Medsurg- Respiratory
The emergency nurse admits a semiconscious client with periorbital bruising and severe tongue edema after a laceration sustained in an unwitnessed tonic-clonic seizure. The health care provider prescribes a nasopharyngeal airway to maintain airway patency. Which initial action by the nurse is appropriate? 1. Contact the health care provider and clarify the prescription(42%) 2. Ensure correct placement after insertion by auscultating the lungs(8%) 3. Select an appropriate size by measuring from nose tip to earlobe(22%) 4. Verify that the client has no history of bleeding disorders or aspirin use(25%)
A nasopharyngeal airway (NPA) is a tube-like device used to maintain upper airway patency. NPAs are frequently used in alert or semiconscious clients, as they are less likely to cause gagging, and in clients with oral trauma or maxillofacial surgery. NPAs should never be inserted in clients who may have head trauma (eg, facial or basilar skull fractures), such as might occur during an unwitnessed seizure. NPAs inserted in clients with skull fractures may be malpositioned into underlying tissues/structures (eg, brain). Therefore, the nurse should immediately clarify prescriptions for NPAs in clients with head trauma (Option 1). An NPA may be inserted after imaging (eg, CT scan) rules out fracture. (Option 2) Once skull fracture is ruled out and an NPA is inserted, the nurse verifies appropriate airway placement by auscultating the lungs. (Option 3) Inappropriate NPA size increases the risk for airway obstruction, sinus blockage, and infection. To select an appropriate size, the nurse measures from the tip of the client's nose to the earlobe and selects a diameter smaller than the naris. (Option 4) Bleeding disorders and use of anticoagulant or antiplatelet medication (eg, aspirin) are relative contraindications to NPA insertion, as these increase the risk of bleeding. However, skull fracture must be excluded prior to placement.
A client with chronic kidney disease has a large pleural effusion. What findings characteristic of a pleural effusion does the nurse expect? Select all that apply. 1. Chest pain during inhalation 2. Diminished breath sounds 3. Dyspnea 4. Hyperresonance on percussion 5. Wheezing
A pleural effusion is an abnormal collection of fluid (>15 mL) in the pleural space that prevents the lung from expanding fully, resulting in decreased lung volume, atelectasis, and ineffective gas exchange. It is usually secondary to another disease (eg, heart failure, pneumonia, nephrotic syndrome). Pleural effusions are diagnosed by chest x-ray or CT scan. Thoracentesis can be performed to remove fluid from the pleural space and resolve symptoms. Clients commonly report dyspnea with a nonproductive cough, as well as pleural chest pain with respirations (Options 1 and 3). On assessment, clients have diminished breath sounds, dullness to percussion, decreased tactile fremitus, and decreased movement over the affected lung (Option 2). (Option 4) Fluid outside the lung interrupts the transmission of sound, resulting in decreased fremitus and dullness with percussion in pleural effusion. Percussion is hyperresonant in clients with pneumothorax. (Option 5) Wheezing indicates an obstructive process (eg, asthma, chronic obstructive pulmonary disease) and is not typical in pleural effusion.
The nurse is caring for a client receiving mechanical ventilation via tracheostomy 2 weeks following a tracheotomy. The nurse enters the client's room to address a ventilator alarm and notes the tracheostomy tube dislodged and lying on the client's chest. Which action by the nurse is appropriate? Click on the exhibit button for additional information. 1. Apply a nonrebreather face mask with 100% oxygen(35%) 2. Apply dry, sterile gauze over the stoma and secure with tape(8%) 3. Insert a new tracheostomy tube using the bedside obturator(46%) 4. Insert a sterile catheter into the stoma and suction the airway(9%)
A tracheostomy tube, an artificial airway inserted into the trachea through the neck, may be secured with sutures or tracheostomy ties. Accidental dislodgment of a tracheostomy tube is a medical emergency often resulting in respiratory distress from closure of the stoma and airway loss. If accidental dislodgment of mature tracheostomies (ie, >7 days after insertion) occurs where the tract is well formed, the nurse should attempt to open the airway by inserting a curved hemostat to maintain stoma patency and insert a new tracheostomy tube with an obturator (Option 3). (Option 1) Application of supplemental oxygen via nonrebreather face mask may not resolve respiratory distress because air can escape from the stoma. (Option 2) Covering the stoma with a sterile, occlusive dressing (eg, petroleum gauze, foam tape) and ventilating the lungs with a bag-valve mask over the nose/mouth may be necessary if the tube cannot be reinserted or the stoma is immature. Dry gauze is porous and does not adequately seal the stoma for ventilation. (Option 4) Tracheal suctioning may be necessary once the airway is resecured. However, suctioning prior to establishing an airway does not improve ventilation and may further reduce the oxygen supply.
