Med-Surg: Respiratory

A nurse is assessing the respiratory status of a client who has COPD. Which of the following manifestations should the nurse identify as an indication of impending respiratory failure? A. Wheezing B. Bradypnea C. Tachycardia D. Diaphoresis

C. Tachycardia Indications of impending respiratory failure include tachycardia, dyspnea, restlessness, headaches, and increased blood pressure. - A: Wheezing indicates asthma, not respiratory failure - B: Bradypnea is an indication of respiratory depression. Tachypnea is an indication of respiratory failure. - D: Diaphoresis develops as hypoxemia worsens; therefore, it is a manifestation of worsening, not impending, respiratory failure.

A nurse is auscultating the lungs of a client who is having an acute asthma attack. Which of the following sounds should the nurse expect to hear? A. Soft blowing B. Loud bubbling C. Dry grating D. Noisy wheezing

D. Noisy wheezing - Asthma causes the bronchioles of the lungs to constrict, creating a wheezing sound - A: A soft blowing or rustling sound is an expected vesicular lung sound - B: Loud bubbling or gurgling indicates coarse crackles, which reflects moisture in the lungs. Crackles are not a manifestation of asthma. - C: A dry, grating, creaking, or rubbing sound indicates a pleural friction rub, which is not a manifestation of asthma.

A nurse is planning postoperative education for a client who will undergo a radical neck dissection for cancer of the larynx. The nurse should include which of the following topics? (Select all that apply.) A. NPO status B. Alternative methods of communication C. Endotracheal intubation D. Changes in body image E. Swallowing exercises

A, B, D, E A. NPO status B. Alternative methods of communication D. Changes in body image E. Swallowing exercises - The client will receive fluids and nutrition via an enteral tube while healing from the surgery - Radical neck dissection interrupts vocal communication, so the nurse should determine with the client and family how the client will prefer to communicate - Extensive resection can result in some disfigurement and a permanent tracheostomy; the nurse should help prepare the client for these changes - Swallowing can be challenging after an extensive resection. The client might require the assistance of a speech-language pathologist to provide swallowing exercises and techniques - Option C is incorrect. Following a radical neck dissection, the client will have a laryngectomy or a tracheostomy tube. The client will receive any necessary supplemental ventilation and oxygenation plus suctioning via the laryngectomy or tracheostomy tube, not an endotracheal tube.

A nurse is preparing a client for a bronchoscopy. Which of the following actions should the nurse take? (Select all that apply.) A. Explain that the client will receive sedation and will not remember the procedure B. Verify that the client understands the purpose and nature of the procedure C. Offer the client sips of clear liquids until 1 hr before the test D. Obtain a pre-procedural sputum specimen E. Instruct the client to keep his neck in a neutral position

A, B A. Explain that the client will receive sedation and will not remember the procedure B. Verify that the client understands the purpose and nature of the procedure For a bronchoscopy, clients typically receive premedication with a benzodiazepine or an opioid to ensure sedation and amnesia. The client will have signed a consent form, so the nurse should verify that the provider explained the procedure and that the client understands it. - C: The client should be NPO for 4-8 hours prior to the procedure to minimize aspiration risk - D: The provider can obtain necessary sputum specimens during the procedure - E: The client's neck will be hyperextended to bring the pharynx into alignment with the trachea and to allow insertion of the scope without trauma

A nurse on a medical-surgical unit is caring for 4 clients. Which of the following clients should the nurse monitor for crepitus? A. A client who has a chest tube following a pneumothorax B. A client who has an acute exacerbation of Crohn's disease C. A client who is postoperative following a laparoscopic appendectomy D. A client who is recovering from thyroid storm

A. A client who has a chest tube following a pneumothorax Crepitus is a cracking sound resulting from air trapped under the skin. It can be palpated following a pneumothorax.

