EAQ 2 - Respiratory

A client with a puncture wound of the chest wall is transported to the emergency department. Which action would the nurse take? Prepare for a thoracentesis Apply a wound dressing Set up a chest tube closed drainage system Suction fluid from the wound

Apply a wound dressing The wound must be covered to prevent atmospheric air from entering the pleural cavity until closed chest drainage can be instituted. Although some sources specify an airtight dressing, others suggest that a side or corner of the dressing be left unsecured to prevent tension pneumothorax. A thoracentesis is used to drain fluid from lungs. There is not enough information to indicate whether a chest tube is needed to drain fluid or air. Suctioning fluid from the wound is traumatic to lung tissue and is contraindicated.

Which client would the nurse consider to have the highest risk of pneumonia? Client 1 Client 2 Client 3 Client 4

Client 4 Client 4, who is an older adult with chronic lung disease and has received the pneumococcal vaccination more than 5 years ago, has the highest risk of pneumonia. An infection may occur because older adults with chronic lung disease are at a higher risk of infection. Client 1 received the pneumococcal vaccination in the past 3 months and thus has a lower risk of pneumonia. Client 2 received a pneumococcal vaccination in the past 2 years and may not have an elevated risk of pneumonia. Client 3 may have a lower risk of pneumonia due to receiving the pneumococcal vaccine a year ago.

Which pathophysiological changes in the lungs occur with emphysema? Collapse oof alveolar walls Trapping of air in distal lung structures Increase in pulmonary artery pressures Increase in surface area for gas exchange Movement of fluid from capillaries into alveoli

Collapse of alveolar walls Trapping of air in distal lung structures Increases in pulmonary artery pressures Destruction of alveolar walls in emphysema leads to alveolar wall collapse and trapping of air in distal lung structures, leading to poor gas exchange. Chronic hypoxemia causes pulmonary hypertension. As alveolar walls collapse, less surface area is available for gas exchange. The alveoli do not become filled with fluid in emphysema. Left-sided heart failure causes pulmonary congestion with fluid-filled alveoli.

When a client with COPD reports a 5-lb weight gain in 1 week, the nurse will assess for other signs and symptoms of which complication? Polycythemia Cor pulmonale Compensated acidosis Left ventricular failure

Cor pulmonale Fluid retention and weight gain caused by right ventricular failure is a clinical manifestation of cor pulmonale, or right ventricular failure caused by pulmonary hypertension associated with COPD. Polycythemia may be caused by COPD, but it does not cause weight gain. Compensated respiratory acidosis is caused by COPD, but it would not lead to weight gain. Left ventricular failure may lead to weight gain, but it is not a complication of COPD.

When a client has difficulty swallowing after a stroke, which action by the nurse would be most important in preventing pneumonia? Giving influenza vaccine to the client Having suction available during meals Assisting the client to take deep breaths Teaching about incentive spirometer use

Having suction available during meals Because a client with difficulty swallowing is at risk for aspiration, having suction available will be the most effective intervention in preventing aspiration pneumonia. Giving the influenza vaccine is important in preventing viral pneumonia, but would not help prevent aspiration. Deep breathing is important to prevent atelectasis, but would not prevent aspiration pneumonia. Incentive spirometer use is important in preventing atelectasis, but not helpful in preventing aspiration.

The nurse provides education about self-care management to a client who was recently diagnosed with emphysema. The nurse concludes that further teaching is needed when the client makes which statement? I will try to avoid smoking I will maintain complete bed rest I'll control the temperature in my home I'll need to clean my mouth several times a day

I will maintain complete bed rest Although energy should be conserved, it is not necessary to restrict all activity; the client needs further teaching. Smoking should be avoided because it is a respiratory tract irritant and it interferes with gas exchange in the alveoli. Extremes in environmental temperature and humidity place stress on the respiratory system, interfering with gaseous exchange. Meticulous oral care is advisable because of the presence of excessive mucus; also, it reduces the amount of microorganisms that can enter the tracheobronchial tree, which can precipitate infection.

The nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. The nurse would include which information in the education? Purpose of bronchodilators Importance of meticulous oral hygiene Technique used in pursed-lip breathing Methods used to maintain a dust-free environment

Importance of meticulous oral hygiene Microorganisms in the mouth are transferred easily to the tracheobronchial tree and are a source of potential infection; meticulous oral hygiene is essential to reduce the risk of respiratory infection. Bronchodilators will not prevent infection; they dilate the bronchi. Pursed-lip breathing will not prevent infection; it promotes gas exchange in the alveoli and facilitates more effective exhalation. It is impossible to maintain a dust-free environment.

A client with a chest tube is to be transported via a stretcher. When transporting the client, what would the nurse do? Keep collection device attached to mechanical suction Keep chest tube clamped distal to the water-seal chamber Keep collection device below the level of the client's chest Keep chest tube end covered with sterile gauze pads taped to the client

Keep collection device below the level of the client's chest The collection device must be kept below the level of the chest to prevent backflow of fluid into the pleural space. A chest tube clamped distal to the water-seal chamber is contraindicated. The chest tube should not be clamped because it may precipitate a tension pneumothorax. A chest tube end covered with sterile gauze pads taped to the client is contraindicated. There is no reason to disconnect the chest tube from the water-seal system; this will allow atmospheric air to enter the pleural space, causing a pneumothorax.

For a client with a chest tube, which action would the nurse take to check for the presence of subcutaneous emphysema? Palpate around the tube insertion sites for crepitus Auscultate the breath sounds for crackles and atelectasis Observe the client for the presence of a barrel-shaped chest Compare the length of inspiration with the length of expiration

Palpate around the tube insertion sites for crepitus Subcutaneous emphysema occurs when air leaks from the intrapleural space through the thoracotomy or around the chest tubes into the soft tissue; crepitus is the crackling sound heard when tissues containing gas are palpated. Crackles and atelectasis are unrelated to crepitus. They occur within the lung; subcutaneous emphysema occurs in the soft tissues. Observing the client for the presence of a barrel-shaped chest is related to prolonged trapping of air in the alveoli associated with emphysema, a chronic obstructive pulmonary disease. Comparing the length of inspiration with the length of expiration is unrelated to subcutaneous emphysema, which involves gas in the soft tissues from a pleural leak.

The registered nurse is delegating care for a client who underwent a tracheostomy. Which task could be delegated to the licensed practitional nurse? Developing a plan to avoid aspiration Assessing the client's condition after tracheostomy Providing tracheostomy care using sterile techniques Teaching a client and caregiver about home tracheostomy care

Providing tracheostomy care using sterile techniques The licensed practical nurse (LPN) provides tracheostomy care using sterile techniques. Developing a plan to avoid aspiration in a client with tracheostomy is done by the RN. Assessing the client's condition after tracheostomy is done by the RN. Teaching a client and caregiver about home tracheostomy care is done by the RN.

Which observation by the nurse indicates a client with pneumonia is able to use an incentive spirometer correctly? Select all that apply Records the volume of the air inspired Performs 10 breaths per session every hour Inhales air fully before inserting the mouthpiece Takes a long, slow, deep breath keeping the mouthpiece in place Exhales deep breaths with the mouthpiece in their mouth

Records the volume of the air inspired Performs 10 breaths per session every hour Takes a long, slow, deep breath keeping the mouthpiece in place The use of incentive spirometry is to improve inspiratory muscle action and to prevent or reverse atelectasis in clients with pneumonia. The client would exhale fully, then insert the mouthpiece and inhale. Having the client inhale the air before inserting the mouthpiece may cause harm to the client and needs correction. After the process is completed, the volume of air inspired is recorded. A client with pneumonia is instructed to perform 10 breaths per session every hour while awake. Taking a long, slow, deep breath while keeping the mouthpiece in place helps improve inspiratory muscle action. The client should not inhale air fully before inserting the mouthpiece or exhale deep breaths with the mouthpiece in their mouth.

