Evolve: Respiratory System

A nurse is caring for several postoperative clients. For what clinical manifestations of a pulmonary embolus should the nurse monitor these clients? (Select all that apply.)

-Dyspnea -Hemoptysis -Feeling of impending doom

A client's respiratory status may be affected after abdominal surgery. The nurse documents the behavioral objective for this client. What statement is a behavioral objective?

-Demonstrates the technique of coughing and deep breathing

Clients are encouraged to perform deep-breathing exercises after most types of surgery. The nurse teaches clients that the reason for these exercises is to help:

Prevent the buildup of carbon dioxide in the body Retention of carbon dioxide in the blood lowers the pH, causing respiratory acidosis; deep breathing maximizes gaseous exchange, ridding the body of excess carbon dioxide. Deep breathing improves oxygenation of the blood, but it does not stimulate red blood cell production. Although regular deep breathing improves the vital capacity of the lungs, residual volume is unaffected. Deep breathing increases, not decreases, the partial pressure of oxygen.

After surgery for cancer of the posterior pharynx, a client is receiving gavage feedings through a nasogastric tube. A family member asks why this is necessary. What is the nurse's best response?

"Tube feedings promote healing by reducing the risk for infection."

What technique should a nurse use when cleaning a tracheostomy tube that has a nondisposable inner cannula?

-Apply a precut dressing around the insertion site with the flaps pointing upward. To prevent unraveling and potential aspiration into the airway, only a precut dressing should be used around the site. It should be positioned to collect expectorations. An obturator is used only for inserting the outer cannula.

A client is admitted to the hospital with a diagnosis of an exacerbation of asthma. What should the nurse plan to do to best help this client?

-Give prescribed drugs to promote bronchiolar dilation.

After multiple bee stings a client experiences an anaphylactic reaction. The nurse determines that the symptoms the client is experiencing are caused by:

-Bronchial constriction and decreased peripheral resistance Hypersensitivity to a foreign substance can cause an anaphylactic reaction; histamine is released, causing bronchial constriction, increased capillary permeability, and dilation of arterioles. This decreased peripheral resistance is associated with hypotension and inadequate circulation to major organs.

A client just had a thoracentesis. For which response is it most important for the nurse to observe the client?

-Expectoration of blood Expectoration of blood is an indication that the lung itself was damaged during the procedure; a pneumothorax or hemothorax may occur. It is too soon after a thoracentesis for an infection to develop. Signs of infection are important for the client to assess for several days after the procedure. Increased breath sounds are anticipated because the lung is closer to the chest wall after the fluid in the pleural space is removed. A decreased rate may indicate improved gaseous exchange and is not evidence that the client is in danger.

A skier skied off the marked trail into the woods and collided with a tree. After several hours, the skier was found by the ski patrol and brought to the emergency department of the hospital. Moderate hypothermia (temperature range 87° to 90° F) is diagnosed. What clinical findings specific to moderate hypothermia should the nurse expect the client to exhibit?

Rigidity and slowed respiratory rate

A client develops increased respiratory secretions because of radiation therapy to the lung, and the health care provider prescribes postural drainage. What client assessment leads the nurse to determine that the postural drainage is effective?

-Has a productive cough A productive cough indicates that mucus is being raised from the lungs, which is an expected outcome. Crackles are unaffected by postural drainage or coughing. Saliva comes from the mouth; it does not indicate that the lungs are clear. Depth of respirations may not be altered by postural drainage.

Two portable drainage catheters with hemovacs attached were placed during a client's hemiglossectomy and right radical neck dissection. Six hours after the catheters were placed, the nurse empties 180 mL of serosanguineous drainage from one of the drainage catheters. The priority nursing intervention is to:

-Notify the health care provider immediately Serosanguineous drainage of 80 to 120 mL is expected during the first 24 hours; more than this amount of drainage should be reported. Placing the client in the side-lying position will have no effect on the portable wound drainage system;

A client is admitted to the hospital for a surgical resection of the lower left lobe of the lung. After surgery the client has a chest tube to a closed-chest drainage system. What should the nurse do to determine if the chest tube is patent?

