Evolve Respiratory Quiz

A nurse receives a call from the emergency department about a client with tuberculosis (TB) who will be admitted to the medical unit. Which precaution should the nurse take?

A high-particulate filtration mask that meets Centers for Disease Control (CDC) performance criteria (Canada: Public Health Agency of Canada [2013] Canadian Tuberculosis Standards, 7th edition) for a tuberculosis respirator must be worn to protect healthcare providers from exposure to the Mycobacterium tuberculosis organism. Airborne transmission-based precautions do not require a gown unless contact with respiratory secretions is anticipated. The client should be placed in a private room with negative pressure and multiple full air exchanges per hour vented to the outside environment. A surgical mask with a face shield is inadequate to prevent transmission of the tuberculosis microorganism.

A person's bathrobe ignites while the individual is cooking in the kitchen on a gas stove. What is the priority intervention after the flames are extinguished?

A patent airway is most vital; if the person is not breathing, cardiopulmonary resuscitation (CPR) should be initiated. The person should be kept nothing by mouth because extensive burns decrease intestinal peristalsis, and the person may vomit and aspirate. Covering the person with a warm blanket is not done until the assessment for breathing is completed. Calculating the extent of the person's burns is not the priority; this assessment is done after transfer to a medical facility.

The nurse provides teaching about self-care management to a client who recently was diagnosed with emphysema. The nurse concludes that further teaching is needed when the client makes which statement?

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.

A client who is receiving peritoneal dialysis reports severe respiratory difficulty. What immediate action should the nurse implement?

Always assess the client first to determine if the lung sounds are indicative of fluid overload. When respiratory distress occurs, possibly from pressure of the dialysate on the diaphragm, respiratory status and vital signs should be assessed. The healthcare provider should be notified and arterial blood gases should be obtained after immediate action is taken. Never apply pressure to the abdomen, as that could worsen the respiratory status.

A client arrives in the emergency department with multiple crushing wounds of the chest, abdomen, and legs. Which are the priority nursing assessments?

Assessing breathing and circulation are the priorities in trauma management; basic life functions must be maintained or reestablished (ABC's: Airway, Breathing, Circulation). Level of consciousness and pupil size are assessments associated with head injury; in this situation these follow determination of respiratory and circulatory status, which are the priorities. Although blood pressure is an important assessment associated with adequacy of circulation, it is obtained after assessments associated with patency of airway and breathing; a client's pain is addressed after airway, breathing, and circulation needs are assessed and interventions implemented to support life. Assessment for abdominal injury and other wounds follows determination of respiratory and circulatory status, which are the priorities.

A nurse teaches a client how to perform diaphragmatic breathing. Which instruction should the nurse provide?

Expanding the abdomen on inhalation aids descent of the diaphragm so that more air can enter and fill the lungs. Rapid breathing promotes respiratory alkalosis; diaphragmatic breathing includes slow deep breathing. The hands should be placed lightly on the abdomen to verify abdominal excursion. Diaphragmatic breathing may be performed in any position, but the best is supine; leaning forward may prevent the client from moving the abdomen properly.

A client is extubated in the postanesthesia care unit after surgery. For which common response should the nurse be alert when monitoring the client for acute respiratory distress?

Inadequate oxygenation of the brain from acute respiratory distress may produce restlessness or behavioral changes. The pulse increases with cerebral hypoxia from acute respiratory distress. The pupils dilate with cerebral hypoxia. Clubbing of the fingers is the result of prolonged hypoxia.

Which diagnostic test may be used to distinguish vascular from nonvascular structures?

Magnetic resonance imaging is used for distinguishing vascular from nonvascular structures. An X-ray is useful to screen, diagnose, and evaluate changes in the respiratory system. A pulmonary angiogram is used to visualize pulmonary vasculature and locate obstruction of pathologic conditions. Computed tomography is performed for diagnosis of lesions difficult to assess by conventional X-ray studies.

A nurse is a preceptor for an orientee (newly hired nurse). The orientee is providing postoperative care to a client who recently returned from a laryngoscopy. The orientee reminds the client not to eat or drink anything until instructed to do so. How does the preceptor evaluate the suitability of the instructions given to the client by the orientee?

Oral intake should not be attempted after the procedure until the return of the gag reflex. Even an alert person may choke and aspirate if eating or drinking is attempted while the pharyngeal wall is anesthetized. Although some slight irritation may occur after the procedure, there usually is no painful sequela. Clients do not receive general anesthesia for a laryngoscopy. The procedure does not produce a fluid deficit. The client needs to remain nothing by mouth.

Besides providing reassurance, what should nursing interventions for a client who is hyperventilating be focused on?

Reassurance decreases anxiety and slows respirations; the bag is used so that exhaled carbon dioxide can be rebreathed to resolve respiratory alkalosis and return the client to an acid-base balance. Administering oxygen is not necessary because there is no evidence of hypoxia. Using an incentive spirometer is used to prevent atelectasis. The client is already alkalotic; bicarbonate ions will increase the problem.

A client presents to the emergency room with coughing and sudden wheezing. The nurse notes the client is progressing quickly into respiratory distress. The nurse identifies that the client is experiencing what problem?