A nurse in an urgent care clinic is collecting data from a client who reports exposure to anthrax. Which of the following findings is an indication of the prodromal stage of inhalation anthrax? A. Dry cough B. Rhinitis C. Sore throat D. Swollen lymph nodes

A. Dry cough A dry cough is a clinical manifestation of the prodromal stage of inhalation anthrax. During this stage, it is difficult to distinguish the condition from influenza or pneumonia because there is no sore throat or rhinitis. - B: Rhinitis is not a manifestation of inhalation anthrax; however, rhinitis is typically seen with colds and influenza - C: A sore throat is not a manifestation of inhalation anthrax; however, a sore throat is typically seen with colds and influenza - D: Swollen lymph nodes with a swollen edematous lesion can be a clinical manifestation of cutaneous anthrax

A nurse is providing teaching to a client about pulmonary function testing. Which of the following tests measures the volume of air the lungs can hold at the end of maximum inhalation? A. Total lung capacity B. Vital lung capacity C. Functional residual capacity D. Residual volume

A. Total lung capacity Pulmonary function tests are used to examine the effectiveness of the lungs and to identify lung problems. - Total lung capacity measures the amount of air the lungs can hold after maximum inhalation - B: Vital lung capacity measures the amount of air the client can exhale after maximum inhalation - C: Functional residual capacity measures the amount of air in the lungs after normal expiration - D:Residual volume measures the amount of air in the lungs after forced expiration

A nurse is preparing to administer cisplatin IV to a client who has lung cancer. The nurse should identify that which of the following findings is an adverse effect of this medication? A. Hallucinations B. Pruritus C. Hand and foot syndrome D. Tinnitus

D. Tinnitus An adverse effect of cisplatin is ototoxicity, which can cause tinnitus

A nurse is developing a teaching plan for a client about preventing acute asthma attacks. Which of the following should the nurse plan to discuss first? A. Eliminating environmental triggers that precipitate attacks B. Addressing the client's perception of the disease process and what might have triggered past attacks C. Overviewing the client's medication regimen D. Explaining manifestations of respiratory infections

B. Addressing the client's perception of the disease process and what might have triggered past attacks The nurse needs to assess before any other steps

A nurse is assisting a provider with a comprehensive physical examination of a client. When the provider uses transillumination, the nurse should explain to the client that this technique helps evaluate which of the following structures? A. Lymph nodes B. Maxillary sinuses C. Intercostal spaces D. Salivary glands

B. Maxillary sinuses Transillumination is a procedure that allows the passage of light, often bright halogen light, through body tissues. Occluded sinuses prevent the passage of light rays through the sinus air sacs. Clear sinus air spaces allow transillumination. - Options A, C, and D are incorrect because transillumination cannot help the provider evaluate lymph nodes, intercostal spaces, or salivary glands.

Which of the following findings is a clinical manifestation of acute respiratory distress syndrome (ARDS)? A. Tympanic temperature 38c (100.4f) B. PaO2 50 mmHg C. Rhonchi D. Hypopnea

B. PaO2 50 mmHg The client who has manifestations of ARDS has a low PaO2 level, even after the administration of oxygen. Hypoxemia after treatment with oxygen is a manifestation of ARDS. - C: A client who has ARDS will have clear breath sounds because edema occurs in the interstitial spaces, not in the airway. - D: A client who has ARDS will manifest hyperpnea, which is an increased rate and depth of breathing; this indicated increased work of breathing

A nurse is caring for an older adult client who has chronic obstructive pulmonary disease (COPD) with pneumonia. The nurse should monitor the client for which of the following acid-base imbalances? A. Respiratory alkalosis B. Respiratory acidosis C. Metabolic alkalosis D. Metabolic acidosis

B. Respiratory acidosis - Respiratory acidosis is a common complication of COPD. This occurs because clients who have COPD are unable to exhale carbon dioxide due to a loss of elastic recoil in the lungs. - A: Respiratory alkalosis occurs when a client exhales too much carbon dioxide. Clients who hyperventilate often experience this complication. - C: Metabolic alkalosis occurs when a client has an excess of bicarbonate. Clients who use bicarbonate of soda as an antacid are at a risk for developing metabolic alkalosis. Excessive vomiting also places a client at risk for developing metabolic alkalosis. - D: Metabolic acidosis occurs when a client has a decrease in bicarbonate. Clients who have severe diarrhea or kidney failure are at a risk of developing metabolic acidosis.

