Mod 5

pH: 7.48 HCO3: 23 PaCO: 31

respiratory alkalosis, partial uncompensated

pH: 7.48 HCO3: 25 PaCO: 33

respiratory alkalosis, partial uncompensated

An emergency room nurse is caring for a client who sustained a blunt injury to the chest wall. Which sign if noted in the client would indicate the presence of a pneumothorax?

shortness of breath Rationale: This client has sustained a blunt or a closed chest injury. Basic symptoms of a closed pneumothorax are shortness of breath and chest pain. A larger pneumothorax may present with tachypnea, cyanosis, diminished breath sounds, and subcutaneous emphysema. There may also be hyperresonance on the affected side.

A nurse has taught a client about the use of a respiratory inhaler. Which statement by the client indicates a need for further teaching?

"I need to inhale quickly the mist and also quickly exhale. Rationale: The client should be instructed to hold his or her breath for at least 5 to 10 seconds before exhaling the mist.

A nurse has instructed a client diagnosed with tuberculosis (TB) about how to prevent the spread of infection after discharge. The nurse determines that the client needs further reinforcement of information if the client makes which of the following statements?

"I should have food placed on disposable plates, forks, and knives." Rationale: Because tuberculosis is transmitted by droplets, it cannot be carried on clothing, eating utensils, or other possessions. It is important to perform proper hand washing after contact with body substances, tissues, or facemasks. The client should cover the mouth with a tissue when laughing, coughing, or sneezing, and dispose of tissues the carefully.

A nursing student prepares to instruct a client to expectorate a sample of sputum that will be sent to the laboratory for Gram stain, culture, and sensitivity and describes the procedure to the licensed practical nurse (LPN), who is the primary nurse. The LPN corrects the student if which incorrect description is provided?

"I will have the client take a breath and gather his saliva before shallow coughing.

A client is seen in the health care clinic and a diagnosis of acute sinusitis is made. The nurse reinforces home care instructions to the client regarding measures that will promote sinus drainage and comfort. Which statement by the client indicates a need for further education?

"I will need surgery asap to drain the sinuses."

A female client is scheduled to have a chest x-ray. Which question is most important to ask the client during data collection?

"Is there any possibility that you could be pregnant?" Rationale: The most important question to ask is about the client's pregnancy status, because pregnant women should not be exposed to radiation. Clients are also asked to remove any chains or metal objects that could interfere with obtaining an adequate film. i chest x-ray is most often done at full inspiration, which gives optimal lung expansion. If a lateral view of the chest is ordered, the client is asked to raise the arms above the head. Most films are taken.

The physician ordered 100 mg of Cleocin (clindamycin) IM q6h. The drug is available in a vial labeled 300 mg/2 mL. Using a 1-mL syringe and rounding off to the nearest tenth, how many milliliters of Cleocin would the nurse give for each dose?

0.7

A client has been started on long-term therapy with rifampin (Rifadin). A nurse teaches the client that the medication:

Causes red-orange discoloration of sweat, tears, urine, and feces Rationale: Rifampin causes orange-red discoloration of body secretions and will permanently stain soft contact lenses

A nurse is suctioning a client through a tracheostomy tube. The nurse plans to apply suction during the withdrawal of the catheter for a period of time no greater than:

10 seconds Rationale: During suctioning, the nurse would apply suction during the withdrawal of the catheter for a period of 5 to 10 seconds. Suction applied longer than this can cause hypoxia in the client.

Which nursing intervention does the nurse add to the care plan to help a patient with thick sputum mobilize and expectorate those secretions?

Encourage drinking about 3 to 4 L of water a day. Rationale: Encourage fluids to liquefy secretions and aid in their expectoration.

Zyloprim 250 mg PO every day. Supply: scored tablets of 100 mg. What is the quantity to administer?

2.5

ORDER: Tetracycline syrup 0.5 g PO Q6h. SUPPLY: liquid labeled 250 mg per 10 ml. What is the quantity to be administered?

20mL

The physician ordered 1000 mL of D5W to infuse over 16 hours with a drop factor of 20 gtt/mL. Calculate the correct IV flow rate in drops per minute. Round off to the nearest whole number.

21

A client who has had a radical neck dissection related to laryngeal cancer begins to bleed at the incision site. Which action by the nurse would be contraindicated?

