Med-Surg HESI EAQ - Pulmonary

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? a. polycythemia b. cor pulmonale c. compensated acidosis d. left ventricular failure

Cor pulmonale Fluid retention and weight gain caused by R ventricular failure is a CM of cor pulmonale, or R 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

Which finding in a client with pulmonary edema requires the most rapid action by the nurse? a. weak, rapid pulse b. O2 sat 82% c. BP 99/54 d. crackles throughout both lungs

O2 sat 82% Oxygen saturation less than 90% indicates hypoxemia, which affects functioning of all tissues and organs and needs to be quickly corrected through administration of high oxygen levels, typically via non-rebreather mask. The other findings are also of concern but are not as essential as correcting hypoxemia. A weak, rapid pulse and low blood pressure occur in pulmonary edema because of decreased left ventricular function and poor cardiac output. The blood pressure indicates that cardiac output is currently low but adequate to perfuse tissues. Crackles heard throughout both lungs are consistent with pulmonary edema and need to be rapidly treated with diuresis, after oxygen is started to correct hypoxemia.

In which order would the nurse take these prescribed actions when caring for a client with chronic obstructive pulmonary disease (COPD) who is admitted with fever, increased dyspnea, and oxygen saturation of 86%?

1. Start O2 per nonrebreather 2. Obtain blood and sputum cultures 3. Infuse ceftriaxone 1 g IV 4. Administer acetaminophen for fever

The arterial blood gases for a client with acute respiratory distress are pH 7.30, PaO2 80 mm Hg (10.64 kPa), PaCO2 55 mm Hg (7.32 kPa), and HCO3 23 mEq/L (23 mmol/L). How would the nurse interpret these findings? a. hypoxemia b. hypocapnia c. compensated metabolic acidosis d. uncompensated respiratory acidosis

Uncompensated respiratory acidosis The increased PaCO2 indicates respiratory acidosis and the low pH indicates that the respiratory acidosis is uncompensated. The PaO2 is normal, indicating that the client is not hypoxemic. The elevated PaCO2 indicates hypercapnia. The HCO3 is normal, indicating that there is no metabolic acidosis.

After surgery, a client is extubated in the postanesthesia care unit. Which clinical manifestations would the nurse expect if the client is experiencing acute respiratory distress? Select all that apply. a. confusion b. hypocapnia c. tachycardia d. constricted pupils e. slow respiratory rate

a, b, c Inadequate cerebral oxygenation produces restlessness and confusion. Tachycardia occurs as the body attempts to compensate for the lack of oxygen. A low carbon dioxide level in the blood (hypocapnia) occurs with an increase in respiratory rate. The pupils dilate, not constrict, with hypoxia. An elevated respiratory rate (tachypnea), not a slow respiratory rate (bradypnea), occurs.

A client with which diagnosis will be at risk for development of a pulmonary embolism? a. A-fib b. forearm laceration c. migraine headache d. respiratory infection

A-fib Inadequate atrial contraction that occurs during fibrillation leads to pooling of blood in both atria that may result in thrombus formation. Dislodgement of thrombus in the right atria will lead to pulmonary embolism, whereas dislodgement of thrombus in the left atria may lead to embolic stroke. A forearm laceration does not increase pulmonary embolism risk. Pulmonary embolism is not a complication of migraine headache. Respiratory infections do not increase pulmonary embolism risk.

The nurse is caring for clients on a medical-surgical unit and identifies that which client has the highest risk for developing a pulmonary embolism? a. an obese client with leg trauma b. a pregnant client with acute asthma c. a client with diabetes who has cholecystitis d. a client with pneumonia who is immunocompromised

An obese client with leg trauma An obese client with leg trauma has 2 risk factors for the development of a PE: obesity and leg trauma. Options b and c only have one risk factor, while option d has no risk factors associated with the development of a PE

The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which is appropriate to include? a. they are indicative of pleural rubbing b. they are signs of bronchial constriction c. crackles are located in the smaller air passages d. crackles are heard during respiratory expiration

Crackles are located in the smaller air passages Fine crackles (sometimes called rales) are the sounds of fluid bubbling within the smaller airways and alveoli, usually attributable to pulmonary edema. Pleural rubbing causes a sound with a grating quality heard over the anterolateral area of the chest; it is attributable to decreased pleural lubrication. Bronchial constriction causes rhonchi or wheezes. Crackles are heard during inspiration.

A client is admitted to the intensive care unit with pulmonary edema. Which clinical finding would the nurse expect when performing the admission assessment? a. weak, rapid pulse b. decreased BP c. radiating anterior chest pain d. crackles at bases of the lungs

Crackles at bases of the lungs Crackles are the sound of air passing through fluid in the alveolar spaces; in pulmonary edema, fluid moves from the intravascular compartment into the alveoli. Hypervolemia leads to pulmonary edema. The pulse is bounding with hypervolemia. The blood pressure usually is increased with hypervolemia. Radiating anterior chest pain occurs with angina or a myocardial infarction.