A nurse is caring for a client with the following ABG results: pH 7.50, PaCO2 27 mmHg, and HCO3 25 mEq/L. The nurse should identify that the client has which of the following acid-base imbalances? A. Respiratory acidosis B. Respiratory alkalosis C. Metabolic acidosis D. Metabolic alkalosis

B. Respiratory alkalosis

A nurse is providing discharge teaching to a client who has emphysema. Which of the following instructions should the nurse include? A. Be sure to take cough medicine to avoid coughing B. Try to drink at least 2-3 liters of fluid per day C. Try to reduce your smoking to 2 cigarettes per day D. Be sure to eat 3 full meals each day

B. Try to drink at least 2-3 liters of fluid per day - Although adequate hydration is essential for all clients, clients who have emphysema should drink 2-3 liters of fluid per day to help liquefy secretions - A: The nurse should remind the client of the importance of coughing for removing excess mucus. The client should cough after getting out of bed, before mealtime, and before bedtime. - C: The nurse should encourage clients who have emphysema to quit smoking completely. - D: The client should eat 4 to 6 small meals per day to prevent the exhaustion and shortness of breath that can result from ingesting large meals

A nurse is caring for a client with pneumonia who is experiencing thick oral secretions. Which of the following actions should the nurse take first? A. Provide chest physiotherapy B. Perform oropharyngeal suction C. Encourage deep-breathing and coughing D. Assist the client with ambulation

C. Encourage deep-breathing and coughing - The first action the nurse should take when using the airway, breathing, and circulation (ABC) approach is to encourage the client to breathe deeply and cough to clear secretions from the airway - The nurse should provide chest physiotherapy, possible oropharyngeal suctioning, and should help the client to ambulate; however, encouraging deep-breathing and coughing should take place first

A nurse in a provider's office is assessing a client who states he was recently exposed to tuberculosis. Which of the following findings is a clinical manifestation of pulmonary tuberculosis? A. Pericardial friction rub B. Weight gain C. Night sweats D. Cyanosis of the fingertips

C. Night sweats - Night sweats and fevers are clinical manifestations of tuberculosis - Other manifestations of tuberculosis include coughing, anorexia, and fatigue

A nurse is teaching breathing techniques to a client who has emphysema. Which of the following statements indicates that the client understands the mechanics of pursed-lip breathing? A. I'll inhale slowly through pursed lips to help me breathe better B. When I do my pursed-lip breathing, I'll lie down first C. When I breathe out through pursed lips, my airways don't collapse between breaths D. I'll relax my stomach muscles when I am doing pursed-lip breathing exercises

C. When I breathe out through pursed lips, my airways don't collapse between breaths Breathing through pursed lips slows exhalation and maintains inflation of the distal airways, which enhances respiration for clients who have emphysema. The client should use this technique during physical activity and episodes of dyspnea. - A: The client should first inhale slowly through the nose, then exhale slowly through pursed lips - B: The client should practice pursed-lip breathing while sitting upright or walking - D: The client should tighten the abdominal muscles when using the pursed-lip breathing technique

A client comes to the emergency department in severe respiratory distress following left-sided blunt chest trauma. The nurse notes absent breath sounds on the client's left side and a tracheal shift to the right. For which of the following procedures should the nurse prepare the client? A. Tracheostomy placement B. Thoracentesis C. CT scan of the chest D. Chest tube insertion

D. Chest tube insertion The client's manifestations indicate pneumothorax due to blunt chest trauma. The nurse should prepare for the provider to insert a chest tube and connect it to a water-seal drainage system.