Calling the physician immediately Rationale: If the client begins to hemorrhage from the surgical site following radical neck dissection, the nurse elevates the head of the bed to maintain airway patency and prevent aspiration. The nurse applies pressure over the bleeding site, and calls the physician immediately

A nurse is assisting in monitoring the functioning of a chest tube drainage system in a client who just returned from the recovery room following a thoracotomy with wedge resection. Select the expected findings (Select all that apply).

50 mL of drainage in the drainage collection chamber Occlusive dressing in place over the chest tube insertion site Fluctuation of water in the tube in the water seal chamber during inhalation and exhalation

What is the most common cause of atelectasis?

A bronchiole becomes blocked with secretions and distal alveoli collapses with no proper gas exchange occurring

A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to note in evaluating this client?

A hyperinflated chest on x-ray Rationale: Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, and the use of accessory muscles of respiration. Chest x-ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.

The end structures of the bronchial tree are saclike structures that resemble a bunch of grapes wherein gas exchange takes place.

Alveoli

A tuberculin test (Mantoux test) is administered to an individual infected with human immunodeficiency virus (HIV). Seventy-two hours later, the nurse evaluates the test site and documents the results as positive, indicating that the individual has been exposed to tuberculosis. Which of the following findings did the nurse note to make this interpretation?

An area of induration at the test site measuring 7 mm Rationale: Normally, an area of induration greater than 15 mm is considered positive in low-risk individuals. However, an area of induration that measures 5 mm or greater in people with HIV infection is considered positive. Redness and swelling do not indicate a positive test result.

A patient comes into the clinic complaining of a nonproductive cough and muscle aches that she has had for 5 days. She has no sore throat, temperature elevation, or swollen lymph nodes. She is coughing so much that she is unable to sleep at night. The physician might order which of the following?

Antitussive Rationale: Antitussives are used for the relief of overactive or nonproductive coughs.

A nursing instructor is observing a nursing student suctioning a client through a tracheostomy tube. The nursing instructor intervenes if the student performed which incorrect action?

Applying suction during insertion of the catheter Rationale: The client should be hyperoxygenated with 100% oxygen prior to suctioning. Sterile technique is always used. Suction is not applied during insertion of the catheter, and intermittent suction and a twirling motion of the catheter are used during withdrawal.

Which independent nursing measures are effective in helping ease a patient to expectorate thick secretions? (Select all that apply)

Assisting to deep breathe first before coughing Positioning in sitting position Providing hydration Suctioning

What does a nurse teach an adult male who has had a tonsillectomy?

Avoid coughing vigorously and clearing the throat during the first week postoperatively. Rationale: The nurse should teach the patient to avoid attempting to clear the throat immediately after surgery and to avoid coughing, sneezing, or vigorous nose blowing for 1 to 2 weeks. Maintain IV fluids until the nausea subsides, at which time the patient may begin drinking ice- cold clear liquids. The diet is advanced to custard and ice cream and then to a normal diet as soon as possible. Apply an ice collar to the neck for comfort and to reduce bleeding by vasoconstriction.

A clinic nurse is providing instructions to a client with a diagnosis of pharyngitis. The nurse instructs the client to:

Avoid foods that are citrus, spicy and highly seasoned. Rationale: The client with pharyngitis should be instructed to consume cool clear fluids, ice chips, or ice pops to soothe the painful throat. Citrus products should be avoided because they irritate the throat. Milk and milk products are avoided because they tend to increase mucus production. Foods that are highly seasoned are irritating to the throat and should be avoided, and the client should be instructed to drink 2000 to 3000 mL of fluid daily unless contraindicated.

A client is at risk of developing a pulmonary embolism. The nurse monitors for which of the following, which is the most commonly reported initial symptom?

Chest pain that occurs suddenly with dyspnea Rationale: The most common initial symptom in pulmonary embolism is chest pain that is sudden in onset. The next most commonly reported symptom is dyspnea, which is accompanied by an increased respiratory rate. Other typical symptoms of pulmonary embolism include cough, tachycardia, fever, diaphoresis, anxiety, and possibly syncope.

A nurse is admitting a client to the hospital with a diagnosis of chronic bronchitis. The physician has also documented the suspicion of pulmonary emphysema and has prescribed diagnostic studies. The nurse collects data from the client and notes that which of the following signs of chronic bronchitis is unassociated with emphysema?