-Observe for fluctuations of the fluid in the water-seal chamber Fluctuations of the fluid in the water-seal chamber indicate effective communication between the pleural cavity and the drainage system. Milking the chest tube toward the drainage unit should be avoided because it raises pressure in the pleural space, which can result in a tension pneumothorax. Bubbling in the suction control chamber is expected and should be continuous. Extent of chest expansion in relation to breath sounds does not directly reflect the patency of the chest tube.

A client is admitted to the hospital with a tentative diagnosis of pneumonia. The client has a high fever and is short of breath. Bed rest, oxygen via nasal cannula, an intravenous antibiotic, and blood and sputum specimens for culture and sensitivity (C&S) are prescribed. Place these interventions in the order in which they should be implemented.

1. Bed rest 2. Oxygen via nasal cannula 3. Specimen C&S 4. Administration of an antibiotic

There is a fire on an inpatient unit at the hospital. List the actions the nurse should take in the order in which they should be performed

1. Move clients and others away from the immediate vicinity of the fire. 2. Initiate the fire code alarm system. 3. Close the doors to the rooms on the unit. 4. Evacuate clients and others to a safe area off the unit with the fire. 5. Inform the clients' families that a fire is occurring.

A nurse auscultates a client's lungs and hears a fine crackling sound in the left lower lung during respiration. The nurse charts, "crackles and rhonchi in the left lower lung." What does this documentation represent?

An inaccurate interpretation Rhonchi are coarse sounds heard over the larger airways; including rhonchi in the record makes the documentation inaccurate. Crackles and rhonchi are clinical indicators, not a nursing diagnosis. It is incorrect to use the term rhonchi to refer to crackling sounds in the lower lung. Crepitus, which indicates subcutaneous emphysema, is unrelated to auscultated breath sounds.

A client reports having a bad cold and chest pain that worsens when the client takes deep breaths. Where should the nurse place the stethoscope to determine the presence of a pleural friction rub?

Answer D is the lower-lateral chest, which is the area of greatest thoracic excursion. With visceral and parietal pleural inflammation (pleurisy), a low-pitched, coarse, grating sound is heard when the client breathes, particularly when approaching the height of inspiration

A nurse is caring for a client with a history of chronic obstructive pulmonary disease (COPD). What complications are associated most commonly with COPD? Correct 1 Cardiac problems 2 Joint inflammation Incorrect 3 Kidney dysfunction 4 Peripheral neuropathy

Cardiac problems

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears coarse rhonchi. They are described best as:

Moist rumbling sounds that clear after coughing

Polycythemia frequently is associated with chronic obstructive pulmonary disease (COPD). When assessing for this complication, the nurse should monitor for:

-Elevated hemoglobin The body attempts to compensate for decreased oxygen to tissues by increasing the number of blood cells, the oxygen-carrying component of the blood. With polycythemia, the skin, especially the face, appears flushed, not pale. Dyspnea on exertion is not specific to polycythemia; there is more than one cause of dyspnea on exertion. The hematocrit is increased with polycythemia

A client develops subcutaneous emphysema after a chest injury with suspected pneumothorax. What assessment by the nurse is the best method for detecting this complication?

-Palpating the neck or face. Subcutaneous emphysema refers to the presence of air in the tissue that surrounds an opening in the normally closed respiratory tract; the tissue appears puffy, and a crackling sensation is detected when trapped air is compressed between the nurse's palpating fingertips and the client's tissue.

What should the nurse expect when assessing a client with pleural effusion?

-Reduced or absent breath sounds at the base of the lung Compression of the lung by fluid that accumulates at its base reduces expansion and air exchange

A client who is a pipe smoker is diagnosed with cancer of the tongue. A hemiglossectomy and right radical neck dissection are performed. To ensure airway patency during the first hours after surgery, the nurse should:

-Suction as needed After a hemiglossectomy a client will have difficulty swallowing and expectorating oral secretions because of the trauma of surgery.

A client with emphysema has a history of smoking two packs of cigarettes a day. What is the best approach for the nurse to help the client stop smoking?

Suggest that the client limit smoking to one pack of cigarettes a day