A nurse is caring for a client who is postoperative following a rhinoplasty. Which of the following findings should the nurse report to the surgeon? A. Nasal edema B. Mouth breathing C. Periorbital ecchymosis D. Frequent swallowing

D. Frequent swallowing Frequent swallowing indicates posterior nasal bleeding and possibly hemorrhage. The nurse should notify the surgeon promptly about this finding. - Options A, B, and C are all expected findings following a rhinoplasty

A nurse is providing discharge teaching to a client who is postoperative following a rhinoplasty. Which of the following instructions should the nurse include? A. Apply warm compresses to the face B. Take aspirin 650 mg by mouth for mild pain C. Close your mouth when sneezing D. Lie on your back with your head elevated 30 degrees when resting

D. Lie on your back with your head elevated 30 degrees when resting - The nurse should instruct the client to rest in the semi-Fowler's position to prevent aspiration of nasal secretions - A: The client should apply cold compresses to the face to decrease swelling - B: The client should avoid taking aspirin because it increases the risk of bleeding by decreasing platelet aggregation - C: The client should open the mouth when sneezing to reduce strain on the incisional site

A nurse is planning care for a client who is postoperative following a hip arthroplasty. In the client's medical record, the nurse notes a history of COPD. Which of the following oxygen-delivery methods should the nurse plan to use for this client? A. Simple face mask B. Nonrebreather mask C. Bag-valve-mask device D. Nasal cannula

D. Nasal cannula A nasal cannula delivers precise concentrations of oxygen; therefore, it is an appropriate device for a client who has COPD and requires a precise percentage of inspired oxygen.

A nurse is preparing a client for thoracentesis. In which of the following positions should the nurse place the client? A. Lying flat on the affected side B. Prone with the arms raised over the head C. Supine with the head of the bed elevates D. Sitting while leaning forward over the bedside table

D. Sitting while leaning forward over the bedside table When preparing a client for thoracentesis, the nurse should have the client sit on the edge of the bed and lean forward over the bedside table. This position maximizes the space between the client's ribs and allows aspiration of accumulated fluid and air. - Options A, B, and C do not allow access for draining the accumulated fluid and air

A nurse is reviewing the laboratory results of a client who has metabolic alkalosis. Which of the following laboratory values should the nurse expect? A. pH 7.31, HCO3 22, PaCO2 50 B. pH 7.48, HCO3 23, PaCO2 25 C. pH 7.32, HCO3 18, PaCO2 40 D. pH 7.49, HCO3 32, PaCO2 40

D. pH 7.49, HCO3 32, PaCO2 40 - Option A shows respiratory acidosis - Option B shows respiratory alkalosis - Option C shows metabolic acidosis

A nurse is providing preoperative teaching to a client who has lung cancer and will undergo a pneumonectomy. Which of the following statements should the nurse include? (Select all that apply.) A. You will have a chest tube in place after surgery B. We'll frequently help you turn, cough, and breathe deeply after surgery C. You will have to remain in bed for about 2 days after the surgery D. We'll give you oxygen to support your breathing if you need it E. You should expect pain for the first few days after surgery

A, B, D A. You will have a chest tube in place after surgery B. We'll frequently help you turn, cough, and breathe deeply after surgery D. We'll give you oxygen to support your breathing if you need it After a pneumonectomy, some clients have a clamped chest tube briefly to help reduce mediastinal shift. They do not usually have closed-chest drainage. Helping the client turn, cough, and breath deeply is standard preventative postoperative care after thoracic surgery. After thoracic surgery, clients typically receive oxygen by nasal cannula or mask for the first 2 days and then as needed. - C: As soon as possible following a pneumonectomy, the nurse should help the client into a semi-Fowler's position or to sit upright in a chair - E: Although clients do have pain after surgery, the nurse should focus on pain management. To avoid frightening the client unnecessarily, the nurse should inform the client about how the staff will help manage the pain.