Chronic cough that began before the onset of dyspnea Rationale: Key features of pulmonary emphysema include dyspnea that is often marked, late cough (after onset of dyspnea), scant mucus production, and marked weight loss. By contrast, chronic bronchitis is characterized by an early onset of cough (before dyspnea), copious purulent mucus production, minimal weight loss, and milder severity of dyspnea.

A nurse is caring for a client who has a chest tube. While collecting data from the client, the nurse notices that the chest tube has accidentally been removed from the client's chest. Which of the following is the first action the nurse should take?

Cover the insertion site with petroleum sterile gauze. Rationale: it is important to maintain the intrathoracic pressure as changes can cause immediate respiratory distress to the patient

A client with chronic obstructive pulmonary disease (COPD) who is beginning oxygen therapy asks the nurse why the flow rate cannot be increased to more than 2 L/minute. The nurse responds that this would be harmful because it could:

Decrease the client's carbon dioxide-based respiratory drive Rationale: Normally respiratory rate varies with the amount of carbon dioxide present in the blood. In clients with COPD this natural center becomes ineffective after exposure to high carbon dioxide levels for prolonged periods. Instead, the level of oxygen provides the respiratory stimulus. The client with COPD cannot increase oxygen levels independently because it could deplete the respiratory drive, leading to respiratory failure.

A patient with allergic rhinitis is prescribed an antihistamine. To prevent which of the following conditions should the nurse instruct the patient to suck on a sugarless hard candy?

Dryness of the oral mucosa and the throat

A nurse is caring for a client hospitalized with acute exacerbation of chronic obstructive pulmonary disease (COPD). Which of the following would the nurse expect to note in this client?

Dyspnea on exertion and activity Rationale: Clinical manifestations of COPD include hypoxemia, hypercapnia, dyspnea on exertion and at rest, oxygen desaturation with exercise, use of accessory muscles of respiration, and a prolonged expiratory phase of respiration. The chest x- ray will reveal a hyperinflated chest and a flattened diaphragm if the disease is advanced.

A client with a chronic airflow limitation is experiencing respiratory acidosis as a complication. The nurse who is trying to enhance the client's respiratory status would avoid doing which of the following?

Encouraging the client to breathe slowly and shallowly Rationale: The client with respiratory acidosis is experiencing elevated carbon dioxide levels due to insufficient ventilation. The nurse would encourage the client to breathe slowly and deeply (not shallowly) to expand alveoli and to promote better gas exchange. The actions listed in options 1, 2, and 3 are helpful actions on the part of the nurse.

A client who has laryngeal nodules being evaluated for cancer of the larynx is scheduled for out-patient surgery to have them removed. The nurse collects data on the client and expects the client to complain of which typical symptom associated with this condition?

Hoarseness Rationale: Hoarseness is a typical symptom associated with laryngeal nodules. Aphonia is associated with laryngitis. Sore throat typically occurs with pharyngitis. Swollen glands usually accompany tonsillitis.

A nurse is preparing a client for the administration of a Mantoux test. The nurse determines that which body area is the most appropriate area for injection of the medication?

Inner aspect of forearm that is not heavily pigmented Rationale: Intradermal injections are most commonly given in the inner aspect of the forearm. Other sites include the dorsal area of the upper arm or the upper back beneath the scapulae. The nurse finds an area that is not heavily pigmented and is removed from hairy areas or lesions, which could interfere with reading the results.

Which of the following are considered primary drugs (first-line) to treat tuberculosis? (Select all that apply):

Isoniazid (Nydrazid) Rifampin (Rifadin) Ethambutol (Myambutol) Rationale: These drugs are the first line of medications for TB

Treatment for active tuberculosis includes which of the following?

Long-term treatment with at least 4 drug combination for about 6-9 months Rationale: Antitubercular drugs are classified as primary or secondary agents to describe the way they are used in treating tuberculosis. The combination of drugs helps to slow the development of bacterial resistance.

A nurse is caring for a client following segmental resection of the upper lobe of the left lung. The nurse notes 700 mL of grossly bloody drainage in the chest tube drainage system during the first hour following surgery. The nurse is aware that this finding:

May represent hemorrhage and requires further assessment and checking the patient's vital signs Rationale: Within the first 2 hours following surgery, 100 to 300 mL of drainage is expected (around 70-100ml/hr.). An amount of 700 mL is excessive and indicates that hemorrhage may be occurring and that the client requires further data collection. The physician should be notified.