After change-of-shift report, which client would the nurse assess first? A client with possible lung cancer who is scheduled for bronchoscopy A client with left pleural effusion who is scheduled for a thoracentesis A client with HAP and decreased breath sounds A client with an acute asthma exacerbation and 85% oxygen saturation

A client with an acute asthma exacerbation and 85% oxygen saturation A client with an oxygen saturation of 85% requires immediate assessment and interventions to improve oxygenation, such as administration of prescribed rapid-acting bronchodilators and administration of higher oxygen concentrations. There is no data indicating that the client who is scheduled for bronchoscopy needs any urgent interventions. The client with a pleural effusion does not have symptoms that indicate any need for urgent assessment or interventions. Decreased breath sounds would be expected in a client with pneumonia and are not an indicator of a need for immediate assessment.

Which actions will the nurse take when caring for a client with a chest tube in place after thoracotomy? Select all that apply. Administer prescribed analgesic medications Check around chest tube insertion site for crepitus Clamp the chest tube before the client ambulates Add fluid to the suction control chamber as needed Milk the tubing toward the collection chamber Check for air bubbling in the water-seal chamber

Administer prescribed analgesic medications Check around chest tube insertion site for crepitus Add fluid to the suction control chamber as needed Check for air bubbling in the water-seal chamber Because the intrapleural space has many sensory nerves, the chest tube will be uncomfortable and the nurse will assess for pain and administer analgesics as needed. Crepitus around the chest tube insertion indicates air leakage into the subcutaneous tissue and will be monitored. Fluid in the suction control chamber may evaporate; the fluid level controls the amount of negative pressure applied to the intrapleural space and must be kept at the prescribed level. The water-seal chamber is assessed for bubbling, which indicates that air is exiting the pleural space. Clamping the chest tube is avoided unless there is damage to the drainage system that requires attachment of a new chest drainage system. Milking of the chest tubes is avoided because milking causes increased negative intrapleural pressure that may lead to pleural trauma and bleeding.

Which information is needed to determine oxygen administration for a client with COPD and an oxygen saturation of 87%? Level of orientation Arterial blood gases Bilateral lung sounds Complete blood count

Arterial blood gases Clients with COPD who have low oxygen levels respond to oxygen administration. However, some clients with COPD have a respiratory drive that stimulates breathing that is dependent on carbon dioxide. The administration of too much oxygen in these clients lowers respiratory drive and decreases breathing. Therefore, the nurse would assess the client's arterial blood gases to determine how much oxygen to administer. Level of orientation shows the amount of hypoxia the client is experiencing. Clients may have abnormal lung sounds that can impede oxygenation, but this is not the basis for determining oxygen administration. A complete blood count assesses red blood cells, hemoglobin, and hematocrit; these values can be diminished in clients with COPD, but they do not determine oxygen needs.

When a client is newly diagnosed with COPD, which action by the nurse has the highest priority? Teach the client how to use the prescribed inhalers Discuss the normal progression of the disease process Ask whether the client is interested in quitting smoking Explain the purpose of a pulmonary rehabilitation program

Ask whether the client is interested in quitting smoking Smoking cessation slows the progression of COPD and is the most important action that the client can take to help maintain lung function. Although many clients may not be ready to stop smoking, the nurse will assess the client's interest in smoking cessation at every encounter. Teaching correct inhaler use is important, but inhaled medications only treat the symptoms of COPD and do not slow disease progression. The client will be educated on the progression of COPD, but education alone does not change the progression of the disease. Pulmonary rehabilitation programs are helpful in improving ability to do activities of daily living and also will assist the client with tobacco cessation, but assessment of readiness to quit smoking is done before developing a plan to quit.

