Iggy Ch 27-MC- Assessment of the Respiratory System

A client is admitted to the surgical floor with chest pain, shortness of breath, and hypoxemia after having a knee replacement. What primary assessment will the nurse make while preparing the client for a computed tomography (CT) scan?

-"Are you allergic to iodine or shellfish?" R: While preparing the client for a CT scan, the nurse's primary assessment would be to determine whether the client has any sensitivity to the contrast material by asking if the client has a known allergy to contrast, iodine or shellfish. CT scans, especially spiral or helical CT scans, with injected contrast can detect pulmonary emboli.

The nurse is preparing a client with possible pulmonary embolism for a CT scan with contrast. Prior to the scan, which of these assessment questions is essential for the nurse to ask?

-"Are you allergic to peanuts?" R: The assessment question that is essential for the nurse to ask is, "Did you take metformin today?" IV contrast material can be nephrotoxic. Metformin is stopped at least 24 hours before contrast dye is used and is not restarted until adequate kidney function is confirmed.

The nurse is providing education on preventing pulmonary disorders at a community health fair. Which of these groups does the nurse target?

-Bakers -Coal Miners -Furniture refinishers -Potters The groups the nurse targets as people at risk for pulmonary disorders include bakers, coal miners, furniture refinishers, and potters. Being exposed to flour as a baker for prolonged periods of time may cause a condition called occupational asthma. Coal miners are at risk for developing pneumoconiosis as the result of inhalation of coal dust. Owing to the chemicals used to refinish furniture (paint strippers, solvents, etc.), masks and adequate ventilation are essential for furniture refinishers. One of the main solvents involved will metabolize in the body to carbon monoxide and will impair the ability of the tissue to extract oxygen. Silicosis or inhalation of silica dust is a hazard for professional and recreational potters.Except in unique situations, electricians and plumbers do not need to wear masks or utilize special ventilation for their jobs.

Which assessment finding in the client with exacerbation of emphysema requires intervention by the nurse?

-Bronchial breath sounds heard at the bases The client with bronchial breath sounds needs intervention by the nurse. These sounds are not normally heard in the periphery and may indicate atelectasis or increased lung density, as might present with a tumor or an infectious process such as pneumonia.

The nurse is assessing a client with chronic bronchitis who smoked 3 packs of cigarettes daily for 32 years. How does the nurse document pack-year history of smoking in the medical record?

-Client has a 96 pack-year history R: This client has a 96-year pack history. Pack-year history refers to the number of packs per day multiplied by the number of years the client smoked.

Which client does the charge nurse on the medical-surgical unit assign to an RN who has floated from the postanesthesia care unit (PACU)?

-Client who had 1200 mL of pleural fluid removed by thoracentesis R: A nurse working in the PACU would be most familiar with assessing vital signs and respiratory status for a postoperative client after an invasive procedure such as thoracentesis. When a large volume of fluid has been removed, there is a greater risk for instability. This client is within this nurse's skill set.

The nurse is working in an urgent care clinic where four clients are waiting to be seen. Which client needs to be evaluated first by the nurse?

-Client who is speaking in three-word sentences and has an SpO2 of 90% R: The client that requires first and immediate evaluation by the nurse is the client who is speaking in three-word sentences and displaying dyspnea. This, coupled with an SpO2 of 90%, indicates hypoxemia.

The RN has received report about four clients. Which client needs the most immediate assessment?

-Client with acute asthma who has an oxygen saturation of 89% by pulse oximetry The client in need of the most immediate assessment is the one with acute asthma with an oxygen saturation of 89% by pulse oximetry. An oxygen saturation level less than 91% indicates hypoxemia and instability requiring immediate assessment and intervention to improve blood and tissue oxygenation.

The home health nurse is assigned to visit these clients when a change in agency staffing requires that one of the clients be rescheduled for a visit on the following day. Which client will be best to reschedule?

-Client with emphysema who has been on home oxygen for a month and has SpO2 levels of 91% to 93% R: The best client for the nurse to reschedule for a home visit is the client with chronic emphysema who is on home oxygen and who has an appropriate SpO2 level. A SpO2 level of between 89% and 92% is appropriate and satisfactory.The client with a positive Mantoux test, in addition to a history of cough, weight loss, and night sweats, is highly suspicious for tuberculosis and needs to be seen that day. The nurse needs to perform follow-up assessment and coordinate follow up testing. The nurse may need to provide reporting to the public health department and to develop a plan for close personal contacts. A client with a newly diagnosed pleural effusion needs a complete and thorough admission and intake assessment to ensure that oxygenation and underlying needs are addressed. A percutaneous lung biopsy may be performed as an outpatient procedure. The client who had a percutaneous lung biopsy and is experiencing increased dyspnea needs to be assessed that day to determine whether a life-threatening pneumothorax or hemothorax has developed.

The nurse is caring for a client who just returned from an open lung biopsy and has a prescription for morphine by client controlled analgesia (PCA). Which of these actions to detect early opioid induced respiratory depression does the nurse recommend?

-Continuous capnography R: For early detection of opioid-induced respiratory depression, the nurse recommends continuous capnography. Capnography detects exhaled carbon dioxide which increases during opioid-induced respiratory depression.Capnography, to detect opioid-induced respiratory depression, has been proven to be superior for early detection of respiratory changes and is a more sensitive indicator of respiratory depression than pulse oximetry.

The nurse is caring for a client with heart failure and acute kidney injury. For which of these breath sounds will the nurse assess?