A nurse is assisting in the care of a client who had an ileostomy created a few days ago. Owing to the normally high output of drainage from this type of ostomy, the nurse monitors the client for signs of what acid-base imbalance?

Metabolic acidosis Rationale: Intestinal secretions are high in bicarbonate because of the effects of pancreatic secretions. These fluids may be lost from the body before they can be reabsorbed in conditions such as diarrhea or creation of ileostomy. The decreased bicarbonate level creates the actual base deficit of metabolic acidosis.

When caring for a client who has TB, the nurse is required to wear:

N-95 mask Rationale: Patients on airborne precaution needs to wear the N-95 tp prevent from inhaling the infectious agent.

Which of the following diets would be prescribed to the patient who just had bronchoscopy?

NPO until gag reflex returns Rationale: Patient after bronchoscopy should be kept on NPO until return of gag reflex and bowel sounds. Clear and soft diet first and if tolerated may resume to previous diet as not to vause aspiration to the irrited throat.

Which of the following can cause a low pulse oximetry reading? (Select all that apply)

Nail polish Edema Inadequate peripheral extremity circulation

A nurse is reading the results of a Mantoux skin test on a client with no documented health problems. The site has no induration and a 1-mm area of ecchymosis. The nurse interprets this as:

Negative

A nurse is caring for the client who is at risk for lung cancer due to an extremely long history of heavy cigarette smoking. The nurse tells the client to report which most frequent early symptom of lung cancer?

Nonproductive dry hacking cough Rationale: Cough is the most frequent early symptom of lung cancer, which begins as nonproductive and hacking, and progresses to productive. In the smoker who already has a cough, a change in the character and frequency of the cough usually occurs. Hoarseness and blood-streaked sputum are later signs. Pain is a very late sign and is usually pleuritic in nature.

A nurse is assisting in caring for a client with an endotracheal tube attached to a ventilator when the high-pressure alarm sounds. The nurse checks the client and system for which most likely cause?

Obstruction that can be caused by accumulation of secretions in the client's lungs Rationale: When the high-pressure alarm sounds on a ventilator, it is most likely due to an obstruction. The obstruction can be caused by the client biting on the tube, kinking of the tubing, or mucus in the lungs that requires suctioning. It is also important to assess the tubing for the presence of any water and determine if the client is out of rhythm with breathing with the ventilator. The incorrect options list items that may be responsible for a low-pressure alarm on the ventilator

A 55-year-old man comes to the health nurse at his place of work with epistaxis. He reports he has frequent nosebleeds that he can usually control himself. What would be the most helpful assessment after the nurse has stopped the bleeding?

Obtain or check blood pressure Rationale: Check the blood pressure for hypotension to assess for hypovolemic shock. Adults can lose as much as 1 L of blood in an hour with heavy epistaxis.

A nurse assists in preparing a care plan for the client who will be returning from surgery following a right wedge resection. Included in the plan is that in the postoperative period the nurse should avoid positioning this client:

On the right side Rationale: Following a wedge resection, the client should not be placed on the operative side. Lying on the operative side hinders expansion of remaining lung tissue and may accentuate perfusion of poorly ventilated tissue. This further impedes normal gas exchange,

A client has been taking isoniazid (INH) for 1 ½ months. The client complains to the nurse about numbness, paresthesias, and tingling in the extremities. The nurse interprets that the client is experiencing:

Peripheral neuritis Rationale: A common side effect of isoniazid (INH) is peripheral neuritis. This is manifested by numbness, tingling, and paresthesias in the extremities. This side effect can be minimized with pyridoxine (vitamin B6) intake.

The appropriate nursing intervention for a patient, age 40, who is diagnosed with active tuberculosis would be to

Place the patient in acid-fast bacillus (AFB) Isolation Precautions Rationale: If TB is suspected, permission to place the patient in acid-fast bacilli (AFB) isolation precautions should be requested immediately.

A nurse is assisting a client who underwent radical neck surgery to get out of bed. The nurse provides the most support to the client who is afraid to move the head by doing which of the following?