A client with a severe asthma exacerbation following influenza infection is transferred to the intensive care unit due to rapidly deteriorating respiratory status. Which clinical manifestations support the nurse's assessment of impending respiratory failure? Select all that apply. 1. Arterial pH 7.50 2. PaCO2 55 mm Hg (7.3 kPa) 3. PaO2 58 mm Hg (7.7 kPa) 4. Paradoxical breathing 5. Restlessness and drowsiness
Acute severe asthma exacerbations (status asthmaticus) occur when severe airway obstruction and lung hyperinflation (air trapping) persist despite aggressive treatment with bronchodilators and corticosteroid therapy. Clinical manifestations indicating impending respiratory failure include: PaCO2 ≥45 mm Hg (6.0 kPa): Indicates hypercapnia and hypoventilation resulting from fatigue and labored breathing. As initial tachypnea subsides and respiratory rate returns to normal, PaCO2 rises and respiratory acidosis develops (Option 2). PaO2 ≤60 mm Hg (8.0 kPa): Indicates hypoxemia resulting from increased work of breathing, decreased gas exchange (hyperinflation and air trapping), and inability of the lungs to meet the body's oxygen demand (Option 3) Paradoxical breathing (ie, abnormal inward movement of the chest on inspiration and outward movement on expiration): Indicates diaphragm muscle fatigue and use of respiratory accessory muscles (Option 4) Mental status changes (eg, restlessness, confusion, lethargy, drowsiness): Sensitive indicators of hypoxemia and hypoxia (Option 5) Absence of wheezing and silent chest (ie, no sound of air movement on auscultation): Ominous signs indicating severe hyperinflation and air trapping in the lungs Single-word dyspnea: Inability to speak >1 word before pausing to breathe due to shortness of breath (Option 1) Normal arterial pH is 7.35-7.45. A pH of 7.50 indicates alkalosis, which could be respiratory or metabolic. Clients with respiratory failure have respiratory acidosis (low pH and elevated pCO2).
A client is scheduled for allergy skin testing to identify asthmatic triggers. Which medications should the nurse instruct the client to withhold before the test to ensure accurate results? Select all that apply. 1. Acetaminophen 2. Albuterol 3. Diphenhydramine 4. Enalapril 5. Loratadine
Allergy skin testing involves introducing common environmental and food allergens (ie, antigens) into the skin surface and then observing the site for an allergic reaction (eg, formation of a wheal, erythema). Several different antigens, as well as positive and negative controls, are usually tested at the same time for accuracy. To ensure an accurate result, the client should avoid antihistamines (eg, diphenhydramine [Benadryl], loratadine [Claritin], promethazine [Phenergan]) for up to 2 weeks prior to the test (Options 3 and 5). Antihistamines block mast cell release of histamines that are responsible for allergic symptoms. Systemic corticosteroids, used to treat the inflammatory component of asthma, may also affect the accuracy of allergy skin testing; therefore, the use of these medications is assessed by the health care provider. (Option 1) Acetaminophen does not have antihistamine properties and will not interfere with allergy skin testing. (Option 2) Albuterol, an inhaled short-acting beta adrenergic agonist, will not interfere with allergy skin testing results and should not be discontinued, as it is necessary to ensure client safety during acute asthma exacerbations. (Option 4) Enalapril, an ACE inhibitor, is used to treat high blood pressure and heart failure and will not impact the results of allergy skin testing.