A charge nurse receives notification of the admission of a client who is coughing frequently and whose sputum is pink, frothy, and copious. The client has a history of night sweats, anorexia, and weight loss. Which of the following actions should the nurse take? (Select all that apply.) A. Assign the client to a private room with negative-pressure airflow B. Add contact precautions to the client's plan of care C. Wear an N95 respirator when entering the client's room D. Ensure the client's environment provides 4 exchanges of fresh air per minute E. Institute protective environment precautions as soon as the client arrives on the unit

A, C A. Assign the client to a private room with negative-pressure airflow B. Add contact precautions to the client's plan of care C. Wear an N95 respirator when entering the client's room - The client's history and present status suggests tuberculosis. TB is a communicable infection that requires a private room with negative-pressure airflow. - Airborne precautions will be required, including wearing an N95 respirator when entering the client's room - B: The client will be on airborne precautions, not contact precautions - D: TB mandates the provision of a well-ventilated room with 6-12 exchanges of fresh air per minute - E: Protective environment precautions are for immunocompromised clients who are at high risk of infection (I.e. clients who had chemotherapy)

A nurse is caring for a client following a right pleural thoracentesis. The nurse measures a total of 35 mL of purulent drainage. Which of the following findings should the nurse recognize as an indication of a tension pneumothorax? (Select all that apply.) A. Tracheal deviation to the left B. Temperature of 38.8c (102f) C. Absent breath sounds on the right side D. Neck vein distention E. Bradypnea

A, C, D A. Tracheal deviation to the left C. Absent breath sounds on the right side D. Neck vein distention A tension pneumothorax can occur following a thoracentesis. - A trachea that is deviated to the unaffected side instead of being in the center of the neck is a manifestation of a pneumothorax - Absent breath sounds on the affected side and neck vein distention are also manifestations of a pneumothorax. As the client's difficulty to breath increases, the blood flow return compresses, causes the neck veins to distend. - B: An elevated temperature is a sign of an infection and can be associated with the purulent drainage obtained. However, this is not a s/s of a pneumothorax - E: Clients who experience a tension pneumothorax exhibit respiratory distress and tachypnea until a chest tube is inserted to re-inflate the lung

A nurse on a medical-surgical unit is assessing a client who recently transferred from the ICU following endotracheal extubation. Which of the following findings should the nurse identify as a possible manifestation of tracheal stenosis and should report to the provider? A. Increased coughing B. Diaphragmatic breathing C. Hemoptysis D. Kussmaul respirations

A. Increased coughing - Increased coughing is a manifestation of tracheal stenosis. Other manifestations include an inability to cough up secretions and difficulty talking or breathing. - B: Diaphragmatic breathing is the act of inhaling deeply by flexing the diaphragm. It is not a manifestation of tracheal stenosis. - C: Coughing up blood, otherwise known as hemoptysis, is an abnormal finding following endotracheal extubation that should be reported to the provider. However, it is not a manifestation of tracheal stenosis. - D: Kussmaul respirations are a deep and labored breathing pattern that is most often seen in clients who have metabolic acidosis. It is not a manifestation of tracheal stenosis.

A nurse is caring for a client who has a tracheostomy and is receiving mechanical ventilation. When the low-pressure alarm on the ventilator sounds, it indicates which of the following? A. Excessive airway secretions B. A leak within the ventilator's circuitry C. Decreased lung compliance D. The client coughing or attempting to talk

B. A leak within the ventilator's circuitry - The low-pressure alarm means that either the ventilator tubing has come apart of the tubing detached from the client. Low-pressure alarms are often the result of a malfunction or displacement of connections somewhere between the endotracheal or tracheostomy tube and the ventilator. - A: The activation of a high-pressure alarm indicates an increase in resistance each time the ventilator administers a breath to the client. Excessive airway secretions could generate a high-pressure alarm, not a low-pressure alarm. - C: Resistance during the delivery of a specific volume of oxygen to the client triggers the ventilator's high-pressure alarm, not a low-pressure alarm. A possible cause is decreased lung compliance due to disorders such as COPD. - D: When a client is coughing or trying to talk, the ventilator must exert greater force to deliver the preset volume of oxygen. The increased resistance of the airway against the machine can trigger a high-pressure alarm, not a low-pressure alarm.