Placing a hand behind the client's head to support while getting up Rationale: The nurse provides the most support to the surgical site by placing a hand behind the client's head. Options 1 and 4 involve little assistance or support by the nurse. Option 3 is unnecessary and could occlude a tracheostomy if one is in place

Which is the hallmark of pulmonary edema?

Productive coughing with frothy pink-tinged sputum

A nursing diagnosis for the patient with a new laryngectomy would be Social isolation related to impaired verbal communication related to removal of the larynx. What is an appropriate nursing intervention?

Provide a pad and pencil or magic slate to write on Rationale: Provide patient with implements for communication. Rapidly completing care and provision of solitary activities does not reduce social isolation.

Which interventions are health promotions to prevent pneumonia? (Select all that apply.)

Provide for good health habits (nutrition, hygiene, exercise). Check for placement before administering tube feedings. Encourage elder patients to receive influenza and pneumococcal vaccines. Rationale: Older adults should receive pneumococcal and influenza vaccines. Good health habits are the basis for preventing disease. Aspiration can occur if the nasogastric tube is not correctly placed in the stomach. New stroke patients should be assisted with eating until the gag reflex is established.

Which test is a quick and reliable aid to diagnosis latent TB?

QFT-G Rationale: Sputum smears, cultures and PPD skin test are still done. However. OFT-G offers a quick and reliable diagnosis for the patient and health care provider. The results of QFT-G are greater specificity and results are available 24 hours after the blood is collected.

A nurse is caring for a client who had a Mantoux skin test 48 hours ago on admission to the nursing unit and reads the result of the skin test as positive. Which action by the nurse is the priority?

Report the findings. Rationale: The nurse who interprets a Mantoux test as positive notifies the physician immediately. The physician would order a chest x-ray to determine whether the client has clinically active tuberculosis (TB) or old. healed lesions. A sputum culture would be done to confirm the diagnosis of active TB. The client is placed on TB precautions prophylactically until a final diagnosis is made. The findings are documented in the client's record but this action is not the highest priority. Calling the employee health service would be of no benefit to the client.

A client is to begin a 6-month course of therapy with isoniazid (INH). A nurse plans to teach the client to:

Report yellow eyes or skin immediately Rationale: INH is hepatotoxic and therefore the client is taught to report signs and symptoms of hepatitis or liver dysfunction immediately.

A nurse has just been given an order to administer albuterol (Proventil HFA) to a client. The nurse evaluates the effectiveness of the medication by noting which of the following before and during therapy?

Resolving dyspnea and clear lung sounds Rationale: Albuterol is an adrenergic bronchodilator. The nurse monitors respiratory pattern, lung sounds, pulse, and blood pressure prior to and during therapy. The color, character, and amount of sputum also are noted. The medication is not given to affect the parameters listed in any of the other options

A nurse is caring for a client who witness a bombing incident is nervous and hyperventilating. The nurse would monitor the client for signs of which of the following acid-base imbalances?

Respiratory alkalosis Rationale: A client who hyperventilates blows off excessive carbon dioxide. This would have the effect of inducing alkalosis. Because a respiratory problem is triggering the alteration, it is called a respiratory alkalosis.

Which patient assessment indicates the most severe respiratory distress?

Substernal retraction, SaO2 84% Rationale: Observe the patient's facial expressions and signs of respiratory distress, such as flaring nostrils, substernal or clavicular retractions, asymmetrical chest wall expansion, and abdominal breathing. The lower the SaO2, the more severe the respiratory distress.

A nurse is caring for a client following pulmonary angiography via catheter insertion into the left groin. The nurse monitors for an allergic reaction to the contrast medium by noting the presence of:

Respiratory distress Rationale: Signs of allergic reaction to the contrast medium include localized itching and edema, respiratory distress, stridor, and decreased blood pressure. Hypothermia is an unrelated event. Discomfort is expected. Hematoma formation is a complication of the procedure, but does not indicate an allergic reaction.

A nurse is assisting in caring for a client with a newly inserted tracheostomy. The nurse reviews the nursing care plan and notes documentation of a nursing diagnosis of Impaired Gas Exchange. The nurse should monitor for which item as the best indicator of an adequate respiratory status?