The nurse reviews and reinforces an asthma action plan with a client who has moderate persistent asthma. Which statement by the client indicates an understanding of how to follow a plan appropriately when peak expiratory flow (PEF) readings are in the green, yellow, or red zones? 1. "If I am in the green zone (PEF 80%-100% of personal best) but am coughing, wheezing, and having more trouble breathing, I will not make any changes in my medications."(5%) 2. "If I am in the yellow zone (50%-80%) and I return to the green zone after taking my rescue medication, I will not make any changes in my daily medications."(53%) 3. "If I am in the yellow zone (50%-80%), I will take my rescue medication every 4 hours for 1-2 days and call my health care provider (HCP) for follow-up care."(33%) 4. "If I remain in the red zone, my lips are blue, and my PEF is still <50% of my personal best reading after taking my rescue medication, I will wait 15 minutes before calling an ambulance."(6%)
An asthma action plan is an individualized management plan developed collaboratively between the client and the HCP to facilitate self-management of asthma. It includes information on daily and long-term treatment, prescribed medicines and when to take them according to a zone system, how to manage worsening symptoms or attacks, and when to call the HCP or go to the emergency department. The action plan uses traffic signal colors to categorize into zones degrees of asthma symptom severity and airway obstruction (peak flow meter readings): Green zone indicates asthma is under control and PEF is 80%-100% of personal best. When in this zone, there is no worsening of cough, wheezing, or trouble breathing (Option 1). Yellow zone means caution; even on a return to the green zone after use of rescue medication, further medication or a change in treatment is needed (Option 2). Red zone indicates a medical alert and signals the need for immediate medical treatment if the level does not return to yellow immediately after taking rescue medications (Option 4).
A 64-year-old hospitalized client with chronic obstructive pulmonary disease exacerbation has increased lethargy and confusion. The client's pulse oximetry is 88% on 2 liters of oxygen. Arterial blood gas analysis shows a pH of 7.25, PO2of 60 mm Hg (8.0 kPa), and PCO2 of 80 mm Hg (10.6 kPa). Which of the following should the nurse implement first? 1. Administer PRN nebulizer treatment(23%) 2. Administer scheduled dose of methylprednisolone IV(11%) 3. Increase client's oxygen to 4 liters(25%) 4. Place client on the bilevel positive airway pressure (BIPAP) machine(39%)
An elevated carbon dioxide (CO2) level (normal: 35-45 mm Hg [4.7-6.0 kPa]) is usually an indicator of hypercapneic respiratory failure. The bilevel positive airway pressure (BIPAP) machine will provide positive pressure oxygen and expel CO2 from the lungs. This client is already showing signs of lethargy and confusion, which is usually a late indicator of respiratory decline. Therefore, the nurse's priority should be to get the client on the BIPAP machine as soon as possible. (Option 1) Nebulizer treatments are commonly part of the treatment plan for a client with chronic obstructive pulmonary disease (COPD). However, these do not take priority when the client has CO2 retention and is deteriorating. If mental status worsens further (due to continued CO2 retention), the client will need intubation. Many BIPAP machines are able to deliver nebulizer treatment while providing positive pressurized oxygen. (Option 2) Steroid therapy is a common pharmaceutical intervention for COPD exacerbation, but it does not take priority over BIPAP in this deteriorating client. In addition, steroids take hours to days to have an effect. (Option 3) In a client with an elevated CO2 level and a history of COPD, the nurse should not increase the oxygen level as this could cause an increase in CO2 retention, resulting in further respiratory failure.
The nurse in the outpatient procedure unit is caring for a client immediately post bronchoscopy. Which assessment data indicate that the nurse needs to contact the health care provider immediately? 1. Absence of gag reflex(14%) 2. Bright red blood mixed with sputum(31%) 3. Headache(4%) 4. Respirations 10/min and saturation of 92%(48%)
An endoscopic bronchoscopy is a procedure in which the bronchi are visualized with a flexible fiberoptic bronchoscope that is passed down through the nose (or through the mouth, or endotracheal or tracheostomy tube). The client receives mild sedation (eg, midazolam) to provide relaxation and promote comfort. A topical anesthetic (eg, lidocaine, benzocaine) is applied to the nares and throat to suppress the gag and cough reflexes, prevent laryngospasm, and facilitate passage of the scope. The procedure is done to diagnose, obtain tissue samples for biopsy, lavage, and to remove secretions (mucus plugs), foreign objects, or abnormal tissue with a laser. Blood-tinged sputum is common and can occur from inflammation of the airway, but hemoptysis of bright red blood can indicate hemorrhage, especially if a biopsy was performed. Other complications include hypoxemia, hypercarbia, hypotension, laryngospasm, bradycardia, pneumothorax (rare), and adverse effects from medications used before and during the procedure. (Option 1) Absence of the gag reflex for about 2 hours following the procedure is expected from the topical anesthetic. (Option 3) Headache is not a complication of bronchoscopy. (Option 4) Respirations of 10/min and saturation of 92% are expected after mild sedation before and/or or during the procedure.
