MS1 Respiratory EAQ

At which interval are humidified oxygen systems replaced to prevent infection?

1 day

Which procedure is shown in the picture?

A thoracentesis

Nursing actions after a client has had general anesthesia are directed at preventing which postoperative respiratory complication?

Atelectasis

When a client has a superficial tumor involving only 1 vocal cord, which surgery would the nurse anticipate?

Cordectomy

The nurse auscultates fine crackles in a client who has arrived in the emergency department with respiratory distress. When the nurse is providing information to the client about crackles, which is appropriate to include?

Crackles are located in the smaller air passages.

When a client has a right pneumothorax, which type of breath sounds will the nurse expect to hear on the right chest?

Decreased sounds

Which substance will the home care nurse instruct a client to use after laryngectomy to cleanse the stoma site?

Mild soap and water

The nurse repositions a client who is diagnosed with emphysema to facilitate breathing. Which position facilitates maximum air exchange?

Orthopneic

Which is the function of the water-seal chamber on a closed chest drainage system for a client with hemothorax?

Prevents reflux of air back into the pleural space

The nurse is teaching a client with a diagnosis of pulmonary tuberculosis about recovery after discharge. Which is the most important intervention for the nurse to include in this plan?

Taking medications as prescribed

Which statement describes a client's tidal volume?

Tidal volume is the volume of air inhaled and exhaled with each breath.

A client with a coronary occlusion is experiencing chest pain and distress. Which is the primary reason that the nurse administers oxygen?

To increase oxygen concentration to heart cells

Which parameter describes the maximum volume of air a client's lungs may contain?

Total lung capacity

How would the nurse position a client to practice supraglottic swallowing after tracheostomy?

Upright

After the nurse teaches a client about self-management techniques for smoking cessation, which client statement indicates the need for further teaching?

"I should visit all the places where I started smoking."

After a client with multiple fractures of the left femur is admitted to the hospital for surgery, the client experiences a sudden onset of cyanosis, tachycardia, dyspnea, restlessness, and petechiae on the chest. Which is the priority nursing action?

Administer oxygen

Which intervention would the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma?

Encourage coughing and deep breathing.

Which is the purpose of an occlusive dressing over a client's sucking chest wound?

Maintains negative pressure within the chest cavity

Which change in the arterial blood gases would the nurse expect in a client with hyperventilation due to anxiety?

Respiratory alkalosis

How would the nurse position a client with epistaxis?

Upright leaning forward

When auscultating a client's chest, the nurse hears swishing sounds of normal breathing. How would the nurse document this finding?

Vesicular breath sounds

Which assessment finding is consistent with bronchospasm?

Wheezing

After the nurse has finished teaching a postoperative client about prevention of pulmonary embolism, which client statement indicates that the teaching has been effective?

"I will avoid crossing my legs."

Which response will the nurse provide when a family member asks why a client who is intubated and receiving mechanical ventilation has restraints in place?

"Restraints are a last resort to prevent accidental extubation."

When a client with newly diagnosed chronic bronchitis tells the home health nurse about continuing to smoke 1 or 2 cigarettes a day and not doing the prescribed pulmonary physiotherapy exercises, which response by the nurse is best?

"Tell me about your typical day before you were diagnosed with chronic lung disease."

When a client with a health care-acquired respiratory tract infection asks the nurse what this means, which response will the nurse give?

"Your infection occurred because of exposure to a health care facility. "

Which assessment finding of a client being treated in the emergency department after a motor vehicle collision indicates the need for immediate health care provider intervention? Select all that apply. One, some, or all responses may be correct. Facial edema Septal deviation Clear nasal drainage Oxygen saturation 89% Bilateral periorbital bruising

All the above

Which trigger would the nurse instruct a client to avoid to decrease the incidence of asthma attacks? Select all that apply. One, some, or all responses may be correct. Mold Cold air Pet dander Air pollution Cigarette smoke

All the above

When the nurse educator is observing a student performing tracheal suctioning of a client with thick secretions, which student action requires intervention?

Applies suction during insertion of the catheter

An orientee (newly hired nurse) provides postoperative care to a client after a laryngoscopy. The orientee reminds the client not to eat or drink anything until instructed to do so. How would the orientee's preceptor evaluate the instructions given by the orientee?

Appropriate; oral intake after the procedure may result in aspiration

A client with chronic obstructive pulmonary disease is admitted to the hospital with a tentative diagnosis of pleuritis. It is important for the nurse to perform which intervention?

Assess for signs of pneumonia.

Which action would the nurse plan to take to prevent respiratory complications after abdominal surgery?

Assist client to use the incentive spirometer.