Respiratory rate of 18 breaths per minute and regular Rationale: Impaired Gas Exchange could occur following tracheostomy from excessive secretions, bleeding into the trachea, restricted lung expansion caused by immobility, or concurrent respiratory conditions. An oxygen saturation of 89% is less than optimal. The respiratory rate of 18 breaths per minute is well within the normal range of 14 to 20 breaths per minute.

A nurse is monitoring a client following a motor vehicle accident. The nurse determines the need to prepare for chest tube insertion when the client exhibits:

Shortness of breath and tracheal deviation Rationale: Shortness of breath and tracheal deviation result when lung tissue and alveoli have collapsed. Air entering the pleural cavity causes the lung to lose its normal negative pressure. The increasing pressure in the affected side displaces contents to the unaffected side. Shortness of breath results from decreased area available for diffusion of gases.

A patient with TB is undergoing initial therapy in the treatment. The nurse has to administer three or more drugs in combination to the patient. The patient wishes to know the reason for administering a combination of drugs. Which of the following explanations does the nurse offer related to the combination of medications?

Slows down bacterial resistance

The nurse has reinforced instructions with a patient with pleural effusion about strategies to promote comfort during recuperation. The nurse evaluates that the patient has understood the instructions if the patient states that he or she will do which of the following?

Splint the chest wall during coughing and deep breathing Rationale: Effective coughing out of secretions can be achieved by splinting the chest wall which also decreases pain and discomfort

Which of these terms describes an asthma attack that persists and does not respond to treatment?

Status asthmaticus

A nurse is preparing to assist a physician with the insertion of a chest tube. The nurse anticipates that which of the following supplies will be required for the chest tube insertion site?

Sterile petrolatum gauze Rationale: The first layer of the chest tube dressing is petrolatum (Vaseline) gauze, which allows for an occlusive seal at the chest tube insertion site. Additional layers of gauze cover this layer, and the dressing is secured with a strong adhesive tape or Elastoplast tape. Povidone-iodine may be used to clean the insertion site before insertion of the chest tube. Sterile dressings will be used to cover the Vaseline gauze.

A physician is about to remove a chest tube from a client. Once the dressing is removed and the sutures have been cut, the nurse assisting the physician asks the client to:

Take a deep breath, exhale, and bear down Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is then quickly withdrawn, and an airtight dressing is taped in place. The pleura seals itself off and the wound heals in less than a week. Therefore options 1, 3, and 4 are incorrect.

A patient is prescribed an inhalational corticosteroid therapy along with bronchodilator therapy. Which of the following points should the nurse include in the patient teaching plan?

Take the corticosteroid several minutes after the bronchodilater dose

A client has a new order to take guaifenesin (Humibid) every 4 hours as needed. The nurse giving medication instructions to the client tells the client to be sure to:

Take the tablet with a full glass of water and increase fluid intake. Rationale: Guaifenesin is an expectorant. It should be taken with a full glass of water to decrease viscosity of secretions. Sustained- release preparations should not be broken open, crushed, or chewed. The medication occasionally may cause dizziness, headache, or drowsiness as side effects. The client should contact the physician if the cough lasts longer than 1 week or is accompanied by fever, rash, sore throat, or persistent headache.

A nurse in an ambulatory clinic is preparing to administer a Mantoux skin test to a client who may have been exposed to an individual with tuberculosis (TB). The client reports having had the Bacille Calmette Guerin (BCG) vaccine before moving to the United States from a foreign country. The nurse interprets that:

The client's Mantoux test will be positive and will require chest x-ray for evaluation. Rationale: The Bacille Calmette-Guerin vaccine is routinely given in many foreign countries to enhance resistance to TB. The vaccine uses attenuated tubercle bacilli, so the client will always test positive on Mantoux skin testing after receiving the vaccine. This client needs to be evaluated for TB with a chest x-ray.

Interpret the ABG with included compensatory mechanism pH: 7.28 HCO3: 28 PaCO: 46

respiratory acidosis, partial uncompensated

On your patient's third post-op day, the intermittent bubbling stops and the fluctuation in the water seal container stops and the patient is not in any kind of distress. The most probable cause of this finding is:

The lungs might have re-expanded Rationale: No activity in the chest tube drainage even when the integrity of the setup is maintained and the patient is not in any distress, breathing is relaxed, might mean the lungs have re-expanded and doctor needs tobe notified to confirm with chest x-ray.