Which client is at an increased risk for HAP? Client who was admitted yesterday with hypoxia and fever Client who has been on mechanical ventilation for 5 days Client who reports being on an airplane with other sick individuals Client who was admitted to the hospital 5 days ago for abdominal pain

Client who was admitted to the hospital 5 days ago for abdominal pain Hospital-acquired pneumonia occurs in nonintubated clients and begins 48 hours after admission. A client admitted 5 days ago with abdominal pain would meet the criteria and is at increased risk for hospital-acquired pneumonia. A client admitted the previous day has not been in the hospital at least 48 hours. A client on mechanical ventilation is intubated and does not meet the criteria for hospital-acquired pneumonia. A client who has been on an airplane with other ill individuals would be at risk for community-acquired pneumonia.

Which finding in a client who has had a chest tube removed would be of most concern to the nurse? Poor cough effort Pain at chest tube site Crepitus at the chest tube site Two centimeters of pink drainage on dressing

Crepitus at the chest tube site Crepitus at the chest tube site may indicate ongoing pneumothorax and the nurse would take actions such as listening to breath sounds, checking oxygen saturation, checking results of the postremoval chest x-ray, and notifying the health care provider. A poor cough effort may indicate the need for action such as pain management, but is not likely to be caused by removal of the chest tube. Pain at the chest tube site may occur because of inflammation and indicates the need for pain management, but would not indicate any complications associated with chest tube removal. A small amount of serosanguinous drainage is common after removal of chest tubes.

Which breathing exercises would the nurse teach a client with the diagnosis of emphysema? An inhalation that is prolonged to promote gas exchange Abdominal exercises to limit the use of accessory muscles Sit-ups to help strengthen the accessory muscles of respiration Diaphragmatic exercises to improve contraction of the diaphragm

Diaphragmatic exercises to improve contraction of the diaphragm With emphysema the diaphragm is flattened and weakened; strengthening the diaphragm is desirable to maximize exhalation. Prolonged exhalations are more desirable; clients with emphysema have an increased residual volume, which eventually causes a barrel chest. Abdominal exercises enhance, not limit, the accessory muscles of respiration that are needed as a compensatory mechanism for clients with emphysema. Sit-ups are too strenuous for clients with emphysema.

Which assessment finding of the client with laryngeal trauma and hemoptysis would require immediate nursing intervention? Dyspnea Aphonia Hoarseness Subcutaneous emphysema

Dyspnea Bleeding from the airway, aphonia, hoarseness, and subcutaneous emphysema are the clinical manifestations of laryngeal trauma. Maintaining a patent airway is a priority; therefore dyspnea should be corrected to prevent life-threatening consequences. Aphonia is of moderate priority and can be corrected by clearing the throat. Hoarseness can be cleared slowly because it does not threaten the client's life. Subcutaneous emphysema is of moderate priority because it does not affect the client's life directly.

Which action would the nurse take to prevent aspiration recurrence in a client with aspiration pneumonia who is NPO status with a NG tube and a prescription for antibiotics? Obtaining VS after feeding Administering IV abx Elevating the head of the bed to 30 degrees Determining residual every 4 hours

Elevating the head of the bed to 30 degrees The nurse would elevate the head of the bed a minimum of 30 degrees to prevent aspiration of tube feedings in a client with a nasogastric tube. Obtaining vital signs after tube feedings would not prevent aspiration. Intravenous antibiotics would be administered to treat the current pneumonia but would not prevent aspiration recurrence. Determining residual every 4 hours would assess the client's tolerance of tube feedings but would not prevent aspiration.