Symptoms for an acute asthma attack often are wheezing, coughing, dyspnea, and chest tightness. Cough, fever, and fatigue are often symptoms exhibited with acute bronchitis. Fatigue, breathlessness, weakness, shortness of breath, and fluid accumulation in the lungs are often signs of left-sided heart failure. Tiring easily, shortness of breath with exertion, lower leg edema, chest pain, and heart palpitations often are exhibited with cor pulmonale.

Which part of the upper respiratory system is involved in equalizing the pressure within the middle ear while swallowing?

The Eustachian tubes connect the nasopharynx to the middle ears; these tubes open during swallowing to equalize pressure within the middle ear. The glottis is the opening between true vocal cords. The paranasal sinuses are air-filled cavities within the bones that surround the nasal passages. Palatine tonsils are a part of the immune system and are located on the sides of the oropharynx. These tonsils protect against invading organisms.

Which statement is true regarding the Hering-Breuer reflex?

The Hering-Breuer reflex prevents overdistention of the lungs. An increase in hydrogen ion concentration will cause an increase in the tidal volume via central chemoreceptors. A decrease in the hydrogen ion concentration will cause a decreased respiratory rate via peripheral chemoreceptors. The Hering-Breuer reflex does not cause a reduction in the number of functional alveoli.

A client with laryngeal cancer has a partial laryngectomy and tracheostomy. To best facilitate communication postoperatively, what should the nurse do?

The client needs a means to write. The client will be unable to speak because a tracheostomy tube is in place to prevent edema. The client cannot speak with a tracheostomy tube in place. The client's ability to see and hear is not affected. The client can receive information but cannot speak. The client's ability to hear or understand is not affected.

A client with a history of hemoptysis and cough for the last six months is suspected of having lung cancer. A bronchoscopy is performed. Two hours after the procedure the nurse identifies an increase in the amount of bloody sputum. What is the nurse's priority?

The observation may be indicative of bleeding, and the healthcare provider should be notified. Overlooking the first signs of hemorrhage may permit the client to go into shock. Continuing to only monitor the client is unsafe. Monitoring vital signs every hour for four hours is a potentially life-threatening situation; the healthcare provider should be notified immediately. Increasing the coughing and deep breathing regimen can precipitate bleeding because of an increase in intrathoracic pressure.

A client with a history of rheumatic fever and a heart murmur reports gaining weight in spite of nausea and anorexia. The client also reports shortness of breath several times each day and when performing minor tasks. Which additional information should the nurse obtain?

The presence of a cough and pulmonary secretions, in addition to a history of rheumatic fever, requires an assessment for other cardiopulmonary problems and fluid overload. Anorexia and weight gain do not indicate a nutritional problem but a fluid balance problem. Loss of appetite in conjunction with shortness of breath and the history of rheumatic fever makes gastrointestinal (elimination) symptoms secondary in importance. There is no reason to investigate the gynecological and sexual history in relation to the current problem.

While preparing the client for a diagnostic procedure, the nurse positions the client upright with elbows on an overbed table and the feet supported. The nurse also instructs the client not to talk or cough during the procedure. Which diagnostic test is the client undergoing?

A thoracentesis is performed to obtain a specimen of pleural fluid for diagnosis. The client should be positioned upright with elbows on an overbed table with the feet supported. The client should not talk or cough during the procedure because the inserted needle may cause trauma. A lung biopsy or mediastinoscopy may not require the client to be seated upright. No special precautions are needed after performing ventilation-perfusion scan because the gas and isotope transmits radioactivity for only a brief interval.

A client who just returned from surgery reports shortness of breath and chest pain. Which should the nurse initially administer?

Oxygen supports vital centers of the body while the cause of the problem is investigated. Although an intravenous morphine may be done eventually if the client is experiencing a myocardial infarction, it is not the initial action and requires a prescription. Endotracheal intubation is not implemented by a nurse. Later, endotracheal intubation may be necessary if the client experiences respiratory failure or obstruction. Although a sublingual nitroglycerin may be done eventually if the client is experiencing angina, it is not an initial action and requires a prescription.

The nurse is providing postoperative care to a client with lung cancer who had a partial pneumonectomy. When inspecting the client's dressing, the nurse notes puffiness of the tissue around the surgical site. When the nurse palpates the site, the tissue feels spongy and crackles can be felt. How does the nurse describe this assessment finding?

There is air in the tissues and palpation results in a crackling sound referred to as subcutaneous emphysema. Respiratory stridor is a harsh, high-pitched sound usually produced on inspiration because of airway obstruction. Bilateral 2+ pitting edema is excessive accumulation of fluid in tissue spaces. The size of the chest is determined by the bony structure; a barrel chest with an increase in the anteroposterior (AP) diameter is associated with chronic obstructive pulmonary disease (COPD), not cancer of the lung.

A client is admitted with suspected atelectasis. Which clinical manifestation does the nurse expect to identify when assessing this client?

Because atelectasis [1] [2] involves collapsing of alveoli distal to the bronchioles, breath sounds are diminished in the lower lobes. The client will have rapid, shallow respirations to compensate for poor gas exchange. Atelectasis results in an elevated temperature. Atelectasis results in a loose, productive cough.