A nurse is observing a nursing student listening to the breath sounds of a client. The nurse intervenes if the student performs which incorrect procedure?

The student auscultates and places the stethoscope on the client's gown Rationale: To listen to breath sounds, the stethoscope is always placed directly on the client's skin, and not over a gown or clothing. The nurse asks the client to sit up and breathe slowly and deeply through the mouth. Breath sounds are auscultated using the diaphragm of the stethoscope, which is warmed prior to use.

A nurse checks the water seal chamber of a closed chest drainage system and notes as the patient is breathing, fluctuations or tidaling is present in the chamber. The nurse analyzes this finding as indicative of which of the following?

The system is functioning as expected Rationale: Fluctuations (tidaling) in the water seal chamber are normal during inhalation and exhalation. Fluctuations of 5 to 10 cm (2 to 4 inches) during normal breathing are common. The absence of fluctuations could mean that the tubing is obstructed by a kink, the client is lying on the tubing, or dependent fluid has filled a loop of tubing. Expanded lung tissue can also block the chest tube eyelets during expiration. The absence of fluctuations could also mean that air is no longer leaking into the pleural space.

pH: 7.27 HCO3: 24 PaCO: 53

respiratory acidosis, partial uncompensated

pH: 7.28 PaCO: 40 HCO3: 18

respiratory acidosis, partial uncompensated

A nurse is assigned to assist in caring for a client who has a pneumothorax. The nurse notes continuous bubbling in the air leak chamber of the client's closed-chest drainage system. The nurse determines that which of the following is occurring?

There is an air leak somewhere in the system. Rationale: Continuous bubbling through both inspiration and expiration indicates that there is air leaking into the system. A resolving pneumothorax would not cause bubbling with respiration in the water seal chamber. The system does not necessarily have a crack in it; there could be air leaking into the system due to a loose connection or through the pleural cavity. Shutting the suction off to the system stops bubbling in the suction control chamber but does not affect the water seal chamber.

A young mother tells the nurse that her 6-month-old baby has a cough and that she is giving the baby an OTC cough and decongestant preparation. Which of the following statements would the nurse teach this young mother?

These products are not safe for infants. Rationale: In 2007, the FDA announced that over-the- counter cold products should not be used in infants because they are unsafe.

A postoperative client with incisional pain complains to the nurse about completing respiratory exercises. The client is willing to do the deep breathing exercises but states that it hurts to cough. The nurse provides gentle encouragement and appropriate pain management to the client, knowing that coughing is needed to:

To expel mucus from the airways Rationale: Coughing is one of the protective reflexes. Its purpose is to move mucus that is in the airways upward toward the mouth and nose. Coughing is needed in the postoperative client to mobilize secretions and expel them from the airways. The other options do not accurately address the purpose of coughing in the postoperative client.

This is a tube-like structure that extends to the mid- chest, where it divides into the right and left bronchi. It contains C-shaped cartilaginous rings that keep it from collapsing:

Trachea

A nurse is listening to the client's breath sounds and hears musical whistling noises on inspiration and expiration scattered throughout the right lung fields. The nurse interprets that this client has:

Wheezes Rationale: Wheezes are musical noises heard on inspiration, expiration, or both. They are the result of narrowed air passages. Crackles have the sound that is heard when a few strands of hair are rubbed together near the ear and indicate fluid in the alveoli. Rhonchi are usually heard on expiration when there is excessive production of mucus, which accumulates in the air passages. A pleural friction rub is characterized by sounds that are described as creaking, groaning, or grating in quality. The sounds are localized over an area of inflammation of the pleura and may be heard in both the inspiratory and expiratory phases of the respiratory cycle.

A client taking theophylline (Theo-24) has a serum theophylline level of 15 mcg/mL. The nurse interprets that this result is:

Within the therapeutic range. Rationale: The normal therapeutic range for theophylline levels is 10 to 20 mcg/mL. A level greater than 20 mcg/mL is considered toxic. The value of 15 mcg/mL places the client in the middle of the therapeutic range.

A patient, age 54, is on postoperative day 2 after undergoing an open cholecystectomy. Immediately after the surgery, she vomited and may have aspirated some emesis. The nurse is concerned that the patient will develop pneumonia. In planning for her care, the nurse suspects the patient may have

aspiration pneumonia Rationale: Aspiration pneumonia occurs most commonly as a result of aspiration of vomitus when the patient is in an altered state of consciousness due to a seizure, drugs, alcohol, anesthesia, acute infection, or shock.