-Crackles R: When caring for a client with heart failure and acute kidney disease, the nurse would assess for crackles. Crackles are described as a popping, discontinuous sound caused by air moving into previously deflated airways or areas of fluid.

A client is admitted to the medical floor with a new diagnosis of lung cancer. How will the nurse initially assist the client in managing the anxiety associated with the new diagnosis?

-Encourage the client to ask questions and verbalize concerns. R: The best way for the nurse to initially assist the client in managing anxiety related to a new diagnosis of cancer is to encourage the client to ask questions and voice concerns. The availability of the nurse to answer questions and listen to the client's concerns will help to decrease anxiety.

The nurse in the outpatient clinic is scheduling a client for pulmonary function tests. When teaching the client about pulmonary function testing (PFT), which point is essential for the nurse to emphasize?

-Ensure the client does not smoke for 6 hours before the test. R: The essential nursing intervention for a client being prepared for a PFT is to make sure that the client does not smoke for 6 hours before the test. Smoking can alter parts of the PFT (diffusing capacity [DLCO]), yielding inaccurate results.

The nurse is preparing the client for a diagnostic bronchoscopy. Which nursing intervention is essential for the nurse to perform prior to the procedure?

-Ensure the client has had nothing by mouth. R: When preparing a client for a diagnostic bronchoscopy, it is essential for the nurse to make sure the client is NPO for 4 to 8 hours before the procedure to reduce the risk for aspiration.

A client with asthma reports shortness of breath. Which of these findings does the nurse anticipate when assessing this client's chest?

-Expiratory wheezing not cleared by coughing R: In a client with asthma and shortness of breath, the nurse expects to hear expiratory wheezing not cleared by coughing. Wheezes are squeaky, musical, continuous sounds associated with bronchospasm, typical with asthma. They may be heard without a stethoscope and usually do not clear with coughing.

The nurse in the medical clinic is performing an assessment on an older adult client. Which finding requires further assessment by the nurse?

-Inability to state name and date of birth R: The nurse would further assess the client who is unable to state name and date of birth. The older adult has a higher risk for hypoxemia than a younger client. The older adult can become confused during acute respiratory conditions, which requires additional investigation.

A client has returned to the medical surgical unit after a bronchoscopy. Which nursing task is best for the charge nurse to delegate to the experienced unlicensed assistive personnel (UAP)?

-Monitor blood pressure and pulse. R: The best nursing task for the charge nurse to delegate to the experienced unlicensed assistive personnel (UAP) is monitoring blood pressure and pulse. An experienced UAP would have experience in taking client vital signs after procedures requiring conscious sedation or anesthesia.

The RN and the LPN/LVN are working together to provide care for a group of clients on a medical surgical unit. Which of these actions is most appropriate for the RN to perform?

-Plan client and family teaching regarding upcoming pulmonary function testing. R: The most appropriate action for the RN to perform is developing the teaching plan for upcoming pulmonary function test. These skills are complex, requiring use of the nursing process, and are not in the scope of practice of the LPN/LVN.Medication administration and monitoring of vital signs and client status after procedures can be accomplished by the LPN/LVN. Monitoring of oxygen saturation by pulse oximetry can also be included in the vital signs assessment.

When caring for a client who has just undergone thoracentesis, which of these interventions does the nurse perform first?

-Schedule an immediate chest x-ray. R: After thoracentesis, the nurse first makes sure a chest x-ray is performed to rule out possible pneumothorax and mediastinal shift (shift of central thoracic structures toward one side).

The emergency department nurse is assessing a client who believes he has sustained a pneumothorax after an outpatient thoracentesis earlier today. For which of these symptoms will the nurse assess?

-Sensation of air hunger -Tracheal deviation -Blue discoloration of the lips R: The nurse would assess for a pneumothorax if the client has a sensation of air hunger, tracheal deviation, and blue discoloration of the lips. All clients need to be taught to go to the ED for symptoms of a pneumothorax after a thoracentesis. Symptoms include pain on the affected side, rapid heart rate, rapid, shallow respirations, sensation of air hunger, prominence of the affected side that does not move in and out with respiratory effort, tracheal deviation to the unaffected, new onset of "nagging" cough and cyanosis.

The nurse is caring for four clients who came to the emergency department with a productive cough. Which of these clients requires immediate intervention by the nurse?

-The client with pink, frothy sputum R: The nurse would immediately assess and interview the client with a productive cough and pink, frothy sputum. Pink, frothy sputum is common with pulmonary edema, a life-threatening exacerbation of heart failure. This client requires immediate assessment and intervention.

The nurse in a life care community for geriatric clients is providing education to a group of residents on expected changes during aging. Which of these activities does the nurse encourage the older adult to perform to maintain respiratory function?

-Walk as tolerated each day. R: The best activity for the older adult to perform in order to maintain respiratory function is to try and walk each day. Ambulation to the client's ability is easily performed in an older adult facility as it does not require special equipment. Health and fitness help keep losses in respiratory functioning to a minimum.Older clients have less tolerance for exercise and may need increased rest periods during exercise.

A pleural friction

A pleural friction rub sounds grating, loud, or scratchy as inflamed surfaces of the pleura rub together. Wheezes are frequently referred to as musical or squeaky sounds caused by bronchospasm. They may occur on inspiration or on expiration as air rushes through narrowed airways.

Rhonchi

Rhonchi are low-pitched, coarse snoring sounds caused by thick secretions in larger airways.

Weezes

Wheezes are frequently referred to as musical or squeaky sounds caused by bronchospasm. They may occur on inspiration or on expiration as air rushes through narrowed airways.