A nurse is providing instructions about pursed-lip breathing for a client who has chronic obstructive pulmonary disease (COPD) with emphysema. This breathing technique accomplishes which of the following? A. Increases oxygen intake B. Promotes carbon dioxide elimination C. Uses the intercostal muscles D. Strengthens the diaphragm

B. Promotes carbon dioxide elimination - Pursed-lip breathing slows the client's pace of breathing, making each breath more effective - Pursed-lip breathing releases trapped air in the lungs and prolongs exhalation in order to slow the breathing rate. This improved breathing pattern moves carbon dioxide out of the lungs more efficiently. - A: Pursed-lip breathing prolongs exhalation, rather than increasing oxygen intake on inhalation. The nurse should increase oxygen cautiously because the client depends on low oxygen to stimulate breathing. - C: A client who uses pursed-lip breathing breathes in through the nares and out through pursed lips rather than concentrating on using chest-wall muscles - D: A client who uses pursed-lip breathing breathes in through the nares and out through pursed lips rather than concentrating on using the diaphragm

A client is admitted to the emergency department following a motorcycle crash. The nurse notes a crackling sensation upon palpation of the right side of the client's chest. After notifying the provider, the nurse should document this finding as which of the following? A. Friction rub B. Crackles C. Crepitus D. Tactile fremitus

C. Crepitus Crepitus, also called subcutaneous emphysema, is a coarse crackling sensation that the nurse can feel when palpating the skin surface over the client's chest. Crepitus indicates an air leak into the subcutaneous tissues, which is often a clinical manifestation of pneumothorax. - A: A friction rub is a scratching a squeaking sound heard when auscultating the client's lungs. This condition occurs due to the pleural surfaces rubbing together. - B: Crackles (sometimes called rales) are wet, popping sounds heard when auscultating the client's lungs. This condition occurs when fluid is present in the client's airways or alveoli. - D: Tactile fremitus is a vibration of the chest wall that the nurse can feel when palpating the client's chest as the client repeats a syllable such as "nine, nine, nine." Increased tactile fremitus is a clinical manifestation of pneumonia.

A nurse is caring for a client for whom the respiratory therapist has just removed the endotracheal tube. Which of the following actions should the nurse take first? A. Instruct the client to cough B. Administer oxygen via face mask C. Evaluate the client for stridor D. Keep the client in a semi- to high-Fowler's position

C. Evaluate the client for stridor - Using the nursing process, the first action the nurse should take is to assess the client. After extubation, the nurse should continuously evaluate the client's respiratory status. - Stridor is a high-pitched sound during inspiration that indicates laryngospasm or swelling around the glottis. Stridor reflects a narrowed airway and might require emergency re-intubation. - A: The nurse should instruct the client to cough immediately to help dislodge and remove the oral secretions that commonly accumulate; however, the nurse should evaluate for stridor first - B: The nurse should give the client oxygen via face mask or nasal cannula to help maintain oxygen saturation; however, the nurse should evaluate for stridor first - D: The nurse should keep the client upright to help improve gas exchange and reduce edema of the larynx; however, the nurse should evaluate for stridor first

A nurse is providing discharge teaching to a client who had a pulmonary embolism. Which of the following statements indicates that the client understands the information? A. I'll expect a little leg swelling since I won't be that active for a while B. I'll see the doctor every week to change my vena cava filter C. I'll call the doctor if I see any blood in my urine or stool D. I'll have to take the blood thinner for a few more days

C. I'll call the doctor if I see any blood in my urine or stool - Bleeding precautions are essential for clients who had a pulmonary embolism because they will be taking an anticoagulant. They should report any signs of bleeding immediately. - A: The client might have to limit activities for a while but should report any leg swelling or tenderness as an indication of clot formation - B: The vena cava filter remains in place either until the provider determines there is not a high risk for clot formation or permanently - D: Clients who had a pulmonary embolism typically require anticoagulant therapy for weeks to years after the acute event