Which finding for a client with pulmonary edema who received furosemide is the best indicator that the treatment has been effective? a. urine output over 1 hr is 200 mL b. O2 sat per pulse ox is 99% c. cardiac monitor shows sinus rhythm, rate 98 bpm d. no JVD seen with HOB elevated to 90 degrees

O2 sat per pulse ox is 99% Because pulmonary congestion associated with pulmonary edema causes severe hypoxemia, the client's oxygen saturation is the best indicator of effective treatment. A good urine output also shows that furosemide is effective, but is not as clear an indicator of improvement in pulmonary edema as the high oxygen saturation. Tachycardia is a common finding with pulmonary edema and having a heart rate in the high normal range may indicate improvement in the client's condition, but improvement in pulmonary parameters is a better indicator for this client. Jugular vein distention is an indicator of right heart failure, whereas pulmonary edema is caused by left ventricular failure.

When caring for a client with a possible pulmonary embolism, the nurse will anticipate preparing the client for which test? a. chest x-ray b. thoracic ultrasound c. CT d. MRI

CT Helical CT is the most commonly used test to detect pulmonary embolism. Chest x-ray may be normal with pulmonary embolism and is not useful as a diagnostic tool. Thoracic ultrasound might be used for pleural effusion, but not to diagnose pulmonary embolism. MRI testing is not used for diagnosis of pulmonary embolism.

Which rationale would the nurse use when teaching a client with chronic obstructive pulmonary disease (COPD) to use pursed-lip breathing? a. decrease air trapping b. prevent bronchial dilation c. strengthen intercostal muscles d. reduce diaphragmatic excursion

Decrease air trapping Pursed-lip breathing prolongs the expiratory phase and increases airway positive pressure, leading to more complete expiration and reduced air trapping. Bronchi and bronchioles stay open longer and are expanded during pursed-lip breathing. Pursed-lip breathing does not strengthen the intercostal muscles or reduce diaphragmatic excursion.

Which action would the nurse anticipate implementing when caring for a client with ARDS who is intubated and on mechanical ventilation? a. deflate the ETT cuff hourly b. schedule a change in ventilator tubing q 24 hr c. determine need for suctioning based on client assessments d. leave FiO2 at the highest setting as the client oxygenation improves

Determine need for suctioning based on client assessments Suction is likely to be needed and will be done based on assessment data such as client oxygen saturation, breath sounds, and activation of the high pressure alarm signifying endotracheal tube obstruction. The endotracheal tube cuff is kept inflated to protect the lower airways and improve delivery of breaths to the lungs. Research indicates that daily changes in ventilator tubing increase the risk for ventilator-associated pneumonia; the ventilator tubing should be changed only when soiled. Because high FiO2 levels can cause damage to the lungs, the FiO2 is reduced as the client's oxygenation improves.

Which action would the clinic nurse take when a client with chronic obstructive pulmonary disease (COPD) has a 10-mm area of induration after Mantoux testing? a. document the result as a negative finding b. teach the client about the need for a chest x-ray c. discuss latent tuberculosis with client d. notify the local health department

Document the result as a negative finding A 10-mm induration in a client with COPD would be interpreted as negative and no further action is needed. In this client, a chest x-ray to check for evidence of tuberculosis would be needed for an induration of 15 mm or more. Because the client's Mantoux test is negative, no discussion of latent tuberculosis is needed. The public health department does not need notification for negative Mantoux testing.

Which diuretic would the nurse anticipate administering to a client admitted with acute pulmonary edema? a. furosemide b. chlorothiazide c. spironolactone d. acetazolamide

Furosemide Furosemide acts on the loop of Henle by increasing the excretion of chloride and sodium; is available for intravenous administration; and is more effective than chlorothiazide, spironolactone, and acetazolamide. Although it is used in the treatment of edema and hypertension, chlorothiazide is not as efficacious as furosemide. Spironolactone is a potassium-sparing diuretic; it is less efficacious than thiazide diuretics. Acetazolamide is used in the treatment of glaucoma to lower intraocular pressure.

The nurse is caring for a client with COPD. The client's ABGs deteriorate, and respiratory failure is impending. Which clinical manifestation is consistent with the client's condition? a. cyanosis b. bradycardia c. mental confusion d. distended neck veins

Mental confusion Decreased O2 to the vital centers in the brain results in restlessness and confusion. Cyanosis is a late sign of respiratory failure. Tachycardia, not bradycardia, will occur as a compensatory mechanism to help increase O2 to cells. Distended neck veins occur with fluid volume excess

The laboratory data for a client with prolonged vomiting reveal arterial blood gases of pH 7.51, Pco2 of 45 mm Hg, HCO3 of 58 mEq/L (59 mmol/L), and a serum potassium level of 3.8 mEq/L (3.8 mmol/L). The nurse concludes that the findings support which diagnosis? a. hypocapnia b. hyperkalemia c. metabolic alkalosis d. respiratory acidosis

Metabolic alkalosis Elevated plasma pH and elevated bicarbonate levels support metabolic alkalosis. The arterial carbon dioxide level of 45 mm Hg is within the expected value of 35 mm Hg to 45 mm Hg; no hypocapnia is present. The client's serum potassium level is within the expected level of 3.5 mEq/L to 5 mEq/L (3.5-5 mmol/L). With respiratory acidosis the pH will be less than 7.35 and the Pco2 will be elevated.