A client with chronic bronchitis tells the home health nurse of being exhausted all day due to coughing all night and being unable to sleep. The client can feel thick mucus in the chest and throat. Which interventions can the nurse suggest to help mobilize secretions and improve sleep? Select all that apply. 1. Increase fluids to at least 8 glasses (2-3 L) of water a day 2. Sleep with a cool mist humidifier 3. Take prescribed guaifenesin cough medicine before bedtime 4. Use abdominal breathing and the huff cough technique at bedtime 5. Use pursed-lip breathing during the night
Chronic bronchitis is characterized by excessive mucus production, chronic cough, and recurrent respiratory tract infections. Interventions to help reduce viscosity of mucus, facilitate secretion removal, and promote comfort include the following: -Increasing oral fluids to 2-3 L/day if not contraindicated prevents dehydration and keeps secretions thin -Cool mist humidifier increases room humidity of inspired air -Guaifenesin (Robitussin) is an expectorant that reduces the viscosity of thick secretions by increasing respiratory tract fluid; drinking a full glass of water after taking the medication is recommended. -Abdominal breathing with the huff, a forced expiratory cough technique, is effective in mobilizing secretions into the large airways so that they can be expectorated -Chest physiotherapy (postural drainage, percussion, vibration) -Airway clearance handheld devices, which use the principle of positive expiratory pressure to help loosen secretions when the client exhales through the mouthpiece (Option 5) Pursed lip breathing prolongs exhalation, reduces air trapping in the lungs, and decreases dyspnea. It does not help to thin secretions.
The nurse takes the admission history of a 70-year-old client diagnosed with chronic obstructive pulmonary disease (COPD). Which of the following statements by the client does the nurse recognize as contributing to the development of COPD? Select all that apply. 1. "I have been drinking alcohol almost daily since age 20." 2. "I have been overweight for as long as I can remember." 3. "I have smoked about a pack of cigarettes a day since I was 16 years old but quit last year." 4. "I know I eat too much fast food." 5. "I was a car mechanic for about 40 years and had my own garage."
Chronic obstructive pulmonary disease (COPD) generally refers to two conditions: emphysema and chronic bronchitis. A combination of the two is common. COPD affects approximately 12 million people and is the third leading cause of death in the United States, occurring most commonly in the seventh decade of life. It is characterized by slowly progressive, persistent airflow obstruction, and its etiology is closely associated with chronic airway inflammation. The major risk factor for COPD is current or former tobacco smoking (eg, cigarette, pipe, cigar). An additional contributing factor is prolonged exposure to respiratory irritants (eg, chemical fumes, smoke, dust) related to the client's occupation (eg, car mechanic, firefighter, coal miner). Risk for COPD is even higher if the client both smokes tobacco and has occupational exposure to respiratory irritants (Options 3 and 5). Chronic exposure to air pollution and genetic predisposition (eg, alpha1-antitrypsin deficiency) also contribute. (Option 1) Alcohol consumption is not associated with the development of COPD. (Options 2 and 4) Although obesity can worsen COPD symptoms by contributing to dyspnea, obesity and poor nutrition are not factors that directly contribute to the development of COPD.
The nurse cares for a child newly diagnosed with cystic fibrosis. What should be included in the client's multidisciplinary plan of care to be discussed with the parents? Select all that apply. 1. Aerobic exercise 2. Chest physiotherapy 3. Financial needs 4. Low-calorie diet 5. Oral fluid restriction
Cystic fibrosis (CF) is a genetic disorder involving the cells lining the respiratory, gastrointestinal (GI), and reproductive tracts. A defective protein responsible for transporting sodium and chloride causes secretions in these areas to be thicker and stickier than normal. These abnormal secretions plug smaller airway passages and ducts in the GI tract, which can impair digestive enzymes and result in ineffective absorption of essential nutrients. These sticky respiratory secretions lead to a chronic cough and inability to clear the airway, eventually causing chronic lung disease (bronchiectasis). As a result of these changes, the client's life span is shortened; most affected individuals live only into their 30s. Chest physiotherapy helps remove sticky secretions that cause ineffective airway clearance (Option 2). Aerobic exercise is beneficial to promote removal of airway secretions, improve muscle strength, and increase lung capacity (Option 1). Financial needs must be discussed, as clients with CF have a large financial burden due to health care costs, medications, and special equipment (Option 3). (Option 4) A diet high in fat and calories is recommended due to defective digestive enzymes and impaired nutrient absorption. (Option 5) Fluids are not restricted; liberal intake is recommended to assist in thinning respiratory secretions.