A nurse is caring for a client who is scheduled to have his chest tube removed. Which of the following actions should the nurse take? A. Cover the insertion site with a hydrocolloid dressing after removal B. Provide pain medication immediately after removal C. Instruct the client to perform the Valsalva maneuver during removal D. Delegate removal of the chest tube to a licensed practical nurse (LPN)

C. Instruct the client to perform the Valsalva maneuver during removal The nurse should instruct the client to perform the Valsalva maneuver during removal to maintain the appropriate amount of negative pressure in the chest in order to prevent air entry into the pleural space. - A: The nurse should cover the insertion site with an occlusive dressing to prevent air entry into the pleural space - B: The nurse should provide the client with pain medication prior to the procedure to promote comfort during the removal of the chest tube - D: The nurse should expect a provider or a specially trained RN to remove the client's chest tube. The nurse should not delegate this procedure to an LPN, as it is beyond the LPN's scope of practice.

A nurse is caring for a client who had a left lower lobectomy to treat lung cancer. Which of the following factors will have a significant impact on the plan of care for this client? A. The client will need intensive smoking-cessation education B. After surgery, the prognosis for clients with lung cancer is usually good C. Lung cancer usually has metastasized before the client presents with symptoms D. Oxygen therapy is ineffective following a lobectomy

C. Lung cancer usually has metastasized before the client presents with symptoms - The nurse should be aware that lung cancer is usually at an advanced stage before the client has any manifestations - A: Although many clients with lung cancer have been smokers, this is not a certainty because many clients had exposure to secondhand smoke or other toxins over their lifetime. Smoking cessation is a primary prevention intervention, not a tertiary prevention intervention. - B: Despite the various treatment options for lung cancer, the prognosis remains poor unless surgery occurs early enough in the disease to remove all traces of cancer. Treatment is typically palliative, not curative. - D: Besides helping correct hypoxemia after a lobectomy, oxygen therapy can help alleviate dyspnea and anxiety.

A nurse is preparing to assist a provider with an arterial blood withdrawal from a client's radial artery for ABG measurement. Which of the following actions should the nurse plan to take? A. Hyperventilate the client with 100% oxygen prior to obtaining the specimen B. Apply ice to the site after obtaining the specimen C. Perform an Allen's test prior to obtaining the specimen D. Release the pressure applied to the puncture site 1 minute after the needle is withdrawn

C. Perform an Allen's test prior to obtaining the specimen - The nurse should ensure that circulation to the hand is adequate from the ulnar artery in case the radial artery is injured from the blood draw. The most common site for withdrawal of arterial blood gases is the radial artery. - A: The nurse should not administer oxygen prior to the blood draw because the test measures the client's arterial blood gases when breathing on room air - B: The nurse should use ice to preserve the arterial blood gas specimen during transportation to the laboratory. If the sample is not placed on ice, the pH and PO2 values can be inaccurate. It is not necessary to place ice on the withdrawal site. - D: The nurse should apply pressure to the puncture site for 5 to 10 minutes after the needle is withdrawn. The high pressure of the blood in the arteries places the client at risk for hemorrhaging from the withdrawal site.

A nurse is planning care for a client following placement of a chest tube 1 hr ago. Which of the following actions should the nurse include in the plan of care? A. Clamp the chest tube if there is continuous bubbling in the water seal chamber B. Keep the chest tube drainage system at the level of the right atrium C. Tape all connections between the chest tube and drainage system D. Empty the collection chamber and record the amount of drainage every 8 hr

C. Tape all connections between the chest tube and drainage system - The nurse should tape all connections to ensure that the system is airtight and prevent the chest tubing from accidentally disconnecting - A: The nurse should expect bubbling in the water seal chamber on forced expiration or coughing, which is an indication that the system is working properly. The nurse should avoid clamping the chest tube unless the drainage unit needs to be replaced or an air leak must be located. - B: The nurse should ensure the chest tube drainage system is below the level of the chest at all times to facilitate proper drainage by gravity. - D: The nurse should not empty the collection chamber or change the system unless it is almost full.

