MedSurg Ch 19

The nurse is caring for a patient with pleurisy. What symptoms does the nurse recognize are significant for this patient's diagnosis?

stabbing pain during respiratory movement

The nurse is using an in-line suction kit to suction a patient who is intubated and on a mechanical ventilator. What benefits does inline suction have for the patient? (Select all that apply.) 1. Decreases hypoxemia 2. Decreases patient anxiety 3. Sustains positive end expiratory pressure (PEEP) 4. Increases oxygen consumption 5. Prevents aspiration

1, 2, 3

The nurse has instructed a client on how to perform pursed-lip breathing. The nurse recognizes the purpose of this type of breathing is to accomplish which result? 1. Promote more efficient and controlled ventilation and to decrease the work of breathing 2. Improve oxygen transport; induce a slow, deep breathing pattern; and assist the client to control breathing 3. Promote the strengthening of the client's diaphragm 4. Promote the client's ability to take in oxygen

2

A nurse is teaching a client about using an incentive spirometer. Which statement by the nurse is correct? 1. "Breathe in and out quickly." 2. "You need to start using the incentive spirometer 2 days after surgery." 3. "Before you do the exercise, I'll give you pain medication if you need it." 4. "Don't use the incentive spirometer more than 5 times every hour."

3

Acute respiratory failure (ARF) occurs when oxygen tension (PaO2) falls to less than __________ mm Hg (hypoxemia) and carbon dioxide tension (PaCO2) rises to greater than __________ mm Hg (hypercapnia). 60; 50 60; 40 75; 50 75; 40

60, 50

A client with a respiratory condition is receiving oxygen therapy. While assessing the client's PaO2, the nurse knows that the therapy has been effective based on which of the following readings? 45 mm Hg 58 mm Hg 84 mm Hg 120 mm Hg

84 mm Hg

The ICU nurse is caring for a client who was admitted with a diagnosis of smoke inhalation. The nurse knows that this client is at increased risk for which of the following?

ARDS

A client hospitalized with pneumonia has thick, tenacious secretions. Which intervention should the nurse include when planning this client's care?

Encourage increased fluid intake

A nurse is caring for a client who was admitted with pneumonia, has a history of falls, and has skin lesions resulting from scratching. The priority nursing diagnosis for this client should be: Risk for falls. Ineffective breathing pattern. Impaired tissue integrity. Ineffective airway clearance.

Ineffective airway clearance

A client has been receiving 100% oxygen therapy by way of a nonrebreather mask for several days. Now the client complains of tingling in the fingers and shortness of breath, is extremely restless, and describes a pain beneath the breastbone. What should the nurse suspect? Oxygen-induced hypoventilation Oxygen toxicity Oxygen-induced atelectasis Hypoxia

Oxygen toxicity

The nurse is admitting a patient with COPD. The decrease of what substance in the blood gas analysis would indicate to the nurse that the patient is experiencing hypoxemia?

PaO2

The nurse is caring for a client with an endotracheal tube (ET). Which nursing intervention is contraindicated?

Routinely deflating cuff

The patient with a chest tube is being transported to X-ray. Which complication may occur if the chest tube is clamped during transportation? Tension pneumothorax Cardiac tamponade Flail chest Pulmonary contusion

Tension pneumothorax

A nurse is assessing a client who comes to the clinic for care. Which findings in this client suggest bacterial pneumonia?

dyspnea and wheezing

Which intervention does a nurse implement for clients with empyema?

encourage breathing exercises

constant bubbling in the water-seal chamber of a closed chest drainage system indicates...

system has an air leak

dysrhythmias during suctioning indicates

patient is hypoxic from suctioning

Which statement would indicate that the parents of child with cystic fibrosis understand the disorder? "Early treatment can stop the progression of the disease." "The mucus-secreting glands are abnormal." "There are fibrous cysts in the lungs." "Allergic reactions cause inflammation in the lungs."

"The mucus-secreting glands are abnormal."

A client has been hospitalized for treatment of acute bacterial pneumonia. Which outcome indicates an improvement in the client's condition? 1. The client has a partial pressure of arterial oxygen (PaO2) value of 90 mm Hg or higher. 2. The client has a partial pressure of arterial carbon dioxide (PaCO2) value of 65 mm Hg or higher. 3. The client exhibits restlessness and confusion. 4. The client exhibits bronchial breath sounds over the affected area.

1

When caring for a client with acute respiratory failure, the nurse should expect to focus on resolving which set of problems? 1. Hypotension, hyperoxemia, and hypercapnia 2. Hyperventilation, hypertension, and hypocapnia 3. Hyperoxemia, hypocapnia, and hyperventilation 4. Hypercapnia, hypoventilation, and hypoxemia

4

What may induce acute bronchitis? Aspiration Drug ingestion Chemical irritation Direct lung damage TAKE ANOTHER QUIZ

Chemical irritation

A client who has just had a triple-lumen catheter placed in his right subclavian vein complains of chest pain and shortness of breath. His blood pressure is decreased from baseline and, on auscultation of his chest, the nurse notes unequal breath sounds. A chest X-ray is immediately ordered by the physician. What diagnosis should the nurse suspect? Pulmonary embolism Myocardial infarction (MI) Heart failure Pneumothorax

Pneumothorax

When the high-pressure alarm on the mechanical ventilator sounds, the nurse starts to check for the cause. Which condition triggers the high-pressure alarm?

kinking in the ventilator tubing

The nurse is assessing a client who, after an extensive surgical procedure, is at risk for developing acute respiratory distress syndrome (ARDS). The nurse assesses for which most common early sign of ARDS?

rapid onset of severe dyspnea