A client with type 2 diabetes, coronary artery disease, and peripheral arterial disease developed hospital-acquired pneumonia (HAP) and has been receiving intravenous (IV) antibiotics for 4 days. Which parameter monitored by the nurse best indicates the effectiveness of treatment? 1. Color of sputum(7%) 2. Lung sounds(37%) 3. Saturation level(6%) 4. White blood cell count (WBC)(48%)
HAP is a bacterial infection acquired in a health care facility that was not present on admission. Almost all clients with bacterial pneumonia develop leukocytosis (WBC >11,000/mm3). Antibiotic therapy is the first-line treatment, but antibiotic resistance frequently occurs in HAP. If antibiotic therapy is effective, clinical improvement usually occurs within 3-4 days of initiation of IV antibiotics. The nurse monitors WBC as the best indicator of treatment effectiveness as antibiotics cause bacterial lysis or hinder bacterial DNA reproduction. The reduced number of bacteria and the resulting decrease in inflammation cause a decrease in the number of white blood cells needed to fight the infection. Other indicators of treatment effectiveness include improvement of infiltrates on chest x-ray, oxygenation, and signs and symptoms (cough, fever, sputum production). (Option 1) The color of sputum (eg, clear, yellow, green, grey, rusty, blood-tinged) can vary with different types of pneumonia; it is not the best indicator of treatment effectiveness. (Option 2) Adventitious/abnormal lung sounds (crackles, low-pitched wheeze, bronchial breath sounds) can be present as the pneumonia resolves or can be a sign of further complication (pleural effusion). However, these are not the best indicators of treatment effectiveness. (Option 3) Saturation is an indicator of oxygenation but can be affected by many other factors, such as coexisting disease, peripheral circulation, and drugs. It is not the best indicator of treatment effectiveness.
A client had a thoracotomy 2 days ago to remove a lung mass and has a right chest tube attached to negative suction. Immediately after turning the client to the left side to assess the lungs, the nurse observes a rush of approximately 125 mL of dark bloody drainage into the drainage tubing and collection chamber. What is the appropriate nursing action? Click on the exhibit button for additional information. 1. Document and continue to monitor chest drainage(46%) 2. Immediately clamp the chest tube(5%) 3. Notify the health care provider(38%) 4. Request repeat hematocrit and hemoglobin levels(8%)
Immediately following a thoracotomy, chest tube drainage (50-500 mL for the first 24 hours) is expected to be sanguineous (bright red) for several hours and then change to serosanguineous (pink) followed by serous (yellow) over a period of a few days. A rush of dark bloody drainage from the chest tube when the client was turned following a period of minimal drainage is most likely related to retained blood due to a partial blockage in the tube. Bright red drainage indicates active bleeding and would be of immediate concern. (Option 2) The chest tube should not be clamped because it is placed to drain the fluid leaking after surgery. (Option 3) The nurse would notify the health care provider immediately of bright red drainage or continued increased drainage (>100 mL/hr) and of changes in the client's vital signs and cardiovascular status that could indicate bleeding (eg, hypotension, tachycardia, tachypnea, decreased capillary refill, cool and pale skin). This is not the appropriate action. (Option 4) It would be appropriate to request repeat serum hematocrit and hemoglobin levels if active bleeding is suspected, but the postoperative levels are stable at this time. This is not the appropriate action.