Which medical intervention would the nurse anticipate will be included in the management of a client with acute respiratory distress syndrome (ARDS)? a. chest tube insertion b. aggressive diuretic therapy c. administration of beta-blockers d. PEEP

PEEP Mechanical ventilation with PEEP will help prevent alveolar collapse and improve oxygenation. Fluid is not in the pleural space, so chest tube insertion is not indicated. Aggressive diuretic therapy and administration of beta blockers are contraindicated because of severe hypotension from the fluid shift into the interstitial spaces in the lungs.

The nurse is providing hygiene care to a immobile client who was admitted for exacerbation of chronic obstructive pulmonary disease (COPD). Which nursing intervention is correct when the client becomes short of breath during the care? a. obtain a pulse ox to determine the client's O2 sat level b. put the client in high fowler's c. darken the lights and provide a rest period of at least 15 mins d. continue the hygiene activities while reassuring the client

Put the client in high fowler's Putting the client in the high Fowler position will help expand the lungs and decrease the severity of shortness of breath. Leaving the client to obtain a pulse oximeter while the client is experiencing shortness of breath places the client in danger. Providing a rest period of at least 15 minutes may be appropriate but is not the priority. The nurse needs to acknowledge the change in the client's condition, such as shortness of breath, and take care of this immediate client need before continuing the hygiene activities.

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco2 of 60 mm Hg. These blood gas results require nursing attention because they indicate which condition? a. metabolic acidosis b. metabolic alkalosis c. respiratory acidosis d. respiratory alkalosis

Respiratory acidosis The normal blood pH range is 7.35 to 7.45; therefore, a blood pH of 7.25 indicates acidosis. The parameter for respiratory function is CO2, and the acceptable range of arterial Pco2 is 35 to 45 mm Hg; therefore, 60 mm Hg is elevated, resulting in respiratory acidosis. HCO3 is the parameter for metabolic functions. A pH of 7.25 is acidic, indicating acidosis and not alkalosis.

Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety? a. respiratory acidosis b. respiratory alkalosis c. respiratory compensation d. respiratory decompensation

Respiratory alkalosis Hyperventilation causes excess amounts of carbon dioxide (CO2) to be eliminated, causing respiratory alkalosis. Respiratory acidosis is caused by excess CO2 retained in the lungs from conditions such as hypoventilation or chronic obstructive pulmonary disease (COPD). Respiratory compensation and decompensation are terms not associated with this situation.

When assessing the breath sounds of a client with chronic obstructive pulmonary disease (COPD), the nurse hears moist rumbling sounds that improve after the client coughs. How will the nurse document the lung sounds? a. rhonchi b. wheezes c. fine crackles d. vesicular sounds

Rhonchi Rhonchi are coarse and moist sounds caused by obstruction of the airway with thick mucus, and they usually clear or change with coughing as the mucus moves or is expectorated. Wheezes are high-pitched continuous sounds. Fine crackles are high-pitched popping noises. Vesicular sounds are the normal breath sounds.

A client is experiencing severe acute respiratory distress. Which response would the nurse expect the client to exhibit? a. tremors b. anasarca c. bradypnea d. tachycardia

Tachycardia The heart rate increases in an attempt to compensate for the lack of oxygen to body cells. Tremors are not associated with respiratory distress; tremors are associated with neurological problems. Severe generalized edema (anasarca) is not associated with respiratory distress; anasarca is associated with renal failure. An increased respiratory rate (tachypnea), not a decreased respiratory rate (bradypnea), is associated with respiratory distress.

Which clinical indicators would the nurse expect to identify in a client with acute respiratory distress syndrome (ARDS)? Select all that apply. a. crackles b. atelectasis c. hypoxemia d. severe dyspnea e. increased PWP

a, b, c, d Crackles occur as fluid leaks into the alveolar interstitial space. The alveoli collapse from surfactant dysfunction and infiltrate from inflammation. Arterial hypoxemia that does not respond to supplemental oxygen is a characteristic sign of ARDS. Severe dyspnea can occur 12 to 48 hours after the initial onset of ARDS, which usually is an inflammatory trigger. Pulmonary wedge pressure is unaffected in ARDS; pulmonary wedge pressure is elevated in problems with cardiogenic origin.