A nurse is caring for a client who is postoperative following a thoracic lobectomy. The client has 2 chest tubes in place: 1 in the lower portion of the thorax and the other higher on the chest wall. When a family member asks why the client has 2 chest tubes, which of the following responses should the nurse make? A. Two tubes were necessary due to excessive bleeding from the area of the surgery B. The tubes drain blood from 2 different lung areas C. The lower tube will drain blood, and the higher tube will remove air D. The second tube will take over if blood clots block the first tube

C. The lower tube will drain blood, and the higher tube will remove air - The tube that is lower on the thorax will drain blood, and the tube that is higher on the thorax will allow for removal of air - A: Excessive bleeding indicates a complication that the surgeon must address - B: Blood typically drains from the base of the lung, not the apex - D: If a tube becomes blocked, the nurse should report it to the surgeon and prepare to attempt to re-establish potency or remove and replace the tube

A nurse is providing postoperative care for a client who has 2 chest tubes in place following a lobectomy. The client asks the nurse the reason for having 2 chest tubes. The nurse should inform the client that the lower chest tube is placed for which of the following reasons? A. Removing air from the pleural space B. Creating access for irrigating the chest cavity C. Evacuating secretions from the bronchioles and alveoli D. Draining blood and fluid from the pleural space

D. Draining blood and fluid from the pleural space - The nurse should inform the client that blood and fluids tend to accumulate in the bases and posterior areas of the pleural cavity following a lobectomy. For this reason, the lower chest tube primarily drains blood and fluid from the pleural space. - A: The upper chest tube removes air from the pleural space. - B: The chest tubes are not used for irrigation following a lobectomy - C: Secretions are removed from the airways via tracheal suctioning rather than chest tubes

A nurse is providing preoperative teaching to a client who will undergo a total laryngectomy. Which of the following statements indicates that the client understands the impact of the surgery? A. I'm not going to be able to cough for a while after the surgery B. After I recover from the anesthesia, I'll be able to eat regular food again C. After the surgery, my voice will gradually return but might be weak D. I understand that I will have a permanent tracheostomy after the surgery

D. I understand that I will have a permanent tracheostomy after the surgery - With a partial laryngectomy, the tracheostomy is temporary. This client is having a total laryngectomy, so the tracheostomy will be permanent. - A: After the surgery, the client should be able to carry out postoperative exercises such as coughing and deep breathing to help clear secretions - B: After the surgery, the client will receive enteral nutrition via a feeding tube for 7-10 days - C: After a total laryngectomy, the client will have no natural voice because the surgeon will remove the entire larynx

A nurse is caring for a client with chronic obstructive pulmonary disease (COPD) and is experiencing shortness of breath. Which of the following actions should the nurse perform first? A. Monitor the client's arterial blood gas results B. Instruct the client to perform controlled coughing C. Teach the client how to use pursed-lip breathing D. Place the client in an upright position

D. Place the client in an upright position The nurse should place the client in an upright position to facilitate chest expansion and proper diaphragmatic contraction. Positioning the client upright will also assist with mobilizing secretions that might be impeding airflow.

A nurse is caring for a client immediately following extubation. Which of the following manifestations indicates that the nurse should call the rapid response team? A. Stridor B. Coughing C. Hoarseness D. Extensive oral secretions

A. Stridor - The nurse should identify that stridor (a high-pitched crowing sound heard during inspiration) is caused by laryngeal edema and can indicate impending airway obstruction. The nurse should call the rapid response team for assistance before the airway becomes completely obstructed. - B: The nurse should encourage the client to cough after extubation to help clear the secretions. Coughing can be an early manifestation of obstruction, but it does not require the rapid response team - C: Hoarseness is expected after extubation and can last several days - D: Extensive oral secretions are an expected finding after extubation. The nurse should monitor these secretions for indications of potential airway obstruction.