The nurse assesses a client with a history of cystic fibrosis who is being admitted with a pulmonary exacerbation. Which assessment finding would require immediate action? 1. Current pulse oximetry reading is 90% on room air(30%) 2. Expectorating blood-tinged sputum(49%) 3. Loss of appetite and recent 5-lb (2.3-kg) weight loss(8%) 4. No bowel movement in the past 48 hours(11%)
In cystic fibrosis (CF), a defective protein responsible for transporting sodium and chloride causes the secretions from the exocrine glands to be thicker and stickier than normal. The sticky respiratory secretions lead to the inability to clear the airway and a chronic cough. The client eventually develops chronic lung disease (bronchiectasis) and is at risk for recurrent lung infections. These clients are also at risk for rupture of the damaged alveoli, which results in sudden-onset pneumothorax. Findings of pneumothorax include sudden worsening of dyspnea, tachypnea, tachycardia, and a drop in oxygen saturation. Because many of these findings can be seen with lung infection, a sudden drop in oxygen saturation could be the only early clue. The client with CF will often have a decreased pulse oximetry (reflects oxygen saturation in the blood) reading due to the chronicity of the disease process and damage to the lungs; however, a reading of 90% requires urgent intervention. (Option 2) Clients with CF often cough up blood-streaked sputum (hemoptysis) as a result of damage to blood vessels in the airway walls secondary to infections. However, this usually resolves with treatment of the infection. Frank hemoptysis needs urgent assessment. (Option 3) Maintaining weight is a challenge in those with CF due to the malabsorption of carbohydrates, fats, and proteins caused by the impaired enzyme secretions in the gastrointestinal tract. In addition, weight and appetite loss may indicate an undiagnosed underlying lung infection. This will need to be addressed, but oxygenation is the priority. (Option 4) Fecal retention and impaction are common in CF due to decreased water and salt secretion into the intestines. This will need to be addressed, but oxygenation is the priority.
The nurse caring for a client with left lobar pneumonia responds to an alarm from the continuous pulse oximeter. The client is short of breath with an oxygen saturation of 78%. After applying oxygen, the nurse should place the client in which position to improve oxygenation? 1. Left lateral(43%) 2. Right lateral(42%) 3. Supine(5%) 4. Trendelenburg(7%)
Pneumonia is a lung infection resulting in decreased gas exchange in the affected lung lobes. The alveoli in the affected lobes become blocked with purulent fluid, which impairs ventilation. However, these alveoli continue to receive perfusion from the pulmonary artery, resulting in poorly oxygenated or deoxygenated blood. This ventilation-to-perfusion (V/Q) mismatch, or pulmonary shunt, may result in hypoxia and respiratory distress. Blood flow in the lungs is partially influenced by gravity, meaning that blood flows in higher volumes to dependent parts of the lung. Therefore, a client with left lobar pneumonia should be positioned in right lateral position with the unaffected (good) lung down (eg, right lung) to increase blood flow to the lung most capable of oxygenating blood (Option 2). (Option 1) Left lateral positioning will worsen hypoxia by decreasing blood flow to the unaffected (ie, right) lung. (Options 3 and 4) Positioning in supine or Trendelenburg position does not promote increased perfusion to the unaffected lung, which is needed to improve hypoxia.
The nurse assesses a client with left-sided pneumonia who has an intermittent, productive cough with copious amounts of thick, yellow sputum. Which of the following interventions help to facilitate secretion removal? Select all that apply. 1. Chest physiotherapy 2. Cough suppressant 3. Huff coughing technique 4. Pursed-lip breathing 5. Right side-lying position
Pneumonia is an inflammatory reaction in the lungs, often due to infection, that causes alveoli to fill with cellular debris and thick, purulent exudate (ie, consolidation), which may cause impaired ventilation and oxygenation. Interventions to facilitate secretion removal in clients with pneumonia include: -Performing chest physiotherapy (percussion, vibration, postural drainage) to loosen and break up thickened secretions (Option 1) -Assisting the client to perform huff coughing, which raises secretions from the lower to the upper airway for expectoration (Option 3) -Ensuring adequate hydration through increased oral fluid intake (≥2-3 L/day) and administration of prescribed IV fluids, which thins pulmonary secretions to promote improved secretion clearance -Positioning the head of the bed to 45-60 degrees (ie, Fowler position) to promote effective coughing and optimal lung expansion (Option 2) Cough suppressants reduce the urge to cough triggered by airway irritants (eg, purulent secretions) and ultimately impair secretion removal. (Option 4) Pursed-lip breathing prolongs exhalation and prevents airway collapse, which alleviates dyspnea relating to air trapping (eg, chronic obstructive pulmonary disease). However, it does not facilitate secretion removal. (Option 5) Side-lying positioning is utilized in hypoxic clients with unilateral pneumonia to increase perfusion to the healthy lung by gravity and improve oxygenation by positioning the client with the unaffected (good) side down. However, side-lying position alone does not improve secretion clearance