A client who is receiving peritoneal dialysis reports severe respiratory difficulty. Which immediate action would the nurse implement?

Auscultate the lungs.

Which instructions would the nurse share with the client being discharged after rhinoplasty?

Avoid items that may trigger sneezing.

Which instruction would the nurse include when teaching a client how to perform diaphragmatic breathing?

Expand the abdomen on inhalation.

The community health nurse is educating a client who is interested in discontinuing cigarette smoking. Which would the teaching plan include?

Helping the client set a date to stop smoking

The nurse teaches a client with a diagnosis of emphysema about the importance of preventing infections. The nurse would include which information in the education?

Importance of meticulous oral hygiene

While in the postanesthesia care unit, a client reports shortness of breath and chest pain. Which is the most appropriate initial response by the nurse?

Initiate oxygen via a nasal cannula

A client presenting with an acute asthma attack is being assessed in the emergency department. The client's spouse reports that the client currently is undergoing treatment for an upper respiratory infection. The nurse would understand that the client most likely has which type of asthma?

Intrinsic

Which instruction would the nurse teach the client concerned about dislodging a laryngectomy tube at a 3 week postoperative follow-up visit?

Keep calm because this is not an immediate emergency.

Which action would the nurse take to prevent complications when caring for a client with a chest tube to water seal drainage system for a pneumothorax?

Marking the time on the drainage unit every shift

Report content error After reviewing information about oxygenation for 4 clients with chronic obstruction pulmonary disease, which client will the nurse plan to teach about use of home long-term continuous oxygen therapy?

PaO2 of 55; SpO2 of 88

The nurse reviews the principles of oxygen administration. Which is the primary consideration when determining which method of oxygen delivery will be the most effective for a client?

Pathological condition

The nurse is teaching Hands-Only Basic Life Support for adults in the community. After determining that the victim is not responding and the emergency medical system has been activated, which action would the rescuer take?

Perform chest compressions at a rate of 100/min.

A client is admitted to the hospital with a diagnosis of emphysema. When teaching the client about breathing exercises, the nurse would include which instruction?

Perform diaphragmatic exercises to improve contraction of the diaphragm.

Which action will the nurse take to support safe oral intake after tracheostomy?

Position client as upright as possible.

The nurse is caring for a client with a tracheostomy. Which action would the nurse implement when performing tracheal suctioning?

Preoxygenate the client before suctioning.

The nurse provides education to a group of student nurses about pursed-lip breathing. The nurse would include which primary purpose of the respiratory exercise?

Promotes elimination of CO2

The nurse provides immediate postoperative care to a client. The client reports a sudden onset of shortness of breath and chest pain. Which action would the nurse take?

Provide supplemental oxygen

Which color tag would the triage nurse working at a train accident use to label a client experiencing respiratory distress?

Red

A client has a closed chest drainage system in place. How would the nurse determine the amount of chest tube drainage?

Refer to the date and time markings on the outside of the collection chamber.

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and Pco 2 of 60 mm Hg. These blood gas results require nursing attention because they indicate which condition?

Respiratory acidosis

A client with chronic obstructive pulmonary disease (COPD) has a blood pH of 7.25 and a partial pressure of carbon dioxide (PCO 2) of 60 mm Hg. Which complication would the nurse suspect the client is experiencing?

Respiratory acidosis

Which intervention would the nurse offer the client to help relieve the symptoms of sinusitis?

Saline irrigation

A client is admitted to the hospital with a diagnosis of chronic obstructive pulmonary disease (COPD). Which action would the nurse take to prevent client fatigue?

Schedule nursing activities to allow for rest.

In which position will the nurse place a client who has been transferred from the postanesthesia care unit to the intensive care unit after a radical neck dissection?

Semi-Fowler

The nurse provides teaching to a client who is being discharged after treatment for a pneumothorax. The nurse instructs the client to notify the health care provider immediately if experiencing which symptom of a recurring pneumothorax?

Severe shortness of breath

Which finding by the home health nurse who is visiting a client who has had laryngeal cancer surgery indicates a need for further intervention?

The client smokes 4 cigarettes per day.

A client is hospitalized with a diagnosis of emphysema. The nurse provides teaching and would begin with which aspect of care?

The disease process and breathing exercises

Which action would the nurse take when a client with tuberculosis (TB) is admitted to the nursing unit?

Wear a particulate respirator when caring for the client.

Which risk factor for head and neck cancer would the nurse assess for in a client with a persistent, nagging cough? Select all that apply. One, some, or all responses may be correct. Type of employment Presence of ear pain History of tobacco use Oral hygiene practices Amount of alcohol intake

all the above