia

A client who must begin oxygen therapy asks the nurse why this treatment is necessary? What would the nurse identify as the goals of oxygen therapy? Select all that apply. a) To provide adequate transport of oxygen in the blood b) To clear respiratory secretions c) To reduce stress on the myocardium d) To decrease the work of breathing e) To provide visual feedback to encourage the client to inhale slowly and deeply

• To provide adequate transport of oxygen in the blood • To reduce stress on the myocardium • To decrease the work of breathing Oxygen therapy is designed to provide adequate transport of oxygen in the blood while decreasing the work of breathing and reducing stress on the myocardium. Incentive spirometry is a respiratory modality that provides visual feedback to encourage the client to inhale slowly and deeply to maximize lung inflation and prevent or reduce atelectasis. A mini-nebulizer is used to help clear secretions