A client's arterial blood gases (ABGs) are shown in the exhibit. The nurse would expect which finding to demonstrate that the client is compensating for the ABGs? Click on the exhibit button for additional information. 1. Decrease in bicarbonate reabsorption(26%) 2. Decrease in respiratory rate(14%) 3. Increase in bicarbonate reabsorption(21%) 4. Increase in respiratory rate(37%) Incorrect Laboratory resultsPH7.25PO279 mm Hg (10.5 kPa)PaCO235 mm Hg (4.66 kPa)HCO3-12 mEq/L (12 mmol/L)
The client's ABGs have low pH consistent with acidosis. If it is a primary respiratory acidosis, pCO2 would be higher. If it is metabolic acidosis, bicarbonate would be lower. Because this client has low pH coupled with low bicarbonate, the most likely diagnosis is primary metabolic acidosis. Respiratory alkalosis is the body's natural compensation for metabolic acidosis. Respiratory alkalosis is achieved by blowing more CO2 off from the system through rapid breathing. (Option 1) Decreased bicarbonate reabsorption would produce metabolic acidosis; this would occur as a compensation for primary respiratory alkalosis (decreased pCO2 and high pH). (Option 2) When the respiratory rate is decreased, pCO2 would increase, creating a respiratory acidosis; this would occur in response to a primary metabolic alkalosis. (Option 3) Increased bicarbonate reabsorption would produce metabolic alkalosis; this would occur as a compensation for primary respiratory acidosis (increased pCO2 and low pH).
A client is brought to the emergency department due to loss of consciousness after binge drinking at a college party and then taking alprazolam. Pulse oximetry shows 87% on room air. Which findings would the nurse expect to assess on an arterial blood gas? 1. Metabolic acidosis and hyperventilation(9%) 2. Metabolic alkalosis and hypoventilation(17%) 3. Respiratory acidosis and hypoventilation(63%) 4. Respiratory alkalosis and hyperventilation(9%)
The combination of excessive alcohol ingestion and the benzodiazepine alprazolam (Xanax) causes respiratory depression, which leads to alveolar hypoventilation secondary to carbon dioxide retention, and respiratory acidosis. Therefore, clients should be advised not to take multiple substances that increase the risk of respiratory depression (eg, opioids, benzodiazepines, alcohol, sedating antihistamines). (Option 1) Diarrhea, ketoacidosis, lactic acidosis, and renal failure can cause metabolic acidosis due to loss of bicarbonate or retention of acids; the lungs would compensate by hyperventilating. (Option 2) Vomiting, gastrointestinal suction, and administration of alkali (ie, sodium bicarbonate) are common causes of metabolic alkalosis; the lungs would compensate by hypoventilating. (Option 4) Hypoxia, anxiety, and pain are common causes of respiratory alkalosis, which is due to alveolar hyperventilation (rapid breathing).
The nurse cares for a client who returns from the operating room after a tracheostomy tube placement procedure. Which of the following is the nurse's priority when caring for a client with a new tracheostomy? 1. Changing the inner cannula within the first 8 hours to help prevent mucus plugs(14%) 2. Checking the tightness of ties and adjusting if necessary, allowing 1 finger to fit under these ties(41%) 3. Deflating and re-inflating the cuff every 4 hours to prevent mucosal tissue damage(11%) 4. Performing frequent mouth care every 2 hours to help prevent infection(33%)
The immediate postoperative priority goal for a client with a new tracheostomy is to prevent accidental dislodgement of the tube and loss of the airway. If dislodgement occurs during the first postoperative week, reinsertion of the tube is difficult as it takes the tract about 1 week to heal. For this reason, dislodgement is a medical emergency. The priority nursing action is to ensure the tube is placed securely by checking the tightness of ties and allowing for 1 finger to fit under these ties. (Option 1) Changing of the inner cannula and tracheostomy ties is not usually performed until 24 hours after insertion; this is due to the risk of dislodgement with an immature tract. However, the dressing can be changed if it becomes wet or soiled. Suctioning can be performed to remove mucus and maintain the airway. (Option 3) The cuff is kept inflated to prevent aspiration from secretions and postoperative bleeding. Cuffs are not regularly deflated and re-inflated. The respiratory therapist should monitor the amount of air in the cuff several times a day to prevent excessive pressure and mucosal tissue damage. (Option 4) Frequent mouth care to help prevent stomal and pulmonary infection is important in a client with an artificial airway, but it is not the priority action immediately following tracheostomy.