Which information would the nurse educator include in a presentation on how to care for clients with a chest tube drainage system? Select all that apply. Ensure the chest tube dressing is tight and intact Palpate the skin to detect subcutaneous emphysema Place the chest tube drainage system below the chest Quickly attempt to reinsert the chest tube if it falls out Strip the chest tube with long strokes to promote drainage

Ensure the chest tube dressing is tight and intact Palpate the skin to detect subcutaneous emphysema Place the chest tube drainage system below the chest Care of clients with chest tubes includes ensuring the chest tube dressing is tight and intact to prevent tube dislodgement and air leak. The nurse will palpate the skin to detect subcutaneous emphysema. The chest tube drainage system is placed below the chest. If a chest tube falls out, the nurse will cover the site with sterile gauze and immediately notify the health care provider. The chest tube should not be stripped because this causes negative pressure that can cause trauma to the pleura.

A client who had thoracic surgery is admitted to the PACU. The nurse notes that a chest tube is in place and is attached to a disposable plastic, water-seal drainage system. To provide appropriate care of the chest tube and drainage unit, which steps would the nurse take next? Ensure the security of the connections from the client to the drainage unit Empty the drainage container and measure and record the amount Verify that there is vigorous bubbling in the wet suction control compartment Check that the fluid level in the water-seal compartment increases with expiration

Ensure the security of the connections from the client to the drainage unit The system must remain airtight (closed) to prevent collapse of the lung. The system is kept closed; a record of drainage is kept by marking the outside of the container or chamber. It should bubble but not vigorously; vigorous bubbling will not increase the suction but will cause the fluid to evaporate more rapidly. The water level will fluctuate as the client inhales and exhales. The level will increase with inspiration and decrease with expiration; this is known as

Which statement describes the rationale for palpation of the trachea after a client has had a pneumonectomy? Examining for any mediastinal shift Assessing for subcutaneous emphysema Monitoring for possible tracheal edema Checking for endotracheal tube cuff inflation

Examining for any mediastinal shift After pneumonectomy, the mediastinum may shift toward the affected side because of the absence of lung tissue on that side after surgery. Mediastinal shift can cause compression of the heart, aorta, and vena cava, leading to decreased cardiac output. Subcutaneous emphysema would typically be noted around the chest incision site or at the insertion site for any chest tubes. Tracheal edema occurs inside the trachea and would not be palpable on the neck. The cuff of the endotracheal tube cannot be assessed through palpation of the trachea.

A client is admitted with multiple injuries as a result of an accident. A tracheostomy was performed. While the nurse is caring for this client, the client coughs, expelling the tracheostomy tube onto the bed. Which action would the nurse take? Hold the tracheostomy open with a tracheal dilator and call for assistance Insert an obturator into the tracheostomy and gently reinsert the tracheostomy tube Pick up the tracheostomy tube from the bed and replace it until a new tube is available Obtain a new tracheostomy tube, prepare the new holder, and insert the tube using the obturator

Hold the tracheostomy open with a tracheal dilator and call for assistance By holding the tracheostomy open with a tracheal dilator and calling for assistance, an immediate airway is provided without causing trauma; with assistance, a new tracheostomy tube can be inserted. The obturator will obstruct the airway. Replacing the tube that fell on the bed linen is contraindicated because it is contaminated; a sterile tube should be inserted. If the airway is not held open, the client will experience hypoxia.

How would the nurse plan to position a client with a diagnosis of emphysema who is experiencing dyspnea? Supine Contour Orthopneic Semi-Fowler

Orthopneic The orthopneic position lowers the diaphragm and provides for maximum thoracic expansion. The supine position will not facilitate thoracic expansion because it permits abdominal organs to press against the diaphragm. The contour position will not facilitate thoracic expansion because it permits abdominal organs to press against the diaphragm. Although the semi-Fowler position can help, it is not as beneficial as the orthopneic position.