When a patient has experienced a pneumothorax, chest auscultation reveals:

bilateral unequal breath sounds, with no breath sounds over the affected area. Rationale: Findings on auscultation are bilaterally unequal breath sounds, with no breath sounds over the affected area. A larger pneumothorax causes respiratory distress, including rapid shallow respirations, air hunger, dyspnea, and oxygen desaturation.

An 83-year-old patient is admitted with a temperature of 102° F (38.8° C), chest pain, and fatigue. The chest radiograph reveals an accumulation of fluid in the pleural space, which the physician removes by performing a thoracentesis. The nurse correctly records the purulent exudate pus as:

empyema. Rationale: If the fluid between the lung and the membrane lining the pleural cavity becomes infected, it is called empyema.

The leaf-shaped cartilage that covers the larynx during swallowing is the

epiglottis

A patient, age 69, has emphysema. On assessing him, the nurse notes the presence of a "barrel chest." This pathology results from a(n)

increased anteroposterior diameter caused by overinflation of the alveoli. Rationale: The patient will eventually appear barrel chested (an increased anteroposterior diameter caused by overinflation).

These structures of the brain are responsible for the nervous control of breathing and regulates the basic rhythm and depth of respirations.

medulla oblongata and pons

pH: 7.25 HCO3: 19 PaCO: 45

metabolic acidosis, partial uncompensated

Determine the ABG and the compensatory mechanism: pH: 7.55 HCO3: 31 PaCO: 37

metabolic alkalosis, complete compensated

pH:7.5 HCO3: 28 PaCO:46

metabolic alkalosis, partial compensated

pH: 17.35 HCO3: 22 PaCO: 45

normal ABG

pH: 7.40 HCO3: 25 PaCo: 35

normal ABG

The patient has COPD. To teach him pursed-lip breathing, the nurse should instruct him to inhale slowly through his:

nose, then exhale more slowly through pursed lips. Rationale: The nurse should instruct the patient and family on effective breathing techniques (such as pursed-lip breathing) and relaxation exercises for anxiety control. The patient should inhale through the nose and exhale through pursed lips. The exhalation should be 2 - 3 times longer than the inhalation.

A nurse is assisting in planning care for a client scheduled for insertion of a tracheostomy. What equipment would the nurse plan to have at the bedside when the client returns from surgery?

obturator Rationale: A replacement tracheostomy tube of the same size and an obturator is kept at the bedside at all times in case the tracheostomy tube is dislodged. Additionally, a curved hemostat that could be used to hold the trachea open if dislodgement occurs should also be kept at the bedside. An oral airway and epinephrine would not be needed.

The patient has been admitted for possible carcinoma of the larynx. The first sign or symptom that may be present in carcinoma of the larynx is often

persistent hoarseness Rationale: Progressive or persistent hoarseness is an early sign.

A 62-year-old patient is seen in the emergency department with an epistaxis. When a patient has an epistaxis, the correct nursing interventions would be

place the patient in Fowler's position with the head leaning forward. Rationale: Elevate head of bed. Place patient in Fowler's position with the head forward. Compression of nostrils should be for 10-15 minutes. Hot compresses will increase bleeding-ice should be applied.

A nurse is gathering data on a client with a diagnosis of tuberculosis (TB). The nurse reviews the results of which diagnostic test that will confirm this diagnosis?

sputum culture Rationale: A definitive diagnosis of TB is confirmed through culture and isolation of Mycobacterium tuberculosis. A presumptive diagnosis is made on the basis of a tuberculin skin test, a sputum smear that is positive for acid-fast bacteria, a chest x-ray, and histologic evidence of granulomatous disease on biopsy.

The substance that reduces the surface tension of alveolus and prevents it from collapsing after each breath is called

surfactant

A patient, age 22, is admitted with acute asthma. It is important to monitor his oxygen saturation levels. The quickest way to assess his saturation of oxygen is to

use pulse oximetry Rationale: In acute asthma, oxygen therapy should be started immediately, and its administration should be monitored by pulse oximetry. Pulse oximetry is noninvasive and provides continuous monitoring of SaO2.