The nurse is caring for a client involved in a motor vehicle collision who had a chest tube inserted to evacuate a pneumothorax caused by fractured ribs. Where would the nurse observe an air leak?
The presence of an air leak is indicated by continuous bubbling of fluid at the base of the water seal chamber. If the client has a known pneumothorax, intermittent bubbling would be expected. Once the lung has re-expanded and the air leak is sealed, the bubbling will cease. The nurse is expected to assess for the presence or absence of an air leak and to determine whether it originates from the client or the chest tube system. (Option 1) Section A is the suction control chamber. Gentle, continuous bubbling indicates that suction is present. (Option 2) Section B is part of the water seal chamber, but an air leak will not be evident in this upper portion. Tidalingof fluid is expected in this portion of the chamber and indicates patency of the tube. (Option 4) Section D is the collection chamber, where drainage from the client will accumulate. The nurse will assess amount and color of the fluid and record these as output.
A self-employed auto mechanic is diagnosed with carbon monoxide poisoning. Admission vital signs are blood pressure 90/42 mm Hg, pulse 84/min, respirations 24/min, and oxygen saturation 94% on room air. What is the nurse's priority action? 1. Administer 5 mg inhaled albuterol nebulizer treatment to decrease inflammatory bronchoconstriction(12%) 2. Administer 100% oxygen using a nonrebreather mask with flow rate of 15 L/min(48%) 3. Administer methylprednisolone to decrease lung inflammation from toxic inhalant(21%) 4. Titrate oxygen to maintain pulse oximeter saturation of >95%(17%)
The purpose of hemoglobin (Hgb) is to pick up oxygen in the lungs and deliver it to the tissues. It must be able to pick up oxygen and release it in the right places. Carbon monoxide (CO) has a much stronger bond to Hgb than oxygen does. Consequently, CO displaces oxygen from Hgb, causing hypoxia that is not reflected by a pulse oximeter reading. The nurse's primary action is to administer highly concentrated (100%) oxygen using a nonrebreather mask at 15 L/min in order to reverse this displacement of oxygen. (Option 1) Albuterol is not a priority action as bronchoconstriction is not a consequence of CO poisoning. (Option 3) Administration of corticosteroids is not a priority/primary action as direct inflammation of the lungs is not an underlying cause for hypoxemia and hypoxia associated with CO poisoning. (Option 4) When all available Hgb binding sites are occupied (oxyhemoglobin or carboxyhemoglobin), saturation (SaO2) is 100%. The conventional pulse oximeter cannot differentiate carboxyhemoglobin from oxyhemoglobin as both absorb the oximeter's red and infrared light wavelengths. Consequently, the pulse oximeter reading may be adequate (>90%), but severe hypoxemia and hypoxia may be present. Alternate methods of CO saturation measurement (eg, multiple wavelength CO pulse oximeter, spectrographic blood gas analysis) are recommended.
The nurse is caring for a client with a chest tube that was placed 2 hours ago for a pneumothorax. Where would the nurse expect gentle, continuous bubbling? 1. Air leak monitor(3%) 2. Collection chamber(4%) 3. Suction control chamber(41%) 4. Water seal chamber(50%)
The suction control chamber (Section A) maintains and controls suction to the chest drainage system; continuous, gentle bubbling indicates that the suction level is appropriate. The amount of suction is controlled by the amount of water in the chamber and not by wall suction. Increasing the amount of wall suction would cause vigorous bubbling but does not increase suction to the client as excess suction is drawn out through the vent of the suction control chamber. Vigorous bubbling would increase water evaporation and therefore decrease the negative pressure applied to the system. The nurse should check the water level and add sterile water, if necessary, to maintain the prescribed level. (Option 1) The air leak monitor (Section C) is part of the water seal chamber. Continuous or intermittent bubbling seen here indicates the presence of an air leak. (Option 2) The collection chamber (Section D) is where drainage from the client will accumulate. The nurse will assess amount and color of the fluid and record as output. (Option 4) The water seal chamber contains water, which prevents air from flowing into the client. Up and down movement of fluid (tidaling) in Section B would be seen with inspiration and expiration and indicates normal functioning of the system. This will gradually reduce in intensity as the lung reexpands.