An older client with shortness of breath is admitted to the hospital. The medical history reveals and a diagnosis of pneumonia 3 days ago. Which vital sign assessment would be seen as a sign that the client needs immediate medical attention? Oxygen saturation: 89% Body temperature: 101 F Blood pressure: 130/80 mm Hg Respiratory rate: 26 beats/minute

Oxygen saturation: 89% An oxygen saturation of less than 90% observed in a client with pneumonia indicates that the client is at risk of respiratory depression. Oxygen saturation would take priority in initiating the care. The client's body temperature indicates fever due to pneumonia, which should be considered secondary to the oxygen saturation problem. The blood pressure reading is normal. The increased respiratory rate may be due to fever, which would be considered secondary to the oxygen saturation problem.

When caring for a client after a thoracotomy, which action would the nurse take to keep the chest tube and closed chest drainage system patent? Position the drainage system below the level of the client's heart Empty the collection chamber and measure contents every 12 hours Assure that a daily CXR is done to chest chest tube position Keep the client on bed rest until the chest tube is discontinued

Position the drainage system below the level of the client's heart Positioning the chest drainage system below the level of the heart assists with the movement of drainage out of the pleural space and into the collection chamber. Because the chest drainage system is a closed system, the collection chamber is not drained. If the collection chamber is full before the chest tube is removed, the whole drainage system is replaced. A chest x-ray is done to check initial chest tube position, but the position does not have to be rechecked every day. Clients with chest tubes should get up, ambulate in place, and sit at the bedside to avoid the many complications of prolonged bed rest.

After being notified that a client with a sucking chest wound is being transported to the emergency department, the nurse will anticipate which initial collaborative intervention? Obtaining a chest x-ray Notifying the on-call surgeon Preparing for chest tube insertion Drawing blood for laboratory studies

Preparing for chest tube insertion The initial collaborative action would be to stabilize the client's respiratory status with insertion of a chest tube to treat the open pneumothorax. A chest x-ray will be needed, but would be done after treating the pneumothorax with chest tube insertion. The client may need surgery, but needs further assessment and stabilization before surgery. Laboratory studies such as complete blood count and arterial blood gases will be needed, but would be done after the client's respiratory status is stabilized.

When a client with newly diagnosed chronic bronchitis tells the home health nurse about continuing to smoke 1 or 2 cigarettes a day and not doing the prescribed pulmonary physiotherapy exercises, which response by the nurse is best? Tell me about your typical day before you were diagnosed with chronic lung disease Smoking and not doing the exercises will make your lung disease continue to get worse I can't make you stop doing what you are doing, and it's your choice to be sick or well Your shortness of breath is probably because of your smoking and not doing the exercises

Tell me about your typical day before you were diagnosed with chronic lung disease Asking the client to describe a typical day is the best response. More data are needed about the client's usual activities of daily living so that the plan can be adapted to the client's preferences. The statement indicating that smoking and not doing the pulmonary exercises will allow the lung disease to progress is probably not news to the client and does not help in determining factors that might be contributing to nonadherence. The statement that the nurse cannot stop the client's behaviors indicates that the client is to blame and will place the client on the defensive. The statement that the client's dyspnea is caused by smoking and not doing the pulmonary exercises places the client on the defensive and will decrease trust, preventing the nurse from obtaining more information about why the client is nonadherent with the treatment plan.

A client with a tracheostomy tube attached to a tracheostomy collar for the delivery of humidified oxygen. What is the primary reason that suctioning is included in the client's plan of care? Humidified oxygen is saturated with fluid The tracheostomy tube interferes with effective coughing The inner cannula of the tracheostomy tube irritates the mucosa The weaning process increases the amount of respiratory secretions

The tracheostomy tube interferes with effective coughing Because the tracheostomy tube enters the trachea below the glottis, the client is unable to close the glottis to retain air in the lungs; this prevents an increase in the intrathoracic pressure and the ability to open the glottis to expel an explosive cough. Humidified oxygen decreases the need for suctioning because it liquefies secretions, which then are easier to expel. The outer, not inner, cannula of a tracheostomy tube irritates the mucosa. Weaning begins when the respiratory status improves and the amount of respiratory secretions subsides.